International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 53 Integrative Psychotherapy and Mindfulness: the Case of Sara Mihael Černetič Abstract: The article explores the relationship between Integrative Psychotherapy and mindfulness on a theoretical as well as practical level. Although mindfulness is not an explicit constituent of Integrative Psychotherapy, the two are arguably a natural fit. Mindfulness has the potential to enhance internal and external contact, a central concept in Integrative Psychotherapy, as well as strengthen a client’s Adult ego state. This article presents a case study whereby Integrative Psychotherapy is analysed from the perspective of mindfulness. Within the course of therapy, parallels were observed between the client's increased mindfulness, improved internal and external contact, strengthened Adult ego state, mastery of introjections, as well as diminished feelings of guilt, improved mood, self care and ability to engage in appropriate separation and individuation. These gains support the conclusion that Integrative Psychotherapy and mindfulness are inherently related and that explicit incorporation of mindfulness may enhance the therapeutic process of Integrative Psychotherapy. Key words: integrative psychotherapy, mindfulness, awareness, acceptance, contact ______________________ Throughout human history, mindfulness has been used to lessen the sting of life's difficulties (Germer, 2005). In this we can see a parallel to one of the main goals of psychotherapy, which is to alleviate mental suffering. The concept of mindfulness can be defined as a non-judgemental accepting awareness of one's own experience in the present moment (Černetič, 2011a). In the last two decades, mindfulness has been integrated into psychotherapy in various ways. Moreso, it has been identified as one of the common factors which has always been implicitly present in all psychotherapy orientations (Martin, 1997). An example of mindfulness might be when one is sitting in a sunny window, taking a moment to become mindful and aware as in, “Right now I feel the sun on my shoulders. I am thinking about the chores I have to do later, and fully tasting the warm tea I am drinking.” In a therapeutic encounter, the therapist may mindfully note, “My client seems anxious today, speaking quickly, and fidgeting with her scarf. I begin to wonder about this, and think of how to ask about her process.” International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 54 Mindfulness can be incorporated into psychotherapeutic work in several ways. Firstly, as a part of the fundamental therapeutic philosophy, which includes an understanding of pathogenesis and the process of healing and personal growth, with an emphasis on the client's awareness and acceptance of their experience. Secondly, as a specific intervention package or therapeutic approach, intended to be the full focus of treatment, or as one of the major elements. Thirdly, as the application of individual mindfulness interventions or techniques, and lastly as a tool for the psychotherapist for coping with their stress, catalyzing the therapeutic relationship, and/or for professional and personal growth (Černetič, 2011a). Mindfulness practice and research are very compatible with the framework of Integrative Psychotherapy (Žvelc, 2009). Theories and methods of Integrative Psychotherapy are based upon the philosophy of accepting awareness within an attuned therapeutic relationship. The main methods of Integrative Psychotherapy, inquiry, attunement, and involvement (Erskine, Moursund, & Trautmann, 1998), invite the client into the state of awareness and acceptance of their internal experience – the main mechanism of mindfulness (Žvelc, 2012). In this article, I present possibilities for the integration of mindfulness and Integrative Psychotherapy on a theoretical level, beyond what Norcross (2005) termed technical eclecticism in psychotherapy integration. I focus on the exploration of how processes of Integrative Psychotherapy and mindfulness intertwine in the course of therapy and how they mutually enhance each other. In the presentation of the case study, theoretical findings are illustrated and further elaborated. Mindfulness, Contact and Relationship The concept of contact plays a central role in Integrative Psychotherapy. According to Erskine and Trautmann (1997), contact takes place on an internal and external level within an individual and thus includes full awareness of sensations, feelings, needs, sensorimotor actions, thoughts and memories which occur within the individual, as well as full awareness of external events as they are registered by sensory organs. However, regaining full internal and external contact involves hard work and the client cannot do it alone, for it is based on the unfolding of awareness within a relationship with another (Erskine et al., 1998). The therapist nurtures the therapeutic relationship with the client and that relationship becomes a vehicle for enhancing contact for the purpose of growth and healing. The contact between the therapist and the client promotes and supports the client's contactful experiences with others (Erskine & Moursund, 1998). Whereas the therapeutic relationship is a key factor in Integrative Psychotherapy for increasing the client's contact, mindfulness can be of great help in promoting this awareness. As mindfulness is a type of awareness, the client's sense of mindfulness International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 55 promotes contact. The nature of mindful awareness is non-judgemental and therefore, non-criticizing and non-threatening. As such, it enables the client to open up to their experience, which further increases contact. Mindfulness thus becomes a facilitator of internal and external contact, or of the client's relationship with themself, as well as with others. My experience as an Integrative Psychotherapist has led to an awareness of how mindfulness can help implement the core methods of attunement, inquiry, and involvement (Erskine et al., 1998). A mindful therapist is fully present in the here and now of the on-going therapeutic process with the client. He or she is fully involved and available in the therapeutic relationship, accepting of the client and of whatever feelings and thoughts the client is experiencing. A mindful therapist is also attuned to the current state and processes of the client, and openly aware of the subtlest signals of the client's body language and para-verbal expressions, such as tempo of speaking, pauses, sighs and so on. Consequently, a mindful therapist is better equipped for using the method of inquiry. When he or she is attuned to the client and involved in the therapeutic relationship, he or she is more prepared to properly implement inquiry (Erskine et al., 1998). In addition, it seems that the therapist's mindfulness catalyses mindfulness in the client and, as previously noted, the client's mindfulness enhances their contact. The therapist's mindfulness may be helpful in the process of establishing and sustaining an optimal therapeutic relationship with a client. The two key elements of mindfulness are awareness and acceptance of one's experience (Černetič, 2011b), and the same may apply to the therapeutic relationship. Without an awareness of, and respect for another human being's experience (i.e. allowing that experience and accepting it), no interpersonal relationship can function well, let alone the therapeutic relationship, which is a particularly refined form of human relationship. In Integrative Psychotherapy, the three core methods – attunement, involvement, and inquiry – represent the foundation of the therapeutic relationship (Erskine et al., 1998). In the course of psychotherapy, a mindful therapist – regardless of their psychotherapy orientation – becomes aware of (i.e. attuned to) the client's experience and accepts it (i.e. properly involved, validating and normalizing the client's experience). As curiosity is one of the characteristics of mindfulness (Kabat-Zinn, 1990), a mindful therapist inquires about the client with a sincere interest. The therapist's mindfulness can also be helpful in working with counter-transference, identifying counter-transference reactions and using them for diagnostic purposes (Černetič, Jančar, & Vlašič Tovornik, 2010), as well as for regulating such reactions. In addition, mindfulness facilitates the development of the therapist's empathy (Morgan & Morgan, 2005). Siegel (2010) argued that the presence of the therapist, and how the therapist forges a connection with the client, are the most crucial factors affecting the healing process in the client. An engaged, committed and caring therapist who is mindful of their own self, and how that self relates to the client, is the key determinant of how well the client will International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 56 respond to therapy. Similarly, Surrey (2005) describes the therapist's application of mindfulness as a three-fold process of attention to themselves, the client, and the movement or flow of their relationship. The therapist is therefore attentive to the changes that are happening from moment to moment with regard to their own sensations, feelings, thoughts, and memories. As the client is describing their feelings, thoughts, perceptions, and sensations, the therapist is also attentive to the experience of the client. The therapist perceives the client's experience as the object of their awareness, and uses these perceptions to better navigate the course of their relationship. From moment to moment, the focus is on paying attention to the reality of the other – to the client's words, voice, feelings, expressions, body language, breathing and so on. Furthermore, the therapist pays attention to the flow of the relationship with the client, to the changing qualities of contact and to its interruptions. For clients, mindful contact has proven to be a useful tool for coping with symptoms such as unpleasant thoughts (such as intrusions, ruminations, flashbacks), feelings (such as depression or excessive anxiety) and body sensations (such as muscle tension, trembling) (Černetič, 2005, 2011b). For example, a client with generalized anxiety disorder would be invited to simply observe their worries instead of constantly dwelling and harping on them. When in the state of mindfulness, the client non- judgementally observes, and thus tolerates, the ebb and flow of their anxiety and fear, without resorting to avoidance of their emotions through worrying, excessive safety- seeking behaviours, or other forms of experiential avoidance. They are aware that thoughts and feelings are not facts – they are merely sometimes unpleasant, but nevertheless interesting events in someone's mind and they do not necessarily reflect the real situation. When mindful, the client is able to de-center from their symptoms. A de-centered perspective is an important mechanism of mindfulness (Teasdale, Segal, & Williams, 1995), which involves adopting the stance of an impartial observer or a witness to one’s experience. The client is in contact with their experience in the present moment, without over-identifying with the contents of that experience. Mindfulness and Ego States Mindfulness can be readily integrated with the theory of ego states. Being mindful has been associated with the Adult ego state (Žvelc, 2010; Žvelc, Černetič, & Košak, 2011). In Integrative Psychotherapy and Transactional Analysis, the Adult ego state is conceptualized as a person being in the here and now, being aware of and functioning in accordance with the present reality, and being autonomous from intrapsychic influences of rigid and outdated material which resides in the archeopsyche and exteropsyche (Berne, 1961; Erskine, 1991; Tudor, 2003). Being mindful is very similar to being in one’s Adult ego state. A mindful person is in full internal and external contact, without suppressing or avoiding in other ways their own unpleasant thoughts, feelings and body sensations. Correspondingly, a mindful person is clearly aware of the situation in the here and now. They are ready to act in accordance with that situation and do not International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 57 feel forcefully directed by the Parent's introjections or the feeling and/or thinking of the Child ego state. According to Žvelc and colleagues (Žvelc et al., 2011), mindfulness may be at the heart of the integration process of the Adult ego state. Observing one's current experience with de-centered awareness is not only a defining feature of being mindful, it is also an inherent characteristic of the Adult ego state. Both mindfulness and the Adult ego state are focused on the here and now, being de- centered from the material which pertains to the past or to the future, such as introjections in the Parent ego state and traumatic experiences in the Child ego state. When being mindful, an individual is able to observe and then let go of their pleasant or unpleasant thoughts and feelings. This cannot be achieved in the Child or in the Parent ego state due to the rigidity of these two ego states, which by definition lack awareness, because they have emerged as a consequence of contact interruptions (Erskine et al., 1998). Yet another parallel between mindfulness and the Adult ego state can be observed on the neuropsychological level. It seems that being mindful and being in the Adult ego state are both characterized by the engagement of an individual's executive functions. These functions, which include attention management and working memory, mental flexibility and task switching, initiation and monitoring of actions, have been associated with prefrontal cortex of the brain (Miller & Cohen, 2001). Mindfulness and Script According to Berne (1964/1975), the final goal of psychotherapy for an individual is to achieve autonomy, which comprises awareness, spontaneity and the capacity for intimacy. To attain autonomy, a person must be "cured," as much as possible, of the intrapsychic control exerted by their script patterns. The script limits their spontaneity and flexibility in problem solving and relating to people, because the story of one's life, including the ending and all the major events, is already written, usually in early childhood (Erskine & Moursund, 1998). In letting go of the influences that a person's script exerts on their life, mindfulness may be of a great help. One of the key mechanisms of how mindfulness works is attenuating the automatic nature of a person's reactions. In the field of mindfulness, reacting in an automatic way is often called being on "automatic pilot." It means doing something with little or no awareness, in a way that is predetermined by old, rigid, often non-adaptive patterns of thinking, feeling and behaving. The concept of being on automatic pilot, or being mindless, and the concept of the script thus largely overlap. Being mindless often involves reacting out of one's script. In both cases, the person lacks autonomy, as defined by Berne (1964/1975), to be truly aware of things as they are, to be spontaneous in all forms of behaviour, and thus capable of real intimacy in relationships with other people. Mindfulness, which is a process of de-automatization and of increasing awareness, can therefore help a person attain flexibility and freedom in responding. It helps them to think, feel and behave in a way that is relevant to the International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 58 specific situation in the here and now, free from "the old stuff," such as introjections and other materials from the Parent and the Child ego states. Mindfulness is not related to the script only in the process of its dissolution, but also in the very development of script patterns. Living mindfully means to be in contact, and if a person is in contact, there is no need for script formation. As Erskine and Moursund (1998) explain, the story of life scripts is the story of contact and contact distortion between an individual and the outside world of people and things. When contact is distorted or denied, needs are not met. Since the experience is not closed naturally, it seeks an artificial closure. These artificial closures are the substance of childhood reactions and decisions that become fixated and may also create a situation where introjection of another person's personality is likely to occur (Erskine & Moursund, 1998). Conversely, an individual’s needs are processed spontaneously and naturally when the person is in the state of mindfulness. Being mindful of one's need and being in contact with it, enables a person to satisfy the need more easily, or at least close the gestalt through awareness that the need cannot be met for the time being. Coming Home – The Case of Sara Sara, a primary school teacher and married mother in her early thirties with two pre-school children, came to psychotherapy due to several years of depression, and upon the recommendation of her psychiatrist. Several months before the start of the psychotherapeutic process Sara had stopped taking her antidepressant by her own decision. She did not like the side effects of her medication and wanted to overcome her depression without psycho-pharmaceutical assistance. At the beginning of the psychotherapeutic process, Sara reported suffering from low self- esteem. She was dissatisfied with herself and often experienced feelings of guilt. She experienced an understanding relationship with her husband, with occasional conflicts that were due to her irritable outbursts. As a parent, she was caring and responsible. She was committed to her family and tried hard to be a good housekeeper. Sara was not satisfied with her job. She wanted to do something else professionally, particularly because she experienced her pupils as naughty and exhausting. She perceived herself as not being competent enough to deal with them. Sara grew up in a nuclear family of two children. She was the older child and her brother was several years younger. The parents were demanding towards Sara and she was expected to help a lot in the household. They often criticized her help in the house, but did not expect so much from her brother. Sara told me her brother was often praised for completing a chore, and in contrast, she would be criticized. Sara’s developmental history was marked by strong criticism from her mother. Sara told me that she was never good enough for her mother, who behaved towards her in a very demanding way. At school, Sara was learning for her mother. She had excellent grades International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 59 in primary school, but felt that her mother took this for granted. Sara was clearly trying hard to please her mother in order to avoid the mother's criticism and receive positive affection from her. Such “mother-pleasing” behaviour persevered into Sara's adult life. It is also important to note that while growing up, Sara provided much emotional support to her mother. For example, when mother had a miscarriage, Sara tried to help her emotionally, trying to comfort her. For a young child, the burden of this task was simply too heavy. As a child, Sara had a somewhat better relationship with her father than with her mother. On occasions, Sara and her father would cover up an event that mother could find embarrassing, for example a telephone call from grandmother, in order to avoid her angry acting out. Unfortunately for Sara, her father quite often failed to take her feelings seriously, and sometimes he ridiculed them. When Sara was in high school, her psychological symptoms began to appear. She experienced feelings of meaninglessness and considered suicide. Her headaches started in that period as well. They did not have a somatic cause, but frequently became worse when she relaxed. While attending university, about a decade before beginning psychotherapy, Sara’s parents divorced. This triggered significant distress and marked the beginning of her depression. During the process of her parents' divorce, Sara put herself on the side of her mother, even though her relationship with father had been better than her relationship with mother prior to the divorce. Sara invested a lot of time and energy into providing emotional support to mother during and after the divorce. However, this support was not reciprocal. Even though Sara also needed emotional support at that time, she did not receive it from her parents. Before the divorce her father was a source of support for Sara, but as a consequence of the divorce, she felt abandoned by him and he moved out of their house. Sara said she experienced the divorce as if she herself had divorced her father. In her early twenties, Sara began to experience depressive symptoms. In the years that followed, she received two outpatient psychiatric treatments, which included taking the antidepressant medication sertraline. She was referred to psychotherapy by her psychiatrist. According to the DSM-IV-TR classification (American Psychiatric Association, 2000), Sara’s diagnosis in the months preceding the beginning of the psychotherapy is consistent with an Axis 1 disorder (296.32 Major Depressive Disorder, Recurrent, Moderate), with two additional problems on Axis 4; problems with primary support group (disruption of family due to parents' divorce) and occupational problems (job dissatisfaction). Her GAF score (Global Assessment of Functioning Scale, Axis 5) equalled 55. In Integrative Psychotherapy diagnosis, assessment of the client's ego states is an important element. At the beginning of the psychotherapeutic process, Sara was frequently in her Child ego state. Such states were usually related to events with her mother and were most pronounced in the days following a quarrel. Sara experienced a lot of guilt, sorrow and a feeling of being misunderstood by her mother. In the first months of our therapy, Sara was very fragile in her Child ego state and was very International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 60 sensitive to criticism by her mother. At the same time, she still tried hard to please the mother and meet her expectations through frequent housecleaning of her own home and manner of raising her children. In doing so, Sara hoped to receive her mother's approval and positive affection, but mostly she did not. This stirred up old feelings of guilt, sadness and of being misunderstood. Generally speaking, Sara felt almost no anger, but especially not towards her mother. After about two months in therapy, Sara's depression worsened to the degree that she needed a sick leave from her job. During a therapy session when she had been on sick leave for just a few days, she reported feeling better due to not working, but also thought that she ought to return back to work. Even though her psychiatrist recommended three to four weeks of sick leave, Sara – on her own initiative - made an arrangement with her general physician to shorten her sick leave to only two weeks, and then stated at the beginning of this session that she was determined to go back to work after just one week of absence. To illustrate Sara's structure of ego states and their typical dynamic, I present an example in Figure 1. Figure 1. An example of Sara's ego states and conflict regarding the length of her sick leave. Later in that session, with the help of chair work technique, two aspects of Sara revealed themselves: "the Wise Ass" and "Sara." The “Wise Ass” part represented Sara’s Parent ego state, which emphasized the disadvantages of her sick leave, such as the deprecating words of her co-workers and her work assignments piling up. Her Parent was trying to persuade her to return to work with statements such as "It is necessary to endure," "It is not so hard," "It is necessary to do [this and that]". These statements stemmed from the introjections, which Sara acquired from her mother. The essence of International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 61 these introjections overemphasized "shoulds" and "musts" and underemphasized consideration of Sara's own feelings and needs. The second part named "Sara" represented her Child ego state. This part told Sara that returning to work at that time was simply too much for her and that she was unable to do that. Perhaps even more importantly, this part told Sara that she would have pulled herself together if she had the ability to do so. She told me that she was scared. "Sara" also told me that she was, in a way, clinging to her depression because it enabled her to finally be "a small child" and have her parents take care of her. Before, it was often Sara who had been providing, or at least trying to provide, support to her mother, as in the previous example of mother’s miscarriage during Sara’s early childhood. In contrast to her Child and Parent ego states, Sara’s Adult ego state was quite weak during this early stage of psychotherapy, and her daily experience was to a significant extent under the control of her Child and Parent ego states. Her capacity to critically reflect on the content of her introjections and of her archeopsyche was quite limited at that time. A core model of Integrative Psychotherapy, also fundamental for making an Integrative Psychotherapy diagnosis, is the Script System (Erskine & Moursund, 1998; O’Reilly- Knapp & Erskine, 2010). Figure 2 illustrates Sara’s script system. Figure 2. The script system of Sara. International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 62 Sara held a core belief that she was not good enough. Most of the time she felt guilty in one way or another. She believed that life was hard and that other people were demanding and hard to satisfy. Consequently, she tried hard to meet the perceived expectations of others. However, often it was Sara who perceived other people's expectations in an exaggerated way. When working with her colleagues, she was sometimes taken advantage of because she took upon herself an unfairly big amount of work. Yet due to her script pattern, Sara was constantly reminded, in one way or another, of her "insufficient" and "inadequate" performance. This perpetuated her script- driven vicious cycle. For example, when her mother came to look after Sara’s children, she would sometimes comment on such things as dust being visible on the furniture, which made Sara feel very bad about herself. Sara had difficulty accepting that her mother might be overly critical. She would interpret her mother's comment as an indicator of her own faults and, as a consequence, she would feel guilty and sad. Similarly, when she was having difficulties with the troubled kids at school, she would attribute the children's naughty behaviour to her professional incompetence. In general, Sara was highly demanding of herself. In one of the initial therapy sessions, she said she usually expected a "120 per cent" performance from herself. Old emotional memories reinforced Sara's script system. For example, memories of being criticized by her mother, and memories of trying hard, yet still not being good enough, persisted. No matter how hard Sara tried as a child, she could not prevent her mother's biting, painful comments. While talking about such situations in therapy, I expected at least some anger to occur in her. However, in the beginning of psychotherapy, Sara's feelings of anger were repressed. Sara's relational needs to be in a secure relationship where she was accepted, protected and valued the way she was were partly repressed as well. While growing up ridiculed for her feelings by her father and humiliated by her mother's frequent criticism, important relational needs were often unmet and, as a consequence, Sara avoided the pressure of those needs by repressing them. Sara also held a script belief that she was not important. While growing up, her feelings and needs were often not validated. As a result, she came to the conclusion that she did not matter. Although in college when her parents divorced, Sara nonetheless provided a lot of emotional support to her mother, whilst neglecting her own feelings. For example she had to suppress positive emotions towards father, and her needs to receive emotional support. In her adult life, it seemed that Sara was not quite able to take enough time for herself. Providing the necessary care to her family as a mother and a wife sometimes served as a rationalization for neglecting herself. Sara's quiet voice during therapy sessions was one of the indicators of her belief that she was not important. International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 63 Unsurprisingly, Sara indulged in a fantasy of going somewhere far away. She said that, in her ideal life, she would be a manager of a hotel in an exotic tourist destination in Asia, or a tourist worker in some other tourist destination in the South. Doing that would make her feel happy and at ease. This fantasy, of a rather escapist nature, was valuable to me as her therapist, for it revealed the depth and significance of Sara's distress. Curiously, even in such an escapist fantasy, Sara was taking care of other people – she was a tourist worker, but not a tourist herself. The Self-in-Relationship model (Erskine & Trautmann, 1997; O'Reilly-Knapp & Erskine, 2003) shows how a client establishes contact with themselves internally and externally with others, on different dimensions of personality. Sara was initially open to internal cognitive and behavioural contact, and partially open to physiological contact. She was able to think about her problems and understand them, and was quite receptive to behavioural interventions in the psychotherapeutic process. Physiologically, she was able to report some of her body sensations related to her distress. However, she had very little contact with her emotions. On the one hand, she was often overwhelmed with some feelings, such as sorrow, but on the other hand, she repressed some other feelings such as anger. In the beginning of her therapy, I had to pace our work very carefully, otherwise the intensity of Sara's emotional arousal in therapy sessions would quickly rise above her tolerance level. When it did, she would shut off and lose contact with her painful emotions. As the therapy progressed, she became more able to tolerate her feelings. In the beginning of therapy Sara's external contact was also limited. She was often quite absorbed in her intrapsychic experiences and was less contactful in the interpersonal domain. Several different contact interruptions (Clarkson, 2004) such as introjection, retroflection and deflection were the most notable in Sara's functioning. Deflection corresponded to her feeling of being empty-headed, which was quite common in situations when Sara was overwhelmed with negative emotions. In order to protect herself from feeling distress, she unconsciously broke off her awareness of these emotions. In Sara's relationship with her mother, introjection was a characteristic contact interruption, also often tied to retroflection. The Psychotherapeutic Process from the Perspective of Mindfulness At the start of our therapy, Sara and I made a therapeutic contract that we would work on the issues that were contributing to her depressive experiences and irritability. The goal was to gradually improve her general mood and make it more stable and positive. Our work lasted for two years and four months, and followed the principles and methods of Integrative Psychotherapy. Our work was not a mindfulness-based therapy. However, I used mindfulness as a therapeutic intervention, and we occasionally talked about mindfulness as an alternative way for her to approach her experiences. My clinical observation was that Sara's level of state and trait mindfulness increased during the course of the psychotherapeutic process. In other words, Sara was increasingly able International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 64 to experience the state of mindfulness in various situations, and mindfulness was also gradually gaining strength as a personality trait. In the first few months of therapy, Sara was quite avoidant of her painful emotional experiences. It was hard for her to be mindful of unpleasant feelings, to be in contact with them as they were. When she could not tolerate an emotion, she interrupted internal contact. Therefore, I had to pace the therapy carefully and not rush the process. My attunement to Sara, or my mindfulness of what was going on with her in a given moment was crucial, for it ensured that my inquiry was not too intense for her. My therapeutic attunement, as well as involvement, also helped her to stay in contact with feelings despite their unpleasantness. Consequently, she resorted to fewer contact interruptions. Among the themes that Sara avoided, her relationship with her mother was at the top of the list. This relationship was very painful for Sara, yet at the same time it represented a topic of key importance for her psychotherapy. In her primary family, Sara received a lot of criticism and was mocked for her feelings. In therapy, however, Sara had a chance to experience a relationship that was different from her experiences in her developmental past. I tried to be attuned to Sara's experience and take her feelings seriously. Criticism, which had caused so much psychological harm to her in the past, was not present in our relationship. Through the processes of attunement, involvement and inquiry, Sara could feel understood. For this reason, our therapeutic relationship represented for Sara what Stern (1994) called the needed relationship, a place where her relational needs could be met to a greater extent than in her past. This different relationship also helped Sara relate differently to herself, in a less critical way and with more acceptance, which weakened her internal critic. My attunement to Sara, my acknowledgement and validation of her experience helped her to become aware of a wider spectrum of her feelings, instead of repressing them. Her feelings were important and accepted in our therapeutic relationship, which helped her build her own awareness and accept her inner experience. Awareness of one's own experience and acceptance of it are probably the two most pivotal elements of mindfulness (Černetič, 2011b). The manner in which Sara's feelings were approached in our therapeutic relationship helped her build a mindful stance towards them. Strengthening Sara's capacity for self-care was another important theme in our work. Sara was learning to take better care of her important physiological needs, such as getting enough rest, as well as her psychological needs, such as the need to relax. Becoming aware of a need is the necessary first step in ensuring that any need will be met. During our work, Sara developed an increased mindful awareness of her various needs, such as the need for rest, relaxation and socializing, which enabled her to then take a proactive role in satisfying them. As a therapist, my efforts to be mindful helped me to implement the methods of Integrative Psychotherapy with greater skill. It enabled me to be involved in the International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 65 therapeutic relationship with greater presence, to be more attuned to what was going on with Sara, either in the present or in the past, and which was being relived in the here and now of therapy. I was able to inquire in a more attuned manner. When I was mindful in a therapy session, I was more able to provide a calm presence and be completely present for Sara, who was often suffering from painful feelings. I was able to psychologically hold her, calmly and strongly. My own mindfulness in a therapy session helped Sara to be mindfully aware of her experience. It thus contributed to establishing the circumstances needed for the realization of her internal contact and processing of important material. In addition, I noted that being mindful as a therapist contributed to my awareness of counter-transference, and the impact of Sara's depressive affect on me. When a therapy session was over, I often felt somewhat melancholic compared to my mood before the session. This usually happened for no reason that I could attribute to my personal circumstances. It was interesting, though, that I was often simultaneously aware of another feeling in myself that could be described as a release from melancholy and sadness. When Sara came to a resolution and diminution of her painful emotions in the therapy session, her relief was probably often reflected in my counter-transference. Being mindful of counter-transference widened the scope of my attunement to Sara, deepened our therapeutic relationship, and provided valuable information about her on- going process. This information was often related to the material which Sara was not yet ready to explore on the conscious level, warding it off instead. Yet, due to the mechanism of projective identification, the material became observable through my counter-transference. Being mindful of my counter-transference reactions also enabled me to put these reactions into the right perspective and deal with them in an appropriate manner. As our work progressed, and Sara became more contactful internally and externally. She was less avoidant of her unpleasant emotions and came more easily in contact with them. She used interruptions of contact less frequently and became more mindful. Increased mindfulness helped her therapy to run more smoothly and progress faster. Sara was more able to talk about her core issues, particularly her relationship with her mother. Although the unpleasant events in this relationship still hurt her, and the two were still quarrelling occasionally, Sara changed her inner relationship to the problem. She now perceived those events and circumstances more mindfully, from a decentred perspective, with more equanimity and calmness. Consequently, mother's critical remarks and their now less frequent quarrels, did not, in her words, "completely crush her,” as they previously had. The first months of therapy were marked with Sara's frequent, intensive, and often overwhelming, depressive symptoms. Sara was frequently in her Child ego state, feeling sad and hopeless, reliving her past, instead of being present and mindfully in the here and now. International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 66 When Sara was in her Child ego state, our therapeutic work, especially during the first year, was often centred around attuning to the Child and processing the Child material. Part of this work included exploring the Child's unmet relational needs for security, validation and acceptance. In addition to focusing on the Child, we also worked on strengthening Sara's Adult ego state to enable "dual awareness" (Rothschild, 2000). The aim of this was to help Sara calmly observe and reflect upon her own experiences of distress when they were happening. It is important to note that enhancing Sara's capacity for reflective self-observation also strengthened her capacity for mindfulness, and developed what Žvelc (2009, 2010) named the Mindful Adult. It helped Sara in her efforts to merely observe, with equanimity, whatever was going on inside her, without getting overwhelmed by distressful experiences so characteristic of Child ego states. During the course of therapy, Sara gradually became less vulnerable to her mother's criticism, and her behaviour and feelings during these difficult situations with her mother changed, as she became more able to stay in her Adult ego state. Her previously strong Child ego state reactions diminished. She was able to view the mother's behaviour more objectively and less as a threat to her very self. Such decentred, mindful perspective is reflected in Sara's statement, "I do not only say this to myself now, I really feel in this way, more and more, that this is all that mother is capable of, that it is the best she can give me." In another statement Sara reflects on her non-reactive, mindful stance towards mother. "Well, she just has to say that. […] That's the way it is, she cannot do differently. And I try to make it go in at one ear and out at the other, and not react at all. It is easier." In this period of therapy, Sara cried less, her mood was more stable, and she remained more balanced when faced with challenges. Sara’s strengthened Adult ego state enabled her to be more mindful of other aspects of her present experience, which did not comply with her life script. In addition to having negative, unpleasant feelings, she could be simultaneously aware of positive feelings. For example, in one session, after sixteen months in therapy, Sara felt trapped, unfree, unworthy and guilty. However, she was aware that this only applied to the situations at home and at work, because when she was in town that day, running errands, she felt self-confident. When experiencing negative, unpleasant affect and cognitions, Sara did not become so overwhelmed with them in comparison to when she first came into psychotherapy. Instead, she was more able to stay in her Adult ego state and tolerate, as well as regulate, such unpleasant feelings and thoughts. She managed her sadness, tension, anger and frustrations more efficiently and in ways that were more adaptive and healthy for her. For example, in stressful moments she ate less sweets and less frequently resorted to cuticle biting, compared to the past, when her fingers would often bleed as a result. It is important to note that, especially from the perspective of mindfulness, tolerating negative affect, without interrupting contact, in fact means regulating them. Staying mindful with unpleasant feelings, in a non-judgemental and accepting manner, International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 67 usually brings a surge of relief. With the development of a stronger Adult ego state, Sara's affective tolerance markedly increased. In our work, it was necessary to decontaminate Sara’s Adult ego state in regard to her parents. In this process, Sara learned that respecting parents does not mean one needs to be submissive, self-belittling, or even self-humiliating. On the contrary, real respect of parents implies respecting oneself, too. For Sara, this realization was the necessary prerequisite for developing the real freedom that she had been longing for so much – the inner freedom from the tyranny of the introjected Parent. In the process of establishing this psychological freedom, Sara developed a new way of coming home. Her own family and her mother lived in separate apartments in the same building. Before therapy, she felt obliged to first visit her mother when she came home, even though she would have preferred to go to her own apartment first and then, sometimes, visit mother. Sara did not feel free to do what she wanted to do. Instead, she felt an inner compulsion to first say hello to her mother. It even seemed to her that she would have betrayed her mother if she had gone straight to her own apartment. Sara did not feel adult in what she was doing. As we worked on a behavioural change regarding this issue, I suggested to Sara, and she agreed, to try something different. After coming home, she was to go to her own apartment first and then, if she wished to, visit her mother. At first, it was quite a challenge for Sara to carry out our agreement. I encouraged her to be present in the here and now when she came home, to be in that very moment with awareness, and then to mindfully ask herself, "Now, what do I want to do? Where exactly do I want to go?" After a while, she mastered a new way of coming home, and it strengthened her feelings of freedom, independence, and of being an adult. She lived more in the present, in accordance with what she was - an adult woman. She was no longer chained by her past, no longer a child trying to please her mother and avoid her critique. Being more mindful in crucial, decisive moments was helpful for her in transcending a part of her script and developing new, more mature and more adaptive patterns of behaviour. Coming home in a different way also bore an important symbolical meaning - Sara managed to "come home" – to get a bit closer to her true self. The aforementioned tyranny of the introjected Parent is probably the single most suitable phrase to describe Sara's script system. A prototype of her script dynamics is demonstrated in the previous description of her dilemma of how long should she stay on sick leave (see Figure 1). These dynamics also became part of Sara's personality structure which contained a demanding, low-empathic Parent acting out towards the sad, helpless, but struggling Child who is trying hard to please the Parent in order to gain the Parent's recognition and possibly, love. Although the psychiatrist recommended about a month of sick leave, Sara felt a lot of guilt for staying at home, and she wanted to go back to work after just a week. Working on this dilemma was an opportunity for us to deepen contact with the vulnerable part of Sara – the part that needed the sick leave International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 68 – and to become more aware of her needs. As a consequence, she remained on sick leave longer, despite her feelings of guilt. She said that such a "long" sick leave – two weeks – was a success for her and she attributed it to our therapeutic work. She was becoming better at acknowledging her own needs and taking proper care of them. Another important part of Sara’s work was related to her repressed and retroflected anger. I often wondered where her anger towards mother was hiding. Even though mother was often unkind to her, I noticed that Sara did not feel much anger towards her. Instead, she would "feel broken," very sad, desperate, not understood, and with bad feelings about herself. She retroflected angry feelings that were originally directed towards her mother and less often towards other people. Her anger was often over- controlled, but sometimes under-controlled, as when she acted out in irritable outbursts directed at her family members. For Sara, our work on anger was important for several reasons. First, being mindfully in contact with anger lessened the need for retroflection. Consequently, depressive symptoms, which to a certain extent represented retroflected material resurfacing, were less likely to occur. Secondly, anger as such was oriented against the script beliefs Sara held, such as "I'm not important" or "I'm not good enough." Due to the unique characteristics of the emotion of anger, it is less likely for an angry person to feel that they are not important or not acceptable to others. Thirdly, anger became a helpful resource to Sara in regulating relationships. Often, Sara had only limited success in setting efficient boundaries in relationships and saying "no" to others. Through her therapy, she was learning to use the progressive energy of anger to be more assertive with others, and especially with her mother. Sara needed this constructive aspect of anger to transform her relationship with mother, and in her words, "build her independence." Feeling anger mindfully, instead of retroflecting or repressing it, supported Sara in her process of separation and individuation. It was also helpful in her journey from an anxious-avoidant attachment style towards an active and authentic engagement in relationships. At the end of the psychotherapeutic process, Sara's relationship with herself was considerably improved in comparison to the beginning of therapy. She was less critical and demanding of herself, more lenient and self-compassionate. She also became more able and willing to take care of herself than before. She actively took time for herself and engaged in recreational activities that were beneficial for her. She was more relaxed, satisfied and calm. In contrast to her previous script beliefs, therapy helped Sara develop an increased sense of self-respect and self-worth. She also became more able to set boundaries in her relationships at home and at work. Importantly, her psychological well being became significantly less dependent on the dynamics of the relationship with her mother. Sara's sensitivity to her mother's criticism decreased considerably. At the end of therapy, she was psychologically more separated and more independent from her mother, and she was able to manage this relationship more effectively and mindfully. International Journal of Integrative Psychotherapy, Vol. 5, No. 1, 2014 69 Conclusion This theoretical presentation of the integration of Integrative Psychotherapy and mindfulness, supported with a case presentation, demonstrates that Integrative Psychotherapy and mindfulness are not only mutually compatible, but also implicitly intertwined on theoretical and on practical level. The process of Integrative Psychotherapy may enhance mindfulness in clients, just as increased mindfulness may enhance a client’s process of Integrative Psychotherapy. Therefore, we can hypothesize that encouraging and introducing mindfulness more explicitly in the process of Integrative Psychotherapy will bring even more benefit to our clients. In further investigations of the relationship between Integrative Psychotherapy and mindfulness, it would be helpful to explore in greater depth how various elements of Integrative Psychotherapy might be related to mindfulness. 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