Integrative Psychotherapy Articles

THE PROCESS OF INTEGRATIVE PSYCHOTHERAPY

Richard G. Erskine, Ph.D.
Rebecca L. Trautmann, RN, MSW
Institute for Integrative Psychotherapy
New York, NY

Just as people and relationships are dynamic processes, so is the development of theory, originating as it does from the dynamic process of the individual theorist(s) and from the dynamic process of each therapeutic relationship which guides and informs that theory. Thus we would like to take the opportunity in this workshop to talk about how Integrative Psychotherapy has developed and how we think about it and practice it today.

The term “integrative” of Integrative Psychotherapy has a number of meanings. It refers to the process of integrating the personality: helping the client to assimilate and harmonize the contents of his or her ego states, relax the defense mechanisms, relinquish the life script, and reengage the world with full contact. It is the process of making whole: taking disowned, unaware, unresolved aspects of the ego and making them part of a cohesive self. Through integration, it becomes possible for people to have the courage to face each moment openly and freshly, without the protection of a preformed opinion, position, attitude, or expectation.

"Integrative" also refers to the integration of theory, the bringing together of affective, cognitive, behavioral, physiological, and systems approaches to psychotherapy. The concepts are utilized within a perspective of human development in which each phase of life presents heightened developmental tasks, need sensitivities, crises, and opportunities for new learnings. Integrative psychotherapy takes into account many views of human functioning: psychodynamic, client centered, behaviorist, family therapy, Gestalt therapy, Reichian, object relations theories, psychoanalytic Self psychology and Transactional Analysis. Each provides a valid explanation of behavior, and each is enhanced when selectively integrated with the others. The psychotherapeutic interventions are based on research-validated knowledge of normal developmental process and the theories describing the self-protective defensive processes used when there are interruptions in normal development.

The ABC’s and P

The preliminary ideas of Integrative Psychotherapy were first presented by Richard Erskine in 1972 in lectures at the University of Illinois. An outline of these ideas was published in the article, "The ABC's of Effective Psychotherapy" (Erskine, 1975) and are then elaborated upon in the article, "Script Cure" (Erskine, 1980). Some of the clinical methods that will be briefly described here are presented transaction-by-transaction in Integrative Psychotherapy in Action (Erskine & Moursund, 1988).

The focus of integration was on three primary dimensions of human functioning and therefore of psychotherapeutic focus: cognitive, affective, and behavioral. The cognitive theories stress the mental processes of a person and focus on the question, "Why?" The cognitive approach explains and provides a model of understanding. Why do we have the problems that we have? Why does our mind work the way it does? It assumes that psychotherapy is an intellectual process and when the client comes to understand why he or she behaves and thinks in a particular manner, he or she will solve the conflicts involved.

Significantly different from the cognitive is the behavioral approach which deals with the question of "What?" Behavioral therapy describes what exists and attempts to shape appropriate behavior. What is the specific problem? What contingencies shaped and now maintain the behavior? What changes are necessary in the reward system to produce new behavior? And since behavioral therapy emerged out of experimental psychology, there is a great deal of attention given to what measures are to be applied to evaluate the changes made. The application of behavioral therapy involves a shift away from the question of "Why?" and instead is focused on "What?" The goal of behavioral therapy is to identify and reinforce desired behaviors.

Both cognitive and behavioral therapy are significantly different from an affective psychotherapy. An affective approach deals with the question "How?" How does a person feel? Here the focus is on the internal experiential process: how each person emotionally experiences what has happened. The major focus is not on the Why of cognitive therapy or the What of behavioral therapy, but on How we emotionally experience ourselves in the Here and Now. A basic premise in affective therapy is that people are out of touch with their feelings. It is assumed that removing blocks to emotions and fully expressing repressed affect will produce an emotional closure and provide for a fuller range of affective experiences.

In addition to the dimensions of affect, behavior, and cognition , we have included the physiological dimension. As many of the mind/body theories and modalities have developed, including the research on psychoneuroimmunology, it became imperative to include a focus on the body as an integral aspect of psychotherapy. Disturbances in affect or cognition can adversely affect the body as physiological dysfunction can impact changes in behavior, affect, and cognition.

The affective, behavior, cognitive, and physiological foundations of the human organism are viewed from a systems perspective--a cybernetic model wherein any dimension has an interrelated effect on the other dimensions. Just as the individual is affected by others in a family or work system, they in turn contribute to the uniqueness of the system. In a similar systemic way the intrapsychic and observable dimensions of an individual are inherently influenced in the psychological function of the individual. The systems perspective leads to the question, "What is the function of a particular behavior, affect, belief, or body gesture on the human organism as a whole?” A major focus of an integrative psychotherapy is on assessing whether each of these domains--affective, behavioral, cognitive, and physiological--are open or closed to contact and in the application of methods that enhance full contact.

Contact

A major premise of integrative psychotherapy is that contact constitutes the primary motivating experience of human behavior. Contact is simultaneously internal and external: it involves the full awareness of sensations, feelings, needs, sensorimotor activity, thought and memories that occur within the individual and a shift to full awareness of external events as registered by each of the sensory organs. With full internal and external contact, experiences are continually integrated. To the degree that the individual is involved in full contact needs will arise, be experienced, and be acted upon in relation to the environment in a way that is organically healthy. When a need arises, is met, and is let go, the person moves on to the next experience. When contact is disrupted, however, needs are not met. If the experience of need arousal is not closed naturally, it must find an artificial closure. These artificial closures are the substance of reactions and decisions that may become fixated. They are evident in the disavowal of affect, habitual behavior patterns neurological inhibitions within the body, and the beliefs that limit spontaneity and flexibility in problem solving and relating to people.

Each defensive interruption to contact impedes full awareness. It is the fixation of interruptions in contact, internally and externally, that is the concern of Integrative Psychotherapy.

Relationships

Contact also refers to the quality of the transactions between two people: the full awareness of both one's self and the other, a sensitive meeting of the other and an authentic acknowledgement of one's self. Relationships between people are built on contact, the primary motivation for establishing and maintaining relationships.

Integrative psychotherapy makes use of many perspectives on human functioning. For a theory to be integrative it must also separate out those concepts and ideas that are not theoretically consistent in order to form a cohesive core of constructs that inform and guide the psychotherapeutic process. The single most consistent concept in the psychology and psychotherapy literature is that of relationship. From the inception of a theory of contact by Laura and Frederick Perls (1944; Perls, Hefferline & Goodman, 1951) to Fairbairn's (1952) premise that people are relationship-seeking from the beginning and throughout life, to Sullivan's (1953) emphasis on interpersonal contact, to Guntrip's (1971) and Winnicott's (1965) relationship theories and corresponding clinical applications, to Berne's (1961, 1972) theories of ego states and script, to Rogers' (1951) focus on client-centered therapy, to Kohut (1971, 1977) and his followers' (Stolorow, Brandschaft, and Atwood, 1987) application of "sustained empathic inquiry," (p. 10) to the relationship theories developed by the Stone Center (Surrey, 1985; Miller, 1986; Bergman, 1991), there has been a succession of teachers, writers, and therapists who have emphasized that relationship--both in the early stages of life as well as throughout adulthood--are the source of that which gives meaning and validation to the self.

The literature on human development also leads to the premise that the sense of self and self-esteem emerge out of contact in relationship. Erikson's (1950) stages of human development over the entire life cycle describe the formation of identity (ego) as an outgrowth of interpersonal relations (trust vs. mistrust, autonomy vs. shame and doubt, etc.). Mahler's (1968, 1975) descriptions of the stages of early child development place importance on the relationship between mother and infant. Bowlby (1969, 1973, 1980) has emphasized the significance of early as well as prolonged physical bonding in the creation of a visceral core from which all experiences of self and other emerge. When such contact does not occur in accordance with the child's needs there is a physiological defense against the loss of contact, poignantly described by Fraiberg in "Pathological Defenses in Infancy” (1983).

From a theoretical foundation of contact in relationship coupled with Berne's concept of ego states (particularly Child ego state) comes a natural focus on child development. The works of Daniel Stern (1985) and John Bowlby (1969, 1973, 1980) are presently most influential, largely because of their emphasis on early attachment and the natural, life-long need for relationship. Based on his research of infants, Stern delineates a system for understanding the development of the sense of self which emerges out of four domains of relatedness: emergent relatedness, core relatedness, intersubjective relatedness, and verbal relatedness. As we take this view of the developing person into our psychotherapy practice, we have a deep appreciation for the vitality and active constructing that is so much a part of who our client is. By looking at the client from a simultaneous perspective of what a child needs and how he/she processes experiences as well as these being on-going life processes, we use our self in a directed way to assist the process of developing and integrating. What is frequently very significant in the psychotherapy is the process of attunement, not just to discrete thoughts, feelings, behaviors, or physical sensations, but also to what Stern terms "vitality affects," such that we try to create an experience of unbroken feeling-connectedness. The sense of self and the sense of relatedness that develop seem crucial to the process of healing, particularly when there have been specific traumas in the clients life, and to the process of integration and wholeness when aspects of the self have been disavowed or denied because of the failures of contact in relationship.

Psychological Constructs

Integrative Psychotherapy correlates constructs from many different theoretical schools resulting in a unique organization of theoretical ideas and corresponding methods of clinical intervention. The concepts of contact in relationship, ego states, and life script are central to our integrative theory.

Ego States and Transference

Eric Berne’s (1961) original concept of ego states provides an overall construct that unifies many theoretical ideas (Erskine, 1987, 1988). Berne defined the Child ego states as an archaic ego consisting of fixations of earlier developmental stages; as “relics of the individual’s own childhood” (1961, p. 77). The child ego states are the entire personality of the person as he or she was in a previous developmental period (Berne, 1961; 1964). When functioning in a Child ego state the person perceives the internal needs and sensations and the external world as he or she did in a previous developmental age. This includes the needs, desires, urges, and sensations; the defense mechanisms; and the thought processes, perceptions, feelings, and behaviors of the developmental phase when fixation occurred. The Child ego state fixations occurred when critical childhood needs for contact were not met and the child’s use of defenses against the discomfort of the unmet needs became habitual.

The Parent ego states are the manifestations of introjections of the personalities of actual people as perceived by the child at the time of introjection (Loria, 1988). Introjection is a defense mechanism (including disavowal, denial, and repression) frequently used when there is a lack of full psychological contact between a child and the adults responsible for his or her psychological needs. By internalizing the parent with whom there is conflict, the conflict is made part of the self and experienced internally, rather than with that much-needed parent. The function of introjection is in providing the illusion of maintaining relationship, but at the expense of a loss of self.

Parent ego state contents may be introjected at any point throughout life and, if not reexamined in the process of later development, remain unassimilated or not integrated into the Adult ego state. The Parent ego states constitute an alien chunk of personality, imbedded within the ego and experienced phenomenologically as if they were one’s own, but, in reality, they form a borrowed personality, potentially in the position of producing intrapsychic influences on the Child ego states.

The Adult ego state consists of current age-consistent emotional, cognitive, and moral development; the ability to be creative; and the capacity for full contactful engagement in meaningful relationships. The Adult ego state accounts for and integrates what is occurring moment-by-moment internally and externally, past experiences and their resulting effects, and the psychological influences and identifications with significant people in one’s life.

The object relations theories of attachment, regression, and internalized object (Bolles, 1977, 1987; Fairbairn, 1952; Guntrip, 1971; Winnicott, 1965) become more significant when integrated with the concepts of the Child ego states as fixations of an earlier developmental period and the Parent ego states as manifestations of introjections of the personality of actual people as perceived by the child at the time of introjection (Erskine, 1987, 1988 1991).

The psychoanalytic self psychology concept of self object function (Kohut, 1971; 1977) and the Gestalt therapy concept of defensive interruptions to contact (Perls, Hefferline & Goodman, 1951) can be combined within a theory of ego states to explain the continued presence of separate states of the ego that do not become integrated into Adult ego state (Erskine, 1991).

Ego state theory also serves to define and unify the traditional psychoanalytic concepts of transference (Brenner, 1979; Friedman, 1969; Langs, 1976) and non-transferential transactions (Berne, 1961; Greenson, 1967; Lipton, 1977). Transference within an Integrative Psychotherapy perspective of ego states can be viewed as:

1) the means whereby the client can describe his past, the developmental needs which have been thwarted, and the defenses which were erected to compensate;

2) the resistance to full remembering and, paradoxically, an unaware enactment of childhood experiences;

3) the expression of an intrapsychic conflict and the desire to achieve intimacy in relationships; or

4) the expression of the universal psychological striving to organize experience and create meaning.

This integrative view of transference provides the basis for a continual honoring of the inherent communication in transference as well as a recognition and respect that transactions may be non-transferential.

Script

The concept of script serves as the third unifying construct and describes how as infants and small children we begin to develop the reactions and expectations that define for us the kind of world we live in and the kind of people we are. Encoded physically in body tissues and biochemical events, emotionally, and cognitively in the form of beliefs, attitudes, and values, these responses form a blueprint that guides the way we live our lives (Erskine, 1980).

Eric Berne termed this blueprint a “script” (1961, 1972) and Fritz Perls, innovator of Gestalt therapy, described a self-fulfilling, repetitive pattern (1944) and called it “life script” (1975).

Alfred Adler referred to this as “life style” (Ansbacher & Ansbacher, 1956); Sigmund Freud used the term “repetition compulsion” to describe similar phenomena (1923/1961); and recent psychoanalytic writers have referred to a developmentally preformed pattern as “unconscious fantasy” (Arlow, 1969b, p. 8) and as “schemata” (Arlow, 1969a, p. 29; Slep, 1987). In psychoanalytic self psychology the phrase “self system” is used to refer to recurring patterns of low self-esteem and self-defeating interactions (Basch, 1988, p. 100) that are the result of “unconscious organizing principles” termed “prereflexive unconscious” (Stolorow & Atwood, 1989, p. 373). Stern (1985), in analyzing research on infant and toddler development conceptualizes these learned patterns as “representations of interactions that have been generalized (RIG’s)” (p. 97).

Recent psychotherapy literature has described such blueprints as “self-confirmation theory” (Andrews, 1988; 1989) and as a self-reinforcing system or “a self-protection plan” referred to as the “script system” (Erskine & Moursund, 1988). The script system is divided into three primary components: Script Beliefs, Script Manifestations, and Reinforcing Experiences.

Script beliefs. In essence, the script answers the question, “What does a person like me do in a world like this with people like you?” Both the conscious and unconscious answers to this question form the Script Beliefs--the compilation of the survival reactions, RIG’s, decisions, conclusions, defenses, and reinforcements that occurred in the process of growing up. Script beliefs may be described in three categories: beliefs about self, beliefs about others, and beliefs about the quality of life. Once adopted, script beliefs influence what stimuli (internal and external) are attended to, how they are interpreted, and whether or not they are acted upon. They become the self-fulfilling prophecy through which the person’s expectations are inevitably proven to be true (Erskine & Zalcman, 1979).

The script beliefs are maintained in order a) to avoid re-experiencing unmet needs and the corresponding feelings suppressed at the time of script formation, and b) to provide a predictive model of life and interpersonal relationships (Erskine & Moursund, 1988). Prediction is important, particularly when there is a crisis or trauma. Although the script is often personally destructive, it does provide psychological balance or homeostasis: it gives the illusion of predictability (Perls, 1944; Bary & Hufford, 1990). Any disruption in the predictive model produces anxiety: to avoid such discomfort, we organize our perceptions and experiences so as to maintain our script beliefs (Erskine, 1981).

Script manifestation. When under stress or when current needs are not met in adult life, a person is likely to engage in behaviors that verify script beliefs. These behaviors are referred to as the Script Manifestations and may include any observable behaviors (choice of words, sentence patterns, tone of voice, displays of emotion, gestures and body movements) that are the direct displays of the script beliefs and the repressed needs and feelings (the intrapsychic process). A person may act in a way defined by script beliefs, such as saying "I don't know" when believing "I'm dumb." Or he may act in a way that socially defends against the script beliefs, as, for example, excelling in school and acquiring numerous degrees as a way of keeping the "I'm dumb" belief from being discovered by others.

As part of the script display, individuals often have physiological reactions in addition to or in place of the overt behaviors. These internal experiences are not readily observable; nevertheless, the person can give a self-report: fluttering in the stomach, muscle tension, headaches, colitis, or any of a myriad of somatic responses to the script beliefs. Persons who have many somatic complaints or illnesses frequently believe that "something is wrong with me" and use physical symptoms to reinforce the belief--a cognitive defense that serves to keep the script system intact.

Script display also includes fantasies in which the individual imagines behaviors, either his or her own or someone else's, that lend support to script beliefs. These fantasized behaviors function as effectively as overt behaviors in reinforcing script beliefs/feelings--in some instances, even more effectively. They act on the system exactly as though they were events that had actually occurred.

Reinforcing experiences. Any script display can result in a reinforcing experience--a subsequent happening that "proves" that the script belief is valid and thus justifies the behavior of the script display. Reinforcing experiences are a collection of emotion-laden memories, real or imagined, of other people's or one's own behavior; a recall of internal bodily experiences; or the retained remnants of fantasies, dreams, or hallucinations. Reinforcing experiences serve as a feedback mechanism to reinforce script beliefs. Only those memories that support the script belief are readily accepted and retained. Memories that negate script beliefs tend to be rejected or forgotten because they would challenge the belief and the whole defensive process.

Each person's script beliefs provide a distorted framework for viewing self, others, and the quality of life. In order to engage in script display, individuals must discount other options; they frequently will maintain that their behavior is the "natural" or "only" way they can respond. When used socially, script displays are likely to produce interpersonal experiences that, in turn, are governed by and contribute to the reinforcement of script beliefs.

Thus each person's script system is distorted and self reinforcing through the operation of its three interrelated and interdependent subsystems: script beliefs/feelings, script displays, and reinforcing experiences. The script system serves as a defense against awareness of past experiences, needs, and related emotions while simultaneously being a repetition of the past.

Principles and Domains

Two principles guide all Integrative Psychotherapy. The first is our commitment to positive life change. Integrative Psychotherapy is intended to do more than teach a client some new behaviors or a handful of coping skills designed to get him through today’s crisis. It must somehow affect the client’s life script. Without script change, therapy affords only temporary relief. We wish to help each client integrate his or her fixed perspectives into a flexible and open acceptance of learning and growing from each experience.

The second guiding principle is that of respecting the integrity of the client. Through respect, kindness, compassion, and maintaining contact we establish a personal presence and allow for an interpersonal relationship that provides affirmation of the client’s integrity. This respectfulness may be best described as a consistent invitation to interpersonal contact between client and therapist, with simultaneous support for the client to contact his or her internal experience and receive recognition for that experience.

The four dimensions of human functioning that were outlined above--affective, behavioral, cognitive, and physiological--also indicate the domains in which therapeutic work occurs. Cognitive work takes place primarily through the therapeutic alliance between the client’s Adult ego state and the therapist. It includes such things as contracting for change, planning strategies for change, and searching for insight into old patterns.

Behavioral work involves engaging the client in new behaviors that run counter to the old script system and that will evoke responses from others inconsistent with the collection of script-reinforcing memories. We sometimes assign “homework” so that the therapeutic experience can be extended beyond formal therapy sessions and during sessions invite clients to behave differently with us, with group members, and in fantasy with those people who helped him or her build and maintain the life script through the years.

Affective work, while it may involve current feelings, is more likely to involve archaic and/or introjected experiences. This is often experienced as going back to an age when the original introjects were taken on or life script decisions were made, or when those introjections or decisions were strongly reinforced. In this regressed state clients feel and think like a younger version of themselves, exhibiting many of the attitudes and decisions that went into the creation of their life scripts. In this supported regression there is an opportunity to express the feelings, needs, and desires that had been repressed and to experiment with contact that might not before have been possible. The inhibiting decisions of years before are vividly recalled and can be reevaluated and redecided

The fourth major avenue into script is the physical: working directly with body structures. As Wilhelm Reich (1945) pointed out, people live out their character structures in their physical bodies. Life script decisions inevitably involve some distortion of contact and such distortions often carry with them a degree of muscular tension. Over time the tension becomes habitual and is eventually reflected in actual body structure. Working directly with this structure through muscle massage, altering breathing patterns, and/or encouraging or inhibiting movements, we can often help the client to access old memories and patterns and experience the possibility of new options.

We seldom limit a piece of work to a single domain; most work eventually involves several or all of them. This is another aspect of the integrative nature of our work. When a person is not defended against his or her own inner experience, he or she is able to integrate psychological functioning in all domains, taking in, processing, and sending out messages through each avenue and translating information easily from one to another internally.

Another way of looking at Integrative Psychotherapy is in terms of the primary ego state focus of the work. A given segment may deal primarily with Child, with Parent, with Child-Parent dialogue, or with Adult ego states. Work with the Child ego state usually opens with some sort of invitation to the client either to remember or to relive an old experience from childhood. In the Child ego state the client has direct access to old experiences and is able to relive those memories, which may be actual or representative. Through the process of remembering, re-experiencing the needs and feelings from that time, sometimes by expressing what was unexpressed, and having those needs and feelings responded to, the early fixated experience can become integrated. The invitation may be something like, “Go back to a time when you felt this way before,” or it may involve invoking visual, auditory, and kinesthetic cues that assist the client in moving into old memories unavailable to Adult ego state awareness. Sometimes physical movement or massage work will stimulate the cathexis of earlier experiences. The therapist often paces and leads the client into childhood experiences through a series of verbal interchanges during which the Child ego state is increasingly elicited. Occasionally a structured relaxation exercise might be used.

Once the client is into the necessary experience, the therapist is then able to help the Child (with the Adult observing) to uncover the way in which the life script was formed and lived out through the years. The client remembers or relives the early trauma, the early unmet needs, and re-experiences the process of reaction or decision through which he or she created a defensive artificial closure to deal with those needs. This recreation of an old scene is both the same as the original experience (the feelings, wants, and needs are felt again, along with the constraints that led to that early resolution) and different from the original, in that the presence of the observing Adult ego state and the supportive therapist create new resources and options that were not available before. It is these new resources that make possible a different decision this time (Goulding & Goulding, 1979). Because the self-in-the-world is literally experienced in a different way in the therapeutic regression, making a change in the archaic survival reaction or decision can break the old life script pattern. The client sees, hears, and feels self and the world in a new way and therefore can respond to self and others in new ways. Sometimes when there are no specific memories or no specific traumas, the Child is integrated through on-going, consistent contact with the attuned therapist who responds to the client’s needs in an acknowledging, validating and normalizing manner. Such contact in relationship provides a therapeutic space for the client to drop the contact interrupting defenses and relinquish script beliefs. This is the essence of the integration of the Child ego state into the Adult ego state.

When the script pattern is primarily linked to an internally influencing Parent ego state (introject), the client might be invited to cathect that Parent: to “be” Mom or Dad and to enter into a conversation with the therapist as Mom or Dad might have done. (McNeel, 1974). The therapist first gets acquainted with the introjected Parent much as if a new and unknown person had actually come into the room. As the Parent ego state begins to experience and respond to the therapist’s joining, the quality of the interaction gradually shifts into a more therapeutic mode and the Parent is encouraged to deal with his or her own issues. This is working through the life script issues of the parenting person that the client has taken on as his or her own. Many of the methods used to treat the Child ego state may be used here if the Parent needs to deal with repressed experiences. Or the therapist may intervene on behalf of the child involved--the client--to advocate for and provide protection if the introjected Parent is unyielding or continues to be destructive in some way. As the Parent begins to respond to challenges to his or her life script pattern, the introject loses its compulsive, binding quality. The thinking patterns, attitudes, emotional responses, defenses, and behavioral patterns that were introjected from significant others no longer remain as an unassimilated or exteropsychic state of the ego but are decommissioned as a separate ego state and integrated into an aware neopsychic or Adult ego (Erskine & Moursund, 1988).

Most enduring and problem-creating life script patterns are maintained by both Parent and Child ego states--that is, they contain elements of both Child decisions and Parent introjects. To facilitate full integration, a given piece of therapeutic work may involve both Parent and Child ego states, either in sequence (as the therapist deals first with the Parent, brings that segment to closure, and then helps the Child to explore and respond to the new information) or in the form of a dialogue between Parent and Child ego states.

Our work also incorporates direct interaction with the client’s Adult ego state. This is particularly important for making contact, clarifying goals, and to serve as an observer and ally when working with the Child or Parent ego states. For some clients psychotherapy requires neither focus on fixated defense mechanisms or regression to childhood traumas that have been unresolved, nor a decommission of introjections, but rather to the concerns of the adult life cycle. We evaluate what the client presents in light of developmental transitions, crises, age-related tasks, and existential experiences. When life cycle transitions and existential crises are respected as significant and the client has an opportunity to explore his or her emotions, thought, ideals, and borrowed opinions and to talk out possibilities, there emerges a sense of meaningfulness or purpose in life and its events.

Methods

Inquiry

Inquiry is a continual focus in contact-oriented, relationship-based psychotherapy. It begins with the assumption that the therapist knows nothing about the client’s experience and therefore must continually strive to understand the subjective meaning of the client’s behavior and intrapsychic process. Through respectful investigation of the client’s phenomenological experience the client becomes increasingly aware of current and archaic needs, feelings, and behavior. It is with full awareness and the absence of internal defenses that needs and feelings which are fixated due to past experiences can be integrated into a fully functioning Adult ego.

It should be stressed that the process of inquiring is as important, if not more so, than the content. The therapist’s inquiry must be empathic with the client’s subjective experience to be effective in discovering and revealing the internal phenomena (physical sensations, feelings, thoughts, meanings, beliefs, decisions, hopes, and memories) and uncovering the internal and external interruptions to contact.

Inquiry begins with a genuine interest in the client’s subjective experiences and construction of meanings. It proceeds with questions from the therapist as to what the clients are feeling, how they experience both themselves and others (including the psychotherapist) and what conclusions they make. It may continue with historical questions as to when an experience occurred and who was significant in the person’s life. Inquiry is used in the preparatory phase of therapy to increase the client’s awareness of when and how they interrupt contact.

It is essential that the therapist understand each client’s unique need for a stabilizing, validating, and reparative other person to take on some of the relationship functions that the client is attempting to manage alone. A contact-oriented relationship therapy requires that the therapist be attuned to these relationship needs and be involved, through empathic validation of feelings and needs and by providing safety and support.

Attunement

Attunement is a two-part process: the sense of being fully aware of the other person’s sensations, needs, or feelings and the communication of that awareness to the other person. Yet more than just understanding, attunement is a kinesthetic and emotional sensing of the other; knowing their experience by metaphorically being in their skin. Effective attunement also requires that the therapist simultaneously remain aware of the boundary between client and therapist.

The communication of attunement validates the client’s needs and feelings and lays the foundation for repairing the failures of previous relationships. Attunement is demonstrated by what we say, such as “that hurt,” “you seemed frightened,” or “you needed someone to be there with you.” It is more frequently communicated by the therapist’s facial or body movements that signal to the client that their affect exists, is perceived by the therapist, that it is significant, and that it makes an impact on the therapist.

Attunement is often experienced by the client as the therapist gently moving through the defenses that have protected him or her from the awareness of relationship failures and the related needs and feelings, making contact with the long-forgotten parts of the Child ego state. Over time, this results in a lessening of external interruptions to contact and a corresponding dissolving of internal defenses. Needs and feelings can then be increasingly expressed with the comfort and assurance that they will be met with an empathic response. Frequently the attunement provides a sense of safety and stability which enables the client to begin to remember and to endure regressing into childhood experience, becoming fully aware of the pain of traumas, the failure of relationship(s), and the lost self.

It is not unusual, however, for the communication of attunement by the therapist to be met with a reaction of intense anger, withdrawal, or even further dissociation. The juxtaposition of the attunement by the therapist and the memory of the lack of attunement in previous significant relationships produce intense emotional memories of needs not being met. Rather than experience those feelings clients may react defensively with fear or anger at the contact offered by the therapist. The contrast between the contact available with the therapist and the lack of contact in their early life is often more than clients can bear, so they defend against the present contact to avoid the emotional memories.

It is important for the therapist to work sensitively with juxtaposition. The affect and behavior expressed by the client are an attempt to disavow the emotional memories. Therapists who do not account for the defensive reactions may misidentify the juxtaposition reaction as negative transference and/or experience intense countertransference feelings in response to the client’s avoidance of interpersonal contact. This concept helps therapists to understand the intense difficulty the client has in contrasting the current contact offered by the therapist with the awareness that needs for contactful relationship were unfulfilled in the past.

Juxtaposition reactions may signal that the therapist is proceeding more rapidly than the client can assimilate. Frequently it is wise to return to the therapeutic contract and clarify the purpose of the therapy. Explaining the concept of juxtaposition has been beneficial in some situations. Most often a careful inquiry into the phenomenological experience of the current interruption to contact will reveal the emotional memories of disappointment and painful relationships.

With the dissolution of the interruptions to contact, the relationship offered by the therapist provides the client with a sense of validation, care, support and understanding--"someone is there for me." This involvement by the therapist is an essential feature in the total dissolving of the defenses and a resolution and integration of traumas and unrequited relationships.

Involvement

Involvement is best understood through the client's perception--a sense that the therapist is contactful. It evolves from the therapist's empathic inquiry into the client's experience and is developed through the therapist's attunement with the client's affect and validation of his/her needs. Involvement is the result of the therapist being fully present, with and for the person, in a way that is appropriate to the client's developmental level of functioning. It includes a genuine interest in the client's intrapsychic and interpersonal world and a communication of that interest through attentiveness, inquiry, and patience.

Involvement begins with the therapist's commitment to the client's welfare and a respect for his/her phenomenological experiences. Full contact becomes possible when the client experiences that the therapist 1) respects each defense; 2) stays attuned to his/her affect and needs; 3) is sensitive to the psychological functioning at the relevant developmental ages; and 4) is interested in understanding his/her way of constructing meaning.

Therapeutic involvement that emphasizes acknowledgement, validation, normalization, and presence diminishes the internal discounting that is part of the defensive process. These engagements allow previously disavowed feelings and denied experiences to come to full awareness. The therapist's acknowledgement of the client's feelings begins with an attunement to his/her affect, even if it is unexpressed. Through sensitivity to the physiological expression of emotions the therapist can guide the client to express their feelings or to acknowledge that feelings or physical sensations may be the memory--the only memory available. In some situations the child may have been too young for the availability of linguistic and retrievable memory. In many cases of relationship failure the person's feelings were not acknowledged and it may be necessary in psychotherapy to help the person gain a vocabulary and to voice those feelings. Acknowledgement of physical sensations and affect helps the client claim her/his own phenomenological experience. Acknowledgement includes a receptive other who knows and communicates about the existence of non-verbal movements, tensing of muscles, affect, or even fantasy.

There are times in clients' lives when their feelings were acknowledged but were not validated. Validation communicates to the client that his/her affect or physical sensations are related to something significant in their experiences. Validation is making a link between cause and effect. Validation diminishes the possibility of the client internally discounting the significance of affect, physical sensation, memory, or dreams. It provides the client with an enhanced value of their phenomenological experience and therefore an increased sense of self-esteem.

Normalization is to depathologize the client's or others' categorization or definition of their internal experience or their behavioral attempts at coping. It may be essential for the therapist to counter societal or parental messages such as, “You're crazy for feeling scared” with “Anyone would be scared in that situation.” Many flashbacks, bizarre fantasies, nightmares, confusion, panic, defensiveness, are all normal coping phenomena in abnormal situations. It is imperative that the therapist communicates that the client's experience is a normal defensive reaction, not pathological.

Presence is provided through the psychotherapist's sustained empathic responses to both the verbal and non-verbal expressions of the client. It occurs when the behavior and communication of the psychotherapist, at all times, respects and enhances the integrity of the client. Presence includes the therapist's receptivity to the client's affect--to be impacted by their emotions, to be moved and yet to stay present with the impact of their emotions, not to become anxious, depressed, or angry. Presence is an expression of the psychotherapist's full internal and external contact. It communicates the psychotherapist's responsibility, dependability, and reliability.

Therapeutic involvement is maintained by the therapist's constant vigilance to providing an environment and relationship of safety and security. It is necessary that the therapist be constantly attuned to the client's ability to tolerate the emerging awareness of past experiences so that they are not overwhelmed once again in the therapy as they may have been in a previous experience. When the inquiring of the client's phenomenological experiences and the therapeutic regressions occur in a surround that is calming and containing, the fixated defenses are further relaxed and the needs and feelings of the past experience(s) can be integrated.

The psychotherapist's involvement through transactions that acknowledge, validate, and normalize the client's phenomenological experiences and sustain an empathic presence fosters a therapeutic potency that allows for the client to safely depend on the relationship with the psychotherapist. Potency is the result of engagements that communicate to the client that the therapist is fully invested in his/her welfare. Acknowledgement, validation, and normalization provide the client with permission to know their own feelings, value the significance of their affects, and relate them to actual or anticipated events. Therefore such therapeutic permission to diminish defenses, to know his/her physical sensations, feelings, and memories and to reveal them must come only after the client experiences protection within the therapeutic environment. Such therapeutic protection can be adequately provided only after there is a thorough assessment of the intrapsychic punishment and the client has a sense of safety that the therapist is consistently invested in his/her welfare. Intrapsychic punishment involves the child's perceived loss of bonding or attachment, shame, or threat of retribution. Protective interventions may include supporting a regressive dependency, providing a reliable and safe environment wherein the client can rediscover what has been lost to awareness, and pacing the therapy so the experiences may be fully integrated.

There are times when a client will attempt to elicit attunement and understanding by acting out a problem that they cannot talk out or express in any other way. Such acting out expressions are simultaneously both a defensive deflection of the emotional memories and also an attempt to communicate their internal conflicts. Confrontations or explanations can intensify the defenses making the awareness of needs and feelings less accessible to awareness. Involvement includes a gentle, respectful inquiring into the internal experience of the acting out. The therapist's genuine interest in and honoring of the communication, which often may be without language, is an essential aspect of therapeutic involvement.

Involvement may include the therapist being active in facilitating the client's undoing repressive retroflections and activating responses that were inhibited, such as screaming for help or fighting back. The therapist's considered revealing of his/her internal reactions or showing compassion are further expressions of involvement. It may also include responding to earlier developmental needs in a way that symbolically represents need fulfillment, but the goal of a contact-oriented therapy is not in the satisfaction of archaic needs. This is an unnecessary and impossible task. Rather, the goal is the dissolving of fixated contact-interrupting defenses that interfere with the satisfaction of current needs and with full contact with self and others in life today. This is often accomplished by working within the transference to allow the intrapsychic conflict to be expressed within the therapeutic relationship and to be responded to with appropriate empathic transactions.

A contact-oriented psychotherapy through inquiry, attunement, and involvement responds to the client's current needs for an emotionally nurturing relationship that is reparative and sustaining. The aim of this kind of therapy is the integration of the affect-laden experiences and an intrapsychic reorganization of the client's beliefs about self, others, and the quality of life.

Conclusion

Contact facilitates the dissolving of defenses and the integration of the disowned parts of the personality. Through contact the disowned, unaware, unresolved experiences are made part of a cohesive self. In Integrative Psychotherapy the concept of contact is the theoretical basis from which clinical interventions are derived. Transference, ego state regression, activation of the intrapsychic influence of introjection, the presence of defense mechanisms, are all understood as indications of previous contact deficits. The four dimensions of human functioning--affective, behavioral, cognitive, and physiological--are an important guide in determining where someone is open or closed to contact and therefore of our therapeutic direction. A major goal of Integrative Psychotherapy is to use the therapist-client relationship--the ability to create full contact in the present--as a stepping stone to healthier relationships with other people and a satisfying sense of self. With integration it becomes possible for the person to face each moment with spontaneity and flexibility in solving life's problems and in relating to people.

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