Integrative Psychotherapy Articles
Inquiry, Attunement, and Involvement
in the Psychotherapy of Dissociation
Richard G. Erskine
essay distills a quarter century of experience as a psychotherapist with
clients who use dissociation as a strategy for coping with traumatic events
and stressors. My most challenging professional developments have resulted
from my therapeutic errorserrors that demonstrated either ineffectiveness
or the reinforcement of defenses that result from the methods of interrogation,
confrontation, and explanation and the techniques of behavioral change, redecision,
and reparenting. When using these methods and techniques, we as psychotherapists
often fail to value the clients sense of vulnerability and perceived
need for self-protection; we fail to respect the clients integrity
in constructing his or her system of making meaning, and we fail to realize
how our interventions may increase the clients sense of shame for having
his or her experiences and defenses.
clinical experience has demonstrated that the defense of dissociation results
not only from traumatic experiences but, equally or even more importantly,
from the lack of a protective and reparative relationship. Therefore, clients
who use dissociation require a relationship-oriented psychotherapy that emphasizes
contact through gentle inquiry into the clients experience, attunement
to the clients affect and developmental level of functioning, and an
interpersonal involvement that provides consistency and dependability through
acknowledgment, validation, normalization, and the reliable presence of the
therapist. I invite you to share in my professional journey and to expand
on the therapeutic experiences and methods I present here so that together
we may evolve an even more effective psychotherapy.
is a complex defensive process that maintains mental and physical stability.
During a traumatic experience, dissociation allows a person to remove himself
or herself cognitively and emotionally from the experience and to physically
adapt and behaviorally conform to external demands. Continuing the dissociation
after a traumatic event enables a person to disengage from related needs
and emotions and to evade the memory and its devastating impact.
is the predominant defense present in multiple personality disorder, post-traumatic
stress disorder, and schizoid disorder. It is also found in many less pronounced
disorders, often masked by anxiety or depression. The presence of dissociation
is a highly reliable indicator of previous mental, physical, and/or sexual
abuse. In some cases dissociation is a reaction to early abandonment, severe
sustained pain, near-death experiences, and/or prolonged neglect. These overwhelming
experiences, usually, but not always, in childhood, threaten the cognitive
and emotional stability and physical security, if not the life, of the individual.
defenses protect against the pain of overwhelming stimuli, unmet needs, and
unexpressed emotions. In order to get on with life and to adapt as well as
possible, many people keep these needs, feelings, and traumatic memories
out of awareness. This results in a fixation of defensesthe habitual
maintenance today of patterns of coping and psychological defense that were
necessary at a previous time. These fixated defenses interrupt an individuals
ability to be contactful both internally with self and externally with others.
It is because of the fixation of contact-interrupting defenses that traumatic
experiences remain dissociated as separate states of the ego or self rather
than being integrated into a here-and-now wholea neopsychic ego.
neopsychic egoat every ageis a continually contacting, integrating,
and emerging process. If a traumatized person also suffered from a failure
of contact in a caretaking relationship, clinical experience indicates that
the traumatic experience will most likely not be integrated. The unmet needs
for empathy, nurturing, and protection during the trauma are not acknowledged
or validated satisfactorily, further compounding the trauma. This initiates
the process of isolating the experience from awareness and, in more extreme
situations, may lead to isolating aspects of self from awareness as well.
The person must engage in a complex set of defenses in order to limit internal
contact and to encapsulate the awareness of the traumatizing experience,
related feelings, and unmet needs. These needs, feelings, and experiences
reside within the ego in a separate state of consciousness, neither contacting
nor contactable. Thus the fixated trauma does not become integrated with
later experience and learning.
fragmentation and dissociation. Following traumatization there is an intense
need for a reliable other to respond empathically to the individuals
extreme emotional reactions and unmet needs, to be attuned to the unspeakable,
to offer a realistic understanding of what happened, and to provide safety
through continued involvement and problem solving. Dissociation begins because
those in the persons life fail to provide necessary restorative and
nurturing functions. In many incest situations the child was told that he
or she liked it, or the childs withdrawal and depression
were ignored by adults. Without attunement, validation, and empathic transactions
from a significant person, a child does his or her best to deeply sequester
those feelings, needs, and memories, sometimes to the point of no longer
even realizing his or her need for relationship. This is the process of ego
fragmentation and dissociation.
Inquiry, Attunement, and Involvement
internally is the full awareness of internal sensations, feelings, needs,
sensorimotor activity, thoughts, and memories, and externally it involves
the rapid 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. Defenses interrupt full contact and impede awareness
internally and/or externally. Contact is thus the medium through which the
process of dissociation can be dissolved and the encapsulated traumatic experiences,
hidden needs, and feelings can be integrated into a cohesive sense of self
(a neopsychic ego). Contact also refers to the quality of the transactions
between two people, that is, the full awareness of both ones self and
the other as exemplified in an authentic and sensitive encounter.
guiding principle of contact-oriented psychotherapy is respect for the clients
integrity. Through respect, kindness, and compassion, a therapist establishes
an interpersonal relationship that provides affirmation of such integrity.
This respectfulness may be described best as a consistent invitation to interpersonal
contact between client and therapist, with simultaneous support for the clients
contacting his or her internal experience and receiving external recognition
of that experience. Withdrawing from contact may often be identified and
discussed, but the client is never forced, trapped, or tricked into more
openness than he or she is ready to handle.
between client and therapist is the therapeutic context in which the client
explores his or her feelings, needs, memories, and perceptions. Such contact
is possible when the therapist is fully present, that is, attuned to his
or her own inner processes and external behaviors, constantly aware of the
boundary between self and client, and keenly observant of the clients
psychodynamics. Contact within psychotherapy is like the substructure of
a building: It cannot be seen, but it undergirds and supports all that is
above ground. Contact provides the safety that allows the client to drop
defenses, to feel again, and to remember.
often begins with conversation and engagement in a contracting process. The
ongoing negotiation of therapeutic contracts is an important element in establishing
a contactful therapeutic relationship. The traumas that produce the defenses
comprising dissociation usually occur in situations in which clients could
not negotiate with regard to their own needs for physical and mental security.
Instead, they were deprived of a sense of impact, valuation, and efficacy.
Rather than relying on negotiation as a means of achieving satisfaction of
needs, such clients may anticipate either being overwhelmed or having to
use strong methods of manipulation or control, including dissociation. Therefore,
the use of contracts is an essential part of the initial therapeutic contact
with clients who dissociate (perhaps even more than with other clients) because
their mental and/or physical being has been violated.
traumatic experiences are being actively remembered or relived, it is important
to have a contract that specifically defines the therapeutic territory in
advance. In therapy, vividly remembered experiences may arise that surprise
both client and therapist. These spontaneous memories may not be predictable,
and responses to them cannot always be specifically negotiated beforehand.
Therefore, procedures should be agreed on in advance as to how the client
can signal that the experience is becoming overwhelming and how the therapist
will stop the intervention. For example, one client used a specific word
to indicate an entire set of feelings, needs, and impending defenses; others
have used gestures or sounds.
Inquiry is a constant focus in contact-oriented psychotherapy. It begins
with the assumption that the therapist knows nothing about the clients
experience and thus must continually strive to understand the subjective
meaning of the clients behavior and intrapsychic process. As a result
of respectful investigation of the clients phenomenological experience,
the client becomes increasingly aware of both current and archaic needs,
feelings, and behaviors. It is with full awareness and the absence of internal
defenses that needs and feelings that were fixated as a result of past traumas
are integrated into a fully functioning neopsychic ego.
The process of
inquiry is as important, if not more so, than the content. The therapists
inquiry must be empathic with the clients 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 involves constantly focusing on the clients experience of affect,
motivation, beliefs, or fantasy and not on behavior alone or on a problem
to be solved.
begins with a genuine interest in a clients subjective experience and
construction of meaning. It proceeds with questions from the therapist as
to what the client is feeling, how he or she experiences both self and others
(including the psychotherapist), and what conclusions are reached. It may
continue with historical questions about when an experience occurred and
who was significant in the persons life.
the treatment of dissociation, inquiry is used in the preparatory phase of
therapy to increase the clients awareness of when and how he or she
dissociates. It involves investigating the clients experience of the
component interruptions to contact that constitute the dissociation. What
does he or she do? Are self-hypnotic activities being used? Some clients
report that they roll their eyes back, get small inside, or wag a finger.
treating a client who dissociates it may be important to assess the function
of the dissociation relevant to the needs of the whole person and to the
needs of fragmented ego states. With multiple personalities, one might ask
each part, What is your role? Each personality may have a specific
function to fulfill, such as expressing a particular feeling (only anger
or only sadness), engaging in an isolated defense (compulsive cleaning or
amnesia), or coping with lifes demands (organization or productivity).
Frequently a personality serves a protective and/or nurturing function that
was missing in the past and that may still be unfulfilled in current relationships,
such as validation, attunement to needs and feelings, or providing safety
is essential to inquire about who failed to provide the developmentally necessary
functions that should have been fulfilled by a responsible caretaker. How
did they fail? Inquiry is also essential about the clients likely anticipation
that others will again fail him or her in a relationship. This anticipation
constitutes one of the dimensions of transferencethe dread of retraumatizationand
the justification for maintaining defenses against contactful relationships.
the psychotherapy of dissociation it is crucial that the therapist understand
each clients 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
Attunement is a two-part process: It involves both being fully aware of another
persons sensations, needs, or feelings and communicating that awareness
to the other.
requires understanding the developmentally based needs and related feelings
that were fixated in the traumatic experience and that are now requiring
expression. More than just understanding, attunement is a kinesthetic and
emotional sensing of the otherknowing the others experience by
metaphorically being in his or her skin. Effective attunement also requires
that the therapist simultaneously remain aware of the boundary between client
and therapist. It is enhanced by focusing on the client at the developmental
age of the trauma and knowing what a traumatized person of that age is attempting
to express, what he or she requires in the way of experiencing needs, and
his or her need for a protective, safe, and validating relationship with
communication of attunement validates the clients needs and feelings
and lays the foundation for repairing the failures of previous relationships.
Attunement may be 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 therapists facial or body movements
signaling to the client that his or her affect exists, that it is perceived
by the therapist to be significant, and that it makes an impact on the therapist.
is often experienced by the client as the therapist gently moving past the
defenses that protect the client from awareness of trauma and its related
needs and feelings and making contact with the long-forgotten parts of the
clients 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 that enables the
client to begin to remember and to endure regressing into the traumatic experience,
becoming fully aware of the pain of the trauma, the failure of relationship(s),
and the loss of a sense of self.
The juxtaposition of the therapists attunement with the memory of the
lack of attunement in previous significant relationships produces intense,
emotional memories of needs not being met. Rather than experience those feelings,
the client may react defensively to the contact offered by the therapist
with fear, anger, or even further dissociation. The contrast between the
contact available with the therapist and the lack of contact in the original
trauma(s) is often more than clients can bear, so they defend against the
current contact to avoid the emotional memories.
is important for the therapist to work sensitively with the process of juxtaposition.
The affect and behavior expressed by the client are an attempt to disavow
emotional memories. Therapists who do not account for these defensive reactions
may mistakenly identify the juxtaposition reaction as negative transference
and/or experience intense countertransference feelings in response to the
clients avoidance of interpersonal contact. The concept of juxtaposition
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.
reactions may signal that the therapist is proceeding faster 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.
the interruptions to contact have dissolved, the relationship offered by
the therapist provides the client with a sense of validation, care, support,
and understandingsomeone is there for me. This involvement
is an essential factor in dissolving the defenses that constitute dissociation
and in resolving and integrating previous traumas and unrequited relationships.
Involvement is best understood via the clients perception; it is a
sense that the therapist is contactful. It evolves from the therapists
empathic inquiry into the clients experience and is developed through
the therapists attunement with the clients affect and validation
of the clients needs. Involvement is the result of the therapist being
fully present, with and for the client, in a way that is appropriate to the
clients developmental level. It includes a genuine interest in the
clients intrapsychic and interpersonal world and a communication of
that interest through attentiveness, inquiry, and patience.
begins with the therapists commitment to the clients welfare
and a respect for the clients phenomenological experience. Full contact
becomes possible when the client experiences that the therapist: (1) respects
each defense; (2) stays attuned to his or her affect and needs; (3) is sensitive
to the psychological functioning at the developmental age when the trauma(s)
occurred; and (4) is interested in understanding the clients way of
constructing the meaning of the trauma(s).
complex set of defenses that constitutes dissociation was erected in the
absence of a caring and respectful involvement by a reliable and dependable
other. Clients who have relied on dissociation as a protective measure experienced
that they had to protect and comfort themselves in the face of impinging
and overwhelming stimuli. It is in the absence of reliable and consistent
need-fulfilling contact with a dependable other that defenses become fixated.
involvement that emphasizes acknowledgment, validation, normalization, and
presence diminishes the internal discounting that is part of dissociation.
These engagements allow previously disavowed feelings and denied experiences
to come to full awareness. The therapists acknowledgment of
the clients feelings begins with attunement to the clients affect,
even if the affect is unexpressed. Through sensitivity to the physiological
expression of emotions the therapist guides the client to express his or
her feelings or to acknowledge that feelings or physical sensations may be
the memorythe only memory available. For instance, if the persons
eyes were closed during a traumatic event there will be no visual memory.
In other situations the child may have been too young to remember cognitively.
In many cases of trauma, the persons feelings were not acknowledged,
and it may be necessary in psychotherapy to help such individuals develop
a vocabulary with which to voice those feelings. Acknowledgment of physical
sensations and affect helps the client claim her or his own phenomenological
experience. Acknowledgment includes a receptive other who knows and communicates
about the existence of nonverbal movements, tensing of muscles, affect, or
are times in clients lives when their feelings were acknowledged but
not validated. Validation communicates to the client that his or her
affect or physical sensations are related to something significant. Validation
is linking cause and effect. For example: Based on what you described,
you feel sad because no one was there for you, or Your fantasies
and dreams are saying something important. Validation diminishes the
possibility of the client internally discounting the significance of affect,
physical sensation, memory, or dreams. It enhances for the client the value
of his or her phenomenological experience and therefore an increased sense
the clients or the others categorization or definition of internal
experience or behavioral attempts to cope with the effects of trauma. Under
extreme circumstances it is normal to dissociate. It may be essential for
the therapist to counter societal or parental messages such as, Youre
crazy for feeling scared, with Anyone would be scared in that
situation. Many flashbacks, bizarre fantasies, and nightmares as well
as much confusion, panic, and defensiveness are normal coping phenomena in
abnormal situations. It is imperative that the therapist communicate that
the clients experience is a normal defensive reaction, not pathological.
provided by the psychotherapists sustained empathic responses to both
the verbal and nonverbal expressions of the client. It occurs when the behavior
and communication of the psychotherapist respects and enhances the clients
integrity. Presence includes the therapists receptivity to the clients
affect, that is, to being impacted and moved by the clients emotions
and yet not to become anxious, depressed, or angry. Presence is an expression
of the psychotherapists availability for full internal and external
contact. It communicates the psychotherapists responsibility, dependability,
traumatic and neglectful experiences may be frightening and painful for the
client; therefore, therapeutic involvement is maintained by the therapists
constant vigilance in providing an environment and a relationship that is
safe and secure. The therapist, of necessity, must be constantly attuned
to the clients ability to tolerate the emerging awareness of the traumatic
experience(s) so that he or she is not overwhelmed again in the therapy as
he or she was in the original traumatic situation. When inquiry into the
clients phenomenological experiences and therapeutic regressions occurs
in surroundings that are calming and containing, the fixated defenses are
relaxed further, and the needs and feelings that derive from the traumatic
experience(s) are integrated.
psychotherapists involvementthrough transactions that acknowledge,
validate, and normalize the clients phenomenological experience and
sustain an empathic presencefosters therapeutic potency that allows
the client to safely depend on the relationship. Potency is the result of
engagement that communicates that the therapist is fully invested in the
clients welfare. Acknowledgment, validation, and normalization provide
the client with permission to know his or her own feelings, to value the
significance of his or her affects, and to relate them to actual or anticipated
events. Such therapeutic permission to diminish defenses, to know his or
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 is adequately provided only after
there is a thorough assessment of dynamics related to intrapsychic punishment
and the client feels safe.
punishment involves the childs 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 in which
the client can rediscover what has been dissociated, and pacing the therapy
so experiences may be fully integrated. Putting some memories on hold until
others are dealt with is a way to ensure that the client will not be flooded
with overwhelming anxiety. For example, for one client, traumatic memories
first emerged in nightmares. She was often overwhelmed by terror and exhausted
by lack of sleep. Periodically she was encouraged to stop dreaming until
the material already dreamed had become clear and had been worked through.
Once she connected her dreams to memories of childhood events and understood
and resolved the ramifications of those events in her adult life, the therapist
encouraged her to dream the next episode. The client was also encouraged
to draw the dreams on a sketch pad so that she could go back to sleep or
concentrate on her job the next day. She brought the sketch pad to therapy
sessions as an aid to remembering and deciphering the dreams. Postponing
or sketching her dreams served as a protection from overwhelming sensations.
are times when a client attempts to elicit attunement and understanding by
acting out a problem that cannot be expressed in any other way. Such acting
out expressions are simultaneously a defensive deflection of the emotional
memories and also an attempt to communicate the persons internal conflicts.
Confrontations or explanations can intensify the defenses making the awareness
of needs and feelings less accessible. Involvement includes a gentle, respectful
inquiring into the internal experience connected with the acting out. The
therapists genuine interest in and honoring of the communication, which
often may be without language, is an essential aspect of therapeutic involvement.
may include the therapist actively facilitating the clients undoing
repressive retroflections and the inhibition of activating responses, such
as screaming for help or fighting back. The therapists considered revelation
of his or her internal reactions or compassion is further expression of involvement.
This 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 the satisfaction of archaic needs. Rather, the goal is the
dissolution of fixated, contact-interrupting defenses that interfere with
the satisfaction of current needs and full contact with self and others.
This is often accomplished by working transferentially to allow the intrapsychic
conflict to be expressed within the therapeutic relationship and to be responded
to with appropriate empathic transactions.
In work with dissociative clients, a contact-oriented psychotherapy using inquiry, attunement, and involvement responds to the individuals current needs for an emotionally nurturing relationship that is reparative and sustaining. The aim of the therapy is the integration of affect-laden experiences and the intrapsychic reorganization of the clients beliefs about self, others, and the quality of life. Contact facilitates the dissolution of defenses and the integration of the dissociated parts of the personality. Through contact, disowned, unconscious, and unresolved experiences are made part of a cohesive self. With integration it becomes possible for a person to face each moment with spontaneity and flexibility in solving lifes problems and in relating to people without resorting to the defense of dissociation.
This article was originally published in the Transactional Analysis Journal, Volume 23, Number 4, October 1993, pp. 184-190. Portions of this paper were also presented at the Symposium on the Treatment of Dissociation held at the 29th Annual International Transactional Analysis Association Conference, October 26, 1991, in Stamford, Connecticut, U.S.A. The author wishes to thank the members of the Professional Development Seminars of the Institute for Integrative Psychotherapy in New York, New York, Kent, Connecticut, Chicago, Illinois, and Dayton, Ohio, for their valuable suggestions in the development of this essay.