Integrative Psychotherapy Articles

         In Beyond Empathy: A Therapy of Contact-in-Relationship (Erskine, Moursund, & Trautmann, 1999), we have characterized the skills of inquiry and the qualities of attunement and involvement as central to effective psychotherapy.  Empathy is the foundation for inquiry, attunement and involvement.  Each of the three, however, goes "beyond empathy" in some way -- or, at least, beyond the definitions of empathy that one finds in the general psychotherapy literature.  It is likely that truly empathic therapists are also skilled inquirers, sensitively attuned to their clients, and appropriately involved in the therapeutic process.  If so, then attunement and inquiry and involvement are not extensions of empathy so much as subdivisions:  aspects or facets of the overall empathic frame within which change and growth are nurtured.

         Whichever they are, extensions or subdivisions, attunement and inquiry and involvement are central to the therapeutic process.  To the degree that we can provide them, our therapy is likely to be more effective and satisfying to both our clients and ourselves.

As is true for nearly every other effort to describe or define some important aspect of psychotherapy, discussing attunement or inquiry or involvement alone requires an artificial and unrealistic teasing apart of what  is  essentially  indivisible.   Inquiry  without  attunement  and involvement is sterile and inquisitorial; involvement and attunement without inquiry have no sense of direction or purpose.  All three, moreover, are useful only when they are guided by therapeutic intent:  a committment that the client's growth and healing take priority over anything else that may happen in the therapy session.

Inquiry

         Of all the things that therapists do, asking questions and listening to the answers is probably the most common.  Questions are asked at all stages of therapy, from initial diagnosis to the final termination process.  By "questions," we do not refer just to those sentences which end in a question mark; questions include any sort of intervention that requests the client to search internally Ð to discover oneÕs self.  Replying with an "Oh?" or a "Hmmm," repeating what the client has just said, lifting an eyebrow or smiling encouragingly, even waiting patiently for what may come next -- all of these are forms of inquiry.  Indeed, insofar as the essence of therapy is to help the client explore his internal world and re-establish contact with self and others, most of what we do as therapists can be seen as a kind of inquiry.

         Asking questions is easy.  Questions occur naturally in conversations between friends, in consultations with professionals, in the classroom and in the workplace.  Children learn to ask questions as soon as they learn to talk, as anyone who has faced the endless "why" of a pre-schooler can tell you.  Inquiring therapeutically, on the other hand, requires skill.  It requires, among other things, that we know -- and remember -- the purpose of our inquiry.   Questions can be asked for a variety of reasons:  in order to provide the questioner with some information  ("Where do you keep the napkins?"), to continue an argument ("Why won't you let me have the car tonight?"), as an implied criticism ("Why are you watching TV when you have homework?"), or simply to demand attention ("What are you doing, Mommy?").  In a relationship-focused integrative psychotherapy, inquiry has but one purpose:  to assist the client in expanding his awareness, increasing internal and external contact and enhancing the sense of self-in-relationship.

         If the purpose of inquiry is to expand the client's awareness, it follows that what the therapist may learn from the client's answer is secondary.  While we certainly listen to the answers to our questions (verbal and nonverbal), and learn from those answers, what the client learns is much more important.  Part of the skill involved in therapeutic inquiry is that of getting out of the client's way, postponing our need to understand fully in order not to interrupt his process of discovery.  It also follows that the easily-answered question, the question to which the client already knows the answer, is generally less valuable than the question that requires him to search for a response.  Clients don't learn much from stating what they already know; they learn by being challenged to discover something new or something that has been forgotten.  Uncertainty and ambiguity stimulate people to learn more, to solve the problem and clarify what is happening.  Questions that ask about what is not yet known tend to invite the client into his areas of uncertainty and ambiguity, and challenge him to explore those areas.  Well-executed inquiry is a spiral process, with each response leading to a new question, and each question opening the door to a previously out-of-awareness response.

Characteristics of effective inquiry

         The most basic characteristic of therapeutic inquiry is that of respect.  The questions the therapist asks, and the way in which she asks them, must be respectful -- respectful of the client's needs, of his problem-solving efforts, of his internal wisdom.  Her respect springs from what Rogers (1951) has termed "unconditional positive regard," a fundamental conviction that every client is doing, and has done, the best he is capable of at any given moment.  Without this kind of respect, inquiry is likely to turn into interrogation, the therapist becomes "she-who-knows-better," and the whole process can disintegrate into advice-giving or sermonizing.  Respecting the client's wisdom and intentions, in contrast, leads to genuine interest and healthy curiosity about how the client experiences his world. Interest and curiosity, in turn, are vital in helping the therapist to frame the sorts of questions that will further the client's explorations.

         Inquiry should be open-ended.  The therapist's questions, and her questioning behaviors, invite the client to search for answers; they do not restrict him or demand that the answer meet the therapist's expectations.  Indeed, willingness to abandon expectations and let go of preconceived ideas is another hallmark of successful inquiry.  Even though the therapist's theoretical training and clinical experience may lead her to expect a certain kind of answer (and may have suggested her question or comment in the first place), she is glad to be surprised.  Getting a response that she did not expect whets her curiosity, pops her out of the rut of the conventional, allows her as well as her client to discover something new. 

         Neimeyer  (1995) recommends "a willingness to use the client's personal knowledge system, to see the problem and the world through his or her eyes, though not necessarily to be encapsulated by it.  To this is added ... a curiosity or fascination with the client's perspective and its implications." (p. 114)  The therapist's theoretical and clinical expectations provide a background for this fascination, but must not blind her to what the client is really telling her.  Open-ended questions help to keep the therapist open to learning something new from the client, something not predicted by her past experience.

         What does a therapist do when the client tells her something that she finds difficult to believe?   When he changes the subject, insists on telling long, rambling stories, or simply says "I don't know" and then waits?  These sorts of behavior suggest that the client may be retreating into an old defensive system, rather than being honest with himself.  The first rule of good inquiry is:  don't argue.  The therapist should never try to persuade the client that his answer is wrong.  How could it be "wrong" when it came from him?  It is his response, and the therapist's job is to help him understand it.  She may express curiosity, or confusion; she may ask him about what he means or what lies behind his response.  "You surprised me; help me to understand how you came to that conclusion,"  "What happened inside, just before you said that?" "How is this story related to the problems you were talking about earlier?"

         Inquiry grows out of a constant attention to contact.  Its goal is contact-enhancement; all of the therapist's questions are designed to help the client establish and maintain contact of some sort.  The focus at one point may be on his internal contact ("What are you experiencing?") or at another on his external contact ("Tell me what you are noticing and attending to right now"); often we deal with the contact between therapist and client ("What's it like for you to hear me say that?").  Contact leads to health and growth, and lack of contact to fragmentation and constriction and shutting down.  To the degree that our inquiry promotes the former, and moves away from the latter, it will be therapeutic.

Areas of inquiry

         Attending to contact, and remembering that her purpose is to enhance it, helps the therapist to construct and frame her inquiry.  She must be careful, though, not to neglect one aspect of contact as she pursues another.  Therapeutic inquiry is like a web, spun out of many strands; the therapist follow first this strand, then that, but eventually all must be woven into the pattern.  Let's look, for a moment, at these strands. 

         One of the most obvious strands is that of affect:  therapists are used to asking clients about their feelings, helping clients to explore and deepen their emotional responses.  Many clients, though, are relatively closed to affect.  They don't know what they are feeling; they have learned to disavow or close off their awareness of painful emotions and don't know how to open those doors.  For such clients, inquiring about physical sensations and reactions can be useful.  The therapist can invite her client to be aware of his body, and of what his body is doing. Is he breathing shallowly, and what does that shallow breathing feel like?  Is he aware of a swinging foot or a balled fist?  Simply noticing, and talking about, physical experiences is a first step toward increased contact with self.

         Cognition is another natural area of inquiry.  What is the client thinking?  What are those thoughts connected to, and how does he get from one thought to another?  What is he remembering?  What decisions is he making, and how is he making them?  Thoughts and memories and decisions (past and present) often weave back into affect, just as affect can take him into thinking and remembering.

         Inquiry about fantasies provides another window into the client's phenomenological world.  Fantasies involve thinking, feeling, sensation.  They are not only the client's daydreams and night dreams; they also include the client's hopes and fears and expectations.  They are his imaginings about what has happened in the past and about what is yet to come.  Because they are built upon past experience, experience that has often been blocked from awareness, they can help him re-connect with himself, with long-buried thoughts and feelings.  Fantasies and expectations determine the way in which he makes and maintains relationships with others and they shape the therapeutic relationship as well.  Clients use fantasy to transform painful internal experiencing into that which can be born; to provide substitute gratification of needs that cannot be met in reality; to manage behaviors that they fear may run out of control.  It is a rich vein of information, and mining it can lead to rich rewards.

         Inquiry is a basis for forming a therapeutic relationship. The experience of being in a relationship that is qualitatively different from past, script-forming relationships is a key factor in dissolving that script.  The impact of this relationship experience is heightened when inquiry is used to call attention to it.  Questions like "What are you wanting from me right now?" or "How do you feel about what I just said?" or "What do you think my response would be if you told me the whole story?" invite the client to explore his reactions to what the therapist is offering.  Is he defending against a level of contact that would be too threatening?  He and the therapist can talk about the threat, and the means of defense as well.  Does he disagree, disbelieve, or discount what the therapist says?  The therapist asks about his disagreement or disbelief or discounting.  She is open to the client's criticism, cares about his disbelief, is interested in the ways in which he supports the discount.  She is also interested in how the client experiences her support and concern.  She asks about it all.

         As the therapist improves her inquiry skills, learns to gather up the various strands of experiencing and help the client to explore their interrelationships, she is guided by attunement.  She notices the client's rhythms, his thinking and feeling, his developmental level, his moment-to-moment relational needs; and what she notices directs what she asks about and how she does the asking.  But there is another element at work here.  Therapists are not simply skilled machines, taking in information and forming interventions.  The therapeutic process is a relationship, formed in the in-between of two living, thinking, feeling human beings. 

Attunement

         Attunement involves sensitizing oneself to the client, and responding accordingly.  Kohut (1977) defined empathy, as a kind of "vicarious introspection," in which the therapist understands the client by finding something akin to the client's responses within himself.  Attunement involves using both conscious and out-of-awareness synchronizing of therapist and client process, so that the therapist's interventions fit the ongoing, moment-to-moment needs and processes of the client.  It is more than simply feeling what the client feels:  it includes recognizing the client's experience, and moving -- cognitively, affectively, and physically -- so as to complement that experience in a contact-enhancing way (Erskine & Moursund, 1988/1998).

         In this sense, attunement is not a subdivision of empathy but does extend the concept: 

Attunement goes beyond empathy: it is a process of communion and unity of interpersonal contact.  It is a two-part process that begins with empathy - being sensitive to and identifying with the other person's sensations, needs, or feelings; and includes the communication of that sensitivity to the other person.  More than just understanding or vicarious introspection, attunement is a kinesthetic and emotional sensing of the other - knowing their rhythm, affect and experience by metaphorically being in their skin, and going beyond empathy to create a two-person experience of unbroken feeling connectedness by providing an reciprocal affect and/or resonating response. (Erskine, 1998a, p. 236)

         The attuned therapist leads by following.  Her interventions often feel, to the client, more like confirmations than questions: they direct his attention to what he is ready to know but has not yet quite realized. She anticipates and observes the effects of her behavior on the client; she decenters from her own experience in order to focus on the client's process.  Yet she also is aware of her own internal responses, her thoughts and feelings and associations.  She is "multi-tasking," simultaneously following both the client and herself, as well as noting the intricate interactions between self and other.   And she communicates this synchrony:  with body language and voice tone as much as (or more than) with words, she weaves a fabric of understanding and concern, and at the same time conveys her belief in the client's ability to grow and change.  "I know where you are," she seems to be saying, "and we will travel from there together." 

         To the degree that the therapist is attuned to the client and conveys that attunement, the client feels respected.  "This therapist not only understands me -- she's really with me!  Maybe the things I'm thinking/feeling/doing/wanting aren't so hopeless after all."  Attunement conveys interest, as well:  one of the ways we know if someone is interested in us is by their interest and understanding and involvement, their close attention to our story and their acknowledgment of our needs and wants.

         Respect and interest, in turn, create a climate of safety.  The therapist who respects me won't turn on me, laugh at me, be disgusted by me.  She is interested enough to take the time and make the effort to understand, all the way through, what I am trying to say; she won't leap to the wrong conclusions and steer me in a wrong direction.  It's okay to be here, okay to be who I am, okay to (maybe, just a little) let the defenses down and peek at the things I really haven't wanted to see.

         A client who feels respected and secure in the presence of his therapist can get on with the primary aim of therapy:  reclaiming that which has been closed off, healing that which has been fragmented, making both internal and external contact where contact has been interrupted.  Attunement reaches beyond the client's concern with an immediate problem, down into the hopes and fears and beliefs that keep the problem from being fully solved.  Attunement encourages the client to come to grips with those deep hopes and fears and beliefs, to explore them and update them in the light of more recent learnings. And attunement provides a constant invitation to contact, a gentle but firm and dependable "I'm here" when the client is feeling overwhelmed and hopeless.

         One last benefit of attunement:  when the therapist does get it wrong and makes that inevitable error,  her previous level of attunement will ease the process of re-synchronizing and re-establishing a climate of trust.  The general level of attunement sensitizes the therapist to the client's reaction to having been missed, and allows her to catch her error quickly, acknowledge it, and request clarification.  Acknowledging and apolgizing for an error are usually, in fact, another demonstration of attunement; when the therapist goes off the track, what the client most needs and wants is that the therapist admit it, apologize, and re-establish contact. (Giustalise, 1997)

         Attunement comes in many varieties, for there are many aspects of the client's experience with which to be in tune.  Let us attend particularly to five areas of attunement:  affective, cognitive, developmental, rhythmic, and relational (i.e., attunement to relational needs).

Affective attunement

   Most therapists are trained to be aware of, and even encourage, clients' affect.  We learn to be comfortable with our clients' tears, anger, fear, and joy.  We help clients to deepen their affect (or heighten it, depending on whose vocabulary is being used), and to access emotional responses that they had previously closed off and hidden from others and even from themselves.  The therapist's ability to respond empathically helps clients to do this affective work.  We've talked a lot about empathy already -- so what does affective attunement add?

         In an empathetic response, the therapist feels what the client is feeling.  She metaphorically crawls inside the client's skin and shares the client's affective experience.  The affectively attuned therapist goes beyond empathy, meeting the client's affect with her own personal and genuine affective response. (Erskine, Moursund & Trautmann, 1999) 

Moreover, affective attunement requires that the therapist attend not only to the emotion itself, but also to the message being sent by the emotional display.  Emotion is a two-person phenomenon; it is a way of communicating with others who are present physically or in fantasy.  Attunement -- being in resonance with the client -- allows us to distinguish between, for example, tears that plead "please take care of me and make things better" and tears that say "I'm ashamed to be so upset about this," and to respond appropriately.

         An attuned response, by the way, is really a three-stage phenomenon -- although the stages may follow each other so rapidly that they are difficult to distinguish.  The first stage of an attuned response is that of noticing, recognizing, and empathizing with the client's affect:  the client's eyes fill with tears, for example, and the therapist recognizes and sympathizes with the client's sadness.  The second stage involves the therapist's internal reaction: perhaps first one of vicariously feeling the client's emotion, or a less intense echo of it, and then moving to her uniquely personal response to that emotion.  Recognizing that the client is sad, the therapist finds herself feeling compassionate, wishing she could make things better, and at the same time glad that the client's sadness is finally breaking through the defensive barrier that has kept him stuck and miserable for so long.  Finally, the third stage of the therapist's response is what she communicates to the client.  She may simply reflect that the client looks sad, or she may share some of her own feelings -- or she may simply wait quietly, or hold out her hand in a gesture of comfort.

         Affective attunement is achieved in a variety of ways.  The first of these is simply attending to the cues that signal an emotional response in our clients.  It is easy to get so caught up in the content of the client's story, or in our eagerness to find a solution to his problem, that we fail to notice the tiny facial, gestural, or voice tone changes that often accompany a feeling response.  It is equally easy to attend just to the display of affect and ignore the message that the emotion is sending.  When we make either of these errors, the usual result is that the affect goes underground:  the client either decides that it was inappropriate (because we didn't validate it), or that the therapist is insensitive and therefore not safe to be emotionally vulnerable with.  Not only is the current opportunity lost, but the therapist may have to prove herself all over again before regaining the client's trust.

         Lee (1998) has suggested that emotional tuning in between two individuals involves one person unconsciously imitating the other's facial expression and in so doing setting up a similar affective response in himself.  Affectively attuned therapists probably do some of this sort of unconscious imitation, but the imitation quickly gives way to a more authentic and personal response to what has been sensed in the client.  Tuning in to oneself is as important as tuning in to the client; internal contact combines with external contact to take affective attunement an important step beyond empathy.

         Some internal responses to someone else's feelings, of course, may not be therapeutic.  Partners who become enraged at each other, or parents who are either over-critical or over-protective of their children, may be observing the other person's emotion quite accurately and responding to it quite authentically -- and hurting the other person in doing so.  In order for affective attunement to be therapeutically useful, it must be combined with therapeutic intent and with clinical competence. Therapeutic intent keeps us focused on the client's welfare, and competence helps us to understand what sorts of things the client may need from us at any given moment and how to create a response to that need.  Together, therapeutic intent and clinical competence provide a framework for our internal response to the client, ensuring (in most cases) that that response will be helpful -- or at least not destructive.

         Each general class of affect seems to call for a certain kind of reciprocal response, whether the responder be a therapist or someone else in close relationship to the "sender" of the emotional message. Sadness, for example, requires compassion -- not a gushy, "oh you poor thing" sort of sympathy, but a genuine sorrow that the other person is in pain.  Anger involves a request to be taken seriously:  the attuned therapist will attend, will be respectful, will not make light of or try to diffuse or explain things away.  Anger is a serious thing, and in order to take it seriously the therapist must see the world from the perspective of the angry client and allow herself to be impacted by his anger.  It is not necessary that she too feel angry, but it is certainly unhelpful (and relationally destructive) to be amused by or frightened of what the client is experiencing.

         The most appropriately attuned therapeutic response to a client's fear is a sense of protectiveness.  This does not mean that the therapist acts so as to protect the client -- in most cases, such behavior would get in the way of the client's working through his fear -- but rather that the impulse to protect is stirred in her.  The impulse to protect stems from the therapist's sensitivity to the nuances of the client's feelings.  Taking those feelings seriously, she is roused to activate her clinical skills, to figure out what sort of intervention will be most useful in helping the client deal with his fear; her efforts also convey to him that she is contact-available, that she has received and is responding to his message.

         We've talked about the three most common uncomfortable affects -- what about the pleasant ones?  How do we appropriately attune ourselves to a client's feelings of happiness, joy, triumph?  Here the answer is simple: share them.  Feel the joy ourselves -- but slightly less intensely than the client does.  It's the client's joy, not ours; the client leads and we follow (Erskine, 1998b).

Cognitive attunement 

         Humans are thinking creatures.  How we experience our world is largely determined by how we think about it, by what meanings we make of it.  A given event can be experienced as amusing, frightening, boring, or exciting -- watch people emerging from a carnival "fun house" and you will see variants of all of those reactions.  Our emotions do affect how we think, to be sure, but equally strong is the effect of our thoughts on how we feel.  Cognitions, says Lee, interact with affects so as to magnify or attenuate the affective processes. (1998, p. 145).  We can talk ourselves out of experiencing a strong emotion ("I just won't think about it; it really isn't so bad; I'll feel better in the morning") or, as Ellis and the rational-emotive therapists (Ellis, 1997) are fond of pointing out, we can "awfulize" a situation and make ourselves feel intensely bad about it.

         Cognitive attunment involves understanding and temporarily borrowing the process by which a client makes meaning -- not only as those meanings affect his emotions, but as they affect his whole way of making internal and external contact.  How does he "sort out" his world?  How clearly does he distinguish between his various perceptions, suppositions, and memories?  How does he go about solving problems -- or avoiding them?  What are the rules that determine what he allows himself to think about, and what is forbidden ground?  In Beyond Empathy: A Therapy of Contact-in-Relationship (Erskine, Moursund & Trautmann, 1999), we  described cognitive attunement in this way:

Cognitive attunment is more than simply attending to content.  It is not the same as "understanding the client's cognitions" because it goes beyond simple understanding.  It involves attending to the client's logic, to the process of stringing ideas together, to the kinds of reasoning that the client uses in order to create meaning out of raw experience.  It's about what the client is thinking; but more importantly, about how the client is thinking it.  As we attune to the client's cognitions, we enter the client's cognitive space, moving into a kind of resonance with the client and using our own thoughts and responses as a sounding board to amplify the tiny cues that the client is giving.  We bring the client's words and nonverbal expressions into ourselves; take on their meanings, implications, connections; experience this way of thinking ourselves in a kind of internal "as if." (p. 54)

         Just as affective attunement requires a kind of alternation between attending to the client's affect and attending to our own affective response, so cognitive attunement requires that we alternate between the client's way of thinking and our own.  We adopt the client's thought process, as closely as we are able, in order to see the world through his eyes, experience its events as he does, discover what it is like to live with his blind spots and his defenses.  But we cannot allow ourselves to stay in that place; it is the contrast between his cognitive process and our own that allows us to note those distortions and defenses.  Without such a contrast, we would be as blind to his process as he is, and as unable to imagine any other way of thinking.  We move back and forth, thinking about the client's frame of reference, then thinking within that frame of reference, then thinking about what it was like to be within it.

         Because we are attuned to the client's cognitive process, we can better understand and respond to what he is trying to tell us.  Indeed, sometimes we will understand even before he spells it out:  thinking in the same way, we often know where he is going and what conclusions he may reach.  With the trust and the sense of safety that comes from being understood in this way, the client is increasingly open to pushing the boundaries, both by exploring new areas on his own and through our invitations and suggestions that he review a memory, consider a possibility, examine an interaction. 

         Sometimes, of course, we will be wrong.  Cognitive attunement can never be perfect; we can never fully enter into another person's stream of thought.  We must constantly remind ourselves that our understanding of the client's cognitive world is a hypothesis, not a fact, and that our trying on of his meaning-making process is an experiment that requires validation from the client himself before it can be fully trusted.  If we do get it wrong, the most important thing we can do is acknowledge our error and ask the client to help us get back on track.  Sometimes these sorts of error-and-correction sequences are extraordinarily helpful:  they signal the therapist's willingness to respect the client's wisdom and to admit her own fallibility, and they invite the client into a process of shared exploration in which he and the therapist each make a uniquely valuable contribution (Giustalese, 1997).

Developmental attunement 

         "In all therapies, including psychoanalysis and psychodrama," write James & Goulding (1998), Òregression occurs whether it is planned by the therapist or client or whether it is spontaneous.Ó (p.16)  Regression has been defined in a variety of ways; for our purposes we shall define it as a return to patterns of thinking, feeling, and/or behaving that were present for the client at an earlier time in his life.  It occurs not only in psychotherapy, but in daily life: whenever we find ourselves responding as we did in a previous developmental period, we have regressed.  Regression is a common phenomenon; it occurs most often under stress but may also be observed during states of childlike joy or excitement.

         Psychotherapeutically, regression is of therapeutic interest when it represents a fallback to old patterns of dealing with the world, patterns which were learned earlier in life and remain available to us when our current strategies are not working.  The therapist may invite a client to regress ("take yourself back to a time when...") in order to facilitate discovering what those old patterns are and how they relate to the client's current difficulties.  Other therapeutic regressions may be spontaneous, a response to the "safe emergency" (Perls, 1973) of the therapy session.  The client may be aware that he has regressed, and indeed be actively cooperating in achieving and maintaining the regression, or  may be quite unaware of it.  In either case, it is important that the therapist be attuned to the level of regression and respond accordingly.  We refer to this sort of attunement as "developmental attunement" because it requires sensitivity to the developmental level to which the client has returned, cognitively or emotionally or behaviorally.

         Depending upon one's theory of psychotherapy, regression may be seen as useful, as irrelevant, or as an impediment to achieving the client's goals.  Therapists who take a strict behavioral or cognitive-behavioral position are likely to discourage regression, seeing it as interfering with the client's ability to evaluate, problem-solve, and follow through on a plan for change.  Others, more psychodynamically oriented, believe that regression is useful in that it allows clients to access  defended memories  and experience otherwise forbidden affect. We believe that the value of regression depends upon when and how it occurs, and how the therapist chooses to use it.  Contact is the key here:  a regression in which contact between client and therapist is lost (usually because the therapist is still responding to a here-and-now adult client, rather than to a psychologically younger person),  is likely to interfere with the therapeutic process.  In contrast, the client who experiences the therapist's contactfulness throughout a regression is likely to feel deeply understood.  Developmental attunement helps us to maintain contact with a regressed client, and either invite him back to a more here-and-now appropriate level of functioning or support his continuing regressive experience.

         Recognizing that a client has regressed, and identifying the level to which that regression has taken him, is essential for maintaining contact.  Using adult language with and expecting adult responses from someone who is experiencing the world the way a 4- or 8- or 12-year-old does, is not likely to enhance the client's sense of connectedness or trust.  Children, like adults, yearn to be understood; the phenomenological child that is the product of a client's regression wants to be seen and heard and respected, not ignored or missed altogether.  How, then, can we recognize and identify a client's level of regression?  How can we keep ourselves developmentally attuned?

         Obviously, in order to attune oneself to a client's developmental level, one must have a sense of what that level is.  Eric Berne (1961) has suggested four ways in which a therapist can assess the client's developmental level of functioning.  The first of these is the client's own phenomenology.   We may ask the client how old he is feeling at this moment, or the client may spontaneously report a regression:  "I feel like a five-year-old," or "I'm scared, just like when my Dad used to come home drunk."  A second aid to identifying regression and maintaining developmental attunement is the therapist's awareness  of the client's unique developmental history.  If we know that the client was raped when he was in high school, or that he was sent to live with his grandmother when he was ten years old, it can help us to interpret the meaning of verbal and nonverbal communications, and of the developmental level from which they spring.  We can also call upon our general understanding of child development to relate the client's current behavior to behaviors typical of a younger stage or -- and it behooves us to have a good knowledge of the typical stages and phases through which young children move.  This is particularly important when the client is regressing to a relatively early stage of life, and his ability (and desire) to communicate verbally may be limited.

         Probably the most important set of guidelines, though, comes from our own intuitive, emotional response to the client's behavior.  How old does the client feel to us?  What sort of younger person seems to be looking out of his eyes?  If we put to one side the adult body in front of us, what seems to be the most natural way of responding to what he is doing and saying?  We are often able to pick up tiny cues, cues of which we are consciously unaware, from the nonverbal behavior of our clients; such cues can aggregate out of our awareness and make themselves known as a general hunch about how to respond most effectively.  Spending time with children, learning to interact with them at their level and sensitizing oneself to one's own reactions to them, is a good way to hone one's ability to attune in this way.

         Developmental attunement, if it is to be useful, must be communicated.  You may know that your client is, at this moment, seeing the world and responding to it as he did when he was a toddler; but this knowledge will be of little use unless the client feels your understanding and your support.  At the same time, the client also needs to know that you are aware of the adult, here-and-now self who is also participating in the process.  Maintaining attunement with a regressed client requires a kind of therapeutic "double vision," an ability to recognize and acknowledge both the regressed-to-childhood (or adolescence, or young adulthood) person and the self-observing adult.  Both are present, both require contact, and both play an important part in the client's growth.

         One of the most potent ways to maintain developmental attunement is to use the client's own language and language patterns.  As he regresses, his vocabulary is likely to shift too -- the developmentally attuned therapist shifts with him.  If the therapist senses that the client is moving into the psychological world of a 6-year-old, she talks to him as she would to a 6-year-old.  Her own body language is keyed to his:  not imitating it, but responding to it as an adult responds physically to a child.  The therapist can facilitate a client's regression by encouraging childlike gestures and movements; conversely, she can invite him out of the regression by requesting that he assume a more adult posture and by using adult language and phrasing in her responses to him.

         We have found, over years of working with clients, that therapeutic regression is a powerful tool in enhancing contact with self and, eventually, with others as well.  It is useful in overcoming the unconscious defenses which prevent full awareness of thoughts and feelings and memories.  Developmental attunement is the single most vital factor in developing and therapeutically facilitating a client's regression.  Without developmental attunement, regressions are likely to be short-lived and therapeutically sterile; with it, they can lead to the corrective emotional experience that lies at the heart of a relationship-focused integrative psychotherapy.

Rhythmic attunement 

         In a sense, it is odd to give rhythmic attunement a special section of its own, since attuning to the client's rhythm is an essential aspect of cognitive, affective, and developmental attunement.  When we are out of synch with the client's rhythm and timing, he will not experience us as being attuned in any other way.  But there are some particularly interesting aspects of rhythmic attunement, and dealing with it as a separate topic is one way to make sure we remain sensitive to those aspects.

         The term, "rhythmic attunement," really defines itself:  being sensitive to and responding within the client's rhythmic patterns.  Rhythm is one of the primary ways in which people, out of awareness, assess the quality of their contact with each other.  When two people are rhythmically attuned, their transactions mesh together easily.  Their silences are comfortable; there is no competition for who will speak when.  Even when they interrupt each other, it is as if one of them is stimulated by the other's thought, and the interruption does not jar or derail their process.  In contrast, when they are not attuned rhythmically, their conversation is jerky and their silences strained.  Neither is likely to feel at ease with the other, though they often cannot explain their discomfort.

         In ordinary conversations, each person is responsible for adapting to the other's rhythm, maintaining a pacing and style that is comfortable for both.  In therapy, the primary responsibility for attunement falls to the therapist.  The therapist must attune to the client, not the other way around; expecting the client to match the therapist's  rhythm will force him into an artificial way of speaking and thinking and feeling that will interefere with his work.  Tuning in to and matching a client's rhythm requires, first, that the therapist attend to that rhythm and how it may differ from her own.  Does he use long pauses to collect his thoughts, and is the therapist impatient with those pauses?  Or does he jump from idea to idea, illustrating his words with quick gestures, and appearing uneasy if the therapist speaks slowly or has to search for words?

         It is relatively easy (at least in theory) to slow oneself down in order to attune to the rhythm of a client who is processing his experience more slowly than we ordinarily do.  Speeding oneself up to match a rhythmically rapid client is more difficult:  how can a therapist think and feel faster, without losing important information?  Rather than try to push herself to keep up, and risk distorting or disrupting contact with herself and/or the client, it is best for the therapist to acknowledge the differences, and openly request time to digest what the client has been telling her:  "You are moving through these ideas very quickly, and I don't want to miss anything.  Give me a moment to think about what you've been telling me..."

         While each person does develop his or her own unique rhythm, there are some general rhythmic patterns which seem to hold for nearly everyone.  Most of these involve slowing down, rather than speeding up.  A major goal of therapy is to attend to what has been overlooked, to explore what has been defended against, and this generally requires that we move more slowly than usual; indeed, racing along from one association to the next is a way to not notice things, and not feel one's feelings.  One of the paradoxes of our work is that slowing down is likely to speed up the therapeutic process, while going too fast is likely to slow the client's overall progress.

         Affective work, in general, proceeds at a slower pace than cognitive work.  It is not that we experience emotions more slowly than we think -- quite the contrary; emotions spring up quickly and can shift and move with lightning speed.   A loud, unexpected noise can create an immediate startle-scare feeling; it takes no time at all to experience tenderness and love when we look at our infant grandchild; but putting those feelings into words can be a slow and laborious process.  Talking about feelings requires translation, from a global, wordless experience, mediated primarily through body chemistry, to a linear, verbal process.  Moreover, many clients have trained themselves not to attend to their feelings, and they accomplish this by rushing past them, moving on to a new thought.  Giving such clients permission to slow down, so that they can feel and think and talk about their internal experience, will further their ability to make and maintain full contact with themselves and with others.

         Developmental level -- regression -- also affects one's rhythm, and developmentally attuned therapists recognize that as clients move to younger and younger psychological levels, their rhythms tend to slow.  Indeed, a slowing of rhythm may be a major indicator that the client is regressing.  Just as we tend to talk more slowly to a young child, the therapist needs to attune herself to the slower rhythm of the client who is at this moment experiencing the world from a younger, less verbally sophisticated place.

         It is easier to review what we already know than to explore what is unknown; clients who exhibit a quite rapid pace when sharing well-rehearsed material are likely to slow down as they begin to explore new thoughts and previously walled-off emotions.  Like someone feeling their way around a dark and unfamiliar (and often frightening) room, they need to take time to find out what is there, to examine it fully.  They need time to integrate the new with the old, to figure out how their discoveries fit with the familiar and comfortable parts of themselves that they've known about all along.

         For all of these reasons, errors in rhythmic attunement are much more likely to involve going too fast rather than going too slowly.  As therapists, we pride ourselves on being quick to understand, being good at putting things together; we've been rewarded throughout our schooling for coming up with right answers quickly.  Now we need to put that skill to one side, slow ourselves down, slip gently into the client's rhythm of speaking and moving.  When we do so, the client is likely to feel joined, met, in contact.  Our matched rhythms will create a sense of moving together; the need for lengthy explanations will decrease; the client will feel protected by our willingness to be together in his way.

         Rhythmic attunement extends beyond the sort of transaction-by-transaction rhythms that we have been discussing.  People differ in the length of time they are comfortable in spending on one topic, one idea, before moving on to the next.  They differ in the amount of "warm up" time they need at the beginning of a session before moving into full contact with themselves and with the therapist.  There are even differences in rhythm over much longer periods of time:  clients often differ in the length of time they need between sessions to process their work.  Some do best with shorter sessions, more frequently spaced; others prefer longer sessions at greater intervals.  The weekly, 50-minute session is convenient for the therapist, but it may not match the client's rhythm. (Efron, Lukins & Lukins, 1990) If a client would benefit by changing the length or frequency of his sessions, it is advisable to do so; when such changes are not possible, one can at least acknowledge his need.  If the therapist lets the client know that she recognize his preferred rhythm, and shares her reasons for not adapting to that preference, the absence of attunement here will be less jarring.

         As we said at the beginning of this section, rhythmic attunement flows through all of the other aspects of attunement.  In order for the client to experience cognitive or developmental or affective attunement, the therapist must be operating within that client's rhythm -- his rhythm is a part of his cognition, his affect, his developmental level.

          Verbal and nonverbal messages sent by the therapist are like the instrumental voices of a symphony. When one or more of those voices is off tempo, the whole performance sounds wrong.  Moreover, just as we respond to one piece of music or another depending on the state or mood we find ourselves in, so the client will respond differently to different therapist "symphonies" depending on his or her own state -- dealing with affect or cognition, regressed or not, energized or fatigued, and so on.  It is no accident that a musical metaphor like this fits with the notion of "attunement." Hearing all of the nuances of the client's melody and rhythm, and responding from and with the harmony of one's whole therapeutic orchestra, verbally and nonverbally, is what attunement is all about. (Erskine, Moursund & Trautmann, 1999)

Attunement to relational needs

         Relational needs:  those needs that arise in the context of a relationship.  When I need something from you, some particular kind of response or behavior, I am experiencing a relational need.  Not surprisingly, clients have relational needs in therapy, needs to which they want their therapist to respond.  Some of these needs can be met by the therapist, and some can -- or should -- not.  Whether or not the therapist chooses to meet her client's relational need, she must still acknowledge and respect it; to do so, she must be attuned to the way in which those needs come up for and are expressed by the client.

         Therapists, too, of course, experience relational needs, and sometimes we find ourselves needing/wanting something from our clients.  If we didn't, our relationship would be sterile and superficial:  choosing to be contactful and real in our therapeutic relationships guarantees that we will sometimes have feelings about our clients, emotional reactions to them, and will want them to think and feel and behave toward us in certain ways.  However, being attuned to and responding appropriately to their relational needs will often require that we put our own wants and needs to one side.  Calaghan, Naugle & Folette (1996) warn us that even when the therapist is expressing appropriate feelings, the client may misunderstand or misinterpret what is said. "Therapists must be able to express their reactions and feelings in their interactions with clients while being sensitive to how this impacts the individual clients with whom they work." (p. 387)  Attuning to the client's view of us, being sensitive to what he is needing from us at a given moment, helps us to make sound decisions about sharing our own inner experience.

         The client's needs come first.  If sharing her own feelings will serve the client's interest, the therapist may choose to do so.  If decentering from her needs and wants, and focusing on the client, is the most growth-enhancing choice, that is the choice the therapist should make.  It must be emphasized, though, that focusing on the client's needs is not the same as trying to meet those needs.  Whether or not to act so as to actually meet a client's relational need will be determined by a host of factors.  The client's developmental history, the availability of other social support in his life and the way in which he uses that support, the nature of the need itself, the point in treatment at which the need is expressed, the way in which it is expressed -- all of these enter into the therapist's clinical judgement about what sort of intervention will best serve the client's interests.  Let's review eight major relational needs, looking at how each need might arise and manifest itself in the therapy session, and some of the therapist responses that may be helpful.

         Security.  The need for security in relationship is the most basic of all relational needs.  The client needs to know that his therapist is trustworthy, competent, and has his best interests at heart; but beyond that he needs the visceral experience of having his physical and emotional vulnerabilities protected. He needs to know that he will be neither humiliated nor pathologized as he begins to reveal his most secret thoughts and feelings. The need for relational security is most likely to be foreground at the outset of treatment, when the client may be ambivalent about the whole process and does not yet know much about this therapist in whom he is expected to confide.  Once the therapist has established herself as worthy of the client's trust, the security need tends to recede into the background.  It will arise again if the therapist makes a mistake, or if old issues around trust and safety are being explored.  Rather than being expressed directly, the client's need for security is most often signaled by his drawing back from contact:  coming late for sessions or cancelling them altogether; becoming quiet, or talking about superficial matters; misunderstanding or accusing or blaming the therapist for things that happen both in and out of session.

         A client's security needs must always be attended to, for little substantive work can be accomplished if the client does not feel safe in the therapeutic relationship.  However, direct reassurances will be of little value.  "I want this to be a safe place for you to work" or "I will never do anything to hurt you" can be mere empty words to a client who is feeling unsafe.  Acknowledging the client's concern, along with the therapist's desire to allay his fears and her recognition that words alone will not suffice, is generally helpful.  Even more important is attuning and responding appropriately to all of his other relational needs:  over time, this is the behavior that will demonstrate that the relationship is, indeed, safe for him.

         Valuing.  The client's need for valuing, has to do with valuing the significance and function of his psychological processes - the "why" of what he does and says, more than the actual behavior.  This sort of valuing is conveyed through the therapist's contactful presence, and through her respectful attention to and interest in the client's phenomenology.  Rather than focusing on the client's external behaviors, the therapist talks about those behaviors in the context of the clients ongoing experience within himself and in relationship to others - including the therapist herself.  Her conviction that every behavior, every response, serves an understandable and important function, allows her to inquire with no hint of criticism or judgment.  If the client doesn't seem to make sense, if his behavior seems hurtful or silly, then the therapist (and quite probably the client as well) have simply not yet understood it fully.

         While all clients need to feel valued by their therapists, the need for valuing emerges most intensely in the context of shame (Erskine, 1997/1994).  Feeling shame about something he has shared, about some part of himself that he has exposed, the client's ability to value himself is undermined; not valuing himself, he imagines that nobody else can value him either.  He withdraws, huddles inside himself -- or moves into an exaggerated, whistling-in-the-dark sort of psuedo-confidence.  Acknowledging and normalizing his need, and the sense of shame that precipitated it, will help him to re-establish contact.  Once contact is re-established, he will be more receptive to the therapist's verbal and non-verbal indications that he is indeed valued and respected.

         A client who does not experience being valued in his outside-of-therapy relationships may become overly dependent upon the therapist's valuing.  He may demand frequent evaluations of his behavior and progress in therapy, or may compliment the therapist in the hope of getting some positive stroke in return.  Verbal reassurances are generally less than helpful for these clients, since they tend to reinforce the client's dependency; acknowledging the need,  engaging the client in exploring its significance, and helping him to find other relationships in which it can be met, is usually a better strategy.

         Acceptance by a dependable other.  "The degree to which an individual looks to someone and hopes that he or she is reliable, consistent and dependable is directly proportional to the quest for intrapsychic protection, safe expression, containment or beneficial insight." (Erskine, 1998a, p. 239)  The need for acceptance by a dependable other is closely related to the need for relational security, but it goes farther:  it has to do with our experience not only of the other person's competence, but of her genuine willingness to understand and to help.    And it has to do with being allowed to make the other person special to us, without having to be  ashamed of how we feel toward her. When we experience this need, we want to be with someone from whom we can draw strength, guidance, or wisdom, and who will not criticize or belittle us for wanting that kind of support.

   The need for this sort of acceptance is sometimes manifested through idealization of the therapist - she is wonderful, she's different from anyone else in my life, I think about her all the time... Such idealization is a normal and natural stage through which many clients pass; it is an out-of-awareness request for protection and support, and its function should be respected and valued just as we respect and value every other aspect of the client's behavior.

         When the need for acceptance by a dependable therapist is foreground for a client, it is not particularly helpful for the therapist to express her own uncertainty or concerns.  At this moment, the client needs her strength, her reliability; he needs her to be a kind of good parent who can be depended upon to care for him with wisdom and skill.   "As an example of the crucialness of responding," comments Lee (1998), "when a therapist detects a client's fear, yet responds to this fear in an anxious way, the client experiences the therapist's exacerbating response as unempathic." (p. 130)  Although the therapist in this example accurately notes the client's fear, she allows herself to be contaminated by it:  she allows her affective attunement to outweigh her attunement to relational needs and thus misses the client's need that she be able to contain his fear rather than share it.

         Mutuality.  Experienced in the therapy session, this is the need to be with a therapist who has shared one's experiences:  she really understands, because she has been there herself, and her acceptance is based on that understanding.  Moreover, the client who feels a mutuality with the therapist can experience a sense of "I'm okay, and what I do/think/feel is okay, in part because this person I trust has done/thought/felt the same sort of thing."  Clients for whom the need for mutuality is foreground may want their therapist to have had (and dealt with) the same sorts of problems that they have, or to have shared a similar childhood history.  The need for mutuality may be expressed through direct questions (  "Do you have children too?" "Have you ever lost a job, like I just did?") or through probing comments ("I'm not sure anybody can understand this unless they've been abused themselves."  "Straight people don't know what it's like to be gay.")

         While a therapist cannot possibly know first-hand everything her clients have gone through, she has had (in reality or in fantasy) similar experiences. When she senses the need for mutuality in a client, it can be useful to talk about herself, her thoughts or feelings or experiences that parallel the client's experience in some way.  Meeting the need for mutuality, then, requires a degree of self-revealing; each therapist must decide for herself, on the basis of her personal comfort level as well as of her sense of what will be helpful to the client, how much self-revelation she is willing to provide.  And, to the degree that she does choose to self-reveal, it is essential to acknowledge that she can never know completely what it was/is like for this client, because he is the only person who lives inside of his skin.

         Asking personal questions of the therapist is not always a signal that the client is experiencing a need for mutuality.  Sometimes this sort of question is used as a smoke screen, a way for the client to avoid dealing with his own painful issues.  And even when the mutuality need is foreground, it may not always be in the client's best interest to meet that need; the client may be trying to use his relationship with the therapist as a substitute for satisfying relationships outside of therapy.  Nowhere is the need for a discussion of the therapeutic process itself more essential than when dealing with a client's repeated requests that the therapist talk about herself.

         Self-definition.  I am me.  I can think for myself.  My feelings are my own.  The need for self-definition is the need to know and express one's own uniqueness and to receive acknowledgement and acceptance of that uniqueness from others.  Many clients come to therapy hungry for validation of their uniqueness.  They have been discounted, treated as unimportant or second-best, not allowed to argue or to say "No."  They are not so much interested in other people's similar experiences as in having their own experiences attended to.  At moments when this need for self-definition arises, therapist self-disclosure is not only irrelevant -- it is evidence that the therapist does not understand the client's needs or is not fully invested in the therapeutic relationship.  Failure to support the need for self-definition can be a further reinforcement of the client's script belief that he is unimportant and that nobody really cares about him.

         The need for self-definition is the complement of the need for mutuality.  A client experiencing the need for mutuality may want to know about the therapist in order to gain a sense of closeness and similarity; when the need is for self-definition, the client needs the focus to be on himself.  If the client appears impatient when the therapist shares her own thoughts or feelings, or seems to withdraw, the therapist may have misjudged his state of relational need.  At such a moment, it is a good idea to shift back, ask him what it's like for him when she talks about herself, and use the exchange as an opportunity to validate his need to be who he is.  Encouraging his disagreements with or challenges of the therapist will encourage him to define himself as different and valuable in his own right.

         Making an impact.  Clients can do a great deal of self-exploration by keeping a journal, or talking into a tape recorder.  One problem with this strategy is that the journal or the tape recorder doesn't answer back, is not impacted by the client's input.  Relationships in which one does not experience having an impact on the other person are one-sided if not actually abusive; just as with a thwarted need for self-definition, they foster the belief that one is unimportant and that others don't care.  The therapeutic relationship is no exception:  just as the therapist, in order to feel valued and competent, needs to feel that her behaviors have an effect on the client, so the client needs to feel that he can make an impact on the therapist - can attract her attention, and can influence the way she thinks and/or feels about things that are important to him.

         Unlike the "blank screen" therapist model espoused by traditional psychoanalytic theory, relationship-focused integrative psychotherapy insists that the therapist be present as a person, caring about the client, willing to be changed by what happens in the relationship.  If she is moved to tears, she allows those tears to show; if she is angry on the client's behalf, the client knows about her anger; if the client corrects her, she is willing to be corrected and to think seriously about what change may be required. If the client demands a greater impact than the therapist is willing or able to allow, she acknowledges his desire and shares her honest response to that desire.  Whether the need is actually met, or simply recognized, her acknowledgement is a validation of the legitimacy of the client's need, and proof that he does, indeed, have an impact on her.

         Other-initiation.  When the need for the other to initiate is foreground, the client needs the therapist to do just that:  step in and make the first move.  He wants her to offer a new idea, suggest a direction, reach out a hand.  Sometimes clients will signal this need by closing down and becoming silent, and sometimes they will do the opposite: talk faster, jump from one topic to another, do whatever they think will please the therapist.  Clients who are starved for other-initiation expect to be ignored, tolerated, or forced to prove themselves, and that expectation limits and distorts their relationships with others -- including their therapist.

         "The therapist's willingness to initiate interpersonal contact or to take responsiblity for a major share of the therapeutic work normalizes the client's relational need to have someone else put energy into reaching out to him or her." (Erskine, 1998a, pp. 240-241)  There are many ways to accomplish this.  In the therapy session, the therapist can break a silence (rather than always waiting for the client to speak), or choose a topic (rather than expecting the client to decide what to talk about), or respond to some nonverbal request (rather than insisting that the client express his needs directly).  She can suggest a more frequent appointment schedule, or ask her client if he would like a different length session.  She can phone him to ask about an important life event that she knows has occurred -- a hospitalization, a job change, a public performance.  Overdoing this sort of initiation is, of course, counter-therapeutic; it can be an invitation to dependency and may constitute a quite unwarranted intrusion into the client's private life.  But when the client's need for the therapist to initiate is genuine, taking that first step can provide a corrective emotional experience that effectively challenges his whole script pattern.

         Expressing love.  Of all the relational needs that are dealt with in therapy, this is perhaps the most difficult -- and how ironic!  Expressing love and appreciation, and receiving that expression, should be a joyful experience.  When the therapist has been close to the client, seen his confusion and his pain, accepted him and valued him, and helped him to grow and heal, it is only natural that the client should feel loving and appreciative; to stifle such feelings would be to retreat into phoniness and fragmentation again.  Yet most therapists have been trained to be suspicious and distrustful of their clients' gestures of affection, always looking for some underlying motivation, some toxic transferential remnant that must be rooted out and done away with.

         It is usually not difficult to tell the difference between a manipulation and a genuine expression of caring.  When a client, out of such genuine feeling, thanks his therapist or tells her how much she has meant to him or brings her a gift, she should accept it gracefully and let him see her pleasure.  It does feel good to be appreciated; being real in the relationship means enjoying the good parts as well as being impacted by the bad.

Attunement Errors

         Relational needs shift from moment to moment, and being attuned to those shifts requires close attention to the client's responses to the therapist's behavior.  What begins as an attuned response to, say, the need for mutuality or other-initiation can change into a failure to deal with the need for self-definition.  Because therapists are human, and imperfect, such misses are inevitable; when they occur, one simply goes back and talk about the miss. 

         "Go back and talk about it" is good advice for failures in every facet of attunement.  Missing an affective shift, not understanding a cognitive process, misjudging the client's psychological level of development, moving too quickly or too slowly -- all are bound to occur sooner or later.  The therapist who castigates herself internally for her error, or tries to gloss it over so the client won't notice that it happened, takes herself away from the client and distorts the contact between them.  This sort of contact distortion, in turn, is likely to create a repeat for him of the very kinds of relational experience that support his script and have gotten him into the situation that brought him to therapy in the first place.  In contrast, the therapist's acknowledgment of what has happened and re-attuning (to herself and to him) allow the therapeutic process to move on.

Involvement       

         "Involvement" is one of those words that most of us think we understand, but that turns out to be very difficult to define.  The "involved" therapist is there for her client, present in the relationship, real, honest.  She cares what happens to this person, and she is willing to put energy and effort into helping him achieve his goals.  She is genuinely interested in his client's intrapsychic and interpersonal worlds, and communicates that interest through attentiveness, patience, and respectful inquiry.  She risks being vulnerable:  she does not insulate herself from contact, but instead allows herself to be emotionally touched.  She doesn't hide behind a mask of phoney professionalism; she lets her caring show, talks about her feelings, admits to her errors.  "By embracing a technique of self-disclosure," says Billow (2000), "the patient may feel the analyst's emotion, without which emotion an authentic analysis is impossible." (p. 62) Involvement, then, involves emotion and authenticity -- emotion and authenticity that arise out of committment to and genuine caring about the client.  It is best understood in terms of the client's perception:  his sense of his therapist as contactful and truly committed to his welfare.

Acknowledgement

         There are four therapist activities that are especially crucial in maintaining and demonstrating involvement.  The first of these, and the one that tends to be called for earliest in therapy, is acknowledgement.  The therapist acknowledges the client by means of her attunement to his thoughts, feelings, behaviors, and desires, and her sensitive inquiry about all of those facets of his experience.  She hears what he is telling her, and she lets him know that she hears.   She is willing to talk about what is important to him; she doesn't force him to deal with her agenda.  While she is listening to him she is also listening to herself, in full contact with her own internal experience, and willing to acknowledge that as well.  Again, there is no pretending, no hiding behind some sort of clinical mask.   "The analyst is not a blank screen, but a quite human other presence whose emotionality the patient both correctly perceives as well as misperceives"  (Billows, 2000, p. 63).

         Acknowledgement of the client's affect, relational needs, and physical sensations helps him to reclaim his own phenomenological experience.  He is in the presence of a respectful other who recognizes and talks about his non-verbal responses, his muscular tensions, his feelings, even his fantasies.  Through this kind of sensitivity the therapist can guide the client toward awareness and expression of needs and feelings; she can help the client understand that emotions and physical sensations may be a form of memory - the only kind of memory that may be available to him right now.  In essence, acknowledgement of the client's internal experience reverses the relational failures of the past, providing permission and protection for him to express that which was ignored or punished in previous relationships.

          Perhaps most importantly of all, the therapist acknowledges her part in the creation of the therapeutic relationship.  What happens during the therapy session is jointly created; therapist and client both are responsible for the successes and the failures, the stuck spots and the leaps ahead.  They both are responsible for the misunderstandings, the insights, the feelings of care and closeness.  Acknowledging the therapist's contribution to relationship issues, as well as the client's contribution, breathes life into that relationship.  Such acknowledgement requires, enhances and demonstrates authentic involvement.

Validation

         Validation communicates to the client that his affect, defenses, physical sensations or behavioral patterns are related to something significant.  The involved therapist lets the client know that what he says or does is important, that his internal experience has meaning, even though she may not yet understand what that meaning is.  One of the tenets of relationship-focused integrative psychotherapy is that every behavior -- every act, thought, and feeling -- has a function; people do not behave randomly.  The therapist validates the function of the client's behaviors, and  of his reported internal experiences.  The behavior itself may appear hurtful to self or others -- telling oneself that life is hopeless, or feeling panic when crossing a bridge, or sending poison-pen letters, are not desirable behaviors -- but there is an underlying purpose to even the most irrational-appearing response.  Moreover, that purpose is positive; ultimately, the behavior was acquired and is maintained in order to protect the client from some danger or to achieve some important goal.  It is this positive function that the therapist validates.

         Sometimes simple acknowledgement serves as a validation.  By attending to the client's story, believing that what he says is true as he understands it (or, if he is being untruthful, that the untruth too serves an important function), the therapist lets the client know that she values his communication.  Greenberg & Paivio (1997) characterize this aspect of the therapeutic relationship as a new experience for most clients: "... feeling that a fragile sense of oneself is heard, received, valildated, and accepted is a source of new transformative experience." (p. 83)

         Going beyond simply acknowledging what the client is saying and doing, the therapist may explicitly validate some client behavior.  This is a particularly useful intervention when the client himself discounts the behavior.  "I don't know why I react that way," or "I keep doing the same dumb thing over and over," says the client; the therapist responds with "There's an important reason for that reaction/behavior.  Part of our job is to discover what that reason is."

         It is a truism that clients often experience the therapeutic relationship in the same way that they have experienced important relationships in the past.  These past relationships have taught them how to be with people, how to communicate their needs and respond to the needs of others, what to expect and what to avoid in human interactions.  It is inevitable that some of those learnings and expectations will generalize to the therapeutic relationship, and that the therapist will be understood in light of how other people have behaved in the client's past.  It is especially important, then, to note and to validate the client's responses to the therapist -- the way the client deals with the therapeutic relationship -- since these responses may have more to do with old, script-determined functions than with actual here-and-now events.  Uncovering script-determined functions is a first step in dissolving that script and re-establishing the spontaneity and creativity of full internal and external contact.

         A final aspect of therapeutic validation is confrontation.  Confrontation involves calling attention to a discrepancy:  between words and behaviors, between what the client actually does and how he or she describes it, between thoughts and affect, between expectations and actual events.  Like geological fault lines, discrepancies signal something important going on beneath the surface.  The confrontation, implicitly or explicitly, calls attention to the underlying  process.  Again, we assert that a purpose is being served, that the discrepancy has a function.  Far from being a punitive "gotcha!", confrontation that validates an underlying positive goal respectfully invites the client to look more closely at what he is thinking, feeling, doing, saying, and to value the purpose of that behavior even as he may strive to change the behavior itself.

Normalization

         The involved therapist normalizes her clients' responses.  Clients need reassurance that their behavior is not crazy, not shameful or disgusting.  They come for treatment because they are doing/thinking/feeling things that they don't want to do/think/feel, and because they have not been able to change their responses; they are likely to believe that they are different from (and less than) other people, who obviously are much better able to take care of themselves.  Normalizing interventions point out the similarities between clients and others:  "Given the situation you were in, and the resources available to you, it makes sense that you would have acted (thought, felt) as you did.  Anybody would."

         The intent of normalization is to counter a client's categorization or definition of his internal experience or his behaviors from a pathological, "something's-wrong-with-me" perspective.  Instead, the therapist presents a point of view that respects the client's attempts - archaic though they may be - to resolve conflicts and to protect himself.  The client's confusion, panic, defensiveness, memory flashbacks, or bizarre fantasies all derive from coping strategies developed in difficult and painful situations.  It is imperative that the therapist let the client know that his experience is a normal self-protective reaction, and that others experiencing similar life circumstances might well respond in similar ways. Normalization involves both acknowledgment and validation.  The therapist acknowledges what the client is telling him, verbally or nonverbally.  Validating the function of the behavior implies that the function is a reasonable and rational one; this paves the way for talking about how the client did the best he could do, under the circumstances, to maintain that function.  His choices may not have been good ones, but they were the best that he -- or anyone else in his situation -- could have made.  Now that the situation is changing, he is in a position to do something different.

Presence

         Acknowledgement, validation, and normalization are specific therapist behaviors that emerge naturally and inevitably from the conviction that every client is fundamentally a good person, doing the best he can given his history, belief system, and current resources.  They emerge because the therapist is present in the relationship, willing to be known as well as to know, in contact both with the client and with her own experience.  Presence is the fourth ingredient of involvement, and it is fundamental to the process of relationship-focused integrative psychotherapy.

         Presence is provided through the therapist's sustained attunement to the client's verbal and non-verbal communication, and through her constant respect for and enhancement of the client's integrity. It is an expression of the therapist's full internal and external contactfulness, and it communicates her dependability and her willingness to take responsibility for her part in whatever happens in this relationship.  It includes receptivity to the client's affect:  willingness to be impacted by the client's emotions, to be deeply moved while not becoming anxious, depressed or angry.

         There is a kind of duality to presence, a quality that we have touched on before:  a simultaneous attending to other and to self.  The therapist de-centers from her own needs, feelings, fantasies or desires and makes the client's process her primary focus but she does not lose touch with her own internal process and reactions.  "The therapist's history, relational needs, sensitivities, theories, professional experience, own psychotherapy and reading interests all shape unique reactions to the client.  Each of these thoughts and feelings within the therapist are an essential part of therapeutic presence." (Erskine, Moursund & Trautmann, 1999, p. 242) It is not just that the therapist has a unique history, a unique set of past experiences and present interests and needs and wants.  She also uses her experience as a kind of reference library that sheds light upon the client, upon her responses to him, upon their interactions with each other.  Most importantly, the therapist is willing to be transparent in her uniqueness, willing to let the client see who she is and what she is experiencing, willing to be impacted by that which impacts the client, and willing for that impact, too, to be seen.  The respectful interplay between self-awareness and de-centering opens the way for what Buber (1958) calls an "I-Thou" relationship, a relationship between two connected, contactful, self-and-other-aware individuals.  The "I-Thou" relationship, in turn, is the primary source of the transformative potential of relationship-focused integrative psychotherapy.

         One of the immediate consequences of therapeutic presence is that it serves as a model.  The client, seeing that the therapist is willing to be open and vulnerable, is encouraged in his own openness and vulnerability.  Presence also serves as a container for the therapeutic interaction (Schneider, 1998); it is a sort of psychological safety net, marking an interpersonal space that supports without constraining and protects without demeaning the client. 

         Inquiry, attunement, and involvement are the basic elements of a relationship-focused integrative psychotherapy.   They are based on a set of beliefs, a set of attitudes, about people in general and clients in particular.  They grow out of a committment to the premise that each client strives to be the best he can be, and that his problems and pains have developed out of a set of beliefs and decisions, acquired over time, that constrict and distort his way of being-in-the-world.  Yet they are more than attitudes, more than just a general way of thinking and feeling about clients:  they involve skills, skills that can be acquired, skills that are applied through all the stages and phases of the therapeutic endeavor.    

Richard G. Erskine, Ph.D., visiting Professor of Psychotherapy, University of Durby, U.K. and Training Director, Institute for Integrative Psychotherapy, 500 East 85^th Street, PH-B, New York, NY 10028.

Phone: 212-734-5291

Email: Richard@IntegrativeTherapy.com

Website: IntegrativeTherapy.com               

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