Integrative Psychotherapy Articles
Constantly Present: A Therapy for Julie
Julie came to my practice four and a half years ago, at the age of thirty-three. She was married, had two boys aged five and one. She was an intensive care nurse at a regional hospital. She was a beautiful young woman, who hid her emotional experience behind a charming smile. She had a pretty, smooth face. Difficult to know who was hiding behind this warm, friendly mask.
I decided to use Richard Erskine’s “Self-in-Relationship” model to organize my observations (Erskine & Trautmann,1997). This diamond in a circle describes a relational-systems perspective on the affect, behavioral, cognitive, and physiological dimensions of the human functioning and a model to aid in assessing whether each of these domains are open or closed to contact.
Julie’s affect was turned off. I made the assumption that with a violent, alcoholic father and a depressive, contemptuous mother, the environment in which Julie grew up was unfavourable to expressing one’s emotions freely. The insecurity was such that she learnt to control her emotions and numb them. As a child, she would hide in a hut at the back of the garden or under her quilt. In her own words: “Hide so as not to be found.” The adult facing me continued to reproduce this mechanism within herself. She hid even when she was looking at me. However, my presence, my involvement, my constant interest in her, created a trusting environment in the therapeutic relationship. Over time, she was able to unfreeze and access her emotional memories.
Cognition was particularly invested, she strove to understand things, to analyze them. Thinking was also a way of distracting herself from an emotion, understanding in order to avoid feeling. I observed her analysing to avoid feeling many times as the sessions went on, and taught her to pause and dare make room for the emotion before thinking.
Another way of getting away from interpersonal contact in the present was to escape into a fantasy. For example, when she felt too intense an emotion, she would start thinking about her shopping list or family organisation. That was one of her hiding place.
Julie also invested behaviours a lot. She was very active. In order to feel that she was a good mother, she would offer numerous activities to her children; not doing so made her feel guilty. She had to have a perfectly tidy home to get acknowledgement from others and to protect herself from her husband’s criticism. She gave a lot of attention to that same husband, who – according to her – needed her to look after him. At work, she had to be dedicated to her patients and to please her colleagues. When she was on the morning shift, she would always bring breakfast for the whole team. She could not imagine bringing only her own, she would have felt too guilty. A deep feeling of guilt caused her to over-invest this pole. Her professional choice had been the right one. She was an accomplished nurse who took care of everyone else but herself. She pretended to be happy in her beautiful and successful life. “Doing” protected her from deeper emotions related to abandonment.
Her body was painful, with tensions in her trapezius muscles, jaws, and back. I made the assumption that she hid her emotions, fear, sadness, anger, shame and resignation in them. Her body expressed what the emotions did not express. She had asthma and her breathing was often shallow. We subsequently found out that reducing her breathing as much as possible was a way of making herself the most unobtrusive possible, of making herself invisible. It was necessary when her father came home drunk at night. She would hide under her quilt and stop breathing so as to make as little noise as possible and also avoid feeling the fear that overcame her.
Her relationships consisted mainly of competition and over-adaptation. For example, when her husband came home from work, she would start bustling about to show him that she too did a lot of things, because she was afraid of his reproaches. She used that over-adaptation a lot with me. When I would ask her a question, she would rush to give me an answer, and sometimes give me three different answers to choose from, relieved that she had been able to respond to my request. Noticing this enabled us to talk about the agitation that she would feel before she could at last find an answer which would suit her interlocutor, and about the fear that she would feel of not “doing things right”.
My therapeutic work
For four years, I patiently, and sometimes impatiently, waited for my sessions with Julie, and involved myself in the relationship. I was gently helping her to get accustomed, respecting her pace, and offering her my constant presence. I built safety in our relationship, which enabled her to open up increasingly to her emotional world. I offered her the experience of relying on someone stable, dependable and protective. Julie came every two weeks, a decision which was surely linked to her relational pattern of avoidant attachment (Erskine, 2009; Main, 1995).
Over the course of those four years, I often had the impression that Julie was slipping through my fingers, that she was escaping me, and I experienced moments of helplessness and annoyance. Especially when she would cancel at the last minute because she had no one to look after her children and she had no space in her diary to reschedule the session. I would then not see her for a month, which felt like a long time. On those occasions, I would feel powerless, and I then felt anger towards her, I felt like rejecting her by telling her: “Since you’re not investing more energy than this, sort it out on your own!” In the next session, she might tell me that all those sessions were actually quite expensive! I would then alternate between anger and guilt. I was able to calm down when I remembered the various psychological functions of the script: predictability, identity, continuity and stability (Erskine, Moursund, & Trautmann, 1999). I then made the following assumption: for her, what was predictable was contact interruption, rejection, anger. Her father into violence, and her mother into contempt. With me, she went about it so as to make the predictable happen: to make me reject her. This insight enabled me to continue to offer her constant contact and warmth. In each session, I showed her that I still had the same intention of welcoming her. From one session to the other, she regularly forgot the content of our sessions, especially when they had been emotionally intense. She forgot how she had been able to be close and in contact the previous time. She was so afraid. She called this process “my eraser”, an eraser which had been useful for her to forget the terror, loneliness, despair and shame she had felt as a child.
As time went on, it became increasingly difficult for Julie to keep her mask on around me, and under this mask, to retain the loneliness she was so familiar with, the quietness she experienced all by herself. Her loneliness provided her with precious safety, and losing it endangered her. I was now able to give Julie a quiet and serene presence, having gained in inner safety myself. After four years, to the day, she announced me that she wanted to stop the therapy. At that moment, I thought that my constant presence was destabilizing for her, something which she was not familiar with, and that she was starting to feel the juxtaposition (Erskine, Moursund, & Trautmann, 1999) Stopping, interrupting the contact with me enabled her to maintain a certain stability, as well as her identity: “Julie, be strong, manage on your own, and above all don’t let the others get you, hide yourself, don’t show your vulnerability, others are dangerous!” That is when I took the opportunity to show her that she mattered to me; I got particularly involved by taking the initiative to say the following words to her: “I don’t think that this is the time, and I would like to continue seeing you.” At first she defended herself, she became angry, and I held my position, calmly but firmly. Then I saw tears running down her cheeks, tears of relief saying “I am seen”. If I had not insisted at the time, she would have felt abandoned and told herself: “Okay, I’ll stop breathing again in order to continue on my own.” At the end of that session, she was glad that I had taken a stance, she felt supported and protected. Two weeks later, she had forgotten the content of the session and was smiling, saying she was fine; she had put on her mask again to forget the closeness of our last contact.
That intervention on my part was important in the therapy and opened Julie up to deeper emotional work. Through moments of visual or physical contact with me, she opened up more to her emotions, first sadness, loneliness and despair, then fear and trembling. She was also able to feel in her body a very archaic decision, which she shouted to me in a moment of emotional work: “I can’t rely on you, I need to manage on my own!” Cognitively, she had known that decision, but at that point she was able to feel it on a physical level, feel her vital need to control everything, to control herself and to rely only on herself. As I was talking to her, I used the image of a small wild cat that I felt like taming. She replied: “How strange, I’ve been trying for the past six years to tame a wild cat that regularly comes to my home, I’d never made the connection. It took me six years before I could stroke it for the first time!” I replied: “And we’ve been seeing each other for only four years now…” She gave me an amused smile, she who would often complain that the therapeutic work was not moving fast enough.
During the fall holidays, knowing that she easily lost contact with herself and with me, I sent her a text message saying “I’m thinking of you”. In that way I showed her how she had an impact on me. This text message enabled her to keep me with her “a little bit more” for those three weeks, and also increased the complicity between us.
In the following session, she told me she was afraid of feeling, scared of being vulnerable. Her inner Child was telling her: “Be strong, keep your mask on!” She was afraid of letting go of her survival system, and at the same time she was exhausted by it, as in her everyday life she was experiencing constant agitation and over-adaptation. She could feel this inner ambivalence extremely strongly. I therefore suggested that she come more often. At first she refused, quoting financial difficulties as an excuse. At that moment I told her the following words: “I want to see you more often, I want you to come, I deeply think that it would be good for you. If we continue at this rate, the permanent fear of attachment will remain permanent. The more you repeat the presence, the smaller the fear will become.” And I quoted the wild cat’s example again: “What makes you successful in taming your cat? How about coming every week?” With these words, I was sowing seeds in her representation of a secure, lasting relationship. I was putting some cat food out to make her feel like wanting to come and see me more often. Her first reaction was “you won’t get me!” and at the same time, she could very well feel that she needed to come more often. She could feel her inner ambivalence: maintaining predictability, continuity and stability, or responding to her deep need for contact, and consequently feeling the pain of juxtaposition as well as exposing herself to the fear of losing. I suggested she close her eyes and I put my finger next to her finger. I touched her for a while, then I took my finger away. She felt increased inner calm when I was present. When I left, she started to fear that I might not come back. Driven by my interest, I went back to the contact with her finger. In that contact, she let herself feel sadness and sobbed. Then I tried the following experiment: I touched her repeatedly, only briefly withdrawing my finger, and then I touched her again, but kept away longer between the contacts. She told me: “It’s worse when you increase the space between contacts.” Then she added with a knowing smile: “I got your message, I’ll come more often.”
In the following sessions, I accompanied her as she shuttled back and forth between feeling and taking refuge in her hiding place. I followed her, inquired, helped her put her inner experience into words, and occasionally I put mine. I supported her as she met with both her deep emotions and her protection system. In her hiding place, it was calmer, although still a bit oppressive, but not as bad as feeling the deep emotions. Her breathing was shallow. I encouraged her to appreciate her hiding place, I validated her, which enabled her to come up with the words “a swaying bubble”, and she started crying. After a moment of rest in her bubble, I asked her if she was willing to take her hand out of her hiding place, and she accepted. I put my hand on hers. She then shuttled back and forth between being present with the contact and feeling, and thinking about something else to distract herself. Between experiencing the intimacy and feeling the juxtaposition, or taking refuge in the fantasy. When she was present in the contact, she struggled between wanting to feel my presence and her decision to manage on her own: “don’t let her get you.”
Allowing herself to be in contact with me awakened two fears in her. First, the fear that that contact might end forever and that she would end up alone again. She was anticipating the loss and loneliness which she was so familiar with. I make the assumption that the baby in her could not integrate the other’s constant presence, for lack of safe contact, but kept the emotional memories of absence. Another fear was that she would be found out and that her true self would not correspond to my expectations, and that I would reject her. In both cases, she was anticipating what she knew, contact interruption and loneliness. A third possible source of fear also occurred to me, one that might have been even worse for her: the fear that the meeting might actually take place. The fear of juxtaposition. And I shared my thought with her. I accompanied her in this struggle, I was simply present and let her go where she wanted. The goal was for her to integrate my unconditional constant presence, whether she was in contact or not.
We now continue our sessions at a more sustained pace, three times a month: this pace suits her! The increased trust within our relationship has enabled her to access a new emotion, anger, and to dare feel it in her daily life, and use it to assert herself…
After an extended period of separation, for example after the Christmas holidays, she continues to completely forget the content of our previous sessions, especially the elements regarding the relationship between the two of us, the attachment.
Through Julie, I learnt a fundamental posture: remaining constantly present, even if she interrupted contact, and trusting the attachment process. To achieve that, I needed to allow myself to be lastingly supported and guided by several people in whom I put my trust, and who were able to slowly approach me. Their unconditional support enabled me to keep hope when I would lose it, their trust in me enabled me to trust myself. Thanks to them, I was able to deepen my reflection about the attachment process, and above all, I was able to develop it and feel it myself, in order to be able to share it with Julie.
Erskine,R.G.(2009). Life Scripts and Attachment Patterns: Theoretical Integration and Therapeutic Involvement . Transactional Analysis Journal, 39(3),p. 207-218.
Erskine, R. G., Moursund, J. P., & Trautmann, R. L. (1999). Beyond Empathy: A Therapy of Contact-in-Relationship. Philadelphia: Brunner/Mazel.
Erskine, R.G.& Trautmann, R.L. (1997). The Process of Integrative Psychotherapy. In. R.G. Erskine (Ed.), Theories and Methods of an Integrative Transactional Analysis. San Francisco: TA Press
Main, M. (1995). Recent studies in attachment: Overview with selected implications for clinical work. In S. Goldberg, R. Muir, & J. Kerr (Eds.), Attachment theory: Social, Developmental and Clinical Perspectives (pp. 407-474). Hillsdale, NJ: The Analytic Press.