Integrative Psychotherapy Articles
Attunement and involvement: therapeutic responses to relational needs*
RICHARD G. ERSKINE
Institute for Integrative Psychotherapy, New York, NY, USA and University of Derby, UK
Abstract Eight relational needs, unique to interpersonal contact and essential factors in effective psychotherapy, are presented. Prolonged disruption in the satisfaction of relational needs is evidenced by a sense of emptiness, anxiety, frustration and aggression. Therapeutic attunement goes beyond empathy to provide a unity of interpersonal contact and the facilitation of psychological healing. Involvement is expressed by the psychotherapist's respectful inquiry into the client's experience and being fully present with the client in a way that is appropriate to the client's developmental level of functioning and current need for relationship.
Standardized protocols or treatment manuals define the practice of psychotherapy from either a quantitative research-based behavioural model or symptom-focused medical model. The therapeutic relationship is not considered central in such practice manuals. In this era of industrialization of psychotherapy it is essential for psychotherapists to remain mindful of the unique interpersonal relationship between therapist and client as the central and significant factor in psychotherapy. This article outlines several dimensions of the therapeutic relationship that have emerged from a qualitative evaluation of the practice of psychotherapy conducted at the Institute for Integrative Psychotherapy in New York City.
A major premise of a relationship-oriented psychotherapy is that the need for relationship constitutes a primary motivation of human behaviour (Fairbairn, 1952). Contact is the means by which the need for relationship is met. In colloquial language, 'contact' refers to the quality of the transactions between two people: the awareness of both one's self and the other, a sensitive meeting of the other and an authentic acknowledgement of one's self. In a more theoretically exact meaning, 'contact' refers to the full awareness of sensations, feelings, needs, sensorimotor processes, thought and memories that occur within the individual, and a shift to full awareness of external events as registered by each sensory organ. With the capacity to oscillate between internal and external contact, experiences are continually integrated into a sense of self (Perls et al., 1951).
When contact is disrupted, needs are not satisfied. If the experience of need arousal is not satisfied or closed naturally, it must find an artificial closure that distracts from the discomfort of unmet needs. These artificial closures are the substance of survival reactions that become fixated defensive patterns, or habitual behaviours that result from rigidly held beliefs about self, others or the quality of life. They are evident in the disavowal of affect, the loss of either internal or external awareness, neurological inhibitions within the body, or a lack of spontaneity and flexibility in problem-solving, health maintenance, or relating to people. The defensive interruptions to contact impede the fulfilment of current needs (Erskine, 1980).
The literature on human development also leads to the understanding that the sense of self and self-esteem emerge out of contact-in-relationship (Stern, 1985). Erikson's (1950) stages of development over the entire life cycle describe the formation of identity as an outgrowth of interpersonal relations (trust vs mistrust, autonomy vs shame and doubt, etc.). Mahler's (1968; Mahler et al, 1975) descriptions of the stages of early child development place importance on the relationship between mother and infant. Bowlby (1969, 1973, 1980) has emphasized the significance of early as well as prolonged physical bonding in the creation of a visceral core from which all experiences of self and other emerge. When such contact does not occur in accordance with the child's relational needs, there is a physiological defence against the loss of contact-, poignantly described by Fraiberg in 'Pathological Defenses of Infancy' (1982). These developmental perspectives foster a deep appreciation for the need for interpersonal connection and active construction of meaning that is so much a part of who the client is.
In a relationship-oriented psychotherapy the psychotherapist's self is used in a directed, involved way to assist the client's process of developing and integrating full contact and the satisfaction of relational needs. Of central significance is the process of attunement, not just to discreet thoughts, feelings, behaviours or physical sensations, but also to what Stern terms 'vitality affects,' such that an experience of unbroken feeling-connectedness is created (1985, p. 156).
The client's sense of self and sense of relatedness that develop are crucial to the process of healing and growth, particularly when there have been specific traumas in the client's life and when aspects of the self have been disavowed or denied because of the cumulative failure of contact-in-relationship (Erskine, 1997).
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 (Rogers, 195 1) or vicarious introspection (Kohut, 1971), attunement is a kinesthetic and emotional sensing of others 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 a reciprocal affect and/or resonating response. Attunement is communicated by what is said as well as by the therapist's facial or body movements that signal to the client that his or her affect and needs are perceived, are significant and make an impact on the therapist. It is facilitated by the therapist's capacity to anticipate and observe the effects of his or her behaviour on the client and to de-centre from his or her own experience to focus extensively on the client's process. Yet, effective attunement also requires that the therapist simultaneously remains aware of the boundary between client and therapist as well as his or her own internal processes.
The communication of attunement validates the client's needs and feelings and lays the foundation for repairing the failures of previous relationships (Erskine, 1997). Affective attunement, for example, provides an interpersonal contact essential to human relationship. It involves the resonance of one person's affect to the other's affect. Affective attunement begins with valuing the other person's affect as an extremely important form of communication, being willing to be affectively aroused by the other person and responding with the reciprocal affect. When a client feels sad, the therapist's reciprocal affect of compassion and compassionate acts complete the interpersonal contact. Relationally, anger requires the reciprocal affects related to attentiveness, seriousness and responsibility, with possible acts of correction. The client who is afraid requires that the therapist respond with affect and action that convey security and protection. When clients express joy, the response from the therapist that completes the unity of interpersonal contact is the reciprocal vitality and expression of pleasure. Symbolically, attunement may be pictured as one person's yin to the other's yang that together form a unity in the relationship.
Attunement is often experienced by the client as the therapist gently moving through the defences that have prevented the awareness of relationship failures and related needs and feelings. Over time this results in a lessening of internal interruptions to contact and a corresponding dissolving of external defences. Needs and feelings can increasingly be expressed with comfort and assurance that they will receive a connecting and caring response. Frequently, the process of attunement provides a sense of safety and stability that enables the client to begin to remember and endure regressing into childhood experiences. This may bring a fuller awareness of the pain of past traumas, shaming experiences, past failures of relationship(s) and loss of aspects of self (Erskine, 1994).
Attunement also includes responding to relational needs as they emerge in the therapeutic relationship. Relational needs are the needs unique to interpersonal contact. They are not the basic needs of life such as food, air or proper temperature, but are the essential elements that enhance the quality of life and a sense of self-in-relationship. Relational needs are the component parts of a universal human desire for relationship.
The relational needs described in this article have emerged from a study of transference and a qualitative investigation of the crucial factors in significant relationships conducted at the Institute for Integrative Psychotherapy in New York City. Although there may be an infinite number of relational needs the eight described in this article represent those needs that, in my experience, clients most frequently describe as they talk about significant relationships. Other client-therapist inter-subjective experiences may reveal a different cluster of relational needs beyond the eight described here. This further illustrates that the client-therapist relationship is irreproducible. No two therapists will produce the same therapeutic process. [See the article, 'Psychotherapy in the USA: a manual of standardized techniques or a therapeutic relationship? (Erskine, 1998) in this issue]. Some of the relational needs described here are also described in the psychotherapy literature as fixated needs of early childhood, indicators of psychopathology or problematic transference. While the tendency to pathologize dependence or transference does exist in the psychotherapy literature, in the context of the time and theoretical milieu, Kohut in 1971 and 1977 made strides to connect transference to developmental needs. Kohut distinguishes relational, developmental needs that have suffered disruption or rupture from the classical transference based on a drive model of psychoanalysis. Although he identifies mirroring, twinship and idealization as problematic transferences, he also relates them to essential needs. However, his methods remain psychoanalytic and do not make full use of a relationship-oriented integrative model of psychotherapy. Bach (1985), Basch (1988), Stolorow et al. (1987) and Wolf (1988) have expanded on Kohut's concepts, each emphasizing the importance of a relational perspective in understanding transference. Clark's (1991) integrative perspective on empathic transactions bridges the concepts of transference and relational needs and emphasizes a therapy of involvement.
Relational needs are present throughout the entire life cycle from early infancy through old age. Although present in early childhood, relational needs are not only needs of childhood or needs that emerge in a developmental hierarchy: they are the actual components of relationship that are present each day of our lives. Each relational need may become figural or conscious as a longing or desire while the others remain out of consciousness or as background. A satisfying response by another person to an individual's relational need allows the pressing need to recede to ground and another relational need to become figural as a new interest or desire. Often it is in the absence of need satisfaction that an individual becomes most aware of the presence of relational needs. When relational needs are not satisfied the need becomes more intense and is phenomenologically experienced as longing, emptiness, a nagging loneliness, or an intense urge often accompanied by nervousness. The continued absence of satisfaction of relational needs may be manifested as frustration, aggression or anger. When disruptions in relationship are prolonged the lack of need satisfaction is manifested as a loss of energy or hope and shows up in script beliefs such as 'No one is there for me' or 'What the use?' (Erskine & Moursund, 1988/1998). These script beliefs are the cognitive defence against the awareness of needs and the feelings present when needs do not get a satisfying response from another person (Erskine, 1980).
The satisfaction of relational needs requires a contactful presence of another who is sensitive and attuned to the relational needs and who also provides a reciprocal response to each need. Security is the visceral experience of having our physical and emotional vulnerabilities protected. It involves the experience that our variety of needs and feelings are human and natural. Security is a sense of simultaneously being vulnerable and in harmony with another.
Attunement involves the empathetic awareness of the other's need for security within the relationship plus a reciprocal response to that need. It includes respectful transactions that are non-shaming and the absence of actual or anticipated impingement or danger. The needed response is the provision of physical and affective security where the individual's vulnerability is honoured and preserved. It communicates, often non-verbally, 'Your needs and feelings are normal and acceptable to me.' Therapeutic attunement to the relational need for security has been described by clients as 'total acceptance and protection,' as a communication of 'unconditional positive regard' or 'I'm OK in this relationship.' Attunement to the need for security involves the therapist being sensitive to the importance of this need and conducting him or herself both emotionally and behaviourally in a way that provides in the relationship.
Relational needs include the need to feel validated, affirmed and significant within a relationship. It is the need to have the other person validate the significance and function of our intrapsychic processes of affect, fantasy and constructing of meaning, and to validate that our emotions are a significant intrapsychic and interpersonal communication. It includes the need to have all of our relational needs affirmed and accepted as natural. This need is a relational request for the other person to be involved through providing a quality of interpersonal contact that validates the legitimacy of relational needs, the significance of affect and the function of intrapsychic processes.
Attunement with a client's need for validation is conveyed through the psychotherapist's phenomenological inquiry and contactful presence. The therapist's affective reciprocity with the client's feelings validates the client's affect and provides affirmation and normalization of the client's relational needs. The psychotherapist's focus on the psychological function stability, continuity, identity, predictability-of rigidly held beliefs or behaviours lessens the likelihood of the client experiencing shame while validating the psychological significance of the beliefs or behaviours. Such validation is a necessary prerequisite to lasting cognitive or behavioural change.
Acceptance by a stable, dependable, and protective other person is an essential relational need. Each of us as children had the need to look up to and rely on our parents, elders, teachers and mentors. We need to have significant others from whom we gain protection, encouragement and information. The relational need for acceptance by a consistent, reliable and dependable other person is the search for protection and guidance that may be manifested as an idealization of the other. In psychotherapy, such idealization is also the search for protection from a controlling, humiliating introjected ego's intrapsychic effect on the vulnerability of child ego states (Fairbairn, 1952; Guntrip, 1971; Erskine & Moursund, 1988/ 1998). It can also be the search for protection from one's own escalations of affect or exaggerations of fantasies. The therapist protects and facilitates integration of affect by providing an opportunity to express, contain and/or understand the function of such dynamics. 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. Idealizing or depending on someone is not necessarily pathological as implied in the popular psychology term, 'co-dependent,' or when misinterpreted as 'idealizing transference' (Kohut, 1977), or as Berne's psychological game of 'Gee, You're Wonderful-, Professor!' (1964). When we refer to some clients' expressions of this need to be accepted and protected as 'a Victim looking for a Rescuer,' we depreciate or even pathologize an essential human need for relationship that provides a sense of stability, reliability and dependability.
In psychotherapy, attunement involves the therapist's recognition of the importance and necessity of idealizing as an unaware request for intrapsychic protection. Such recognition and attunement by the therapist to the client's relational need most often occurs in the accepting and respecting nature of the interpersonal contact and therapeutic involvement and may not necessarily be spoken about directly. Such a therapeutic involvement includes both the client's sense of the psychotherapist's interest in the client's welfare and the use of the therapist's integrated sense of self as the most effective therapeutic tool (Erskine, 1982; Erskine & Moursund, 1988/1998). It is this relational need to be accepted by a stable, dependable and protective other person that provides a client-centred reason to conduct our lives and psychotherapy practice ethically and morally.
The confirmation of personal experience is also an essential relational need. The need to have experience confirmed is manifested through the desire to be in the presence of someone who is similar, who understands because he or she has had a like experience, and whose shared experience is confirming. It is the quest for mutuality, a sense of walking the same path in life together with a companion who is 'like me'. It is the need to have someone appreciate and value our experience because they phenomenologically know what that experience is like.
Affirmation of the client's experience may include the therapist joining in or valuing the client's fantasies. Rather than define a client's internal story-telling as 'just a fantasy', it is essential to engage the client in the expression of the needs, hopes, relational conflicts and protective strategies that may constitute the core of the fantasies. Attunement to the need for affirmation of experience may be achieved by the therapist accepting everything said by the client, even when fantasy and reality are intertwined, much like the telling of a dream reveals the intrapsychic process. Fantasy images or symbols have a significant intrapsychic and interpersonal function. When the function of the fantasy is acknowledged, appreciated and valued the person feels affirmed in his or her experience.
When the relational need for confirmation of personal experience is present in a client's communication, he or she may be longing for a model with a similar experience. An attuned psychotherapy may include the sharing of the therapist's own experiences: telling how he or she solved a conflict similar to the client's and providing a sense of mutuality with the client. Attunement is provided by the therapist valuing the need for confirmation by revealing carefully selected personal experiences, mindfully (i.e. client-focused) sharing vulnerabilities or similar feelings and fantasies, and by the therapist's personal presence and vitality. The client who needs confirmation of personal experience requires a uniquely different reciprocal response than the client who needs validation of affect or who needs to be accepted by a dependable and protective other. In neither of these latter two relational needs is the sharing of personal experience or the creating of an atmosphere of mutuality an attuned response to the client's need.
Self-definition is the relational need to know and express one's own uniqueness and to receive acknowledgement and acceptance by the other. Self-definition is the communication of one's self-chosen identity through the expression of preferences, interests and ideas without humiliation or rejection.
In the absence of satisfying acknowledgement and acceptance, the expression of self-definition may take unconscious adversarial forms such as the person who begins his or her sentences with 'No' even when agreeing, or who constantly engages in arguments or competition. People often compete to define themselves as distinct from others. The more alike people are the greater the thrust for self-defining competition.
Attunement begins with the therapist's sensitivity to and understanding that adversary and competition in relationships may be an expression of the need for self-definition with acknowledgement and acceptance by the other. Therapeutic attunement is in the therapist's consistent support for the client's expression of identity and in the therapist's normalization of the need for self-definition. It requires the therapist's consistent presence, contactfulness and respect even in the face of disagreement.
Another essential relational need is to have an impact on the other person. Impact refers to having an influence that affects the other in some desired way. An individual's sense of competency in a relationship emerges from agency and efficacy-attracting the other's attention and interest, influencing what may be of interest to the other person, and affecting a change of affect or behaviour in the other.
Attunement to the client's need to have an impact occurs when the psychotherapist allows him or herself to be emotionally impacted by the client and to respond with compassion when the client is sad, to provide an affect of security when the client is scared, to take the client seriously when he or she is angry, and to be excited when the client is joyful. Attunement may include soliciting the client's criticism of the therapist's behaviour and making the necessary changes so the client has a sense of impact within the therapeutic relationship.
Relationships become more personally meaningful and fulfilling when the need to have the other initiate is satisfied. Initiation refers to the impetus for making interpersonal contact with another person. It is the reaching out to the other in some way that acknowledges and validates the importance of him or her in the relationship.
The psychotherapist may be subject to a theory-induced counter-transference when he or she universally applies the theoretical concepts of non-gratification, rescuing or refraining from doing more than 50% of the therapeutic work. While waiting for the client to initiate the psychotherapist may not be accounting for the fact that some behaviour that appears passive may actually be an expression of the relational need to have the other initiate.
The therapist's attunement to this relational need requires a sensitivity to the client's non-action and the therapist's initiation of interpersonal contact. To respond to the client's need it may be necessary for the therapist to initiate a dialogue, to move out of his or her chair and sit near the client, or to make a phone call to the client between sessions. The therapist's willingness to initiate interpersonal contact or to take responsibility 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. Such action communicates to the client that the therapist is involved in the relationship.
The need to express love is an important component of relationships. Love is often expressed through quiet gratitude, thankfulness, giving affection or doing something for the other person. The importance of the relational need to give love-whether it be from children to parents, sibling or teacher, or from a client to a therapist-is often overlooked in the practice of psychotherapy. When the expression of love is stymied the expression of self-in-relationship is thwarted. Too often psychotherapists have treated clients' expression of affection as a manipulation, transference or a violation of a neutral therapeutic boundary.
Attunement to the client's relational need to express love is in the therapist's graciously accepting the client's gratitude and expressions of affection, and in acknowledging the normal function of love in maintaining a meaningful relationship.
Those clients for whom the absence of satisfaction of relational needs is cumulative require a consistent and dependable attunement and involvement by the psychotherapist that acknowledges, validates and normalizes relational needs and related affect. It is through the psychotherapist's sustained contactful presence that the cumulative trauma (Khan, 1963; Lourie, 1996) of the lack of need satisfaction can now be addressed and the needs responded to within the therapeutic relationship.
Involvement is best understood through the client's perception-a sense that the therapist is contactful and is truly invested in the client's welfare. It evolves from the therapist's respectful inquiry into the client's experience and is developed through the therapist's attunement to the client's affect and rhythm and to the validation of his or her needs. Involvement includes being fully present with and for the person in a way that is appropriate to the client's developmental level of functioning and current need for relationship. It includes a genuine interest in the client's intrapsychic and interpersonal world and a communication of that interest through attentiveness, inquiry and patience.
Therapeutic involvement is maintained by the therapist's constant vigilance to providing an environment and relationship of safety and security. It is necessary that the therapist be constantly attuned to the client's ability to tolerate the emerging awareness of past experiences so that they are not overwhelmed once again in the therapy as they may have been in a previous experience. Therapeutic involvement that emphasizes acknowledgement, validation, normalization and presence diminishes the internal defensive process.
The therapist's acknowledgement of the client begins with an attunement to his or her affect, relational needs, rhythm and developmental level of functioning. Through sensitivity to the relational needs or physiological expression of emotions the therapist can guide the client to become aware and to express needs and feelings or to acknowledge that feelings or physical sensations may be memory-the only way of remembering that may be available. In many cases of relationship failure the person's relational needs or feelings were not acknowledged and it may be necessary in psychotherapy to help the person gain a vocabulary and learn to voice those feelings and needs. Acknowledgement of physical sensations, relational needs and affect helps the client claim his or her own phenomenological experience. It includes a receptive other who knows and communicates about the existence of non-verbal movements, tensing of muscles, affect or even fantasy.
There may have been times in a client's life when feelings or relational needs were acknowledged but were not validated. Validation communicates to the client that his or her affect, defences, physical sensations or behavioural patterns are related to something significant in his or her experiences. Validation makes a link between cause and effect; it values the individual's idiosyncrasies and way of being in relationship. It diminishes the possibility of the client internally disavowing or denying the significance of affect-, physical sensation, memory or dreams; and it supports the client in valuing his or her phenomenological experience and transferential communication of the needed relationship, thereby increasing self-esteem.
The intent of normalization is to influence the way clients or others may categorize or define their internal experience or their behavioural attempts at coping from a pathological or 'something's-wrong-with-me' perspective to one that respects the archaic attempts at resolution of conflicts. It may be essential for the therapist to counter societal or parental messages such as 'You're stupid for feeling scared' with 'Anyone would be scared in that situation.' Many flashbacks, bizarre fantasies, nightmares, confusion, panic and defensiveness are all normal coping phenomena in abnormal situations. It is imperative that the therapist communicates that the client's experience is a normal defensive reaction - a reaction that many people would have if they encountered similar life experiences.
Presence is provided through the psychotherapist's sustained attuned responses to both the verbal and non-verbal expressions of the client. It occurs when the behaviour and communication of the psychotherapist at all times respects and enhances the integrity of the client. Presence includes the therapist's receptivity to the client's affect-to be impacted by their emotions; to be moved and yet to stay responsive to the impact of their emotions and not to become anxious, depressed or angry. Presence is an expression of the psychotherapist's full internal and external contact. It communicates the psychotherapist's responsibility, dependability and reliability. Through the therapist's full presence the transformative potential of a relationship-oriented psychotherapy is possible. Presence describes the therapist's providing a safe interpersonal connection. More than just verbal communication, presence is a communion between client and therapist.
Presence is enhanced when the therapist de-centres from his or her own needs, feelings, fantasies or hopes and centres instead on the client's process. Presence also includes the converse of de-centring; that is, the therapist being fully contactful with his or 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. The therapist's repertoire of knowledge and experience is a rich resource for attunement and understanding. Presence involves both bringing the richness of the therapist's experiences to the therapeutic relationship as well as de-centring from the self of the therapist and centring on the client's process.
Presence also includes allowing oneself to be manipulated and shaped by the client in a way that provides for the client's self-expression. As effective psychotherapists we are played with and genuinely become the clay that is moulded and shaped to fit the client's expression of their intrapsychic world towards the creation of a new sense of self and self-in-relationship (Winnicott, 1965). The dependable, attuned presence of the therapist counters the client's sense of shame and discounting his or her self-worth. The quality of presence creates a psychotherapy that is unique with each client: attuned to and involved with the client's emerging relational needs.
What gives psychotherapy its transformative effect in people's lives is the psychotherapist's focus on the client's relational needs and the relationship between client and therapist. Such a relationship can never be standardized or prescribed or even quantified by research. The uniqueness of each therapeutic relationship emerges out of the therapist's attunement and involvement that is responsive to the client's cluster of relational needs - a therapy of contact-in-relationship.
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* This paper was presented as a keynote speech entitled, 'A Therapeutic Relationship?' at the I st Congress of the World Council for Psychotherapy, Vienna, Austria, 30 June to 6 July, 1996. Portions of this paper were also included in a closing address, 'The Psychotherapy Relationship', at the 7th Annual Conference of the European Association for Psychotherapy, Rome, Italy, 26-29 June 1997.
Correspondence should be addressed to: Richard G. Erskine, Ph.D., Institute for Integrative Psychotherapy, 500 East 85th Street, New York, NY 10028, USA.
(©) 1998 European Association for Psychotherapy
Published in International Journal of Psychotherapy, Vol. 3 No. 3, 1998