Integrative Psychotherapy Articles
Integrating Expressive Methods in a Relational-Psychotherapy
Richard G. Erskine, Ph.D.
Therapeutic Involvement is an integral part of all effective psychotherapy. This article is written to illustrate the concept of Therapeutic Involvement in working within a therapeutic relationship – within the transference -- and with active expressive and experiential methods to resolve traumatic experiences, relational disturbances and life shaping decisions.
Recent discussions with colleagues have focused on two different perspectives of therapeutic involvement in psychotherapy. One perspective emphasizes the effectiveness of a psychotherapist working only in the “present moment” of the therapy relationship -- of working solely within the transference/countertransference matrix. This first approach is referred to as a “two person therapy” because of the emphasis on the centrality of the therapeutic dialogue between client and psychotherapist in facilitating change in clients’ dysfunctional relational patterns. In this point of view the most important factor in the therapeutic process is the psychotherapist’s sustained empathic presence. Fixated archaic wounds, traumas, script conclusions and relational disruptions are resolved through a fully involved, person-to-person therapeutic relationship.
The second perspective describes an approach wherein the psychotherapist makes use primarily of experiential and expressive methods that facilitate the client’s resolution of intrapsychic conflict and archaic decisions. It has been labled by some as a “one person therapy” because it is viewed as though the psychotherapist is “doing something” to the client. The psychotherapy sessions emphasize the use of expressive methods and emotionally evocative techniques, the active expression of intrapsychic dialogue, and/or experimentation in new behaviour and physiological expression. Involvement is in the psychotherapist being fully present, actively inquiring about the client’s phenomenological perspective and engaging with the client in creating experiences that make unconscious material conscious. In this point of view the psychotherapist’s active engagement with the client, while using the various expressive and experiential methods, is the most important factor leading to change both in clients’ self perception and in their relationships with others.
The two key questions in this discussion are: “Are we in a contactful, involved therapeutic relationship with a client when we use expressive, experiential or intrapsychic methods that facilitate the awareness, expression and change in the client’s fixated archaic experiences?” and “Is relational psychotherapy in and of itself sufficient to heal the life-shaping effects of cumulative neglect, traumas and relational failures?”
I believe that the answers depend on the quality of the therapeutic relationship, whether we use expressive methods or not. Healing occurs through a contactful therapeutic relationship! A healing relationship depends on the psychotherapist’s willingness to be contactful and fully present with and for their client in such a way that they co-discover the function of the client’s unconscious relational patterns as they emerge both within the therapeutic relationship and in the transferences of everyday-life. Equally important is the psychotherapist’s emotional presence and full involvement that offers a new and unique response to the client’s archaic patterns of relationship, affect, developmental level of functioning, and cognitive style of making meaning. Such a healing relationship includes attunement to the client’s unique rhythm and a responsiveness to both the client’s current and archaic relational-needs. Much of the healing power of a therapeutic relationship depends on the psychotherapist’s authenticity, reliability, and willingness to take responsibility for therapeutic errors.
I have found that an involved psychotherapist is consistently invested in the client’s welfare and spends considerable amounts of time building and maintaining a quality relationship with the client through phenomenological inquiry, acknowledgment, validation and sustained empathy – not as a set of techniques but as a genuine interest in knowing the client while helping the client to know and express him or her self.
The annotated transcript in this article provides an example of the use of both perspectives: working within the transference/countertransference dyad – focusing on an authentic person-to-person relationship -- and also making effective use of expressive, experiential, and intrapsychic methods to change life-shaping decisions. Rather than thinking in terms of a one or two person therapy, I find it more professionally useful to think about Therapeutic Involvement, that unique experience of client and psychotherapist working in harmony, co-creating a mutual transformative experience.
I invite you, the reader, to join in this interesting discussion, to read this transcript with a discerning eye, to reflect on your own clients, and to articulate your own perspectives. What would you have done differently? Why? What is your experience of Therapeutic Involvement as a client and as a psychotherapist? As we discuss these professional concerns together the result may well be that we will all learn how to be fully involved psychotherapists. Our clients will reap the benefits.
Paul is a 40 year-old psychotherapist who has attended a couple of previous training workshops with me. In this particular workshop I have just finished a long theoretical presentation when Paul asked to do some personal therapy. Usually he has a good understanding of himself yet, on this day, he is troubled by unresolved thoughts and feelings. The session begins with Paul and me sitting in chairs facing each other. Paul sits with his legs crossed; his body language is relaxed and comfortable.
Richard: Paul, what are you experiencing?
Paul: You have just given me a smile. You have touched me and I got emotional.
Richard: What kind of emotion?
Paul: Sadness. Better said, it is sadness and pain. My intention about working with you is precisely because I noticed that I easily enter into transference with you.
Richard: Please tell me your story about transference.
Paul: I notice that in some moments I have difficulty in relating with you in a natural way. But that it is not your fault. I am conscious enough to realize that I am having fantasies. I notice that I have a big mistrust of you and that I want to withdraw. Then I say to myself “Look for the contact”.
Richard: In these fantasies what are the ways in which I might I hurt you….so the drawing back is absolutely necessary?
Paul: Let me tell you my internal movie. The first day you made a comment to me about what I had said following Martin’s therapy demonstration. I understood that what you wanted me to do was to reflect on why I had said it. But the following day I felt out of my center. I felt that I was in trouble with you.
Richard: So I must have shamed you.
This is the fifth transaction that I have made. It contains several elements of an involved therapeutic relationship: acknowledgement, vicarious empathy, responsibility for the therapist’s errors, and my introducing the concept of shame that could possibly enhance Paul’s understanding of his experience. It sets a stage for how the work may proceed; we could build on any and perhaps all of these elements. And it may be too soon; most likely Paul has much more to say before we focus on a particular element or two.
This transaction follows four transactions that are examples of phenomenological inquiry. They are not all questions but each phenomenological inquiry invites an internal search – a discovery and expression of what is internal – a revealing of one’s subjective experience. Together these four inquires form a unit of involvement that supports Paul in further describing his internal process.
Paul: (pauses for several seconds) The fantasy I got was what I call a black fantasy. I imagine that you think or …even that you comment to other people that what I do is not right. You say, “Paul does not behave well”.
Richard: You mean that at dinnertime or on a walk in the evening that I am gossiping about you?
Paul: Not gossiping, but maybe having a commentary with somebody.
Richard: What’s the difference? In either case I would be belittling you. In either case, I would be making a humiliating comment.
Paul: Or at least a disapproving comment.
Richard: It seems that what makes your fantasy painful is that I would be doing it behind your back and not to your face.
In the three previous transactions I am clarifying and identifying the significance of Paul’s distress. This transaction and the one to follow are examples of two types of empathy: vicarious and emotional. First I am making use of vicarious introspection---using my own experience to cognitively identify and explore Paul’s possible subjective experience of belittlement or humiliation. This is coupled with the next transaction, a second aspect of empathy -- an expression of my affect: “That would hurt”. At this moment we are engaged in a shared affective experience: the essence of emotional empathy. The core of therapeutic involvement is in the capacity of the psychotherapist to express empathy accurately within a tone or facial expression that provides the reciprocal to the client’s affect; in this situation affective attunement is in the compassionate tone that responds to Paul’s sadness.
Paul: Correct.
Richard: (said compassionately) That would hurt!
Paul: Of course. If there is something between you and me, and you would come and tell me, that would give me a lot of security and trust.
Richard: So as a result of the fantasy that you are telling me about …you pull away… and you are not centered within yourself. (Richard pauses for a few seconds)
Paul, those are all the symptoms of shame.
Paul: (Pauses for several seconds, looking sad and looks to the ground and shrugs his shoulders)
Richard: Can you tell me about those feelings of sadness?
Paul: (pauses for 10 seconds) I feel it inside of me as an old companion. I don’t really know where it originated from, but it is familiar to me.
I have introduced the concept of “shame”. Paul has not mentioned it, but his sense of hurt and sadness, long pauses and lack of eye contact all hint that he may be experiencing shame. All the person may know is that he or she is sad, nervous, feels small, or cannot make contact. The origins of shame are often not immediately available as explicit memory – only as procedural memory---until there is safety-in-relationship. It is often necessary that the psychotherapist introduce a concept such as shame, envy, revenge, or betrayal so that the client can begin to think about his or her relational experiences.
Richard: Well then, let’s stay between you and me. Here you had trust in me and in your internal movie I betray you by talking about you behind your back.
Rather than take Paul to some unknown historical story, I keep the focus on the two of us in the present moment. I am building on the trust in our relationship that Paul previously experienced by suggesting to him that he maintain the sad feelings that have arisen as a result of my behaviour and that we talk about those feelings and his self-regulating reactions, as if transference did not exist.
If there have been misattunements or therapeutic errors, or even humiliating comments that I have made, they are more likely to be evident, and resolved, if the therapeutic work is in the present, between us, rather than searching for an origin of Paul’s feelings. We can always do the historical work later if it proves necessary. Keeping the dialogue about our current relationship seems most important at this point in the therapy. It is “between us” that Paul can form a new relational pattern; perhaps I too will learn and grow from this encounter.
Paul: That is it. When I lose contact with you and I enter into old stories, I lose my trust in you. (Paul starts to cry).
Richard: Those tears are important.
(Paul nods while he cries) Just close your eyes and go where that cry takes you. (Paul closes his eyes … a few seconds pass) It looks like you are stopping your body from weeping, as though your body knows a sense of betrayal .… having trusted someone and they don’t live up to your trust.
Paul: (takes some deep breaths and pauses for 30 seconds with his eyes closed. He opens his eyes and smiles at Richard) These words touch me. Your words describe that I trust somebody that betrays my trust. I’m sad and I feel like I am shaking inside. (Paul wipes the tears from his face… and after a pause is no longer crying)
In this last set of transactions I validated Paul’s feelings and experiences while also bringing his attention to the connection between his crying, shaking body and the betrayal of trust from a significant other. His shaking body is telling a significant story that he is not yet putting into language. He has been able to tell a bit about his emotional experience by using the metaphor of an internal movie – a movie in which he is humiliated.
Is his yet untold story solely about how my behaviour has impacted him? Or is it about other significant relationships? Or both? It may be time to explore beyond our relationship (he did mention that this feeling is “familiar”) and then perhaps return to articulating the quality of connection we have with each other: both his former trust and now his “big mistrust” of me.
An effective, relationally focused integrative psychotherapy continually weaves the client’s and psychotherapist’s experiences of their relationship in the present moment with an exploration of the emotional and self-stabilizing results of past relationships in the client’s life. It is this dual focus that provides a double opportunity to resolve the troubling effects of relational disruptions with introjected others while also establishing new patterns of relationship with the psychotherapist. I then take the risk of expressing my intuition about why he may be crying. I phrase it as a tentative question rather than as an interpretation.
Richard: Paul, what was your relationship with your previous mentor? You mentioned at lunch that you no longer see him.
Paul: I always kept a secure distance from him. I did not feel sufficiently protected and taken care of to open up for a closer relationship.
Richard: Did you want a closer relationship with him before you kept him distant … or even while you kept him distant?
Paul: It is like a double movement. A wish to be nearer, while a part of me says “Stay away!”
Richard: Have you done that double movement with me these past two days…. after I made that comment? Had your mentor also done something that kept you away, or did you sense something would go wrong and never got close?
Here I open two possible avenues of discovery: the nature of the relationship between Paul and me and the nature of the relationship between Paul and his previous mentor. This multifaceted question allows for discovering where Paul will go; he has referred to “old stories” but he also has a strong emotional reaction to me. If he talks about our relationship it will provide the opportunity to explore new possibilities between us. If he chooses to talk about his mentor, we can work on resolving that relational conflict first and then I will also use it as a metaphor about our relationship, eventually bringing our therapeutic dialogue back to what is both present and missing in the contact between us.
Paul: He did not do any negative or hurtful comments to me, but I saw his behaviour with other people and so I said to myself, “I am not getting into this!
Richard: Previously you used the word “transference” . Do you suppose with him that was transference or observation? (a few seconds pause) Can you tell me about both?
Paul: Both are there. I think my observations were correct. But, also, when I can relate with somebody in a relaxed and a natural manner, that is one thing ….. But when I notice that I feel uncomfortable and I don’t know how to be ….. That happened to me on the second day with you. That used to happen often with (he speaks the name of his former trainer and supervisor.)
Richard: Then I will assume that I hurt you the other day by either the content or the style in which I spoke to you …. or at least in the context of doing it in front of your colleagues here. That was a break in our relationship!
At this point I am bringing the focus back to my failure -- to the error I made that ruptured Paul’s trust. That rupture in trust resulted in his sadness and silence and perhaps stimulated memories of previous breaches in trust. But, for now, I want to keep the work between us; there is no rush to explore any possible unfinished business with his mentor or any other person. I have some reparation to do before we turn our attention to his disappointments in other significant relationships or to explore his sense of shame. If I take responsibility for how I have failed or betrayed him and make the necessary corrections, then it may not be necessary to explore his loss of trust with his previous mentor or any other significant person. The healing of his shame or sense of betrayal may occur in how I repair our relationship.
Paul: I think for me it was your tone of voice.
Richard: Can you share with me the tone of voice that you heard? I don’t remember it.
Paul: For me it was strict.
Richard: So it is the tone that is shaming; … the strictness of it?
(Paul pauses and nods) Does the tone say, “You did it wrong”? (Richard says shaking his finger at Paul to emphasize the “tone” with a body gesture)
My gesture is used to validate Paul’s experience of the tone – a shaming gesture that describes the strict tone that Paul heard. At this point acknowledging and validating Paul’s experience are the most important transactions -- transactions that signal my involvement. Any explanation or description of what I felt or meant would be non-therapeutic and may create an even greater rupture in his sense of trust. It is therapeutically necessary that I de-center from my own experience and stay with Paul’s. How Paul makes meaning of our transactions is most important in understanding how he organizes his experience and in eventually co-creating a new set of relational anticipations. My immediate therapeutic priority is in re-establishing a trusting relationship.
Paul: Yes, that gesture shows how I received it. The content was a question, but the tone got me in a different manner.
Richard: What was the psychological message you heard? Not the social message … the psychological?
Paul: I felt that at that moment you did not approve my words that I addressed to Martin. It is like you said, “You did wrong by saying that at that moment”.
Richard: It is true that I did not approve of it. That is true. (small pause) What do you think?
Being straightforward and honest about my behaviour is important in our relationship. I could imply that the disapproval Paul is experiencing is the result of his misunderstanding and/or transference, but the effect would be a loss of my authenticity and genuine involvement. Truth telling is essential if we are to have a healing relationship. In the next several transactions my honesty and authenticity, as well as making Paul’s point of view central, are significant in establishing Paul’s security-in-relationship.
Paul: (paused for five seconds) You linked this comment of mine with other comments, saying to me that after other pieces of work I also make diagnostic comments of this type.
Richard: That’s true. I did say something to that effect. I had seen a pattern in two other workshops.
Paul: For me, this comment was not correct.
Richard: Do you think I made a mistake…. and that I was not correct?
Paul: I think you are not precise.
Richard: Tell me about that. You know, I could be wrong.
Paul: (pauses and starts to talk, but hesitates and stops)
Richard: You just interrupted yourself there. What did you interrupt inside?
Paul: (pauses for a couple of seconds, looks to the ground and sighs) A commentary about what I did in other workshops leaves me defenceless, because we can either reflect on what is happening at this moment .... such as my comment on the work that Martin did ….this for me is here and now. But when you connect it with other stories and you say “it is like this”, I get lost.
Richard: That makes sense. So, in the future, if I think you are misunderstanding someone, you want me to keep it only in the now. And you need me not to bring in other events …. only the current event.
Paul: Yes, that is it. In the present I can find myself and understand myself. And I can understand what you are saying.
Richard: I can do that for you!
Graciousness is an important aspect of Involvement. “I can do that for you!” is one of the most wonderful interpersonal transactions, provided there are no strings attached – no “you owe me”. A freely given, “I can do that for you!”, is a form of unconditional positive regard for the other, an intimate connection. It is beyond apology; it is a commitment to future action and therefore reparative.
Paul: (Paul nods his head) While we are talking I noticed that my body is tense….and for the last five minutes I have noticed that it has tensed a bit more.
Richard: Well, let’s go back to your movie. Run it ahead at fast speed and see what the terrible ending could be from this conversation.
Paul: This conversation or of my movie?
Richard: It could be mixed, so you choose.
Paul: (closes his eyes and thinks for 30 seconds) In the ending of my movie I remain alone. And not only alone regarding you, but alone in a deeper sense of being really alone. (pause) What moved me, especially yesterday, was the theme of “belonging” that you were illustrating
Richard: Earlier this week you seemed very relaxed and free … when you made that comment about Martin. Perhaps it would have been much better for you if I just kept my mouth shut.
Paul: (sighs) To exchange and also not to agree with ideas and opinions seems all right to me. I see how you work and I appreciate you a lot. I sometimes see a piece of work that I don’t agree with, but that does not change my appreciation for you.
Richard: Oh, I did not know that you disagreed with it. I would like to know about that.
Paul: (Laughs) Some I have told you.
Richard: Yes, but it’s the ones you have not told me that I am curious about now. But you have also said it was my tone, not specifically the content, but the tone.
There are many potentially therapeutic directions to follow in these previous few sentences: what was occurring between us in the past five minutes that increased his body tension, his internal movie, his deep sense of aloneness, the theme of belonging, his different opinions, and my errors. Investigating each of these may well reveal useful therapeutic material; each will take Paul to different awarenesses, memories, and beliefs about self and others. I have only seconds to make a choice. Therapeutic Involvement includes making use of all the personal and professional experience that the psychotherapist has accumulated: from our understanding of theory, from supervision, from working with similar clients, from cinemas and novels, from out own personal therapy, and from our unique sensitivities. We then selectively use these experiences to choose our areas of inquiry. Therapeutic Involvement includes a sense of somatic resonance with our clients. As an outcome of my somatic resonance with Paul I steered the therapy to what I suspected was the source of Paul’s body tension -- that tension which may have been building up in the past several minutes. I thought it was important to bring Paul’s attention back to the tone of my voice and how he sensed my “strict” tone. But I was not certain. I wondered if his body tension was a reaction to my tone, or something that has happened between us that we were not yet talking about, or if he was having a bodily reaction to some emotional memory?
Paul: Yes, and the tone was badly done. That is how I received it. (Paul shakes his finger at Richard)
Richard: Please do that gesture again. (Richard shakes his finger at Paul in imitation of a gesture that Paul has just made…a gesture that Richard made earlier to emphasize the strict tone that Paul heard) You did this (shaking his finger).
Paul: (shakes his head) No, I was not conscious that I did that.
Richard: So the tone is badly done. Can you translate those words into German and say it? “Badly done” … or something similar? (Paul no longer lives in Germany, but the language of his first twenty five years was German)
Paul: Das hast du falsch gemacht. You did it wrong. (Shaking his finger at Richard).
Richard: Now do that again with your hand.
Paul: Das hast du falsch gemacht. You did it wrong. ( Shakes his finger, then fist at Richard).
Richard: Now close your eyes and do it.
I have directed Paul to speak in his original language. At this moment I am relying on my previous experiences in doing psychotherapy with bilingual people. I am also assuming that his body tension is because of what he is not saying. Having him express himself in German may facilitate self-expression and new awarenesses. Closing his eyes may also be effective because it may take him out of the present context and activate memories that have not been conscious until now. Speaking in German with his eyes closed will likely intensify the “familiar feeling” that Paul has mentioned and may allow us to work with both his body tension and his old self-stabilizing reactions.
In the last four transactions I am using the method of Therapeutic Direction. In these transactions the therapeutic work is not directly in the transactions between us but, rather, it is in the client’s discovery of his internal processes. Therapeutic Direction is not in the moment directly
“relational” but it does facilitate the client’s self-exploration -- a learning about his unconscious or intrapsychic processes. Therapeutic Direction should only be used within the context of a securely established relationship -- the relational dynamics bracket any intrapsychic work. In the next several transactions please observe how the Therapeutic Direction is based on the psychotherapist’s full involvement with the client.
Paul: (closes his eyes). Das hast du falsch gemacht. You did it wrong.
Richard: Now with the right tone and louder.
Paul: Das hast du falsch gemacht. You did it wrong.
Richard: Keep going.
Paul: Das hast du falsch gemacht! You did it wrong!
Richard: Now, keep going and finish the sentence.
Paul: Das hast du falsch gemacht!! You did it wrong!!
Richard: Keep going … keep talking.
Paul: Das macht man nicht so. Das hast du falsch gemacht! – One does not do it like this. You did it wrong! (Takes a heavy sigh and looks like he is close to crying).
Richard: You know that tone.
This transaction and my next are examples of validating what has been significant in Paul’s life. My validating comment opens the possibility for Paul to express emotions that have remained unexpressed. Prior to these last few transactions I was not sure if he was expressing how he experienced my behaviour, the meaning in my tone of voice, or whether he was quoting someone else. From the intensity of his emotional reaction I assumed that he was speaking from an archaic experience, hence my comment, “You know that tone”.
Paul: (nods his head then bows his head and cries for over a minute.)
Richard: You know that tone very well. (said very gently)
Paul: (long pause . He sighs and nods his head) That is true.
(He wipes the tears from his face with a tissue and blows his nose) It takes me back directly to the two years I lived alone with my father after my parents’ separation and my mother moved back to England, when I was 14 to 16. I realize now that there was nobody else. I think that before then, when we lived together, his tone did not hurt me because there were five people. After their separation I was there with him alone.
Richard: (touches Paul’s hand) Show me again
(after a pause Richard shakes his finger at Paul)
“Badly done, badly done”.
At this point there are two primary nonverbal transactions that I am doing. I tenderly touch Paul’s hand to make physical contact and provide a sense of security between us before he goes on with his story. He may need our physical contact as a safe reference point as he uncovers old memories. Secondarily, I repeat the gesture of a pointing finger while simultaneously repeating the words, “badly done”. My finger pointing and critical words constitute an enactment that may stimulate his memories. An important aspect of a relationally focused integrative psychotherapy is in the psychotherapist’s willingness to be actively involved by engaging the client in re-experiencing difficult or even traumatic events. Through a combination of a well established secure relationship and the judicious use of experiential methods, the psychotherapist creates a “safe emergency” in which the client can recover previously unconscious memories, feelings, and life-script forming conclusions and decisions.
Paul: I have one memory that stands out. For me it is so incoherent that I always kept it apart. For me it is not understandable and it only happened once.
Richard: What is that?
Paul: That my father at a certain moment told me: “I wish your were dead”.
Richard: What a betrayal. It may have lasted only a moment, but the memories lasted for years and years and years.
Paul: Yes, It disturbed me completely. I could not understand, but I never forgot.
Richard: Say it again so it makes an impact on me.
Paul: Ich wünschte, du wärest tot. I wish you were dead.
Richard: Now do it in his tone.
Paul: (in a strict voice) Ich wünschte, du wärest tot! I wish you were dead!
Richard: And with the same gesture.
Paul: No, I don’t remember his gesture.
Richard: But you know the tone and you know the message.
Paul: He said it with total disapproval.
Richard: Not only disapproval of your behaviour.
Paul: (points to himself with his finger to his chest) But of myself …. that is what I felt with him. (He places his hand on the side of his face, put his head down and cries). I feel tremendous loneliness.
Richard: “Tremendous loneliness”.
Here I am using the technique of Therapeutic Highlighting, repeating the client’s words, therefore acknowledging and validating what the client has just said as a way to underscore the significance of his words and affect. The previous enactment has stimulated Paul’s memory of his father’s words, “I wish you were dead!”. Now Paul is aware of the context of his “tremendous loneliness” and his anticipation of disapproval.
Paul: I remember this year as the most difficult year in my life; a black year.
Richard: Did he destroy something that day?
Paul: Not only that day but with everything that happened.
He never said these words again, but his message was that I was not valuable.
Richard: And I did a mini-version of the same thing when you heard my tone. The tone in my voice implied that you were of no value.
I am again bringing the focus back to the relationship between Paul and me. I am taking responsibility for implying that he is of no value. Even though I did not say those words, for Paul my tone implied that he was “not valuable”. It would be easy to keep the focus only on his father’s behaviour but if this is going to be a healing relationship, my taking responsibility and making the necessary corrections will be extremely important. The work will now weave back and forth between a focus on us – our present relationship, as Paul experiences it -- and a focus on his relationship with his father.
Paul: This was the trigger. Do you remember the first work we did together?
Richard: At this moment no, but if you keep going I will. You have to press the right buttons on my computer.
Paul: Four or five years ago in London.
Richard: I remember meeting you there, but at the moment I don’t remember, so keep going.
Paul: I worked there for the first time with respect to my father and I couldn’t talk to him in an empty chair.
Richard: Yes. I remember that you could only talk to me about him.
Paul: Because my experience of that period of my life was that he was this big (Paul opens his arms outward and wide) and I without power.
Richard: Now I remember that session we had. So, is it accurate to assume that when you got the verbal message from your father -- at age 16 -- that you were of “no value”, that it had been happening all along, but much more subtly?
Rather than make a pronouncement or an interpretation about the psychological dynamics between Paul and his father, I ask Paul a question that solicits his understanding. This is based on an important principle of a relationally orientated psychotherapy: the absence of certainty on the part of the psychotherapist. The therapist’s theory, interpretation or wish for behavioral change is less important than the mutual experience of client and psychotherapist. There is no certainty in our theory, opinions or even observations. If we are to be effective in building a new relationship with the client we need to co-create with the client a fresh understanding of his or her psychological dynamics. If I take the position that I know nothing abut the client’s internal experience, then I must engage in a continual phenomenological inquiry about what he or she is feeling, thinking, fantasizing, remembering, or sensing in the body. Involvement then includes holding the self-expressions and opinions of the client in high esteem. Both client and therapist learn and grow from this shared experience.
Paul: In some manner, yes. When my parents separated and my two sisters went to England with my mother, I chose to be with my father … to not leave him alone … the family broke and that was horrible for him. Two years later, when I was 15, his mother died and that for him was like the last blow. I think he was not there for me.
Richard: So it was the last blow to you also. (Paul nods his head intensely and says yes). A real knockout?
Paul: Enough that I left.
Richard: So yesterday … were you leaving me?
Here I again bring Paul’s attention to our relationship. I inquire about how he may be using his self-stabilizing strategies with me that he learned to use when his father was “not there”. It is in our current therapeutic relationship that he can relax his old self-stabilizing patterns that interfere with both full internal and interpersonal contact.
Paul: The day before yesterday. Yesterday I re-encountered myself and therefore I felt more comfortable with you.
Richard: So how did you re-encounter yourself? Can you teach me how you do that?
Paul: No. (Paul laughs out loud)
Richard: No? You don’t know how?
Paul: It is a matter of time; it is like recovering the tranquility. There comes a moment when the movie stops.
Richard: Why didn’t you stay distant? Why give me a second chance?
Paul: I feel a need to be near to you.
Richard: So what happens if I continue to make other mistakes like this one? Let’s look at the future film. Let’s say I make these mistakes again.
Now I am shifting the focus of our therapeutic work to the future. What have we each learned from this session? How will we be different with each other? I have already committed myself to speaking only about a current event and not bringing external events into any discussion.
The therapy that follows has a distinctive cognitive and behavioral focus --- thinking together about how to do “it” differently in the future. This is still an integral part of a relational psychotherapy. If done with respect, it constitutes a shared experience: inquiring about how Paul envisions being different and me sharing my perspective of how he can change his reactions.
Paul: I think that with two or three occasions we will repeat ourselves and then I would withdraw in a definite manner.
Richard: So to withdraw is a self-stabilizing solution for you?
Paul: That is one solution, to protect myself.
Richard: Oh, … you call that protection?
Paul: (Laughs) Yes. Not because you are so dangerous, but because when I connect with this disapproval and loneliness it leaves me knocked out.
Richard: Yes, and then you probably stabilize yourself by withdrawing. (pause)
Can I argue with you?
Paul: Ok.
Richard: The real protection …. the most effective protection … is to do what you did here today.
Paul: (nods his head) Yes. I woke up this morning and I felt that I had to work for two reasons. Because our relationship matters to me.
Richard: And for that I am very happy. I did not know that you were distancing; I could not tell. And the second reason?
Paul: Because I want to heal this wound.
This is a mini-contract from Paul that allows me to take the next therapeutic direction -- a direction that takes Paul back to his original relationship difficulties with his father. As I emphasized earlier, the healing of relational-disruptions can occur in two dimensions: between us by working within our relationship and intrapsychically by expressing his feelings and needs to his introjected father. As we do both in the therapy we strengthen the possibility that he can again find security-in-relationship rather than in his use of a self-stabilizing withdrawal.
Richard: Then just close your eyes and go back into that house where you lived alone with father. Go right into that situation…. right into the room where he said that cruel comment that day. Look at his image, the way he looked then. And this time, Paul, don’t go silent. This time when he tells you not to live, respond to him.
Paul: (his eyes are closed and he pauses for several seconds)
Richard: Do the opposite.
Paul: (pauses for another 30 seconds with his eyes still closed) I cannot believe what you are telling me!
Through this experiential method of talking to the representation of his father, Paul is undoing an old retroflection, the holding in of his feelings and self-expression. He is speaking out. He is telling his truth. He has broken his silence. Over the past twenty-five years, in the face of relational discord, Paul has re-stabilized himself through remaining silent and withdrawing rather than speaking about what he needs in a relationship. He could not rely on his father for a sense of stabilization and security so he relied on his own ability to remain quiet. Yet, in life today, this old pattern of managing relationships through silence and withdrawal is no longer working. Here he is experimenting with a new way of being in relationship with at least the internal-image of his father –- a new way that may carry over into other relationships. In a previous workshop Paul was reluctant to speak to the internal-image of his father. Now he is speaking his mind.
Richard: Keep going.
Paul: It is completely out of place.
Richard: (grabs Paul’s hand and with each word he bangs Paul’s hand on the pillow) I can’t believe it!
Here, again, I am using therapeutic highlighting. I repeat Paul’s words, “I can’t believe it”, to emphasize the emotional significance of what he has previously said. Helping Paul hit the pillow is a bodily-active method of encouraging him to express his retroflected energy, feelings and words. It is a means to express all that has been held inside in silence. It is also a gesture of making an impact. It is not about releasing a specific amount of feelings; it is about undoing the process of retroflecting so that he has a physical as well as a verbal sense of expressing himself.
Paul: (He starts to cry and his voice gets loud; he is banging his hands on the pillow while he yells the words) How can you say something like that?
Richard: Paul, make it a statement. Make it a statement rather than a question.
Paul: (eyes still closed, crying and very emotional; as he yells he bangs his hands on the pillow) You cannot say something like this to your son! Fuck!
Richard: Keep going, Paul.
Paul: (crying with his eyes closed, shaking his head and banging his hands on the pillow while he yells out the words) Do you have any idea how this hurts? It hurts me when you say that. (sobbing for 30 seconds….Paul pauses for another 40 seconds, calmer now and his eyes open)
I have a clear feeling that I need to have you near, Richard. (pauses for 10 seconds)
Richard: (reaches out and takes Paul’s hand)
I will hold on to this hand and you talk to him with this one.
Paul: (looks at Richard and smiles, then looks again to the pillow that represents his father) My head says it cannot be. How can you say that?
Richard: Now just turn that question into a statement.
Several times Paul has asked questions and most of the time I have urged him to turn his questions into statements. His questions to the image of a father will go without answers and will avoid his experience and feelings. Changing his questions into statements allows him to express his feelings and reactions – to speak his own mind. Statements express his need to make an impact; questions get into the endless loop of “why”. Statements will empower him! His growth will be in telling his previously silent story to his father, by expressing his feeling and relational-needs.
Paul: Papa, das kannst du einfach nicht sagen, dass geht nicht. Dad, you just cannot say something like this, no way.
Richard: yeah, say it louder.
Paul: Du kannst frustriert sein, es kann dir schlecht gehen, was auch immer. Aber es gibt was, das geht nicht! Es geht einfach nicht. Du kannst mich nicht so behandeln! You can be frustrated, you can be down, whatsoever. But there are things you cannot do! No way. You cannot treat me like this!
Richard: Yeah
Paul: (cries and bangs his one hand again and again on the pillow while still holding onto Richard’s hand and continuing to speak in German). Da gibt es eine Grenze, da kann man einfach nicht drüber! Du kannst da nicht drüber. Das geht bis dahin! Es gibt Sachen, die kannst du nicht sagen, es gibt Sachen, die kannst du nicht tun! Das ist einfach zu unmenschlich, das ist bestial! There is a limit that you cannot pass! Until there! There are things you just cannot say, there are things you just cannot do! That is just too inhuman, that is brutal!
Richard: Tell him what you decided that day.
Paul: (pauses for 20 seconds and takes some deep breaths) Dazusein und nicht dazusein. Einerseits brauche ich dich, aber andererseits traue ich dir nicht. To be there and to not be there. On the one hand I need you and on the other hand I don’t trust you.
Paul made an explicit decision as an adolescent –- a decision that he has not forgotten, but one that has effected some of his relationships since then. When decisions are made in response to specific events they are often available as explicit memory and therefore an active re-decision is possible. In this piece of work we do not yet know if this decision is the only source of Paul’s self-limiting silence and withdrawal. It is possible that he has made a number of similar implicit conclusions that have built up over a long period of time. Such implicit conclusions are usually not conscious or thought about because they seem to the person to be a natural reaction to repeated relational failures. Implicit conclusions, as well as explicit decisions, form self-limiting script beliefs. When I am working with a client whose life script was composed primarily from implicit conclusions in response to cumulative neglect, the therapy must be relational. The healing process occurs through the psychotherapist’s consistent attunement to the client’s affect, rhythm, relational-needs and representation of self-in-relationship. It is often not useful to use the active methods that I am using here with Paul if the life script is formed primarily from Implicit Conclusions. Even with Paul I would not want the therapy to end with only a re-decision. He said that “there was nobody” and implied that his father was too occupied with his own losses to be contactful. Paul may need the ongoing presence of a respectful, caring psychotherapist who offers an alternative way of being in relationship. But, for now, it seems as though an awareness of the profoundness of his original decision and a possible re-decision will make a tremendous difference in his life.
Richard: (moves the hand he is holding) On one hand, (points to Paul’s other hand) …..and, on the other hand.
Paul: (looks at Richard) Yeah.
Richard: Paul, talk to your daddy. Stay with him. Tell him about being torn inside. “On one hand and on the other”. Tell him how that decision affected all of your relationships.
Paul: Ich traue dir nicht. Heute kann ich mit gewissen Dingen zählen, aber gefühlsmässig traue ich dir nicht. Ich brauche diesen Sicherheitsabstand, und nicht nur mit dir, sondern mit allen Menschen, wo ich mich in Gefahr fühle. Und es ist nicht einfach für mich. I don’t trust you. Today I can count on certain things, but emotionally I don’t trust you. I need this safe distance. And not only with you but with all the people I feel in danger. And this is not easy for me.
Richard: (moves Paul’s hand that he is holding) Now tell him what this hand needs.
Paul: Papa, ich brauche dich, und ich hätte dich damals sehr gebraucht. Heute kann ich mich selber behaupten, aber ich hätte mich damals sehr gebraucht. Dad, I need you and I would have needed you then very much. Today I can take care of myself, but then I needed you very much. (pause of 30 seconds) Ich hätte gebraucht, dass du mich richtig findest; dass du mich bestärkt hättest in meinem Eigensein; dass ich dich um Rat hätte fragen können; dass du mir geholfen hättest, mich zu orientieren. Ich habe meinen ganzen Weg selbst gemacht. (switches from German into Spanish) Nadie me ha dicho como hacerlo. I would have needed you to have found me appropriate and valuable. That would have confirmed me in being as I am. That I could have asked you for advice. That you would have helped me to orient myself. I have done all of my way on my own. Nobody told me how to do it.
Richard: (holds up the hand he is holding, then points to Paul’s other hand) That one pushes him away.
Paul: Yes. (pause)
Richard: Now what just happened inside? The muscles in your face changed just slightly; something happened.
Paul: (looks at Richard with a calm smile) It makes me feel so good to have you next to me, looking at me with an expression of love and appreciation. It relaxes me and it makes me feel happy.
Richard: Now tell that to father. “Father, what I need from you is….”
This last therapeutic direction is called “priming the pump”. It is an active method that encourages the person to say what they are holding back from saying. Yet the psychotherapist does not complete the sentence; we only prime the client to speak and the client finishes the sentence in his or her own manner. Most of the time it is essential that the therapist not finish the sentence so the client can have the experience of saying ‘it” in their own way and/or to avoid compliance with the psychotherapist. I have often been surprised by how a client ends the sentence when I have primed the pump and refrained from finishing the sentence. On rare occasions I may finish the sentence: if the client cannot get the words out because of inhibition or threat of punishment; or, if my cognitive attunement is such that I sense that I can provide the words that reflect the clients internal experience – words that the client has not yet thought about speaking.
Paul: Was ich von dir brauche, ist, dass du einfach zu mir stehst. What I need from you is to simply be on my side and back me.
Richard: Let me add one more: “And believe in me, papa, believe in my way, not just backing me”.
Here I am going beyond priming the pump. I am actually saying what I think the client is not saying. I take this risk of saying it for the client as a way to show my attunement with what the client needs to say and has not put into words. The attunement is the important ingredient; if I am misattuned and say something that is not in accord with the client’s inner experience, then I will rupture our relationship. Paul’s laughter and next response indicates that I made an appropriate expression of what he could not yet say. Sensing what to say at a moment like this is an expression of involvement.
Paul: (laughs) For me they go together.
Richard: “Believe in me, trust me”.
Paul: Yeah. Vertraue mir, dass ich das Richtige mache. Trust me that I am doing the right thing. (Pause for 30 seconds.)
Paul: (said angrily) Für mich warst du unendlich brutal. In deinen Worten, in deinem Ton, in deinem Verhalten. Du hast mich nicht geschlagen, aber warst unendlich brutal. For me you have been infinitely brutal, in your words, in your tone, in your acts. You did not beat me, but you have been infinitely brutal.
(Pause for one minute. Paul sits with his eyes closed. Richard remains silent while keeping his gaze on Paul the whole time.)
Paul: (loud with anger) Du hast mir sehr wehgetan. Es war wirklich das schlimmste Jahr in meinem Leben. Ich wünsche das keinem. You have hurt me a lot. It has really been the worst year in my life. I don’t wish that for anybody else.
Richard: And tell him what you decided that year.
Paul: Es gibt keinen, auf den ich zählen kann; zumindest keinen Mann. Im Grunde bin ich allein. There is nobody, I cannot count on anyone; at least not on any man. Basically I am alone. (Pause for 40 seconds; then Paul switches from German into English) There are some people where it is better to protect my fragility. And where I don’t dare show myself; it is better to withdraw instead.
(pause for 40 seconds, then lovingly looks at Richard)
It is a little bit complicated to deal with me in our relationship.
Paul has just spoken his script decision. He is now aware of the decision and how it has affected his life for the past 25 years. I do not push Paul to make a re-decision out-loud; I trust that a re-decision is going on inside. His emotionally intense awareness is powerful enough that his life will change significantly. In the next few transactions Paul is already anticipating a different quality to our relationship.
Richard: What do you mean, Paul?
Paul: Predicting the future, I assume that it will happen again with you.
Richard: Yes, a probability.
Paul: Therefore it will be a bit complicated sometimes (laughs)
Richard: Ok. So then the question is, “What do we do about it?”
Paul: What I am going to do is to bring my difficulty with you to the relationship.
Richard: Well, thank you. That would be good for both of us because then I don’t have to be guessing about what is going on inside of you.
Paul: And I would like it that when I signal my distress you would take me seriously.
Richard: Taking you seriously would be no difficulty at all. In fact, it would probably be quite pleasing to do… just as it is to sit here and hold your hand at this moment.
With this transaction I am making a commitment to Paul – a commitment to respecting him and taking him seriously. This is Therapeutic Involvement! Another element of Therapeutic Involvement is in my question to Paul, “What do we do about it?” Notice the use of “we”, a small but significant word that signals that he is not alone and that I will take his concerns seriously. “We”, a word that means some one else is there to help him resolve potential conflicts. The “we” communicates our relationship and my commitment to a co-constructive prosess. The healing of relational disruptions and psychological distress occurs through a contactfull therapeutic relationship. Observe the next few transactions: when I say that it would be pleasing to take him seriously, Paul becomes aware of both new possibilities and another script decision.
Paul: Something interesting is happening in the meantime (slowly points his finger to himself then to Richard) I am realizing that… is it possible that a man can love me? It is like a question (moves his body back and laughs), which brings me to another decision of that time.
Richard: Can you put it in words?
Paul: Back then I decided that there are no men that can love me. (Richard and Paul look caringly at each other while sitting with relaxed body language for 20 seconds, then they smile at each other.)
Paul: I feel that you love me. (Richard reaches out and again takes Paul’s hand)
Richard: For children…and that is what you were when your father did that; you were still a child… Love is not in the abstract words, “I love you”. (Paul begins to cry…after a pause he wipes the tears from his eyes and nods yes) Love is in action …. through the action that the child needs. And your father’s behavior that day was not loving.
Paul: Not on that day… and neither on many other days.
Richard: I am so sorry to hear that.
Paul: This is the wound in here (points to his heart).
Richard: So maybe now that we have cleaned the infection the wound can heal naturally. That wound has been infected for a long time by the decision you made.
Paul: I understand. (pauses for several seconds then lets go of Richard`s hand) I would like to have a hug.
Richard: A standing up one?
Richard and Paul stand up and they have a long embrace.
Although Paul has not verbalized a re-decision, the way in how he relates to me at the end, and after this session, is different; this is evident in his desire for affection from a man and saying “I feel loved by you”. There may be more relational work to do. But, for today, we have accomplished much in this therapy. In this work I have focused the therapy on both the centrality of the therapeutic relationship and the use of experiential and expressive methods. Without a quality relationship the experiential methods would simply be “doing something” to the client. Within a caring therapeutic relationship the expressive and experiential methods are used in a co-creative process with and for the client. When the psychotherapist is fully contactful and completely involved in the relationship with the client, the client can then risk experimenting with active methods that create a re-enactment of old relational failures and traumas.
I would like to conclude our discussion by articulating some of the important principles that are inherent in therapeutic involvement. My first awareness in establishing a therapeutic relationship with Paul was of being curious about his perspective, feelings , and how uniquely different he is from me. I became particularly curious about exploring Paul’s description of my tone of voice and the meaning he ascribed to my words and tone. I am not suggesting that psychotherapists become confluent with the client, but rather that we temporarily get out of our own frame of reference and appreciate the client’s way of organizing his or her experience. With Paul, as with all clients, I assume that I know nothing about his (their) experience or inner life. All of my observations and theories are mere impressions. These impressions do not tell me enough about what it is like to be in Paul’s experience. It is therefore essential that I engage in an ongoing phenomenological inquiry to discover Paul’s perspective, feelings and what he needs in a therapeutic relationship.
When I am dependable, reliable, and consistent in how I establish an environment of emotional stability for my clients, I experience a sense of integrity. My honesty in telling Paul that I did not approve of what he said was significant and necessary in providing a dependable working relationship. Honesty and truth telling are important aspects of integrity. I find it essential to repeatedly ask myself the question, “What is the effect of my inner affect or behaviour on the client?” Taking responsibility for how I affect the other is part of maintaining my inner sense of integrity.
When I am less certain of the truth, or the right way, then I allow clients to influence me; as a result, they become more self-expressive. I want my clients to have the sense that in this therapeutic relationship they can make an impact on me. Paul went silent with his father; he withdrew and did not make an impact. In the work with Paul I listened and accepted his description of my “strict” tone rather than focusing on or explaining my experience.
I strive to provide my clients with an opportunity for choice whenever possible. My wish to provide choice is based on the assumption that the client’s behaviour seems to him or her to be the best possible option given his or her past experiences and motivation. Paul was without choice in his family. He had no voice in his parents’ separation. He said that he chose to stay with his father but that choice was made out of his wanting to take care of his father; it was not a choice for his own welfare.
In my clinical experience, I have found that clients become less guarded and self-protective in an atmosphere of graciousness. When I am both respectful and gracious, it provides the client with a sense of security and the opening to express him- or herself more fully. When I said to Paul, “I can do that for you”, I said it with a sense of respect and an honouring of his “Okness”. Shortly after making this statement of reparation, Paul was able to shift his focus to the necessary work with his father.
When I have made a commitment to the welfare of the client, I am touched by a sense of compassion. This sense of compassion includes both emotion and attitude of being with and for the other person; it is the highest form of being interpersonally contactful. Compassion involves a commitment to understanding my client’s feelings and motivations while valuing their uniqueness and differences. Throughout Paul’s therapy I felt a strong sense of compassion for the man who was pained by my “strict” tone and the adolescent whose father said, “I wish you would be dead”. Paul’s years of loneliness touched my heart; I wanted to be fully present with him!
Curiosity, personal integrity, the absence of certainty, the opportunity for choice, and a sense of compassion are all aspects of contact-in-relationship. Each of these is an internal attitude and feeling about being in relationship; they are the characteristics of Therapeutic Involvement.
Copyright: Institute for Integrative Psyshotherapy, New York, NY/Vancouver, BC and Richard G. Erskine, PhD, January 3, 2011