Integrative Psychotherapy Articles
Relational Healing of Early Affect-Confusion
Part 3 of a Case Study Trilogy
Richard G. Erskine, PhD.
Institute for Integrative Psychotherapy
Part 3 of a case study trilogy on early affect-confusion describes the use of therapeutic dialogue, relational presence and supportive age regression in the psychotherapy of a client who lived on a "borderline" of early affect confusion. The concepts and methods of an in-depth, integrative and relational psychotherapy include a sensitivity to the client's physiological and emotional expressions of implicit and sub-symbolic memories, therapeutic inference, an awareness of the client's relational-needs, the effective use of a developmental image, as well the identification of an introjected other and the use of therapeutic interposition.
Our Therapeutic Relationship in Years Four and Five:
When our psychotherapy sessions began again in
September, I often had in mind an impressionistic, developmental image of Theresa as a kindergarten and school age child who lived in fear of expressing her own ideas, needs and what she liked or disliked. I felt an intense concern for the psychological safety of such a frightened and helpless child. I focused on staying attuned to her loneliness and felt a constant sense of compassion for her as a sad little girl. I often spoke in a calm way to engage that frightened and despairing child that she once was, to help her identify and talk about her feelings, needs and how she made sense of her relational experiences.
When Theresa would lead a session into complaints about her boyfriend or concerns about work, I would return to that neglected and emotionally abused little girl by inquiring about Theresa's physiological and affective reactions in living with an angry and confrontational mother. My frequent focus on the lonely or hurt or frightened child stimulated many new memories of her mother's disdain. Now the memories were of the interactions with her mother at a younger age. Session after session was filled with deep crying and a number of painful memories of how "my mother squashed my desires" and "always told me that something was wrong with me". We were now getting to her childhood experiences of feeling helpless and worthless.
One day, when she was describing her mother's typical over-controlling behavior, Theresa suddenly screamed out,
"She treated me like I was a piece of shit.
But I was only a little girl with needs.
I needed her help. I was too little to do
everything like a grown-up. I am NOT
a piece of shit. You, Mother, missed
seeing the precious child that I was".
This emotional outburst marked a major step forward in Theresa's psychotherapy. We talked at length about the difference in acting helpless in life today (her crying spells and demands on her boyfriend) and actually needing to depend on her parents when she was a child. Together we imagined how her life could have been if she had been treated as "precious" and contrasted it with her experience of life as "a piece of shit". The psychotherapy had a whole different tone than in the previous three years. We were no longer talking about crises or Theresa's self-destructive behaviors; we were talking about her needs as a child and her self-worth today.
It was mid-morning when Theresa called me from her office. "I'm just so crazy! I do not know what to do. I'm in a rage inside. But this time I did what you told me to do; I did not scream at anyone. I cannot stand it when anyone is disrespectful. I need to talk to you". This was again a major step forward in her psychological growth. She contained her explosive rage, used my counsel about how to manage disagreements, and called me for support. I complimented her on not raging in the office and made a lunch hour appointment that was only two hours later.
When she first arrived she ranted about the disrespect from a woman at work and her boss's lack of support. Once she had aired her anger and had told me some of the details of what had occurred that morning, I asked her about what "disrespect" meant to her. After several inquiries it became clear that she defined disrespect as any disagreement with her point of view. She went on to describe how she often perceives disagreement as confrontational. As I asked her to tell me more about what she associated with the word "confrontational", she had a sudden realization that this was how her mother reacted in most situations. "I am being just like my mother" she shrieked; "I hate her for how she is so aggressive and makes even the slightest difference into a fight". She went on to say, "I have lived with her anger all my life and now I'm shocked to think that I am being just like her". She then began to cry and express her despair and utter hopelessness in trying to express her own ideas, likes or dislikes, wishes, and needs as a child.
I now had two clear focal points for our continuing psychotherapy: first, it seemed important to address the relational–needs and survival reactions of a neglected and verbally abused child; and, second, it would eventually be beneficial to therapeutically engage with the internalized mother who was influencing Theresa's current life. In working with other clients suffering from early affect-confusion it has been extremely useful to decommission the influence of the introjected other, but only after a secure therapeutic relationship with the distraught "child" is well established.
I continued to address the previously untold experiences of that little girl while also acknowledging and normalizing her aspirations. As our psychotherapy continued, her unfolding narrative ebbed and flowed with my phenomenological and historical inquiry. My consistent inquiry stimulated her to remember numerous painful and humiliating experiences that she had never talked about. And each inquiry was also a form of acknowledging what she had just said and in turn stimulating the next memory, feeling, or insight. Our therapeutic dialogue included my frequent inquiry into how she coped and regulated herself when her mother was critical, aggressive or rejecting. I periodically acknowledged her intelligence and creativity in managing the deficits in the relationship with her parents and verbally applauded how she managed to get a semblance of psychological needs met outside the family.
I continued to remember that she had said, "I am being just like my mother". I started to impose myself between Theresa and her internalized mother by telling Theresa what I would have said to her mother if I had been visiting in their home when her mother was being so criticizing and rejecting of Theresa. Examples of these therapeutic interpositions included: "I would have told your mother to stop yelling at you and to sit down listen to your feelings"; "I want to tell your mother that 'your little girl needs your care and compassion NOT YOUR CRITICISM!'"; "You need to go to therapy, Mother, and not take out your anger on your daughter." She would sometimes cry when I would make such statements. On other days she would angrily say, "That is the protection I needed from my father".
It was too soon to provide actual therapy for the introjection of her mother's personality. My therapeutic interpositions would suffice for now since they were effective in stimulating Theresa's awareness of what she needed as a younger child and how she was creative in adjusting and coping with her mother's critical and controlling behaviors. Before I attempted any therapy with her parental introjects, more time was needed to support Theresa's self-definition, her need to make an impact and her need for security and validation. Acknowledging and normalizing these relational-needs seemed to be essential to her psychological growth. She was now depending on our therapeutic relationship for her internal support. Theresa described the qualities of that support as having someone in her life on whom she could "rely on and receive guidance…even protection when I am overwhelmed with feelings"
Many of Theresa's early childhood relational experiences –experiences in which she had been deprived of an opportunity to be put into language -- were now coming to consciousness because we had co-created a safe place to talk about her childhood feelings, desires, needs and bodily sensations. Her parents had not provided the necessary validating conversations that could have given words, concepts and meanings to Theresa's experiences; her experiences had remained without linguistic symbolization until we talked about them in our psychotherapy. My phenomenological inquiry, curiosity, concerns, and personal presence stimulated Theresa's awareness of memories that she was unable to recall on her own. She had an increasing realization that much of her current life's conflicts were motivated by her emotional reactions to many unresolved relational conflicts with her parents.
I asked Theresa to describe the quality of conversations she had with her parents over breakfast or before going to school in the morning. All she could recall was her father's absence and her mother's insistence that she be on time, be dressed neatly, and that she stay clean. She could not remember any discussion about her excitement or fears, who she liked and who liked her, or her joys or stresses that could possibly be occurring during the school day. I asked about her returning from school and the quality of conversations with her parents at that hour. She could remember being criticized for getting dirty or being late but she was unable to recall any dialogue that acknowledged her experiences, feelings, or wishes. "My mother was only interested in my doing all my homework before I could play", she said angrily.
In several sessions I continued this type of historical inquiry with the focus of my inquiry shifting to the qualities of her maternal relationship at an ever-younger age. I spent three sessions inquiring about her bedtime routine and the quality of possible conversations with her parents at that relationally crucial hour. She said that during her school years she had to be in bed by nine each night and that she could read alone for fifteen minutes. Her father always watched TV and that she would sometimes give him a kiss on the cheek before going to her room alone. Her mother demanded that the lights be off at 9:15; she never read to Theresa or sat on the bed to discuss the day's events or prepare for the next day. Often her mother never said, "good night"; it was expected that Theresa would obey the rules. There was no one to help Theresa understand and manage her own world. As I focused my inquiry on bedtime for the preschool child, Theresa had no memory of being cuddled, read to, or having any pre-sleep conversations with either parent. Now I fully understood the cumulative neglect, over many years, that led to Theresa's conclusion: "No one is there for me".
Theresa's answers to my initial inquiries about her day-to-day life with her parents were often short and factual but each of these historical inquiries was followed by many phenomenological inquiries about her sensations, feelings, associations, thought processes and desires. This often led to an inquiry into how she survived, accommodated, and stabilized herself when no one was emotionally or conversationally there for her. My questions were not aimed at merely gathering the facts of her history; my inquiry was always focused on her inner experiences and subjective processes in response to those historical experiences. My inquiry, attunement, acknowledgement and normalization facilitated her to put her previously non-conscious body, affective, and relational experiences into words. It was slow work, yet Theresa and I were now co-constructing a narrative of her young life. Through our therapeutic dialogue we were acknowledging, giving meaning to and validating what she called her "unthought about" experience.
I continued to focus my inquiries on a younger and then even younger child. Our work often involved long silences as Theresa struggled to put her physiological sensations and feeling into words. I proceeded by inquiring about her pre-school experiences and eventually asked what she knew about her infancy and toddler years. I raised questions about her play activities when she was three or four years old. During this phase of our therapy together her first answer to many of my questions was, "I don't know".
In response to Theresa's "I don't know" I would ask her to close her eyes and imagine herself as a pre-school child. In addition to many implicit images of "rules" and "nothingness", she did have three explicit memories: she could remember being about three years old and climbing on her father's lap and his laughing with her; she could remember her mother "being harsh" with her when she "could not use scissors properly when I was four"; she remembered playing alone with her stuffed animals when she was between three and four years and having an overwhelming sense of deep loneliness. As we talked at length about her loneliness Theresa said that all of her life, until now, she could not understand why all her "stuffed animals were lonely and scared". Much of this period of time was spent attending to Theresa's profound sense of loneliness – an early childhood loneliness that previously had no means of interpersonal expression except for her to imagine it in her stuffed animals or to deflect it into conflicts with people. She needed a consistent therapeutic presence and compassionate attunement to her loneliness and fear even though she sometimes angrily complained, "My loneliness and fears did not exist before this therapy".
Were Theresa's descriptions of her pre-school years an accurate recall of actual interactions with her parents or were they her impressions? I'm not sure. However, I assumed that such impressions were created from many sub-symbolic and implicit memories and therefore were an avenue for inquiring further about Theresa's subjective world. As I listened to Theresa's phenomenological experience of her early childhood, I attended to my own sensations and impressions, my own affective pull to comfort and protect her, and my knowledge of child development and what any child needs in a parental relationship in order to form a secure attachment. All of this, and all that I had learned about her in the previous four years, became the data in forming many inferences about her affective/ relational life.
Therapeutic inference was my most important tool when I was striving to understand and help Theresa express her pre-symbolic and non-linguistic memories. Her memories of early-childhood and infancy were not available to consciousness through language because her experiences were either preverbal or did not have a relational- opportunity to be put into language. Although Theresa lacked a coherent narrative of her life's experiences, her sub-symbolic memories were expressed in body sensations, emotional reactions, and self-regulating patterns. Her unconscious attachment patterns were disorganized, often on an oscillating borderline between avoidant and anxious. Theresa lived on a "borderline" of intense neediness and rage, despair and self-reliance, impulsivity and manipulation.
In observing her oscillations between avoidant, anxious, and disorganized attachment patterns, I assumed (even though I had no explicit data) that the first few years of her life were as psychologically tumultuous as her school and teenage years had been. My attunement to her affect, rhythm, and developmental levels were essential in forming an involved connection that facilitated a communication of her preverbal experience. I attended to how her pre-verbal story was expressed in nonverbal enactments, encoded in her stories and metaphors, embedded in her relational conflicts, and engendered in my emotional reactions to her. It was up to me to make use of all of this information to create a healing relationship for this distressed infant and toddler.
I asked Theresa to imagine being a child about sixteen or eighteen months of age, who was sitting in a high chair and being fed by her mother. I inquired about the look she imagined would have been on her mother's face, how her mother would have reacted if she disliked the food, her mother's tempo in feeding her, her mother's joy or disapproval, and all the body sensations that went with each inquiry. I also asked similar questions about her emotional and physiological experience of nursing, diaper changing, bath time, toilet training, and mutual play.
This whole series of inquiries lasted several months and provided both of us with a plethora of information about Theresa's early affect-confusion: her physiological sense of feeling both repulsion towards her mother and simultaneously a painful longing for an intimate connection. She remembered being frightened by the harsh looks on her mother's face, squirming as her body sensed her mother's rough touch, disgusted with how she was forced to eat, and the muscle contractions in her body in reaction to her mother's rhythm. In many sessions Theresa wept over what she had missed in a mothering relationship and she raged at her mother's callous behavior. She also cried in terror as she sensed her mother's harsh treatment of her. In our therapeutic work together Theresa re-experienced the trembling body sensations of emptiness and emotional abandonment when her mother would not look at or talk to her for "hours or even days". She now identified her "gnawing, hungry feeling" as a need for nurturing. At the same time she realized that "even as a baby I must have avoided her rough touch and mean face". Theresa had many reasons to be profoundly confused as an infant and to have formed a relationally-avoidant life pattern.
I was reminded how loving and forgiving young children can be; in several sessions Theresa wept and pleaded: "Momma, please love me"; "Momma, don't leave me… I'll be good"; and, "Please, please, please, Momma". Sometimes she would curl up on the couch and just moan the word "Momma". She feared the deep sensations of loneliness that would come when Mother ignored her. She described how, as a pre-school child, she would do anything to get her mother to talk kindly to her. In another session, while experiencing herself as an older child, she screamed in anguish, "I have adapted, adjusted, accommodated and conformed my entire life just to get my mother to stop hating me". Theresa became increasingly able to relate her infant and early childhood loneliness to the clinging demands she made on her boyfriend. She realized that she was demanding that Robert be a "good mother" to her.
Following these and other realizations Theresa's age regressions began to lose their thrust of urgency. In our ongoing therapeutic dialogue we reviewed these childhood experiences many times to understand their significance in her life and we also returned to these expressive early childhood emotion-filled sessions when a supportive-regression seemed to be an important form of communicating and resolving her previously non-conscious story. But Theresa now had less and less of an urge to regress to earlier periods of relational-neglect. Theresa was now able to make many associations and connections to her adult life behaviors and emotional reactions. She had a good understanding of her habit of pushing people away, her fear of intimacy, her rage (particularly at women), and her "tremendous longing for someone to be there for me".
As the spring of our 5th year together approached and we would again be taking a summer recess, I began to turn my attention to finding opportunities to inquire about Theresa's aspirations. What were her future plans? What did she always want to do and had never got around to doing? She said that she was tired of the subservient position of being a legal assistant and had always hoped to become an attorney. She added that she wanted to "have a loving relationship …. with Robert". This was how we ended in May of our fifth year. Theresa was enthusiastic about returning in September "in order to better understand myself".
In these previous two years, while I attended almost exclusively to Theresa's experience as an infant and very young child, I kept in mind her words, "I'm just like my mother". Since I would be traveling most of the summer this was not the time to approach this issue. Previously I had postponed doing any psychotherapy with her introjected mother; I would postpone it again until autumn. The therapeutic interpositions that I periodically made between the criticizing comments of an introjected mother and the natural expressions of a little girl had been effective in quieting much of Theresa's internal criticism and distress. But the psychotherapy was not complete. I considered the resolution of Theresa's introjection of her mother's personality to be essential to our doing a comprehensive and in-depth psychotherapy.
During this time my first two priorities had been to establish a greater sense of relational security for Theresa and to facilitate her expression of her own relational-desires, what she liked and disliked, and her private aspirations. I was primarily focused on the child's unrequited need for self-definition and the need to make an impact-in-relationship while always keeping in mind Theresa's needs for security and validation. As a child, Theresa was never effective in making an impact on her angry mother. Her attempts at self-definition were met with confrontation and ridicule, an absence of validation and a lack of security-in-relationship. To avoid the unending conflicts with her mother, Theresa reactively sacrificed her natural forms of self-expression.
As this year came to an end, I reviewed what I had learned in my work with Theresa; I had a renewed appreciation of Theresa's aggressive behavior towards people being a non-conscious expression of her unmet relational-needs for validation, self-definition, and her need to make an impact. By picking fights at home and at work she was expressing these unrequited developmental needs, never achieving satisfaction because her angry expressions were out of their original context. Our psychotherapy co-created a therapeutic space that simulated memories of her original family context – a therapeutic space in which her vital needs could be expressed, validated and normalized. It was also clear to me as to why I intuitively had never used confrontation as part of my therapeutic dialogue with Theresa; confrontation would have been non-therapeutic, perhaps even reinforcing of the psychological damage that she had already experienced. She seemed to thrive on my sustained affective and developmental attunement, my gentle phenomenological inquiry, and my firm and respectful involvement.
When I returned from vacation in August there was an urgent phone message from Theresa requesting "a special session as soon as possible". Two days later I discovered that she had been waiting a month to give me her "good news". Her boyfriend had been offered a job promotion; he had to move to a distant city. Theresa had decided that since they had been having a "great relationship" for the past couple of years that she would "take the risk of moving with Robert". She talked at length about how much she had changed and how she and Robert were now capable of intimate discussions instead of fighting. They had discussed their future: with her savings and his increased income, she could afford to go to law school and become an attorney. She was full of joy and excitement. She added that she had a secret: "I've been thinking of getting married. I am planning a big surprise for Robert when he comes home this Saturday night. I am going to propose that we have a wedding just before we move".
I had tears of joy in my eyes as I reflected on our five-year therapeutic relationship. I was personally enriched by what we had shared together. Theresa had taught, or at least re-taught, me about the importance of patience, respect, kindness, uncertainty, priorities, parameters, and the need to attend to sub-symbolic and implicit memory in its many forms of non-verbal expression.
In the first couple of years it had been a difficult journey for both of us but she had grown in many ways. For the past couple of years Theresa was no longer acting helpless at home by having "crying spells" or making demands on her boyfriend; she was no longer getting into conflicts at home or work; she self-regulated her affect-confusion and understood how her early relational life had influenced both her helplessness and ragging conflicts; and she now had a satisfying sense of self-worth and aspirations. Theresa had changed in significant ways. My only concern was with Theresa's lingering internal criticism and the lack of opportunity to provide therapy for her introjected mother. But now it was time to say "good-bye"; Theresa was no longer living on a psychological "borderline" of early affect-confusion.
Copyright Institute for Integrative Psychotherapy, New York & Vancouver, BC and Richard G. Erskine, PhD., July 20,2011.
This three part case study illustrates the principles, theoretical concepts, and relational methods of Integrative Psychotherapy in the treatment of a client who lived on a "borderline" between intense neediness and rage, despair and self-reliance, impulsivity and manipulation. The Integrative Psychotherapy methods of therapeutic inference, bifurcated questions, juxtaposition reactions, developmental image, and phenomenological inquiry are described as key concepts in a relational psychotherapy of early affect-confusion.
Key words: Therapeutic presence, Relational-needs, developmental image, sub-symbolic memory, implicit memory, age regression, non-verbal enactments, supportive-regression, introjected other, therapeutic interposition, in-depth psychotherapy, aspirations, therapeutic dialogue, therapeutic inference, integrative psychotherapy, affect-confusion, phenomenological inquiry, borderline, affective attunement, developmental attunement.
Richard G. Erskine, PhD. is a Licensed Clinical Psychologist, Licensed Psychoanalyst, Certified Transactional Analyst, Gestalt Therapist, and Certified Group Psychotherapist. Since 1976 he has served as the Training Director of the Institute for Integrative Psychotherapy in New York City and Vancouver, BC, Canada.