Psychothérapie Intégrative Articles

Psychotherapy of Contact-in-Relationship:
Conversations with Richard

Richard G. Erskine and Grover E. Criswell

Preface: Below is a conversation with Dr. Richard Erskine about the psychotherapeutic relationship. He is to be one of the plenary speakers at the Institute and Conference of the American Academy of Psychotherapists in Atlanta, GA, October 24 to 28, 2012.

Richard G. Erskine, PhD, is a licensed Clinical Psychologist and Psychoanalyst, a certified Transactioanl Analysis and Group psychotherapist, who has been practicing Gestalt Therapy and body psychotherapy since 1967. He is the author of numerous articles and coauthor of 5 books on the theory and methods of psychotherapy. Many of his articles are available on the web site: www.IntegrativeTherapy.com

Grover E. Criswell was a pastoral psychotherapist in Dayton, Ohio from 1968 until he retired in 2011 to create a new identity. He had the privilege of studying integrative psychotherapy with Richard for over eight years. He is a past president and Fellow of the Academy.

 

GEC: Where I would like to begin is with a statement from one of your presentations, Richard. It seems pivotal to integrative psychotherapy: “Relational dynamics bracket any interpsychic work.”

RE: Absolutely. The quality of the relationship we build becomes the heart of everything else that happens in the therapy. This relationship we develop before, during, and certainly after any emotionally expressive, experiential, or interpsychic-work flows from our sustained empathy, our sense of attunement, our being with and for the client. The psychotherapeutic relationship is about our being fully present.

GEC: The holding environment for whatever evolves?

RE: Yes, whatever experiential activity we may attempt – whether an empty chair technique, a two-chair dialogue, an expression of anger or deep crying, or some bioenergetics exercise or deep bodywork – the therapeutic relationship is central.

It is not the techniques that heal; techniques enhance the therapy but they are not the essence of psychotherapy. It is the contactful therapeutic relationship that heals our clients’ relational wounds. Our therapeutic involvement is honed by the way in which we understand the client’s experience and how we bring our own experience into the therapeutic relationship.

GEC: What are the elements supporting the qualities of an effective therapeutic relationship?

RE: I begin with the assumption that I know nothing about my client’s experience. The errors I have made as a therapist were often based on the assumption that knew what was going on with the client. If I take the position that I know nothing about the clients’ experience, then I have to inquire and inquire and inquire about what they feel, what they are experiencing, how they make sense of their world, what associations they make, and what memories are emerging.

GEC: A story related to your point recently happened in the national football league where a quarterback on this one team had just thrown his second pass interception. The commentator gave this evaluation: “The quarterback was so focused on throwing the ball to a particular receiver that he didn’t see the defensive players in a position to intercept.” Seems to me that is what you are saying about assumptions.

RE: Yes, it is staying open to the nuances of what is going on ---receptive to the unconscious communication.

GEC: This involves more than just asking questions?

RE: I liken it to “listening with my whole self” – not just with my ears but also with my affect, my senses and body, and using all my years of experience. This means that I must attune to the client so as to meet him or her with reciprocity to his or her affect and relational-needs. Such an involvement includes a constant striving to make sense of the client’s personal, subjective world while relying on my one history, training, supervision and reading as an important resource library. I am describing this in a linear way but it is really like a hologram wherein many dynamics are happening at once.

GEC: One way of listening to the client is being aware of how their presence and words register with me. Simultaneously I am focusing both on the client and my own internal processes.

RE: This is one of the reasons it is essential to have good psychotherapy both in our initial training and as an ongoing resource. Included is the need for regular supervision and consultation. Our therapy and supervision provides the background to clearly know what we are bringing to our therapeutic involvement .The therapeutic relationship is always co-created; it is not only about the client. The partnership creates the therapeutic alliance. It is through the quality of a contactful therapeutic relationship that healing occurs.

GEC: I have often heard you use the word “attunement” in the evolution of the therapeutic relationship.

RE: In the book “Beyond Empathy: The Therapy of Contact in the Relationship,” coauthored with Janet Moursund and Rebecca Trautmann, (Bruner/Mazel, 1998) we used the word “attunement” in several different ways: affective attunement, rhythmic attunement, development attunement, cognitive attunement, and attunement to relational-needs.

GEC: I am assuming that while each is a part of the whole, the accent mark is put at a slightly different place.

RE: That’s right. Affective attunement is the ability to go beyond empathy. It is the ability to provide a reciprocal meeting with the person’s affect. When they are sad, we meet them with reciprocity of compassion. When they are fearful, we meet them with security. When they are angry we take them seriously. When they are joyful we provide the recripical affects of vitality. We tune to their frequency and respond with a corresponding affect.

GEC: Some might hear this as a therapeutic trick, a subtle form of manipulation.

RE: That is why it is so essential that the psychotherapist’s affect is authentic – that the therapist brings a true and full sense of self to the relationship. Such authenticity is an expression of caring for the other person’s welfare –- being fully present and involved.

GEC: The second was rhythmic attunement?

RE: Rhythmic attunement involves sensing each client’s unique rhythm and adjusting ourselves to his or her natural internal rhythm. Some clients think rapidly and others more slowly. Some are slow to express their emotions and with other clients intense feelings jump readily to the surface.

GEC: I would guess that the pace could also vary greatly when the client is tapping into different points in their developmental journey?

RE: Or they may access and express thoughts or feelings at a different pace when feelings such as guilt, shame, or disgust are involved. These feeling in the client are often the opportunity to attune developmentally. Developmental attunement is about thinking developmentally, sensing the developmental age at which the client may need therapeutic attentitiveness, and responding to what would be normal in a child of that developmental age. Often in the beginning stages of therapy, and sometimes even later, this phenomena is like a black hole in space. But if we sensitize ourselves to think developmentally we begin to sense what a traumatized or neglected child of that particular age may require form a caring and contactfull adult.

GEC: I often have an energy reaction. I know there is something going on but I can’t quite get it into focus or find the words to describe it, sometimes for a long time. This is the element that teaches me patience and humility. You had one more.

RE: Cognitive attunement means focusing on how they make sense of the world, such as: “Something is wrong with me”; “People can’t be trusted”; “Life is a struggle.” These script beliefs as well as their core values shape how they organize their experiences and shape the events in their lives.

GEC: In our focus on attunement, do you believe in psychotherapy there is always the need for regression?

RE: No. Not always. Yet, I think many psychotherapists do not provide the support for a therapeutic regression when it is needed. Some clients require the support for a deep regression and a responding reparative relationship. Even when there is not a need for regression there is a need to address archaic issues contained in transference. The transference of archaic feeling and childhood ways coping may be enacted with the therapist, but these are more often expressed in the “transferences-of- everyday-life”.

I have clients who don’t seem to be in transference with me, but they do have transferential conflicts with their boss, anxious or avoidant attachments to their children, troubled relationships with their intimate partners, and many other kinds of emotionally-problematic relationships shaped by unresolved archaic ways of coping with relational disruptions. I think that some clients struggle with the unconscious question “Is this current relationship going to be the same or different than what I have grown up knowing and have come to expect?” They are often on guard against getting hurt, criticized, or emotionally-abandoned again.

GEC: Okay. So even if we are not working with them regressively, the transferential story often takes them back to those early childhood experiences and the decisions they made about themselves, other people, and the meaning of life? Some would call these life-script decisions.

RE: Yes. I think back to the work of Robert and Mary Goulding (1979) and their focus on the redecision of specific script decisions. The client’s decisions with which the Goulding worked tend to be rather cognitive; they are formed later in a child’s life when he or she is capable of concrete operations and the retention of explicit memory.

There are two other levels of life-script that are formed prior to vivid recall of explicit memory. Life-scripts may be formed during the period of life prior to concrete operations wherein implicit experiences build through little event, after little event, after little event. It is this accumulation of emotionally-laden experiences that begin to form into a rudimentary symbolization. These partially-symbolized conclusions, based on implicit memory, shape the individual’s sense of realty and generate the beliefs that that form and organize future experiences. The person’s experience is not one of having made a decision but rather on of “this is reality” or “this is how it has always been”.

With such implicit experiential conclusions no particular event is significant. The limiting script beliefs are formed from a series of relational disruptions and cumulative neglect of the child’s relational-needs. Some clients report that they have “always felt unloved,” “always been mistreated”, “always felt like shit”, or always known that “people are not trustable”.

GEC: It would seem that in the decision process, or rather in the concept of implicit conclusions, you are describing a process that is so minuscule and unrelenting. It is more like a systemic infection than a disease that has a locus. At a pre-school age it would probably be composed of a series of conclusions rather than a decision. This is a level much younger from where the Gouldings were focusing.

RE: That’s right. Implicit experiential conclusions represent a developmentally younger period of time and often reflect a pervasive sense of relational disruption that takes many repetitions before the child can begin to form a symbolic representation of that experience.

In addition to explicit decisions and implicit experiential conclusions there are also physiological survival reactions that form the basis of one’s life script. They are the pre-symbolic recordings within the body – in the muscular tissue and internal organs – that reflect the person’s emotional and relational history. They are composed from the tensions and muscular constrictions, the retroflection of the need for protection and self –expression. These survival reactions are physiological -- the holding of pre-conscious, sub-symbolic memories within the body. This is why we must work physically with some clients. The way in which we do experiential therapy depends on what combinations of physiological survival reactions, implicit experiential conclusions, or explicit memory are emerging within the client.

An expressive, experiential psychotherapy, such as redeicision therapy, Gestalt chair work, or the psychotherapy of introjection is often the treatment of choice for issues that are formed around explicit memory. I have illustrated various examples of an experiential psychotherapy in the book, “ Integrative Psychotherapy in Action” (2010).

When we are dealing with clients who’s cumulative neglect and trauma is formed as implicit memory we need to engage in a much longer process of a relational psychotherapy composed of attunement to affect, rhythm, developmental level, and relational-needs. The therapeutic principles and the therapeutic stance of a relational and integrative psychotherapy are defined and described in “Beyond Empathy: A Therapy of Contact-in-Relationship. (1999).

When we are faced with the bodily retroflections composed of physiological survival reactions it is essential that we engage in a body-oriented psychotherapy such as described by Edward Smith in his book, The Body in Psychotherapy (1985). For some clients it is necessary to integrate the experiential, relational, and physiological approaches in our therapeutic engagement.

GEC: The current negative climate concerning touch in psychotherapy makes working physiologically with clients more difficult?

RE: That is true. I attended a state psychological association’s ethics meeting and was sharing how I use touch and do physiological psychotherapy with some clients who are traumatized by early relational neglect or who have experience physical trauma. The chairperson of the ethics committee jumped out of his seat and declared, “If you touch clients in the way you are describing, you are absolutely unethical !” In his cognitive-behavioral therapy perspective he had no concept of how trauma is carried within the body and the profound positive effects of an ethically sensitive and relationally contactfull body psychotherapy.

GEC: So much for an open professional dialogue. I think a lot of scary assumptions sabotage what could be a meaningful conversation on this subject.

RE: Such a professional dialogue would provide the opportunity to explore the whole spectrum of physiological psychotherapy. I have many clients who I don’t touch. We don’t have that quality of relationship, or the need for touch has not yet emerged in the therapy because they need to focus on something other than possible restrictions in their body. With many of those clients who I do not touch I certainly use physical metaphors or activity such as: having them put their hands on their “aching heart”; asking them to fantasize that some loving person is holding them; exaggerating the pressure in their jaw when they “want to bite his head off”; or identifying where in their body they hold their anger, fear, or love. With some clients I may encourage them to do certain movements, to get up and stretch, or use a bioenergetics exercise to facilitate increased awareness or to relax a dissociative processes. In many cases I am doing body psychotherapy but I am not directly touching the client.

GEC: For sure, but I wouldn’t want you to downplay those times in intensive experiential psychotherapy where the work involves and requires an explicit physical component. Of course, it is never just working physically; it is the relating on a physical level deepens the client’s whole experience.

RE: There are other clients with whom I have intense physical contact. I hold them during a regression to a pre-verbal age or when they are expressively confronting the image of an abuser. I do deep mussel massage to release body tensions, unexpressed physiologically-based emotions, and to undo retoflections. Such physiological-psychotherapy can produce profound results. However any bodywork, experiential exercise, or redecision therapy must be done within a contactful therapeutic relationship – an involved relationship that exists before, during, and after the expressive methods are used. At that state psychological association’s meeting I wanted to have a through discussion about how, with whom, and when to do an ethical body therapy. Such discussion was not possible at that meeting – the American Academy of Psychotherapy is one of the few associations were such a frank discussion is possible

GEC: What you have been describing are the various parts of involvement. Can you say more about that?

RE: In the book, Integrative Psychotherapy: The Art and Science of Relationship (2003) we used the terms “involvement” and “presence” as categorical terms to describe our sense of being with and for the client -- this involves the therapists constant centering of the welfare of the client. Involvement includes our attunement to the client’s affect, rhythm, and developmental needs, in truly acknowledging each transaction of the client, and in being recriopically responsive to each verbal and non-verbal transaction .

GEC: You are consistently letting the client know you are there with them.

RE: That’s right. Another domain of involvement includes the process of “validation”. Validation is about respecting the significance of what the client thinks, feels, fantasizes, or how they behave, even if it doesn’t make much sense to us. There is always something being communicated in each gesture, set of words, each bodily movement, or how they organize their experience. Our clients need us to acknowledge, validate, and normalize their phenomenological experience –- to be fully involved in their discovery of their own psychological process

GEC: By leaving out criticizing judgments they are encouraged to own all of the different parts of themselves and set aside some of the judgment they may have harbored.

RE: That takes us into another dimension that I refer to as “ normalization”. Normalization includes discovering how the client’s behaviors, fantasies, and ways of making sense of the world were normal in a previous, often abnormal, situation. During the pre-operational and concrete operations phases of development a young child may make sense of their relationship by concluding such things as:

“ No one is there for me”; “Something’s wrong with me”; “People can’t be trusted”; or, ”There is no use”. These sense making conclusions or decisions may continue later in life as restricting script beliefs --- beliefs that were a “normal” way of making sense of dysfunctional relationships by a child at a time when he or she was ignored, criticized, or physically punished. These script beliefs that made sense to a child in a dysfunctional or abnormal situation years ago may form the blueprint and the schemas that will organize an adult’s life’s experiences years latter. I find it extremely important to normalize, within a developmental context, what many schools of psychotherapy define as “pathological”. I hope to talk more about the distinction between “normalization” and “psycho-pathology” at the conference in October.

GEC: I think you are talking about how the therapist helps to create a safe holding environment in which the therapeutic issues can be addressed rather than labeling or diagnosing the person.

RE: Yes, my goal is to de-pathologize the client’s labeling of there own psychological processes.

Perhaps we should save this discussion for the October conference and go on to the last subcategory of involvement called “presence”.

With presence the therapist sets aside her or his own goals, wishes, desires, and experience and focuses on being with the client. The concept of presence appears to be a paradox; it is both the giving of undivided attention to the client and the capacity to periodically shift awareness to our own phenomenological experience – the awareness of aspects of our own experiences that are used in helping us to understand what the client is experiencing. This is akin to what Kohut called “vicarious introspection” (1977). We then use this introspection and our developmental and affect attunement to form our phenomenological inquiries. So these four things together - acknowledgement, validation, normalization, and presence – are what I consider the core aspects of involvement. Our sensitive use of attument and involvement is much more than communication; these dimensions of a relational psychotherapy establish a sense of communion between client and therapist. Once this communion is established and maintained then the experiential methods of psychotherapy have a lasting effectiveness.

GEC: Okay. I would see all of these as being part of what you talk about as “contact-in- relationship”. Is that accurate?

RE: Yes, yes! They are all subcategories or dimensions of a therapy of contact-in-relationship. During the 1980’s a seminar of senior psychotherapists and supervisors at the Institute for Integrative Psychotherapy in New York listened to numerous tapes of psychotherapy sessions, transaction by transaction, looking for the components of an involved, contact-oriented psychotherapy. Our goal was to determine what quality of affect and action by the psychotherapist produced a healing quality in the relationship with the client. Our qualitative research produced dozens of descriptive terms that we factor analyzed into three main categories: inquiry, attunement, and involvement (Erskine, 1998). We took each of these categories and investigated the various dimensions or subcategories that included, among others, acknowledgement, validation, normalization, presence, in addition to the concept of relational-needs. I will talk much more about the therapeutic importance of relational-needs at the conference.

The purpose of our research was to understand what was effective in establishing a relational psychotherapy --- a psychotherapy where healing of the client’s internal disturbance occurs through the contactful presence of the psychotherapist. As a result we are now better able to teach other psychotherapists about the subtlities of making full-contact in the therapeutic relationship.

GEC: This seems like a good place to stop. Thanks Richard.

 

References:

Erskine, R. G. (1998). Attunement and involvement: therapeutic responses to relational needs. International Journal of Psychotherapy, 3: 235-244.

Erskine, R.G., Coursed, J.P. & Trautmann, R.L. (1999).

Beyond empathy: A therapy of contact-in-relationship. Philadelphia, PA & London: Bruner/Mazel.

Erskine, R.G. & Moursund, J.P. (2010). Integrative psychotherapy in action. Karnack Books, London.

(Originally published 1988, Sage Publications, Newbury Park, CA & London.)

Goulding, M.M. & Goulding, R.L. (1979). Changing lives through redecision therapy. New York: Brunner/Mazel.

Kohut, H. (1977). The Restoration of the Self. Chicago: University of Chicago Press.

Moursund, J.P. & Erskine, R.G. (2003. Integrative psychotherapy: The art and science of relationship. New York: Thompson/Wadsworth (Brooks/Cole).

Smith, E. (1985). The body in psychotherapy. North Carolina: McFarland & Co.

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