Psychothérapie Intégrative Articles

Methods of an Integrative Psychotherapy

Richard G. Erskine and Rebecca L. Trautmann

The term “integrative” as it is used in our approach to integrative psychotherapy has a number of meanings. Primarily it refers to the process of integrating the personality, which includes helping clients to become aware of and assimilate the contents of their fragmented and fixated ego states into an integrated neopsychic ego, to develop a sense of self that decreases the need for defense mechanisms and a life script, and to reengage the world and relationships with full contact. It is the process of making whole: taking disowned, unaware, unresolved aspects of the ego and making them part of a cohesive self (Erskine & Trautmann, 1993).

“Integrative” also refers to the integration of theory—the bringing together of affective, cognitive, behavioral, physiological, and systems approaches to psychotherapy. A central focus of an integrative psychotherapy is assessing whether each of these domains—affective, behavioral, cognitive, and physiological—is open or closed to contact (internally and externally) and applying methods that enhance contact (Erskine, 1975, 1980, 1982a). The concept of internal and external contact is used within a perspective of human development in which each phase of life presents heightened developmental tasks, unique sensitivities in relationship with other people, and opportunities for new learning. The term integrative psychotherapy, as used in this article, includes both meanings.

Integrative psychotherapy takes into account many views of human functioning: psychodynamic, client-centered, behaviorist, family therapy, Gestalt therapy, Reichian-influenced body psychotherapy, object relations theories, and psychoanalytic self psychology in addition to transactional analysis, which forms the main basis of our theory and method. Each provides a valid explanation of psychological function and behavior, and each is enhanced when selectively integrated with the others (Erskine & Moursund, 1988).

Contact and Relationships

A major premise of integrative psychotherapy is that the need for relationship constitutes a primary motivating experience of human behavior, and contact is the means by which the need is met. We especially emphasize the importance of contact in using the range of modalities just mentioned. Contact occurs internally and externally: It involves the full awareness of sensations, feelings, needs, sensorimotor activity, thoughts, and memories that occur within the individual and a shift to full awareness of external events as registered by each of the sensory organs. With internal and external contact, experiences are continually integrated. When contact is disrupted, however, needs are not satisfied. If the experience of need arousal is not satisfied or closed naturally, it must find an artificial closure that distracts from the discomfort of the unmet need. These artificial closures are the substance of survival reactions and script decisions that may become fixated. They are evident in the disavowal of affect, habitual behavior patterns, neurological inhibitions within the body, and the beliefs that limit spontaneity and flexibility in problem solving and relating to people. Each defensive interruption to contact impedes awareness (Erskine, 1980; Erskine & Trautmann, 1993).

Contact also refers to the quality of the transactions between two people: the awareness of both one’s self and the other, a sensitive meeting of the other, and an authentic acknowledgment of one’s self.

Integrative psychotherapy correlates constructs from many different theoretical schools. For a theory to be integrative, as opposed to merely eclectic, it must also separate out those concepts and ideas that are not theoretically consistent to form a cohesive core of constructs that inform and guide the psychotherapeutic process. A review of the psychology and psychotherapy literature reveals that the single most consistent concept is that of relationship (Erskine, 1989). From the inception of a theory of contact by Laura and Frederick Perls (Perls, 1944; Perls, Hefferline, & Goodman, 1951) to Rogers’s (1951) focus on client-centered therapy, to Fairbairn’s (1952) premise that people are relationship seeking from the beginning of and throughout life, to Sullivan’s (1953) emphasis on interpersonal contact, to Winnicott’s (1965) and Guntrip’s (1971) relationship theories and corresponding clinical applications, to Berne’s (1961, 1972) theories of ego states and script, to Kohut (1971, 1977) and his followers’ application of “sustained empathic inquiry” (Stolorow, Brandchaft, & Atwood, 1987, p. 10), to the relationship theories developed by the Stone Center (Bergman, 1991; Miller, 1986; Surrey, 1985), to Buber’s (1923/1958) philosophy of an I-Thou relationship, there has been a succession of teachers, writers, and therapists who have emphasized that relationships—both in the early stages of life as well as throughout adulthood—are the source of that which gives meaning and validation to the self.

The literature on human development also leads to the understanding that the sense of self and self-esteem emerge out of contact-in-relationship. From a theoretical foundation of contact-in-relationship coupled with Berne’s (1961) concept of ego states (particularly fixated Child ego states) (Erskine, 1987, 1988; Trautmann & Erskine, 1981) comes a natural focus on child development. The works of Stern (1985, 1995) and Bowlby (1969, 1973, 1980) are presently influential in informing an integrative perspective, largely because of their emphasis on early attachment and the natural, lifelong need for relationship. Bowlby emphasized the significance of early as well as prolonged physical bonding in the creation of a visceral core from which all experiences of self and other emerge. When such contact does not occur in accordance with the child’s relational needs, there is a physiological defense against the loss of contact (Fraiberg, 1982).

Integrative psychotherapy makes use of many perspectives on human functioning, but always from the point of view that the client-therapist relationship is crucial. The concepts of contact-in-relationship, ego states and intrapsychic function, transference and transactions, relational needs and affective reciprocity, and developmental process and life script are central to our integrative theory. The psychotherapist’s self is used in a directed way to assist the client’s process of developing and integrating contact and satisfying relational needs (Erskine, 1982a). Of central significance is the process called attunement, which involves not just a focus on discrete thoughts, feelings, behaviors, or physical sensations, but also on what Stern (1985) termed “vitality affects” (p. 156). We aim to create an experience of unbroken feeling-connectedness. The client’s sense of self and sense of relatedness that develop seem crucial to the process of integration and wholeness, particularly when there have been specific, ego-fragmenting traumas in the client’s life and when aspects of the self have been disavowed or denied because of the cumulative failures of contact-in-relationship (Erskine, 1991a, 1993, 1994).

The central premise underlying the practice of integrative psychotherapy is that integration can occur through a variety of modalities—affective, behavioral, cognitive, and physiological (Erskine, 1975, 1980)—but most effectively when there exists a respectful, contactful interpersonal therapeutic relationship (Erskine, 1982a). Inquiry, attunement, and involvement are sets of contact-facilitating, relationship-oriented methods. Previous publications defined and described the methods of inquiry, attunement, and involvement (Erskine & Trautmann, 1993), applied the methods to the treatment of dissociation (Erskine, 1991a, 1993) and shame and self-righteousness (Erskine, 1994), and demonstrated the application through actual therapy transcripts (Erskine, 1982b, 1991b; Erskine & Moursund, 1988). What follows is an outline of some of the methods that foster contact-in-relationship.

Inquiry

Inquiry begins with the assumption that the therapist knows nothing about the client’s experience and therefore must continually strive to understand the subjective meaning of the client’s behavior and intrapsychic process. The process of inquiry involves the therapist being open to discovering the client’s perspective while the client simultaneously discovers his or her sense of self with each of the therapist’s awareness-enhancing statements or questions. Through respectful exploration of the client’s phenomenological experience, the client becomes increasingly aware of both current and archaic relational needs, feelings, and behavior. Affect, thoughts, fantasy, script beliefs, body movements or tensions, hopes, and memories that have been kept from awareness by lack of dialogue or by repression may come to awareness. With increased awareness and the nonactivation of internal defenses, needs and feelings that may have been fixated and left unresolved due to past experiences are integrated into a more contactful self.

It should be stressed that the process of inquiring is as important, if not more so, than the content. The therapist’s inquiry must be empathic with the client’s subjective experience to be effective in discovering and revealing the internal phenomena and in uncovering the internal and external interruptions to contact.

This type of inquiry requires a genuine interest in the client’s subjective experiences and construction of meanings. It proceeds with questions about what the client is feeling, how he or she experiences both self and others (including the psychotherapist), and what meanings and conclusions are made. With sensitive questioning, our experience is that clients will reveal previously repressed fantasies and out-of-awareness intrapsychic dynamics. This provides both the client and the therapist with an ever-increasing understanding of who the client is, the experiences he or she has had, and when and how he or she interrupts contact.

Therapeutic inquiry about the client’s fears, anticipations, and expectations often reveals the transferring of historical experiences, archaic defenses, and past relational disruptions into current life, including the therapy relationship. Transference within this integrative perspective can be viewed as:

1. the means whereby the client can describe his or her past, the developmental needs that have been thwarted, and the defenses that were created to compensate;
2. the resistance to remembering and, paradoxically, an unaware enactment of childhood experiences (the repeated relationship);
3. the expression of an intrapsychic conflict and the desire to achieve the satisfaction of relational needs and intimacy in relationships (the therapeutically needed relationship); or
4. the expression of the universal psychological striving to organize experience and create meaning.

This integrative view of transference provides the basis for a continual honoring of the inherent communication in transference of both the repeated and the needed relationship (Stern, 1994), as well as recognition of and respect for the fact that transactions may be nontransferential and may have to do only with the here-and-now relationship between therapist and client (Erskine, 1991c).

Inquiry may include an exploration of intrapsychic conflicts and unaware enactments of childhood experiences and continue with historical questions as to when an experience occurred and the nature of the significant relationships in the person’s life. Through inquiry we explore the client’s script beliefs and related behaviors, fantasies, and reinforcing experiences (Erskine & Zalcman, 1979). In accordance with the client’s welfare, we integrate Gestalt therapy experiments, behavioral change contracts, body psychotherapy, intensive Parent ego state psychotherapy, or developmental regression (Erskine & Moursund, 1988). Through a combination of these techniques for enhancing self-awareness and through our respectful inquiry, experiences that in the past were necessarily excluded from awareness can again be remembered in the context of an involved therapeutic relationship. With memories, fantasies, or dreams coming to awareness, the therapist’s inquiry may return to the client’s phenomenological experience or proceed to the client’s strategies of coping, that is, to an inquiry about the defensive internal and external interruptions to contact.

As we explore defensive processes we make use of observable, external interruptions to contact as representative of internal interruptions to contact. Archaically fixated defensive interruptions to contact—for example, introjections and script beliefs—interfere with the satisfaction of today’s relational needs and emerge in the therapeutic relationship.

To be vulnerable is to be highly aware of relational needs and to be open, without defenses, to the other’s response to those needs. Inquiring about vulnerabilities both outside of and in the therapeutic relationship uncovers relational needs and the effects within the client of both the satisfaction or nonsatisfaction of those needs. The focus of the therapeutic dialogue may then cycle to phenomenological, transferential, or defensive levels of experience. The process of inquiry is not linear but moves in harmony with the client’s ever-increasing internal awareness and awareness of self-in-relationship.

The goal of therapeutic inquiry is for the client and therapist together to discover and distinguish the functions of intrapsychic processes and defensive dynamics. Each defensive dynamic has unique intrapsychic functions of identity, stability, continuity, and integrity that require specific emphasis in psychotherapy. Our thesis is that attunement and involvement allow the client to effectively transfer these intrapsychic functions to the relationship with the therapist. In what follows we will refer to the classifications shown in Figure 1.

It is essential that the therapist understand each client’s unique need for a stabilizing, validating, and reparative other person to take on some of the relationship functions that the client is attempting to manage alone. A contact-oriented relationship therapy requires that the therapist be attuned to these relationship needs and be involved, through empathic validation of feelings and needs and by providing safety and support.

A contactful inquiry about a client’s phenomenological experience enhances the client’s sense of self through facilitating the client’s awareness of the existence of feelings, fantasies, internal sensations, and thought processes as well as the existence of interruptions to contact. A patient, nonhumiliating inquiry into the client’s transferential dynamics reveals the significance of the internal and external interruptions to contact, how the person organizes experience, and the significance of both the repeated and the therapeutically needed relationship. The needed relationship is the client’s call for the reciprocal involvement by an essential other who can respond to relational needs. A respectful inquiry about the client’s defensive process—his or her means of coping—reveals the client’s integrity and unique style of resolving disruptions in relationship. This level of inquiry also brings to the client’s awareness other avenues of coping with relational disruptions and new possibilities for resolving interpersonal conflicts. A sensitive inquiry about the client’s vulnerabilities and his or her unique combination of relational needs increases the client’s value of self (see Figure 1). In the presence of an attuned, involved, and self-aware therapist who can respond to those relational needs, the client will feel a stronger, clearer sense of self and self-in-relationship. Psychological well-being is enhanced through full interpersonal and intrapsychic contact.

Attunement

Attunement is a two-part process: It begins with empathy—that is, being sensitive to and identifying with the other person’s sensations, needs, or feelings—and the communication of that sensitivity to the other person. More than just understanding or vicarious introspection, attunement is a kinesthetic and emotional sensing of the other—knowing his or her rhythm, affect, and experience by metaphorically being in his or her skin, thus going beyond empathy to provide a reciprocal affect and/or resonating response.

Attunement is more than empathy: It is a process of communion and unity of interpersonal contact. Effective attunement also requires that the therapist simultaneously remain aware of the boundary between client and therapist as well as his or her own internal processes. Attunement is facilitated by the therapist’s capacity to anticipate and observe the effects of his or her behavior on the client and to decenter from his or her own experience to extensively focus on the client’s process.

Figure 1

 

Methods of an Integrative Psychotherapy

The communication of attunement validates the client’s needs and feelings and lays the foundation for repairing the failures of previous relationships. Attunement is communicated not only by what the therapist says, but also by facial or body movements that signal to the client that his or her affect and needs are perceived, are significant, and make an impact on the therapist.

Attunement is often experienced by the client as the therapist gently moving through the defenses that have prevented the awareness of relationship failures and the related needs and feelings. Attunement facilitates contact with long-forgotten parts of Child ego states. Over time this results in a lessening of internal interruptions to contact and a corresponding dissolving of external defenses. Needs and feelings can increasingly be expressed with comfort and assurance that they will receive an empathic and caring response. Frequently the process of attunement provides a sense of safety and stability that enables the client to begin to remember and to endure regressing into childhood experiences that may bring a fuller awareness of the pain of past traumas, past failures of relationship(s), and loss of aspects of self. The process of attunement can be categorized according to the resonance and reciprocity required for contact-in-relationship. This attunement may be to rhythm, level of development, nature of affect, or relational need.

Rhythmic attunement is the pacing of the therapeutic inquiry and involvement at a tempo and cadence that best facilitates the client’s processing of both external information and internal sensations, feelings, and thoughts. In our experience the mental processing of affect often occurs at a rate different from cognitive processing. In the presence of intense affect the use of perception or cognition may be slower than when affect is not intense. For example, the compounded affective components of shame often make the processing of information and the organizing of behavior occur at a diminished rate. Shame is a complex process involving the disavowal and retroflection of anger, the sadness of not being accepted as one is, the fear of rejection because of who one is, and confluence and compliance with the relationship-interrupting humiliation (Erskine, 1994). The affective, perceptual, cognitive, behavioral, and physiological reactions occur at differing rhythms than would otherwise occur in the absence of shame.

Some clients are quickly aware of visceral and kinesthetic sensations while others process them slowly. Internal interruptions to contact or any of the complex psychological defenses such as desensitization, disavowal, denial, or dissociation disrupt the natural rhythm of processing physical sensations, affects, perceptions, and thoughts.

Affective attunement refers to one person sensing the other’s affect and responding with a reciprocal affect. It begins with valuing the other person’s affect as an extremely important form of human communication, being willing to be affectively aroused by the other person, and responding with the resonating affect.

“Affect is transactional-relational in its nature, requiring a corresponding affect in resonance” (Erskine, 1994, p. 99). The resonance of one person’s affect to another’s provides affective contact that is essential to human relationships. Symbolically, affective attunement may be pictured as one person’s yin to the other’s yang, which together form a unity. Affective attunement is the resonance with the other’s affect that provides nonverbal interpersonal contact—a unity in the relationship.

When a client feels sad, the therapist’s reciprocal affect of compassion and his or her acts of compassion complete the interpersonal contact. Relationally, anger requires the reciprocal affects related to attentiveness, seriousness, and responsibility, with possible acts of correction. The client who is afraid requires that the therapist respond with affect and action that conveys security and protection. When clients express joy the response from the therapist that completes the unity of contact is the reciprocal affect of vitality and expression of pleasure.

Affective attunement involves nonverbal communication from the therapist that acknowledges, validates, and normalizes the client’s affect. The therapist’s affective presence communicates that affect has an important function in relationship and thereby values the client—a communication of unconditional positive regard or “You’re OK with me.”

Developmental attunement. Attunement to the client’s developmental level of psychological functioning and organization of experiences is essential in a contact-oriented, relationship-centered psychotherapy. The purpose of the developmental focus is to respond to the client at the age level at which there was a lack of contact-in-relationship, when fixations occurred in the representational system of self, others, and the quality of life. The script beliefs and related archaic defenses represent attempts of a younger person to cope with life situations.

To attune to a client’s developmental needs, the therapist listens with a “third ear” or watches with a “third eye” the words and behaviors of the client in the moment to sense what may be the communication of a child. Often based on the age when a particular trauma occurred or when a script decision or survival reaction was made, the therapist begins to develop a sensitivity for the Child ego states as they are unconsciously manifested in current transactions. Having a sense of this child and its needs, its developmental challenges, ways of thinking and organizing, unique vulnerabilities, and relationship needs guides the therapist in the way he or she may inquire, interpret, or interact with the client.

As an example, in response to a client who was expressing frustration at her inadequacy in finding ways to talk about her feelings, the therapist commented that learning to use language brings a child two different experiences. On the one hand, words allow for increased communication and understanding, which is gratifying and fosters closeness. On the other, as the child experiences that words do not adequately convey feelings or experiences, there is a greater sense of separateness and sometimes aloneness (Stern, 1985). The tears in the client’s eyes conveyed that the therapist had understood her developmental frustration and at least one significant aspect of her lifelong difficulty with relationships—that unspoken experience of aloneness.

Attunement to the developmental level is easiest when the client enters a regressed state or is able to describe his or her Child ego state experiences. A subtler and sometimes more powerful experience occurs when the therapist is attuned to the client’s developmental needs, level of functioning, and childhood experiences while the client is completely unaware of them. For example, with a client who grew up anxiously trying to please his separated parents and who used compulsive checking to ward off anxiety, it seemed important not to make an issue of his consistent lateness until he was able to identify and express his anger at his parents. Near the end of the therapy he talked about how significant it was to him that the therapist never confronted his lateness, making his therapy a place of safety in which he could be free of his compulsions.

By being attuned to the archaic level of a person’s functioning and placing it directly in the context of the therapeutic relationship, the therapist makes it possible for fixed ways of being and relating to be integrated into a more dynamic whole.

Relational needs. The process of attunement also includes responding to relational needs as they emerge in the therapeutic relationship. Relational needs are the needs unique to interpersonal contact (Erskine, 1995). They are not the basic needs of life—such as food, air, or proper temperature—but the essential elements that enhance the quality of life and a sense of self-in-relationship. Relational needs are the component parts of a universal human desire for intimate relationship. Although there may be a large number of relational needs, the eight that we describe in this article represent those needs that our clients most frequently describe as they talk about significant relationships. Some of these relational needs have also been described in the psychotherapy literature as fixated needs of early childhood, indicators of psychopathology, or problematic transference (Bach, 1985; Basch, 1988; Kohut, 1971, 1977; Wolf, 1988), while Clark’s (1991) integrative perspective on empathic transactions bridges the concepts of transference and relational needs.

Relational needs are not only needs of childhood or needs that emerge in a developmental hierarchy; they are components of relationship that are present every day of our lives. Each of the eight relational needs may become figure or conscious as a longing or desire while the other seven remain out of consciousness or as background. A satisfying response by another person to an individual’s relational need allows the pressing need to recede to ground and another relational need to become figure as a new interest or desire.

Often it is in the absence of need satisfaction that an individual becomes most aware of the presence of relational needs. When relational needs are not satisfied the need becomes more intense and is phenomenologically experienced as longing, emptiness, a nagging loneliness, or an intense urge often accompanied by nervousness. The continued absence of satisfaction of relational needs may be manifested as frustration, aggression, or anger. When disruptions in relationship are prolonged, the lack of need satisfaction is manifested as a loss of energy or hope and shows up in script beliefs such as “No one is there for me” or “What’s the use?” These script beliefs are the cognitive defense against the awareness of needs and the feelings that occur when needs do not get a satisfying response from another person (Erskine, 1980).

The satisfaction of relational needs requires the contactful presence of another who is sensitive and attuned to the relational needs and who also provides a reciprocal response to each need. The eight principal relational needs that we observe are the needs for:

1. Security: the visceral experience of having our physical and emotional vulnerabilities protected. This involves the experience that our variety of needs and feelings are natural. Security is a sense of simultaneously being vulnerable and in harmony with another. It includes the absence of both actual or anticipated impingement or danger.

Attunement involves the empathic awareness of the other’s need for security within the relationship plus a reciprocal response to that need. The needed response is the provision of physical and affective security in which the individual’s vulnerability is honored and preserved. It communicates, often nonverbally, “Your needs and feelings are normal and acceptable to me.” Therapeutic attunement to the relational need for security has been described by clients as “total acceptance and protection,” a communication of “unconditional positive regard” or “I’m OK in this relationship.” Attunement to the need for security involves the therapist being sensitive to the importance of this need and conducting himself or herself both emotionally and behaviorally in a way that provides security in the relationship.

2. Validation, affirmation, and significance within a relationship: the need to have the other person validate the significance and function of our intrapsychic processes of affect, fantasy, and constructing of meaning and to validate that our emotions are a significant intrapsychic and interpersonal communication. It includes the need to have all of our relational needs affirmed and accepted as natural. The therapist’s affective reciprocity with the client’s feelings validates the client’s affect and provides affirmation and normalization of the client’s relational needs.

3. Acceptance by a stable, dependable, and protective other person: the need to look up to and rely on parents, elders, teachers, and mentors. The relational need for acceptance by a consistent, reliable, dependable other person is the search for protection and guidance and may manifest as an idealization of the other. In psychotherapy such idealization is also the search for protection from a controlling, humiliating Parent ego state’s intrapsychic effect on the vulnerability of Child ego states. It can also be the search for protection from one’s own escalation of affect or exaggeration of fantasies.

The therapist protects and facilitates integration of affect by providing an opportunity to express, contain, and/or understand the function of such dynamics. The degree to which an individual looks to someone and hopes that he or she is reliable, consistent, and dependable is directly proportional to the quest for intrapsychic protection, safe expression, containment, or beneficial insight. Idealizing or depending on someone is not necessarily pathological as implied in the popular psychology term, “codependent,” or when misinterpreted as “idealizing transference” (Kohut, 1977), or as Berne’s game of “Gee, You’re Wonderful, Professor!” (1964). When we refer to some clients’ expressions of this need to be accepted and protected as “a Victim looking for a Rescuer,” we potentially depreciate or even pathologize an essential human need for relationship that provides a sense of stability, reliability, and dependability.

In psychotherapy, attunement involves the therapist’s recognition, often unspoken, of the importance and necessity of idealizing as an unaware request for intrapsychic protection. Such a therapeutic involvement includes both the client’s sense of the psychotherapist’s interest in the client’s welfare and the use of the therapist’s integrated sense of self as the most effective therapeutic tool (Erskine, 1982a). This relational need to be accepted by a stable, dependable, and protective other person provides a client-centered reason to conduct our lives and psychotherapy practices ethically and morally.

4. Confirmation of personal experience: The need to have experience confirmed is manifested through the desire to be in the presence of someone who is similar, who understands because he or she has had a like experience, and whose shared experience is confirming. Attunement is provided by the therapist valuing the need for confirmation by revealing carefully selected personal experiences—mindfully (i.e., client-focused) sharing vulnerabilities or similar feelings and fantasies—and by being personally present and vital.

For example, affirmation of the client’s experience may include the therapist joining in or valuing the client’s fantasies. Rather than define a client’s internal storytelling as “just a fantasy,” it is essential to engage the client in the expression of the needs, hopes, relational conflicts, and protective strategies that may constitute the core of the fantasies. Attunement to the need for affirmation of experience may be achieved by the therapist accepting everything said by the client, even when fantasy and reality are intertwined, much like the telling of a dream reveals the intrapsychic process. Fantasy images or symbols have significant intrapsychic and interpersonal functions that may include stability, continuity, identity, and predictability. When the function of the fantasy is acknowledged, appreciated, and valued, the person feels affirmed in his or her experience.

The client who needs confirmation of personal experience requires a uniquely different reciprocal response from the client who needs validation of affect or who needs to be accepted by a dependable and protective other. In neither of the latter two relational needs is the sharing of personal experience or the creating of an atmosphere of mutuality an attuned response to the client’s need.

5. Self-definition: the relational need to know and express one’s own uniqueness and to receive acknowledgment and acceptance by the other. Self-definition is the communication of one’s self-chosen identity through the expression of preferences, interests, and ideas without humiliation or rejection.

In the absence of satisfying acknowledgment and acceptance, the expression of self-definition may take unconscious adversarial forms such as the person who begins sentences with “No, . . . .” even when agreeing, or who constantly engages in arguments or competition. People often compete to define themselves as distinct from others in order to maintain a sense of their own integrity. The more alike people are the greater the thrust for self-defining competition.

Therapeutic attunement occurs in the therapist’s consistent support for the client’s expression of identity and his or her normalization of the need for self-definition. It requires the therapist’s consistent presence, contactfulness, and respect even in the face of disagreement.

6. The need to have an impact on the other person: Impact refers to having an influence that affects the other in some desired way. An individual’s sense of competency in a relationship emerges from agency and efficacy—attracting the other’s attention and interest, influencing what may be of interest to the other person, and effecting a change of affect or behavior in the other.

Attunement to the client’s need to have an impact occurs when the psychotherapist allows himself or herself to be emotionally impacted by the client and to respond with compassion when the client is sad, to provide an affect of security when the client is scared, to take the client seriously when he or she is angry, and to be excited when the client is joyful. Attunement may include soliciting the client’s criticism of the therapist’s behavior and making the necessary changes so the client has a sense of impact within the therapeutic relationship.

7. The need to have the other initiate: Initiation refers to the impetus for making interpersonal contact with another person. It is the reaching out to the other in some way that acknowledges and validates the importance of him or her in the relationship.

The psychotherapist may be subject to a theory-induced countertransference when he or she universally applies the methodological concepts of nongratification, rescuing, or self-responsibility. While waiting for the client to initiate, the psychotherapist may not be accounting for the fact that some behavior that appears passive may actually be an expression of the relational need to have the other initiate.

To respond to the client’s need it may be necessary for the therapist to initiate a dialogue, to move out of his or her chair and sit near the client, or to make a phone call to the client between sessions. The therapist’s willingness to initiate interpersonal contact or to take responsibility for a major share of the therapeutic work normalizes the client’s relational need to have someone else reach out to him or her.

8. The need to express love: Love is often expressed through quiet gratitude, thankfulness, giving affection, or doing something for the other person. The importance of the relational need to give love—whether it be from children to parents, sibling, or teacher, or from client to therapist—is often overlooked in the practice of psychotherapy. When the expression of love is stymied, the expression of self-in-relationship is thwarted. Too often psychotherapists have treated clients’ expression of affection as manipulation, transference, or a violation of a neutral therapeutic boundary.

Those clients for whom the absence of satisfaction of relational needs is cumulative require a consistent and dependable attunement and involvement by the psychotherapist that acknowledges, validates, and normalizes relational needs and related affect. It is through the psychotherapist’s sustained contactful presence that the cumulative trauma (Khan, 1963) of the lack of need satisfaction can be addressed and the needs responded to within the therapeutic relationship.

Involvement

Therapeutic involvement that includes acknowledgment, validation, normalization, and presence diminishes internal defensive processes. The therapist’s acknowledgment of the client begins with an attunement to the client’s affect, relational needs, rhythm, and developmental level of functioning. Through sensitivity to relational needs or physiological expression of emotions the therapist can guide the client to become aware of and to express needs and feelings or to acknowledge that feelings or physical sensations may be memory—the only way of remembering that may be available. In many cases of relationship failure the person’s relational needs or feelings were not acknowledged, and it may be necessary in psychotherapy to help the person gain a vocabulary and learn to voice those feelings and needs. Acknowledgment of physical sensations, relational needs, and affect helps the client claim his or her own phenomenological experience. It includes a receptive other who knows and communicates about the existence of nonverbal movements, tensing of muscles, affect, or even fantasy.

Occasionally, selectively chosen, caring confrontations are also a part of acknowledgment. Confrontation is a statement or question used by the therapist to bring into the client’s awareness a discrepancy between his or her perceptions and behaviors or between script beliefs and actual events (Erskine, 1982b, 1991b). The goal of confrontation is for both client and therapist to acknowledge the existence and then the significance of behaviors, interruptions to contact, or script beliefs. The usefulness of the confrontation is related to the client’s discovering the psychological function (e.g., stability, continuity, identity, and/or predictability) of the behavior or defensive reaction and the therapist’s validation of its archaic significance. Confrontations are only effective if done respectfully and without humiliation so that the client experiences his or her welfare being enhanced.

There may have been times in a client’s life when feelings or relational needs were acknowledged but not validated. Validation communicates to the client that his or her affect, defenses, physical sensations, or behavioral patterns are related to something significant in his or her experience. Validation makes a link between cause and effect; it values the individual’s idiosyncrasies and way of being in relationship. It diminishes the possibility of the client internally disavowing or denying the significance of affect, physical sensation, memory, or dreams. And it supports the client in valuing his or her phenomenological experience and transferential communication of the needed relationship, thereby increasing self-esteem.

The intent of normalization is to change the way clients or others categorize or define their internal experience or their behavioral attempts at coping from a pathological or “something’s-wrong-with-me” perspective to one that respects archaic attempts at resolution of conflicts. It may be essential for the therapist to counter societal or parental messages such as “You’re stupid for feeling scared” with “Anyone would be scared in that situation.” Many flashbacks, bizarre fantasies, and nightmares as well as much confusion, panic, and defensiveness are normal coping phenomena in abnormal situations. It is imperative that the therapist communicate that the client’s experience is a normal defensive reaction—a reaction that many people would have if they encountered similar life experiences.

Presence is provided through the psychotherapist’s sustained, attuned responses to both verbal and nonverbal expressions of the client. It occurs when the behavior and communication of the psychotherapist at all times respect and enhance the client’s integrity. Presence includes the therapist’s receptivity to clients’ affect—to be impacted by their emotions, to be moved and yet to stay responsive to the impact of their emotions and not to become anxious, depressed, or angry. Presence is an expression of the psychotherapist’s full internal and external contact. It communicates the psychotherapist’s responsibility, dependability, and reliability. Through the therapist’s full presence, the transformative potential of a relationship-oriented psychotherapy is possible. Presence describes the therapist’s providing a safe interpersonal connection. More than just verbal communication, presence is a communion between client and therapist.

Presence is enhanced when the therapist decenters from his or her own needs, feelings, fantasies, or hopes and centers instead on the client’s process. Presence also includes the converse of decentering, that is, being fully contactful with his or her own internal process and reactions. The therapist’s history, relational needs, sensitivities, theories, professional experience, own psychotherapy, and reading interests all shape unique reactions to the client. Presence involves both bringing the richness of the therapist’s experiences to the therapeutic relationship as well as decentering from the self of the therapist and centering on the client’s process.

Presence also includes allowing oneself to be manipulated and shaped by the client in a way that provides for the client’s self-expression. As effective psychotherapists we are played with and genuinely become the clay that is molded and shaped to fit the client’s expression of his or her intrapsychic world toward the creation of a new sense of self and self-in-relationship (Winnicott, 1965).

The therapist’s involvement through transactions that acknowledge, validate, and normalize the client’s phenomenological experience, system of organization, and integrity is the antidote to the toxicity of discounting the existence, significance, or responsibility for resolving disruptions of contact-in-relationship. The dependable, attuned presence of the therapist counters the client’s discounting of his or her self-worth (Erskine, 1994).

Juxtaposition

The psychotherapist who is involved and responsive to the therapeutically needed relationship may stimulate a reaction in the client to the juxtaposition between the attuned contact offered by the therapist and the emotional memories of previous misattunements (Erskine, 1991a, 1993). The juxtaposition is in the contrast between what is provided in the therapy, such as the attuned, reciprocal responsiveness of the therapeutic relationship, and what was previously needed, longed for, and not experienced. It represents a challenge to the client’s script system and psychological homeostasis (Bary & Hufford, 1990). The juxtaposition stimulates emotional memories that the client may then try to push out of consciousness. Often juxtaposition is manifested by pushing the therapist away after a close encounter, finding fault with the therapist for focusing on the client’s “neediness,” or coming late or canceling a session following one in which the client allowed himself or herself to depend on the therapist’s affective reciprocity or responsiveness to relational needs.

Such a reaction to the juxtaposition between the attuned involvement of the therapist and the client’s emotional memories may indicate that the psychotherapist is pacing the therapy faster than the client can integrate the experience. In cases of physical and sexual abuse or cumulative trauma from prolonged misattunements to affect and relational needs, the client’s reactions to juxtaposition may also indicate that the intensity of the therapeutic involvement is too great and does not allow for a sense of safety. The reaction to juxtaposition occurs when the client’s coping or defensive system is relaxed and the self-protective functions are transferred to the therapeutic relationship faster than the homeostatic process allows. The therapist’s sensitive involvement is in the continual adjustment of the rhythmic and affective attunement, the quality of responsiveness to relational needs, and a respect for the homeostatic function of the client’s coping style and integrity.

Summary

A contact-oriented relationship psychotherapy that centers on inquiry, attunement, and involvement responds to the client’s current needs for an emotionally nurturing relationship that is reparative and sustaining. The aim of this kind of therapy is the integration of affect-laden experiences and fragmented states of the ego and an intrapsychic reorganization of the client’s fixated script beliefs about self, others, and the quality of life.

Contact facilitates the dissolving of defenses and the integration of the disowned parts of the personality. Through contact, the disowned, unaware, unresolved experiences are made part of a cohesive self. In integrative psychotherapy the concept of contact is the central focus from which clinical interventions are derived. Transference, ego state regression, activation of the intrapsychic influence of introjection, and the presence of defense mechanisms and script beliefs are all understood as indications of previous contact and relationship deficits. Full intrapsychic and interpersonal contact becomes possible when a client experiences that the therapist (1) stays attuned to the client’s rhythm, affect, and needs; (2) is sensitive to the client’s psychological functioning at the relevant developmental ages; (3) respects each interruption to contact and self-protective defense; and (4) is interested in understanding the client’s way of constructing meaning.

The four dimensions of human functioning—affective, behavioral, cognitive, and physiological—are an important guide in determining where someone is open or closed to contact and therefore to therapeutic support. A major goal of integrative psychotherapy is to use the therapist-client relationship—the ability to create contact in the present—as a stepping-stone to satisfying relationships with other people and a unified, fulfilled sense of self.

A guiding principle of this contact-oriented, interactive psychotherapy is respect for the integrity of the client. Through respect, kindness, compassion, and maintaining contact we establish a personal presence and allow for an interpersonal relationship that provides affirmation of the client’s integrity. The methods that ease intrapsychic conflict, facilitate script cure, resolve transference, and promote the integration of a fragmented ego are based on the belief that healing occurs primarily through the interpersonal contact of a therapeutic relationship. With integration it becomes possible for the person to face each moment with spontaneity and flexibility in solving life’s problems and in relating to people.

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This article was originally published in the Transactional Analysis Journal, Volume 26, Number 4, October 1996, pp. 316-328. The authors gratefully acknowledge the members of the Professional Development Seminars of the Institute for Integrative Psychotherapy, New York, New York; Kent, Connecticut; Dayton, Ohio; Chicago, Illinois; and Vancouver, British Columbia, Canada, for their contributions in forming the ideas in this article. A special thank you to Steven Roberts, M.S.W., and Barbara Clark, Ph.D., for their clarification of ideas. Portions of this article were presented as a keynote speech entitled, “A Transactional Analysis Theory of Methods,” and also as a workshop entitled, “Inquiry, Attunement, and Involvement: The Application of Transactional Analysis Theory,” at the 33rd Annual Conference of the International Transactional Analysis Association, San Francisco, CA, August 11, 1995.

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