Integrative Psychotherapy Articles

Abstract

    This article explores the nature of the schizoid process, in which withdrawal serves to protect the individual in the face of psychological collapse. Someone who uses schizoid defenses for survival fears living in relationship and splits off from both the external world of experiences and the inner self. Caught between external and internal conflicts, the person may withdraw into autistic encapsulation, a primitive method of protection, and life is endured in a state of isolation, ambivalence, and confusion. This article considers how the schizoid condition may manifest as dissociative and autistic states, and a fourth pattern of insecure attachment is introduced. Case vignettes are used to illustrate the phenomenological experiences of the schizoid’s unspoken and sequestered world and to identify how contact and the methods of inquiry, involvement, and attunement are used in an intensive therapeutic relationship.

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    In the schizoid condition, a person lives an isolated and insulated existence with the outer world cut off and the inner world compartmentalized. This invisible fortress, as it was described by Bettleheim (1967), severely restricts the person’s contact with others and reinforces ideas that are self-generated and based on fantasy. Participation in living is seen as threatening, so others are only tolerated in order to survive. For schizoid individuals, the emergence of the self was arrested in childhood, and the self is now maintained in an encapsulated state that supports the integrity and continuity of a self, however limited and confined this may be.

    Understanding how the schizoid condition develops requires examining early stages of development, formation of the script system, and the impact of relationships on the organization and consolidation of a sense of self and self with others.

    In the earliest years, experience is known and organized in terms of sensation or the body ego. The very spirit of the infant is experienced in felt body experiences and the early relationship with the primary caregiver. Within that relationship, a sense of interrelatedness evolves in which the infant experiences a “me.” When the child’s earliest experiences consist of impingements and threats, with no one around to offer protection or comfort, and subsequent life experiences reinforce the world as dangerous and undependable, a large part of the person’s potential for fully experiencing the self is affected. Shut out of awareness, fundamental parts of self-states (states of “me-ness”) are stored as encapsulated mental structures that preserve the integrity and the continuity of a subjective sense of self. Archaic fixations—those parts of childhood experiences that have not been integrated—are also closed out of awareness as dissociative states.

    What is required in a therapeutic relationship so that the uncommunicable, walled-off parts of the schizoid client can be spoken, heard, and understood? And, at the same time, how can the integrity and consistency of the client be maintained so that self-emergence is facilitated? These two questions, along with a description of the schizoid world as dissociative and autistic, are the central subject of this article.

    As transactional analysts, we are in a unique position to work with both the intrapsychic and interpersonal components of a self hidden from the world and even from the person himself or herself. We understand the formation of ego states (Berne, 1961), the script system (Erskine & Zalcman, 1979), and the theory and methods of an integrative transactional analysis (Erskine, Moursund, & Trautmann, 1999), all ofwhich support an in-depth, relational psychotherapy. I find that an effective way to reach the withdrawn, isolated part of the person is to use Berne’s archaic Child ego state construct, a script system analysis, and the methods of inquiry, attunement, and involvement—the last of which are central to integrative psychotherapy as developed by Erskine and Trautmann.

Splits in the Self: Constructs from

Fairbairn and Guntrip

    In describing schizoid withdrawal, object relations theorists Fairbairn (1952) and Guntrip (1968/1995) suggested that the ego splits into four parts. Fairbairn described two splits. In the first, there is the central ego in touch with the outer world and another part of the ego that withdraws into the inner world. The second split occurs when the withdrawn ego splits into the libidinal ego and the antilibidinal ego. As the central ego desperately tries to cope with the outer world, the needs and wants of the child (libidinal ego) are obstructed by a persecutory ego (antilibidinal ego). The inner conflict created between needs desired and needs diminished or discounted leaves the intrapsychic domain in confusion and turmoil. When asked what they need, these schizoid individuals usually answer, “I don’t know” or “It really does not matter.”

    Guntrip added a third, ultimate split of the libidinal ego into the oral ego and the regressed ego. This then  is the dilemma of the schizoid position:

The primitive wholeness of the ego is now lost in a fourfold split, a depleted Central Ego coping with the outer world; a demanding Libidinal Ego inside persecuted by an angry Antilibidinal Ego; and finally a Regressed Ego which knows and accepts the fact that it is overwhelmed by fear and in a state of exhaustion, and that it will never be fit to live unless it can, so to speak, escape into a mental convalescence where it can be quiet, protected, and be given a chance to recuperate. (Hazell, 1994, p. 178)

A person who has split off parts of the self has lost perspective on the outer world as well as on inner experience. Ego formation becomescompromised. Erskine (1997) described how a part of the self becomes lost; I characterize it as the hidden self. In fact, the withdrawn part of the person is both lost and hidden.

Marie came to treatment because she was depressed and felt that she was alone and isolated. She reported that she always did things herself because there was never anyone there to help her. She said she felt like she was invisible when growing up. When asked what she wants or needs she has “no idea.” She experiences herself as “frozen in time and space.”

Between Objects: Withdrawal and

Dissociation as Defenses

    With the schizoid defense there is no relationship with another, no connection even with oneself. In working with people who use the schizoid condition as a protective position, I observe that there is not only a primitive withdrawal (e.g., to an autistic state of being), but also a dissociative defensive stance used to protect the continuity of existence. The ability to separate experiences from awareness, to use dissociation when the self is being threatened, allows the individual to escape from perceived danger. Withdrawal, as well as separation from internal and external experiences, becomes the shield against overpowering circumstances.

    In a study of 12 infants whose mothers were severely depressed, Fraiberg (1987) observed states of physiological shutdown in which withdrawal led to immobilization and freezing. Similarly, with schizoids, retreat into isolation and compartmentalization of unintegrated experiences allow them to continue to exist in a defensive system marked by continual vigilance, confusion, and solitude. Attempts to connect, followed by withdrawal from others and even the self, keep the person in perpetual isolation, revoking external object relations and living as what Guntrip (1968/1995) characterized as a “detached spectator” (p. 18).

    Schizoid individuals withdraw from internal objects that are disturbing and powerful. They may find temporary relief in the encapsulated isolation, a place in which to rest from the exhaustion and intensity of both internal and external upheaval. However, this farthest andextreme withdrawal is so remote that the person is totally cut off: Wants, needs, and demands are unknown. Primitive barriers keep the person isolated and lost even from the self.

    My premise is this: In the schizoid condition, the person lives in a world of isolation created by withdrawal from others; the person also lives in a matrix of unintegrated life experiences, while at the same time attempting to cope with the real world. He or she lives between—suspended as it were—because there is no sense of where to settle and what to call “me.” The withdrawal, along with the dissociated parts of the self, remains compartmentalized. For example, in recounting her autistic state, Williams (1993) described living in a world of perpetual blindness, deafness, and muteness even though she could see and hear and had the ability to speak. She used her withdrawal and dissociative states for protecting and sustaining her life. Such an autistic encapsulation is a protection of the child, and when maintained into adulthood, it constitutes a fixated, protective dynamic in the Child ego state. Being able to identify ego states, and especially Child ego states, has helped me to work with this early archaic position and to deal with the primary process that is inherent in the schizoid condition.

    Understanding and appreciating Winnicott’s (1988) work on impingements has also been useful in working with schizoid individuals. One way to deal with an impingement is to try to get away from the disruption or shock because it is overwhelming. If there is no one to soothe or comfort, then another solution is attempted. It appears that the autistic encapsulation comes about because the world is too much, so the person retreats into a space described by clients as “nothingness,” “a black hole,” “a shell,” “frozen,” and “not belonging to the world.” Khan (1974) reported a client who described herself as “living in a blanket” (p. 142). One of my own clients wrote, “The pain is too much; I want it to go away. I can make it go away because I go away, even from me.”

    For such individuals there can be little connection to the real world because there is no way to connect even with their own sense ofwho they really are. Fantasy supersedes reality. The world becomes dangerous, with no one to support, validate, or normalize thoughts and feelings. The norm becomes precarious attachment, at best, and most often avoidance of others. Such withdrawal to a fixated Child ego state enables the individual to cope; however, these adaptations reinforce archaic responses rather than enable the evolution of the self and new possibilities for dealing with problems. Often these individuals report feeling like an “it,” and they project this sense of being an object onto others, expecting to be treated in return as an object rather than a person.

    In summary, the works of Fairbairn, Guntrip, Bettleheim, Khan, Ogden, and Winnicott support my conclusion that autistic encapsulation is the psyche’s most primitive form of organization and the earliest form of withdrawal. This withdrawn existence as a protection is at the core of the schizoid condition. Also at the core are the developmental fixations and the dissociative states that reinforce the withdrawal. These are discussed in the next part of this article.

Detachment and Encapsulation:

The Hidden Self

     As a result of recent developmental research, we now know that the infant is a distinct, active participant in his or her environment (Cassidy & Shaver, 1999; Marrone, 1998; Stern, 1985). We also realize that for healthy development to proceed, babies need the presence of a loving mother figure who helps orient the baby to the world and eventually to his or her own being. As Bettleheim (1976) wrote: “The infant must first become important to a human being he can influence and who therefore becomes important to him” (p. 229). Mutual influence facilitates development by giving to the baby a sense of who “me” is. Through the infant’s actions and the appropriate responses from a caring other, the baby is invited to move out into the world with a beginning awareness of his or her self and a connection to others in the environment. In contrast, someone with a schizoid defense has no perception of invitations to be in theworld and with others. Within the schizoid structure the splitting keeps the need for contact and connection with others out of awareness.

    Work on attachment may help us to understand how the isolation and detachment from others endures in the schizoid compromise. (The compromise involves remaining suspended between desired contact with others and withdrawal from others.) In developing his theory of attachment, Bowlby (1958, 1969, 1973, 1988) identified affectional bonds as the basis for the growth of a secure and self-reliant personality. When there is separation, threat of separation, or no response to a need for attachment, the child first protests by crying and moving his or her body in an attempt to recover the mother. The child is not only angry, but anxious. If there is no response, the child realizes that no one is going to come and he or she becomes sad and quiet. Exhausted and left alone, the child ultimately detaches from the situation and even from his or her own sense of being. With cumulative trauma (Kahn, 1974), in which there are breaches in the mother’s role and perhaps also trauma involving major boundary impingements, detachment may be one of the primary components for survival and coping. Responsiveness from another, usually a preferred other, is the reciprocal response that is needed when needs are activated. When a responsive caretaker is missing, detaching from the needs and wants may become the norm.

As Marie went back to her early years she began to realize how depressed her mother had been. Marie remembers when she was very small being told by her mother to “go to your father” when she asked for her mother’s help. She went to her father and was abused. She separated herself from everyone. She separated herself from the abuse memories by pushing them out of awareness. With no one there, she disowned her wants and needs.

    As the child becomes detached, needs and desires from infancy through adolescence are solidified or frozen in time. Affect cannot be modulated and integrated. No sense of being a self can exist when internal and externalexperiences are perceived as chaotic; the wholeness of the ego states is lost, and the withdrawn, regressed part of the individual lies encapsulated. In his description of impingement on the child’s boundaries, Winnicott (1988) illustrated through his drawings the infant’s return to a state of “isolation in quiet” (p. 128) in order to gain some sense of being alive. For her part, Fraiberg (1987) described a “conservative withdrawal” after flight from threat (p. 200). This primitive isolated place is what sequesters the person in the withdrawn, schizoid position and protects a sensitive, vulnerable state of being from internal and external disturbances.

    However, maintaining this protective position inhibits activity and has a profound effect on mastery and self-efficacy. A system of organizing experiences is constructed to avoid the feelings and memories of life experiences. An armor of detachment and indifference, along with withdrawal surrounded by an autistic barrier, places the person in a hidden world in which fantasy runs rampant and overwhelming feelings are the norm. Basic needs and wants become lost in a massive psychic withdrawal, and relationships are dismissed because what is most needed is also what is most feared. The person is left suspended between both internal and external world encounters with no real relationship with either. The inner world consists of object relations filled with fantasies and dreams and a shell created by primitive isolation; with regard to the external world, the person is uninvolved and neither wants another nor has any expectations of help from another. It is as if the person cannot stay in either place and ends up lost, frightened, and alone. Cut off from relationships, there is no authentic sense of self. The experience of self-loss is considered to be “the result of an intersubjective catastrophe in which sustaining relations have been broken down at their most basic level” (Orange, Atwood, & Stolorow, 1997, p. 55).

The Fixated Child Ego State

    One of my intentions here is to help clarify some of the confusion that exists about archaic ego states, fixated defensive processes, and thepsychological neglect in trauma. It is useful for transactional analysts to consider Fairbairn’s and Guntrip’s levels of splitting in working with the archaic Child ego state. Berne (1961) stated that “the child includes an archaic Parent, an archaic Adult, and a still more archaic Child representing a still earlier ego state to which under stress it may return” (p. 301). Withdrawal as a protective procedure was described by Winnicott (1988) when he illustrated the infant’s return to a state of “isolation in quiet” in order to regain some sense of being alive. So it is with Guntrip’s model of splitting, which details an early preverbal withdrawal. Berne’s archaic Child contains a primitive state of being that becomes a place to maintain life; this seems identical to the considerations of Guntrip and Winnicott. The massive withdrawal, a temporary reprieve, becomes a way of life—an aspect of the life script. In transactional analysis, the script patterns of isolation, withdrawal, and splitting need to be considered when doing script analysis. Beliefs, feelings, desires, fantasies, behavioral patterns, and reinforcing memories are the focus of treatment in a therapeutic, relationship-oriented, integrative psychotherapy (Erskine & Moursund, 1988; Erskine & Zalcman, 1979). In the withdrawn and hidden place there is only existence, with no true sense of self and no sense of self with another. The person remains uninvolved, unintegrated, and lives in quiet desperation. Patterns of withdrawal and dissociation comprise the schizoid condition.

The “Between” Space

    An intensive psychotherapy is needed to affect the childhood core in individuals manifesting schizoid structures. Uncovering the conflicts underlying the problem, understanding the unconscious material, and creating a relationship are important in reaching the core of the Child ego state and its archaic content. Effective therapy with these clients requires working with both the hidden, sequestered part of the person’s being and the unintegrated historical experiences. It involves understanding the unconscious emotional conflicts, the unmet needs, and the loss ofrelationship. These individuals come to know and understand their experience through contact with their unmet needs and internal conflicts within the therapeutic relationship. Both the here-and-now relationship with the therapist and regression to stages of fixation and dissociation provide the path for unfreezing the early ego formation and the unfolding of a self. This is not an easy task, nor is it easy to put into words. For both client and therapy, the therapeutic process is unique to the relationship, and so it varies from moment to moment. Theory and technique are used as a guide, with the relationship as the medium.

    The theory and methods I use derive from an integrative psychotherapy approach (Erskine & Moursund, 1988; Erskine, Moursund, Trautmann, 1999). For those struggling with schizoid symptoms, the therapeutic relationship provides the contact-in-relationship that facilitates healing and the emergence of the withdrawn, lost self. Through gentle inquiry, the person’s subjective experiences can be explored, historical content examined, ways of coping understood, and the vulnerability of a hidden, frightened self supported. The therapeutic relationship becomes the matrix in which meaning and affective memories can be constructed so that the person’s narrative can be better understand and integrated. Cognitive, affective, sensory, and behavioral components are analyzed through inquiry into the person’s phenomenological, historical, and script systems.

    The ultimate purpose of the relational space created by the client and the therapist is to provide a place in which the client can reorganize an internal sense of being and emerge from isolation and historical detachment. Winnicott (1958) first described this place as “potential space” (p. 54); he identified this intersubjective field as an intermediate area of experiencing in which client and therapist work with the client’s repetitive patterns of feelings, thoughts, actions, and sensations. What is unknown and unthought becomes known and understood, what is disavowed and alienated becomes connected to feelings and sensations, and in this process, actions and behaviors arerecognized.

    In the reorganization of the personality, therapeutic interventions that deal with regression must be considered.

In one session Marie’s finger was barely moving as she laid curled up in her withdrawn “nothingness.” I reached out and with the tip of my finger touched the tip of her finger. She responded by curling her finger against mine and increasing the skin-to-skin pressure. Contact was made.

In such situations, a secure foundation forms out of contact with another who is present, attentive, and responsive to the person’s wants and needs. Such merger or attachment allows for the feeling of one-with-the-world that may evolve into an immersion in relationship in which interpersonal involvement is sought and received. Clearly, relational needs are not present only in childhood; “they are components of relationship that are present every day of our lives” (Erskine & Trautmann, 1996, p. 322). In relationship we engage with others; in a secure relationship, spontaneity, flexibility, and intimacy can be exhibited, and each person can be who he or she is.

Patterns of Insecure Attachment

    From our earliest attachments, we form a secure or insecure base. When relationships are not predictable and one’s sense of being is threatened, then uncertainty can result, and the child experiences that the sought-after relationship is sometimes there and sometimes not. This is called ambivalent attachment. A second type of insecure attachment, avoidant attachment (Bowlby, 1973), is characterized by minimizing the need for connection such that the child does not expect the other to be present or responsive. A third pattern of insecure or anxious attachment—disorganized attachment (Marrone, 1973)—has also been identified. In these cases the person’s life narrative is forgotten or confused, as seen in dissociative disorders (Barach, 1991; Liotti, 1992), and connection with the attachment object is haphazard.

    I propose a fourth pattern of insecure attachment, which I call “isolated” attachment.” In this pattern, relationships with others are notsustained in the representational system of the psyche. Internalized objects are exterminated by a barrier or shell. Cut off from people and the world, cut off from his or her needs and wants, the person withdraws so far into “nothingness” that no one is there, and even the sense of one’s being is nullified. This annihilation of the sense of self, of one’s own personhood, makes this pattern of attachment different from ambivalent, avoidant, or disorganized attachment; with isolated attachment there are no objects, no relationship at all. The person may take on the appearance of disinterest, indifference, and/or disdain and seem unapproachable or unreachable.

Methods of Dealing with the Encapsulated

Self in Therapy

    Because of the extreme isolation and annihilation of self and others that characterize those with schizoid disorders, therapy with such individuals needs to respectfully and consistently support the client’s unique position, deal with his or her motivation and the need for contact, and take into account intrapsychic processes such as ego states and life script. I have found the following methods to be particularly useful in this work.

    Contact with the withdrawn ego state. Providing a safe place for the emergence of the self and the establishment of a therapeutic bond is primary in therapy with severely withdrawn individuals. A major premise of integrative psychotherapy is that humans are relational and that the need for relationship is a primary motivating factor. The way we experience relationship is through contact, both internally and externally (Erskine & Trautmann, 1996). By making and being aware of contact and disruptions to it, the fixations and withdrawal that are part of the schizoid person’s psychic system and the relationship with the therapist can be analyzed. What has been imbedded in a history of helplessness, disorganization, and the threat of disintegration of the person’s being can be carefully uncovered and understood in the context of today’s life experiences. In working at the boundaries of hidden self—but one that is being invited into the world—the schizoid dilemma is revealed: to stay inside orto surface into the world. How the individual, with the therapist’s support and encouragement, can move from a position of avoidance of contact to connection with others becomes a major focus of the therapeutic work. Inquiry into the schizoid experience will help the person recognize: (1) the existence of withdrawal; 2) the significance of interruptions to contact through withdrawal; (3) the use of withdrawal as a coping strategy; and (4) the vulnerable self, hiding and lost to contact.

    The withdrawn space of encapsulation and the loss of relationship in the withdrawal need to be understood as an attempt to resolve internal and external conflicts experienced in the past.

Marie silently walked into my office and sat down on the couch. She withdrew into that empty and private space; she became more distant. I have often sat with her, usually in silence, honoring the withdrawal. Out of fear she withdraws and out of intense loneliness she reconnects.

    Involvement. Involvement has been described as the therapist’s willingness to be affected by the client, a reciprocal affective response from the therapist, a sensitivity to the client’s developmental level, a commitment to the client’s welfare, and an appropriate therapeutic relationship (Erskine, 1993; Erskine, Moursund, & Trautmann, 1999). In therapy with severely withdrawn individuals, the therapist must have the capacity and willingness to enter into a merger with the client and to remain committed to the therapeutic relationship. In relation to schizoid withdrawal, involvement as a therapeutic method pertains to: (1) acknowledging the existence of withdrawal: “You have this withdrawal . . .”; (2) validating the importance of the withdrawal: “There are important reasons for your withdrawal”; (3) normalizing the withdrawal: “This was a way for you to maintain your self”; and (4) using the therapist’s attuned responses: “I am here with you.”

    Involvement encourages acknowledging both the client’s internal process and the relationship with the therapist. This is crucial with schizoids because encapsulating reactions result when“attention has been deflected away from the objective world . . . in favor of a subjective, sensation dominated world which is under [the person’s] direct control” (Tustin, 1986, p. 25). Moving from the intrapsychic to the interpersonal realm allows the client to be heard, seen, and understood by another (the therapist) and to bring into consciousness the “black hole” or “shell” of disconnectedness. Finding points of contact and sharing the therapeutic space empowers the client to move out of the frozen, autistic shell. One client related to me that he had never before let anyone know about his hidden place; he was afraid if he did he would be labeled crazy and locked away just as his sister had been.

    As clients begin to deal with their protective defenses, they will, at times, enter the archaic encapsulation. At such points the therapist’s involvement is crucial to the reorganization of internal experience. This merging was described by Little (1981) as “basic unity” or “primary total undifferentiatedness” (p. 109). There is no clear sense of self or other, no distinction between inner and outer stimuli (Pine, 1985). In such cases, there is a merging of client with therapist that is “near absolute” (Kahn, 1974, p. 149). In this fusion the therapist must “be there, alive, alert, embodied, and vital” (p. 157), but without impinging on the client’s experience.

    If the therapist is successful, a magical state is created in which the illusion of uninterrupted unity through involvement exists. Such oneness allows the client’s emerging self to grow by interacting with the therapist as a part of the environment. A return to oneness gives the client a chance to find his or her psychic roots and to repair what Balint (1968) described as the “basic fault” (p. 21). One woman described her experience of oneness with the therapist as floating in an ocean—she had no boundaries, no beginning, and no end. From this place she reported she could begin to be in touch with herself.

    In the therapeutic relationship the therapist joins with the client in experiencing the affective connections needed for oneness and for emergent self states. The therapist, who is actively involved in the process, invites theclient into relationship by monitoring the client’s experiences and the meaning given by the person to contact with the therapist. For individuals who have walled themselves off through massive withdrawal, as in the schizoid position, the therapeutic relationship can serve as the site of the “undisturbed, harmoniously functioning other . . . [where] ‘twines’ coexists with oneness” (Ogden, 1990, p. 212). What we as therapists perceive of our clients’ signals and our responses to these signals is important for the development and preservation of the therapeutic relationship. While working with a regressed client, body sensations and movements are monitored. The therapist responds with words, motions, or even physical contact to the client’s sounds or movements. As Brazelton and Barnard (1990) wrote, “Human experience originates in empathic forms of actual physical touch” (p. 57). Telling a client that I hear her silent cry or see the tear trickling down her cheek is often enough to let the person know I am there. A touch of a finger tip, as with Marie, permits contact. Focusing on sounds and movements also encourages activity that has been suppressed.

    This regressive state, one of basic union as described by Balint, Little, Ogden, Pine, and Tustin, illustrates the essential role of the therapist in being with a client who has returned to the hidden self. A regression-in-relationship permits the client to be in the experience and at the same time to have someone present in a way that is enough, yet not too much. Therapists must be sensitive and respectful of the wants, needs, and fantasies that are awakened for the client in this regressed place and accepting of the intense affects that result without themselves becoming either overwhelmed or withdrawn in response.

There were times in session when Marie would not say a word. Even her body appeared lifeless. At other times she would pace or walk out of sessions in rage or panic. She reported watching me “from deep inside” to see how I responded when she was hopeless, raging, or fearful. She often expressed how important my aliveness was to her because it helped sustain her in her darkest moments. Myacceptance of her, wherever she was, was also important to our connection.

    The relationship with a regressed, withdrawn person involves consummate patience, tact, and skill (Tustin, 1986). In his work, Arieti (1974) wrote that the therapist needed perseverance in reaching such individuals. With regression, the therapist needs to be aware of the moments when the client is reaching out of the isolation. Through the intersubjective field, the therapist can monitor his or her own personal experience as well as the client’s meanings and affective experiences in the enactments. Contact with the client is initiated gently through a calm, interested presence. In the shared space between client and therapist, activity and inquiry should be minimized so that the emergence of the withdrawn Child ego state is encouraged.

    As the client moves through the psychic agony of loss and desolation and the physical pain of the regression, the therapist takes on a more active role in holding the desperate feelings. The therapist must bear both the client’s intense affects and his or her own countertransference reactions. Regression takes the client and therapist to “areas where psychotic anxieties predominate [and need to be] explored, early experiences uncovered, and delusional ideas recognized and resolved” (Little, 1990, p. 83). (Little is using the British term “psychotic anxieties” to refer to the child’s attempt to deal with a chaotic and unmanageable situation, one that overwhelms sensory perception.) The regression experiences enable the person to give meaning to what has not been reachable by encountering in the presence of another what was unknown and making meaning of these events. The experience of regression and relationship are both needed and dreaded for the client. However, working with the regression as regression-in-relationship facilitates awareness and growth in a person’s sense of being. Once constructed as a closed system, the person begins to slowly open up to the outside world.

    Attunement. The method of attunement supports the development of a core self by providing the sensitivity necessary for establishing a basic oneness or basic unity.Erskine and Trautmann (1996) conceptualized attunement as “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. . . . It is a process of communion and unity of interpersonal contact” (p. 320). Attunement is also categorized by the degree of resonance and reciprocity needed for contact-in-relationship. With the use of attunement the therapeutic relationship is enhanced by serving as the therapist’s inner guide to inquiry and the meanings that are given to the client’s experiences. Cognitive, affective, rhythmic, and developmental attunement are the major categories that the therapist blends into the therapeutic relationship to enhance contact (Erskine, Moursund, & Trautmann, 1999).

    Another way to view attunement is to look at internal disruptions to contact on four levels: existence, importance, resolution, and the self. In this way I have identified four components of the attunement process: affect resonance, attentiveness, mutuality, and openness and sharing.

    Affect resonance is the ability to resonate physically. The development of the self was described by Winnicott (1988) as moving from the merging of the infant with the environment, to the strengthening of the body-self as a unit dependent on physical care, to “the dawning of awareness” and recognition of another, and finally to the gradual development of socialization (p. 8). Affect resonance permits the client’s sounds and movements to be perceived and taken in by the therapist. “I hear you” and “I see you”—whether indicated verbally or nonverbally—acknowledge the client’s existence and strengthens his or her body ego. Much as the mother in the infant-mother dyad mirrors her child, the therapist reflects the client’s experiences, and the contact between the client and therapist thus becomes a pattern of relationship. Quiet moments (Pine, 1985) or “stillness at the center” (Little, 1981, p. 125) also facilitate a sense of body identity. In therapy, the strengthening of the body self is accomplished by the physical presence of the therapist and with words from the therapistsuch as: “I am here with you. You are here with me. I am aware of you in the space we are creating. You have an impact on me.” For the person who is withdrawn and lost to self and others, this is the beginning of a long process during which a self can begin to unfold.

    Attentiveness or attention to the present and immediate circumstances involves the interest and consideration the therapist gives to contact patterns and responses in meeting the client’s aliveness. The therapist must be attentive in such a way that his or her responses are instantaneous, what Guntrip (1968/1995) called “immediate relatedness” (p. 312). Without this immediacy, the client may again withdraw. The therapist’s attention to the client’s patterns of disconnection and attempts at connection provide information on when contact can be initiated. The therapist must also attend to concrete symbols used by the client so that archaic subjective experiences can be given meaning and understood. The therapist’s inquiry into the client’s symbolic world validates the client’s symbols in the context of the client-therapist relationship and transforms these symbols cognitively into abstract thought. With the therapist’s guidance, the client becomes the interpreting subject (Ogden, 1990) who can generate his or her own thoughts and interpret his or her own symbols. This provides the individual with the necessary cognitive experience to move out of fantasy and imagination into the real world.

    Mutuality is another important component in contacting the hidden self. Khan (1989) described “how the clinical process gradually involves two persons in a mutuality of relating and, if things fare well, in time enables them to part from each other in a state of grace and awakened unto their hidden selves” (p. 9). Mutuality focuses on the intersubjective field, that is, a sense of two people working together in a shared, reciprocal relationship. Much like the mother who teaches her young child to balance strong affects by supporting feelings for the child, the therapist absorbs (via countertransference) and embraces the affect through involvement in the client’s experience. Thus the organization of the client’s self comes about through the sustenance and help of another whoresponds to needs, wants, and feelings within the context of shared events. Both client and therapist benefit in a mutuality of relating.

    Exploring how the client currently tries to get his or her needs met reveals the protective mechanisms established in relation to earlier objects. The therapist’s interest in and consideration of the client’s needs, wants, and fantasies communicates the therapist’s commitment to and responsibility for the client’s well-being and increases his or her awareness of internal processes. Attention to breaks in the relationship and to therapeutic failures provides the therapist with a guideline about where and when to connect with the client. Disruptions in contact also provide the client with information on how, when, and under what circumstances he or she disengages from contact.

    Openness and sharing are also important elements in attunement. Not only does the client open himself or herself to the process, the therapist must also be an active part of the relationship, both candid and sensitive, vulnerable and open. Openness is facilitated by owning capabilities and limitations and acknowledging criticisms. The therapist’s participation in ongoing supervision allows for monitoring the course of treatment and supports an outcome of growth for both client and therapist.

Conclusion

    We do not yet understand all the factors involved in psychic healing or psychotherapeutic failure. However, specific factors can be identified that help us as therapists to help clients in their growth and development. One variable that is well documented in the clinical literature is that a consistent and dependable relationship with another provides an organizing experience that facilitates the emergence of the self for the client. The chaos of a “broken line of being” (Winnicott, 1988, p. 135) lessens through the experience of continuity provided by a relationship with a caring and responsive other.

    One of my clients, an artist, brought one of his sculptures to a session. On the outside were three pieces of clay that looked like rhinocerosskin, which he described as a protective wall. When he removed the outer shell he held a heart in his hand—his broken heart—which he had been able to uncover in the therapeutic relationship. Dealing in therapy with his isolation, withdrawal, dissociation, and developmental stages of fixation allowed him to reclaim himself. This illustrates how working with the dissociative parts of the schizoid position is not unlike working with dissociative identity disorder; both require integrating fragmented, compartmentalized experiences.

    The secret citadel, described by some clients as a bunker or a fortress, is a survival adaptation, a compromise between isolation and commitment to relationships. Coming out of that citadel means giving up a familiar way of life and requires immense support and encouragement. In therapy, the relationship between client and therapist facilitates these experiences as the client discovers, “This is who I am, how I feel, what I believe, and what I do; this is my past and where I came from; and this is what I need to do now to be responsible for myself and others.” For seriously withdrawn clients, regression-in-relationship can provide a safe environment in which client and therapist work and live together safely over time while the client goes through the essential experiences required for the formation of a stable sense of self. As one client wrote: “In my withdrawal I can sense you [the therapist] and I do not feel so alone. I get to know and understand this place I created a long time ago. I am not as afraid of this place or of you as I used to be. I am beginning to come out a little. A place for me to be with you is growing.”

    “The rebirth and regrowth of the lost living heart of the personality . . . is the ultimate problem” (Guntrip, 1968/1995, p. 12). As therapists we are entrusted with the very heart and spirit of the schizoid client, the part that has clung to a thread of hope, no matter how thin, that life can be different. We owe it to each of them to reach into our own hearts and souls as we do the therapeutic work, using our sensitivity, intelligence, and awareness as we invite their hidden, encapsulated selves to joinus in the real world.

    Marye O’Reilly-Knapp, D.N.Sc., C.S., is a Certified Transactional Analyst, a psychotherapist in private practice, and codirector of Phoenix Centers, Devon, Pennsylvania. She is also an adjunct professor for Widener University in Chester, Pennsylvania, and an associate of the Institute for Integrative Psychotherapy, New York. Please send reprint requests to her at 905 Newtown Rd., Devon, PA 19333, U.S.A.

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    Special thanks to Richard G. Erskine, Ph.D., for his lectures and discussions on the schizoid process, to the Professional Development Seminar in Kent for their support, and to Robin Fryer for her editorial assistance.