Working Relationally and Developmentally in Integrative Psychotherapy:

Working Relationally and Developmentally in Integrative Psychotherapy:

Facilitating Significant Change

Silvia Allari

Abstract

This article describes a developmentally based, relationally focused integrative psychotherapy with a man who, as the result of an injury in infancy, had come to believe that I will never have a good life. The author recounts this V individual psychotherapy and the therapeutic work he did in the context of a relational group process. The therapeutic descriptions highlight the concept of relational needs.

Keywords: Group therapy, integrative psychotherapy, relational needs, relational group therapy, reactive and responsive countertransference, therapeutic relationship, Richard Erskine

This article is about Giuseppe and the ways in which I as his therapist have been both professionally and personally impacted by the impassioned story of his early life. Giuseppe had to fight for survival because he was born with a congenital disease. Although he has endured many painful and troubling experiences, he remains eager to live life fully. He is highly motivated and works hard in therapy to achieve a healthy and vital self even though he is burdened with a physical disability. I want to share Giu \ bcaH I H c aG acQ I have for him and because the work reflects my own growing competence as an integrative psychotherapist.

Giuseppe psychotherapy is ongoing. During a group therapy session a few months ago, sparkling with excitement, hope, and faith. Our group session was about to begin, and Giuseppe's happiness was contagious. I waited with anticipation because it was obvious that he had some important news that he was bursting to share. When the session began, Giuseppe immediately asked to speak. He could not sit still in his chair and rubbed his hands together in aac. I am thrilled to share it with you all. I signed the contract. Starting in September, I will work in that place I told you

ab.T! This was a cause for celebration.

I was emotionally moved and spontaneously clapped as well. Something positive

Giuseppe went on to talk about his future job, how he would be trained, and his excitement about learning new things. The others asked him many questions. Luca, who works as an accountant, asked Giuseppe about the financial aspects of the job since Giuseppe was new to the business world. Giuseppe revealed the financial details to Luca, who asked him about it. I thought that Luca was acting like a caring, protective father who was offering support in a gentle, sensitive way. Francesco stood up and gave Giuseppe a high : You have. I Z X aH . FaccR H a b R G. H a \ K G , aG im express his own feelings. Cecilia asked Giuseppe who his coworkers would be and about the relational aspects of the new situation. She is like a sister to Giuseppe, H aG a. Sa H : G, H bQ a. Caa! When Giuseppe first joined the group, Sofia responded to him like an elder sister who was jealous, with a tendency to exclude rather than include. She had now built a strong maternal bond with Giuseppe, one made of love, support, encouragement, and caregiving. Maria gave her opinion as well. She had built her life around her job, which was essential to her in terms of identification and valuation of herself. Now she had begun to identify with the positive parts, which her recent professional success had alloG R . I c\ aG H a, G. BcG a a aO a.

I bG H ac aG a K a . Schildhood H

beginning, we had been engaged in a relational group process in which each member was encouraged to be actively invested in the welfare of the others (Erskine, 2015).

Although Giuseppe has not arrived at the end of his psychotherapy, he has reached an important milestone. He has been reevaluating the early childhood reactions, conclusions, and decisions that constituted the core of his life script, one in which he had lost hope and faith in both himself and others, in which it seemed impossible to find a sense of internal calmness and meaning in life, and in which H ca\ ccG cJ childhood R W ccQ aW I aa. N, H session just described, Giuseppe was different aca,I caQ cc. IaH ca. LH aa! (OR-Knapp & Erskine, 2010).

Giuseppe Hior\

Giuseppe was born with a serious intestinal dysfunction. He had his first kidney surgery right after he was born and the second when he was just 2 months old. The second surgery led to a medical error that required five additional surgeries. Giuseppe, who is now 33 years old, lives with a permanent external prosthesis.

After his birth, Giuseppe spent a long time in an incubator, and later in childhood he was confined to a hospital bed for prolonged periods of time. His only companions were the nurses, doctors, and other patients. When Giuseppe was born, his mother was only 18 and his father only 20. They lived in a small village in the south of Italy and were quite poor. When Giuseppe was 4, his younger sister was born. He reports that she is physically healthy but suffers from serious psychological problems.

G a ienced in life and unprepared to face their aJ aK a. TH V aG abchildhood GH experienced, which he referred to often in psychotherapy, was more the result of a K aG childhood aQ U caac\ U emotional connection and attunement.

The Psychotherapy

Giuseppe began psychotherapy 3 years ago. I worked with him in individual sessions for 18 months. A year and a half ago I invited him to join the relational psychotherapy group I conduct weekly in which each member is committed to

, ac, aG b\ H ac c.

Erskine (2010) described such a group as follows:

The healing of stress and trauma may also occur through the multiple

relationships in an effective group psychotherapy where the group members

a G aG aG R acK ac, , aaO ,

cognition, and developmental age of shame, neglect or trauma. (p. 1)

The group has provided Giuseppe with a therapeutic space in which to redefine himself, create new attitudes about life, embrace his own adult capacities, and strengthen his trust in relationships with people. Several aspects of a relational a aca G a a :

.

The shared humanity of the other members of the group

.

The contactful presence of both other group members and me as the therapist

.

Authentic inquiry about each person

.

Honest exchange and clear feedback

.

An atmosphere of acceptance, warmth, and love

G aO J aG Z -esteem began with maternal neglect when he was an infant and continued with repeated disruptions in interpersonal contact throughout his childhood. In the group, he found relationships that were caring and supportive of who he was and what he could become. Groups members particularly responded to his various relational needs. Erskine has described eight relational needs and their significance at various developmental ages (Erskine, Moursund, & Trautmann, 1999). I find this integrative psychotherapy concept particularly useful in individual and group psychotherapy because it makes explicit the therapeutic function of the group as a setting centered on interpersonal relationships.

In the group, Giuseppe experimented with how to be in relationship with others. The group helped him to identify and appreciate the relational needs that he had started acknowledging in his individual therapy. The group provided Giuseppe with others who:

.

Offered a steady, consistent, and safe presence as well as a place in which he could be himself without fear of losing respect (the need for security)

.

Were interested in listening to him express himself and who appreciated his uniqueness (the need for self-definition)

.

Offered sensitive responses to his life history and self-expressions as though his thoughts, feelings, fears, and behaviors were meaningful and valuable (the need for validation, affirmation, and significance within a relationship)

.

Provided him with reliable, encouraging, and useful information (the need for acceptance by stable, dependable, and protective others)

.

Shared their own life experiences that mirrored his physical, emotional, and relational experiences (the need for mutuality and confirmation of personal experience)

.

Responded to his efforts to elicit an emotional response and who were influenced by his requests, opinions, and preferences. Maria once said to him,

We I a ab \ aG X O H X abW , I a emotional, a I cG . (T a a ac aU person)

.

Initiated by asking his opinion and inquiring about his health and what was occurring in his daily life. For instance, Francesco and Cecilia frequently asked if he was being compliant in the group or if he was truly expressing himself. Others asked if he cleaned his prosthesis, which is essential to avoid infections and severe back pain (the need of having the other initiate).

.

Willingly accepted his appreciation, gratitude, and affection. Giuseppe is a friendly, loving person, and in the group he meets people like him. For example, Andrea hugs him; Claudia is learning to express her feelings and Giuseppe helps her, like a teacher (the need to express love).

In the group, Giuseppe has found a place where he can feel alive, confident in himself, and that it is OK to have his relational needs satisfied. Previously, in his individual psychotherapy, he had started to define his identity in relationship with a significant other (me as his therapist) and to feel safe, mirrored, and respected. Ia b c Gc ; support, he began to do just that.

Individual Psychotherapy

G achildhood acaQ H therapy group became possible only after the intense 18 months of individual psychotherapy that we did together. I liked Giuseppe from the first session. He has black eyes, vivid and deep, curious and needy, yet experienced in life. He has a small body, a beard, and thick black hair. Physically, he looks to me like both a man and a child in the same body. Later, I would learn that my impression of his physical structure reflected his psychological structure: In the foreground is the man (who is aware, knowledgeable, with full reasoning capacity), and in the background, is the child (withdrawn and suffering in silence).

Giuseppe came to therapy because he was experiencing mood swings bQ S a G b\ \ achildhood Q H , aW R . T caW J a aJ aG W P K H energy. In our initial session, it was evident that I would be working with two people in one body: a sad Giuseppe and a Giuseppe full of life and energy.

On the one hand, I was facing a guy with a great desire to do things, to meet new people (he had recently moved to Milan), and to start new professional projects. Giuseppe told me about his projects with enthusiasm, with energy in his voice and his attitude. On the other hand, when he told me about his health problems, Giuseppe coldly described his medical conditions in minute detail, with scientific precision. Although he was like a talking medical record, I was deeply moved by how much physical and psychological suffering he had endured. Emotions, linked to difficult experiences of care and hospitalization, were blocked and frozen, not yet integrated.

Giuseppe spoke in a detached, emotionless manner about past events in his life, and I listened with rapt attention. His story did not have any emotional color; it was all black or white. There were no emotional shades showing that Giuseppe had fully lived, with his body and his mind, the experiences he described. A double Giuseppe sat in my office that first day: a man who looked rational, skilled, and smart, and a hidden Giuseppe who was privately suffering. Giuseppe stimulated me to feel with and for him. I wanted to express all the emotions he was not expressing while he talked in a detached way about his hospitalizations, surgeries, and postsurgical pain.

When he stopped talking, there was something incomplete. I realized that I was engulfed in countertransference. I wondered if my feelings were a reactive countertransference to some unresolved conflict in me or if I was being emotionally responsive to what he needed from a sensitive, involved other person. Giuseppe could see the expressions on my face, my sorrow for the pain he felt, and my anger toward the doctor who made the devastating error that damaged him forever. I discovered that I was putting myself in his shoes and telling him what I felt. He could see that he was eliciting emotional reactions in me. As we discovered later in our therapy work, I offered him a model that daya model of how relationships that respect, support, and facilitate psychological growth and change stimulate an a aQ b, , aG .

In the beginning, therapy was not easy for Giuseppe. He was cautious, constantly studying me. Because of his muscle rigidity and shortness of breath, I assumed that it was difficult for him to trust me even though he was trying to. He was never late for our meetings, and he was always eager to speak about himself. From his questions, I wondered if he was doubtful about the processes and possible outcomes of our work or if he had disagreements that he was not expressing. I knew I had to be patient, consistent, attentive, and caring.

In several sessions, Giuseppe told me that his preceding week had been hard to manage, that he had experienced acute kidney pain and had to struggle to continue working. He described his nights as a sleepless, living hell. I felt sorry for his pain and many difficulties and hoped that my face and empathetic words communicated my sorrow for his misfortune. Intuitively, I knew that I had to stay fully present with Giuseppe. He needed my exquisite attention, emotional openness, and responsiveness but in amounts that he could manage. I could be neither intense nor waver in my attentiveness. It was necessary that I attune myself to his natural rhythm. My main therapeutic work was in building our relationship.

As the sessions continued, I realized that something was not working in the therapy. I was uncomfortable. No matter how carefully I listened to his descriptions of his current life, I knew I was missing something. I began to feel irritated with him and his stories. I wondered if I was becoming immersed in a reactive countertransference whereby some issue in my own life was interfering with my capacity to be empathic.

When I began my supervision in integrative psychotherapy, I had an important realization. I described to my supervisor that Giuseppe had a whining c a caG ab a . G baG H U a his therapy, that despite all his efforts, the therapy was not working and he did not feel better. I felt overwhelmed, powerless, and was tired of his whiny voice. My a, HZ GH Q H ? Wa W ? I a\ aZ an image of a baby crying in his cradle and was filled K ca. M\ G P J ab G baV and attitudes and instead centered on the emotional and physical development of a baby and young child.

I thought about Giuseppe and what he must have endured in his first few months: a baby in pain, not being touched, exhausted from relentless and lonely crying, a cry within himself, with no expectation of relief, a cry of mute pain. I aG a G J a expressing both physical pain and the emotional numbness of not bonding with a stabilizing and comforting maternal person. I wondered about the kind of attachment patterns he had formed and how he stabilized and regulated himself. Was his whining a form of self-stabilization? I often had moments during which I revisited the developmental image I had formed of Giuseppe as an infant in need of physical relief and maternal nurturing. This image was deeply moving, and I felt love and compassion for that child.

IQ H Q K , I R aH I R G unspoken affect and rhythm, to envision again the developmental image of the suffering baby, and to make the kind of relational contact that a neglected infant would have needed. My countertransferential reaction was now responsive: an emotion-filled responsiveness to what that infant needed in order to heal from the relational injury of prolonged maternal neglect that he had suffered during his many hospitalizations. I was filled with affection and a desire to tenderly attend to him as he therapeutically reexperienced his past. I told Giuseppe about the image I had of him as a baby, in pain and crying alone in the hospital. I described how close I felt to him and how I imagined that he felt helpless. The image had a strong impact on Giuseppe: His eyes lit up, as if he were waking from a long sleep. He seemed to come from a distant world as he looked into my eyes and started to cry. He asked me to hold him, and I held him like I would a baby, stroking his head while he cried in deep sobs. I cried in resonance with him. That was an important moment in the therapy, one that opened a new way of working together.

Without that developmental image of Giuseppe as a neglected baby, I most likely would have lost a chance to make real interpersonal contact with the overwhelmed infant inside him and to reach him in his inner world of implicit memories. Instead, I joined Giuseppe in his emotional experience. I was with him, saw him, and felt both what he must have felt and what he needed in a healing relationship.

During the following sessions, we dedicated time to the physical and emotional experiences of the little hospitalized baby and the quality of healing cK a H : I without anyone touching me; I remember the c a. We H , \ ca, bW W a.

We also spent time cognitively processing our work together. These discussions were moments of profound relational sharing. Giuseppe said he felt G K a S ca H : We X G H a, I felt seen, as if I had suddenly remembered what happened to me in my early life. I saw myself and I felt that you really saw me, in my pain, in my c.

FJ , a a caH G b. H a aW he no longer felt alone and helpless. He had a sense that someone was there to share wholeheartedly in his experience. My holding him had provided several minutes of stJ ca bJ aG a aaQ V c: IW aV , through you, I was closer to myself. I realized that it must have been really hard for , b Q I ca a a .

Finally, together with me, Giuseppe was able to recover sensations and images to which he previously not had access. We brought to awareness and gave meaning to his presymbolic visceral memories. We uncovered the physical and emotional story and began to use words to make the implicit memories understandable. Giuseppe was integrating his physiological and affective memories with his current cognitive capacity to see how his pervasive sense of loneliness and his repetitive behaviors were linked to his early childhood relational . N, en I feel physical pain, I know that a sense of heavy discomfort engages me, one of distrust about the possibility of making it. It is as if I , a, I a a b a.

Once I was able to use the concept of a developmental image, attune to the physical and relational needs of the infant, and be fully engaged with both the infant and the man, I could understand more deeply how his early physiological survival reactions and implicit experiential conclusions shaped his life script. Because of the hospitalizations and the inability of his immature, inexperienced parents to provide him with relief from his physical pain, Giuseppe lived with a loss of hope and an omnipresent sense of mistrust both of relying on others and of himself. I a G I E (E, ) c I H aO a cI a ac , c G N with Giuseppe from a developmental perspective.

GH aG G a Q I I a a V . TV definition provided the psychological functions of self-stabilization, identity, and insurance against disappointment (Erskine et al., 1999). His script beliefs included IO acK \ aG aG b\ O aH , I aH R c \ Q , IO aaH b\ , aG I ca . TH cG b aaG his internal suffering and interfered with the quality of his interpersonal contact with others. Our psychotherapy sessions addressed each of these script beliefs and how they reflected his actual experiences as a child. We also focused on how each of these beliefs interfered with his having his current adult needs met in relationship.

Our therapy dialogue often centered on his constant physical pain and J a, H bJ bH P R aH a aO , aaac aa. WH worked repeatedly on the trauma of cumulative neglect. Giuseppe discovered what caa, a , a c b a bcaacaP time to time. He could begin to see the difference between his life today and his way of understanding when he was a child.

During an important session, Giuseppe described his struggle to live every a: T a c H . I G aG H a H a, a aO H I R a a. I caG P R H c speak out loud, and I listened as he raged about all the wrongs he has suffered. He damned everyone and everything, including his fianc e and his job. I invited him to go back in time and let himself experience with whom he was originally angry. He imagined talking to the surgeon who made the major error that left him medically injured. Giuseppe screamed at the doctor with strong words that conveyed his resentment and anger. He revealed his strength and newfound determination to seek justice, to tell the world the truth he had kept inside for so many years. I suggested that he express himself using his body as well as his words, and he hit his clenched fists violently on the couch. For the first time, he stood up to assert himself.

Despite his history, GiuH Z a a J H , , aQ internal thrust for health and growth, the urge to do something different and novel, H aaQ R bH \ , aG R aH cc ab Q (Erskine, 2011, p. 2). He struggled to survive as a child, he endured physical pain and cumulative neglect, he committed to an in-depth psychotherapy, and he changed his life script. Massimo Recalcati, a Lacanian psychoanalyst who is popular in Italy, said, our birth is not just a biological event, but also something aJ bcaH b\ a , a aG c bK (Rcaca, 2016). TH GH a Z aQ V aH aG U than his first surgery, the one that almost denied him a normal life.

As a result of this work, Giuseppe was able to make some significant behavioral changes. These included initiating a new narrative about his life that allowed him to integrate a split within his sense of self: the emotionally constricted hospitalized child and the intellectually vibrant young man, psychologically alert and skilled. Giuseppe now had excitement and plans for his future while concurrently having compassion and understanding of the relational disruptions in his early life and how he coped with the physical pain and emotional neglect.

TH caV G H H a aa\ cG psychotherapy. We worked with and through our relationship, focusing on the relational disruptions in his early life and the reparative relationship that was possible in the therapy. The therapeutic work was developmentally based, drawing on the knowledge of primary attachment and the psychological disturbance that occurs when a child does not have a secure base (Bowlby, 1988; Erskine, 2009). A safe attachment with me provided Giuseppe with a secure base. I had to be an attentive, valuing, supportive, and protective psychotherapist, a mother substitute, who had consistent faith that he could overcome the hurt and neglect of his past and create a new vibrant, relationship-filled life.

Giuseppe Today

Our work together is not finished. We are proceeding toward our agreed on therapeutic goal: awakening a sense of faith in people and in his future, establishing full contact with himself, and creating intimate relationships. Giuseppe remains committed to our weekly group therapy sessions. He lives his experiences in the world and returns to the group to report, confirm, and deepen his cc aG cchildhood . H ab a ad how he may experience a lack of faith and powerlessness from time to time. He also knows that he can rely on both his internal strength and on real contactful relationships. He knows how to have faith and hope in a life full of healthy relationships.

Author:

Silvia Allari is a clinical psychotherapist with a transactional analysis orientation as well as a trainer, supervisor, and Certified International Integrative Psychotherapist. She lives and works in Milan, does individual and group psychotherapy, and is a partner in the ESca del Centro Berne in Milan. Silvia can be reached at Via Balilla 36, 20136, Milan, Italy; email: allari.silvia@gmail.com.

References

Bowlby, J. (1988). A secure base. New York, NY: Basic Books.

Erskine, R. G. (2009). Life scripts and attachment patterns: Theoretical integration and therapeutic involvement. Transactional Analysis Journal, 39, 207218. doi:10.1177/036215370903900304

Erskine, R. G. (2010). Relational group psychotherapy: The healing of stress, neglect and trauma. International Journal of Integrative Psychotherapy, 1, 110.

Erskine, R. G. (2011). The challenges of change and growth. Retrieved from www.integrativepsychotherapy.com. Erskine, R. G. (2015). Relational patterns, therapeutic presence: Concepts and practice of integrative psychotherapy. London: Karnac Books. Erskine, R. G. (in press). Child development in integrative ca: Ec E H a. International Journal of Integrative Psychotherapy.

Erskine, R. G., Moursund, J. P., & Trautmann, R. L. (1999). Beyond empathy: A therapy of contact-in-relationship. New York, NY: Brunner/Mazel.

OR-Knapp, M., & Erskine, R. G. (2010). The script system: An unconscious organization of experience. In R. G. Erskine (Ed.), Life scripts: A transactional analysis of unconscious relational patterns (pp. 291308). London: Karnac Books.

Recalcati, M. (2016). La religione del corpo, il corpo e l inconscio [The religion in the body, the body and the unconscious]. Retrieved from www.psichiatryonline.it.