http://www.medicinenet.com/psychotherapy/article.htm
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Introduction

Psychotherapy is often the first form of treatment recommended for depression. Called “therapy” for short, the word psychotherapy actually involves a variety of treatment techniques. During psychotherapy, a person with depression talks to a licensed and trained mental healthcare professional who helps him or her identify and work through the factors that may be causing their depressiondepression.

Sometimes these factors work in combination with heredity or chemical imbalances in the brain to trigger depression. Taking care of the psychological and psychosocial aspects of depression is important.

How Does Psychotherapy Help Depression?

Psychotherapy helps people with depression:

* Understand the behaviors, emotions, and ideas that contribute to his or her depression.
* Understand and identify the life problems or events — like a major illness, a death in the family, a loss of a job or a divorce — that contribute to their depression and help them understand which aspects of those problems they may be able to solve or improve.
* Regain a sense of control and pleasure in life.
* Learn coping techniques and problem-solving skills.

Types of Therapy

Therapy can be given in a variety of formats, including:

* Individual — This therapy involves only the patient and the therapist.
* Group — Two or more patients may participate in therapy at the same time. Patients are able to share experiences and learn that others feel the same way, and have had the same experiences.
* Marital/couples — This type of therapy helps spouses and partners understand why their loved one has depression, what changes in communication and behaviors can help, and what they can do to cope.
* Family — Because family is a key part of the team that helps people with depression get better, it is sometimes helpful for family members to understand what their loved one is going through, how they themselves can cope, and what they can do to help.

Approaches to Therapy

While therapy can be done in different formats — like family, group, and individual, there are also several different approaches that mental health professionals can take to provide therapy. After talking with the patient about their depression, the therapist will decide which approach to use based on the suspected underlying factors contributing to the depression.

Psychodynamic Therapy

Psychodynamic therapy is based on the assumption that a person is depressed because of unresolved, generally unconscious conflicts, often stemming from childhood. The goal of this type of therapy is for the patient to understand and cope better with these feelings by talking about the experiences. Psychodynamic therapy is administered over a period of weeks to months to years.

Interpersonal Therapy

Interpersonal therapy focuses on the behaviors and interactions a depressed patient has with family and friends. The primary goal of this therapy is to improve communication skills and increase self-esteem during a short period of time. It usually lasts three to four months and works well for depression caused by mourning, relationship conflicts, major life events, and social isolation.

Psychodynamic and interpersonal therapies help patients resolve depression caused by:

* Loss (grief)

* Relationship conflicts
* Role transitions (such as becoming a mother or a caregiver)

Cognitive Behavioral Therapy

Cognitive behavioral therapy helps people with depression to identify and change inaccurate perceptions that they may have of themselves and the world around them. The therapist helps the patient establish new ways of thinking by directing attention to both the “wrong” and “right” assumptions they make about themselves and others.

Cognitive-behavioral therapy is recommended for patients:

Who think and behave in ways that trigger and perpetuate depression.

* Who think and behave in ways that trigger and perpetuate depression.
* Of all ages who have depression that causes suffering, disability, or interpersonal problems.

Therapy Tips

Therapy works best when you attend all of your scheduled appointments. The effectiveness of therapy depends on your active participation. It requires time, effort and regularity.

As you begin therapy, establish some goals with your therapist. Then spend time periodically reviewing your progress with your therapist. If you don’t like your therapist’s approach or if you don’t think the therapist is helping you, talk to him or her about it and/or seek a second opinion, but don’t discontinue therapy abruptly.

Tips to Help You Get Started

* Identify sources of stress: Try keeping a journal and note stressful as well as positive events.
* Restructure priorities: Emphasize positive, effective behavior.
* Make time for recreational and pleasurable activities.
* Communicate: Explain and assert your needs to someone you trust; write in a journal to express your feelings.
* Try to focus on positive outcomes and finding methods for reducing and managing stress.

Remember, therapy involves evaluating your thoughts and behaviors, identifying stresses that contribute to depression, and working to modify both. People who actively participate in therapy recover more quickly and have fewer relapses. Therapy is treatment that addresses specific causes of depression; it is not a “quick fix.” It takes longer to begin to work than antidepressants, but there is evidence to suggest that its effects last longer. Antidepressants may be needed immediately in cases of severe depression, but the combination of therapy and medicine is very effective.

Reviewed by the doctors at The Cleveland Clinic Department of Psychiatry and Psychology.
Edited by Brunilda Nazario, MD, WebMD, February 2006.

Portions of this page © The Cleveland Clinic 2000-2005

http://www.integrativetherapy.com/en/articles.php?id=59
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Richard G. Erskine, Ph.D.

Portions of this paper were presented as the keynote ad­dress entitled “Unconscious Processes: The Intimate Con­nection between Client and Therapist” at the Inter­na­tional Integrative Psychotherapy Association conference 12-15 April 2007 in Rome, Italy. The author thanks mem­bers of the Professional Development Seminar of the In­sti­tute for Integrative Psychotherapy for their valuable con­tri­butions in formulating the concepts in this article. His heartfelt gratitude also goes to Kay and Andrew for pro­viding him with the opportunity to enhance his learning about psychotherapy through their work together.

Abstract

Freud defined the unconscious as a result of repression. However, recent findings in neu­rology and developmental psychology in­dicate that unconscious experience may be com­posed of presymbolic, subsymbolic, im­plicit, and procedural forms of memory, as well as being the result of trauma. In this article, preverbal, never-verbalized, un­ac­knowl­edged, nonmemory, and avoided ver­ba­li­zation are categories of unconscious ex­perience used to describe two psychotherapy cases. Five prereflective patterns—attach­ment style, self-regulation, relational needs, script beliefs, and introjection—are sug­gested as a way to organize treatment plan­ning. A relational and in-depth integrative psychotherapy is described for the treat­ment of unconscious experience.

Sigmund Freud’s theoretical formulation that the unconscious determines motivation and be­havior was revolutionary a century ago. Today that same theoretical formulation may be equal­ly accurate in understanding motivation and behavior, but contemporary conceptualizations of the dynamics of “unconscious” experience have changed the focus from one emphasizing de­fensive repression to a developmental and neu­rological perspective. In response to current neurological research and contemporary psy­cho­logical theory, I no longer think of a dy­nam­ic unconscious as formed exclusively from defensive repression; rather, I view it as an ex­pres­sion of developmental and neurological pro­cessing of significant experiences (Bucci, 1997; Fosshage, 2005; Howell, 2005; Kihl­strom, 1984; Lyons-Ruth, 1999; Orange, At­wood, & Stolorow, 1997; Siegel, 2003).

Freud postulated that “the unconscious” was like a vault in the mind where emotionally con­flictual experiences were stored and forgotten. Such a “dynamic unconscious” was the result of the defensive activity of repression (Freud, 1900/1958b, 1915/1957). Ian Suttie (1935/1988), an early psychoanalytic object relations theorist, described such repression as an “en­tirely unconscious process” and distinguished it from “suppression,” which is a conscious re­ac­tion to coercion (p. 97). With repression, par­ticularly uncomfortable affect-laden or trau­ma­tic experiences of self with others are psy­cho­logically prevented from coming to awareness. Other self-protective and defensive reactions—such as desensitization, disavowal, disso­cia­tion, and psychological splitting—may accom­pany and reinforce repression.

In working with many clients in psy­cho­therapy, especially those who have experienced acute or cumulative trauma, it has become clear to me that particular memories, fantasies, feel­ings, and physical reactions may be repressed because they may bring to awareness relational experiences in which physical and relational needs were repeatedly unmet and related affect cannot be integrated because there was (is) a fail­ure in the significant other person’s attuned responsiveness (Erskine, 1993/1997; Erskine, Moursund, & Trautmann, 1999; Lourie, 1996; Stolorow & Atwood, 1989; Wallin, 2007).

Winnicott (1974), in writing about clients’ “fear of breakdown” and their potential regres­sion to early childhood emotionally charged ex­peri­ences, departed from classical psycho­ana­ly­tic theory that postulated that the dynamic un­con­scious was composed of repressed drives and conflictual experience. He described the un­conscious as the ego’s inability to encompass intense emotional experience. In light of cur­rent findings in neurology and child devel­op­ment, Winnicott’s premise about the formation of unconscious experience appears accurate. It is now evident that the brain’s frontal cortex may not process intense emotional and phy­sio­logical reactions that are occurring in the as­cend­ing reticular formation (Cozolino, 2006; Damasio, 1999; Siegel, 2007) and that con­scious­ness is directly the result of the brain’s ability to symbolize experience (Bucci, 2001; Lyons-Ruth, 2000).

Gestalt therapy (Perls, Hefferline, & Good­man, 1951) theory dispensed with the psycho­analytic concept of “unconscious” and replaced it with the concept of “loss of awareness.” In ges­talt therapy, “unconscious” became a pro­cess rather than a place in the mind. A person’s loss of awareness was the result of having fixed perceptions (gestalten) that inhibit or prevent alternative ways of perceiving experience. The loss of awareness is maintained by the contact-interrupting mechanisms of retroflection, con­fluence, introjection, projection, and egotism. Gestalt therapy postulates that through the integration of here-and-now awareness, fixed ges­talten are dissolved and the person is con­scious of his or her current experience.

Although most of the transactional analysis literature does not address the “unconscious” per se, Berne made several references to un­con­scious process with little reference to the term or concept of “unconscious.” In his origi­nal conceptualization of ego states, both the for­mation and influence of Child and Parent ego states are not conscious to the Adult ego state (Berne, 1961). He borrowed the psy­cho­analytic concept of unconscious but changed the ter­mi­nology. In his writings about psy­cho­logical ca­thex­is, he referred to unconscious, sub­con­scious, and conscious as bound, un­bound, and free energy. In the “monkey in the tree” metaphor, it is clear that Berne’s de­scrip­tion of bound energy refers to emotional ex­peri­ence that is locked away and excluded from awareness, similar to Freud’s repression. Un­bound energy refers to experience that is sub­conscious or pre­conscious and with the right stimulus is avail­able to awareness. And, free energy refers to ex­perience that is conscious (pp. 40-41).

In Berne’s description of ulterior trans­ac­tions, he referred to them as coming from the psychological level rather than the social level. In the case of ulterior transactions from Child or Parent ego states, the individual’s Adult ego state may not be aware of the psychological com­munication—an unaware or unconscious communication. Here, psychological level seems to be equated with unconscious (Berne, 1961, pp. 103-105, p. 124). Perhaps the clearest ex­am­ples in Berne’s writing of the concept of un­conscious process are in his description of script protocol and palimpsests. Script protocol and palimpsests refer to the presymbolic, sub­symbolic, and procedural forms of memory that form the unconscious relational patterns and implicit experiential conclusions that are the core of life scripts (pp.116-126).

Berne specifically addressed unconscious ex­perience in his description of the client’s “pri­mal judgments” and “primal images”: “It ap­pears that the most important and influential judg­ments which human beings make con­cern­ing each other are the products of preverbal processes—cognition without insight—which function almost automatically below the level of consciousness” (Berne, 1955/1977b, p. 72). He went on to describe the therapist’s symbolic-nonverbal processes in connection with the cli­ent’s unconscious expression of experience and referred to it as the therapist’s “ego image”—the image in the psychotherapist’s mind when he or she envisions the troubled child that the cli­ent once was (Berne, 1957/1977a). Berne also used the term “intuition” to describe the thera­pist’s unconscious connecting with the cli­ent’s unconscious communication: “Intuition is subconscious knowledge without words, based on subconscious observations without words” (Berne, 1947/1976, p. 35).

Rogers (1951) emphasized the importance of empathy—feeling what the client feels—as a non­verbal yet significant form of connecting with the client’s unconscious communication. Reik (1948/1964) and Heinmann (1950) were two of the early psychoanalytic writers who em­phasized the psychotherapist’s emotional response to the client as one of the most im­portant instruments of research into the client’s unconscious experience. Later, Kohut (1977) described empathy as a vicarious introspection, a way of knowing the client’s unconscious thought processes by imagining being in his or her affective and relational experience. Over the past several years, the transactional analysis literature has increasingly focused on the sig­nifi­cance of both the client’s and the therapist’s unconscious process as being central to the thera­peutic relationship (Erskine & Trautmann, 1996/1997; Hargaden & Sills, 2002; Novellino, 1984, 2003).

In-depth Psychotherapy

When there is a therapeutic contract for in-depth psychotherapy aimed at fundamental change in the client’s script, deconfusion and resolution of Child ego state conflicts, and de­commissioning of influencing Parent ego states, the therapeutic goal is to facilitate making con­scious what has been unconscious. This in­volves bringing to the client’s awareness the memo­ries, feelings, thoughts, sensations, and as­sociations that were previously not con­scious. Such a recovery of consciousness al­lows the cli­ent to be aware of his or her moti­va­tion, per­son­al history, coping style, and rela­tional needs, thus providing the opportunity for be­havior to be determined by current choice rath­er than by compulsion, fear, or pro­grammed obe­dience.

In practicing in-depth psychotherapy, I find it essential to take into account that specific memo­ries of experiences, relationships, feel­ings, or fantasies may be actively repressed be­cause they bring to awareness emotionally pain­ful relational conflicts and unmet needs. This is in accordance with Freud’s original prem­ise. Such unconscious functioning is main­tained by cognitive denial, emotional disavo­wal, physiological desensitization, psycho­logi­cal dissociation, and schizoid distancing. These self-protective and defensive interruptions to con­tact contribute to making and keeping ex­peri­ence unconscious. However, experience that is unconscious is not only the result of psy­cho­logical defenses. Experience that is un­con­scious may also result from a physiological survival reaction in response to trauma or may reflect fixated developmental levels of func­tion­ing. Trauma may be defined as the intense overstimulation of the amygdala and the limbic system of the brain such that the physiological centers of the brain are activated in the direc­tion of flight, freeze, or fight. There is little ac­tivation of the frontal cortex or integration with the corpus callosum, so thought, time se­quenc­ing, language, concepts, narrative, and the ca­pa­city to calculate cause and effect are not formed (Cozolino, 2006; Damasio, 1999; How­ell, 2005). Such trauma often results in disso­cia­tion and/or schizoid isolation.

Experience may be unconscious because both acute trauma and prolonged neglect are not re­corded as explicit and symbolic memory but as physiological survival reactions, intense and un­differentiated affect, subsymbolic memory, implicit memory, and procedural memory of re­lational patterns that may become manifested as avoidance, ambivalence, or aggression (Wal­lin, 2007). Most of what we colloquially refer to as “unconscious” may best be described as presymbolic, subsymbolic, symbolic nonverbal, implicit, or procedural expressions of early child­hood experiences that are significant forms of memory (Bucci, 2001; Kihlstrom, 1984; Lyons-Ruth, 2000; Schacter & Buckner, 1998). These forms of memory are not conscious in that they are not transposed to thought, con­cept, language, or narrative. Such subsymbolic or implicit memories are phenomenologically communicated through physiological tensions, undifferentiated affects, longings and repul­sions, tone of voice, and relational patterns that may stimulate physiological and affective reso­nance in the psychotherapist. The transference-countertransference dyad is an unconscious un­folding of two intersubjective life stories and a window of opportunity into both the client’s and the therapist’s unconscious experience.

It is our task as psychotherapists to be at­tuned to the client’s affect, rhythm, develop­mental level of functioning, and relational needs while inquiring about the client’s phe­nome­no­logical experience. Phenomenological inquiry provides an opportunity for the client’s af­fec­tively and physiologically charged memories to be put into dialogue with an interested and in­volved person —perhaps for the very first time. What was never “conscious” has an oppor­tuni­ty to become conscious through an involved therapeutic relationship.

I find it important to think not only in terms of unconscious process as reflecting either trau­ma or repression, but also to think develop­men­tally. I generally conceptualize subsymbolic or implicit memory as being composed of six de­velopmental and experiential levels: preverbal, never verbalized, never acknowledged within the family, nonmemory, actively avoided ver­ba­lization, and prereflective relational patterns. I will briefly describe each type of subsymbolic and implicit memory, but first, I offer a case ex­ample that illustrates how archaic and un­con­scious memory becomes conscious through an involved therapeutic relationship.

Kay’s Cumulative Trauma. Kay was a 54-year-old woman who worked as an accountant. She came to psychotherapy because of a deep sense of loneliness as well as her anger toward those she perceived to be controlling of her. She had never married and had never had a boyfriend, although in high school and college she had some secret crushes on a few young men. She had been in therapy with two pre­vi­ous therapists. The first therapist had helped her set some educational and career goals and to attain a good job, while the second therapy ended in a “disaster” because she experienced the therapist as “controlling” and “con­front­ing.” In our early sessions, she was often very talkative about current events but would lapse into silence when I inquired about her phe­nome­nological experience, such as her feelings, bodily sensations, fantasies, or hopes. I was at­tempting to connect with her deep sense of lone­liness, which she frequently made passing reference to, but she often managed to distract me by talking about what was in the news or her job situation. The obvious transferences with me involved her constant fear that I would abandon her and also her constant anticipation that I would become controlling. She distrusted my phenomenological inquiry. It seemed that she often lacked the concepts, or even the vo­cabu­lary, to describe her feelings and internal experience. She had only vague memories of her early childhood and school years and most of those memories centered around her family’s religious activities.

In the second year of therapy a remarkable event occurred when a spider slowly descended from the ceiling on a long silvery strand and then proceeded to climb back up and drop down again over and over. She had a little girl’s thrill and fascination, and I could feel myself emo­tion­ally moved in resonance with her ex­cite­ment over the spider’s activities. But, within about 15 minutes, she became distant and si­lent. As I adjusted to her slow rhythm and psy­chic distancing, she commented that she had al­ways liked spiders since she had been in the hos­pital. I was surprised, because in our intake interview and subsequent therapy sessions over the previous year she had never mentioned be­ing hospitalized. Kay had never thought to tell me, or her two previous therapists, that she had spent 2 years in an iron lung recovering from polio between the ages of 2 and 4. When I learned of her 2-year hospital confinement, my heart went out to her. In subsequent sessions, I often imagined taking that young child out of the iron lung and holding her in my arms. Sev­eral times Kay described how her only “friend” during that time was a spider that had made its web on the ceiling above her iron lung, way out of touch. She spent hours being entertained by its movements, and I spent hours attuned to the importance that the spider had in this young girl’s life.

Amid long silences, Kay eventually talked about how the nurses would come in and poke and prod her and how she hated being mani­p­u­lated by them. Prior to each session, I found my­self looking forward to talking to the little girl who was in the iron lung. We cried to­geth­er about her loneliness. I took her anger seri­ously as she described being a “prisoner.” Kay talked about how she would pass the hours of the day watching a large hospital clock tick the seconds away. In several sessions she described how the second hand makes a different clicking sound as it drops from 12 to 6 than it does when it ticks upward from 6 to 12. She even­tually remembered imagining that the hands of the clock were reaching down from the wall to stroke her head and face.

As the therapy progressed, she became less verbally descriptive of her hospital experience and had no vocabulary to express her affect or needs. There were long periods of silence and sad­ness. I sat closer to her where we could reach out and touch our fingers together. With finger-to-finger contact, she seemed more alive. We played the finger game of itsy-bitsy spider over and over. We laughed together at our silli­ness. Then she would cry as she experienced the juxtaposition between our playfulness and her years of loneliness.

Kay often used her fingers and face muscles to describe the agony of being confined to the iron lung. She would silently rage at me with her facial movements and hand gestures when I did not match her rhythm or respond with the appropriate affect. She was nonverbally telling me the story of her developmental needs, lone­li­ness, and abandonment. Together we co­crea­ted both a nonverbal and verbal narrative of her experiences between ages 2 and 4. My thera­peutic involvement was to repeatedly validate her sadness, fear, anger, and sense of aban­don­ment as affective expressions of real events. We developed a vocabulary and created mean­ing for the physiological and affective experi­ence of her cumulative trauma. We normalized both her developmental and current needs and explored how she could have her adult rela­tion­al needs responded to by people in her current life. My sense of personal presence was ex­pressed in the combination of affective, rhyth­mic, and developmental attunement that was cen­tral to our relationship. In the 10 years since the therapy, Kay has still not formed a romantic relationship with a man. But she reports that she is “in love with the children” at the hospital where she volunteers 3 days a week.

Forms of Unconscious Memory

Preverbal. Early childhood memory is pre­sym­bolic and nonlinguistic. It is not available to consciousness through language because the experience is preverbal. Such memory may be expressed in self-regulating patterns, emotional reactions, physiological inhibitions, and styles of attachment and relationships. Later in life, pre­verbal relational patterns are experienced but not usually thought about. The therapist’s at­tune­ment to affect, rhythm, and develop­men­tal level are essential in forming an emotional connection that facilitates a communication of preverbal experience. The client’s story may be expressed in nonverbal enactments and/or crea­ted by therapeutic inference. This is often the situation when dealing with the client’s un­conscious but felt experience about being an in­fant, toddler, or even preschool-age child. For example, in Kay’s therapy, the 3- and 4-year-old child in the hospital was regressed to a much younger preverbal age wherein only her physical gestures and our finger-to-finger touch could express Kay’s agony, loneliness, irri­ta­tion, and longing for relationship. Both my con­­stant attentiveness while she was silent and our finger-to-finger contact allowed the pre­ver­bal memo­ry to be expressed.

Never Verbalized. Presymbolic and implicit memory reflect childhood experiences that were not verbalized in the original situation. The child may have had some language, such as nouns and verbs, but lacked the concepts to de­scribe feelings and needs and/or did not have a responsive other person who was interested in a way that gave significance and meaning to the child’s experience. The narrative about the child’s experience was never formed because there was no relationship that fostered the child’s self-expression and concept formation.

When a child has the opportunity to talk about his or her experience, each experience takes on a vocabulary and description; it be­comes understood because concepts are formed. It becomes conscious. When there is an ab­sence of interpersonal dialogue, an experience is less likely to become conscious and form usable concepts and a self-expressive narrative. Phenomenological inquiry and affective at­tune­ment are important dynamics in a person ex­pres­sing his or her emotional experience. The at­tuned, interested other helps to provide a dia­logical language that allows the phenome­no­logical experience to be formed, expressed, and have meaning as autobiographical memory. In Kay’s case, she had never spoken to anyone, neith­er her friends nor her previous therapists, about her experience in the hospital. Together we cocreated a story that facilitated con­scious­ness and provided meaning to her previously never-verbalized emotional experiences.

Unacknowledged. Some developmental ex­peri­ences may be unconscious because the child’s emotions, behaviors, or relational needs were never acknowledged within the family. When there is no conversation that gives meaning to the child’s experience, the experience may re­main without social language. Cozolino (2006) describes the effects of both acknowledgment and lack of acknowledgment of the child’s ex­perience:

Parental concern and curiosity make child­ren aware that they have an inner ex­peri­ence of their own. . . . Because this inner ex­perience can be understood, discussed and organized through a coconstructed nar­rative, it becomes available for con­scious consideration. . . . When a child is left in silence due to parental inability to verbalize internal experience, the child does not develop the capacity to un­der­stand and manage his or her world. . . . When verbal interactions include refer­ences to sensations, feelings, behaviours, and thoughts, they provide a medium through which the child’s brain is able to integrate the various aspects of experience in a coherent manner. (p. 232)

Psychotherapy provides the opportunity to address that which has never been acknowl­edged. For example, Kay’s parents actively prayed for her recovery while she was in the hospital and, once she was home, continually thanked God that she did not die. But they never talked to her about her hospital ex­per­i­ence of loneliness, physical agony, and intense fear. In the hospital there was almost no con­versation with the nurses. She was alone in her experience. As a result, these unacknowledged memories unconsciously dominated her life.

If the spider had not descended from the ceil­ing of my consulting room, Kay might never have told me about her hospitalization. The spi­der provided a special, emotionally filled mo­ment in which I resonated with vitality to Kay’s excitement and then, with quiet patience, to her silence and distance. This was a crucial turning point in our therapeutic work together. I was fin­ally able to form a developmental image (i.e., Berne’s “ego image”) of a hospitalized, and perhaps traumatized, little girl that enabled me to begin to communicate with both the 2-to-4-year-old as well as the 2-to-4-year-old child who was regressed to a preverbal infant state. Later, when we processed our therapeutic work about her regressive experience, Kay told me that she had never spoken to anyone about her hospitalization because she just assumed that “no one would be interested,” a transferring of her parent’s lack of acknowledgment onto all others, including all three of her therapists.

Nonmemory. A lack of memory may seem un­conscious because significant relational con­tact did not occur. When important relational ex­periences never occurred, it is impossible to be conscious of them. If kindness, respect, or gentleness were lacking, the client will have no memory; there will be a vacuum of experience. This is often the situation with childhood ne­glect. Lourie (1996) described the absence of memory in clients with cumulative trauma that reflects the absence of vital care and an ig­nor­ing of relational needs. Kay’s story illustrates “unconscious” as nonmemory—comforting touch, validation of her affective needs, clari­fy­ing explanations, and active companionship were all missing during Kay’s hospital years. The juxtaposition between my providing touch, validation, explanations, and companionship and the absence of these important relational elements stimulated her awareness that they were absent in her early life and that her un­conscious compensating reactions to missing relational connections dominated her current life.

Kay’s story reflects four types of un­con­scious processes: never verbalized, un­ac­knowl­edged, nonmemory, and regression to a pre­ver­bal period. In Kay’s psychotherapy, the reso­lu­tion of her cumulative trauma is also an ex­ample of the therapist’s providing a relational psy­cho­therapy that allows previously unconscious ex­periences to become conscious through an in­tersubjective and affective connection. For many years, Kay lived and acted out various un­con­scious subsymbolic and implicit memo­ries. The story of her therapeutic journey is one of her becoming conscious of preverbal and never ver­balized but lived experiences. She was not conscious of the relationships that nev­er oc­curred (the nonmemory) yet needed to oc­cur for healthy development, such as the need for a dependable and consistent other re­spon­sive to her feelings and needs. Much of the psy­cho­therapy was aimed at helping her reflect on and appreciate her various archaic relational pat­terns and self-regulating behaviors as attempts to communicate and seek reparation for numer­ous unrequited relational needs. In addition to Freud’s concept of an unconscious resulting from repression, I organize my therapy per­spec­tive to include the possibility that the client may have unconscious and unexpressed de­vel­opmental experiences that are preverbal, never ver­balized, unacknowledged, or nonmemory—the basis for fixated relational patterns.

Avoided Verbalization. When experience is actively devoid of conversation, it may become unconscious, that is, not remembered as a ser­ies of specific events and no longer available to nar­rative. This is similar to Freud’s (1915/1957) dynamic unconscious, where shameful ex­peri­ences or guilt become unconscious because the person is acutely uncomfortable in talking to someone about the experience. For example, Andrew came to therapy with a number of in­tense obsessions, including shame about ob­ses­sing. I focused on several dimensions of the treat­ment of obsession, including under­stand­ing the psychological functions, script beliefs, and, specifically, the ways his obsessions were an attempt to tell a lost but important story. We explored how his shame about obsessing was an avoidance of a deeper sense of shame. Even­tually, Andrew was able to tell me about the wonderful summer he had had when he was 12 years old. His family spent the summer at a lake­side cottage; another boy his age lived near­by. The two boys spent their time playing ball, swimming, and riding their bicycles. But, the most exciting part of the summer was their sexual play with each other. They explored each other’s penises and performed fellatio on each other. Andrew loved the sexual experi­ence, and he loved the other boy, whom he missed intensely when the summer was over. He was extremely afraid to tell anyone about his wonderful experience. The two boys had nev­er spoken to each other about their sexual play or what they were feeling. Andrew silently relished in the pleasure, but he could not tell his parents because “Father would beat me if he knew and Mother would go hysterical.” He could not tell the nuns or priests at school be­cause he knew “it was a sin.” And, importantly, he could not tell any of the other boys what he had experienced that summer because he was afraid they would call him a “homo.” Andrew’s exciting story was kept a secret for 24 years, a secret even unto himself. Yet, the actively avoided telling of his story was acted out in his intense and diverse obsessions, obsessions for which he was deeply ashamed and that seemed to distract him from the socially imposed shame about his sexual experience.

Prereflective Patterns. Many psycho­dy­nam­ics operate outside of the individual’s aware­ness. They are prereflective patterns of self in re­lationship (Stolorow & Atwood, 1989). The five prereflective patterns described here—attach­ment style, self-regulation, relational needs, script beliefs, and introjection—are not clearly conscious to most clients in the early phase of psychotherapy, even though they often talk about their script beliefs, self-regulation, and reactions to relationships. Rather, they are un­con­scious of the pervasive influence such pat­terns have in their lives. An important aspect of psychotherapy is creating the quality of rela­tion­ship in the context of which these pre­reflec­tive patterns become conscious, understood, and experienced as choice.

Attachment styles are unconscious pre­sym­bolic procedural forms of memory based on early relational patterns (Bowlby, 1988). In in-depth psychotherapy I often talk with clients about their style of attachment, both with me and with significant other people. We examine whether their relationships are secure, am­biva­lent, avoidant, disorganized, or isolated and ex­plore the early family dynamics and implicit ex­periential conclusions that led to these pat­terns. Clients’ awareness of attachment styles and their resources for building meaningful re­lationships become an important aspect of our dialogue. For example, in Kay’s psycho­thera­py, she eventually began to appreciate how her ambivalent attachment style was formed and how she was maintaining it in her adult life. Andrew’s isolated attachment was compensated for with many forms of obsession. He was even­tually able to identify how each obsession created isolation in relationship.

People are often not conscious of their pat­terns of self-stabilization and self-regulation, which were developed to reduce intense affect. Clients often engage in particular gestures, re­petitive behaviors, or script beliefs to calm over­stimulating emotional reactions in the ab­sence of need-fulfilling relationships. It is im­perative that the psychotherapist eventually bring these self-regulating patterns to the cli­ent’s awareness and investigate what is hap­pen­ing phenomenologically within the client in re­sponse to the therapeutic relationship or within the client’s memory in the moments prior to the self-regulating action. Such behaviors might take the form of stroking one’s hair, wringing one’s hands, or ending sentences with “you know.” Body language is an important con­vey­er of unconscious communication, and there­fore it is essential in psychotherapy to focus on clients becoming aware of the communication inherent in their physical movements, gestures, and postures. For example, it took me almost 2 years to realize that Kay’s constant movement of her fingers against each other was an un­con­scious attempt to tell the story of emotional and physical abandonment. In Andrew’s case, he would momentarily, but frequently, turn his eyes away from me to regulate his affect when the contact between us was intense. Together we learned to use these moments of self-soothing withdrawal to understand his sense of isolation and my misattunement.

The concept of relational needs (Erskine & Trautmann, 1996/1997) is usually not con­scious to most clients. The lack of satisfaction of relational needs is expressed as nervousness, irritation, preoccupation, or prolonged dis­com­fort. Such sensations then shape the interac­tions or avoidance of interactions with people. Relational needs are inherent, yet often un­con­scious, dynamics in the transferences of every­day life and in the intersubjective therapeutic engagements. It is the psychotherapist’s task to help the client gain awareness of his or her need for security in relationship; a sense of vali­dation of one’s affect and internal experi­ence; a sense of reliance, dependability and con­sistency from a significant other; a shared experience; the opportunity for self-definition; the capacity to make an impact in relationship; the other to initiate; and an expression of one’s appreciation and gratitude. In both Kay’s and Andrew’s therapy, the need for security, vali­da­tion, and dependability of the other were ex­treme­ly important. Neither client was aware of the significance of these needs when entering therapy.

Clients’ script beliefs about self, others, and the quality of life (Erskine & Zalcman, 1979/1997) are usually unconscious, although they are often evident in social conversation. These prereflective sets of script beliefs provide a self-regulating mental framework and represent implicit experiential conclusions that have been formulated over a number of developmental ages. Once formulated and adopted, script beliefs influence what stimuli (internal and external) are attended to, how they are inter­pre­ted, and whether or not they are acted on. Script beliefs serve to distract against aware­ness of past experiences, relational needs, and related emotions. At the beginning of therapy, neither Kay nor Andrew was conscious of her or his script beliefs and how those beliefs or­gan­ized her or his experiences in life. Andrew’s script beliefs were “Something is wrong with me,” “No one is there for me,” and “No one un­derstands me.” Kay’s script beliefs were “I’m all alone in the world,” “My feelings are un­important,” and “People will control me.” Each of these script beliefs unconsciously de­ter­mined their behaviors, fantasies, and quality of relationships.

Introjection, by definition, is an unconscious, defensive identification with elements of the per­sonality of a significant other that occurs in the absence of full relational contact (Erskine, 2003). Clients, although often aware of an in­ter­nal cr­i­­tical voice, are not aware of the per­va­sive in­flu­ence of their Parent ego state. In in-depth, inte­grative psychotherapy, it may be es­sen­tial to in­vestigate and even decommission the intro­jec­tion of the attitudes, behaviors, or emotions of significant others that have been unconsciously identified as one’s own (Erskine & Trautmann, 2003). With Kay and Andrew, we did not focus on psychotherapy of the Par­ent ego state; it did not seem germane to the treat­ment. For other clients, affects, attitudes, bodi­­ly reactions, and/or defensive patterns in­tro­jected from sig­ni­fi­cant others may internally influence or even domi­nate their lives. Aware­ness and resolution of introjections is an impor­tant aspect of in-depth, integrative psycho­thera­py.

The Process of Psychotherapy

Our psychotherapeutic task is to help clients make conscious what is “unconscious”! What most people generally consider “conscious mem­­ory” is usually composed of explicit memory—the type of memory that is described as sym­bolic: a photographic image, impressionistic painting, or audio recording of what was said in past events. Such explicit or declarative mem­ory is usually anchored in the capacity to use social language and concepts to describe ex­peri­ence. Experience that is unconscious usu­ally lacks explicit recall of an event because it is subsymbolic or presymbolic, physiological or procedural, repressed or the result of trauma (Bucci, 2001; Fosshage, 2005; Howell, 2005; Lyons-Ruth, 1999). Such unconscious memory is potentially “felt” as physiological tensions, undifferentiated affect, longings, or repulsions and manifested as prereflective relational and self-regulating patterns. These are the symp­toms that bring clients to psychotherapy.

Clients like Kay and Andrew require a psy­cho­therapist who is aware of the various dimen­sions of implicit, pre- and subsymbolic, and pro­cedural memories. It is necessary in a rela­tional and integrative psychotherapy that the therapist remain sensitive to the unconscious com­munication inherent in the transferential ex­pressions both within the therapeutic rela­tion­ship and, importantly, within the trans­fer­ences of everyday life (Freud, 1912/1958a). Affective escalations, relational conflicts, habi­tual worries and obsessions, absence of affect, and even some physical ailments may represent a form of unconscious expression of implicit and emotional memory. Unconscious pro­cedu­ral memory may be expressed in attachment styles marked by ambivalence, avoidance, or ag­gression (Main, 1995; Wallin, 2007). It is through the psychotherapist’s awareness of his or her own personal emotional reactions and as­sociations to the client, together with an un­der­standing of child development and self-protective reactions, that the therapist can sense the client’s unconscious communication of re­lational conflicts or traumatic experiences of early childhood. Through affective and rhyth­mic attunement and an awareness of the impor­tance of relational needs, the psychotherapist can create a sensitive phenomenological and his­torical inquiry that allows unconscious, pre- and subsymbolic emotional memory to be sym­bolically communicated through a shared lan­guage with an attuned and involved listener (Ers­kine, Moursund, & Trautmann, 1999).

For example, Kay could not put her hospital ex­perience into words with either her first thera­­pist, who focused on educational and career goals, or her second therapist, whose meth­ods emphasized confrontation and ap­pro­priate be­havior. When a psychotherapist focuses pri­mari­ly on behavioral change, providing ex­pla­na­tions, and encouraging a redecision or is bound by a theoretical perspective, the op­por­tunity for the client’s unconscious process of communication to be received, understood, and processed into language may be overlooked in the psychotherapy. It is through our sustained affective and rhythmic attunement that we sense the unconscious developmental nature of the client’s pre- and subsymbolic experiences. Through our empathy, we sense what relational needs were unrequited and how to respond thera­peutically to those unrequited needs and the client’s resulting styles of compensation and attachment.

Kay required a psychotherapist who could be emotionally responsive to her fear of aban­don­ment, her profound loneliness, and her anger at being controlled. She needed attunement to both the 2-to-4-year-old child’s agony and that child’s regression to a preverbal developmental level—a regression that was a desperate at­tempt at self-regulation. She needed a psycho­therapist who would attune to her silence, rhythm, and despair; who would play with her; and who would help her put her preverbal, nev­er verbalized, unacknowledged, and nonmemo­ry unconscious experiences into interactive com­munication and language. Kay required a therapist who could decode her nonverbal ex­periences through being sensitive to the under­lying meaning in her distracting comments, her silences, her facial and hand gestures, and her developmental needs; a therapist who, through affective reciprocity and therapeutic inference, could supply the necessary words and concepts that would make it possible to put her experi­ences into words—to make the unconscious hos­pital experience conscious.

Andrew required a therapist who was sen­si­tive to his overwhelming sense of shame and his terror about punishment as well as to the psy­chological functions and script beliefs under­lying his numerous obsessions. He also needed a combination of therapeutic protection against punishment and an understanding of his previously unconscious prereflective patterns of attachment, self-regulation, and relational-needs (Moursund & Erskine, 2004). Andrew’s avoidance of telling about his sexual experi­ence resulted in the experience becoming un­conscious. In the psychotherapist’s consistent use of phenomenological inquiry, Andrew’s un­conscious memories were formed into an ex­plicit memory and symbolic narrative. He no long­er obsessed to distract himself from his origi­nal fear of punishment.

The stories of Kay and Andrew reflect the importance of the psychotherapist’s attunement and involvement in decoding the various as­pects of presymbolic and subsymbolic uncon­scious communication. The aim of an in-depth integrative psychotherapy is to provide the quali­ty of therapeutic relationship, under­stand­ing, and skill that facilitates the client in be­com­ing conscious of what was previously un­conscious so that he or she can be intimate with others, maintain good health, and engage in the tasks of everyday life without preformed re­stric­tions.

Richard G. Erskine, Ph.D., Training Direc­tor of the Institute for Integrative Psycho­therapy, New York, is a clinical psychologist, licensed psychoanalyst, and Teaching and Su­per­vising Transactional Analyst (psycho­thera­py). He is visiting professor of psycho­thera­py at the University of Derby and runs several in­ternational training programs and workshops as well as maintaining a private psychotherapy practice in New York City. He may be reached at the Institute for Integrative Psychotherapy, 500 East 85th St., PH B, New York, NY 10028, U.S.A.; e-mail: integpsych@earthlink.net ; Web site: www.integrativetherapy.com .

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http://psychcentral.com/lib/2006/an-introduction-to-psychotherapy/
psychcentral.com
By John M. Grohol, Psy.D.

Psychotherapy is a process focused on helping you heal and learn more constructive ways to deal with the problems or issues within your life. It can also be a supportive process when going through a difficult period or under increased stress, such as starting a new career or going through a divorce.

Generally psychotherapy is recommended whenever a person is grappling with a life, relationship or work issue or a specific mental health concern, and these issues or concerns are causing the individual a great deal of pain or upset for longer than a few days. There are exceptions to this general rule, but for the most part, there is no harm to going into therapy even if you’re not entirely certain you would benefit from it. Millions of people visit a psychotherapist every year, and most research shows that people who do so benefit from the interaction. Most therapists will also be honest with you if they believe you won’t benefit or in their opinion, don’t need psychotherapy.

Modern psychotherapy differs significantly from the Hollywood version. Typically, most people see their therapist once a week for 50 minutes. For medication-only appointments, sessions will be with a psychiatric nurse or psychiatrist and tend to last only 15 to 20 minutes. These medication appointments tend to be scheduled once per month or once every six weeks.

Most psychotherapy tends to focus on problem solving and is goal-oriented. That means at the onset of treatment, you and your therapist decide upon which specific changes you would like to make in your life. These goals will often be broken down into smaller attainable objectives and put into a formal treatment plan. Most psychotherapists today work on and focus on helping you to achieve those goals. This is done simply through talking and discussing techniques that the therapist can suggest that may help you better navigate those difficult areas within your life. Often psychotherapy will help teach people about their disorder, too, and suggest additional coping mechanisms that the person may find more effective.

Most psychotherapy today is short-term and lasts less than a year. Most common mental disorders can often be successfully treated in this time frame, often with a combination of psychotherapy and medications.

Psychotherapy is most successful when the individual enters therapy on their own and has a strong desire to change. If you don’t want to change, change will be slow in coming. Change means altering those aspects of your life that aren’t working for you any longer, or are contributing to your problems or ongoing issues. It is also best to keep an open mind while in psychotherapy, and be willing to try out new things that ordinarily you may not do. Psychotherapy is often about challenging one’s existing set of beliefs and often, one’s very self. It is most successful when a person is able and willing to try to do this in a safe and supportive environment.

Common Types of Psychotherapy

* Behavior Therapy
* Cognitive Therapy
* Family Therapy
* Group Therapy
* Interpersonal Therapy
* Psychodynamic Therapy
* Frequently Asked Questions (FAQs) about Psychotherapy