http://www.integrativetherapy.com/en/articles.php?id=59
integrativetherapy.com
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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