Integrative Psychotherapy: An Application

by Debbie Hegarty

Introduction
The client I am using to illustrate my work has been assigned a fictitious name, and details of his story have been altered to disguise his identity and protect his anonymity. I will refer to my client as Markus. I have been working with him since early 2010. I will include quotes that I recall the client using during our sessions but will only use those that keep the client safe from becoming identifiable.

My approach to psychotherapy practitioning is integrative. In my view integration and working integratively is inevitably a personal process and, as such, my practitioning reflects my life experiences, professional trainings, temperament, personal style, the theories and methods that best fit my style, as well as my understanding of them. I believe that any one theory cannot possibly answer the diversity and complexity of being human, dealing with human distress, and supporting clients to manage their lives better. For that reason I am committed to upskilling and learning more from the wealth of available material that exists in this field.

I hold the view that although human beings are capable of being hateful, selfish, aggressive, rigid and uncooperative, that is not how they are fundamentally. At the core of human nature is the potential for love, altruism, compassion, flexibility, mutuality and cooperation. Schore (2001) states the core of the self is non-verbal and unconscious. So how can I best facilitate my clients in bringing what is non-verbal and unconscious to conscious awareness? The approach I use combines bottom-up and top-down therapy, merging brain, body and mind functions, towards a fundamental goal of integration.

I like to consider the uniqueness of the client, as well as what the client may share with others. I believe there is a universal way of responding to distress, stress and trauma, and then there is what each individual does with it. I am always paying attention to what the client has done with what has happened to him/her, as well as my subjective responses to what is being shared.

Markus initially presented in denial of his part of why his life was ‘spinning out of control’ and unsure why he was in therapy. I like to consider Roger’s “Seven Stages of Process Model” (Rogers, 1957: 132) during the initial intake session, and with the use of this model I was able to assess that Markus was in stage two of the therapeutic process, meaning whilst he appeared rigid and seemed to be blaming others, there were the beginnings of acceptance that things were not right. It concerned me that he was increasingly isolating himself from friends and family. He had also shared that a significant long-term relationship had broken down. In addition, his profession was in decreasing demand. Because of this he was spending more time than usual alone with his thoughts and not reaching out for support or help from others. And yet he was sitting in front of me.

I identified work-related stress, esteem issues and relationship difficulties. I then established that the immediate tasks and goals of the therapy were shared and that he was satisfied I was competent in working with him. He was, and I certainly felt experienced enough to work with his presenting issues. It is important during the initial session to consider whether I am competent in working with the client’s presenting problem, and if not, who or where I might refer the client on to. We discussed other contractual issues such as the fee, etc., and arranged to meet weekly.

What ails Markus?
A philosophy that underpins my work is existentialism. Existentialism values the importance of subjectivity and phenomenology, and promotes self-actualization, autonomy, freedom, personal choice and social responsibility (Hegel, 1977). Sartre (1958) suggests one person can never fully know the experience of another. I believe this to be true. Nonetheless, I prefer to focus on what I can fully know, which is how I am thinking, feeling, sensing and responding as I work with clients. I also like to consider what I can do rather than what I can’t. I can gather as much information as possible. Not just for the purposes of hearing a story. I am much more interested in what Markus did with what happened to him. It always helps me in this endeavour to ask open questions such as: ‘And what was that like for you?’

The findings of Attachment Theory, as conceptualised by Bowlby (1969, 1973, 1980, 1988) and Ainsworth et al. (1978), influence how I formulate a case more than any other theoretical orientation. According to Bowlby (1988), infants come into the world necessarily oriented towards, and seeking proximity to, their caregivers for survival. Wallin (2007) argues that secure attachment is only possible if the caregiver has a willingness, and ability to accurately understand, reflect and contain the child’s affect. If the child experiences their attachment figure as available in this way, and capable of holding their distress, they will form positive mental representations, or “working models” (Bowlby, 1973: 203), of self, others and the world. Markus had formed an abysmal working model. The reasons for this will become evident as his story unfolds.

Ainsworth et al.’s (1978) research findings identified distinct individual differences among infants in the strategies used to respond to caregivers. They categorised these mechanisms into four attachment behaviours:

1. Secure/autonomous.
2. Insecure/dismissing or avoidant. 3. Insecure/preoccupied or resistant. 4. Unresolved/disorganised.

Several studies have examined how these attachment styles, and the working models that underlie them, affect how people process interpersonal information (Collins & Feeney, 2004; Feeney & Cassidy, 2003; Fraley, Garner & Shaver, 2000; Kirsh & Cassidy, 1997). Findings from these studies suggest that highly avoidant and highly anxious people perceive their social environment more negatively than do securely attached people. In addition, Fraley and Brumbaugh (2004) found that memories of adolescents who had attached insecurely to their caregivers became more negative and distorted over time than did the memories of adolescents with secure attachment styles. Subsequent memories that are consistent with the working model are more easily assimilated into the working model, and therefore help to maintain these mental representations. Markus had set up his world to ensure that any memories he experienced subsequent to the time he formed his worldview fitted nicely into his existing rigid map.

I used some of the questions from the Adult Attachment Interview (Steele & Steele, 2008) to assess Markus’ attachment pattern. In Markus’ case I was able to assess an avoidant attachment style. His relationship with his mother was ‘conditional’ and he described her as ‘aggressive, distant and busy’. His father ‘always appeared aloof and distracted’, and developed an increasing dependency on alcohol during his lifetime, for which he never sought professional help. Markus was bitter about this, and angry that his mother ‘enabled his drinking’. Markus was admired for being hard-working, and received attention for achieving good grades at school initially (over time his grades become increasingly appalling). Throughout the interview he seemed to discount or “devalue early relationships” (Fonagy, 2002: 73) which can also be an indication of an avoidant style. There was also evidence of unresolved trauma in the way Markus told his story and this indicated a disorganised attachment style. At times Markus’ answers became incoherent. Other times he seemed to trail off mid-sentence.

According to Johnson (1994) there are “therapeutic objectives for each character structure” (302). He presents a theoretical and research- based model of character development that illustrates how events in early development sometimes result in psychological pain and injury to the self. The child develops defences to cope with pain. Over time severe pathology can occur when the innate needs of that child become frustrated due to a failure that occurs in the environment’s capacity to attune to, and be responsive to those needs. In addition a conflict emerges between compliance to adapt to the demands and requests of others, and the drive to “operate independently” (193). Because the innate need is dissatisfied, it remains in a developmentally arrested and immature form, unconscious, and therefore unavailable for the “optimal indulgence and optimal frustration that would mature it” (210). I like this developmental theory. It fits with what I witness in my work.

Johnson (1994) categorises seven character structures, and states that it is what motivates the behaviour, rather than the behaviour itself, that “determines the issue representing its expression” (212). Markus showed characteristics of a Narcissistic Character Style. He relied on achievement and acquisition to feel good and showed “persistent grandiosity of false self-accomplishment” (Johnson, 1987: 125). He seemed to have a sense of entitlement in the few close relationships he described, expecting that others should accept his behaviour, and becoming angry when these behaviours were challenged or rejected by others. He showed “little or no empathy” (133) towards his most recent partner in the aftermath of the incidents that had led to their break-up.

Assessing the possibility of a narcissistic character structure, as well as an avoidant or unresolved/disorganized attachment style, supported me in formulating a plan for our therapy. And yet there were relationship dynamics occurring between us that left me confused and intrigued. I began to read more about childhood adversity and came across articles by van der Kolk (2009) describing the term “Complex Trauma” (2) which seemed relevant. Complex trauma was adopted as a term to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature. Van der Kolk explains that when children are unable to achieve a sense of control and stability they feel and become helpless:

If they are unable to grasp what is going on and unable to do anything about it to change it, they go immediately from (fearful) stimulus to (fight/flight/freeze) response without being able to learn from the experience (5).

Later on in life when exposed to reminders of that trauma (sensations, feelings, images, sounds, smells and situations) they tend to deal with it in a rigid and unrealistic way as if the past trauma is still happening. Markus was certainly showing a rigid and unrealistic response to what was happening currently for him.

I found myself consulting the Diagnostic and Statistical Manual of Mental Disorders (DSM, American Psychiatric Association, 2013) when attempting to make sense of Markus’ symptoms. The latest and fifth edition (DSM-V) was released at the American Psychiatric Association’s Annual Meeting in May 2013, and in my view it is a comprehensive and concise classification system. It is certainly not my intention to become the expert in the therapy room, and I am never interested in putting clients in boxes. Having said that, being able to make sense of a presenting symptom, or cluster of symptoms, allows for accuracy in devising a plan for the therapy, as well as safety in deciding on interventions. I am always careful to involve my client at each stage of an assessment, in any plan I devise, and in any intervention I consider might be useful. In my experience, case formulations, plans for the therapy, and interventions are more likely to result in a successful outcome if they are co-created, flexible, regularly reviewed, and altered accordingly, depending on the feedback I receive from the client (Lambert, 2010; Mearns & Cooper, 2005).

Some of what Markus described in terms of what he was experiencing seemed to indicate complex trauma or “Developmental Trauma Disorder” (van der Kolk, 2009: 10). This relatively new diagnosis has been developed by “The Complex Trauma taskforce of the National Child Traumatic Stress Network” (10) in an attempt to more clearly delineate what children who have been exposed to trauma sometimes present with. Markus had been exposed to emotional neglect, alcoholism, sexual abuse from his older brother, as well as significant loss. His maternal grandmother, who lived with the family throughout his growing up years, was ‘the only person who liked me for me and not for what I achieved’. She had died suddenly and tragically when he was eleven years of age. During his lifetime he experienced repeated dysregulation (both high and low) when faced with stressful situations or events, and he always found it hard to ‘return to baseline (homeostasis) when he became triggered. He was distrustful of others, and compulsively self-reliant. He seemed to be having trouble regulating anger and rage recently (often showing up at his ex- girlfriend’s home at inappropriate times, making improper demands of her). He shared he has always been troubled by recurring unwanted images, thoughts and sensations relating to the alleged sexual abuse, but has managed to normalise the symptoms declaring that ‘it’s par for the course’. Markus took a while in sharing that his older brother had sexually molested him. I understood that he was experiencing a “crisis of loyalty” (6) and that he needed the timing to be okay with disclosing this part of his story.

Fonagy and his colleagues (Fonagy & Target, 1997; Fonagy et al., 1997) suggest that the causation of emotional avoidance, impulsivity, self-harm, emotional distress, feelings of worthlessness (negative affect), emotional dysregulation, and the subsequent formation of problematic internal working models of self and others, is chaotic or traumatic attachment relationships. According to van der Kolk (2009), exposure to trauma often occurs within a child’s family system and these experiences, coupled with unhealthy attachment relationships, leave the individual vulnerable to rejection, abuse, and feelings of emptiness, worthlessness and stress (Fonagy at al., 1997) and therefore reliant on defence mechanisms such as dissociation, emotional avoidance and distortion of memory that provide partial relief from feelings of helplessness (Mikulincer & Shaver, 2007).

As a wounded healer (Sedgwick, 1994; Zerubavel & O’Dougherty, 2012) on a journey toward self-healing for some time now, I have come to trust and know myself well. I find knowing myself integral in meeting and holding the client. In addition, I aspire to providing the attitudinal core conditions of genuine empathy and authentic presence.

How I helped
I believe change is possible in therapy that feels safe, but not too safe (Ogden, 2009). I work relationally and as aforementioned I encourage client participation in all aspects of the therapy.

As a wounded healer (Sedgwick, 1994; Zerubavel & O’Dougherty, 2012) on a journey toward self-healing for some time now, I have come to trust and know myself well. I find knowing myself integral in meeting and holding the client. In addition, I aspire to providing the attitudinal core conditions of genuine empathy and authentic presence.

My goal is not to get rid of any part of the client, including any defensive/protective strategies or enactments, because I believe these were developed at a time when protection was deemed essential to survival. Instead, once safety and trust has been established, and the relationship is sufficiently strong enough, I begin to challenge the effectiveness of these mechanisms.

Client characteristics, extra-therapeutic factors, therapist qualities and the therapeutic relationship, collectively referred to as common factors, or “non-specific factors” (Asay & Lambert, 1999: 31), are necessary, but not sufficient, components in achieving successful outcomes (i.e., change that is stable and enduring). In my experience change can only occur when I have included common factors and specific factors.

Some of the specific factors I have trained in, and integrated over time, are Developmental Psychology, Psychopathology, Awareness Therapy, Gestalt Psychotherapy, Transactional Analysis, Somatic Experiencing, Mindfulness, Family Systems Therapy (The Hellinger Institute) and Reality Therapy. I have also specialised in working with couples and families and often invite family members into my individual work. This never seemed relevant or potentially helpful when working with Markus.

A specific approach to practitioning that I find particularly effective, and hold closest to my heart, is Awareness Therapy. The skills, principles and philosophies I integrated during the four-year training in Awareness Therapy, under the wonderful tutelage of Brendan Connelly (deceased) and Marie Herlihy, allow me to facilitate clients in developing awareness of the language of feeling and sensation, which can often lie in stark contrast with the language of thinking. The language of feeling and sensation is often strange at first for clients and I adapt my expression of it accordingly to my client’s spontaneous speech (Ecker et al., 2012). In my view, if integration is an intrinsic goal of therapy, then feelings, sensations and cognition must at least become congruent.

As I see it, the effectiveness of Awareness Therapy lies in its simplicity. Practicing Awareness Therapy supports the integration of brain, body and mind. Once this is accomplished (although I am sure that it is rarely fully achieved) clients begin to trust themselves more. From that place of trust, relationships get better, decision-making improves, and the capacity to manage stressful situations is developed or enhanced.

Primarily, Awareness Therapy interventions focus on the client paying specific and intentional attention to bodily sensations and feelings using breath. In essence, breath is used as a medium for accessing the body process. Facilitating awareness of how his body processes experiences using breathing techniques offered Markus an opportunity to experience rare moments where the focus of his attention was on himself, rather than on things and people outside of himself. Over time Markus learned to make sense of, accept, and thus manage the symptoms of his distress. One of Markus’ goals was ‘to get rid of’ his symptoms. My aim was to help Markus make sense of these symptoms. As I often say to clients, ‘symptoms are information… so let’s get curious’!

A fundamental aspect of using Awareness Therapy as an intervention is to encourage clients to close their eyes throughout the exercises. Initially, as was demonstrated to me, I suggest that clients pick a spot on the floor in front of them rather than closing their eyes if doing so creates too much discomfort.

Sometimes I encourage clients to breathe in such a way that focuses on the out breath, using the in breath to compensate for the out breath. Other times I suggest that clients simply stay with the organic ebb and flow of their breath in their body without deepening it or changing it (unless it feels right for them to do so). With each out breath I encouraged clients to imagine that they are releasing any unnecessary muscular tension. In Markus’ case, muscular tension was creating psychological/somatic pain.

According to Husserl (1927/2006) there can be no accuracy in perception without awareness of the complex bodily system of feelings, sensations, muscular tensions, physiological pain (which tends to remain in one spot) and psychological pain (which I notice tends to move around the body). Markus shared that his pain moved across the upper section of his back, down his arms, and then seemed to stop short at his wrists. I suggested to Markus, as I might to other clients, that he imagine that he can breathe directly to the place where there is pain and be curious about it instead of frightened by what he might meet there. Can I just say that the outcome of this type of intervention is astonishing, and I wonder have I captured it using merely words?

I like to keep a soft, small blanket in my room which I offer to my clients when they are coming out of an exercise such as the one I have just described. This helps clients experience being nurtured and cared for as we both discuss the sense we can make of what just occurred. A word of warning: when attempting this type of technique with clients they sometimes describe experiencing temporary dizziness. Explain this possibility in advance. It is normal and natural, and dissipates with time, so don’t introduce this technique too near to the end of the session.

Awareness Therapy practitioners observe rather than interpret what is taking place in the moment-to-moment contact between client and therapist, and then repeatedly call attention to, and explore those immediate experiences with the client. When appropriate I will hold eye contact when the client emerges from an awareness exercise. I try to hold off on verbalizing for as long as feels natural. These moments of absolute contact are rare and beautiful, and are my most memorable experiences of practitioning. Awareness Therapy interventions helped Markus in developing more of an understanding of his overall responses to his complex experiences. He spoke of feeling more in ‘control of his impulses’. He began to accept that although he has very little control over others, what he can control is how he responds.

A Word on Neuroscience
I would like to briefly discuss the findings in neuroscience that are relevant to practitioning. I find having knowledge of neuroscience and the geography of the brain is particularly helpful when considering how dysfunction might occur. Neuroscience seeks to describe and explain function and dysfunction in terms of nerves and chemicals in the body, specifically in the brain. As human beings we have innate desires and drives, as well as the ability to learn and remember.

In 2008, Ecker and Toomey declared that up until the later decades of the 20th century neuroscientists held the view that certain neural networks were hard-wired and therefore not capable of changing. Since then neuroplasticity has gained acceptance throughout the scientific and psychotherapeutic community. Neuroplasticity refers to the capacity of neural networks in the brain to organise and reorganise their specific functions in response to new information, sensory stimulation, development, damage or dysfunction (Ecker et al., 2012). Siegel (2012) states that developmental plasticity occurs most profoundly in the first few years of life as neurons grow rapidly, sprout branches, and form synapses. As the brain begins to process sensory information, those connections between synapses that are reinforced by experience strengthen, and those that are not reinforced weaken (conditioning). Eventually some unused synapses are eliminated completely, a process known as synaptic pruning. Throughout a lifespan neural connections are fine-tuned by the experiences we have with our surroundings (representational mapping). Once the critical early childhood period ends, only those connections that have been strengthened by sensory experiences remain. This seems to explain the correlation between sensitive mirroring, unconditional positive regard and the development of a healthy working model (Schore, 2002).

I have learned that the capacity to regulate arousal, whether hyper or hypo, in the face of adversity is not an innate human function. It is “experience dependent” (Schore, 2002: 443) and only develops in the kind of “growth-facilitating emotional environment” (440) that I am committed to developing with clients. I like to draw the following two diagrams for clients that present with unresolved trauma:

(Diagrams taken from: www.sensorimotorpsychotherapy.org/articles. html. Date retrieved: 30 December 2013).

The ‘window of affect tolerance’ concept explains the process of arousal that occurs during extreme stress/trauma. Arousal initially rises beyond, or breaks the boundary, of the optimal arousal zone. In this zone it is possible to contain, and therefore experience, feelings and sensations associated with the experience without dissociation (Ogden, 2009). A primary aim during therapy with Markus was to help him to expand the regulatory boundaries of the window of tolerance so that he could learn to return to baseline (otherwise known as the Optimal Arousal Zone) when faced with stressful situations that engender a hyper or hypo arousal response.

This task was made possible using a combination of Awareness Therapy and Somatic Experiencing. Both approaches encourage interactive regulation, or right-brain-to-right-brain connection. What does that mean? My understanding of this way of making contact is that it is less about talking and thinking, and more about sensing and noticing. Most of you will have a picture in your minds of a mother and child making contact in this non-verbal way. The end goal is to support the client in developing the capacity to self-regulate. Schore (2002) states that self- and other-regulation functions cannot develop in a child whose affect is not soothed and regulated by their care-givers and who are witness to childhood adversity and trauma.

Conclusion
Markus required a longer period of psychotherapy than might be the case if I had stayed with the initial assessment of work-related stress, self esteem, or relationship issues. The story of unresolved trauma emerged during phenomenological enquiry. Utilising the available literature on stress and trauma and character development, the findings of the AAI interview I conducted with Markus, and the consultation with the DSM-V, I understood that the unresolved trauma needed to be worked through before we could work through the more explicit presenting problems. This took time. We devised a carefully thought- out plan together that would allow Markus achieve integration. The slow and painful process of constructing a meaningful story of his childhood experiences required that he focus on the past, which he had successfully avoided up until the time we met. As aforementioned, Markus had constructed an abysmal working model. His father’s dependency on alcohol increased around the time of Markus’ birth. Consequently his mother was distracted from the task of meeting his needs as a newborn and he did not develop the capacity for affect regulation. He gained self esteem via acquisition and achievement. At times he would become fragmented during attempts at Awareness Therapy or Somatic Experiencing, yet we persevered. I became adept at anticipating these occurrences, and in containing his distress until such time as I assessed that he was sufficiently self-supported. His part in why the therapeutic outcome was effective was his commitment to our therapy from the start, as well as his willingness to trust me.
I have no doubt it helped that many of the distressing symptoms dissipated in the first trimester of the therapy. This offered us both hope during times when we became stuck, or when Markus seemed to present to our sessions more distressed rather than less. It has been a privilege for me to witness and be part of his astounding journey toward integration.

Debbie Hegarty, MA is an integrative psychotherapist and trainer and works with individuals, couples and families in private practice. In addition, she provides short-term counselling to individuals with mild to moderate psychological difficulties within the Counselling in Primary Care (CIPC) services.

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