Integrative psychotherapy

1. Introduction

Version followed: Richard G. Erskine's developmentally based, relationally focused Integrative Psychotherapy as published by Erskine and colleagues through the Institute for Integrative Psychotherapy (New York): the methods of inquiry, attunement and involvement (Erskine & Trautmann 1996), relational needs and presence (Erskine 2011), the script system (O'Reilly-Knapp & Erskine 2010), Parent ego state therapy as written up by Institute-affiliated trainers (Zaletel, Potočnik & Jalen, citing Erskine & Trautmann 2003 and Erskine & Moursund 1988/1998), and the schizoid-process adaptations (Erskine 2020). Erskine's books are not drawn on beyond publisher front matter; their content is used only where the articles above reproduce it.

What it is. Not a manualised protocol but an integrative relational framework. "Integrative" has two meanings here: (a) integrating the personality, i.e. making disowned, unaware or unresolved ego states part of a cohesive self, and (b) selectively combining affective, cognitive, behavioural, physiological and systems approaches, with transactional analysis (TA) as the main organising framework, plus Gestalt, psychoanalytic self-psychology, object relations and body psychotherapy. Erskine's later writing stresses "internal integration" of physiology, affect and cognition rather than blending techniques. [source: Erskine & Trautmann 1996; Karnac/Routledge description of Relational Patterns, Therapeutic Presence]

How change happens. People are relationship-seeking; psychological needs are met through contact-in-relationship (internal contact with sensations, feelings, needs, thoughts, memories; external contact with others). When relational needs go repeatedly unmet, the person forms defensive "artificial closures" (disavowed affect, habitual behaviour, body inhibition, limiting beliefs) that crystallise into a life script. Healing occurs primarily through the interpersonal contact of an attuned therapeutic relationship, which dissolves defensive interruptions to contact, lets archaic needs and feelings be acknowledged and validated, and allows script beliefs to be reorganised so the client can meet life with spontaneity and flexibility. Techniques are aids; the relationship is the healing factor. [source: Erskine & Trautmann 1996; Erskine & Criswell, Conversations with Richard; Erskine 2011]

2. Framework

No formal stage model is given in the primary sources. O'Reilly-Knapp & Erskine (TAJ 33(2)) explicitly describe no formal stages but a typical pattern; the course below follows that pattern, with the assessment dimensions the authors use to choose interventions. [source: O'Reilly-Knapp & Erskine, Core Concepts of an Integrative TA] [uncertain: phase labels and transition criteria are partly synthesis]

Format. Individual, face-to-face, open-ended and often long-term (the published schizoid case ran about 4 years). Parent ego state work may take one or several sessions; Erskine is reported to suggest about 90 minutes for it. Erskine also works in workshops and groups, but no group protocol was found. Time-limited applications exist in the IIPA case literature but are not drawn on. [source: Erskine 2020; Zaletel et al.; Erskine & Criswell] [uncertain: typical session count; frequency not specified]

Ongoing assessment dimensions (the decision procedure)

The framework is mainly a way of choosing interventions moment to moment. The clinician continuously assesses: [source: Erskine & Trautmann 1996; O'Reilly-Knapp & Erskine 2003, 2010; Erskine 2011; Erskine & Criswell]

Four domains open or closed to contact: affective, behavioural, cognitive, physiological. Apply methods to enhance contact in the closed domains.
Script system: script beliefs (self, others, quality of life), script manifestations (observable behaviour, reported internal/bodily experience, fantasies and dreams), reinforcing memories, and the repressed needs and feelings beneath.
Level at which the script was laid down, matched to method: explicit childhood decisions → expressive methods (redecision, chair work, introject work); implicit experiential conclusions built pre-verbally → longer relational work attuned to affect, rhythm, development and relational needs; physiological survival reactions held as muscular/visceral patterns → body-oriented work. Often all three are combined.
Which of the eight relational needs is figural (security; validation/affirmation/significance; acceptance by a stable, dependable, protective other; confirmation of experience; self-definition; having an impact; having the other initiate; expressing love).
Attachment pattern and its implicit fear (inconsistent care → clinging, fear of loss of relationship; predictable unavailability → avoidance, fear of vulnerability; predictable punishment of needs → disorganisation, fear of violation; invasive control → façade/withdrawal, fear of invasion), and severity on a continuum from style to pattern to disorder.
Ego state source of a problem: fixated archaic Child, introjected Parent, or Adult contaminated by either; and whether a harsh inner voice is the real introject or a self-generated "Internal Saboteur".
Function of a transference moment: describing the past and thwarted needs; resisting remembering by re-enacting; expressing the wish for a needed relationship; the universal drive to make meaning (or no transference at all).
Developmental age at which the current affect, belief or survival reaction seems organised.

Typical course

Establishing contact and involvement. Goal: a dependable, attuned relationship; begin inquiry into present experience and history; map the script system and relational needs. Move on when the client can tolerate attuned contact and begins to bring affect, body experience or transference into the room. [source: O'Reilly-Knapp & Erskine; Erskine & Trautmann 1996]
Juxtaposition and transference enactment. Goal: work with the reactions provoked by the contrast between present attunement and past misattunement, and with archaic patterns appearing with the therapist or in daily relationships. Move on when the client can reflect on these patterns with the therapist rather than only enact them. [source: as above]
Regression, Parent work and repair. Goal: revisit fixations and introjections with the therapist present, rework old decisions, and experience what was missing; Parent ego state work only after substantial Child work and secure trust. Caring confrontation of discrepancies is reserved until a strong empathic relationship exists. [source: O'Reilly-Knapp & Erskine; Zaletel et al.]
Integration and ending. Signs of readiness [synthesis from Erskine 2020 and Erskine & Trautmann 1996 aims]: script beliefs loosened across behaviour, body, fantasy and memory; client distinguishes current from archaic needs; can disagree with the therapist and define self; uses contact flexibly in current relationships. Erskine notes that relationships around the client may be disrupted as the client changes. [uncertain: no published ending protocol found]

3. Guiding principles

Seven fundamental principles [source: O'Reilly-Knapp & Erskine, Core Concepts]:

People are relationship-seeking and interdependent throughout life. Read symptoms as attempts to manage relationship, not as isolated deficits.
Human beings have innate value. Never relate from superiority; protect the client's dignity in every intervention.
Psychological processes are normal. De-pathologise: frame defences and symptoms as understandable adaptations.
The client is committed to positive change. Treat apparent resistance as protective, not oppositional.
Internal and external contact are central to functioning. Track where contact is open or closed in each moment.
Development is ongoing. Respond to the developmental age that is active now, and expect needs to shift over the lifespan.
The therapeutic relationship is significant. The relationship, not the technique, heals; techniques sit inside it.

Stance principles [source: Erskine & Trautmann 1996; Erskine & Criswell; Erskine 2011; Erskine 2020]:

Respect for the client's integrity is the guiding principle. Ask of every intervention whether it respects and enhances the client's integrity.
Assume you know nothing about the client's inner experience. Ask rather than infer; Erskine locates his own past errors in assuming he understood.
Respect every interruption to contact. Each defence serves identity, stability, continuity or integrity; explore its function rather than remove it.
Be interested in how the client makes meaning. Inquiry is about the client's discovery, not your data gathering.
Attune before you intervene. Inquiry, validation and normalisation lose their healing effect without sustained affective attunement.
Process over content. How you ask (curious, respectful, non-humiliating) matters as much as what you ask.
Do not try to gratify archaic needs directly. A need from decades ago cannot be met now; acknowledge, validate and help the client separate current from archaic needs.
Avoid theory-driven countertransference. Do not apply rules such as non-gratification, rescuing or "self-responsibility" universally; e.g. waiting for a client to initiate may repeat an unmet need for the other to initiate.
Do not treat affection or idealisation as automatically pathological. Needs to express love or to lean on a protective other are legitimate.
Notice and own your misattunements. Take responsibility for therapeutic errors and repair quickly, as attuned caregivers do.
Presence = decentring plus self-contact. Set your own needs and goals aside while staying aware of your own reactions as information.
Let yourself be affected, and stay steady. Receive the client's affect without becoming anxious, depressed or angry.
Bring vitality and reciprocal enjoyment. Attunement includes shared pleasure, not only containment of pain.
Match rhythm. Pace to the client's processing speed, which slows under intense affect and shame.
Confront only within a strong empathic bond, and never humiliate.
Monitor yourself continuously. Ongoing personal therapy, supervision and consultation are part of the method; supervision that merely confirms your current approach is a warning sign (Erskine 2020).
Bodywork and touch occur only inside an established relationship that continues before, during and after the work.

4. Intervention inventory

The three core methods (inquiry, attunement, involvement) were derived, Erskine reports, from a 1980s Institute seminar that reviewed session recordings and factor-analysed what helped. They are used together, continuously, not in sequence. All example language below is illustrative wording written for this guide, not Erskine's. [source: Erskine & Criswell; Erskine & Trautmann 1996]

A. Inquiry

General rules for all forms [source: Erskine & Trautmann 1996; Žvelc 2010; Erskine & Criswell]: inquiry is respectful, empathic, curious and non-humiliating; it serves the client's self-discovery, not the therapist's hypothesis; closed, investigative "interrogation" questioning is poor practice; the dialogue moves non-linearly between phenomenological, transferential and defensive levels; observable (external) interruptions are taken as signs of internal ones.

1. Phenomenological inquiry

Purpose / when: Throughout; to bring the existence of feelings, sensations, needs and interruptions into awareness. [source: Erskine & Trautmann 1996]
Steps: (1) Notice a shift (breath, posture, a sigh, a pause, a qualifier like "it's OK"). (2) Ask an open question about present experience: what is felt, where in the body, how the client experiences self, others and the therapist right now, what they expect or fear. (3) Wait; let the pause unfold. (4) Follow the client's answer down one more layer rather than changing topic. (5) Check how the question itself landed.
Example language (illustrative): "What are you aware of as you say that?" / "Where do you notice that in your body?" / "What happens inside when you imagine me hearing this?"
Watch for: questions that feel like demands or judgements (especially with withdrawn or shame-prone clients); flat, intellectual answers suggesting the affective domain is closed. Working when the client's descriptions become richer, more embodied and more spontaneous.

2. Historical inquiry

Purpose / when: To locate when an experience began and who the significant people were; to link present reactions to developmental history. [source: Erskine & Trautmann 1996; O'Reilly-Knapp & Erskine 2010]
Steps: (1) Start from a present feeling or belief. (2) Ask when the client first remembers feeling this way, how old they were, who was there. (3) Ask what the people around them did and did not do. (4) Ask what the child concluded about self, others and life. (5) Return to the present: how that conclusion shows up now.
Example language (illustrative): "Does this feeling have a history? When do you first remember it?" / "Who was around then, and what did they do with your feelings?"
Watch for: turning into data-collection; pressing for memories that are not there. Treat what emerges as the client's experience and meaning, not as historical fact to be verified, and never suggest content. [synthesis, consistent with brief's trauma rule]

3. Inquiry into coping strategies (defensive inquiry)

Purpose / when: To reveal the client's means of resolving disruptions: the internal and external interruptions to contact, and the function each defence serves (identity, stability, continuity, integrity). [source: Erskine & Trautmann 1996]
Steps: (1) Name an observed interruption neutrally (changing the subject, laughing while describing pain, going numb). (2) Ask what happens just before it. (3) Ask what it protects against or helps with. (4) Acknowledge its value before exploring its cost.
Example language (illustrative): "I notice you smiled just as you mentioned your father leaving. What does the smile do for you there?" / "If you didn't go blank at that moment, what might you have to feel?"
Watch for: the client hearing criticism of the defence. Working when the client becomes curious about the defence instead of defending it.

4. Transferential inquiry

Purpose / when: To reveal the significance of feelings and interruptions as they appear in the relationship with the therapist (and with partners, bosses, children). [source: Erskine & Trautmann 1996; Erskine & Criswell]
Steps: (1) Notice a reaction toward you (deference, anticipation of criticism, withdrawal after closeness). (2) Ask how the client is experiencing you right now and what they expect you to do. (3) Explore which of the four functions is active (describing the past, re-enacting instead of remembering, wishing for a needed relationship, meaning-making). (4) Consider your own contribution before interpreting.
Example language (illustrative): "You paused before telling me that. What did you imagine I might think?" / "Is there a question in you about whether I'll react the way others have?"
Watch for: reducing a genuine here-and-now response to transference; Erskine notes some transactions are simply present-day.

5. Inquiry into vulnerability and relational needs

Purpose / when: Increases the client's value of self; brings unmet relational needs into awareness. [source: Erskine & Trautmann 1996]
Steps: (1) When longing, emptiness, loneliness, frustration or hopelessness appear (markers of unmet need), slow down. (2) Ask what the client needed then and what they need now, including from you. (3) Help distinguish archaic from current needs. (4) Validate the need itself as normal.
Example language (illustrative): "What did you need from someone back then?" / "And right now, here with me, what would help?"
Watch for: shame at having needs; minimising ("it's fine"). Working when the client can name a need without apologising for it.

B. Attunement

Two parts: sensing the other's sensations, needs or feelings, and communicating that sensing back, while keeping a clear self-other boundary and using one's own resonance as information. Described by Erskine as going beyond empathy toward reciprocal affective resonance. [source: Erskine & Trautmann 1996; Žvelc 2010]

6. Rhythmic attunement

Purpose / when: Always; pace inquiry and involvement to the client's processing speed. [source: Erskine & Trautmann 1996; Erskine & Criswell]
Steps: (1) Notice the client's tempo of speech, thought and affect (affect and cognition often process at different speeds; intense affect, shame, guilt, disgust, dissociation slow processing). (2) Slow your speech, lengthen pauses, ask one thing at a time. (3) Allow silence. (4) Re-check pace when the client tightens or drifts.
Example language (illustrative): "Take your time; there's no hurry here."
Watch for: your own urge to fill silence; signs you are going faster than the client can integrate (juxtaposition reactions, see #24).

7. Affective attunement

Purpose / when: To meet affect with a corresponding, authentic affect so the client experiences being received. [source: Erskine & Trautmann 1996; Erskine & Criswell]
Steps: Respond reciprocally, largely non-verbally: to sadness with compassion and comforting acts; to anger with attentiveness, seriousness, taking responsibility and, if warranted, corrective action; to fear with security and protection; to joy with vitality and shared pleasure. The affect must be genuine; performed affect risks feeling manipulative.
Example language (illustrative): (softly, with slowed voice) "That was so lonely for you." / (to anger, serious and steady) "You're right to be angry about that. I want to understand exactly what happened."
Watch for: mirroring the client's affect instead of answering it (e.g. becoming frightened with a frightened client). Working when the client's affect deepens and then settles.

8. Cognitive attunement

Purpose / when: To track and communicate understanding of the client's core beliefs, script conclusions and logic about self, others and life. [source: Erskine & Criswell; Žvelc 2010 lists attunement to cognition]
Steps: Listen for prefixes, parenthetical phrases, concluding statements and absolutes; reflect the underlying belief tentatively; check for fit.
Example language (illustrative): "It sounds like somewhere you decided that if you need anything, people leave. Is that close?"
Watch for: premature intellectual interpretation.

9. Developmental attunement

Purpose / when: When the client's affect, language or behaviour seems organised at an earlier age, whether or not the client is aware of it. [source: Erskine & Trautmann 1996; Erskine & Criswell; Aguado Rodríguez 2021 (secondary)]
Steps: (1) Listen with a "third ear" and watch with a "third eye" for the child in the present communication. (2) Form a working image of the age at which the trauma, decision or survival reaction occurred. (3) Ask yourself what a neglected or traumatised child of that age would need. (4) Respond to that need in tone, words and pace (simpler words, more warmth, more structure). (5) Hold the hypothesis loosely; Erskine says the age can stay unclear for a long time.
Example language (illustrative): "When you were that little, nobody explained what was happening. Of course it felt like the world had ended."
Watch for: infantilising the adult client. Erskine's published example: a compulsively late client was deliberately not confronted about lateness until he could express anger toward his parents, after which the compulsion eased.

10. Attunement to relational needs

Purpose / when: To identify which relational need is figural, which was unmet historically, and how to respond now. Needs alternate between figure and ground. [source: Erskine & Trautmann 1996; Erskine 2011]
Steps (responses per need):
- Security: conduct yourself so the client's physical and emotional vulnerability is protected; convey that needs are normal.
- Validation, affirmation, significance: affirm that affect, fantasy and meaning-making matter; reciprocal affect validates emotion.
- Acceptance by a stable, dependable, protective other: allow idealisation as a legitimate search for protection; provide reliability and containment.
- Confirmation of experience: selective, client-focused self-disclosure; engage with fantasies rather than dismissing them.
- Self-definition: support the client's uniqueness and accept disagreement.
- Impact on the other: let yourself be affected, invite criticism, change what you do when appropriate.
- Other initiates: reach out, start the dialogue, and in Erskine's account occasionally call between sessions.
- Expressing love: receive gratitude and affection without treating it reflexively as manipulation or a boundary threat.
Example language (illustrative): (impact) "You're telling me I got that wrong last week. Thank you. Tell me more about how it was for you." / (initiation) "You've been quiet about your sister for a few weeks. I've been wondering about her."
Watch for: trying to fill the archaic need directly; help the client grieve it and meet current needs now. Between-session contact and self-disclosure should follow your service's policy and be documented. [synthesis]

C. Involvement

Four elements that reduce internal defensive processes and loosen defences that block current needs and full contact. [source: Erskine & Trautmann 1996; Žvelc 2010; Erskine & Criswell]

11. Acknowledgement

Purpose / when: Recognise the client's affect, needs, rhythm and developmental level, including physical sensations that may be the only available form of memory. [source: Erskine & Trautmann 1996]
Steps: Name what you perceive (feeling, sensation, need) tentatively; include bodily signals the client has not named.
Example language (illustrative): "Your hands have curled up as you talk about her." / "There's a lot of grief here."
Watch for: naming too much too fast; check fit.

12. Caring confrontation (part of acknowledgement)

Purpose / when: Only within a strong empathic relationship; to highlight discrepancies between perception and behaviour, or between script beliefs and events, so the function of a defence becomes visible. [source: Erskine & Trautmann 1996; O'Reilly-Knapp & Erskine]
Steps: (1) Check the bond is strong. (2) Name the discrepancy descriptively, without judgement. (3) Link it to protective function. (4) Return to attunement if the client feels shamed.
Example language (illustrative): "You say no one is ever there for you, and you also told me your friend drove two hours last month. Can we look at both?"
Watch for: humiliation (shame worsens processing); never use with withdrawn clients early.

13. Validation

Purpose / when: Link affect, defences, sensations or behaviours to something meaningful in the client's history; reduces disavowal and supports self-esteem. Respect meaning even where the client's logic seems illogical. [source: Erskine & Trautmann 1996; Erskine & Criswell]
Example language (illustrative): "That tightness in your throat makes sense: in your family, crying got you sent to your room."
Watch for: validation that is generic rather than tied to the client's specific history.

14. Normalisation

Purpose / when: Reframe symptoms (flashbacks, fantasies, panic, defensiveness) as understandable coping with abnormal circumstances, countering the client's self-pathologising labels. [source: Erskine & Trautmann 1996; Erskine & Criswell]
Example language (illustrative): Client: "I'm stupid for being scared." Therapist: "Anyone in that house would have been scared. Being scared was the sensible response."
Watch for: normalising in a way that minimises distress.

15. Presence

Purpose / when: The sustained, attuned, reliable, responsible engagement that holds everything else; the client's experience of a dependable relationship counters insecure attachment. [source: Erskine & Trautmann 1996; Erskine 2011]
Steps: Decentre from your needs, goals, fantasies and hopes; attend to small gestures, sounds and silences; at the same time stay in contact with your own reactions; let yourself be shaped by the client; stay calm and steady while affected; combine contact with clear therapeutic intent, competence and ethics.
Example language (illustrative): Mostly non-verbal; e.g. "I'm here. I'm staying with you in this."
Watch for: drifting attention, drowsiness or wishing to fix, which are data about the process (see #23).

D. Script work

16. Mapping the script system

Purpose / when: From early in therapy; to understand how the life script operates now (not to trace history for its own sake). The system keeps unmet needs and feelings out of awareness while preserving some connection, and protects the person from the anxiety of an unpredictable world. [source: O'Reilly-Knapp & Erskine 2010]
Steps (the article gives no formal protocol; this sequence follows its discussion):
1. Notice markers: unaware prefixes, parenthetical remarks, concluding statements ("that's just how it is"), posture, forgotten appointments, misplaced objects, repeated injuries, errors of judgement. Script beliefs often show in the therapy relationship before the client can say them.
2. Decode through phenomenological and historical inquiry and developmentally informed inference.
3. Map four components with the client: script beliefs (about self, others, quality of life); script manifestations (observable behaviour, including absences such as no eye contact; reported internal experience such as muscle tension, breathing, stomach sensations, headaches; fantasies and dreams); reinforcing experiences (affect-laden memories, real or imagined, that confirm the beliefs); repressed needs and feelings beneath.
4. Explore what the system does for the client: avoiding re-experiencing unmet needs, generalising self-in-relation experience, regulating homeostasis, predicting relationships.
5. Work across all subsystems (beliefs, behaviour, body, fantasy, memory, needs); a change in one shifts the whole. "Script cure" is defined as change in behavioural, intrapsychic and physiological components.
Example language (illustrative): "When you say 'of course they forgot', what's the 'of course' about?" / "What do you imagine will happen if you ask?"
Watch for: pathologising beliefs, which were once creative, adaptive meaning-making. Working when the client spots their own markers in daily life.

17. Loosening script beliefs: absolutes, fantasy versus reality, contradicting memories

Purpose / when: Once the belief is identified and the relationship is solid. [source: O'Reilly-Knapp & Erskine 2010]
Steps: (1) Question the absolute wording of a core belief ("ever", "always", "no one"). (2) Invite the client to compare a confirming fantasy with what actually happened (in the published case, a fantasy of being cheered versus the reality that nobody cheered). (3) Notice which memories the client repeats and gently bring forward experiences that contradict the belief, which the script system tends to discard. (4) Validate the need the belief protects.
Example language (illustrative): "No one, ever? Has there been even one time someone was there?" / "In your picture of it, what are they doing? And what did they actually do?"
Watch for: turning this into a debate; if the client argues for the belief, return to inquiry about its function.

E. Experiential, regressive and body methods

18. Expressive methods (chair work, redecision, imagery dialogue, emotional expression)

Purpose / when: Best fit for scripts laid down as explicit childhood decisions; used within the relationship. Erskine names empty chair, two-chair dialogue, redecision (Goulding), expression of anger, deep crying, bioenergetic exercises and imagery work, and says they help but are not what heals. [source: Erskine & Criswell; O'Reilly-Knapp & Erskine 2010; Relational Patterns contents, ch. "expressive methods"]
Steps (general structure; detailed Erskine procedures not drawn on) [synthesis for sequencing]: (1) Agree the experiment and a stop signal. (2) Set the scene (the person imagined in a chair or in imagery; in the published case, the client re-imagined a childhood speech and spoke to a former friend in imagination). (3) Invite the client to speak directly and in the first person, staying with body and breath; encourage sounds and tears when they come. (4) Track for a new decision or realisation. (5) Debrief and link to current life.
Example language (illustrative): "Imagine she's sitting there. Tell her what it was like when you were nine." / "Let the sound come; you don't have to hold it in here."
Watch for: expressive work pushed before readiness; Erskine (2020) reports that pressing withdrawn clients toward anger work increased silence and self-criticism.

19. Supported (therapeutic) regression

Purpose / when: When the client needs to revisit original fixations and introjections with the therapist present, rework old decisions and experience what was missing. Erskine says it is not always needed but is often under-provided when it is; it is used in accordance with the client's welfare and only within a reparative relationship. [source: O'Reilly-Knapp & Erskine; Erskine & Trautmann 1996; Erskine & Criswell]
Readiness [synthesis; the sources give no explicit criteria]: established trust and secure enough attachment to the therapist; client can return to adult awareness when asked; no active psychosis, severe dissociative disorder without stabilisation, acute suicidality or current abuse; enough time in session and support afterwards.
Steps [structure is synthesis around Erskine's described elements]: (1) Contract: purpose, stop signal, how you will bring the client back. (2) Begin from a present feeling or body sensation the client is already in contact with. (3) Use developmental attunement: speak to the age that emerges, with tone and words suited to it. (4) Provide what was missing in attuned form (protection, comfort, explanation, someone staying); Erskine reports holding clients during preverbal regression (see #21 cautions). (5) Support any new decision or expression. (6) Bring the client back: orient to the room, the date, their adult age; feet on floor; eyes open. (7) Debrief in Adult: what happened, what it means now. (8) Plan contact before the next session if needed.
Dosing [synthesis]: one regressive episode per session; leave at least the last third of the session for return and integration; stop if the client cannot track your voice.
Example language (illustrative): "Stay with that feeling in your chest. How old do you feel?" / later: "Now let's come back. You're here with me, it's [day], you're an adult. Look around the room."
Watch for: loss of dual awareness, dissociation, flooding (see section 5). Treat what emerges as the client's experience, not as recovered historical fact; do not use suggestion or hypnosis to recover memories. [synthesis, per brief trauma rule]

20. Body-oriented work without touch

Purpose / when: For scripts held as physiological survival reactions (muscular and visceral patterns), and to open a closed physiological domain. [source: Erskine & Criswell; O'Reilly-Knapp & Erskine; O'Reilly-Knapp & Erskine 2010]
Steps: Use one at a time: locate an emotion in the body; ask what a sigh or tension carries; invite a hand on the chest where it aches; exaggerate a tension (e.g. a clenched jaw) and notice what comes; slow or deepen breathing; stretching, movement or bioenergetic exercises; imagine being held. Follow each with inquiry.
Example language (illustrative): "Would you be willing to put your hand where it hurts and just notice?" / "Let your jaw tighten a little more. What does it want to say?"
Watch for: hyperventilation, dizziness, sudden numbness; slow down or stop. Working when sensations link to feelings and the body softens.

21. Touch-based body work (high-risk; flag)

What the sources describe: Erskine reports that touch is not routine; many clients are never touched. With some clients, inside an established relationship and when the need has emerged, he describes holding during preverbal regression, physical support while a client expresses toward an image of an abuser, and deep muscle massage to release chronic tension and retroflections. He criticises blanket prohibitions on touch and calls for open professional discussion of how, with whom and when. [source: Erskine & Criswell; O'Reilly-Knapp & Erskine (touch, massage, breathing, movement)]
Risk flag [synthesis]: Many licensing boards, insurers, employers and ethics codes restrict or prohibit therapeutic touch, and touch carries risks of re-traumatisation, sexualised transference, boundary violations and complaints, particularly with survivors of abuse. Do not use touch unless you are trained in body psychotherapy, it is permitted in your jurisdiction and setting, the client has given explicit, specific, revocable consent in an adult state beforehand, the purpose is documented, and you have supervision. Non-touch alternatives (#20, imagined holding) come first. Never touch during a regressed state that was not consented to in advance.

22. Psychotherapy with the Parent ego state ("Parent interview")

Purpose / when: When an introjected parent drives self-doubt, a critical inner voice, chronic anxiety or depression, feeling controlled, or lost desires; only after substantial Child work and secure trust (removing the introject's power too early leaves the Child unprotected). Distinguishes from the Empty Chair: here the client becomes the parent and the therapist does therapy with the parent. [source: Zaletel, Potočnik & Jalen (Institute article citing Erskine & Trautmann 2003; Erskine & Moursund); Relational Patterns ch. 16–17]
Steps:
1. Differential assessment: history of family and script; ask the client to step into the critical voice and speak to the child part, then notice whose voice it is (actual introject versus self-generated "Internal Saboteur", which is harsher and more fragmented).
2. Contract: explain the role-taking; acknowledge the Child's loyalty; say the work aims to help both client and parent and that you will respect the parent; get consent and a stop signal; allow about 90 minutes.
3. Enter the role: client adopts the parent's posture and expression and names themselves as the parent.
4. Alliance with the parent: introduce yourself, ask how the parent feels about being here, pace slowly, keep focus on the parent's own story. If the parent is dismissive, explain how this helps their child; if refusal persists, stop.
5. Therapy for the parent: phenomenological inquiry, validation, no confrontation yet; explore the parent's own family, painful memories, life stages and script decisions; invite forbidden feelings and unmet needs.
6. Parent–child relationship: ask how the parent experienced the child and what they expected; link the parent's script to how they treated the child; begin balanced confrontation of excuses on the Child's behalf; when resistance rises, slow down and validate. Aim for insight, empathy for the child, regret, apology. If the parent stays destructive, limit their authority and support the Child.
7. Parent to child (chair): the parent speaks to the imagined child, names what they appreciate, what they passed on, and gives permission to change script decisions.
8. Close the parent: thank them, ask them to step back.
9. Child response (chair): the client changes seats, speaks to the parent, states boundaries, returns burdens, names appreciations then resentments, makes a new decision. If the Child shuts down or is attacked, pause the parent and protect the Child.
10. Return to Adult and debrief: never skip; ask what helped and how insights will be used.
Example language (illustrative): "Can you be your mother for a while? Sit the way she sits. What's your name?" / (to the 'parent') "I'm [name]. I'd like to get to know you. What was it like growing up in your family?" / (to the Child afterwards) "What would you like to tell her now?"
Watch for: Child feeling abandoned because the therapist empathised with the parent; headaches, confusion or rupture if the debrief is skipped. Working when the parent expresses regret or gives permission, and the client reports relief, compassion, freedom and less inner criticism. [source: Zaletel et al., based on five transcripts and one video]

F. Relational process methods

23. Using countertransference and self-monitoring as data

Purpose / when: Continuously; your reactions are information about the client's relational process and about what you bring. [source: Erskine 2020; Erskine & Criswell; Žvelc 2010; Erskine & Trautmann 1996]
Steps: (1) Notice drowsiness, confusion, distraction, frustration, urges to rescue or to make change happen. (2) Ask what the reaction mirrors (Erskine found his push for behaviour change paralleled a client's controlling mother and husband) and what your urge protects you from (in his case, anxiety about being effective). (3) Decide whether to change your interaction style implicitly or to use careful, client-focused self-disclosure. (4) Take it to supervision or personal therapy.
Example language (illustrative): "I realise I've been pushing you to change things, and I wonder if that's felt like one more person telling you what to do."
Watch for: disclosures that serve your needs rather than the client's.

24. Working with juxtaposition reactions

Purpose / when: When attuned contact contrasts with past misattunement and triggers emotional memories: pushing the therapist away after closeness, criticising the therapist for focusing on "neediness", cancelling or arriving late after a close session. [source: Erskine & Trautmann 1996; O'Reilly-Knapp & Erskine; Aguado Rodríguez 2021]
Steps: (1) Recognise the pattern rather than personalising it. (2) Consider that you may be moving faster or more intensely than the client can integrate (especially after abuse or cumulative trauma). (3) Adjust rhythm, affective intensity and responsiveness. (4) When the client can reflect, explore the contrast and what was missing. (5) Respect homeostatic coping.
Example language (illustrative): "Last week felt close, and then you cancelled. I wonder if closeness here stirred something that's hard to be with. We can go slower."
Watch for: reading it as resistance and confronting it.

25. Rupture repair and owning therapist errors

Purpose / when: After any misattunement or enactment; ruptures are also interruptions to contact and examining them reveals archaic failures. [source: Erskine 2011; Žvelc 2010; O'Reilly-Knapp & Erskine]
Steps: (1) Notice the rupture (withdrawal, compliance, irritation, missed session). (2) Disembed from the enactment, either implicitly (change your way of relating) or explicitly. (3) Explicitly own your part without over-explaining. (4) Invite the client's experience of it, including criticism, and let it have impact. (5) Link, when useful, to how ruptures were (not) repaired in the client's history.
Example language (illustrative): "I think I missed you just now. I went to explanations when you were hurting. I'm sorry. What was that like?"
Watch for: defensiveness; attributing the rupture only to transference.

G. Methods for withdrawn (schizoid-process) clients

From a single four-year case report. [source: Erskine 2020]

26. Supported withdrawal (attunement to silence)

Purpose / when: With clients who narrate flatly, avoid eye contact, go silent, jump topics and forget sessions, and for whom active methods (asking for feelings, requiring eye contact, reframing, behavioural goals, group, anger work) increased silence or self-criticism.
Steps: (1) Explain that hiding inside can be protective and does not need fixing. (2) Invite the client to close their eyes and go inward for a short paused moment; ask if there is a "quiet place" inside. (3) Start at about a minute and extend over sessions to several minutes and eventually 20–30 minutes. (4) Stay still and watchful, and say clearly that you are staying present. (5) Limit questions during withdrawal. (6) Regulate your own arousal (e.g. slow breathing) to stay alert.
Example language (illustrative): "You don't have to talk. I'll stay right here with you while you go inside."
Watch for: compliance mistaken for engagement; fear that the therapist has left. Working when silences lengthen comfortably, the body softens and the client reports feeling quieter or more alive.

27. Therapeutic description

Purpose / when: During withdrawn states only, not in face-to-face cognitive work; and not too early.
Steps: Offer slow, soft, tentative statements naming the likely inner experience, with long pauses and a non-authoritarian tone; watch nods, breathing and tension in hands, neck, arms; back off if the client tightens. Use sparingly.
Example language (illustrative): "Maybe... it feels scary right now." (pause) "It makes sense to hide when you're sad."
Watch for: descriptions that feel defining or invasive.

28. Building language for body and feeling

Purpose / when: With clients who have sensations but no words, as with a young child learning to talk.
Steps: Help the client describe tension, softness or breath; link sensations to emotion words; mirror and respond with compassionate sounds; accept that expression may begin silently (tears without sound) and become vocal later.
Example language (illustrative): "Is it more tight, or more heavy?" / "Those tears might be sadness."
Watch for: supplying words the client does not own.

H. Other named methods

29. Free association with an active witness

Purpose / when: To let unconscious material emerge; as in psychoanalysis, but the therapist is an active partner who witnesses and responds. [source: O'Reilly-Knapp & Erskine]
Example language (illustrative): "Let whatever comes come, and say it as it arrives. I'll be listening and I'll tell you what I notice."
Watch for: drift into intellectualisation. [uncertain: no detailed procedure]

30. Behavioural change contracts and Gestalt experiments

Purpose / when: Named by Erskine & Trautmann (1996) as methods integrated with inquiry, and process contracting is described by Žvelc (2010) as an ongoing negotiation that guides direction. [source: Erskine & Trautmann 1996; Žvelc 2010]
Steps [synthesis]: agree a specific, client-chosen behaviour or experiment; link it to the script belief it tests; review what happened with phenomenological inquiry rather than success/failure judgement.
Watch for: behavioural goals becoming the main focus with withdrawn clients (Erskine 2020). [uncertain: no detailed procedure]

5. Handling problems

Stuck client / therapy going round in circles. Check which domain is closed (affective, behavioural, cognitive, physiological) and switch to a method for that domain (e.g. body inquiry if talk is fluent but flat). Check the level of script formation: an explicit decision may need expressive work; implicit, pre-verbal conclusions need slower relational work, not more technique. Ask whether you are trying to make something happen (Erskine 2020). [source: Erskine & Trautmann 1996; Erskine & Criswell; Erskine 2020]

"Resistance" and defences. Treat each interruption as protective; inquire into its function (identity, stability, continuity, integrity) before any confrontation. When resistance rises in Parent work, you have likely reached the script: slow down and return to validation. [source: Erskine & Trautmann 1996; Zaletel et al.]

Juxtaposition and pulling away after closeness. See #24: reduce pace and intensity, avoid interpreting it as resistance. [source: Erskine & Trautmann 1996]

Shame. Shame is described as a compound of disavowed anger turned inward, sadness at not being accepted, fear of rejection and compliance with humiliation; it slows processing. Respond with non-humiliating inquiry, slower rhythm, no confrontation that adds humiliation, and normalisation. [source: Erskine & Trautmann 1996]

Overwhelm, flooding or dissociation during regression, body or expressive work [synthesis; the sources give no specific protocol]: stop the technique; shift from developmental to present-time language; orient (name, date, room, feet on floor, eyes open, describe objects); slow your voice; offer choice and control; return to Adult before the session ends; do not leave the client regressed. Afterwards, reduce dosing, strengthen stabilisation and review readiness. For clients with known dissociative disorders, use a phase-oriented trauma approach and specialist supervision before regression work.

Withdrawn or silent clients. Use supported withdrawal, therapeutic description and very limited inquiry; avoid demands for eye contact, feelings or anger expression (#26–28). [source: Erskine 2020]

Idealisation, dependency, expressions of love. Treat them as legitimate relational needs (a stable protective other; expressing love), not automatically as manipulation; respond within clear boundaries. [source: Erskine & Trautmann 1996]

Clinging / demands for more contact [synthesis]: acknowledge the need and its history; explain that archaic needs cannot be met by you directly but can be grieved and understood; set predictable availability (e.g. agreed contact between sessions only if your setting allows); explore current relationships where needs can be met.

Non-adherence to agreements or experiments. The approach does not rely on homework; treat non-completion as information about the script (e.g. compliance versus self-definition) and inquire into it rather than re-assigning. [synthesis] Erskine's example of not confronting chronic lateness until underlying anger emerged illustrates the stance. [source: Erskine & Trautmann 1996]

Ruptures and therapist errors. See #25; take responsibility promptly. Using supervision that merely endorses your approach is itself a risk. [source: Erskine 2011; Erskine 2020]

Parent work going wrong. Parent refuses after explanation: stop. Child attacked or shut down: pause the parent and protect the Child. Client feels you sided with the parent: reconnect with the Child and repair. Headaches or confusion afterwards: the Adult debrief was skipped or rushed. [source: Zaletel et al.]

Client's relationships destabilise as they change. Anticipate; in Erskine's case the husband pressured the client to end therapy. Discuss this early and plan for it. [source: Erskine 2020; planning is synthesis]

Suicide or self-harm risk [synthesis]: use your service's standard structured risk assessment and safety planning, including lethal-means counselling (safe storage and removal); suspend regression and expressive work while risk is acute; increase structure and contact.

Memory and suggestion [synthesis, per brief]: in historical inquiry and regression, follow the client's material; avoid leading questions about abuse; treat emerging memories as the client's experience; do not use hypnosis or imagery to recover memories; if a client asks whether something "really happened", explore meaning and uncertainty rather than confirming.

Boundaries around touch, self-disclosure and between-session contact [synthesis]: these are relationally justified in Erskine's writing but are frequent sources of complaints. Document the rationale and consent, check professional codes and setting policy, and use supervision.

Training and certification. Erskine is Training Director of the Institute for Integrative Psychotherapy (New York City); the International Integrative Psychotherapy Association (IIPA) exists and publishes the International Journal of Integrative Psychotherapy. Erskine recommends solid training, ongoing personal therapy and regular supervision. [source: Karnac/Routledge book page; Erskine & Criswell] [uncertain: formal certification routes]

Sources

Sources:

Further reading (not drawn on beyond front matter or publisher descriptions):

Erskine, R. G., & Moursund, J. P. (1988; 2nd ed. 2022). Integrative Psychotherapy in Action.
Erskine, R. G., Moursund, J. P., & Trautmann, R. L. (1999). Beyond Empathy: A Therapy of Contact-in-Relationship.
Erskine, R. G. (Ed.) (2010). Life Scripts: A Transactional Analysis of Unconscious Relational Patterns.
Erskine, R. G. (2015; Classic ed. 2025). Relational Patterns, Therapeutic Presence: Concepts and Practice of Integrative Psychotherapy.
Erskine, R. G. (2021). A Healing Relationship: Commentary on Therapeutic Dialogues.

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