Integrative-relational therapy

1. Introduction

Version followed: the UK relational-integrative tradition, as set out in Ken Evans & Maria Gilbert, An Introduction to Integrative Psychotherapy (Palgrave Macmillan, 2005), Linda Finlay, Relational Integrative Psychotherapy: Engaging Process and Theory in Practice (Wiley, 2016; imprint dated December 2015, foreword by Ken Evans), Maria Gilbert & Vanja Orlans, Integrative Therapy: 100 Key Points and Techniques (Routledge, 2011), and the published programme descriptions of Metanoia Institute (London), Sherwood Psychotherapy Training Institute (SPTI, Nottingham, with the University of Staffordshire) and UKCP's Humanistic and Integrative Psychotherapy College (HIPC).

Sources. The sources are publisher pages, library tables of contents and institute course pages; the full texts of the three books are not drawn on. The structure, named processes, relationship dimensions and technique headings below follow those tables of contents and programme pages. The step-by-step instructions and example wording inside each item are mostly the writer's [synthesis], written to fit the sourced headings. They are not the authors' procedures. Check them against the books before teaching them as "the model" [uncertain].

Relation to guide 021. Richard Erskine's developmentally based, relationally focused Integrative Psychotherapy (inquiry, attunement and involvement; relational needs; the script system) is covered in guide 021. This guide covers the related but separate UK tradition centred on Metanoia and Sherwood. The two overlap: SPTI's module on the Integrative and Relational schools of transactional analysis (TA) teaches "relational needs in the therapeutic relationship" as its Integrative-school content [source: Staffordshire module PSYC70870]. For Erskine's methods themselves, use 021.

What it is. This is a framework and a training tradition, not a single manualised therapy.
- Evans & Gilbert offer "a relational-developmental approach to theory and practice". They critique the philosophical bases of their model, examine resistance in different phases of therapy, give an extended case study, and look at the cultural, ecological and transpersonal dimensions of therapy [source: Canterbury bookshop and cede.ch listings]. When the book appeared, Evans was Director of SPTI and Gilbert headed Metanoia's MSc in Integrative Psychotherapy [source: cede.ch listing].
- Finlay's approach puts the client first and integrates varied techniques within "a strong therapeutic relationship". It draws on cognitive, existential-phenomenological, gestalt, psychoanalytic, systemic and TA ideas. It divides practice into "Being and Doing Processes" (Part I) and "Theory applied to practice" (Part II) [source: Wiley-VCH; e-bookshelf]. Finlay is described as a UKCP-registered relational-centred, existential integrative psychotherapist [source: Wiley-VCH].
- Gilbert & Orlans integrate physiological, affective, cognitive, contextual and behavioural systems into a relational framework that is "built anew" for each client [source: Routledge page; paraphrased].
- Metanoia describes psychotherapy as "the considered and intentional use of a relationship". Its stance is intersubjective, and it states that it "is not teaching a particular model of integration". Each trainee builds their own evolving integrative model [source: Metanoia course page].
- SPTI's MSc teaches a "developmental-relational approach". It integrates object relations theories, psychoanalytic self psychology and aspects of humanistic psychology [source: University of Staffordshire course page].
How change happens. The self develops in relationship from infancy, through affect regulation, attachment and internalised "relationship maps". Problems are understood as relational and developmental patterns, and these patterns are repeated, often implicitly, in present relationships, including the one with the therapist. Change comes through a co-created therapeutic relationship. That relationship offers attunement and the repair of misattunement. It provides new, developmentally needed relational experience. It also helps implicit patterns become felt, understood and narrated [source: Gilbert & Orlans contents, Parts III, IV and VI; Metanoia course page]. Gilbert & Orlans include a section on "the role of love and hope" in change. Their exact causal account is not given here [uncertain].

2. Framework

No fixed stages or session count. No manualised protocol was found in the available sources. Metanoia states that its approach serves both brief and longer-term therapy [source: Metanoia course page]. SPTI's TA module covers individual, group and couples work [source: Staffordshire module PSYC70870]. Evans & Gilbert discuss resistance in "different phases of therapy", but how they name or define those phases is [uncertain]. Finlay's Part I runs from "Meeting and Contracting" to "Ending", and she stresses that real-world practice is fluid rather than linear [source: Wiley-VCH; e-bookshelf]. The four-phase arc below follows the order of her chapters and of Gilbert & Orlans's Part VI. The criteria for moving between phases are the writer's [synthesis].

Phase A: Meeting, assessment and contracting (typically the first 1 to 4 sessions [synthesis])

Goals: handle the first-session considerations, assess the client, decide "what therapy for which client in what context", and agree a contract covering aims, frame, fees, confidentiality and its limits, and how you will review progress [source: Gilbert & Orlans contents, Part VI; Finlay ch. 2 title].
Move on when there is an agreed focus and frame, the initial risk assessment is complete, the client can use the session, and you have a first working formulation [synthesis].

Phase B: Engaging, attuning, containing and resourcing

Goals: build the working alliance and empathic attunement, provide holding and containment, strengthen the client's coping and self-regulation, and build an integrative problem formulation across the dimensions listed below [source: Finlay chs. 3–6 titles; Gilbert & Orlans Parts V–VI].
Move on when the alliance survives small misattunements, the client can feel affect in session without becoming overwhelmed, and recurring relational patterns are becoming visible [synthesis].

Phase C: Working through

Goals: intuit, imagine and interpret; challenge; work with transference, countertransference and enactments; repair ruptures; process trauma when the client is ready [source: Finlay chs. 7–8 titles; Gilbert & Orlans Parts VI–VII].
Move on when the client recognises their patterns outside sessions, relates differently in the therapy relationship, and regulates themselves with less help from you [synthesis].

Phase D: Integrating and ending

Goals: consolidate new experience into a coherent narrative and a way of living, then end in a planned way [source: Finlay chs. 9–10 titles; Gilbert & Orlans "Developing a Narrative to Make Sense of Life – and Psychotherapy"].
End when the agreed aims are met or reviewed, and the ending itself has been worked with as a relational event [synthesis].

Decision procedure for an integrative framework. These items are taken from section titles; the procedure that links them is [synthesis].

Assess across the dimensions of self-experience [source: Gilbert & Orlans Part IV]:
- biological (self to body)
- intrapsychic (self to self)
- interpersonal and intersubjective (self to others)
- intercultural (culture, race and wider context)
- transpersonal Also note internalised relationship maps, how coherent the client's narrative is, their capacity to mentalise, and any traumatic memory processes or dissociation [same source].
Formulate [source: Gilbert & Orlans Part V]. Combine a relational perspective with a developmental one, and add existential life issues. Weigh the advantages and drawbacks of a diagnostic label. Distinguish chronic relational trauma from a single traumatic event, and consider complex PTSD. Then write a single integrative formulation.
Choose which relationship dimension to bring to the foreground at this point [source: Gilbert & Orlans Part VI]:
- working alliance
- person-to-person ("real") relationship
- transference and countertransference
- reparative or developmentally needed relationship
- transpersonal relationship
- representational relationship
Choose a theoretical lens and its techniques to suit the client and the moment: cognitive, existential-phenomenological, gestalt, relational psychoanalytic, systemic or TA [source: Finlay Part II]. Keep the relational frame as the container [synthesis].
Monitor. Gilbert & Orlans have a section on "The Integrative Psychotherapist as Researcher" [source: contents]. In practice, use a brief routine outcome measure and a short alliance check at regular intervals, and review the contract every 6 to 12 sessions [synthesis].

Format. Mainly individual adult therapy, usually weekly in 50-minute sessions [synthesis]. Group and couples applications are taught at SPTI [source: module PSYC70870].

3. Guiding principles

The relationship is the vehicle of change. Treat each choice of technique as a relational act: ask what it does to the contact between you [source: Metanoia, "intentional use of a relationship"; Staffordshire course page; Finlay].
Client first; integrate for this person. Choose methods for this client's needs and context, not because you favour a school [source: Wiley-VCH; Routledge].
Developmental lens. Read present difficulties as adaptations shaped by early relationships and affect regulation [source: Evans & Gilbert listing; Gilbert & Orlans Part III; SPTI "developmental-relational"].
Two-person psychology and co-creation. You are part of what happens in the room. Your reactions are data, and patterns are co-created [source: Gilbert & Orlans "Reciprocal Mutual Influence", "Co-Created Unconscious"; SPTI module on Summers & Tudor co-creation].
Attunement, misattunement and repair. Misattunement is inevitable, and repairing it is therapeutic. Track ruptures actively [source: Metanoia].
Communicate verbally and non-verbally, consciously and non-consciously. Attend to tone, posture, rhythm and your own body as much as to content. Metanoia cites Schore's description of psychotherapy as the "communicating cure" [source: Metanoia].
Holism. Keep body, feelings, mind and spirit in view [source: UKCP HIPC].
Context matters. Bring culture, race, power, ecology, economics and politics into formulation and the room [source: Evans & Gilbert listing; Metanoia; Gilbert & Orlans "Anti-Oppressive Practice"].
Being as well as doing. Your presence and stance carry as much weight as your interventions [source: Finlay, "Being and Doing Processes"].
Recognition precedes interpretation. Show you understand before you offer meaning [source: Gilbert & Orlans section title].
Phenomenological attitude. Describe and explore before you explain or diagnose [source: Finlay ch. 12; Whatuni page for Metanoia MSc].
Inclusion as a process goal. Aim to experience the client's side of the meeting while keeping your own [source: Gilbert & Orlans section title; meaning: synthesis].
Build your own coherent integration. You should be able to explain why you are combining these methods for this client [source: Metanoia, "not teaching a particular model of integration"; Gilbert & Orlans "Developing One's Own Unique Style"].
Reflective practice and self-supervision. Use supervision, personal therapy and self-reflection to find where your own patterns enter the work [source: Metanoia; SPTI teaching methods include personal therapy and journaling].
Process stance on ethics. Treat ethics as an ongoing reflective process, not only as rule-following [source: Gilbert & Orlans Part VIII title; meaning: synthesis].

4. Intervention inventory

How to read this section:

Headings are verified. Every heading is a process or technique that the sources name: Finlay's chapters (4.1 and 4.3–4.10), Gilbert & Orlans's section titles (4.2 and 4.11–4.33, with 4.33 also drawing on Evans & Gilbert), Finlay's Part II lenses (4.34), and the Metanoia and SPTI course pages. None is invented.
Contents are mostly synthesis. No published step-by-step procedures were found for these items. Within each entry, the Steps, the Example language and the Watch-for points are the writer's [synthesis] unless a source tag says otherwise. They are written to fit the heading and the tradition's stated principles.
Example language is illustrative. All example wording is mine, labelled "(illustrative)".

4.1 Meeting and contracting

Purpose: begin the relationship, assess, and agree what the work is for and how it will run [source: Finlay ch. 2 title; Gilbert & Orlans "The First Session", "Assessment in Psychotherapy"].
Steps [synthesis]:
1. Greet the client and orient them to how the session will go.
2. Invite their story in their own words.
3. Ask what they hope will be different.
4. Screen for risk, physical-health factors and current supports.
5. Agree the frame: frequency, fees, cancellations, confidentiality and its limits, contact between sessions, and when you will review progress.
6. Agree an initial aim in the client's own words, plus a provisional, revisable focus.
7. Ask how the first meeting felt.
Example language (illustrative): “Before we finish, can we agree what you’d like to be different, and how we’ll both know if this is helping?”
Watch for: aims that are only yours; a contract that is too rigid or too vague; how the client meets you, which is early relational data.

4.2 Assessment and integrative problem formulation

Purpose: build a shared, working understanding of the client's difficulties that combines relational, developmental, existential and diagnostic perspectives [source: Gilbert & Orlans Part V titles].
Steps [synthesis]:
1. Map the five dimensions of self-experience (body, self to self, self to others, cultural context, transpersonal), with one or two examples of each.
2. Note recurring relational patterns, and any patterns already appearing with you.
3. Set out the developmental history, including attachment and trauma: chronic relational trauma versus single events.
4. Note existential themes, such as loss, meaning, freedom and death.
5. Weigh what a diagnostic label would add or cost.
6. Write a short narrative formulation and share it in plain words.
7. Revise it as therapy unfolds.
Example language (illustrative): “My current sense, and correct me, is that when someone gets close you brace for criticism, which made sense growing up, and now it keeps people at a distance.”
Watch for: a formulation that blames or pathologises; the client's response to hearing it (relief and recognition, or compliance); missing cultural context.

4.3 Engaging the therapeutic process

Purpose: move from telling a story to experiencing and exploring in the present, and build the working alliance [source: Finlay ch. 3 title; Gilbert & Orlans "The Working Alliance and Effective Therapy"].
Steps [synthesis]:
1. Slow down and track what is alive now, in feeling, body and the relationship.
2. Reflect back what you notice and invite curiosity about it.
3. Balance exploration with enough structure for safety.
4. Check agreement on goals, tasks and bond as you go.
Example language (illustrative): “As you tell me this, what are you noticing right now?”
Watch for: intellectualising or reporting without feeling; a client working to please you; signs that the alliance is thin.

4.4 Empathising, attuning and empathic enquiry

Purpose: understand the client from inside their frame and convey that understanding, so the client feels recognised [source: Finlay ch. 4 title; Gilbert & Orlans "Empathic Enquiry and Empathic Resonance: Recognition Precedes Interpretation", "Empathic Attunement"; Metanoia "attunement, mis-attunement and repair"].
Steps [synthesis]:
1. Ask open, curious questions about the client's experience.
2. Let their affect resonate in you and use that to sense what is unsaid.
3. Reflect content, feeling and implicit meaning, matching their pace and intensity.
4. Check accuracy.
5. Hold back interpretation until the client feels recognised.
Example language (illustrative): “It sounds as if it wasn’t only the words, it was being dismissed again, by someone you trusted.”
Watch for: deepening (the client says more, softens, or their affect shifts); flattening or correcting you, which signals a misattunement to repair (see 4.29).

4.5 Holding, containing and boundarying

Purpose: offer a reliable frame and emotional containment so difficult material can be borne and thought about [source: Finlay ch. 5 title].
Steps [synthesis]:
1. Keep the time, place and contract consistent.
2. Stay steady and non-retaliatory when the client is distressed or angry.
3. Name and process feelings rather than act on them.
4. Manage endings of sessions carefully: signal the remaining time and help the client close.
5. Hold boundaries on contact between sessions, gifts and dual relationships, and explore what boundary requests mean.
Example language (illustrative): “We have ten minutes left. Let’s use them to help you leave feeling steadier.”
Watch for: boundary tests; your own pull to rescue or retreat; the client gradually trusting the frame.

4.6 Resourcing: nurturing skills and mobilising coping strategies

Purpose: strengthen self-support and coping before and during deeper work [source: Finlay ch. 6 title].
Steps [synthesis]:
1. Identify the strengths, supports and coping the client already has.
2. Teach or rehearse specific skills where needed, such as grounding, breathing, self-soothing, assertive requests or problem-solving.
3. Link the skills to real situations and agree small between-session practice.
4. Review it.
Example language (illustrative): “What has helped you get through weeks like this before? Let’s build on that.”
Watch for: resourcing used to avoid feeling; skills offered too early, which the client may experience as dismissive; the client using the skills on their own.

4.7 Intuiting, imagining and interpreting

Purpose: use intuition, imagery and interpretation to bring patterns and meanings into awareness [source: Finlay ch. 7 title].
Steps [synthesis]:
1. Notice your own images, hunches and bodily responses.
2. Offer them tentatively, as your experience, not as truth.
3. Link present, past and the therapy relationship when the client is ready.
4. Invite the client to correct or extend what you offered.
Example language (illustrative): “An image came to me of a child standing very still so as not to be noticed. Does that fit at all?”
Watch for: interpretations that come before recognition; compliance or defensive agreement; new memories or associations that follow, which suggest the offering was useful.

4.8 Challenging

Purpose: confront contradictions, self-limiting beliefs or harmful behaviour from within a secure alliance [source: Finlay ch. 8 title].
Steps [synthesis]:
1. Check that the alliance can bear a challenge.
2. Describe the discrepancy concretely and without judgement.
3. Link it to the client's own aims.
4. Invite their view.
5. Afterwards, check how the challenge landed.
Example language (illustrative): “You’ve said you want more closeness, and I notice you cancel whenever someone gets nearer. Can we look at that together?”
Watch for: shame responses (see 4.24); a challenge driven by your frustration; the client starting to make the link themselves.

4.9 Integrating

Purpose: help the client weave new awareness and experience into a coherent sense of self and narrative [source: Finlay ch. 9 title; Gilbert & Orlans "Developing a Narrative to Make Sense of Life"].
Steps [synthesis]:
1. Periodically review what has changed and how.
2. Help the client put their changes into their own words and story.
3. Connect insights across the dimensions: body, feelings, thoughts, relationships, meaning.
4. Agree how the client will keep this going in daily life.
Example language (illustrative): “If you told the story of these months to a friend, how would you describe what’s shifted?”
Watch for: insight that has not changed behaviour or relating; a story that is too tidy.

4.10 Ending

Purpose: end in a planned, relational way that consolidates gains and works with loss [source: Finlay ch. 10 title].
Steps [synthesis]:
1. Agree the ending date well ahead, in proportion to how long the therapy has run.
2. Review the contract and the gains.
3. Work with the feelings and history the ending stirs.
4. Agree how the client will handle setbacks, and the terms for any return.
5. Mark the final session.
Example language (illustrative): “Endings haven’t always gone well for you. How would you like this one to be?”
Watch for: missed final sessions; sudden new problems; ending carried out by avoiding it.

4.11 Working across the relationship dimensions

Purpose: notice which dimension of the therapeutic relationship is in the foreground and respond in the way that dimension calls for [source: Gilbert & Orlans Part VI titles: "Therapeutic Relationship Dimensions: An Overview", working alliance, person-to-person or "real", transference and countertransference, reparative or developmentally needed, transpersonal, representational]. Three of these dimensions (reparative or developmentally needed, person-to-person, transpersonal) are also named as relationships in Petruska Clarkson's The Transpersonal Relationship in Psychotherapy (2002) [source: Wiley-VCH contents page], and UK integrative training teaches Clarkson's relational model together with Gilbert & Orlans's additional modes [source: University of Warwick module CE9C2-20].
Steps [synthesis]:
1. After each session, ask which dimension was most active.
  - Alliance: are goals and tasks shared?
  - Real relationship: an authentic human moment between you.
  - Transference and countertransference: old patterns replaying.
  - Reparative or developmentally needed: the client needs an experience they missed.
  - Transpersonal: meaning, spirit or something beyond the two of you.
  - Representational: the client's inner relationships as they show up in the room [uncertain: Gilbert & Orlans's exact definition is not given here].
2. Choose responses that fit that dimension. For example, renegotiate tasks for the alliance, explore the pattern for transference, or offer steady provision for the reparative dimension.
3. Notice when a shift in the foreground calls for a different stance.
Example language (illustrative): “I think something just happened between us that felt familiar to you. Can we slow down and look at it?”
Watch for: getting stuck in one dimension, for example only interpreting transference or only being “real”; reparative provision that turns into gratification without exploration.

4.12 Working with the transference: repetitive and selfobject dimensions

Purpose: distinguish transference that repeats old harmful patterns from transference that seeks a missing developmental function (Kohut's selfobject needs), and respond to each [source: Gilbert & Orlans "Repetitive and Selfobject Dimensions of the Transference", "Working with Kohut's Self-Object Dimensions of the Transference", "Different Views on Working with the Transference"]. SPTI teaches self psychology's selfobject needs "played out unconsciously in relationship", with attention to empathy and the "empathic transaction" [source: Staffordshire module PSYC70870].
Steps [synthesis]:
1. Notice the client's expectations of you.
2. Ask whether you are being experienced as the old figure (repetitive) or needed to mirror, be idealised, or be like them (selfobject).
3. For the repetitive dimension, gently explore it and contrast it with present reality.
4. For the selfobject dimension, allow the need, provide attuned understanding, and name it only when the client can use the naming.
5. Expect and repair the selfobject failures that will occur.
Example language (illustrative): “It seems important that I really see how hard you’ve worked. When I missed it last week, something collapsed.”
Watch for: premature interpretation of selfobject needs, which the client may hear as shaming; idealisation that hides disappointment.

4.13 Working with countertransference

Purpose: use your own responses as information about the client and about the co-created field [source: Gilbert & Orlans "Working with Countertransference", "The Co-Created Unconscious or 'Analytic Third'", "Reciprocal Mutual Influence"].
Steps [synthesis]:
1. Track your feelings, images, bodily states and urges during sessions.
2. Afterwards, sort what belongs to you from what may be induced by the client or co-created.
3. Take it to supervision.
4. Use it to guide a stance or an exploratory comment. Disclose it only selectively (see 4.15).
Example language (illustrative, used as an internal question): “Why do I feel sleepy whenever she talks about her father?”
Watch for: acting out (rescuing, punishing, colluding); disowning your own contribution.

4.14 The therapist's use of self

Purpose: bring your personhood (presence, responsiveness, honesty) deliberately into the work [source: Gilbert & Orlans "The Therapist's Use of the 'Self' in the Therapeutic Process"; Finlay "being" processes; Whatuni page for Metanoia, "unique therapeutic presence and style"].
Steps [synthesis]:
1. Ground yourself before sessions.
2. Stay present and responsive rather than hiding in technique.
3. Let your authentic reactions shape your tone.
4. Check that the use of self serves the client, not you.
Example language (illustrative): “I’m moved hearing that.”
Watch for: performance; over-involvement; your own unresolved issues (take these to personal therapy and supervision).

4.15 Self-disclosure: uses and abuses

Purpose: share selectively about your here-and-now experience, or rarely your life, when it serves the client [source: Gilbert & Orlans "Self Disclosure in Psychotherapy: Uses and Abuses"].
Steps [synthesis]:
1. Before disclosing, ask: whose need is this? What is the likely effect? Is it brief?
2. Prefer here-and-now disclosure (your response to the client) over personal history.
3. Return the focus to the client.
4. Explore how the disclosure landed.
Example language (illustrative): “When you said that, I noticed I felt shut out. I wonder if that’s close to what others feel with you?”
Watch for: the client starting to look after you; boundary drift; disclosure as a way to avoid your own discomfort.

4.16 Implicit relational knowing: working with self and interactive regulation

Purpose: work with non-verbal, procedural patterns of relating and regulating that show up moment to moment [source: Gilbert & Orlans "Implicit Relational Knowing: Working with Self and Interactive Regulation", "Implicit and Explicit Levels of Relationship"; Metanoia on verbal and non-verbal, conscious and non-conscious communication].
Steps [synthesis]:
1. Track micro-shifts in gaze, voice, posture and breath, both the client's and yours.
2. Notice when the client regulates alone (withdraws) versus with you (reaches).
3. Adjust your pace, tone and proximity to co-regulate.
4. Name a pattern only when it would help the client become aware of it.
Example language (illustrative): “I notice that when you talk about needing help, you look away and speed up.”
Watch for: arousal settling within the session; the client starting to use you for regulation.

4.17 Working with unconscious process and unformulated experience

Purpose: help experience that has never been put into words take form [source: Gilbert & Orlans "Working with Unconscious Process and Unformulated Experience"].
Steps [synthesis]:
1. Tolerate vagueness.
2. Invite associations, images, bodily sensations and half-thoughts.
3. Offer provisional words and let the client refine them.
4. Notice slips, repetitions and enactments as signs of what cannot yet be said.
Example language (illustrative): “There’s something here without words yet. Let’s not hurry it. What comes, even if it doesn’t make sense?”
Watch for: rushing to closure; new words that bring relief and feel exactly right to the client.

4.18 Body awareness techniques

Purpose: bring the biological dimension (self to body) into therapy, for affect awareness, grounding and implicit memory [source: Gilbert & Orlans "Body Awareness Techniques", "The Biological: Relationship of Self to Body"; UKCP HIPC holism].
Steps [synthesis]:
1. Ask permission.
2. Invite attention to sensation, posture, breath and impulses to move.
3. Explore gently, for example by exaggerating or slowing a gesture.
4. Link bodily experience to feelings and meaning.
5. Ground the client before the session ends.
Example language (illustrative): “As you say that, what happens in your chest?”
Watch for: dissociation or flooding (see 4.26); the client's right to decline. Any physical touch needs explicit consent and your training and professional body's guidance [synthesis].

4.19 Mindfulness techniques

Purpose: build present-moment awareness, decentring and self-regulation [source: Gilbert & Orlans "Mindfulness Techniques"].
Steps [synthesis]:
1. Offer brief in-session practices, such as breath awareness, a body scan or noticing thoughts as events.
2. Debrief the experience.
3. Agree short home practice.
4. Adapt for clients with trauma: eyes open, shorter practices, external anchors.
Example language (illustrative): “Let’s take a minute just to notice the breath, and whatever pulls your attention away.”
Watch for: rising distress in traumatised clients; using mindfulness to avoid relational material.

4.20 Heightened affective moments: improvisation and spontaneity

Purpose: use charged “now” moments, when something new and authentic can happen between client and therapist [source: Gilbert & Orlans "Heightened Affective Moments: Working with Improvisation and Spontaneity in Psychotherapy"].
Steps [synthesis]:
1. Recognise a moment of heightened feeling or relational tension.
2. Resist retreating into technique.
3. Respond authentically and spontaneously within ethical limits.
4. Afterwards, explore together what happened.
Example language (illustrative): “That was different, the way we just laughed together. What was that like for you?”
Watch for: spontaneity that serves you rather than the client; the moment being followed by withdrawal, which calls for repair.

4.21 Inner dialogue between self-states, and ego-state models

Purpose: bring conflicting parts or self-states into dialogue, so the client has more awareness of them, more choice and a more integrated self [source: Gilbert & Orlans "Inner Dialogue Between Different Self States"]. SPTI frames object relations and self psychology through TA's first- and second-order ego-state models [source: Staffordshire module PSYC70870].
Steps [synthesis]:
1. Identify the self-states, for example a critic and a frightened part.
2. Give each a voice, using two chairs or written dialogue as the client prefers.
3. Help each state say what it feels and needs.
4. Look for negotiation or softening rather than victory.
5. Debrief from the adult, present-day self.
Example language (illustrative): “Let that critical part speak directly. What does it want for you?”
Watch for: one state dominating; dissociative clients losing orientation (go slower and keep the present-day self engaged). For Erskine-style Parent ego-state work, see guide 021.

4.22 Working with the script as a narrative approach

Purpose: identify the life story or “script” that shapes the client's choices, and help them author a new one [source: Gilbert & Orlans "Working with The 'Script' as a Narrative Approach"; Finlay ch. 16 (TA) title].
Steps [synthesis]:
1. Elicit recurring life themes and early messages.
2. Map how these themes are repeated in current relationships.
3. Explore the beliefs the client formed about self, others and life.
4. Name the script together.
5. Experiment with alternative endings in session and in life.
Example language (illustrative): “If your life so far were a story, what would its title be, and what ending does it seem to be heading towards?”
Watch for: a script turned into a fixed identity; new choices appearing in everyday life.

4.23 Working with symbolism and metaphor

Purpose: reach experience that is hard to put into literal words, through the client's own images and metaphors [source: Gilbert & Orlans "Working with Symbolism and Metaphor"].
Steps [synthesis]:
1. Notice the metaphors the client uses.
2. Stay inside the metaphor and explore it: its size, colour, what it wants.
3. Let it develop or change.
4. Only then link it to the client's life, if that helps.
Example language (illustrative): “You said it’s like a wall. What’s it made of? What’s on the other side?”
Watch for: imposing your own metaphors; a change in the metaphor that matches a shift in how the client feels.

4.24 Working with shame and shame-based systems

Purpose: recognise and gently work with shame, which often drives hiding, rage, perfectionism or collapse [source: Gilbert & Orlans "Working with Shame and Shame-Based Systems"].
Steps [synthesis]:
1. Learn shame's signs: averted gaze, freezing, sudden topic change, self-attack.
2. Slow down and reduce exposure, for example by easing direct eye contact or normalising.
3. Acknowledge any part you played in triggering the shame.
4. Explore the shame only when the client feels safe enough.
5. Trace it to its relational origins.
6. Build self-compassion.
Example language (illustrative): “Something just made you want to disappear, I think. We can take that slowly.”
Watch for: interpretations or challenges that shame the client again; the client staying in contact while they talk about the shame.

4.25 Working with dreams

Purpose: use dreams as material about the client's inner world and relationships, including the relationship with you [source: Gilbert & Orlans "Working with Dreams"].
Steps [synthesis]:
1. Ask the client to tell the dream in the present tense.
2. Explore the feelings and images in it.
3. Explore it in whatever way fits your lens, for example a Gestalt approach of speaking as each element, associations, or the dream's link to current relationships and the therapy.
4. Let the client decide what it means.
Example language (illustrative): “Tell it to me as if it’s happening now. Where are you?”
Watch for: imposing your own meaning; nightmares linked to trauma, which call for a stabilisation-first approach (see 4.27).

4.26 Working with dissociation

Purpose: recognise dissociation, keep the client within a manageable window of arousal, and gradually work with dissociated states [source: Gilbert & Orlans "Working with Dissociation: Possible Strategies", "Traumatic Memory Processes and Dissociation"].
Steps [synthesis]:
1. Screen for dissociation at assessment.
2. Agree grounding strategies in advance.
3. In session, notice glazing, numbing, sudden shifts of voice or age, or lost time.
4. Stop processing and orient the client to the present: name the date and place, describe objects in the room, feel the feet on the floor.
5. Reconnect with them and debrief.
6. Pace the work so that it stays manageable.
Example language (illustrative): “Let’s pause. Can you feel your feet on the floor? Tell me three things you can see in this room.”
Watch for: frequent or severe dissociation. Refer to or consult a specialist in dissociative disorders [synthesis].

4.27 An integrative approach to trauma

Purpose: work with chronic relational trauma, single-incident trauma and complex PTSD in phases, safety first [source: Gilbert & Orlans "An Integrative Approach to Trauma", "Chronic Relational Trauma and Single Traumatic Events", "Complex Post-Traumatic Stress Disorder", "Early Relational Trauma and its Effects"].
Steps [synthesis]:
1. Stabilise. Establish safety, resources (4.6), grounding and the alliance.
2. Check readiness for memory work. The client:
  - can return to the present when prompted
  - has adequate supports
  - is not in current danger
  - has stable housing and no active substance crisis
  - consents
3. Process in small doses. Approach one memory or fragment at a time. Keep part of attention in the present. Stop well before the client is overwhelmed. Leave at least 10 to 15 minutes to ground and close.
4. Integrate. Help the client make meaning of the experience and reconnect with others.
5. Treat memories as the client's experience. Never use suggestion or imagery to “recover” memories.
6. Refer when needed. Refer to, or combine with, NICE-recommended trauma-focused therapies when they are indicated.
Example language (illustrative): “We’ll only go as far as feels manageable, and you can stop at any time. We’ll leave time to settle before you go.”
Watch for: overwhelm or dissociation (4.26); an increase in self-harm or substance use (pause processing and return to stabilisation).

4.28 Working with enactments and therapeutic impasse

Purpose: recognise when you and the client are co-creating a repetition of an old pattern, and turn it into understanding [source: Gilbert & Orlans "Working with Enactments and Therapeutic Impasse"].
Steps [synthesis]:
1. Notice the signs: repetitive stuck exchanges, unusual behaviour from you (lateness, over-running, irritation), or a sense that you are both going round in circles.
2. Take it to supervision.
3. Name your part non-defensively.
4. Explore the pattern together and link it to the client's history.
5. Agree a new way forward.
Example language (illustrative): “I think we’ve got into a pattern where you bring a problem, I suggest something, and you explain why it won’t work, and we both end up flat. Can we look at what’s happening between us?”
Watch for: blaming the client for the impasse; the relief and new energy that follow when the pattern is named.

4.29 Addressing rupture and repair

Purpose: notice and repair breaks in the alliance or in attunement. The tradition treats repair as a key route to change [source: Gilbert & Orlans "Therapeutic Alliance Ruptures: Research and Clinical Perspectives", "Addressing the Process of Rupture and Repair"; Metanoia "attunement, mis-attunement and repair"].
Steps [synthesis]:
1. Watch for withdrawal ruptures (going quiet, agreeing, changing topic) and confrontation ruptures (complaints, anger).
2. Raise the rupture gently and invite the client's experience.
3. Acknowledge your part, without excess apology.
4. Explore what the rupture means for the client, including any links to the past.
5. Agree what would help.
6. Check how the repair landed.
Example language (illustrative): “I think I missed you just now. You went quiet after I said that. What happened for you?”
Watch for: an alliance that is stronger after repair; repeated ruptures that point to an enactment (4.28).

4.30 Accepting and working with mistakes

Purpose: treat your errors as inevitable and usable rather than shameful [source: Gilbert & Orlans "Accepting and Working with Mistakes"].
Steps [synthesis]:
1. Own the mistake clearly.
2. Explore its impact on the client.
3. Repair it (see 4.29).
4. Learn from it in supervision.
5. For ethical breaches, follow your professional body's requirements.
Example language (illustrative): “I got the time wrong last week. That was my mistake. How was it for you?”
Watch for: defensiveness; over-apologising that shifts the focus onto you.

4.31 Working with erotic transference

Purpose: explore sexual or romantic feelings toward the therapist safely, as meaningful material, with firm boundaries [source: Gilbert & Orlans "Working with Erotic Transference"].
Steps [synthesis]:
1. Stay calm and non-shaming.
2. Acknowledge that the feelings are real.
3. Hold the boundary clearly.
4. Explore the meaning together, such as longing, the wish to be special, old patterns, or a need for safety.
5. Use supervision promptly.
6. Never act on the feelings.
Example language (illustrative): “Thank you for telling me. Those feelings matter and we can understand them together. And our relationship will stay a therapy relationship.”
Watch for: your own countertransference; signs of exploitation risk. Consult your supervisor and follow your professional body's code [synthesis].

4.32 Sexuality, gender identity and sexual orientation

Purpose: work affirmingly and knowledgeably with the client's sexuality, gender identity and orientation, and notice your own assumptions [source: Gilbert & Orlans "Sexuality, Gender Identity and Sexual Orientation"].
Steps [synthesis]:
1. Ask rather than assume, including names and pronouns.
2. Explore how minority stress and others' reactions affect the client.
3. Examine your own biases in supervision.
4. Do not practise conversion therapy. The UK Memorandum of Understanding on Conversion Therapy, signed by the main UK counselling and psychotherapy bodies, calls it unethical and potentially harmful; it does not stop you helping a client who is unhappy or unsure about their sexual orientation or gender identity, provided you hold no agenda favouring one outcome [source: MoU, version 2 revision A, July 2024 printing]. UKCP stated in May 2021 that it is a signatory and expects registrants to comply [source: UKCP statement]; it is not listed among the signatories of the 2024 printing, so check UKCP's current guidance [uncertain].
Example language (illustrative): “How would you like me to refer to you, and to the people in your life?”
Watch for: the client correcting you, or holding back.

4.33 Intercultural, anti-oppressive and transpersonal work

Purpose: bring culture, race, power, ecology and the spiritual or transpersonal into the work, as Evans & Gilbert and Gilbert & Orlans do [source: Evans & Gilbert listings ("cultural, ecological and transpersonal"); Gilbert & Orlans "The Intercultural Dimension: Culture, Race and Wider Context", "The Transpersonal Dimension", "Anti-Oppressive Practice"; Metanoia, which includes social, cultural, economic, ecological and political context].
Steps [synthesis]:
1. Invite the client's cultural, racial, faith and community identities into assessment.
2. Name differences between you when they are relevant.
3. Consider structural causes as well as personal ones.
4. Respect the client's spiritual frameworks and explore their meaning.
5. Check your own cultural assumptions in supervision.
Example language (illustrative): “We come from different backgrounds. How might that affect what it’s like to talk with me?”
Watch for: colour-blindness or over-attribution to culture; imposing your own spiritual or secular views.

4.34 Drawing on modality lenses within the relationship

Purpose: bring in methods from specific traditions when they fit the client and the moment, while keeping the relational frame [source: Finlay Part II chapter titles: cognitively orientated therapy; existential phenomenology; gestalt theory and therapy; relational psychoanalytic theory in practice; systemic theory and therapy; transactional analysis; Gilbert & Orlans "Technical Eclecticism", "Assimilative Integration", "Complementarity: Combining two methods"].
Steps [synthesis]:
1. From the formulation (4.2), identify a need that a specific lens addresses well:
  - cognitive work for unhelpful thinking and behaviour patterns
  - existential exploration for meaning, choice and loss
  - gestalt experiment for unfinished business and awareness
  - relational psychoanalytic work for unconscious relational patterns
  - systemic work for family and wider systems
  - TA for ego states, transactions and script
2. Explain the rationale and get consent.
3. Use the method collaboratively.
4. Notice what the switch does to the relationship.
5. Review whether it helped.
Example language (illustrative): “I’d like to try something more structured, writing down the thoughts that come in those moments. Would that be useful?”
Watch for: a muddled eclecticism without rationale (Gilbert & Orlans include a section on “Criticisms of Integration”); techniques used to avoid relational difficulty.

5. Handling problems

The sources name several of these problems in section titles: resistance across phases (Evans & Gilbert), ruptures, enactments and impasse, mistakes, shame, dissociation, erotic transference, and the shadow side of organisations (Gilbert & Orlans). Their texts are not reproduced here, and all the concrete responses below are the writer's [synthesis] unless a source tag says otherwise.

Resistance at different phases [topic: Evans & Gilbert listing; specific responses: synthesis]. Treat resistance as self-protection that made sense, not as opposition.
- Early: protect against exposure. Go slower and give more choice and clarity about the frame.
- Middle: protect against change. Explore what change would cost and who it would betray.
- Late: protect against loss. Name the ending and its echoes.
- Example language (illustrative): “Part of you seems to want to keep this at arm’s length. That part probably has good reasons. Can we hear from it?”
Stuck or circular sessions.
1. Check the contract: are the aims still shared?
2. Look for an enactment (4.28).
3. Consider whether a different relationship dimension (4.11) or lens (4.34) is needed.
4. Review with the client and in supervision.
5. If nothing has moved after a joint review, discuss referral or a change of approach.
Overwhelm or dissociation in session. Stop processing. Ground the client (4.26), lower the intensity, and leave time to stabilise before they go. Return to resourcing (4.6). Use smaller doses in future sessions. Agree a plan for between sessions if distress continues.
Ruptures. Use 4.29. Pay particular attention to quiet withdrawal ruptures, which are easy to miss. Over-compliance can also be a rupture.
Non-adherence to agreed practice (skills, mindfulness, experiments). Explore it with curiosity rather than compliance pressure. Is the task too big? Does it carry a hidden meaning, such as being told what to do? Is the task yours rather than the client's? Co-design a smaller version.
Shame triggered by the work. Slow down and acknowledge it, own your part, and reduce exposure (4.24). Avoid confronting while shame is active.
Client wants only techniques, or only advice. Respect this. Offer a structured lens (4.34) within the relationship, and over time explore what being helped means to them.
Integration becomes muddled. If you cannot state why you are using a method, pause. Return to the formulation (4.2) and take it to supervision. Gilbert & Orlans list “Criticisms of Integration” and “Challenges for the Integrative Psychotherapist”, which shows the tradition sees this risk [source: Routledge contents].
Erotic transference, or a pull to over-involvement. Hold boundaries firmly, use supervision, and explore the meaning (4.31). If you notice a boundary drifting, seek consultation at once.
Cultural misattunement. Acknowledge it directly, invite the client's correction, and learn rather than defend (4.33).
Risk: suicide or self-harm. Assess risk directly and collaboratively at intake and whenever it is indicated. Agree a safety plan that includes lethal-means counselling (safe storage and removal) and crisis contacts. Increase contact and liaise with the GP or crisis services as needed. Document your decisions and consult. Keep the relational stance, but do not let it delay action.
Endings that go badly (missed final sessions, sudden crises). Name the pattern, offer a review session, and link it to the client's history of loss (4.10).
Problems in the training or organisational context. Gilbert & Orlans have a section on “The Shadow Side of Psychotherapy Organisations” [source: contents]. Use external supervision and your professional body's procedures if institutional dynamics affect client care.

Sources

Sources

Books cited (known through listings and contents pages)

Evans, K. & Gilbert, M. (2005). An Introduction to Integrative Psychotherapy. Basingstoke: Palgrave Macmillan.
Finlay, L. (2016). Relational Integrative Psychotherapy: Engaging Process and Theory in Practice. Chichester: Wiley. Imprint dated December 2015.
Gilbert, M. & Orlans, V. (2011). Integrative Therapy: 100 Key Points and Techniques. London: Routledge.
Schore, A. N. (2012). Cited by Metanoia for psychotherapy as the “communicating cure”.
Summers, G. & Tudor, K. on co-creative TA. Named in SPTI's module; the specific work is [uncertain].
For Erskine's Integrative Psychotherapy, see guide 021 and its sources.

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