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Attunement and Involvement:
Therapeutic Responses to Relational Needs
Standardized protocols or treatment manuals define the practice
of psychotherapy from either a quantitative research-based
behavioral model or symptom-focused medical model
(Erskine,1998). The therapeutic relationship is not considered
central in such practice manuals. In this era of industrialization of
psychotherapy it is essential for psychotherapists to remain
mindful of the unique interpersonal relationship between therapist
and client as the central and significant factor in psychotherapy.
This article outlines several dimensions of the therapeutic
relationship that have emerged from a qualitative evaluation of the
practice of psychotherapy conducted at the Institute for Integrative
Psychotherapy in New York City.
A major premise of a relationship-oriented psychotherapy is that
the need for relationship constitutes a primary motivation of
human behavior (Fairbairn, 1952). Contact is the means by which
the need for relationship is met. In colloquial language, 'contact'
refers to the quality of the transactions between two people: the
awareness of both one's self and the other, a sensitive meeting of
the other and an authentic acknowledgement of one's self. In a
more theoretically exact meaning, 'contact' refers to the full
awareness of sensations, feelings, needs, sensorimotor
processes, thought and memories that occur within the individual,
and a shift to full awareness of external events as registered by
each sensory organ. With the capacity to oscillate between
internal and external contact, experiences are continually
integrated into a sense of self (Perls et al., 1951).
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When contact is disrupted, needs are not satisfied. If the
experience of need arousal is not satisfied or closed naturally, it
must find an artificial closure that distracts from the discomfort of
unmet needs. These artificial closures are the substance of
survival reactions that become fixated defensive patterns, or
habitual behaviors that result from rigidly held beliefs about self,
others or the quality of life. They are evident in the disavowal of
affect, the loss of either internal or external awareness,
neurological inhibitions within the body, or a lack of spontaneity
and flexibility in problem-solving, health maintenance, or relating
to people. The defensive interruptions to contact impede the
fulfilment of current needs (Erskine, 1980).
The literature on human development also leads to the
understanding that the sense of self and self-esteem emerge out
of contact-in-relationship (Stern, 1985). Erikson's (1950) stages of
development over the entire life cycle describe the formation of
identity as an outgrowth of interpersonal relations (trust vs
mistrust, autonomy vs shame and doubt, etc.). Mahler's (1968;
Mahler et al, 1975) descriptions of the stages of early child
development place importance on the relationship between
mother and infant. Bowlby (1969, 1973, 1980) has emphasized
the significance of early as well as prolonged physical bonding in
the creation of a visceral core from which all experiences of self
and other emerge. When such contact does not occur in
accordance with the child's relational needs, there is a
physiological defence against the loss of contact-, poignantly
described by Fraiberg in 'Pathological Defenses of Infancy'
(1982). These developmental perspectives foster a deep
appreciation for the need for interpersonal connection and active
construction of meaning that is so much a part of who the client is.
In a relationship-oriented psychotherapy the psychotherapist's
self is used in a directed, involved way to assist the client's
process of developing and integrating full contact and the
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satisfaction of relational needs. Of central significance is the
process of attunement, not just to discreet thoughts, feelings,
behaviours or physical sensations, but also to what Stern terms
'vitality affects,' such that an experience of unbroken feeling-
connectedness is created (1985, p. 156).
The client's sense of self and sense of relatedness that develop
are crucial to the process of healing and growth, particularly when
there have been specific traumas in the client's life and when
aspects of the self have been disavowed or denied because of
the cumulative failure of contact-in-relationship (Erskine, 1997).
Attunement
Attunement goes beyond empathy: it is a process of communion
and unity of interpersonal contact. It is a two-part process that
begins with empathy-being sensitive to and identifying with the
other person's sensations, needs or feelings; and includes the
communication of that sensitivity to the other person. More than
just understanding (Rogers, 195 1) or vicarious introspection
(Kohut, 1971), attunement is a kinesthetic and emotional sensing
of others knowing their rhythm, affect and experience by
metaphorically being in their skin, and going beyond empathy to
create a two-person experience of unbroken feeling
connectedness by providing a reciprocal affect and/or resonating
response. Attunement is communicated by what is said as well as
by the therapist's facial or body movements that signal to the
client that his or her affect and needs are perceived, are
significant and make an impact on the therapist. It is facilitated by
the therapist's capacity to anticipate and observe the effects of his
or her behavior on the client and to decentre from his or her own
experience to focus extensively on the client's process. Yet,
effective attunement also requires that the therapist
simultaneously remains aware of the boundary between client
and therapist as well as his or her own internal processes.
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The communication of attunement validates the client's needs
and feelings and lays the foundation for repairing the failures of
previous relationships (Erskine, 1997). Affective attunement, for
example, provides an interpersonal contact essential to human
relationship. It involves the resonance of one person's affect to
the other's affect. Affective attunement begins with valuing the
other person's affect as an extremely important form of
communication, being willing to be affectively aroused by the
other person and responding with the reciprocal affect. When a
client feels sad, the therapist's reciprocal affect of compassion
and compassionate acts complete the interpersonal contact.
Relationally, anger requires the reciprocal affects related to
attentiveness, seriousness and responsibility, with possible acts of
correction. The client who is afraid requires that the therapist
respond with affect and action that convey security and
protection. When clients express joy, the response from the
therapist that completes the unity of interpersonal contact is the
reciprocal vitality and expression of pleasure. Symbolically,
attunement may be pictured as one person's yin to the other's
yang that together form a unity in the relationship.
Attunement is often experienced by the client as the therapist
gently moving through the defenses that have prevented the
awareness of relationship failures and related needs and feelings.
Over time this results in a lessening of internal interruptions to
contact and a corresponding dissolving of external defenses.
Needs and feelings can increasingly be expressed with comfort
and assurance that they will receive a connecting and caring
response. Frequently, the process of attunement provides a
sense of safety and stability that enables the client to begin to
remember and endure regressing into childhood experiences.
This may bring a fuller awareness of the pain of past traumas,
shaming experiences, past failures of relationship(s) and loss of
aspects of self (Erskine, 1994).
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Relational needs
Attunement also includes responding to relational needs as they
emerge in the therapeutic relationship. Relational needs are the
needs unique to interpersonal contact. They are not the basic
needs of life such as food, air or proper temperature, but are the
essential elements that enhance the quality of life and a sense of
self-in-relationship. Relational needs are the component parts of a
universal human desire for relationship.
The relational needs described in this article have emerged from
a study of transference and a qualitative investigation of the
crucial factors in significant relationships conducted at the
Institute for Integrative Psychotherapy in New York City. Although
there may be an infinite number of relational needs the eight
described in this article represent those needs that, in my
experience, clients most frequently describe as they talk about
significant relationships. Other client-therapist inter-subjective
experiences may reveal a different cluster of relational needs
beyond the eight described here. This further illustrates that the
client-therapist relationship is irreproducible. No two therapists will
produce the same therapeutic process. Some of the relational
needs described here are also described in the psychotherapy
literature as fixated needs of early childhood, indicators of
psychopathology or problematic transference. While the tendency
to pathologize dependence or transference does exist in the
psychotherapy literature, in the context of the time and theoretical
milieu, Kohut in 1971 and 1977 made strides to connect
transference to developmental needs. Kohut distinguishes
relational, developmental needs that have suffered disruption or
rupture from the classical transference based on a drive model of
psychoanalysis. Although he identifies mirroring, twinship and
idealization as problematic transferences, he also relates them to
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essential needs. However, his methods remain psychoanalytic
and do not make full use of a relationship-oriented integrative
model of psychotherapy. Bach (1985), Basch (1988), Stolorow et
al. (1987) and Wolf (1988) have expanded on Kohut's concepts,
each emphasizing the importance of a relational perspective in
understanding transference. Clark's (1991) integrative perspective
on empathic transactions bridges the concepts of transference
and relational needs and emphasizes a therapy of involvement.
Relational needs are present throughout the entire life cycle from
early infancy through old age. Although present in early childhood,
relational needs are not only needs of childhood or needs that
emerge in a developmental hierarchy: they are the actual
components of relationship that are present each day of our lives.
Each relational need may become figural or conscious as a
longing or desire while the others remain out of consciousness or
as background. A satisfying response by another person to an
individual's relational need allows the pressing need to recede to
ground and another relational need to become figural as a new
interest or desire. Often it is in the absence of need satisfaction
that an individual becomes most aware of the presence of
relational needs. When relational needs are not satisfied the need
becomes more intense and is phenomenologically experienced as
longing, emptiness, a nagging loneliness, or an intense urge often
accompanied by nervousness. The continued absence of
satisfaction of relational needs may be manifested as frustration,
aggression or anger. When disruptions in relationship are
prolonged the lack of need satisfaction is manifested as a loss of
energy or hope and shows up in script beliefs such as 'No one is
there for me' or 'What the use?' (Erskine & Moursund,
1988/1998). These script beliefs are the cognitive defence against
the awareness of needs and the feelings present when needs do
not get a satisfying response from another person (Erskine,
1980).
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The satisfaction of relational needs requires a contactful presence
of another who is sensitive and attuned to the relational needs
and who also provides a reciprocal response to each need.
Security is the visceral experience of having our physical and
emotional vulnerabilities protected. It involves the experience that
our variety of needs and feelings are human and natural. Security
is a sense of simultaneously being vulnerable and in harmony
with another.
Attunement involves the empathetic awareness of the other's
need for security within the relationship plus a reciprocal response
to that need. It includes respectful transactions that are non-
shaming and the absence of actual or anticipated impingement or
danger. The needed response is the provision of physical and
affective security where the individual's vulnerability is honoured
and preserved. It communicates, often non-verbally, 'Your needs
and feelings are normal and acceptable to me.' Therapeutic
attunement to the relational need for security has been described
by clients as 'total acceptance and protection,' as a
communication of 'unconditional positive regard' or 'I'm OK in this
relationship.' Attunement to the need for security involves the
therapist being sensitive to the importance of this need and
conducting him or herself both emotionally and behaviourally in a
way that provides in the relationship.
Relational needs include the need to feel validated, affirmed and
significant within a relationship. It is the need to have the other
person validate the significance and function of our intrapsychic
processes of affect, fantasy and constructing of meaning, and to
validate that our emotions are a significant intrapsychic and
interpersonal communication. It includes the need to have all of
our relational needs affirmed and accepted as natural. This need
is a relational request for the other person to be involved through
providing a quality of interpersonal contact that validates the
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legitimacy of relational needs, the significance of affect and the
function of intrapsychic processes.
Attunement with a client's need for validation is conveyed through
the psychotherapist's phenomenological inquiry and contactful
presence. The therapist's affective reciprocity with the client's
feelings validates the client's affect and provides affirmation and
normalization of the client's relational needs. The
psychotherapist's focus on the psychological function -- stability,
continuity, identity, predictability-- of rigidly held beliefs or
behaviours lessens the likelihood of the client experiencing
shame while validating the psychological significance of the
beliefs or behaviours. Such validation is a necessary prerequisite
to lasting cognitive or behavioural change.
Acceptance by a stable, dependable, and protective other person
is an essential relational need. Each of us as children had the
need to look up to and rely on our parents, elders, teachers and
mentors. We need to have significant others from whom we gain
protection, encouragement and information. The relational need
for acceptance by a consistent, reliable and dependable other
person is the search for protection and guidance that may be
manifested as an idealization of the other. In psychotherapy, such
idealization is also the search for protection from a controlling,
humiliating introjected ego's intrapsychic effect on the vulnerability
of child ego states (Fairbairn, 1952; Guntrip, 1971; Erskine &
Moursund, 1988/ 1998). It can also be the search for protection
from one's own escalations of affect or exaggerations of fantasies.
The therapist protects and facilitates integration of affect by
providing an opportunity to express, contain and/or understand
the function of such dynamics. The degree to which an individual
looks to someone and hopes that he or she is reliable, consistent
and dependable is directly proportional to the quest for
intrapsychic protection, safe expression, containment, or
beneficial insight. Idealizing or depending on someone is not
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necessarily pathological as implied in the popular psychology
term, “co-dependent”, or when misinterpreted as “idealizing
transference” (Kohut, 1977), or as Berne's psychological game of
“Gee, You're Wonderful,Professor”(1964). When we refer to some
clients' expressions of this need to be accepted and protected as
“a Victim looking for a Rescuer”, we depreciate or even
pathologize an essential human need for relationship that
provides a sense of stability, reliability and dependability.
In psychotherapy, attunement involves the therapist's recognition
of the importance and necessity of idealizing as an unaware
request for intrapsychic protection. Such recognition and
attunement by the therapist to the client's relational need most
often occurs in the accepting and respecting nature of the
interpersonal contact and therapeutic involvement and may not
necessarily be spoken about directly. Such a therapeutic
involvement includes both the client's sense of the
psychotherapist's interest in the client's welfare and the use of the
therapist's integrated sense of self as the most effective
therapeutic tool (Erskine, 1982; Erskine & Moursund, 1988/1998).
It is this relational need to be accepted by a stable, dependable,
and protective other person that provides a client-centred reason
to conduct our lives and psychotherapy practice ethically and
morally.
The confirmation of personal experience is also an essential
relational need. The need to have experience confirmed is
manifested through the desire to be in the presence of someone
who is similar, who understands because he or she has had a like
experience, and whose shared experience is confirming. It is the
quest for mutuality, a sense of walking the same path in life
together with a companion who is 'like me'. It is the need to have
someone appreciate and value our experience because they
phenomenologically know what that experience is like.
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Affirmation of the client's experience may include the therapist
joining in or valuing the client's fantasies. Rather than define a
client's internal story-telling as “just a fantasy”, it is essential to
engage the client in the expression of the needs, hopes, relational
conflicts and protective strategies that may constitute the core of
the fantasies. Attunement to the need for affirmation of experience
may be achieved by the therapist accepting everything said by the
client, even when fantasy and reality are intertwined, much like
the telling of a dream reveals the intrapsychic process. Fantasy
images or symbols have a significant intrapsychic and
interpersonal function. When the function of the fantasy is
acknowledged, appreciated and valued the person feels affirmed
in his or her experience.
When the relational need for confirmation of personal experience
is present in a client's communication, he or she may be longing
for a model with a similar experience. An attuned psychotherapy
may include the sharing of the therapist's own experiences: telling
how he or she solved a conflict similar to the client's and providing
a sense of mutuality with the client. Attunement is provided by the
therapist valuing the need for confirmation by revealing carefully
selected personal experiences, mindfully (i.e. client-focused)
sharing vulnerabilities or similar feelings and fantasies, and by the
therapist's personal presence and vitality. The client who needs
confirmation of personal experience requires a uniquely different
reciprocal response than the client who needs validation of affect
or who needs to be accepted by a dependable and protective
other. In neither of these latter two relational needs is the sharing
of personal experience or the creating of an atmosphere of
mutuality an attuned response to the client's need.
Self-definition is the relational need to know and express one's
own uniqueness and to receive acknowledgement and
acceptance by the other. Self-definition is the communication of
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one's self-chosen identity through the expression of preferences,
interests and ideas without humiliation or rejection.
In the absence of satisfying acknowledgement and acceptance,
the expression of self-definition may take unconscious adversarial
forms such as the person who begins his or her sentences with
'No' even when agreeing, or who constantly engages in
arguments or competition. People often compete to define
themselves as distinct from others. The more alike people are the
greater the thrust for self-defining competition.
Attunement begins with the therapist's sensitivity to and
understanding that adversary and competition in relationships
may be an expression of the need for self-definition with
acknowledgement and acceptance by the other. Therapeutic
attunement is in the therapist's consistent support for the client's
expression of identity and in the therapist's normalization of the
need for self-definition. It requires the therapist's consistent
presence, contactfulness and respect even in the face of
disagreement.
Another essential relational need is to have an impact on the
other person. Impact refers to having an influence that affects the
other in some desired way. An individual's sense of competency in
a relationship emerges from agency and efficacy-attracting the
other's attention and interest, influencing what may be of interest
to the other person, and affecting a change of affect or behaviour
in the other.
Attunement to the client's need to have an impact occurs when
the psychotherapist allows him or herself to be emotionally
impacted by the client and to respond with compassion when the
client is sad, to provide an affect of security when the client is
scared, to take the client seriously when he or she is angry, and to
be excited when the client is joyful. Attunement may include
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soliciting the client's criticism of the therapist's behaviour and
making the necessary changes so the client has a sense of
impact within the therapeutic relationship.
Relationships become more personally meaningful and fulfilling
when the need to have the other initiate is satisfied. Initiation
refers to the impetus for making interpersonal contact with
another person. It is the reaching out to the other in some way
that acknowledges and validates the importance of him or her in
the relationship.
The psychotherapist may be subject to a theory-induced counter-
transference when he or she universally applies the theoretical
concepts of non-gratification, rescuing, or refraining from doing
more than 50% of the therapeutic work. While waiting for the
client to initiate the psychotherapist may not be accounting for the
fact that some behaviour that appears passive may actually be an
expression of the relational need to have the other initiate.
The therapist's attunement to this relational need requires a
sensitivity to the client's non-action and the therapist's initiation of
interpersonal contact. To respond to the client's need it may be
necessary for the therapist to initiate a dialogue, to move out of
his or her chair and sit near the client, or to make a phone call to
the client between sessions. The therapist's willingness to initiate
interpersonal contact or to take responsibility for a major share of
the therapeutic work normalizes the client's relational need to
have someone else put energy into reaching out to him or her.
Such action communicates to the client that the therapist is
involved in the relationship.
The need to express love is an important component of
relationships. Love is often expressed through quiet gratitude,
thankfulness, giving affection, or doing something for the other
person. The importance of the relational need to give love
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--whether it be from children to parents, sibling or teacher, or from
a client to a therapist -- is often overlooked in the practice of
psychotherapy. When the expression of love is stymied the
expression of self-in-relationship is thwarted. Too often
psychotherapists have treated clients' expression of affection as a
manipulation, transference, or a violation of a neutral therapeutic
boundary.
Attunement to the client's relational need to express love is in the
therapist's graciously accepting the client's gratitude and
expressions of affection, and in acknowledging the normal
function of love in maintaining a meaningful relationship.
Those clients for whom the absence of satisfaction of relational
needs is cumulative require a consistent and dependable
attunement and involvement by the psychotherapist that
acknowledges, validates and normalizes relational needs and
related affect. It is through the psychotherapist's sustained
contactful presence that the cumulative trauma (Khan, 1963;
Lourie, 1996) of the lack of need satisfaction can now be
addressed and the needs responded to within the therapeutic
relationship.
Involvement
Involvement is best understood through the client's perception-a
sense that the therapist is contactful and is truly invested in the
client's welfare. It evolves from the therapist's respectful inquiry
into the client's experience and is developed through the
therapist's attunement to the client's affect and rhythm and to the
validation of his or her needs. Involvement includes being fully
present with and for the person in a way that is appropriate to the
client's developmental level of functioning and current need for
relationship. It includes a genuine interest in the client's
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intrapsychic and interpersonal world and a communication of that
interest through attentiveness, inquiry and patience.
Therapeutic involvement is maintained by the therapist's constant
vigilance to providing an environment and relationship of safety
and security. It is necessary that the therapist be constantly
attuned to the client's ability to tolerate the emerging awareness
of past experiences so that they are not overwhelmed once again
in the therapy as they may have been in a previous experience.
Therapeutic involvement that emphasizes acknowledgement,
validation, normalization and presence diminishes the internal
defensive process.
The therapist's acknowledgement of the client begins with an
attunement to his or her affect, relational needs, rhythm, and
developmental level of functioning. Through sensitivity to the
relational needs or physiological expression of emotions the
therapist can guide the client to become aware and to express
needs and feelings or to acknowledge that feelings or physical
sensations may be memory -- the only way of remembering that
may be available. In many cases of relationship failure the
person's relational needs or feelings were not acknowledged and
it may be necessary in psychotherapy to help the person gain a
vocabulary and learn to voice those feelings and needs.
Acknowledgement of physical sensations, relational needs, and
affect helps the client claim his or her own phenomenological
experience. It includes a receptive other who knows and
communicates about the existence of non-verbal movements,
tensing of muscles, affect, or even fantasy.
There may have been times in a client's life when feelings or
relational needs were acknowledged but were not validated.
Validation communicates to the client that his or her affect,
defences, physical sensations or behavioural patterns are related
to something significant in his or her experiences. Validation
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makes a link between cause and effect; it values the individual's
idiosyncrasies and way of being in relationship. It diminishes the
possibility of the client internally disavowing or denying the
significance of affect, physical sensation, memory or dreams; and
it supports the client in valuing his or her phenomenological
experience and transferential communication of the needed
relationship, thereby increasing self-esteem.
The intent of normalization is to influence the way clients or others
may categorize or define their internal experience or their
behavioural attempts at coping from a pathological or
“something's-wrong-with-me” perspective to one that respects the
archaic attempts at resolution of conflicts. It may be essential for
the therapist to counter societal or parental messages such as
“You're stupid for feeling scared” with “Anyone would be scared in
that situation.” Many flashbacks, bizarre fantasies, nightmares,
confusion, panic, and defensiveness are all normal coping
phenomena in abnormal situations. It is imperative that the
therapist communicates that the client's experience is a normal
defensive reaction -- a reaction that many people would have if
they encountered similar life experiences.
Presence is provided through the psychotherapist's sustained
attuned responses to both the verbal and non-verbal expressions
of the client. It occurs when the behaviour and communication of
the psychotherapist at all times respects and enhances the
integrity of the client. Presence includes the therapist's receptivity
to the client's affect -- to be impacted by their emotions; to be
moved and yet to stay responsive to the impact of their emotions
and not to become anxious, depressed or angry. Presence is an
expression of the psychotherapist's full internal and external
contact. It communicates the psychotherapist's responsibility,
dependability and reliability. Through the therapist's full presence
the transformative potential of a relationship-oriented
psychotherapy is possible. Presence describes the therapist's
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providing a safe interpersonal connection. More than just verbal
communication, presence is a communion between client and
therapist.
Presence is enhanced when the therapist de-centres from his or
her own needs, feelings, fantasies or hopes and centres instead
on the client's process. Presence also includes the converse of
de-centring; that is, the therapist being fully contactful with his or
her own internal process and reactions. The therapist's history,
relational needs, sensitivities, theories, professional experience,
own psychotherapy, and reading interests all shape unique
reactions to the client. Each of these thoughts and feelings within
the therapist are an essential part of therapeutic presence. The
therapist's repertoire of knowledge and experience is a rich
resource for attunement and understanding. Presence involves
both bringing the richness of the therapist's experiences to the
therapeutic relationship as well as de-centring from the self of the
therapist and centring on the client's process.
Presence also includes allowing oneself to be manipulated and
shaped by the client in a way that provides for the client's self-
expression. As effective psychotherapists we are played with and
genuinely become the clay that is moulded and shaped to fit the
client's expression of their intrapsychic world towards the creation
of a new sense of self and self-in-relationship (Winnicott, 1965).
The dependable, attuned presence of the therapist counters the
client's sense of shame and discounting his or her self-worth. The
quality of presence creates a psychotherapy that is unique with
each client: attuned to and involved with the client's emerging
relational needs.
What gives psychotherapy its transformative effect in people's
lives is the psychotherapist's focus on the client's relational needs
and the relationship between client and therapist. Such a
relationship can never be standardized or prescribed or even
16
quantified by research. The uniqueness of each therapeutic
relationship emerges out of the therapist's attunement and
involvement that is responsive to the client's cluster of relational
needs -- a therapy of contact-in-relationship.
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19
This paper was presented as a keynote speech entitled “A Therapeutic Relationship?”
at the Ist Congress of the World Council for Psychotherapy, Vienna, Austria, 30 June to
6 July, 1996. Portions of this paper were also included in a closing address, “The
Psychotherapy Relationship”, at the 7th Annual Conference of the European
Association for Psychotherapy, Rome, Italy, 26-29 June 1997. Copyright (1998)
European Association for Psychotherapy. Reprint by permission of the International
Journal of Psychotherapy. The citation for the original article is: Erskine, R.G.(1998).
Attunement and Involvement: Therapeutic Responses to Relational Reeds.
International Journal of Psychotherapy, 3:3,p.235-244.
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