Psychoanalytic Inquiry

A Topical Journal for Mental Health Professionals

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/hpsi20

An Integrative Approach to Relational

Psychoanalysis

Kenneth A. Frank

To cite this article: Kenneth A. Frank (2020) An Integrative Approach to Relational

Psychoanalysis, Psychoanalytic Inquiry, 40:6, 448-460, DOI: 10.1080/07351690.2020.1782145

To link to this article: https://doi.org/10.1080/07351690.2020.1782145

Published online: 31 Aug 2020.

Submit your article to this journal

Article views: 15

View related articles

View Crossmark data

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=hpsi20
PSYCHOANALYTIC INQUIRY
2020, VOL. 40, NO. 6, 448–460
https://doi.org/10.1080/07351690.2020.1782145

ORIGINAL ARTICLES

An Integrative Approach to Relational Psychoanalysis

Kenneth A. Frank, Ph.D.

ABSTRACT
Recent research in cognitive neuroscience, as well as in therapeutic
approaches such as Internal Family Systems Therapy (IFS) and
Sensorimotor Psychotherapy, offer ways of empowering psychoanalytic
therapy within the framework of contemporary psychoanalysis’s basic prin-
ciples. A clinical vignette illustrating an effective application of psychother-
apy integration is presented. In order to benefit from importing these
outside insights and methods, some analysts will need to overcome single-
mindedness and relax elitist notions of the superiority of their staunch
approach. As the hegemony of psychoanalysis continues to decline, an
integrative strategy of this sort can vitalize psychoanalysis and ensure its
legacy while also helping nonanalytic therapists realize the ways their
approaches intersect with and can benefit from ours.

Historical background
During the 1970’s and 80’s, American psychoanalysis found itself in the throes of a major shift. For
decades, the orthodox mainstream had dominated, suppressing alternative approaches. But then, as
Robert Wallerstein (1988) observed in his Presidential Inaugural Address to the International
Psychoanalytic Association, a new psychoanalytic pluralism was developing. Because, at the time,
factions were forming – among classical analysts, object-relations analysts, and psychoanalytic self
psychologists, for example – concerns arose over the fragmentation of psychoanalysis as a unified
science and profession. If not enthusiastic, Wallerstein was at least reassuring about the effects of the
new pluralism. He opined that psychoanalysis could successfully retain its identity while accommo-
dating a variety of substreams based on a shared desire to use psychoanalytic principles and methods
to heal people’s psychic distress. Quoting Freud (1914), he cited the requirement that “Any line of
investigation which recognizes [transference and resistance] and takes them as the starting-point of
its work has a right to call itself psycho-analysis” (p. 16).
Today, most practitioners would agree that pluralism turned out to be a positive development.
During the late 1980’s and beyond, the consolidation of Object-Relations theory, Psychoanalytic Self
Psychology, and Interpersonal Psychoanalysis, an integration that became known as Relational
Psychoanalysis (Mitchell, 1988), continued constructively to reshape our discipline while preserving
its basic ideological integrity. Gradually, the relational “movement” gained ascendency over the
constraining orthodox position. And its “two-person” (versus classical “one-person”) conceptualiza-
tions have resulted in a liberalization of psychoanalytic methodology.
My thesis in this article is that pluralism followed by consolidation, has represented a very
positive trajectory for psychoanalysis; yet it is a path whose potentialities are far from fully devel-
oped. I wish to advance that trend here. For instance, as psychoanalysts struggled narrowly in the
1980’s and beyond, exploring avenues that would advance their own discipline, others in the field of
psychotherapy, mostly academic psychotherapy researchers, defined their fundamental professional
objective more broadly – if no less self-servingly – as the pursuit of best therapy outcomes. Those in
that specialty area, called psychotherapy integration, showed that combining diverse therapies, like

CONTACT Kenneth A. Frank, Ph.D. kennethafrank@gmail.com 71 West 23rd Street, 14th Floor, New York, NY 10010.
Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald Silver
 INTEGRATIVE RELATIONAL PSYCHOANALYSIS 449

Cognitive and Behavior Therapy (CBT) can produce superior outcomes. Except for a small handful
of individuals, we analysts are arriving quite late to the integration party.

Why an integrative psychoanalytic approach?

Notwithstanding many favorable psychoanalytic developments, numerous sociocultural, political,
and economic influences have brought about the decline of the hegemony that psychoanalysis once
enjoyed over the field. Although traditional psychoanalytic psychotherapy provided sensible mod-
ifications of the standard technique and its guiding triumvirate of analytic anonymity, abstinence,
and neutrality, it does not look far beyond its own strictly psychoanalytic borders. As I see it,
analysis’s major limitation is not its basic tenets or essential methods, but its exclusivity, as it reflects
a rejection of recent developments capable of strengthening it.
When we look at psychological change through the wide-angle lens of multiple disciplines, like
neuroscience and nonanalytic approaches like behavior and trauma therapies, rather than the
psychoanalytic vision alone, we discover new ways of thinking and working. Schools of cognitive-
behavior therapy, mindfulness-based, body-based, imagery-based, and trauma therapies, among
others, have revealed insights that can be applied broadly to analytic patients. As Messer (1992)
first described, many outside insights can be assimilated and methods interwoven with “single”
orientations, analytic and others, to enhance psychotherapy.
Relational psychoanalytic integration is concerned specifically with assimilating these newer,
outside approaches into psychoanalytically-based clinical work. But in addition to its direct ther-
apeutic benefits, there are other reasons that make an integrative approach desirable. Perhaps most
compellingly, it is responsive to a radical change in contemporary practice. It is no secret that the
number of people willing to commit to the time and financial obligations necessary to undergo
a three-times-a-week or more psychoanalytic experience is small and shrinking. This change in the
frequency of sessions necessitates a shift in how we understand and apply transference analysis, the
centerpiece of the analytic approach. Transference experience and interpretation always have, and
always will play an important role in psychoanalytic therapy. Additionally, as Kohut (1977) and
others have emphasized, for example, the analyst’s affirming (selfobject) functions provide an
important vehicle for growth, and repairing ruptures in the relationship, ordinarily traced back to
transference and countertransference reactions, is a powerful therapeutic resource.
Problematically, however, most of our understanding of transference analysis is based on
a literature addressing patients who attend three or more sessions a week. Reduced session frequency
often brings lessened transference reactivity and intensity. Further, lessened frequency brings
therapeutic pressure to employ a more results-oriented methodology, with analysts’ associative
listening and transference interpretation more often subordinated to patients’ practical therapeutic
goals. With transference interpretation having less primacy, we must discover additional avenues to
heighten the mutative experiential and relational possibilities of analysis. Many nonanalytic
approaches increase that potential and apply not only to the many patients who come, say, weekly
or even less frequently, but also to many of those identified as analytic patients.
If analysts can assimilate the useful insights and methods of other approaches and thereby
strengthen analysis as both theory and practice, then the diversity that could potentially threaten
psychoanalysts’ contributions could, in fact, be turned to advantage. Such a strategy would vitalize
psychoanalysis and ensure its legacy while also helping nonanalytic therapists realize the ways their
approaches intersect with and can benefit from ours.

Building blocks: A psychoanalytic baseline

In the following sections, I will develop several key elements, or building blocks, of a framework for
practice using this integrative analytic approach. I am proposing that we revisit analytic therapy,
based on the technically liberating distinction between psychoanalysis as a system for understanding
450 K. A. FRANK

individual psychology, on one hand, and psychoanalytic practice narrowly defined (Gill, 1993), on
the other. We undertake the integrative project with Freud’s (1919) prophecy in mind – that “the
pure gold of psychoanalysis” (p. 168) be retained. In what I propose here, the defining features of the
psychoanalytic point of view have not been lost. These include: (1) the influence of the past on
current functioning; (2) the enduring effects of interpersonal patterns laid down in childhood; (3) the
importance of unconscious cognitive, affective, and motivational processes; (4) conflicting mental
processes; (5) the role of sexual, aggressive, and other motives, such as the need for self-esteem and
relatedness to others; (6) reliance on defenses and self-deception; and (7) compromises among
competing psychological tendencies that may be negotiated unconsciously (Westen et al., 2008).
Further, the analytic process continues to play a centrally grounding role in this methodology.
Essential elements include the analyst’s associative listening, the joint articulation of subsymbolic
processes, the shared re-narration of the patient’s life story through retrospective insight, internali-
zation of self-regulating and other therapeutic interactions, and the pair’s openness to uncertainty
and surprise.
However, in contrast with Freud’s psychoanalysis, in this view, outside methods are imported
precisely to facilitate integrative functions. Freud (1919) was at pains to emphasize the reductive aim
of analysis, which he explicitly contrasted with therapists adopting “psychosynthetic, i.e., integrative”
approaches. He saw the latter as both unnecessary and inimical to psychoanalytic work. It is not that
Freud saw synthesis as undesirable but as something that automatically and inevitably arises within
the patient and in which the analyst plays no direct part. Nor was Freud’s rejection of “psychosynth-
esis” based on rejection of the notion of personality integration, but on the term’s association with
mystical, directive, holistic, and interpersonal connotations resulting from the work of Assagioli
(1927) and others.1
Another building block is the relationality of this integrative psychoanalytic point of view, which
asserts that while methods can and do make a significant difference, either alone or in combination,
the core of any successful therapy is a strong relationship. In a book I edited forty years ago, called
“The Human Dimension in Psychoanalytic Practice” (Frank, 1977), I stated emphatically that
psychotherapy:

… is of limited value unless implemented within a relationship characterized by an affectional bond of mutual
trust and respect (and with a therapist who is) willing to fully experience and to be experienced, on an
authentically human level. [Frank, 1977, p. 6]

That assertion, which I stand by and is shared by many others today, was radical forty years ago,
before relational psychoanalysis as such existed. In a subsequent paper, I (Frank, 2005) privileged the
healing role of the personal, or person-to-person relationship between patient and analyst, and that
of the developing new relationship, and framed much transference analytic work as the protector of
that essentially healthy relational bond. That relationship is at the core of our work, both as an
accomplishment in itself, and as the fertile soil for further growth.
Relational psychoanalysis, with its scholarly articulation of the therapeutic relationship and its
ideas about approaching it therapeutically, is, on that basis alone, well suited as the therapeutic
baseline for an integrative approach. Although no single framework, including the psychoanalytic,
can entirely explain or implement the complexity of psychological change, only analysis so sensi-
tively and informedly explains and fosters the role of the therapy relationship itself as the crucible of
change.

1
Assagioli began publishing his ideas as early as 1906 in Italian. His correspondence with Jung, with whose model he found
greater agreement than Freud’s, began in 1907 (Rosselli & Vanni, 2014).
 INTEGRATIVE RELATIONAL PSYCHOANALYSIS 451

A template for change: Neuroplastic memory reconsolidation

An expansive examination of the relevant literature suggests a useful template for change – neuro-
plastic memory reconsolidation, in which synaptic memory traces are activated and undergo change –
and which operates in virtually all therapies. This template adds another building block to our
framework for combining modalities.
Exposure methods are not limited to behavior therapy. Most other approaches also embody
a method for exposing people to things they fear and thus avoid. The following seemingly dissimilar
methods, selected from an array of therapies, all are exposure activities intended to find ways to help
patients engage in mental content or activities they find uncomfortable or distressing, and therefore
avoid: psychoanalytic interpretation (Nicholas, 2010), the paradoxical intention of Existential
Therapy (e.g., Ascher, Bowers, & Schotte, 1985), the empty-chair method of Gestalt Therapy (e.g.,
Kolmannskog, 2018), behavioral experiments (e.g., Bennett-Levy et al., 2004), engaging the parts of
the self, such as a dissociated exile in IFS (Schwartz, 1995), recollecting traumatic events in EMDR
(Shapiro, 2018), and the Diffusion strategies of Acceptance and Commitment Therapy (e.g., Hayes,
Strosahl, & Wilson, 2012). Exposure researchers question whether exposure, alone, is therapeutic, or
as a component among other elements (Carey, 2011).
Animal and human studies including the brain suggest that exposure alone is not enough to produce
change (Eker et al., 2012). It becomes therapeutic when emotionally activated patients face their fears
paired with corrective new learning experiences (Lane et al., 2015). This process, known as neuroplastic
memory reconsolidation, occurs when a discrepancy is detected between what is expected and what
occurs. Accordingly, when an emotionally charged schema, memory, or fear is triggered and confronted
with consequences that vividly mismatch what is anticipated, the result is a revision of the meaning of
the emotional memory, including the attendant affect. The patient remembers that once horrifying
event, but now without the emotional intensity of the past (Eker et al., 2012; Lane et al., 2015).
What is meant by an activated patient? Learning is facilitated when a patient experiences
emotional activation at a high level of the individual’s affect tolerance, but before reaching an
intensity level at which attentional and reflective skills are disrupted. Such activation leads to
a state of alert attentiveness and receptivity to new learning. Since much maladaptive behavior has
been learned procedurally, the more fully and immediately experiential a clinical moment becomes,
the more amenable the patient is to new learning and change. In the experiential mode, the person
has a heightened sense of what is happening organismically versus talking about oneself intellec-
tually. If the patient says, “I was really scared when I saw that,” the clinician might say, “Picture it
now and notice what happens.” This observation will come alive in the case illustration later.
Psychoanalysis conforms to the reconsolidation template in that both the narrative method and
the intense relationship that can develop around it, are themselves evocative and activating. The
therapy relationship itself provides a medium for the cumulative learning of new relational experi-
ences that differ from negative transference expectations. Activated emotional memories can be
processed through a variety of channels, as described next.

Unifying diverse approaches in therapeutic action

A multi-systemic conception adds an additional building block to our integrative way of thinking. In
Somatic Experiencing (Levine, 2015), the SIBAM model – the acronym distinguishing Sensation,
Imagery, Behavior, Affect, and Meaning – calls attention to the various psychological subsystems
that are active in, and address the change process. Although Levine described these as the elements
of Trauma treatment that must be addressed, this model is very helpful when we think about
expanding psychoanalytic psychotherapeutic opportunities using an integrative model. Each of the
five systems identifies a point of entry for interventions, as well as an associated channel of
therapeutic action. At different times, and for different individuals, each channel may represent
the leading edge of change, which requires methods directly suited for change via that channel.
452 K. A. FRANK

Change in any one system leads toward, or results in change in the others (Rosenzweig, 1936). This
latter observation, suggested many years ago, deserves renewed attention and elaboration as we
expand our psychoanalytic model of therapeutic action.
I will summarize the major integrative methods I used with my patient, “Richard,” a chapter from
whose treatment I will describe shortly. I’ll begin with the psychoanalytic and then cover three
additional nonanalytic modalities spanning the SIBAM channels. I’ll include each’s therapeutic entry
point and channel of action.

Relational analytic therapy

I have assumed the reader’s familiarity with psychoanalysis, so I will be especially brief here. In
a nutshell, the therapeutic entry point is the patient’s narrative and behaviors with the analyst, via
their joint exploration by the pair. The channel of action involves gradually articulating the patient’s
previously unformulated material, including emotions, motivations, behavior patterns, and conflicts,
and through insightful awareness and new relational experiences with the analyst, to constructively
integrate these previously unintegrated personality elements.

Cognitive and cognitive-behavior therapy (CT and CBT)

CT and CBT have many streams, as traced by Gaudiano (2008). CT was developed independently by
Albert Ellis and Aron Beck. Its therapeutic entry point is the patient’s conscious thoughts related to
a specific activating event or change objective. CT’s channel of therapeutic action is constructively to
affect cognitive-perceptual processes. Simply put, helping patients learn to change their thoughts to
make them more rational changes associated feelings and behavior. Cognitive-behavior therapy
(CBT) itself is a form of psychotherapy integration. It refers to the merger of behavior therapy
with cognitive therapy. By targeting the individual’s thinking as well as behavior, practitioners
increase the effectiveness of both types of interventions.
A major development in CBT – and a point of convergence with the psychoanalytic – is the
constructivist influence that developed during the 1980’s and 90’s. Constructivist cognitive
approaches, unlike traditional ones, do not concentrate narrowly on making target thought patterns
more rational but, like analysis, look at cognitions in the light of one’s past and the therapy
relationship to help the patient understand and insightfully modify learned meaning-making activ-
ities that lead to distress, symptoms, and problematic behavior.
The most recent, or “Third Wave” of Cognitive Therapy, includes several mindfulness-based
approaches, Acceptance and Commitment Therapy, for example, called ACT. Rather than teaching
patients how to better control their thoughts and other private events, the ACT therapist helps
patients learn to “disidentify” and just notice, accept, and embrace inner events as such, especially
unwanted, disturbing ones, while remaining on course to fulfill their values.

Sensorimotor psychotherapy (SMP)

SMP was developed by Pat Ogden and advanced by Janina Fisher (Ogden & Fisher, 2015). While
most other approaches stress rational-analytic processing, in SMP, the therapy’s primary entry point
is the body, the method being mindful observation and tracking of bodily actions, reactions, and
somatosensory experience. Therapists heighten body awareness by sensitively helping patients “go
inside” through physical interventions such as mindful experiments with different postures and
actions. The channel of action is the integration of sensorimotor with cognitive and emotional
processing, body with mind. Using imagery to constructively relive and complete actions that
were not consummated during traumatic happenings (“acts of triumph”) are also seen as healing.
A major difference from the other models of therapeutic action is Sensorimotor’s emphasis on the
body’s procedural processing of information – that is, what we do, largely unconsciously, rather than
 INTEGRATIVE RELATIONAL PSYCHOANALYSIS 453

what we know. Often, the body, speaking procedurally, can express what the dissociated patient
could not verbally articulate. SMP helps clients become aware of and track their bodily sensation,
and implement physical actions that promote awareness, empowerment, and competency.

Internal family systems therapy (IFS)

Last, let us consider Internal Family Systems Therapy (IFS), another method that informed my work
with Richard. IFS was developed by Richard Schwartz (1995). The approach distinguishes the
overarching, true Self, or center of initiative, from multiple subparts – some adaptive and some
harmful – comprising it. A core tenet of IFS is that every part has a positive intent for the person,
even if its effects cause dysfunction. To achieve integration, there is never any reason to fight with,
coerce, or try to eliminate a part.
The therapeutic entry point is the patient’s experiencing of a part or parts of the self that are
associated with a felt issue. That part may be accessed through an emotion, imagery, body sensation,
an internal voice, or direct knowing. The channel of action is healing the exiled and/overburdened
parts of the self, such as Richard’s traumatized, frightened, and neglected child part, through
promoting the Self’s healing qualities of curiosity, connectedness, compassion, and calm, in relation
to that part. Then parts can enter into harmonious collaboration, or integration.

Some practical considerations2

In this section, building blocks take the form of rules of thumb that enable the integrative practi-
tioner to effectively maintain the analytic baseline while assimilating outside methods.

Levels of technical skill

One might wonder, if it takes years of training and clinical practice to develop clinical expertise in
any one modality, how, then, practically speaking, can we expect therapists to become proficient in
more than one? Indeed, clinicians are expected to possess considerable expertise in their baseline
modality, here, psychoanalysis. But, although it is desirable to have comparable expertise in supple-
mental modalities, it is not essential. It is sufficient to master several helpful, supplemental methods,
along with supporting rationales, with a moderate level of mastery. That can enhance practitioners’
work in many instances.

Therapeutic choice points

We can frame choice points (Messer, 1992) in terms of whether for this patient, at this clinical
moment, the goals of treatment can best be furthered by continuing with the baseline method of
analytic therapy alone, or by the addition of some outside technique and the exploration that results
from it. The exploration supports the analytic baseline.

“Switching” and “blending”

Two basic ways of importing outside modalities are “switching” and “blending” (Bresler, 2014).
When we switch methods, we experience a clear transition from method A to method B. The shift is
explicit, the new method is usually structured, and the patient agrees to it. As an example, an analyst
can teach a formal relaxation strategy, or work on an explicit exposure hierarchy with a patient, then
switch back. Blending, in contrast, is seamless. We seamlessly blend outside methods in ways that
typically go unnoticed by patients. One example is when analysts subtly introduce cognitive
2
Some material in this section originally appeared in Frank (1999) and has been elaborated and updated for this article.
454 K. A. FRANK

reframing. The depressed patient says, “I feel hopeless.” The therapist reflects: “You’re feeling
hopeless,” but adds, “just now,” encouraging the patient that now is not forever. This is a state
and will pass. As you will see, my work with Richard seamlessly and thematically blended analytic,
CBT, and other approaches.
Many therapists are at first intimidated by the prospect of switching explicitly (rather than
blending) to another modality that alters the usual therapeutic ambience. However, the introduction
of an ancillary method can be far simpler than expected and can be handled straightforwardly.
A decision to switch is a co-created development and can be arrived at collaboratively. One might
simply say, “A method occurs to me that you might find helpful,” and describe the method. Once it
is outlined and accepted, the specifics are worked out jointly and the pair switches. With experience,
practitioners usually prefer seamlessly integrative ways of working. This is not surprising, for each of
us tends to develop our own “personal therapeutic approach” (Rihacek & Roubal, 2017), “integrat-
ing,” if you will, or selecting from the vast array of ostensibly “single” theories and methods and
metabolizing them into a uniquely personal mélange. Some who have followed a staunch approach –
analytic or otherwise – may have concerns that shifting from strict practice might reflect a loss of
confidence in the baseline approach. This does not occur if, for example, the practitioner embraces
and conveys a metabolized “analytic/integrative” model, rather than a strictly analytic one.

Patients’ autonomy
Promoting a patient’s sense of personal agency is important, even while fostering the attitude that
one must accept, rather than try to change something distressing. In implementing outside methods,
therapists try to minimize to the extent possible the taking of initiative from the patient. After
a method is introduced as a potential resource, without undue pressure from the therapist, the
patient can decide whether s/he wishes to pursue it. The therapist might encourage a patient to
attempt a formal exposure technique, for example, but not too forcefully. Unlike the strict behavior
therapist overcoming a simple “compliance” problem, we hope to promote understanding as we help
the patient master that avoidance. Even if the patient rejects these techniques, their introduction
alone often stimulates important associative material. Rejection may be used interpretively to
advance the therapy, to develop alternative methods, and/or to facilitate their effective use later in
treatment. The rejection also can crystallize a patient’s unwillingness to face change and, sometimes
clarifies the reasons.

Transference and countertransference

In understanding our and patients’ reactions to our importing outside methods, we must not lose
sight of transference and countertransference. The introduction of an intervention that deviates from
the usual therapeutic format is often uniquely evocative. In addition to direct effects, the therapist
must consider transference meanings and possibly explore the effects on the relationship interpre-
tively. For instance, introducing the very same CBT method into analytic therapy may cause one
patient to feel especially cared about, but another to feel humiliated and condescended to as a kind of
“special needs” patient.

Enactments
Because when practicing integration, we are prepared to break from the traditional analytic frame,
we do so thoughtfully; the therapist must try to be aware of enacting detrimental past relational
patterns, for example, and instead offer interventions constructively, hoping they will contribute
beneficially to new relational experiences. We remain alert to enactments, in which the analyst is
given a specific role to play that has historical relevance. Both the patient and the analyst may lose
their sense of distance from the process in this context, interacting unreflectively with each other
 INTEGRATIVE RELATIONAL PSYCHOANALYSIS 455

verbally and nonverbally in a manner leading to interactions within the therapeutic relationship that
express problematic psychodynamics. A central aspect of therapeutic change is through the libera-
tion of the patient and the analyst from repetitive unconscious patterns. Knowledge of the potentially
counterproductive role of enactments gives us pause, quite literally. That is, a therapist is usually best
able to evaluate the indications and contraindications for introducing an outside technique over time
once the therapist is relatively confident that the technique is responsive to a patient’s valid
therapeutic needs. They must be considered in relation to the changing clinical and psychodynamic
context, including transference and countertransference. While we try to mindfully guide our
behavior, we may at times need to draw quite spontaneously from our knowledge of outside
techniques to productively engage an emergent clinical moment.

Resistance and counterresistance

When insight is a priority, the integrative therapist first evaluates her inclination to action, for it
might potentially carry information about projective identifications, enactments, and other impor-
tant material, including that about the therapist-patient interaction. The felt pressure to act may
reflect a patient’s call to action to avoid emerging insight and the attendant discomfort, rather than
a desire to move forward. Such “supervision” by our patients can at times be helpful, but at other
times not. For example, pressure to switch could enact an earlier, damaging pattern of parental
“rescue” from challenging opportunities for growth. In that case, the therapist does best by staying
the course and helping the patient understand the enactment. Like undertaking counterresistive
action, a therapist’s failure to actively offer an integrative method may also reflect potential
counterresistance.

Therapeutic “standstills”
Unfortunately, there are no specific formulas clarifying when to use integrative methods.
Psychotherapy is a highly individualized process; each pair is unique, and, to a large extent, analytic
therapy is improvisational. One development that frequently invites a supplemental intervention is
when therapy stalls. Imported interventions can revitalize a stalled therapy that involves unduly long
periods of time when the pair shares a sense that there is interrupted movement toward goals. When
a standstill is occurring, one might well be able to reactivate movement via clarifying material
provided by a different approach and/or channel. The therapist can only estimate, but not predict
with certainty when and which outside intervention to use or what its impact necessarily will be on
the patient and the relationship. That is why, afterward, it is important to remain open to consider-
ing the patient’s reactions, as well as results.

Strangers to ourselves
Any intervention, analytic or nonanalytic, involves unconscious or unformulated elements of our
own personalities that may come to light as we engage in the analytic inquiry that follows. Here we
initiate more than is customary and are likely to reveal more of ourselves, with our actions subject to
patients’ interpretations. Given our implicit influence, we do well to know as much as possible about
our motives. The pair’s open and mutual exploration and understanding of their differing percep-
tions creates a basis for furthering the analytic work, which also may involve our own grappling with
formerly unrecognized aspects of our personal participation (Frank, 2012).

“Richard”: A clinical example

Richard had reached the milestone age of 50 when he came for therapy. He was married, successful
in business, and father of three daughters, the youngest going off to college. For a variety of reasons,
456 K. A. FRANK

including a loveless, asexual marriage, Richard felt it was time for him to leave his wife. Threatened
by the prospect of single life, he came for therapy.
I learned that his extremely simple lifestyle was emblematic of his need to play down his wealth,
along with his other personal resources. This defined an issue we would spend a good deal of time
discussing during his twice weekly sessions. We would understand this as his pervasive fear of
standing up, feeling and being seen as a competent male. On a psychodynamic level, I came to
understand Richard’s development as impeded by several factors. His father, generally indifferent to
him, was subject to rages when he felt threatened. His mother, afraid of her volatile husband, had
fostered a mutually protective bond with Richard. A prime example was her support of her son’s
preadolescent school phobia, which was masterfully hidden from the no-nonsense father. The closely
interdependent mother-son bond, being oedipally tinged, apparently infuriated the father, causing
him to feel disdain toward his sissified son. A brother, five years older, and openly preferred by the
father, intensified Richard’s beaten down sense of self by constantly tormenting, ridiculing, and
bullying him. In addition, his mother, with the father’s extramural sexual activities in mind,
constantly preached to Richard, “Don’t be like your father,” a directive that inhibited Richard’s self-
assertive as well as sexual development.
Richard described an anguished history of trying desperately and failing to win his indifferent
father’s love and appreciation. Yet he feared him as well, and remained at a distance. Unfortunately,
his needy mother’s credibility was low, so her generous praise and support had little traction. Still,
Richard was no sissy. He was determined to overcome the fragility resulting from these childhood
experiences and became a strong athlete and fine classical musician. His unusual sense of determi-
nation was a terrific asset throughout his therapy.
Two prior, failed therapies defined him. The second, major one, occurred when Richard entered
a Freudian analysis after flunking out of a small, southern college. He began to make significant
strides, resuming college coursework locally and dating with some success. But then he developed
what I’m quite certain was a Panic Disorder. However, as Richard recalled it, his therapist thought he
had become psychotic. The psychiatrist rushed him off to a hospital psych ward and, as Richard
remembered it, abandoned him there. We cannot know with certainty what happened, but appar-
ently the analyst failed to help Richard understand critical, internalized object relationships; on
a subsymbolic level, his success meant renouncing mother’s protection and challenging father, which
triggered a terrifying fear of retaliation. Moreover, intense anxiety was likely to have intensified in
a paternal transference that, as far as I could tell, was not addressed. On a subconscious level, we
later realized, Richard experienced that scarring episode, including hospitalization and abandon-
ment, as the father’s overwhelming retaliation for Richard’s showing strength. Keenly aware of his
earlier therapy abandonments, I handled that point of vulnerability in our relationship as sensitively
as I could. For instance, I interpreted his abandonment fears, attributing them largely to prior
therapist abandonments, and also explicitly committed to work with him until he no longer chose or
needed to work with me.
When I first met Richard, he felt himself as deeply and hopelessly flawed – undeveloped as a male,
unattractive and unlovable. His fear of psychosis, or “falling off the edge of the earth again,” as he
put it, defined and tortured him, causing him to lead a life that minimized taking risks.
Understandably, his mood was melancholy. After assessing what occurred, I reassured him of his
sanity, and in the spirit of CBT’s psychoeducation, explained our newer understanding of Panic
Disorder (Barlow, 2004), which I believed was the syndrome he had experienced. Discussing this
syndrome with him, and providing appropriate readings, I emphasized that panic could be terrifying,
but was self-limiting and ultimately benign. Because I saw no clinical signs, I reassured him
truthfully that I would be shocked if ever he were to become psychotic (which is as far as I ever
go in offering clinical “guarantees”). In a variation on CBT’s cognitive restructuring, whenever he
became highly anxious and feared he would “flip out,” we worked collaboratively with his negative,
anxiety engendering thoughts, relating to them simply as “old habit patterns.” We went over actual
evidence repeatedly. After a while, he realized his reasoning was emotional and grew able to reassure
 INTEGRATIVE RELATIONAL PSYCHOANALYSIS 457

himself, “This is just anxiety – not psychosis, scary but ultimately I’m safe.” As he mastered this
exercise in the fuller context of our work together, gradually, his alarmist thoughts diminished and
virtually dropped out. He became more trusting of his integration and felt himself on solid new
ground.
How did I frame the therapeutic action with Richard? My primary and basic treatment approach
was psychoanalytic, or psychodynamic. Attending to his personal narrative, together we undertook
to understand and progressively revise how he saw himself, present, past, and future, based on the
major sources of his difficulties along the psychogenetic lines I have outlined. That outline provided
an understanding of how his problems developed and what could help him heal. Interpretive work
with negative transference, limited though it was, helped him identify sporadic reactions to me “as if”
I was his distracted or scornful father. Different from his previous analyst, he noted that I remained
approachable, encouraging transference disclosures. I handled them authentically and therapeuti-
cally. We could discuss our relationship to repair ruptures, so our relationship offered a healing
corrective emotional experience, radically different from his pathogenic attachments to both his
parents.
We followed another, intersecting theme that I formulated in CBT terms as an experience of
exposure and mastery, involving his undertaking and mastering progressively challenging outside
experiences that he had avoided and failed to master earlier in life. Throughout the process of
therapy, it was necessary to support Richard’s shaky belief that he was capable of the next step,
sustain him through facing each successive challenge, and make sure his takeaway was balanced
rather than skewed toward the negative. Accordingly, he progressed.
Gradually, he was realizing he was not the shameful loser his father, mother, and brother all had
related to, each from their own perspective, but could be a capable man. We worked productively
together for four years when Richard decided to sell his business and relocate to the West Coast near
friends. I heard from him occasionally over the years, and then one day I received an S.O.S. He was
entering a relationship with an exceptional woman, who unlike many he had dated before, was
highly capable, socially prominent, and immensely attractive to him. In her idealized presence, he
felt damaged and puny again, and feared he never could measure up to her
We resumed our work, largely by telephone but with periodic in-person sessions whenever he
came east. The basic treatment themes – insightful new relational experience and exposure and
mastery – continued. But now I introduced an additional therapy approach. Since Richard left, I had
become influenced by progress in psychoanalytic dissociation and self-states theory, especially its
intersection with IFS “Parts” theory, and I was applying these understandings.
One day, while reflecting on his childhood experience together, I with Parts in mind, Richard and
I accessed and gradually became acquainted with a shameful, disavowed part of him that we came to
call “Little Ricky.” When we first met Little Ricky, he was hiding anxiously in his room, his ear
pressed to the wall listening to a parental quarrel. Would they divorce? Would there be violence?
And then there was his big brother, Marshall, on the prowl, seeking to torment him. This terrified
child part told us he was afraid of his father’s raging eruptions and brother’s bullying in a home
charged with marital strife. He felt like he was living in a battle zone or concentration camp, in other
words, in mortal danger. Little Ricky learned to survive by hiding.
During our explorations, Richard recalled a traumatizing childhood experience. He estimated his
age at six or so. That was a time when Marshall, age eleven, would unpredictably sneak upstairs
beforehand and terrorize Ricky when he went upstairs to bed. He never knew if, when, or from
where Marshall might leap out at him from hiding and scare or pummel him. Ricky felt helpless.
Marshall’s motives, hardly playful, seemed sadistic (a paternal identification?). This pattern repeated
for some time without his parents’ stepping in.
Over several sessions, we followed what came up in a way of working that was informed by CBT,
Guided Imagery, Sensorimotor, and IFS therapies, among others. I asked him if he would be willing
to “go inside” himself and describe what he was feeling as he remembered these events. He agreed
and reported feeling dread, a generalized body tension, shoulders drawn tight and up, pronounced
458 K. A. FRANK

tightness in his upper back and neck, and holding his breath. He described that he was hunching his
back and drawing up his shoulders, as if to protect against an attack from behind. He felt a physical
sense of disgust and nausea and nearly threw up as he called up this repugnant memory. A surreal
visual alteration hinted at childhood dread and depression; through his eyes, his childhood home
was achromatic, in shades of gray, with hidden, menacing figures, as in a child’s night terror. The
dimly lit house felt cold. I found the telephonic experience facilitative, more couch-like and hence
freeing the patient for intrapsychic imaginal work.
My aim was to help him recollect and constructively reexperience these distressing events that
had lasting negative effects on him. As we did this work, I had in mind the importance of
experiential arousal and neuroscientific evidence that in such states the brain does not necessarily
distinguish between mental imagery and that which is externally occurring (See Kappes &
Morewedge, 2016; Ji et al., 2016, for example). Richard, as it turned out, had quite a flare for
visualization – such a flare that at times during this work he seemed to be revealing an altered state
of consciousness, a hypnotic-like state of receptiveness, what imaging theorists call absorption, or
openness to absorbing self-altering experiences. Usually, the capacity for such concentrative atten-
tional ability develops with practice. Remember, too, these sessions were telephonic; being at
a distance, and not seen, ironically may have facilitated his ability to go inside by suspending
practical reality and reducing self-consciousness.
Agreeing to attempt an experiment, Richard was willing to “be” his six-year-old self. He soon
became activated as he fearfully imagined his boyhood self hesitating at the foot of the stairs of his
childhood home. Immersing himself in the memory of that experience, his eyes closed, he visualized
the scene in the moment. Now Richard virtually became Little Ricky. He said, “I’m afraid Marshall’s
up there waiting to scare me or beat me up. I call my mother to do something, maybe go up with me,
but she doesn’t respond. She seems very far away in the dark house. She couldn’t handle Marshall,
anyway. And, of course, my father isn’t there at all.” Gathering himself, bracing himself, Little Ricky
began tentatively crawling upstairs on hands and knees, hoping he wouldn’t be noticed. But feeling
intense fear, he turned back halfway.
With IFS and EMDR in mind, I switched the imagery from memory to fantasy and asked what might
allow him to feel safe. It didn’t occur to him at first to have a protective adult accompany him or wait at
the foot of the stairs to assure his safe passage. He couldn’t even imagine at six that such help might be
forthcoming. I explained, “Remember, this is fantasy. Now you can have anyone or anything that would
help you.” Addressing the six-year-old. I offered a menu of possibilities – having his idealized Uncle
David there, one of the “big kids” from the block, me, the Lone Ranger (a childhood hero), anyone or
anything. “Back then,” I said, “there was little you could do to protect yourself, but this time, if there’s
trouble with Marshall, there’s help. You’re safe.” He asked if I would stand at the foot of the stairs and
come upstairs if he called. “Of course,” I agreed. Cautiously, he continued his imagined climb upstairs,
narrating his journey step by step – his thoughts, feelings, and body sensations. We tracked and observed
his experience together as, this time, despite his fear, he made it safely to his room. No Marshall.
Becoming emboldened over similar sessions, Ricky decided spontaneously that he would like to stand up
to Marshall if he were to attack. “Let the chips fall where they may,” he said, “I’m just sick and tired of
being scared.” At age 6, he didn’t realize that standing up for himself or fighting back were options. He
had to be his mother’s good boy, and unlike his father, nonaggressive. But he was now feeling courage,
and wanted to change that, to go upstairs to prove and free himself.
I asked if he’d like to take a time out to first rehearse and he agreed. With new relational
experience in mind, I coached him by offering possibilities and exploring associated feelings. As in
Sensorimotor Psychotherapy, we explored different postures as he imagined confronting Marshall.
Guided through some experiments, he agreed to stand up very tall, legs braced, hands extended as if
to form a protective barrier; then hands on his hips, chin up, chest protruding, boldly leaning
a shoulder forward into the imagined Marshall. He noticed how in this position he felt bolder, more
grounded in physical space, sturdier. I encouraged him to slow down and notice what he felt as he
imagined confronting Marshall again, alone, in this position. He said with surprise and pride, “Solid,
 INTEGRATIVE RELATIONAL PSYCHOANALYSIS 459

safe, actually bigger and stronger.” I was imagining how enormously helpful a strengthening father
figure’s support would have been to him as a struggling child.
Again, he closed his eyes and we returned to the staircase. He reported beginning to feel
determination and courage swelling within against the more familiar shame and shrinking.
I remain at the foot of the stairs as he imagines himself slowly going upstairs, this time, erect,
braced, and ready. Marshall then leaps out at the top of the stairs, blocking his way. Ricky is
surprised to notice that at first, he is inclined to play the familiar role of willing prey. But he resists
that impulse, and instead, checking inside and recalling the body work we did, girds himself by
assuming his strongest position. Now he is confronted by Marshall. As we rehearsed, he turns his
shoulder, raises a hand like a police officer stopping traffic, and says, “You have to stop this. And I’ll
do whatever I have to, to get you to stop.” With a twinge of fright at hearing his own strong words,
he nevertheless maintains his firm physical stance and takes time to sense the unfamiliar solidness
within and beneath him. As he imagines speaking firmly to his brother, he observes that Marshall is
responding reasonably, respectfully, and yields.
Safely in his room now, Ricky has a new experience – freedom from intimidation associated with an
ability to stand up for himself and a readiness even to fight back if needed. I ask Richard, “How do you
feel toward Little Ricky now?” He answers, “More compassionate; actually, some pride in him.”
Reflecting on the avoidant pattern he had adopted and brought to adulthood, he said, “He – I – did
what I could to survive. Under those circumstances, that little guy was acting in an understandable
way.” He continued, “It could have been different. It should have been! I should have been protected,”
followed by his sadness, squelched tears, and then relief. “It wasn’t, it isn’t me – not something wrong
with me,” he says. “The situation was all fucked up. I did what I could. I feel good, relieved, lighter.”
The adult Richard apparently was ready for this inner shift to occur. Following our psychoanalytic
model, we could frame this as a shift in an influential internal object relationship. Following
a sensorimotor model, we might say that a virtually real “moment of triumph” had been achieved.
The damaged exile was healed through qualities of curiosity, connectedness, compassion, and
calmness. The next time we met at the base of the stairs he felt secure enough to go upstairs
alone. He told me I could leave. So we resumed our more traditional analytic work.

Concluding comment
Each valid psychotherapy approach, having its own theory of therapeutic action, illuminates our under-
standing of different, interacting aspects of the overall change process. Focusing on only one channel is too
limiting. But we can conduct a psychotherapy practice in which psychoanalytic understanding and essential
analytic methods play a primary grounding role, yet not an exclusive one, and allows us to constructively
look beyond it for understanding and methodology. If the narrative flow of psychoanalysis is the river, its
current is strengthened as we selectively introduce into it the source streams of other modalities.

Disclosure statement
No potential conflict of interest was reported by the author.

Notes on contributor
Kenneth A. Frank, Ph.D., is Co-Founder and Board member of the National Institute for the Psychotherapies, where
he is also Founder and Co-Director of its Psychotherapy Integration Training Program. He is formerly Clinical
Professor in Psychiatry (Part-time), Columbia University College of Physicians and Surgeons, is Senior Consulting
Editor of the journal, Psychoanalytic Perspectives, and has published more than 60 articles, chapters, and books, many
on psychoanalysis and psychotherapy integration. He practices in New York City and Bergen County, New Jersey.
460 K. A. FRANK

References
Ascher, L. M., Bowers, M. R., & Schotte, D. E. (1985). A review of data from controlled case studies and experiments
evaluating the clinical efficacy of paradoxical intention. In G. R. Weeks (Ed.), Promoting change through paradoxical
therapy (pp. 216–251). Dow Jones-Irwin.
Assagioli, R. (1927). A new method of healing: Psychosynthesis. Institute of Psychosynthesis. London: L.N. Fowler and
Co.; New York, NY: Lucis Publishing Co.
Barlow, D. (2004). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). The Guilford Press.
Bennett-Levy, J., Butler, G., Fennell, M., Hackman, A., Mueller, M., & Westbrook, D. (Eds.). (2004). Cognitive behaviour-therapy:
Science and practice series. Oxford guide to behavioural experiments in cognitive therapy. Oxford University Press.
Bresler, J. (2014). Driving me sane: Integrating CBT and relational psychodynamic psychotherapy. Chapter 4. In Bresler, J. &
Starr, K. (Eds.), Relational psychoanalysis and psychotherapy integration: An evolving synergy. Routledge.
Carey, T. (2011). Exposure and reorganization: The what and how of effective psychotherapy. Clinical Psychology
Review, 31(2), 236–248. https://doi.org/10.1016/j.cpr.2010.04.004
Eker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using
memory reconsolidation. Routledge.
Frank, K. A. (1977). The human dimension in psychoanalytic practice. Grune & Stratton.
Frank, K. A. (1999). Psychoanalytic participation: Action, interaction, and integration. The Analytic Press.
Frank, K. A. (2005). Toward conceptualizing the personal relationship in therapeutic action: Beyond the “real”
relationship. Psychoanalytic Perspectives, 3(1), 15–56. https://doi.org/10.1080/1551806X.2005.10472918
Frank, K. A. (2012). Strangers to ourselves: Exploring the limits and potentials of the analyst’s self–and mutual
awareness. Psychoanalytic Dialogues, 22(3), 311–327. https://doi.org/10.1080/10481885.2012.679601
Freud, S. (1914). On the history of the psycho-analytic movement. Standard Edition, 14, 1–66. Hogarth.
Freud, S. (1919). Lines of advance in psycho-analytic therapy. Standard Edition, 17, 157–168. Hogarth.
Gaudiano, B. A. (2008). Cognitive-behavioral therapies: Achievements and challenges. Evidence Based Mental Health,
11(1), 5–7. https://doi.org/10.1136/ebmh.11.1.5
Gill, M. M. (1993). Interaction and interpretation: Commentary on Morris Eagle’s “enactments, transference, and
symptomatic cure”. Psychoanalytic Dialogues, 3(1), 111–122. https://doi.org/10.1080/10481889309538963
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of
mindful change (2nd ed.). The Guliford Press.
Ji, J. L., Heyes, S. B., MacLeod, C., & Holmes, E. A. (2016). Emotional mental imagery as simulation of reality: Fear and
beyond—A tribute to peter lang. Behavior Therapy, 47(5), 702–719. https://doi.org/10.1016/j.beth.2015.11.004
Kappes, H. B., & Morewedge, C. K. (2016). Mental simulation as substitute for experience. Social and Personality
Psychology Compass, 10 (7), 405–420. Retrieved from. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673298/.
Kohut, H. (1977). The restoration of the self. University Chicago Press.
Kolmannskog, V. (2018). The empty chair: Tales from gestalt therapy. Routledge.
Lane, R. D., Ryan, L., Nadel, L., & Greenberg, L. (2015). Memory reconsolidation, emotional arousal, and the process
of change in psychotherapy: New insights from brain science. Behavioral and Brain Sciences, 38, e1. https://doi.org/
10.1017/S0140525X14000041
Levine, P. A. (2015). Trauma and memory: Brain and body in a search for the living past: A practical guide for
understanding and working with traumatic memory. North Atlantic Books.
Messer, S. B. (1992). A critical examination of belief structures in integrative and eclectic psychotherapy. In J. C.
Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 130–165). Basic Books.
Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Harvard University Press.
Nicholas, P. (2010). Common factors of psychoanalytic theory and exposure therapy for treating select anxiety disorders.
Common Knowledge. Pacific Grove, OR: Pacific University. Retrieved July 23 2010, from https://pdfs.semanticscho
lar.org/45f1/2f3341b6c12732381c4bd1ddd870dc6e7f37.pdf
Ogden, P., & Fisher, J. (2015). Sensorimotor psychotherapy: Interventions for trauma and attachment. W. W. Norton and
Company.
Rihacek, T., & Roubal, J. (2017). Personal therapeutic approach: Concept and implications. Journal of Psychotherapy
Integration, 27(4), 548–560. https://doi.org/10.1037/int0000082
Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of
Orthopsychiatry, 6(3), 412–415. https://doi.org/10.1111/j.1939-0025.1936.tb05248.x
Rosselli, M., & Vanni, D. (2014). Roberto Assagioli and Carl Gustav Jung. The Journal of Transpersonal Psychology, 46(1), 7–34.
Schwartz, R. C. (1995). Internal family systems therapy. The Guilford Press.
Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy (3rd ed.). New relational experi-
ence. York: The Guilford Press.
Wallerstein, R. S. (1988). One psychoanalysis or many? The International Journal of Psycho-analysis, 69(Pt 1), 5–21.
Retrieved from https://pubmed.ncbi.nlm.nih.gov/3042654/
Westen, D., Gabbard, G. O., & Ortigo, K. M. (2008). Psychoanalytic approaches to personality. In John, O. P.,
Robins, R. W., & Pervin, L. A. (Eds.), Handbook of personality: Theory and research (pp. 61–113). Guilford Press.