This short article outlines one dimension of the therapeutic relationship that has emerged from a qualitative evaluation of the practice of therapy conducted at the Institute for Integrative Therapy in New York City.

A major premise of relationship-oriented psychotherapy is that the need for relationships constitutes a primary motivation of human behavior. Contact is the means by which the need for a 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 acknowledgment 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.

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 effect, 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 fulfillment of current needs. The literature on human development -also leads to the understanding that the sense of self and self-esteem emerge out of contact-in-relationship. Erik Eriksen’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, Pine & Bergmann, 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 others emerge.

When such contact does not occur in accordance with the child’s relational needs, there is a physiological defense against the loss of contact, poignantly described by Fraiberg in ‘Pathological Defenses of Infancy’ (1982). These developmental perspectives foster a deep appreciation of the need for interpersonal connection and active construction of meaning that is so much a part of who the client is. In 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 satisfaction of relational needs.

Of central significance is the process of attunement, not just to discreet thoughts, feelings, behaviors, 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 develops is 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.

Attunement 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, 1951) or vicarious introspection (Kohut, 1971), attunement is kinaesthetic 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 effect 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 effect 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 de-center from his or her own experience to extensively focus on the client’s process. Yet, effective attunement also requires that the therapist simultaneously remain aware of the boundary between client and therapist as well as his or her own internal processes.

The communication of attunement validates the client’s needs and feelings and lays the foundation for repairing the failures of previous relationships. Affective attunement, for example, provides an interpersonal contact essential to human relationships. it involves the resonance of one person’s effect to the other’s effect. Affective attunement begins with valuing the other person’s effect as an extremely important form of communication, being willing to be effectively aroused by the other person, and responding with reciprocal effect. When a client feels sad, the therapist’s reciprocal effect of compassion and compassionate acts complete the interpersonal contact.

Relationally, anger requires the reciprocal effects related to attentiveness, seriousness, and responsibility, with possible acts of correction. The client who is afraid requires that the therapist responds with effect 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 forms a unity in the relationship.

Attunement is often experienced by the client as the therapist gently moves 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 and receive the therapeutic involvement so essential to emotional healing. It is through the psychotherapist’s sustained contact presence and attunement 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.


  1. Bowlby, J. (1969) Attachment and Loss, Vol. I: Attachment New York: Basic Books.
  2. Bowlby, J. (1973). Attachment and Loss, Vol. II: Separation: Anxiety and. New York: Basic Books.
  3. Bowlby, J (1980). Attachment and Loss, Vol. III: Loss: Sadness and Depression. New York: Basic Books.
  4. Erikson, E (1950). Childhood and Society. New York: Norton.
  5. Fraiberg, S (1982). ‘Pathological defenses in infancy’, Psychoanalytic Quarterly, vol.51, pp. 612-635.
  6. Khan, MMR (1963). ‘The concept of cumulative trauma’, in RS Eissier, A Freud, H Hartman, & M Kris (Eds), Psychoanalytic Study of the Child, vol. XVIII, (pp. 286-301).
  7. Kohut, H (1971). The Analysis of the Self. New York: International Universities Press.
  8. Lourie, 3 (1996). Cumulative trauma: The non-problem problem. Transactional Analysis Journal, vol. 26, pp. 276-283. 2001 ITA Conference
  9. Mahler, M (1968). On Human Symbiosis and the Vicissitudes of Individuation. New York: International Universities Press.
  10.   Mahler, M, Pine, F, & Bergman, A. (1975). The Psychological Birth of the Human Infant: symbiosis and individuation. New York: Basic Books.
  11.   Rogers, CR (1951). Client-centered therapy. Boston: Houghton Mifflin.
  12.   Stern, D (1985). The interpersonal world of the infant. New York: Basic Books.

Author Richard G. Erskine, Ph.D. is Training Director of the Institute for Integrative Psychotherapy, New York, NY and Visiting Professor of Psychotherapy, University of Derby, UK.