INTEGRATION STATEMENTS

Interventions Designed to Facilitate Remembering

 

by Martha Stark, MD / Faculty, Harvard Medical School

 

In order to contextualize my use of integration statements for a broad range of clinical moments, I would like to start by referencing borderlines, for whom integration statements are particularly useful.

 

Because borderlines have only tenuously established evocative memory capacity (also known as libidinal object constancy), it is difficult for them to remember having felt good about either someone or something when, in the moment, they are disappointed and feeling bad.

 

Parenthetically, this impaired capacity to remember is majorly responsible for the notorious difficulty that borderlines have taking in good when disappointed...

 

...because, in order to internalize good, a patient – in the aftermath of a disappointment – must be able to remember the good that had been there prior to the introduction of the bad.

 

Remembering the previous good will then enable the patient, adaptively, to internalize that good – a dynamic process described in self psychology as transmuting internalization.

 

Transmuting (or structure-building) internalization is indeed an adaptive, growth-promoting process that accompanies the grieving of optimal disillusionment occasioned by empathic failure.

 

But in the moment of upset, and now experiencing the disappointing object as all bad, borderlines – because of their tenuously established evocative memory – will have trouble remembering that it had ever been good!

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So although I developed integration statements to use in my work with borderline patients who struggle to hold in mind simultaneously both their good and their bad feelings about someone or something, I subsequently realized – with the help of my colleague Gina Kwon – that these interventions work beautifully with other patients as well – patients who are either so upset, frustrated, angry, sad, or despairing that they too, at least in the moment, are struggling to remember ever having felt better.

 

In order to formulate an effective integration statement, the therapist must be able to enter so deeply into the patient’s internal experience of, say, devastation that the therapist will indeed be able to articulate, on the patient’s behalf, the difficulty the therapist senses the patient is having not only remembering the good that had been in the past but also recognizing the possibility for good again in the future.

 

Consider the situation of a patient who, happy and excited during the previous week's session, is now feeling deep despair about her life and her future.

 

The therapist, a little confused about how best to respond, might – somewhat thoughtlessly and impatiently – blurt out something like – “But just last week you were feeling so good…”

 

An integration statement, however, will both contextualize the patient’s current despair and resonate empathically with the difficulty the patient is having remembering that earlier time when she had been happy –

 

“When you’re feeling this much despair about your life and your future, it’s hard for you to remember that you had ever felt hopeful…”

 

Alternatively, the integration statement can resonate empathically with the difficulty the patient is having imagining that she could ever feel better in the future because of how hopeless she is feeling in the present –

 

“When you’re feeling this much despair about your life and your future, it’s hard for you to imagine that you could ever feel hopeful again...”

 

Or consider the situation of a patient who is feeling very stuck in her marriage and is complaining bitterly about how powerless she feels.

 

The therapist (perhaps the same one as that earlier one!) might – somewhat thoughtlessly and impatiently – blurt out – “But it was you who chose to stay in the marriage...”

 

An integration statement, however, will both contextualize the patient’s current feelings of powerlessness and resonate empathically with the difficulty the patient is having remembering that it was actually she who had decided to stay in the marriage –

 

“When you’re feeling this desperately unhappy and helpless, it’s hard for you to remember that it was you who, after much consideration, had made the conscious – and strategic – decision to stay in the marriage, at least until the financial piece had been straightened out.”

 

Alternatively, the integration statement can resonate empathically with the difficulty the patient is having envisioning something different for the future because of how powerless and stuck she is feeling in the present –

 

“When you’re feeling this desperately unhappy and stuck in the marriage, it’s hard for you to remember that you could choose to revisit the decision you had made those years ago and could therefore decide that perhaps now would be a good time to leave after all.”

 

Other examples of integration statements include the following –

 

“When you’re feeling this upset with Alicia, it’s hard for you to remember that you had ever felt good about her and hard for you to imagine that you could ever feel good about her again.”

 

In essence, the therapist is resonating empathically with the reality that the patient is feeling in the moment (in other words, the patient’s current upset) – at the same time that the therapist is indirectly reminding the patient that things had once been different and therefore that things could potentially be different again.

 

In essence, integration statements enable the therapist to “go with the resistance” and not to “counter” the patient’s defensive stance with statements that start with “But...” (for example, “But you had said…” or “But you are not remembering that you had once felt…”).

 

“When I have so disappointed you, in the moment it’s hard for you to remember that you had ever felt good about me and our work together.”

 

“When you are feeling this upset and angry with me, it’s hard for you to imagine that you could ever dare to trust me again.”

 

“When you are feeling this kind of lonely, it’s hard for you to imagine that you could ever find a soulmate partner with whom you could spend the rest of your life.”

 

“When your heart is breaking as it is now, it’s hard for you to imagine that you could ever be in a relationship that would make you happy.”

 

There you have it!

 

I hope you like these nifty – but powerfully effective – little interventions that deftly focus attention on what’s going on intrapsychically for the patient (“At times like this, it’s hard for you to remember…”) and not on the intersubjective space between patient and therapist ("But you'll never find a soulmate unless you at least try...").

 

In essence, use of these integration statements will avert a potential power struggle between patient and therapist, which can happen when the therapist's interventions start with the word "But…”

 

In sum, integration statements indirectly ask of patients that they attend to their own process and to the conflict going on inside them and not to what's happening in the space between patient and therapist or to something that the therapist thinks they should be feeling.

 

I would love to hear from any and all of you – perhaps with your own examples of integration statements (either ones that you had intuitively already used in the past or ones that you could imagine using in the future)!!

 

…although perhaps, in the moment, it’s hard for you to remember that you had ever intuitively used an integration statement to advance the therapeutic process!!