If you’ve spent any time looking for a therapist, you’ll doubtlessly have seen the words relational, integrative, psychodynamic, person-centred, attachment-focused, somatic, trauma-informed, and more. It probably doesn’t help that in the profession these are referred to as ‘modalities’ rather than approaches. You may have tried to work out what distinguishes one from another, or what any of them would actually feel like as a client. You might even, quite reasonably, given up and gone by gut feeling instead. The latter can be a really good guide in finding the right therapist for you, so don’t discount it!
Therapists aren’t always good at explaining how they work in language that’s meaningful unless you’re already well-acquainted with the field. In this post, I want to explain what ‘relational’ and ‘integrative’ mean in my own practice. This won’t necessarily be the same as what you encounter in other therapists’ websites or directory listings. I can’t cover everything here, but hopefully you’ll get a sense of the way I work and why.
The relational integrative psychotherapy in which I’m trained is a form of psychotherapy which understands that emotional difficulties are developed in relationship and are healed through relationship, and which draws flexibly from multiple therapeutic traditions rather than one or two fixed models.
What do I mean by ‘relational’?
The relational part is, in some ways, the more fundamental of the two. It refers to a way of understanding both how we came to be who we are and also how change happens in therapy.
We’re shaped by our relationships, particularly the early ones, and we’re likely to carry the patterns formed in those relationships into our adult lives, often without quite knowing we’re doing so. The relational patterns we develop don’t remain in the past, in our childhood or adolescence. They might, for example, show up later as repeatedly finding yourself in one-sided relationships, people-pleasing, struggling to say ‘no’ without guilt, feeling responsible for other people’s emotions, never quite believing you’re ‘enough’, or becoming overwhelmed despite understanding perfectly well what you’re supposed to do differently. Relational therapy is interested in where those patterns came from and how they continue to shape your life today.
Crucially, working relationally in psychotherapy also means that the relationship between therapist and client is not simply the backdrop to the real work, but is integral to it. Decades of psychotherapy research has consistently found that the quality of the therapeutic relationship is one of the strongest predictors of positive outcomes across different therapy approaches (Norcross and Lambert, 2018).
What does this look like in a session? Obviously, that depends on you as much as me, as we are both there together co-creating what happens between us. Partly, it’s a matter of where attention goes. I’m interested in what’s happening inside you, the feelings, sensations, thoughts and impulses you’re aware of in any given moment. Sometimes you will share that with me spontaneously, sometimes I’ll ask you about it, and at other times, I might notice or be curious but sense it’s not the right moment for us to bring it into view. For example, I might notice when you pull back in a session, or when a topic is approached and then set aside, or when something between us shifts in a way that’s hard to name at first. I won’t interrogate you about these things, but perhaps if there seems to be a pattern, I might share my thoughts with you. Often these things tell us something about how you are in relationship (to yourself as well as to others) more broadly. I might suggest something that makes a lot of sense to you. If it doesn’t resonate, however, that is just as important as when it does: my open invitation to you is to tell me, as we together are trying to understand you.
It’s also a matter of how you typically engage with the world. If you’re a ‘think-y’ person, for instance, we want to start there, not immediately delve into feelings that don’t yet make much sense to you; or perhaps you need to feel your way into understanding what’s going on for you before we think about it; or, you might be more comfortable exploring body sensations first, allowing thoughts and feelings to emerge gently. We work this out together by being genuinely curious about how it is for you to be you.
Equally important is what’s happening between us: how it feels, right now, to be in this exchange. Both matter, and they’re connected. The quality of contact we can make with our own inner experience and the quality of contact we’re able to make with another person tend to develop together. For instance, someone who learnt early in life to hide their feelings of sadness, anger or fear in order to stay connected with important people often loses touch with those feelings themselves. Therapy becomes a place where both kinds of contact – with yourself and with another person – can gradually deepen together. This is partly why the relationship itself does so much of the work in this kind of therapy. It doesn’t just provide the conditions under which we apply techniques or theories.
My way of being with you in session is also informed by something beyond ordinary empathy. The importance of this was instilled in me during my core training but especially in the further trainings I undertook with a psychotherapist called Richard Erskine, who along with various colleagues deserves much credit for developing the practice and theory of a truly relational integrative psychotherapy. It’s one thing to understand that you’re angry, or frightened, or sad; it’s another to respond to those feelings in a way that actually meets them (Erskine, 1998). Sadness tends to need compassion, not being jollied out of it. Anger tends to need to be taken seriously, not smoothed over or disapproved of. Fear tends to need someone who can feel protective towards you without rescuing you from the thing itself. Getting this wrong (because I am bound to sometimes) is not a failure of the work; misattunements happen in any relationship, therapeutic or otherwise, and what we do with them, noticing, naming, repairing, often turns out to matter more than getting it right the first time.
There’s a further layer to this that I think is worth naming, and which doesn’t always make it onto therapy websites. That is, that many of the issues that people bring to therapy have roots in what Erskine has described as universal relational needs. We come into the world with certain needs that can only be met in relationship: to feel safe, to be valued, to be accepted as we are, to have our experience genuinely understood rather than corrected, to know and express our own particular way of being without humiliation, to matter to someone, and, sometimes, simply to have another person think of us and reach out rather than waiting to be asked. When these needs go unmet, early on or since, we tend to find ways of coping that made complete sense at the time, but which might no longer serve us. Part of what happens in relational therapy is that some of these needs get met, often for the first time in a sustained way, within the safety of the therapeutic relationship itself. That’s not incidental to the work. It’s a good part of how transformation happens.
Whether our patterns show up in relationships, perfectionism, chronic burnout, emotional overwhelm, people-pleasing or a persistent sense of not really knowing yourself, they rarely exist in isolation. That’s one reason I don’t work from a single therapeutic model. Moreover, this is particularly important when working with neurodivergent clients, as I explain below.
Of course, there is a lot of psychological and psychotherapeutic theory that underpins what I’ve said here, which brings me onto the other part of my approach:
What is integrative psychotherapy?
At its simplest, integrative can mean drawing on more than one theoretical tradition or approach. What it looks like in practice varies considerably between therapists, and it’s worth asking directly about. Some loosely mean little more than ‘I adapt various theories and techniques to the client’. Others list the theories that were covered in their initial training (e.g., CBT, Gestalt and Person-Centred therapy), which means they sound much more eclectic than truly integrative. In fact, so many therapists describe themselves as ‘integrative’ that the term may seem meaningless, especially given that there are potentially above 500 types of counselling and psychotherapy that might be integrated (Cooper 2019, p. 2). I encourage you to ask any potential therapist about how and not just what they integrate into their work.
For me, integrative means weaving together various the traditions in which I am trained to integrate different aspects of the self, including parts that an individual might find hard to acknowledge or which they experience as confusing or challenging, or which are split off from current awareness. This involves working at depth combining a psychodynamic understanding which attends to unconscious patterns, our developmental and attachment history, and the parts of ourselves we don’t have easy access to with Gestalt work, parts-based therapy (including Internal Family Systems and TA), somatic approaches that attend to what the body carries as well as the mind, and EMDR for trauma processing. My engagement with each of these is additionally informed by developments in neuroscience. These aren’t interchangeable lenses or tools selected at random. They each contribute something important to how I have come to understand how it is to be human and what therapy is for. Our experience is made up of our feelings, our thoughts, behaviours, and bodily experiences, which are all operating simultaneously, but not necessarily smoothly. We might at once have a desire to do something and an urge to resist doing that very thing, experience thoughts and feelings which seem contradictory, or simply a sense of confusion or being unsettled without knowing why.
One of the aims of this kind of integrative therapy is to support you to recognise and understand the parts of yourself you’ve had to disown, suppress or hold at arm’s length, and integrate them within a coherent sense of who you are. Those parts were not tolerated for good reason. They held feelings or needs that weren’t safe to show, or weren’t met, or didn’t fit with who you were allowed to be. Integration, in this sense, isn’t about eliminating those parts. Rather, it’s about no longer having to keep them at a distance, working towards understand them with self-compassion, acknowledging their positive intention, and re-considering whether the job they’re doing is still in your best interests. Whether we conceptualise them as ‘parts’ or ‘patterns’ will depend on what feels most right to you. Either way, we can work towards freeing them up to support you in new ways of being that feel more authentic and serve you better as you are now.
That’s also why, in this kind of therapy, presenting difficulties tend to be approached as things with roots worth exploring, rather than as symptoms to be managed or talked out of. That’s not because symptom relief doesn’t matter; it does, and most people understandably want relief sooner rather than later. But most lasting change tends to come from understanding and working through rather than around what hasn’t always been obvious or comfortable.
And if you’re neurodivergent?
All of this also means being cautious about imposing psychological explanations where a neurodevelopmental one may make more sense, and vice versa. My role isn’t to fit your experience into a preferred theory, but to understand it with you.
Some of the people I see have spent years trying to understand themselves through frameworks that assumed something was wrong with them, when what they were really experiencing was a mismatch between their nervous system, the expectations placed upon them, and the environments in which they found themselves. A relational approach helps us ask not simply ‘What’s wrong?’ but ‘What happened?’ and, crucially, ‘What has it been like to move through the world as you?’ That means taking care not to mistake differences in communication, emotional expression, sensory processing, attention or ways of relating for evidence that something is inherently wrong with the person. It’s important too to recognise the ways in which masking and adaptation may themselves have become deeply embedded relational patterns. In other words, the relational consequences and costs of living as a neurodivergent person becomes part of what we acknowledge together.
For neurodivergent people, the work (and the gift) of therapy can be about understanding themselves more accurately, unmasking intentionally and safely, grieving what has been misunderstood or missed, and finding ways of living that are more congruent with who they are rather than who they have felt they needed to be.
Although I work extensively with neurodivergent adults, the same relational principles apply whether or not someone identifies as neurodivergent.
Who is relational integrative psychotherapy most suitable for?
Relational integrative therapy tends to suit people who are curious about themselves, even if they sometimes find that curiosity uncomfortable. They’ve often spent years trying to understand why they keep repeating the same patterns: becoming the one who holds everything together, losing themselves in relationships, feeling driven by perfectionism, burning out despite appearing highly capable, or finding that insight alone hasn’t brought the change they hoped for. Indeed, this way of working often appeals to people who have tried more cognitive or structured approaches such as CBT and found that they helped a bit but didn’t reach something which remains underneath: the sense that something persists, unchanged, even when they understand it better and have better strategies for managing it.
Relational integrative psychotherapy, by its nature, tends to be medium- or longer-term work. Not everyone needs or wants that, and that’s okay. But if what you’re carrying seems to have a life of its own, if it hasn’t shifted in response to understanding or technique alone, there may be something here that goes deeper, which a more exploratory and relational approach is better placed to reach.
A note on diagnosis: ADHD, autism and more
A question I’m sometimes asked is whether clients need a formal diagnosis of ADHD, autism, AuDHD, or anything else before working with me. They don’t. A diagnosis, where it exists, can be useful context. But many of the people I work with are in the middle of an assessment process, have decided not to pursue one, or have a clear lived sense of their neurodivergence without any documentation behind it. None of that changes what we can do together. At the same time, I’ve worked with many clients who’ve had various other diagnoses in the past which don’t seem to fit who they are now or treatment for which hasn’t led to lasting change.
Choosing a therapist isn’t really about finding the ‘right’ modality. It’s about finding a therapist by whom you feel sufficiently understood and who practices in a way that allows you to do meaningful work. I hope this post has helped you decide whether my way of working might suit you. For more information about what to expect regarding practicalities (session length, frequency, fees, etc), please see my homepage. If you’d like to get more of a sense of whether my approach might suit you, I offer a free 20 to 30-minute initial conversation. There’s no obligation to proceed beyond that, and no pressure to have your experience neatly categorised before we speak.
Garthine Walker is a UKCP-registered psychotherapist based in Cardiff, offering online therapy across the UK. She specialises in trauma, attachment wounds, neurodivergence, burnout and maladaptive daydreaming.
REFERENCES
John C. Norcross and Michael J. Lambert (2018). ‘Psychotherapy relationships that work III’. Psychotherapy 55:4, 303–315. DOI: 10.1037/pst0000193
Richard G. Erskine (1998), ‘Attunement and involvement: therapeutic responses to relational needs’, International Journal of Psychotherapy, 3:3, 235-244. DOI: 10.4324/9780429479519-3
Mick Cooper (2019). Integrating Counselling & Psychotherapy: Directionality, Synergy and Social Change. Sage Publications.