THE GOAL OF THERAPY IS NOT ONLY TO FACILITATE symptom reduction and memory processing but also to empower clients to develop a life after trauma—a life no longer dominated by the shadow of traumatic events or their intrusions into ordinary or pleasurable experience. In phase 3 the therapeutic focus shifts to themes of self-development, adaptation to normal life, and relationships (Brown et al., 1998; Chu, 1998; Courtois, 1999; Herman, 1992; Steele et al., 2005b), addressing the profound developmental neglect endured by so many clients whose attempts to engage in normal life activities, particularly intimate relationships, bring up unresolved developmental deficits (Steele et al., 2005b). Although phases 1 and 2 treatment reduce symptoms and resolve traumatic memories, full engagement in life is often not achieved without completion of phase 3 work (Steele et al., 2005b). In this final phase of treatment, the abilities and skills gained in phases 1 and 2 are applied to enable flexible, adaptive responses to the arousal of action systems governing normal life: sociability, attachment, exploration, caretaking, play, energy regulation, and sexuality. With increased integrative capacity and a window of tolerance wide enough to better tolerate arousal, clients are now ready to expand their social connections, overcome their fears of daily life, evaluate and take appropriate risks, and explore change and intimacy. They also begin to develop other neglected areas of their lives, such as occupational and professional needs and goals, recreational activities, and spiritual interests (Brown et al., 1998; Courtois, 1988).
Discovering and changing cognitive distortions and corresponding physical tendencies that hinder clients in meeting these goals becomes a major focus of phase 3. In this last phase of treatment, clients are more able to sustain participation in activities they find meaningful and pleasurable, increasing their tolerance for positive affect. Eventually, their increased capabilities for integration and meaning making imbue past and current experience with new import and significance (Herman, 1992).
Although the phases of treatment are presented in a linear fashion, therapy is not a linear process. Frequently new memories or previously unknown fragments of memories arise in phase 3, perhaps partially due to the client’s increased integrative capacity that enables tolerance for previously dissociated memories (Steele et al., 2005b). For example, working with relationship problems inevitably evokes formative memories of interactions with attachment figures who shaped the cognitive distortions and behaviors that prevent satisfying current relationships. Additionally, life changes such as birth, death, marriage, loss of employment, retirement, or illness, as well as the imminent termination of therapy, frequently stimulate unresolved traumatic memories and feelings of grief and loss (Herman, 1992). These memories, as well as healthy risk taking, may temporarily destabilize the client, requiring the use of phase 1 resources or a return to phase 2 work with traumatic memories. Thus the therapist incorporates interventions for each of the three phases of treatment as the need arises. This flexibility permits the client to retain emotional, somatic, and cognitive stability (phase 1), process and integrate memories as they emerge (phase 2), and apply the skills learned in these two phases to new challenges and satisfaction in daily life (phase 3). Helping clients develop an ever more integrated self entails a balance between providing support, facilitating resourcing, guiding trauma processing, challenging maladaptive action tendencies, and practicing alternatives in “real” life, always proceeding at a pace that allows them to stay resourced and maintain or expand their window of tolerance.
MAKING MEANING: CHANGING COGNITIVE DISTORTIONS
Trauma “shatters” basic core beliefs about self, others, and the world, and the resulting posttraumatic cognitive distortions may persist long after symptoms have subsided and memories have been processed (Janoff-Bulman, Timko, & Carli, 1985). Kurtz noted that “the goal of therapy is not any particular experience; it is a change which organizes all experiences differently, a change in the way of experiencing. To make that kind of change, we must deal with meanings”. The importance of even small shifts in meaning, made in the first phases of treatment and developed further in phase 3, cannot be underestimated. Individuals who are able to construct more realistic or positive meanings in the wake of trauma are more successful in overcoming the impact of traumatic experience than those whose interpretations remain distorted or negative (Janoff-Bulman, 1992). Although, as noted, some shifts in belief occur in the first two phases, effecting successful and enduring change in beliefs early in treatment is unlikely (Brown et al., 1998). The tendency to revert to the old beliefs under stress typically continues.
These remaining trauma-related beliefs, as well as cognitive distortions not directly related to trauma, are both addressed in phase 3 (Brown et al., 1998). Sue, who suffered ongoing sexual abuse in childhood from a non-family member, had developed two trauma-related beliefs: “I’m damaged goods” and “All men are dangerous.” These beliefs prevented her from engaging in sexual relations. Her body mirrored these beliefs in rounded shoulders that Sue said “hid” her breasts so that men would not notice her, a tendency to keep her head down, which echoed her sense of being damaged, and chronic hyperarousal. Sue also had formed the non-trauma-related belief, “I have to be a high achiever to be loved,” which grew out of being raised by extremely accomplished parents who insisted upon excellence in all endeavors. Sue’s body was mobilized for action by an overall tension, her breath was high and shallow, and her movements were quick and incessant. Even when she was sitting, some part of her body was in motion: Her leg jiggled, and she squirmed in her chair. These physical tendencies supported her need to stay active and achieve at all costs, which combined with her trauma-related beliefs, drove her to workaholism and an inability to relax. In therapy Sue learned about the interplay between her trauma and non-trauma-related cognitive distortions. She discovered that the trauma-related hyperarousal she so often experienced propelled her into constant activity, and that her unrelenting professional obligations distracted her from her sorrow at feeling too damaged to be attractive to a man.
In phase 3, cognitive distortions are evoked by attempts to increase participation in daily life. When faced with even minor challenges, mental and physical action tendencies will reflexively engage, leading clients down well-worn pathways that include these cognitive distortions. As Janet stated long ago, “Older [actions] are the most fixed and the easiest; the more recent ones, which are still in the process of formation [such as the ability to reflectively separate past from present], are variable and difficult”. Becoming aware of cognitive distortions is a reflective process as well as an emotional one because these beliefs “come with conviction and all the emotional charge that created them” (Kurtz). By the time of phase 3 treatment, clients have developed the integrative capacity to tolerate and process the strong emotions that accompany these beliefs. Major goals of phase 3 are to help clients (1) identify reflexive beliefs, (2) explore how they interface with physical tendencies, (3) endure the associated affects, (4) consider the inaccuracies of the beliefs, and (5) further develop their integrative capacity to challenge and restructure these beliefs and their somatic counterparts.
THE DYNAMIC RELATIONSHIP OF CORE AND PERIPHERY
Physical tendencies are “a statement of…psychobiological history and current psychobiological functioning” (Smith). When trauma has induced a negative belief about oneself, others, or the world, the harmonious interaction between core and peripheral areas of the body is typically sacrificed. A belief such as “I’m bad” may set off physical tendencies of constriction, hunched shoulders, held breath, shortened neck muscles, and restricted movement. The corresponding emotions of shame, anxiety, or hopelessness further exacerbate the physical tendencies. These physical tendencies support cognitive distortions and trauma-based emotions, and, in turn, cognitive distortions and concomitant emotions manifest in physical tendencies that hinder the integration of core stability and peripheral movement.
In phase 1, clients learn resources for both auto-and interactive regulation, resources that loosely correspond, respectively, with the core and periphery of the body. In phase 3, the relationship and dynamic balance between the core and periphery are explored, with an emphasis on achieving integration between core and periphery and exploring how this integration supports new meaning and adaptive action.
Clients are encouraged to define their inner desires and goals and to develop the initiative to fulfill them. Such fulfillment requires “courage to move out of the constricted stance of the victim to…dare to define [one’s] wishes” (Herman). Becoming aware of the core—the symbolic and physical center of the body that represents the core sense of self—helps clients accomplish this task. In a “core state,” which in sensorimotor psychotherapy includes connection to the core of the body, clients are “deeply in touch with essential aspects of [their] own experience” (Fosha). From this awareness, clients learn to execute actions that are balanced and integrated between core and periphery, moving in a more self-possessed manner that is consistent with their desires and goals.
To review, the core involves the intrinsic muscles of the thorax, the pelvis, and the small muscles that join the segments of the spine and are responsible for holding the body upright. A strong and balanced core provides a stable axis around which peripheral movements, involving the large, gross muscles of the limbs and torso, are made—locomotion, actions of the arms, turning of the head and trunk. Core support allows extrinsic peripheral movement of the arms, legs, and head to be made with less effort and energy. A strong core provides an internal physical and psychological sense of stability, helping a person feel “centered,” and strengthening an internal locus of control.
Actions that are adaptive in response to action systems require sufficient strength, flexible movement, and integration between core and periphery of the body. Whether they occur in the form of peripheral gross motor movement, such as walking, running, or reaching, the inner movements of the deep, core intrinsic muscles, or the fine movements of facial expression, all actions involve movement. However, “if movement is restrained, structurally limited in range, or painful, or one’s muscular strength and capacity are not adequate to the task, then the actions taken will be limited or inadequate” (Kepner). For example, when the pelvic muscles constrict and the body recoils at the mere thought of sexual intimacy, sexual difficulties are likely to ensue even if the individual expresses the desire for a sexual relationship.
Janet (1925) wrote about the inability of traumatized clients to complete actions and the necessity of facilitating the completion of actions in treatment. During phase 2, truncated mobilizing defenses incipient in traumatic memories are completed. In phase 3, clients become increasingly aware of their physical and psychological center and learn to execute actions that stem from the core of the body, completing them through peripheral movements such as walking, running, reaching, grasping, holding on, and letting go. When actions are integrated and used to both initiate and respond to contact with the environment and with other people, a stronger somatic sense of self is facilitated—a felt sense of a connected, embodied self, rather than an abstract concept or image of the self. In Kurtz’s words: “As the core becomes vitalized…emotional dependency and the constrictions of defensive attitudes yield to a sense of self, and open flexible interchange with others. [The client] finds he no longer needs the external support or extrinsic rigidity to hold himself up. He can surrender these, and begin to feel the pleasure of…an integrated self” (Kurtz & Prestera).
The intrinsic muscles of the core are sometimes considered the “being” muscles, whereas the extrinsic muscles of the periphery are thought of as the “doing” muscles. The extrinsic muscles of the periphery mediate mobility, enabling movement through space and thus interaction with the environment. Included in the periphery are the movements of the legs, feet, shoulder girdle, arms, and hands. The head and muscles of the face communicate emotions and social engagement and include both core and periphery. Facial expression reflects core experience and also facilitates interaction with others. Whereas the intrinsic skeletal muscles of the core are deeper in the body, moving more slowly and precisely, the extrinsic muscles are closer to the surface and tend generally to move more quickly but with less precision (with the exceptions of some movements, such as the precise movements of the hand required for handwriting). Phase 3 treatment endeavors to integrate core and periphery, being and doing, so that clients learn to execute ever more adaptive actions that stem from a core sense of self.
Peripheral movements that are integrated with a stable core lead to well-coordinated action and engender a sense of integrity, harmony, and satisfaction. The person can move with precision as well as with strength and speed, as needed. Conversely, “without the internal balance given by the core, the actions carried out by the limbs lack flow, grace and harmony” (Kurtz & Prestera). When the core muscles are weak, rigid, or unstable, peripheral movements of the arms, legs, neck, and head lack coordination and poise (Laban, 1975). When the core is unstable, movements are also unstable; when the core is rigid, movements lack grace and flow; when the core is weak, movements may be initiated from the large muscle groups rather than from the center.
These physical tendencies usually feel “normal” to the individual, who may only be aware of them when they are so extreme as to cause pain, but they look unbalanced to the trained observer. This lack of balance between core and periphery reflects cognitive distortions. For example, the tension of the periphery (e.g., the pulling in of one client’s shoulders toward the spine) combined with a weak core (e.g., an exaggerated spinal curve) reflected the belief “I’m worthless, I must hide.” Even if the person is unaware of these maladaptive tendencies when the core and periphery of the body are not well-integrated, he or she may unconsciously experience a corresponding lack of integration psychologically.
Without a strong and stable core, the spine may flex and sag, resulting in a physical structure that is slumped and an appearance of “not being able to hold yourself up.” This physical tendency may correspond to the propensity to feel “spineless,” needy, helpless, incompetent, and dependent. In this case, both the core and the extensor muscles are underutilized and lack tone. An impulse to take action in the world may be felt, but the person does not possess sufficient psychological motivation, will, or peripheral strength to carry the action through to completion—as was true for the client who said that she felt “weak” and that it was too “hard” to reach out to others or apply for a job: “It makes me tired.”
A person may utilize tension in the extrinsic peripheral musculature to compensate for a weak or unstable core (Kurtz & Prestera, 1976). The body is held upright by a heightened tonicity in the extrinsic muscles, rather than by a strong core. Subsequently, this increased superficial tension inhibits movement from the core outward and may contribute to beliefs such as, “I can’t express myself” and “It’s not okay to connect with others—I’ll get hurt.” Concomitant physical manifestations may include tightness in the throat, immobility in facial muscles, resulting in an inability to express emotions associated with impulses for interpersonal connection and affiliation. Yet the needs for attachment and affiliative relationships remain because they stem from psychobiological action systems that engender hard-wired “core” needs. The movements related to seeking connection, such as reaching out, may be experienced or initiated from the core of the body—the spine or pelvis, for example—but when they meet rigidity and tension from the periphery and in the extrinsic musculature, they remain incomplete. When clients with this physical tendency are approached by another, they are likely to pull back and stiffen.
Both the core and periphery can be overly tense, in which case the person may be excessively rigid, lack flexibility and mobility, and report that that he or she feels “stuck” or “unable to move.” Such an individual may not have much awareness of his or her core. Executing movements that originate in the core and extend smoothly out into peripheral action may be problematic. If movements are initiated, they are met with peripheral tension. With diminished internal awareness and self-expression, this person may feel stuck, sluggish, and disconnected, and expend effort in attempt to take action, with little satisfaction or sense of progress.
The consecutive or simultaneous approach-and-avoidance/defensive movements of clients with unresolved disorganized-disoriented attachment patterns form a focus for treatment in phase 3. These movements clearly reflect a lack of integrated movement between core and periphery. The concurrent impulses of approach and avoidance result in a body that is “going in different directions,” as when proximity-seeking actions are combined with simultaneous avoidance or defensive actions. One client could not reach out without simultaneously pulling back in the core of his body; another could not sustain a movement away from an unwanted encounter; she would quickly shift back to approach movements when she attempted to move away. Other clients exhibit uncoordinated, jerky movements such that the parts of the body do not move together in an integrated fashion, such as the client whose pelvis was thrust forward as he walked, while his chest was pulled back. The concomitant beliefs accompanying these discordant actions were also conflicted: “I want to be close, but it is dangerous; others will take advantage of me if I get close; I will be hurt if I honor my own boundary.”
Assessment of Incomplete Actions in Core and Periphery
Assessment of which actions remain incomplete or unexpressed is accomplished by noting the relationship between the spine, neck, head, arms, and legs. Is the core stable yet flexible and able to support peripheral movement? Or is it weak and slumped, so that peripheral movement cannot be supported? Is movement, such as reaching out, restrained by peripheral tension, or does the movement progress gracefully from core to periphery? Is the extrinsic, surface musculature flexible so that movement emanating from the core is unrestrained? Is there grace and integrity in the movement as it progresses from core to periphery, or is the movement jerky and disjointed?
In working to help the client achieve greater integration and more adaptive action tendencies, the therapist is careful not to convey the notion that there is a “right” way to move. Rather, the objective is to facilitate a client’s mindfulness, so that he or she develops an ever-increasing ability to be aware of body sensation and physical action. With awareness, clients begin to identify their own maladaptive actions, choose to inhibit them, and decide to initiate and sustain actions that bring them more satisfaction. As Juhan noted: “The goal…should not be to impose universalized standards of posture and movement upon an individual, but rather to help the individual to cultivate the mental awareness and the physical flexibility to continually adapt to the changing needs of the moment”. Thus control and choice always remain with the client whose movement, with practice, becomes self-correcting.
ACTIONS IN PHASE 3 TREATMENT
Insistent engagement with certain action systems, such as caregiving or professional endeavors (exploration), to avoid the expected disappointment and pain that occurred in past attachment relationships is common for traumatized individuals (Sable, 2000). In phase 3, clients are encouraged to balance their responsiveness to the arousal of all action systems and are challenged to integrate and respond adaptively to complex situations that evoke several action systems simultaneously. Relationships may include the complex interactions of several action systems related to daily living: attachment, sexuality, caregiving, friendship (sociability), exploration, energy management(e.g., eating together), and play. Clients learn to distinguish between various kinds of relationships correlating with different actions systems and to differentiate among kinds of intimacy: emotional, physical, sexual, intellectual, spiritual.
Clients are especially challenged in intimate partnerships, where cognitive distortions and physical tendencies learned in the context of their early attachment relationships interfere with the ability to form a constructive intimate relationship in adulthood. A variety of attachment disturbances are explored in phase 3: repetition of traumatic attachments, attachment to the perpetrator, isolation (a denial of attachment needs), insecure attachment patterns, and unresolved disorganized-disoriented attachment. For mature intimacy to occur when intimacy was formerly accompanied by abuse or loss (which is the “pinnacle of successful treatment”), integrative capacity must be high enough to allow the person to tolerate frustration, resolve conflict, and separate the present from the past (Steele et al., 2005b).
The phobia of intimacy (Steele et al., 2005b) is articulated through the body’s communication. Because the phobic response is a precognitive sensorimotor/emotional one, it is crucial to treat it on a sensorimotor level as well as on the level of cognitive processing. Relational connection includes expression and movement of the arms: reaching, grasping, letting go, holding on, embracing, and so on. Physical experiments with action of the arms, such as asking a client to reach out, are revealing in the assessment of relational disturbances. As Kepner stated, “If you want to reach out to others but restrain your arms at your side, you will have difficulty completing your need. If you wish to express your joy in movement but are structurally bound up and muscularly inflexible in your movements, you cannot fully express your internal feeling”. If a client has difficulty initiating, sustaining, or responding to relational contact, experimenting with reaching out can be a useful somatic intervention. Some clients reach out with the elbow bent, some reach from the shoulder, some keep their upper arms pinned to their torso. Clients may reach with the whole body, leaning forward, eyes intensely focused on the therapist, whereas others pull back and look away even as their arm is reaching forward. For some, the gesture is weak, lacking tone and energy; for others, the gesture is strong but stiff. Each pattern holds significant psychological information. When people cannot initiate this impulse from the core and carry through the act of connection with their arms in an integrated fashion, communication in relationship is typically limited.
Expanding Intimacy through Integrated Action
Goaded into therapy by a wife who threatened divorce if he did not work on his “intimacy issues,” Sam grudgingly agreed to explore his aversion to emotional intimacy. Sam’s posture and arm movements were tense; his spine was stiff, reflecting tension in both core and periphery, and he had a habitual gesture of putting his bent arms out in front of him with palms facing outward. Furthermore, he had an abrasive manner that his wife described as intimidating. Raised by a father who was physically abusive and alcoholic, Sam was left to his own devices throughout his childhood. He learned at an early age that he could depend on no one but himself. Although Sam was able to autoregulate, his ability to interactively regulate and engage fully in relationships was compromised.
During therapy sessions Sam unconsciously made movements of defense, including putting his hands up in front of his body, backing away from the therapist when standing, and bracing and pulling back while seated. These peripheral movements became stronger and more frequent when discussing his relationship with his wife, despite Sam’s stated conviction that he wanted to deepen his intimacy with her. Although his conscious response to the arousal of the attachment action system in relation to his wife was to seek proximity, his movements expressed the opposite.
Within the context of an attuned relationship, the therapist gently pointed out these movements, drawing them to Sam’s attention, and he agreed to explore them. When Sam made the defensive movements voluntarily and mindfully, he realized that from this posture he did not feel connected to his desire for intimacy with his wife; in fact, he did not desire a connection with anyone. As he explored further, executing various defensive movements as an experiment, he reported a childhood memory of approaching his father and became aware that, as a child, he never knew if his father would receive him or turn violent. Sam reexperienced the fear and unpredictability that he had endured during childhood, which led to the spontaneous realization that these defensive arm movements were telling others to keep away: “It’s not safe to be close. People might turn on me.”
During therapy, Sam was encouraged to experience his need to connect with others and to become more fully aware of the core of his body—his spine and pelvis—as he did so. Sam felt the rigidity of his spine and experimented with gentle movements and breathing that softened the core of his body. He reported feeling less defensive and more vulnerable as his spine softened, and then said he could also feel the desire for connection with others “deep in my belly.” Sam’s therapist suggested that he experiment with making the gesture of reaching out with his arms, sensing the desire in his belly, and initiating the movement from the core of his body. In these initial experiences, only the physical action was practiced, devoid of thoughts about reaching out to another person, thus reducing the risk of reaching. Nevertheless, Sam first said the mere thought of reaching out made him uncomfortable. When he did, his arm was stiff, the movement was mechanical, and his spine became rigid again. Sam said that the gesture felt unfamiliar and that he felt more vulnerable because he didn’t expect a response to his reaching—no one had ever responded to him supportively. He became sad and said, “What’s the use of reaching out? Others will only hurt me.” Verbalizing these abuse-and abandonment-related beliefs with increasing anger and hurt in the context of a relationally attuned therapy served to soften Sam’s aversion to intimacy and as well as to relax his spine and his extrinsic musculature.
Sam’s therapist then encouraged him to explore various kinds of actions related to reaching out, maintaining the softening in his spine and always initiating the action from his core: stepping forward, softening his chest, and so on. The therapist observed the movements and helped Sam to perform the action efficiently and without undue physical tension, such as first sensing and softening his core, then relaxing his arm and leaning slightly forward instead of pulling back. Executing these movements that reflected greater integration between core and periphery brought more insight and affect about the impact of his early attachment history on his current relational capacity. Sam realized that his feelings of vulnerability increased as he executed these relational movements from a more relaxed physical core—but that it also felt “good.”
Appropriate Challenges: Graduated Actions
Assessing the degree of difficulty of a particular challenge offered to the client and evaluating its impact are key to successful integration of a new skill. The specific action requested of clients should be appropriately challenging: that is, at a level that facilitates the likelihood of success and evokes the highest integrative capacity possible, while avoiding discouragement or failure (Janet, 1925). Practicing new actions of incremental complexity builds clients’ integrative capacity and confidence over time. With graduated or step-by-step instruction for executing the actions integrating core and periphery, the client “will then make correct and automatic reactions which will spare him the loss that would be caused by failure” (Janet).
Sam first practiced actions of reaching out merely as a physical exercise, attending only to integrating core and periphery, with no focus on psychological content, until that task was accomplished. He then practiced reaching out to the therapist, which brought up long forgotten childhood longing for his mother, and Sam wept with grief. Eventually, he practiced reaching out while imagining his wife standing before him. The therapist addressed Sam’s fear that reaching out to his wife would make him too vulnerable and that he would get hurt; his impulse was again to pull away and disconnect from his core. After processing these erroneous beliefs, formed in the context of an abusive childhood, Sam was able to reach out while imagining his wife standing before him, but he said he felt ungrounded. The therapist suggested the use of grounding resources Sam had learned in phase 1: sensing his legs under him and the support of his upper body by his legs. Eventually Sam was able to carry through the reaching movement from core to periphery while imagining reaching out to his wife.
Sam gradually became able to execute actions of connection with relative ease and comfort, sensing his need to reach out in a particular sensation in his belly, executing the movement in a fashion that integrated the core and periphery of the body, and staying grounded. Naturally, these new motor actions were accompanied by new meanings: He began to express the conviction that perhaps it would be safe to reach out in his current life, that he knew everyone was not like his father. He reported that the intimacy and satisfaction in his relationship with his wife correspondingly improved. Sam found himself spontaneously reaching out to others instead of remaining isolated, which had been his tendency for so long. He reported a difficult visit to his childhood home to reconnect with his best childhood friend, who unbeknownst to Sam had become a rageful alcoholic like his father. After this visit, he wrote:
The reaching out in therapy had a profound effect in terms of recognizing how I don’t reach out and doing something different. When I was back home, I realized I don’t have to just pull in and endure; I can find something different. I stayed connected to my core, and did a lot of reaching out to people when I was there, and I would attribute it to the practice in therapy. Talking about it doesn’t touch it—I have talked about how I have difficulty acknowledging my needs and connecting with others, but it didn’t change anything. On that trip I talked to my wife and to friends, and even cried a little. I would never do that before.
Janet (1925) wrote that previously incomplete or undeveloped actions, both mental and physical, when practiced and completed, are the starting points of more sophisticated, creative, and complex tendencies. Therapists often find that unexpressed grief must be experienced and completed. Sam expressed grief for his childhood and his loss of relational intimacy during all the years he had “pulled in and endured” in solitude. This, along with his completion of the action of reaching out in a somatically integrated way, incipient in his childhood longing for contact but never satisfactorily executed, diminished his isolation and freed him for increasing intimacy with his wife and with friends. Ultimately, it altered the cognitive distortion that he always had to “do it alone.”
Exploring New Actions to Meet Daily Life Challenges
In the final phase of treatment, clients are encouraged to consider which of their daily activities are meaningful to them (Brown et al., 1998; Janet, 1925) and to rediscover old dreams and desires (Herman, 1992). Phase 3 can be a time of discovery and self-fulfillment as
the therapist helps the patient identify a range of new interests and aspirations, explore new possibilities, discover previously unrecognized talents and human potentials, and playfully experiments by engaging in a variety of new activities, until the patient can better discern which activities, talents, potentials, interests, and activities seem most identified with core aspects of the self and which do not. (Brown et al.,)
This is not an easy process. When nondefensive action systems are enlivened and their interaction with other systems fostered, traumatic reactivation inevitably occurs. Negative cognitions, maladaptive somatic tendencies, and trauma-related phobias fuel clients’ conviction that they are not ready to navigate the world when, in fact, they may be capable of doing so. Clients may misread unfamiliarity with an ordinary experience as a warning of its danger.
The everyday life challenges that clients face are used to create opportunities to explore, develop, and practice new, more adaptive actions. Mindfulness and curiosity are used to track what happens in both the core and periphery of the client’s body as he or she thinks about or remembers a challenging situation, such as making a phone call, leaving the house, going on a date. Client and therapist together notice the building blocks of present experience: thoughts, emotions, sensations, movements, and sensory perceptions, and assess these tendencies. Is the tendency a familiar, habitual traumatic response associated with past trauma? Is it an orienting response to novelty, in which excitement and arousal naturally increase? Does this tendency contribute to a new sense of self, creating a more adaptive relationship with the world, or does it reenact a tendency from the past? Does it feel empowering? Does the response further the development of a neglected action system, such as that of play or sexuality?
Paying special attention to what happens in the core and periphery of the client’s body is essential to detect actions that are not adequately completed or satisfying and work on changing them. For example, when one client thought about picking up the phone to schedule a job interview, a risk he wanted to take, the therapist observed that his arm tightened by his side. Another client considered accepting a date, and the therapist and client both noticed that her jaw tensed. The therapist helps the client become curious about the meaning of these maladaptive actions. For example, what is the meaning of tightening the arm when considering reaching for the phone? Is it: “I will open myself to danger? Failure? Loss? Shame? Criticism?” Does the client expect to be rejected or abused when she thinks of dating?
Together, therapist and client explore these reactions by considering their cost–benefit ratio: whether the defensive action tendency is serving the client (as it would in a truly dangerous or undesirable situation), whether it is an accurate perception of danger that could benefit from a more active response (flight instead of freeze, or social engagement and dialogue instead of fight), or whether it is an archaic response to an old situation imposed upon current reality.
For example, when Sally thought of asking her boss for a raise, her newly found sense of extension in the spine (developed in phase 1) suddenly collapsed into the familiar tendency of caving in her chest and a “weakness” in her arms and legs (her periphery). To work with this issue, the therapist placed a pillow in the corner of the room to represent the boss and observed Sally’s reactions as she began to covertly orient toward “him.” As Sally sensed “his” presence in the room, she had thoughts that “I don’t deserve a raise” and “I’m not good enough.” As she slowly oriented toward the pillow, turning her body to face her “boss,” she noticed that her breathing became shallow, her shoulders began to draw up, followed by a gradual downward movement of her chin, which tucked down toward her chest. She reported: “I lose my arms and legs—they feel like they’re not there.” Sally remembered the feelings of submission and low self-esteem she felt as a child with her physically abusive father. She began to realize that this maladaptive pattern was outdated, no longer appropriate for her current life. With this realization, she found herself able to lengthen her spine, and her cognitive distortions of disempowerment began to shift (“I am powerful; I am okay just as I am; I did not deserve to be abused”). She reported “feeling my legs under me” and “energy in my arms.” Sally described a different relationship to her boss when she was able to maintain elongation in her spine and connection to the strength in her limbs while facing his pillow representative.
The next step for Sally was to deliberately change her maladaptive tendency of collapsing in the core and losing tone in her limbs in her daily life. She began to purposely maintain extension in her spine and awareness of her arms and legs when talking with her boss. As this posture became comfortable, she was better able to separate past and present, her father and her boss. To prepare to ask her boss for the raise, Sally and her therapist used a variety of experiments to promote her ability to sustain feelings of competence and to keep her spine lengthened and connected to her center. At this stage of treatment, the change in alignment and connection with her core served phase 1 goals of modulating arousal within a window of tolerance and supported Sally’s healthy risk taking by carrying her new impulse out through her extrinsic musculature. Eventually Sally asked her boss for a raise, with positive results.
As new physical actions are evoked, memories, emotions, and new insights emerge and are addressed. The therapist then supports the client to embody the needed resources (e.g., grounding, eye contact, centering) and inhibit certain actions (e.g., tightening the arm, collapsing the core) that interfere with completing the movement. The therapist encourages slow, mindful motion and helps the client become meticulously aware of the moment-by-moment changes in the body and in feelings and thoughts as he or she executes a new, risky movement. Through this process, the new movement is guided by the therapist, who
is carefully generating a flow of sensory [and motor] information to the mind of the client, information that is not being generated by the client’s own limited repertoire of movements—new information that the mind can use to fill in the gaps and missing links in its appraisal of the body’s tissues and physiological processes. It is then the mind of the client that does the “fixing”—the appropriate adjustment of postures…the fuller and more flexible relationship between neural and muscular responses. (Juhan)
With sufficient mindfulness, resources, time, interactive support of the therapist, and iterations of the movement, the client begins to manifest more adaptive movements that emanate from the core, or center, of the body and are carried out by gross motor movements, expanding the client’s capacity to fulfill his or her desires.
Mindful Arm Movements: Paths to Change
In addition to reaching out, exploring a variety of other arm movements can be vehicles for change. Grasping motions, holding on, letting go, boundary motions of pushing, hitting, circular motions that define one’s personal boundary, expressive movements of opening the arms widely in gestures of embrace or expansion, movements of self-touch, such as hugging oneself—all are significant and the manner in which they are executed reflects beliefs about oneself, others, and the world.
Meg complained of always being worried about money. As she spoke about her desire to earn more money, she spontaneously made motions of reaching out and then bringing her arms toward her torso as if drawing something in toward her chest. Her therapist asked her to repeat that motion mindfully, exploring it for meaning and memories. Meg said that the movement felt connected to “taking in” and “receiving for myself.” Memories emerged of being raised by a single mother: Money was tight and Meg remembered feeling ashamed when she wanted a new dress. Through exploring this gesture, the belief of “I don’t deserve good things” emerged, accompanied by sadness and grief. After these emotions were expressed, the cognitive distortions of their veracity were challenged.
In a follow-up session, Meg and her therapist worked with reaching, grasping, and pulling movements. Meg chose a pillow to represent “good things” and then experimented with the movements of reaching, grasping, and pulling the pillow to her as it was held by her therapist. At first, her grasping and pulling movements were feeble. The core of her body weakened, and her arms had little strength or endurance. She gave up quickly. Again, emotions, beliefs, and memories emerged, this time involving her “right” to assertively reach for and take what she wanted. Meg worked to sustain support from her core and strength and persistence in her arm movements, especially when pulling the pillow—the “good things”—toward her. Feelings of guilt and selfishness for “going for what I want” and concomitant beliefs were again challenged. Through this process, those movements gradually became easier for Meg, and she chose the homework of practicing them daily until they felt effortless and natural.
Whereas reaching out, grasping, and pulling movements can be a challenge for many traumatized clients, holding on and being unable to let go can be equally challenging. Kay habitually did not want to end her therapy sessions. When the therapy session neared completion, she would express an intense need to tell her therapist something “really important.” Her therapist discussed this tendency with her at the end of a session, and they decided to explore it further at the next session. At the end of therapy sessions, Kay and her therapist normally shook hands, and her therapist suggested that they mindfully study this gesture as if it were the end of the session, noticing what happened when it was time to “let go.” Kay’s reaction was to tighten her grip rather than let go. As this tendency was explored, Kay noticed that she leaned forward, reaching toward her therapist with her body and her eyes. Instead of letting go and saying goodbye, Kay was holding on. Her therapist asked her to sense these “holding on” movements and to see what her body was saying: “If your body could talk instead of hold on, what would it say?” Softly, Kay began to cry and whispered: “Don’t leave me; I’m all alone…only you understand me.”
Her underlying beliefs seemed to replay an old script in which the separation would be permanent and she would be abandoned. Reminding Kay that she had her regular appointment for the following week, the therapist encouraged her to experience and study the body sensations that were evoked. Even as Kay heard these words, she felt a physical sense that she could not bear the pain of separation; these physical sensations became even more intense just as it was time for her to let go. Memories emerged of being left alone in a hospital for surgery when she was very young. Her therapist helped Kay process these painful memories and then focused on developing a tolerance for normal separation, assisting Kay to sense the physical support of her spine, the feeling of her feet firmly on the ground, the calming effect of taking deep, regular breaths, and the difference between her experience as a dependent child and her experience as an adult. Kay’s therapist asked her to notice her reactions to a verbal experiment in which the therapist repeated, “I will be here next week.” At first, Kay reported images of her parents leaving her and from the “little girl place” within, said that she did not believe that her therapist would remember her next appointment. She also realized that from this “child place,” she lost connection with her center, the core of her body. Eventually, Kay felt she could endure the grief and sadness triggered as she let go of her therapist’s hand. Gradually, as this and other experiments were practiced week after week, Kay was able to sense her therapist as different from her parents, stay connected with her center, and eventually endure feelings that the separation evoked. She slowly became more familiar with managing separation, which led to the new meaning that perhaps separation was normal and tolerable—and often temporary.
The Ability to Mentalize: Attuned Actions in Relationships
Early childhood experiences replete with cognitive distortions, faulty belief systems, and maladaptive defensive tendencies result in less than optimal adult interpersonal interactions (McCann & Pearlman, 1990). Moreover, clients who are insensitive to social cues are not able to respond appropriately in social situations.
The ability to “mentalize” is the ability to be aware of our own internal experience as differentiated from that of others (personification), combined with the ability to “resonate” with others in such a way that we can speculate about their motivations and intentions (Fonagy, Gergely, Jurist, & Target, 2002). If we can mentalize, we can “put ourselves in someone else’s shoes” and make guesses about his or her motivations. Mentalizing helps us predict not only the possible results of our own actions with regards to others, but also the intentions and actions of others in a way that is somewhat accurate and based on present reality.
The capacity to mentalize also includes identifying, distinguishing, and predicting another person’s actions at visceral and motor levels. A lack of awareness or misinterpretation of these sensorimotor cues disrupts accurate mentalizating and can lead to distortions of communication. People without the capacity to mentalize cannot successfully read the emotional intention or social cues of others. This inability reflects low integrative capacity. Mentalization is especially central in making adaptive responses to relational action systems of sociability, attachment, sexuality, and caregiving; this capacity is strengthened in phase 3 treatment. Fonagy and Target (1997) have suggested that the capacity to mentalize is not an all-or-none phenomenon and is, to some extent, context dependent, as is illustrated by the following example.
Susan came to therapy with her husband Jim because Jim complained that there was “no room for him” in the relationship and that Susan didn’t “connect.” Susan’s movements were the opposite of Jim’s: Susan leaned forward, talking animatedly, her eyes were bright, her face was very expressive, and frequent gestures punctuated her speech. She was dynamic, funny, loud, and entertaining. Although her movements appeared integrated and fluid, she seemed wrapped up in her own expression rather than engaged in a genuine connection. She appeared oblivious to social cues, such as her husband’s slight shrinking back as she spoke. When the therapist pointed out her husband’s response, Susan was shocked; she said she was “just being herself” and was surprised that she apparently had a negative effect on her husband. This exploration led to memories of “performing” for her father: She reported that he was often absent, and she had to work hard for his attention: “I had to be really cute and funny or my father just ignored me.” Susan had formed the cognitive distortion that she must “work” at relationship; otherwise men would ignore her.
Susan’s therapist encouraged her to become mindful of the sensations in her spine and pelvis and to practice centering exercises (explained in Chapter 9). As she developed the capacity to stay connected to herself and the core of her body, Susan gradually learned to sense the changes in her body when she was interacting with Jim. She learned to orient and attend to social cues, specifically tracking her husband’s reaction to her, moment by moment. Gradually, as Susan became aware of Jim’s reactions and sensed the effect of his reactions on the sensations in the core of her body (her feelings of being centered), her interactions began to be slightly less animated and more spacious. She hesitated when she saw her husband pull back and learned to ask him about his feelings and his response to what she had said. This shift in Susan gave her husband room to come forward in approach movements instead of withdrawing repeatedly. Gradually, as Susan became familiar with the sensation of feeling centered and recognized the impact of her interactions on Jim and others in her life, she was able to allow room and space for more reciprocal interactions. Correspondingly, she also addressed and changed the belief that she had to entertain to get attention.
In summary, the directional flow between core and periphery is a two-way street. Not only do actions emanate from the core outward, but the impact of environmental stimuli upon the person must progress from the periphery inward to the core in ever-changing dynamics of interaction. As clients are encouraged to pay attention to both sensorimotor directional responses, their capacity to mentalize increases. And correcting distorted interpersonal difficulties and cognitive distortions also supports an environment within which mentalizing can develop (Green, 2003).
INTIMACY AND BOUNDARIES: A DELICATE BALANCE
Good boundaries are critical for healthy intimacy, but survivors of trauma are susceptible to engaging in relationships that repeat past boundary violations (Briere, 1992; Chu, 1988, 1998; Harper & Steadman, 2003) and often come to therapy with little understanding of adaptive boundaries. Steele et al. explained (2005b):
Patients generally have to learn the importance of personal boundaries, how and when to apply them, and how to respond effectively to others’ boundaries without feeling rejected by recognizing that “good fences make good neighbors.” Effective boundaries reduce fear of intimacy, giving some sense of personal control, and equalize the balance of power in relationships.
In phase 1 clients acquire somatic boundary resources to assure safety and regulate arousal, and in phase 2 they reestablish the ability to mobilize self-protective defenses. In phase 3 the focus shifts to developing boundaries that are flexible, resilient, and ever-changing, depending upon the client’s internal state and relational interactions. With safety assured and arousal within the window of tolerance, the subtler effects of inadequate boundaries, related more to rights and preferences than safety, can be addressed.
In the wake of trauma, some people become “underboundaried”—that is, unable to set adaptive boundaries, and thus are vulnerable to submissive behaviors such as acquiescing, complying, always being “nice,” and rarely making appropriate demands in relationship. Others, such as Sam, above, become “overboundaried”—that is, they have difficulty allowing people to come close and are likely to avoid contact with others or remain physically and/or psychologically distant when in relationships. Both boundary styles are defensive in nature and therefore compete with adaptive responses to relational action systems.
The somatic sense of boundary is based on the felt sense of one’s preferences, wishes, and rights, as well as on the felt sense of safety. This somatic sense is differentiated from a cognitive understanding of boundaries. For example, Sue said that she wanted to take a vacation from work—something she had not done for years. However, as she stated her verbal preference was incongruent with her physical expression. The therapist observed muscular tightening, slightly held breath, and pulling back of her body. As Sue learned to listen to and translate the language of her body (her body was saying, “I can’t tell my boss I want a vacation; I don’t deserve a vacation”), her beliefs about her right to set her own boundaries were brought to awareness and challenged. In this way, trauma-related sensorimotor schemata can be changed, so that clients then begin to experience, often for the first time, a felt sense of personal boundary, rights, and ability to discern appropriate preferences. This felt sense is palpable, and its barometer is the body.
When clients’ sense of self is relatively undifferentiated, their internal locus of control, connection with the core, and capacity for intimacy are all diminished. Working with boundary exercises helps to restore a sense of self that is differentiated and capable of intimacy. Tanya suffered early childhood abuse and neglect. In phases 1 and 2 Tanya worked with mobilizing defensive actions of pushing and flight and establishing a somatic sense of her ability to defend herself and escape danger. In phase 3, however, as she sat in the therapist’s office, her body was tense and still, her movements restricted. She showed decreased emotion, expression, relational connection, and shallow breathing. As she explored her responses to significant others in her life, she eventually said, “I feel like a Geiger counter or a radar. My whole body is constantly gauging what is happening with everyone and everything else. I’m always trying to please them.” When asked about her internal sense of herself and her connection with her core, she made statements about how others in her world respond to her. Here Tanya demonstrates a boundary style based on the perceived needs of others.
In phase 3 treatment the therapist first worked to develop her awareness of internal somatic barometers to the environment by helping Tanya observe her core and peripheral movements. For instance, the therapist asked Tanya to notice what happened as she moved closer to, or further away from, him—particularly if she noticed any change in her muscular tension, quality of movement, or breath (Heckler, 1984; Rosenberg et al., 1989). To her surprise, Tanya found that her body relaxed more when she was a little further away from her therapist. Before she began the exercise, Tanya had thought that she was “fine” with a closer proximity, but this thought was based on cognitive and emotional appraisals, not felt somatic responses. Tanya continued the experiment until she experienced what she called the klunk, the distance from her therapist at which her body felt most comfortable. The klunk was palpable: her muscular tension began to release, her breathing deepened, and her activation began to settle. Over phase 3 treatment, this klunk became the indicator that, as Tanya said, “tells me what is right for me.” In this way, the therapist helps clients find a word or phrase, to develop a lexicon of their own with which they can describe their sensorimotor/somatic experience of a boundary. For Tanya, the word klunk expressed her experience of an adequate boundary. The client’s word or phrase can be used intermittently throughout treatment to help bring the somatic sense of boundary to conscious awareness. As Tanya reported real-life problems, she and her therapist noted what solutions elicited the klunk that indicated an appropriate choice for Tanya.
Next the therapist asked Tanya to construct a symbolic boundary around her body, using a piece of string as an outline and adding pillows to form a little buffer between her body and the world. At first Tanya made a cognitive judgment that this experiment was “silly and childish,” but she soon found that her body responded to the construction of a tangible boundary and that she felt more “centered.” The relationship between core and periphery kept changing as this exercise continued; her breath deepened, eye contact increased, the klunk felt stronger, movement became more integrated, and Tanya began to experience a sense of self-referential awareness. She began to feel her body respond to environmental stimuli, and as time progressed, she was able to identify her own needs and wants. She no longer felt that she needed to monitor every move that another person made or adapt her actions to suit him or her. She began instead to experience her own internal world; her core, her breath, the klunk that informed her about her preferences in relationship.
Tanya challenged this process by asking what good it is to construct a boundary in the therapy session because she cannot go through life with pillows around her, nor can she ask everyone to take a step back from her body. The therapist explained that the exercise functions to assist her in discovering an internal locus of control, a new way of feeling “boundaried.” The klunk signaled Tanya’s somatic sense of boundary. By experiencing a physical sense of boundary and preference in the therapist’s office, Tanya began to acquire a somatic barometer attuned to her inner experience of nondefensive self-awareness, security, well-being, groundedness, and openness in her body, which slowly began to carry through to relationships. Gradually, Tanya began to move from the phobia of intimacy toward the experience of knowing what it would be like to tolerate and even enjoy intimacy, and not have to worry all the time about pleasing others. It had not been possible previously to entertain the idea of intimacy without a stronger sense of her own preferences and desires. Tanya subsequently began to work in therapy with peripheral movements of reaching out, walking nearer to the therapist, able to tolerate less distance.
Conflicting movements and sensations frequently accompany boundary-setting, resulting in physical actions that are not synchronous or mobilized in a unified direction. When clients attempt to execute a previously conflicted, ineffective, impeded, or disabled action, they may use the body inefficiently, often at odds with their conscious intent. The core and periphery are not working together. A client who is conflicted about her right to turn away from an unpleasant stimulus will execute that action in an unintegrated fashion; a person whose survival strategy was characterized by collapse and submission will encounter difficulty lifting her chest or breathing deeply and stating preferences without tightening elsewhere in her body.
The body holds past traumatic experiences, whether or not the details of these traumas are remembered, and these past traumas contribute to disorganized actions and inadequate boundaries. Karen, a victim of chronic childhood sexual and physical abuse by her father, struggled with establishing appropriate boundaries that reflected her preferences. The first goal in phase 3 treatment was for Karen to develop a healthy dating pattern in the wake of pervasive childhood violation. She had experienced increasing satisfaction from her success as a college sophomore, had a strong social support system, but reported that sometimes she acquiesced to the sexual overtures of men she dated and later had the feeling that her dates were “taking advantage” of her sexually. Karen and her therapist decided that boundary work was needed. Karen first explored setting a boundary by pushing against a pillow held by the therapist, in a symbolic gesture of saying “no” to an interpersonal overture she did not want. Both noticed that her body pulled backward while her arms pushed forward and her spine curved backward and down. Her head was bent forward, her gaze averted. She appeared to be moving backward while simultaneously trying to push. This conflicted physical action was the physical counterpart of the “mixed message” she gave to others, particularly to the men she dated.
As she studied the conflict in her movements, Karen expressed a loss of connection with her core and reported the thought that pushing away meant that she would be alone—the very same conflict inherent in her childhood relationship with her father. If she had tried to push him away or move away from him, the price would have been loss of connection. It should be noted that many clients prefer inappropriately close proximity when they have learned in childhood that saying “no” or verbalizing their preferences results in a loss of a needed attachment relationship.
Teaching Adaptive Boundary Actions: The Role of the Therapist
In sensorimotor psychotherapy it is the therapist’s objective to teach the client how to study habitual patterns and then to organize and carry out unfamiliar actions, thus helping him or her move from reflexive to reflective movement. Even a century ago, Janet noted how necessary the therapist is to this process: “The [client]…is not familiar with the mechanism of the action which he is trying to learn. He would not know how to decompose it into its elements; he would not be able to repeat the useful elements of the movement one by one or to eliminate the futile elements, and he would not be able to perform the action”. Because the way in which Karen moved was habitual and felt “right” to her, she could not sense that there was a way to move that integrated both the core and periphery of her body: The therapist had to help her become aware of how the familiarity of her habitual way of moving made it “invisible” to her (Gelb, 1981).
The therapeutic objectives, coformulated by the therapist and Karen, included teaching Karen to execute an integrated and coordinated movement of pushing away with her arms, with this extrinsic movement emanating from her core. First, the therapist modeled the action so that Karen could visually see it. The therapist also demonstrated Karen’s own unintegrated action to help her see her habitual movement in contrast to an integrated movement. When Karen observed the therapist’s demonstration of her disorganized action, she was astonished, saying, “I didn’t know if you were trying to tell me to stop or not!” Karen then experimented with exercises to increase her awareness of her spine and pelvis, mindfully pushing against a pillow held by the therapist, initiating the movement from the base of her spine. The therapist encouraged Karen to lengthen her spine so that her core was aligned, and to lift her head to make eye contact. These movements were executed while pushing not only with her arms but also with her back and legs, thus involving her entire body—the core and periphery—in one coordinated, intentional, and directional movement.
After performing this movement several times, with progressively more integration and efficiency, Karen noted the unfamiliarity of this economical, well-organized, and integrated action, reporting that the movement was “entirely new—it makes me wonder what’s been going on all this time.” She realized that although she had said “no” on those dates, her body had said both “yes” and “no”—an artifact of her conflict between her own needs and desires, reminiscent of her earlier fear of loss of contact with her father if she refused his advances. Through this exploration, Karen gradually began to experience integration of boundaries with relationships, as well as integration between her core and peripheral movement. After practicing this more integrated movement of pushing away while working simultaneously with the trauma-related belief “I will always be alone,” Karen reported being able to maintain clearer sexual boundaries with men, as well as risk verbalizing her preferences in other relationships.
REFLEXIVE ACTION TENDENCIES AND SOCIABILITY
As a result of the work in phases 1 and 2, phase 3 relationships are less intense, more harmonious. Crises and disruptions in the therapeutic relationship are rare, signaling a readiness to challenge other less dramatic but more pervasive patterns of relating (Herman, 1992). Characteristic ways of coping in social situations, such as submitting, acquiescing, becoming aggressive, or withdrawing, are explored and changed (Brown et al., 1998; Herman, 1992; Van der Hart, Nijenhuis, & Steele, 2006). Clients develop the skills that allow them to remain relatively autonomous, connected to their core, while in relationship with others.
In phase 3 the client’s integrative capacity must be raised to expand the range and improve the quality of actions to include increasingly more complex, diverse, sophisticated, and integrated actions. Many clients have reflexively avoided responding to certain action systems, and thereby avoided certain actions, or if they have tried to execute those actions, they have been less integrated and less successful.
Therapists can encourage clients to address the mental actions that impede and accompany the physical actions. Mental actions of perception, planning, initiation, execution, and completion are required for every physical action. When their integrative capacity is low, traumatized individuals are likely to engage in mental actions of low quality, such as avoidance, compliance, and cognitive distortions (Van der Hart et al., 2006). Therapy helps clients raise their integrative capacity to the level at which they can discover, initiate, execute, and complete these mental and physical actions that require reflection, inhibition of defensive tendencies, self-awareness, affect regulation, thinking “on your feet,” and separating the past from the present.
After completing phases 1 and 2, Marika, age 46, was ready to work on her tendencies to avoid relationships. She had never experienced a sexual relationship, had few friends, and felt that she wanted to find out more about these patterns, after having discovered that she had a terminal illness. Her body reflected chronic peripheral tension in a hunch of her shoulders and constriction in her breathing. Her spine was stiff with very little flexibility. These patterns suggested an “overbounded” boundary style, and when talking about her childhood, Marika’s tense body tightened even more.
Marika expressed a desire to expand her capacity for social relationships. To reveal Marika’s tendencies as she sought proximity, her therapist suggested an experiment in which she asked Marika to walk slowly toward her from across the office. This experiment caused Marika to tighten from her spine out to her extrinsic musculature, and her movements were uncoordinated and jerky. She reported feeling uncomfortable, feeling the “familiar” tightening of her body when in social relationships. Her physical tendency was accompanied by the thought that she needed “space” along with irritability toward others. Underpinning these actions was a belief that proximity leads to being forced to submit to more contact than she wanted. These physical and mental actions conspired to produce a tendency that persisted even in the absence of abuse.
Although Marika maintained a high level of functioning in her profession as a lawyer, she had difficulty suspending reflexive distancing tendencies in nonprofessional relationships and could not reflect thoughtfully on the appropriateness of her reflexive behavior. The complex mental actions of mindfulness, the ability to observe the internal organization of experience (thought, emotion, body sensation, and movement), and the reflective ability to give careful thought and consideration to observations, actions, present demands, and goals are difficult for traumatized clients, particularly when their reflexive tendencies are active. Mindfulness and reflection are sophisticated actions that require much more integrative capacity—observation, reflection, delayed gratification, planning, reasoning, and critical thinking—than longstanding reflexive action tendencies possess (Janet, 1925; Van der Hart et al., 2006).
In phase 3 clients are encouraged to become increasingly aware of the sequence of mental and physical actions that comprises maladaptive tendencies. Over the course of therapy, Marika learned that her first action when exposed to social contact, prior to actually physically withdrawing, was holding her breath, followed by a sensation of tightening in her spine and viscera. She then noticed that the thought “Now they want something from me, and I will have to give it to them” came up repeatedly. She felt “stuck” in an emotional numbing and a physical preparedness to move away from proximity with others. Through reflection on these experiences, Marika became aware that they recapitulated being forced to submit to abuse during her childhood, a realization that was accompanied by the pain and despair that she had felt as a child.
Through mindfulness of mental and physical actions, insight into the origin of these reflexes is achieved, typically accompanied by increased affect and adaptive emotional expression. In Marika’s case, her mindful awareness of her somatic responses allowed her to gradually refrain from tightening the core of her body and to remain more relaxed when in social situations. Marika reminded herself to take a breath, sense her spine, and soften her extrinsic musculature. She also tried new mental actions, such as repeating to herself that she was no longer a child and that she did not have to do anything she did no want to do. In order to execute these complex actions, she had to inhibit her longstanding reflexive physical and mental tendencies.
Complex physical actions that integrate core and periphery require practice, time, and the development of integrative capacity. Marika achieved a new baseline after repeated practice and hard work in therapy, until the benefits of reflection and practicing new actions were literally incorporated. Marika’s response to social situations gradually and reliably became more adaptive to her present reality. She developed a responsive quality of restful alertness, connection with her core, ergonomic efficiency in the sequencing of movement from core to periphery, and increased capacity to orient to social cues, sense her response to them, and engage in adaptive actions. This progress was attributed to her capacity to reflect upon the reflexive tendencies and practice new, more complex actions that involved relaxation of both core and periphery, as well as engage in movements that promoted social contact. A new tendency had been established that brought Marika more satisfaction in response to the arousal of her sociability system. Even while Marika battled her terminal illness, she was able to form more deeply rewarding relationships with her friends and family and engage in satisfying interactions with medical personnel.
PLEASURE AND POSITIVE AFFECT TOLERANCE
As Janet noted, a vital characteristic of successful treatment is the client’s increased capacity for pleasure, “which we must do our utmost to obtain however difficult it may be”. Helping clients increase their capacity for pleasure may engender “substantial gains in resiliency” (Migdow) and provide an antidote to trauma-related ills. (Resnik, 1997). However, achieving this goal is complicated. Individuals with trauma-related disorders demonstrate significant impairments in their capacity to experience pleasure (Migdow, 2003). Many traumatized people are chronically depressed, anhedonic, or even hedonophobic. Both posttraumatic depression and fear are associated with the lack of a capacity for pleasure, and there is some evidence that disruptions in the dopaminergic system may underlie this difficulty (Cabib & Puglisi-Allegra, 1996; Depue, Luciana, Arbisi, Collins, & Leon, 1994; Watson, 2000).
After years of reliving and/or fending off traumatic memories and being consumed by cognitive distortions and traumatic preoccupations, traumatized individuals may have little experience with, or room for, pleasure (Luxenberg, Spinazzola, Hidalgo, et al., 2001; Luxenberg, Spinazzola, & Van der Kolk, 2001; van der Kolk et al., 1996). Their capacity for positive affect is also markedly reduced. They have come to associate positive affect with vulnerability to danger, especially if relaxing, laughing, playfulness, and pride and pleasure in accomplishment rendered them at risk for humiliation or exploitation. In addition, although elevated sympathetic arousal is associated with “intense elation” (Schore) in infants the same arousal may evoke defensive subsystems in the traumatized person. The fine line between pleasurable excitement and traumatic arousal may be hard to differentiate for individuals whose most common experiences of physiological activation have been trauma-related (Migdow, 2003). Although many of the pleasurable activities of life are paired with excitement, excitation itself may become something to avoid. This avoidance response interferes with adaptive responses to action systems of exploration, play, and sexuality, whose arousal includes varying degrees of excitement. Moreover, the cognitive distortions formed out of traumatic experiences further limit the positive affect that clients are able to experience (Kurtz, 1990; Migdow, 2003).
During some forms of trauma, clients may have experienced a complex mixture of sensations of pain and pleasure, as in cases of sexual abuse that was coupled with sexual arousal and orgasm. They may thereafter feel guilty or bad for the pleasure they felt during the abuse, or fear that pain and shame will come with pleasure, or even habitually seek the coupling of pain and pleasure, as seen in some clients who engage in harmful, sadomasochistic encounters.
Generally, traumatized individuals have become more accustomed to actions and goals that involve avoiding pain and fear rather than seeking out positive affect associated with pleasure. Preoccupied with the possibility of danger, they have not learned to attend to activities that might bring them pleasure. Such clients report that they do not know their own preferences—what activities would bring them pleasure, satisfaction, joy, or other feelings of well-being, what they are curious about or interested in, or what sensory stimuli feel good or meaningful to them (Migdow, 2003; Resnik, 1997).
Pleasure and Action Systems
The experience of pleasure is intimately related to action systems. The amplification of pleasure in infancy (and in adulthood) creates a “positively charged curiosity that fuels the burgeoning self’s exploration of novel socio-emotional and physical environments” (Schore), facilitating risk taking and fuller engagement in the action systems of daily living. Pleasant movements and sensations “are pleasant because they are recognized by the organism as fit to trigger and steer the behavior systems” (Frijda). Panksepp (1998) expanded upon this point:
A general scientific definition of the ineffable concept we call pleasure can start with the supposition that pleasure indicates something is biologically useful…. Useful stimuli are those that inform the brain of their potential to restore the body toward homeostatic equilibrium when it has deviated from its biologically dictated “set-point” level.
Pleasure ensues when we take action to restore balance or mitigate disequilibrium (Damasio, 1999; Panksepp, 1998). The internal motivation, emanating from the core, to accomplish the goals of psychobiological action systems also fuels desire for the pleasure of that completion. Thus pleasure can be seen as the stimulation of an action system and the fulfillment of its goals (Frijda, 1986).
Stimuli that are useful to survival are appealing and pleasurable as long as the action system is aroused but not when it is dormant or sated. Once the goals of an action system have been met, we no longer seek the stimuli that would fulfill those goals: After a full meal, food is no longer appealing, and the sight or smell of it may even be unpleasant. When satiation is accomplished, the capacity of the action-system-related stimuli to bring pleasure is markedly diminished.
Damasio stated that “pain is aligned with punishment and is associated with behaviors such as withdrawal or freezing [and other defensive subsystems]. Pleasure, on the other hand, is aligned with reward and is associated with behaviors such as seeking and approaching”. Pleasure is experienced when one anticipates reward, finds solutions to unfulfilled goals of a particular action system, and fulfills those goals. The need to restore equilibrium, and the accompanying expectation of pleasure, “cause[s] organisms to open themselves up and out toward their environment, approaching it, searching it, and by so doing increasing both their opportunity of survival and their vulnerability” (Damasio). Thus, the search for the pleasure of meeting the goals of action systems is coupled with increased risk-taking, often frightening to traumatized individuals.
All too often, the traumatized person’s attempts to seek pleasure through actions of approach and expansion, even when initiated from the core, are met by a collapse and loss of energy or by a contraction, either of which hinders and dampens the experience of pleasure (Lowen, 1970). The movements reflect a lack of integration between core and periphery and may be tense, jerky, uncoordinated, or weak. In contrast, pleasure is felt in “quiet and harmonious movements” or, when accompanied by excitement, intense and lively movements (Lowen, 1970) that are executed smoothly, from the core out to the periphery.
The Pleasure of Completing Actions
For the traumatized individual in phase 3 treatment, a primary goal is to discover the physical and mental tendencies that encourage the completion of seeking and approaching actions. Janet (1925) noted that traumatized patients seek the joy that emerges when challenges are met and actions are satisfactorily completed. The “stage of triumph” thus includes not only completing truncated mobilizing defensive actions but also completing a variety of mental and behavioral actions: physical actions such as reaching, mental actions such as changing cognitive distortions, and expressing emotions. “This joy and this triumph are…present after every action that has been well completed” (Janet).
In this final phase clients learn to sense the core of their body, which helps them reestablish an internal locus of control and define their true desires and impulses. From an increased connection, clients begin to initiate, implement, and complete actions in a manner that increases satisfaction and joy. For example, Marika learned to form rewarding relationships by practicing sensing the core of her body, relaxing her habitual core tension in social situations, and eventually reaching out to significant friends—all actions that brought her deep satisfaction. As Janet (1925) wrote:
When an action is being functionally restored, and when improvement is taking place, we almost always notice at a certain moment that satisfaction reappears in one form or another, a sort of joy which gives interest to the action, and replaces the feelings of useless absurdity, and futility which had formerly troubled the patient in connection with the action.
Helping clients experience the pleasure of completed actions by asking them to find ways of executing actions that feel “good” and “right” assists them in learning to distinguish pleasurable actions from unpleasurable ones.
Interventions for Pleasure
In phase 3 clients are challenged to expand their ability to experience and tolerate increasing levels of pleasure and excitement without triggering the fear, anxiety, or numbing that accompany defensive tendencies (Brown et al., 1998). Pleasure is experienced on a continuum, and it is intimately related to, as well as a trigger for, certain emotions such as happiness or joy (Damasio). Migdow wrote: “The first developmental task in the evolution of the capacity for pleasure is awareness of sensation”. Clients are encouraged to risk becoming aware of pleasurable sensations, feelings of aliveness and increased energy, challenging their perceptions that body sensations, or even the actual awareness of having a body, will lead to pain rather than pleasure. They are taught new skills of discerning what they are curious about, what sensory experiences feel good to them, even what clothes, foods, and activities they enjoy or prefer (Migdow, 2003). Clients are also encouraged to learn new things and discover the internal joy and satisfaction in mastering difficult tasks (Brown et al., 1998). They might acquire new skills and competencies such as increasing their prowess at sports, playing a musical instrument, or becoming comfortable in large groups. In these endeavors they learn to tolerate frustration and the pleasurable experience of achievement and success.
Therapists should be aware that an increase in positive affect may be anxiety producing to the client who has little or no history in relation to the new experience. Often such clients are unable to tolerate the unfamiliar pleasurable experience and quickly return to their old tendencies, seeking refuge in the familiarity of longstanding numbing and avoidance strategies. “By moving [from pleasurable states] back to the accustomed dysphoria, the separation anxiety from that familiar experience-identity is quelled” (Krueger). They need the support and encouragement of the therapist to resist the pull of trauma-related tendencies and persevere in tolerating positive affect.
The sensitive and judicious use of touch can be a means of reintroducing clients to, and reeducating them on, the experience of pleasure. With a torture survivor, for example, gentle touch was used to reestablish the pleasure of body sensation and counteract the torture experience. For a client who experienced childhood beatings, the therapist gently touched his back and asked him to compare that somatic sensation to the memory of the beatings. This comparison began to enable the client to attend to and feel neutral and pleasurable sensations in his back, which had previously been “screened out” in favor of the more vividly remembered experience of the beatings. A childlike quality of wonder and amazement may accompany the reconnection with pleasurable sensations of the body, a phenomenon observed in the late 1800s:
When the restoration of [sensation] is complete, when the patient has been fully reawakened, he usually gives utterance to feeling of astonishment and joy, in such terms as…“It is strange how large everything is here; the furniture and the other objects in the room seem brighter, I can feel my heart beating….” These feelings of well-being make the patient laugh, and give him a general aspect of gaiety and health. (Sollier, 1897, in Janet)
Teaching patients to find pleasure in bodily sensation and actions during therapy sessions paves the way for their finding pleasure, on their own, in other activities such as eating, touch, warm baths, and other sensual pursuits. Focusing on becoming acutely aware of present-moment sensory perceptions—colors, smells, sounds, sensations on the skin from textures, air currents, and temperature—can also be helpful ways for clients to learn about, and tolerate, pleasurable sensations.
As with all challenges given to the client, enjoyment is highest when the goal is met but lowest when it is beyond his or her capabilities (Frijda, 1986) and a sense of failure ensues, the opposite of enjoyment (Janet, 1925). Phase 3 interventions must be designed to maximize chances for success so that clients learn to tolerate and enjoy incrementally greater experiences of pleasure, thereby counteracting past traumatic experiences. When goals are achieved and actions are completed, clients experience the pleasurable sense of accomplishment and are encouraged to continue to expand their capacity for pleasure. As Herman pointed out: “The best indices of resolution are the survivor’s restored capacity to take pleasure in her life and to engage fully in relationship with others. She has become more interested in the present and the future than in the past, more apt to approach the world with praise and awe than with fear”. The pleasure and satisfaction gleaned from these interactions with others and the world are augmented by integration between the core and periphery of the body, resulting in movements that are graceful and aligned and that, in turn, increase the somatic sense of pleasure.
The therapist can track when a present experience is pleasurable by noting a slight smile, a deep breath, an integrated movement, increased energy, and so on. These moments can be acknowledged and expanded through awareness of the body and associated memories, thoughts, affective tone, and words. It is also important to help clients find movements and postures that they experience as pleasurable or, at least, as not uncomfortable. One client, for instance, felt an absence of disturbing sensations when she curled up on the therapist’s couch, wrapped in a blanket. She was encouraged to identify these sensations and savor the absence of discomfort.
For some clients, even the mere presence of the therapist in the room, attentive to their pain, is pleasurable. One client tearfully said to her therapist, “I’m here because you’re here—I couldn’t hold this on my own.” Her therapist gently helped this client sense the pleasurable feelings in her body in this tender and powerful moment—feelings that the client described as “solid” and “substantial” through her tears of old pain mixed with the new pleasurable feeling of no longer being alone.
Joan grew up under very stressful conditions as the oldest of eight children with abusive, poor, and drug-addicted parents. Joan adapted to this dysfunctional environment by learning to “hunker down,” a mental tendency that was mirrored in tension across her shoulders, a compression in her spine, a lack of movement and freedom in her upper body, and a plodding quality to her gait. Joan felt she could endure nearly any hardship, but this ability “to bear up under difficult conditions” left her with “little sense of joy and lightness” (Kurtz). When Joan first became aware of her body, she discovered that her core felt compressed and her extrinsic muscles were tight. She felt weighted downward, with little spontaneous movement or “aliveness” in her body. Exploring different styles or habits of walking (tentative steps, heavy, plodding steps, quick, rigid movements, or slow, “sloppy” movements) assisted her in studying how she literally “moved” in the world. In becoming aware of her heavy, plodding, slow gait, Joan discovered the words that correlated with her movements: “I have to work hard; I can never have any fun.” A primary focus of Joan’s final phase of therapy then became to change these limiting beliefs and to increase her capacity for positive affect and pleasure. Alignment of posture and integrated movement were practiced to correspond with and support changes in her cognitive schemas. Joan practiced bringing more movement into her upper body and being “lighter” on her feet to mitigate the belief “I can never have any fun.” Practicing reaching out with a relaxed arm supported her desire to take action to connect with others. As healthy beliefs about attachment, intimacy, and the other action systems were developed, she was encouraged to discover new physical actions compatible with these new orientations, and to savor the pleasurable sensations when she achieved the goals of these action systems.
CONCLUSION: INTEGRATION OF A NEW SENSE OF SELF
By the conclusion of phase 3, the skills learned in previous stages have become automatic, and previously underutilized action systems now can emerge without intrusions from defensive subsystems. A new capacity for positive states allows integration of a new somatic and linguistic sense of self. The systems of defense that served the client in the past become integrated with the other action systems that foster a normal life environment. The ability to self-regulate and self-soothe makes possible the risk of attempting social reconnection and engaging in all the action systems of daily life, including the cultivation of an expanded sense of pleasure. As successful mastery of skills learned in phase 3 transmutes clients’ earlier experience of themselves, they discover a new sense of self that is more flexible, adaptive, and capable of pleasure and positive affect (Siegel, 2006).
EPILOGUE: FROM TRAGEDY TO TRIUMPH
Although words are indispensable in the treatment of trauma, they cannot substitute for the meticulous observation of how clients attempt to defend themselves in the present or how such defenses were thwarted during the original traumatic event. Nor can words replace the empowering therapeutic facilitation of the physical defensive actions that were impossible to implement during the actual traumatic event, or the satisfying actions that serve the goals of action systems related to daily life. As we have described over the course of this book, bodily experience becomes a primary avenue for intervention in sensorimotor psychotherapy, and emotional expression and meaning making arise out of the subsequent somatic reorganization of habitual trauma-related responses. Sensorimotor approaches synthesize top-down and bottom-up interventions, attending to the body directly, so that it becomes possible to address the more primitive, automatic, and involuntary tendencies that underlie traumatic and posttraumatic responses.
Since the time of Freud, most psychotherapeutic approaches have focused on cognitive and emotional processing over sensorimotor processing, and many of those approaches have been successfully utilized to relieve trauma symptoms. However, because somatoform symptoms are particularly significant in traumatized individuals, treatment efficacy may be increased by the addition of interventions that facilitate sensorimotor processing. Regardless of the nature of the trauma’s origin, we find that confronting somatic issues by directly addressing sensorimotor processing can be useful in restoring normal healthy functioning for victims of trauma. A hierarchical information-processing model emphasizes that integration must always entail all three levels of experience. No experience that we encounter, including traumatic events, affects only a single level of information processing. Thus sensorimotor processing alone is insufficient; the integration of all three levels of processing—sensorimotor, emotional, and cognitive—is essential for trauma recovery.
Physical interventions can provide clients with the somatic resources and skills to deal with disturbing bodily reactions. As they begin to learn how to limit the amount of information they must process at any given moment by focusing attention solely on their sensations and tracking physical responses and arousal, clients frequently report increasing feelings of calm. Similarly, as they experience the potential to physically protect and defend themselves through executing empowering actions, feelings of safety in the world begin to develop. The events they endured have not changed, but the negative effects on mind and body have been transformed. Rather than feeling helpless, alone, and vulnerable in a threatening world, they begin to feel a sense of solidness and solidarity—an ability to protect themselves and a sense that others are there for help and support—thereby achieving mastery over arousal coupled with the feeling that they are not alone.
Moreover, the satisfaction and pleasure experienced when a client is finally able to execute direct physical actions related to defense or other action systems alter the somatic sense of self in a way that talking alone does not. Knowing, feeling, and doing—and thus experiencing—these physical actions help to transform the way in which clients consciously and unconsciously hold and organize past traumas in their bodies and minds, the way they respond (cognitively, emotionally, and physically) in their current lives, and the way they envision the future. Synthesizing these bottom-up interventions with top-down approaches combines the best of both worlds and enables chronically traumatized clients to find resolution by finally being able to integrate past and present, emotion and meaning, belief and body. As one traumatized client wrote months after termination:
Working with my body has helped me work with the beliefs that were doing so much damage—that I don’t deserve to have a good life, I don’t deserve anything from others, that I deserve to be hurt, that it’s better to just disappear and be hurt now than to wait for it to happen. But now I can bring the strong resourced adult that I am to these feelings and not have to blindly act them out…. I can now feel and experience my past from a strong place that knows I survived and am so much bigger and more compassionate as a result. This is a big shift from feeling that I have no substance and must be some sort of awful abhorrent low-life to have deserved these experiences.
Out of the transformations in her physical experience, this client emerged finally with compassion for herself and a felt sense of worth. Our hope for all our clients is that they too can take up their lives as people who survived terrible experiences but were ultimately strengthened, not destroyed, by them. These hard-won achievements are the definitive mark of the successful completion of treatment. In the words of Victor Frankl, “Even the helpless victim of a hopeless situation, facing a fate he cannot change, may rise above himself, may grow beyond himself, and by so doing, change himself. He may turn a personal tragedy into a triumph”.