THE DRAMATIC ADVANCES IN NEUROSCIENCE over the past decade have led to important new insights into how mind and brain process traumatic experiences. The work of neuroscientists such as Antonio Damasio, Joseph LeDoux, Jaak Panksepp, Steve Porges, Rodolfo Llinas, and Richie Davidson has shown that living creatures more or less automatically respond to incoming sensory information with relatively stable action patterns: predictable behaviors that can be elicited over and over again when they are presented with similar input. The function of the “mind”—that extraordinary human capacity to observe, know, and predict—is to inhibit, organize, and modulate those automatic responses, thereby helping us manage and preserve our relationships with our fellow human beings, on whom we so desperately depend for meaning, company, affirmation, protection, and connection.
However, the mind, although able to organize our feelings and impulses, does not seem to be particularly well equipped to entirely abolish unacceptable emotions, thoughts, and impulses. In fact, it seems to be geared more toward creating a rationale for troublesome behavior (e.g., “it’s for your own good” or “to create a better world”) than toward eliminating it. As a consequence, people seem to be condemned to accommodating their “irrational” longings and unacceptable feelings of fear, anger, helplessness, lust, and despair without ever being able to completely master them.
Fundamentally, life is about making our way in the world, and how we do that depends on the hard-wiring of our brains. This hard-wiring is derived from the evolutionary legacy that we more or less share with all living creatures, combined with the imprints of our own personal early experiences. The basic blueprint of our map of the world and the way we move through it consists of connections between the arousal system of the brain (the reptilian brain) and the interpretive system in the mammalian brain (the limbic system). These connections organize how all animals, including humans, organize their responses to sensory stimuli—and these responses, first and foremost, concern movement.
Neuroscience research has come a long way in helping to clarify why the same stimulus that pleases some people, irritates others. Emotional responses occur not by conscious choice but by disposition: limbic brain structures such as the amygdala tag incoming sensory stimuli to determine their emotional significance. The interpretation by these subcortical brain structures is based largely on prior experience, which determines our disposition to approach or avoid whatever we encounter. Moreover, it is becoming more and more apparent that response refers to an action we are impelled to take—that is, how we are physically inclined to move after receiving any particular stimulus. Neuroscience has confirmed earlier observations by scientists such as Darwin and William James that physical, bodily feelings form the substrate of the emotional states that shape the quality of our decision-making efforts and the solutions we create to deal with particular dilemmas. These physical feelings in turn, propel the human organism to take certain actions: as Roger Sperry, who won the Nobel Prize for medicine in 1981, said, “The brain is an organ of and for movement: The brain is the organ that moves the muscles. It does many other things, but all of them are secondary to making our bodies move” (1952). Sperry claimed that even perception is secondary to movement: “In so far as an organism perceives a given object, it is prepared to respond to it…. The presence or absence of adaptive reaction potentialities, ready to discharge into motor patterns, makes the difference between perceiving and not perceiving” (1952).
The neuroscientist Rodolfo Llinas summarized the relationship between action and the brain as follows: In order to make its way in the world any actively moving creature must be able to predict what is to come and find its way where it needs to go. Prediction occurs by the formation of a sensorimotor image, based on hearing, vision, or touch, which contextualizes the external world and compares it with the existing internal map. “The…comparison of internal and external worlds [results in] appropriate action: a movement is made” (Llinas, 2001). People experience the combinations of sensations and an urge for physical activation as an emotion.
Both Charles Darwin (1872) and Ivan Pavlov (1928) clearly understood that the goal of emotions is to bring about physical movement: to help the organism get out of harm’s way, in the case of negative emotions, and to move it in the direction of the source of the stimulus in the case of positive ones. Darwin, in particular, pointed out that human beings are not any different from animals in this regard. Emotions activate the organism to respond in prescribed ways, such as defending oneself, preparing to fight, turning one’s back on someone, or approaching someone for greater intimacy and care. In short, emotions serve as guides for action.
Nina Bull, Jaak Panksepp, Antonio Damasio, and others have demonstrated that each particular emotional state automatically activates distinct action tendencies: a programmed sequence of actions. When people process incoming perceptions, they interpret the new information by comparing it with prior experience. On the basis of this comparison the organism predicts the outcome of various possible actions and organizes a physical response to the incoming stimulus. As Damasio said, “Physical actions are creating the context for mental actions; bottom-up processes are affecting upper level processes. [This is] the feeling of what is happening” (1999). Damasio(1999) further explained:
It makes good housekeeping sense that [the brain] structures governing attention and structures processing emotion should be in the vicinity of one another. Moreover, it also makes good housekeeping sense that all of these structures should be in the vicinity of those which regulate and signal body state. This is because the consequences of having emotion and attention are entirely related to the fundamental business of managing life within the organism, while, on the other hand, it is not possible to manage life and maintain homeostatic balance without data on the current state of the organism’s body proper.
What makes people unique in the animal kingdom is their flexibility: their capacity to make choices about how they respond to their environment. This flexibility is the result of the property of the human neocortex to integrate a large variety of different pieces of information, to attach meaning to both the incoming input and the physical urges (tendencies) that these evoke, and to apply logical thought to calculate the long-term effect of any particular action. This allows people to continually discover new ways of dealing with incoming information and to modify their responses on the basis of the lessons they have learned in a much more complex way than the conditioning we see in dogs and other animals.
However, this capacity to respond in a flexible manner emerges only slowly over the course of human development and is easily disrupted. Small children have little control over their crying and clinging when they feel abandoned, nor do they have much control over expressing their excitement when they are delighted. Even adults are prone to engage in automatic behaviors when they are stirred by intense emotions. They are likely to execute whatever “action tendency” is associated with any particular emotion: confrontation and inhibition with anger; physical paralysis with fear, physical collapse in response to helplessness; an inexorable impulse to move toward sources of joy, such as running toward people we love, followed by an urge to embrace them, and so on. Since at least 1889 (Janet) it has been noted that traumatized individuals are prone to respond to reminders of the past by automatically engaging in physical actions that must have been appropriate at the time of the trauma but that are now irrelevant. As Janet noted: “Traumatized patients are continuing the action, or rather the attempt at action, which began when the thing happened and they exhaust themselves in these everlasting recommencements” (1919/1925).
The current discoveries in the neurosciences about the automatic activation of hormonal secretions, emotional states, and physical reactions in response to sensory input have once again confronted psychology with a reality that was first emphatically articulated by Freud: that most human actions and motivations are based on processes that are not under conscious control. The implications of these discoveries are particularly relevant for understanding and treating traumatized individuals. Realizing that they are prone to activate automatic trauma-related hormonal secretions and physical action patterns clarifies why they would tend to respond to certain triggers with irrational—that is, subcortically initiated—responses that are irrelevant and even harmful in the context of present demands: They may blow up in response to minor provocations, freeze when frustrated, and become helpless in the face of trivial challenges. Without a historical context to understand the somatic and motoric carryover from the past, their emotions appear out of place and their actions bizarre. These symptoms of an uncompleted past tend to become a source of shame and embarrassment to those who experience them.
One of the most robust findings of the neuroimaging studies of traumatized people is that, under stress, the higher brain areas involved in “executive functioning”—planning for the future, anticipating the consequences of one’s actions, and inhibiting inappropriate responses—become less active (van der Kolk, in press). Just like small children loose the veneer of socialization and throw temper tantrums when they are frustrated, traumatized adults are prone to revert to primitive self-protective responses when they perceive certain stimuli as a threat. Once sensory triggers of past trauma activate the emotional brain to engage in its habitual protective devices, the resulting changes in sympathetic and parasympathetic activation interfere with effective executive function: The higher brain functions have less control over behavior, causing a behavioral “regression.” Without well-functioning rational brains, individuals are prone to revert to rigid “fixed action patterns”: the automatic behavioral flight, fight, or freeze responses that are our evolutionary heritage of dealing with threat, and our individual implicit memories of how our own bodies once attempted to cope with the threat of being overwhelmed. The legacy of trauma is that these somatic (i.e., endocrine and motoric) patterns can be triggered by the slightest provocations, reactivating the physical response of the organism to past terror, abandonment, and helplessness, sometimes in exquisite detail.
Psychology and psychiatry, as disciplines, have paid scant attention to the behavioral (i.e., muscular, organic) responses that are triggered by trauma reminders and, instead, have narrowly focused on either the neurochemistry or the emotional states associated with the reminders. They thereby may have lost sight of the forest for the trees: Both neurochemistry and emotions are activated in order to bring about certain bodily postures and physical movements that are meant to protect, engage, and defend. The dramatic advances in pharmacotherapy have helped enormously to control some of the neurochemical abnormalities caused by trauma, but they obviously are not capable of correcting the imbalance.
The fact that triggers reinstate some of the hormonal and motoric responses to the original trauma raises some important issues: The DSM-IV definition of posttraumatic stress disorder (PTSD) emphasizes physiological hyperarousal in response to traumatic reminders. However, trauma is not simply a physiological response. The essence of trauma is utter helplessness combined with abandonment by potentially protective caregivers. Probably the best animal model for this phenomenon is that of “inescapable shock,” in which creatures are tortured without being unable to do anything to affect the outcome of events (van der Kolk, Greenberg, Boyd, & Krystal, 1985). This causes them to collapse and stop trying to fight or escape. For human beings the best predictor of something becoming traumatic seems to be a situation in which they no longer can imagine a way out; when fighting or fleeing no longer is an option and they feel overpowered and helpless. As Darwin already pointed out: the emotions of fear, disgust, anger, or depression are signals to communicate to others to back off or protect. When a person is traumatized, these emotions do not produce the results for which they were intended: The predator does not back off, desist, or protect, and whatever action the traumatized person takes fails to restore a sense of safety.
After one or more confrontations with the futility of their emotions and automatic action patterns to restore safety and control, many traumatized children and adults seem to lose the capacity to utilize their emotions as guides for effective action. Their emotions may get activated, but they don’t recognize what they are feeling. This is called an inability to verbally identify the meaning of physical sensations and muscle activation, alexithymia. This inability to recognize what is going on inside—to correctly identify sensations, emotions, and physical states—causes individuals to be out of touch with their needs and incapable of taking care of them, and often extends to having difficulty appreciating the emotional states and needs of those around them. Unable to gauge and modulate their own internal states, they habitually collapse in the face of threat or lash out in response to minor irritations. The hallmark of daily life becomes futility.
When contemporary trauma studies rediscovered the profound disruptions in the subjective experience of physical sensations and the automatic activation of fixed action patterns in traumatized children and adults (the French psychiatrist Pierre Janet had done extensive research on this issue a century ago, but we did not recognize his contribution till later), the mainstream therapeutic community found itself at a loss as to how to address the deficits in those areas. One point was clear: The rational, executive brain—the mind, the part that needs to be functional in order to engage in the process of psychotherapy—has very limited capacity to squelch sensations, control emotional arousal, and change fixed action patterns. The problem that Damasio (1999) articulated had to be solved:
We use our minds not to discover facts but to hide them. One of things the screen hides most effectively is the body, our own body, by which I mean, the ins and outs of it, its interiors. Like a veil thrown over the skin to secure its modesty, the screen partially removes from the mind the inner states of the body, those that constitute the flow of life as it wanders in the journey of each day. The elusiveness of emotions and feelings is probably…an indication of how we cover to the presentation of our bodies, how much mental imagery masks the reality of the body.
Given that understanding and insight are the main staples of both cognitive–behavioral therapy (CBT) and psychodynamic psychotherapy, the principal therapies currently taught in professional schools, the discoveries in neuroscience research have been difficult to integrate with contemporary therapeutic practice. Neither CBT nor psychodynamic therapeutic techniques pay much attention to the experience and interpretation of physical sensations and preprogrammed physical action patterns. Given that Joseph LeDoux had shown that, at least in rats, “emotional memories are forever” and that the dorsolateral prefrontal cortex, the center for insight, understanding, and planning for the future, has virtually no connecting pathways to affect the workings of the emotional brain, the best verbal therapies can offer is to help people inhibit the automatic physical actions that their emotions provoke. In short, verbal therapies can help people with “anger management” (i.e., quieting themselves down before blowing off the handle) such as in counting to ten and taking deep breaths.
The realization that insight and understanding are not enough to keep traumatized people from regularly feeling and acting as if they were traumatized all over again forced clinicians to explore techniques that offer the possibility of reprogramming these automatic physical responses. It was only natural that such techniques would have to involve methods that address people’s awareness of their internal sensations and their physical action patterns. Of course, many different cultures have healing traditions that activate and utilize physical movement and breath, such as yoga, chi qong, tai chi, and other Asian and African traditions. However, in the West, approaches that involve working with sensation and movement have been fragmented and have remained outside the mainstream of medical and psychological teaching. Nevertheless, working with sensation and movement has been extensively explored in such techniques as focusing, sensory awareness, Feldenkrais, Rolfing, the F. M. Alexander Technique, bodymind centering, somatic experiencing, Pesso–Boyden psychotherapy, Rubenfeld synergy, authentic movement, the Hakomi method, Middendorf breath work, and many others. Although each of these techniques involves very sophisticated approaches, the nature and effects of these practices are not easily articulated, and, as Don Hanlon Johnson noted, their meanings are not easily captured in the dominant intellectual categories. The most noteworthy integration of body work and mainstream science occurred when Nikolaas Tinbergen discussed the Alexander technique in his 1973 Nobel Prize acceptance speech.
During the past few decades, several body-oriented practitioners specifically have addressed the somatosensory impact of trauma. To my mind, the three outstanding teachers in this area—those who have had the most profound influence on myself and many of the clinicians I work with—have been Pat Ogden, the author of this book, Peter Levine, and Al Pesso. After decades of training in Rolfing, Hakomi, and other body-oriented techniques, Pat Ogden integrated the psychological and neurobiological effects of trauma with body work and has founded a new school of therapy that incorporates work with sensorimotor processes firmly anchored in attachment theory, neuroscience, and traditional psychotherapeutic practice.
Sensorimotor psychotherapy is sensitive to the fact that most trauma occurs in the context of interpersonal relationships. This reality means that trauma involves boundary violations, loss of autonomous action, and loss of self-regulation. When people lack sources of support and sustenance, such as is common with abused children, women trapped in domestic violence, and incarcerated men, they are likely to learn to respond to abuse and threats with mechanistic compliance or resigned submission. Particularly if the brutalization has been repetitive and unrelenting, they are vulnerable to ongoing physiological dysregulation (i.e., states of extreme hypo-and hyperarousal) accompanied by physical immobilization. Often, these responses become habitual. As a result, many victims develop chronic problems initiating effective, independent action, even in situations where, rationally, they would be expected to be able to stand up for themselves and “take care of things.”
Many traumatized individuals learn to dissociate and compartmentalize: They may be competent and focused most of the time, but they may suddenly collapse into primitive and inflexible states of helplessness and immobilization when they are confronted with situations or sensations that remind them of the past. Some may remain aware of what they are feeling, what is going on around them, about potential escape routes, and physical impulses to protect themselves, whereas others space out and lose contact with both their internal sensations and what is going on in their environment. Many clinicians, when assessing for dissociative problems, focus on emotions and behaviors. However, sensorimotor psychotherapy specifically deals with dissociative symptoms that involve body sensations, movement disorders, dysregulated physiological arousal, lack of body sensations, and reexperiencing the trauma in somatosensory fragments.
Describing traumatic experiences in conventional verbal therapy is likely to activate implicit memories in the form of trauma-related physical sensations, physiological dysregulation, involuntary movements, and the accompanying emotions of helplessness, fear, shame, and rage, without providing the resources to process these nonverbal remnants of the past. When this sequence occurs, trauma victims are likely to feel that it still is not safe to deal with the trauma; instead they will tend to seek a supportive relationship in the present. The therapist thereby becomes a refuge from a life marked by ineffectiveness and futility.
Sensorimotor psychotherapy directly addresses the fact that the traumatic past continues to influence how people perceive themselves and their surroundings, and how they position themselves in relationship to the world around them. Rather than focusing on how people make meaning of their experience—their narrative of the past—the focus is on clients’ physical self-experience and self-awareness. Body-oriented therapies are predicated on the notion that past experience is embodied in present physiological states and action tendencies: The trauma is reenacted in breath, gestures, sensory perceptions, movement, emotion, and thought. The role of the therapist is to facilitate self-awareness and self-regulation, rather than to witness and interpret the trauma. Therapy involves working with sensations and action tendencies in order to discover new ways of orienting and moving through the world.
Working with traumatized individuals entails the overcoming of several major obstacles. One is that, although human contact and attunement are cardinal elements of physiological self-regulation, interpersonal trauma often results in a fear of intimacy. For many people the anticipation of closeness and attunement automatically evokes implicit memories of hurt, betrayal, and abandonment. As a result, feeling seen and understood—which helps most people feel calm and in control—may precipitate a reliving of the trauma in individuals who have been victimized in intimate relationships. Therefore, before trust can be established, it is important to help clients create a physical sense of control by working on the establishment of physical boundaries, exploring ways of regulating physiological arousal (using breath and body movement), and focusing on regaining a physical sense of being able to defend and protect themselves. It may be useful to explore previous experiences of safety and competence and to activate memories of what it feels like to experience pleasure, enjoyment, focus, power, and effectiveness. Working with trauma is as much about the person remembering how he or she survived as it is about addressing what was broken. As Pat Ogden emphasizes in this book, “Discover[ing] the abandoned empowering active defenses that were ineffective at the time of the trauma.”
Another problem is that, neurobiologically speaking, the only part of the conscious brain that is capable of influencing emotional states (which are localized in the limbic system) is the medial prefrontal cortex, the part that is involved in introspection (i.e., attending to the internal state of the organism). Various neuroimaging studies reviewed in this book have shown decreased activation of the medial prefrontal cortex in individuals with PTSD (Lanius, 2002; Clark & McFarlane, 2000). This means that traumatized individuals, as a rule, have serious problems attending to their inner sensations and perceptions. When asked to focus on internal sensations, they tend to feel overwhelmed or deny having any. When they finally do pay attention to their inner world, they usually encounter a minefield of trauma-related perceptions, sensations, and emotions (van der Kolk & Ducey, 1989). They often feel disgusted with themselves and usually have a very negative body image; as far as they are concerned, the less attention they pay to their bodies, the better. Yet one cannot learn to take care of oneself without being in touch with the demands and requirements of one’s physical self.
Hence, Pat Ogden proposes that therapy is about learning to become a careful observer of the ebb and flow of internal experience, mindfully noticing whatever thoughts, feelings, body sensations, and impulses emerge. Traumatized individuals, first and foremost, need to learn that it is safe to have feelings and sensations. In this process it is critical for clients to become aware that bodily experience never remains static. Unlike at the moment of a trauma, when everything seems to freeze in time, physical sensations and emotions are in a constant state of flux.
In order to deal with the past, traumatized people need to activate their medial prefrontal cortex, their capacity for introspection. Therapy needs to help them develop a deep curiosity about their internal experience. This curiosity is essential in learning to identify their physical sensations and to translate their emotions and sensations into communicable language—communicable, most of all, to themselves. Once people realize that their internal sensations continuously shift and change, that they have considerable control over their physiological states, and that remembering the past does not inevitably result in overwhelming emotions, they can start to explore ways to actively influence the organization of their internal landscape. As patients learn to tolerate being aware of their physical experience, they discover physical impulses and options that they had abandoned for the sake of survival during the trauma. These impulses and options manifest themselves in subtle body movements such as twisting, turning, or backing away. Amplifying these physical impulses and experimenting with ways to modify them ultimately bring the incomplete trauma-related action tendencies to completion.
Traumatized people often lose the effective use of fight or flight defenses and respond to perceived threat with immobilization. Sensorimotor psychotherapy helps them reorient to the present by learning to attend to nontraumatic stimuli. This focus opens them up to learning from new experiences, rather than reliving the past over and over again, without modification by subsequent information. Once they learn to reorient themselves to the present, individuals can experiment with responding to perceived threats by rediscovering their lost capacities to actively defend and protect themselves.
Sensorimotor psychotherapy is based on the premise that, in order to overcome the tendency to be trapped in the past, the traumatized person needs to (1) become aware of old automatic maladaptive action tendencies, (2) learn to inhibit the initial impulses, (3) experiment with various alternatives to bring to completion the incomplete, frozen actions that proved to be futile at the moment of the trauma, and (4) practice ways to execute alternative, effective actions. Pat Ogden’s book is the first work to integrate our knowledge of body-oriented therapy, neuroscience, and attachment theory into a composite treatment method. Hopefully, after this wonderful integration, therapy for traumatized individuals will take a giant leap forward and never be the same.