THE BODY, FOR A HOST OF REASONS, has been left out of the “talking cure.” Psychotherapists who have been trained in models of psychodynamic, psychoanalytic, or cognitive therapeutic approaches are skilled at listening to the language and affect of the client. They track clients’ associations, fantasies, and signs of psychic conflict, distress, and defenses. They register the various narrative threads clients bring, bearing in mind how and where the childhood story repeats itself in the present. They are skilled in creating the therapeutic alliance, working within a therapeutic frame, and recognizing transference and countertransference nuances and enactments. They monitor physical symptoms, using psychopharmacological interventions when indicated. And they invariably take note of the physical presentation of their clients, such as the mannerisms, subtle changes in weight or choice of clothing, the slumped posture of a depressed client, or agitated movements of an anxious client. Yet although most therapists are trained to notice the appearance and even the movements of the client’s body, working directly with the client’s embodied experience is largely viewed as peripheral to traditional therapeutic formulation, treatment plan, and interventions.
Sensorimotor psychotherapy builds on traditional psychotherapeutic understanding but approaches the body as central in the therapeutic field of awareness and includes observational skills, theories, and interventions not usually practiced in psychodynamic psychotherapy. Theoretical principles and treatment approaches from both the mental health and body psychotherapy traditions are integrated in this approach. Sensorimotor psychotherapy draws heavily from the Hakomi method, a form of body-oriented psychotherapy pioneered by Ron Kurtz (Kurtz, 1990), as a foundation for therapeutic skills and incorporates theory and technique from psychodynamic psychotherapy, cognitive–behavioral therapy, neuroscience, and theories of attachment and dissociation. The premise of this book is that traditionally trained therapists can increase the depth and efficacy of their clinical work by adding body-oriented interventions to their repertoire.
We use the term sensorimotor psychotherapy generically to indicate an approach that incorporates somatic interventions that are used by most body psychotherapists. However, sensorimotor psychotherapy is also a school that has developed body psychology theory to guide the use of somatic interventions, so the term is also used to refer to the synthesis unique to this school. The school teaches working with body sensation and movement, but generally excludes the use of touch. The judicious use of touch in psychotherapy may occasionally be helpful in specific situations, but is also potentially problematic, and is not a necessary component of this method (see Chapter 9 for further explanation).
We know that trauma has profound effects on the body and nervous system and that many symptoms of traumatized individuals are somatically driven (Nijenhuis & Van der Hart, 1999; Van der Hart, Nijenhuis, Steele, & Brown, 2004; van der Kolk, 1994; van der Kolk, McFarlane, & Weisaeth, 1996). Clients suffering from unresolved trauma nearly always report unregulated body experience; an uncontrollable cascade of strong emotions and physical sensations, triggered by reminders of the trauma, replays endlessly in the body. This chronic physiological arousal often is at the root of the recurring posttraumatic symptoms for which the client seeks therapy. The capacity to assimilate the traumatic experience within a life narrative is not yet available for these individuals, both because traumatic memories are not encoded in autobiographical memory and because the recurring trauma-related arousal continues to create a somatic sense of threat—a “speechless terror” (van der Kolk, Van der Hart, & Marmar, 1996; see also Siegel, 1999).
Traditional therapeutic models are based primarily on the idea that change occurs through a process of narrative expression and formulation in a “top-down” manner. For example, one principle of psychodynamic treatment models, stated simplistically, is that successfully facilitating affective connection to painful past experience and addressing the accompanying cognitive distortions within the context of a therapeutic relationship will bring about a positive change in sense of self and thereby a relief of suffering and improvement in well-being. The working premise is that a significant change in the client’s cognitions and emotions will effect change in the physical or embodied experience of the client’s sense of self. The prime target for therapeutic intervention is therefore the client’s language; that is, the narrative is the entry point into the therapeutic process. The client’s verbal representation, beliefs, and affects are engaged, explored, and reworked through the therapeutic relationship.
Improving ego functioning, clarifying meaning, formulating a narrative, and working with emotional experience are fundamentally helpful interventions that accomplish real gains for the client. To these already useful cognitive and dynamic practices and techniques, we propose the addition of “bottom-up” interventions that address the repetitive, unbidden physical sensations, movement inhibitions, and somatosensory intrusions characteristic of unresolved trauma. Traumatized clients are haunted by the return of trauma-related sensorimotor reactions in such forms as intrusive images, sounds, smells, body sensations, physical pain, constriction, numbing, and the inability to modulate arousal. By including body sensation and movement as a primary avenue in processing trauma, sensorimotor psychotherapy teaches the therapist to use body-centered interventions to reduce these symptoms and promote change in the cognitions, emotions, belief systems, and capacity for relatedness in the client.
The practice of sensorimotor psychotherapy blends theory and technique from cognitive and dynamic therapy with straightforward somatic awareness and movement interventions, such as helping clients become aware of their bodies, track bodily sensations, and implement physical actions that promote empowerment and competency. Clients are taught to observe the relationship between their physical organization and beliefs and emotions, noticing, for example, how a self-representation uttered in a here-and-now therapy moment, such as “I’m a bad person,” affects physical sensation, posture, autonomic arousal, and movement. They also learn how their physical sensations, postures, and movements affect their emotional state and influence the words and content they describe in therapy. Such interventions actively incorporate the body into therapy, providing a more unified mind–body approach to the treatment of trauma. Within the context of a relationally attuned therapy, clinicians can help clients become curious and interested in how the body’s responses to past trauma continue in the context of present-day life, and in how to change these responses to enable more adaptive functioning.
Most psychotherapeutic approaches do not provide a methodology that directly addresses trauma-related bodily responses and chronically activated somatic symptoms. Instead they focus primarily on cognitive, behavioral, psychodynamic, and psychopharmacological interventions that, despite having been validated through research, are only somewhat successful in treating the trauma-related disorders seen in clinical practice (Bradley, Greene, Russ, Dutra, & Westen, 2005; Foa et al., 1999; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Tarrier, Sommerfield, Pilgrim, & Humphreys, 1999; Ursano et al., 2004). Therapists of all disciplines are often puzzled and frustrated by the limitations of existing treatment modalities to resolve the symptoms of trauma in their clients.
This book responds to the need for a somatic approach to trauma therapy that addresses the scarcity of literature on this subject and is accessible and appropriate for use by psychotherapists. The primary audience to whom this book is addressed includes psychologists, psychiatrists, social workers, psychotherapists, counselors, and family doctors who are treating traumatized individuals. In addition, we provide guidelines to help practitioners understand how the body contributes to both the maintenance and resolution of trauma-related disorders—information that may be valuable to psychiatric nurses, occupational therapists, rehabilitation workers, crisis workers, victim advocates, disaster workers, body therapists, as well as graduate students and interns entering the fields of mental health and trauma treatment. Furthermore, with the understanding that knowledge is empowering, this book is designed to be accessible to, and informative for, traumatized clients who are seeking to understand the causes and cures for their suffering.
Trauma and the Body: A Sensorimotor Approach to Psychotherapy is divided into two sections, theory and treatment. Part I explores the theoretical foundation and rationale for sensorimotor psychotherapy interventions, drawing on the century-old insights of Pierre Janet as well as the work of contemporary experts in the areas of trauma treatment, neuroscience, attachment, affect regulation, dissociation, and the body.
Chapter 1, “Hierarchical Information Processing: Cognitive, Emotional, and Sensorimotor Dimensions,” provides a rationale for a somatic treatment approach, describing how traumatic experience disrupts the body’s physiological and emotional regulation, causing profound effects on information processing. The hierarchical information-processing model is described and related to maladaptive patterns of “top-down” and “bottom-up” processing common to survivors of trauma. The requirements for effective treatment of traumatic experience, including attention to how mind and body process information and the role of bottom-up processing, are discussed.
Chapter 2, “Window of Tolerance: The Capacity for Modulating Arousal,” describes the low tolerance for arousal and affect dysregulation as core symptoms of trauma-related disorders. Focusing on the central role of autonomic dysregulation in perpetuating the symptoms and complicating the treatment of trauma, this chapter examines the regulatory patterns of hypo-and hyperarousal related to the survival-oriented functions of the sympathetic and parasympathetic nervous systems. These posttraumatic regulatory patterns challenge information processing by interfering with optimal arousal states and integrative capacity: Under conditions of arousal that are either too high or too low, traumatic experiences cannot be integrated. These regulatory parameters provide a foundational premise for the “modulation model” of sensorimotor psychotherapy.
Chapter 3, “Attachment: The Role of the Body in Dyadic Regulation,” describes regulatory role of attachment experience, its disruption by early traumatic experience, and its effect on the body. Literature from the field of attachment research, Allan Schore’s (1994) work on affect regulation, and the distinction between interactive and autoregulation are utilized to describe the specific tendencies of self-regulation and autonomic dominance embodied in each of the four childhood attachment patterns. An example of how to address the dysregulatory effects of attachment failure in treatment at a bodily and autonomic level is described.
Chapter 4, “The Orienting Response: Narrowing the Field of Consciousness,” explains the process of orienting whereby we select sensory stimuli from the myriad possible cues from the environment and from internal experience. Various kinds of orienting are described and the stages of the orienting response are delineated in a detailed case example. For the traumatized individual, the ability to orient to, interpret, and integrate sensory stimulation in an adaptive fashion is notably impaired and must be addressed as part of effective trauma treatment.
Chapter 5, “Defensive Subsystems: Mobilizing and Immobilizing Responses,” describes various animal defensive subsystems, their origin and physical components, that ultimately may contribute to posttraumatic symptoms. The stages of the defensive response are explained in relation to the case example introduced in the previous chapter. In treatment, traumatized persons are helped to (1) reorganize survival-related defensive responses that exacerbate their symptoms, and (2) achieve more adaptability and flexibility in their defensive patterns.
Chapter 6, “Adaptation: The Role of Action Systems and Tendencies,” describes the psychobiological systems that have evolved to support adaptive responses that optimize survival. These systems provide the impetus to explore the world, play, participate in social relationships, regulate energy, form pair bonds, and care for others. Traumatized individuals typically experience difficulty in effectively utilizing these systems because chronic deployment of defensive subsystems takes precedence over other systems. The purpose of this chapter is to describe these action systems and their associated physical tendencies, examine how they relate, and consider how therapists can work with them so that clients can satisfactorily fulfill their objectives. This chapter also describes why there is a propensity to implement actions at a particular level of organization, ranging from reflexive to adaptive. The impact of trauma and early life experiences on the action systems and on physical action tendencies is also addressed.
Chapter 7, “Psychological Trauma and the Brain: Toward a Neurobiological Treatment Model,” authored by Ruth Lanius, Ulrich Lanius, Janina Fisher, and Pat Ogden, draws upon the neuroscience research to illuminate the effects of trauma on brain structures and functioning, as well as to explore the implications for treatment using body-based interventions. Neuroimaging technology has made possible the detailed study of how trauma impacts both cortical and subcortical processing of information; this research has profound implications for the treatment of trauma-based symptoms. An understanding of how treatment interventions may affect brain areas implicated in trauma can enhance both the specificity and the effectiveness of psychotherapy. This chapter also describes the differences observed in brain activity related to hyper-versus hypoarousal responses to trauma.
Part II of Trauma and the Body: A Sensorimotor Approach to Psychotherapy describes the treatment philosophy and techniques of sensorimotor psychotherapy. Because clients with complex trauma can be triggered by interventions that access the body too quickly, attention is given to approaches and techniques that promote pacing, boundaries, and safe, gradual reconnection with the body. Clinical examples and explanations throughout the second section illustrate and clarify sensorimotor psychotherapy theory and practice.
Chapter 8, “Principles of Treatment: Putting Theory into Practice,” translates the theoretical material described in previous chapters into practice, providing an orientation to the principles underlying sensorimotor psychotherapy and applying hierarchical information-processing theory to clinical intervention. Working in the present moment is emphasized, and transference and countertransference concepts are related specifically to the somatic experience of the client in treatment. Janet’s (1898) pioneering work on phase-oriented treatment for traumatized individuals is integrated with contemporary theoretical perspectives to provide an umbrella under which to position sensorimotor psychotherapy interventions and treatment planning.
Chapter 9, “The Organization of Experience: Skills for Working with the Body in Present Time,” describes specific techniques, drawn primarily from the Hakomi method (Kurtz 1990), that allow client and therapist to safely observe, articulate, and explore present experience. With an emphasis on working with the organization of experience rather than insight, mindfulness techniques that facilitate the regulation of arousal and allow exploration of the client’s organization of present experience are described. How these skills are integrated and utilized in sensorimotor psychotherapy is explored along with a section for clinicians on the pitfalls and benefits of the therapeutic use of touch.
Chapter 10, “Phase 1 Treatment: Developing Somatic Resources for Stabilization,” describes the use of somatic resources to facilitate the management of traumatic triggers, the modulation of arousal, self-soothing, tolerance of therapeutic attachment and collaboration, and improvement in daily functioning. The challenge for the therapist during this phase is that of bringing autonomic dysregulation under greater conscious control so that hyper-and hypoarousal do not exacerbate the symptoms. The concept of the physical core/periphery is introduced as it relates to auto-and interactive self-regulation. This chapter explains how the development of somatic resources contributes to gradual expansion of self-regulatory skills and paves the way for the processing of traumatic memories at the next phase of treatment.
Chapter 11, “Phase 2 Treatment: Processing Traumatic Memory and Restoring Acts of Triumph,” describes how the client, having attained sufficient integrative capacity in the first phase of treatment, is now ready to develop a sense of mastery or triumph over the intense feelings, body sensations, and impulses associated with traumatic memories. This chapter explores the nature of traumatic memory and delineates how the client is enabled to process these memories somatically in order to experience a sense of success and triumph. How memory is safely reevoked, how resources are retrieved, and how empowering actions are discovered and executed are discussed.
Chapter 12, “Phase 3 Treatment: Integration and Success in Normal Life,” describes how the focus of treatment now shifts to establishing a life beyond trauma. Somatic interventions are used to help the client resolve relational issues, reengage in society, and tolerate increased intimacy, risk taking, and change. At this stage the therapeutic relationship can be used as a laboratory or template for trying out new actions/options, which can be practiced until they become automatic tendencies. The dynamic relationship between the client’s physical core and periphery is a template and metaphor for enabling somatic integration and the capacity for flexible adaptation to life in the present. The transformation of cognitive distortions that impede full engagement with life and increasing positive affect tolerance and capacity for pleasure are explored in this chapter.
Traditionally trained therapists who are new to the idea of working with the body may hesitate to incorporate a sensorimotor approach. It may seem that utilizing the body states and movements that manifest during a psychotherapeutic session necessitate learning a whole new language and method of observation. These concerns are natural and many psychotherapists find this new terrain to be intimidating. However, what we have found in teaching this method to clinicians since 1981 is that attuning to body cues is something that is already built into virtually every therapist’s method of working with clients and their internal states. The majority of human communication is not through verbal language but rather through body language: facial expression, eye contact, movement, behavior, posture, autonomic arousal, gestures, muscular tension, and so forth. In other words, the meaning and interpretation of each conversation that we have with another human being is built on observing, inferring, compiling, and making meaning of the other person’s body movement, posture, and expression, and much of how we communicate in response is through our body reactions to the other.
Indeed, at this juncture, the reader may actually be asking the opposite question: If this book is discussing a method that is based on a seemingly innate and highly sophisticated skill of interpreting body language and interactively regulating our co-conversant through this language, why are we not already adept at the method described in this book? The art and science of the sensorimotor psychotherapist lies in making this unconscious processes conscious, thus giving language to the non-verbal communication that is so integral to our interactions with others, including our clinical practice, that we have almost completely overlooked it as a primary object of study. In sensorimotor psychotherapy, understanding and translating the language of the body’s communication is central. Thus the process of learning sensorimotor psychotherapy includes the mindful study of how another’s physical states and communications resonate in and affect our own body experience, and how they can be interpreted as a useful basis for consciously formulating both our verbal and non-verbal responses to our client. This book expresses the thoughtful study of this interactive process over the last two-and-a-half decades.
Weaving sensorimotor psychotherapy theory and practice into psychodynamic or cognitive–behavioral models of therapy, including EMDR and exposure treatments, helps to unify body and mind in the treatment of trauma. Moreover, this work can be effectively used as an adjunct to already existing psychotherapeutic modalities. It should be noted that the methods introduced in this book are not only applicable to trauma; a sensorimotor approach is equally applicable to the normal, non-traumatic range of childhood and family dynamics that shape the development and formation of the client’s personality and interactive capacity. The ultimate aim of combining somatic and cognitive interventions is not only to alleviate symptoms and resolve the traumatic past, but also to help clients experience a new, reorganized sense of self. The sense of self develops not only in the context of beliefs, metaphors, and emotional responses but evolves organically as the physical organization of the client’s body changes. Some traumatized clients have a habitually collapsed, frozen, or immobilized body and an accompanying sense of self as ineffectual. Others experience chronic hyperaroused, affect-dysregulated bodies and a sense of a self that seems “out of control.” Sensorimotor psychotherapy helps these clients regulate their physical experiences and learn more adaptive actions so that their corresponding sense of self feels grounded, competent, and oriented toward present experience. As the arousal level, sensation, posture, and movement of the body adaptively change, a different, more positive, sense of self emerges, supported by these physical changes. Thus, by synthesizing bottom-up and top-down interventions, we hope to combine the best of both worlds to help chronically traumatized clients find resolution and meaning in their lives as well as develop a new, somatically integrated sense of self.