Trauma and the Body: A Sensorimotor Approach to Psychotherapy.
|Publication:||Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 Society for Existential Analysis ISSN: 1752-5616|
|Issue:||Date: July, 2010 Source Volume: 21 Source Issue: 2|
Trauma and the Body: A Sensorimotor Approach to Psychotherapy
Pat Ogden, Kekuni Minton and Clare Pain (2006). London: Norton
The opening section of this book introduces the discipline of interpersonal neurobiology, which attempts to offer an integrated view of what it means to be human by drawing from findings of various fields such as science, clinical experience and the contemplative and expressive arts. The central idea of this approach is ' integration' and how this is linked to well-being. The primary focus is 'experiential reality'; how we sense our bodies within the wider world of relationships and objects, how our minds flow or feel rigid, how chaotic or grounded we feel and how these senses of ourselves translate into how our bodies move and are felt.
The sensorimotor approach with its theoretical background of neuroscience, is being introduced in this dense book on Trauma and the Body. As well as being founded in and using theories, practices and skills from psychodynamic and cognitive-behavioural approaches, including attachment and dissociation theories, it is heavily influenced by a bodyoriented psychotherapy called the Hakomi method. The evocation of experience in a mindful way is central here and draws on philosophies and practices of Buddhism, Mindfulness and Taoism. Physical interventions in the form of experiments and explorations rather than touch are central in this approach.
This approach is presented as an ' addition' to the traditional 'talking-therapies', which from this perspective are regarded as top-down approaches, where the prime focus is language and the exploration of cognition and emotions as the main vehicle of change. In contrast, the sensorimotor approach pays close attention to bottom-up processing, i.e. it addresses physical sensations and movement inhibitions, and explore somatosensory intrusions that block or inhibit present-moment experiencing. By teaching clients body-centred interventions posttraumatic symptoms are reduced and the quality of thinking and feeling improved. The idea is to implement physical actions that promote a sense of empowerment and competency. It is a blend of theory and techniques that aims to integrate trauma so that clients may encounter the world as it is now instead of as if it was the past.
This first part of the book, the theory, introduces information and assumptions on the workings and processes of the brain; how our thoughts, emotions and physical sensations are processed and how they interact with each other. The second part of the book illustrates interventions sensorimotor psychotherapy uses. The theoretical density and the almost handbook-type approach may put many a reader off. A treatise on neuroscience can seem like a long way from what seems relevant in the moment-to-moment being with the client. As an existential psychotherapist I have been trained to question the nature and purpose of science in the psychotherapeutic field and certainly have not been taught techniques. I often feel more comfortable in thinking about my work as an artistic rather than scientific endeavour. Furthermore, in my training, and I suspect in most experiential/humanistic orientated approaches, Being is given equal if not more weight than doing.
However, for its density and focus on theory and techniques, this book nonetheless has been of interest and relevance to my practice. The first most useful aspect of the book is the authors' argument that the body often gets neglected in talking therapies. They place the body, its sensations and ways of being, centre stage and back this up with neuroscientific findings, which show how the body is a central vehicle of a range of human expressiveness. We usually don't pay much attention to the body when it performs and supports us more or less well in our daily comings and goings. And yet, as convincingly illustrated in this book, our body tells a story of our feelings, beliefs, memories and life events. It's like a landscape picture of the trajectory of our life with drawings of tensions, bumps and creases. The body stores memories in its cells, muscles, and joints, and leaves an imprint in our posture and the flow of our movements; how close or far away do we position ourselves to others? How do we 'carry' ourselves and how do we move our hands, arms and legs? How do we habitually sit and speak? What's the quality of our breath?
The central clinical theme of the book is trauma. Although the authors don't explicitly seem to offer a definition of trauma, which perhaps is problematic, a distinction seems to be made between Post Traumatic Stress Disorder (PTSD) that is integrated and therefore manageable because recall of trauma is part of a normal autobiographical narrative and PTSD which presents in the form of dissociations, a sense of timelessness, and interruptions in memory or sensations. The authors argue that such unintegrated trauma can be experienced as states of either hypoarousal (numbness, dissociation) or hyperarousal (feeling overwhelmed or flooded) where clients can swing between these two states. The psyche and soma (body) are inseparable in that overwhelmed feelings, concentration difficulties, memory loss and altered beliefs (psychoform) go hand in hand with too much or lack of body sensations, movement inhibitions, and pain (somatoform).
In terms of processing systems, the authors invite us to think of three levels of brain processing; Cognitive processing, Emotional processing and Sensorimotor processing whereby the sensorimotor level is associated developmentally with the oldest and least flexible of the systems, on which the other systems are dependent and built upon. The same areas of the brain that generate reason and help us to solve problems are also involved in movement. Movement is essential for the development of all brain functions. If a person is attacked and has experienced the urge to fight back but was not able to, the sequence of possible defensive actions may persist in distorted forms; muscles held in a chronically tightened pattern, an exaggerated tendency to be easily triggered into aggression, or a chronic lack of tone or sensation in particular muscle groups.
The authors write about working with the window of tolerance which refers to the optimum level at which information can be taken in and processed. Hypo- and hyperaroused states inhibit information processing. The somatosensory therapist helps clients to become aware of their arousal signs and states and works with them to expand their window of tolerance so that they can start taking in information from the here and now. The window of tolerance gets then associated with the social engagement system (the ability to create and sustain relationships). When this system has repeatedly failed to avoid dangerous situations as is the case of chronic trauma, the long-term consequence of this may be a decreased use of this system. A major focus of treatment is increasing the functioning of the social engagement system and a decreasing of emotional and physiological arousal associated with the trauma.
The empathic matching of one's own state to that of another is a sensorimotor event that promotes social engagement, through tone of voice, volume, touch, pace or gestures. For example, the mother's matching of her state to the baby's state can help a distressed baby to relax and calm down. The same can be said about the therapist's ability to align and empathize. Affect regulation doesn't only involve a reduction in too much arousal but equally an amplification of positive emotions.
The authors talk about action systems, a speculative concept and a way of thinking about different areas that are pertinent to engaging with others. Action systems help us to meet the challenges of the world and to adapt to change. Apart from the defense action system the authors have identified action systems to do with attachment, exploration, energy regulation, caregiving, sociability, play and sexuality. These systems interact with each other, are mutually dependent and complementary--a social being engages in a complex and highly sophisticated web of juggling, holding, experiencing and adapting to the world and others depending on situation. Traumatized individuals can often find this complexity difficult to manage. Just consider the sophistication for example of what is involved in balancing work, play, rest, friendships, intimate and family relationships all these areas require flexibility, cooperation and coordination among these different action systems.
The authors argue that trauma clients typically orient and attend to stimuli reminiscent of traumatic events, without conscious recollection that the stimuli are, in fact, reminders of the past. Such orientation is largely unconscious, can be extremely robust, easily evoked, and challenged with difficulty. Mindfulness of the orienting process as it occurs in the therapy hour can teach and help clients to observe rather than habitually fall into patterns of orienting responses and can evoke their curiosity--the first step towards changing the trauma-related orienting tendencies. A hypothesis that is put forward, based on brain imaging, is that interventions on a sensorimotor level seem to bridge more easily the right and the left hemisphere than language-based interventions, thus facilitating learning new patterns and embodying experience from the here and now.
The treatment the authors suggest must address the here-and-now experience of the traumatic past, rather than its content or narrative, in order to challenge and transform procedural learning. Treatment is thought of and organized in the book as consisting of three Phases: Phase I consists of grounding clients and developing somatic resources for stabilization, Phase II consists of processing traumatic memory and regain a sense of empowerment and Phase III consists of integrating what has been learned in day-to-day life. The authors see the therapist assuming the role of an interactive psycho-biological regulator for the client's dysregulated nervous system whereby the therapist is not only mindful and present to the minutiae of shifts in body tension, presence and way of being of the client and validates or feeds those back but also models, role plays and actively experiments for or with the client different somatic possibilities.
Here are some examples of interventions this approach uses:
* Becoming aware of breathing patterns and incorporating breathing exercises.
* Thinking about the body consisting of a core support system (pelvis, spine, ribcage) and periphery support system (arms, legs) and explore the different ways in which core and periphery are used in communication.
* Asking clients to oscillate between negative and positive feelings and try out their corresponding postures.
* Recognize and track precursors to arousal and identifying and verbalizing body sensations.
* Working with the somatic sense of boundaries; what feels too close or too far away.
* Exploring somatic actions like pushing, pulling, kicking, walking, turning away etc.
* Using props in the room to represent others and reactions to them.
* Recognizing incomplete actions caused by trauma (immobilizing defences) and complete them in the here and now (mobilizing defence).
Some therapists may argue that these interventions are too directive, perhaps even invasive, and some may see similarities to Gestalt and Focusing techniques and find this less problematic. One could argue that working with the body in such a way is a rigorous application of phenomenological principles where the therapist is as present as possible to the (somatic) phenomena arising by tracking, naming and feeding them back to the client from moment-to-moment. These phenomena are then linked to the client's background history, presenting issues, beliefs and ways of being in order to make sense of how past and present interact. The authors do talk about the need to be gentle, sensitive and creative with the interventions and stress the importance of building a good working alliance so that these interventions work. The authors also place a value on explaining to clients the theory behind their interventions. This approach is therefore both didactic and experiential.
Overall, I found this book both instructive and inspirational, particularly in terms of working with chronic trauma and thinking about at what developmental stage a client may have experienced trauma and how this may have affected them structurally. I would recommend this book to students and professionals alike, since neuroscience is increasingly talked about in connection to mental health. To me its findings give a picture and a voice to the psyche and emotions, which so often in the medical world still get dismissed. Psychosomatic disorders in common parlance still are thought of as 'it's all in the mind', by which is meant that they have no basis in reality. There still is a common attitude amongst medics that if they can't find any physical basis for a problem no treatment is offered. Neuroscientific findings might change these attitudes and help the world move towards healing the body-mind split.
From an existential point of view, I think this book helps to contextualize processes within the whole human system and helps to see that what we call a client's sedimentation might be more ingrained and more complex than just a pattern that can be changed once insight and awareness reached. Many clients say 'I know it but I still do it or I still feel that way and things still haven't changed' and encapsulates perhaps the saying 'habits die hard'. With some more complex client presentations there may be more needed than working towards insight alone. In this context it is interesting to think about what embodiment means, which makes me think of the difference between reflexive and reflective. The trauma client is perhaps at the mercy of reflexes and the journey from reflexes to reflection and therefore choice is perhaps longer and more complex than hitherto thought. What I take from this book is the lifting of the body out of forgetfulness and to integrate it more courageously into the therapeutic process, and to be mindful of not recreating the body/mind split in the therapy room as well.
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