This article has been substantially updated with links to explanations of all technical terms, as well as uniform type size.
With major thanks to Drs. Ogden and Minton for
inventing SP4T -- and for allowing their original work to be published in the
public domain -- I've attempted here to illustrate how SP4T can be utilized in the 11th of Wilson's 12 Steps and the 9th of the 10
StEPs of Emotion Processing to "mechanize" or "operationalize" the process of affective "digestion / metabolization / processing" to discharge and detachment.
My notions at this time are 1) that SP4T may be the best explained and operationalized, as well as the most research-proven and widely known of the relatively new (or at least, second wave of), somato-sensory (or interoceptive) processing psychotherapies, and 2) that -- as is the case with the 10 StEPs -- it can be adapted to many uses beyond trauma processing and recovery from complex PTSD.
Such additional uses include the recognition, acceptance and appreciation of -- and disengagement from -- unrecognized paradoxical injunctions of concurrent reward and punishment used to set up ostensibly "inescapable" double-binds leading (just as Seligman did with his rats) to unconscious "learned helplessness" and gross misuse of defense mechanisms to ineffectively try to deal with incompetence (as per Erikson) low self-esteem.
The not quite complete text of Ogden's and Minton's article appears below in black. My comments relative to its use with the 10 StEPs in the framework of the three states of cognitive consciousness appear in dark red.
Sensorimotor
Psychotherapy:
One Method for Processing
Traumatic Memory
Pat Ogden, Ph.D. and
Kekuni Minton, PhD.
Sensorimotor Psychotherapy Institute and Naropa University
Boulder, Colorado
Traumatology, Volume
VI, Issue 3, Article 3 (October, 2000)
See the unabridged
original in its entirety at...
Abstract
Traditional psychotherapy
addresses the cognitive and emotional elements of trauma, but lacks techniques
that work directly with the physiological elements, despite the fact that
trauma profoundly affects the body and many symptoms of traumatized individuals
are somatically based. Altered relationships among cognitive, emotional, and
sensorimotor (body) levels of information processing are also found to be
implicated in trauma symptoms.
Sensorimotor Psychotherapy is a method that
integrates sensorimotor processing with cognitive and emotional processing in
the treatment of trauma. Unassimilated somatic responses evoked in trauma
involving both arousal and defensive responses are shown to contribute to many
PTSD symptoms and to be critical elements in the use of Sensorimotor
Psychotherapy. By using the body (rather than cognition or emotion) as a
primary entry point in processing trauma, Sensorimotor Psychotherapy directly
treats the effects of trauma on the body, which in turn facilitates emotional
and cognitive processing. This method is especially beneficial for
clinicians working with dissociation, emotional reactivity or flat affect,
frozen states or hyperarousal and other PTSD symptoms.
In this article, we
discuss Sensorimotor Psychotherapy, emphasizing sensorimotor processing
techniques which can be integrated with traditional approaches that treat these
symptoms. Because the therapist's ability to interactively regulate clients'
dysregulated states and also to cultivate clients' self-awareness of inner body
sensations is crucial to this approach, three sessions are described
illustrating the clinical application of this method. Sensorimotor
Psychotherapy is a method for facilitating the processing of unassimilated
sensorimotor reactions to trauma and for resolving the destructive effects of
these reactions on cognitive and emotional experience. These sensorimotor
reactions consist of sequential physical and sensory patterns involving
autonomic nervous system arousal and orienting/defensive responses [latter aka "defense mechanisms"] which seek
to resolve to a point of rest and satisfaction in the body. During a traumatic
event such a satisfactory resolution of responses might be accomplished by
successfully fighting or fleeing. However, for the majority of traumatized
clients, this does not occur. Traumatized individuals are plagued by the return
of dissociated, incomplete or ineffective sensorimotor reactions in such forms
as intrusive images, sounds, smells, body sensations, physical pain,
constriction, numbing and the inability to modulate arousal.
These unresolved
sensorimotor reactions condition emotional and cognitive processing, often
disrupting the traumatized person's ability to think clearly or to glean
accurate information from emotional states (Van der Kolk, 1996). Conversely,
cognitive beliefs and emotional states condition somatic processing. For
instance, a belief such as "I am helpless" [as in Seligman's "learned helplessness"] may interrupt sensorimotor
processes of active physical defense; an emotion such as fear may cause
sensorimotor processes such as arousal to escalate. Most psychotherapeutic
approaches favor emotional and cognitive processing over body processing, and
it has been shown that such approaches can greatly relieve trauma symptoms.
However, since somatic symptoms are significant in traumatization (McFarlane,
1996, p. 172) the efficacy of trauma treatment may be increased by the
addition of interventions that facilitate sensorimotor processing. We propose
that sensorimotor processing interventions can help regulate and facilitate
emotional and cognitive processing, and we find that confronting somatic issues
by directly addressing sensorimotor processing can be useful in restoring
normal healthy functioning for victims of trauma regardless of the nature of
the trauma's origin. However, we also find that sensorimotor processing alone
is insufficient; the integration of all three levels of processing –
sensorimotor, emotional and cognitive – is essential for recovery to occur.
In this article we will
discuss Sensorimotor Psychotherapy, a comprehensive method that utilizes the
body as a primary entry point in trauma treatment, but one which integrates
cognitive and emotional processing as well. We will emphasize sensorimotor
processing, which entails mindfully tracking (following in detail)
the sequential physical movements and sensations associated with unassimilated
sensorimotor reactions, such as motor impulses, muscular tension, trembling and
various other micromovements, and changes in posture, breathing and heart rate.
These body sensations are similar to Gendlin's (1978) "felt sense" in
that they are physical feelings, but while the felt sense includes emotional
and cognitive components, the sensations we refer to are purely physical.
Clients are taught to distinguish between physical sensations and trauma-based
emotions through cultivating awareness of sensations as they fluctuate in
texture, quality and intensity until the sensations themselves have stabilized,
and clients are able to experience these sensations as distinct from emotions.
Sensorimotor processing is
similar to Peter Levine's (1997) "Somatic Experiencing" in the
tracking of physical sensation, but it differs in intent. For Levine, tracking
physical sensation is an end in itself; his approach does not specifically
include therapeutic maps to address cognitive or emotional processing. Similar
to "Somatic Experiencing," Sensorimotor Psychotherapy encourages
sensorimotor processing when necessary to regulate sensorimotor reactions,
often the case in shock and non-relational trauma, but sensorimotor processing
is most often used as a prelude to holistic processing on all three levels
(cognitive, emotional, and sensorimotor). For example, a traumatized client's
affective and cognitive information processing may be 'driven' by an underlying
dysregulated arousal, causing emotions to escalate and thoughts to revolve
around and around in cycles. When the client learns to self-regulate her
arousal through sensorimotor processing, she may be able to more accurately
distinguish between cognitive and affective reactions that are merely
symptomatic of such dysregulated arousal and those cognitive-emotional contents
that are genuine issues that need to be worked through. As this occurs, the
approach of Sensorimotor Psychotherapy might shift from sensorimotor processing
alone to include cognitive and emotional processing, and to address relational
and transferential dynamics as well. Sensorimotor Psychotherapy's use of the
therapeutic interaction to work through relational issues and promote
self-regulation can be very effective in the resolution of relational trauma.
Thus, Sensorimotor Psychotherapy lends itself to the treatment of relational
trauma as well as shock and non-relational trauma [for example: severe financial loss].
Before discussing
Sensorimotor Psychotherapy more fully, we will first address the question of
how experience is processed on cognitive, emotional and sensorimotor levels,
and the effects of unresolved sensorimotor reactions on all levels of
information processing. Ken Wilber's (1996) notion of hierarchical information
processing describes the evolutionary and functional hierarchy among these
three levels of organizing experience -- cognitive, emotional and sensorimotor
-- a hierarchy that reflects the evolutionary development of the human brain.
While functionally the
three levels of information processing are mutually dependent and intertwined
(Damasio, 1999; LeDoux, 1996; Schore, 1994), clinically we find that it is
important for the therapist to observe the client's processing of information
on each of these three related but distinct levels of experience, differentiate
which level of processing will most successfully support integration oftraumatic experience in any moment of therapy, and apply specific techniques
that facilitate processing at that particular level. Such an approach
ultimately fosters "holistic" processing where all three levels will
operate synergistically.
The hierarchy of levels of
information processing – sensorimotor, emotional, and cognitive – generally
correlates with the three levels of brain architecture described by MacLean
(1985): the sensorimotor level of information processing (including sensation
and programmed movement impulses) is initiated primarily by lower rear portions
of the brain, emotional processing by more intermediate limbic parts of the
brain, and cognitive processing by the frontal cortical upper parts of the
brain. These three levels interact and affect each other simultaneously,
functioning as a cohesive whole, with the degree of integration of each level
of processing affecting the efficacy of other levels, as described by Fisher
& Murray (1991): The brain functions as an integrated whole, but is
comprised of systems that are hierarchically organized. The "higher
level" integrative functions evolved from and are dependent on the
integrity of "lower-level" structures and on sensorimotor experience.
Higher (cortical) centers of the brain are viewed as those that are responsible
for abstraction, perception, reasoning, language, and learning. Sensory
integration, and intersensory association, in contrast, occur mainly within
lower (subcortical) centers. Lower parts of the brain are conceptualized as
developing and maturing before higher-level structures; development and optimal
functioning of higher-level structures are thought to be dependent, in part, on
the development and optimal functioning of lower-level structures. (p. 16)
Sensorimotor processing is
in many ways foundational to the others and includes the features of a simpler,
more primitive form of information processing than do its more evolved
counterparts. With its seat in the lower, older brain structures, sensorimotor
processing relies on a relatively higher number of fixed sequences of steps in
the way it does its work. Some of these fixed sequences are well known, such as
the startle reflex and the fight, flight or freeze response. The simplest
sequences are involuntary reflexes (e.g., the knee jerk reaction) which are the
most rigidly fixed and determined. More complex are the motor patterns that we
learn at young ages, which then become automatic, such as walking and
running. In the more highly evolved emotional and cognitive realms, we find
fewer and fewer fixed sequences of steps in processing, and more complexity and
variability of response. Thus, sensorimotor processing is more directly
associated with overall body processing: the fixed action patterns seen in
active defenses, changes in breathing and muscular tonicity, autonomic nervoussystem activation and so forth. The nature of this hierarchy is such that the
higher levels of processing often influence and direct the lower levels. We can
decide (cognitive function) to ignore the sensation of hunger and not act on
it, even while the physiological processes associated with hunger, such as the
secretion of saliva and contraction of stomach muscles, continue. In cognitive theory,
this is called "top-down processing" (LeDoux, 1996, p. 272),
indicating that the upper level of processing (cognitive) can and often does
override, steer or interrupt the lower levels, elaborating upon or interfering
with emotional and sensorimotor processing.
Adult activity is often
based upon top-down processing. Schore (1994) notes that, in adults,
"higher cortical areas" act as a "control center," and that
the orbital cortex hierarchically dominates subcortical limbic activity (p.
139). A person might think about what to accomplish for the day, outline
plans, and then structure time to meet particular goals. While carrying these
plans through, one may override feelings of fatigue, hunger, or physical
discomfort. It's as though we hover just above our somatic and sensory
experience, knowing it's there, but not allowing it to be the primary
determinant of our actions.
In contrast, the
activities of very young children are often dominated by sensorimotor (Piaget,
1952) and emotional systems (Schore, 1994), in other words by bottom-up
processes. Tactile and kinesthetic sensations guide early attachment behavior
as well as help regulate the infant's behavior and physiology (Schore, in
press-a). Infants and very small children explore the world through these
systems, building the neural networks that are the foundation for later
cognitive development (Piaget, 1952; Hannaford, 1995). Hard-wired to be
governed by somatic and emotional states, infants respond automatically to
sensorimotor and affective cues and are unregulated by cognition or
cortical control (Schore, 1994). The infant is a "subcortical
creature ... [who] lacks the means for modulation of behavior which is made
possible by the development of cortical control" (Diamond, Balvin and
Diamond, 1963, p. 305). Similarly, traumatized people frequently experience
themselves as being at the mercy of their sensations, physical reactions and
emotions, having lost the capacity to regulate these functions.
In summary, bottom-up and
top-down processing represent two general directions of information processing.
Top-down processing is initiated by the cortex, and often involves cognition.
This higher level observes, monitors, regulates, and often directs the lower
levels; at the same time, the effective functioning of the higher level is
partly dependent on the effectiveness of bottom-up processing, on the other hand,
is initiated at the sensorimotor and emotional realms. These lower levels of
processing are more fundamental, in terms of evolution, development and function:
these capacities are found in earlier species and are already intact within
earlier stages of human life. They precede thought and form a foundation for
the higher modes of processing.
The interplay between
top-down and bottom-up processing holds significant implications for the
occurrence and treatment of trauma. Psychotherapy has traditionally harnessed
top-down techniques to manage disruptive bottom-up processes, through the
voluntary and conscious sublimation of sensorimotor and emotional processing.
This is achieved through activity, behavioral discharge, cognitive override or
distraction [which may be helpful if mindfully applied... but
counter-productive if mis-applied or over-applied due to unconsciously
conditioned, socialized, habituated, and/or accustomed and, thus, normalized
programming]. When sensorimotor experience is disturbing or overwhelming,
conscious [mindful] top-down regulation can allow a person to pace
herself, modulating the degree of arousal or disorganization in the system, as
evidenced by the following example: Harriet.... had a problem and had found a
way to begin to control it. When a hallucination began, she would try to
picture her library at home. She would look at the imaginary shelves and start
to count the books, focusing on each one as best she could as she counted.
Soon, her hallucination would stop – she was imposing top-down control, which
quashed the bottom-up hallucination signal. She was purposefully lighting up
her cortex so that it drowned out her lower brain, snapping her out of her
episode just as cognition wakes us up out of a dream. (Hobson, 1994, p. 174)
While the above technique
is an effective way to manage hallucinations and provide significant relief,
and thus can be an important first step in therapy, it may not address the
entire problem. It engages cognition, but ignores sensorimotor processes. Such
top-down processing alone may manage sensorimotor reactions, but may not
effectuate their full assimilation. [Meaning: The uncomfortable or even (supposedly) "intolerable" feelings are "managed" (as in DBT's "affect regulation") but not integrated and "processed" towards at least partial extinction.] For instance, a client may learn to
mitigate arousal by convincing herself that the world is now safe, but the
underlying tendency for arousal to escalate to overwhelming degrees may not
have been fully resolved. The traumatic experience and arousal from the
sensorimotor and emotional levels may be redirected through top-down
management, but the processing, digestion and assimilation of sensorimotor
reactions to the trauma may not have occurred.
[Eye>I+Eye has
observed > notice > recognize > acknowledge > accept > own >
appreciate > understand that I-Eye jumps
in and hijacks I+Eye to
utilize what I+Eye has stored cognitively / intellectually to defend itself (in
the precise manner described in and/or intuited from Goleman's Vital
Lies, Simple Truths) with "activity, behavioral discharge, cognitive
override or distraction," as described above herein. So doing -- it
appears -- interrupts, prevents, defeats and quashes the emotional and
sensorimotor processing. It appears to Eye>I+Eye that, regardless of how
"unsocialized" and embarrassing it may look to allow the emotional
and/or sensorimotor experiences to surface and have the opportunity to
integrate with cognitive process in "genteel company," it is far
healthier to do so without projecting the energy onto others. "Impression management"
and "appearing competent to others" can -- in invalidated adult children -- be so
over-in-struct-ed, over-learned and over-valued in I-Eye's and narcissitically
instrumentalistic I-Eye^I+Eye's cognitive
schemata that it is a major -- potentially disastrous -- impediment
to further recovery. It can also be the case that one's family-of-origin's and
the common culture's values, in-struct-ions, conditioning, socialization,
habituation and normalization are way too deeply and unconsciously introjected
for one's own good.]
In much the same way that
a client who comes to therapy with unresolved grief must identify and
experience the grief (emotional processing), a client who exhibits unresolved
sensorimotor reactions must identify and experience these reactions physically (sensorimotor
processing). Additionally, the client's awareness and processing of
sensorimotor reactions on the sensorimotor level will exert a positive
influence on emotional and cognitive processing, since, as we have seen,
optimal functioning of the higher levels is somewhat dependent upon the
adequate functioning of the lower levels. Sensorimotor processing is often a
precursor to holistic processing –the synergistic functioning of cognitive,
emotional and sensorimotor levels of processing.
In Sensorimotor
Psychotherapy, top-down direction is harnessed to support, rather
than manage, sensorimotor processing. [Pretty much what occurs in the relationship between SP4T and the 10 StEPs, though I would assert that the first eight of the 10 StEPs provide the cognitive "set-up" that identifies, clarifies and amplifies the cognitive-affective feedback loop causing emotional discomfort. In my experience, the 10 StEPs is a mechanism of "motivational enhancement" -- as per Rollnick & Miller -- that brings the patient to the ACTion -- as per Hayes, Follette, Pistorello, et al -- of SP4T] The client is asked to mindfully
track (a top-down, cognitive process) the sequence of physical sensations and
impulses (sensorimotor process) as they progress through the body, and to
temporarily disregard emotions and thoughts that arise, until the bodily
sensations and impulses resolve to a point of rest and stabilization in the
body. The client learns to observe [precisely as in the first of the 10 StEPs] and follow the unassimilated sensorimotor
reactions (primarily, arousal and defensive reactions) that were activated at
the time of the trauma. Bottom-up processing left on its own does not
resolve trauma, but if the client is directed to employ the cognitive function
of tracking and articulating sensorimotor experience while voluntarily
inhibiting awareness of emotions, content, and interpretive thinking,
sensorimotor experience can be assimilated. [Functional grasp of the 10 StEPs provides the skills base to separate the former from the latter and package it in the form of memorized experience.]
Furthermore, it is crucial
that the cognitive direction is engaged to help clients learn self-regulation. To
harness such top-down cognitive direction, a specific kind of therapeutic
relationship is imperative. Similar to a mother's interaction with her infant
[as per Stern, and Schore in their work on "maternal attunement" of an infant's temporary "affect dysregulation"], the therapist must serve as an "auxiliary
cortex" (Diamond et al., 1963), for clients through observing and
articulating [articulating verbally I'm not so sure about; see further
below] their sensorimotor experience until they are able to notice,
describe and track these experiences themselves.
[My experience is that while noticing and tracking are absolutely mandatory, verbal description all too often disrupts the therapeutically critical, sensory experience leading to reducing the neural transmission of the specific affects along the insular > amygdalar > hypothalamic > pituitary > adrenal pathway that induce the fight, flight or freeze response and/or (if continued long enough) lead to parasympathetic exhaustion, adrenal fatigue and/or the truly awful symptoms of "freak and fry" "dieseling" that resemble chronic "manic panic." What I have seen repeatedly when verbal description is mandated is depletion and reduction of the therapeutic sensory experience itself, and displacement by cognition in the manner of intellectual, psychodynamic "repression."]
Such relational
communication is a process of "interactive psychobiological
regulation," which resembles a mother's attunement to and interaction with
her infant's physiological and emotional states (Schore, 1994). Schore writes
that the therapist must act as an "affect regulator of the patient's
dysregulated states to provide a growth-facilitating environment for the
patient's immature affect regulating structures" (Schore, in press-b, p. 17).
In defining
self-regulation, Schore (in press-b) differentiates between interactive and
non-interactive forms, describing self-regulation as both "interactive
regulation in interconnected contexts via a two-person psychology," and
"autoregulation [self-regulation] in autonomous contexts via a one-person psychology"(
p. 13-14). When self-regulation is fully developed, clients can observe,
articulate, and eventually integrate sensorimotor reactions on their own as
well as utilize relationships to self-regulate. Without what Schore calls the
"adaptive capacity to shift between these dual regulatory modes" (p.
14), the sensorimotor reactions of arousal and defensive responses are subject
to becoming either hyperactive or hypoactive, as we shall see in the following
section, leaving traumatized persons at the mercy of their bodies.
Physical Defensive
Responses
Threat calls forth both
psychological and physical defenses, the objectives of which are to evaluate
and reduce stress and maximize the chances for survival (Nijenhuis & Van
der Hart, 1999). For the purpose of this article, we will focus on physical
defenses, rather than psychological defenses (such as projection, reactionformation, displacement, rationalization or minimization), acknowledging
that both types may be responses to traumatic situations. Physical
defenses are examples of the relatively fixed action patterns mentioned in
the previous section, the effective functioning of which upper levels of
processing depend upon for their efficacy.
Physical defenses may
precede cognitive and emotional reactions in acute traumatic situations. Hobson
writes: Bottom-up processing takes precedence in times of emergency, when
it is advantageous to short-circuit the cortex and activate a motor-pattern
generated directly from the brain stem. If we suddenly see a car careening
toward us, we instantly turn our car away; we react automatically, and only
later (even if it is only a split second later) do we realize there is
danger and feel afraid. (1994, p. 139)However, during a more prolonged trauma,
voluntary physical defensive impulses that are mediated through the cognitive
level – such as thoughts of striking out or reaching for the phone – might also
come into play.
Physical defenses may be
active or passive (Levine, 1997; Nijenhuis and Van der Hart, 1999). Active
defenses manifest through a wide variety of physical impulses and movements
depending on the nature of the threat, and vary in intensity of activity. They
include fight/flight and a multitude of other possible reactions such as
engaging the righting reflexes to regain balance, turning away from a falling
branch, lifting an arm to avoid a blow, slamming on the brakes to prevent an
accident, twisting out of the grip of an assailant, and so on. Additionally,
the orienting response (scanning and adjusting to the environment) is
heightened and all of the organism's attention is focused on the threat. The
senses become hypersensitive to better smell, hear, see and taste the danger
(Levine, 1997; Van Olst, 1972) in preparation for further assessment and
response (Hobson, 1994).In the animal kingdom, active defensive responses turn
to passive freezing when active responses are likely to threaten survival
(Nijenhuis and Van der Hart, 1999). For humans as well, when active defenses
are impossible or ill advised, they may be replaced by passive defenses such as
submission, automatic obedience, and freezing (Nijenhuis & Van der Hart,
1999). Nijenhuis and Van der Hart (1999) write:... . applying problem-solving
coping (attempted flight, fight or assertiveness) would be inevitably
frustrating and nonproductive for a child being physically or sexually abused
or witnessing violence. In some situations, active motor defense may actually
increase danger and therefore be less adaptive than passive, mental ways of
coping ... (p. 50)
Furthermore, passive
defenses may be the best option when active ones are ineffective, as when a
victim is unable to outrun an assailant. While Levine (1997) claims that
hyperarousal and active defenses precede passive defense and immobility, both
Nijenhuis (e.g., Nijenhuis, Vanderlinden & Spinhoven, 1998) and Porges (1995,
1997) note that frozen states are not always preceded by active defenses or
arousal. In some cases, such as those mentioned above, an individual might
automatically engage passive defenses without first attempting active defense.
Also, passive defenses alone are employed in infancy, long before capabilities
for fight/flight.
In passive defense, the
ordinarily active orienting response, which includes effective use of the
senses, scanning mechanisms and evaluation capacities, may become dull and
ineffective. The cognitive function of problem-solving may become severely
diminished and confused, which may lead to a general dulling of cognition or
"psychic numbing" (Solomon, Laror, and McFarlane, 1996, p. 106), a
numbing of sensation, and the slowing of muscular/skeletal responses (Levine,
1997). Muscles may be extremely tense but immobilized, or flaccid. Clients may
report that in this state, they find moving difficult, and they may even feel
paralyzed.
Frequently, the complete
execution of effective physical defensive movements do not take place during
the trauma itself. As we have seen, a victim may instantaneously freeze rather
than act, a driver may not have time to execute the impulse to turn the car to
avoid impact, or a person may be overpowered when attempting to fight off an
assailant. Over time, such interrupted or ineffective physical defensive
movement sequences contribute to trauma symptoms. Herman (1992) observes: When
neither resistance nor escape is possible, the human system of self-defense becomes
overwhelmed and disorganized. Each component of the ordinary response to
danger, having lost its utility, tends to persist in an altered and exaggerated
state long after the actual danger is over. (p. 34)
[Precisely what occurs in parasympathetic exhaustion -- with complete inability to return the limbic system to homeostasis -- leading to the "manic panic" mentioned above. Physiologically this is amygdalar "battering" of the hippocampus and hypothalamus resulting in terror-stricken confusion, inability to process at either cognitive or affective levels, and dieseling of the sympathetic branch of the autonomic nervous system. In my personal experience, it was like being in a "tunnel of terror" from the moment of awakening until the point of exhaustion each evening, day in, day out, for many months at a time on several occasions (over 30 months total between 1994 and 2003), usually to the point that even dopamine-chain-suppressing, neuroleptic medications like risperidone and ziprasidone were wholly ineffective.]
Traumatized people may
exhibit a propensity for either hyperactive or passive defense or an
alternation between the two. When defenses become hyperactive, they manifest as
habitual defensiveness, aggression against self or others, hyper-alertness,
hyper-vigilance, excessive motoric activity and uncontrollable bouts of rage,
and so on. Habitual passive defenses may manifest as chronic patterns of
submission, helplessness, inability to set boundaries, feelings of inadequacy,
automatic obedience, and repetition of the victim role.
The person may appear
lifeless and non-expressive, and may fail to defend against ["give
up" or act confused, disoriented and/or inappropriately -- maybe even
embarrassingly -- to the circumstances] or orient toward danger, or even
attempt to get help. Interrupted or ineffective physical defensive
movements can disrupt the overall capacity for sensorimotor processing, similar
to the way a repeated suppression of a particular emotion disrupts the overall
capacity for emotional processing. Unsuccessful patterns of sensorimotor
responses may become habitual, negatively affecting the normal and healthy
interplay between top-down and bottom-up processing, and thus contribute to
trauma symptoms.
Poor tolerance for arousal
is characteristic of traumatized individuals (Van der Kolk, 1987). The top and
bottom lines of the above diagram depict the limits of a person's optimum
degree of arousal, which Wilbarger and Wilbarger (1997) call the "optimal arousal zone." When arousal remains within this zone, a person can contain
and experience (not dissociate from) the affects, sensations, sense perceptions
and thoughts that occur within this zone, and can process information
effectively. In this zone, modulation can occur spontaneously and naturally.
This optimum zone is similar to Siegel's "window of tolerance,"
within which "various intensities of emotional arousal can be processed
without disrupting the functioning of the system" (1999, p. 253). During
trauma, arousal initially tends to rise beyond the upper limits of the optimal
zone, which alerts the person to possible threat (Van der Kolk, Van der Hart,
and Marmar, 1996). In successful and vigorous fight or flight, this
hyperarousal is utilized through physical activity (Levine, 1997) in serving
the purpose of defending and restoring balance to the organism. In the ideal
resolution of the arousal, the level returns to the parameters of the optimum
zone. However, this return to baseline does not always occur, which contributes
significantly to the problems with hyperarousal that are characteristic of the
traumatized person.
In relation to energy
dissipation following hyperarousal, Levine (1997) writes that trauma symptoms
" ... stem from the frozen residue of energy that has not been resolved
and discharged..." and the individual exposed to trauma must
"discharge all the energy mobilized to negotiate that threat or [the
person] will become a victim ... " (p. 19-20). Although we agree that
discharge of energy may be an element in trauma therapy, just as expression of
emotion also may be an element of trauma therapy, we disagree with the
discharge model. We believe that trauma symptoms stem from unassimilated reactions
on all three levels of information processing, and that these reactions must be
integrated through restoring the balance and synergy between top-down and
bottom-up processing. Rather than to "complete the freezing response"
by discharging energy (Levine, 1997, p. 111) our immediate intention is to
teach the client to modulate sensorimotor processes, which sometimes means
stimulating arousal if the client is hypoaroused.
[While the 10 StEPs was initially conceived as a "mantra" for moving towards reduction of arousal, familiarization with it via application to a variety of contexts demonstrates that it can be used to modulate arousal "upwards" as well as "downwards." Observation can be used to increase perception, recognition, acknowledgement, accept, ownership, appreciation and understanding to energize effective and functional, cognitive and behavioral responses.]
Hyperarousal involves
"excessive sympathetic branch activity [which] can lead to increased
energy-consuming processes, manifested as increases in heart rate and
respiration and as a "pounding" sensation in the head" (Siegel,
1999, p. 254). Over the long term, such hyperarousal may disrupt cognitive and
affective processing as the individual becomes overwhelmed and disorganized by
the accelerated pace and amplitude of thoughts and emotions, which may be
accompanied by intrusive memories.
[It's very clear to Eye>I+Eye that
"intrusive memories" per se are NOT required to set off the cascade
of excessive sympathetic branch activity > PTSD or present stress
presentations > fast pace and high affective amplitude of thoughts > overwhelm and
disorganization > disruption of cognitive and affective processing. For example, hyperarousal can
occur when one slips into potentially embarrassing, humiliating or otherwise
homeostasis-threatening acting out of defense mechanisms believed to be
unacceptable to the opposite polarity of one's introjected, paradoxical injunctions or double-binds. "I need to push this away, but I will look like a fool when I
do" owing to unconscious, contrary, double-binding instructions, usually
received in childhood, but typically reinforced by common, cultural norms.]
As Van der Kolk, Van der
Hart, et al. (1996) state, "This hyperarousal creates a vicious cycle:
state-dependent memory [or introjected but unconscious instruction] retrieval
causes increased access to traumatic memories and involuntary intrusions of the
trauma [or threat of intolerable emotional experience], which lead in turn
to even more arousal" (Van der Kolk, Van der Hart, et al., 1996, p. 305).
Such state-dependent memories may increase clients' tendency to "interpret
current stimuli as reminders of the trauma" (p. 305), perpetuating the
pattern of hyperarousal. Van der Kolk points out that high arousal is easily
triggered in traumatized persons, causing them to " ... be unable to trust
their bodily sensations to warn them against impending threat, and cease to
alert them to take appropriate action" (p. 421) [or mindfully and
calmly withdraw from further, potentially embarrassing or humiliating
expression of the inappropriate defense mechanism, because once the sympathetic
branch is set off by the insular > amygdalar > hypothalamic >
pituitary > adrenal axis, it is probably too late to block the neurochemical
spray], thereby disrupting effective defensive responses.
At the opposite end of the
Modulation Model, " ... excessive parasympathetic branch activity leads to
increased energy conserving processes, manifested as decreases in heart rate
and respiration and as a sense of 'numbness' and 'shutting down' within the
mind" (Siegel, 1999, p.254). Such hypoarousal can manifest as numbing, a
dulling of inner body sensation, slowing of muscular/skeletal response and
diminished muscular tone, especially in the face (Porges, 1995). Here cognitive
and emotional processing are also disrupted, not by hyperarousal as above, but
by hypoarousal. Both hyperarousal and hypoarousal often lead to
dissociation. In hyperarousal, dissociation may occur because the intensity and
accelerated pace of sensations and emotions overwhelm cognitive processing so
that the person cannot stay present with current experience. In hypoarousal,
dissociation may manifest as reduced capacity to sense or feel even significant
events, an inability to accurately evaluate dangerous situations or think
clearly, and a lack of motivation.
[Precisely as described
above, hyper- and hypoarousal kick Eye>I+Eye off the observer's platform,
the mind is suddenly in the hands of I-Eye^I+Eye (at
best) or I-Eye (worse yet), and the bus is headed for the cliff of unconscious,
affect-triggered acting out of defense mechanisms. Yuck.] [The ^ above stands
for "hijacking" or taking over and instrumentally utilizing.]
The body, or a part of the
body, may become numb, and the victim may experience a sense of
"leaving" the body. Additional long term and debilitating symptoms
might include "emotional constriction, social isolation, retreat from
family obligations [and other social behavior], anhedonia and a sense of
estrangement" (Van der Kolk, 1987, p. 3) along with " ... depression
... and a lack of motivation, as psychosomatic reactions, or as dissociative
states" [the defense mechanisms become unconsciously habituated,
automated, normalized and institutionalized] (Van der Kolk, McFarlane, and
Van der Hart, 1996, p. 422). As we can see, these symptoms are reminiscent of
passive defenses, in which a person does not actively defend against danger
[or, even worse, finds himself triggered again and again in reciprocal
reactivity, acting out his defense mechanisms to "protect" (not) his
fractured ego in such a manner as to set that ego up for recycling of shame,
guilt, worry, remorse, regret and morbid reflection].
The traumatized individual
may reside primarily either above or below the parameters of the optimum
arousal zone, or swing uncontrollably between these two states (Van der Kolk,
1987, p 2). This bi-phasic alternation between hyperarousal and numbing or
freezing (Van der Kolk, p. 3) -- the top and bottom segments of the
modulation model in Figure 2 -- may become the new norm in the aftermath of
trauma. When a person's arousal is outside the
optimum zone at either end of the spectrum, upper levels of processing will be
disabled, and holistic processing will be replaced by bottom-up reflexive action.
As Siegel (1999) notes, internal states outside the "window of
tolerance" are "characterized by either excessive rigidity or
randomness. These states are inflexible or chaotic, and as such are not
adaptive to the internal or external environment" (p.255). Siegel goes on
to say, "In states of mind beyond the window of tolerance, the
pre-frontally mediated capacity [cognitive processing] for response flexibility
is temporarily shut down. The 'higher mode' of integrative [cognitive]
processing has been replaced by a 'lower mode' of reflexive [sensorimotor]
responding" (bracketed text added; pp. 254-255).
Stephen Porges's (1995,
1997) work, which elucidates a hierarchical relationship among the levels of
the autonomic nervous system, has important implications for the regulation of
both arousal and defensive responses. He concludes that hypoarousal (described
above) is due to a specific branch of the parasympathetic nervous system, the
"dorsal vagal complex," which causes the organism to conserve energy
by drastically slowing heart and breath rates. The other branch of the
parasympathetic nervous systems, the "ventral vagal complex", which
Porges calls the "Social Engagement System," is the
"smart" vagal because it regulates both the dorsal vagal and sympathetic
systems. This "smart" system is much more flexible than the other two
more primitive levels of the autonomic nervous system, which if unregulated,
tend to the extremes of hyperarousal or hypoarousal. The Social Engagement
System gives humans immense flexibility of response to the environment (1995,
1997). For example, during social engagement, interaction and conversation can
rapidly shift from strong affect and animation one moment, to calm listening
and reflection the next. This "smart" branch of the parasympathetic
nervous system regulates the sympathetic and "freeze" (dorsal vagal
parasympathetic) responses to trauma and allows human beings to fine-tune their
arousal to the needs of the situation. This sophisticated
"braking" mechanism of the Social Engagement System facilitates the
regulation of overall arousal and is akin to Schore's "interactive psychobiological regulation."
In effective modulation,
the Social Engagement System regulates the more extreme behavior of the
autonomic nervous system. Under the stress of trauma, an individual may at
first attempt to use the Social Engagement System to modulate, but, if
ineffective, social engagement/interactive regulation will tend to shut down.
As this occurs, the person has a compromised capacity to use relationships [and
functional cognition] for regulation and instead reverts to the more
primitive sensorimotor and emotional systems [as well as dysfunctional
cognition, including defense mechanisms]. The healthy functioning of cognitive
direction is diminished.
As we shall see below, in
Sensorimotor Psychotherapy the Social Engagement System is activated as the
therapist/client interaction effectively serves to regulate and modulate
arousal. After the therapist fulfills this role (in other words, becomes an
"auxiliary cortex" for the client), the client can learn the
auto-regulation capacities of observing and tracking [10 StEP noticing,
recognizing, acknowledging, accepting, owning, appreciating, understanding,
digesting and discharging] sensorimotor reactions. That is, the
therapist's ability to interactively regulate the client's dysregulated arousal
creates an environment in which the client can begin to access his own ability
to regulate arousal (Schore, in press-b) independent of relational interaction.
Through this process, the
client is helped to move from frozen states and/or hyperarousal to full
participation with the Social Engagement System.
Sensorimotor
Psychotherapy: Essentials and Case Discussion
Essentials of Sensorimotor
Psychotherapy are 1) regulating affective and sensorimotor states through the
therapeutic relationship, and 2) teaching the client to self-regulate by
mindfully contacting, tracking and articulating sensorimotor processes
independently. We believe that the former promotes the reinstatement and
development of the client's Social Engagement System through interactive
regulation, while the latter promotes an independent assimilation of
sensorimotor reactions. The former is a prerequisite for the latter. As Schore
observes, the therapist's "interactive regulation of the patient's state
enables him or her to begin to verbally label the affective [and sensorimotor]
experience" (bracketed text added; Schore, in press-b, p. 20). Interactive
regulation provides the conditions under which the client can safely contact,
describe and eventually regulate inner experience.
The therapist must
cultivate in the client an acute awareness of inner body sensations, first via
the therapeutic interaction as the therapist observes and contacts sensorimotor
states, and second as the client herself notices [10 StEP recognizes,
acknowledges, accepts, owns, appreciates, understands, digests and discharges] these
inner body sensations without prompting by the therapist.
[Eye>I+Eye sees
that some patients would prefer to do this without therapeutic interaction
owing to a very high level of toxic shame about the nature of embarrassing or
humiliating, compensatory ego-defenses being processed, though perhaps not at
all about traumatic memories. Recognizing, acknowledging, accepting, owning and
appreciating this, Eye>I+Eye observes > notice > recognize, etc., the
cognitive and emotional -- as well as the somato-sensory -- aspects of the shame,
guilt, worry, remorse, regret and morbid reflection involved in contemporaneous
inclusion with the 10 StEP processing of the body sensations as they occur
during the "panic attack," "shame attack," "intense
anxiety" or whatever one may wish to label the mental events. (I+Eye now
defers from such labeling; see below).]
Inner body sensations are
the myriad of physical feelings that are continually created within the body
through biochemical changes and the movement of muscles, ligaments, organs,
fluids, breath, and so on. These bodily feelings are of a distinctly physical
character, such as clamminess, tightness, numbness, and electric, tingling, and
vibrating sensations, and of course many others. However, when clients are
asked to describe sensations, they frequently do so with words such as
"panic" or "terror," which refer to emotional states rather
than to sensation itself. When this occurs, clients are asked to describe how
they experience the emotion physically: for example, panic may be felt in the
body as rapid heart beat, trembling and shallow breathing. Anger might be
experienced as tension in the jaw, an impulse to strike out accompanied by a
sense of heaviness and immobility in the arms. Similarly, a belief about
oneself, such as "I'm bad" might be experienced as collapse through
the spine, a ducking of the head, and tension in the buttocks.
Through cultivating such
awareness and ability for verbal description, clients learn to distinguish and
describe the various and often subtle qualities of sensation. Developing a
precise sensation vocabulary helps clients expand their perception and
processing of physical feelings in much the same way that familiarity with a
variety of words that describe emotion aids in the perception and processing of
emotions.
[The more
"Asian," "Buddhist," "Brahman" and Taoist one's
orientation is, however, the more the tendency to at least wonder if "the
words get in the way" and suggest caution with verbal description that may
interfere with direct and accurate sensory experience. I+Eye is among them.
Eye>I+Eye's direct experience is that while such verbal descriptions likely
facilitate interaction with a therapeutic interlocutor, they have invariably
disrupted the internal process I have learned to use to "be with what is
in relationship" (as per Krishnamurti, Trungpa, Goenka, Maharshi, S.
Levine, Batchelor, Tart, Deikman, Brach, Klein and many, many others) with the
sensory experience. To the extent that I have acquired the capacity to tolerate
and process my PTSD -- and, evidently, ego defense -- related affects, I have
done better with the "Asian" approach than with the verbal
description of affects suggested by Linehan, Marra, Dimeff, Koerner,
Hayes, Block, P. Levine, Van der Kolk, Williams, et al., although my notion of
"better" is subject to further evidence collection.]
As clients describe
traumatic experiences or symptoms, the therapist observes their arousal level,
tracking for either hyperarousal or hypoarousal. The therapist's task is to
"hold" the client's arousal at the optimal limits of the Modulation
Model, accessing enough traumatic material to process but not so much that
clients become too dissociated for processing to occur.
[Eye>I+Eye has been
able to acquire -- or perhaps more accurately, "cobble together" --
this ability from the sources listed above. Once Eye>I observes
> notice > recognize what is going on (which, of course, presumes
vigilance without hyper-vigilance), the rest of the 10 StEP process --
including the "holding" of the arousal within optimal range during
"digestion / metabolization" -- is now doable even when the arousal
level is considerable (a SUDS level eight or nine, even).]
When arousal reaches either
the upper or lower limit, clients are asked to temporarily disregard their
feelings and thoughts and instead follow the development of physical sensations
and movements in detail until these sensations settle and the movements
complete themselves.
[This is precisely what
Eye>I+Eye has learned to do in 10 StEP processing and/or "being with
what is in relationship." I+Eye did not -- or, at least, not consciously
-- acquire this skill from SP4T, however. I+Eye pieced it together from vipassana
and other forms of Asian meditation practice.]
In this way, the therapist
acts as an auxiliary cortex, interactively modulating clients' levels of
arousal, keeping them from going too far outside the optimum arousal zone,
where it becomes difficult or impossible to process information without
dissociating.
[Here is where I+Eye has
its most major difficulties with therapist-facilitated or interpersonal -- as
opposed to intrapsychic -- SP4T: Eye>I+Eye simply cannot conceive how any
therapist (let alone one who has not him- or herself experienced this type of
affective experience) can know with sufficient accuracy what is really
going on between the patient's ears at either cognitive or affective levels of
experience. I am sure I appear to be completely whacked when I am in
the throes of a temporary, allostatically overloaded "tailspin," even though I+Eye can quite easily (now)
tolerate the affective loading and "be with what is in relationship"
for quite some period of time (often a half hour or more, and I have done so
for as long as several hours). What does the therapist look for? How does the
therapist know what the patient's SUDS level actually is?]
At the same time, clients
develop their capacity to self-regulate as they learn to limit the amount of
information they must process at any given moment, which develops the capacity
for self-regulation independent of their relationship with the therapist and
prevents their being overwhelmed with an overload of information coming from
within.
[Because SP4T is a pretty successful method, I presume that what is described above does in
fact occur, at least for many patients. But what I+Eye continues to wonder is,
"If the patient is as conditioned, socialized, habituated and normalized
to rule- and regulation-binding as I-Eye is (and most neurotic or borderline patients are), how quickly -- if at all -- will
he learn to parse out what is "too much" (or "too little")
while he is in such affective extremis that his rule-binding is inoperative in any
other fashion than trial-and-error?"]
When a client describing a
past trauma experiences panic, the therapist asks her to disregard the memory
content and just sense the panic as bodily sensation. When the client then
reports a trembling in her hands and a rapid heart rate, the therapist
instructs her to track these sensations as they change or "sequence." As Levine notes, "Once you become aware of them, internal sensations
almost always transform into something else" (Levine, 1997, p. 82).
[Eye>I+Eye agrees, but
it has also experienced that there's almost always a recycling of one or more
of the most prominent sensations in a "flow" of affective experiences
that may go on for quite some time. Moreover, there's a moving out of mindful
awareness into dissociation and then back again.]
The trembling changes from
affecting only the hands to involving the arms, which begin to shake quite
strongly, then gradually quiet and soften; the heart rate also eventually
returns to baseline. Only when this sensorimotor experience has settled is
additional content described and emotional and cognitive processing included.
[That's how Eye>I+Eye
experiences it, but I+Eye has learned to not force the content description or
the emotion and cognitive processing, but, rather, to allow it to evolve by
"being with what is in relationship," in the Asian manner.
Integration is like "God." It works in its own time.]
The therapist must learn
to observe in precise detail the moment-by-moment organization of sensorimotor
experience in the client, focusing on both subtle changes (such as skin color
change, dilation of the nostrils or pupils, slight tension or trembling) and
more obvious changes (collapse through the spine, turn in the neck, a push with
an arm, or any other gross muscular movement). These sensorimotor experiences
usually remain unnoticed by the client until the therapist points them out
through a simple "contact" statement such as, "Seems like your
arm is tensing," or "Your hand is changing into a fist," or
"There's a slight trembling in your left leg." Any therapist is
familiar with noticing and contacting emotional states ("You seem
afraid") to facilitate clients' awareness and processing of emotions;
the procedure is similar for sensorimotor reactions.
[Recalling Memories from a Third Person Perspective Changes how the brain Processes them. See the new research at this link. This is mindfulness in operation at the level of physiology.]
Mindfulness is the key to
clients becoming more and more acutely aware of internal sensorimotor reactions
and in increasing their capacity for self-regulation. Mindfulness is a state of
consciousness in which one's awareness is directed toward here-and-now internal
experience, with the intention of simply observing rather than changing this
experience. Therefore, we can say that mindfulness engages the cognitive
faculties of the client in support of sensorimotor processing, rather than
allowing bottom-up trauma-related processes to escalate and take control of
information processing. To teach mindfulness, the therapist asks questions that
require mindfulness to answer, such as, "What do you feel in your body?
Where exactly do you experience tension? What sensation do you feel in your
legs right now? What happens in the rest of your body when your hand makes
a fist?" Questions such as these force the client to come out of a
dissociated state and future- or past-centered ideation and experience the
present moment through the body. Such questions also encourage the client to
step back from being embedded in the traumatic experience and to report from
the standpoint of an observing ego, an ego that "has" an experience
in the body rather than "is" that bodily experience.
For traumatized
individuals, fully experiencing sensations may be disconcerting or even
frightening, as intense physical experience may evoke feelings of being
out-of-control or being weak and helpless. On the other hand, traumatized
individuals are often dissociated from body sensation, experiencing the body as
numb or anesthetized. Our view is that failed active defensive responses [e.g.:
Goleman's "vital lies" and Freud's, Freud's and Valliant's defense
mechanisms in general] along with the inability to modulate arousal can be
sources of such distressing bodily experiences, and that this distress can be
at least somewhat alleviated [in my experience, substantially alleviated] by
helping clients experience the somatic sequence of an active defensive response.
Subsequently clients may access sensation without dissociating or feeling
uncomfortable.
To illustrate the above
points, we will describe three sessions with Mary, a middle aged, successful
businesswoman who suffered both relational and shock trauma from being raped
repeatedly by her uncle from ages four to ten. Although she suffered from panic
attacks, depression, and what she described as having "no
boundaries," she had no clear memory of the trauma until a recent
altercation with an authority figure triggered flashbacks accompanied by
insomnia and disturbing physical symptoms such as hyperarousal, uncontrollable
shaking, unprecedented vaginal bleeding, and a bout of immobility that lasted
for over an hour. Mary reported that during the abuse she had tried to fight
her uncle at first, but eventually she submitted and "watched from the
ceiling."
[Abridged at this point for the sake of merciful brevity. The clinical report here refers exclusively to a case of PTSD.
Eye>I+Eye have used virtually identical techniques -- albeit in a sort of
zen-cum-DBT distress tolerance and emotion regulation schematic -- to deal with
lingering PTSD rooted in childhood, early adult and late adult trauma. Lately,
I have begun to use these techniques to attempt to process the emotions of shame,
guilt, worry, remorse and regret in combination with morbid cognitive
perseveration when they appear as sensorimotor "attacks" or
"events." These emotions seem to be upshots of Goleman's description
of complex defense mechanisms he called "vital lies." I am hopeful
that the processing of these emotions will reduce the "pressure in the
pipe" and lead to reduction -- if not outright extinction -- of the
defense mechanisms I-Eye has employed to very ineffectively deal with those
supposedly "intolerable" affects.]
Conclusion
Sensorimotor Psychotherapy
was developed entirely from clinical practice, and although there has been no
formal empirical research at this time, there are many anecdotal reports from
both clients and therapists that attest to the efficacy of the method.
Professionals who have learned Sensorimotor Psychotherapy report that it often
reduces PTSD symptoms such as nightmares, panic attacks, aggressive outbursts
and hyperarousal, and that the ability to track body sensation helps clients experience
present reality rather than reacting as if the trauma were still occurring.
Such reductions of distressing bodily-based symptoms and increased capacity for
both tracking body sensation and interactive self-regulation appears to help
clients become increasingly able to work with other elements of trauma, such as
attachment, meaning-making, and dissociative patterns that were previously
overshadowed by bodily states and the inability to utilize interactive
self-regulation.
Sensorimotor Psychotherapy
provides clients with tools to deal with disturbing bodily reactions, and they frequently
report feeling increasingly safe as they begin to learn how to limit the amount
of information they must process at any given moment by focusing attention on
sensation. Clients also report that their feeling of safety is enhanced when
they experience the potential to physically protect and defend themselves. It
should be noted that clients who experience hyperactive defenses in the form of uncontrollable
rage may also increase their feeling of safety by learning to sense the
physical precursors to full-blown aggressive outbursts, and at that moment
begin to engage mindfulness. This intervention increases self-regulation and
prevents the escalation of arousal to the point of discharge through aggression
or other undesirable behavior.
Although we have focused
almost exclusively on sensorimotor processing in this article, the full
spectrum of Sensorimotor Psychotherapy integrates sensorimotor processing with
emotional and cognitive processing. During therapeutic sessions, the therapist
must evaluate moment by moment which level of processing to address that will
produce the most positive overall effect. Emotional or cognitive processing is
often called for, and in fact can have a positive effect on further
sensorimotor processing.
It should also be noted
that while this article has emphasized sensorimotor processing, numerous other
therapeutic maps and body-inclusive techniques exist in the overall approach
developed by the authors and their colleagues that deal in different ways with
relational dynamics, psycho/structural patterns and dissociation. Above all, it
is important to stress that the ultimate and overriding goal of Sensorimotor
Psychotherapy is to foster holistic processing by integrating the three levels
of our being: cognitive, emotional, and sensorimotor.
On the other hand, therapists using Sensorimotor Psychotherapy report that some
clients are not so available for, or interested in, body processing as was Mary.
Such clients must slowly and painstakingly learn to experience sensation and be
open to the potential value of doing so. They must gradually learn from their
own somatic experience that paying full attention to body sensation and
movements can be safe and even pleasurable.
Additionally, severely
disorganized or dissociated individuals may be unable to be mindful of
sensation without becoming further disorganized or dissociated. It must be
realized that accessing too much sensation too quickly, particularly before
clients are able to observe their experience and put aside content and
emotional states, may be counterproductive and may in fact increase
dissociation and exacerbate PTSD symptoms. Therefore therapists must proceed
appropriately according to each client's pace and ability to integrate.
Nevertheless, an occasional client may remain unable or unwilling to work with
sensorimotor processing, finding body sensations too overwhelming and
distressing, or otherwise finding a somatic approach uninteresting or
unappealing. In such cases, sensorimotor processing is contraindicated and the
therapist must use other techniques.
Ogden's & Minton's
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