EMOTIONS ARE ONE of the most salient components of psychotherapy. The neuroscience view of emotion is related to, but distinct from, the way clini- cians usually define and think about emotion. In usual clinical parlance, the terms emotions, feelings, and affects are all used interchangeably. In contrast, the neuroscience view of emotion refers specifically to subcortical, often body- based experiences and not the conscious awareness of a feeling. Often, thoughnot necessarily, the body-based experience serves as a platform or scaffolding upon which the subsequent consciously experienced feeling or affect is built. Emotions form in the subcortical systems, are often experienced in the body before entering consciousness, and have a significant effect on judgment and decision making. This view of emotion affirms that a lot is happening within a person nonconsciously before there is any conscious aware- ness of it. Alerting patients to their bodily experience may help attune them a bit more quickly to what might lie below the surface. For some patients, alerting them to attend to their bodies’ signals gives them a way of accessing their emotions when language does not suffice. The neuroscience view of emotion can be integrated into mainstream psychody- namic clinical practice to offer another rich pathway for clinical exploration, intervention, and transformation. As most psychodynamic therapists would likely agree, the body as a source of understanding emotion is underutilized in mainstream clinical practice.
There is consensus among neuroscien- tists, neurobiologists, and neuropsycholo- gists that emotions are not necessarily “felt experiences” but are formed in the body prior to any conscious awareness of a feel- ing (e.g., see the work of Da-masio, 1994, 1999; Ekman, 2003; LeDoux, 1996; Pally, 1998a; Pally, R. & Olds, D., 2000; Siegel, 1999). There are some nuanced definitional differences among leading neuroscientists, with Panksepp noting that emotions can start in the subcortical part of the brain before finding body equivalents (Panksepp, 2011), whereas others, such as Damasio (1994), assert that emotions always start as bodily based experiences. Through the subcortical systems, a person registers an emotion that has a strong somatic compo- nent. Emotions prime us to detect danger or reward. When we perceive danger, our bodies prepare to avoid; when we perceive or anticipate reward, our bodies prepare to approach. These seemingly simple percep- tions activate a cascade of bodily reactions (autonomic, hormonal, etc.) that prime us for action—for doing something. The doing can be either an approach or avoidance behavior. Basic emotions, hardwired by evolution and then increasingly elaborated throughout the mammalian kingdom, give us simple and elegant value-coding mechanisms. For example, if we feel hungry we know to search for food (approach). If we feel threatened by the possibility of a predator, we know to get out of the way or hide (avoid). These coding mechanisms steer us through present and future actions (Panksepp, 1998).
Within the reptilian kingdom these basic signals are simple and stereotypic. They al- low for rudimentary survival needs, such as getting food, reproducing, and staying safe from predators. Mammals use similar sur- vival strategies that build on the reptilian responses but that also include the realm of social emotions. The latter are intertwined with social bonds, attachment needs, and their disruption (Panksepp, 1998). Cozo- lino (2006), building on earlier work from Tomkins and Karon (1962) and others, speculated that social emotions evolved as mammals began caring for their offspring outside of the body. Reptiles bear eggs and protect the eggs, but less so the offspring once the eggs are hatched. In contrast, mammals care for their young outside the body. Social emotions ensure that mothers and babies communicate in order to stay close and attached. Through these social emotions and their concomitant commu- nications, the mother remains available to feed, protect, and nurture her young.
Hofer (1995) demonstrated that infant rats separated from the mother automati- cally emit the distress cry and automatically huddle together in the litter and try to follow the mother. The mother rat, in response to the distress cry, automatically initiates a search-and-retrieve action. Upon reunion with her young she picks each up, returns it to the nest, and begins licking and feeding (soothing behaviors). This research indicates that attachment and its concomitant emotions are biological as well as developmental/psychological phenomena (Cozolino, 2006; Pally & Olds 2000; Panksepp, 1998).
Although humans share and utilize the same subcortical systems as other mammals as part of their emotional lives, higher brain functions filtered through the neo- cortex help to mediate and transform their emotional lives that begin as emotional bodily based responses. Thus, judgment, prioritizing, and other executive functions are brought to bear upon subcortical emo- tional responses, thereby adding complexi- ties and nuances. We are not only biology; rather we are both biology and lived experi- ence (Damasio, 1994). Mainstream psycho- therapy and psychoanalysis have privileged experience (nurture) and minimized biology (nature).
Willa, (from Chapter 2 of my book Infant Research & Neuroscience at Work in Psycho- therapy: Expanding the Clinical Repertoire), is a good example of the body serving as the pathway for accessing emotions and subse- quently feelings. Just as her body posture served as the pathway to understanding a central component of her relational experi- ence, working with her bodily experiences helped her to find language for her intense emotional experiences.
As we explored her social shyness, Willa was unable to describe her feelings or emo- tional reactions. In fact, this was true in any situation. As I switched my focus and asked her to attend to her body, she became aware that she experiences uneasiness as a “heavy pain in my chest” and that “my stomach feels like a bunch of little knots all squeezed together.” Willa showed me the pain in her chest by repeatedly thumping that area. These physical manifestations spoke to me in a visceral way. Willa eventually learned to translate these physical experiences into feelings of fear. Once she moved from her body to a feeling state described in lan- guage, we were able to connect the emotion of fear to the repetitive template of needing to hide when in the company of a significant other.
There is a preponderance and conver- gence of evidence from neuroscience, psychology, and experimental psychology that emotions are bodily based experiences, in that there is a strong physiological component, often occurring outside of reflective awareness, to emotional reactions.
The next section summarizes some of the leading points of view from neuroscience and psychology. This is not meant to be a comprehensive review, but is sufficient for a clinician to better integrate and use the emotions held in the body of both patient and therapist to expand the clinical dialogue. I describe the neuroscientist Antonio Damasio’s Somatic Marker hypothesis and then move to the psychologists Sylvan Tomkins and Paul Ekman. Both Tomkins and Ekman defined basic emotions that they believe are universal and exist across cultures. Ekman than went on and correlated these basic emotions with specific facial, musculature configurations that serve as powerful, nonconscious communications between individuals and between an individual and its important groups. This latter perspective is especially relevant to a two-person psychology.
Damasio’s Somatic Marker Hypothesis
Since most neuroscientists agree that body-based experiences are central to emotions and subsequent feelings, I’ll focus on only one theory: Antonio Damasio’s somatic marker theory, as described in his book Descartes’ Error (1994). Damasio calls our bodily experience of emotions or bodily states somatic markers. These bodily states bias and inform conscious decision making. The cognitive mechanisms use the body’s readings for prioritizing, assessing, judging, and ultimately taking action: Should I approach or avoid this situation? Secondary cognitive processes have their own somatic markers that help to order and prioritize potential activity and bring nuance to any situation. Is the matter urgent? If so, how urgent? Will I feel better doing it now or should I wait until later? Cognitive process- es, like emotional processes, are shaped by prior experience. The point is that the body holds numerous biases prior to any conscious or felt experience that informs conscious judgment and decision making. They tilt us in particular directions.
The body and brain interact through two routes of interconnection. The first includes the sensory and motor peripheral nerves, which carry signals from every part of the body to the brain and from the brain to every part of the body. The second is the bloodstream, which carries signals such as neurotransmitters and neuromodulators throughout the body. These two intercon- nected “highways” of the brain function as an ensemble that interacts with the envi- ronment. While interacting with the envi- ronment, the bodily experiences along both highways have already begun to tilt toward action in a particular direction (approach or avoid) before there is any conscious aware- ness of a feeling or any felt requirement to make a decision.
In complex organisms interactions with the environment generate internal re- sponses that include sensory experiences and images (auditory, somatic, visual). According to Damasio (1994), it is this interac- tion with the environment and the subse- quent formation of somatosensory images that composes mind. Thus, body–brain becomes mind. Since emotional responses are also informed by lived experience, the body–brain–mind amalgam forms a unique response to the environment. According to Damasio, “having a mind means the organ- ism forms neural representations which can become (images) that can be manipulated and organized by thought and eventually influence behavior by helping to predict the future, plan accordingly and choose the next-action” (1994, p. 90). These combi- nations of body–brain–thought influence behavior and decision making by helping to predict the future based on past experi- ence. Because there is thought involved, which is reliant on the higher part of brain function, we experience all of this in a conscious way. And, once consciousness is involved, the experience is one that feels as if it belongs to us.
The body holds numerous biases prior to any conscious or felt experience that informs conscious judgment and decision making. They tilt us in particular directions
Iowa Gambling Experiment
Damasio (1994), building on work with others in his laboratory, conducted several experiments to show that emotional/bod- ily reactions function as somatic markers that guide fundamental decision-making processes. Patients with ventromedial prefrontal damage were chosen for this experiment because it is believed that the ventromedial area of the brain is involved in creating emotional (salience) associa- tions between visceral bodily feedback and external events. The results of the patients with ventromedial brain damage were compared with the results of normal subjects (i.e., those without any brain damage).
Damasio (1994) in a series of studies with Daniel Tranel, a psychophysiologist and experimental neuropsychologist, first determined that those with ventromedial damage had emotional/bodily reactions. Using a skin-response conductance test (the polygraph or lie detector), Damasio tested those with frontal lobe damage using a startle stimulus and determined that those individuals have the capacity for skin conductance responses. Damasio then tested both the control group and the patients with frontal lobe damage for skin conductance responses to disturbing events. Both groups were hooked up to skin conductance response monitors and shown a series of pictures. Some pictures were bland and others showed horrifying and/or disturbing images, designed to ac- tivate an emotional response. The results were unequivocal. All people in the control group (normals) and people with brain damage to parts of the brain other than the ventromedial area registered an emotional reaction at the moment of viewing the dis- turbing pictures. Those with prefrontal lobe damage did not register any skin conduct- ance response to the disturbing pictures. However, later when asked to describe what they had seen, they noted the horrifying pictures. This response demonstrated that the disturbing images had registered with them, but they did not appear to have a concomitant emotional reaction.
Damasio (1994) next used a risk-taking gambling experiment designed by a post- doctoral student, Antoine Bechara, in col- laboration with Hannah Damasio and Steven Anderson (Bechara, A., Damasio, H., Tranel, D., & Damasio, A., 2005). Each player was given four decks of cards (A, B, C, D) and $2,000 in pretend currency and told to either make money or to lose as little money as possible. Players were instructed to turn over one card at a time. In two decks each card offered $50 when turned over; in the other two decks, each card gave $100. Pe- riodically, the deck that paid $100 slammed the player with a very large penalty. Al- ternatively, the decks with $50 cards had very small penalties. The experiment was designed so that, over time, choices from the decks paying $50 would result in fewer losses and more net gain. The assumption was made that humans will prefer reward to punishment.
As the subjects began their play, the control group of normals sampled the vari- ous decks, bit by bit, and eventually began to form hunches that led them to approach the decks that did not have large penal- ties, but resulted in a small and steady gain. Alternatively, the people with prefrontal lesions kept going for the high-paying decks with high penalties. Ultimately, they lost everything. It seems as though they never learned from their previous experiences. Damasio hypothesized that those with frontal lobe damage do not register the emotional reaction correlated with the experience of punishment and/or reward. Thus, they don’t have the “somatic mark- ers” that help them make good decisions.
Damasio (1994) tested this hypothesis further with a second component of the same experiment. This time, all partici- pants were hooked up to skin conductance response machines. Using the same gam- bling protocol described above, Damasio saw that after a high-reward or high-penal- ty event, all subjects, including those with frontal lobe damage, registered a skin con- ductance response indicating some form of emotional reaction. That is, unlike the lack of response to emotional pictures, the pa- tients did react to the “in-the-moment” ex- perience of loss in which they were directly involved. As play continued, the controls registered skin conductance responses as they approached each deck. This response indicated that they were deliberating which deck to choose from before making their decision. Damasio hypothesized that they were developing hunches about the various decks. In people with frontal lobe damage the process is different. They avoided the offending deck for one or two plays, indi- cating that they had registered a skin con- ductance response. But after one or two rounds they kept going back to the high- reward and high-penalty decks. It seemed apparent that they were not able to use the registered somatic marker to inform their decision-making process. Damasio hypoth- esized that the “negative somatic state” associated with the penalty registered with them, but those with prefrontal lobe damage could not use the bodily emotional experience (somatic marker) to guide future behavior. He termed this myopia for the future. Alternatively, in a normal person, the somatic marker served to guide a person to safety and/or reward.
For Damasio (1994) and others, the body is seen as contributing more than life support; it is seen as part and parcel of the workings of a normal mind. In this sense the mind can be viewed as arising from activity in the neural circuits, which contain basic representations of the organism as
it continuously receives stimuli from the internal and external environments.
Some emotions are species-wide and innate. Different species are primed to fear particular things so that they can avoid natural predators or be drawn to some- thing necessary for survival. For example, several species of birds run (flight) or freeze in response to a large horizontal shape. The horizontal shape is resonant with the shape of a hawk’s spread wings, the natural predator of these birds (Tinbergen, 1951). Monkeys are naturally fearful of an S shape, the shape of a moving snake, their natural predator. Alternatively, mammals are primed to pursue things that bring reward and satisfaction; for example, pheromones send out subtle sexual odors that attract the opposite sex. Each zebra has a pattern of stripes that is unique, similar to human fingerprints; baby zebras recognize their mothers’ signature stripes and thereby can stay close and safe (Rustin & Sekaer, 2004).
Humans have basic emotions that serve to help them meet their need for physiological, social, and psychological survival as they function in this complex world (Panksepp, 1998). These primary emotions serve as an automatic appraisal system that is influenced by both our evolutionary and personal pasts. These emotions prime us, through a set of immediate physiological changes (somatic markers), for a particular situation (Ekman, 2003; Tomkins & Karon, 1962). An example of an evolutionary fear common to most humans was described by Charles Darwin (Darwin, C., 1872/1998) almost 150 years ago in The Expression of the Emotions in Man and Animals. Humans, for the most part, are innately primed to fear snakes. Darwin described putting his face close to the glass (in a safe setting) in front of a puff-adder snake with the intention of not backing away if the snake attempted to strike at him. But as soon as the snake “struck,” Darwin’s resolve crum- bled. He automatically jumped a yard or two backward, even though he knew he was protected from the snake by the glass. His will and reason meant little in the face of the automatic subcortical system that anticipated danger.
Similarly, individuals form automatic emotional appraisal systems based on their own personal histories. For example, a child who has been hit by her father might have a reaction similar to Darwin’s when- ever she sees a man raise his hand above his head. The man might be reaching for something innocuous, but the poise of the arm triggers the instant emotional apprais- al of the possibility/probability of being hit. In each instance, the body prepares for the “attack.” What the outside observer sees is the behavior of backing away. Inside the woman’s body, a lot more would be going on: increased heart rate; possibly sweaty, cold, and clammy hands; and a cascade of chemical reactions that prime her to act in the face of danger.
Prior to the advent of high-tech imaging machinery, research psychologists devel- oped theories about emotions that were then tested experimentally. Silvan Tomkins (Tomkins & Karon, 1962), a pioneer in affect theory, defined nine primary affects (what Tomkins called affects, neuroscientists more usually lean toward the term emotions). Tomkin’s originally identified 8 basic affects (with disgust and dismell as separate) as biologically programmed emotions. The ninth one (shame) he believed developed later. Eventually, he grouped disgust and dismell together. Despite the difference in terms, most theorists today subscribe to some version or combination of these basic emotions originally defined by Tomkins. Panksepp organizes his emotional systems somewhat differently, but his systems seem to cover the same primary emotions with different clustering. Despite differences in language and organizational coding, each emotional system seems to have its own neural and physiological mechanisms that function in ways to provide solutions for survival and/or advancement.
Survival might mean:
How do I obtain what I need for my physiological existence?
How do I keep myself safe?
How do I protect my territory?
Advancement might mean:
How do I make sure I have the necessary social contacts for emotional support?
The Basic Emotions
I use the emotional systems defined by Tomkins and Karon (1962) and later refined by Ekman (2003). Tomkins believed that humans are equipped with innate affective responses. Tomkins (1962, 1963) was using affects to describe the biological compo- nents of emotion. These innate responses bias him to stay safe, avoid death, to desire sexual experiences, to seek novelty and avoid boredom, to want to communicate
to remain in close proximity with others of his species and to resist the experience of shame (as cited in Demos, 1995). Each of these primary emotions facilitates meeting of our basic needs for survival and/or en- hancement. Tomkins describes emotions in terms of their usual intensity and their more extreme form.
Both Tomkins and Ekman focused on the importance of the face as the locus for communication of emotions in important interchanges. In addition to serving the individual’s need, emotions exist in order to communicate meaning to others. The snarl of anger or the facial agony of distress communicates a lot to the observer. It asks for a response. Furthermore, as emotions morph into the experience of feelings, they provide the bridge between rational and nonrational processes. In the following list, I use Ekman’s grouping derived from Tom- kins. The basic emotions and their defini- tions follow:
1. Anger/rage prepares the organism to defend itself against adversity.
2. Disgust/dismell primes the organism to avoid something that is dangerous or toxic.
3. Distress/anguish communicates pain and attempts to solicit comfort from the environment.
4. Fear/terror alerts the organism to danger and prepares the body for fight, flight, or freeze.
5. Shame/humiliation protects the organism, primarily humans, from unbear- able social pain.
6. Startle/surprise pertains to level of intensity. It is similar to interest, but has greater intensity in positive and negative directions. For example, seeing a dreaded person unexpectedly startles, and the emo- tion then turns to fear. In the positive direc- tion, surprise turns to excitement.
7. Enjoyment/joy primes the organism to continue rewarding experiences. In a healthy trajectory, this includes experi- ences that further the physiological and emotional growth of the individual and the species.
8. Interest/excitement provides the or- ganism with the impetus to seek out expe- riences and find things in the environment that it needs for continued survival, growth, and development.
Regina Pally suggests that the baby “reads” the emotion in the mother’s face by experiencing it in his or her own facial musculature, thereby experiencing the emotion in him or herself.
Each one of these primary emotions has its own set of bodily based reactions, including hormones, neurotransmitters, and skeletal, muscular, and postural responses. Paul Ekman’s work on the facial musculature underlying different emotions builds on the work of Tomkins and reinforces the thesis of this chapter that the body and emotion are inextricably interwoven. Note that the descriptions of the facial musculature underlying basic emotions has only been defined for 6 of these emotions (sadness, anger, surprise, fear, happiness, and disgust). Other emotions have physi- ological components, but the underlying facial musculature has not been identified for these, if it exists at all. The value of Ekman’s work lies in the fact that in inter- personal relationships we are always trying to read the meaning of the other’s commu- nication. The face is one of the most visible and accessible loci for person-to-person communication. Conversely, the facial musculature itself can activate the concur- rent emotional response. In Descartes’ Error, Damasio (1994) gives the example of the acting method used by Laurence Ol- ivier. Olivier would convey specific human emotions by attempting to mimic the be- havioral postures that convey a particular emotion. By placing his body in these posi- tions he believed it conveyed the appropri- ate emotion. (We do not know whether Ol- ivier actually experienced the emotion once he figured out how to position his body and face.) Ekman (2003) would argue, using his theory, that the specific musculature of the face indeed activates the specific emotion being conveyed. For Ekman, each emo- tion had a specific underlying musculature configuration. If the facial muscles are configured a particular way, the emotion is felt. If the emotion is felt, inevitably the facial muscles take on a specific configuration, however subtly.
Humans have additional appraisal systems that use higher levels of brain function via the neocortex. These higher- level systems also trigger the bodily based experiences, but they may not be as direct. According to Ekman (2003), these systems include:
• Memory of past emotional experiences
• Imagining an emotional situation
• Talking about an emotional situation
• Empathy for others
• Instruction by others about what to feel emotionally
• Violation of social norms
Each of these appraisal systems may also have bodily equivalents, but according to Ekman they may not be as strong as the facial musculature equivalents.
Emotions and Facial Musculature
Ekman’s facial coding system evolved from his work with the sequestered tribal people of Papua, New Guinea. They spoke no English, and many of his subjects had never heard radio or seen television. Using a set of facial photographs taken of a different remote tribe, Ekman noticed there wasn’t
a single facial expression he did not recog- nize. Editing out the social context, he then showed the photographs to Silvan Tomkins, who was also able to immediately identify each emotion and describe the underlying facial musculature. Armed with these pho- tographs, Ekman returned to Papua, New Guinea, and designed an experiment that involved a very simple story told in the na- tive language of the Papuan people. Three photographs of the face, each one depict- ing a different emotion, accompanied each story. As the simple story was read in the native language, the subject was asked to point to one of the photographs that con- veyed what the main character in the story felt. For, example, the lady goes to the house and learns that her friend has passed away. The subject invariably selected the face portraying sadness and agony. Or, the lady in the house is alone with no weapon or stick. The lady sees a wild pig approaching her door. The subject invariably selected the photograph of fear and/or surprise. Af- ter testing nearly 300 subjects, Ekman was able to statistically verify the uniformity of selection for happiness, disgust, anger, and sadness. Only fear and surprise could not be clearly distinguished from each other (surprise often morphs into fear; alterna- tively, one might hypothesize that our first response to fear may be surprise). But, at least these two emotions were consistently linked to the same stories. The experiment was repeated and verified using another secluded tribal people, the Dani, in West Irian (part of Indonesia). Ekman took this verification to support his theory that facial expressions and the underlying facial musculature convey a universal language that communicates emotional meaning to others, regardless of native tongue or country of origin.
The point of universal facial expressions is to communicate a fundamental need to others in order to get a desired response. Sadness and agony, for example, are al- most always in response to separation or loss. It might be the loss of a loved one, the loss of a thing that is valued and precious to the person, the loss of social status, or rejection by a friend or intimate. The facial expression communicates to the social environment that the individual needs and wants comfort, soothing, or some form of reparative attachment. The receiver (reader of the facial expression) may not want to provide what is being asked for, however.
Some people respond to the request for comfort and soothing with anger. They may not want to be bothered. Or, they defend against the emotion in themselves and don’t want to provide what is needed for the other. Perhaps the desire for com- fort even disgusts them because they feel burdened by the implicit request. The look of anger involves clenched teeth, glare (staring hard), and puckered, lowered eye- brows. The face of anger or rage can incite rage in the observer, or it can be experi- enced as a communication of danger and a warning signal to stay away. The observer can ignore it, pretend it is not happening, and continue the social interaction without engaging or responding to it. Although the response of the observer is certainly not guaranteed, the communication of the subject through the facial expression is universal, according to Ekman.
Ekman’s work ... confirms that the brain and body are inextricably interwoven and that both contribute to our ongoing human efforts to construct meaning and to interact meaningfully with our immediate environment.
Ekman’s work on the correlation of facial musculature and emotions confirms that the brain and body are inextricably interwoven and that both contribute to our ongoing human efforts to construct mean- ing and to interact meaningfully with our immediate environment. Of note, the em- phasis on facial musculature adds another dimension to the importance of face-to- face play between infants and mothers. Regina Pally (2011) suggests that the baby “reads” the emotion in the mother’s face by experiencing it in his or her own facial mus- culature, thereby experiencing the emotion in him or herself. One might hypothesize that a baby with a depressed (sad) mother actually experiences, through her own facial musculature, the same sadness when she is with her mother. In adult psycho- therapy, Pally (2001) suggests that there might be different brain systems that read and interact with these nonconscious com- munications that are expressed through the subtle facial musculature. Patient and therapist in face-to-face interactions are implicitly reading and communicating to each other.
The case of Andrew, contributed by my colleague Elly Huber, provides a literal depiction of the mind–body connection. Patients like Andrew carry the majority of their relational conflicts in their bodies, through various somatic illnesses and com- plaints. Because their feelings and relation- al conflicts remain primarily bodily based experiences, they can be frustrating and challenging patients for a psychodynamic therapist. Prior to becoming a psychoana- lyst, Elly was trained as a mind–body prac- titioner in the Rubenfeld synergy method. With this special training, Elly is unusually attuned to body experience and to facilitat- ing a translation from somatic to linguistic language with her patients. She has found ways to integrate her knowledge of how the body speaks into mainstream psycho- dynamic psychotherapy. Using the body as a portal for exploration, in the case of Andrew she demonstrates how speaking to and with his body, she helped to facilitate the translation of a narrative that emerged from Andrew’s body into words. In this process she helped Andrew transform his relational configurations and conflicts. The case is presented in the first person, with “I” being Elly Huber.
Andrew:Embodied Relational Conflict
Andrew, a 30-year-old professional, came for therapy for treatment of his fibromyalgia. He had made many attempts to heal his symptoms, but he remained chronically symptomatic. Andrew heard of my somatic orientation to psychotherapy and hoped that I could help to alleviate the chronic symptoms of his fibromyalgia: pain, fatigue, cognitive disorganization, and de- pression that accompanied all of the above. Fibromyalgia is a poorly understood disease. Although considered a legitimate disease, it is nevertheless considered by many in the medical community to be purely psycho- somatic. To date, little has been successful in treating the pain, discomfort, and other symptoms that patients suffer.
Based on my bodywork training, I sub- scribe to the belief that emotion itself is a somatic experience and that grounding a person in his or her body can sometimes help him or her develop greater access to feeling states. I began the psychotherapy with Andrew from this perspective. Imme- diately, as I explored his reasons for therapy, it became clear that he had very little aware- ness or experience of his own body. He was aware of pain, though. And, if he didn’t feel pain, he experienced himself as “numb.”
“I don’t know what I feel,” he said, and he seemed confused when I tried to elicit other bodily areas of experience. Over time, it became clear that for Andrew, the only way of feeling his body was through pain.
Using the principle of starting with where the patient is psychically, I inquired about the parts of his body that were in pain, and asked him to describe the pain in as much detail as possible. I used this detailed ques- tioning to get a better picture of his self experience. In describing his pain, he used words such as squeezed, pushed, pressed, poked, and prodded. From his associations to these harsh words and the images they evoke, Andrew’s body slowly revealed his relational history. Beyond the pain, it was difficult for Andrew to come up with much experientially. When I asked him about parts of his body that were not overtly in pain,
he had no answer. Because Andrew had so little awareness of his body, I started with the basics in order to help orient him to his body. I asked him about his awareness of his heartbeat, his breathing, and his tempera- ture. This was difficult for me. I experienced the work as painstakingly slow and very constrained, and Andrew expressed frustra- tion at this line of questioning. Awareness of his body did not come easily to him.
Through the process of trying to ori- ent him to his body, a relational dynamic emerged that I labeled the “right answer” theme. It became apparent that Andrew had so much trouble focusing on and exploring his body because his primary attention was focused on me. He was try- ing to puzzle out the “right answer” to my questions. He was convinced that there was a right answer and that he was unable to “figure it out.” He was vigilantly moni- toring me in order to “ferret out” what he thought I wanted to hear.
As we explored the “right answer” theme, details about Andrew’s early rela- tionships began to emerge. Andrew, the youngest of four boys, grew up in a highly ambitious family. All four sons were ex- pected to meet high intellectual, athletic, and social expectations. Whereas the three older boys seemed to comply easily with these expectations, Andrew felt pressed, pushed, prodded, and squeezed to conform and measure up. He was relentlessly com- pared with his highly successful brothers, and he always felt that he came up short. The competitive sparring in the family was often in the form of debate and intellectual dominance. Andrew felt unsuccessful or overwhelmed in this environment and was often ridiculed by his family. He was filled with shame. As this relational configura- tion emerged, I acknowledged that I did indeed want something from him, but what I wanted was to share in an exploration of his inner world and his self experience. Despite this explanation and reassurance, Andrew was convinced that I knew some- thing that he was supposed to figure out; he was panicked and frozen because he kept coming up blank. Thus frozen was expressed in his body: It was devoid of any and all feelings because he expressed his fear through freezing.
Slowly, Andrew became aware of the anxiety that accompanied self-exploration. If he felt something that he deemed was wrong, he feared I would shame and ridi- cule him. Historically, he experienced this very shaming in his family when he offered himself up in an unwanted or incorrect way. Exploring one’s feelings or felt sense was anathema to him and to what his family prized. His focus on others as the source of the right continues today. It shows up in his dependence upon his partner and his parents. He relies on both to direct the important decisions in his life, as well as his ongoing search for some professional to heal him.
A second self experience emerged when I asked Andrew to experiment with gently moving his knees and ankles to explore some tension he described there. He responded either “They won’t move” or “I can’t move them.” The tension in these parts seemed to orient around an unwant- ed feeling of being “pushed, directed, or forced.” His response was to tighten all his muscles. Despite my suggestions that he come up with imagery that might soften the experience of the various joints, he couldn’t. Thus a second component of his relational configuration emerged. He felt pushed or prodded by me. He was afraid to soften and let go of the muscles, not know- ing what would happen. He was afraid of feeling lost and not knowing where to go. This led to increasing anxiety and fear, which he experienced in his chest as rapid movement and a racing heart, the classic physiological expressions of anxiety. While he didn’t like the feeling of pain and tension in his joints, that now-familiar sensation was preferable to the experience of loss of control. Loss of control made him feel nauseated, wobbly, and weak.
Not surprisingly, I often experienced myself in a power struggle with Andrew. He had a way of changing, in some nu- anced way, everything I said. If I said “You seem sad,” he might say, “Well, I’m not sad, I’m frustrated” or “It’s not really difficult, it’s more exhausting.” This reflexive “no” was constant enough that I made a connection to the struggle in his body over releasing tension in the muscles. I pointed out that there seems to be a parallel. I interpreted to him that he feared having his experience co-opted, and thus he tries to take control by stating it exactly in his own words.
Andrew’s internal struggle over being controlled showed up in other patterns. While he was exhaustive in his search for healing from his symptoms from all kinds of practitioners and healers, he has also developed a sense of himself as a challeng- ing and frustrating patient—the patient who outfoxes and defies any attempt to heal.
In this way, he maintains control. Andrew developed a feeling of strength and power in being able to thwart and control the healing process. He longed for his suffering to be seen and attended to, yet he also derived some satisfaction in being able to say “You can’t help me.” This ambivalence toward being helped served other functions as well. It served to contain his fears of letting go and getting to know his body (his self) out of fear of further wounding.
As we explored Andrew’s issues around control, he revealed that he had been pushed rather relentlessly to succeed in many areas by his very controlling, anxious mother. She placed a high premium on looking attractive, on social status, and on professional success. Andrew often did not measure up to her high standards, and his mother freely showed her disapproval and frustration. In relation to these demands Andrew developed all sorts of somatic com- plaints—headaches, body aches, chronic sicknessall of which were dismissed as essentially unimportant or, at worst, fabri- cated. He received very little understand- ing, empathy, or support. In fact, his physi- cal symptoms seem to have frustrated his mother and stimulated her anxiety. When I expressed empathy for his pain and distress, he rejected these words. It was as if he had internalized his mother’s attitudes toward soothing and comfort and couldn’t let himself recieve it.
As we explored Andrew’s issues around control, he revealed that he had been pushed rather relentlessly to succeed in many areas by his very controlling, anxious mother.
As the treatment progressed, Andrew developed much greater body awareness and was able to move quickly and sponta- neously from his somatic experience to a conscious feeling state. He translated ten- sion building in his chest to an awareness that he was in an emotionally charged situ- ation. He began to connect the sensation of his throat tightening to feelings of hurt and sadness. Slowly, he allowed the vari- ous feelings to arise. In one session he felt some heat in his body as he discussed an anticipated conversation with his partner in an attempt to set a boundary. He was able to stay with the heat and from this somatic place, to state his boundary. In so doing he connected to a sinking feeling in his stom- ach. He interpreted this feeling as a sense of futility and turned the heat image into a feeling of power. This grounded him and gave him confidence to proceed.
By helping Andrew connect to himself through his body, many aspects of his self experience changed. Primarily he gained access to his psychic pain and sadness. This affective/emotional experience was an experience that existed separate and apart from the pain in his body through the fibromyalgia. He is now more willing to share these painful, vulnerable feelings with me and with intimate others. I would parallel this softness with relaxation and greater flexibility of his muscles. He yields emotionally and physically.
Andrew has shown significant growth in developing self-reflective capacities. He is curious about valuing himself as a chal- lenging patient and about how his behavior relates to the pushing and prodding. He tolerates not having the answer, and his need to control the interaction and create distance with corrections, negations, or wordy explanations has abated. Most importantly, Andrew has become less pre- occupied with the bodily pain of his fibro- myalgia, more patient with it when it does flare, and more accepting of the limitations the pain causes. At the same time, because he is less preoccupied with his pain, there is more “space” for him to inhabit his body in a more complete and engaged way. He seems more energetic, and he no longer takes antidepressant medication.
I believe that exploring somatic realities with Andrew afforded entrance into his self experience in a way that working solely with the narrative, on the explicit level of discourse, might not have allowed. Because fibromyalgia is a condition that ex- presses itself somatically, it proved fruitful and therapeutic to bypass the more usual psychodynamic, narrative work and go directly to the source of the pain: his body.I was able to use the body to help Andrew interpret its messages in a language that he both spoke and understood. It gave him access to himself in a way that words alone did not seem able to provide.
Because he is less preoccupied with his pain, there is more “space” for him to inhabit his body in a more complete and engaged way. He seems more energetic, and he no longer takes antidepressant medication.
Because feelinsg start as body based experiences, it is essential to integrate this knowledge into one’s clinical repertoire. The value of working with the body exists along a continuum. Patients such as An- drew speak primarily through their bodies. When the body is the primary language, working with that language can facilitate an effective therapeutic process. Other patients, such as Willa, also speak through their bodies as one of their languages but not the only one. A therapist who attends and attunes to the body will find his or her practice enhanced with these additional tools.
Working Through Past Trauma with a somatic focused approach at Trauma Recovery Institute
Trauma Recovery Institute offers unparalleled services and treatment approach. Trauma Recovery Institute offers unique individual and group psychotherapy. We specialise in long-term relational trauma recovery, sexual trauma recovery and early childhood trauma recovery. We also offer specialized group psychotherapy for psychotherapists and psychotherapy students, People struggling with addictions and substance abuse, sexual abuse survivors, people suffering with cancer or recovering from cancer and their family members, People struggling with Personality disorders, Parents exploring the art of conscious parenting and people looking to function in life at a higher level. Trauma recovery Institute offers a very safe supportive space for deep relational work with highly skilled and experienced psychotherapists accredited with Irish Group Psychotherapy Society (IGPS), which holds the highest accreditation standard in Europe. Trauma Recovery Institute uses a highly structured psychotherapeutic approach called Dynamic Psychosocialsomatic Psychotherapy (DPP). Info@TraumaRecoveryInstitute.com
Dynamic Psychosocialsomatic Psychotheyapy (DPP)
Dynamic Psychosocialsomatic Psychotherapy (DPP) is a highly structured, once to twice weekly-modified psychodynamic treatment based on the psychoanalytic model of object relations. This approach is also informed by the latest in neuroscience, interpersonal neurobiology and attachment theory. As with traditional psychodynamic psychotherapy relationship takes a central role within the treatment and the exploration of internal relational dyads. Our approach differs in that also central to the treatment is the focus on the transference and countertransference, an awareness of shifting bodily states in the present moment and a focus on the client’s external relationships, emotional life and lifestyle.
Dynamic Psychosocialsomatic Psychotherapy (DPP) is an integrative treatment approach for working with complex trauma, borderline personality organization and dissociation. This treatment approach attempts to address the root causes of trauma-based presentations and fragmentation, seeking to help the client heal early experiences of abandonment, neglect, trauma, and attachment loss, that otherwise tend to play out repetitively and cyclically throughout the lifespan in relationship struggles, illness and addictions. Clients enter a highly structured treatment plan, which is created by client and therapist in the contract setting stage. The Treatment plan is contracted for a fixed period of time and at least one individual or group session weekly.
“Talk therapy alone is not enough to address deep rooted trauma that may be stuck in the body, we need also to engage the body in the therapeutic process and engage ourselves as clients and therapists to a complex interrelational therapeutic dyad, right brain to right brain, limbic system to limbic system in order to address and explore trauma that persists in our bodies as adults and influences our adult relationships, thinking, beliefs and behaviour.” Trauma Recovery Institute
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