Including the Body in Mainstream Psychotherapy for Traumatized Individuals
Volume VI, Issue 3, Article 3 (October, 2000)
One Method for Processing Traumatic Memory
Ogden, Ph.D. and Kekuni Minton, PhD.
Sensorimotor Psychotherapy Institute
and Naropa University
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.
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 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
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" 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.
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.
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 of traumatic 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
nervous system 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 effective functioning of the lower
levels. 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.
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. When
sensorimotor experience is disturbing or overwhelming, conscious 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. 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.
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. 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 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. 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, the therapist must serve as an "auxiliary
cortex" (Diamond et al., 1963), for clients through observing and articulating
their sensorimotor experience until they are able to notice, describe and track
these experiences themselves. 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 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.
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, reaction formation, 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.
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
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.
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.
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)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 or orient toward danger, or even attempt to get help.
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.
The Modulation Model
1 Modulation Model: Optimum Arousal Zone
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.
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. As Van der Kolk, Van der Hart, et al. (1996) state, "This hyperarousal
creates a vicious cycle: state-dependent memory retrieval causes increased access
to traumatic memories and involuntary intrusions of the trauma, 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), 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.
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. 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, 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"
(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.
Figure 2 The Modulation Model: The Bi-Phasic Response
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 prefrontally 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 for
regulation and instead reverts to the more primitive sensorimotor and emotional
systems. 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 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.
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 these inner body sensations without prompting by the therapist.
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.
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
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. 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. 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. 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.
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). 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.
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
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 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 by helping clients experience
the somatic sequence of an active defensive response. Subsequently clients may
access sensation without dissociating or feeling uncomfortable.
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
As Mary recounted her history, she spoke rapidly with few pauses
that would provide opportunity for verbal interaction with the therapist. Her
Social Engagement System was markedly diminished; it was almost as though she
were talking to herself, unable to utilize the relationship to interactively regulate
her arousal. Mary appeared increasingly isolated and alone as she spoke.
At times she experienced panic and hyperarousal, and she repeatedly spoke in judgment
of herself for having allowed the abuse: "Why did I ever change clothes in front
of him? Why didn't I tell my mother what was happening?" She also condemned herself
for her inability to defend against the abuse, interpreting her dissociation and
freezing as a personal weakness, a common response among trauma survivors (Nijenhuis
& Van der Hart, 1999, p. 54).
This first session with Mary illustrates
an important point: The initial stage of therapy usually entails the therapist
helping the client to begin to regulate arousal. This is accomplished at first
through the interactive regulation within the therapeutic relationship,
which sets the conditions under which the client can learn self-regulation. Obviously,
a healthy relational rapport between client and therapist must be present for
interactive regulation to occur. In Mary's case, the therapist facilitated interactive
regulation through tracking changes and movements in her body, making contact
statements, demonstrating an ability to understand Mary's distress and tolerating
the description of her traumatic experience without withdrawing or becoming hyperaroused
himself. Gradually, Mary began to soften slightly in her body, slow her speech,
and engage in reciprocal interaction with the therapist.
It was difficult at
first for Mary to be mindful of her bodily sensations because when she tried to
do so, the hyperarousal, shaking, panic and terror became overwhelming. Similar
to Levine's notion of "exchanging ... an active response for one of helplessness"
(Levine, 1997, p. 110), the therapist knew that if Mary could fully experience
a physical defensive sequence, these symptoms might lessen. To accomplish this,
he asked Mary if she would be willing to experiment by pushing with her hands
against a pillow that he held, and to notice what happened in her body. Mary consented
and as she performed this action, she first experienced nausea and increased fear,
not uncommon when first working with activating a defensive sequence that has
failed in the past. The therapist then asked Mary to temporarily disregard all
memory and simply focus on her body to find a way to push that felt comfortable.
Mary's sense of control was increased as she was encouraged to guide this physical
exploration by telling the therapist how much pressure to use in resisting with
the pillow, what position to be in, and so on. As Mary began to experience the
active physical defense, the therapist tracked her body and made contact statements
such as, "The strength of the pushing is increasing," and "You seem to be settling
down," etc. Mary was also instructed to be mindful of the details of her sensations:
"What's happening in your body as you push? What do you feel in your back and
Mary eventually experienced a full sequence of active defensive response:
lifting the arms, pushing tentatively at first with just her arms, then increasing
the pressure and involving the muscles of her back, pelvis, and legs. The therapist
continued to evoke mindfulness of sensation, and Mary began to experience the
physical pleasure of pushing, reporting, "This feels good!" Because many traumatized
clients are anhedonic (unable to feel physical pleasure), experiencing and savoring
pleasurable sensations can increase their overall capacity for experiencing pleasure
and also can change their relationship with the body, which heretofore may have
felt like "the enemy," the source of disconcerting sensations and physical pain.
When the defensive sequence had been thoroughly explored and completed, Mary was
calmer and able to be mindful of sensations without becoming hyperaroused -- in
other words, she was now situated within the optimum arousal zone of the Modulation
The intention in Sensorimotor Psychotherapy is to work at the edge of
the Modulation Model, accessing enough of the traumatic material to work with,
but not so much that the client becomes overwhelmed and dissociated. To serve
this end, as Mary returned to describing the trauma (her decision, not the therapist's),
she was instructed to stay mindful of her body sensations. As she described her
abusive experience her jaw began to tighten, her right shoulder and arm began
to constrict, and her breath became labored -- all possible signs of defensive
responses emerging spontaneously. After making contact statements with these physical
observations by saying, "Your jaw and arm seem to be tightening up and your breathing
is changing," the therapist directed Mary to be mindful of her bodily sensations:
"Let's take a few moments to sense what's happening in your body before we go
on with the content." Mary described the tension and stated that her head seemed
to want to turn to the left, at which point she remembered a wall being on her
left during the childhood abuse. Instead of interpreting her statements, or returning
to the content of the memory, the therapist directed her to "allow that turning
in your neck and notice what happens next."
At this point, Mary was no longer
describing the past but was attentive only to present bodily experience. As she
was mindful of her head and neck turning to the left, she was also aware of physical
impulses that seemed involuntary, as if they were happening "by themselves." Her
body seemed to take on a life of its own as she was encouraged to be mindful of
her sensations and movements. Mary reported that "my hand wants to become a fist"
and the therapist encouraged her to "feel the impulse and allow that to happen"
without doing it voluntarily. While the previous pushing motion against the pillow
was entirely voluntary, Mary's hand now slowly began to curl into a fist spontaneously.
Mary reported that her arm wanted to "hit out." The defensive movement sequence
was now emerging without conscious top-down direction from either the client or
the therapist. The therapist said, "Feel that impulse to hit out and just notice
what happens next in your body." Mary was encouraged to simply track and allow
the involuntary micromovements and gestures, rather than "do" them voluntarily.
Sensorimotor processing was occurring spontaneously through mindful attention
to body sensation and impulses, and by harnessing cognitive direction in suspending
content and emotion to support the body's processing.
As the therapist directed
Mary to track her sensations and involuntary movements, and as her right hand
formed a fist, her forearm also tightened, and her arm slowly rose off her lap
without conscious intention on her part. Mary stated that she was starting to
feel panicky, and the therapist asked her to just experience the physical elements
of the panic (which Mary reported as increased heart rate and constriction) rather
than the emotion. This was an important directive to separate trauma-based emotions
from sensation so that sensorimotor processing could occur without interference
from emotional or cognitive processes, and without overloading Mary with more
information than she could effectively handle. Gradually, Mary's head and body
turned back toward the center, and her right arm progressed through a slow rising
and hitting motion accompanied by shaking. (Inwardly this experience of shaking
is similar to shudders passing through the body when one is cold.) After several
minutes of sensorimotor processing during which both Mary and the therapist followed
the slow and unintended progression of movements, Mary's arm finally came to rest
in her lap. Mary continued to shudder, and she was instructed to "stay with the
shudders and sensations as long as you are comfortable doing so."
All the while,
Mary was encouraged to trust her body by allowing the movements to occur without
trying to direct them or change them in any way, and she was also encouraged to
stop at any moment if she felt too much discomfort to go on. Since physical constriction
from the gradual "exposure" to the traumatic memory can be extremely intense before
it begins to unwind and soften, clients need the therapist's help in following
the sensorimotor process. They are also encouraged to self-regulate -- to stop
if ever it becomes too intense.
Eventually the shudders ceased, and Mary said
she felt relief and a sensation of tingling throughout her body. The therapist
instructed her to savor her bodily feeling and sense of relief, and to describe
these physically in detail. Reporting a softening in her musculature, a slowed
heart rate and a good feeling of heaviness throughout her body, Mary stated that
she felt peaceful for the first time in weeks. In speaking about the abuse, Mary
was less judgmental of herself, saying she was angry that her mother had turned
a blind eye to her uncle's behavior, and that no four-year-old girl should have
to worry about changing clothes in front of a relative. While she had not worked
directly with her self-judgments, beliefs, or emotions associated with the traumatic
experience, working with sensorimotor processing had a positive effect on both
her emotional and thinking processes. Toward the end of this session, the
therapist helped Mary address emotional and cognitive processing. Mary gave full
expression to her sadness and arrived at new meanings while she also became more
fully conscious of her sensorimotor reactions. Mary experienced a new integration
and reorganization of the physical, emotional, and cognitive levels of her experience
as these three levels were addressed simultaneously.
At her next session, Mary
reported that her sleep pattern had returned to normal, and she was much calmer
in general. Her panic attacks had nearly ceased, and she wanted to continue to
explore her childhood trauma, more confident in her ability to do so with an expectation
of personal mastery. Mary was increasingly able to interact with the therapist,
which was demonstrated by her asking questions, engaging in more dialogue in contrast
to her original monologue, and in her using the relationship with the therapist
to soothe herself. In subsequent sessions, Mary further developed her ability
to actively defend herself and to set boundaries, which expanded her capacity
to engage in interactive regulation, for the ability to actively defend and set
boundaries increases one's safety in relationship. Mary was increasingly able
to process emotional and cognitive elements of the trauma and to address relational
issues with the therapist, while frequently returning to sensorimotor processing
when physical impulses and sensations emerged, or when she again felt hyperaroused
Eventually, Mary experienced a therapy session in which she
confronted the memory of the moment she first dissociated and "watched from the
ceiling to what he [her uncle] was doing to another little girl," while another
part of her submitted to the abuse. However, she now had developed the
skill of tracking her body sensations, and she felt more confidence in being able
to get through these experiences. Mary writes: At the time of this
session I had recently been experiencing what seemed like a new wave of earlier
memories that had brought an increase both in the level of physical activation
and in emotional terror and despair. This time though, it felt like I knew I could
get through this, I'd been here before and knew there was a process and steps
that led to a better, more whole experience.In this session, Mary
was again instructed by the therapist to be mindful of her body, and as she remembered
the trauma, she became aware of the physical reactions she had experienced as
a child. She experienced the physical components of submitting and dissociating
from her body (numbness, muscle flaccidity, feeling paralyzed) along with the impulse to fight back (tension in her jaw and arms). Awareness of sensation
became the unifying force in resolving this "dissociative split," as Mary realized:
"This disintegration is not real...I'm two bodies in the same body, doing two
different things." As Mary experienced this split somatically and processed the
physical components of it (such as the impulse to fight her uncle), she was able
to experience the grief associated with the abuse without dissociating from her
body. More able to process cognitively, her negative beliefs about herself eventually
were replaced by a sense of accomplishment of having been able to defend herself
through dissociation and submission, acknowledging that these passive defenses
had been effective in her particular situation and realizing that active defenses
at that time would probably have made her trauma worse. At one point in the session,
Mary proudly says, "There's nothing wrong with me -- look what I did!" referring
to her dissociation as a way to survive unbearable abuse.
Shortly after this
session, Mary's therapy terminated. Six months later, she writes: I
am aware that there has been a lasting and profound change in both my body (the
way I hold it) and my sense of integration and ability to stay present with fearful
situations, memories and sensations that would previously have been so overwhelming
that they would be suppressed ...
I also feel emotionally integrated in a new
way. It's as though the part of me that had been the victim of ... abuse is not
alone any more but has other stronger, more whole and resistant parts mixed up
with it. I no longer so desperately need the contact [with the therapist] to go
into the memories. It's though I can be there for myself.
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.
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
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
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.
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Volume VI, Issue 3, Article 3 (October, 2000)