Treating Complex Traumatic Stress Disorders

Christine Courtois and Julian Ford, Editors

(in press)

Chapter 14

Sensorimotor Psychotherapy

Janina Fisher, Ph.D.

The Trauma Center, Boston, MA.

Sensorimotor Psychotherapy Institute

Pat Ogden, Ph.D.

Sensorimotor Psychotherapy Institute

Naropa University, Boulder, CO

Psychological trauma affects not only the mind but the body. When individuals

experience overwhelming emotional or physical threat, prefrontal cortical activity in the brain is

inhibited as mind and body prepare for the defensive operations of flight, fight, freeze or

submission (see Chapter 1). Decades after the original traumatic experience(s), these automatic

survival responses can persist in the form of symptoms of post-traumatic stress disorder (PTSD)

and the more complex elaborations associated with complex traumatic stress disorders. The

hallmark symptoms of PTSD (re-experiencing, emotional numbing, threat-related hyperarousal

and, in some cases, aphasia or “speechless terror”) and the symptom presentation associated with

complex traumatic stress disorder (such as difficulties with affect regulation due to hypoarousal

and/or alternating hyper- and hypoarousal, disorganized and insecure attachment patterns,

somatoform and psychoform dissociation, disorders of the self, and relationship difficulties;

Ford, 2005; van der Kolk, 2005) are characterized by psychological and somatic components.

Most approaches to psychotherapy lack the tools and intervention methods to directly

address post-traumatic physiological alterations. Cognitive behavioral therapies may assist the

client in learning relaxation skills to address states of hyperarousal, but they do not directly

remediate the other complex physiological symptoms associated with these traumatic stress

disorders. Experiential psychotherapies (see Chapters 14 and 16) serve to help clients to

become more aware of the bodily changes associated with certain emotional states, but they do

not facilitate the achievement of altered physiological responses. The absence of direct

interventions to assist clients in regaining the ability to regulate bodily states that have been

altered by traumatic stress disorders is a very significant omission. If these symptoms are not

therapeutically addressed, the autonomic and physiological responses often maintain and

exacerbate the psychological symptoms associated with both PTSD and complex traumatic stress

disorders despite otherwise adequate treatment. To address body-based symptoms, in addition to

the social-emotional and cognitive effects, a different approach to treatment may be helpful.

Traditional treatments of traumatic disorders are often complicated by the wide variety of

disturbances in sensation, perception, and movement typically reported by individuals with

traumatic stress disorders, symptoms which often prove baffling to clinicians and medical

professionals and disorganizing for their patients (McFarlane & Yehuda, 1996). Among these

disturbances are those that involve reliving/re-experiencing (such as pain and sensory

distortions), unbidden movements, autonomic responses (such as rapid heart rate, constricted

breathing, and muscle tension), as well as symptoms related to numbing and avoidance, such as

anesthesia and analgesia, disconnection from one’s body (depersonalization), and loss of pain

perception (termed somatoform dissociation; Chapter 6), all of which can further aggravate the

dysregulated emotions and distorted body and self-concepts typical of traumatic stress disorders.

In most available approaches to treating trauma-related disorders, the primary focus is the

patient’s verbalizations: however, when individuals describe traumatic events, the narrative re-

telling evokes associated non-verbal implicit memory states: internal sensations, images,

emotions and autonomic dysregulation (Van der Kolk & Fisler, 1995). In daily life, the same

sensations and emotions can also become “situationally accessible” when activated by trauma-

related stimuli or triggers, some of which are consciously identifiable by clients and some of

which are not (Brewin et al, 1996). Faced with fragmented event memories that reactivate

traumatic stress symptoms in the form of altered bodily reactions, many individuals find the

tasks of identifying traumatic memories and assimilating traumatic experiences within a life

narrative challenging at best. In these cases, interventions that enable clients to become aware of

somatic responses and their origins, appreciate their adaptive function, and then modify them to

become more appropriate to current reality may provide important avenues for therapeutic

intervention and, ultimately, healing.

Within the context of an attuned therapeutic relationship that promotes collaboration and

engagement, somatic interventions facilitate clients’ growing ability to remain socially engaged,

maintain states of optimal autonomic arousal, and increase their ability to take adaptive action

even in the face of physical activation resulting from trauma-related stimuli. If body-centered

interventions are employed simply as rote physical exercises, rather than emerging organically

within an intersubjective relational context, it is anticipated that therapeutic benefit would be

minimal. Intersubjectivity from a somatic perspective emphasizes “right brain to right brain”

attunement: the therapist, like the caregiver to an infant, uses his or her presence, voice tone,

prosody, energy, and seriousness versus playfulness to maximize pleasurable states and

minimize states of distress (Schore, 2003a, 2003b). The approach described here proposes that it

is only within the context of a therapeutic dyad characterized by relational attunement and

collaboration can fears and phobias of trauma-related body experience be successfully overcome.

Evolution of Sensorimotor Psychotherapy for Trauma

Originating in the 1980s as a new model of body psychotherapy developed by Pat Ogden,

Ph.D., Sensorimotor Psychotherapy has evolved into a comprehensive psychotherapy model with

interventions specifically designed to treat the effects of PTSD and complex traumatic stress

disorder, as well as associated attachment and developmental disturbances (Ogden & Minton,

1999; Ogden, Minton & Pain, 2006). By integrating theory and technique from the worlds of

psychodynamic and cognitive-behavioral psychotherapy with somatic psychotherapy

approaches, as well as incorporating research from the fields of attachment, dissociation, and

neuroscience, Sensorimotor Psychotherapy utilizes approaches derived from both research and

practice. As a foundation for its therapeutic interventions and body orientation, Sensorimotor

Psychotherapy has drawn heavily on the Hakomi method of Body Psychotherapy (Kurtz, 1990).

The direct somatic interventions used in this work have been influenced by a number of physical

disciplines, including yoga, dance, movement work, and Structural Integration (Rolf, 1987), all

of which emphasize physical alignment, integrated posture, and movement. A diversity of other

psychological influences have also specifically shaped this method’s interventions for trauma

and attachment disturbance: the pioneering work of Janet (1925) at the beginning of this century

and, more recently, the work of Nijenhuis (1999/2006) and Steel and Van der Hart (Chapter 6)

on the dissociative and somatoform nature of trauma symptoms. These influences are reflected in

such Sensorimotor Psychotherapy elements as the emphasis on the practice of new physical

action patterns, focus on somatoform dissociation, completion of frozen and incomplete

defensive responses, and attention to how the relational patterns stemming from disorganized

attachment are related to and driven by bodily experience.

Allan Schore’s (2003a, 2003b) groundbreaking work on the developmental

psychobiological underpinnings of affect regulation in human development has directly shaped

the emphasis on attunement and interactive regulation in Sensorimotor Psychotherapy, as well as

its emphasis on addressing disorganized attachment-related symptoms. Porges’ (2001, 2003)

elucidation of the autonomic nervous system’s hierarchical response to safety, danger and life

threat has contributed to the focus on the social engagement system, modulation of autonomic

arousal, and reorganization of self-protective active defenses, all of which are integral aspects of

the Sensorimotor method. In addition to Kurtz (1992)’s focus on mindfulness as a tool for self-

discovery, the research and writing of LeDoux (2002) and those of Siegel (2006), that both

emphasize the role of mindfulness in restoring autonomic stability, have contributed to the

understanding of mindfulness as a facilitator of integrative activity, reflected in the central role

of mindfulness in Sensorimotor interventions and treatment.

In addition, research has demonstrated that mindfulness meditation directly impacts brain

functioning. It results in activation of the ventromedial prefrontal cortex, an area of the prefrontal

cortex hypothesized to be related to integration of cognition, emotion, and somatosensory

experience (ref???). Since individuals with PTSD often demonstrate decreased activation in the

medial prefrontal cortex (Lanius, 2002; Clarke & McFarlane, 2000), the use of mindfulness as an

intervention is intended to increase the activity in this part of the brain and to facilitate regulation

of autonomic arousal and improved stimulus discrimination (i.e., the ability to differentiate a

traumatic event from a stimuli reminiscent of that event). “Observing presence,” or the ability to

mindfully self-witness one’s experience, is thought to counteract “speechless terror” (Van der

Kolk, 1995) and to offset the amygdala’s sympathetic alarm activation in response to threat

(LeDoux, 2002). According to LeDoux (2002), pathological fear may occur when the amygdala

is unchecked by the prefrontal cortex, and treatment of pathologic fear may require that the

patient learn to increase activity in the prefrontal region which can serve as a brake on amygdale

activation. Similarly, the work of Schore (2003a, 2003b) on attachment and self-regulation and

Porges’ (2001, 2003) polyvagal theory lead to the postulation that attunement and social

engagement as deliberate strategies in the therapeutic relationship may also serve to regulate

post-traumatic somatic dysregulation. Although there is currently little research validating the

use of movement as an intervention in traumatic stress disorders treatment, Van der Kolk (2002)

reports preliminary findings correlating participation in a yoga class with reduction in PTSD and

complex traumatic stress disorder symptoms. Because yoga practice combines focused attention

(mindfulness) and mastery of body movement, yoga as an intervention in the treatment of trauma

may address two phenomena common to most traumatic experiences: loss of conscious

witnessing and loss of control over the body and body movement.

Currently, no formal research has been conducted to attest to the efficacy of Sensorimotor

Psychotherapy as a general treatment strategy or one that is specific to the treatment of traumatic

stress, though a multi-site research studyis planned for 2008. As noted above, Sensorimotor

Psychotherapy for the treatment of trauma has been developed entirely from clinical practice,

guided by research findings and theoretical developments in the areas of attachment, trauma

(developmental traumatology), and neuroscience which have been integrated with techniques

derived from other physically focused therapeutic methods. In single case studies, subjects have

reported satisfaction with the effectiveness of the Sensorimotor techniques in resolving traumatic

stress disorder symptoms and in increasing feelings of mastery and well-being, both when used

as a “stand-alone” treatment or when incorporated into more traditional psychodynamic or

cognitive-behavioral therapies. Clinical observations and experiences, as well as feedback from

clients, have been utilized to develop and modify specific interventions. Until research studies

are undertaken, however, the effectiveness of the Sensorimotor Psychotherapymethod is

unknown as are the mechanisms underlying its principles and interventions.

Major Clinical Interventions of Sensorimotor Psychotherapy for Trauma

Mindful Self-Awareness of Body Experience. In Sensorimotor Psychotherapy, focus on

the body as well as the mind is the central distinguishing feature: the body is utilized both as a

source of information and as an avenue for treatment intervention. Instead of emphasizing

verbal/analytical skills, as is done in talking therapy, the client is asked to mindfully observe and

describe the interaction of thoughts, feelings, inner body sensations, and movements as these

occur in the present moment. The therapist not only carefully attunes to the client’s words and

physical reactions but simultaneously communicates empathy by closely mirroring the client’s

statements and movements. This co-attunement, with its encouragement to pay close attention to

reactions that are usually automatic and go noticed, is often inherently regulating for clients and

enables them to begin to observe relationships between patterns of movement, physical response

and reactivity, and posture with accompanying thoughts, beliefs and emotions. As an example:

when a self-attribution (such as, “It was my fault”) comes into awareness, the client is asked to

notice “What happens inside when you have this thought?” and “ How does that thought affect

your body’s sensations, posture, autonomic arousal, and movement”?

Through the therapist’s repeated drawing the attention of clients to the relationship

between thoughts or beliefs and body responses, clients may begin to discern that their posture

can inadvertently reinforce beliefs about helplessness and hopelessness, that those same beliefs

can affect body posture as the body responds to the thought, and that emotions are likely to both

affect body experience and cognition and to be affected by them. For example, the therapist may

help a client to notice that his cognitive distortion, “It’s not safe to be seen,” corresponds with a

slump in his spine and eyes cast to the floor. After observing this and asking the client to be

curious about it, the therapist may suggest exploring if a physical intervention—such as sitting

up, rather than slumping, or lifting his gaze—might affect the strength of this belief or even offer

the opportunity for changing the belief. Rather than studying the results of verbal interpretations,

the client is encouraged to allow emotional meaning-making to occur organically and “bottom

up” through increased recognition of physical sensations and reactions and their modification

through experimentation and practice of new responses.

Clients with complex traumatic stress disorders typically have negative views of their

bodies: they may be frightened of their own physical functions and somatic experiences, numb

and disconnected, or perhaps even angry at their bodies for “betraying” them in some way. They

may cope through ongoing depersonalization and disregard of their bodies to the point of extreme

neglect and even deliberate self-injury and risk-taking. These clients often view the prospect of

experiencing physical sensation as terrifying, foreign, repulsive, or simply not possible.

Unprocessed and unassimilated traumatic experience that results in emotional (and accompanying

physiological) arousal which, in turn, leads to automatic and intense physical dysregulation can

confirm the client’s worst fears, namely, that “going there” will be overwhelming and too much to

bear. In Sensorimotor Psychotherapy, clients first learn how to put aside narrative content and

emotional states to focus on their body.responses in order to be increasingly aware of their mind-

body experience Attention is always given on an ongoing basis to pacing the intensity of the

work and to facilitating therapist-client attunement and collaboration so that autonomic arousal

can be modulated and maintained at a level that is tolerable and not overwhelming, that allows for

re-organization rather than re-living of past experience.

Self-Regulating Bodily Arousal. Since a hallmark of both PTSD and complex traumatic

stress disorders is persistent physiological dysregulation, attention to regulating arousal must be

a key feature of any effective treatment for trauma. Allowing clients to repeatedly access

feelings common to traumatic experience, such as fear, horror, helplessness, anger, and shame,

without the ability to modulate the reactions or “put the brakes on” (Rothschild, 2000) is of little

therapeutic benefit: overwhelming emotions and autonomic dysregulation only tend to

exacerbate the symptoms. Dysregulated arousal subsequent to trauma tends to occur both

situationally and habitually, not always tied to specific images or events, and is easily interpreted

by traumatized individuals as a sign of threat in the here-and-now environment. For the client to

experience a somatic sense of safety in the present, the autonomic nervous system must be

stabilized and the capacity for optimal arousal developed. In Sensorimotor Psychotherapy, the

therapist helps the client to regulate arousal by carefully tracking physical sensations for signs of

dysregulation, by asking questions that direct attention to relationships between bodily responses

and narrative content, by teaching clients to recognize the physical signs that indicate

dysregulated hyper- or hypoarousal, and by encouraging them to experiment with specific

somatic interventions that promote regulation. In this way, clients experience confidence in their

bodies as a resource, rather than a hindrance or a threat, and are able to develop a sense of

mastery over what were overwhelming autonomic states driving their post-traumatic symptoms.

Sensorimotor Memory Processing. As memories come up spontaneously in session or

are deliberately accessed for therapeutic memory processing, the Sensorimotor psychotherapist

approaches work with memories not by exclusively “talking about” them, but by first helping the

client become mindful of how that experience has been “organized” in mind and body. As

individuals respond to events, what they actually experience or remember is a function of the

unique interaction of their thoughts, feelings, body sensations, perceptions and movement

impulses: for example, individuals might first perceive something, then react to it physically,

then have a thought or a feeling—together, these stimuli will organize the “feeling of what

happens” (Damasio, 1999). Even when different individuals have been exposed to the same

traumatic event, their subjective experience of it will be different and hence their organization of

the experience will differ (Terr, 1992). Human beings develop “procedurally-learned” habits of

responding: they react to all future experience with the most adaptive combination of automatic

cognitive, emotional, motor, visceral, and behavioral reactions learned from past experience.

Traumatic memories often are encoded implicitly in the form of images, visceral and

muscular sensations, movements and impulses, smells, sounds, feelings without words, and

autonomic responses, as well as verbally-articulated emotions, thoughts, and life narratives. The

focus in Sensorimotor Psychotherapy is on studying and then re-organizing how the traumatic

event has been encoded in the body and mind so the memory can be experienced as “finally

being over, in the past,” rather than “still happening” or “impossible to get over.”

Mindful awareness of bodily reactions to the recall of traumatic events may also

contribute to the prevention of inadvertent re-traumatization during work with traumatic

memories. Clients are encouraged to become curious rather than fearful as the therapist evokes

mindfulness by querying the client as to emerging thoughts, emotions, sense perception, body

sensation, and movements that accompany the recall. As clients learn to recognize how the

trauma has been encoded in mind and body and then are helped to implement techniques that

somatically re-organize it, they are supported in experiencing the threat as “finally over.” The

sense of finality or closure can be achieved in a number of different ways: for example, a client

whose traumatic experience ended at age 6 subsequently experienced her mother’s inability to

tolerate hearing what had happened as a signal that she could no longer speak of it. The sense of

“it’s over now’ for her resulted from her therapist’s encouragement to notice what it felt like in

her body to sense the therapist’s attuned presence and ability to tolerate hearing what happened.

Action and Movement. Trauma-related symptoms are reflected in both mobilizing

(fighting, fleeing) and immobilizing (freezing, collapsing) physical reactions and impulse. With

ongoing threat, when fight/flight and other mobilizing defensive responses are ineffective, these

must be inhibited and movement impulses frozen or subdued to enhance survival. For example,

during a rape, attempting to fight or to flee could provoke more injury. In a violent family

environment, a child’s healthy defensive actions could lead to more violence: for both the rape

victim and the child, it may be safer and more effective to be immobilized, quiet, and frozen.

Thus, in treatment, action and movement can be effective targets for treatment

intervention. “Even when immobilization is the only survival option, the impulses to actively

defend remain, as urges concealed within the body long after the original trauma is over”

(Ogden, Minton & Pain, 2006). The “actions that wanted to happen” might include pushing

away, hitting out, kicking, raising an arm in self-defense, leaving the situation, calling for help,

screaming “No,” fighting back, or standing one’s ground. Aware that these impulses to action

remain encoded in the body as truncated, incomplete body sensations and preparatory

movements, the therapist carefully tracks the client’s body for signs of those incipient action

impulses, as well as for movements that reflect immobilizing defenses, such as freezing (body

held stiffly, eyes widened) or collapsing in submission (head down, gaze averted, spine slumped,

tonic immobility). When these responses are noted, the therapist intervenes to help the client

reorganize habitual defensive physical patterns to be more effective, active, and expansive.

The most powerful uses of movement involve asking clients to observe their own

spontaneous small preparatory movements that signal larger actions “that wanted to happen” and

then to repeat or even exaggerate those. When subtle signs of mobilizing responses are noted

(such as a lifting of the hand, the making of a fist), the therapist helps the client to first notice and

then mindfully and deliberately carry through the physical execution of this new action until a

sense of mastery, rather than discharge, is achieved. For example, a young woman who had been

molested by a photographer was observed to lift her hands slightly as she talked about her

passive, mute, frozen response to his advances. Noticing this gesture, the therapist asked if she

would be willing to repeat the movement again as an experiment and observe what happens.

Each time the client repeated the movement of lifting her hands up, she instinctively oriented to

her left side, saying, “This feels like keeping him away.” Repeated movements of holding her

hands up as if to block the unwanted intrusion gradually resulted in feelings of greater solidness

and safety in her body.

Sensorimotor Psychotherapy in Phase-Based Complex Traumatic Stress Disorder Treatment

Because of its focus on the psychophysiological re-organization of traumatic experience, rather

than on recalling or abreacting memories, Sensorimotor Psychotherapy is appropriate and effective

during all three stages of phase-oriented treatment. With its unique ability to increase access to somatic

and cognitive resources and thus to stabilize autonomic responses, Sensorimotor Psychotherapy is very

useful during the Phase One stabilization (Ford et al., 2005; Van der Hart & Steele, this volume).

Phase One Stabilization: Composite Clinical Case

Jeanette entered therapy soon after an alcohol relapse and suicide attempt precipitated

by months of out-of-control autonomic arousal. At the very first session, the therapist gently

interrupted her each time the arousal escalated, asking Jeanette to take a breath and just attend

to the feeling of her feet on the ground. Each time she became activated, the therapist would

again slow the pace, offering psychoeducation to explain the need for attention to autonomic

arousal and mindful noticing. Next, the therapist taught her to observe the somatic signs of

increasing activation and to respond somatically by standing up, orienting to the room, walking

around, or placing a hand over her heart until her heart rate stabilized. Thus, she was taught to

slow down and “put on the brakes” in order to experience mastery over her reactions.

Sensorimotor Psychotherapy During Phase Two Memory/Emotion Work

Sensorimotor Psychotherapy’s emphasis on dual awareness of mind-body reactions can

help to maximize safe, effective processing of memory. By accentuating the use of newly

acquired somatic resources and skills learned in Stage 1 to regulate autonomic arousal and

maintain a connection to present time, attention is given both to memory processing and relapse

prevention. The sense of mastery over overwhelming experience achieved in this way is further

enhanced when frozen or submissive responses are replaced by empowering ones brought to

effective completion through movement interventions (Ogden, Minton & Pain, 2006).

For example, Miriam, a victim of a home invasion and sexual assault, had been unable to

sleep through the anniversary of this event for years. On the day before the anniversary, as she

described the distress associated with her inability to defend herself to her therapist, saying,

“I’m so ashamed I just gave in,” the therapist noticed a slight movement in her hands.

Recognizing this movement as potential preparation to defend, the therapist asked Miriam to

repeat her words and movements. This time, her hands came up so that they formed a “stop”

gesture. Repeating the movement again, she experienced an impulse to shout, “Go away!” She

was invited next to push against a pillow held by the therapist while both repeated the words,

“Go away!” until she reported feelings of power and solidness in her body. As she made

meaning of this transformation in her responses to the memory, she was also helped to

understand how her “submission” was in fact an effective defensive response that effectively

enabled her to not further enrage her assailant. That anniversary, after 22 years, she reported

with great glee that she had finally slept soundly through the night. In the weeks that followed,

she experienced increasing relief and a heightened sense of self-understanding and self-

compassion that challenged the shame and self-blame she had experienced previously..

Sensorimotor Psychotherapy During Phase Three Integration Work

Phase Three work focuses on overcoming core phobias that prevent full resolution of

trauma: the phobias of normal life, change and exploration, and healthy connection to others,

including the ability to be intimate (Chapter 6). In this phase, Sensorimotor work focuses equally

on the body and on discovering and changing cognitive distortions (such as, “I do not deserve an

intimate relationship” or “I can’t be normal”) and corresponding physical habits (such as failure

to sustain eye contact or inability to tolerate physical touch). As clients attempt to master these

challenges and fully resolve their post-traumatic symptoms, habitual somatic responses are often

re-evoked: autonomic dysregulation, impulses to either avoid or act out, frozen or hyperactive

movement impulses. Often, therapist and client discover that the old responses are fueled by

trauma-related cognitive schemas that activate the body’s survival responses and defenses. At

this stage, the emphasis is on “homework,” on practicing new, more adaptive responses that

challenge trauma-related cognitive distortions and facilitate fuller engagement in normal life.

For example, although Evelyn now reported few traumatic stress disorder symptoms, she

still avoided self-disclosure and emotional intimacy with others, even with her partner of 17

years. Asked to imagine sharing ordinary day-to-day feelings,, she felt a tightening in her chest

and an intrusive thought, “I’ll be humiliated,” which she associated with “hiding.” Her

therapist asked, “Is there an image or memory that goes with those words?” Spontaneously, an

image came to mind: she was trying to tell her mother about her fear of being left with her with

her abusive stepfather, only to be criticized for being “too sensitive” and “disrespectful.”

Emotions of sadness emerged as she felt a connection to the little girl she had been in that

frightening environment, and her therapist encouraged her to feel the sensations of sadness and

pain in her body, “stay with them,” and to just notice “what it feels like to tell someone right

here, right now.” Evelyn reported feeling relief and lightness, as if a weight had lifted: “Right

here, right now, it’s OK to share my feelings,” she reminded herself, “I don’t have to hide.” As

she was able to apply this learning by disclosing to her partner more about both her needs for

closeness and her past history of abuse, the emotional intimacy between them deepened, and she

was able to both verbalize and physicalize her love and attachment to her partner.

Composite Case Example: A Sensorimotor Psychotherapy Session

“Annie” is a 55-year-old married mother of two grown sons with a history of chronic

childhood trauma, including severe neglect, physical and emotional abuse, childhood

pornography, and incest. Like many patients with complex traumatic stress disorders, she

carries a number of diagnoses: PTSD, ADHD, Major Depression, and DID. In the past few

years, she has had difficulty holding jobs because her symptoms overwhelm her capacity to be

fully engaged, think clearly, and tolerate normal stress and interpersonal stimulation. Prior to

coming for Sensorimotor Psychotherapy, Annie had a ten-year course of treatment with a

therapist who focused almost exclusively on the retrieval and abreacting of trauma memories.

Although Annie became deeply attached to the therapist, her symptoms and functioning

worsened over the ten years. In her treatment with JF, the focus was initially on Phase One

stabilization and skill-building through somatosensory awareness and self-regulation and, more

recently, on overcoming her phobia of the traumatic memories.

In this session, Annie arrives for her session literally trembling, reporting feelings of

fear and hopelessness.

Annie: [tearfully] “I don’t think you understand—I’m alone, all alone in that horrible

lonely house—I have no friends anymore—I just want to die!”

Therapist: “That loneliness is so painful, isn’t it? When you say those words, ‘I’m

alone—all alone,’ what happens inside?”

Annie: “My heart is racing—my chest feels tight—my stomach is in knots . . .”

[As she speaks of feeling so painfully alone, past and present are merged: her stable

family and home life are forgotten as she interprets the body sensations and emotions as

evidence that something is terribly wrong with her present environment.]

Therapist: “I wonder if we could try something . . . Notice what happens in your body

when you say those words again, ‘I’m so alone’. . . “

Annie: “The tightness gets worse, especially along my sides—I feel like I’m in a vise—

I’m so scared!” [becomes tearful again].

Therapist: “I wonder if we could study what happens in your body when you ‘let go’ of

those thoughts to just attend to the feelings and sensations—would that be OK?’

Annie: [lowers her eyes, indicating a turn of her attention inward] “Well, my heart isn’t

just racing—it’s pounding. Like a hammer: ba-ba-boom, ba-ba-boom . . . I can feel my lower

lip trembling. But now it’s settling a little bit as I talk about it.”

[Often, this resolution or settling of the body sensations and arousal often accompanies

the client’s ability to attend to experience with mindful dual consciousness in the context of

therapist’s affect-regulating co-attunement (Schore, 2003a, 2003b). Next, the therapist

facilitates a reorganization of trauma-related patterns via the use of “mindful experiments:”

that is, the conscious and voluntary execution of a new movement, word, gesture, or response

which is then studied to evaluate its effect (Ogden, Minton & Pain, 2006). Experiments do not

have to “succeed:” they are exploratory, meant to gather information and challenge habitual

tendencies, as discussed below.]

Therapist: “I’m wondering if you would be willing to try an experiment. . . Notice what

happens when I make this movement. . .” [therapist reaches out her hand to indicate connection

with Annie, non-verbally challenging her perception of aloneness]

Annie: “My heart beats faster—I can feel all the muscles along my sides tighten up—it’s

worse. I don’t want to be alone, but it’s not safe to be with someone either.”

Therapist: “Yes, it’s not safe to be alone, and it’s not safe to be with people either.

Would you be willing to try another experiment? Notice what happens if you make a boundary

with your hands . . . “ [holds both hands up in a “stop” gesture, demonstrating the boundary to

Annie physically]

Annie: “I can feel the relaxation immediately! But, almost as soon as I say that, I start to

have thoughts that now I’ll be more alone, and I want to cry again.”

Therapist: “So, it doesn’t feel safe to have connection or to have a boundary. [Annie

nods] Let’s try both at once, and just sense whatever feels right . . .” [Therapist models putting

up one hand in ‘stop’ gesture and reaching out with the other]

Annie: [after some experimenting, makes ‘stop’ movement with dominant hand and

reaches out with the other] “This feels better—my heart is slowing down now, my stomach is

untwisting—things are relaxing a little more.”

Therapist: “So, just enjoy that feeling! When you have a boundary, it actually feels

safer to reach out to others and let them reach out to you.”

Annie: “Sure does! But I’m sick of living this way—spending all my time trying not to

be overwhelmed! I want to understand and change it.”

Therapist: “I wonder if you would be willing to ‘rewind the tape’ back to when you first

started to feel these feelings and sensations . . . When was that, do you recall?”

Annie: “It actually started a few days ago. . . . I took the dogs out at dusk, and I was

walking in the woods, noticing the beautiful fall light, and then I suddenly got panicked! I

literally ran home and sat and trembled for the next few hours!”

This illustrates the paradoxical experience of normal daily life for so many survivors of

trauma: Annie is engaged in enjoying her walk and the fall light on the trees when suddenly

there is an intrusion of memory, precipitating related physical reactions and emotions. In this

case, the memories that came up were implicit memories not clearly identifiable as “memory:”

body sensations, autonomic arousal, impulses to run , and emotions of fear and panic.

Therapist: “As you recall noticing the fall light and then the feelings of panic, is there an

image or memory that goes with those?”

Notice that the therapist evokes only a “sliver” of memory, rather than asking her to

discuss the events in detail. In Sensorimotor Psychotherapy, the event memory is a vehicle for

evoking the organization of that memory in the body. Rather than processing memories using

narrative recall, they are processed “bottom-up”: first, the body sensations and movement

impulses, then the emotions and cognitive meaning-making.

Annie: “The image that comes up is Halloween night—I’m young, and I’m all by myself

outside, and this lady is coming over to me with a smile. [The ‘nice lady’ took advantage of

Annie’s isolation to take her away to a man who used her in a child pornography ring.] As soon

as I see the image of her face, my heart starts racing, and I can feel shaking and trembling all

through my body—I want to run, but I can’t.”

Therapist: “What happens in your body as you recall that?”

Annie: “I can feel my heart starting to beat really fast, and there is this strong muscular

pull in my chest and stomach, like I’m going to double up in pain.”

Therapist: “You know, sometimes, muscle tension can be a precursor to movement.

Notice how the tension would like your body to move. . .”

Annie: “It’s somehow connected to my legs. . . The pull would bring my head down and

my legs up over my chest. Wow! It wants me to curl up into a ball—I just want to huddle and

wait for it to be over.” [makes a motion as if to collapse to the floor]

Therapist: [continuing to mirror Annie’s words] “Yes, your body wants to huddle and

wait for it to be over . . . And what happens as you say those words?”

Annie: “I can feel the pull to curl up getting stronger! This is really weird—it was so

long ago—but my body is still waiting for it to be over! No wonder I isolate.”

Once Annie observes the relationship between her thoughts and body experience, she

becomes more curious about the “huddle and wait for it to be over” response that has been

driving her symptoms of agoraphobia and social phobia.

Therapist: [recognizing the opportunity to introduce alternatives to the passive defense of

“huddling and waiting for it to be over”] “I wonder if your body ever wanted to move in a

different way, a more active way. Just sense that: is there is any other action that ‘wants to

happen’ right now? Does your body want to push away? Hit out? Kick? Run away?”

Annie: “Yes, what my body needs is a new action that says, ‘You don’t have to huddle

and wait for it to be over! You don’t have to go with that woman at all!’”

Therapist: “What happens when you say, ‘I don’t have to go with her!’”

Annie: “I want to run—I want to leave.”

Therapist: “How is your body telling you that?”

Annie: “My feet want to take a step—it’s amazing: I felt so frozen before.”

Therapist: “Notice what happens if your legs and feet take one step . . .”

Annie: [stands and takes a step, noticing herself doing it] “That small step felt so

effortful, like I was fighting with the wish to huddle up! Let me try another one . . . [takes a

step] That definitely felt a little easier. I feel more solid—I realize how much strength I have in

my legs and body. [After taking several steps, Annie is quieter and more serious as she begins to

make sense of her symptoms and anticipate more adaptive options for the future] Wow! That is

a lot to take in . . . When I was triggered on that walk, my body freaked out—everything felt

threatening and desperate—it wanted to do what worked when I was a child: ‘huddle down and

wait for it to be over.’ But when I do something a little bit different, my body has other

possibilities. All I have to do now, each time I’m triggered, is to notice what my body is telling

me to do—and then do one tiny thing differently.”

In this vignette, key elements of Sensorimotor Psychotherapy are illustrated: the close

attention and attunement of the therapist to the client’s physical responses; the focus on the body

and on physical sensations; the direction to “just notice” physical sensations while letting go of

verbalization and cognitive interpretations; the encouragement to focus not on the details of the

memory itself but rather on the physical impulses experienced; and, the practice of interventions

to reverse physical immobilization by experimenting with the completion of truncated defensive

responses that result in a sense of mastery. From this body-based experience, new insights and

meaning-making spontaneously arise and can be integrated with the somatic experience.

Summary and Conclusions

In Sensorimotor Psychotherapy practice, the therapist carefully attends to the client’s

narrative, empathically interrupting tendencies toward either hyper- or hypo-arousal before either

causes dysregulation and encouraging alternative physical actions that challenge habitual, trauma-

related reactions. When clients have difficulty experiencing or observing their somatic

experience, the therapist tries to determine the reason: Is the client phobically avoidant of body

awareness? Or numb and disconnected? Does connecting to the body trigger shame or alarm?

How can the client be helped to cultivate curiosity, rather than engage automatic phobic reactions,

about the body-based symptoms of the traumatic events? If clients are uneasy with the word,

“body,” avoiding the word itself helps to increase comfort. The use of specific language, such as

“activation,” “visceral sensation,” “movement impulse,” is rarely problematic for clients.

Providing a concrete “menu” of words and phrases with which to label physical sensations may

also be more comfortable than a general instruction about body awareness.

Normalizing somatic experience through psychoeducation or therapist modeling is often

useful, especially for clients more comfortable with cognitive experience and verbalization. The

process of re-connecting with the body should not be made effortful for clients, nor should it be

dysregulating or painful. Often, capitalizing on existing somatic strengths (such as the ability to

feel grounded or a client’s athletic ability) fortifies confidence and stimulates enthusiasm for

further somatic exploration. Increasing the client’s awareness of survival resources (for example,

immobilizing defensive responses that helped to ensure survival) may have the side effect of

facilitating increased curiosity about and pride in the body’s many built-in resources and

challenging the physical antipathy that many adult survivors experience toward their bodies.

In Sensorimotor Psychotherapy treatment, clients are first encouraged to learn how to

simply and mindfully observe the physical sensations that accompany their emotions and

cognitions, to gradually become more familiar and equally “at home” with thoughts, feelings, and

bodily sensations or movements (whether that process takes a single or many sessions), and

eventually to begin to experiment with and practice new, more adaptive physical actions. Over

time, the trauma-related feelings and cognitions begin to re-organize as clients experience new

physical responses and the sense of mastery in physical control.

Somatic interventions must be tailored to the unique needs and therapeutic goals of each

client. One client might need to become more aware of body sensation and involuntary

movements in order to better modulate autonomic activation, while another might find

involuntary sensations autonomically dysregulating and might need to work with controlled

movement and physical action. Although dual awareness is helpful in and of itself, it is not

sufficient to simply help clients become aware of the body: the therapist must also be familiar

with effective interventions to work with sensations and movements, to regulate autonomic

arousal, and to transform habitual trauma-related patterns of response.

Focus on narrative memory can be helpful in the treatment of trauma: to understand the

client’s history, design a treatment plan, and to provide clients the opportunity for a witness for

their overwhelming experiences. However, to change the body’s response to the telling of the

story requires meticulous observation of clients’ trauma-related procedurally learned action

tendencies. Neither insight nor understanding can replace therapeutic interruption of these

automatic reactions in order to teach clients to trust their body sensations, regulate arousal, and

learn new, empowering physical actions that were impossible during the actual traumatic events.

In the words of Bessel van der Kolk (2002), “Trauma treatment must restore a sense of safety in

the body and complete the unfinished past.” Rather than focusing on the verbal and narrative

remembering or re-processing the event memories of the trauma, Sensorimotor Psychotherapy

aims to achieve this goal by enhancing clients’ ability to first witness and then transform trauma-

related somatic, cognitive and emotional experience until they achieve not only cognitive

understanding that the past is finally behind them but also experience at a deep somatic level that

they are safe now.

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