Body-mind psychotherapy is a dynamic approach to transforming anxiety
It is very normal for people to experience anxiety. The experience of feeling moderate levels of anxiety can improve your performance, such as playing in a sporting event, writing an exam, sitting for a job interview, or dating someone in the initial stages of a relationship. With the presence of some anxiety you feel more alert and motivated to perform well. Equally when you experience high arousal in a dangerous situation instinctively you are able to act quickly to escape from or ward off danger. However severe anxiety becomes problematic when it decreases your capacity to take in new information, plan an appropriate response and complete complex activities (Management of Mental Disorders Vol. 1).
A person with an anxiety disorder usually has specific and recurring fears that they recognise as being irrational or unrealistic and intrusive. There are several anxiety disorders that include panic disorders, agoraphobia, social phobia, specific phobias, generalised anxiety disorder, obsessive compulsive disorder, adjustment disorder, hypochondriacal disorder and unexplained somatic complaints. People do not always fit neatly into one disorder. They can have symptoms that relate to more than one disorder. For example a person struggling with panic attacks may also have agoraphobia or a social phobia. Their anxiety may expand to a generalised anxiety where they worry excessively and persistently about lots of things, including family, health, job or finances.
In the initial phase of therapy it is helpful to provide psycho-education to clients about their anxiety disorder as it relates to them, and how certain thinking and breathing patterns can contribute to their anxiety. Hyperventilation plays a big role in people suffering from anxiety. It involves over breathing and negatively impacts the brain and the body causing symptoms of anxiety. These can include feeling hot or sweaty, dizziness, confusion, numb or tingling feet, breathlessness, cold or clammy hands, stiffness in the muscles, irregular or rapid heartbeats and feelings of unreality. Hyperventilation is often subtle and not obvious to the person experiencing it. Hyperventilation contributes to low levels of carbon dioxide in the brain causing the body to be susceptible to experience these symptoms of anxiety. In order to reduce the symptoms it is necessary to increase and steady the level of carbon dioxide in the blood which results from a more even and natural way of breathing. The first step in preventing and controlling hyperventilation is for a person to recognise how and when it occurs.
Some psychiatrists and mental health therapists work with their patients to change their breathing patterns. They may suggest you practice breathing from your belly to your diaphragm in a slow and deep way four or five times a day to help form better breathing patterns. This can be useful in raising the client’s awareness of how they breathe, but it is possible that the emotional overwhelm that is causing the anxiety remains held in the client’s body and mind (Management of Mental Disorders Vol. 1).
Often people that suffer anxiety choose to take anti-anxiety medication to manage their anxiety as it can dampen the destabilising feelings of panic. A feeling of panic can feel like a shock in the body. People commencing therapy with anxiety may have experienced challenging periods in their lives. I provide psycho-education and explain how the brain and body work in tandem, and if there is unresolved trauma the traumatic imprint on the brain can continue to perform as if the trauma is still occurring, and this can lead to anxiety.
People sometimes feel uneasy about starting therapy as they may not have spoken about their feelings in the past. I explain how I work which is to move slowly and incrementally in bite sizing their experience in the therapy sessions. I provide information about working within the ‘Window of Tolerance’ (WOT). Psychiatrist Dan Siegel first named it the WOT as written in his book called ‘The Developing Mind’. Sensorimotor Psychotherapy Institute developed a diagram called the Modulation Model. The founder of the Sensorimotor Psychotherapy Institute Pat Ogden describes how there is an optimal range of activation or arousal for a person that is containing and comfortable enough for them to process information. This is called the WOT (www.nicabm.com, Ogden, P. ‘Body-Mind-Spirit Integration: Sensorimotor Psychotherapy for Treating Trauma’).
Conversely when the level of activation experienced in the body-mind is overwhelming from remembering the trauma, understanding information becomes difficult. Ogden writes in her book that psychiatrist Bessel van der Kolk talks about a bi-phasic response to trauma. A person with trauma and anxiety can alternate their arousal levels from hyperactivity to hypo-arousal (both levels of activations are experienced outside the WOT). Hyper-arousal behaviour includes explosive and aggressive outbursts and a re-enactment of situations similar to the trauma, while hypo-arousal behaviour can involve social isolation. These level of activations are found at contrasting sides of the WOT. Hyper-arousal can heat the body, while hypo-arousal can freeze the body. As such it is important for the therapist to help the client to stay within the edges of the WOT for them to transform and integrate traumatic material. The WOT is an essential therapeutic tool used to create safety for the client and for the therapist to proceed with the correct therapeutic interventions (Ogden, P, & Minton, K.).
My initial assessment of clients with anxiety is to establish whether they are suffering from trauma, developmental trauma or developmental wounding. When a client has experienced trauma I work closely with the WOT. Sometimes clients do not want to speak in much detail about their trauma. I respect their need for internal boundaries and help them to place firm boundaries around the trauma story. An indicator of a client not wanting to talk too much is when they choose not to go into great verbal detail about what had happened to them.
The thought of speaking about traumatic events causes clients to leave their WOT. I may observe a client begin to talk about events and notice their pupils dilate, the prosody of their voice flatten and tremble, and their shoulders drop to a rounded collapsed posture.
I respect clients’ need for containment and boundaries implemented to keep them feeling resourced and within the WOT. Ogden says it clearly “that in the first phase of treatment we are looking at physical actions that will help the person’s arousal remain within the window” (www.nicabm, Ogden, P., Body-Mind-Spirit Integration: Sensorimotor Psychotherapy for Treating Trauma).
When I gain a more informed background of a client’s family history I can notice that apart from struggling with the unintegrated memories of trauma, they may also have some developmental wounding. This can include how much power they had to say no, to create change in their world, and whether or not receiving love was conditional on them being obedient. Clients learn how to behave in their family of origin. For example they may learn to be responsible, respectful and adhere to their parents’ routines and rules. This character strategy is called burdened enduring and is recognised for the person’s ability to ‘bear it up and wait it out’. Following this trend a client can develop great skills in being a loyal companion, socially confident, and well-mannered and groomed person.
The developmental wounding can be connected to the trauma wound as it may have been difficult to set boundaries and have people listen and respond to them. Developmental beliefs about self-worth can also contribute to feelings of anxiety. When a person’s mind automatically thinks, “I am not worth being respected’ for example. These kinds of thoughts can stem from enduring a trauma. Difficulty feeling self-worth is another character strategy called industrious over-focussed. It becomes a character strategy when parents are overly critical of their child about making mistakes or not achieving. The individual pays a lot of attention on how they look, how they perform and how people receive them in the world. There is rigidity in the body and a focus on doing rather than relaxing and being (Kurtz, R.).
It is important when gathering information about a client’s family history to notice how their parents interacted. For example, a mother who is more subservient and quiet as she handles the running of a family home, may be contrasted with a father who is the income earner and ‘voice’ for the family. He is likely to be the decision maker, and the mediator or person that resolves family conflict.
Parents can often have a relationship where there is an over-functioning and under-functioning reciprocity. A person’s father may seem to have an over-functioning role where they provide advice, think they know what is best for others, and talk more than listen. In contrast a mother may listen more than talk. (Gilbert, R. M.). There can be family patterns where people do not like talking about their feelings and where emotional issues are ignored.
Clients struggling with anxiety sometimes realise that they too find it difficult to talk about their feelings and that their anxiety is kept locked down in their body due to unresolved emotions. In this instance I may contact a client’s feelings of vulnerability in commencing therapy by naming their fear. A client in the present moment that feels understood often notices their nervousness subside. They then feel more present to their physical body and emotions. An indicator of this happening is noticing a client’s eyes moisten and become alert and watchful, their breathing steady and body relax. Often when this happens I can feel a palpable resonance between my client and myself.
Ogden confirms that when the client and therapist are in this resonant contact, a felt sense of their connection creates an atmosphere where the healing can take place (Ogden, P., Minton, K.). This resonant client-therapist connection provides the corner stone for a successful therapeutic outcome. Sometimes when a client feels safe, and the therapy progresses easily the client can feel for the first time in a long while that they are not going crazy. Ogden agrees that as therapists when we accept and validate our client’s conscious and unconscious experiences, their unconscious does not have to hide away or defend itself (Ogden, P., Minton, K.).
When a person has a collapsed body posture and finds it difficult to stay in the WOT while remembering their trauma this can inform my decision on how to work with them. In this instance I am more likely to begin assisting a client with developing somatic resources to stabilise them. I also keep in mind whether or not a person can set adequate boundaries. Clients learning about boundaries are still in phase one of healing their trauma by being assisted in stabilising and resourcing themselves.
I maximise on a client’s strengths by noticing what is healthy and well in the client first, and then look at what they have missed in their childhood development. For example, I may notice that a client has a tall body and strong shoulders showing strength, but their arms may be limp and hang loosely by their side. A limp arm movement can suggest a lack of experience in being assertive. Ogden and Minton write that our “psychological capacities and beliefs are inextricably linked with the structure and movement of the body” (Ogden, P. and Minton, K.). I can suggest to a client a number of somatic resource exercises to strengthen their ability to be assertive.
A client can stand in front of a wall feeling their feet firmly on the ground and gain a sense of their breathing pattern while finding their body’s alignment through their spinal column. Then a nice straight line in a client’s body can arise. While standing a client may push one foot into the floor and the other foot into the wall and carpet as one does with a hamstring stretch. At the same time a client can push both arms and hands against the wall. Sometimes a client will notice that their left side of their body is weaker than their right side.
A person that is not used to being assertive and feeling the strength of their body is likely to enjoy feeling the weight of their body push into the wall and simultaneously sense their own body strength. This can give a client a sense of what it is like to use their body to impact its environment rather than being submissive to it. Each movement is conducted in present moment mindfulness. A client is able to feel each body movement with their awareness of their entire body and its capacity to feel and breathe as a solid living being. As they drink in this experience of solidity they can grow in their confidence as a strong and self-empowered person.
It is good to observe the client as they transition back to their chair and away from the exercise to see how their body’s alignment has shifted. I may notice a client’s body being more upright and a brighter colour in their face. Sometimes a client’s eyes look more sparkly, but show dilation in the pupils suggesting the trauma memory is still impacting them. A client may practice feeling the same body awareness of their feet placed on the floor and sensing where their spinal column ends in their lower back and can feel the length of their spine. I may suggest a client imagine placing their eyes in the middle of their back and looking out into their environment from that position. The client can try this on as a new way to take in more of their environment. A client often notices that they have a wider peripheral vision and feel safer from this vantage point. The client also often finds it self-empowering to choose to look with their eyes, or from their back with imagining their eyes positioned on their back and looking outward.
When a client experiences a traumatic event where there are lots of people present, such as at a social event they may recognise that their anxiety is triggered now when attending social events. Clients when they realise this can make better decisions about whether or not to go out or stay at home. A client with social phobia caused by a traumatic incident that involved socialising and being amongst many people may be more inclined to go out socially when they know they can leave early and return to the safety of their home.
This kind of anxiety is often referred to as agoraphobia with or without a panic disorder. In this instance individuals can be anxious about being in a situation where escaping is difficult, or where help is not easily available should a panic attack occur. Often the client’s anxiety is triggered by social situations that are reminiscent of their earlier trauma. In this situation an important aspect of a person feeling safe is in them being able to scan their environment for safety and know that they can get away if the situation becomes unsafe (Management of Mental Disorders vol. 1).
Another empowering somatic resource exercise for clients struggling with setting boundaries is when a client sits slightly forward in their chair with their feet firmly on the floor. A client can find their body’s alignment feeling the vertical length of their spine. It is healing when a client can feel their body’s strength, balance and grounded quality. Then they can also feel their own body boundary being their skin first, then the boundary of the periphery around their skin and then out further where their hands can reach. I may ask the client what it is like to sense their boundary.
Often a client may report that they liked knowing that they had a boundary. I may ask the client what tells them that they have a boundary. The client may say they could feel their skin, then feel the air around their skin and then feel further space outwards beyond their hands. With this in place I can invite a client to practice setting a boundary by pushing their hands outward and saying the words “No!” I first do the movement to model it for the client and to encourage them. A client may push their hands outward and say no, but their head and eyes may drop. This can be a natural response for someone that has been habitually submissive. I often suggest to my clients that they practice this motion and verbal statement as part of their homework.
Clients usually became stronger and more assertive with practice. A client with social phobia may also like to practice saying to their friends the words ‘maybe’, as opposed to a ‘yes’ or ‘no’. Again it is great for a client to feel self-powered and be able to choose whether they feel comfortable or not to go out to a social event and verbally say it, rather than simply ignoring the invitation. Each somatic resource and boundary exercise can broaden a client’s awareness of their body, their boundaries and know that the locus of control resides within them.
Sometimes clients can find certain boundary exercises surprising. With the client’s agreement they mindfully create a physical boundary around them using tape. As a client sits with the boundary in place they can report back about how they feel. Sometimes a client may feel more secure and relaxed with the physical boundary in place. A client may become more aware of their internal body experience, and notice there was a settling of their breath which deepened and the tension in their shoulders subsided.
A client may become aware of thinking less and their eyes relaxing without a need to scan the environment for safety. I may ask a client if their boundary had words what would it say. A client may say the words “you can have some of me, but not all of me.” Often clients learn about certain habitual patterns they learned within their family. For example, a client may say that their parents wanted them to be transparent about their thoughts and feelings. With this new knowledge and insight they can choose to share or withhold information.
The somatic resourcing and boundary exercises are useful ways to strengthen client’s awareness of their body, their body’s strength and their ability to verbally set boundaries. These kinds of exercises also tend to widen a client’s WOT, and with this their ability to think, feel and sense their body increases. Clients also rediscover the wisdom of their own body (www.nicabm, Ogden, P. Integrating the Body in Trauma Treatment: A Sensorimotor Approach).
Positive memory resources are another method used to stabilize an individual’s activation in their nervous system. A client that remembers a joyful memory can feel relief in being able to focus on the positive aspects of their lives. They may also feel sadness if the memory triggers a loss for example. Somatic resources can be found in anything a person enjoys, appreciates and gains safety and satisfaction from. These resources can be creative outlets, physical exercise, spiritual activities, and a love for nature, intellectual pursuits, or relational events, such as being with a friend, partner or pet. Clients may be able to identify with solid resources such as enjoying their partner’s company, socialising with close friends, and enjoying sporting events.
A somatic resource can also be a physical gesture that a person finds themselves doing to self soothe. Often naturally a client’s physical gesture will emerge to help resource a client as they feel painful emotions. For example in present moment mindfulness a client may become aware of their right hand gently touching their left hand. It helps a client stay in contact with their body and steady their mind as they learn to self-regulate their emotional activation. With this movement can come greater relaxation in the body and the mind’s chatter can slow down and become clearer. A client is able to focus on a few more core organisers as their brain’s neo cortex which is the brain’s thinking and reasoning centre becomes more available to them. This is a great example where anchoring the client with their personal resource can modulate their body activation while processing bite sizes of the trauma memory.
A client can discover that certain habitual thoughts that they think about contribute to them feeling anxious. For instance a client may wonder why significant people in their life do not listen or believe them. With mindfulness and deepening the therapeutic process, the client can become aware of how futile it is trying to think their way out of a situation. It may have felt exhausting thinking so much and these kinds of thoughts lead to feelings of anxiety. These are some of the sorts of thoughts that can cause anxiety, ‘I’m wrong’, ‘bad’ or ‘guilty’ for standing up for myself. Sometimes clients that have been physically or sexually assaulted experience people not believing them about the incidents.
This can cause further trauma if the person is unable to seek help from a skilled therapist. It can take a lot of courage to talk about the events if the client has been disbelieved by significant others. As a result a client may doubt their thoughts, while their body’s unconscious reveals another reality of panic, which can feel like they are going crazy. The thought that one could be going mad is one of the main symptoms one has when having a panic attack (Management of Mental Disorders, Vol. 1).
In this instance, clients may feel alone with the knowledge that something was not quite right. They may ask themselves ‘how can the people they love the most not believe or support them’. It may also be difficult for clients to trust people again. For example the ‘stranger danger’ theory of being weary of people you do not know can lose its validity when the trauma included people they knew well. This can happen when the traumatic event involves close family or friends. Clients struggling with social phobias in therapy begin to understand why they sometimes feel anxious when out socially with friends. It is helpful therapeutically to give space to these intense feelings of fear and aloneness (Schulmeister, M.).
A change in the client often becomes apparent after doing resourcing work and working with a client’s core organisers. As a client’s beliefs change, their body changes to accommodate a new way of being. A client may shift from feeling guilty and unsupported to sensing their body strength, and knowing their thoughts and feelings are congruent with their trauma experiences. I also help clients shift the trauma into a context and time that was in the past, and no longer happening now. This includes working with their child state that could have taken on an identity of being wrong. As the client’s adult-self grows to understand that their younger selves were abandoned by the adults present, the adult-self can care for these insecure younger parts.
A client may become aware of a physical impulse or movement, such as need to scream. I may encourage a client to stay with this impulse and to gain a sense of how their body would scream. For example does the scream arise from their belly up to their throat and then to their mouth. A client may say the scream felt like it wanted the whole body to make a sound. I may ask them if there were any body sensations that went with the body’s impulse to scream. A client could say they felt trapped in their body. With this trapped feeling comes a thought, “how can family and friends not understand.” The body movement to scream could be like a purging of supressed anger and frustration of being misunderstood and abandoned. A client may say that they can see the scream, when asked if there were any images or memories present. I could suggest that a client draw the scream. If a client agrees I could with paper and pen invite them to draw their image. With present moment mindfulness a client can witness their experience of drawing something that until now was hidden from their awareness.
A client can become their own wise self as they witness their own drawing. With surprise and relief tears may follow and the body soften with renewed vigour and colour. Founder of Hakomi psychotherapy Ron Kurtz said “we help people study the organisation of their own experience …and encourage them to hang out a little longer with the anxiousness so that they can learn from it” (Johanson, Greg). After some silence I could then offer some contact, and say the words, “shocking, and there’s some relief now.” A client could reply that they were surprised and shocked to see what they had been carrying inside, and glad to let it go. It is important for the therapist to be silent and sensitive to a client’s needs. Kurtz wrote “at such important moments, this helps to gain the cooperation of the adaptive unconscious” (Kurtz, R., Five Recent Essays). Often after a client has cried from a big process comes a softness in the eyes and the pupils relax. Their body may also become suppler and less defended while the cheeks glow with a brighter colour.
The client may feel like something deep inside the body let go of the trauma and with that came the realisation that it was in the past and not part of the present. The body all by itself can naturally melt away any fear that lies under the anger of the scream. As Ogden said, the client “understood that her body was a resource rather than a liability” (www.nicabm.com, Ogden, P., Body-Mind-Spirit Integration: Sensorimotor Psychotherapy for Treating Trauma).
A client can transform and integrate something so true like a felt experience of needing to scream, and the actual physicalizing of it was made possible through drawing. Kurtz wrote “when therapy is successful, things change. Feelings arise and are expressed. The client relives and resolves painful memories” (Kurtz, R., The Healing Relationship). A client can forgive themselves and deepen the connection with themselves and others. The client senses their own internal boundaries and knows how to set them.
Concluding therapy using a meditation exercise can be a great way to integrate what has already occurred. A client notices the surfaces of their body, inside and outside and grounding body points that let them know that they are solid, grounded and safe. The client has the opportunity to see for themselves how they are feeling inside their body. The client may describe themselves experiencing their body with the absence of anxiety. This is a breakthrough for a client, and with completing therapy they can think of other thoughts such making a career change to something more fulfilling and inspiring.
References
1. Gilbert, R. M., Extraordinary a New Way of Thinking Relationships About Human Interactions, 1992.
2. Johanson, G., Hakomi in the Trenches.
3. Kurtz, R., Body-Centered Psychotherapy The Hakomi Method, 1990.
4. Kurtz, R., The Healing Relationship.
5. Kurtz, R., On the Uniqueness of Hakomi.
6. Kurtz, R., Five Recent Essays, Summer 2006.
7. Management of Mental Disorders, Vol. 1, Treatment Protocol Project, 2004.
8. Ogden, P., Hands-On Psychotherapy.
9. Ogden, P., www.nicabm.com, Body-Mind-Spirit Integration: Sensorimotor Psychotherapy for Treating Trauma.
10. Ogden, P., Integrating the Body in Trauma Treatment: A Sensorimotor Approach.
11. Ogden, P., Mintorn, K., Pain, C., Trauma and the Body A Sensorimotor Approach to Psychotherapy.
12. Schulmeister, M., Grace in Therapy: What a Therapist Must Trust In.