Sensorimotor Psychotherapy
Developing Sensorimotor Awareness and Literacy
Graphics courtesy of Amen ClinicsOpens in new window
A specific type of somatic psychotherapy, sensorimotor psychotherapy, combines talking therapy with body-centered interventions and movement to address the dissociative symptoms inherent in trauma (Ogden et al., 2006). Sensorimotor Psychotherapy is a body-oriented talking therapy developed by Pat Ogden. Drawing from principles of interpersonal neurobiology and the work of Ron Kurtz (1990), this approach is informed by contemporary research on trauma, dissociation, neuroscience, attachment, and development. Sensorimotor Psychotherapy integrates traditional psychotherapy techniques with body-centered interventions specifically developed to treat the effects of psychological trauma, attachment failure, grief and loss, and developmental arrest. Sensorimotor Psychotherapy is founded on the premise that “the brain functions as an integrated whole but is comprised of systems that are hierarchically organized. The ‘higher level’ [cognitive] integrative functions evolve from and are dependent upon the integrity of ‘lower-level’ [limbic (emotional) and reptilian] structures and on sensorimotor experience” (Fisher, Murray, & Bundy, 1991, p. 16). By working with movement, posture, gesture and sensation as primary targets of clinical intervention, it directly addresses the more primitive, automatic and involuntary physical and physiological functions of the subcortical brain that underlie traumatic and post-traumatic responses. Working from the “bottom-up” rather than “top-down,” sensorimotor experience becomes the main entry point for intervention, and new emotional expression, meaning-making and positive cognitions arise out of the subsequent somatic reorganization of habitual trauma-related responses. As the arousal level, sensation, posture and movement of the body changes, a more positive sense of self emerges, supported by these physical changes. Starting with the body, and integrating cognitive, emotional levels of information processing in an atmosphere of play and exploration, Sensorimotor Psychotherapy helps chronically traumatized children discover their natural instinct toward integration and healing through the body. In Sensorimotor Psychotherapy treatment for traumatic memory, a step-by-step approach is used. As the client accesses a sliver of memory by thinking about the trauma, or reporting either triggering images or resources available during the traumatic experience, the therapist and client both track how the client’s body responds. When resources are reported, time is taken to embody these resources. When arousal approaches the regulatory boundaries of the window of tolerance, or when preparatory movements that indicate truncated defenses emerge, the focus shifts to attending to the physiology and movement impulses of the body. By using the memory content to evoke the trauma-related bodily experience, the Sensorimotor Psychotherapist attends first to how the body has “remembered” the trauma and helps the client to resolve these phenomena on a sensorimotor level, through the body. Thus, an emphasis is on physical action and following body sensation as it progresses through the body (see section on Sensorimotor Sequencing), based on the knowledge that since trauma profoundly affects the body and nervous system, many trauma-related symptoms are somatically driven (van der Hart, Nijenhuis, Seele, & Brown, 2004). Subsequently, another “sliver” is discussed, and the process is repeated, integrating cognitive and emotional elements as they emerge. Trauma was described by Pierre Janet (1898; 1907) as a “failure of integrative capacity,” and thus the primary focus in therapy is to increase the client’s integrative capacity on all levels of information processing and expand the window of tolerance. When a traumatic event occurs, it is often accompanied by strong negative feelings and dissociation. Recall of the traumatic event is thereafter linked with the strong negative emotionsOpens in new window that accompanied the actual event. EMDR is a technique to reprocess the traumatic memory while disconnecting it from the associated negative emotions and thoughts. EMDR contains elements of other therapies including psychodynamicOpens in new window, cognitive-behavioral (CBT)Opens in new window, interpersonalOpens in new window, experientialOpens in new window, and body-centeredOpens in new window therapies. The key component in EMDR is the use of bilateral (two-sided) stimulation. The bilateral effect is provided by having the client visualize a distressing scene or memory while the therapist stimulates rapid back-and-forth eye movements, alternates right and left hand taps, or alternates sounds between the right and left ears. During the visualization, the client brings to mind thoughts and feelings related to the distressing memory (Rubin, 2003). The term EMDR comes from the idea that eye movements (or other bilateral stimulation) while reprocessing a traumatic memory can lead to desensitization of the anxiety associated with the memory. EMDR goals include anxiety reduction, elicitation of positive affect (emotion), changes in beliefs, insights, and behavioral shifts (Shapiro, 2002). A course of treatment may consist of 12 or more sessions over a period of several weeks, depending on the client’s needs and response to treatment. EMDR is usually administered on an outpatient basis (Bisson et al., 2007). Since Dr. Shapiro’s (1989) first article on EMDR was published, over 30,000 mental health practitioners have been trained in EMDR. In the early 1990s, EMDR was depicted by the popular media and early proponents as a miracle cure for a wide range of problems. The dramatic results of early EMDR studies were misinterpreted as implying that a single EMDR session could lead to long-lasting resolution of distress associated with traumatic memories in posttraumatic stress disorder (PTSD)Opens in new window and that clinicians could anticipate success rates as high as 80 or 90 percent. PTSD may occur afer experiencing or witnessing military combat, domestic violence, sexual trauma, auto accidents, natural disasters, and other types of trauma. However, Shapiro acknowledged some of the media reports as hype and cautioned EMDR proponents not to make claims about miracle cures (Rubin, 2003). EMDR has been used to treat many conditions, including PTSD, grief, eating disorders, phobias, panic disorder, test anxiety, performance difficulties (e.g., work, sports, performing arts), conduct disorders, personality disorders, chemical dependency, marital and relationship problems, dissociative disorders, and physical pain. The most compelling evidence exists for the effectiveness of EMDR in treating PTSD. Some extreme claims have contributed to the controversy and skepticism surrounding the use of EMDR. For example, Allan L. Botkin, PsyD, claims that an offshoot of EMDR he calls induced after-death communication can help resolve the deep sadness associated with grief by helping bereaved individuals “experience what they believe is actual spiritual contact with the deceased” (Botkin, 2000, p. 181). Theories about the mechanism of action responsible for the effects of EMDR include resetting of cells in the brain’s septum (which includes the hippocampus and amygdale), disconnection between the affective (emotion) and cognitive (thought) parts of the anterior cingulated cortex, and increase in the interaction between right and left brain hemispheres. Evidence from electroencephalogram (EEG) studies suggest that brain stimulation during EMDR increases the power of a naturally occurring low-frequency rhythm in the amygdale of the brain, which processes fear. When fearful memories are recorded (encoded), the memory is closely linked to the fearful emotion experienced during the traumatic event. This low-frequency rhythm produced by EMDR stimulation causes a mechanical change in fear memory, allowing the memory to be disconnected from the extreme emotions previously associated with the traumatic memory (Harper, 2009). There has been a great deal of controversy about the effectiveness of EMDR. In a 2007 review of the research into treatment of PTSD, EMDR was found to be as effective as trauma-focused CBT, both of which were more effective than stress management, other therapies, or no treatment. Results may be affected by the populations being studied. For example, a study of Vietnam vets with PTSD showed EMDR to be less effective than a control group receiving no treatment (Bisson et al., 2007). While EMDR appears to be a well-supported treatment for adults with PTSD resulting from a single trauma, there is less compelling evidence supporting the effectiveness of EMDR to treat PTSD in children, combat veterans, or individuals who have sustained multiple traumas (Rubin, 2003). As not all individuals will benefit from EMDR, a variety of treatment approaches should be considered. Other treatment options may include alternative forms of trauma-focused treatment (e.g., CBT or exposure therapy) or psychotherapy augmented with medication (Bisson, 2007; Rubin, 2003). More research is needed to establish the effectiveness of EMDR as a treatment for various populations and conditions, to see whether beneficial effects are maintained over time, and to explore and document any negative outcomes or side effects. Side effects of EMDR may include unanticipated reactions, a temporary increase in distress (emotional or physical), or ongoing reexperiencing of traumatic material (e.g., in memories, dreams, or flashbacks) after the session has ended. For understanding or knowing that a person is in a mental state, or to reflect on one’s own mental states, one has to be able to represent that state. In order to be able to represent a state, one needs a concept of that state—that is, a rich enough theory of mind. The study of how children acquire the requisite theory of mind is therefore essential for our understanding of how children come to understand memory. Furthermore, since some memorial states are reflective or self-referential, children need a theory of mind for being in such states or having such memories. Why We Need a Theory of Mind for MemoryWe probably do not need a theory of mind for implicit (nondeclarative Opens in new window) memory, but for explicit (declarative Opens in new window) memory we do, since “explicit memory is revealed when performance on a task requires conscious recollection of previous experiences.” (Schacter, 1987). To be conscious of a fact one requires to be also aware of the state with which one beholds that fact. The higher-order-thought theories of consciousness make this their core claim (Armstrong, 1980; Rosenthal, 1986). For instance, if one sees a state of affairs X (e.g., that the chocolate is in the cupboard), then this seeing is a first-order mental state (attitude). To be conscious of this state of affairs means, according to theory, that one entertains a second-order thought about the seeing—that is, the second-order thought represents the first-order seeing. A weaker version does not require that one has to entertain the second-order thought, but only that one has to have the potential for having the second-order thought (Carruthers, 1996). That some such condition must be true can be seen from the following consideration: “Could it ever be that I can genuinely claim that I am consciously aware of the chocolate being in the cupboard, but claim ignorance of the first-order mental state by which I behold this state of affairs—that is, by claiming that I have no clue as to whether I see, or just think of, or want the chocolate being in the cupboard?” The important point of these conceptual analyses is that to be conscious of some fact requires some minimal concept of knowledge or of some perceptual state like seeing. Unfortunately, there is no clear evidence when children understand a minimal state of this sort. There is some evidence of understanding (mother’s) emotional reactions and seeing (direction of gaze) in the first year of life (see Perner, 1991, chap. 6; Baldwin & Moses, 1996; Gopnik & Meltzoff, 1997, for summaries and discussion of problems of interpretation). There is also some recent evidence that between 8 and 12 months children might be inferring people’s intentions to grasp an object from where that person looks (Spelke, Philips, & Woodward, 1995) and even between 5 to 9 months from how a person touches an object (seemingly intentional or accidentally). And by 18 months (where children’s understanding of mental phenomena seems to flourish in general) children imitate people’s intended actions even when they observe a failed attempt (Meltzoff, 1955a) and they understand differences in preferences (e.g., that someone else can prefer cauliflower over biscuits, Repacholi & Gopnik, 1997). Evidence that children distinguish their knowledge from ignorance is available at a relatively late age. Povinelli, Perilloux, and Bierschwale (1993) asked children to look for a sticker under one of three cups. Children were first trained to look under the cup at which the experimenter had pointed. After some training even the youngest were able to do this. When asked to look without the experimenter pointing, an interesting developmental difference emerged. Children older than 2 years and 4 months acted without hesitation when they knew which the cup the sticker was under, but hesitated noticeably when—in the absence of the experimenter’s poining—they had to guess where it was. Interestingly this is also the age at which children start using the phrase “I don’t know” (Shatz, Wellman, & Silber, 1983). In contrast, children younger than that showed no comparable difference in reaction time. This may indicate that young 2-year-olds do not yet reflect on what they do and do not know. So, theory of mind research is not yet able to give a guideline for when infants might develop explicit, conscious memories. Memory development may help out on this point. Meltzoff (1985, 1995b) demonstrated that 14-month-old infants can reenact a past event (e.g., they imitate the experimenter leaning forward to touch a panel with forehead so that panel lights up) after several months. Recently this has been demonstrated in 11-month-olds with a delay of 3 months. Since this is achieved from a brief observational period and does not require prolonged learning, and since patients with amnesia cannot do this (McDonough, Mandler, KcKee, & Squire, 1995), it is tempting to conclude that such enactment demonstrates explicit, conscious memory. One should, though, keep in mind that delayed imitation that is based on a single event (third-person view) is not to be equated with a memory (knowledge) of that event as a single, past event (first-person view).
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