Pat Ogden- Trauma and the Body

[obyvatel]

 I recently finished "Trauma and the Body: A Sensorimotor Approach to Psychotherapy" by Pat Ogden, Clare Pain and Kekuni Minton. IMO this goes well with Peter Levine's "In An Unspoken Voice", Stephen Porges's "Polyvagal Theory" and Jaak Panksepp's work on Affective Neuroscience. I had posted an excerpt from Pat Ogden's writings in the Affective Neuroscience thread and that is what got me interested in her book. This book clarified and solidified certain concepts which were introduced in the above texts as well as other psychological books, and gave a good neuro and behavioral science based background on the mechanics of "running programs". It has a good balance of theory and practical case studies which help in understanding the theoretical concepts. Here are some excerpts.

Three levels of Information Processing
 
  Those familiar with Peter Levine's "In An Unspoken Voice" would have encountered Maclean's triune brain model. Essentially

   The reptilian brain, first to develop from an evolutionary perspective, governs arousal, homeostasis of the organism, and reproductive drives, and loosely relates to the sensorimotor level of information processing, including sensation and programmed movement impulses.
   
Correlating with emotional processing, the “paleomammalian brain” or “limbic brain,” found in all mammals, surrounds the reptilian brain and mediates emotion, memory, some social behavior, and learning (Cozolino, 2002).

  Last to develop phylogenetically is the neocortex, which enables cognitive information processing, such as self-awareness and conscious thought, and includes large portions of the corpus callosum, which bridges the right and left hemispheres of the brain (MacLean, 1985) and helps consolidate information (Siegel, 1999).

Thus the three levels of information processing— cognitive, emotional, and sensorimotor— can be thought of as roughly correlating with the three levels of brain architecture. Different kinds of knowledge originate from each of these brains.
The reptilian brain produces “Innate behavioral knowledge: Basic instinctual action tendencies and habits related to primitive survival issues” (Panksepp, 1998).
The limbic system provides “Affective knowledge: Subjective feelings and emotional responses to world events” (Panksepp, 1998).
The neocortex generates “Declarative knowledge… propositional information about world” (Panksepp, 1998).

Panksepp further clarified the behavioral and functional interface of these three “brains”: The inner most reptilian core of the brain elaborates basic instinctual action plans for primitive emotive processes such as exploration, feeding, aggressive dominance displays, and sexuality. The old-mammalian brain, or the limbic system, adds behavioral and psychological resolution to all of the emotions and specifically mediates the social emotions such as separation distress/ social bonding, playfulness, and maternal nurturance. The highly expanded neomammalian cortex generates higher cognitive functions, reasoning, and logical thought. Each of the three levels of the brain thus has its own “understanding” of the environment and responds accordingly. A particular level may become dominant and override the others, depending on the internal and environmental conditions. At the same time, these three levels are mutually dependent and intertwined.
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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 and optimal functioning of higher-level structures are thought to be dependent, in part, on the development and optimal functioning of lower-level structures. In many ways sensorimotor processing is foundational to other types of processing and includes the features of a simpler, more primitive form of information processing than do its more evolved counterparts. More directly associated with overall body processing, sensorimotor processing includes physical changes in response to sensory input; the fixed action patterns seen in defenses; changes in breathing and muscular tone; and autonomic nervous system activation. 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 works. Some of these fixed sequences are well known, such as the startle reflex and the fight/ flight 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, such as walking and running, which then become automatic. In the more highly evolved cognitive and emotional realms, we find fewer and fewer fixed sequences of steps and more complexity and variability of response. Panksepp (1998) likened this variance in complexity to the operating systems of a computer: Higher functions are typically more open, while lower ones are more reflexive, stereotyped, and closed. For instance, the basic vital functions of the brain— those that regulate organic bodily functions such as respiration— are organized at very low levels. Higher levels provide increasingly flexible control over these lower functions….

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Cognitive processing refers to the capacity for conceptualizing, reasoning, meaning making, problem solving, and decision making. It encompasses the ability to observe and abstract from experience, weigh a range of possibilities for action, plan for the accomplishment of goals, and evaluate the outcome of actions. As adults, we can override emotional and sensory responses with voluntary cognitive processing - and this is referred to as "top-down processing".

  However, there is evidence to indicate that cognitive processing is inextricably linked with our bodies. Bodily feelings, or “somatic markers,” influence cognitive decision making, logic, speed, and context of thought (Damasio, 1994, 1999). The background body sensations that arise during cognitive processing form a biasing substratum that influences the functioning of the individual in all decision-making processes and self-experiences. ( This is a component of Kahneman's System 1).  If the body shapes reason and beliefs— and vice versa— then the capacity for insight and self-reflection— our ability to “know our own minds”— will be correspondingly limited by the body’s influence (Lakoff & Johnson, 1999). How, then, can we begin to know our own minds? If the patterns of the body’s movements and posture influence reason, cognitive self-reflection might not be the only or even the best way of bringing the workings of the mind to consciousness. Reflecting on, exploring, and changing the posture and movement of the body may be as valuable.

Emotions  add motivational coloring to cognitive processing and act as signals that direct us to notice and attend to particular cues. Emotions help us take adaptive action by calling attention to significant environmental events and stimuli (Krystal, 1978; van der Kolk,McFarlane et al., 1996). The “emotional brain directs us toward experiences we seek and the cognitive brain tries to help us get there as intelligently as possible” (Servan-Schreiber, 2003). According to Llinas, “As with muscle tone that serves as the basic platform for the execution of our movements, emotions represent the premotor platform as either drives or deterrents for most of our actions” (2001).
Traumatized people characteristically lose the capacity to draw upon emotions as guides for action. They might suffer from alexithymia, a disturbance in the ability to recognize and find words for emotions (Sifneos, 1973, 1996; Taylor, Bagby, & Parker, 1997). They may be detached from their emotions, presenting with flat affect and complaining of a lack of interest and motivation in life and an inability to take action. Or their emotions may be experienced as urgent and immediate calls to action; the capacity to reflect on an emotion and allow it to be part of the data that guides action is lost and its expression becomes explosive and uncontrolled.

The term emotional processing refers to the capacity to experience, describe, express, and integrate affective states (Brewin, Dalgleish, & Joseph, 1996). Emotions usually follow a phasic pattern with a beginning, middle, and an end (Frijda, 1986). However, for many traumatized individuals, the end never arrives. Emotional responses to very strong stimuli, such as trauma, do not appear to extinguish (Frijda, 1986)— a phenomenon that has been demonstrated in animal research by LeDoux that emotional memory may be forever (LeDoux, 1996). Traumatized individuals are often fixated on trauma-related emotions of grief, fear, terror, or anger. There might be a variety of reasons for this fixation: denial or lack of awareness of the connection between current emotions and past trauma; attempts to avoid more painful emotions; the inability to “think clearly” (Leitenberg, Greenwald, & Cado, 1992); or the inability to distinguish emotions from bodily sensations (Ogden & Minton, 2000). Moreover, the emotions may relate to a variety of past events rather than only one (Frijda, 1986). All these elements contribute to a circular, apparently never-ending reexperiencing of trauma-related emotions.

   Emotions are matters of the body -  of the heart, the stomach, and intestines, of bodily activity and impulse.Whether we are aware of these internal sensations or not, they both contribute to, and are the result of, emotions. Butterflies in the stomach tell us we are excited, a heavy feeling in the chest speaks of grief, tension in the jaw informs us we are angry, an all-over tingling feeling indicates fear. Damasio stated that emotions have two features: first, the internal sensation, which is “inwardly directed and private,” and second, visible feature, which is “outwardly directed and public” (1999). Internal emotional states are thus experienced as subjective bodily sensations and are reflected in our outward presentation, giving signals to others around us about how we feel. Anger might be visible in the purse of the mouth, clenched fists, narrowed eyes, and general bodily tension. Fear may be communicated in hunched shoulders, held breath, and a pleading look in the eyes or in a bracing or moving away from the frightening stimulus. These bodily stances might be an immediate response to a current situation or a chronic, pervasive emotional state.

  However, despite the inextricable involvement of emotions with the body and cognitions, when trauma-related emotions such as terror are coupled with body sensation, such as trembling, the client is encouraged to distinguish body sensations and movements from emotions. In these instances, we help clients differentiate emotional processing from sensorimotor processing. In our vernacular, emotional processing pertains to experiencing, articulating, and integrating emotions, whereas sensorimotor processing refers to experiencing, articulating, and integrating physical/ sensory perception, body sensation, physiological arousal, and motor functioning. This differentiation between these two levels of processing is important in trauma therapy because clients often fail to discriminate between body sensations of arousal or movement and emotional feeling, which can lead to the escalation of both. If body sensations (e.g., trembling, rapid heart rate) are interpreted as an emotion (e.g., panic), each level of experience— sensorimotor and emotional— inflates and compounds the other. Both the rapid heart rate and the panic are exacerbated when experienced simultaneously. If cognition in the form of a belief is then added, such as “I am not safe,” physical sensation and emotion will further intensify. In such a situation, arousal can escalate beyond the person’s tolerance, and integrative capacity will be compromised. Physiological arousal can be addressed, and often diminished, by uncoupling trauma-related emotion from body sensation through attending exclusively to the physical sensations of the arousal (without attributing meaning or emotion to them). Then, after the physiological arousal returns to a tolerable level, the client can look at the emotional contents of the traumatic experience and integrate both.


In the clinical practice of sensorimotor psychotherapy, we identify three general components of sensorimotor processing : inner-body sensation, five-sense perception, and movement.

The term inner-body sensation refers to the myriad of physical feelings that are continually created by movement of all sorts within the body. When a change occurs in the body, such as a hormonal shift or a muscular spasm, this change may be felt as an inner-body sensation. The contraction of the intestines, circulation of fluids, biochemical changes, the movements of breathing, or the movements of muscles, ligaments, or bones all cause inner-body sensations.

  People with trauma-related disorders suffer from both “feeling too much” and “feeling too little” (van der Kolk, 1994). They often experience inner-body sensations as overwhelming and distressing. The “rush” of adreneline or the sensations of a rapid heartbeat or of bodily tension are felt acutely and become more disconcerting when interpreted as indicating current danger. Conversely, traumatized individuals commonly suffer from an inability to be aware of body sensation, or an inability to put words to sensation, known as alexisomia (Bakal, 1999; Ikemi & Ikemi, 1986). The absence of body sensation and the accompanying interpretation (e.g., “There is something wrong” “I can’t feel my body” “I feel dead”) can be just as distressing as experiencing too much sensation.

Five sense perception Sometimes called exteroception, the sensory nerves of our five senses receive and transmit information from stimuli in the external environment. The process of taking in information through the five senses can be thought of as having two components: the physical act of sensing and the individual’s perception of the sensory input (Cohen, 1993). Sensory perceptions may dominate traumatized individuals’ capacity to think rationally.

  Because it is based on the comparison of sensory input with internal frames of reference, our perception— and thus our behavior— is self-referential (Damasio, 1994). Our beliefs and emotional reactions to previous similar sensory stimuli condition our relationship with current stimuli. Without the expectations that influence perceptual priming, each sensory experience would be novel, and we would be quickly overwhelmed. Instead, we fit sensory input into learned categories. Ratey pointed out that “we are constantly priming our perceptions, matching the world to what we expect to sense and thus making it what we perceive it to be” (2002). This priming function becomes maladaptive for traumatized individuals, who repeatedly notice and take in sensory cues that are reminiscent of past trauma, often failing to notice concomitant sensory cues indicating that current reality is not dangerous.

  Movement is included in the sensorimotor level of information processing because of its obvious somatic component, although the frontal lobes of the cortex, rather than the subcortical areas of the brain, are home to the motor cortex and premotor cortex and are responsible for many forms of movement. The same areas of the brain that generate reason and help us solve problems are also involved in movement. Thus movement has shaped, and continues to shape, our minds (Janet, 1925), and vice versa, as articulated by Llinas: “The mind… is the product of evolutionary processes that have occurred in the brain as actively moving creatures developed from the primitive to the highly evolved” (2001). Movement is essential for the development of all brain functions: Only organisms that move from one location to another require a brain; organisms that are stationary do not (Ratey, 2002).

  Todd (1959) taught that function precedes structure: The same movement made over and over again ultimately molds the body. For example, when the muscular contractions that prime defensive movements are repeated many times, these contractions turn into physical patterns that affect the body’s structure, which in turn, further affects function. Over a long period of time, this chronic tension interferes with the body’s natural alignment and movement, creates physical problems (most notably, back, neck, and shoulder pain), and even sustains corresponding emotions and cognitions. Kurtz and Prestera noted: “Such physical patterns become fixed by time, affecting growth and body structure, and characterizing not just the moment, but the person. Rather than simply a present disappointment, the crushed posture of hopelessness could be pointing to a lifetime of endless frustration, and bitter failure” (1976).

Repetitive movements and postures thus contribute to the maintenance of cognitive and emotional tendencies by creating a position from which only select emotions and physical actions are possible (Barlow, 1973). We often notice the posture of the startle response in traumatized clients: shoulders up, breath held, head pulled down and forward into the shoulder girdle, similar to a “deer in the headlights.” The action of the startle response disturbs the aligned balance between head and shoulders and is usually temporary, but if this normal response to a sudden novel stimulus becomes chronic, the physical organization itself may predispose the individual to experience emotions of fear and distrust and thoughts of impending danger on a chronic basis.
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COGNITIVE, EMOTIONAL, AND SENSORIMOTOR ACTION TENDENCIES

 An action tendency is a propensity to implement or carry out a particular action. Action tendencies are formed on cognitive, emotional, and sensorimotor levels. Tendencies stem from procedural memory of processes and functions, reflected in habitual responses and conditioned behavior (Schacter, 1996). Procedural learning involves repeated iterations of movements, perceptions, cognitive and emotional processes, or combinations of these (Grigsby & Stevens, 2000). The original events from which these automatic personal processes and routines are learned have usually been forgotten. Actions that are procedurally learned “do not require conscious or unconscious mental representations, images, motivations or ideas to operate” (Grigsby & Stevens, 2000). Operating nonconsciously, procedural learning on all three levels of information processing turns into automatic action tendencies that become crucial organizers of behavior. Long after environmental conditions have changed, we remain in a state of readiness to perform the mental (cognitive and emotional) and sensorimotor actions that were adaptive in the past. For example, the child who learns that it is safer to back away from adults when either she or they are distressed, instead of seeking proximity, might develop action tendencies of avoidance-oriented postural adjustments (turned away, looking at the ground to avoid eye contact), movement impulses that lead to backing away, emotional responses such as fear, and cognitive belief systems such as “It’s not safe to seek comfort.”

  These action tendencies “have the character of urges or impulses. They lie in waiting for signs that they can or may be executed; they, and their execution, tend to persist in the face of interruptions; they tend to interrupt other ongoing programs and actions; and they tend to preempt the information processing facilities” (Frijda, 1986). In broad terms, an action tendency is a readiness for specific behavior. This “readiness” means that the action tendency exists within the person in latent form and becomes activated in response to specific internal or external stimuli. Maladaptive actions tendencies conditioned from the past are triggered by internal and environmental reminders of the past and take precedence when other actions might prove more adaptive. Once procedures become automatic tendencies, we no longer use top-down processes to regulate them.
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    As we know, roots of most action tendencies lie in early childhood experiences. Bowlby's attachment theory gives a framework to look at such patterns. Secure attachments give a child a stable foundation to embark on the life journey. Insecure attachment patterns give rise to certain deficits which continue to affect lives as adults.

INSECURE-AVOIDANT ATTACHMENT
 
Mothers of insecure-avoidant infants actively thwart or block proximity-seeking behavior of the infant, responding instead by withdrawing or even pushing the child away (Ainsworth et al., 1978; Schore, 2003a). These mothers appear to have a general distaste for physical contact except on their terms and may respond to the infant’s overtures with wincing, arching away, or avoiding mutual gaze (Cassidy & Shaver, 1999; Schore, 2003a; Siegel, 1999). The child adapts to this affectively laden somatic communication of unavailability by expressing little need for proximity, and apparently little interest in adult overtures for contact. And, when contact is made, the avoidant child does not sustain it, focusing instead on toys and objects rather than on the mother. He generally avoids eye contact with her and shows few visible signs of distress upon separation, although some researchers (Fox & Card, 1999; Main, 1995) have found evidence of autonomic arousal in these toddlers even when they appear behaviorally indifferent to the mother. Upon reunion, they actively ignore or even avoid the mother by moving or leaning away when picked up (Main & Morgan, 1996). They generally do not seek proximity with caregivers and are reserved emotionally.

  Children with insecure-avoidant attachment patterns are described as having a dismissive stance towards the importance of attachment in adulthood. They often distance themselves from others, undervalue interpersonal relationships, become self-reliant, and tend to view emotions with cynicism. Clients with insecure-avoidant attachment histories tend to withdraw under stress and avoid seeking emotional support from others. With a compromised social engagement system and limited access to internal states, these clients typically minimize their attachment needs. Preferring autoregulation to interactive, they may find dependence frightening or unpleasant and avoid situations that stimulate attachment needs.

  The body tendencies vary; through muscular tonicity or rigidity these clients might show that they are more comfortable with defensive movements than with reaching out or moving toward. For example, one adult client found it unfamiliar and uncomfortable to reach out with her arms and did so awkwardly and stiffly, saying that it was easier to push away than to reach out for contact when no one had ever responded. As they are approached, these clients may pull back or become more armored. Others withdraw through a demeanor of passivity, often reflected in low muscular tonicity, and lack of response to relational overtures. Many clients demonstrate mixed tone: high tone in certain areas of the body, and low tone in other areas, as in the client who was strong and muscular through her legs but weak and flaccid through her arms. A lack of emotional expression and eye contact and a lower level of overall arousal are also correlated with this attachment group (Cozolino, 2002).

  In a sensorimotor approach, somatic interventions that strengthen interactive regulation and social engagement (reaching out, seeking proximity, eye contact) provide effective avenues of exploration. Children with insecure-avoidant attachment histories have a more complicated balance to attain between their need for caregiver proximity and their tolerance of anxiety; this adaptation may be subsequently reflected in a disjunction or disconnection between their interior needs and their external behavior.   These incongruent patterns are apparent in our adult clients, too. For instance, the client who sits on the couch, visibly uncomfortable, may respond to the question “How are you doing?” or “How are you feeling in your body” with a smile and “Fine.” This client’s disconnection between her physical or emotional discomfort and her reported psychological state demonstrates an incongruence or mismatch between her inner psychological and somatic states, of which she is frequently genuinely unaware. Treatment for these clients includes becoming aware of internal states and practicing physical movements that accurately correspond to these states.


INSECURE-AMBIVALENT ATTACHMENT

 
  The mother of the infant who develops insecure-ambivalent attachment patterns is inconsistent and unpredictable in her response to the infant. She may either over-arouse the infant or fail to help the infant engage. Because her interactions are often a response to her own emotional needs and moods rather than the infant’s, this caregiver might stimulate the infant into high arousal even when the infant is attempting to down-regulate by gaze aversion. Thus, when the mother’s own emotional need for engagement overrides the infant’s need, her behavior intrudes on the infant causing dysregulation of the infant’s arousal. Because the car giver is inconsistent in her availability, sometimes allowing and encouraging proximity and sometimes not, the child is unsure of the reliability of the caregiver’s response to his or her somatic and affective communications (Belsky, Rosenberg, & Crnic, 1995; Carlson, Armstrong, Lowenstein, & Roth, 1998; Main, 1995). This uncertainty results in infants who appear cautious, distraught, angry, distressed, and preoccupied throughout both separation from, and reunion with, the mother. Upon reunion, they typically fail to be comforted by the caregiver’s presence or soothing (Main & Morgan, 1996), often continuing to cry. These infants characteristically appear irritable, have difficulty recovering from stress, show poor impulse control, fear abandonment, and engage in acting-out behavior (Allen, 2001). One example of the ambivalence such infants show with the unpredictable parent is to alternate between angry, rejecting behaviors and contact-seeking behaviors upon reunion with the mother after separation.

   Children with insecure-ambivalent patterns have a “difficult temperament” with “tendencies to intense expressiveness and negative mood responses, slow adaptability to change, and irregularity of biological functions” (Schore, 2003a).  Children with insecure-ambivalent insecure-ambivalent attachment histories are described as having a preoccupied stance toward attachment in adulthood. They are preoccupied with attachment needs, overly dependent on others, and might have a tendency toward enmeshment and intensity in interpersonal relationships, with a preference for proximity. They focus excessively on internal distress, often pursuing relief frantically (Cassidy & Shaver, 1999). With a compromised social engagement system, these clients are often unable to recognize safety within the relationship. Preoccupied with the availability of attachment figures (including the therapist), they frequently experience increased affect and bodily agitation and increase or loss of muscular tone at the prospect of separation.

  A sensorimotor approach would facilitate autoregulatory capabilities through a development of grounding, boundaries, and core internal support as well as promote adaptive interactive regulatory abilities (see Chapter 10). Children with insecure-ambivalent attachment patterns may demonstrate more congruency between internal states and external physical movement than insecure-avoidant children, but their behavior is often dysregulated. Their physical movement may be uncontained, geared more toward discharge of high arousal than toward the purposeful achievement of a specific goal. For example, a child may frantically cry and flail when the attachment system is aroused, rather than execute directional, purposeful movement toward the caregiver. The movement may take the form of agitation that does not translate into a tempered, purposeful movement that accomplishes a particular goal. In a sensorimotor approach with adult clients with insecure ambivalent attachment histories, learning to tolerate high emotional and physiological arousal and execute thoughtful, purposeful action rather than dysregulated, non-directional movement is essential.


Disorganized/ Disoriented Attachment



   Main and her colleagues (Main, 1995; Main & Hesse, 1990; Main & Solomon, 1990) observed a group of children who had puzzling and contradictory sets of responses to their mothers upon reunion after separation. The researchers also observed the mothers, whose behavior they evaluated as “frightening” (e.g., looming behaviors, sudden movements, sudden invasion, attack postures) or “frightened” (e.g., backing away, exaggerated startle response, retraction in reaction to the infant, a fearful voice or facial expression) (Main & Hesse, 1990). In addition, these mothers may exhibit role confusion (e.g., eliciting reassurance from the child), disorientation( e.g., trance-like expression, aimless wandering in response to the infant’s cries), intrusive behavior (e.g., pulling the child by the wrist, mocking and teasing, withholding a toy) or withdrawal (e.g., not greeting the infant, not interacting verbally, gaze avoidance) (Lyons-Ruth, 2001). These caregivers often provoked sudden state switches without providing interactive repair. Sometimes the caregivers (usually the mother) of these children may be abusive or neglectful or both. Such a caregiver induces traumatic states of enduring negative affect. Because her attachment is weak, she provides little protection against other potential abusers of the infant…. This caregiver is inaccessible and reacts to her infant’s expressions of emotion and stress inappropriately and/ or rejectingly, and shows minimal or unpredictable participation in the various types of arousal-regulating processes. Instead of modulating, she induces extreme levels of stimulation and arousal, either too high in abuse or too low in neglect, and because she provides no interactive repair, the infant’s intense negative emotional states last for long periods of time. (Schore, submitted) Because this misattuned caregiver shows little or no attempt to recognize or repair breaches in relatedness, the infant is left in hyper-or hypoaroused zones for extended periods of time. Main and Solomon (1986, 1990) named the attachment pattern that developed from such caregiving the disorganized/ disoriented style and identified seven categories of behavior indicative of this style:

1) Sequential contradictory behavior; for example, proximity seeking followed by freezing, withdrawal, or dazed behavior.

2) Simultaneous contradictory behavior, such as avoidance combined with proximity seeking.

3) Incomplete, interrupted, or undirected behavior and expressions, such as distress accompanied by moving away from the attachment figure.

4) Mistimed, stereotypical, or asymmetrical movements,and strange, anamolous behavior, such as stumbling when the mother is present and there is no clear reason to stumble.

5)  Movements and expressions indicative of freezing, stilling, and “underwater” actions.

6) Postures that indicate apprehension of the caregiver, such as fearful expressions or hunched shoulders.

7) Behavior that indicates disorganization or disorientation, such as aimless wandering around, labile affect, or dazed, confused expressions.

 
   Main and Solomon observed that these infants’ “approach movements were continually being inhibited and held back through simultaneous activation of avoidant tendencies. In most cases, however, proximity-seeking sufficiently ‘over-rode’ avoidance to permit the increase in physical proximity. Thus, contradictory patterns were activated but were not mutually inhibited” (1986). Versions of these incongruent behaviors are observed in traumatized adults, especially in the context of discussing past relational trauma or past or current attachment relationships, including the relationship with the therapist. In clinical contexts, therapists often are confused by what seem like paradoxical responses to contact and apparent relational discontinuity. For example, Lisa frequently complained that “no one is there for me” and begged her therapist for more contact: to sit closer, to hold her hand if she cried, to call to see how she felt during the week. Yet, in sessions, Lisa consistently seated herself in such a way that she was facing away from the therapist and orienting toward the floor and sofa, and her body stiffened when the therapist moved her chair closer (at Lisa’s request). Proximity seeking emerged in her verbal communication, whereas avoidance was communicated physically: her body held back the approach, avoiding even eye contact. The often confusing incongruent and contradictory behavior observed in these infants, and in clients such as Lisa, can be understood as the result of simultaneous or alternating stimulation of two opposing psychobiological systems: attachment and defense (Liotti, 1999a; Lyons-Ruth & Jacobvitz, 1999; Main & Morgan, 1996; Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997; Van der Hart et al., 2004). An infant predictably seeks proximity to the caregiver when distressed, but if the caregiver further distresses the infant instead of providing comfort and safety, an irresolvable paradox ensues (Main & Solomon, 1986). The infant cannot satisfactorily approach, flee, or reorient his or her attention. When the attachment system is aroused, proximity-seeking behaviors are mobilized. But when the defensive system is aroused, flight, fight, freeze, or hypoarousal/ feigned death responses are mobilized. The disorganized/ disoriented infant experiences the alternating or simultaneous stimulation of these two opposing psychobiological systems. Steele, Van der Hart, and Nijenhuis (2001) have challenged the notion that this attachment paradigm is, in fact, “disorganized” (see also Jaffe et al., 2001). They have proposed that, in the context of frightened and/ or frightening caregiving, disorganized/ disoriented attachment is actually an organized, logical response caused by the concurrent activation of both the defensive and attachment systems: the social engagement system and the sympathetic and dorsal vagal systems are thought to be simultaneously or alternately stimulated. In childhood trauma and neglect, disorganized/ disorientated attachment as a strategy is a logical outcome. The ongoing threat of frightened and frightening caregiving evokes the action tendencies of both proximity seeking and defense. This attachment behavior has been demonstrated in 80% of maltreated infants (Carlson et al., 1998) and is a statistically significant predictor of both dissociative disorders (Carlson et al., 1998; Liotti, 1992) and aggressive behavior (Lyons-Ruth & Jacobvitz, 1999).

    Each attachment pattern show some distinctive features of emotional self- regulation. In auto-regulation, the person relies on him/herself while in interactive regulation, others are sought via the social engagement system. For securely attached individuals, both auto and interactive regulatory abilities are developed and applied appropriately.

 
  The child with an insecure-avoidant history may depend upon autoregulation and parasympathetic (dorsal vagal) dominance (Cozolino, 2002;Schore, 2003a) to self-regulate, most likely experiencing increased dorsal vagal tone characterized, in the extreme, by feelings of helplessness and lower levels of activity (i.e., a state of conservation and withdrawal) (Schore, 2003a). With a tendency to curtail the expression of emotion (Cassidy & Shaver, 1999), this “overregulation” indicates a reduced capacity to experience either positive or negative affect and may contribute to a low threshold of arousal in socioemotional contexts and to modulation imbalances( i.e., difficulty shifting out of low arousal states and moderating high arousal). This child, in the relative absence of an available caregiver, is robbed of the opportunity for satisfying social engagement and typically develops a preference for autoregulatory tendencies that do not depend on another’s presence. He or she may learn to modulate arousal in solitude, turning inward through reading, daydreaming, and worlds of fantasy. Although generally compliant, the child may express frustration in peer relationships where avoidant attachment behaviors are sometimes associated with hostility, aggressiveness, and conduct problems (Allen, 2001; Crittenden, 1995; Sroufe, 1997; Weinfield, Stroufe, Egeland, & Carlson, 1999). Interactive regulatory and social engagement abilities necessary for resolving interpersonal conflicts are often underdeveloped in such individuals.


On the other hand, children with insecure-ambivalent attachment patterns tend to have a sympathetically dominant nervous system (Cozolino, 2002; Schore, 2003a) with a low threshold of arousal and concurrent difficulty maintaining arousal within a window of tolerance. The inconsistent responsiveness of the primary caregiver has taught the child to increase signaling for attention, escalating distress in order to solicit caregiving (Allen, 2001). These children are biased toward undercontrolled high-arousal states, with increased emotional reactivity combined with an inability to modulate distress, leaving them vulnerable to underregulatory disturbances (Schore, 2003a). Less able to autoregulate, as adults these individuals find isolation stressful: Because they have trouble tolerating solitude, they cling to relational contact, becoming overly dependent on interactive regulation but simultaneously experiencing a lack of ability to be easily calmed and soothed in a relationship.  Although social engagement is sought, the person remains biased toward hyperarousal, in part due to hypervigilence developed from previous experience of intrusive behavior by the primary attachment figure.


Disorganized-Disoriented Attachment and Regulation:  Hyper-and hypoarousal are both involved in the infant’s psychobiological response to frightened or frightening caregivers, with whom the social engagement system is functionally off-line for much of the time. Disorganized/ disoriented attachment patterns in children has been associated with elevated heart rates, intense alarm reactions, higher cortisol levels, and behavior that may indicate increased dorsal vagal tone, such as stilling, going into a brief trance, unresponsiveness, and shutting down (Schore, 2001). In the initial stage of threat, infants demonstrate sympathetic activation accompanied by startle reactions, elevated heart rate, respiration, and blood pressure, and usually crying or screaming (Schore, submitted). However, when sympathetic arousal cannot be regulated, a quick shift to hypoarousal may occur. The body undergoes “the sudden and rapid transition from an unsuccessful strategy of struggling requiring massive sympathetic activation to the metabolically conservative immobilized state mimicking death associated with the dorsal vagal complex” (Porges, 2001a). Thus sympathetically mediated responses quickly change “from interactive regulatory modes into long-enduring less complex autoregulatory modes” (Schore, submitted). During these hypoaroused conditions, observed in newborns (Bergman, Linley, & Fawcus, 2004; Spitz, 1946), the infant is unresponsive to interactive regulation (Schore, submitted). Early relational trauma generates prolonged negative affective and physiological states in the infant, which, in turn, “generate immature and inefficient orbitofrontal systems, thereby precluding higher complex forms of affect regulation” (Schore, submitted). These negative states also leave the child with a compromised social engagement system. .....underdeveloped or ineffective interactive regulatory abilities, as well as impaired autoregulatory capacities; they remain in, or alternate between, hyper-or hypoarousal zones for extended periods of time.

[obyvatel]

ORIENTING RESPONSE

Physical and psychological responses to both internal and external stimuli are predicated on, and extrapolated from, orienting responses. What we turn our attention to, or orient to, determines not only our physical actions but our mental actions as well. We sustain a preparation to orient at all times, during sleep as well as during wakefulness (Sokolov, Spinks, Naatanen, & Heikki, 2002), and this preparation is both physical and psychological. The components of orienting include turning the head and focusing the sensory organs on the object of orientation. In addition, “perceptual enhancement, motor preparation, and appropriate sensorimotor tuning” occur and “the nature of these changes [are] mapped onto a prognosis of future events, action, or information processing” (Sokolov et al., 2002). Thus, the constant preparation for, and the act of, orienting are fundamental to information processing. Orienting determines the quality, kind, and amount of data received by sensorimotor, emotional, and cognitive processing systems that then serve to guide our actions.
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Orienting occurs on both overt and covert levels.

Overt orienting involves visible physical actions of turning the sensory organs, particularly the eyes, and often the head and body, in the direction of an environmental stimulus. This form of orienting is often highly automatic, largely independent of conscious awareness, and commonly generated reflexively via an unexpected or novel stimulus However, as the cortex matures over the course of development, overt orienting also comprises top-down components whereby we voluntarily select certain objects in an active, strategy-driven process.

In contrast, covert orienting does not require muscular change. Instead, an “inner” or “mental” shift in attention from one environmental stimulus to another indicates an internal orienting that is often invisible to an observer (Posner,Walker, Friedrich, & Rafal, 1984).

These two forms of orienting are closely related: A sudden change in the environment will normally induce both overt (observable) and covert (nonobservable) orienting simultaneously. An initial response of overt orienting is often immediately followed by covert orienting, when internal attention is also focused on the object of orientation, and the visible behavioral changes of overt orienting then may cease Overt and covert orienting can also operate independently of one another; for example, we can overtly orient by looking at one object in the environment while simultaneously focusing our internal attention on something else altogether.

People with trauma-related disorders often have difficulty in synchronizing overt and covert orienting. They may overtly orient toward everyday stimuli while covertly orienting toward trauma-related  internal stimuli: their rapid heartbeat, an intrusive image, or thoughts of inadequacy and failure.
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For the traumatized individual, maladaptive orienting tendencies include
( 1) a hypersensitivity to minor environmental or internal changes;
(2) a tendency to overorient to archaic trauma-related stimuli; and
(3) an inability to discriminate and evaluate the context of stimuli, especially regarding cues that may indicate danger in certain contexts but not in others.
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Traumatized individuals have typically established dysfunctional orienting tendencies that are overhabituated or oversensitized. In either case, these responses are embedded in posture and movement tendencies.  Bettina developed orienting tendencies in the context of a violent early family history. These tendencies of ignoring her surroundings helped her to regulate her arousal: She predictably oriented inward, rather than outward, away from what she perceived as a threatening environment. Postural habits of looking down and away further diminished her ability to orient toward and evaluate environmental stimuli, leaving her preoccupied with distressing internal sensations, thoughts, and emotions.
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  The degree of concentration or alertness brought to the awareness of a stimulus is referred to as the quality of attention or level of consciousness.
In order for attention to be adaptive, the ability to maintain both alert concentration and top-down (executive) control is required.

Many traumatized individuals are both reflexively fixated and reflexively inattentive; they alternate between the extremes of fixation and distractibility. They may scan the environment hypervigilantly, orienting briefly to a variety of stimuli without discrimination, or they may become involuntarily and compulsively fixated on a particular stimulus and unable to redirect attention. Shifting orientation and attention from external to internal stimuli, or from internal to external, presents further difficulty, because the traumatized person is often strongly distracted by both internal and environmental stimuli. Psychotherapeutic interventions must help clients reorient and redirect attention in an effort to become “unstuck” from particular stimuli and more concentrated on others of immediate relevance. Directing clients to physically orient their body toward new stimuli and asking them questions that help to focus attention, such as “What do you see there?”, “What color is it?”, “Can you see the little patterns in the fabric?”, “What do the patterns look like?” may move them out of the impasse. To help clients focus attention on the body, the therapist can ask them questions that can only be answered by giving acute attention to sensations in the body: “How big is the sensation? About the size of a grapefruit? Baseball? Pinprick? Which way is the tension pulling: in or out, left or right?”
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THE IMPACT OF BELIEFS ON ORIENTING AND ATTENTION

Adaptive behavior requires anticipation of significant information-carrying events and preparation of responses in advance. We have an evolutionary advantage if we can predict meaningful events and prepare beforehand by deciding how to process, and respond to, the upcoming information (Sokolov et al., 2002). Orienting is thus “characterized by an active search for new information based on comparison and re-evaluation of working hypotheses present in the brain” .
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Much of what we see is colored and organized by what we expect to see. The cues toward which clients are compelled to orient, and which sustain their attention, are likely to be those that verify implicit beliefs held about the self and the world. Susan had tendencies of orienting and attention that stemmed from the beliefs formed through early relationship dynamics. She grew up with parents who were preoccupied with their careers and each other, and she reported feeling unsupported and uncared for throughout her childhood. She said that she felt “on her own” for most of her life and described a childhood of fixing her own meals, telling her parents when she needed new clothes, and becoming self-sufficient at a very young age. The hypothesis, or belief, she formed was, “No one will ever be there for me, so I have to do it all myself.” Her body posture and language reflected this belief: Susan’s body was highly toned and fast moving; her arms hung with her palms facing backward (which she described in therapy as indicating a reluctance to reach out to others), and she had difficulty looking people in the eye. Her belief, supported by her physical posture and movement, caused Susan to habitually orient away from cues that indicated the availability of reliable support. She did not notice the offers of help from other people. Susan complained that her husband failed her in ways similar to those of her parents; however, her frustrated husband stated that he repeatedly extended support to Susan but that she consistently refused, or simply did not respond, so he had finally given up trying. Susan clearly was not orienting or attending to cues that would disprove her belief; instead she focused on cues reminiscent of her past that verified her belief that no one would support her.
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Mindfulness of the orienting process places a therapeutic gap between stimulus and response (Kurtz, 1990): Rather than orienting unconsciously to traumatic stimuli, the client learns to observe the process of orienting and to witness the stages of the orienting response. Rather than be driven by habitual responses, the client becomes curious and increasingly observant— the first step toward changing the trauma-related orienting tendencies and habitual defensive responses that are bound to follow.

[Aragorn]

Thanks! This sounds like a must read for me... 

[Zadius Sky]

Thanks! This sounds like a must read for me... 

Ditto.

Thanks for recommending another one, obyvatel. You already mentioned Pat Ogden in the "Affective Neuroscience" thread to which I made note of. 

[obyvatel]

  Three Phase Treatment of Trauma

  Trauma treatment in the sensorimotor approach is broken up into three phases. The first phase is devoted to symptom reduction and stabilization; the second phase to treatment of traumatic memory and the third to personality integration and rehabilitation. The phases are not strictly sequential but proceed organically, often in a spiral fashion in therapy. For example, after stabilization in phase1, one can get destabilized while working with traumatic memory in phase 2 which would necessitate some phase1 interventions to bring arousal back within the tolerance window.

 
  The body is engaged in different ways in the three phases of treatment. In phase 1, clients learn to keep arousal within a window of tolerance by recognizing triggers, changing orienting tendencies, and limiting their access to overstimulating situations. The unnecessary activation of defensive responses that usurps the functioning of other action systems is mitigated through the use of somatic resources. Awareness of the body is emphasized so that clients can learn to recognize the beginning somatic signs of hyper-and hypoarousal and use somatic resources to return arousal to the window of tolerance.  Clients learn about the core and periphery of the body and utilize autoregulatory resources that pertain chiefly to the core of the body, and interactive– regulatory resources that concern primarily the periphery of the body, to change the movement and sensation of their bodies to facilitate optimal arousal. Self-care skills that stabilize the energy regulation system, such as regular sleep and eating habits, are also established in phase 1.


  In phase 2, unintegrated memory fragments— the physical sensations, sensory intrusions, emotions, and actions— are addressed. Clients identify and embody the resources that helped them cope with traumatic events and learn to use the body to discover actions that provide a sense of mastery even when remembering those past traumatic events.   Through awareness of the physical impulses that emerge when the memory is evoked, clients find and complete the innate “acts of triumph,” the mobilizing defenses that were ineffective at the time of the original trauma. Practicing these empowering defensive actions diminishes feelings of helplessness and shame. As mobilizing actions are exchanged for the immobilizing defenses and newly associated with the traumatic memory, a sense of mastery over the traumatic past ensues.

  In phase 3, with the somatic skills to maintain arousal at a tolerable level, the embodied experience of empowering actions in relationship to traumatic memories, and a developing awareness of, and confidence in, the body as an ally instead of an enemy, clients are psychologically equipped and somatically reinforced to turn their attention to enriching their everyday lives. The resources learned in previous phases of treatment are used again in phase 3 to support healthy risk taking and more active engagement in the world. Clients learn about the dynamic relationship between the core and periphery of the body and discover how the integration of core and periphery supports adaptive action and new meaning. Cognitive distortions— and the ways in which the body sustains them— are explored to help clients change negative beliefs and engage in the action systems of daily life with increasing satisfaction.

 The major goals of phase 3 are :
 (1) identify reflexive beliefs,
(2) explore how they interface with physical tendencies,
(3) endure the associated affects,
(4) consider the inaccuracies of the beliefs, and
(5) further develop their integrative capacity to challenge and restructure these beliefs and their somatic counterparts.

 
Traumatic Memory

Memory is not a unitary process but a network of interconnecting systems that contributes to the storage and retrieval of information (Cordon, Pipe, Mayfan, Melinder, & Goodman, 2004). A careful clinical recognition of, and ability to distinguish between and work with, memory that is declarative or explicitly held in a conscious, narrative verbal format and nonverbal, implicit memory that is evoked by traumatic reminders is vital to the work of sensorimotor psychotherapy.

   When we recall a past experience with a subjective sense that we are remembering something, we are retrieving explicit memory. This type of memory is verbally accessible and “supports ordinary autobiographical memories that can be retrieved either automatically or using deliberate, strategic processes (Brewin). Explicit memory retrieval is often a kind of “memory modification” rather than an exact recall of events (Siegel, 2003). Thus recall is not necessarily “factually” accurate; rather, it is an “active and constructive” process, subject to distortions and revisions based on the emotional state of the person at the time of recall and associations with both previous and subsequent experiences (Van der Kolk, 1996b). Schachtel explained that explicit memory “can be understood as a capacity for the organization and reconstruction of past experiences and impressions in the service of present needs, fears, and interests”. Like all narratives, explicit memories become elaborated in the service of “telling the story”: Those details essential to the story’s main points are elaborated, whereas other details may be discarded or become part of the subtext (Janet, 1928; Van der Kolk & Van der Hart, 1989). The elements of traumatic memory that are verbally accessible can be revised, edited, and placed in relationship to the individual’s autobiographical knowledge so that the trauma is “represented within a complete personal context comprising past, present, and future” (Brewin).


   In contrast, implicit memory is memory for the nonverbal aspects of experience: the smell of your grandmother’s attic, the tensing of your body at the sound of a siren, an opening in your chest when you remember seeing the dawn break over the ocean, and so on. Implicit memories are best thought of as somatic and affective memory states that are not accompanied by an internal sense that something from the past is being remembered (Siegel, 1999, 2001). The implicit memories are often “situationally accessible,” activated in the client’s present life by both internal and external stimuli reminiscent of the trauma: They “[ contain] information that has been obtained from more extensive, lower level perceptual processing of the traumatic scene( e.g. visuospatial information that has received little conscious processing) and of the person’s bodily (e.g. autonomic, motor) response to it” (Brewin) This form of memory includes the reactivated sensorimotor components of memory that emerge in response to traumatic reminders and are not usually integrated with verbally accessible, explicit components.
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  When memories cannot be organized through language, they are organized on a more primitive level of information processing (Piaget, 1962) that comprise three forms of implicit memory: procedural, perceptual, and emotional (Siegel, 2003). The traumatized person “remembers” via all three avenues: through somatic action tendencies (procedural), sensory intrusions and sensations (perceptual), and emotional storms (emotional).

   Of particular importance in a sensorimotor approach to traumatic memory is procedural memory, which is “expressed in behavioral acts independent of cognitive representational storage” (Sokolov et al.,). The unconscious nature of procedural memory is efficient. It enables us to automatically perform many tasks, and accounts for many of the behavioral tendencies that help us cope with trauma as well as defensive tendencies that persevere long after the danger is past.
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Disrupting Procedural Memory

  Grigsby and Stevens suggested that disrupting what has been implicitly, procedurally learned is more effective in changing dysfunctional patterns than talking about what initially happened to cause them: “Talking about old events (i.e., episodic memories), or discussing ideas and information with a patient (the semantic memory system), may at best be indirect means of perturbing those behaviors in which people routinely engage”. For change to occur, the procedural learning— especially the body’s tendencies— must be “disrupted.” It may not be enough to gain insight: the tendency to enact the old pattern somatically must be changed. New actions must replace the old. (Here, cognitions are useful in motivating engagement in new actions.)

  Grigsby and Stevens described two ways that procedural learning can be addressed in therapy: “The first is… to observe, rather than interpret, what takes place, and repeatedly call attention to it. This in itself tends to disrupt the automaticity with which procedural learning ordinarily is expressed. The second therapeutic tactic is to engage in activities that directly disrupt what has been procedurally learned”.

Core and the Periphery of the Body

   For the purpose of mapping somatic resources, an oversimplified distinction is made between the core of the body and its periphery. The physical core of the body comprises of the pelvis, spine and ribcage. The physical periphery of the body is comprised of the arms and legs. The core provides support and stability to the structure and is grounded through the inside of the legs. The periphery provides mobility and interaction with the environment.

  Generally speaking, somatic resources that involve awareness and movement of the core of the body (centering, grounding, breath, alignment) provide a sense of internal physical and psychological stability and therefore support autoregulation. Somatic resources that develop awareness and movement of the periphery (pushing away, reaching, locomotion) tend to facilitate social skills and interactions with the world at large and support the capacity for interactive regulation. In this oversimplified schema, the core is a “supporting pillar” for the movement of the extremities in turn, positive interactions with the environment support and develop the core and provide a sense of “having a core.”

  As a consequence of childhood neglect or abuse, the trauma survivor “may [either] seek to surround herself with people at all times, or she may isolate herself completely”. The interactive regulatory pattern suggests a reliance more on the periphery for regulation and a lack of connection with the core of the body and the self. The autoregulatory strategy relies more on the core and is accompanied by corresponding deficits in the ability to use the arms effectively in reaching out to, and setting personal boundaries with, others; or the legs in moving toward and away from objects or people in the environment.
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  Physical tendencies are “a statement of… psychobiological history and current psychobiological functioning” (Smith). When trauma has induced a negative belief about oneself, others, or the world, the harmonious interaction between core and peripheral areas of the body is typically sacrificed. A belief such as “I’m bad” may set off physical tendencies of constriction, hunched shoulders, held breath, shortened neck muscles, and restricted movement. The corresponding emotions of shame, anxiety, or hopelessness further exacerbate the physical tendencies. These physical tendencies support cognitive distortions and trauma-based emotions, and, in turn, cognitive distortions and concomitant emotions manifest in physical tendencies that hinder the integration of core stability and peripheral movement.

   This is what Gurdjieff had to say about this interconnection between physical tendencies, thoughts and emotions.

  "If a man were able to work on himself everything would be very simple and schools would be unnecessary. But he cannot, and the reasons for this lie very deep in his nature. I will leave for the moment his insincerity with himself, the perpetual lies he tells himself, and so on, and take only the division of the centers. This alone makes independent work on himself impossible for a man. You must understand that the three principal centers, the thinking, the emotional, and the moving, are connected together and, In a normal man, they are always working in unison. This unison is what presents the chief difficulty in work on oneself. What is meant by this unison? It means that a definite work of the thinking center is connected with a definite work of the emotional and moving centers—that is to say, that a certain kind of thought is inevitably connected with a certain kind of emotion (or mental state) and with a certain kind of movement (or posture); and one evokes the other, that is, a certain kind of emotion (or mental state) evokes certain movements or postures and certain thoughts, and a certain kind of movement or posture evokes certain emotions or mental states, and so forth. Everything is connected and one thing cannot exist without another thing.

   
   

[Orange Scorpion]

Thanks, obyvatel. Looks very interesting, I have to translate it in stride...

This book is great news for Spanish users. It has been translated into Spanish. I just buy it online at lacasadellibro.com

Unfortunately "In An Unspoken Voice" has not yet been translated into Spanish. So this book is a great comfort.