Sensorimotor Approaches To Trauma Treatment: MS ID#: APT/2009/007054 MS TITLE: Sensorimotor Psychotherapy
Sensorimotor Approaches To Trauma Treatment: MS ID#: APT/2009/007054 MS TITLE: Sensorimotor Psychotherapy
physical symptoms. In the aftermath of traumatic experiences, individuals are left with a
(Van der Kolk 2002; Van der Kolk et al 1996). They report baffling, intense emotional
responses without words having no apparent connection to the events which precipitated
them. Uncertain of what happened and how she or he endured it, the survivor of trauma
tends to interpret these re-activated somatic responses as data about identify or selfhood:
such beliefs gradually come to be reflected in the body: affecting posture, breathing,
Long after the events have ended, traumatized individuals continue to experience intense
emotions of fear, shame, and rage; numbing of feelings and body sensation; loss of physical
energy or agitation, and an inability to take purposeful action. Painful, negative beliefs about
the self often further intensify the distressing feelings and bodily responses (van der Kolk et al
1996; Courtois & Ford 2009). As a consequence of trauma, it is also common for individuals to
experience alterations in autonomic nervous system responsiveness to daily life stress and to any
subtle or obvious reminder of the traumatic events. With a nervous system that does not easily
recover from either heightened states of emotion or states of depression and numbing, survivors
of trauma often report difficulty with affect regulation (van der Kolk 2006). Autonomically-
driven emotional arousal may feel overwhelming and unmanageable, or affect may be blunted,
collapsed and passive. Non-threatening situational cues may activate sympathetic nervous
system activity and fight-flight responses, while dangerous situations paradoxically elicit
When the traumatic experiences have been chronic over many years or have occurred in the
coupled with neglect, the body and nervous system procedurally learn habitual responses
sensation, heightened tolerance for pain. Because the procedural memory system (which
governs the learning of habit and function) is operational at birth, prior to the capacity for
independent of any conscious narrative context that might account for them (Grigsby & Stevens
2001). Affect regulation is one such procedurally-learned capacity. The somatic ‘learning’
process leading to good self-regulatory ability occurs in the context of a secure attachment
relationship providing a reliable source of external regulation (Schore 2003). Under conditions
of neglect and trauma, with caregivers who not only fail to regulate but actively dysregulate the
infant, individuals are more likely to develop autonomic tendencies toward sympathetic
detachment and passivity (Ogden et al 2006) that facilitate “total submission” responses (Porges
2001).
complicated not just as a result of autonomic and affect dysregulation but also because of the
potential array of secondary symptoms that may develop as “survival resources” (Ogden et al
2006) to offer temporary autonomic regulation. These include addictive disorders, eating
exposure techniques) can effectively address the emotional, relational, and cognitive symptoms
of trauma-related disorders and/or manage the secondary symptoms to ensure patient safety, but
traditional psychotherapy models generally lack techniques that directly treat the autonomic and
somatic effects perpetuating the psychological symptoms. It is in this arena that the use of
specifically address both the cognitive-emotional aspects and the bodily and autonomic
symptoms of traumatic stress and attachment-related disorders without requiring the use of
therapy, cognitive-behavioral treatments, and the Hakomi method of body psychotherapy (Kurtz
1972). Its theoretical principles draw heavily on the work of Pierre Janet, Bessel van der Kolk,
Allan Schore, Steven Porges, Onno van der Hart, Ellert Nijenhuis, Kathy Steele, and Daniel
autonomic arousal, and re-instatement of adaptive defensive action (Van der Kolk et al 1996;
Van der Hart et al 2006). A typical session begins as would most psychotherapy sessions: with a
MS ID#: APT/2009/007054
MS TITLE: Sensorimotor psychotherapy
client’s narrative. However, rather than using narrative techniques to “talk about” the
psychotherapist instead directs the client’s focus to the procedurally-learned patterns evoked by
the recollection. As the patient speaks of the traumatic event, the therapist observes his or her
emotional and bodily responses to discover how these experiences have been “organised” or
encoded as non-verbal, implicit memories in mind and body (Ogden et al 2006). Even when
different individuals are exposed to the same traumatic event, their organisation of it will differ
(Terr 1992). Each traumatized individual uniquely encodes an event or events in the form of
images, smells, sounds, autonomic responses, visceral and muscular sensations, movements and
Rather than focusing on the events themselves, the Sensorimotor psychotherapist works
with the encoding of the event (i.e., the effects of the memory in present time), helping clients
become mindful of the persistent physical, cognitive and emotional responses evoked by the
narrative or by trauma-related stimuli. When the therapist focuses on helping the patient become
curious about the ways in which the trauma has been encoded in mind and body, the result is
two-fold. First, the emphasis on mindful curiosity is often affectively and autonomically
as ‘It was my fault’) activate left hemisphere long-term memory areas, resulting in emotional and
autonomic reactivity, while curiosity and mindfulness activate the medial prefrontal cortex
(Davidson et al 2003), thought to be an integrative center and the part of the brain responsible for
MS ID#: APT/2009/007054
MS TITLE: Sensorimotor psychotherapy
interoception or internal awareness. The medial prefrontal cortex has deep connections to both
cortical and subcortical areas, including the amygdala, which facilitates its ability to regulate
mindfulness and the fostering of dual awareness (Ogden et al 2006). The ability to maintain dual
awareness in the face of post-traumatic dysregulation is necessary both for effective resolution of
symptoms and for prevention of inadvertent re-traumatisation during memory work. Long after
patients have reached the intellectual conclusion that they are safe in their current lives, the
body’s post-traumatic responses re-create an internal experience of threat (Van der Hart et al
2006).
In a mindful state that encourages observation rather than reaction, patients become more
curious rather than fearful about their emerging thoughts, emotions, sense perceptions, internal
body sensations, and movements. As patients ‘tell the story’ to the therapist, they are invited to
pause and observe the interplay of thoughts, feelings, and visceral or movement responses that
distressing or overwhelming events. Mindful observation takes not only practice but often
education as well: the therapist may need to teach the patient how to distance from trauma-
related sensations or to understand the role of autonomic activation and the body’s defensive
physical and psychological integrity under threat and how either or both may still be driving the
MS ID#: APT/2009/007054
MS TITLE: Sensorimotor psychotherapy
symptoms now (van der Kolk 2006) is often helpful to clients in lessening self-judgment and
adrenal glands initiates a stress response: heart rate and respiration increase in preparation for
fight or flight, sending oxygen to muscle tissue; and prefrontal cortical activity is inhibited to
facilitate automatic instinctive animal defenses (LeDoux, 2002). However, the price we pay for
engaging these ‘bottom-up’ instinctive defensive responses is loss of the ability to bear witness
to the entirety of the experience. Our bodies have responded instinctively at a time when
observation or reflection might have cost us precious seconds needed to survive in the face of
danger. Subsequently, each time we face the same threat, a reminder of it, or a potential danger
cue, the body responds with the same defensive responses that were once adaptive and effective,
whether or not they are still appropriate. The effect of repeated activation of the emergency
stress response system on affect tolerance and regulation predispose many traumatized
individuals to chronic mental illness: chronic depression or anxiety, chronic PTSD, or borderline
personality disorder.
patients about trauma’s effect on body experience and to increase their capacity to sustain ‘dual
restoration of the ability to self-witness without becoming overwhelmed (Ogden, Minton & Pain,
2006). In each session, patients are asked to practice observing and naming, without judgment or
interpretation, any thoughts, feelings, body sensations, and movement impulses that arise as they
MS ID#: APT/2009/007054
MS TITLE: Sensorimotor psychotherapy
are sitting with the therapist. Mindfully study of how an event was once organised somatically
and emotionally is the precursor to its potential re-organisation and encoding as an event that is
In the course of these observations, patients typically begin to notice patterns of response.
Guided by the therapist, the patient might observe how a trauma-related body sensation
immediately leads to thoughts or ‘conclusions,’ how the thoughts evoke emotional responses
which in turn evoke body responses, how the visceral reactions lead to another negative thought,
then another, resulting in increased emotional overwhelm. Through the practice of mindful
observation, patients gradually develop increased ability to become aware of these inner
study and which to put aside for the time being. As they increase the ability to maintain greater
distance from distress and to deliberately shift focus away from disturbing material until the
autonomic arousal subsides, their confidence and sense of mastery are enhanced and feelings of
helplessness diminished. In those moments, their relationship to the memory or event is ‘re-
organised.’ An ability to recall the event as distressing without becoming overwhelmed, to feel
emotions without flooding, represents a transformation of the memory from ‘here now’ to
‘finally over.’
In addition to increasing the patient’s capacity to maintain dual awareness and thereby
the capacity for states of optimal arousal, the sensorimotor therapist also teaches the use of
somatic skills that prevent overwhelm, increase ability to recover from traumatic reminders, and
MS ID#: APT/2009/007054
MS TITLE: Sensorimotor psychotherapy
restore states of calm. For example, the therapist may help a patient to notice that, each time he
has the thought, ‘It was my fault,’ he experiences an emotional flooding of shame leading to a
simultaneous slump in his spine, collapse in the chest, and movement of the head down and
away. Having noticed the pattern, the therapist then begins a process of helping the patient to
reorganise it, first by noticing it and becoming curious, then by exploring how a physical
intervention (such as lengthening the spine or lifting the head) affects this habitual organization
of experience. If the patient lengthens his spine and raises his head slightly, what happens? Or
what happens if he exaggerates the collapse and gaze aversion? Does the fear increase or
decrease? If the issue is ‘being seen,’ the therapist might offer to close his or her eyes, giving the
patient control over the experience of ‘being seen.’ Can she now lift her gaze spontaneously?
Or is ‘not being seen’ even more dysregulating? And if it is, then what happens if therapist and
patient continue to experiment with a relational distance and gaze that re-organises the
experience of ‘being seen.’ Does the novelty of sitting with a therapist whom she can see, but
who cannot see her, lead to increased energy and aliveness? Is there a change in the experience
of being seen?
Such interventions for increasing somatic and ego functioning are termed “somatic
resources” (Ogden et al 2006). Many somatic resources, such as feeling the ground under one’s
feet, placing a hand over the heart, lengthening the spine, turning toward or away, moving closer
physically stronger, more solid, or more flexible. Acceptance or compassion are often
accompanied by a warmth in the chest, sense of opening, relaxation of the musculature. The
English language includes many expressions that capture this relationship between body and
psyche: ‘keep your head high,’ ‘hang-dog,’ ‘having backbone,’ ‘weak in the knees.’
Dysregulated arousal occurs both situationally and habitually in traumatized patients, not
always specifically tied to images or events, and it is easily interpreted as a sign of threat in the
here-and-now environment. For the client to experience a somatic sense of safety now, the
autonomic nervous system must be stabilized and the capacity for optimal arousal cultivated.
Allowing patients simply to access traumatic reactions of fear, horror and helplessness is of little
organisation rather than re-experiencing. Without an observing ego or the ability to regulate
these intense emotional states, many patients are unable to resolve their post-traumatic
symptoms. Thus, attention to the regulation of arousal must be a key feature of any effective
patients observe their trauma-related tendencies toward either hyper- or hypoarousal moment-by-
moment long before they cause dysregulation. For example, a therapist might notice that, as the
client begins to speak about a traumatic event, her body tightens, and her breath becomes
shallow. The therapist might then ‘empathically interrupt’ the patient’s narrative and help her to
pause and take a few minutes to establish dual awareness so that she can orient away from the
MS ID#: APT/2009/007054
MS TITLE: Sensorimotor psychotherapy
event and toward the body sensations, physical impulses or movements that have been evoked by
the memory. By continually ‘tracking’ the patient’s body for signs of increasing regulation
versus dysregulation, the therapist senses when to direct attention back to the relationship
between narrative content and somatic or emotional responses and when to focus on ‘just what is
happening in the body.’ The patient is frequently reminded to maintain a curious, observational
attitude, rather than becoming frightened by the activation, and to notice the physical signs that
indicate dysregulated hyper- or hypoarousal. Next, the therapist teaches the client how to make
use of somatic resources, such as body posture, gesture, and movement, to regulate arousal. As
patients learn to notice their habitual reactions and to practice alternative somatic interventions,
notice the results, and then repeat or discard them in favor of yet another experiment, a sense of
greater control is facilitated, the very experience they were denied at the time of their traumatic
experiences.
These interventions, like those of the mother interactively regulating the child’s distress
or dysregulation, rely for their effectiveness on the attunement of the therapist. Just as peek-a-
boo provides children a way of non-verbally ‘working through’ proximity and mastery issues,
enabling them to affectively tolerate separation, the mindful experiments of the sensorimotor
therapist also increase regulatory ability and a somatic sense of mastery. As the ‘mindful
experiments’ are practiced, patient curiosity is enhanced and shame generally mitigates. Without
verbal interpretation or cognitive re-structuring, the exploration of how the body ‘supports’ and
reinforces cognitive distortions leads to their gradual or spontaneous alteration and diminishes
MS ID#: APT/2009/007054
MS TITLE: Sensorimotor psychotherapy
their effect on the affective state of the patient. Because loss of interpersonal support and
neurobiological regulator for the patient whose affect and arousal are unregulated (Schore 2003),
much like an adult might with a young child, experimenting to find just the right combination of
voice tone, pace of speech, energy versus calm, and amount of information versus comfort and
reassurance, until the client experiences a sense of greater equilibrium and support. Within the
somatic interventions facilitate the client’s growing ability to maintain states of optimal
autonomic arousal even in the face of trauma-related stimuli. If somatic interventions were
employed simply as rote physical exercises, without the therapist’s ability to facilitate mindful
exploration of the interface between body, emotion, and cognition, therapeutic benefit would be
minimal. Only within the context of attunement and collaboration can fears and phobias of the
unrelated stimuli: for example, the stimulus of a male person might become associated with
autonomic hyperarousal; increases in heart rate can become coupled with a sense of dread and
the belief that something bad is going to happen. The result is that normal or even positive
experiences (for example, enjoyment of being in male company or increased sympathetic tone
interventions that “uncouple” traumatic memories from their intense emotional and somatic
responses, Sensorimotor patients are helped to experience a sense of safety in the body even
when faced with reminders of past psychological trauma. The “uncoupling” process involves
learning to shift focus from the details of a memory to the way in which the body is responding
during the remembering. For example, as a patient recalls being beaten by his father as a child,
what is his internal experience of that event? Does the recall trigger increased arousal or body
way? With the guidance of the therapist, he is asked to notice, “What is happening right here,
right now?” One of the characteristics of trauma-related disorders is the loss of present time
differentiate past and present: “When you remember that experience then, what happens here
focused on the task of creating a narrative in order to access and express the affects connected to
it (Herman 1992). In a Sensorimotor treatment, the narrative is used first to understand the
patient’s history and design a treatment plan and then as an entry point into the unresolved
somatic and affective components of the memory. As the patient relates a traumatic experience,
the therapist continues to listen attentively until signs of unresolved emotional, muscular, visceral
or autonomic activity are observed. Neither insight nor understanding can replace what happens
allows these intense somatic experiences to be witnessed as sensations and emotions rather than a
signal of danger. Through the patient’s growing ability to maintain dual awareness, arousal and
affect gradually come under greater control. The ‘window of tolerance’ (Siegel 1999) for affect
and arousal increases in breadth and depth. Re-organisation of the experience (impossible during
the actual event itself) enables the patient to trust the body’s resources and ability to protect.
Affect regulation is restored via a physical-somatic “dyadic dance” that enables the patient to
gradually achieve self-regulation in the context of attunement and physical experience, the very
process observed in secure attachment relationships. The patient now has a narrative that places
the events in the past and a body that experiences these events as ‘over.’
References
Treating complex traumatic stress disorders: an evidence-based guide. Wiley & Sons.
LeDoux J (2002) The synaptic self: how our brains become who we are. Guilford
Press.
Schore A (2003) Affect regulation and the repair of the self. W.W. Norton
Van der Hart O, Nijenhuis E, Steele K (2006) The haunted self: Structural
Norton.
Van der Kolk B (2006) Clinical implications of the neuroscience research. New
Van der Kolk B (2002) Beyond the talking cure: Somatic experience and
Van der Kolk B, McFarlane A, Weisaeth L (eds) (1996) Traumatic stress: the
Declaration of Interest: