Brain to Brain: January/February 2010

The talking cure goes beyond words

Magazine Issue
January/February 2010
Man and Woman forehead to forehead

As I’m trying to prepare dinner, my 6-year-old granddaughter, Ruby, is tormenting her little sister with pokes and pushes. Tired, too, I feel myself tighten up, ready to bark, “Ruby, leave your little sister alone!” But instead, I pause and relax my body. I can see that Ruby is wired after a long, adventurous day at the park. If I reprimand her, I know I’m just piling on stress and asking for trouble. So I take a breath and notice a different impulse about what to do.

Whispering her name with a big smile and secretive air, I motion for her to come over to me. “Ruby,” I say in hushed tones, as if conveying a top-secret message, “in a few minutes, Nika is going to start crying,” I say sadly, “and then I’ll have to give her all my attention.” My body takes on the language of disappointment, “And I don’t want that: then I won’t be able to give any attention to you.” She gives me a knowing look, cocks her head, and smiles. Nothing more needs to be said.

So what does this grandmotherly anecdote have to do with brain science? For millions of years, parents of all mammalian species, particularly humans, have had to undergo a crash course in “interactive neurobiology” to nurture their young. Most parents soon learn which postures are soothing, which tones of voice, which kinds of rocking, how much movement. Why do we learn so quickly? Because we ourselves are biologically thrown off-kilter by an infant’s cries. Alan Schore calls this trait “adaptive projective identification”: an infant communicates distress directly to our bodies, and in offering comfort, we regulate our own discomfort. The sense of soothing and warmth we feel as the baby falls asleep in our arms reflects this phenomenon.

Over time, as parents consistently respond to an infant’s distress or pleasure, minimizing the former and maximizing the latter, a nervous system is neurobiologically sculpted to be well-regulated: able to tolerate strong emotions and return to optimal states. Dan Siegel calls this the “window of tolerance,” a window that may be wide or narrow, depending upon our experience. Attuned parents, without intellectual awareness of the neurobiological changes happening in their bodies, autoregulate their responses to infants and young children, overcoming boredom, fatigue, and frustration to find—and then repeat endlessly—just the right combination of movements, facial expressions, and tones of voice to elicit optimal arousal states in them.

But while parents clearly need to be attuned in this way, what does “interactive regulation” have to do with psychotherapy? The more we learn about the brain, the more apparent it becomes that, if we’re to guide people in the process of change, we need to pay at least as much attention to the body and nervous system—theirs and ours—as to words, emotions, and meaning-making—which, until recently, have been the major focus of therapy.

The Impact of Early Parenting

Years of therapy have focused Bob on early memories of his needy mother and abusive father and their mistreatment of him. All that discussion of the past has left him with greater perspective on his history, but hasn’t altered his sense of being burdened, his automatic compliance with the demands of others (his body’s survival response to his parents’ demands), and his periodic rages, usually directed at his children. Parental failure to provide consistent safety and interactive regulation has left Bob and his wife, Kathleen, with nervous systems that are easily dysregulated by strong feelings, leaving them with little tolerance for a child’s tears or cries.

What brings Bob and Kathleen to my doorstep is that their adolescent children are suffering the secondary effects of the parents’ traumatized nervous systems. Their son has just been discharged from a drug-treatment program, and their daughter is showing all the symptoms usually associated with borderline personality disorder. Having interviewed the children and parents, I think I understand what’s been happening, but how can I express what I see in a way that’ll have the most positive impact?

I know I have bad news to deliver, and, as a parent, my heart goes out to them. Like so many parents, Bob and Kathleen want me to fix their children magically—which I know I can’t do—and my body responds to that unstated request with tension. I have to focus away from my indignation (it’s because of them that their children are so screwed up!) to communicate to their right brains and reach their hearts. As I focus on the pain they must be feeling, I relax and feel an opening to them. Now I can genuinely speak to them with a heavy heart and soft facial expression.

“When Emmy and Jason were little and you felt overwhelmed by their needs and incessant crying,” I begin, “their tantrums triggered you so much it felt as if they were abusing you. It’s so sad. These beautiful little babies felt like monsters instead of babies.” My face reflects my words, and I pause for a moment to let them sink in. “Instead of being able to soothe them and comfort them, you felt threatened yourselves. Because their needs dysregulated you, you couldn’t soothe them. And they were too little to soothe themselves, so the crying and tantrums got worse and worse, and went on forever—which further dysregulated you—which made it even harder for you to soothe them, and so it went, until they were overwhelmed, and so were you.”

Again, I pause, and my body language shifts. “I want you both to understand something important. No one is at fault here.” I say these words deliberately, with a serious face and gentle but firm tone, knowing that most parents at this point will be experiencing strong somatic responses of anger or shame, which might lead to a defensive argument. I go on.

“The trauma in your bodies isn’t your fault, and the kids’ reactivity isn’t their fault, but Jason and Emmy still need parents who can regulate them, and that’s our work here.” My face is still soft, but my body is communicating that this isn’t up for negotiation. I’m sitting up straight, leaning slightly forward, looking at them intently, and there’s a feeling of steel in the core of my body. If they want to work with me, we need to work on their ability to reverse the harm being done when they flee or fight, rather than parent their children, however distressed they may be or difficult it may seem. I don’t need to say, “If you want to work with me” because my body is saying it for me more effectively than words.

Both parents look relieved and thank me effusively. I know that I delivered this news far more resonantly than I would have before I’d become so attuned to neurobiological interplay in the therapy room. Over many years, I’ve learned how to use my body as a vehicle for communication in a way that underscores and extends my words. Madir Pels, a gifted acupuncturist, calls this phenomenon “sensing the points of receptivity, rather than pushing.” As therapists, we have to look for the points of receptivity, but while the mind knows where they’re likely to be found, the body can actually sense them and deepen into them. This session with Bob and Kathleen was powerful for me as well as them: I felt a tenderness toward them, while I experienced a sense of strength in having acted decisively to protect their children.

Sensorimotor Psychotherapy

How did I learn to use my body as well as my mind in psychotherapy? These are the lessons taught by Sensorimotor Psychotherapy, a body-centered talk-therapy approach, developed by Pat Ogden for the treatment of attachment failure and trauma-related disorders. Although its techniques are drawn from the body-psychotherapy world, its theoretical foundation lies in neuroscience and attachment research. What first attracted me to it after 20 years of traditional psychodynamic practice was the opportunity to work with the somatic legacy of trauma and neglect without any requirement to use touch. Now, I value even more how it’s added years to my “tread life” as a psychotherapist. Studying (and later, teaching) a method that capitalizes on an understanding of the body and nervous system has decreased the stress of psychotherapy practice while increasing its pleasures for me. It allows me to navigate tumultuous transferential relationships and therapeutic impasses in creative, satisfying, and often moving ways, as it has with Bob and Kathleen and their family.

A Sensorimotor Psychotherapy visit begins just like any other talk-therapy session: with the client’s “story.” It might be a story about last night’s dream, a childhood memory, or the description of a problem, disappointment, or hurt in the client’s current life. However, the therapist listens not just to the narrative and emotions, but also to the body, observing carefully the somatic language accompanying the language of words. Changes in posture, gesture, breathing, face color, stillness vs. agitation, stiffness vs. floppiness or heaviness—all these changes tell us about the client and the story.

At her first visit, Andrea describes her need to put others’ wishes ahead of her own and her fear of displeasing people—a circumstance that’s brought her to psychotherapy. As she tells the story of her attempts to create a more self-directed, meaningful life for herself and the obstacles that defeat her time after time, I’m tracking her body and my own. I observe the details of her physical and verbal presentation, looking for recurring patterns. I notice that her body is stiff and still. Her hands are folded in her lap, and her arms are held close to her torso. The only movement she makes is a sweeping gesture with her left arm each time she talks about a freer, more independent future. As she describes “folding” whenever her desires get blocked by some obstacle, her arm comes in, and her hand makes a pushing-down gesture.

As I see those movements, I notice a feeling of excitement in my own body. I lean forward, wanting to interrupt a monologue that drains her energy and mine. But she doesn’t pause for breath. As I try and fail to create dialogue, I begin to feel a resignation in my body, like a balloon deflating. My body is giving up in the face of the “wall of words” she’s creating. Finally, she pauses long enough for my energy to come back, though in a more thoughtful way. I find myself speaking to her in a slow, soft tone, as if talking to a frightened animal.

“Andrea, I want to share something wonderful that I saw as you were telling me about these frustrating experiences,” I tell her. “I notice that each time you talk about what you want to do, your arm makes this movement, and every time you talk about what you have to do, your body becomes very still.” She looks at her left arm for a moment, as if discovering it for the first time, and then says, “Yes, when I think about everything I want to do, I get excited.” And, suddenly, she smiles broadly, leans forward, and opens up both arms wide as if reaching out. Her face lights up, her spine lengthens, and she begins to sway as if to music. I mirror her movements so we are facing each other, swaying, with our arms outstretched. We’re smiling and laughing. I say, “Yes, I can see your excitement! You come alive, don’t you?” Her monologue is now a dialogue, but a somatic one. As sessions proceed, I notice a consistent pattern: verbal dialogue is cut off by the “wall of words,” but somatic dialogue brings Andrea alive and into relationship.

It’s Over Now

In addition to memories for events, the body and brain hold muscle memories, autonomic arousal patterns, visceral and perceptual responses, which attest to our experiences. Brain-scan research on traumatic memory informs us that, when trauma is remembered, subcortical, nonverbal areas of the brain, rather than narrative memory areas, are activated. Narrative retelling of events causes these neural networks to fire, but doesn’t necessarily contribute to changing them in a way that leads to an experience of relief. What therapist hasn’t treated dozens or even hundreds of clients who continue to experience a sense of threat and danger long after they’ve found physical safety? Before neuroscience research, we had no way of knowing that their experiences were encoded in body structure—in the nervous system, and in patterns of movement and sensation. To know that “It’s over now,” these clients must feel a sense of safety in the body.

How do we help our clients experience that sense, both in therapy and in the wider world? Here, neuroscience comes to aid us once again. Brain-scan research on the effects of meditation has pinpointed a part of the brain that becomes active when we meditate or simply observe our experience, moment-by-moment, without reacting to it: the medial prefrontal cortex, located just behind the middle of your forehead, has direct connections to the amygdala, our emotional memory center. When that area becomes more active, the amygdala becomes less active.

Translated into psychotherapy, mindful observation yields a state of dual awareness, by which observers can reach into their inner worlds without becoming overwhelmed by emotions and body responses. Although I have always liked the psychodynamic concept of an “observing ego,” teaching clients to have an “observing ego” has often been challenging. Each time my client Terry was faced with a family health problem of any kind, this daughter of an alcoholic mother would suddenly experience intense anxiety: a worried thought would set off body sensations of an increased heart rate and tightness in the chest, which, in turn, would lead to negative predictions, which would quickly escalate from simple anxiety to panic. The link between mind and body gives us humans an evolutionary advantage: thoughts and instincts alert us to danger. Unfortunately, this link feeds anxiety, as thoughts activate body sensations and body sensations activate thoughts. Terry would arrive for sessions in a state of desperation, convinced that her husband had cancer or her daughter would never be able to function without her.

At such times, I quickly found my body responding with equal desperation, eager to help her see that these were thoughts, not truths; but each time I heeded my body’s first message, she’d respond, “But you don’t understand!” If I wanted her to engage her mindful brain, I needed to use my body and mind in a different way. Remembering her quick, curious intellect and her observation that her fears irritated her family members, the next time I felt my body tighten up and my heart rate increase, I paused to let the sensations settle. As I felt the calm and relaxation in my own body, I let her come to the end of her litany before speaking softly and gently, “It’s so frightening, isn’t it? To think that something could happen to your loved ones. It drives you to find something to prevent it, and that drives them crazy!”

I lean forward with warmth and excitement, “Terry, I know you hate it when these fears push your husband and daughter away, and I’m so happy to say that I’ve just thought of a way for you to get some relief. Isn’t that exciting?” Now, I’m smiling broadly, and I can feel the excitement in my body. She responds. My left brain has spoken to her left brain, reminding it that her husband and daughter are pushing her away in response to the anxiety, while my right brain speaks to her right brain, offering a comforting tone and the pleasurable excitement of a way out. Over the next few weeks, as I teach her how to be mindful of the anxiety, rather than react to it, we practice observing each symptom as “just” a body sensation or “just” a thought or “just” an emotion.

As we do so, Terry finds herself relaxing and feeling calmer, which is followed spontaneously by a more positive thought or two. The use of mindful tracking helps her recognize the interaction between her thoughts and her body’s autonomic responses. She now can see how body reactions to a traumatic trigger in turn trigger fearful beliefs, and how changing the body responses leads naturally, without effort, to more positive thoughts. She looks and feels solider now, and can catch herself when the more familiar patterns of her anxiety response engage automatically. In her presence, my body feels like that of a mother seeing her child able to negotiate the world successfully and independently. I feel warmth and pride. I feel solider, too.

Escaping Induction

Bettina, a 40-year-old woman diagnosed with borderline personality disorder, enters my office. Week after week, the content of her communication is the manifold deficiencies of her therapist, me: I’m not available enough, I don’t care enough, I try to teach her things (rather than empathize with her pain), I don’t sit close enough to her, I don’t call her back between sessions in a timely manner when she’s upset. She complains that there’s never time to talk about her feelings—without recognizing that we spend most of our time talking about her anger at me! I notice that, even as I usher her into the office, my body is tense and pulled in. When we sit down, she points out that I’ve moved my chair back and away from her. My jaw is tight, and I feel defensive. My boundary muscles (the muscles across the midriff and down the sides) are tightly engaged—or “armored,” as we say in Sensorimotor Psychotherapy.

Determined not to get led into a struggle with her, as I have in countless sessions, I deliberately relax my body as I feel it tensing in response to her criticism. It takes effort, but I begin to feel a new sense of lightness and freedom. I unexpectedly find myself laughing as she complains that I’m rigid. “Poor Bettina!” I say, “I’m truly a nightmare as a therapist for you, aren’t I? You poor thing! I don’t know how you put up with me.” She relaxes slightly, and a tiny smile plays on her face. “I don’t know how I put up with you either. I’m glad you appreciate that,” she responds.

Although my body tenses slightly at that last remark, I relax it again. More words come to me spontaneously: “It’s just too bad that you came to me at this stage of my career: I’m pretty set now in my ways of doing psychotherapy. I’m an old dog that can’t learn new tricks, and it’s so hard on you.” Now we’re both smiling and laughing.

The rest of the session proceeds smoothly. Both our bodies are relaxed, and there’s a sense of connection between us, the kind of connection for which she yearns. I remind myself to pay more attention to my bodily responses than to her words next week. I’m aware of feeling warmth toward Bettina that’s both new and refreshing.

Neurobiological regulation in psychotherapy requires right-brain-to-right-brain communication. It requires therapists to attend more closely to the impact of words and body language on clients’ nervous systems and somatic experiences. My brilliant words will fail to be heard if I dysregulate the client as I utter them. Instead of overattending to clients’ stories, I’ve learned that I must pay equal or greater attention to clients’ nervous systems and bodily communications. This is an art that most of us instinctively express when we relate to babies and small children, as I did with Ruby, or when we play with a puppy or scratch a kitten’s tummy. Without conscious thought, we experiment with the language and body language that engages small, sentient, sometimes furry, beings until they respond positively. Why not bring that intuitive ability into the office?

Janina Fisher

Janina Fisher, PhD, is a licensed clinical psychologist and former instructor at The Trauma Center, a research and treatment center founded by Bessel van der Kolk.  Known as an expert on the treatment of trauma, Dr. Fisher has also been treating individuals, couples and families since 1980.

She is past president of the New England Society for the Treatment of Trauma and Dissociation, an EMDR International Association Credit Provider, Assistant Educational Director of the Sensorimotor Psychotherapy Institute, and a former Instructor, Harvard Medical School.  Dr. Fisher lectures and teaches nationally and internationally on topics related to the integration of the neurobiological research and newer trauma treatment paradigms into traditional therapeutic modalities.

She is author of the bestselling Transforming the Living Legacy of Trauma: A Workbook for Survivors and Therapists (2021), Healing the Fragmented Selves of Trauma Survivors: Overcoming Internal Self-Alienation (2017), and co-author with Pat Ogden of Sensorimotor Psychotherapy: Interventions for Attachment and Trauma.(2015).