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Books
Roz has contributed two chapters: Orbach S. & Carroll R (2006) 'Contemporary approaches to the body in psychotherapy: Two psychotherapists in dialogue' and Carroll, R.(2006) 'A new era for psychotherapy'
Orbach S. & Carroll R (2006) ‘Contemporary approaches to the body in psychotherapy: Two psychotherapists in dialogue‘ The extract includes my opening statement but not the dialogue which follows – this can be found in the book. My basic proposal is that the sense of the self is rooted in the body and catalysed by relationships and the environment. Neuroscience confirms two things that have always been basic parameters of body psychotherapy: that the body essential to the sense of self and we are social creatures designed to interact with other humans (Damasio 1994; Trevarthen 2001). I am going to map out some of the basics of body psychotherapy which include characteristics which are general to most therapies, and specifics which are more particular to the body psychotherapy field. There are four broad aspects to working with the body some of which of course apply to therapists in all traditions. Firstly, basic relatedness, attunement, ordinary empathy requires responsiveness to the clients' body (Schore 2003a). Secondly, a more sophisticated elaboration of this basic relatedness is the use of self, the use of the therapist's embodied awareness of their own process (sensations, images etc) which we know of as countertransference. Thirdly, there are interventions designed to highlight the client's awareness of sensory elements, impulses, breathing, feelings, defences. A defence in body psychotherapy terms, for example, would be the muscular tension that holds back, distorts or cuts off a basic impulse or sensation (Reich 1972). And finally, there are the specialised bodywork skills. These are quite wide-ranging skills including working with knowledge of specific developmental patterns such as reflexes, with body systems (fluid, motor, digestive) and directly to re-establish healthy functioning of the nervous system. It encompasses the dance movement field, and body psychotherapists working with or without touch (Totton 2003). Following and facilitating a body process depends on a perceptual capacity in the therapist. The kinds of bodily phenomena to be perceived fall into three broad groups. First are the visually observable signs: colour change, breathing, levels of tension in the client's body, posture, gesture, facial expression and micromovements. Second is the sense of contact quality that we know through a variety of senses. We assess how present the client is: what is their eye contact like, their voice quality? We sense the variations and shifts in mood and attitude. And thirdly the therapist uses their countertransference. This is the therapist's awareness of their own body, of sensations, images, impulses, feelings and fantasies that offer a link to the client's process and the intersubjective field (Orbach 1999, Carroll 2004). In psychotherapy, the therapist is constantly making decisions about which level to engage with, moving back and forth between levels. All interventions - interpretations, questions, bodywork, attention to breath, sensation, image – are forms of feedback that can heighten the client's sense of themselves (Carroll 2003). Most people have a preferred sense (vision, hearing, proprioception) and a preferred mode of access. Some clients are very tuned into dreaming; others like narrative, and have immense curiosity for the detail of the stories of their life. Some clients gain most from exploring contact-specific sensory detail; others, from free association through movement. There are many royal roads to the unconscious. Some clients like to go with the sense that feels more developed – where they have a sense of mastery. Others choose the undeveloped sense. Often clients choose to come to body psychotherapy because they have an underdeveloped sense of their own body (Carroll 2002). By increasing body awareness through the process of therapy, they get more immediate access to unconscious and unprocessed feeling. This links with Jung's idea of inferior and superior functions (Jung 1968). Strengthening or amplifying one aspect or sense can lead to a greater connection in the whole. As Panskepp argues that ‘all levels of information processing in the generation of emotional responses interact with each other’ (Panksepp 1998:33). If there is enough information coming through, you don't need to set up special ways to increase it. Indeed, body-based interventions are often about finding a point of equilibrium or containment - this is especially true of working with clients who dissociate (Rothschild 2000). Many clients have come to body psychotherapy because they want to work with explicit body interventions. This presents its own challenge – the desire for touch, or to move, or to release through catharsis may come loaded with a fear of the inner world and of relating. The client may have an unconscious need to re-enact, or a wish to expel, painful and intolerable feelings and sensations. In this case the therapist may need to support the client in slowing down and to focus on how it is to be with the therapist and notice what is happening already. When my new client, Tony, comes in and talks about his family, he appears to be a long way away. “How are you?”, I ask. Referring to his strained forward posture, I ask him if he is uncomfortable. His head moves back to rest on the chair with a sudden movement. He closes his eyes and his hand waves desperately in my direction. Making physical contact with a client is a process I'm confident with, but I don't want to rush in here, because this is very dramatic. I want to address both his anxiety about contact and the urgent communication of his gesture, so I ask him, “Shall we experiment with the distance between our chairs and see what feels right?” Having found a position that feels right for him, he talks about his feelings of longing, and we explore how much he can manage, and not manage, eye contact. With any client, there are issues around timing and focus: when to wait, listen, hold the pieces that a therapist hears, sees, feels and senses or when to draw attention explicitly to contact. By contact I mean the experience of being with another. This may involve physical contact, eye contact, or a sense of connectedness through a shared feeling, or an idea. Body psychotherapy, like other integrative and humanistic therapies, employs a variety of structures to support the client in exploring ways of being. The therapist considers when to suggest or support a structure that brings in the experiential element to develop something embryonic, emerging, stuck or unconscious and when to bring him or herself in directly to heighten or make explicit a dynamic in the relationship. It is widely recognized now in contemporary psychotherapy that the client needs to experience feelings in the relationship with the therapist. Surviving intensity of feeling, transitions between feelings, and identifying of unfamiliar feelings, are all part of embodied insight (Carroll 2003). And so the therapist's work involves moving between supporting the client's self and meeting it (Hycner and Jacobs 1995). Relationship feeds the sense of self, but the elaboration of self also occurs in a self-preoccupied way, as the client takes time to tune into the self. It's a pulsation back and forth. Some clients have their most powerful therapeutic experiences through exploring in a particular modality, such as working with movement, or touch, or sensing, even though the most valuable thing in the end is the relationship with the therapist. Some clients experience a particularly strong sense of agency or self through moving. Others find a sense of connection and containment through touch – which feels like a vital food for them. Others don't require touch and wouldn't dream of moving spontaneously as a way of processing but discover aspects of the self through sensing, through tracking the breath in the body and discovering their own innate imagery (Landale 2002). And still others find the greatest satisfaction in words, in recognizing the self through the act of finding the right words, exploring the detail of the story. When awareness is felt to come from inside the client, it is an experience. This enhances agency because it creates a sense of ownership. The function of experiential work is not only to express or to gain insight, but to find out what helps the client self-regulate. Psychotherapy is, among other things, about finding how to help the client get to what they need. What increases anxiety for some lowers it for others. So, for example, with some clients actually asking about a movement they make or the sensation in the body would be a bit counter-productive, because it would feel intrusive or invasive or scary, because they have no sense of their body. So we would have to proceed in other ways. Perhaps by just talking more directly, allowing the client to get to know the therapist. What begins as an experiment in bodily processes within psychotherapy develops into a relational experience of psychotherapy. As the client is talking, sitting, wherever they are sitting on a chair, on the floor, they may make spontaneous gestures or movements. The therapist's work would be to bring awareness to these spontaneous movements by drawing attention to them, or perhaps moving with the client, or interacting with them. A client who came with a tremendous feeling of shame from being looked at told me about a man who had looked at her in a very sexual way. She had felt very humiliated and wanted to disappear. Those were her words. She had a history of being very uncertain about sexual signals and it was something we had been exploring in the therapy. We talked about this for a while but then she moved on to talk about the experience of going to see a Spanish dancer. She became very animated as she spoke. It was a single male dancer surrounded by adoring women. As she was talking about him I noticed that her colour was rising, her face was wreathed in smiles, her eyes were sparkling, her movements were very animated and alive. So I took the risk of feeding back to her this excitement and wondering with her where she would place her feelings in her body right now on a spectrum of sexual feeling from just pleasure in observing him, or flirtation or was she turned on. As we were talking about this I noticed that she kept going back into his posture which involved expanding her chest, lifting her head and her chin. She looked as though she was really enjoying this posture, so I encouraged her to go into this movement more, to become him, to see how it felt to be this gorgeous man surrounded by adoring women. This led to her contacting the other side of the polarity of shame: from being exposed to feeling the part of her that wanted to be surrounded by attention and to feel attractive. It was from the movement pattern rather from any words she used that I went from thinking that she fancied him to thinking that she fancied being him. Body psychotherapy is associated with the use of touch although some body-psychotherapists don't use touch and it is not a ‘given’. Using touch within psychotherapy is not an intervention, it is a multiplicity of possibilities, each with a context in a specific therapeutic relationship at a particular moment. Touch can be provoking, intensifying feelings of fear, rage, loss, shame, helplessness, sexual desire etc. Touch can equally have a profoundly containing effect, providing safety and contact, through a connection to the client's own body in the context of a therapeutic relationship (Carroll 2002). With Tony, some sessions later, I suggested that he lay down on the mattress and I did hold his hand. With this, waves of feelings came up, as well as an anxious driven need to be doing something therapeutic, like having insightful connections to his childhood. I was more interested in whether he could actually allow the experience of me being there with him. A small proportion of clients really get a lot from touch. A skin-hunger from early deprivation is key and working with touch begins to initiate an experience of self. A connection to body is possible because of the combination of touch with attention and the therapist's sensitivity to understanding and working with the defences against touch. The effect of physical contact with a sense of being held emotionally is mutually enhancing and can enable the client to experience support, relaxation, acceptance and self-recognition. And on some occasions I use my body to literally support the client in states of distress, trembling and shaking. Much of the process of body psychotherapy is about weaving together an experience of the body with an understanding of process and the developing sense of self-in-relationship. Sometimes I will ask certain question that may help to increase the client's own awareness of their body. I might ask them to be aware of their breathing, or guide them with specific questions “How does your chest feel? Can you feel your feet?” in order to build a sensory picture. I might particularly do this with areas that either look very charged or look quite cut off. Then perhaps I feedback the details that they have given me – these are their words, not mine – and I give them back as a summary and ask them to see what emerges, whether a character or metaphor is there. One client, Julian, who was addicted to looking at porn sites on the internet, found that when I asked him about his body picture in this way he connected to a sense of his body being inflated. He became aware of a subtle feeling of his body changing size and becoming huge, almost as if he might burst out of his clothes, “Like the Incredible Hulk” he said. From there he could sense for the first time his rage and remembered himself as a child setting fire to his toys (this case is described in more detail in Carroll 2005a). Finally I want to comment on countertransference, which is a term I use to mean a sophisticated relational response to the client. The elements of countertransference include the therapist’s perception of sensation, images, fantasies within herself, as well as catching unusual details or incongruences in the client’s behaviour. With these wide-ranging phenomena, I believe we are responding with an extreme sensitivity to relational cues. For the therapist, these response often exist on the border between compulsion and improvisation, receptivity and activity. So, when I am observing my countertransference response, my questions to myself are: What role does this client want me to play? Is this impulse to act a therapeutic response, a relational response or a re-enactment? Carroll, R.(2006) ‘A new era for psychotherapy’This chapter was written as a commentary on the two chapters by acclaimed neuroscientist Jaak Panksepp, looking at the implications for psychotherapists. Introduction Jaak Panksepp (1998) is one of a handful of key contributors to the emerging field of neuropsychoanalysis and neuropsychology. He stands along side others such as Antonio Damasio (1994, 1999), Mark Solms ((2000, 2002), Colwyn Trevarthen (2001) and Allan Schore (1994, 2003a, 2003b) who have bridged the worlds of science and psychotherapy in recent years (Carroll 2003). All of these thinkers are involved in overturning the “perspectives handed from pre-neuroscientific behaviourist and cognitive eras” (Panksepp 2006a: 16). This discussion of Panksepp’s chapters for this book aims to set his thinking in the contexts of other developments in neuroscience, as well as considering its implications for psychotherapy. Neuroscience is useful to psychotherapy where it can confirm, or re-frame, or challenge intuitions which have become established clinical theory (Corrigall & Wilkinson, 2003; Carroll 2005b). One theme of this chapter is that many different approaches to psychotherapy have been ‘on track’ one way or another. Panksepp’s work is based on the study of affective states as they emerge from the neurodynamics of brain circuits. These are being mapped with increasing precision through the combination of animal research, molecular biology, evolutionary psychology and experimental and behavioural psychology with humans and animals. In the first of these chapters he makes a case for studying affect in its own right (apart from cognition) and briefly describes seven basic emotional systems which mediate core psycho-behavioural states. He argues that “at least half of the problem for understanding ‘mental disorders’ depends on clarification of the neural processes of affective processes in the brain” (2006a: 4). In his second chapter Panksepp illustrates this by commenting on autism and Attention Deficit Hyperactivity Disorder (ADHD), with their very different genetic and social-developmental profiles. The ‘emotional operating systems’ identified by Panksepp organize complex neurobiological processes for priming communicative and action states and for shaping relational responses. They can be divided into a) the primordial set, FEAR, RAGE, and SEEKING, basic to survival; and b) the social set, LUST, PANIC, CARE and PLAY which are characteristic of mammals, which depend on the creation and maintenance of social bonds for survival. It is this differentiation of basic affect states that opens up the possibility of radically re-structuring psychiatric and psychotherapeutic diagnostic categories around new principles. Affect, cognition and the bodyHistorically, from a behaviourist perspective, certain complex behaviours in animals and humans were seen as largely reflexive responses to the environment involving an automated symphony of actions and physiological changes (Hess 1957). Affect was not considered central to the understanding of animals, and it was perceived to be too ephemeral in humans to be studied through brain research which instead focussed on cognition (Panksepp 1998). Panksepp’s work is of outstanding importance because of its wide interdisciplinary research base, which enables him to navigate the ‘difficult triangulation’ of studying ‘affective experience, behavioural/ body changes, and the operation of neural changes concurrently’ (1998: 34). Part of Panksepp’s rationale for drawing on animal research is that the core structure of the mammalian brain is very similar across all mammalian species. Although species vary in terms of the strength and fine details of various basic emotions, the main difference in their brains is a great variability in size and interconnecting complexities of the neo-cortex. In mammals these underlying structures of behaviour - mating, nurturing, defending territory, etc - are explicit observable activities within a relatively predictable range. The neural circuits and neurochemistry which underpin and correlate with these fundamental behaviours in mammals are closely paralleled in the neurobiology of the human sub-neocortical limbic regions. Panksepp stresses that the deep organisational structures of affect can be distinguished from higher cortical systems that are essential for most cognitive activities. The neo-cortex is a mushrooming structure with rapidly-firing neural systems generating vast networks of sensory and semantic associations. Whereas the sub-neocortical limbic regions seem to initiate or ‘prime’ affects, the cortex enables emotions to be filtered, elaborated and extended in time. Patterns of behaviour which are clear in animals are often obscured and interrupted by the human capacity for self-reflexivity. Many cortico-cognitive activities tend to suppress (or heavily modulate) sub-cortical emotional processes. Although everything in Panksepp’s argument implies the body, it is worth spelling out more fully how the body’s fleshes out our multi-dimensional emotional nature. The robust but slowly-firing systems of the sub-neocortical limbic regions are rich in neuro-chemicals which influence attention, emotions, and motivations, as well as perceptions and memories. Neuro-modulators like hormones and other peptides, produced in endocrine glands and organs of the viscera, generate very specific effects which feedback into the brain. It has been established that many neuro-chemicals found in the brain, such as serotonin, are produced in the gastrointestinal system as well (Gershon 1998). The brain is not the ‘sole executor’, but rather part of a complex system of feedback loops (Damasio 1994). What we experience as affect involves dynamic movement at many levels of the body: cellular processes, blood circulation, muscular contractions, facial expressions, changes in electrical conductivity of the skin, and shifts in the peripheral nervous system (Carroll 2005a, 2005b). These changes are perceived and registered through the processes of proprioception (the felt sense of muscular changes and the position and orientation of the body in space), kinesthesis (a subset of proprioception which refers to the perception of the sensation of movement) and interoception (perception of neuro-chemical and visceral activity in the body). This information from the body is registered in many different parts of the brain. In fact, Douglas Watt has proposed that ‘emotion binds together virtually every type of information the brain can encode… [it is] part of the glue that holds the whole system together’ (Watt 1998: 3-5). Panksepp argues that, from a practical evolutionary perspective, ‘affect has to be grounded in action tendencies’ (2006a: eds to add page number later?). In other words, affect is accompanied by the impulse to move, express, or act in some way which fulfils the function of the emotional operating system. With the FEAR system, for example, freezing is evoked at low levels of arousal and at higher levels the flight reflex is triggered, demanding that the body run. With the activation of the PANIC system, we are wired to cry and wail. In RAGE.., muscles tense especially around the forearms and hands, the eyes glare, etc. In terms of psychotherapy, this does not means that clients need to act out those impulses, but that therapist and client must recognise the reality of the feeling (Orbach 2005). Otherwise, as Panksepp suggests, we are vulnerable to “psychosomatic disorders from repressed bodily urges” (Panksepp 2006a Reich (1972) was one of the first to recognise the link between illness and chronic disconnection between body, impulse, and affect, and research into the suppression of specific affects supports this (Traue and Pennebaker 1993). It is common for people to be unaware of powerful feelings. For some, talking to another opens up the possibility of getting in touch with feelings. However, Panksepp’s model sheds some light on why other approaches are valuable too. Body Psychotherapy, Dance Movement Therapy, Psychodrama, Gestalt Psychotherapy, Process Oriented Psychology, Arts Therapies all provide therapeutic contexts for the client to find the hidden affective imperative through moving or expressing or tuning into the body (Carroll 2005a; Totton,. 2005). Much of the data used by the brain is secondary, deriving from the body, which has sensory nerve endings in every cell (Damasio 1994). Whereas the sub-cortical areas respond rapidly to (unconscious) perceptions, the cortex, especially the left cortex, which is related to language, may be the last part of the brain to ‘know’. A little help from JungThe implications of Panksepp’s model do no stop with active body-centred modalities. In fact, there are interesting parallels between Panksepp’s model of core affects and Jung’s ideas about archetypes, instincts and affect. Jung’s interest in the self-regulating psyche led him to proposals which can be used to extend and enrich the perspective offered by Panksepp’s rigorous theoretical model: Though "instincts" or "drives" can be formulated in physiological and biological terms, they cannot be pinned down in that way, for they are also psychic entities which manifest themselves in a world of fantasy peculiarly their own. They are not just physiological or consistently biological phenomena, but are at the same time, even in their content, meaningful fantasy structures with a symbolic character. An instinct does not apprehend its object blindly and at random, but brings to it a certain psychic "viewpoint" or interpretation, for every instinct is linked a priori with a corresponding image of the situation (Jung, 1955 CW14: 602). Jung was influenced by ethology (the study of the evolution of animal behaviour patterns) and anthropology in the relatively early phase of their development as disciplines. These and other sources such as mythology and philosophy inspired his idea of the archetype as a structuring principle (CW6: 748). Jung suggested that "instincts are typical modes of action" (8: 273), while "archetypes are typical modes of apprehension" (8: 280, cited in Haule 2005). He argues that instinct and archetype “determine one another" (8: 271), and he suggests that the archetypal may be experienced as an affective state through an image or a metaphor (9i: 267). Jung’s theory emphasizes the dynamic creativity of the human mind in which the unconscious is “the totality of all archetypes” (CW8: 339). Jung’s archetypes represent both a collective pattern and a state that can be experienced in a highly personal and individual way. Panksepp insists that “certain states of the nervous system may have affectively experienced contents without any objects in the world to which they are intrinsically attached” (2006a: eds-add page later). In other words, we may experience a particular affect before we have ascribed meaning and a set of associations to it. Let me give an example. In Affective Neuroscience Panksepp (1998: 230) writes about ‘vasopressin, a molecule which is important in the mediation of courtship and territorial marking’; it is associated with aggression and jealousy. It is one element of the chemistry of care, the maternal/paternal instinct. As I was reading about this, I vividly remembered a moment ten years ago when I was eight months pregnant. I was in an authentic movement group, moving with my eyes closed, feeling the fullness of my belly, sensitive to the preciousness of the life inside me. I had an image of myself as a brown bear in the wild, standing and alert to my environment. I had a very clear sense that if any creature approached to threaten my baby, I would swipe them with my great heavy paw. At the time I felt a certain awe at the fierce clarity of motive and action embodied in this image, which resonated so powerfully in every cell of my body. I had of course had experiences in my life of feeling protective, possessive, jealous etc but at this moment, without external stimulus, I was aware of an impulse arising from deep inside. The image was ‘the instinct’s perceptions of itself’ (Jung 1937: 117). Of course, these heightened moments of connection to instinct become relatively rare after childhood, so huge is the part played by socialisation and the effects of language on human beings. Internal bodily information (interoceptive processes) and information from external senses (exteroception) are sent to specific areas of the cortex to be processed, and then this information is forwarded into association cortices where it is re-inscripted, leading to increasing abstraction and re-categorisation. The neuroscientist Llinas ((Llinas & Churchland 1997) compares the processing in association cortices to ‘sympathetic chords’, internal resonances that are self-activating. These intrinsic continuing processes of the brain often become more prominent than new information, as we increasingly project our expectations on to the world, rather than grasping each new moment afresh (Solms and Turnbull, 2002). Jung’s interest in the image as a means of access to the underlying structure of an experience has influenced many forms of psychotherapy. Whether the image is identified by client or therapist, and whether it is perceived through the emergence of a metaphor in a verbal narrative, or felt to be present, or visualised quite distinctly, or made or drawn, it can enrich and deepen the exploration of a process (Samuels 1989). Some images are simply useful for bringing out unconscious thoughts or feelings, whilst others connect the client to intense feelings. Beverley Zabriskie, in her chapter in this book, gives remarkable examples of how some of her patients’ dreams offered comment on physical disease and impending deaths through symbolic images. Images sensed by the therapist may also be important countertransference clues (Carroll 2005a). Susie Orbach in her chapter herein describes how she felt as though her body was on fire after a session with a client whose brother was burned to death. This account suggests that instincts are not only perceived but also communicated to others via embodied images. Libido, the seeking system and psychotic states Whilst some of Panksepp’s emotional operating systems (FEAR, RAGE, LUST) are predictable, others radically re-formulate our established categories of affect with surprising implications. The SEEKING system was originally conceived of as a reward system but it has subsequently been found that it is not the possibility of reward per se that reinforces seeking but the pleasure of investigation and pursuit. Its prototype is foraging behaviour, with the search for resources (food, shelter, a mate etc) initiated through receptor systems that detect bodily imbalances. Its chemistry is characterised by dopamine, a neurotransmitter described as the ‘power switch’ because it energises and invigorates the individual in relation to their environment. Cocaine, for example, works by increasing dopamine availability. In animals seeking behaviour is quickly spotted: sniffing and persistent forward locomotion are indicators of the SEEKING system in action. SEEKING behaviour is triggered by need and its activation orients the subject towards any object that might fulfil that need; as Lewin said, “need organises the field” (1926: 440-7). From an evolutionary perspective, it is critical for survival that we experience seeking as affectively positive (as intrinsic desire) and that it is focussed and goal-directed. Hope, excitement, anticipation, determination and curiosity provide the motivation and force to keep going, to move forward, to follow the scent. |
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Psychotherapy, Supervision, Consultation and Training email Roz Carroll |