Sensorimotor Psychotherapy

Essentials of Sensorimotor Psychotherapy are 1) regulating affective and sensorimotor states through the therapeutic relationship, and 2) teaching the client to self-regulate by mindfully contacting, tracking and articulating sensorimotor processes independently. We believe that the former promotes the reinstatement and development of the client’s Social Engagement System through interactive regulation, while the latter promotes an independent assimilation of sensorimotor reactions. The former is a prerequisite for the latter. As Schore observes, the therapist’s “interactive regulation of the patient’s state enables him or her to begin to verbally label the affective [and sensorimotor] experience” (bracketed text added; Schore, in press-b, p. 20). Interactive regulation provides the conditions under which the client can safely contact, describe and eventually regulate inner experience.

The therapist must cultivate in the client an acute awareness of inner body sensations, first via the therapeutic interaction as the therapist observes and contacts sensorimotor states, and second as the client herself notices these inner body sensations without prompting by the therapist. Inner body sensations are the myriad of physical feelings that are continually created within the body through biochemical changes and the movement of muscles, ligaments, organs, fluids, breath, and so on. These bodily feelings are of a distinctly physical character, such as clamminess, tightness, numbness, and electric, tingling, and vibrating sensations, and of course many others. However, when clients are asked to describe sensations, they frequently do so with words such as “panic” or “terror,” which refer to emotional states rather than to sensation itself. When this occurs, clients are asked to describe how they experience the emotion physically: for example, panic may be felt in the body as rapid heart beat, trembling and shallow breathing. Anger might be experienced as tension in the jaw, an impulse to strike out accompanied by a sense of heaviness and immobility in the arms. Similarly, a belief about oneself, such as “I’m bad” might be experienced as collapse through the spine, a ducking of the head, and tension in the buttocks.

Through cultivating such awareness and ability for verbal description, clients learn to distinguish and describe the various and often subtle qualities of sensation. Developing a precise sensation vocabulary helps clients expand their perception and processing of physical feelings in much the same way that familiarity with a variety of words that describe emotion aids in the perception and processing of emotions.

As clients describe traumatic experiences or symptoms, the therapist observes their arousal level, tracking for either hyperarousal or hypoarousal. The therapist’s task is to “hold” the client’s arousal at the optimal limits of the Modulation Model, accessing enough traumatic material to process but not so much that clients become too dissociated for processing to occur. When arousal reaches either the upper or lower limit, clients are asked to temporarily disregard their feelings and thoughts and instead follow the development of physical sensations and movements in detail until these sensations settle and the movements complete themselves. In this way, the therapist acts as an auxiliary cortex, interactively modulating clients’ levels of arousal, keeping them from going too far outside the optimum arousal zone, where it becomes difficult or impossible to process information without dissociating. At the same time, clients develop their capacity to self-regulate as they learn to limit the amount of information they must process at any given moment, which develops the capacity for self-regulation independent of their relationship with the therapist and prevents their being overwhelmed with an overload of information coming from within.

When a client describing a past trauma experiences panic, the therapist asks her to disregard the memory content and just sense the panic as bodily sensation. When the client then reports a trembling in her hands and a rapid heart rate, the therapist instructs her to track these sensations as they change or “sequence”. As Levine notes, “Once you become aware of them, internal sensations almost always transform into something else” (Levine, 1997, p. 82). The trembling changes from affecting only the hands to involving the arms, which begin to shake quite strongly, then gradually quiet and soften; the heart rate also eventually returns to baseline. Only when this sensorimotor experience has settled is additional content described and emotional and cognitive processing included.

The therapist must learn to observe in precise detail the moment-by-moment organization of sensorimotor experience in the client, focusing on both subtle changes (such as skin color change, dilation of the nostrils or pupils, slight tension or trembling) and more obvious changes (collapse through the spine, turn in the neck, a push with an arm, or any other gross muscular movement). These sensorimotor experiences usually remain unnoticed by the client until the therapist points them out through a simple “contact” statement such as, “Seems like your arm is tensing,” or “Your hand is changing into a fist,” or “There’s a slight trembling in your left leg.” Any therapist is familiar with noticing and contacting emotional states (“You seem afraid”) to facilitate clients’ awareness and processing of emotions; the procedure is similar for sensorimotor reactions.

Mindfulness is the key to clients becoming more and more acutely aware of internal sensorimotor reactions and in increasing their capacity for self-regulation. Mindfulness is a state of consciousness in which one’s awareness is directed toward here-and-now internal experience, with the intention of simply observing rather than changing this experience. Therefore, we can say that mindfulness engages the cognitive faculties of the client in support of sensorimotor processing, rather than allowing bottom-up trauma-related processes to escalate and take control of information processing. To teach mindfulness, the therapist asks questions that require mindfulness to answer, such as, “What do you feel in your body? Where exactly do you experience tension? What sensation do you feel in your legs right now? What happens in the rest of your body when your hand makes a fist?” Questions such as these force the client to come out of a dissociated state and future- or past-centered ideation and experience the present moment through the body. Such questions also encourage the client to step back from being embedded in the traumatic experience and to report from the standpoint of an observing ego, an ego that “has” an experience in the body rather than “is” that bodily experience.

For traumatized individuals, fully experiencing sensations may be disconcerting or even frightening, as intense physical experience may evoke feelings of being out-of-control or being weak and helpless. On the other hand, traumatized individuals are often dissociated from body sensation, experiencing the body as numb or anesthetized. Our view is that failed active defensive responses along with the inability to modulate arousal can be sources of such distressing bodily experiences, and that this distress can be at least somewhat alleviated by helping clients experience the somatic sequence of an active defensive response. Subsequently clients may access sensation without dissociating or feeling uncomfortable.

To illustrate the above points, we will describe three sessions with Mary, a middle aged, successful businesswoman who suffered both relational and shock trauma from being raped repeatedly by her uncle from ages four to ten. Although she suffered from panic attacks, depression, and what she described as having “no boundaries,” she had no clear memory of the trauma until a recent altercation with an authority figure triggered flashbacks accompanied by insomnia and disturbing physical symptoms such as hyperarousal, uncontrollable shaking, unprecedented vaginal bleeding, and a bout of immobility that lasted for over an hour. Mary reported that during the abuse she had tried to fight her uncle at first, but eventually she submitted and “watched from the ceiling.”

As Mary recounted her history, she spoke rapidly with few pauses that would provide opportunity for verbal interaction with the therapist. Her Social Engagement System was markedly diminished; it was almost as though she were talking to herself, unable to utilize the relationship to interactively regulate her arousal. Mary appeared increasingly isolated and alone as she spoke. At times she experienced panic and hyperarousal, and she repeatedly spoke in judgment of herself for having allowed the abuse: “Why did I ever change clothes in front of him? Why didn’t I tell my mother what was happening?” She also condemned herself for her inability to defend against the abuse, interpreting her dissociation and freezing as a personal weakness, a common response among trauma survivors (Nijenhuis & Van der Hart, 1999, p. 54).

This first session with Mary illustrates an important point: The initial stage of therapy usually entails the therapist helping the client to begin to regulate arousal. This is accomplished at first through the interactive regulation within the therapeutic relationship, which sets the conditions under which the client can learn self-regulation. Obviously, a healthy relational rapport between client and therapist must be present for interactive regulation to occur. In Mary’s case, the therapist facilitated interactive regulation through tracking changes and movements in her body, making contact statements, demonstrating an ability to understand Mary’s distress and tolerating the description of her traumatic experience without withdrawing or becoming hyperaroused himself. Gradually, Mary began to soften slightly in her body, slow her speech, and engage in reciprocal interaction with the therapist.

It was difficult at first for Mary to be mindful of her bodily sensations because when she tried to do so, the hyperarousal, shaking, panic and terror became overwhelming. Similar to Levine’s notion of “exchanging … an active response for one of helplessness” (Levine, 1997, p. 110), the therapist knew that if Mary could fully experience a physical defensive sequence, these symptoms might lessen. To accomplish this, he asked Mary if she would be willing to experiment by pushing with her hands against a pillow that he held, and to notice what happened in her body. Mary consented and as she performed this action, she first experienced nausea and increased fear, not uncommon when first working with activating a defensive sequence that has failed in the past. The therapist then asked Mary to temporarily disregard all memory and simply focus on her body to find a way to push that felt comfortable. Mary’s sense of control was increased as she was encouraged to guide this physical exploration by telling the therapist how much pressure to use in resisting with the pillow, what position to be in, and so on. As Mary began to experience the active physical defense, the therapist tracked her body and made contact statements such as, “The strength of the pushing is increasing,” and “You seem to be settling down,” etc. Mary was also instructed to be mindful of the details of her sensations: “What’s happening in your body as you push? What do you feel in your back and spine?”

Mary eventually experienced a full sequence of active defensive response: lifting the arms, pushing tentatively at first with just her arms, then increasing the pressure and involving the muscles of her back, pelvis, and legs. The therapist continued to evoke mindfulness of sensation, and Mary began to experience the physical pleasure of pushing, reporting, “This feels good!” Because many traumatized clients are anhedonic (unable to feel physical pleasure), experiencing and savoring pleasurable sensations can increase their overall capacity for experiencing pleasure and also can change their relationship with the body, which heretofore may have felt like “the enemy,” the source of disconcerting sensations and physical pain. When the defensive sequence had been thoroughly explored and completed, Mary was calmer and able to be mindful of sensations without becoming hyperaroused — in other words, she was now situated within the optimum arousal zone of the Modulation Model.

The intention in Sensorimotor Psychotherapy is to work at the edge of the Modulation Model, accessing enough of the traumatic material to work with, but not so much that the client becomes overwhelmed and dissociated. To serve this end, as Mary returned to describing the trauma (her decision, not the therapist’s), she was instructed to stay mindful of her body sensations. As she described her abusive experience her jaw began to tighten, her right shoulder and arm began to constrict, and her breath became labored — all possible signs of defensive responses emerging spontaneously. After making contact statements with these physical observations by saying, “Your jaw and arm seem to be tightening up and your breathing is changing,” the therapist directed Mary to be mindful of her bodily sensations: “Let’s take a few moments to sense what’s happening in your body before we go on with the content.” Mary described the tension and stated that her head seemed to want to turn to the left, at which point she remembered a wall being on her left during the childhood abuse. Instead of interpreting her statements, or returning to the content of the memory, the therapist directed her to “allow that turning in your neck and notice what happens next.”

At this point, Mary was no longer describing the past but was attentive only to present bodily experience. As she was mindful of her head and neck turning to the left, she was also aware of physical impulses that seemed involuntary, as if they were happening “by themselves.” Her body seemed to take on a life of its own as she was encouraged to be mindful of her sensations and movements. Mary reported that “my hand wants to become a fist” and the therapist encouraged her to “feel the impulse and allow that to happen” without doing it voluntarily. While the previous pushing motion against the pillow was entirely voluntary, Mary’s hand now slowly began to curl into a fist spontaneously.

Mary reported that her arm wanted to “hit out.” The defensive movement sequence was now emerging without conscious top-down direction from either the client or the therapist. The therapist said, “Feel that impulse to hit out and just notice what happens next in your body.” Mary was encouraged to simply track and allow the involuntary micromovements and gestures, rather than “do” them voluntarily. Sensorimotor processing was occurring spontaneously through mindful attention to body sensation and impulses, and by harnessing cognitive direction in suspending content and emotion to support the body’s processing.

As the therapist directed Mary to track her sensations and involuntary movements, and as her right hand formed a fist, her forearm also tightened, and her arm slowly rose off her lap without conscious intention on her part. Mary stated that she was starting to feel panicky, and the therapist asked her to just experience the physical elements of the panic (which Mary reported as increased heart rate and constriction) rather than the emotion. This was an important directive to separate trauma-based emotions from sensation so that sensorimotor processing could occur without interference from emotional or cognitive processes, and without overloading Mary with more information than she could effectively handle. Gradually, Mary’s head and body turned back toward the center, and her right arm progressed through a slow rising and hitting motion accompanied by shaking. (Inwardly this experience of shaking is similar to shudders passing through the body when one is cold.) After several minutes of sensorimotor processing during which both Mary and the therapist followed the slow and unintended progression of movements, Mary’s arm finally came to rest in her lap. Mary continued to shudder, and she was instructed to “stay with the shudders and sensations as long as you are comfortable doing so.”

All the while, Mary was encouraged to trust her body by allowing the movements to occur without trying to direct them or change them in any way, and she was also encouraged to stop at any moment if she felt too much discomfort to go on. Since physical constriction from the gradual “exposure” to the traumatic memory can be extremely intense before it begins to unwind and soften, clients need the therapist’s help in following the sensorimotor process. They are also encouraged to self-regulate — to stop if ever it becomes too intense.

Eventually the shudders ceased, and Mary said she felt relief and a sensation of tingling throughout her body. The therapist instructed her to savor her bodily feeling and sense of relief, and to describe these physically in detail. Reporting a softening in her musculature, a slowed heart rate and a good feeling of heaviness throughout her body, Mary stated that she felt peaceful for the first time in weeks. In speaking about the abuse, Mary was less judgmental of herself, saying she was angry that her mother had turned a blind eye to her uncle’s behavior, and that no four-year-old girl should have to worry about changing clothes in front of a relative. While she had not worked directly with her self-judgments, beliefs, or emotions associated with the traumatic experience, working with sensorimotor processing had a positive effect on both her emotional and thinking processes. Toward the end of this session, the therapist helped Mary address emotional and cognitive processing. Mary gave full expression to her sadness and arrived at new meanings while she also became more fully conscious of her sensorimotor reactions. Mary experienced a new integration and reorganization of the physical, emotional, and cognitive levels of her experience as these three levels were addressed simultaneously.

At her next session, Mary reported that her sleep pattern had returned to normal, and she was much calmer in general. Her panic attacks had nearly ceased, and she wanted to continue to explore her childhood trauma, more confident in her ability to do so with an expectation of personal mastery. Mary was increasingly able to interact with the therapist, which was demonstrated by her asking questions, engaging in more dialogue in contrast to her original monologue, and in her using the relationship with the therapist to soothe herself. In subsequent sessions, Mary further developed her ability to actively defend herself and to set boundaries, which expanded her capacity to engage in interactive regulation, for the ability to actively defend and set boundaries increases one’s safety in relationship. Mary was increasingly able to process emotional and cognitive elements of the trauma and to address relational issues with the therapist, while frequently returning to sensorimotor processing when physical impulses and sensations emerged, or when she again felt hyperaroused or dissociated.

Eventually, Mary experienced a therapy session in which she confronted the memory of the moment she first dissociated and “watched from the ceiling to what he [her uncle] was doing to another little girl,” while another part of her submitted to the abuse. However, she now had developed the skill of tracking her body sensations, and she felt more confidence in being able to get through these experiences. Mary writes:
At the time of this session I had recently been experiencing what seemed like a new wave of earlier memories that had brought an increase both in the level of physical activation and in emotional terror and despair. This time though, it felt like I knew I could get through this, I’d been here before and knew there was a process and steps that led to a better, more whole experience.

In this session, Mary was again instructed by the therapist to be mindful of her body, and as she remembered the trauma, she became aware of the physical reactions she had experienced as a child. She experienced the physical components of submitting and dissociating from her body (numbness, muscle flaccidity, feeling paralyzed) along with the impulse to fight back (tension in her jaw and arms). Awareness of sensation became the unifying force in resolving this “dissociative split,” as Mary realized: “This disintegration is not real…I’m two bodies in the same body, doing two different things.” As Mary experienced this split somatically and processed the physical components of it (such as the impulse to fight her uncle), she was able to experience the grief associated with the abuse without dissociating from her body. More able to process cognitively, her negative beliefs about herself eventually were replaced by a sense of accomplishment of having been able to defend herself through dissociation and submission, acknowledging that these passive defenses had been effective in her particular situation and realizing that active defenses at that time would probably have made her trauma worse. At one point in the session, Mary proudly says, “There’s nothing wrong with me — look what I did!” referring to her dissociation as a way to survive unbearable abuse.

Shortly after this session, Mary’s therapy terminated. Six months later, she writes:
I am aware that there has been a lasting and profound change in both my body (the way I hold it) and my sense of integration and ability to stay present with fearful situations, memories and sensations that would previously have been so overwhelming that they would be suppressed …

I also feel emotionally integrated in a new way. It’s as though the part of me that had been the victim of … abuse is not alone any more but has other stronger, more whole and resistant parts mixed up with it. I no longer so desperately need the contact [with the therapist] to go into the memories. It’s though I can be there for myself.

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Books and Articles

Trauma and the Body: A Sensorimotor Approach to Psychotherapy by Pat Ogden

“Beyond Words: A Sensorimotor Psychotherapy Perspective on Trauma Treatment”

Authors: Ogden, P.

Located in: Psychological Trauma: Theory, Clinical and Treatment (in press)

“’I Can See Clearly Now the Rain is Gone’: The Role of the Body in Forecasting the Future”

Authors: Ogden, P. Located in: Body-States: Interpersonal and Relational Perspectives on the Treatment of Eating Disorders, (2014)

“Wisdom of the Body, Lost and Found: The Nineteenth John Bowlby Memorial Lecture”

Authors: Ogden, P. Located in: Talking Bodies: How Do We Integrate Working with the Body in Psychotherapy from an Attachment and Relational Perspective?, (2014)

“Integrating Body and Mind: Sensorimotor Psychotherapy and Treatment of Dissociation, Defense, and Dysregulation” Authors: Ogden, P. & Fisher, J.

Located in: Neurobiology and Treatment of Traumatic Dissociation: Towards an Embodied Self, (2014)

“Technique and Beyond: Therapeutic Enactments, Mindfulness, and the Role of the Body”

Authors: Ogden, P. Located in: Healing Moments in Psychotherapy, (2013)

Sensorimotor Psychotherapy as a Foundation of Group Therapy with Younger Clients”

Authors: Ogden, P. & Mark-Goldstein, Located in: The Interpersonal Neurobiology of Group Psychotherapy and Group Process, (2013)

“Brain-to-Brain, Body-to-body: A Sensorimotor Psychotherapy Approach for the Treatment of Children and Adolescents”

Authors: Ogden, P., Goldstein, B, & Fisher, J Located in: Current Perspectives and Applications in Neurobiology; Working with Young Persons who are Victims and Perpetrators of Sexual Abuse, (2012)

“Psychodynamic Psychotherapy: Adaptions for the Treatment of Patients with Chronic Complex PTSD”Authors: Lanius, R., Pain, C., Ogden, P., & Vermitten, E. Located in: The Impact of Early Life and Trauma on Health and Disease: The Hidden Epidemic, (2010)

“Modulation, Mindfulness, and Movement in the Treatment of Trauma-related Depression”

Authors: Ogden, P. Located in: Clinical Pearls of Wisdom: 21 Leading Therapists Offer their Key Insights, (2009)

“Sensorimotor Psychotherapy” Authors: Ogden, P. & Fisher, J. Located in: Treating Complex Traumatic Stress Disorders: An Evidence Based Guide, (2009)

“Emotion, Mindfulness and Movement: Expanding the Regulatory Boundaries of the Window of Tolerance”

Authors: Ogden, P.

Located in: The Healing Power of Emotion: Affective Neuroscience, Development & Clinical Practice, (2009)

“Sensorimotor Approach to Processing Traumatic Memory”

Authors: Ogden, P. & Minton, K.

Located in: Brief Treatments for the Traumatized: A Project of the Green Cross Foundation, (2002)

“Hakomi Integrative Somatics”

Authors: Ogden, P.

Located in: The Illustrated Encyclopedia of Body/Mind Disciplines, (1999)

“Hands-on Psychotherapy: Hakomi Integrative Somatics”

Authors: Ogden, P.

Located in: Getting in Touch, (1997)

Select Journal Articles on Sensorimotor Psychotherapy

“Commentary on Paper by Ellen F. Fries”

Authors: Ogden, P.

Keywords: implicit self, proximity-seeking actions, attachment, body-oriented interventions

Located in: Psychoanalytic Dialogues: The International Journal of Relational Perspectives, 22(5), 606-615 (2012)

“Understanding Dissociation and the Body – Then and Now”

Authors: Ogden, P.

Keywords: trauma treatment, PTSD, dissociative disorders, history of sensorimotor psychotherapy Located in: Interact, 12(2), (2012)

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