Joe: A trauma and body psychotherapy case study

By Mary Spring

Traumatic symptoms are not caused by the “triggering” event itself. They stem from the frozen residue of energy that has not been resolved and discharged; this residue remains trapped in the nervous system where it can wreak havoc on our bodies and spirits.

(Levine, 1997: Loc. 476)

In this case study I will explore a client’s experience of anxiety and consider the probable traumatic roots. I will subsequently document and critique one session where, in collaboration with the client, a body psychotherapy response to uncomfortable, unwelcoming and threatening sensations experienced by the client was facilitated.

The client
Using a pseudonym, ‘Joe’, to maintain the client’s confidentiality, my client is a 23-year-old single Irish-born male. Continuing to live at home, he is the eldest in a family of Mum, Dad, younger brother and two sisters. He has completed a primary degree in the STEM sciences and is now drawing to the end of a further studies programme.

Joe presented with chronic anxiety which rendered him unable to travel abroad for a working summer in 2018. The fact that he had by then signed up to a Masters programme prompted him to seek support from the university’s counselling services where I then worked. Initially contracted to meet weekly over a six-week period, Joe remained house-bound throughout the summer of 2018, so we conversed by phone every Friday at noon and a therapeutic relationship began to evolve. The contact was sustained and later extended through to the end of the academic year. In mid-October we met in person for the first time. By the time I completed this report in mid-June 2019, we had met face to face on 17 occasions with numerous sessions also being conducted by phone when he felt unable to attend in person. We had also enhanced our contract to include a little bit of body work. During this period Joe had refused to consider anti-depressant /anti-anxiety medication as prescribed by his doctor.

Joe’s experience of anxiety is rooted, I suggest, in a myriad of biological, socio-cultural and psychological influences which strongly hint at primal and early life developmental wounding. Reminded that “the child seems to bring very little fear into the world” (Freud, 2015: Loc. 6608), and that “panic always starts in a climate of stress, pressure, fear or anxiety” (Tubridy, 2007: Loc. 542), I consider that the anxiety as observed in Joe’s depiction of his mother generated an insecure anxious attachment, a mother’s probable inability “to tolerate and manage her infant’s anxiety as well as her own” (Maltsberger et al., 2011: 676), communicating an overly cautious perspective of the world. In early infancy, internalising a complex family system, one which included a neighbouring anxiety-ridden relative who did not leave his home for two years, Joe learned to mistrust rather than trust, and core beliefs, translating into ‘life is too much’, ‘life is to be feared’ and ‘I am afraid’ took root.

Separation and autonomy, two crucial developmental movements of early childhood were, in all probability, undermined and his id inevitably censored. Adopting a position not unlike the Kleinian position of the paranoid-schizoid where experience is deeply polarised, he did not, in all likelihood, witness or learn to tolerate ambiguity. Neither did he learn to self-regulate his affective world when triggered. In subsequent years Joe, I hypothesise, adopted a safety armour to survive and protect his overwhelmed ego. Repression, denial, avoidance, fixation and regression smothered spontaneity, adventure, maturation, relationship and actualisation. Such protective caution is now well internalised in his somatised body. Colluding parents supported and re-enforced his organisation of experience.

Herman suggests that “Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection and meaning” (2015: 33). Joe identifies his first overwhelming experience of anxiety in the final year of his secondary education, though it is very possible that there were other earlier experiences of trauma that are “defensively excluded in a desperate attempt to manage personal safety” (Muller, 2010: Loc. 257). One night, he fainted and ended up in the cardiac unit of the local hospital, remaining there for two weeks. Surrounded by older people, one or two who died during this time, Joe became consumed by the thought that ‘there is something wrong with me’ and by the fear that he was going to die. It was here in the hospital that he began to obsessively track his heartbeat, fixatedly seeking out other body sensations for signs that something bad was about to happen. Six years on from when he was unable to ignite his animal instincts and mobilise his escape response, Joe, like many traumatised people, has been left with “a fragmented memory” (Ogden, Minton & Pain, 2006: 3) and remains gripped and “overwhelmed by the event, defeated and terrified” (Levine, 1997: Loc. 584 – 589). He is “compelled to anticipate, orient to and react to stimuli that directly or indirectly resemble the original traumatic experience or its context” (Ogden et al., 2006: 65). Preoccupied by “distortions of time and perception” (Levine, 1997: Loc. 2278), he equates his felt anxiety and the hyper aroused heartbeat with the onset of a heart attack. Working outside a very small window of tolerance, Joe displays the core experiences of psychological trauma – apprehension and hypervigilance (Bourne, 2015: 9), and disempowerment and disconnection from others (Herman, 2015: 134).

It is worth noting here what is happening to Joe neurologically. Constantly reliving the intrusive and fragmented frozen-in-time hospital trauma, Joe’s senses, always hyperalert, perceive a threat and send the threat in two different directions – rapidly downward to the amygdala that lies deep in the limbic unconscious brain and, in a slower movement, up to the observing “watchtower” (van der Kolk, 2014: 62) that is the medial prefrontal cortex. The non-discerning emotional brain that is the amygdala needs only 200 milliseconds to compute whether to fight or flee and adrenaline and cortisol chemicals begin to pump through his body. In contrast, the neo-cortex needs 3-5 seconds to make a more judicious decision. For many people at this point the hippocampus is able to make sense of a situation. The autonomous fight-flight-freeze response slows down and the HPA (i.e. the hypothalamus, pituitary gland and adrenal gland) axis calms. This does not, however happen for Joe. His traumatised orienting response has become profoundly compromised and his amygdala, a part of the old brain likened by van der Kolk to a faulty smoke alarm (2014: 58) has learned never to turn off. In a near perpetual state of hyperarousal and constriction, his HPA axis constantly secretes low levels of stress hormones and when his constant, anxiety-driven thoughts become overwhelming thoughts, his adrenaline is released in a “sudden dam- burst” (Corry & Tubridy, 2001: Loc. 1786). Every bodily system is affected, and he experiences intense and terrifying reactions in the racing heartbeat, an acute shortness of breath, wobbly limb sensations, and a pronounced disconnect from self. He is, to all intents and purposes, back in the hospital, and in that flood of overwhelming bodily sensation and distorted thinking, Joe must flee the place of threat because he believes he will collapse and die.

Interventions
Joe has not felt able to attend in the last two weeks. Lingering in the hallway (he never enters the waiting room) he carries his familiar prop of a bottle of water. Younger looking than his 23 years (he could pass for a 16-year-old) and dressed casually in jeans and a muted-coloured sweatshirt, his light, narrow and contracted frame embodies his fret-filled core beliefs. Martin (2015) notes that “Tracking is an active form of witnessing” (Loc. 3231) and I observe other somatic indicators – his slightly heightened and rounded shoulders arguably indicating “an attitude of fear” (Dychtwald, 1986: 167) and a lopsided torso, veering subtly to the left, hinting at being unbalanced by life events. His unsettled eyes attest to his hypervigilance and are somewhat shielded by black-framed glasses. His pallor is emulsion white.

Using my own body as a point of contact, I extend my hand to welcome him, my conscious motivation being to re-enforce the physical and psychological connection. His hand feels damp and cold. Immediately Joe, with little inflexion, and implementing his well-honed avoidance strategy, expresses doubt that he will be able to stay for more than a few minutes. He feels weak, his legs are wobbly and he ascribes his tiredness to a 10-minute cycle the previous day. As always, his Dad waits outside in the car, ready to ferry him to the nearby hospital if Joe collapses (he hasn’t fainted in five years). Assured by me that he can leave whenever he wants to leave, Joe positions himself at the edge of the armchair in the now familiar downstairs office. Other imprints are visible. He breathes shallowly, a limited breath limiting more expansive feeling while simultaneously feeding his anxiety. His upper frame leans forward and his neck extends, even if only minutely. Unevenly supported by feet which are raised off the ground, his foot muscles are in all likelihood clenched, and indicative, perhaps, of both a tense and wary attitude towards life and a readiness to flee, if required.

Mindful that Joe’s alarm bell-sounding amygdala governs his everyday functioning, and using his body as a point of contact and entry, I gently prompt him to pause and, as I have done before, encourage him to feel his legs and feet that are supported and stabilised by the earth and to inhale and exhale slowly, the latter outward-moving breath activating the parasympathetic response; I mirror the same. In these moments of near quietness the potency of his readily activated amygdala calms and he somatically anchors himself. When he completes this grounding action a few times, I affirm the ability he has displayed to ground and resource himself in the felt sense of his body – a body that is deeply split between the university graduate and the terrified infant-child-teenager-adult who struggles in his daily life.

In effect, a fearful little boy is present; his eyes move restlessly behind his glasses and he muses about his ability to negotiate the beginnings of a part-time job in the coming months. “Body sensation, rather than intense emotion, is the key to healing trauma” (Levine, 1997: Loc. 376) and I follow Joe with a soft focus and encourage him to be curious and notice what is happening in his body in this very moment. My purpose is two-fold: firstly, to enable Joe to resource himself in slowing his reactive response down, and secondly, to encourage him to see his body as the agent of healing and not his enemy.

Confirming Kepner’s observation that “the language of the identified-self becomes predominantly verbal, while the vocabulary of the body-self is kinaesthetic” (2008: 14), Joe deflects to another familiar default setting, that of the victim prophesising a catastrophic future narrative. I deliberately distance myself from a more analytical, why-based enquiry, and attentive to the truth that working in present time encourages a discovery of “action tendencies and responses” (Ogden et al., 2006: 166), I gently nudge him back towards an awareness of a felt sense in his body. He acknowledges feeling unsettled. I acknowledge what he is experiencing. I ask him to pause for a moment and to check in with his lower limbs which he has regularly referenced in previous sessions as being a place of felt weakness. My curiosity is stirred. I have previously wondered about the difficulty he has in ‘standing on his own two feet’ and about the incomplete response, the compromised action and the trapped energy of a young teenager who could not get up and leave a hospital cardiac unit of his own volition six years earlier. He identifies his legs as ‘jellyish’.

Assuring Joe that he is safe in the room, I encourage him to stand and simply notice the sensation in his legs as it (the sensation) moves towards its natural close. He follows the ‘what wants to happen’ movement. Like an athlete before a race, he spontaneously shakes out his legs. Within moments the weakened and jelly-like sensation passes. He estimates that the felt anxiety and weakness in his lower limbs drops from 95% to 40%. What is significant here in this experiment is that the client communicates with the discomfort and the fearful thought associated with the sensation (i.e. he will collapse and die). He becomes present to his body without identifying himself as the felt sense. He creates what Morgan describes as a “witness state” (2015: Loc.888). He tolerates and goes through and out beyond the sensation and out beyond a narrowed “field of consciousness” (Ogden et al., 2006: 65). His body, invariably the enemy, becomes less alien and less threatening in these few moments. He draws in a deep inhalation and exhales slowly. Another deep sigh is released, something he does frequently throughout each session, and he comes to a place of rest, of homeostasis.

As in a game of tennis, Joe then returns to serve his narrative and I let it be. He is more at home, however, in his own skin, more grounded, less fear-filled and he sits back in the chair. His flight mode has been abandoned. The session draws to its end. As we stand up, I spontaneously comment on my very visible yellow highlighter-coloured socks. Unprompted words come “from the mysterious region of unknowing” (Kurtz & Johanson, 1991: 4), and Joe describes the colour as ‘daring’. Everything can be relevant. I linger on the delightfully sounding adjective. I prompt him to simply repeat the word, then again and once more. ‘Daring’ morphs into ‘dare’ – a different word, a verb with a different emphasis. His tone of voice, initially quiet, readjusts and raises its volume and pitch. Invited then to bodily respond to this tantalising word, even if for a few moments, Joe, once again, unfreezes parts of his truncated armour – his censored voice, his holding throat. I encourage him to momentarily hold and notice his frame, his leading right arm, his unclenched fists, his right forwardly positioned leg balanced by the rooted left lower limb and his open and extended torso – all an antithesis to his tightly held body as noted at the beginning of the hour. What I witness is a daring, warrior-like pose. A boundary-challenging pose and an alternative response to the core beliefs that ‘life is too much’, ‘life is to be feared’ and ‘I am afraid’. We shake each other’s hand as we always do at the end of the hour. Joe’s hand feels warm, the original cold, damp feeling has dissipated. I deliberately acknowledge his work. He expresses delight that he stayed, as do I.

Critique of my interpretations and experiments
Underpinned by my humanistic and integrative theoretical perspective and an adherence to the core ethical principles of my accrediting body, the Irish Association for Counselling and Psychotherapy, (i.e. autonomy, beneficence, non-malfeasance, justice and care), I also grow in understanding of the body-minded approach as found in Hakomi (Weiss, Johanson & Monda, 2015) and Sensorimotor psychotherapy (Ogden et al., 2006) and their central tenets of unity, mind-body holism, organicity, mindfulness and non-violence. I have deep respect for Joe. I hold that he, like all of us, is a sometimes-visible, sometimes-invisible union of mind, body, heart and soul. I have regard too for therapeutic process and its three living tenses of past, present and future and am convinced of the primacy of the therapeutic relationship where two hearts, the listened-to heart of the client and the listening heart of the therapist meet.

This session was a significant hour of contact and collaboration and saw a client move to a different beat and respond to the somatic pulses which yearn for healing. My therapeutic approach also stepped away from the more familiar content and process orientation to a less familiar approach which fosters in the therapist an attitude of non-doing and sees the client’s organism as the primary revelatory and healing instrument.

The presence of the transference and countertransference, inherent in the relationship matrix, supported and enabled the movements in this hour. The former, as observed in this session, is a safe neurotic one. Offering an alternative to the insecure anxious attachment, I am the available non-anxious mother-figure and the non-critical parent (as previously seen in the client’s father), thus potentially offering Joe a new way of communicating and being in relationship with himself and with others. I embody safety, trust, presence, containment and proximity – core attachment conditions. As for the counter-transference – I am drawn to this very likable young man who is gripped by anxiety. I care about Joe and am aware of the real possibility of neural and bodily shrinkage, inflammation and disease. His chronic vulnerability reminds me of fragility I have seen in a relative and in a number of teenage lads with whom I worked closely in my previous professional life in education. I am consequently attentive to minding myself, my boundaries and my expectations of self.

In this hour I felt welcoming, present, engaged and steady. Observing van der Kolk’s emphasis that the therapist’s role is not to determine what exactly happened to the client in the past but to “help them tolerate the sensations, emotions and reactions they experience without being constantly hijacked by them” (2014: 174), my pace was slow and relaxed. My eye contact was softly focused, my tone was gentle, and my words, generally clear and concise, invited relaxed curiosity, mindful attention (e.g. ‘see do you notice?’) and participation. The intentional employment of the pronoun ‘we’ encouraged a collaborative experience.

I drew specifically on body orientated experiments, all of which potentially can evoke and unearth information about a client’s organisation of past experience, emotion, core beliefs and meaning. Each intervention encouraged Joe’s curiosity and communion with his body; the opening experiment focused Joe’s attention on his legs and feet on the supporting ground, and the mindful inhalation and exhalation of his breath facilitated awareness, gathering and expansion of breath and the regulation of his heightened arousal. When encouraged subsequently to work in present time, rather than dwell in story, and to notice the sensations of his lower limbs, Joe responded tentatively at first, and then, staying in that place of self- study, succeeded in tolerating and riding through the ebb and the flow of the threatening waves of sensation. In that sequence I learned, in the spirit of non-doing, to release my own need and to trust the client’s wise body to do the work of uncoiling trapped energy.

The closing socks sequence spontaneously invited a little bit of fun yet also encouraged micro-movement release of parts of his body which hold emotions and memory prisoner – his voice and throat. His warrior pose dared then to suggest an alternative to a long-held limiting perspective. Moving, even if momentarily, from being defined by symptoms and present organisation of experience, moving away, even if momentarily, from “the seduction of safety” (O’Donoghue, 2007: 32) to another place, Joe, in this hour, was encouraged not to be threatened or overwhelmed by his body but to follow with awareness the organic sequencing. He widened his window of tolerance as he expanded his frame. He risked re- organising and expanding his experience of body and dared to challenge the bottom-up sensation that his body is the primary threat, accessing too his top-down cognitive processes which says the body is not the threat but a dynamic resource.

On reflection of this session, I grow in awareness that a client’s body (like my own), reflecting a personal history and core beliefs, will always speak. I grow in learning of the client’s ability to self-resource and to self-regulate the hyperarousal reactive response and that bodywork, robed in non-violence, mindfulness, gentleness and compassion, can both access the labyrinths of the unconscious and enable the completion of an action previously unfinished. Working, not directly, but with trauma’s “reflection, mirrored in our instinctual responses” (Levine, 1997: Loc. 1146), the body’s felt sense is the instrument of healing. I am more lacking in confidence than confident in introducing bodywork but this hour reminded me of organicity and the ability of the corporal self to “reconnect with the thread of experience” (Kurtz & Johanson, 1991: Loc. 334) and to find its expression and release. I slowly learn to take the cue from the client and to relinquish control. I slowly learn to risk trusting in what emerges in the moment from the “bottomless bowl” (Kurtz & Johanson, 1991: Loc.334) that is a client’s awareness and experience.

In this session I failed, on occasions, to cultivate silence as I overly affirmed the client’s movements. Perhaps I needed to soothe and affirm myself more so than the client. I felt too, my own reticence as Joe connected with his jelly-like legs. A person’s disowned or relegated place, a part Kepner likens to a boarded-up room in a house (2008: 13), trembles close to the surface. Here I was reminded of the client’s traumatic hospital experience and its “fixed and static” imprints (Levine, 2015: Loc. 344) and felt the need to explain the probable connection between the immobilised and uncompleted action in the hospital setting and the restrained energy in his lower limbs. However, I did not want the client to go to that familiar place of memory and storytelling, so rightly or wrongly, I silenced the possibility of a cardiac unit mini-frame opening up and Joe’s accompanying felt sense. Perhaps that is for another body-minded session.

Conclusion

For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present.

(van der Kolk, 2014: 21)

Joe’s experience of present time is dictated to by a life experience that “continues to occur or keeps happening over and over again” (Rothschild, 2010: Loc. 478), and this fractured trauma is etched in the “the fence of defence” (Siegel, 2011: Loc. 2289) that is his autonomous system. The unpacking and reorganisation of his trauma (perhaps traumas) is slow. This session, however, saw a client who feels unsafe in his body attend to both sensation and movement, resource, regulate and reframe his aroused affective world in a therapeutic process that, for an hour, supported the Ithaca journey home to his becoming, enabling and worthy self.