HEALING TRAUMA IN THE PSYCHE-SOMA: SOMATIC EXPERIENCING IN PSYCHODYNAMIC PSYCHOTHERAPY. A Clinical Research Project submitted by JOHANNA T

HEALING TRAUMA IN THE PSYCHE-SOMA: SOMATIC EXPERIENCING® IN PSYCHODYNAMIC PSYCHOTHERAPY A Clinical Research Project submitted by JOHANNA T. HAYS to PA...
0 downloads 1 Views 3MB Size
HEALING TRAUMA IN THE PSYCHE-SOMA: SOMATIC EXPERIENCING® IN PSYCHODYNAMIC PSYCHOTHERAPY A Clinical Research Project submitted by JOHANNA T. HAYS to PACIFICA GRADUATE INSTITUTE in partial fulfillment of the requirements for the degree of DOCTOR OF PSYCHOLOGY in CLINICAL PSYCHOLOGY with emphasis in DEPTH PSYCHOLOGY This Clinical Research Project has been accepted for the faculty of Pacifica Graduate Institute by: Dr. Oksana Yakushko, Chair Dr. Paula Thomson, Reader Dr. Mary Giuffra, External Reader

UMI Number: 3611759

All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion.

UMI 3611759 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code

ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI 48106 - 1346

ii NOVEMBER 9, 2013

Copyright by JOHANNA T. HAYS 2013

iii ABSTRACT Healing Trauma in the Psyche-Soma: Somatic Experiencing® in Psychodynamic Psychotherapy by Johanna T. Hays Addressing the aftermath of trauma is among the most important contributions of psychology. As the numbers of individuals experiencing posttraumatic symptom sequelae continues to increase, it becomes imperative to research and explore a wider range of trauma treatment approaches in order to provide more individualized care. The goal of this study was to gain insights into the body-based approach of Somatic Experiencing®, a short-term naturalistic approach developed by Peter Levine (2007), through experiences of practitioners. The participants practice the Somatic Experiencing® in integration with psychodynamic psychotherapy. Based on a phenomenological case study approach, 4 licensed psychologists and Somatic Experiencing® practitioners were interviewed in order to learn more about how their integration of the 2 approaches impacts their clinical approach to working with trauma symptoms. Among the key themes that emerged from the analysis was the significance of integration in positive outcomes for individuals experiencing posttraumatic reactions by reducing or resolving their symptoms through a novel approach. The implications of this study for the field of clinical psychology are in further elucidation of the integration and its distinct contributions to treatment of trauma. Keywords: treatment of trauma; somatic psychotherapy; psychodynamic psychotherapy; posttraumatic stress disorder

iv Dedication This journey has not been one of solitude. Every success and setback was felt by all of my beloveds, and it is for this reason I want to extend my heartfelt gratitude to my family and friends who have navigated this sojourn alongside me and have endured its frustrations, constrictions, and elations. Thank you to my parents for their seemingly unending support, interest, and pride; and to my husband, who has been my rock, advocate, foundation, and best friend; to Dr. Solomon and Pearl Axelrod, my uncle and aunt, visionaries who blazed the trail of social consciousness, tending the soul of the world far before I was born; thank you for your wisdom, guidance, and fire. And lastly to Isis, and to Ed, the man in the crystal; thank you for the lessons in healing trauma; I will continue to help others re-member that which has been dismembered.

v

TABLE OF CONTENTS

Chapter 1. Introduction............................................................................................ ............1 Relevance to Clinical Psychology ...........................................................................4 Personal Interest .......................................................................................................6 Statement of the Research Problem .........................................................................6 Chapter 2. Literature Review ...............................................................................................9 Effects of Trauma.....................................................................................................9 Traditional Approaches to Treatment of Trauma...................................................14 Somatic Approaches to Treatment of Trauma........................................................16 Psychodynamic Approaches to Treatment of Trauma ...........................................20 Conclusion .............................................................................................................28 Chapter 3. Methods................................................................................................... .........30 Research Methodology.......................................................................................... 30 Participants .............................................................................................................30 Data Collection ......................................................................................................32 Data Analysis .........................................................................................................33 Reflexivity..............................................................................................................34 Ethical Considerations ...........................................................................................35 Chapter 4. Results.............................................................................................................. 36 Approach................................................................................................................ 38 Personal Rationale and Background.......................................................... 38 Use of Touch.............................................................................................. 40

vi Psychoeducation and Supervision Implications....................................... 42 Effects of Integration................................................................................ 43 External Patient Relational Changes........................................................ 43 Resolution or Reduction of Symptoms..................................................... 43 Value of Integration.................................................................................. 44 Risks and Deficits of Integration.............................................................. 45 Evidence-Based Best Practices..................................................................46 Need for Well-Designed Studies.............................................................. 46 Limitations and Biases.............................................................................. 47 Results Table 1...................................................................................................... 48 Chapter 5. Discussion........................................................................................................ 50 Approach to Treatment.......................................................................................... 51 Effects of Integration............................................................................................. 57 Clinical Relevance................................................................................................. 59 Future Research...................................................................................................... 61 Personal Meaning................................................................................................... 61 REFERENCES.................................................................................................................. 63 Appendix A. Interview Questions...................................................................................... 70 Appendix B. Ethics CommitteeApproval.......................................................................... 72

Chapter 1 Introduction Among the most important contributions of psychology and other mental health professions is addressing the aftermath of traumatic events and their impact on individuals. Individuals who have been diagnosed with posttraumatic stress disorder find themselves dealing with deeply imprinted reactions that are centered on emotions, images, sensations, and somatic reactions connected to their trauma (van der Kolk, 2002). Typically, human memories deteriorate and change over time, and the mind is often incapable of accurately reproducing past experiences (Christianson & Loftus, 1987). Interestingly, individuals who have experienced trauma and have met the criteria for a diagnosis of posttraumatic stress disorder (PTSD) do not appear to have the same degradation of their traumatic memories. Instead, these individuals report that the details of their experiences become deeply imbedded in their minds and become re-experienced in accurate detail for years after the event has occurred (Janet, 1889; van der Kolk, Hopper, & Osterman, 2001; van der Kolk & van der Hart, 1991). Evidence has shown that traumatic stress is the cause of significant and long-term psychological, emotional, and somatic reactions (Bower & Sivers, 1998; Heller & LaPierre, 2012; Levine, 2010a, 2010b; Scaer, 2006; Solomon & Siegel, 2003; Solomon, Laor, & McFarlane, 1996; van der Kolk, 2002). The risk of illness, both physiological and psychological, may be increased by the presence of dysregulation patterns brought on by trauma (Heller & LaPierre, 2012; Levine, 2010a; Sapolsky, 1994). The most common interventions for trauma are cognitive-behavioral therapy (CBT) and eye movement desensitization and reprogramming (EMDR), which have the highest success rate in addressing posttraumatic reactions (Beck, 1995; Shapiro & Maxfield 2002). Studies show

2 CBT and EMDR to have the highest recognition for efficacy for individuals diagnosed with posttraumatic stress disorder. However, what often is not addressed are the dropout rates, which can be as high as 54%, and the nonresponse rates, which are as high as 50% in some studies, as well as an inability to maintain long-term effects (Carr, 2011; Schottonbauer, Glass, Arnkoff, Tendick, & Gray, 2008). Psychodynamic psychotherapy is focused on symptoms that occur beneath the surface of conscious awareness, and has been shown to integrate well with trauma work (Carr, 2011; Heller & LaPierre, 2012; Moss, 2009; Shedler, 2010). It is possible to focus on image, sensation, and feeling without directly addressing the narrative process that has been shown to re-activate trauma (van der Kolk, 2002). This understanding is important because many individuals who experience negative symptoms from early trauma may not consciously connect trauma-related symptoms to their experiences. Uncovering unconscious processes too quickly can overwhelm the individual with responses they may not understand and possibly re-traumatize the individual (Heller & LaPierre, 2012; Levine, 2010a, 2010b; van der Kolk, McFarlane, & Weisaeth, (2006); Turner, McFarlane, & van der Kolk, 1996). Psychophysiology describes bidirectional “top-down” and “bottom-up” processes as interactions that occur between the brain and other systems, such as the immune and cardiovascular systems, and are thought to effect both mental and physical health alike (Taylor, Goehler, Galper, Innes, & Bourguignon, 2010). “Top-down” processing, emerging from the neocortex, involves cognition and executive functioning, and is what traditional psychotherapy relies upon for management of emotions and sensations. The higher cortical areas in the adult brain operate as a center of control, allowing for a buffer

3 from sensory or somatic experiences that might otherwise overwhelm an individual. This enables individuals to maintain awareness of past experiences while minimizing the intrusions the experiences might elicit. Top-down processing engages executive functioning operations such as planning, monitoring, and integrating, though these are effective only when lower brain functions are inhibited (van der Kolk, 2002). “Bottom-up” processing allows an individual to track the sensations and reactions or activations somatically while not directly moving back into the traumatic experiences. Neuropsychology views these mechanisms as originating through stimulation of viscero-, somato-, and chemo-sensory receptors (Taylor et al, 2010). These receptors affect mental and central neural activities through the ascending pathways that flow from brainstem to cerebral cortex. Trauma-activated individuals have difficulty controlling states of emotions that were encoded through physical experiences. Many of talk therapy’s applications are focused on top-down processing and the relationship between thoughts and emotions. This process does not take into consideration the “bottom-up” activation that occurs in the body (Siegel, 2003; van der Kolk, 2002), and the “felt sense” that accompanies it (Damasio, 1999; Levine, 2010a). By observing and tracking the somatic, bottom-up activation that accompanies the trauma narrative, individuals engaging in body-based therapies such as Somatic Experiencing® can reduce trauma symptoms and assimilate the trauma experience (Levine, 2007; van der Kolk, 2002). By titrating the activation, the traumatic experience can be assimilated, the nervous system returned to regulation, and coherence achieved within the system of the individual (Levine, 2007). Since Breuer and Freud’s (1893/1956) original work, it has been shown that traumatized individuals struggle to put their experiences into words. What scholars and

4 practitioners debated was whether this difficulty was a result of dissociation, suppression, or avoidance, but the attempt to put the traumatizing experiences into words caused a retraumatization among individuals (Breuer & Freud, 1893/1956). And although there is a growing interest in understanding the somatic-focused treatments of trauma, less is known about the integration of psychodynamic interpretations and treatment approaches to trauma together with somatic therapies. Therefore, the purpose of this case study is to generalize and document findings of integrative healing work with individuals who have experienced early trauma and continue to experience inexplicable somatic and psychological symptoms as adults. Working with individuals within the context of psychodynamic orientations while amalgamating somatically based interventions has not been widely documented as a method of re-regulating the nervous system. Additionally, releasing trauma that has manifested into body syndromes, and re-integrating the brain’s stress-centers and executive functioning has not been a traditional approach to treatment. By interviewing the clinicians currently conducting integrated sessions of psychodynamically oriented therapy and Somatic Experiencing (Heller & LaPierre, 2012; Levine, 2007) with individuals, the focus of this study is to gain insight and knowledge into reducing the long-term psychological and physical effects of posttraumatic stress formulations. Relevance to Clinical Psychology Information regarding how the body reacts to trauma dates back to the late 1800’s (Janet, 1889). Recent research shows that trauma remains located in the body, creating chronic psychological and physical symptoms (Carr, 2011; Heller & LaPierre, 2012; Moss, 2009; Ogden, Pain, Minton, & Fisher, 2005; Sapolsky, 1994; Solomon & Siegel,

5 2003; van der Kolk, McFarlane, & Weisaeth, 2006), and as the individual cannot access the words to practice talk therapy (Ogden, Pain, Minton, & Fisher, 2005; Solomon & Siegel, 2003; van der Kolk, 2002; van der Kolk, McFarlane, & Weisaeth, 2006), other methods that target the psyche-soma need to be employed. Body-centered approaches to healing trauma are short-term naturalistic approaches based on ethological observations of animals in the wild utilizing innate capacities and mechanisms to re-regulate their systems. Somatic, body-centered approaches bring about homeostasis from arousal states associated with defensive survival behaviors (Levine, 2007). Humans override these built-in capacities by neo-cortical inhibition through the use of the rational cognitive mind (Levine, 2007). Though this process leads to symptoms of pain, anxiety, hypervigilance, cognitive dysfunctions, and a myriad of other symptoms, by focusing on and becoming aware of the somatic reactions, traumatized individuals can release and complete the cycle of arousal, unlocking it from the body and resolving traumatic symptoms (Levine, 1996). Thus, it may be essential for clinicians who treat trauma to address the treatment from both a top-down, cognitive approach and a bottom-up somatic approach in order to resolve trauma from a multidirectional perspective. By researching this multidirectional, consilient approach, my study may help to bring about changes in how trauma is addressed, with the hopes of having a psyche-somatic approach to trauma resolution added in to and included in Evidence-based Best Practices.

6

Personal Interest I have trained in Somatic Experiencing® for 3 years and have witnessed firsthand the power of this work. I have applied this technique as an integrative modality in my work as a psychodynamically oriented psychotherapist and hypnotherapist, and have seen resolution of symptoms that talk therapy alone could not accomplish. The integrative approach of Somatic Experiencing draws on research in neuroscience (Bryant, Harvey, Guthric, & Moulds, 2000; Lanius, Blun, Lanius, & Pain, 2006; Solomon & Siegel, 2003) and is based on the biological basis of the ways in which individuals respond to trauma reflexively and defensively (Levine, 2007; Leitch, Vanslyke, & Allen, 2009; Lorenz, 1981; Porges, 2001). More research showing that psychodynamic therapy on its own can be deemed as an effective treatment for posttraumatic stress disorder (Carr, 2011; Moss, 2009; Shedler, 2010; Woller, Leichsenring, Leweke, & Kruse, 2012) is needed. It is the goal of this study to establish the integration of Somatic Experiencing and psychodynamic psychotherapy as an effective treatment for individuals diagnosed with PTSD. Statement of the Research Problem Although within mainstream psychotherapy and cognitive theory, the cognitive functioning mechanism is a “top-down” process (LeDoux, 1996; Ogden, Minton, & Pain, 2006; van der Kolk, 2002); awareness of these processes may aid in processing sensorimotor reactions, which in turn affect positively the processing of emotions and cognition. The “top-down” processes that attempt to balance and regulate overworked body and mind related systems are imperative in the re-regulating and integrating of

7 traumatic experiences. However, these systems can become hyperresponsive, resulting in over- or under-management of symptoms, which in turn can impede the process of trauma resolution (Ogden, Pain, & Minton, 2006). Thus, this study will examine the integration of Somatic Experiencing (Levine, 2007) with psychodynamic talk therapies. Data collected through interviews with various practitioners will be used to examine the practitioners’ perspectives on the treatment integration of psychodynamic psychotherapy and Somatic Experiencing®. Psychodynamic therapy will be defined as approaches derived from psychoanalytic concepts and applications. These approaches differ from early traditional psychoanalysis in that they utilize less frequent sessions, typically once per week as opposed to several sessions per week. The therapeutic work is typically briefer overall, lasting on average forty weeks (Shedler, 2010). Psychodynamic psychotherapy employs the transference relationship between the therapist and the patient in order to assist in reparation of developmental fractures (Heller & LaPierre, 2012), and includes the ability to acknowledge unconscious processes (McWilliams, 2004). The prototype for psychodynamic psychotherapy is exhibited by the presence of an open dialogue that includes explorations of dream life and fantasy. Repeating themes that originate from the past experiences of the patient are highlighted. Also emphasized is the connection between the patient’s feelings regarding the past and perceptions of them; attention, interpretation, and understanding of disowned and disavowed feelings; the patient’s defensive mechanisms and the therapeutic relationship itself; and lastly, an understanding of the connections between the therapy relationship and other relationships (Shedler, 2010).

8 Somatic Experiencing® is defined as a body-based therapy focused on the reduction and resolution of physical, psychological, and emotional symptoms brought on by traumatic experiences. The theory that Somatic Experiencing® postulates is based on the idea that trauma dysregulates both the sympathetic and parasympathetic nervous systems, which disrupts the innate capacity for self-regulation. Through the sympathetic nervous system, the body is able to mobilize instinctive unexpressed fight/flight responses. Through a process of tracking and observing physical activation in the body, the body experiences and releases traumatic energy, allowing these systems to return to homeostasis (Levine, 2010a).

9 Chapter 2 Literature Review Trauma has a profound effect on human development and the ability to evolve emotionally and psychologically. It compromises one’s perception of safety and boundaries, and changes how an individual views the world as a benign and safe place to exist (Courtois & Ford, 2009; Ogden, Pain, Minton, & Fisher, 2005; Heller & LaPierre, 2012). This chapter is divided into five sections. The first section is an overview of the effects of trauma and the efficacy of current evidence-based best practices. The second section outlines approaches to the treatment of trauma. In the third section, a discussion is offered on psychodynamic approaches to the treatment of trauma, and the fourth section highlights the integration of somatic and psychodynamic approaches to trauma treatment. Section 5 is the conclusion. Effects of Trauma Trauma has always been a part of man’s history (Crocq & Crocq, 2000; Ellis, 1984; van der Kolk, McFarlane, & Weisaeth, 2006).Though not every individual who has had traumatic experiences develops posttraumatic symptoms, some are less adaptable and resilient and develop what is today diagnosed as posttraumatic stress disorder (Lee, Vaillant, Torrey, & Elder, 1996; Solomon, Laor, & McFarlane, 1996). These clusters of symptoms affect people’s capabilities to survive and overcome, and change the ways in which they cope psychologically, biologically, and socially (Heller & LaPierre, 2012; Levine, 2010a; van der Kolk, McFarlane, & Weisaeth, 2006). Today, PTSD is a common disorder (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kessler, Berglund, Demler, Jin, & Walters, 2005). According to the United States Department of Veterans

10 Affairs’ National Center for PTSD, Veterans of the United Stated Military receiving compensation from the Department of Veterans Affairs for service-connected PTSD diagnoses increased by 222% from 1999 to 2010.These 386,882 servicemen and women represent an alarming increase in veterans seeking treatment, and may not reflect individuals who decline to seek treatment because they fear loss of compensation (Marx & Holowka, 2011). According to Kessler et al. (2005), approximately 5.2 million adults have been given a diagnosis of PTSD within a given year, reflecting a small percentage of individuals who have experienced trauma to some degree. By addressing the physiological reactivity effectively, it is likely that other aspects of the traumatic syndrome can secondarily become reduced (Heller & LaPierre, 2012; Levine, 2010a; Ogden, Minton, & Pain, 2006; van der Kolk, McFarlane, & Weisaeth, 2006). Individuals with symptoms of PTSD seem to be unable to release the hold that their traumatic events have on them (Heller & LaPierre, 2012; Janet, 1889; Lee et al., 1996; van der Kolk, 2002; van der Kolk, Hopper, & Osterman, 2001; van der Kolk & van der Hart, 1991). These traumatic memories do not appear to lose the impact of their effects on the person; in fact, the recall and retelling of the event perpetuates the symptoms as though the body and mind are experiencing them again (Heller & LaPierre, 2012; Lee et al., 1996; van der Kolk, 2002). The dissociative reactions of traumatized individuals creates a barrier to the ability to integrate the traumatic memories, and therefore the memories remain active and influential. In the Diagnostic and Statistical Manual (DSM), PTSD was a newly added diagnosis in DSM-III (American Psychiatric Association, 1980). In every revision since, the diagnosis has been expanded and changed. The newly revised DSM-5 now includes dissociative and aggressive symptoms

11 as part of the PTSD cluster of symptoms (American Psychiatric Association, 2013; Paris, 2013). Individuals who did not exhibit symptoms of posttraumatic stress disorder showed typical extinction patterns of their traumatic memories (Lee et al., 1996). Moreover, traumatization appears to be caused by the amygdala, located in the limbic system, which is responsible for interpreting the emotional meanings of one’s experiences (Solomon & Siegel, 2003; van der Kolk, 2002). Additionally, trauma becomes imprinted somatically, resulting in an overcoupling of fear that causes a freeze-immobility response and arousal originating from unexpressed survival-based reactions (Levine, 2010a). Recent research has shown that this system is a major contributor to how persons diagnosed with PTSD interpret nonthreatening situations as life-threatening. These fear reactions cause the individual to react to innocuous situations as though the traumatic events are happening in the moment (Lee et al., 1996; van der Kolk, 2002; Solomon & Siegel, 2003). Several seminal works have laid the foundation for treatment of trauma and the understanding of the biological reactions. An important part of trauma research that has allowed a new perspective and deeper understanding of what happens within the individual after the event is outlined in Herman’s (1997) Trauma and Recovery. In Traumatic Stress, van der Kolk, McFarlane, and Weisaeth (2006) discuss individual and cultural historic responses, adaptations, and treatments to trauma. This collection of work has acted as a springboard from which many other modalities have emerged and are still relevant. The authors explore how unresolved trauma creates a constellation of symptoms of emotional and physical experiences that replay in an ongoing and relentless circuit in the body, and become the basis of recurring PSTD symptom sequelae. This is exacerbated by the inability to find a narrative release because the trauma is encoded in

12 memory subcortically rather than encoded in autobiographical memory. When individuals remember their traumatic events, they actually re-live the trauma through sensation or affective experiences (van der Kolk, 2002). This process has been shown to impede one’s ability to describe the traumatic experience because unresolved trauma diminishes Broca’s area activation. This finding explains that while individuals who have experienced traumatic events are re-experiencing their trauma, there remains a disconnect in the individual that blocks them from understanding and perceiving why they are feeling a past event so vividly (Rauch et al., 1996). Memory appears to play a large part in posttraumatic stress reactions. A study conducted by the research division of the United Stated Army entitled A 50-Year Prospective Study of the Psychological Sequelae of World War II Combat sheds light on an important aspect of the effects of trauma on memory (Lee et al., 1996; van der Kolk, McFarlane, & Weisaeth, 1996). The veterans who did not show signs of PTSD were shown to have normal patterns of memory extinction, but the veterans who suffered from PTSD did not exhibit the same signs of memory extinction. In fact, their memories of the traumatic events appeared to remain quite intact, to the point that the recurring effects were re-traumatizing in themselves. This evidence supports van der Kolk’s (2002) claims that trauma remains unresolved within the limbic system, where it continues to torment the traumatized individual. However, approaches to trauma treatment continue to focus exclusively on cognitive and behavioral manifestations and not somatic experiences (Heller & LaPierre, 2012; Levine, 2010a; Ogden, Minton, & Pain, 2006). The effect that unresolved trauma has on an individual’s ability to integrate representational operations in the brain can leave him or her vulnerable to posttraumatic

13 symptoms. This causes a neural integration impairment that results in the inability to regulate the nervous system and resolve the traumatic experiences (Solomon & Siegel, 2003). In order to understand the effects that memory has on trauma, it is important to outline different kinds of memory. Explicit memory, also referred to as declarative memory, refers to the possession of a conscious awareness of past events, and involves semantic memory based on facts and episodic, autobiographical memory. Autobiographical memory relays a sense of time and self. When explicit memory retrieval occurs, the individual has the subjective experience of recollection (Solomon & Siegel, 2003). In contrast, implicit memory does not involve the subjective experience of recall. It has no sense of time or self. It involves emotional and behavioral elements and is sometimes referred to as procedural memory (Solomon & Siegel, 2003). Because some parts of implicit memory are unconscious, the opportunity emerges for trauma to become imprinted on the psyche-soma. When trauma occurs, the individual engages in procedures that are reactions to an overwhelmed and stressed system and therefore becomes encoded as implicit processes that originate from biological attempts at survival (Levine, 1996). These survival attempts try to find a way to complete, resolve, and integrate the traumatic experience. Because trauma is implicit, it is necessary to allow the procedural memory to reach completion in the body so that the explicit narrative can be formed. Through the process of re-membering, Levine believes the implicit experience can become integrated into an understandable and conscious language (1996). Despite the traditional delineation between the treatment of mind and body in Western psychology (Seligman & Reichenberg, 2007), new somatic approaches have

14 been developed to encourage the integration of psyche and soma (Heller & LaPierre, 2012; Levine, 2010b; Moss, 2009; Ogden, Minton, & Pain, 2006). Traditional Approaches to Treatment of Trauma The traditional approaches to treating trauma have been based on Evidence-Based Best Practices. Evidence-based practices in routine mental health settings are outlined as treatments and interventions backed by scientific evidence that show positive outcomes for patients (Drake et al., 2001). According to Seligman and Reichenberg (2007), the current empirically supported practices for posttraumatic stress disorder (PTSD) are exposure therapy, cognitive therapy, and anxiety management training (AMT). Cognitive-processing therapy (CPT) is a hybrid of exposure therapy, AMT, and cognitive restructuring (Resick & Schnicke, 1992). Stress inoculation therapy (SIT) has been practiced to treat PTSD, and combines education and training in muscle relaxation, thought-stopping, breath control, guided selfdialogue, covert modeling, and role playing (Seligman & Reichenberg, 2007). Eye movement desensitization and reprocessing (EMDR) can be effective with PTSD (Shapiro, 1989), though it is not listed as an effective a treatment for PTSD as AMT or CBT (Keane & Barlow, 2002). The main thrust of this approach is to release the individual from resistant patterns of the past through eye movements, clicking sounds, or hand-taps (Shapiro, 2001). This intervention uses a structured approach that integrates some elements of somatically and interactional-based therapies, as well as cognitivebehavioral, psychodynamic, and person-centered therapies (Shapiro & Maxfield, 2002). In the eight-phase process of EMDR, the goals are to effect the greatest changes in the shortest period of time, while avoiding a decrease in the emotional overwhelm or

15 functioning of the patient (Shapiro & Maxfield, 2002). Eye movement is one component in the approach. Dual attention stimulation is incorporated into elements of other psychological orientations, and a focus is given to physical awareness, images, affective responses, personal beliefs, and interpersonal systems during the EMDR process. Different approaches are emphasized depending upon the pathology category, enabling a customization of treatment to each individual (Shapiro, 2001). Prolonged-exposure therapy was developed for treatment of PTSD and is a therapist-guided approach to the recollection of traumatic memories. The intervention is performed in a controlled manner in order to allow patients to gain control over their reactions to the memories, thoughts, and affective reactions connected to the trauma. The premise behind this approach is that the slowly progressive exposure allows the individual to perform a realistic evaluation and build an understanding of their reactions in the hopes that they may reintegrate them into their lives in a productive manner (Foa, Hembree, & Rothbaum, 2007). The emotional process is often disrupted, retarded, and stalled by adverse reactions to traumatic experiences because they are incongruous with past schemas (Heller & LaPierre, 2012). Therefore, cognitive approaches to trauma treatment have shown success in reducing symptom sequelae (Jaycox, Zoellner, & Foa, 2002). Cognitive behavioral therapy (Beck, 1995) integrates both cognitive and behavioral therapies. CBT builds on the foundations of learning theory and highlights how reactive thoughts and distorted thought processes create distortions in thinking and subsequently their reactions. By imparting to individuals how their patterns of thinking perpetuate their difficulties,

16 CBT empowers the patient with knowledge and applicable tools to change faulty patterns and reduce symptoms (Beck, 1995). Cognitive processing therapy (CPT), a derivative of cognitive-behavioral therapy (CBT) (Beck, 1995), was originally developed by Patricia Resick to treat rape victims. It was later expanded to treat individuals experiencing PTSD (Resick & Schnicke, 1992). CPT employed elements of exposure but focused more on cognitive procedures in order to shift the negative focus of thinking patterns that have resulted from traumatic events. Anxiety management training (AMT, Suinn, 1990) is another derivative of cognitive behavioral therapy (Beck, 1995). The conditioning approach is focused on the reduction of symptoms of anxiety through

an initial purposeful arousal and the

subsequent training of the individual to learn modalities to reduce them by reacting to their activation with relaxation and feelings connected to success. This approach is based on theories that individuals can condition themselves to respond to in order to reverse reactions to external cues through reciprocal inhibition, and is not considered to be a desensitization method (Suinn & Richardson, 1971). Somatic Approaches to Treatment of Trauma The mind-body, psyche-soma split is a developing area of study (Katz, 2010). Researchers believe that lack of early parental attunement predisposes an individual toward psychosomatic illness, and that the body will speak out symptomatically (Herman, 1997; Kalsched, 1998; Lee at al., 1996; Levine, 2008; Levy, 1945; Ogden, Minton, & Pain, 2006; Stolorow, 2007; van der Kolk, McFarlane, & Weisaeth, 2006; Woller, Leichsenring, Leweke, & Kruse, 2012). Cognitive inabilities to contain and maintain affective states create a dissociative split, which causes somatic implications

17 (Solomon & Siegel, 2003; van der Kolk, McFarlane, & Weisaeth, 2006). This developmental theory was mirrored in the 50-year study conducted on combat veterans, which outlined that the individuals who had histories of pre-adolescent stress or trauma tended to develop PTSD (Lee et al., 1996). When individuals are inundated by memories caused by traumatic events, it has been shown that intolerable affect overwhelms the system. Traditional talk therapy attempts to access and resolve these reactions through a language system, which is unavailable (Solomon & Siegel, 2003; van der Kolk, McFarlane, & Weisaeth, 1996). When affect can be processed through the body first, and then through a cognitive process, efficacy is increased (Heller & LaPierre, 2012; Leitch, Vanslyke, & Allen, 2009; Levine, 2010b; Ogden, Minton & Pain, 2006; Solomon & Siegel, 2003). Thus, research that examines alternate modalities to talk therapy may offer the answer to long-term treatment for trauma. Another approach to body-centered healing incorporates the work of Levine (2010a, 2010b) and his development of Somatic Experiencing, which is based on the premise that trauma overwhelms the nervous system. Levine builds on the foundation of biology and an understanding of why animals in the wild do not develop the posttraumatic symptom constellations that humans tend to develop. The physiological release of energy in the body must be resolved in order to psychologically resolve the trauma and re-regulate the nervous system. Somatic Experiencing allows the slow titration of noticing, unlocking, and releasing this trapped energy through a process Levine referred to as “pendulation,” a shifting back and forth from activation and discharge of locked traumatic energy.

18 Levine (2010a) has observed in his last four decades of studying trauma that the nature of the fear-induced immobility carries with it feelings of shame, blame, and rage. Circumstances in which inescapable trauma has occurred, such as accidents, attacks, war, horror, abusive relationships, and developmental neglect or abuse, often leave the individual with feelings that they could or should have done more to protect or defend themselves, when often it was their immobility or compliance that protected them. Additionally, during traumatic experiences, individuals react to their overwhelmed systems by engaging in procedures that result in encoded implicit memory processes. In attempting to resolve these reactions, the trauma energy becomes encoded somatically (Levine, 2010a). According to Levine (2010a), when individuals have experienced trauma, what often occurs is that paralysis, helplessness, and misdirected rage cause an ongoing complex of mental, emotional, and physical disabilities (Heller & LaPierre, 2012; van der Kolk, McFarlane, & Weisaeth, 1996). Imagine a frightened animal that feels the need to protect itself by snarling and snapping at others in spite of its need for help. Utilizing the Somatic Experiencing model, the therapist can assist the individual in building new meanings. This approach makes available a shift in paradigm that allows the healing of trauma while concurrently supporting biochemical and nervous system re-regulation. This leads to strategic uncoupling of fear from immobility and consequently a rapid recovery and resilience (Levine, 2010a). Levine offered that the healing of trauma, which is often referred to as “reassociation” by more mainstream fields of study, is actually a biological, bodily process that both humans and animals experience, and carries with it psychological effects

19 (Levine, 2008). Levine postulated that trauma is a physiological process that occurs first somatically and instinctually, and lastly moves to the mind. If the natural process is resisted or thwarted, the complete energy discharge process that must occur in order to restore functioning to normal cannot take place. Due to the implicit nature of trauma, procedural memory processes need to occur in order for the body to complete its physiological trajectory and develop an explicit narrative (Levine, 1996). Through the application of Somatic Experiencing, practitioners assist traumatized individuals to complete this process and return to normal functioning (Levine, 2010a, 2010b). Ogden et al. (2006) conceptualized a sensorimotor psychotherapy approach that incorporates the traditional aspects of therapeutic perceptions but that additionally integrates somatic responses as an imperative piece of treatment. Through this approach, the body and its reactions are given equal importance and are both considered to be aspects of psychodynamic approaches to treatment. The term sensorimotor psychotherapy is used to indicate an approach to treatment that integrates the somatic approaches usually used by body-based psychotherapies, exclusive of the use of touch. Similar to Somatic Experiencing (Levine, 2010a), sensorimotor psychotherapy is based primarily in the theories developed by Pat Ogden (Ogden et al., 2005), Peter Levine (1996) and Bessel van der Kolk (2002). Sensorimotor psychotherapy focuses on how the traumatic past histories of individuals is an integral part of how these individuals view themselves and their environments, which in turn affects the ways in which they relate and communicate with the world around them. If unresolved bodily experiences are left unchecked, they create uncontrollable emotional and physical sensations that are often triggered by external

20 reminders. By building on traditional psychotherapeutic approaches while integrating somatic interventions, sensorimotor psychotherapy helps unresolved trauma in the body become resolved. Focusing the treatment on the establishment of the patient’s development of a sense of safety and self-care, resources are developed that assist the individual in understanding, reframing, and eventually resolving their past traumatic experiences (Ogden et al., 2006). These emphases parallel some of the psychodynamic focus on treatment of trauma. Psychodynamic Approaches to Treatment of Trauma The first person to conceptualize trauma into a comprehensive theory constellated around traumatic stress was Pierre Janet (Janet, 1889; van der Kolk, 2002). He postulated that stress was the cause of individuals who experienced “vehement emotions” during a trauma (Solomon & Siegel, 2003; van der Kolk, McFarlane, & Weisaeth, 1996). The level of intensity that these reactions caused was an impediment to resolving the trauma, and therefore rendered these individuals unable to organize the event as a linear, integrated experience. These reenactments emerged in the form of behaviors that included aggression, somatic reactions including pain, and intense emotions, causing unrelated events to trigger the same somatic and emotional reactions that the initial event created (Janet, 1919/1925; Solomon & Siegel, 2003). This was the first comprehensive approach to understanding how high affective arousal affects the minds of individuals who have experienced trauma and how reactions of the affected individuals results in an inability to assimilate the traumatic experiences (van der Kolk, McFarlane, & Weisaeth, 1996). Janet offered that the psychological effort necessary to push the memories of the trauma out of the conscious mind and sequester

21 them in unconscious holdings was so debilitating that it began to erode the resiliency of the psyche. What resulted was a diminishment in the ability to function in a healthy and whole manner (van der Kolk & van der Hart, 1989). Janet labeled the array of memories and experiences that become an individual’s schema, the “subconscious”; the guiding principles that allow one to navigate through one’s world and cope with associated challenges (Janet, 1904; van der Kolk & van der Hart, 1989). Freud resuscitated Janet’s theory of “vehement emotions” and conceptualized this as being at the core of traumatic neuroses. He conceptualized trauma as similar to creating a lesion in the psyche, which in turn caused a resistance to healing (Kalsched, 1996). He explicated his theories in two different models (Krystal, 1978); the “unbearable situation” model, and the “unacceptable impulse” model, in which the psyche developed protective mechanisms in order to keep the individual from becoming overwhelmed (van der Kolk & van der Hart, 1989). In 1893, Freud and his mentor, Joseph Breuer, researched and wrote about the relationship between memory, trauma, and therapeutic approaches to resolution. The focus of their inquiry was regarding what made traumatic memory resistant to the typical extinction of nontraumatic memory. Breuer and Freud (1893) believed that in more typical situations, the individual resolved any emotionally distressing symptoms associated with the event through physically discharging emotional energy. They thought that further processing through the telling and retelling of the event was important for the resolution of the emotional distress. They theorized that the “inescapable shock” aspect of trauma created neuroses in individuals that could only be alleviated by verbal and

22 physical expression. This idea eventually led to the birth of Freud’s “talking cure” (van der Kolk, 2002). Differences in therapeutic approaches are an important aspect of conceptualizing trauma resolution. In a comparison of manualized psychodynamic techniques with manualized cognitive behavioral therapy techniques, Blagys and Hilsenroth (2000) determined through empirical examination of recordings and transcripts from actual sessions that psychodynamic psychotherapy differed from other therapies in seven specific features: (1) Focus on affect and the patients’ emotional expressions; (2) exploration of patients’ tendencies to avoid specific topics, as well as behaviors that impede the therapeutic process; (3) the recognition of patterns and themes in the behaviors, thoughts, feelings, relationships, and experiences of patients; (4) focus or emphasis on past experience; (5) focus or emphasis on the interpersonal experiences of the patient; (6) an emphasis on the therapeutic relationship; and lastly, (7) an examination and exploration of the dreams and fantasies of the patient. These empirically unique differences of psychodynamic approaches to therapy account for key curative factors that are essential to positive changes in therapeutic outcomes, and are markedly different from manualized cognitive behavioral approaches (Luborsky, Barber, & Crits-Christoph, 1990). Successful psychodynamic psychotherapy should not only relieve symptoms but also cultivate the development of resources and greater psychological capabilities. These capabilities can include interpersonal relationships, along with greater capacity to tolerate ranges of affect, develop deeper understanding of self and others, navigate difficult

23 situations, develop greater self-esteem, and have more proficient and effective functioning in the world (Shedler, 2010). A recent study on meta-analysis examined the efficacy of somatic disorder-related short-term psychodynamic psychotherapy. This study examined 1,870 patients presenting with various somatic complaints, including immunological, musculoskeletal, gastrointestinal, respiratory, and cardiovascular issues (Abbas, Kisely, & Kroenke, 2009). The analysis examined 23 separate studies. The results showed a .59 effect size for improvement in somatic symptoms, and a .69 effect size regarding improvement in general psychiatric symptoms. Healthcare utilization data reported that 77.8% showed significantly reduced healthcare usage due to psychodynamic psychotherapy. Several studies outlined how psychodynamic studies are widely practiced as a treatment for PTSD (Heller & LaPierre, 2012; Moss, 2009; Ogden et al., 2005; Shedler, 2010; Woller, Leichsenring, Leweke, & Kruse, 2012). Psychodynamic object-relational approaches are valuable in the treatment of trauma, and this orientation has a long history of trauma study going back to its Freudian roots (Breuer & Freud, 1925/1965). Typically, the favored techniques to encompass the transference and countertransference issues that commonly arise in complex trauma patients are the applications of psychodynamic therapies, as well as attachment disorder and mentalization issues that are the underpinnings of these types of trauma cases (Heller & La Pierre, 2012; McWilliams, 2004 Moss, 2009; Shedler, 2010; Woller, Leichsenring, Leweke, & Kruse, 2012). Woller, Leichsenring, Leweke, and Kruse (2012) outlined four important elements as the cornerstones of integrating trauma treatment with psychodynamic therapy. This process includes the focus on the following; (1) modifying the symptoms

24 and influencing the interpersonal relating patterns that are prevalent in the current functioning symptom patterns; (2) resourcing orientation, and the activation of internal resources that affect the patient’s coping and stress management skills; (3) connecting to positive states of well-being, as well as the improvement of coping skills and the activation of positive resource states; and (4) the well-being and positive mental health of the therapist. This process points to the danger of vicarious traumatization and professional burnout, which is increased when working with individuals who have experienced trauma. Woller, Leichsenring, Leweke, and Kruse (2012) proposed a three-phase process for the integration of psychodynamic treatment with trauma resolution. In Phase 1, the focus is on stabilization and structure-building, which includes the building of a solid therapeutic alliance. Some severely traumatized patients may never proceed past Phase 1, especially if they continue to live in a traumatizing environment. But when stability and emotion regulation are achieved, movement to Phase 2 occurs, which focuses on the processing of the trauma and utilizes a “screen technique” in which the therapist and patient repeatedly “watch” the childhood trauma as though it were an old movie, so that the affect is managed, discussed, and processed together, keeping the patient from becoming overwhelmed. The capacity of the patient to differentiate between experiencing and observing is strengthened, allowing integration without causing overwhelming reactions. Moreover, used in Phase 2 is “inner child” work. Phase 3 involves a reintegration phase, in which more typical psychodynamic techniques are employed. Carr (2011) suggested a model for the treatment of adult-onset combat-related PTSD based on a short-term, intersubjective approach. Based on his theory, the adult-

25 onset traumas are inherently different from developmental or childhood-based trauma experiences, which are the types of traumas that psychoanalysis was evolved to resolve. Stolorow’s (2007) work influenced Carr’s perspective of trauma treatment, and was inspiration for Carr’s six-phase short-term approach to intersubjective treatment of trauma. Carr’s phases 1 through 6 include an initial consultation and consent to treatment; addressing shame as the therapy begins; exploration of the phenomenology of trauma; seeking an intersubjective key with the patient; providing a relational home for the patient; and termination. Although Carr sees the value in psychodynamic approaches, he acknowledges that there is a shortage of evidence and popularity as compared to other, more empirically based approaches. Carr emphasized the importance of the therapeutic relationship in the treatment of trauma, which is an important part of the reduction in symptoms and vehicle in which to process the traumatic experiences. Stolorow (2007) based his theories on the possibility that human existence is built into the basic constitution of human beings and the understanding of emotional trauma. Stolorow conceptualizes developmental trauma as “an experience of unbearable affect” and explored how developmental trauma takes on enduring, crushing meanings when relationally conceived (Stolorow, 2007, p. 9). In intersubjective systems theory, affect is a large part of understanding the human mind and interrelatedness, and trauma is framed as an “unendurable affect” (p. 10). The focus moves from the traumatic event itself to the attunement of the experience between the individual and the therapist. It is the “holding context” (p. 10) that allows the trauma to become integrated. With some individuals, the lack of attunement becomes shame, which further impairs the individual in achieving the attunement needed to reintegrate the trauma experience. The loss of time is a disruption

26 of an individual’s sense of time and results in the loss of continuity between the past, present and future. Within a psychodynamic lens, this is viewed as dissociation. Heller and LaPierre (2012) discussed the effects that early trauma has on the ability to self-regulate, and how this in turn compounds issues with self-image and the capacity to engage in meaningful relationships. The researchers developed a model called NeuroAffective Relational Model (NARM) that focuses on five biologically based core needs and five adaptive survival styles. The five core needs outlined are (1) connection, (2) attunement, (3) trust, (4) autonomy, and (5) love-sexuality. When these needs are met early on, individuals develop the capacity to meet these needs in adult relationships. But when these core needs are not met in childhood, compromised psychological and physiological development occur, such as lack of self-regulation, self-esteem, and sense of self. The five adaptive survival styles that the NARM model addresses are (1) the connection survival style, (2) the attunement survival style, (3) the trust survival style, (4), the autonomy survival style, and (5) the love-sexuality survival style. In adulthood, there is a direct correlation between the degree of bodily disconnectedness and the types of adaptive survival styles that control and influence behavior. Kalsched (1998), a Jungian analyst who specializes in early trauma, discussed that patients who have experienced early trauma have experienced unbearable psychic pain— a pain so unbearable to the immature ego that it cannot process the experience symbolically or contain the capacity to integrate the early trauma. Traumatic affect may be symbolized and personified in dreams as violent and horrifying imagery in order to give voice to the archetypal rage and fantasy of the defensive system. In working through and resolving early trauma and its subsequent archetypal defenses, the self-care-system

27 (SCS) can begin to loosen its grip and the spirit can return to the psyche. Success or failure is dependent on the commitment of both patient and therapist in the process of psychotherapy. In his later work, Kalsched (2010) outlined that too much past focus has been on verbal and interpretive treatments, and that psychoanalysis has neglected feelings, somatic reactions, and the therapeutic relationship. More focus needs to be on how trauma distorts the perception of the inner world. Object-relations theory and interpersonal theory offer understanding of how trauma develops but do not provide methods for resolving the trauma. Kalsched discussed the self-care system that moves into place when acute or chronic failures in the relational environment do not provide attunement and empathic responses. When the infant cannot tolerate these failures, trauma occurs. The SCS then becomes actively defensive, and does not allow trust in others for fear of becoming vulnerable to re-traumatization. The SCS becomes an “autoimmune disease of the psyche” (Kalsched, 1998, p. 91). In her book Trauma and Recovery, Herman (1997) suggested that when individuals undergo a traumatic experience, it impacts them on every level. These experiences change the perspectives and expectations to the development of interpersonal relationships. How a person views oneself in relation to others is forever changed, and even the belief systems that sustain us on a basic level are called into question. These damaging relational effects are a primary effect of trauma, along with the damage to psychological structures of the self, as well as the attachments and meanings that connect the individual to their community. The inner schema no longer fits in with the outer experience. Herman offered that the recovery process follows fundamental stages:

28 establishing safety, reconstructing the trauma story, and restoring the connection between survivors of trauma and their support systems. Herman discussed therapeutic techniques for resolving trauma through the telling of the trauma story, outlined in two “highly evolved” techniques referred to as “direct exposure” and “flooding”. Herman (1997) stated that the flooding technique outcomes show reductions in intrusive and hyperarousal symptoms that accompany PTSD. Also reported were reduced nightmares and flashbacks, and an overall improvement in anxiety, depression, problems with concentration, and psychosomatic symptoms. Intrusive and hyperarousal symptoms were reported static 6 months after treatment (Keane, 1990). Herman offered that there were shown to be limitations to this approach to treatment; although the intrusive and hyperarousal abated after flooding, dissociative symptoms and social withdrawal did not improve, nor the effects on marital, social and work problems. Though deemed a necessary part of recovery, flooding alone is not enough (Herman, 1997). Conclusion Prevalence of posttraumatic disorders associated with trauma is increasing (van der Kolk, McFarlane, & Weisaeth, 2006). Though evidence-based treatments appear to help initially, evidence shows they do not appear to offer long-lasting effects (Carr, 2011; Ogden, Pain, Minton, & Fisher, 2005; Schottonbauer et al., 2008; Shedler, 2010; van der Kolk, 2006). Having insight into trauma and understanding is not enough. Evidence suggests that utilizing an integrative approach of body-based interventions with psychodynamic treatments facilitates efficacy of clinical interventions in the treatment of trauma (Heller & LaPierre, 2012; Moss, 2009; Ogden, Pain, Minton, & Fisher, 2005). Retraumatization often occurs during conventional talk therapy, which likely reactivates

29 implicit traumatic memory. Because the implicit memory process is an unconscious process, the result is a re-activation of physical sensation, dysregulation, and feelings of shame, rage, helplessness, and fear (Levine, 1996; van der Kolk, 2006). Somatic Experiencing is a body-based approach that applies bottom-up processing, addressing the trauma in the body from the same direction in which it was encoded. The wisdom of the body’s innate processes accessed through Somatic Experiencing addresses the individual’s somatic symptoms first, and tracks sensations and reactions without deeply revisiting the traumatic experiences (Levine, 2010a). In addition, psychodynamic psychotherapy attends to the unconscious processes related to traumatic experiences and addresses cognitive and executive functions, which can further elucidate the person’s reactions to trauma. However, more research is needed regarding the integration of body-based approaches with psychodynamic psychotherapy treatment approaches. Therefore, this study documented findings of psycho-dynamically focused practitioners who are integrating somatically based interventions with individuals who have experienced symptoms of unresolved trauma, in order to generalize outcomes and resolutions of posttraumatic stress symptoms.

30 Chapter 3 Research Methodology The methods used in this study were a case study research approach (Stake, 1995; Yin, 2004). A case study approach is a method of inquiry that involves an in-depth examination through the research of a program, event, activity, or process, involving one or more individuals. The cases in a case study are within a system bounded by time and activity. Information is collected by researchers utilizing a multitude of data collection procedures over a sustained period of time, such as interviews, observations, documents, and reports (Creswell, 2007. This qualitative approach is relevant when the research question seeks to pinpoint “how” or “why” regarding the workings of a particular social phenomenon (Yin, 2004). In contrast to quantitative case studies, qualitative case studies utilize an in-depth investigation of an individual experience through the interviewing process in order to build an understanding of a phenomenon through researching narratives of individuals who fit case criteria (Creswell, 2007). In this study, qualitative case studies were chosen in order to investigate the experience of integration of psychodynamic psychotherapy together with a Somatic Experiencing approach. Qualitative case studies thus could include individuals who represented a range of experiences and training backgrounds related to this integration. Participants According to Stake (1995), a small number of qualitative case studies (i.e., participants) can facilitate an understanding of a phenomenon. In this pilot study, participants were licensed psychodynamically oriented psychologists who also used the body-oriented modality of Somatic Experiencing® with clients for the treatment of resolving trauma. Case studies allow for more focused collection of data within an overall

31 small sample of population (Creswell, 2007. The method for locating and inviting therapists to participate in the research was through the Somatic Experiencing website, which offered a “Find A Practitioner” link and listed practitioners certified in varying modalities. From this website, several clinicians were contacted, and referrals were received from practitioners who were unable to participate. A series of brief phone interviews were conducted in order to narrow the pool of possible participants. From this pool, the 4 participants were selected based on their experience and level of licensure. The criteria for selecting the participants were licensure as clinical psychologists and a psychodynamic psychotherapeutic orientation, and Somatic Experiencing® certification. Because the community of integrative practitioners was so limited, the backgrounds of the participants were presented jointly rather than individually in order to protect their confidentiality. Four participants were interviewed for this study and included 3 men and 1 woman between the ages of 40 and 68. Participants worked in settings such as private practice, hospitals, community counseling centers, and served on the faculty at major universities and the Somatic Experiencing Training Institute (SETI). Participants ranged in their level of experience as psychologists from 25 to 40 years, and as Somatic Experiencing® practitioners from recent certification to over 23 years of experience. Two participants were trained in EMDR, and specialty focus among the participants ranged from trauma, LGBT issues, group process, and Jungian-focused work. Additional emphases were mindfulness-based psychology, supervision of graduate students, and facilitation of Somatic Experiencing® and other trauma resolution trainings both in the United States and abroad.

32

Data Collection The data was collected through a series of interviews with four psychodynamically oriented psychotherapists and certified (SEP) Somatic Experiencing® Practitioners (Levine, 2007). Each practitioner focused on therapeutic treatment of clients who have been attending regular integrated sessions of psychotherapy and Somatic Experiencing®. The researcher audio-recorded the interviews with the practitioners and transcribed them verbatim to hard copy. The procedures for conducting the collective case study approach (Stake, 1995; Yin, 2004) followed specific steps. First, the researcher compiled a list of possible participant-practitioners from the Somatic Experiencing® website. The researcher focused on practitioners who held a doctoral-level license and degree in psychology who were psychodynamically, Jungian, or psychoanalytically oriented. Additionally, these participants had completed the 3-year Somatic Experiencing® training and were currently utilizing both modalities in a private practice setting. Each participant was interviewed in person in each practitioner’s private office settings. Interviews varied in length from 30 minutes to 2.5 hours. These interviews were recorded by a digital recording device and transcribed by hand in order to highlight themes, similarities and differences (Yin, 2004). The recordings were erased after transcription to hard copy was completed. Transcriptions were conducted by the researcher and not sent out to external resources.

33

Data Analysis Data analysis was conducted by focusing on the details of each individual case by providing a detailed history and themes within each case called a “within-case analysis.” This step was followed by a “cross-case analysis,” in which interpretations and themes were connected (Merriam, 1988). The case study protocol included an introduction and overview to the case study approach. The purpose, data collection procedures, case study interview questions, and a guide for the case studies report were stated, including an outline, format for the data, and bibliographical information (Yin, 2004 p. 69). This process was implemented in order to increase reliability of the case study research. The information gathered from interviews was then systematically categorized into different themes. The themes were formed into subthemes and grouped with corresponding validating evidence. The themes were derived from feedback from each participant regarding his or her experiences in treating patients for trauma symptoms and conceptualization of the effects of the integration. The participant’s interpretation of the effects of the integration was used to highlight similarities and differences between participant experiences. Additionally, an important objective of this study was to obtain the ability to construct naturalistic generalizations in order to develop deeper understandings of the topic. These types of conclusions were obtained through learning experiences gathered from individuals and the individual perspectives gleaned from personal and vicarious knowledge (Stake, 1995, p. 85). In order to facilitate this process, it was important to include a breadth and depth of information regarding the collection and process of the research so that the reader has the opportunity to arrive at alternate

34 conclusions and can therefore contrast their own internal processes and hypotheses to the outcomes of the researcher (Stake, 1995, p. 87). The expectation was that this study would generate meaning and deeper understanding of treatment, which could lend support for the integration to be considered for new evidence-based best practices. Additionally, the objective was to outline nontraditional approaches that could illustrate healing of trauma symptoms through the re-regulation of nervous-system processes. Reflexivity The role that reflexivity played in the formulation of this research project is varied. My own process involved having awareness around how much emphasis to place on different aspects of the study. As the case researcher, I represented several roles including teacher, interviewer, reader, storyteller, advocate, counselor, consultant, and evaluator (Stake, 1995, p. 91). My work was affected as the research progressed, and personal reflections became valuable sources of reference. My process included journaling and recording dreams that emerged in order to create deeper meaning and understanding of how I was affected by the research and documentation process. The role of case researcher was larger than the traditional role of providing information and educating others regarding the topic of integrating body-based treatments with psychodynamic psychotherapies. It additionally involved advocating new perspectives and methodologies to improve the healing and re-regulation of individuals who have experienced trauma but were unable to resolve the experiences. Additionally, I was able to integrate new learning experiences into my own approach to trauma treatment through having completed the Somatic Experiencing ® training (Stake, 1995, p. 95).

35

Ethical Considerations There were several ethical considerations for this research study. As a researcher, I was required to interpret and make assertions regarding what was a logical thread of evidence. The necessity to remain aware of personal interpretations and the possibility of bias toward those outcomes was considered (Stake, 1995, p. 103). Interviews were conducted with the clinicians working with individuals who have experienced trauma. Concerns with the study included interruptions to treatment plans or the flow of the treatment in order to accommodate the study. By working with the practitioners rather than the patients, the risk of interruption to treatment was minimized. To maintain confidentiality, a letter of consent was provided stating that participation in the study was voluntary; the participants retained the ability to decline participating at any time. A signed consent form was obtained from each participant prior to being interviewed. This form outlined the purpose of the study, confidentiality, and the ability to withdraw from the study at any time.

36

Chapter 4 Results This chapter includes results from interviews conducted with 4 individuals who are licensed psychologists and Somatic Experiencing® practitioners. The results of this study were separated into three main themes and several subthemes. These themes and subthemes were compared and contrasted to emphasize similarities and differences. Each case was subjected to a within-case analysis, followed by comparing them in a cross-case analysis to further highlight themes, similarities, differences, and naturalistic generalizations (see Table 1). The main overarching themes were outlined as Approach Effects of Integration, and Evidence-Based Best Practices. The Approach theme discussed how each individual participant built a personal construct around their unique application of the integration of psychodynamic psychotherapy and Somatic Experiencing® based on experience, background, emphases of specific disciplines, and therapeutic choices. The main theme of Approach was further broken down into the following subthemes; Personal Rationale and Background, Use of Touch, and Psychoeducation and Supervision Implications. Personal Rationale and Background discussed how the background of each participant affected clinical choices and how those choices resulted in differing approaches to treatment. Theoretical backgrounds for participants were psychodynamic approaches, but within that orientation were differing emphases and directions, as well as a discussion regarding how each participant conceptualized his or her individual application of the integration of psychodynamic psychotherapy and Somatic Experiencing®.

37 Somatic Experiencing® training is a modality that is available to individuals with clinical background as well as body-working experience. This modality draws from diverse practitioner backgrounds, which cause implications of utilizing the physical touch components explicated in the advanced year of the training. This may be ethically problematic for those with clinical backgrounds. Therefore, the use of touch is explored as part of this study. Psychoeducation and supervisorial implications are discussed as the final subtheme in the Approach section. The decision to use psychoeducation can vary from practitioner to practitioner, and can depend on the circumstance in which the teaching opportunity arises. This theme is discussed in more detail later in the chapter. The second main theme, Effects of Integration, was separated into four subthemes entitled External Client Relational Changes, Resolution or Reduction of Symptoms, Value of Integration, and Risks and Deficits of Integration. External Client Relational Changes reflected how the participants view the effects that utilizing the integration of psychodynamic psychotherapy and Somatic Experiencing® has on the external relational lives of patients. The Resolution or Reduction of Symptoms subtheme discussed the type and degree of resolution and reduction that has occurred as a direct result of utilizing the integration of psychodynamic psychotherapy with Somatic Experiencing®. The Value of Integration subtheme highlighted how this approach is viewed by the practitioners in contrast to other approaches, and why this is viewed to have value over other modalities. Lastly, the Risks and Deficits of Integration subtheme discussed what these participants outlined as general and specific risks and deficits of utilizing the integration of psychodynamic psychotherapy with Somatic Experiencing®.

38 The subthemes that emerged from the main theme of Evidence-Based Best Practices were as follows: Need for Well-Designed Studies and Limitations and Biases in the Study. The discussion of the Need for Well-designed Studies focused on criteria for what study participants felt was important for development for research, for evidencebased best practices. The final subtheme, Limitations and Biases in the Study, outlined possible challenges that could limit the acceptance of the integration as an evidencebased best practice. Approach This section of the chapter outlines the results of the 4 participants interviewed for this case study. These 4 individuals were experienced psychodynamically oriented psychologists. Participants were licensed and were Somatic Experiencing® clinicians who applied both approaches with patients for the resolution of trauma symptoms. Quotes from the 4 participant interviews were employed in order to illustrate each participant’s unique perspectives. Personal rationale and background. The study participants felt that the integration of psychodynamic psychotherapy with Somatic Experiencing® benefitted individuals who were experiencing the symptoms of posttraumatic stress. Each participant had a unique conceptualization that affected his or her personalized approach to treatment. One participant conceptualized his personal approach from the organization of the patient and proposed: People’s bodies and their symptoms and their minds are integrated so it’s one and the same to me . . . the holy Grail of SE is not sensing and tracking, it’s sensation and sound so, when a patient comes in, I’m primarily tending to where they’re organized and I’ll use whatever system seems to be out of their strength to use, and for some people it’s like supporting a cognitive change that leads to a somatic resolution.

39

Thus, according to this clinician, it is the patient that initiates the pace and direction of the work through whatever somatic responses and activations emerge initially in each session. Another conceptualization was expressed by a different participant who felt the practitioner-patient approach involved an intuitive conceptualization of integrating psychodynamic psychotherapy and Somatic Experiencing®. She further indicated, I don’t do straight SE, I really listen to people in the first session, I don’t do a trauma background, I often have started my therapy sessions with someone who is hurting, and I want to hear their story. Sometimes I will later take a trauma history . . . I think that there’s something very special about being able to track, and also, I think almost every SE practitioner has done work on themselves, so that they have internalized the process. This participant expressed her perspective of utilizing the integration of psychodynamic psychotherapy and Somatic Experiencing® as the importance of viewing psychodynamic approach as the unconscious, and to attend to dreams and symbols in order to further facilitate understanding of the patient. Another participant’s approach was based on his belief that early developmental trauma affects an individual’s ability to self-regulate. He shared, Well, the thing is, is that SE in itself is great for shock trauma, but it doesn’t have a developmental, it really isn’t a developmental work. Psychodynamic therapy is a good model for understanding human development, but it’s not a very good psychotherapy because it’s not experiential and it doesn’t reference the body, in terms of the way it’s traditionally done. So, the integration; and NARM is more than just an integration of those two, but those two pieces are integrated in there, the integration, as to both approaches, the combination is much stronger than the separate units. Than either one alone. This participant’s approach is based in the belief that Somatic Experiencing® can bring about some self-regulation, but developmental issues need to be more deeply addressed in order to assist an individual to resolve symptoms of trauma. These examples

40 demonstrate how diversely each practitioner can successfully integrate psychodynamic psychotherapy and Somatic Experiencing® and retain one’s unique application and approach to the work. Use of touch. Another theme that emerged from the integration of psychodynamic psychotherapy and Somatic Experiencing® was use of touch in the clinical setting. The use of touch is covered in the final advanced module of the Somatic Experiencing® training, but there is an additional 1-year extensive training offered to Somatic Experiencing® students having completed at least the intermediate level of training. Practitioners struggled with the ethical implications that the use of touch might involve. Two of the 4 participants have taken and received the postgraduate training certificate. It is these 2 participants who are the most open to utilizing touch in their practice. One of the 2 participants who had completed the touch training certification held the view that using touch in psychotherapy was constellated around his concept that touch can often move patients through being “stuck” and dissolve barriers in the work. And that the impact touch has on the length of time needed for trauma resolution also played an important role in his decision to incorporate touch into his work. He stated that, “Touch therapy reduces the number of sessions because it is so immediate and I have had just mind blowing work with the touch; just mind blowing.” He further made the statement that “touch therapy, which is an aspect of SE (Somatic Experiencing®), is being reformulated now, as it used to be unethical to touch patients. It needs to become unethical not to touch the patient.” Another participant, who had also taken and completed the touch training certification, endorsed the use of touch in her work, but to a lesser degree. She proposed,

41 I use touch as an adjunct. It’s not my major modality. I took the touch training . . . I found it amazing, but I don’t . . . I thought there was a lot of pressure to get a massage table, and my office is small, and I just didn’t want to change my practice in that direction. But, uh, I feel that I use it for support . . . I use a lot of touch to comfort, support, and it does things that . . . if there’s a moment where touch seems to fit, that kind of supportive thing. This participant explained that she feels that touch can be helpful when utilized by an empathic clinician. Though some patients respond more positively than others, overall she has not had any patient state that the use of touch was intrusive or bothersome. She further explained, “I use it intuitively and I’m always careful in checking it out. It’s appropriate when people don’t feel invaded.” Another participant believed that touch in psychotherapy has value as a useful modality, stating that “I believe in touch, I think it’s a very useful modality” but feels that because of the possibility of transference and countertransference issues, enlisting an outside resource to provide the touch component for trauma symptom resolution may be an alternate method of including touch in treatment. Additionally, he offered, “I also think that the psychodynamics of touch are not being taught.” As for his own application of touch in his work, he uses it “very little,” and further stated, In the very few times when I use it, which is very sparingly, I obviously do it because I think it will be particularly helpful . . . I just . . . the only touch that I do, mostly the only touch that I ever do is when someone needs some containment, I just do a little bit of containment of the shoulders because it’s so powerful. But even then, I’m careful with it because I’m aware of all of the things that are involved when you touch somebody. The last participant did not implement any touch in his work and had not completed the touch training certification. This participant reported that he was reluctant and skeptical regarding the use of touch in psychotherapy but remains open to attending the additional

42 touch training in the future. He advocated the use of self-touch or utilizing objects to create physical resistance such as a yoga ball, to induce regulation in individuals, but has not yet incorporated this extensively into his practice. He stated; “There’s enough stigma to psychotherapy. . . . You have to be kind of thoughtful about it. I don’t really ever see myself pulling out a table and doing body work in a session, I’m just not comfortable with that.” Psychoeducation and supervision implications. The practitioners who participated in this study felt there were advantages to providing psychoeducation to their supervisees and patients. One participant stated, “I will offer psychoeducation without actually naming schools of thought; you know, like technique names; you’ll talk to them about what’s happening biologically or physically with them exactly. Less about technique naming.” He concurred with another participant who believed that Somatic Experiencing® should be integrated into a graduate school education for therapists. Other participants regarded psychoeducation as high in importance and stated, I give them a lot of psychoeducation, I never will do an SE intervention without talking about it first. You know, I’ll talk about how these things are held in the body, I’ll talk about how nervous system, the autonomic nervous system, and how it operates normally, and how things can get stuck, and how this work helps to facilitate the body’s natural response to a threat, and how it gets stuck, and if they’re responded positively, it just kind of becomes part of the work. Maybe more psychoeducation comes later, but usually, I’ll just ask . . . I’m careful to introduce SE work before I use it, because I want someone to feel informed before I use it. I want them, as a consumer, to have choice. So, I could see that for some clients, they might be turned off by it. These are examples of how the study participants determined the importance of utilizing psychoeducation during the course of the integration of psychodynamic psychotherapy and Somatic Experiencing®.

43 Effects of Integration The effects of the integration were addressed in this section. The participants discussed positive and negative values of the integration of psychodynamic psychotherapy and Somatic Experiencing®. Additionally addressed were changes in symptoms as a result of the use of the integration, and the speed at which change occurred. External client relational changes. Participants felt that the integrative approach had positive identifiable effects on the interpersonal relationships of their patients as a result of the clinical work. One participant discussed that the release of symptoms in the body, paired with the healing of developmental trauma allowed for his patient to engage in interpersonal relationships more effectively. This participant shared that it was “Amazing. It’s pretty amazing.” Another participant concurred with his statement that some patients just get better, they don’t really care why, and they’ll thank me and they’re done. Other patients come in and report how they’re doing what I’m teaching them, you know, for themselves. You know, they’re actually learning the skill, and they’re applying it. Participants were united in their belief that the integration of the two modalities of psychodynamic psychotherapy and Somatic Experiencing® illustrated benefits that extended beyond the patients and into their interpersonal relationships. Resolution or reduction of symptoms. Additional benefits that developed were the reduction or resolution of trauma symptoms, including recurring nightmares, hypervigilance, somatic-based reactions, irritability, insomnia, and various other symptoms that occur in accordance with a diagnosis of posttraumatic stress disorder. Participants felt that the integration of psychodynamic psychotherapy and Somatic

44 Experiencing® reduced or resolved symptoms in most of their patients, and usually some resolution occurred nearly immediately. Some participants felt it would be difficult to ascertain if these reductions or resolutions occurred within the integration of both modalities or while utilizing one of the two methods, because the implementation of the treatment varied depending upon the needs of the patient. Others described the integration as too interwoven to consider them separately. According to one participant, “Sometimes you see changes right away. One [session]. Sometimes, and it depends on what kinds of changes. Sometimes it takes a long time before something moves.” Another participant made the point that immediate results are noted “when a person connects to it and is open to the work, you can go to it through some somatic work and you get some reaction, immediately you see something.” Therefore, participants described that utilizing the integration of psychodynamic psychotherapy with Somatic Experiencing® rapidly reduced or resolved trauma symptoms. Value of integration. Participants felt that in addition to the resolution and reduction of symptoms, they identified what they believed to be values that emerged as a direct effect of integrating psychodynamic psychotherapy and Somatic Experiencing®. According to one participant, I think it reduces the amount of time the patient needs to be in therapy and I think it rapidly accesses a process that allows a much deeper relief to occur in the patient without their necessarily knowing what we’re doing. Another participant highlighted, I can see that when the patient is open and responsive, the benefit from the combined is just, it moves things along, literally. It goes from constriction to flow. And they just cofacilitate each other really

45 beautifully. So, the benefit is more effective therapy. And people are also learning skills that they can use in their everyday life . . . when you add SE work, you’re adding another dimension to the therapeutic relationship, because you’re relating from one physical being to another physical being . . . I think that’s another benefit is that it improves the therapeutic relationship. Thus, the effects of integrating psychodynamic psychotherapy with Somatic Experiencing® were thought by the participants to show improvements within the relationships of the patient, including the therapeutic relationship itself. Also noted by participants was reduction in the time needed in treatment to identify positive changes. Risks and deficits of integration. The risks and deficits of integrating psychodynamic psychotherapy with Somatic Experiencing® were mainly focused on limitations or misjudgments by the therapist, limitations or resistance of the patient, and fear of re-traumatization of a patient. One participant made the point that even the developer of the approach will not reach every individual every time, and that individualized approach and presence can either affect rapport or the lack of rapport. She shared, You know, I’m going to be really, fully honest with you. I don’t think the SE and SE training is so clear that somebody; anybody, does something called SE; the people I did not succeed with, I always wonder, would Peter [Levine]? Would it have worked differently? I have seen people who have worked badly with Peter; and this sort of thing. It certainly wasn’t because he didn’t know SE. Then, with someone else, that maybe knew something or was maybe more empathic with certain people’s issues; were able to work with that person; so when we say SE works, or SE doesn’t work; it’s a complicated question. Another participant remarked on the conceptualization and organization of each modality: Well, the thing is, is that SE in itself is great for shock trauma, but it doesn’t have a developmental [piece], it isn’t a developmental work. Psychodynamic therapy is a good model for understanding human

46 development, but it’s not a very good psychotherapy because it’s not experiential and it doesn’t reference the body, in terms of the way it’s traditionally done. So, the integration . . . as to both approaches, the combination is much stronger than the separate units. Than either one alone. Additionally addressed were issues of utilizing the integrated approach on an individual who was intoxicated or experiencing effects of substances, or undergoing an acute psychotic state. However, 1 participant proposed that he has conducted integrated sessions with patients experiencing delusional states including ideas of reference, and that he has had some success, even if somewhat limited. Evidence-Based Best Practices An important component of utilizing the integration of psychodynamic psychotherapy and Somatic Experiencing® for the resolution of trauma symptoms is the consideration of evidence-based best practice, which provides validation of approaches and treatments. There were varying responses by the participants, and based on these responses, the subthemes are broken down into the following categories. Need for well-designed studies. Participants outlined criteria for Somatic Experiencing® acceptance as an evidence-based best practice by the following criteria. Conducting well-designed studies would increase support by gaining testimonials from experienced Somatic Experiencing® practitioners. Implementing and documenting the outcomes of controlled studies were discussed. Additionally, standardizing the application of the integration of SE and psychodynamic psychotherapy so that the treatment could be consistent, manualized, and regulated was deemed an important aspect. One participant proposed, So I think we need to have studies. That were well-designed and controlled, and that would demonstrate the advantages of SE before we could say it’s an

47 evidence-based best practice. I think we need evidence to go there . . . so when we develop the resources and are doing that, we’re going to be able to one day. Another participant added, What I’ve learned over time is, what you’re doing, in a way, is getting testimonial. Combine analytical SE and empirically trained background. But what I think it needs to make it evidence-based, you need to have people randomly assigned to the condition, and do some outcome studies. Additionally, this participant suggested, It’s hard to do, but I think it would be doable if you had an SE group . . . and a psychodynamic group, and if you had it standardized enough so it would be what most SE persons would do with this person. Participants concurred that before the integration of psychodynamic psychotherapy and Somatic Experiencing® could be considered as an evidence-based best practice, more research needs to be conducted that would result in the documentation of positive results for the resolution or reduction of trauma symptoms. Limitations and biases. The perspective of the participants regarding possible limitations and biases for the consideration of utilizing the integration of psychodynamic psychotherapy and Somatic Experiencing® for the resolution of trauma symptoms are the consideration of evidence-based best practice were varied. Several participants shared that despite the development of Somatic Experiencing® dating back to the late 1980s, it is only fairly recently that some studies are being conducted, and in that regard, it is still considered to be a growing protocol. One participant indicated, “Well, it’s still new. It’s still new.” Another participant discussed the importance of developing a structured protocol that can be universally applied. She stated,

48 It’s very hard to get a protocol that different people can work. This is an SE protocol, so we’re going to work that way, and we’re going to get evidence by working it with different people that have had trauma. And I think that that’s a necessary step along the way . . . I know that we need the VA to make it happen. But I didn’t want to be the researcher. Even though I’m research-based, I wanted a researcher to research SE. Not a believer. Moreover, this participant shared the importance of conducting outcome studies to further research in this area and increase acceptance of integrating psychodynamic psychotherapy and Somatic Experiencing® as an evidence-based best practice. She indicated: “I think that it has to be accomplished, that it has to be studied, even if it’s not manualized, but it’s in the form of pinning it down completely. By doing outcome studies. Lastly, this participant suggested, “So anyway . . . it’s relatively new, and each step is important along the way, and I hope that sometime some research will be done that will give more resources to places like the VA.”

Results Table 1 Approach Personal rationale and background

Participant Participant 1 2

Participant 3

Participant 4

Patientinitiated pace and direction; Somatically oriented psychology

Mindfulnessbased approaches integrated with SE and psychodynamic psychotherapy

Somatically oriented and psychodynamic psychotherapy

Intuitive conceptualization; Group dynamics, Jungian-based Psychotherapy

Use of touch

Utilizes Utilizes touch touch freely conservatively

Does not utilize touch

Rarely utilizes touch

Psychoeducation and supervision implications

Psychoeducates in order to explain biological

Always psychoeducates prior to beginning integrated

Always includes a psychoeducational component

Psychoeducates if appropriate but not always

49 processes Effects of Integration External client relational changes

sessions

Endorses positive changes relatable to integrated therapy

Endorses positive changes relatable to integrated therapy with many but not all patients

Endorses positive changes relatable to integrated therapy

Endorses positive changes relatable to integrated therapy

Resolution or reduction of symptoms

Endorses positive changes relatable to integrated therapy

Endorses positive changes relatable to integrated therapy with many but not all patients

Endorses positive changes relatable to integrated therapy

Endorses positive changes relatable to integrated therapy

Value of integration

Reduces time needed for therapy; deeper relief of symptoms Therapist moving too quickly

Integrated body experience which allows for a sense of safety in the world

Instills hopefulness, sense of relief, symptom reduction, more effective therapy Sexually molested patients

Helps individuals to self-regulate

Studies need to be welldesigned, controlled, and more resources developed

Outcome studies needed conducted by non-SE-related researchers

Needs more well-designed, controlled studies

N/A

No standardized protocols, lacks testimonials, lacks evidence and documentation

Lacks evidence

N/A

Risks and deficits of integration EvidenceBased Best Practice Need for welldesigned studies

Limitations and biases in the study

Therapist limitations

Developmental issues not highlighted

50 Chapter 5 Discussion Several authors have called for the integration of psychodynamic psychotherapy and Somatic Experiencing® because of the belief that this integration may reduce or resolve symptoms of trauma more quickly than traditional treatments and return the nervous system to regulation (Heller & LaPierre, 2012; Levine, 2010a, 2010b; Ogden, Minton, & Pain, 2006). However, further quantitative and qualitative research is needed in order to verify proposed theories. In addition, when treating individuals who have experienced trauma, typical applications include cognitive behavioral approaches, and protocols such as prolonged exposure for reduction in symptoms (Seligman & Reichenberg, 2007). However, these approaches have shown high drop-out rates and low long-term rates of resolved symptoms (Carr, 2011; Ogden, Pain, Minton, & Fisher, 2005; Schottonbauer et al.; 2008, Shedler, 2010; van der Kolk, McFarlane, & Weisaeth, 2006). Thus, it appears that further explorations of alternative approaches could expand understanding of possible pathways of working with trauma. This study included a pilot qualitative research that offered an initial investigation of a different approach to working with trauma. Specifically, this research focused on the experiences of 4 practitioners who utilized an integrated approach of psychodynamic orientation and Somatic Experiencing® for the long-term resolution or reduction of trauma symptoms. The study used the expertise of 4 participants through a series of separate interviews in order to obtain an in-depth perspective of each participant’s conceptualization of the risks and benefits of the integration of psychodynamic orientation and Somatic Experiencing®. The data were analyzed and compared and contrasted by themes in order to allow similarities and differences to emerge.

51 This chapter has been divided into several sections. In Section 1, the focus is on themes found throughout the analysis: Personal Rationale and Background, Use of Touch, and Psychoeducation and Supervision Implications. Section 2 focused on the Effects of the Integration, and was separated into subsections entitled External Client Relational Changes, Resolution or Reduction of Symptoms, Value of Integration, and Risks and Deficits of Integration. In the final section, Evidence-Based Best Practice was divided into subsections entitled Need for Well-Designed Studies and Limitations and Biases. Lastly, this section provides review of clinical implications of the findings as well as suggestions for future research. Approach to Treatment The participants interviewed for this study were licensed psychodynamically oriented psychologists and were Somatic Experiencing® practitioners. The psychodynamic distinction is important because the unique way in which each practitioner implemented his or her orientation impacts approach to treatment as well as how an integration of psychological theory with Somatic Experiencing® may vary from practitioner to practitioner. A study conducted by Norcross and Prochaska (1983) discussed why psychologists are drawn to certain theoretical approaches. The research illuminated that practitioners choose specific orientations based on their graduate training, personal values, and clinical experience, and that these decisions are predicated by deliberate preferences. Similarly, in this study each participant outlined the choices they made as a practitioner and how these choices resulted in differing approaches and applications. Specifically, theoretical background for participants fell under the overarching umbrella

52 of psychodynamic approaches. The study showed that within that orientation there are differing emphases and directions, as well as how each participant conceptualized his or her individual application of the integration of psychodynamic psychotherapy and Somatic Experiencing®. The therapeutic stance affected the way practitioners conceptualized each case, made choices in sessions, and approached the overall course of treatment, which were consistent with the findings of Norcross and Prochaska, (1983). Therefore, it appears that both personal and clinical experiences directly influence how and why individuals are drawn toward the theoretical modalities, such as those focused in this study. Participants offered unique perspectives to conceptualizing approaches with patients, which were also influenced by their personal and professional choices of clinical orientation. The study showed that intuition was discussed by most participants regarding how treatment was approached and that decisions were made regarding direction, speed, and depth of the work. The use of intuition was shown to be an important component in building trust and rapport. However, misguided or misinterpreted intuition was emphasized as having adverse effects and cause breaks in the therapeutic frame. The use of intuition in clinical practice is consistent with findings by other scholars (e.g., Jeffrey, 2012; Jeffrey & Fish, 2011; Herman, 1997). Specifically, intuition in clinical practice has been defined as a knowledge that emerges without obvious rational thought (Jeffrey, 2012 or a “feeling of knowing with certitude on the basis of inadequate information and without conscious awareness of rational thinking” (Shirley & Langan-Fox, 1996, p. 564). Intuition in a clinical setting included “gut” feelings as well as other similar somatic reactions by practitioners that contribute to clinical decisions.

53 Intuitive insight was derived from “hunches” based on little information or nonrational feelings from the practitioners (Jeffrey, 2012; Jeffrey & Fish, 2011). Jeffrey (2012) outlined that clinicians use intuition to guide themselves, conceptualize cases, and “helping clients to identify feelings, reading subtle, nonverbal behaviors and picking up on what is not being communicated” ( p. 4). However, intuition is an imperfect process of relational exchanges, and should be used with caution and clinical awareness. In addition, maintaining an awareness of the potential risks and benefits to the patient is imperative (Jeffrey, 2012). Not surprisingly, the study participants indicated that malattunement between clinician and patient created therapeutic frame breakdowns or rapport setbacks, which were viewed to be not unlike the lack of parental attunement, which has been shown to predispose individuals to long-term somatic manifestations. This participant view is consistent with several perspectives offered by authors such as by Herman (1997), Kalsched (1998), Lee et al., (1996), Levine (2008) Levy (1945), Ogden, Minton, and Pain (2006), Stolorow (2007), van der Kolk, McFarlane, and Weisaeth (2006), and Woller, Leichsenring, Leweke, and Kruse (2012). Additionally, participants indicated that fractures in the therapeutic alliance are generally expressed by patient dropout rates, which was consistent with the findings highlighted by Carr (2011). Another theme that emerged was the discussion regarding the proportion of psychodynamic psychotherapy that was utilized as compared to the percentage of Somatic Experiencing® applied during each session. Participants in this study elucidated that some patients presented with moderate issues and did not engage in more vulnerable work until a higher comfort level was reached. The successful treatment integration of

54 how much Somatic Experiencing

was practiced within a psychotherapy session by the

practitioner naturally followed the patterns presented by the patients and intuitive decisions made by the practitioners. If the balance between psychodynamic psychotherapy and Somatic Experiencing® was incongruous with the needs of the patient, participants highlighted that disruptions occurred during the treatment process, which adversely affected trust and rapport. Scholarly literature to date has not included studies that highlight how clinicians manage integration, especially integration of talk- and body-based therapeutic modalities. However, integration outlined in this study is consistent with theoretical suggestions that balance between processing cognitive and somatic experiences related to trauma are important (Solomon & Siegel, 2003; van der Kolk, McFarlane, & Weisaeth, 2006). Thus, participants highlighted that integration of psychodynamic psychotherapy with Somatic Experiencing® may not always be a good fit for every patient. Some individuals receiving treatment are not comfortable focusing their attention into their bodies, and therefore do not respond positively to directives to do so. Other individuals may be more open and willing but simply do not respond well or effectively to the protocol. Undoubtedly, this finding is similar to studies that show that in any clinical work involving integration of multiple approaches, the clinicians seek to respond to failures in treatment and modify their work to meet clients’ goals and needs. Another theme that emerged focused on ways different types of trauma led clinicians to choose a specific way in integrating the psychodynamic psychotherapy and Somatic Experiencing®. Participants explained that based on the type of trauma experienced by the individual, they developed different protocols for approaches to the

55 integration of Somatic Experiencing® and psychodynamic psychotherapy. The participants’ experiences were consistent with conclusions by Carr (2011), Heller and LaPierre (2012), and Levine (2010a), as well as Ogden, Minton, and Pain (2006). The practitioners also discussed the importance of the psychodynamic therapeutic contribution that they believed this approach offers to the relational aspect of trauma. The participants suggested that when paired with the foci areas of Somatic Experiencing®, integrated approach may create a more holistic modality. Participants continually highlighted that this integration may be more effective together than either approach separately. The contribution of this study expands the theoretical work that has encouraged the integration (e.g., Heller & LaPierre, 2012; Levine, 2010a, 2010b). Another significant aspect of the findings focused on the use of touch in a psychotherapeutic setting, which remains controversial among mental health practitioners (Bonitz, 2008; Smith, Clance, & Imes, 1998; Westland, 2011). Because Somatic Experiencing® is a modality that emphasizes both clinical and body-focused treatment, the use of touch emerged as part of this study. The study participants highlighted widely varying perspectives regarding their personal use of touch in a therapeutic setting. Some participants felt that the use of touch was important in the integration of psychodynamic psychotherapy and Somatic Experiencing®. However, several participants expressed discomfort with utilizing touch in their work. It is possible that these differences highlight the continued controversies regarding touch in psychotherapy. It is also possible that such integration can be accomplished with or without the use of direct physical touch. Within Somatic Experiencing® community, these differences have been highlighted (e.g., Levine, 2010a; Ogden, Minton, & Pain, 2006). However, this study provides an initial

56 overview of clinicians’ own accounts of how talk-based and somatically based approaches are integrated in practice. Specifically, the participants shared that whether or not to use touch and specific methods of using touch were grounded in perceptions of trust and rapport with clients. Because psychodynamic psychotherapy emphasizes the primary importance of therapeutic relationship and the healing aspects of safe and trusting connection, clinicians integrated somatic interventions (e.g., light body tapping) only when it was consistent with their perception of therapeutic relational stability. Other practitioners who utilize somatic approaches, such as Bonitz (2008), Milakovich (1998), and Westland (2011), also discussed importance of rapport and trust. However, this study elucidates how a therapeutic approach that is specifically relationally focused can be integrated with a somatic approach to trauma. Another aspect that appeared distinct in the findings was practitioners’ use of psychoeducation as a tool in their work with clients. Unlike in traditional psychodynamic therapy, these practitioners embraced the importance of helping clients understand the physical repercussions of traumatic events, and the interaction of the somatic and mental aspects of trauma. Other scholars, such as Phoenix (2007), discussed the role of psychoeducational focus in somatic approaches to clinical work. However, less has been written about how clinicians who integrate insight and relationally based approaches with somatic approaches include client education. In this study, it appeared that the clinicians believed that an inclusion of an educational component to treatment provided clients with better resources for dealing with symptoms related to trauma.

57 Effects of Integration This subsection discusses the different ways that the integration of psychodynamic psychotherapy and Somatic Experiencing® are successful or unsuccessful in effecting change in individuals experiencing trauma symptoms. Participants discussed interpersonal changes, changes in symptoms, and the value of change in their patients’ lives. Finally, participants highlighted the risks and deficits of utilizing the integration of psychodynamic psychotherapy and Somatic Experiencing®. Although scholars such as Heller and LaPierre (2012), Solomon and Siegel (2003) and van der Kolk, McFarlane, and Weisaeth (2006) shared their perceptions of how somatic work can be applied to working with trauma, this study expands these previous theoretical contributions to include perceptions of clinicians who actively involve psychodynamic conceptualization and treatment modalities as well. One of the distinct results of the study showed that consistent with the psychodynamic framework, the integrated approach not only addressed individual trauma symptoms but also the relational aftermath of traumatic events. Since trauma affects the cognitive inability of individuals to manage affective states in a healthy manner, participants noted that when the symptoms decreased through treatment, their patients became more able to engage in their relationships in healthier ways. This result was consistent with theoretical suggestions by Solomon and Siegel (2003) and van der Kolk, McFarlane, and Weisaeth (2006). Participants also emphasized trauma-based symptom reduction, including recurring nightmares, irritability, insomnia, somaticized reactions, and hypervigilance. Participants elucidated that changes or reduction in symptoms became apparent as early

58 as the initial session of integrated treatment, and continued to show a decrease in trauma symptoms as sessions progressed. Participants maintained that it was the integration of both modalities rather than the use of one or the other approach individually that resulted in the decrease of trauma symptoms. Others, such as Kalsched (2010), Leitch, Vanslyke, and Allen (2009), Ogden, Minton, and Pain (2006), as well as Solomon and Siegel (2003) have written about the importance of multi-focused approach to treatment of trauma. Participants also reflected on the risks and deficits of integrating psychodynamic psychotherapy and Somatic Experiencing® related to practitioner limitations, lack of attunement, or misjudgments that may cause fractures in the therapeutic relationship. They indicated that they perceived limitations of treatment arise when they experienced resistance from patients or when working with patients who were not well matched for the integrated approach. Similarly, Carr (2011) and Woller, Leichsenring, Leweke, and Kruse (2012) discussed such limitations. Participants also discussed lack of training in integrative and specifically, in somatic approaches, as a limitation to provision of care to clients. Participants were reflective of their integrative approach in the context of current emphasis on evidence-based treatments. The study participants had varying responses regarding the integration of psychodynamic psychotherapy and Somatic Experiencing® as an evidence-based best practice. There was a general agreement that there was value in achieving that goal and attaining the validation of the integration as a standardized and accepted treatment. However, finding nonbiased researchers to produce that research was an area of concern as well as the ability to structure the application of an integration that has widely varying applications.

59 Participants highlighted the lack of current research currently available that substantiates the efficacy of integrating psychodynamic psychotherapy and Somatic Experiencing®. Additionally, participants emphasized the importance of gaining testimonials and implementing and documenting results from well-designed studies in order to increase evidence. Studies conducted by Drake et al. (2001) offer initial review of evidence of somatic approaches. However, standardizing the application in order to obtain a structured protocol was discussed as an important adjunct in order to maintain standardized applications. Others, such as Carr (2011), Dozois (2012), and Wilczynski (2012), similarly discussed difficulties in examining the evidence of somatic approaches as well as integrative practices. Clinical Relevance The clinical relevance of this research study is multidimensional. Traumatic stress has been shown to impact those affected in significant and long-term psychological, social, emotional, and somatic ways (Bower & Sivers, 1998; Heller & LaPierre, 2012; Levine, 2010a; Scaer, 2006; Solomon & Siegel, 2003; Solomon, Laor, & McFarlane, 1996; van der Kolk, 2002). Considering the alarming and dramatic increases in individuals affected by posttraumatic stress, treatments have been criticized regarding their efficacy and effectiveness (Kessler et al., 2005 Marx & Holowka, 2011). The growing suicide rates among combat veterans with symptoms of trauma have been used as a call for the development and application of new approaches to treatment of trauma (Sher, Braquehais, & Casas, 2012).

60 Integrating psychodynamic psychotherapy and Somatic Experiencing® may be one such novel approach, which integrates two significant and well-developed approaches to treatment of trauma. This study highlights that such integration is varied based on the practitioners who implemented the treatment as well as on the patients who receive it. However, the most significant aspect of this approach is in how the practitioner and the patient may work together intimately, listening to the client’s somatic communication and trusting the body’s ability to find its own resolution. In addition, psychodynamic focus in such integrative psychotherapy allows therapists to stay attuned to the relational dynamics, underlying functioning, and complex emotional communication of trauma-based experiences. The use of touch in a session may also be a powerful amplifier or the stimulus that instigates movement toward healing. This research challenges assumptions about the use of touch in psychotherapy as universally negative, and encourages clinicians to consider appropriate use of touch within a context of relational awareness of trust and rapport. This study also highlights that clinicians can include psychoeducation, which can affect the therapeutic relationship. Within a therapeutic environment, psychoeducation may provide a normalization of what occurs during the session such as stress and activation of trauma symptoms. Psychoeducation may be considered useful for individuals to understand how the biological actions occur and highlighting possible reactions that may be experienced during the course of a session. Therefore it is important from a standpoint of educating patients regarding their own process as well as in facilitating trust in the therapeutic relationship. Lastly, clinicians may explore integrative practices in order to address multiple and complex reactions of trauma not

61 only within the session but within relational context of clients’ lives outside of psychotherapy. Future Research Because the integration of psychodynamic psychotherapy and Somatic Experiencing® is relatively new, it is important to include further investigations of such integration. Individuals who have experienced the work first-hand, such as those included in this study, understand the impact this treatment has, but the approach is still relatively unknown in the field of trauma treatment. Specifically, further studies are needed regarding the mechanisms of change and the dynamic influence of integration. Moreover, it may be important to examine the integrative approach in work with diverse communities. Specifically, little is known whether such an integrative approach may be useful in working with growing veteran population. Lastly, it may be important to develop studies that refine understanding of integrative approaches as well as those that contrast integration of non-psychodynamic treatment (e.g., cognitive behavioral) together with somatic approaches. Personal Meaning At the time I first began to be interested in trauma as my clinical focus, my main experience had been family members who had experienced developmental trauma, and I was fascinated by how resilient some individuals were and how others were not. I experienced a powerful dream in 2009: a huge citrine crystal point I was carefully holding suddenly shattered, revealing within it a figure of a one-armed man. This dream connected with my perceptions of the integration of body and mind, physical and psychological health, wholeness and limitations. This dream consistently informed my

62 journey into the field of trauma. When I started the Somatic Experiencing® training 3 years ago, I wanted to focus my dissertation on traumatic stress. In a lecture I attended given by Peter Levine in 2011, I was moved to hear an Egyptian myth that elucidates typical cultural understanding of trauma. In this myth about the goddess Isis and her husband/brother Osiris, Osiris could only be healed from his traumatic dismemberment by being “re-membered” or put back together by Isis. Trauma, as Levine explained, may be healed by remembering, by the fact that as human beings we need to remember in both psychological and physiological spheres of the self in order to let go. In my experience as a psychotherapist, I have become aware that most individuals experience trauma. I also learned that the body holds within it the wisdom to reregulate itself if individuals can learn to allow the process of healing to unfold naturally. The study further informed me about the ways that an in-depth psychodynamic therapy can be integrated with an emphasis on listening to and including the body within the treatment. It seemed to me that on one hand, traditional psychodynamic therapies excluded the focus on the body, whereas many current somatically focused approaches overemphasized the inclusion of cognitive-behavioral approaches. However, this study elucidated the distinct combination of approaches that address deeply and profoundly human experience of trauma. As a clinician, I feel encouraged to further examine such integration in my work, and to support further research on this integration within the mental health community.

63 References Abbas, A., Kisely, S., & Kroenke, K. (2009). Short-term psychodynamic psychotherapy for somatic disorders: Systematic review and meta-analysis of clinical trials. Psychotherapy and Psychosomatics, 78, 265-274. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed., text revision). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., text revision). Washington, DC: Author. Arnsten, A. E. (1998). The biology of being frazzled. Science, 280, 1711-1712. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford. Blagys, M. D., & Hilsenroth, M. J. (2000). Distinctive activities of short-term psychodynamic-interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice, 7, 167-188. Bonitz, V. (2008). Use of physical touch in the “talking cure”: A journey to the outskirts of psychotherapy. Psychotherapy Theory, Research, Practice, Training, 45(3), 391-404. Bower, G. H., & Sivers, H. (1998). Cognitive impact of traumatic events. Development and Psychopathology, 10, 625-653. Breuer, J., & Freud, S. (1893). On the physical mechanism of hysterical phenomena: Preliminary communication. In J. Strachey (Ed. & Trans.), Standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 1-181). London, England: Hogarth. (Original work published 1956) Breuer, J., & Freud, S. (1965). Studies on hysteria. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 1-335). London, England: Hogarth Press (Original work published 1925) Bryant, R., Harvey, A., Guthric, R., & Moulds, M. (2000). A prospective study of psychophysiological arousal, acute stress disorder, and posttraumatic stress disorder. Journal of Abnormal Psychology, 109, 341-344. Carr, R. B., (2011). Combat and human existence: Toward an intersubjective approach to combat-related PTSD. Journal of Psychoanalytic Psychology, 28(4), 471-496. Christianson, S., & Loftus, E. F. (1987). Memory for traumatic events. Applied Cognitive Psychology, 1, 225-239.

64 Courtois. C. A., & Ford, J. D. (2009). Treating complex traumatic stress disorders: An evidence-based guide. New York, NY: The Guilford Press. Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among five approaches. Thousand Oaks, CA: Sage. Crocq, M. A., & Crocq, L. (2000, March). From shell shock and war neurosis to posttraumatic stress disorder: A history of psychotrauma. Dialogues in Clinical Neuroscience, 2(1),47-55. Damasio, A. (1999). The feeling of what happens. New York, NY: Harcourt, Brace. Dozois, D. J. A. (2012). Psychological treatments: Putting evidence into practice and practice into evidence. Canadian Psychology, 54(1), 1-11. Drake, R. E., Goldman, H. H., Leff, H. S., Lehman, A. F., Dixon, L., Mueser, K. T., & Torrey, W. C. (2001). Implementing evidence-based practices in routine mental health service settings. Psychiatric Services, 52(2), 179-182. Ellis, P. S. (1984). The origins of war neurosis. Part I. Journal of the Royal Navy Medical Service, 70, 168-177. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences; Therapist guide. New York, NY: Oxford University Press. Heller, L., & LaPierre, A. (2012). Healing developmental trauma: How early trauma affects self-regulation, self-image, and the capacity for relationship. Berkeley, CA: North Atlantic Books. Herman, J. (1997). Trauma and recovery. New York, NY: Basic Books. Janet, P. (1889). L’automatisme psychologique. Paris, France: Alcan. Janet, P. (1904). L’amnesie el la dissociation des sovenirs par l’emotion. Journal de Psychologie, 1, 417-453. Janet, P. (1925). Psychological healing (Vols. 1-2) (C. Paul & E. Paul, Trans.). New York, NY: Macmillan. (Original work published 1919) Jaycox, L. H., Zollner, L., & Foa, E. B. (2002). Cognitive behavior therapy for PTSD and rape survivors. Psychotherapy and Practice, 58(8), 891-906. Jeffrey, A. (2012). The clinical intuition exploration guide: A decision-making tool for counselors and supervisors. The Family Journal: Counseling and Therapy for Couples and Families, 20(1), 37-44. Jeffrey, A. J., & Fish, L. S. (2011). Clinical intuition: A qualitative study of its use and experience among marriage and family therapists. Contemporary Family Therapy, 33, 348-363.

65 Kalsched, D. E. (1996). The inner world of trauma: Archetypal defenses of the personal spirit. New York, NY: Routledge. Kalsched, D. E. (1998). Archetypal affect, anxiety, and defense in patients who have suffered early trauma. In A. Casement (Ed.), Post-Jungians today: Key papers in Contemporary Analytical Psychology. New York, NY: Routledge. Kalsched, D. E. (2010). Working with trauma in analysis. In M. Stein (Ed.), Jungian psychoanalysis: Working in the spirit of C. G. Jung (p. 281). Chicago, IL: Open Court. Katz, A. W. (2010). Healing the split between body and mind: Structural and developmental aspects of psychosomatic illness. Psychoanalytic Inquiry, 30, 430444. Keane, T. (1990). PTSD among Vietnam veterans: An early look at treatment outcome using direct therapeutic exposure. Journal of Traumatic Stress, 3, 359-368. Keane, T. M., & Barlow, D. H. (2002). Posttraumatic stress disorder. In D. H. Barlow (Ed.), Anxiety and its disorders (pp. 418-453). New York, NY: Guilford Press. Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age of on-set distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048-1060. Krystal, H. (1978). Trauma and affects. Psychoanalytic Study of the Child, 33, 81-116. Lanius, R. A., Blun, R., Lanius, U., & Pain, C. (2006). A review of neuroimaging studies of hyperarousal and dissociation in PTSD: Heterogeneity of response to symptom provocation. Journal of Psychiatric Research, 12, 33-39. LeDoux, J. E. (1996). The emotional brain. New York, NY: Simon & Schuster. Lee, K. A., Vaillant, G. E., Torrey, W. C., & Elder, Jr., G. H. (1996). A 50-year prospective study of the psychological sequelae of World War II combat. Chapel Hill, NC: United Sates Army Research Institute for the Behavioral and Social Sciences. Leitch, M. L., Vanslyke, J., & Allen, M. (2009). Somatic experiencing treatment with social service workers following hurricanes. Social Work, 54(1), 9-18. Levine, P. (1996). Memory, trauma, and healing. Boulder, CO: Foundation for Human Development.

66 Levine, P. (2007). Somatic experiencing: Healing trauma. Boulder, CO: Foundation for Human Enrichment. Levine, P. (2008). Healing trauma. Boulder, CO: Sounds True. Levine, P. (2010a). In an unspoken voice: How the body releases trauma. Berkeley, CA: North Atlantic Books. Levine, P. (2010b). Resolving trauma in psychotherapy: A somatic approach. Mill Valley, CA: Psychotherapy.net. Levy, D. M. (1945). Psychic trauma of operation in children. American Journal of Diseases of Children, 69, 7-25. Lorenz, K. Z. (1981). The foundations of ethology. New York, NY: Springer-Verlag. Luborsky, L., Barber, J. P., & Crits-Cristoph, P. (1990). Theory-based research for understanding the process of dynamic psychotherapy. Journal of Counseling and Clinical Psychology, 58, 281-287. Marx, B. P., & Holowka, D. W. (2011). PTSD disability assessment. National Center for Posttraumatic Stress Disorder: PTSD Research Quarterly, 22(4), 1-6. McWilliams, N. (2004). Psychoanalytic psychotherapy. New York, NY: The Guilford Press. Merriam, S. B. (1988). Case study research in education: A qualitative approach. San Francisco, CA: Jossey-Bass. Milakovich, J. (1998). Defferences between therapists who touch and those who do not. In E. E. L. Smith, P. R. Clance, & S. Imes (Eds.), Touch in psychotherapy: Theory, research, and practice (pp. 74-91). New York, NY: The Guilford Press. Moss, E. (2009). The place of psychodynamic psychotherapy in the integrated treatment of posttraumatic stress disorder and trauma recovery. Psychotherapy Theory, Research, Practice, Training, 46(2), 171-179. Norcross, J. C., & Prochaska, J. O. (1983). Clinicians’ theoretical orientations: Selection, utilization, and efficacy. Professional Psychology: Research and Practice, 14(2), 197-208. Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York, NY: Norton. Ogden, P., Pain, C., Minton, K., & Fisher, J. (2005). Including the body in mainstream psychotherapy for traumatized individuals. Psychologist-Psychoanalyst, 25(4), 19-24. Paris, J. (2013). The intelligent clinician’s guide to the DSM-5. New York, NY: Oxford University Press.

67 Phoenix, B. J. (2007). Psychoeducation for survivors of trauma. Perspectives in Psychiatric Care, 43(3), 123-131 Porges, S.W. (2001). The polyvagal theory: Phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42, 123-146. Rauch, S. L., van der Kolk, B. A., Fisler, R. E. A., Nathaniel, M., Orr, S. P., Savage, C. R., et al. (1996). A symptom provocation study of posttraumatic stress disorder using positron emission tomography and script-driven imagery. Archives of General Psychiatry, 53, 380-387. Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60(5), 748-756. Sapolsky, R.M. (1994). Why zebras don’t get ulcers: An updated guide to stress. Stressrelated diseases, and coping. New York, NY: Freeman. Scaer, R. (2006). The traumatic spectrum: Hidden wounds and human resiliency. New York, NY: Norton. Schottonbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). Nonresponse and dropout rates in outcome studies of PTSD: Review and methodological considerations. Psychiatry: Interpersonal and Biological Processes, 71(2), 134-168. Seligman, L., & Reichenberg, L. W. (2007). Selecting effective treatments; A comprehensive, systematic guide to treating mental disorders. San Francisco, CA: Wiley. Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York, NY: Guilford Press. Shapiro, F., & Maxfield, L. (2002). Eye movement desensitization and reprocessing (EMDR): Information processing in the treatment of trauma. Journal of Clinical Psychology, 58(8), 933-946. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. Sher, L., Braquehias, M. D., & Casas, M. (2012). Posttraumatic stress disorder, depression, and suicide in veterans. Cleveland Clinic Journal of Medicine, 79(2), 92-97. Shirley, D. A., & Langan-Fox, J. (1996). Intuition: A review of the literature. Psychological Reports, 79, 563-584.

68 Smith, E. W., Clance, P. R., & Imes, S. (Ed.). (1989). Touch in psychotherapy: Theory, research, and practice. New York, NY: The Guilford Press. Solomon, M. F., & Siegel, D. L. (2003). Healing trauma: Attachment, mind, body, and brain. New York, NY: Norton. Solomon, Z., Laor, N., & McFarlane, A. C. (1996). Acute posttraumatic stress reactions in soldiers and civilians. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 102-114). New York, NY: Guilford. Stake, R. E. (1995). The art of case study research. Thousand Oaks, CA: Sage. Stolorow, R. D. (2007). Trauma and human existence: Autobiographical, psychoanalytic, and philosophical reflections. New York, NY: Analytic Press. Suinn, R. M. (1990). Anxiety management training: A behavior therapy. New York, NY: Plenum Press. Suinn, R. M., & Richardson, F. (1971). Anxiety management training: A nonspecific behavior therapy program for anxiety control. Association for Behavioral and Cognitive Therapies, 2(4), 498-510. Taylor, A. G., Goehler, L. E., Galper, D. I., Innes, K. E., & Bourguignon, C. (2010). Topdown and bottom-up mechanisms in mind-body medicine: Development of an integrative framework for psychophysiological research. Explore: Journal of Science and Healing, 6(1), 29. van der Kolk, B., McFarlane, A. C., & Weisaeth, L. (Ed). (2006). Traumatic stress. New York, NY: Guilford Press. van der Kolk, B. A. (2002). Beyond the talking cure: Somatic experience and subcortical imprints in the treatment of trauma. In F. Shapiro (Ed.), EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism (pp. 57-83). Washington, DC: American Psychiatric Association. van der Kolk, B. A., Hopper, J. W., & Osterman, J. A. (2001). Exploring the nature of traumatic memory: Combining clionical knowledge and laboratory methods. Journal of Aggression, Maltreatment, and Trauma, 4, 9-31. van der Kolk, B. A., & van der Hart, O. (1989). Pierre Janet and the breakdown of adaptation in psychological trauma. American Journal of Psychiatry, 146, 15301540. van der Kolk, B. A., & van der Hart, O. (1991). The intrusive past: The flexibility of memory and the engraving of trauma. Imago, 48, 425-454. Westland, G. (2011). Physical touch in psychotherapy: Why are we not touching more? Body, Movement, and Dance in Psychotherapy, 6(1), 17-29.

69 Wilczynski, S. M. (2012). Risk and strategic decision-making in developing evidencebased practice guidelines. Education and Treatment of Children, 35(2), 291-311. Woller, W., Leichsenring, F., Leweke, F., & Kruse, J. (2012). Psychodynamic psychotherapy for posttraumatic stress disorder related to childhood abuse: Principles for a treatment manual. Bulletin for the Menninger Clinic, 76(1), 69-93. Yin, R. K. (2004). Case study research: Design and methods. Thousand Oaks, CA: Sage.

70 Appendix A Interview Questions STRUCTURED INTERVIEW QUESTION SCHEDULE 1. How long have you been integrating psychodynamic psychotherapy and Somatic Experiencing® in your practice? 2. How long have you been a licensed psychotherapist? 3. When did you attend the Somatic Experiencing® training? 4. What are the physical and psychological symptoms patients generally experience when they first entered into treatment with you? 5. What generally were patients’ initial reactions to the treatment? 6. Do you provide psychoeducation about your approach to trauma? About Somatic Experiencing®? 7. Did patients experience any extrinsic changes in relationships or levels of functioning as a result of this work? 8. Do you feel there are individuals who are not suited for this work, or if the integration of SE and psychodynamic therapy is ever contraindicated? 9. Why do you use Somatic Experiencing over other methods/approaches targeted at reducing PTSD symptoms? Do you use any other somatic modalities? 10. What do you find useful about the approach? 11. What is the average number of integrated sessions conducted before you begin to see changes in symptoms? 12. Do you use any touch in your work? Does it make a difference in symptom resolution over a nontouch approach?

71 13. What do you feel this integration of SE and psychodynamic therapy has to offer over other approaches? 14. Would you recommend the integration of SE and psychodynamic psychotherapy to be considered as an evidence-based Best Practice? 15. Has this combination of modalities (SE and psychodynamic psychotherapy) ever been ineffective with a patient? 16. What are the risks and benefits of the integration of SE and psychodynamic psychotherapy? 17. Is there anything that I did not ask about that you would like to share or think I should know about or consider for this study?

72

Appendix B Ethics Committee Approval

Suggest Documents