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Therapists Body Awareness in the Client Therapist Interactive Process

Barbara Karlsen

May, 2012

Submitted in partial satisfaction for the Somatic Counseling Psychology Program requirements of a masters degree in Body Psychotherapy

Naropa University Boulder, Colorado, USA

Title: Therapists Body Awareness in the Client Therapist Interactive Process Author: Barbara Karlsen

Abstract Body psychotherapists focus not only on the clients body in clinical practice, but their own body as well (Field, 1989; Shaw, 2004; Stone, 2006). This moment-to-moment attention to the somatic process emerging between therapist and client is an integral part of the affective dynamics between the body psychotherapist and client, and forms a central part of the therapeutic alliance. Attending to this inner felt sense (Gendlin, 1992) requires the body psychotherapist to have a keen awareness of their bodily response, and to use their body in a sensitized matter. Using a qualitative research design, three body psychotherapists were interviewed to explore the role of their body awareness in the therapeutic relationship. Results showed the therapists body awareness forms a distinct dimension of subtle interaction within the therapeutic dyad and is used to perceive information about the client and the therapeutic alliance. Results also show that clients learn from the therapists body awareness, and the field of body psychotherapy gives clients permission to feel and move their bodies as part of the therapeutic process. Keywords: attunement, body awareness, body psychotherapy, implicit communication, non-verbal communication.

Introduction The role of the therapists body awareness in the therapeutic relationship is largely unexplored and undefined. When the body in the therapeutic encounter is written about, it is predominantly the clients body that is the focus of attention, and there is little reference to the therapists body while working in the therapeutic dyad (Shaw, 2004). In a body psychotherapy session, the therapist has to be aware of and track felt changes within their own body, while at the same time track and help to regulate the clients experience as a source of insight about their health and wellbeing (Aposhyan, 2004). This moment-to-moment attention to the somatic process emerging between therapist and client requires a particular type of attention that reaches beyond tracking body postures and movements, and requires a subtle attention to internal states. The author considers the body psychotherapists body awareness to be a key component of this subtle attention. This qualitative research study is an attempt to explore and determine a therapeutically relevant concept of body awareness and its therapeutic relevance for the body psychotherapist in the therapeutic dyad. This author defines body psychotherapist as a psychotherapist who is trained in specific skills such as body, movement and sensorimotor tracking in the process of psychotherapy. The author will define body awareness using a definition proposed by Bakal (1999), the ability to perceive, interpret, and act on the basis of internal bodily sensations(p. 78). In the therapeutic encounter, a body psychotherapist uses their sensorial experience as a source of knowledge, and recognizes that body- to- body communication between client and therapist is important (Appel-Oper, 2010; Field, 1989; Shaw, 2004; Stone

2006; Tantia, 2011). The therapist tracks his or her own nonverbal body communication by feeling into their body, and receives the patients nonverbal communications through their inner felt sense of the other (Gendlin, 1992). This paper posits that attunement, resonance and nonverbal communication are considered important therapeutic skills, and require that the therapist develop a keen awareness and understanding of their own body (Aron, 1998; Rumble, 2008;Wilkinson, 2010). The author wonders what is it about therapists body awareness that is unique and how then can it be used to facilitate or even augment the therapeutic relationship? Using data from three qualitative interviews with body psychotherapists in the Boulder, Colorado area, key concepts and themes pertaining to the therapists perception and understanding of their body awareness in the therapeutic dyad were compiled. The questions were structured in a way to help the respondents reflect both conceptually and experientially. The respondents were able to stray from the interview questions in the way they needed to describe their personal experience. All interviews were recorded, transcribed and coded. Relevant words, phrases or statements within the text were selected and categorized into Codes. Dominant and repetitive categories from the Codes were then reconfigured into Themes to capture the essence of participants key concepts from their initial descriptions. Themes were then used to formulate theoretical constructs.

Research Literature Literature on the therapists body awareness, and the therapists awareness of their bodily experience as an additional source of information in the therapeutic dyad were reviewed. While the bulk of research focuses on patients verbal and cognitive domains, there is limited reference to the relevance of attending to the therapists or the clients somatic experience

during the therapeutic encounter (Boadella, 1997; Dosamantes- Beaudry, 1997; Kepner, 1993; Shaw, 2004). When therapists somatic reactions during therapy are mentioned, it is mostly pertaining to the idea of somatic countertransference. Somatic Countertransfence is the effect on the therapists body of the patient, and the patients material (Forester, 2007, p. 129). It may be a somatic reaction to something about the patient that evokes the therapists own material (Casement, 1985). For the purposes of this paper, this author feels that classical psychotherapeutic terms like countertransference may be inadequate when addressing the role of the therapists body awareness in the therapeutic alliance. A thematic review of the literature was done to illuminate the therapists bodily experience from a neurobiological and a phenomenological perspective, and the specific processes that may account for the therapists body as an organ of information (Samuels, 1993, p. 33) and vehicle of implicit communication (Chused, 2007, p.879). Key concepts, existing theories and major theorists were reviewed.

Right Hemisphere Implicit Processes in Psychotherapy Recently neuroscience has added much to our understanding of the psychoneurobiological mechanisms involved in nonverbal implicit communications (Schore, 2005). This knowledge has expanded our view of what happens in the interactive process between client and therapist. Right hemisphere implicit structures are associated with the nonverbal, symbolic and unconscious components of neural processing as opposed to the more explicit conscious processing of the left hemisphere (Happaney, Zelazo, & Stuss, 2004). Implicit communication expressed in body movements, posture, gesture, facial expression, voice inflection, and the rhythm and pitch of the spoken words is an ongoing process in any dyad,

and can provide information about one another without explicit acknowledgement ever occurring (Schore, 2011; Dorpat, 2001). This has been referred to as implicit relational knowing- a noninterpretive mechanism of the change process that does not rely on words (Lyons-Ruth, 1998; Schore, Stern et al., 1998). Infant researchers, focusing on the facial expressions, gestures, and prosody of mother/infant pairs have recently emphasized implicit processes, and automatic actions (Beebe, Knoblauch, Rustin, & Sorter, 2005). This ongoing paradigm shift from the explicit, verbal, conscious, and analytic self to the non- verbal, unconscious, corporeal implicit self is becoming increasingly well known within the psychotherapy world and has great implications for the role of the therapists bodily presence as an intervention in the therapeutic relationship (Schore, 2011). Affect attunement is another right hemisphere implicit process that is considered a crucial aspect of the therapists interaction with the client (Beebe and Lachmann 2002; Stern et al; 1998; Tronick et al, 1998; Wilkinson, 2010). According to Wilkinson (2010, p. 45), attunement is being aware of and responsive to another. Rumble (2010) posits, the body forms a distinct dimension of attunement which can be explored by paying careful attention to body sensations (p. 130). This bodily dimension of attunement might also be considered attunement between bodies, where one body impacts another. In other words, the body is there for both for the therapist and the client, and is a direct participant in the interaction (Rumble, 2010). Affect attunement requires the therapist to track and helps to modulate client arousal, and forms a rhythmic background to the ongoing verbal exchange between client and therapist (Beebe & Lachman 2002). A key theorist in this area, Wilkinson (2010) has assembled many theoretical and scientific sources and makes a solid case for right- brain,

implicit intersubjective affective transactions(p.65). She asserts, attunement and embodied empathetic engagement are crucial in transforming the clients internal working model(Wilkinson, 2010, p. 33). A growing number of neuroscience researchers now emphasize the need for giving attention to nonverbal variables such as tone, tempo, rhythm, prosody as well as body signals in the therapists interaction with the client (Hutterer and Liss, 2006; Porges, 2009a; Schore, 2005; Stern, 2004). Schore (2008b) stresses how much more than words is involved in therapy, and endorses the view of Hutterer & Liss (2006) who emphasize the need for nonverbal variables such as tone tempo, rhythm, prosody and amplitude of speech as well as body signals to be considered as crucial aspects of the therapists interaction with the patient. According to Behnke (1995), body awareness is a right hemispheric function that helps us attend to our emotional, ongoing, bodily felt experience and to differentiate its meaning further through words.

Relational Intersubjectivity and Mutual Co-creation To posit the relational role of the body in psychotherapy, contemporary relational and intersubjective theorists were reviewed. Relational psychoanalysis privileges the role of intersubjectivity over subjectivity and objectivity (Mills, 2005). Intersubjectivity refers to a condition of interpersonal interaction. In his critique of relational psychoanalysis, Mills (2005) emphasizes dyadic attachments, affective attunement, and mutual recognition over the role of interpretation (p.155). Mills view demonstrates a relational dynamic that equally applies to the mother- infant dyad and the therapeutic encounter (Beebe & Lachmann, 2003). To help provide a theoretical framework for viewing the relational and intersubjective nature of therapy, infant researchers such as Beebe and Lachmann (2002), Schore (2004), Stern et

al., (1998) and Tronick et al (1998) were reviewed. Their focus is on two bodies in relationship whereby each partner impacts on each other. Of particular interest is their concept of affect attunement which posits that affects (intense emotions) play an intersubjective role in the early pre-verbal relationship between infant and caregiver (Stern, 1985). According to (McCluskey, 2005), the infants affective display is a powerful signal that calls on the caregiver to respond. Interactive regulation flows in both directions on a moment to moment basis so that each experiences influencing, as well as being influenced by the other (Beebe &Lachmann, 1998). The dynamics of this call and response lies in the ability of the caregiver to attune to and modulate affects within tolerable parameters (Mc Cluskey, 2005). Infant researchers with an object-relations perspective such as Winincott (1971), Mahler, Pine and Bergman (1975), focused on the physical and emotional contribution of the caregiver to the infants emotional development, and emphasized the role of the mother in the acquisition of the infants sense of embodiment. The emotional resonance of the caregiver with the infants somatic experience provides the child with a mirror that reinforces and affirms his or her sense of embodied existence (Mahler, Pine &Bergman, 1975). Infant researchers Beebe and Lachmann (2002), Schore (2004), Stern et al., (1998) and Tronick (1998) contend that this view of nonverbal interaction as a coordinated state, is as relevant to adult communication and the client /therapist interaction, as it is to mother infant communication. In somatic psychotherapy practice, body-to-body interaction, nonverbal interaction and affect attunement between therapist and client has always been an important way of working in the therapeutic relationship (Gratton, 2010).

Embodiment Most of the emphasis in somatic psychology to date has focused on subjective experience through the body rather than on embodied relationship (Dosamantes-Beaudry, 1997; Shaw, 2004). There is a prevailing attitude in body psychotherapy that the therapists physical resonances, or reactions, such as subtle changes in postures, gestures, and movements are mainly used for further information on the client (Joyce & Sills, 2001), or are viewed as physical counter-transference (Soth, 2006). To provide a broader conceptual framework for embodied phenomenon relevant to this discussion, this author will turn to Philosopher Merleau- Ponty (1963). The importance of his work in constructing a broader notion of embodiment is summed up by the following quote, it is through my body that I understand other people (1963, p. 186). Embodiment from this approach can be used in conjunction with intersubjective meaning; by providing what Gendlin (1981) might describe as inner felt sense to the others posture, gestures and movements. In a process of moment-to-moment body communication, therapist and client co-create an embodied field in which both relate with and refer to one another (Apel-Opper, 2010). Just like the infant comes to know his or her sense of embodiment through the caregivers handling (Winicott, 1971), the somatic, nonverbal intersubjective dialogue begun in infancy continues to be carried on automatically and unconsciously into adulthood, even after the acquisition of verbal language (Dosamantes-Beaudry, 1997 p. 520). Researchers Field (1989) and Shaw (2003) have investigated the therapists phenomenological experience of their bodies to gain a deeper insight into the embodied experience of the therapeutic encounter. The importance of their research has contributed greatly to the theory of embodiment and in particular psychotherapist embodiment. A major

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theme to emerge from Shaws (2004) research is that the therapists body is used as means to monitor the psychotherapeutic process, and that knowledge of the therapeutic encounter can be acquired somatically by psychotherapists(p. 285). As Stone (2006) reports, the therapists body acts as a tuning fork to resonate with the clients experience(p. 109).

Methods and Participants Participants included three licensed body psychotherapists in Boulder, Colorado. All three psychotherapists who took part in this study were selected based on the fact that they had been in private practice for at least ten years. This was considered an adequate amount of time to have experienced working with a variety of clients, and to have developed a keen sense of bodily awareness in therapy. Two out of the three participants belonged to a professional organization such as the United States Association of Body Psychotherapy, and all three participants completed a recognized body psychotherapy training program. The sample for the study was comprised of two Caucasian women and one Caucasian man. Their ages ranged from 49-55 years old. Two out of the three therapists identified themselves as body psychotherapists and one therapist identified as a somatic psychotherapist.

Procedure Five open-ended questions were asked by the researcher during the interview with the intention of obtaining information the participant deemed pertinent from his/ her experience of perceiving and using their body awareness in the therapeutic encounter. Five questions were formulated prior to the interviews, and expanded upon both conceptually and experientially in the interview process. Questions were asked in order to elicit concepts and

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personal experiences pertaining to how the therapist might describe, and report their body awareness operating in the therapeutic encounter. The interviews were digitally recorded and transcribed. Following the transcription of the interviews common quotes, words and phrases within the text were selected through a first round of coding using an in vivo coding method. The second round of coding led to themes arising from the in vivo coding using a descriptive coding method. Care was taken to incorporate all relevant information as clients described personal accounts of their body awareness while working with the client.

Results Codes are listed in Table 1. Themes arising from codes are listed in Table 2.

Table 1: Codes Interview Questions 1.a. What is your personal definition of body awareness? First Order Themes an informed, full bodied experience a streaming of information through my senses that informs me using my body to observe and listen with allowing myself to be affected attention to bodily sensations and perceptions 1.b. How do you use it in the therapeutic relationship with a client? my primary method of perception to notice how I am in relationship with my client moment to moment tracking of information on many levels

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to notice changes occurring within me and in the client 2.a. Does your body awareness inform you or signal you in the therapeutic relationship with a client? 2.b. How? sensations and impulses moving in me activation, heat, discharge feel responses in my body a lot of perceptions at once a bodily felt sense of something 3.a. How would you define body awareness? a full bodied participation a field of potency within, between and beyond a body intelligence that is tracking and recording integration of emotion, thought and physical 3.b. What does it involve? attention being fully present with a deep listening within and without connection willingness to be affected 4.a. What is your perception of the clients helps them to drop into their feelings helps them to feel something they may not be feeling yet yes

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response to your body awareness in the session?

gives them permission to feel curiosity gives them a body experience

4.b. Do you feel that the client learns from your body awareness? 5.a. Has your body awareness changed over the course of your professional career? 5.b. How? deepened it has become more sophisticated I am able to access more increased my capacity to be with intense feelings more resourcing in myself 6.a. Has this changed your therapeutic relationship with the client? 6.b. How? much more accepting and relaxed with client increased feeling within myself much more present with myself and client offers more possibility where client can go Yes Yes Yes

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I am more aware

Table 2: Themes Arising From Codes Interview Questions 1.a. What is your personal definition of body awareness? 1.b. How do you use it in the therapeutic relationship with a client? 2.a. Does your body awareness inform you or signal you in the therapeutic relationship with a client? 2.b. How? 3.a. How would you define body awareness? 3.b. What does it involve? 4.a. What is your perception of the clients response to your body Presence that Facilitates Connection Permission to Feel Body and Emotions Bodily Felt Sense (Author Discarded as too similar to other questions) Yes Tracking the Therapeutic Relationship Second Order Themes Using my Sensory Experience to Observe, Listen and be Affected by the Therapeutic Relationship

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awareness in the session? 4.b. Do you feel that the client learns from your body awareness? 5.a. Has your body awareness changed over the course of your professional career? 5.b. How? Deepened Capacity to Access More in the Therapeutic Relationship 6.a. Has this changed your therapeutic relationship with the client? 6.b. How? Able to Discern and Accept Differences Between Self and Client Yes Yes Yes

Discussion In this study the role of the therapists body awareness in the therapeutic process was explored. According to the interviewees, the therapists body awareness involves more than just moment-to-moment physiological tracking. It involves an active engagement. This is seen through the therapist using his/her own body to perceive, facilitate and to be affected by

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the therapeutic encounter. All three participants mentioned body awareness as their primary mode of perception in the therapeutic relationship. A second theme to emerge includes body awareness as an educational experience wherein the client is given permission to engage in their bodily states. This suggests that mirroring and reflecting body states, and using statements such as what does your body want to do? and how does your body want to move? gives clients more options/ways to include their bodies in the therapeutic encounter. This has great implications for body psychotherapy and in particular its use as an intervention in therapy that has to do with bodily states involved in trauma. The third theme to emerge from the data is that amount of time in the therapeutic relationship appears to be a factor influencing the development and refinement of body awareness. The data shows that over time, body awareness develops into deeper contact that influences therapists perceived awareness, and capacity to tolerate a wide range of affective and somatic experiences in the therapeutic process. All participants mentioned being more accepting of where the client was at and having the increased capacity to refrain from action and to remain curious. This increased capacity to contain has great implications for the field of body psychotherapy and in particular the field of trauma therapy. In reference to a current and relevant therapeutic concept of body awareness, this researcher proposes the following; therapist body awareness is a subtle and distinct dimension of ongoing somatic interaction, and the primary process of perceiving information for the body psychotherapist in the therapeutic process. Based on the three themes that emerged from the data, the therapists body awareness has a significant role in the

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therapeutic encounter and can be considered to be a vital affective, relational and somatic intervention in the therapeutic process.

Limitations Limitations of this study include a homogenous sample of participants in regards to theoretical orientation, apparent personal identity and educational background. All three participants were affiliated with the same community; with theoretical foundations in body based approaches to therapy. It was noted after the data collection that all three participants were also affiliated with the same academic community, and had a similar educational background. It was noted that participants interviewed had a lack of diversity and shared a similar ethic and racial background. Also, only three interviews were conducted for the study, which likely did not achieve data saturation. Limitations within data collection and methods involved throwing out question # 3 because it was deemed to be similar to question #1, and did not derive any new data. Personal biases of the researcher include a preference towards body- based therapies and a conceptual framework that values body awareness.

Conclusion Body psychotherapists use their body awareness as a crucial source of information and agency in their clinical work. When attended to, the therapists body awareness can inform the therapist, facilitate the therapeutic alliance, and help the client make sense of their bodily experience.

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Body psychotherapy training has always emphasized the somatic component of both the therapist and clients experience in the therapeutic relationship. However this is only one component of somatically oriented psychotherapies. The clinical importance of the therapists embodiment and ability to reflect on his or her sensory experience with acuity and clarity is often underscored. As therapists how do we train and cultivate this capacity for sensory acuity and depth of bodily awareness? It is important to distinguish between therapists bodily awareness in the moment, and therapists ongoing relationship to his or her bodily process and how this is helpful to the therapeutic process. A future study using more participants could look at how body psychotherapists cultivate a personal sense of embodiment- a concept of which body awareness is just one aspect, and what that requires. One could also include and explore how the therapist feels this practice affects the depth of exchange between the client and therapist. This study could also include the clients perspective of the therapeutic exchange and whether this had increased meaning for them as well. This could provide the basis for further research into the notion of therapist embodiment, what this involves, and how it can be addressed and cultivated in the training of therapists.

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