514 Book Reviews

Trauma and the body: a sensorimotor approach to psychotherapy, by P. Ogden,

K. Minton and C. Pain, New York, Norton, 2006, £21.50, ISBN 9780393704570

Reviewed by Dr Ruth Pavlovic, Psychiatry Trainee and Former General Practitioner;

MSc Counselling Student, Bristol University

‘The body, for a host of reasons, has been left out of the talking cure’ (p. xxvii). So
begins this landmark book from the Norton Series on Interpersonal Neurobiology

which explores multidisciplinary views at the consilience of neuroscience and
psychology research. Addressing this challenge, ‘Trauma and the Body’ outlines an
integrated framework to inform our understanding of mind-body structure, function
and well-being; and ultimately the practice of psychotherapy. Daniel Siegel, the series
editor, is a psychiatrist from the University of California, Los Angeles; and a well-
known ‘mindfulness’ proponent. Pat Ogden, main author and founding director of
the Sensorimotor Psychotherapy Institute, is a private psychotherapist of thirty
years’ standing.
Ogden’s goal, clearly realised, is to demonstrate the relevance of somatic (body)
approaches in effective trauma treatment. These insights are essential reading for
psychotherapists, counsellors, mental health practitioners and medical professionals
involved in working with trauma victims
such as adult survivors of abuse or PTSD
sufferers. Ogden suggests the principles and skills may be imported as a
complementary adjunct to existing psychodynamic or cognitive-behavioural ther-
apeutic modalities: ‘The premise of this book is that traditionally trained therapists
can increase the depth and efficacy of their clinical work by adding body-oriented
interventions to their repertoire’ (p. xxviii).
Ogden argues that conventional counselling approaches to trauma resolution
have focused primarily on ‘narrative expression’, with the belief that change occurs in
a ‘top-down manner’. The premise is that engaging with the ‘client’s cognitions and
emotions will effect change in the physical or embodied experience of the client’s
sense of self. The prime target for therapeutic intervention is therefore the client’s
language; that is, the narrative is the entry point into the therapeutic process’
(p. xxviii).
However, to these ‘already useful cognitive and dynamic practices’ she ‘proposes
the addition of bottom-up interventions’ which address the ‘somatosensory
intrusions characteristic of unresolved trauma’. These include reactions of ‘physical
sensation’ and ‘pain’, ‘constriction’ and ‘numbing’, ‘posture’ and ‘movement’, and
dysregulated ‘autonomic arousal’. Clients are taught to ‘become aware of their
bodies, track bodily sensations, and implement physical actions that promote
empowerment’. They are then taught to observe in reverse how lived somatic
experience can influence their emotional and cognitive states in therapy. Sensor-
imotor psychotherapy thus ‘blends cognitive and dynamic therapy’ with ‘somatic
awareness and movement interventions’ (p. xxix).
As a student of narrative therapy (very much a ‘top-down’ approach, seeking
therapeutic entry points in the client’s ‘narrative expression’!) I find Ogden’s work
‘troubling the edges’ (Speedy, 2008) of my therapeutic framework.
The book is divided into two parts. Part One explores the theoretical rationale for
sensorimotor psychotherapy.
 British Journal of Guidance & Counselling 515

Chapter 1, on ‘Hierarchical Information Processing’, explains the triune brain

model, whereby the three information-processing levels correspond to three levels of
brain architecture
cognitive (neocortex), emotional (limbic system) and sensor-
imotor (reptilian brain). Adults normally display top-down hierarchical control,
whereby ‘volitional cognitive processing’ can override ‘sensorimotor and emotional
responses’ (p. 8). Crucially however, in traumatised individuals, ‘the intensity of
trauma-related emotions and sensorimotor reactions hinders the ability of top-down
processing to dominate subcortical activity’ (p. 9). Moreover, trauma often results in
‘compartmentalisation’ and a ‘profound deficit in the ability to integrate experi-
ences’, with dissociation of ‘emotions, thoughts, identity, memory and somatosen-
sory elements’ (p. 4). This indeed begs for direct intervention at somatic as well as
cognitive levels.
Chapter 2, ‘Window of Tolerance’, outlines the vulnerability of traumatised
clients to autonomic dysregulation. Ogden describes how they may oscillate between
extremes of sympathetically-mediated ‘hyperarousal’ (fight or flight responses, with
accompanying hypervigilance, intrusive imagery and affective overreactivity); and
‘hypoarousal’ (immobilisation, passivity, emotional numbing and deadness)
mediated by the ‘dorsal vagal system’. Both states, when triggered, hinder integration
and re-processing of trauma. In therapy, the goal is to maintain the client within the
‘window of tolerance’ of ‘optimum arousal’, activating their ‘social engagement
system’ under ‘ventral vagal’ control (pp. 26
32).
Chapter 3, ‘Attachment’, outlines how these lifelong modes of autonomic and
affective arousal, with fixed sensorimotor tendencies, are embodied in the four child
attachment patterns (secure, avoidant, ambivalent and disorganised). Optimal self-
regulation is described as a balance between interactive regulation (experienced
developmentally through dyadic attunement with a primary care-giver) and auto-
regulation (p. 55). Treatment of dysregulated primary attachments at an autonomic
and somatic level is discussed (pp. 58
61).
Chapter 4, ‘The Orienting Response’, explains our ability to selectively focus on
external and internal stimuli, as a prelude to interpreting and integrating informa-
tion. Traumatised clients however, may either ‘reflexively narrow the field of
consciousness to reminders of the trauma’ or, conversely, ‘fail to notice threatening
stimuli’ (p. 65). Moreover (p. 67), they may struggle to synchronise responses of overt
orienting (physical turning towards an external stimulus) and covert orienting (the
inner focus of attention). Sensorimotor psychotherapy encourages clients to become
‘mindful observers’ of the orienting process, placing a ‘therapeutic gap between
stimulus and response’ (p. 84).
Chapter 5, ‘Defensive Subsystems’, describes the three basic defensive responses
to threat
social engagement; mobilising defences (fight or flight); and immobilising
defences (freezing and submission). Traumatised individuals, however are unable to
modulate their responses adaptively and flexibly to match the changing demands of
present reality. Instead, they ‘get stuck in the particular repetitive action tendencies
of defence that were evoked [by] the original trauma, and are evoked again by cues
reminiscent of that trauma’ (p. 86). Moreover, ‘what began as a necessary defence in
the face of a real threat becomes a pervasive unrelenting reaction to the anticipation
of a threat’ (p. 87). Sensorimotor interventions include mindfully observing fixed
516 Book Reviews

defensive reactions, executing incomplete action tendencies from the time of trauma,
and building a more flexible repertoire of responses to future threats (p. 107).
Chapter 6, ‘Adaptation’, explores the diversity of action systems available for
survival and individuation. These provide the impetus for defence, attachment
formation, energy regulation, exploration, play, sociability, care-giving and sexuality.
Often, in trauma sufferers, activation of the defensive sub-system takes precedence,
blocking utilisation of other action systems (p. 111). Sensorimotor interventions aim
to improve the adaptive functioning, utilisation and integration of all action systems,
while downgrading defensive arousal (p. 138).
Chapter 7, ‘Psychological Trauma and the Brain’, draws on recent neuro-imaging
research to delineate the effects of trauma on brain structure and function, with
implications for the targeting of effective therapeutic interventions.
In Part Two
Chapters 8 to 12
Ogden applies theory to practice, describing the
phased techniques of sensorimotor psychotherapy with the aid of clinical examples.
Treatment approaches include setting somatic boundaries; safely pacing a gradual
reconnection with the body; working with the client’s experience of somatic
transference in the present moment; modulation of autonomic arousal; facilitating
mindful observation of somatic states; somatic processing of traumatic memory;
regaining mastery over somatic states; and somatic interventions to aid in re-
establishing a life beyond trauma (e.g. in tolerating increased intimacy).
One critique of ‘Trauma and the Body’ is a stylistic tendency towards concept
repetition
exacerbated by the division into theory and practice. The book could
have been more succinctly condensed. Alongside the many case vignettes illustrating
dynamic skills, I would have appreciated a more rigorous step-by-step extended
analysis of some cases. The book is well-referenced and correlated with advances in
neuroscience research, psychology and attachment theory. However, against the
harsh reality of NICE appraisals, Ogden does not offer any evidence of clinical
effectiveness from therapeutic trials of sensorimotor psychotherapy. Nor are
objective before-and-after symptom scores cited for a case series. It remains unclear
how many patients have been treated over time and for how many sessions with this
modality.
Nevertheless, this pioneering text serves as an important springboard for future
debate and practice, and would adorn the essential toolkit of any trauma therapist.
Have I found it useful in my medical practice? In a sudden flash of insight, I realised
one patient was locked into a maladaptive freezing defensive response. Originally
formed in a violent context, where alternate defensive strategies (social engagement
or fight/flight) against the perpetrator were futile, this was now being triggered by a
comparatively minor scenario. Here, re-enacting a victim ‘freeze’ was incongruous
when social engagement or evasion were now feasible. I encouraged the patient to
track bodily sensations, tensions and movements the next time this occurred, in order
to discover and mobilise these arrested impulses.
In conclusion, I commend this book for placing the ‘body’ firmly back on the
agenda of ‘talking cures’.

Reference
Speedy, J. (2008). Narrative inquiry and psychotherapy. Basingstoke: Palgrave Macmillan.

# 2009, Ruth Pavlovic