Tag: disorder

John Sarno’s work on the etiology and treatment of psychosomatic disorders

I have been troubled all my adult life by disorders termed, which generally meant dismissed as, psychosomatic. These are disorders for which no physical etiology can be found, although they may have observable physical manifestations. From a psychological point of view, they have also recently been classified as somatoform disorders. As such, I was very interested to discover recently John Sarno‘s work on the subject.

Sarno’s basic premise is that just as emotional conflict can give rise to neuroses, so it also can give rise to pain and other physical conditions. This linkage may be direct, with Sarno positing that localized pain is a result of ischemia ordered by the central nervous system. Such emotional conflicts may also, via mechanisms which are presumably diverse, but which Sarno does not elucidate, result in afflictions to which non-psychological factors also contribute, whether in terms of their etiology or their clinical development. A key feature of Sarno’s posited diagnosis of tension myositis syndrome (TMS) is the variability in its lifetime expression. As such, it is an umbrella diagnosis or metadiagnosis for a variety of syndromes which have in common a non-progressive character. For a fuller discussion, read his 2006 book The Divided Mind.

I suffered in my early teens from clinical depression and situational urinary incontinence. By my mid-teens, this was replaced by muscular fasciculations, which I was convinced for a long time had to be a manifestation of a degenerative condition. Muscular function remained mechanically and electrically normal however, and much later this was officially classified as “benign fasciculation syndrome” (although it has receded, I am not fully free of it to this day). I went on at college to develop chronic fatigue syndrome, which at one point resulted in my being almost unable to walk. I also suffered at that time from migraines and back pain, and peri-orbital migraine was a regular occurrence for many years afterwards. During all this time, there have been no notable biochemical abnormalities observed.

Now I have not been monitoring bodily symptoms against my emotional state for many years and so I cannot provide a full account; it has changed immensely for the better, but I have still had my share of annoying things, in particular abdominal pains, and six or seven years ago Achilles tendinitis. Around May last year I developed plantar fasciitis on the left foot; it took a year to heel but then almost immediately the right foot developed the same symptoms. It has been quite debilitating as strenuous effort has tended to worsen it. All this led me to seek effective relief from the pain in various ways, a subject to which I will return.

Sarno’s notion, therefore, is very appealing. Indeed, given the importance of physical complaints, so called “hysterical conversion“, in the early development of psychoanalysis, it is not quite clear why attention has mostly been subsequently restricted to behavioral neuroses, especially outside of the Reichian tradition. Even if the mechanisms remain obscure, it is attractive to view psychosomatic disorders as somatic forms or expressions of neurosis.

However, I suspect the brain is less involved in mediating this relationship than we think. Sarno claims that the pain is directly generated by the brain as a diversion from unwanted emotions which threaten to break through into consciousness. I fancy this is otherwise: the brain is involved, certainly, in the repression of emotions, and by preventing their expression it prevents their discharge. The bodily symptoms, however, do not necessarily require neurological involvement and may arise on the basis of pure biochemistry. This is illustrated by research on the role of myofibroblasts in the mechanic regulation of connective tissue (see here). To me, the idea that the brain is busy, like some cranky old Wizard of Oz, devising ways to present consciousness with ever-new diversions seems crude, and it is not required to explain Sarno’s clinical outcomes. Variation in the site of pain may have simple biomechanical explanations.

So Sarno’s work is pathbreaking and liberating, definitively contributing to a shift in understanding of psychosomatic disorders, but it nonetheless needs to be taken with the necessary pinch of salt. Sarno offers, in The Divided Mind, no epidemiological data to back up his claim that the syndrome chosen by the brain is a matter of fashion (in a Kuhnian perspective, it is of course much more plausible that it is the diagnosis and corresponding collection of statistics which is driven by fashion, rather than the patient’s symptoms, especially since many of these diagnoses are evidently imprecise). He also offers no evidence to back up the conjecture that local ischemia explains the pain or that this is cerebrally induced (and if so, how). Indeed, the locus of pain is not discussed either, and some statements suggest Sarno does not have a deep understanding of myofascial biochemistry.

Sarno follows the usual path of airbrushing Reich out of the history of psychoanalysis, although it should be obvious that Reich was the first to look at the body and mind as a whole. However, his major error is to follow Freud’s mistrust of the id and misplaced trust in the superego. Freud, as we know, viewed repression as in many ways akin to a virtue upon which civilization depended. Sarno also paints a picture of the “childish, primitive” unconscious as the enemy within, even referring to it, with patent ideological bias, as the “dregs of evolution”, contrasting it to the “ethical and moral” conscious mind, a view hardly conducive to integration and well-being, and one which even Freud would have struggled to maintain (Nietzsche of course having demolished it comprehensively). His negative views of the moral quality of children are particularly depressing in their Calvinist overtones.

Several of Sarno’s statements in relation to brain neurology seem completely wrong: for example he attributes “rational, civilized” behavior to the neocortex, labeling it “that part of the human brain that has been added in the process of evolution”, even though the neocortex developed in the first mammals. The attempted equation between brain structures and Freud’s threefold division of the mind is presented as fact, whereas it is not a notion entertained by any mainstream psychoanalyst or neurologist. Indeed, Sarno oscillates gaily between the unconscious/preconscious/conscious model and the id/ego/superego model as if they were the same thing.

All this aside, this is a book which opened my mind to what now seems like an obvious fact but has long gone unnoticed, namely that the mind does not simply affect the body in vague, unspecified ways but perhaps in very specific ways where a direct link can be drawn between emotional circumstances and pain. It is pretty clear now to me what the circumstances were which led to both episodes of plantar fasciitis, and I am inclined to agree with Sarno that this knowledge is immensely emancipatory.

Trauma releasing exercises

I am just back from the three-day introductory training in David Berceli‘s Trauma Releasing Exercises (TRE). These exercises and Berceli’s work are well worth knowing. Surprisingly enough, there is no Wikipedia article on Berceli and his work. The article on post-traumatic stress disorder (PTSD) does not mention it either, nor somatic approaches to PTSD at all, even though these have been about for a long time and must in any case be more effective than the “recognized” approaches, CBT (cognitive behavioral therapy), EMDR (eye movement desensitization and reprocessing) and medication.

Berceli (as far as I can see) takes his basic model of the somatic effects of trauma from the work of Peter Levine; in any case the models are very similar. To summarize, the basic idea is that the human animal has (for some reason; we shall come onto this) suppressed a natural response to coping with stress, which needs to be reactivated for healing to occur. However, the two differ considerably in terms of methodology. Levine’s approach, known as Somatic Experiencing (SE), which is quite widely practised in Europe (though not a lot in Belgium), requires exploration of the trauma and the felt sense of the body in response to it. As such, it borrows from Gendlin’s ideas on Focusing and more generally is, it seems to me, within the intellectual tradition of Gestalt therapy. By way of contrast, Berceli’s approach, like most somatic psychotherapy, is more purely process-oriented. As such, it does not require or even directly encourage exploration of the traumatizing events, and particularly not by the therapist; rather, the focus is on what the body is doing in the here and now and on the ways in which the body’s natural attempts to self-regulate are hindered or can be supported. The independence of method from the client’s personal history offers some considerable advantages, since it makes possible group work and relies less on the skills of the therapist.

Berceli’s therapeutic method borrows from Bioenergetics (I may update this article when I have read his books, so check back), rather in the tradition of Alexander Lowen. Its aim is therefore to produce involuntary trembling in the body. Unlike Lowen, there is no element of talk therapy within the method, though Berceli does say that his method can be integrated within others, so leaves the door open to syncretic approaches. Significantly, however, the trembling is reinterpreted compared to the Reichian tradition, to which Lowen remained loyal. Rather than being glossed as the release of sexual/life energy held in stasis by the body, it is interpreted as the reactivation of the post-freezing response of animals described by Levine: “When it is out of danger, the animal will literally ‘shake off’ the residual effects of the immobility response and gain full control of its body. It will then return to its normal life as if nothing had happened“.[1]

Why is this response suppressed in humans? For this, Berceli seems to have no deeper or more convincing answer than does Levine: “Most human cultures tend to judge this instinctive surrender in the face of overwhelming threat as a weakness tantamount to cowardice. However, underneath this judgment lies a deep human fear of immobility. We avoid it because it is a state very similar to death. This avoidance is understandable, but we pay dearly for it.“[1] In other words, the response is suppressed by the ego under the weight of social stigma attached to it. Neither Levine, nor Berceli, as far as I can see, has (or even looks for) any evidence of this claimed stigmatization. Many bodily functions may be disrupted by trauma, but this does not mean that those functions themselves are necessarily stigmatized. Thus this appears to me not very convincing, and basically it eschews a psychoanalytic explanation of ego defenses and their role in the developmental process. There are lots of criticisms which can be easily leveled not only at the model, but also at how the practice relates to it. Most basically, the question arises as to why the practice does not endeavor to, nor succeeds, in simply reestablishing this response and allowing it subsequently to play whatever role it needs to play in the individual’s further experience. Rather it is recommended to continue the practice on an ongoing basis. It therefore does not constitute a “cure” for PTSD, but a door into another dimension of experience. Berceli explicitly encourages such an understanding, and views his work as transformative on a global scale. This is laudable and I thoroughly support it because I believe he is on to something; but it is not convincing theoretically.

The great advantage of Berceli’s exercises over classical bioenergetics (and over Reich’s simplified anatomical model of the biological basis of character formation) is that it is more anatomically informed, and results in exercises which are shorter and easier to carry out. This makes it more suitable for the problem it is intended to address, since persons suffering the physical developmental impact of childhood trauma are often limited in their range of motion. These exercises should absolutely be considered for use in all those contexts where people currently employ Lowen’s exercises (though not his whole framework of Bioenergetic Analysis, which he himself acknowledged did not have the clinical success he hoped for) and its derivates, such as Osho’s active meditations. Because Berceli’s exercises directly solicit and progressively release tensions in the hip adductors, iliopsoas and muscles of the pelvic floor, that is, in all of the major muscles primarily involved in the orgastic response, and they are more easily taught and experienced than existing alternatives, they seem to me the basis for a more effective practice which clients will better be able to follow and stick to (they of course do not substitute for other exercises used in group therapy the purpose of which is rather to generate than to release tensions, which will then be released in other ways).

The other great advantage is that the method can be employed in a very wide range of contexts, from schools to palliative care, contexts in which bioenergetics or anything else “explicitly” psychotherapeutic would have no chance of penetrating. It does not need and does not really have a unifying discourse, which minimizes resistance. People are willing to try it out who would never go near (or for that matter be able to afford) a psychotherapist, and stick with it because, after all, it is only their body doing what it wants to do, and it is hard to be against that.

On the other hand it would at least seem not to be a complete system for spiritual liberation in the sense we derive ultimately from Reich. Berceli applies his technique way beyond the boundaries of PTSD, presumably because people have reported positive effects in those contexts, and has some awareness of the endemic and embedded nature of societal trauma, but the need for wide appeal seems to prevent him from going deeply into underlying societal issues in the radical tradition of much psychoanalytic thought. I am not saying this is a bad choice. Perhaps it is an excellent one. But ultimately, personally and at societal level, one does need to go there. Refusing to do so will always limit the benefits that can be attained.

What Berceli’s discourse seems to me to lack is an understanding that the disruption of the trauma response is ultimately due to the fact that social experience, being so far from the natural state of man, continually regenerates trauma. On top of distorting ego development, social experience also acts in the present. Our shared cognitive models of the world and the human need for relationship continually pull us back to a depressed, unhealthy state, and would do so even if all “residues” of specific trauma were somehow dissolved. We touch here on the manner in which Berceli’s approach is most fundamentally incomplete. It is essentially solipsistic, and presupposes, ultimately as a matter of ideology, the ability of the individual body to regenerate in the absence of regeneration of the collective body and the social tissues, which although they are just as ossified as the somatic tissues, are not directly brought into vibration by the practice. This cannot work. An interpersonal dimension of therapy and practice is absolutely indispensable if we are to begin to reprogram the social mechanisms which propagate and perpetuate trauma.

So I guess that makes me a big fan and a big critic at the same time. However I will do and use the exercises and I recommend them to you to.

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[1] See http://www.traumahealing.com/somatic-experiencing/art_chapter1.html