Dr. Bob Evans has been treating TMS/PPD patients for over 24 years, during which time he has seen over 1,000 patients. Throughout his career he has worked with Dr. John Sarno and wrote about his case studies in The Divided Mind. Dr. Evans incorporates a variety of treatment techniques and approaches in treating his patients, which helps him individualize his treatment to a specific patient. A major part of his therapy approach involves using Somatic Experiencing and mindfulness techniques. Dr. Evans has made several contributions to the wiki including writing a fantastic review of the book, Waking the Tiger, completing the Survey Response and an excellent overview on how he incorporates different treatment techniques on his profile page.
Dear TMS Wiki community,
Forest has asked me to write something on the use of SE in the treatment of TMS/PPD which I am most happy to do. I must begin however, by first acknowledging how very grateful I am to have had the opportunity and great privilege to train with Dr. John Sarno, M.D., Dr. Arlene Feinblatt, Ph.D. , and Dr. Eric Sherman, Ph.D., at the Rusk Institute of Rehabilitation Medicine at NYU Medical Center in 1986-1987. Dr. Sarno, as many of you know, is a great pioneer in the diagnosis and treatment of PPD. It is the shoulders of this great man that we stand upon as we expand our view of the nature and treatment of PPD. It is my profound hope that some day soon the 'traditional' medical community will recognize his outstanding and truly trailblazing contributions to the understanding and treatment of Mind-Body disorders.
SE (Somatic Experiencing), developed by Dr. Peter Levine, Ph.D., is a wonderful, natural treatment approach to healing trauma and all its diverse symptomatic manifestations, including PPD. Many aspects of the SE model, including tracking, mindfulness, felt sense, titration, pendulation, regulation and discharge can be utilized by integrating them into the more traditional intensive psycho dynamic approach we originally trained in at the Rusk Institute for treating PPD. The practice of what I call 'Somatic' mindfulness, for example, learning to be fully embodied, IE., a sense of presence in one's body in the here and now, is one very important feature of the SE model. Various forms of mindfulness are utilized by many practitioners working with people with PPD. I hope that people may find it helpful to understand through the 'lens' of SE, how the application of various concepts and techniques such as mindfulness and discharge can be useful in reducing and eliminating symptoms for people experiencing PPD.
The human body has no sense of 'linear' time. There is no sense of past or future experienced in the body. There is only the present moment. Animals in the wild, because they have not evolved certain modern parts of the brain as humans have, possess no capacity to project into the past or future. As the 'joke' goes, if you ask a hippopotamus, "What time is it?", it would look at you a little funny and then answer, "It's Now". Human Beings, on the other hand, have evolved, along with the Limbic system, (the part of the brain responsible predominately for emotions), the Cerebral Cortex, which among many other amazing functions, has developed the ability to project into the past and the future. The development of the frontal cortex has led to many fantastic positive applications through the millennium, beginning at the time we stood erect as a species. We can think of many amazing examples such as the invention of the wheel, the discovery of fire or the advent of the automobile, just to name a few. Many of my patients have heard me say that, "Every 'Yin' has its 'Yang'". (Sir Issac Newton said it more scientifically in his famous quote, "For every action, there is an equal and opposite reaction'). The human mind has developed, discovered, invented, etc., many wonderful, marvelous things. However, each endeavor or enterprise ('Yin'), has it's drawbacks (Yang'). As wonderful and amazing as the invention of the automobile has been, for example, it has played a part in creating pollution, accidents, injury and death. Likewise, although the cerebral cortex has developed this astounding ability to project into the past and the future, with all the positive effects attributed to this incredible function, there are potential downsides even to this remarkable facet of our human evolution.
Over the course of our lives, there are a multitude of stresses and traumas we experience, including those psychological and emotional in nature. Some blatant and profound while others more subtle and transient. In response to certain types of stressful or traumatic experiences, often we 'learn' to detach, to disconnect from parts of ourselves, our bodies and our awareness. This is actually initially adaptive in nature. The Autonomic Nervous System (ANS) has a wonderful adaptive mechanism which is protecting us from what it perceives to be threatening at any given point in time. If the present moment is too uncomfortable, painful or threatening for any reason, among other defense mechanisms, our system may learn to 'tune out', IE., to not be fully present in that moment. Thus we do not have to consciously experience the discomfort or pain associated with being more fully present in our bodies in the moment a particular stressful or traumatic event is taking place. We all do this to some extent at different times in our daily lives. Many of us have had the experience of daydreaming and then realizing that we haven't been present for the last several moments. At times we may not have even been able to ascertain 'where' we were in those past few moments. The ultimate example is Woody Allens' response when asked how he felt about death and dying. He said, "I'm not afraid of dying, I just don't want to be there when it happens".
By way of illustration, let us picture a scenario in which we are at home simply washing the dishes after dinner. At the same time we are behaviorally washing the dishes, a part of our mind (Frontal Cortex) might be preoccupied in thought about something else. This part of our mind might be anxiously thinking about whether or not we'll be able to complete the amount of work we have to get done for our job or school the next day (a 'negative' thought projection about the future). We might be somewhat preoccupied with worrisome thoughts of a confrontation we recently had with a coworker or loved one, (negative thought projection about the past). The 'goodest' in us might be overly concerned as to whether the other person might be angry or disappointed with us. We might have some awareness of this type of thought process occurring or it can be so subtle (what psychologists call 'ego-syntonic') that we have little or no conscious awareness at all that we are, in some fashion, elsewhere lost in thought.
Remember that the body, only knowing the present moment, does not know that the mind is projecting into the past or future. It 'assumes' that the mind is also in the present moment because that is all the body experiences. If the mind, projecting into the past or future, is thus worried, anxious or concerned, the body presupposes that there is something actually happening currently to be worried or anxious about. Like a good soldier, the body takes it's cues from the 'central command center' so to speak, of the mind. The body (ANS) 'thinks' that what the mind is preoccupied with is actually happening or about to. Thus, in the above examples, a 'threat' is perceived to be very real by the body (ANS) even though a real threat in that moment does not exist (we're simply doing the dishes). So the body responds to this perceived threat by going into 'threat response mode' despite the fact that, in actuality, we are home, safe and presumably relaxed. It requires a great deal of 'Tension' in the body to be vigilant and prepare to 'fight or flee' in response to whatever threat it thinks might occur. Keep in mind that the first word in TMS is 'Tension'. The generation of tension at those moments can cause and/or perpetuate pain cycles and/or symptoms. So we have a situation in which there is no actual 'real' reason for the body to be full of fear and thus tension. And yet, that is exactly what the body is having to deal with. If we were more mindfully present in our bodies in the 'here and now', our experience might be much more focused on the warm, soothing sensation of the tap water and soap suds as they gently splash on our hands, delighting in that joyful 'felt sense' experience. The body, in response, would remain fully relaxed, calm and, to use a common SE term, well 'regulated'. Because of past negative, stressful, sometimes traumatic experiences, the ANS does not feel safe to be fully present in the here and now. Some people with very chronic PPD conditions are literally 'stuck' in this perpetual 'worry' mode. They are often disconnected such that they have very little awareness as to the amount of tension they carry constantly in their bodies. Consequently, they have great difficulty understanding why they are in such pain and how the PPD symptom can be stress related. I often have patients try this little experiment. Conjur up some 'negative' thought about tomorrow. Have this thought start with the words, "Uh oh, what if"..... For example, "Uh oh, what if I'm sick tomorrow and therefore I can't get to work". Now simply notice the sensations in your body. Some people might notice some degree of tension. When I try this I even notice my hands and arms firmly rising in the air. Now change the thought slightly. Instead of, "Uh oh, what if..., now say, "If,...then". In other words, for example say, "If I'm sick tomorrow, I'll deal with it then". Again, simply notice the sensations in your body now. See if you detect any change in the amount and/or degree of tension noticeable inside. By partaking in this demonstration, you might be able to have an 'in vivo' sense of noticing the different degrees of tension in the body (ANS) as a reaction to different types of thoughts. The first thought is telling the body there is potential 'danger' to be prepared for (now), while the later is telling the body 'not to worry', any problems occurring in the 'future' (tomorrow) will be dealt with then and so we can now relax.
I do not wish to give the impression that we can practice a little mindfulness and not only become enlightened but have all our pains and symptoms disappear. I often say that the practice of mindfulness is simple but not easy. Nor is mindfulness in and of itself, sufficient for the amelioration of PPD symptoms. Many patients talk about how the stress of day to day life interferes with practicing mindfulness techniques. In a scene from one of my favorite movies, 'The Razor's Edge', from the book written by W. Somerset Maugham, (although the 1946 version with Tyrone Powers is good, the 1984 version with Bill Murray is my favorite) Larry Darrell is leaving the Zen Buddhist Monastery high in the Himalayan Mountains of Tibet after training in the mindfulness ways of the Zen Buddhist Monks. As he is saying farewell to the head Zen Master, he says, "It is easy to be a Holy Man on top of a mountain". In other words, when you're relaxed, away from the daily grind, it's easy to be mindfully present in the moment. To this the Zen Master replies, "The path to enlightenment is as sharp and narrow as a razor's edge". So, given the task at hand, it is important to look at learning the art of mindfulness as one would, the practice of any skill. It is no different than learning to ride a bicycle or learning to walk. It takes time, patience, and self compassion. Like the infant learning to walk, he/she falls, he/she giggles and gets right up again. The infant has not yet learned that to 'fall' is a bad or negative thing. For some people, mindfulness and relaxation exercises will not initially work. In fact, some people can become even more anxious when 'trying to relax'. This experience can often be confusing. The reason this happens is because there was presumably a certain level of stress in the environment growing up such that their ANS needed to always be in 'threat response mode', IE., on guard for what it anticipated might be the next outburst or stressful event or behavior to deal with. So paradoxically, the ANS becomes too uncomfortable when it lets its guard down and relaxes. It's not quite ready to trust that the present moment is, unlike the past, safe to be relaxed in. For this reason, I find that the 'Somatic' mindfulness training in particular, is helpful because it includes the titration of relaxation skills in manageable doses as well as techniques to deal with the impinging negative energetic experiences (thoughts, feeling, images) interfering with the process.
As I intimated above, the practice of mindfulness alone is necessary but not sufficient in terms of utilizing the SE model in treating PPD. Many people struggling with PPD symptoms and issues, as with all stresses and traumas, will need more than just the positive effects of mindfulness itself to heal. By definition, people suffering with painful PPD symptoms have too much arousal (activation) in their bodies. As Bradford Keeney says in his book, "Shaking Medicine", "relaxation and arousal are two complementary sides of the whole healing response". Keeney reflects on Peter Levine's work (P. 31-32) as he says, "when a prey animal in the wild is attacked , it has the 'built-in ability" to rebound. Specifically, the animals 'shake off the serious attack that threatened their lives. They go somewhere and tremble, shake, pant, take deep breaths, and exhibit rapid eye movements. Free from the language-making of the cerebral cortex, they don't get engaged in language-based therapy and treatment. Wild animals simply allow their reptilian brains to trigger 'shaking medicine'". Thus, another integral component to the SE model in the treatment of TMS is what we call 'Discharge'. Some of you may recall the patient 'Helen' in Dr. Sarno's book, "Healing Back Pain". She exhibited what we might call an untitrated discharge. At a given point in her therapy, her ANS began to naturally discharge all the previously stuck energy that was still present in her body at that time.
If you think of PPD in terms of energy, a particular pain symptom can be thought of as stuck energy in the body from a previously thwarted fight or flight response. Our ANS automatically 'thwarts' or shuts down the instinctual impulse to fight or flee when it instantaneously assesses that it would be too dangerous to do either. In terms of a common human interaction for example, a child will 'instinctively' know, or 'learn' over time, that it is 'too dangerous' to hit Dad (fight response) if his father is angry and perhaps yelling at him. In some instances, the child might instinctively know (or have learned) not to run away either (flight response), for his father might become more annoyed, run after him and possibly things could escalate. When these threat responses (fight or flight) are 'thwarted', the energy required to fuel them then becomes trapped, stuck in the body. In Dr. Sarno's nomenclature, we might say that there is much repressed fear and/or rage. In the practice of SE, we utilize mindfulness and titration to help manage the discharge of this previously stuck energy. We can refer to this process as metaphorically 'keeping one foot in the present while putting the other foot in the past'. In other words, when mindfully present in the here and now, we can feel calm, relaxed and safe enough to re-experience the arousal energy of that once thwarted threat response still stuck in our bodies. The significant difference being that here and now we are able to 'discharge' that stuck energy and thus safely complete the threat response that was once too dangerous to do so. When there is no discharge of this energy, symptoms may develop and manifest immediately or even years later. This can be likened to Dr. Sarno's metaphor of the Reservoir (of 'stuck' energy) which fills up over time until at some point it reaches its threshold and overflows manifesting as PPD symptoms. Discharge provides the body with release and relief. Often in session people will notice their bodies start to tremble and shake as we do the work. I assure them that this a very good sign. I let them know that the body is naturally healing itself by discharging that pent up energy. People usually feel very comforted to learn that the body has such a natural healing capacity.
As Keeney states, animals in the wild, by their very nature, when discharging, do not engage in "language-based therapy and treatment". SE, utilizing the natural instincts of the body, similarly does not focus on language, content, narrative, the story of ones life. In fact, the mindfulness component of the SE approach is designed to bypass the cerebral cortex's tendency to 'think' at all (project into past and future). This avoids the tendency for the cerebral cortex to override this natural instinct toward healing. Nevertheless, we are 'human' animals. As such, many people find it very helpful to verbally process and understand the changes taking place in their bodies in order to more fully integrate the experience. When discharge takes place, energy begins to flow more freely in the body. This in turn frees up the flow of energy in all modes of experience. The acronym S.I.B.A.M. stands for Sensation, Image, Behavior, Affect (emotion) and Meaning (thought, insight). These are the five basic modes of experience. As energy flows more freely throughout the entire system upon discharge, thoughts, feelings and images as well as certain impulses to move (behavior) begin to flow more freely as well. People often gain much insight and more comfortably experience certain emotions and memories (images) following ANS discharge. For example, just this past week in session, a patient of mine and I were tracking her activation. She noticed a sense of pressure in her forehead. I asked her to 'pendulate' (shift) her awareness away from this 'activation' and focus her awareness on a part of her body that felt more comfortable. As she focused her awareness on her arms and legs, which felt comfortable and relaxed, the pendulation boosted her ANS from activation back into regulation. This was accomplished by discharging the stuck activation energy experienced as pressure in the forehead. Some people might be content just to experience the psychical release of head pressure and leave it at that. However, this physical release led to a natural flow of all elements of SIBAM. Following the physical discharge, she noticed the thought (insight) that she tends to pressure herself often by saying yes to people when she really wants to say no. This led to the connection that the pressure in her forehead began earlier that day when she felt she had to please her husband by saying yes to some social commitment she didn't want to attend. This in turn led to the association that this tendency to say yes and thus please others had its origin in the still unresolved feelings of grief due to the early loss of her father, an authority figure she was no longer able to please due to his untimely death when she was very young. This allowed her to gently and comfortably experience sad feelings of loss and grief that were previously too painful to feel. Although treating PPD can be at times complex and intense, the SE model provides a wonderful, natural approach to healing that enhances the more traditional psycho dynamic approach many of us PPD clinicians were trained in. It is my sincere hope that people working to rid themselves of PPD might find these ideas comforting and of some value in their healing journeys.
Much Warmth and Light to you all,
Dr. Bob Evans
- Somatic Experiencing, OCD, and Anticipation of Future pain
- A thread posted by Back2-It on Dr. Evans' profile, which he responded to.
- The above essay is discussed in a forum thread, which has many links for further reading.
Frances Sommer Anderson, PhD, SEP Interview
Frances Sommer Anderson, PhD, SEP is another of Dr. Sarno's most trusted psychologists and is also a Somatic Experiencing Practitioner (SEP). She was interviewed about integrating psychoanalysis and somatic experiencing on the SE talk podcast. The podcast was then re-posted in the SE blog. Forest S., posted a detailed essay explaining some points from the interview that nonpractitioners can immediately apply in their own healing in a thread entitled Self Monitoring.
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