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Psychotherapy by Somatic Alteration

Pages: 28-38
Year: 1969
Dr. Ida Rolf Institute

Bulletin of Structural Integration Ida P. Rolf

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When mind-body interactions are considered in psychotherapy, attention is usually directed to the effect of the “mind” on the body. Thus, unexpressed or unexamined feelings of resentment, for example, may be viewed as responsible for elevation of blood pressure or for migraine headache. To remove these “functional symptoms,” psychotherapy attempts to alter the “mind.” The concern for psychodynamics is not misguided, although in some instances it can function as a unnecessary therapeutic limitation.

That chronic fatigue or tension may lead to general hostility is less often considered. The truth is that mind body interactions can flaw in both directions, the soma exercising an influence on thinking and feeling. True, mood changes associated with a common cold, or any more serious illness, are quickly recognized; but that the body may be a contributing factor in emotional disorders or employed therapeutically is hardly recognized, except when pharmacologic attempts are made to alter body chemistry through drugs. Even then, the use of drugs is regarded in the nature of first aid until such time as psychologic variables can be given attention. Somatic alteration as a sole or parallel method of therapy is seldom considered, despite the fact that a group of West Coast psychiatrists who used only relaxation training with anxious and obsessive compulsive patients have reported outstanding results.
1 Although there are philosophic and historic reasons for this omission, perhaps the main reason is that systems of somatic psychotherapy are either not well known or too difficult to rationalize in terms of current views regarding therapeutic processes.

Somatic therapies as defined for present purposes do not include drug administration or the more drastic shock or surgical interventions, but are confined to methods that attempt psychologic insight or behavior change through damping somatic reactivity or altering cortical subcortical balance.
Included in this definition are relaxation procedures, desensitization therapy, Yoga, meditation, and autogenic training. Although an attempt will be made to bridge the gap between all these procedures and more conventional treatment methods, autogenic training will receive the major emphasis. Autogenic training has received the most systematic clinical development in Europe, but is almost totally unknown in the United States. It embodies most of the elements involved in the other, more specialized approaches.

Autogenic training can he crudely described as a modern amalgam of Yoga and hypnosis. It was originated by Johannes Schultz 2 in Germany near the turn of the century, and has been developing there and, more recently, throughout the world ever since. Patients are taught a series of muscle and vascular relaxation procedures through hypnotic conditioning exercises. Once these are effective, a spontaneous alleviation of “symptoms” usually occurs. For more complex conditions, the training is prolonged into a meditative state in which the somatic conditioning allows the visual hallucination of psychodynamic material. This experience may be of an existential nature, with consequent reorganization on values and philosophy, or may disclose significant material for later discussion.

That autogenic training has not received clinical application or stimulated research in this country is something of an enigma. It possesses great therapeutic potential. Clinical studies have shown psychosomatic disorders, such as peptic ulcer and ulcerative colitis, to be successfully treated, and anxiety, phobias, and obsessive compulsive disorders greatly improved, by this method. Furthermore, it is buttressed by an impressive array of experimental research. Findings recently published in an international research compendium on autogenic training 3 include such diverse subjects as iodine metabolism, serum cholesterol, clinical significance of visual phenomena, and stress reactivity following autogenic therapy, behavioral therapy, and interview psychotherapy. Regrettably, the contributors to the research volume are all out side the United States, as are most of the authors of the more than six hundred references cited in the English edition of the training manual.

Because autogenic training is apparently outside the American clinical ZEITGEIST, perhaps the best context in which to discuss it would be that of my own personal experience. when I first came across the manual describing the exercises and case reports, my initial reaction was one of incredulity so much so that, in spite of the warnings against unsupervised experimentation given in the manual, I decided to test its various claims for myself. To report these subjective experiences has limitations; but, on the other hand, the objective aspects of the therapy have already been documented whereas the experiences involved can be got at only through introspection. In any event, the following report, with its numerous digressions and speculations, may help the clinician interpret the training in terms of more familiar concepts and, hopefully, stimulate researchers to investigate the various mechanisms involved.

The autogenic exercises are best performed lying down with eyes closed. Since the first stage of the training is devoted to rapid relaxation, one begins by concentrating on a limb the right arm, for example and repeating to oneself that it is heavy. This is continued for about a minute, after which one ends the exercise by moving the limbs vigorously. Then, after about a minute’s wait, one repeats the same procedure. Three exercises constitute a set, and three sets are to be performed each day. As one exercise is mastered, another suggestive formula is added, through a long series of steps; but the total practice time remains constant.

There is an obvious parallel here to Jacobson’s 4 progressive relaxation therapy, although the method is entirely different. Autogenic training is interrupted after a minute’s practice and employs autosuggestion, which Jacobson abhorred. The approach is more reminiscent of Emile Coue (“Every day in every way I am getting better…”), but, whereas he used suggestion to alter personality directly, autogenic training uses it to alter physiology and thus indirectly to effect a personality change.

My first week or two of practice was disappointing. The suggestions lacked credibility, and the constant re arousal between exercises was irritating. But then, gradually, changes began to take place. First, my body developed a lopsided feeling, as if the bed had tilted to the right; and my right arm became sensitive to itches and pulsations. A few days later it developed a genuine feeling of heaviness, much like the weighty sensation after swimming as one emerges from the water. with one limb now “heavy,” I went on to another, and another, until finally they all became heavy at once with a single suggestive pronouncement.

The heaviness practice had no carryover into my daily life or so I thought, until I took a long trip. After many hours of driving, I developed a sharp, tense pain in my stomach, and my arms became sensitive, but lacked muscular tonus. Since some muscle tension is probably necessary for alertness, it appeared that the training had prevented tension from developing in my limbs, and that my viscera were tensing instead. To test this assumption, I later occasionally interrupted practice during periods of prolonged effort and fatigue. My hunch appeared correct, although eventually the gastric pain disappeared entirely, even under stress. If muscle tension does compensate for fatigue as hypothesized, then the training must have either gradually raised my energy reserve so that tension was no longer necessary or taught me to work with diminished effort.

Continued practice of the heaviness exercise led eventually to relaxation of the peripheral blood vessels and a feeling of warmth. This was reinforced in the next stage of the training with a suggestion of warmth. Attention was systematically directed to limb after limb, as with the relaxation practice, until a single sentence made them all feel heavy and warm at once. The impact was as strong as that of a double Scotch on a cold winter night.

Published plethysmographic studies verify that the sensation of warmth actually involves vasodilatation of the limbs. My own experiences confirm this. In the beginning of the warmth exercises, my fingers became visibly swollen (my ring could not be removed) and easily bruised. Any sudden noise during an exercise, such as the ringing of the doorbell, would produce a startle reaction that felt like an electric shock as my vascular system “snapped back.” These unwanted reactions were transitory, but the swelling could have probably been avoided by terminating each exercise more vigorously luring training. The correct procedure is to open one’s eyes, take a deep breath (causing vasoconstriction), and move about vigorously. In effect, opening one’s eyes then functions as a conditioned stimulus reversing the autogenic state.

Induction of the autogenic state can likewise be seen as a conditioning process, although it is usually seen as an autohypnotic phenomenon. A long time ago, Menzies 5 showed that, if subjects sail the meaningless word “prochaska” each time they plungedtheir hand Into a beaker of ice water, before long the world “prochaska” itself would produce conditioned vasoconstriction. Similarly, in the autogenic exercises, since a moderate amount of relaxation naturally results from lying down, it is necessary only no repeat the word “heavy” in connection with concentration on a limb to condition relaxation (or warmth) to the word “heavy.” Because the rate of relaxation upon lying down most likely decreases after the first minute, concentration prolonged beyond the one minute limit could actually be detrimental in developing a conditioned reaction.

Heart control follows mastery of the warmth exercises, one simply focuses on a calm and regular heart beat. However, the idea of consciously interfering with heart action is unnerving. After a few days of practice. I developed feelings of constriction in .he region of my heart and switched over to the breathing exercise instead. Many trainees reportedly have trouble with the heart exercise, and the instructions advise postponement, in the event of difficulty, until all the other physiologic exercises are mastered.

The breathing exercise is practiced with a suggestion favoring uncontrolled, regular respiration, such as is emphasized in Buddhist meditative “mindfulness” rather than Yoga PRANAYAMA, in which a pattern of control is often imposed. At first dance, uncontrolled respiration seems absurd; but, after a few minutes of self observation, it is apparent that thoughts and external events do constantly interfere with regular breathing. Initially even observation seems to cause interference; but, after a few days of practice, breathing becomes very regular and feelings of relaxation and warmth are enhanced. Observation of breathing has been used by some investigators as a technique for hypnotic induction. Preliminary psycho physiologic investigation in our laboratory indicates that its immediate effect is to regularize breathing and thereby promote relaxation.

Following the breathing exercise, the gastrointestinal tract is relaxed through concentration on abdominal warmth. Patients with peptic ulcer or ulcerative colitis reportedly receive relief from this procedure. In my own case, I found visceral relaxation difficult to attain except in the early morning hours when I was not yet fully awake. Usually only a mildly warm, unpleasant throbbing sensation was obtained. Because the sensation was very distinct, it later made me aware that stress elicited the autogenic state; for, whenever I felt under pressure during the day, I began to experience the same throbbing sensation in my abdomen. Although it disappeared if I discontinued practice for a few days, it did start me wondering whether perhaps the autogenic state in general was called forth by stress. Since the other exercises resulted in pleasant relaxation, I probably would not be aware of their onset, but instead would simply reinterpret a previous stressful situation as innocuous.

Obviously, if autogenic training does no more than permit heightened relaxation when one is lying down, it would have limited usefulness. From the results claimed for the training in many case studies, it must operate during stress; but why stress should come eventually to elicit the trained counter response is unclear. Instructions emphasize one minute practice sessions so that control in later situations will be automatic and rapid, but no explanation is given.

Interestingly, a stress “counter pressure” appeared in one of my dreams, in which I was confronted by a wild animal. My first impulse was to run, whereupon the autogenic state suddenly asserted itself. I faced the animal, and it disappeared.

For the final exercise of the physiologic series, cooling the forehead is suggested. Even though this involves vasoconstriction, not necessarily consequent upon relaxation, it was not difficult to achieve. One needs only to recall previous occasions when one’s forehead was cool and repeat the appropriate suggestion. As a rationale for such a strange seeming exercise, the manual mentions the beneficial effect of a cold head pack during a warm bath. Recent Russian studies of the ORIENTING REFLEX, showing that startle and heightened attention cause, among other things, a shift in blood from the periphery of the body to the brain, offer a more compelling justification.
In conditioning a resistance to excessive orienting activity, autogenic training has carried its stress “counter pressure” one step further.

At this point i made another attempt to learn heart control, but again there were unpleasant side effects “hot flashes” and feelings of constriction around the heart during exertion. Possibly these problems could have been overcome with supervision. One of the difficulties is that the warmth exercises, with their rapid vasodilatation, can lower blood pressure and reflexively accelerate the heart. Obviously, deep relaxation, as in rest or sleep, leads to vasodilatation without an increase in heart rate; but the transition is much slower.

Despite my failure in achieving heart control, the heart exercise did highlight the importance of feedback, which is apparently the crucial factor in directly controlling any of the so called “involuntary” responses, and perhaps relaxation as well. In practicing the heart exercise, one initially places one’s hand over one’s heart to sense its beating while making a suggestion. This is necessary because direct perception of heart beat, as distinguished from peripheral pulse sensations, is not always possible in a relaxed state without training.

That feedback is necessary for control is suggested by a Russian study reported by Razran. 6 Subjects were shocked repeatedly, and their vascular responses were analyzed. When they responded to the shock with vasoconstriction (the normal physiologic response), the shock trials continued; but, if they responded with vasodilatation, the shock trials were temporarily halted. Since the shocks were painful, it was thought that shock cessation would reward and condition vasodilatation. Numerous trials were made; but, until the subjects could observe their vascular record on the polygraph, they were not able to control their responses, despite a reward.

Even in relaxing the voluntary muscles, proprioceptive feedback seems to play an important role; and becoming aware of it may be the sole reason for practice. Jacobson, 4 in his relaxation instructions, mentions that patients must first become aware of what slight tension feels like. Yogic postures employ stretching and contracting to develop an awareness of the muscles. Throughout all the autogenic exercises, I found that the suggestion were effective only if I focused attention on the relevant bodily part. In fact, the suggestions appeared to function largely as a mnemonic device for directing and sustaining attention. Even if a suggestion made mention of an entire limb, such as an arm, if attention were focused mainly on the hand, only the hand became heavy and warm.

Improperly directed or excessive attention can be a major source of difficulty in unsupervised mastery of the exercises. Since, apparently, the state achieved during training later occurs under non training conditions with stress, it is important that concentration lead to a relaxed state. But attention must be passive, as the manual emphasizes. Too much effort to experience a particular result in one bodily part will cause tension somewhere else. On the other hand, with insufficient effort attention will not be focused and no prioceptive “contact” will result.

Meditative training follows mastery of the standard physiologic exercises.
If the whole training procedure up to this point has seemed a grotesque system of sedation and suppression, consider the popular expressions “stiff necked,” “keep your chin up,” “discipline steels one’s character,” “hard,” “solid,” and so on. As Wilhelm Reich intimated with his concept of “muscular armor,” tense muscle are often a means of control and defenses they “freeze” affect, and only as they are relaxed does affect come into conscious awareness or find expression. Hefferline 7 reported an experiment in which students were asked to make a proprioceptive search of their bodies and report muscular blocks. As these blocks were removed and function was restored, many subjects reported vivid, spontaneous memories, some going back to childhood, when the block first occurred.

In meditative training the autogenic state is prolonged for half an hour or longer to facilitate an emergence of feelings. After a few weeks of daily, prolonged practice, a well trained person will find his visual field bursting into a solid hue of colored light. The experience represents a release that deepens relaxation and eventually enables the hallucination to form. In the final meditative stage, questions of an existential nature can be posed and answered with dream like symbols. The process is roughly analogous to having a problem upon retiring and dreaming a solution. The autogenic state simply enhances control and release. In one instance a schizophrenic woman who hallucinated before her training was able to control the content of her hallucinations after the training, even though the hallucinations did not disappear.

My own personal attempt to learn the meditative exercises met with only partial success, possibly because I had not completely mastered the standard exercises. I was never able to visualize color, the first step, although I was briefly able to hallucinate faces and figures.

The most dramatic example occurred one night after a dream. As I began to gain consciousness, it occurred to me that, perhaps if I were to implement the autogenic state in this drowsy condition, I might be able to reinstate the dream process without losing consciousness. Being careful to avoid arousal through minimum of movement, I shifted to the training position and proceeded. Within a few seconds, flashing patterns of light slowly moved to the center of my visual field. The resulting vortex then grew larger and drew me down into its center with a falling sensation. As it did, the light suddenly intensified, and clear, stable images formed. Minute details never present in the imagination of even familiar scenes or faces had the clarity of a glossy photograph. It was like watching an unfamiliar play on television without the sound. Nothing about the scene or characters was familiar. Out of curiosity, I opened my eyes slightly. Dimly lighted windows at the far end of the bedroom were visible, but the image remained as if projected on a translucent screen hung in the center of the room. Then, with growing excitement I felt my heart and breathing rate begin to accelerate; and, as this happened, the process reversed itself.

This largely furtuitous event marked the high point of my experience; subsequent attempts to repeat it were not as dramatic. Although the training in general had a sedating effect that can only be described as a greater joy in being alive, I did not gain any significant insights as a result of the meditative experiences. However, they were too few, and my mastery of the training too tenuous, to make a fair assessment. Claims made for the method, insofar as my experience permits an assessment, are accurate.

The meditative phenomena tend to suggest that input stimulating environmental activity, or residual tension in rigid muscles is the mechanism through which unconscious feelings are repressed or crowded out of consciousness. Thus, in stimulus deprived environments and states of prolonged relaxation, or with hypnotic dissociation, when input stimulation ceases, unconscious thoughts and feelings spring into awareness or even project outward. The system is somewhat analogous to a tape recorder that records when signals are coming in on the line but, when they stop, reverses direction and plays its contents back into the microphone. In the case of the brain, not everything is, of course, played back. It may only be material with emotional content, material that caused an emotional reaction when it was first received. This might well be coded in differential patterns of muscle tension initially aroused to cope with stressful situations.

The formulation is more plausible if viewed from the standpoint of an “attitude theory” of the emotions, as proposed by Bull. 8 Feelings are not given an existence prior to, or independent of, bodily processes, but are seen as derived from a preparatory motor set. Thus a perception leads to a motor set, then awareness of the motor set produces the associated feelings. The observable manifestation of the emotion represents a discharge; for example, crying reduces the feeling of sadness. In a test of the theory, Pasquarelli induced subjects under hypnosis to feel various emotions such as fear, anger, disgust, triumph, or depression. Each emotion appeared to produce its own distinctive bodily sensation or postural set. Subjects were then told hypnotically to “lock” or fix this set, after which a contrasting emotion was suggested. As the theory predicted, no change in emotion was possible while the original postural set was maintained.

Jacobson, 4 whose program demands a degree of relaxation that approaches loss of tonus, also maintains that patterns of minute muscle contraction accompany emotion. For these minute contractions associated with feelings to be perceived, all muscle groups are relaxed to the point of near zero residual tension (which may take many hours of practice to achieve in even a single muscle group). However, he reports that, when patients troubled by phobias and compulsions are able to perceive the tension patterns associated with their problems and then to relax them away, their disturbances eventually disappear.

Deriving feelings from badly reactions need not contradict a cognitive theory of the emotions, as proposed by Arnold to and applied therapeutically by Ellis. 11 These writers state that an emotional reaction depends on how a particular situation or event is evaluated an evaluation being determined by early social learning or psychodynamics. An evaluation, however, is simply an earlier link in the chain of emotional sequence, which is presumably: Evaluation – Bodily Reaction – Feeling. Thus an emotional reaction could be changed by altering one’s philosophy (evaluation), as Ellis argues, or by altering one’s bodily reaction. Conventional therapies alter the prior link in the chain the neurotic predisposition (evaluation) rather than the derived bodily reaction (symptom) directly. But the outcome may be similar if a bodily reaction constitutes the feeling and it is removed or relaxed away in the presence of the idea or situation evoking it. As wolpe 12 has shown with his desensitization therapy, repeated relaxation in the face of emotion producing situations eventually causes them to lose their potency. Thus, with emotional reactivity gone, it would be meaningless to sneak of a neurotic predisposition. A recent study by Cautela 11 even suggests that, as the emotion dissipates during the desensitization process, cognition also changes. Analyzing patients, attitudes and feelings during the course of desensitization therapy, he found that meaningful “insights” appeared spontaneously as relaxation eliminated the “symptoms.”

Relating thinking and, particularly, the emotions to peripheral events has overtones of the old James-Lange controversy. The theory dropped out of vogue largely because Cannon showed that, even when injuries to the sympathetic nervous system prevented autonomic outflow and afferent return from the viscera, overt emotional behavior was still present. However, a recent report by Hohmann 14 contests the implications of that work. In studying paraplegics Hohmann found that they reported a diminution of emotional feeling progressively related to the height of the spinal cord lesion. But overt emotional behavior (not reported feelings), which Cannon studied in his sympathectomized cats, was still observable.

In conclusion, should psychotherapy consider emotional reactions nothing but physiologic changes and try to alter them accordingly, or should it continue to view emotions as basically psychic in origin, the result of a conscious or unconscious evaluation? Perhaps it should do both to be efficient, and consider the possible interaction in each individual case. Some patients may resemble the hypothetical person given an injection of adrenaline without his knowledge. As described by Schachter, 15 he would be in a state of sympathetic arousal, but unable to understand the basis for his feelings:

… he will label his feelings in terms of his knowledge of the immediate situation. Should he at the time be with a beautiful woman, he might decide that he was wildly in love or sexually excited. Should he be at a gay party, he might, by comparing himself to others, decide that he was extremely happy and euphoric. Should he be arguing with his wife, he might explode in fury and hated. Or, should the situation be completely inappropriate, he could decide that he was excited about something that had recently happened to him or, simply, that he was sick. In any case, it is my basic assumption that emotional states are a function of the interaction of such cognitive factors with a state of physiological arousal.

Dr. Grim is a research psychologist in the Department of Psychiatry of the University of Pittsburgh School of Medicine, 3811 O’Hara St., Pittsburgh, Pa. 15213.

REFERENCES
1. Hauqen, G.B., Dixon, H.H., and Dickel, H.A.: A Therapy for Anxiety Tension Reactions. New York, Macmillan, 1958.

2. Schultz, J.H., and Luthe, W.: Autogenic Training: A Psychophysiologic Approach in Psychotherapy. New York, Grune and Stratton, 1959.

3. Luthe, W. (ed.)s Autogenic Training Correlationes Psychosomaticae. New York, Grune and Stratton, 1965.

4. Jacobson, E.: Progressive Relaxation. Chicago, University of Chicago Press, 1938.

5. Menzies, R.: Journal of Psychology, 4:75, 1937.

6. Razran, G.: Psychological Review, 68:81, 1961.

7. Hefferline, R.F.: Learning Theory and Clinical Psychology-An Eventual
Symbiosis? In: Bachrach, A.J. (ed.): Experimental Foundations of Clinical Psychology. New York, Basic Books, 1962, pp. 97-138,

8. Bull, N.: Psychosomatic Medicine, 7:210, 1945.

9. Pasquarelli, B.: Journal of Nervous and Mental Disease, 113:512, 1951.

10. Arnold, M.: Emotion and Personality. New York, Columbia University Press, 1960 (2 vols.).

11. Ellis, A.: Reason and Emotion in Psychotherapy. New York, Lyle Stuart, 1962.

12. Wo1pe, J.s Psychotherapy by Reciprocal Inhibition. Palo Alto, Stanford University Press, 1958.

13. Cautela, J.H.: Behavior Research and Therapy, 3:59, 1965.

14. Hohmann, G.W.: Psychophysiology, 3:143, 1966.

15. Schachter, S.: The Interaction of Cognitive and Physiological Determinants of Emotional State. In: Berkowitz, L. (ed.): Advances in Experimental Social Psychology, vol. 1. New York, Academic Press, 1964.Psychotherapy by Somatic Alteration

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