Bringing Bodies Into Dialogue

Dower, C., 2014. Bringing Bodies Into Dialogue. Reformulation, Winter, pp.15-21.


Prologue

A patient approaches my room from the waiting area. She strides purposely toward me, stamping heavily on the ground. Her gaze fixes on me, but her eyes are hard and her mouth firmly clamped shut. She feels big to me as she brushes past, drops her bag onto the floor and lands heavily in the chair.

I inhale, push through the floor and stand tall as I move directly towards my chair, maintaining the eye contact. I lower myself gently, keeping a strong sense of my feet on the ground. I hold myself upright as I greet her.

She exhales deeply and loudly, and then her shoulders soften. Her eyes soften as her mouth moves to speak.

I settle back into my chair, and as I sense the support behind me and the support of the fl oor beneath my feet, I feel my abdomen relax and open, and so we begin.

Where did we begin? We have already danced together. Our movements have been shaped by the movements of the other. Here we have a whole story of how my patient anticipates the session to come, how she organises her Bringing Bodies Into Dialogue Caroline Dower body to come towards me and the session, how she regulates herself through her movement, how she experiences my presence and how this informs her next move. Then there is my side of the story: how do I anticipate her presence? How do I organise myself to greet her? How is this informed by my most significant relational encounters, by my previous session and by my history with this patient? What can I learn by attending to the nuances of call and response of these two bodies?

Introduction


In this article I would like to share my interest in integrating bodybased awareness, specifi cally relational movement processes, into my therapeutic work. Early in my training we replayed video footage of therapy role-play without the sound. The movement patterns of the two bodies reflected the verbal themes, and since then I have been exploring how our rationality is present in reciprocal movement. I have been trying to make sense of my observation of how, in addition to changes to their internal and relational worlds, patients appear to move differently by the end of therapy.

I have been practising and teaching this material for some time now but my workshops to date have been largely demonstrative and experiential. Here I would like to integrate the methodologies into my CAT theoretical frame and to begin a dialogue with the wider CAT community. Many other CAT practitioners are similarly integrating body-based methodologies, and CAT has historically been a model that has welcomed the integration of ideas from other models. I would argue that core CAT concepts provide a theoretical frame that supports and suggests the inclusion of embodied methodologies.

There is a long tradition and a research basis for asserting that all psychotherapies depend on some common basic factors and processes (Frank 1973; Leiman 2012)

Within the holding environment of the therapeutic relationship which is complex and multi-faceted (Clarkson 1995), the key processes that emerge in common are those that contribute to the clients’ growing capacity for:

1. Self-observation

2. The organisation of these observations to generate insight, integration and selfregulation (Schore 2012)

3. An altered and empowered relationship to the presenting problems or symptoms, defined as the subject position (Leiman 2012, p.127). 

I will use this frame to describe how embodied methodologies add a potent dimension to these key processes, and how CAT theory and practice is particularly well-positioned to integrate these approaches. The theory is interwoven with fictional vignettes of a therapeutic process. I will end with a brief discussion of how embodied methodologies might challenge or extend our core CAT model.

1. Self-observation


All psychotherapies aim at generating self-observation (Leiman 2012 p.125), but they differ in the conceptualisation of the self that is observed/ observing, and in the nature of the material to serve as data for the observation and reflection, for example words, stories, art work, dreams, images or behaviours. Many therapeutic approaches have developed rich methodologies for enquiring into the embodied aspects of distress as it is experienced in the consulting room. They are central to trauma models of psychotherapy (Rothschild 2000; Ogden 2006), experiential methods of practitioners like Gendlin (1996) or Kepner (1987) from Gestalt, or the rich traditions of body psychotherapy (Staunton 2002), Dance Movement Psychotherapy (Chaiklin & Wengrower 2009) and embodied therapies such as Feldenkrais (2010), Authentic Movement or Body-Mind Centring (Hartley 1989). Mindfulness approaches (Kabat-Zinn 2004) include elements of embodied awareness. 


CAT has a concept of self-observation that arises from the centrality of dialogism in the theoretical model. We have a radically social concept of self, “a process of development during which a genotypic self..[ ].. interacts reciprocally with care-giver(s) in a given culture and in time psychologically internalises that experience” (Ryle and Kerr 2002 p.34). The self that is observed is, “a dialogue which reflects and refracts concrete social interactions in which it plays a part” (Burkitt 1991 p.143). The self is seen as an ongoing construction via dialogue, and self-observation is an activity, a continual process, of organising our understanding of ourselves within a shifting relational field but is itself a positioned activity in relation to its objects (Leiman 2012 p.126). Within the process of a CAT therapy the intention is for the client to develop a meta-position, an observer position; through joint activity, the client comes to observe the process of observation as a relational event.


What is the role for embodied relational awareness in the development of the observer position? 


Dialogism as a philosophical tradition has its roots in literary criticism (Bakhtin 1986), and the development of a theory of utterances (Leiman 2004). In this theory it is not just the speaker and the content that are the salient features of an utterance. The addressee and more specifically the anticipated response of the addressee, affects every aspect of the content. Each utterance is created in an intersubjective field. The roots of these theories in studies of language and discourse can serve, unwittingly, to privilege our verbal and narrative modes of sense-making. 


Another root of the CAT model of our sense of self comes from Vygotsky (1978) and later infant observation studies which detail the non-verbal, implicit relational procedures laid down in early life (Stern 1985; Brazelton and Cramer 1991; Tronick 1998; Trevarthen 1993). Here the utterances are the embodied gestures, movements, rhythms and prosody that occur between infant and caregiver that, with repetition, become jointly elaborated psychological signs - not representations of meaning but a jointly created conveyance of meaning (Ryle and Kerr 2002, p.40). These exchanges lay down the earliest foundations for our expectations of what will happen between self and other. For Vygotksy thinking was initially a bodily process (Burkitt 1991, p.149). ‘Higher mental functions’ emerge later through language as a medium and structure for thought, self-reflection and self-regulation, but internalisation of the social world begins first and foremost through the body. This idea has taken root in philosophy in recent years with increasing interest in how our embodiment might shape human consciousness (Gallagher 2005; Sheets-Johnstone 2009) and in the concept of mind as an embodied, relational, self-organising process (Siegel 2012).


I would argue that our embodied relational patterns as adults share the same features as those utterances expressed in language, composed of the three structural aspects of author, addressee and referential content, and expressive aspects which in embodied terms we might define as the qualities of movement (Kestenberg 1977) which parallel the verbal expressive aspects of intonation, composition and stylistic devices (Leiman 2004 p.256). A major influence upon my thinking in this regard has been Developmental Somatic Psychotherapy (Frank 2001; 2011), which although rooted in Gestalt theory and the philosophy of Merleau-Ponty (2004) is highly compatible with Vygotskian development theory (1978). The DSP model outlines the fundamental movement patterns of the infant as they unfold within the relational field, and then works with these movement patterns as they emerge in the therapist-client dyad. Each moment is co-created by two interacting bodies, with different capabilities, preferences and crucially expectations about what the next moment could hold. Referring back to my opening paragraph, my patient in that moment is moving towards me; there is an utterance, coming from her and addressed to me, composed of various moves that together express something of our relational field and anticipate the session ahead. Likewise, my embodied response to her, composed of conscious and less conscious elements, is an utterance back to her, and there will be many thousands of such moments of relational dance within a therapy session. 


A patient diminishes her physical self by collapsing her spine and dropping her head as she experiences a moment of shame. I inquire into the felt sense of that drop, with interest and curiosity. She tells me it feels like someone is pressing down on her head, making her smaller. 


I observe, and in sharing the observation, invite her to simultaneously connect with and observe the movement/ sensation. As she describes the sensation we begin to hear it as a reciprocal relationship; something is in relation to something else, we are ‘moved’ by others in our (internal/external) world. In the moment between us we are enacting a different reciprocal role; interested, inquiring, non-judging to experiencing, open, interesting/interested. These positions provide the foundation for the next inquiry,


“I wonder what happened here between us that might have felt a bit like that, me pressing down on you?”
The observation of the movement/ sensation becomes an observation of our mutual dance, and we can observe together how we impact each other; how we move each other. 


I might offer something of my own embodied experience,
“I notice that when you drop your head and shrink a little, I feel like you are further away, and being further away I feel a sense of stuckness in my body. I don’t know what to do or how to move, so I stay very still. How does it feel for you when I stay so still and quiet?”


Here there is a moment of betweenness. We are co-creating the moment of quietness. I felt uneasy in my quietness, but it might have meant something different for the patient. The enquiry helps us to observe and understand one aspect of how she impacts the other, and how this feeds back into her own experience. By sharing curiosity in both of our embodied selves, we are also building a capacity for the patient to notice and respect our self-agency/ individuality and our pattern of mutual influence. I have worked with mutual posture, gesture and breath patterns to facilitate a rich relational observer position with my clients. How we take in and expel air, how we use the floor, the chair, the eye contact with the other... these are all rich dialogic encounters. Enquiry is informed by our own embodied awareness, a solid base of psychotherapeutic theory and the verbal themes of the dialogue. Its strength as a methodology for developing the observer-position is that it is congruent with, and indeed suggested by, our theoretical model of ongoing self-construction in dialogue. The methodology provides a handover of tools for her to develop her felt-sense of the moment, the information that her body offers her to guide through the relational world, and to understand that felt-sense as a relational moment.

2. Organisation of Observation for Insight, Self-Regulation and Integration
A challenge for all psychotherapies, and especially those of a time-limited nature, is how to generate enough insight through observation and understanding connections for change to take place without generating an overwhelming amount of material that precludes real insight and change. 


In CAT we have a rich set of tools for describing repeated relational patterns with the concepts of reciprocal roles, presented first by Ryle (1985), and procedural sequences that link inter- and intra-personal aims and outcomes with contexts and mental processes. Both concepts are complex linkages of knowledge, memory, feeling, meaning and action. 


The core of the CAT model lies in the conceptualisation of health as flexible access to a wide repertoire of reciprocal roles and states, a relative degree of integration of these roles and a capacity to reflect upon self and other (Ryle and Kerr 2002). The technology of CAT, our tools for mapping and for creating reformulation and goodbye letters, supports us in the task of distilling down to target problems and in drawing out connections between relationships with self and others and between past and present. 


In workshops I have been demonstrating how I might sketch a map (Sequential Diagrammatic Reformulation) by drawing simply upon a breath or movement patterns, or characteristic postures and gestures. My hypothesis is that these moments are richly distilled expositions of key problematic procedures. The attention to the embodied here-and-now is a useful way to cut through the density of narratives that our clients bring, particularly when many of our clients have previous experience of therapy in stepped-care models or long histories of psychological input. Undoubtedly, the embodied enquiry is informed by verbal themes, but as a use of therapeutic time it has the advantage of providing a focused activity that will connect to core themes. The development of her observing-eye of embodiment in the consulting room lends strength to her capacity to observe herself in relational action out there in her everyday life. I asked my client to look out for similar moments of physical diminishment through the week:


“I had that feeling again. I felt it as my son’s teacher was talking to me, I shrunk and just like last week I went all fuzzy in my head, and I don’t know what she said to me after that.”


Many of our clients present with experiences of unmanageable states, whether those are hyper-aroused states of anxiety and fear or the more hypo-aroused states of lethargy and depression. Inherent to embodied methodologies is the attention and interest paid to the regulatory function of the state; and the increased awareness may enable clients to develop their self-regulatory capacities (Schore 2012). The client is encouraged to stay with, or even amplify, certain postural or gestural moments, and hence affective states. 


I enquire, “Feeling everything that you feel in that place, and just notice for yourself what your body wants to do next?”. 
She replies, “I know that some part of me wants to curl down further... but actually my abdomen is feeling a bit squashed, and it feels like there is weight on the back of neck.”


“Stay with that sensation, the place on your neck that is being weighed down”. 


“It really hurts if I concentrate on it, and it is harder to breathe... can I move?” 


The context of the therapeutic relationship may facilitate a greater sense of safety in approaching these dysregulated, embodied states. This is the basis for many of the embodied methodologies employed in trauma-focused therapies (Rothschild 2000; Ogden 2006), but the techniques can usefully be applied across other presenting phenomena. It can certainly be of help when the presenting issues constellate around a poor relationship with their own embodiment, for example in eating disorders or the poor management of long-term conditions like diabetes.


An attention to embodied relationality (often non-verbal and pre-reflexive) and the translation of that into verbal, reflected themes is itself a cross-modal integration. Stern (1998 p.138) describes the centrality of cross-modal translations of experience to the development of intersubjective relatedness. We communicate empathic responsiveness by reading something of the client’s affective state and translating it into a form that is similar enough that the client has the experience of understanding without it being a mere replication or reflection. We do this in many ways in therapy. The shift from embodied utterance to a verbal insight, back and forth, is a cross-modal intervention with particular therapeutic potency. Our CAT technology of mapping and reformulation supports this and harnesses the power and flexibility of language as a symbolic sign-mediator.


We translate our embodied experience onto paper as a reciprocal role. “Diminishing, making small - to - feeling small and alone”. In seeing the words on the page she contributes, “There are lots of ways that I make myself a bit smaller than I really want to be.”

3. The Development of the Subject Position
Leiman’s concept of the subject position (Leiman 2012 p.127) is proposed from within his meta-model of the psychotherapy process. The CAT model, itself, articulates therapeutic outcomes on the basis of an expanded set of reciprocal roles, increased capacity to observe the self and increased levels of integration within the sense of self. These outcomes are implied by the concept of the development of a subject position, defined as, “an altered and empowered relationship to the presenting problems, symptoms or unwanted repetitive action patterns” (Leiman 2012 p.127). However the concept of subject position goes beyond the perception of problems in a new light, which can be didactically taught within a therapy session or elsewhere, instead it captures how a client might find a new position in relation to symptoms and situations. It links well with the work by Knox (2011), which emphasises the importance of restoring a secure sense of self-agency to the client in any psychotherapy. This is a seen as a product of the actual interpersonal agency of the therapist and client, rather than the imposition of the therapist’s ideas upon the client. 

Embodied methodologies seem to be particularly well-placed to support the development of the subject-position. Prior to this integration I remember struggling to find something for the client, maybe with homework or experiments, that would lead neatly towards some (re)solution to the issues identified in the reformulation. The phenomenology of the embodied experience, staying close to the felt sense and allowing the client the space and atmosphere in which to discover their own way through, has been a tremendously empowering experience for my clients, and shifted my sense of myself as a therapist from one with power (or a striving for/ desire for power) towards potency, a capacity to contribute to the conditions for client-generated change. We can maybe trust the body/bodies to lead the way in a more spontaneous and creative way. 
Back to the moment when my client is developing her felt sense of the movement:

“Stay with that sensation, the place on your neck that is being weighed down”. 

“It really hurts if I concentrate on it, and it is harder to breathe... can I move?” 

As she understands the movement as the outcome of a relational process and feels it more, she discovers the desire to move differently and the self-agency to achieve it.

“You can, but as you move, notice in yourself what you do to move, and where else in your body you feel anything...”

“I’m lifting my head, ah that feels better, but to lift it I have sort of pull my tummy in and push down on the chair”. 

Later I observe/ translate,“So for your body to recover from this state you need to gather something inside and to draw on something outside too.” 

The possibility for novelty in the next moment emerges organically and, crucially, non-verbally. Exits 

can then be derived much more from a patient’s subjectivity, from her subject position. The opportunity can also be made to understand the relational nature of the exits. Here, we understand how she will need internal strength and external support to recover from these debilitating moments of shame and that these are intertwined; her strength might develop from the support, and some strength is needed on her side to access the available support. 

Concluding Thoughts


In some ways employing embodied methodologies can be easily integrated into our core CAT model, and the model provides a scaffold to our capacity to use our embodied awareness productively. The above discussion shows how this approach can contribute to the common psychotherapeutic goals of developing self-observation, insight, integration, self-regulation and this more recent concept of the subject position. I enjoy the integration but recognise that this reflects my own movement preferences and reflects the contexts in which I work, and will not appeal to every therapist-client dyad. There can be tendency to idealise bodywork, in a way that risks further separating mind from body, and intimidates therapists from feeling that these are accessible methodologies. A common refrain in my workshops has been, “I know I notice this non-verbal stuff all the time. I didn’t realise I could actually use it”. In responding to the requests for “something written on this” I hope to strike a balance between encouraging practitioners to explore simple ways to integrate relational embodiment into their practice whilst also calling for wider dialogue about the integration of a number of different methodologies that may support as well as challenge and extend our core model.


My integration has extended my CAT practice. It has honed my awareness of the co-creation of each and every therapeutic moment. For all of our theory there can still be a tendency on the part of therapists to create a ‘map of the patient’, which is reinforced by our tendency to draw maps from narrative, from the out-there stories. A more collaborative process creates a map of the dynamics of the relational dance, but this challenges us to develop our awareness of and our willingness to explore our contribution to the relational dance, whilst keeping the exploration of that participation within the client’s interest. 


My practice has also become less linear. In many therapies a great number sessions are spent exploring the history and the present-day narratives, and a lengthy process of reformulation precedes exits. When attending to embodied relationality we would be looking for moments of novelty and expansion of role repertoires from the earliest stages of therapy, a shift in orientation towards the future and experimentation in how the next moment might differ from our expectations. 


My CAT theoretical understanding of the self is not challenged by these approaches, but models of movement patterns between infant and caregiver do open a line of inquiry into how we might restore a role for innate temperament into CAT’s radically social model of the self - as a set of movement styles or preferences. Temperament is acknowledged in our model but it is often overlooked, in ways that do not make sense when we experience the unique embodied temperament of newborns. Restoring temperament as a concept is helpful firstly because it deepens our respect for subjectivity and encourages a more phenomenological stance and a greater quality of inquiry. How often do we see the same familiar reciprocal roles described on a map, ‘Controlling-controlled’, ‘Critical-criticised’? “How does it feel for you, in your body, when you are criticised?” explores the subjective contours of those states, enacting a respect for, interest in and engagement with the self of the patient. Secondly, it helps us to focus on qualities of self-agency, which might add something to the concept of resilience in the face of difficult or traumatic situations, or different sibling responses to family dynamics. 


Working in this way does requires a commitment on the therapist’s part to develop their own embodied awareness, and this has implications for how we structure our trainings and training therapies. I have developed my working models through further specialised training and a regular yoga/ body-based awareness practice. This approach emphasises relational movement; individual awareness through mindfulness is an important but partial contribution. Group work and training is invaluable to experience oneself in a variety of relational fields and to explore each co-created situation. 

Acknowledgements
These ideas have arisen in dialogue, with patients, supervisors, teachers and colleagues. Special thanks to Tim Sheard, Steve Potter, Katri Kanninen, Henrietta Batchelor, Lawrence Welch, Roz Carroll and Ruella Frank for their generous contributions and encouragement.


Caroline Dower is a Consultant Research Psychotherapist, working in Gastroenterology with the County Durham and Darlington NHS FT and in private practice in Newcastle. She has a strong interest in the development of embodied methodologies in psychotherapeutic practice, and in the particular application of this in physical health settings. 
carolinedower@hotmail.com


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Full Reference

Dower, C., 2014. Bringing Bodies Into Dialogue. Reformulation, Winter, pp.15-21.

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