by Halko Weiss
The case above is an example of relating to developmental or chronic trauma, as opposed to the single-incident trauma (accidents, rape, or events related to first-responder work, war, gangs, and so forth, where life is literally at risk) normally diagnosed as PTSD. Though chronic or complex developmental trauma has been identified as a different syndrome than PTSD, it has not yet been included in the diagnostics of the Diagnostic and Statistical Manual of Mental Disorders (van der Kolk, 2005).
Hakomi embraces the various ways in which we experience ourselves. No single way is the right one. The discovery of what works organically for a particular person is deeply honored (Germer, 2006). This goes beyond just being respectful of people and their processing preferences. It also includes the way our brains function to come to terms with a traumatic assault of stimuli and sensory inflation that is often hard to decipher (Rothschild, 2000; van der Kolk et al., 1996).
Through my work with trauma clients with many different trauma histories, I have come to view meeting them where their brains are as the best possibility. For instance, new babies need that eye gaze of delight and the gentle adjustable touch that activates the right orbital prefrontal cortex, or joy center, and teaches them that touch and relationship can be a safe haven and a nurturing template for all relationships to come (Doidge, 2007).
Trauma clients, likewise, need that same recognition and understanding of their arousal and fear contingencies—of how their brains have been affected. They also need the initial limbic restructuring experiences with the therapist to help them regulate parts of themselves lost in their instinctual-level coping with traumatic events (Schore, 2003). Or as one of my first clients put it when I was a beginning therapist, “I thought I came here for therapy, but what I really came for was feeling safe and understood and loved.” This occurred just as I was taking pride in graduating, complete with my newly acquired therapy skills. It helped me realize that the magic ingredient had not simply been my advanced techniques, but rather the quality of the bond that had developed with my client over time.
A deeply respectful relationship allowed my client to unfold, discover, and transform the sensate and content aspects of his narrative (Johanson, 2015). All my techniques would not have mattered if it had not been for this living connection in which he was held and, in fact, I was held as well (Germer, 2006; Mahoney, 1991). We can call it attunement, limbic resonance, empathy, compassion, or love. The fact is, what heals is a deep relationship with our respective humanities, in all aspects of their being (Lewis et al., 2000).
Uses of Mindfulness With Traumatized Clients
Mindfulness is a powerful tool in aiding the bodymind to understand and integrate traumatic experiences. Mindfulness applied in a manner conscious of traumatic dynamics has several functions:
1. Introducing clients to an ambience of calm and quiet.
2. Slowing down nervous system activity of the brain and settling the body. The middle prefrontal cortex is activated, allowing it to weave connections with the hippocampus—important for the structuring and reconsolidation of memories.
3. Providing an opportunity for clients to engage in listening to themselves as they both witness and are present to their experience in the moment—thus “having” as opposed to “being” traumatic processes.
These three functions are actually difficult for the trauma client to achieve without mindfulness. The internal world of the trauma client is often full of noise, physiological arousal, and constant activation of safety and well-being processes arising from more archaic structures of the brain than the neocortex. The fact that the hippocampus, which is crucial for memory consolidation, is bypassed during traumatic events makes initial narrative memory of events disturbingly unavailable (Schacter, 1992).
When my client Sally lay down on the couch, she wanted to relax. As she lay down, she told herself that she was relaxing. In fact, her fists tightened, her jaw clenched, and her breath got shorter and tighter. When I contacted these bodily signs in an observational way, she still maintained her view that she was calming down. It might have seemed that way to her to an extent, since chronic stresses are normally unconscious. A few moments passed. Her body would not calm or release any further. In fact, her body looked like it was becoming even tenser.
The spaciousness of my nonjudgmental observing, and the provision of time for her to sense herself, rather than inviting her into a doing mode, allowed for the following: I again contacted her present-moment experience by saying, “You are working really hard on relaxing.” With that, she smiled. She said that she could not feel any relaxation at all, but rather she felt a sense of fear in her chest, which she was trying to manage.
Now we had an opening to work directly with her fear, and with how she was managing herself in that state. This was a precursor to exploring how she was dealing with her trauma experiences, namely pushing through them while excluding feeling. If we had not created a safe atmosphere, with a slowed-down environment for curious, open-ended exploring (Kurtz, 1990a), we would not have had the opportunity to befriend her experience and see it unfold in new psychosomatic patterns.
Another important aspect of introducing mindfulness is interrupting habitual unconscious patterns in favor of providing an emotional holding space where clients can safely experience their high-affect states without spinning off into a trauma vortex. The mindfulness of therapists is also a crucial element, as they become the temporary nervous system that holds the disorganized states of clients—also true in parenting (Siegel & Hartzell, 2003).
Here are some ways to use aspects of mindfulness to interrupt habitual patterns of managing trauma-based states of fear:
1. Therapists actively engage to calm their own levels of racing or triggered thoughts by slowing down and getting mindful distance on their parts being evoked.
2. As therapists become aware of their own “speediness,” they calm their own body movements. They then employ simple ways to slow down clients physically. Interventions can include bringing awareness to the quality and rhythm of the breath and introducing a slower, more deliberate breath. Or clients can be encouraged to bring their awareness to the immediate knowledge that they are sitting on a chair, and their attention can be guided to the physical contact points with the chair and their feet on the ground. This attention to breath and to grounding the body helps to bring down the activation levels of the nervous system.
3. If they have not done so already, therapists engage their clients in mindful awareness of multiple ways they can resource themselves through body, images, colors, memories, self-state centeredness, and such (Ogden et al., 2006). This is always a first stage of treatment of trauma issues to ensure that clients always go back into traumatic material resourced, and have resources readily available to counterbalance activation outside their window of tolerance.
4. Therapists use their abilities to track and contact (Chapter 14) to stay closely attuned to the client’s experience as it is occurring, thereby enabling the client to bring awareness to the present-moment experience. Trauma is very much about not being congruent with one’s own experience, but rather with the past or the future.
5. Therapists support clients in increasing their ability to feel, sense, taste, and experience what is happening directly through the body. Connecting with the here and now enables clients to put thoughts and feelings into perspective. Therapists continually track clients for signs of hyper- or hypoarousal, and move to center, ground, resource, or titrate sensations when signs of dissociation arise indicating the process is going too far, too fast.
6. Therapists can bring mindfulness to bear on the quality of the therapeutic relationship (Fosha, 2000). This can enable the client to become aware of and enriched by the support, understanding, and empathy the therapist is offering, thus breaking the trance of traumatic isolation (Wolinsky, 1991). Directing the client to notice the therapist in the moment can also help break the trancelike quality clients can fall into when recalling traumatic events.
CHAPTER 25
Strengths and Limitations of the Hakomi Method: Indications and Contraindications for Clients With Significant Clinical Disorders
Uta Günther
LENDING SUPPORT TO the notion that body-oriented approaches offer opportunities otherwise not available in the treatment of clients with early-onset disorders and weak psychological structures, Maaz (2006) has suggested that the royal road to the preverbal unconscious is the body itself. The application of body-oriented approaches, however, is not without risk. If not appropriately practiced and carried out, body-oriented approaches could lead to retraumatization (van der Kolk, 1989), inappropriate touch (Boadella, 1980; Hunter & Struve, 1998), the collapse of defense mechanisms, or malign regression (Marlock, 1993). As a body-centered, experiential approach to psychotherapy, Hakomi incorporates the use of touch alongside the practice of mindfulness. This chapter discusses the indications, contraindications, and risks involved in the utilization of the Hakomi method and Hakomi’s use of touch with clients with early-onset, chronic clinical disorders.
For the purposes of discussing clinical disorders, I utilize an approach to developing and discussing clinical diagnostic pictures in terms of (and in relation to) clients’ hypothesized psychic structure, an approach that has been described by Maaz (2006) as well as others. Interest in this approach has given rise to a practice-relevant instrument, the Operationalized Psychodynamic Diagnosis (OPD) instrument (OPD Task Force, 2006). The OPD, which serves as the framework for the discussion of clients’ psychological organization, is oriented toward looking at disorders and symptoms from within the developmental context from which they are hypothesized to derive. In contrast to the systems of clinical diagnosis that have their roots in Otto Kernberg’s (1996) work on character pathology, the OPD “does not limit its focus to a typology of character pathology; instead, it places primary emphasis on the relationship between experience and behavior as expressed in psychic organization, where the deciding factor is the degree to which experience and behavior have come to be integrated in the psychic structure” (Galuska, 2006, p. 586).
The OPD Task Force has put forth a descriptive system to accompany the OPD that describes the axis of structure as follows:
Psychic structure can . . . be described through the use of four dimensions that can be used to describe both object relationships and the relationship to the self:
Perception (self-and-object relational perception)
• the ability to be self-reflexively aware
• the ability to accurately perceive others
Regulation (self-and-object relational regulation)
• the ability to regulate one’s own impulses, affect, and self-esteem
• the ability to regulate one’s relationships with others
Communication (self-and-object relational)
• the ability to communicate with oneself
• the ability to communicate with others
Connection (self-and-object relational directed connection)
• the ability to make use of good inner objects for the purposes of self-regulation
• the ability to develop and dissolve relationships with others. (1996, p. 118)
The OPD discusses structural disorders in terms of levels of psychological integration along a continuum, describing an inverse relationship between the level of psychological integration and the severity of psychological disturbance, such that the most severe disorders occur within the context of the lowest degree of psychological integration.
The “structure” axis traces the level of psychological integration from the well-integrated psyche found in a “healthy” individual through decreasing levels of fair, and then low, psychological integration, finally ending in psychological disintegration. The psychological organization of a neurotic represents a fair to good degree of integration; that of a borderline represents a fairly low degree of integration; the psychological structure of a psychotic represents a psychological disintegration. (Galuska, 2006, p. 586)
Within the context of an established therapeutic alliance, the OPD is very helpful in assisting in the process of determining a client’s level of structural integration, assessing, for example, a client’s ability to both be and remain connected to the experience of reality, and to differentiate self and object, as well as the maturity level of clients’ defense mechanisms (Maaz, 2006). As such, the utilization of this type of approach to client work highlights the importance of considering clients’ levels of structural organization when considering potential therapeutic interventions. In the case of depression, for example, it is important to utilize therapeutic approaches aimed at specifically targeting the opportunities and strengths available to clients given the coping mechanisms available at their level of organizational integration. Attempting to mindfully immerse clients in their depression prematurely can be contraindicated.
Risks With Clients With Underdeveloped Psychological Structures
An assumption generally held by clinicians is that a relationship experienced by the client as a healing relationship—one that can provide a safe space and a feeling of being accompanied by a competent guide through the processes of self-exploration, as well as the creation, experience, and integration of corrective experiences—is what will make this work possible. The majority of clients that come to us in outpatient settings are generally able to form and maintain therapeutic relationships. However, only fairly well-integrated individuals respond with excitement and relief to therapists’ assumptions about these relationships enabling a “cooperation with the unconscious” or connecting with, experiencing, processing, and working through repressed emotional content. For those who have deficits in psychological structure based on difficult experiences very early in life, or for those destabilized by the active experience of trauma, the thought of lowering defenses against difficult content, becoming mindful, willingly opening oneself to inner space, and listening in and allowing oneself to be surprised by what happens is both scary and, in some situations, actually dangerous. For clients on the extreme end of this spectrum, all the steps that lead to mindfully experiencing the present moment are not only difficult but also not necessarily helpful. There is a certain control for safety built into the Hakomi process, however, in that every therapeutic intervention is carefully tracked for signs of dissociation that would signal clients are outside their window of tolerance (Ogden et al., 2006), and defenses are never overridden, but are supported for their wisdom (Chapter 17).
Clients not met at the appropriate level of their deficits may strengthen their intra- and interpersonal defenses in order to protect against a threatening situation, leave therapy, or run the risk of psychologically decompensating. Depending on the client’s psychostructural makeup, opening oneself prematurely to emotional experience and the accompanying psychophysiological arousal can be taxing or lead to a partial or complete overwhelming of the client’s processing capabilities, or even to an experience of being destroyed, flooded, disintegrated, or extinguished. These clients’ original defense and coping mechanisms were able to maintain enough stability in their very fragile inner systems to be able to function under normal circumstances. Typical Hakomi techniques, uncritically employed, could put such clients at risk.
The standard paradigm of uncovering and working through (Chapter 19) has been repeatedly discussed as contraindicated for traumatized clients (Petzold, Wolff, Landgrebe, & Josic, 2002). Major life stressors and experie
nce-activating and defense-weakening interventions have also been discussed as risking the collapse of coping systems leading to a shift to a more significant crisis state or a chronic increase in symptom severity in clients with other forms of structural vulnerability and disturbance (Rudolf, 1996). There is, of course, a large difference between event-driven PTSD and long-term, developmental trauma (van der Kolk, 2014). In either case, the first step in a therapeutic process might well be resourcing. When the trauma has been life threatening, evoking lower brain responses, Hakomi therapy must switch from top-down processing to bottom-up processing of sensations and such (see Chapter 24; Ogden et al., 2006). Relational attachment work might also be a prerequisite to intrapsychic explorations (Fosha, 2003; Lamagna & Gleiser, 2007). For clients with personality disorders, as well as clients who are severely depressed, increased vulnerability is often attributable to deficits in self-determination and affect regulation that also require interpersonal attachment work. “Given that the disordered difficulties are ego-syntonic (that is, not accessible to the self-perception of the individual author of the experience), it is difficult for the patient to see their own contributions to the difficult situations” (Rudolf, 1996, p. 178). Since people with personality disorders tend to blame the environment as opposed to reflecting on their own contributions, patient interpersonal interventions are often required over time until the level of safety is reached that allows intrapsychic Hakomi work. People with phobias might or might not be amenable to more immediate mindfulness-centered interventions.