Psychoanalysis and body psychotherapy: An exploration of their relational and embodied common ground

Abstract

Working therapeutically with and through embodiment is a topical issue in the psychoanalytic literature. Vice versa, body psychotherapy is deeply rooted in psychoanalytic theory and practice. This paper will explore corresponding themes, historic developments, and recent literature with reference to their actual and potential mutual influences, aiming to demonstrate: (1) that contemporary body psychotherapy practice continues to be informed and influenced by psychoanalytic theory, in particular the relational emphasis in psychoanalysis; and (2) that psychoanalytic psychotherapy, in turn, can be enriched and furthered while utilizing the theoretical paradigm of embodiment and body-oriented, experiential intervention strategies developed in body psychotherapy.

Key words:

• body psychotherapy
• psychoanalysis
• psychoanalytic therapy
• embodiment
• enactivism

All doing is knowing and all knowing is doing. (Maturana & Varela, 1992, p. 27)

The psychotherapy landscape in general is undergoing a significant change process; traditional theoretical paradigms underpinning the intervention strategies in so-called “talking therapies” are being increasingly challenged in the light of emerging scientific findings from affective neuroscience (e.g. Panksepp & Biven, 2012), developmental psychology (e.g. infant observation; Beebe & Lachmann, 2003; Beebe et al., 2010; Stern, 2010), cognitive sciences (i.e. embodied cognition; Borghi & Cimatti, 2010), and philosophy (i.e. enactivism; De Jaegher & Di Paolo, 2007; Gallagher & Bower, 2014). The scientific exploration of common and specific factors through which psychotherapy constitutes benefits, aiming to establish the evidence base for therapeutic practice, has become a matter of concern for all psychotherapy modalities (e.g. Wampold, 2015). One important theme associated with and centrally featuring across all the above scientific domains is the question of how bodily realities (emotion/feeling state, intero- and proprioception, somatosensory perception, motor activity) impact upon what has been the centre of all psychotherapeutic work – “the mind, the psyche.”

Acknowledging that “to date there has perhaps been a denial of the significance of the body in psychoanalytic literature” (Antonio Ferro in his review of Lemma, 2015), there is currently a noticeable reemergence of psychosomatic roots in psychoanalytic theory and practice. Accordingly, contemporary relational psychoanalytic literature is increasingly concerned with the body as subject and object of both the patient and the analyst (e.g. Boston Change Process Study Group, 2018; Lemma, 2015; Sletvold, 2014).

Vice versa, the history of body psychotherapy (BPT) is closely associated with the psychoanalytic community. The theory of BPT is to a large extent rooted in psychoanalytic theory – at the beginning, foremost Sandor Ferenczi and Wilhelm Reich with their efforts to alter psychoanalytic practice (e.g. Geuter, Heller, & Weaver, 2010; Heller, 2012). Significant contributions to the developments in theory and practice of BPT came from reform gymnastics/pedagogy, dance and movement therapies, and psychodynamic theory (Geuter, 2015a; Geuter et al., 2010; Röhricht, 2000). The two most clinically relevant contemporary branches that developed out of those historic context are the German BPT schools of “concentrative movement psychotherapy” and “functional relaxation.”

Emphasizing the intersection in theory and practice, utilizing the notion of intersubjectivity and embodied cognition, this paper will explore themes and historic developments of theory and practice in BPT and psychoanalytic therapy with reference to their actual and potential mutual influences. It will be argued that the relationship between these two traditional psychotherapy schools is fruitful, continuing to stimulate further developments in their respective fields. In the UK (and to a lesser degree in other English-speaking countries) contemporary BPT profoundly integrated themes emerging from relational psychoanalysis (Perlman & Frankel, 2009; Rapoport, 2014; Soth, 2009; Totton, 2018), and – predominantly in the German-speaking area – psychoanalysis integrated concepts and intervention strategies derived from BPT into a distinct school of “analytical body psychotherapy” (ABPT; e.g. Geißler, 2017).

Referring to these two major developments, this paper aims to demonstrate that, despite the methodological variety of the field and notwithstanding its profound influence from humanistic psychology, the clinical practice of BPT remains deeply rooted within psychoanalytic frameworks. At the same time, I will present arguments to emphasize how psychoanalysis can be advanced in order to inform psychoanalytic therapy, thereby supporting the notion of a shift towards an embodied and enacted relational therapy, as exemplified by ABPT. According to this approach, relational psychoanalysts firmly and directly engage clients in psychotherapy not only cognitively, but also in their physicality, that is, their perceptual, affective, and psychomotor organismic realities and their connectedness with the immediate and wider environment.

Two main assertions are accordingly relevant for this paper and are therefore introduced from the beginning. First, mind and consciousness are “embodied,” that is, emerging from or serving the needs of a physical being located in a specific time, place, and social context (e.g. Borghi & Cimatti, 2010). From the perspective of psychanalysis Fonagy and Target (2007, p. 411) emphasize that “This idea has also been at the core of much psychoanalytic thinking, which has historically affirmed the rootedness of symbolic thought in sensory, emotional, and enacted experience with objects.”

Second, mind and consciousness manifest and unfold through enactments. They:

provide therapists a medium for mediating relationships through simultaneous experiential intervention and change at multiple levels of relationships – including specific relationship disagreements and problems, interaction process surrounding these issues, and underlying emotions and attachment issues confounded with those problems. (Davis & Butler, 2004, p. 319)

According to the enactivist view on embodied cognition (e.g. Gallagher & Bower, 2014; Johnson, 2007), “meaning-making” is a process operating through our embodied experiences and emotional encounters, our sensory-motor responses to changes of the environmental milieu, also referred to as “structural coupling”; therefore the mind is not equal to either brain or body, but is a dynamic process arising from the dynamic interplay of brain, body, and environment (e.g. De Jaegher & Di Paolo, 2007; Maturana & Varela, 1992): “‘Mind’ and ‘body’ are merely abstracted aspects of the flow of organism-environment interactions that constitutes what we call experience” (Johnson, 2007, p. 12).

The importance of emotional regulation processes for relational aspects – both interpersonal and also in respect of the wider social environment – are increasingly acknowledged, particularly in relation to findings from longitudinal attachment research (e.g. Sroufe, 2005). A recent literature review on emotion regulation and attachment and a corresponding data analysis (Girme, Jones, Fleck, Simpson, & Overall, 2021) suggests that infant attachment insecurity is associated with distinct emotion regulation strategies in adulthood. Summarizing this paradigm change, Sletvold (2014, p. xv) explains in his book The embodied analyst:

I see the mind (the minding process) as basically an on-going process of registering, feeling and sensing (in ways I would describe as intuitive and generally non-reflective) what is happening and changing in our body as we continually interact with our environment (with particular interest in other human beings).

While the concepts of embodiment and enactments appear in both modern psychoanalytic and BPT literature, they lead to different conclusions regarding the therapeutic implications. On the one hand, psychoanalysis continues to focus upon primary thought processes predominantly in the verbal domain, particularly as they emerge in dreams or through verbal free association. The therapeutic process entails working with mental imagery, helping patients to make the unconscious (representations) conscious, and the therapeutic practice revolves centrally around the systematic use of the transference. De Timary, Wolff, and Philippot (2011), investigating the way the psychoanalytic (and cognitive-behavioral) approach conceives of representations, characterize the analytic work thus:

This entails transforming image-based representations (‘thing-presentations’) into word-presentation and binding together affects and representations … this is called ‘working-through’ or ‘processing’. In addition … an important part … is done via the analysis of representations, actualised in the transference relationship, of earlier relationship patterns … ; these can be analysed thanks to the neutrality of the analyst. (p. 5)

In contrast, ABPT retains the psychoanalytic focus of working with unconscious processes, both in terms of the dynamic unconscious of repressed experiential contents and those life experiences that are captured within implicit-procedural memory systems. It furthermore centrally focuses on subjective relational experiences, placing self- and affect regulation as well as directly engaged and enacted conflict resolution as an overarching concept at the centre of the intervention strategies. Conflict is here understood as an umbrella term for all situative antagonistic processes – past and present – including those resulting from trauma, deprivation, and loss, as well as divergent motivational drives in relation to others and the external world.

ABPT opens up new avenues for relational engagement within the “working-through” process; it recognizes the complex realities of fully embodied and enacted transformational experiences unfolding in the actual context of therapeutic encounters, accessing “the implicit nonverbal matrix of the therapeutic dialogue” (Clauer, 2014, p. 26). This is concurrent with criticism from within the psychoanalytic community: “I agree with Mitchell’s (1997, pp. 13–14) observation that expectations for free association from the analysand or neutrality and objectivity from the analyst create unattainable ideals at best, if not, illusions” (Knoblauch, 2005, p. 811).

The development of body psychotherapy in relation to psychoanalysis

Elisha, who conducted an exploration of the body in therapy in the history of psychoanalytic theory (2011), summarized her investigation in this way: “Each reconstruction of meta-theory carries slightly different implications for the body … each mind body solution implies something about the source of the animating, generative, or motivating energy of life” (p. 179).

Researching the theme of the body–mind relationship in Freud’s meta-psychological thinking, Elisha (2011) concluded that most scholars acknowledged a progression from an earlier monistic-reductionist model toward a metaphorical model of the mind. She emphasized that Freud’s model implied a hierarchical valuation of psyche over soma, “an ascension myth,” possibly encouraging a “notion of disembodiment accompanying notions of maturity” (p. 184). Bodily realities in Freud’s approach are not primarily relational beyond physiological needs. Based upon the evolving theories of his time, Freud suggested that muscular efforts, movement, and/or sensory stimulation should be avoided in a setting of orthodox neutrality as it may distract the mind from mental activity. Steiner (2006) described Freud’s understanding of the boundary between thought and action, quoting Freud from 1921: “restraint upon motor discharge (upon action), was provided by means of the process of thinking” (p. 221). Fuchs (2011) also investigated the concept of the body in Freud’s psychological model and pointed out: “In the end, the body thus remained interesting only as the seat of symbolic or imagined meanings, … as a primary projection field for the psyche, which always had to be scrutinized for hidden meanings” (p. 88). Classical settings advantaged body-related fantasies over bodily existence and affective expression.

Georg Groddeck and Sandor Ferenczi were the first psychoanalysts who communicated with words and hands; they were the pioneers introducing embodiment into psychoanalysis (e.g. Langan, 2007).

Wilhelm Reich developed his concepts of direct body-work into the very first form of an analytical BPT (“Vegetotherapy”). Searching for a new treatment technique to work with negative transference and resistance, Reich systematically observed patterns of embodied interaction, wanting to help patients who did not have a stable ego structure and were therefore not capable of the verbal associative work. Reich explored the importance of nonverbal communication as a modality of free association in order to access the unconscious; he emphasized the importance of what was later termed by Gendlin (1982) as “felt sense,” a kind of intuitive embodied imitation mechanism of knowing through a nonverbal process of awareness, close to what has more recently been described in neuropsychological science as a “mirror neuron mechanism” of simulation (e.g. Gallese, 2005, 2009).

In Reich’s theory emotional processing of experiences featured centrally; he regarded them as deeply “stored” within the muscular system. He described this as “character or body armour” and defined it as habitual and chronic fixed relational positions in his book Character analysis (Reich, 1949), where he developed a detailed description of behavior in response to conflict. The term “character” in Reich’s work is best understood according to Sletvold (2014, p. xvi) from a functional perspective: “Character in this way denotes a person’s characteristic way of self-regulation and interactive regulation as observed and experienced by others.”

The Neo-Reichian period since 1950 has been characterized by a number of extensions and developments in relation to Vegetotherapy, including conceptualizing embodied character structures as a result of ego-development, and an emphasis on the importance of affect regulation systems and also on the intersection between emotions and movement (see the overview in Heller, 2012).

Following Reich’s departure from Norway, a group of analysts and psychologists continued to develop Reichian concepts within the framework of psychoanalysis (see the summary by Sletvold, 2014). Attention was now given to somatic equivalents of psychic instances and the association between reality and pleasure principles. Therapists acknowledged the importance of homeostatic regulation systems (in particular the autonomous nervous and endocrine systems). However, the methods overemphasized the bodily aspects of interpersonal functioning and the cathartic elements of affect regulation, often neglecting psychodynamic aspects of the therapeutic relationship and more specifically of transference dynamics. The focus of body-oriented interventions on cathartic and emotional regression carried simplified assumptions (e.g. regarding the self-regenerative processes).

Psychoanalysts in the USA (e.g. Beebe, Stern, Tronick, and Knoblauch), influenced by infant research and the relational approaches, introduced new ways of thinking for changes in psychoanalytic practice that significantly integrated the physical dimension of dynamic interaction. This signifies a significant turn, effectively resolving Freud’s exclusive therapeutic emphasis on unconscious mental processes, which effectively eliminated the role of the body in psychotherapy (e.g. Carignani, 2012). The relational school in psychoanalysis has subsequently represented integrated intercorporeality and system perspectives into the therapeutic frame (Perlman & Frankel, 2009; Rapoport, 2014). Corresponding with these developments, BPT centres around exactly these (embodied) self-regulation processes while identifying dysfunctional embodied habitual regulation and adjustment pattern. These are understood as attempts to regulate the impact and the intensity of emotional processes in response to adversity through hypo- and hyperembodied modes of experiencing (e.g. Fuchs & Schlimme, 2009; Röhricht, 2009, 2011).

Theoretical building blocks for an overarching theory of analytical, relational body psychotherapy: infant research, affective neuroscience, and cognitive sciences

Infant observation/developmental psychology, (implicit) memory systems, and the unconscious

Considering the relevance of bodily aspects for early ego-/self-development always starts with Freud’s hallmark statement where he emphasizes that the ego is derived from bodily sensations and therefore understood as “first and foremost a body ego; it is not merely a surface entity but it is itself the projection of a surface” (1923, p. 26).

Findings from developmental psychology (foremost the work of Piaget, 1964, and Gibson, 2003) regarding the importance of perception and movement for knowledge acquisition and learning in general influenced the above-described shifts in psychoanalytic theory and practice further, and this is where the lines between BPT and psychoanalytic therapy begin to cross again, deepened and enriched by emerging neuroscientific insights into the neuropsychology of memory systems. Daniel Stern’s research (e.g. 2010) became an important reference point for relational BPT. He introduced key terms such as “affective attunement” and “affective resonance” into the literature in order to describe processes between mother and infant, that is, regulating the degree/intensity of emotional exchanges through a repertoire of adjustments in gestures and postures. “These communications include early mutual imitation, empathic social mirroring, affect attunement and proto-conversations” (Nolan, 2014, p. 30).

According to Carleton and Padolsky (2012), Reich had already emphasized the importance of the mother–infant bond (“the responsive nurturing caregiver”) as the origin of (dyadic) self-regulation; they characterize early self-regulation in infants as a process that “refers to managing arousal, maintaining alertness, reducing arousal when over-stimulated and inhibiting maladaptive behaviour … self-regulation is a crucial factor in attending to and engaging with the environment” (p. 95). Early perinatal experiences (affectively attuned interactions) matter as a first schema, an initial comparative “blueprint,” for postnatal experiences of the body in space and time and in interaction with others. This also led to descriptions of particular attachment styles based upon John Bowlby’s work and studies on nonverbal and affective attachment communication (Ainsworth, Blehar, Waters, & Wall, 1978).

Further research demonstrated how nonverbal behavior (gaze, facial expression, head orientation, and self-touch) already differentiated between attachment styles at four months of age (Koulomzin, Beebe, Anderson, Jaffe, Feldstein, & Crown, 2002). These somatic interactions occur before the development of left hemispheric brain language centers and are regarded as formative for language and hence symbolic thought. Mertens (1998, p. 72), for example, showed how children evaluate other people’s intentions and attitudes on a comparative basis of early experiences. These networks link perception, emotion, and action in the form of memory schemata, constantly modulated and updated in interaction with others and the environment. This crucial early relational process lays the foundation for interactive patterns of behavior and is primarily physical (embodied) and relational; it does not require higher cognitive processes. Meltzoff (2007) explains: “Infants monitor their own bodily actions via proprioception and can detect cross-modal equivalents between their own acts-as-felt and the acts as seen in others” (p. 27).

Developmental processes and the resulting “schemata” have been described by Stern (1985) as “RIGs” (representations of interaction that have been generalized). Downing (1996) came up with a similar concept from the perspective of body-work in psychotherapy while observing those early relational aspects of adjustment in video-based infant observation: he described microprocesses of physical attunement and pattern development as “affect-motor-schemata.” Accordingly, the distinction between explicit and implicit memory systems in memory research, and the shift of focus to the latter, offers additional insights for infant–caregiver interactions and for the understanding of the unconscious as an integrated body–mind phenomenon in close proximity to embodied memory systems:

The unconscious is, above all, an embodied, interactive unconscious within which we are situated in the beginning and from when consciousness emerges. Before and parallel with the conscious thoughts we are able to have as we enter into the therapeutic dyad, we are already embedded in an unconscious interaction constituted by the embodied and implicit memories of both therapist and patient. (Sletvold, 2014, p. 117)

Stern (2004, p. 115) similarly introduced the term “implicit relational knowing,” describing this specific aspect within the therapeutic relationship as “the domain of knowledge and representation that is non-verbal, non-symbolised, un-narrated, and non-conscious.”

Mancia (2006) emphasized that early experiences can only be deposited in implicit memory systems. He developed a concept of the formation of an early unrepressed unconscious nucleus of the self, as belonging to the presymbolic, preverbal, and hence often somatically encoded stage of development, which is why it cannot be remembered. Equally, McGilchrist (2010) and Schore (2012) co-locate the nonconscious and the implicit self-processes in the emotional right hemisphere of the brain (as the seat of human adaptive survival functions).

This is where Reich's concept of “character armour” becomes relevant again because the implicit memory systems and corresponding ritualistic response patterns get in the way of reconstructive efforts and can therefore significantly hamper the therapeutic process if not addressed adequately, that is, in an embodied fashion. “The mind is a periodic system that restraints its own natural tendency towards self-organisation by reflexively damping down entire classes of subjectivity in order to forestall anxiety and maintain equilibrium” (Piers, 2005, p. 252).

Importantly, from a perspective of embodied cognition and enactivism, a revised concept of (implicit) memory systems has challenged the notion of a mere cognitive memory schema (representations), discarding the idea of a container/storage system as implicitly implied by Reich, Stern, and Downing. Instead, from an enactive perspective memory systems are conceptualized in respect of the intrinsic relations between action and cognition, while perception is understood as:

an organism’s way of matching its activities to the world in order to be able to achieve its purposes … he [MacKay] defines a representation as a ‘conditional readiness to reckon’ with something in the environment … abstract neural representations of objects are not necessary, but only the direct detection of action possibilities (affordances)” (Murphy & Brown, 2010, pp. 35–36)

Affective neuroscience, affect regulation, and relational action tendencies

The embodied nature of implicit memory systems is equally relevant while introducing findings from affective neuroscience. Following a period in which the cognitive paradigm with a focus on language, speech, and thinking dominated primary research in psychology, affect has now been accepted as the primary motivator in most object relations clinical accounts (e.g. Fonagy & Target, 2007). “The centralisation of affect is in essence a substitution of the concept of drives as the mediating factor between psyche and soma” (Elisha, 2011, p. 188) or, as Greene (2001, p. 579) put it with reference to Stewart’s (1987) work on “archetypal” or “innate” affects, “They dynamically link the psychic and somatic experiencing of analyst and analysand.”

The literature contains varying definitions and distinctions of the terms feeling, emotion, and affect, the latter here being defined as associated with the expressive component, manifested through facial expression, gestures, or body language in general. Emotional processes dynamically regulate an individual’s relation to a continually changing environment. Given their essential function as indicators of changing environments they always carry meaning and lead to reactive and/or intentional actions, adjusting the organism to emergent new situations. Lane (2008) summarizes this from a neuropsychological perspective:

Primary emotional responses have been preserved through phylogenesis because they are adaptive … They provide an immediate assessment of the extent to which goals or needs are being met in interaction with the environment, and they reset the organism behaviourally, physiologically, cognitively, and experientially to adjust to these changing circumstances. (p. 225)

Panksepp (2006) described seven emotional operating systems and concluded that affect has to be grounded in action tendencies, firmly rooting human cognition in evolutionary biology. He identified the “seeking system” as an overarching expectancy system, which directs subjects according to needs in terms of goal-seeking behavior. It also mediates exploration in its widest sense. Panksepp relates the seeking system to the psychoanalytic concept of libido and as intrinsically aiming at the outside world; as a result it can be regarded as the fundamental biological equivalent of psychological processes of fantasy and curiosity, or, according to Panksepp (2006, p. 25) “as a basic, positively motivated action system that helps mediate our desires, our foraging and … expectancies about the world.”

The seeking system resembles features of what Damasio (2010) described as “primordial feelings” for the very first registrations of our body states, for example pleasure/pain experiences, often occurring already in anticipation, prior to changes within the somatosensory systems caused by an object or event. Importantly, changes in the somatosensory cortices may even occur without being directly caused by forgoing changes in the body. Damasio (2003) terms this the “as-if-body-loop” and this mechanism appears quite relevant for the constitution of implicit memory as described above.

Reviewing the “emotive neuroscience of embodiment” Price, Peterson, and Harmon-Jones (2012) identified a growing body of evidence supporting the notion that bodily manipulations (i.e. facial expressions, hand contractions, and changes in physical posture) influence self-reported emotions (including physical responses to emotional changes) and motivational processes. This opens up into a rich array of therapeutic interventions while working with patients who struggle to regulate their emotional responses to adversity, and it is where implicit memory and affectivity have their common ground. Current perceptions of the world always depend on background emotions based upon prior experience; these can be understood as skeletal emotional baseline conditions. Memory in that sense is not a process of re-activation but rather a dynamic process of affective en-activation.

Embodied cognitive science, relational body-self, and intentionality

In contrast to the classical (computational) model of cognition, embodied cognition refers to more complex realities of a relational body-self, which is not just a summative experience of centrally organized mental processes (representations). “Radical embodied and enactive accounts characterise cognition as essentially a kind of organismic activity taking the form of sensitive interactions stretching across the brain, body and environment” (Röhricht, Gallagher, Geuter, & Hutto, 2014; with reference to the work of Gallagher, 2005, and Thompson, 2007). Referring to embodiment as a potential “key to the unconscious,” Leuzinger-Bohleber (2018) outlines how learning and memory are rooted in sensorimotor coordination, “constructed interactively.” This emphasis on environmentally embedded interaction between individuals who bring their entire embodied presence into the being-with others leads to the concepts of an essentially socially constituted self. From a psychoanalytic perspective Fonagy and Target (2007) refer accordingly to the reality of an “extended self.” There are parallel, synchronic top-down and bottom-up processes involved in generating an embodied self, the body image as a cognitive template for example being as important as body posture and gestures in terms of the resulting mental states.

Neuropsychological research demonstrates mutuality and reciprocal realities between biological and psychological operations. Eisenberger, Lieberman, and Williams (2003), for example, demonstrated how social deprivation induces the same neurobiological responses as physically inflicted pain. Gallagher and Hutto (2008) emphasize that abilities for understanding the intentions and behaviors of others are not reducible to the mentalizing process as described in standard approaches to social cognition: “There is, in primary intersubjectivity, a common bodily intentionality that is shared across the perceiving subject and the perceived other” (p. 21).

The findings from mirror neuron research in neuroscience identified a biological mechanism of embodied simulation, contributing to a process of direct understanding of others. Gallagher (2005), however, claims that simulation or representation are not essentially required, as there are direct ways of understanding each other through implicit embodied experiencing:

The basis for human interaction and for understanding others has already been laid down by certain embodied practices – practices that are emotional, sensory-motor, perceptual and non-conceptual. I want to suggest that these embodied practices constitute our primary access for understanding others and continue to do so even after we attain theories of mind abilities. (p. 224)

Gallese (2009, p. 520) outlined the function of mirror neurons as a “neurally instantiated we-centric space” and discussed the importance of corrective emotional experiences in therapy through implicit and non-conscious interactive empathic exchanges. This involves all aspects of embodied encounters: “The hypothesis being proposed here is that social identification incorporates the domains of action, sensations, affect, and emotions and is underpinned by the activation of shared neural circuits” (p. 520).

Synthesis: therapeutic implications for body psychotherapy and psychoanalytic therapy

What does this entire construct debate mean for psychotherapeutic practice at the interface between psychoanalysis and BPT?

The therapeutic process requires simultaneous addressing of cognitive, perceptive, affective, and motor and vegetative systems, centrally including the historical (biographical) cultural narratives. In relational, analytic BPT, the body features in its embodied “being-with” (intercorporeality) and cognition features as situated activity. This differs from a hierarchical body–mind concept, in which the body is equated with the unconscious and motivation with drive (see Elisha, above). Subjective experience is constituted through and continuously updated as the integral of all inputs; the central focus of attention in therapy must therefore be agency (experience and action tendencies), not contemplation. Bucci (2008, p. 52) elaborates along similar lines: “Unconscious processes are not necessarily primitive and driven by wish-fulfilment; … The goal of treatment is better formulated as the integration, reintegration, of systems where this has been impaired, rather than as replacement of one system, by another.”

Fonagy and Target (2007) discuss the implications of embodiment for therapy and propose an “action-oriented theory of communication and thinking”:

Attachment research, in its alliance with an abstract, epistemically oriented cognitive science, underrated bodily experience and now needs to return more systematically to physical experiences of attachment, or at least the metaphoric twilight zone between the two, which psychoanalysis has long inhabited. (p. 432)

Without offering any particular reason they conclude, however: “This is not an argument for a neo-Reichian body-oriented psychotherapeutic perspective” (p. 432).

Here and elsewhere in the literature, where the issue of “the body in the consulting room” (Lemma, 2015) is discussed, the psychoanalytic theory stops short of translating the notion of embodied cognition into practice. Considering the validity of traditional couch settings versus a face-to-face conduct of psychoanalysis (e.g. Lingiardi & De Bei, 2011), the importance of bodily felt experiences as an implicit part of the analytic relationship is now widely accepted, while proposing to adhere to the verbal meaning-making process without directly utilizing the embodied physicality of psychological processes.

Based upon the theories introduced above and considering their practical implications, this paper comes to a different conclusion. It is argued that working with and through the body in psychoanalytic therapy should be transformed without compromising the core validity and identity of the main tenets of psychoanalytic theory for practice. The body-work includes anything from corporal awareness (“a deep exploration and attunement to one’s own physical sensations”; Shapiro, 2009, p. 100) and more specifically sensory awareness, affect regulation, touch, enactment, and a range of embodied interactions through movement, gestures, posture, facial expression, and voice intonation.

The therapeutic practice in analytic/relational BPT takes its direction from a new paradigm for the understanding of psychotherapeutic change processes. Schore (2012) pointed out that psychotherapeutic changes in conscious cognition alone, without changes in emotion-processing, are limited. Change processes are not:

a result of making unconscious content conscious by means of insight. Rather, key components of change occur in areas of procedural and implicit memory that may never be the direct subject of the verbal exchange in the therapeutic interaction … the goal is to free this dynamic system from rigid patterns embedded in previous, often traumatic experience toward more fluid and flexible capacities. (Elisha, 2011, p. 164)

And Zaccagnini (2011, p. 151), from the perspective of bioenergetics analysis, emphasizes that “it is … the affective experience they [therapist and patient] share and the fruits of their continuous interactive micro-regulations, which are at the centre of the therapeutic process of change.”

Relational and analytical body psychotherapy in practice

Initial diagnostics, therapeutic setting, and gathering of working hypotheses – identifying unconscious drives, conflicts, and enactments

BPT offers a unique way of engaging the complexity of “feeling states.” Therapeutically, these feeling states are accessed experientially and can be recognized and utilized through empathic and attentive embodied interaction, given that emotions are signified through facial expression, gestures/posture, and voice intonation; these indicators are, however, often so subtle that they can easily slip the therapist’s attention and equally occur unnoticed by the patient. It is therefore crucially important for BPT practitioners to engage in experiential personal therapy during their training.

Exploring the relationship between the conscious and the unconscious, the practice of BPT therapists characteristically and explicitly refers to the emotional-procedural aspects of memories – both in terms of presymbolic experiences and in respect of scenic memories. They relate directly to the embodied actual aspects of the therapeutic relationship and enactments as they emerge in the form of “affectively driven repetition of converging emotional scenarios from the patient’s and the analyst’s lives” (Maroda, 1998, p. 520).

BPT practitioners describe how techniques that enable active reconstruction of memorizable, emotionally charged contents should be reenacted in their original aggregate condition, rather than being addressed exclusively verbally. Bodily interventions in the initial phase include the very basic forms of eye contact, bodily self-exploration, and mobilization techniques, followed by interactional movement sequences; the main purpose here is self-awareness and emotional involvement. Exploration in BPT is focused toward the experiential interface between language content and speech or prosody (intonation, tone, force, and rhythm), constituting the specific interactive therapeutic relationship as well as somatic (counter)transference. It is the art of listening to the music behind the words, exploring cognitive themes and corresponding nonverbal behavior. Knoblauch (2005, p. 813) emphasizes that “words are not just symbols, but are also forms of action and thus enactment. Similarly, actions are not always, and just, acting out … but are also ways in which patients communicate affectively and construct meaning in interaction.”

The BPT therapist is paying attention to their own and their client’s “being-with” each other, noticing all the subtle changes in somatic sensations, motor and facial expressions, as well as conflicting gestures, tension, parathymia, ambitendence, etc. This requires the therapist to employ a basic position of somatic curiosity and bodily self-awareness, registering how the therapist’s overall perception and bodily states change in the context of the therapeutic encounter (e.g. boredom, tiredness, arousal, excitement, etc.). Mancia (2006) refers to the same behaviors when he introduces an interesting distinction between “extra- and infra-verbal elements” (p. 91) in the context of his theory of the unrepressed unconscious. Nonverbal aspects are the voice intonation elements in his theory of the analytic encounter. The BPT therapist includes a variety of direct bodily techniques such as mirroring exercises, movement exaggeration, suggestions for explorative changes in gestures, as well as symbolic gestures, all aiming towards further clarification of aspects of conflict regulation pattern and coping resources.

The therapy unfolds in constant oscillation between emotional expression, movement behavior and verbal integration. The issue of how to handle enactment in psychotherapeutic work has been widely debated in psychoanalysis: “Sandler (1976) even suggests that the analyst should cultivate a free-floating responsiveness, as a counterpart to Freud’s free-floating attention, so that his reactions as well as his thoughts and feelings contribute to the understanding of his patients” (Steiner, 2006, p. 315, emphasis in the original). BPT proactively employs intentional expressions of reenactments in therapy. Hereby, the therapist can step beyond mere meaning-giving attributes based upon cognitive processes and verbal interpretations. This enhances the validity of these assertions and provides a certain safeguard against incorrect interpretations.

Working with (counter) transference

The findings from infant development research (introduced above) illustrated how the descriptions of the nonverbal, implicit styles of caregiver–child interactions offer insights for the understanding of actual interactions between therapist and client. At the same time these observations require careful considerations in respect of the therapist’s timing of interventions that are directly aiming to explore those primary schemata (“blueprints”) as they unfold within the therapeutic relationship.

The countertransference in relational BPT is conceptualized inclusive of and embedded in the bodily aspects of the “felt-sense” and nonverbal interactions between client and therapist. Andrade (2005) notes that “It is the affective content of the analyst’s voice – and not the semantic content – that has an impact on the patient’s store of implicit memories” (p. 683). As outlined earlier, the infant’s primary relations with parental persons are of a sensorimotor and affective nature; bodily realities can serve as indicators of early attachment experiences.

Samuels (1993) differentiated between reflected and embodied countertransference in psychoanalytic practice, and referred to the latter as a process, when the therapist seems to be experiencing the client’s unconscious body. This requires specific training in order to enhance the analysts’ right-brain receptivity (see Schore, 2012). In respect of the above-mentioned “infraverbal communication” the voice can be understood as:

an “experience” of one’s self actualized in the act of speech … but is at the same time an experience of the self in relation to the other … All this constitutes, in the analytic encounter, the “musical dimension2 of the transference. (Mancia, 2006, p. 91)

Exploring how embodied transference evolves within the therapeutic process, modes of nonverbal interaction seem particularly relevant: eye contact, gestures, and touch, the latter continuing to attract controversial debates. Gestures serve as signals or as symbolizations of unspoken words, as a means of illustrating the emotional contents of language. While direct face-to-face contact and eye contact feature partially in psychoanalytic practice, the issue of therapeutic touch has been widely dismissed due to abstinence and neutrality rules (i.e. hampering the analytic symbolizing process) and because of theoretical considerations in respect of a perceived risk of induced erotic gratification or sexual abuse. Therapeutic touch will inevitably create a rather different variance of the types of (counter)transference; carefully reassessing both its potential diagnostic or therapeutic value and potential pitfalls it can be reconsidered for psychoanalytic therapy, given that the cultural framework in which the abstinence rules emerged have significantly changed (see, for example, the review by Fosshage, 2000).

Working directly with and through the body can be particularly helpful in fostering positive transference while working with individuals who experienced early traumatization in life in respect of the resulting corrective emotional and attachment experiences. Tschacher, Munt, and Storch (2014) refer in this context to clinical research on the prosocial effects of achieving movement synchronicity on positive (therapeutic) relationship-building; this is due to the coupling of affective, motor-behavioral, and cognitive processes within the social interaction, resulting in coordinated goal-setting and efforts. According to Tschacher et al. (2014) these processes operate mostly implicitly and spontaneously (bodily imitation, mirroring) without conscious awareness. In BPT, non-intrusive touch techniques feature as both exploratory, container and – in exceptional circumstances – also enforcement or catalysator strategies (see, for example, Geuter, 2015a).

Affect regulation and embodied meaning-making – working with and through enactments

In BPT, psycho (“bio”) dramatic embodied actual enactments of conflicts feature as integral aspects of the therapeutic repertoire. This can be a role play using pretence as the main mode of inter(play)action, the bodily expression of (unmet) needs in gestures and posture (e.g. longing, reaching out for), and at times also include elements of symbolic fulfilment or realization (e.g. physical holding and containment with therapeutic touch), the latter in order to facilitate important corrective emotional experiences. This therapeutic work is preferably conducted in group settings while other participants can act as “good” transitional objects. Heuer (2005) called this intervention “negotiated touch.” These bodily exercises are continuously accompanied by dynamic interpretations as verbal interventions in an integrative (verbal, nonverbal) approach, eventually focusing on the here-and-now in respect of solution-focused strategies as well as narrative formation.

From a perspective of functional psychopathology it is important to note how the embodied ego functions control the reemergence of painful/traumatic experiences through a range of processes referred to as “splitting,” “dissociation,” “repression,”, and “avoidance.” All these manoeuvres are aiming to prevent information emerging as coherent and integrated emotional, perceptive, cognitive, and motor aspects of the totality of the experience; only isolated fragments of the entire experience surface. An integrative embodied approach can best pave the path for a careful reconnecting of the fragmented elements into one coherent experience. The assertion here is that actual scenic reenactments of traumatic experiences and the corresponding coping or adjustment as well as calibrating mechanisms are necessary in order to facilitate the therapeutic process on the most fundamental levels. The aggressive and chronic nature of those reinforced barriers against change processes requires at some stage a seemingly catastrophic crisis of an enacted nature. Those moments are critical catalysts for therapeutic growth out of states of resistance and counterresistance.

In relational and analytical BPT patients will be securely guided through a process in which the full force of the pain resulting from unbearable relational trauma can be endured and transformed while simultaneously the therapist contains the spontaneously discharged affective responses and explores the emerging alternative behaviors. This requires the therapist to acquire specific skills in maintaining empathic resonance even when confronted with seemingly catastrophic affective states. As Schore (2012) summarized, the therapist must be able to not dissociate from their own affective states, but engage therapeutically and authentically; this can “creatively provide a novel relational experience via the therapist’s autoregulation of projected negative states and co-participation in interactive repair” (Schore, 2011, p. 84). Arguing in the context of a nonlinear dynamic system theory Marks-Tarlow (2011) helps to further clarify the corresponding therapeutic “healing mechanism”:

As we surrender to deep involvement with our patients, a certain level of autonomy takes over as the two systems become coupled in self-organised fashion, largely beneath the realm of awareness. The resulting therapist-patient system takes on a life of its own as it moves away from equilibrium, toward the edge of chaos, the territory in between and fertile for a switch to somewhere new. (p. 125)

Marks-Tarlow explains that chaos here refers to a hidden order, “invisibly tucked beneath what may appear random at the surface” (2011, p. 120). From a BPT perspective this refers back to Reich’s work on pattern of muscular responses to adversity and their importance as psychological “survival” mechanisms. Nonlinear (dynamic) systems theory inherently refers to the capacity to induce reparative (healing) processes, to initiate self-reorganizing from inside. Different from earlier phases in neo-Reichian therapies this does, however, involve systematic explorations of biographic narratives and therapeutic relationship patterns to guide the therapeutic process out of the chaos of emotional acting-out scenarios: “The dynamic systems view is a much needed alternative to the linear cause-and-effect view. A conception of psychoanalysis and psychotherapy that is both embodied and relational needs a model that is nonlinear in its understanding of therapeutic interactions” (Sletvold, 2014, p. 116).

Reaching those specific transformative moments in BPT, practitioners often observe the reemergence of “somatic wisdom” in form of patterns of motor behavior that lead to more constructive, healthy, and regulated responses to adversity. Using playfulness in therapy and narrative formation helps to prevent clients from regressing into counteracting the overwhelming character of unproductive negativity. Safeguarding against re-traumatization in terms of a disempowering reemergence of the painful memories is otherwise achieved through constantly applied grounding exercises – both verbally and in terms of physical anchor points. Manipulations of any kind and short-cuts out of the clients’ fragmented reality must be strictly avoided. This can be best achieved when any suggestions for bodily interventions are deduced only from the client’s actual intrapersonal state.

As Cozolino (2002) demonstrated, lasting therapeutic change processes and corresponding neural substrate changes can only be achieved while working simultaneously across the domains of cognition, perception, and emotion. Hawkins (1986) pointed out that longer term changes in psychosomatic functioning often require the additional and parallel development of an understanding of symptoms and regulatory therapeutic strategies (such as emotional corrective experiences): “The development of insight is contingent upon historical somatic catharsis. The results also show that where cognitive catharsis occurs without affective release, an increase in psycho-physiologic tension is effected, as shown in both the physiological measures and subjective experiencing” (p. 6/IV). Addressing the question as to which processes in psychotherapy lead to fundamental change in a sense of being truly curative processes, the emphasis is shifting from cognitive understanding to the here-and-now of new formative experiences of unconsciously held rigid patterns of thinking, perceiving, feeling, and – most importantly – acting and relating. The therapy at its core facilitates maturation through corrective emotional experiences, enabling individuals to move forward proactively and in a prosocial, responsive, connected, and grounded manner.

In summary

Relational BPT is historically and developmentally deeply rooted in the theory and practice of psychoanalysis, and has been further advanced in the context of findings from developmental psychology, affective neuroscience, and (embodied) cognitive sciences. Other BPT schools also retain their psychoanalytic roots while moving closer to an integration of theory and practice within the field of humanistic psychology (see Geuter, 2015b). This paper outlined how – vice versa – theory and practice in psychoanalysis is changing in the context of an embodied and enactive paradigm, ultimately resulting in the development of ABPT as a school of therapy that locates itself firmly within the psychoanalytic framework; it has been argued that psychoanalytic therapy in general could be advanced towards an embodied psychoanalysis.

Additional information

Notes on contributors

Frank Röhricht

Frank Röhricht, MD. FRCPsych, is a consultant psychiatrist and body psychotherapist (member of the European Association of Body Psychotherapy); honorary professor of clinical psychiatry at the Wolfson Institute, Queen Mary University of London, UK; and honorary professor of psychiatry, St. George’s Medical School, Nicosia University, Cyprus. He is also medical director for research, innovation and medical education at East London NHS Foundation Trust. His research interests focus on body image phenomenology/embodiment and the evaluation of body-oriented psychotherapy interventions for severe mental illnesses. Other research includes creativity and art therapies, transcultural psychopathology, and community psychiatry recovery care models. He developed the international Clinical Psychology with Body Psychotherapy Certificate master’s programme– at Maltepe University, Istanbul, Turkey. (www.frankrohricht.com)