Psychosomatic osteopathy for trauma using the example of bifocal integration

Course: Psychosomatic osteopathy

• Basic: 30.04. – 02.05.2021 & 17.09. – 19.09.2021
• Course location:Osteopathie Schule DeutschlandMexikoring 1922297 Hamburg
• Course content, registration and further information:https://bit.ly/2SzB9YQ

Summary

Traumatic psychoemotional experiences often manifest themselves in states of arousal with sympathetic overactivity or in immobilization and withdrawal behavior. A person with such a traumatic background may exhibit an autonomic response that keeps them in a perpetual defensive state, which over time becomes a stressor. Similarly, stress related to dysfunctional soma-energy experience patterns that may emerge during osteopathic treatment may be related to the patient’s symptoms and complaints. In this article, the authors discuss an osteopathic approach to psychoemotional trauma and somatic-psychic dysfunction through psychosomatic osteopathy using the example of multimodal bifocal integration (MBI). The focus is on the promotion of physical and mental relaxation and the active involvement of the patient in the healing process. The role of mind-body therapies is discussed, taking into account neuro-psycho-physiological treatment methods. A further focus is on clinical practice and an introduction to the various elements of osteopathic treatment, including the background and integration of top-down and bottom-up dynamics in diagnosis and therapy.

Keywords

Emotional integration, mind-body therapy, psychoemotional trauma, trauma, psychosomatic osteopathy, somatic-psychic dysfunctionPsychoemotional trauma is generally understood to be a highly stressful psychological or physical event. Trauma can be defined as an “unavoidably stressful event that overwhelms a person’s existing coping mechanisms” [1]. This definition of trauma includes reactions to a singular event such as a natural disaster, accident, death or crime, as well as recurring experiences such as childhood abuse, neglect, violent relationships and deficits in need satisfaction and relationship building (deprivation) [2]. It is important to understand that the traumatic event is defined in the context of the experiencer’s experience – if two people experience the same thing, one may perceive this event as traumatic and the other may not [3].The effects of traumatic experiences can be diverse. For example, people who have experienced trauma can develop anxiety and depression, substance abuse, eating or personality disorders or post-traumatic stress disorder (PTSD) [2]. Traumatized children and adults may lose their ability to transform emotions into effective actions. They may not be able to properly recognize their own sensations, feelings and physical states, and may also have difficulty perceiving the emotional states and needs of others [4].On a physiological level, trauma results from the failure of the physiological activation and hormonal response necessary to respond effectively to a threat. While a healthy individual shows a successful fight or flight response, the traumatized individual often remains immobile, resulting in an unconscious behavioral response [4]. Complementary therapy approaches – particularly mind-body therapies (MBT) – are attracting increasing interest as they are thought to reduce trauma-related symptoms and emotional dysregulation [5], [6]. Mind-body therapies focus on the interaction between the brain and the body. The aim is to promote the influence of the mind on the body. The therapy typically includes psychological, behavioral, spiritual and social approaches, such as cognitive behavioral therapy (CBT), meditation, breathwork and imagery, and research has shown that MBT has a positive effect on PTSD symptoms. For example, there have been therapeutic effects on stress reactions, a reduction in anxiety, depression and anger, increased pain tolerance, improved self-esteem and an increased ability to relax and cope with stressful situations [6]. In particular, various guidelines recommend trauma-focused cognitive behavioral therapy for PTSD patients who have experienced a series of traumatic events [7], [8], [9], [10].Mind-body therapies focus on body awareness through interoception and proprioception as well as mindfulness with the aim of accepting and not judging. Patients are supported and guided in a process of reorientation to become more adaptive and resilient to perceived stressors [11], [12]. MBT is an effective tool to regulate vagal function, including better self-regulation skills and resilience of the autonomic nervous system [13], [14], [15], [16].In this article, we describe the principles of psychosomatic osteopathy for psychoemotional trauma and somatic-energetic-psychic dysfunction using bifocal integration in the context of available research. We also describe a brief case report to illustrate the various elements of this treatment approach in clinical practice.

Mechanisms of mind-body therapies

Top-down therapies such as clinical hypnosis, imagery or meditation initiate conscious and voluntary mental processes at the level of the cerebral cortex [29]. They cause a shift in brain function, associated with a reorganization of neuronal representations within the CNS and improved bidirectional communication between the cerebral cortex and the limbic system as well as the brainstem structures that regulate autonomic, neuroendocrine and emotional behavior [21], [22], [23]. In contrast, bottom-up therapies (e.g. progressive muscle relaxation) work by stimulating somatic, visceral and/or chemosensory receptors. They influence central neuronal and mental processes via ascending signaling pathways from the periphery to the cerebral cortex. This leads to increased heart rate variability and reduced expression of cytokines [21], [24], [31], [32].Taylor et al. propose an integrative psychophysiological model to illustrate the mechanisms underlying MBT. They take into account the different levels of the neural axis on which mind-body interactions take place [29]. According to this model, stress symptoms manifest as functional disturbances of the executive homeostatic network, i.e., imbalances in the activation of the prefrontal cortex and higher-level visceral manifestations encoded on the prefrontal, insular, and anterior cingulate cortex. These disturbances subsequently manifest in the periphery as reduced heart rate variability and expression of proinflammatory cytokines [29]. Taylor et al. suggest that effective MBT induce functional changes with the aim of activating the regional executive homeostatic network, increasing heart rate variability and decreasing cytokine production [29]. Behavioral states such as fight and flight, immobilization/”freezing” state and risk assessment – with associated motor, autonomic and endocrine effects – are coordinated by the mesencephalic periaqueductal gray (PAG) [17], [18], [19], [20]. The PAG is connected to the hypothalamus and the limbic system (especially the amygdala and the prefrontal cortex) [18], [19] as well as to various premotor and autonomic brainstem nuclei that coordinate respiration and the emotional motor system [20]. Psychosomatic osteopathy uses various approaches and techniques to try to influence the above-mentioned neuroendocrine networks as well as many other networks and interactions.

Neuroception of safety in the therapeutic relationship

Research has shown that the therapeutic relationship is critical to a desired therapeutic outcome and that therapeutic outcomes may be only minimally dependent on the use of certain techniques [32], [33], [34].Effective therapeutic outcomes are only possible when patients feel safe in the therapeutic environment. Patients’ feelings of safety and the development of a healthy therapeutic relationship often depend on the therapist’s ability to be fully present and engaged [35], [36].Geller and Porges cite the need for the therapist to be grounded, centered, and present, as well as open and receptive to the patient’s experience as a prerequisite for such a relationship [37]. The authors suggest specific characteristics of therapeutic presence that can improve the patient’s sense of safety. For example, certain non-verbal signals are therapeutically beneficial when communicating with the patient, such as a warm voice, friendly eye contact and an open and receptive posture. By being consistently present, the therapist can regulate the client’s stress reactions. This approach can lead to a synergistic relationship in which the patient’s reactions can be transformed over time into a non-defensive social interaction [37]. The therapist should engage with the patient’s experience and physiology and use their behavior to encourage the patient to feel open and present [37]. Additionally, patients may benefit from neural exercises that promote the experience of inner safety, such as deep abdominal breathing, social play, yoga, meditation, mindfulness, and experiences in nature [37].

Psychosomatic osteopathy

Traumatic experiences often manifest themselves in sympathetic overactivity, states of agitation or immobilization and withdrawal behaviour. Over time, these initially life-saving reactions become stressors. In a traumatized person, an autonomic response may emerge that permanently maintains the defensive state so that the defense system can no longer be downregulated.Even in less severe stresses related to dysfunctional soma-energy experience patterns, successful therapy requires addressing the ways in which major and minor everyday stressors affect mind-body communication, especially the ability to pay attention to and interpret internal signals of stress-related emotions.By creating an environment of trust and safety and combining palpation and co-regulation and attention on the part of the patient, osteopaths enable their patients to perceive bodily response patterns such as interoception and improve their ability to recognize, access, understand and respond appropriately to the patterns of internal signals and increase their own regulation.The psychosomatic approach developed by one of the authors (T.L.) integrates bottom-up and top-down dynamics (see below) in the diagnosis and treatment and comprises general principles and models on the one hand and various methodologies, specific approaches and techniques for the diagnosis and treatment of dysfunctional soma-energy experience patterns (=somatic-energetic-psychic dysfunction complexes) and a specific palpation practice on the other. Tissue palpation takes into account human developmental dynamics and integrates elements of breathing techniques from yoga, resource work, positive psychology, bifocal and bilateral stimulation, vagus nerve stimulation [47], Vipassana meditation and body therapy, neuro-linguistic body programming and hypnosis, myofascial vibration, somatic experience, non-violent communication and mindfulness.Examples of approaches and techniques include osteopathic heart-focused palpation (see infobox) and osteopathic “felt sense”, a process in which the osteopath palpates the regions of greatest rhythmic flow and vitality while the patient focuses on sensations associated with the palpated regions [38], and bifocal integration. These approaches enable the patient to understand the relationship between dysfunction, somatic dysfunction and internal and external factors [39] and to resolve distressing soma-energy experience patterns.Indications – Possible indications for psychosomatic osteopathic treatment include.

• if stressful experiences, memories or arousal states occur during osteopathic treatment or palpation
• dysfunctional soma-energy experience patterns
• Chronic pain conditions
• current triggers and habitual patterns that restrict everyday life
• Negative emotions, such as fears, phobias and addictive behavior
• Chronic functional disorders with psychological components, such as possibly learning disorders
• Traumatization

Osteopathic heart-focused palpation for neurovegetative regulation and for the treatment of patients with psychological trauma [38]

• 1 Synchronization of the perception of body sensation, arousal and emotions
• 2 Palpation of the heart field
• 3 Harmonization of heart, abdomen and head
• 4a Palpation of the heart by the osteopath
• 4b Palpation of the heart by the patient
• 5 Identification of the end point of palpation
• 6 Eye contact between patient and therapist so that the patient can establish a new relationship between inner perception and sensory perception of the environment
• 7 Vertical balance between the crown of the head, pelvic region and soles of the feet with the help of breathing

Using these techniques (and a co-regulated customized trauma confrontation during the course of treatment – e.g. bifocal integration), the patient can increasingly associate traumatic experiences with a relaxed body sensation, such as calm breathing, steady heart rate and relaxed facial muscles. This state is achieved and reinforced by vagal cardiopulmonary and trigeminal afferent nerves (from sensors in the myofasciocutaneous system of the face), which activate the PAG-limbic-prefrontal circuits, and if the patient has sufficient resources, he or she also becomes aware of his or her life circumstances, experiences, current behavior and feelings in the course of treatment and recognizes the associated disorders and dysfunctions. The patient is actively involved in the healing process. Through the treatment, the patient should acquire skills to gradually find access to this relaxed state in everyday life. In addition, the patient is encouraged to focus attention on the present rather than the past, to recognize and acknowledge limitations, to build positive and fulfilling relationships with self and others, and to pursue goals that give meaning to their lives [30].The patient will most likely feel safe and secure when in a calm treatment atmosphere and encountering an empathetic therapist who has good communication skills, practices a relaxed palpation style, and delivers treatments without time pressure [39]. Elkiss and Jerome emphasized that, in addition, a powerful and intimate connection is created between the therapist who touches and the patient who is touched, which complements empathic verbal communication and supports synchronized therapeutic healing [40].The foundation of psychosomatic osteopathy is the integration of top-down and bottom-up dynamics into diagnosis and therapy (Fig. 1).Fig. 1. Integration of top-down and bottom-up processes into the therapeutic encounter. In dysfunctionality and also during recovery, various ascending and descending dynamics interact as top-down and bottom-up mechanisms between peripheral tissues and the brain, including the immune system and the nervous system. They contribute to both physical and mental health. For example, the belief that “life is uncertain” can trigger emotions such as anxiety in the limbic system, leading to increased sympathetic activity with rapid, shallow breathing and physical manifestations such as tension headaches, clammy and chilly hands and tension in the neck and shoulders.

Treatment using psychosomatic osteopathy is divided into four phases/aspects:

• 1. establishment of the therapeutic relationship including Diagnostics
• 2nd stabilization phase
• 3rd integration/confrontation phase, e.g. with bifocal integration
• 4. integration into everyday life

Each of these phases/aspects is characterized by specific processes. Even though they build on each other, they are not strictly separated from each other. For example, the therapeutic relationship is essential throughout the treatment. Stabilization resources are also individually adapted in the integration/confrontation phase and applied in doses as co-regulation.

Building the therapeutic relationship

During this phase, the goals of treatment are discussed and agreed upon, and a transparent and stable therapeutic relationship is developed. Both the patient and the therapist recognize the patient’s needs (e.g. to maintain control) and coping strategies [41]. In this phase, it is crucial to slow down the therapeutic process. The therapist confirms the presence of emotional centers in the body by palpating tensions around the solar plexus or coeliac plexus, the suboccipital region, the neck, the eye and heart region, and examining transition areas in the spine and other possible signs of traumatic stress. Palpation includes, for example, the coeliac ganglion, other sympathetic ganglia, the heart region, the throat, the suboccipital region, the eyes, peripheral and central sensitization, pressure gradients and reflex tests.

Stabilization phase

During the stabilization phase, stress reduction concepts are primarily used, including identifying coping strategies, gaining insight into the consequences of trauma, stress reduction exercises, differentiating and regulating emotions/affects and developing confidence. This phase also includes psychoeducation. Additional stress factors that may contribute to the current condition are considered, such as psychological stress, social factors, certain foods and xenobiotics, infections, nicotine, alcohol or drug abuse, oxidative stress, electrosmog, gut microbiome and a sedentary lifestyle.The methods used in this phase strengthen the patient’s emotional state to open up the possibility for confrontational approaches to stressful issues in later phases of treatment. This also includes functional osteopathic manipulation therapy of the body regions in which the effects of the psychological trauma manifest themselves.

Integration/confrontation phase

In this phase, somatic-energetic-psychic dysfunction complexes, burdens, chronic pain, stress or unprocessed trauma experiences are worked through and integrated within a clearly defined framework by means of dosed activation and simultaneous co-regulation on the part of the therapist. A slight activation is necessary in order to be able to work with stressful, unprocessed experiences. At the same time, it is essential to avoid any form of re-traumatization. Several approaches and techniques are possible here. A simplified description of bifocal integration – developed by one of the authors (T.L.) – is used as an example below. This includes a specific osteopathic palpation practice, a bifocal alternating focus, co-regulation, anchoring and perception of interoceptions, body sensations, arousal, emotions, thoughts and images, breathing interventions, reflexive listening, etc.

Integration into everyday life

An important step for patients is the integration of their progress into everyday life. During treatment, essential skills for this integration are continuously promoted, e.g. presence, self-awareness and openness to life [44]. By being able to perceive and regulate themselves in a state of mindfulness for physical sensations, flexible states of arousal, feelings and thoughts in resonance with external and internal influences, patients eventually experience increasing aliveness, connectedness and presence, which no longer support the dysfunctional patterns and self-contractions [43].What is essential in psychosomatic osteopathy in general and in MBI in particular is that the respective findings and “techniques” can only unfold their potential in an appropriate therapeutic relationship. This depends on the osteopath’s ability to be aware of tissue qualities, body sensations, arousal, emotions and cognitions in their own experience and in relationship interactions with the patient in order to enable appropriate, finely tuned intervention and co-regulation.

Methodology in bifocal integration

• 1. preparation: At the beginning, the procedure is explained and a stop signal is agreed in case the patient – for whatever reason – wants to stop. This gives the patient control over the course of treatment. Afterwards, resources independent of the respective stress are anchored, such as the butterfly hug or a safe place, etc.
• 2. identification and evaluation of stress: the patient identifies and focuses on the most stressful situation/image/emotion/pain etc. and scales it from 0 to 10.
• 3. localization of the associated stress region: The patient perceives the body region that reacts most strongly to the focus on the stress image/situation. It may be necessary to support the patient, e.g. by means of reflective listening, to perceive body sensations/interoceptions, to focus attention on these and/or to develop a fine-tuning of attention.
• 4. localization of the associated stress gaze direction: The gaze direction that increases the arousal level of the stress in the specified body region is set by means of feedback from the patient.
• 5. localization of the associated resource region: the patient identifies the body region that feels most pleasant; it may be necessary to support the patient, e.g. by means of reflexive listening, to perceive body sensations/interoceptions, to focus attention on them and/or to develop fine-tuning of attention.
• 6. localization of the associated resource gaze direction: The gaze direction that increases the well-being and sense of well-being in the specified body region is set using feedback from the patient.
• 7. palpation: The therapist palpates the stress region and/or the resource region as well as the associated tension and resource patterns depending on the reactions occurring in the patient. This palpation is performed according to precisely defined parameters of tonality, three-dimensional approach, layer palpation, compression field, centrifugal process, fine-tuning and specific procedures for up- and down-regulation of arousal states, etc., as well as other specific methods of palpatory attention.
• 8. body field perceptions are followed.
• 9. rhythmically alternating focus: The patient shifts the focus dynamically and at his or her own speed between the two identified directions of gaze. For example, the frequency of the alternating focus should be chosen in such a way that it is comfortable for the patient and supports them in entering a flow state characterized by effortless attention and an automatic experience.
• 10. process dynamics: The patient is instructed to allow himself to be surprised without expectation in the “flow state” and to be open to everything that happens or that enters his consciousness. This can be certain bodily sensations, states of arousal, feelings, thoughts, insights, memories, images, etc. With only slight arousal, the process runs at its own speed and dynamics and with only the slightest intervention from the therapist.
• 11. co-regulation and resources: The therapist acts as a co-regulator to support the flow state and associative processing or to regulate arousal. At every moment of the process, the therapist identifies the degree of arousal using somatic markers such as breathing rate, heart rate, heart rate variability, the patient’s facial expressions, pupil size, body posture or other bodily reactions. In the process dynamics, there are virtually an infinite number of resources and possibilities for co-regulation available to keep the process in a dynamic state of balance and flow and adapted to the patient’s changing proximal learning zone. The therapist provides support, for example, in differentiating between thinking and feeling, in the fear of encountering unpleasant physical sensations or feelings, etc. Using the 5 sensory channels (visual, auditory, kinaesthetic, olfactory, gustative and interoception; VAKOGI), behavior and emotion and their meaning, the patient is supported, if necessary, in clarifying and completing the content of the experience. If necessary, the patient is made aware of certain bodily sensations (interoceptions) or bodily reactions “Can you feel how you took a deep breath?”, “How does that feel now?”… Other possible co-regulations are Breathing awareness (with increased arousal, the patient is asked to breathe into the abdomen and more slowly, with a slight “freezing” state, to breathe gently deeper), changing the palpation region and palpation qualities, balancing the ANS, vagus nerve stimulation [47], Changing the direction of gaze, posture/position/movement and facial expressions, slowing down the process, modifying submodalities of sensory perceptions (dissociation, association), music using bilateral sounds and induction of alpha waves, e.g. the CD “Grounding Waves”.e.g. the CD “Grounding Waves” by T Liem 2018, intrinsic myofascial vibrations, addition of archetypes, inner healer, etc.

• 12. squeezing the lemon: at the end of the treatment, when the stress has reached 0-1 out of 10, the patient can try to increase any arousal associated with the situation experienced in order to make further possible stresses accessible to treatment.
• 13. anchoring [48]: As a result of the treatment, insights can develop in the patient that are characterized by a changed understanding, e.g. with regard to their own life relationships/contexts (see “Background” info box), and/or an expanded awareness becomes apparent. If such insights and/or changes in consciousness occur and if the stress is resolved (stress from 0 to 1 out of 10), an anchoring procedure can be carried out. For example, the patient can focus on the sensations and other qualities of the most pleasant part of the body with their eyes closed and perform a butterfly hug. The patient is then given space and time to open their eyes from this experience and possibly make eye contact.
• 14. vault and other distancing techniques: If the treatment time is over or the treatment is interrupted for another reason and there is a stress level above 2 out of 10, the stressful content of consciousness can be “stored” in a visualized safe or by means of other distancing techniques until the next appointment.
• 15. reassessment: At the end, the patient is asked to verbalize the highlights of the treatment and meaningful insights. This supports the integration of the treatment and the implementation of the insights and acquired skills in daily life.

Background

This includes, for example, a new awareness of the connections between physical sensations (e.g. tension in the neck and shoulders) and feelings (e.g. anxiety) and certain belief patterns (e.g. “life is uncertain”) as well as disorders and life circumstances (e.g. tension headaches and unexpressed boundaries in the triple role of working woman, mother and partner vis-à-vis the husband). This new awareness or/and insight enables, among other things, better resilience, emotional regulation and the facilitation of behavioral flexibility in one’s own life relationships.During the process, the patient stays in touch with their resources and with the details of their trauma, while the therapist ensures that the patient, who is normally in a mild sympathetic arousal state, is simultaneously anchored in relaxation [41]. A slight overexcitation of the sympathetic nervous system can occur when the patient mentally makes contact with stressful traumatic situations or experiences. The therapist acts as a co-regulator throughout the treatment. The osteopathic intervention should aim to prevent overexcitation of the sympathetic nervous system by stimulating the limbic PAG circuits. This process is characterized by a transformative dynamic. The main question to be answered is not “What is it?” but “What is happening?” [42], [43] In order to accompany the inner experience of the treatment, palpation of the tissue is essential. Palpation and the energetic interactions in the body fields are combined with breathing, myofascial vibration, meditation, dual consciousness and inner dialog, vagus nerve stimulation [47]. Patients perceive their interoception in a differentiated way, implicit memories become explicit [39].

Case report

A 42-year-old woman presented with low back pain from which she had been suffering for many years. Her medical history revealed evidence of prenatal stress and physical abuse in childhood. She tested positive for adverse childhood experiences (5 out of 10 points). Certain events in her childhood – especially between the ages of 5 and 7, when she was physically abused – were still very stressful for her (9.5 out of 10 points on a numerical rating scale to assess stress levels; where 0 stands for no stress at all and 10 for the worst stress imaginable).A full osteopathic structural examination was performed to assess asymmetries and (pain) sensitivity, among other things [45]. After ensuring that sufficient resources were available, multimodal bifocal integration was initiated. Adapted from the recently developed method of “brainspotting” [46], the patient imagined the most distressing moment of the specific traumatic situation and localized the body region that reacted most unpleasantly to it – in this case the solar plexus, which felt like a tightened fist. The eye position that intensified this unpleasant physical sensation was identified. The patient was asked to slowly move her gaze first horizontally, then vertically, to find the direction of gaze that intensified the stress, and then to locate the area of the body that felt most comfortable. This was the sternum region, which felt strong during palpation. The eye position that reinforced this pleasant body sensation (resource-promoting gaze direction) was then found and the patient was asked to move her eyes rhythmically back and forth from the resource-promoting to the stressful gaze direction. The therapist palpated the sternum region and followed the micro-movements of the tissue. He then palpated the region of the solar plexus and also followed the micro-movements of the tissue; at the same time, the therapist registered all of the patient’s vegetative signs (e.g. breathing) and asked her to remain open to everything that was happening. In the following 30 minutes, the subjective stress on the stress scale decreased from 9.5 to 0.5. The tension in the solar plexus also decreased. Breathing, which had accelerated slightly during the treatment, became deeper and slower. Three weeks later, the patient again rated the perceived stress at the beginning of the session at 6 out of 10 points on the stress scale. In the course of two further treatments, however, the perceived stress level reached a permanent value of 0. Further interventions followed, and the patient also carried out stress-reducing, affect-differentiating and regulating exercises independently between sessions.

Conclusion

The presented neuro-psycho-physiological model of psycho-emotional trauma offers an explanatory approach for possible effects of psychosomatic osteopathy using the example of bifocal integration including effective patient-therapist interaction. Building trust and creating a sense of security for the patient is the first and most important step. This is followed by the stabilization phase with stress-reducing exercises and the integration of coping strategies. In the integration/confrontation phase, the dysfunctional tissue-energy-experience complex, the traumatic event or the stress is worked through in a defined setting. This includes tissue palpation, resource anchoring, the dual consciousness of VAKOGI, vagus nerve stimulation [47] etc., constant co-regulation by the therapist and active awareness work by the patient. Finally, the patient is encouraged to integrate the acquired skills and the newly built emotional and social self-confidence into everyday life. 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1. Top-down and bottom-up mechanisms in mind-body

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