Cognitive Behavioral Therapy (CBT) has been a de facto standard of care within psychotherapy for the last 30 years. Certainly, CBT has shifted and changed over the years—particularly with the mindfulness revolution of the past decade—but the underlying ethos of CBT which places cognition and behavior in positions of elevated primacy in the psychotherapeutic healing process has remained relatively intact—at least within the halls of academe.
There have, however, been recent advances in neuroscience that challenge the completeness of a purely cognitive behavioral model—particularly when dealing with the impact of trauma. What we are learning now is that trauma is not just something that impacts our cognition and behaviors alone.
Trauma impacts much more than just our thoughts and actions. Trauma is far-reaching and systemic—it cuts us to our bones. It can dissolve our sense of identity, diminish our capacity to locate ourselves accurately in time and space, inhibit our tolerance for interpersonal relatedness, disrupt the coherence of our experience, impair our capacity for emotional regulation, and so much more.
Trauma impacts much more than just our prefrontal cortex or our behavioral activation system. It impacts our whole being—and it must be treated from a whole being perspective. Importantly, any legitimate trauma treatment must consider all of our being—the entirety of our body-mind—not just our thoughts and behaviors, alone.
Remembering the Body
There are many brave researchers and practitioners who have made important contributions to our understanding of how to treat trauma. One of the most useful models for understanding how to understand trauma comes from Peter Levine's conceptualization of the constituents of phenomenological experience that he has memorialized through the catchy acronym, SIBAM, and his work of Somatic Experiencing.
In his somatic model, Levine posits five different elements that are important and vital to a complete phenomenological experience: sensation, images, behavior, affect, and meaning (SIBAM). These five elements are sometimes graphically represented as a pentagon.
In ideal circumstances, all of these elements of consciousness freely flow and connect with one another. This is illustrated diagrammatically in the interconnectedness of each vertex with one another as seen in Figure 1.
All of the vertices of this pentagon in Figure 1 are important in creating a complete, whole phenomenological experience. That is to say, under this model, a percept of experience—the fundamental building block of our subjective world—is comprised of the overall holistic gestalt of each of these elements. When we have an experience, what is happening is we are blending together (at least) five constituent elements—the image of what is going on, the feeling and sensations that accompany that experience, our behavioral impulses that are attached to that experience, and the meaning to which we ascribe the event.
All of the vertices (or channels) are vitally important participants in creating a coherent experience. The absence—or the overarching dominance—of any of these channels in our phenomenological experience is indicative of an inability to coherently organize experience. Additionally, the over- or under-coupling of any of the vertices can create psychological pathology.
For example, someone who experiences intrusive psychotic hallucinations or visual flashbacks may be understood as somebody who is being flooded with overly dominant images that are disconnected from underlying meaning. In the case of visual flashbacks, a person's image and affect channels may be overly dominant and their meaning, behavior and sensation vertices may be underdeveloped, as illustrated in Figure 2. They may have a hard time piecing together the meaning behind the flood of image and affect. They may also freeze in their sensate bodies and feel unable to behaviorally respond.
On the other hand, someone who feels deep anxiety and then consequently compulsively driven to behave in a certain way—without understanding why—may have obsessive-compulsive disorder. This may be understood as over-coupling/dominance of their behavior-affect vertices and an under-coupling/under-development of their meaning vertex as illustrated in Figure 3.
Someone who suffers from panic attacks might be understood as someone who has an over-dominance of sensation and affect channels that is uncoupled from (perhaps under-coupled from) images, behavior or meaning. In a panic attack, two of the channels appear to dominate (sensation and affect) to the exclusion of others as illustrated in Figure 4. Experience is not felt as coherent – it is fragmented, disregulating, and dystonic.
What this model suggests—and what contemporary findings in neuroscience seem to validate—is something that we have known all along: trauma creates fragmentation in the coherence of experience. Sensation becomes separated from images. Affect becomes separated from meaning. Behavior becomes separate from affect. In the words of Yeats, the center does not hold. Our inner experience, literally, begins to fall apart.
When people attempt to recount their trauma memory, they frequently only remember fragments of their experience—the sound of a door slamming, the image of a bedpost, chills inside their body that seem to make no sense. Their world is like a scattered, torn puzzle—with pieces cast to the wind—pieces that have not yet found their way back into a whole.
With this deeper understanding of the nature of trauma, it is easy now to see how and why Cognitive Behavioral Therapy—which dominantly prioritizes only two of the channels of the SIBAM pentagon of coherent experience—cannot be considered complete. By placing primary emphasis only on the vertices of cognition and behavior, it neglects three very important aspects of coherent experience: sensation, images, and affect. It misses a very important part of the whole.
So, there is a quiet revolt afoot. Or perhaps not so quiet. Some of this is patient-driven. People need help, and halfway answers are no longer sufficient. Some people who are in deep suffering from trauma, are sometimes no longer willing to stay stuck. Alternate methodologies to the dominant cognitive-behavioral paradigm are afoot. Emotion-focused therapy, embodied neuroscientific methodologies, and the slew of body-oriented psychotherapies are beginning to take hold—if not in the world of academe, at least in the world of public consciousness. A tidal change in our zeitgeist is slowly emerging. The importance of the body—and the felt experience therein, once again, is starting to rise.
Somatic psychology—a psychotherapeutic modality that does, in fact, incorporate and include the body, in all of its messy, visceral glory filled with brimming sensations, preconscious imagery, and storms of affect—has risen to the fore in recent years as a potent methodology for working with trauma. It offers an important window into the impact that trauma has on our body—particularly in those domains that CBT tends to neglect. Somatic psychology does not pretend that the body does not exist, that feelings are immaterial, or that unbidden, persistent images have no meaning. It is a way of treating a whole person—including each aspect, each channel, every vertex.
It is an exciting time for the field of psychology. Our understanding of what trauma is and how we can work with it is deeper now than ever before—much thanks to the field of somatics. With the help of our newfound understandings, we are well poised to make significant differences in the lives of many.
And, indeed, our times need us now, more than ever.
Levine, P. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books.
van der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind and Body in the Healing for Trauma. New York, NY: Penguin Press.