Every muscular rigidity contains the history and meaning of its origin. " (W. Reich 1993)
The body plays a central role in a person's self-awareness throughout his life and importantly in his emergent sense of self from prenatal experiences and throughout childhood development. With the vicissitudes of childhood the child learns a sense of what is acceptable as self, and what is unacceptable, and paradoxically the body plays an important role in blocking self-awareness through the maintenance of areas of chronic muscular tension, denying access to consciousness of forbidden urges and painful memories. The pioneering work of Wilhelm Reich considered the importance of chronic muscular tensions in the process of repression. He said, "It is precisely the physiological process of repression that deserves our keenest attention." (W.Reich 1993). I will give examples of possible ways in which these somatic defence processes present in osteopathic practice and how osteopathy and other forms of bodywork can complement and facilitate a client's change in his psychotherapeutic process.
Two areas of pain with which patients frequently present in osteopathic practice are the neck and lower back. Many patients in this first category are usually found to have tense muscles in the region of their neck and throat, base of the skull, and in the muscles, which act on their mandible. One explanation for the origin of these tensions is considered by some psychoanalysts to date back to the oral stage of development when the child is feeding from the breast or the bottle (G. Frankl 1990, W. Reich 1990). Problems at this stage can lead to a biting rather than sucking action and to a tensing of oral musculature. Melanie Klein in "The Psycho-analysis of Children" wrote, "We find in analysis of our patients that the breast, as the good object, is the prototype of eternal goodness, inexhaustible patience and generosity as well as of creativeness." (from G. Frankl 1990). The polarity to this, the bad breast, could therefore convey a sense of impatience amongst other things. I make this point because this group I find frequently exhibit, in the language of Transactional Analysis (T.A.), a Hurry Up driver. They are always "on the go;" and often say that they can never rest and "do nothing" feeling guilty if they do. I think that symptoms often erupt in these people when they reach an impasse between their internal messages telling them to "get on with it " versus those saying " take your time," the conflict being enacted in their bodies. I suspect that driver behaviour may develop not only from later verbal commands (Stewart & Joines 1987) but also from early pre-verbal experiences.
A further example relates to lower backache. Examination of these patients usually identifies tense muscles in the region of the lower back, pelvis, and thighs. Additionally, many of them have concomitant bowel dysfunction such as constipation or irritable bowel syndrome. A common pattern with many of these patients is that they give a lot of themselves sometimes to the point of feeling resentful, their problem being a difficulty in striking a balance between pleasing themselves versus pleasing others. Looked at in Psychodynamic terms the production of muscular tensions in the lumbo-pelvic area can relate to the anal stage of development; much of the dynamics of this stage being about battles of wills. This stage is typified by toilet training when the child can offer his gift of faeces of which he may be proud or ashamed, dependent on the parent's reaction to it. He can also learn that he can not only exercise self-control but control over the parent by withholding of his product through the tensing of anal sphincter and pelvic muscles. I think with some of this patient group an eruption of pain results from an archaic protest of withholding leading to increased tonus in already taut muscles and a likely explanation for bowel symptoms that sometimes coincide with lower back pain.
These examples look at possible ways in which some bodily tensions may develop as a result of the vicissitudes of child development. I think that the body can also hold the memory of traumatic events and that recent trauma can trigger associations with much earlier experiences. This is the case with some patients I see following a road traffic accident. The symptoms that some of these patients experience often appear disproportionate in relation to the vehicle speeds and masses but not so when put in the context of the patient's history and their whole experience of the accident. Further inquiry into the details of the accident usually reveals how they felt about such things as the unexpected impact, loss of control, or the reaction toward them of a third party. When these factors are considered within the context of the patient's history it comes as no surprise to me that they are experiencing a lot of bodily pain. I believe that for some of these patients it is the rupturing of their psychological defences which provokes the intensity of pain in their bodies through an unconscious tensing of those muscles involved in repressing, in other words keeping a lid on, their history.
Wilhelm Reich identified seven areas of muscular tensioning, which he called armour rings (W.Reich 1990), in his exploration of somatic defence processes; the eyes, jaw, neck, chest, diaphragm, lumbar area, and pelvis. Most patients have degrees of amouring in several of these areas, armouring rarely being isolated to one segment. Osteopathic work is traditionally seen as facilitating a restoration of balance to a person's musculo-skeletal functioning. This balance is indistinct from the balance of their whole life in my opinion and psychosocial factors may well need consideration. Recent research based guidelines from the Royal College of General Practitioners on recommends a consideration of psychosocial factors (RCGP 1996). It is beneficial for physical therapists to have an awareness not only of the mechanical factors that they are dealing with but the manifestation of psychological defences in the form of somatic dysfunction. Equally important is that psychotherapists are also aware of their client's bodily neuroses.
Psychotherapy clients may have physical symptoms on presentation for therapy or may develop them at times in the course of their therapy. It may be possible to look at the meaning of these symptoms and the defence function they represent. These symptoms may, for example, serve as a temporary or chronic escape from the responsibilities of choosing different problem solving options. Sometimes client's/ patient's descriptions of their pain are a metaphor for the wider context of their life; common ones being "I think this is something management of acute lower back pain strongly I have to put up with," others describe their muscular tension " as though it is holding me back." With leg and lower back symptoms some people describe these areas as not supporting them. Another patient connected her bouts of sneezing with times when her partner was "getting up her nose". Other techniques can be used such as two-chair work, where the pain can be given a voice and the client have a dialogue with his pain, and visualisation where imagery can be used to modify the pain and illicit an understanding of its meaning.
On occasion clients may benefit from adjunctive bodywork, particularly in facilitating impasse resolution. It is my view that the likelihood of people somatising is greater when they are at these stuck places in their therapy as their body enacts the internal conflict between the Child desires to do, be or express one thing versus the Parent negations to them. Bodywork, if integrated with the psychotherapeutic process, could be seen as a somatic redecision therapy. If the psychotherapist is skilled in the use of bodywork a contract could be made to use a body-oriented approach, having considered the protection issues for both client and therapist, or the therapist may refer the client to a physical therapist as an adjunct to the psychotherapeutic process. If the latter option is chosen it l s useful to choose a physical therapist sensitive to defence processes presenting as somatic dysfunction. In either event a contract is needed such that the client feedback any unpleasant or anxiety provoking experience in the session and to be aware that he can tell the therapist to stop if any aspect of it is overwhelming. The therapist's side to this contract is to be aware of any adverse bodily reaction that he palpates and to check this with the client's experience. I have found that this is an important factor in providing safe and effective bodywork. William Comell in a recent article in the Transactional Analysis Journal makes a similar observation (W. Comell 1997).
The therapist is aiming to provide consistent supportive and non-threatening bodywork, becoming what Peter Randell, a psychotherapist and osteopath, describes as "a friend of the body" (R. Shaw 1996). Looking at this in T.A. terms in relation to impasse resolution the therapist is acting as an alternative Parent coming alongside the Child in the client providing him with non-verbal permissions to carry out the "forbidden movements" (P. Randell 1989) and allowing spontaneous expressions of emotion. The emotionally literate bodywork therapist may, through his palpatory skill, also be able to put words to the client's pre-verbal experiences providing validation of the client's pain. Through palpatory awareness the therapist can also monitor any resistance in the client's body so that defences can be respected not ruptured. Physical therapy can also facilitate awareness for a client, the work in this instance acting as a pre-therapy for further psychotherapeutic exploration (P. Randell 1997).
This article offers an introduction to an understanding of the inter-relationship between psyche and soma, the two being an indivisible whole. There are many types of therapy that are helpful for patients/clients presenting with problems on this psychosomatic continuum, ranging from physical therapies to psychological therapies. There is a place and need for an integrated model for psychosomatic healthcare on this continuum which I think is being recognised within mainstream health provision, physical therapists being aware of the psychological defences of patients and psychotherapists, aware of the chronic muscular tensions that can encapsulate painful and chaotic experience.