“mom, there’s a monster in the closet” - attach.org · dimensions of development: (pia...
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“Mom, there’s a monster
in the closet”How do attachment, trauma and anxiety disorders interact ?
Doris D’Hooghe www.traumacentrum.be
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2
Early Attachment Trauma
Consequences
Link between EAT and anxiety
disorders
Therapeutic tools
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Agenda
• Ice breaker activity
• Theory
• Interactive component
• Questions and answers
• Positive note
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Learning objectives
• Be able to recognize, identify and categorize early attachment trauma
• Be able to define the developmental impact of early attachment experiences.
• Recognize the clinical symptomatology of EAT and the relationship with the development of anxiety disorders
• Be able to integrate the presented treatment possibilities in the daily practice
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Ice breaker activity
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Ice breaker activity
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Theory
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Trauma?
• The classic vision of trauma
• from the perspective of a traumatizing event
• characteristics
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Impersonal stressors
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Personal stressors
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Attachment trauma
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Attachment
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Attachment
• Attachment is a deep and enduring emotional
bond that connects one person to another
across time and space (Ainsworth, 1973; Bowlby, 1969).
– Persistent and ongoing (from the cradle to the
grave)
– Directed toward a specific person
– Emotionally significant
– Characterized by seeking security, comfort and
pleasure
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THE ABC OF ATTACHMENT
(Siegel & Hartzell, 2004)
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Attunement
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Attunement
• Sensitive responsiveness
• Mentalization
• Reflective functioning
• Containment
• Shared pleasure/ play
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Sensitive responsiveness
Ainsworth and others (1974)
• The infant’s point of view
– Four essential components:
• Her awareness of the signals
• An accurate interpretation of them
• An appropriate response to them
• A prompt response to them
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Mentalization
Peter Fonagy
• A theory of mind
(internal world)
• Oneself and others as psychological
• Mirroring
• Sense of self
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Reflective functioning
• Reflect upon their own history (trauma, attachment)
• Influence
• Trigger
• “Ghosts in the nursery” (Selma Fraiberg)
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Containment
– (Bion, 1959)
• Receive and understand
• Without being overwhelmed by it
• Communicates back
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Shared pleasure/ play
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Confidence, trust, security
Communicate and connect
Reduce stress
Strengthens attachment
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Balance
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Balance
Mother as external regulator
growth-facilitating emotional environment
a child to develop an internal system
adaptively regulate
arousal psychobiological states (affect, cognition, and behavior)
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Coherence
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Coherence
Sense of selfThe availability of a reflective caregiver
Secure attachment
Facilitates the development of theory of mind
"She thinks of me as thinking and therefore I exist”
Child "find itself in the other”
"giving back to the baby the baby's own self" (Winnicott, 1967)
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“Invisible” Attachment Trauma
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“Invisible” Attachment Trauma
The form of traumatization
Child’s experience of threat
Totally dependable on his caregiver
limited behavioral and cognitive coping capacities
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“Invisible” Attachment Trauma
Experiences of threat
include the threat of
separation having little
from the caregiver response to
the signals of distress.
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“Invisible” Attachment Trauma
In the interaction between child and caregiver
Not an obvious event
Caregiver’s Caregiver’s unavailibility inability to
modulate the affective dysregulation
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Early attachment trauma
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Early attachment trauma
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Stressful events in the relationship:
Pre- natal trauma
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Stressful events in the relationship:
Birth trauma
• C-section/ long or short labor/life threateningexperiences/ vacuum extraction etc.
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Disruptions in the attachment bond
Physical inaccessibility
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Disruptions in the attachment bond
Emotional inaccessible/ unavailable
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Quality of the attachment
relationship
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The quality of parenting
– Attunement
• Sensitive responsiveness
• Reflective functioning
• Mentalization
• Containment
• Play
– Balance
• External regulation
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Features of EAT ?
• Early attachment trauma?– Caregiving relationship
– Early
– Repetitive
– Chronic (over time)
– Multiple
• EAT and the overlap with complex trauma– Interpersonal stressor
– Multiple
– Repeated
– Cumulative
– Developmentally vulnerable times
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Developmental Consequences of
EAT
• Developmental immaturity along five core
dimensions of development: (Pia Mellody)
– self esteem (less than versus better than),
– boundaries (too vulnerable versus invulnerable),
– reality issues (bad/rebellious versus good/perfect)
– dependency (too dependent versus
needless/wantless)
– moderation (too little versus too much self-control)
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Consequences of EAT
• Affectregulation
• Attachment style ( IWM)
• Body
• Neurobiology
• Sense of self
• Cognition
• Dissociation
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EAT and affectregulation
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EAT and affect regulation
• Jaak Panksepp (1998, 2009) Affective Neuroscience – 7 emotional circuits at birth
– Subcortical neurocircuitry of the mammalian brain
– Environmental experiences.
– EAT ➔the circuits don’t flow
– EAT ➔ no integration ➔ dissociated states
– EAT ➔ no self
– EAT ➔ no embodiment
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EAT and Internal Working Model
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EAT and Internal Working Model
– Internal working model (IWM)
• Memories of attachment interactions →accessibility
• Mental representations of self/others
• Cognitive structure
• Typical emotions
• Implicit memory
• Open to modification
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EAT and cognition
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EAT and cognition
• Negative IWMs of self:
– Increased appraisals of normal life circumstances as
threatening
– Difficulty in suppressing thoughts
– A tendency to devalue oneself in threatening situations
• Negative IWMs of others:
– failure to suppress when the individual is
experiencing high cognitive loads
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EAT and the body
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EAT and the body
• Attachment dynamics play out at the physical level
• Via the body-to-body communication
• The nature and quality of the attachment relationship.
• Ways in which a mother relates to
and responds to her own physical and bodily needs
• The child relate to his own body.
• Sense of bodily sense
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EAT and dissociation
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EAT and dissociation
Early attachment trauma
Attachment insecurity
Disorganized attachment
Dissociation
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Dissociation
• Liotti’s:
“Failure in organizing multiple and incongruent
models of the self and other
into unitary mental states and coherent
behavioral states
rahter than an intrapsychic defense against
unbearable pain and severely traumatic
experiences”
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EAT and needs
• Babies require a constant stream of “emotional, spiritual, psychological, and physical inputs” (Mary Jo Barrett )
• Left without this input stream learns that its own hard-wired biological needs are terrifying.(Dr. Daniel Siegel)
• Babies are also hard-wired to be flooded with stress chemicals when those needs are not met, (Dr. Bruce Perry)
• The emotional pain and terror are so intense that the child will do anything to distract itself from those needs
• The fight-or-flight stress chemicals flood the bloodstream at a level which feels so terrifying.
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Anxiety
• “Anxiety” and “fear”
• Separate entities in the neuroscientificcommunity.
• Fear is the physiological reaction to something in our external or internal environment.
• Anxiety on the other hand is the psychological and emotional reaction to the afore mentioned environmental stimulus.
• Anxiety is the conscious worry and sense of subconscious unease
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Consequences of EAT resulting in
anxiety disorders• Affectdysregulation➔Affectphobia
• IWM ➔Social Phobia/ Fear of failure
• Cognition ➔OCD
• Body ➔Hypochondria/ Health anxiety
• Dissociation➔Anxiety disorders
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EAT ➔Affectdysregulation ➔
Affectphobia
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EAT ➔Affectdysregulation ➔
Affectphobia• Affect regulation
– awareness of the feeling
– identifying what it is/ name it
– the modulation of that affective experience
• When not achieved
the arousal generated by that affect remainsunmodulated as well
Anxiety
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EAT ➔Affectdysregulation ➔
Affectphobia
• EAT = lack of contingent and responsive
mirroring
• Affectdysregulation
• Emotions are feared
• Anxiety prompts an defensive reaction
• Defense push the feeling back down
• Safety is restored
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EAT ➔Affectdysregulation ➔
Affectphobia
• Triangle of conflict
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EAT ➔ IWM ➔Anxiety
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EAT ➔ IWM ➔Anxiety
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• Dismissive style and anxiety= dealing but notfeeling
Sacrifies his affective life
Minimize the importance of the relationship
Fear of closeness
Suppressing his emotional charge
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EAT ➔ IWM ➔ Anxiety
• Preoccupied style and anxiety = “ feeling but not dealing”
Cannot let go relationnaly
Cannot modulate own affect
Relational maintenance
Cost his independent functioning and exploration
To much anxiety
Separation anxiety
Grief, anxiety and defensive exclusion of anger
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EAT ➔ IWM ➔ Anxiety
• Fearfull style and anxiety= “not feeling not dealing”
Intense anxiety
Rupture the organization of:
➔cognition
➔ Behavior
Fragment the integrity of the self
Dissociation and splitting
Prevent more dis- integration
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EAT ➔ IWM ➔Social Phobia
• EAT
• Lack of appropriate response when the child is
– Frightened
– Threatened
– Seeks proximity
• World = threathening and unsafe
• Self = incompetent in different life domains
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EAT ➔ IWM ➔Social Phobia
• Attachment anxiety• Negative feelings about the self
– Low self esteem/Worthlesness
– Incompetence
– Danger
– Shame/ Quilt
• Negative feelings about others– Others will lack acceptance and support
– Give rise to perfectionism• Perfect social performance
– To assure acceptance
– To ensure loss will not happen
• Hypervigilance to threat
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EAT ➔ IWM ➔Social Phobia
• IWM:
– Feelings
– Thoughts
• Projection of feelings and thoughts to anotherperson
• Believe the other feels/ think that way aboutyou
• Causes anxiety
• Withdrawal and avoidance
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EAT➔ Insecure attachment➔
Fear of failure
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EAT➔ Insecure attachment➔
Fear of failure
• Lack of secure base
• Ongoing concerns about attachment security
• The caregiver not being available, accepting orunconditionally responsive
• Not safe enough to explore
• Avoidance of danger
• Avoidance of failure
• Fear of failure
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EAT➔ Parent-child role- confusion
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EAT➔ Parent-child role- confusion
➔ Fear of failure
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• EAT
• Lack of secure base
• Disorganized attachment
• Role reversal (the child behaves like a parent towards the caregiver)
– Punitive behavior
– Caregiving behavior
• e.g., the child assists, guides, encourages, soothing, or is overly cheerful or solicitous
• Failure experiences
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EAT➔ Parent- child role-
confusion➔Phobia
• EAT
• Withdrawn behavior caregiver
• Child as parent
• Stay close to the parent
• To comfort, guide, soothe…
• Social phobia
• Schoolphobia
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EAT and health anxiety
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EAT and health anxiety
• Caregiver not securely attached to his body
– Negative body image with rejection
– Neglecting the body needs
• Child is deprived of the safety, security, and containment
• Physical needs left unattended
• Resulting in an insecure body attachment
• Vulnerability to concerns about bodily functioning
• A way to seek help from those who were unresponsive ( “attachment cry”)
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EAT and Obsessive Compulsive
Disorder (OCD)
• OCD➔ Intrusive thought
➔appraised as dangereous or threathening
➔ need to be neutralized
➔ obsession
• Attachment is fundamental in formation of
IWM of self and others.
• May influence the development of obsessive
beliefs
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EAT and Obsessive Compulsive
Disorder (OCD)• IWM :4 domains
– Self- esteem:• I’m bad
• I’m worthless
– Competence• I’m a failure
• I can not do it
– Safety• I’m in danger
• I will die
– Responsibility• It is my fault
• I am guilty
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Anxiety treatment = Trauma
treatment• Phase-oriented:
– Stabilization phase
– Confrontation phase
– Integration phase
• Anxiety = 4 levels– Physiology: Heart rate/ fatique/ stomach pain/ muscle
tension/ numbing/ nausea
– Cognitive: Self- critical/ fearful/ catastrophizing/ forgetfullness/ concentration
– Emotional: Fear/ worry/ anger
– Behavioral: Avoidance/ impulsivity/ trembling voice/ avoiding eye contact/ fiht- flight- freeze
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Case
• Child ( 8 years) was referred to me for:
– anxiety especially in his room with nightmares and
frightening dreams
– Another aspect of the anxiety was fear of failure
which manifests itself in the school
– separation anxiety, he doubt whether his mother
loves him
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Phases of the treatment model
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Case- conceptualization
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Early attachment trauma
• Stressful events in the relationship:– birth trauma
– disruptions in the attachment bond
• Quality of the relationship:– quality of parenting
– dismissive attachment style of the mother
• Events outside the relationship:– traumatic childbirth mother
– relationship problems
– absence of the father
– loss experiences
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Stabilization
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Therapy: Calming the physiology
• Recognizing the anxiety symptoms in the
body.
• Write down what you feel in your body when
experiencing anxiety.
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Therapy: Calming the physiology
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FAFA: First aid for anxiety
• Grounding
• Breathing
• Here and now
• Dual awareness
• Safe place
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Therapy: calming the physiology
• Grounding:
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Therapy: calming the physiology
• Diafragmatic breathing
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Therapy: calming the physiology
• Diafragmatic breathing
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Therapy: calming the physiology
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Therapy: calming the physiology
• Grounding: the tree exercise
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Therapy: calming the physiology
• Grounding:
– Eat or drink something
– Nature
– Chewing gum
– Gardening
– Cooking
– Drumming
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Dual awareness
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Safe place
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Safe place script
• Image an Actual or Imaginary place with positive associations, where s/he feels safe, comfortable, peaceful or calm.
• Enhancement– What do you see/ hear/smell/taste/feel
• Say: “I know that I’m save”
• Say: “ I feel safe”
• Which sensations do you experience in your body right now?
• Cue word
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Therapy: calming the physiology
Long term
• Meditation
• Relaxation
• Yoga
• Safe touch
• Sports/ movement
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Therapy: Affectregulation
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Affectregulation: Awareness of the
feeling/ name it
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Emotional flooding
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Down regulation
• Perceive bodily signals (interoceptive
sensitivity)
• Use reappraisal
• Name the emotion
• Increase the opposite feeling
• Changing our bodies ( rest)
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Emotional blocking
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Up- regulation
• Focus on humor
• Think about a positive experience
• Focus on a certain aspect of the situation
• Express positive feelings
• Share your feeling with others
• Build on positive experiences
• Increase the number of pleasant things
• Focus on goals
• Build a life worth living
• Changing our appraisals of a situation.
• Modulating our responses in the situation.
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Therapy: Cognition
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Therapy: Cognition
• Stop!
• Container exercise
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Sorrow eater
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Therapy: Cognition
• Distraction (do something!)
• Another thought
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Restructuring the internal
working model: Dis-identification
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Dis- identification
• I have a body, but I am more than my body. I am the one who is aware: the self, the center. My body may be rested or tired, active or inactive, but I remain the same, the observer at the center of all my experience. I am aware of my body, but I am more than my body.
• I have emotions, but I am more than my emotions. Whether I feel excited or dull, I recognize that I am not changing. I have emotions, but I am more than my emotions.
• I have an intellect, but I am more than my intellect. Regardless of my thoughts and regardless of how my beliefs have changed over the years, I remain the one who is aware, the one who chooses--the one who directs my thinking process. I have an intellect, but I am more than that.
• I am a center of pure awareness. I am the one who chooses. I am the self.
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Reconnecting with the body
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Reconnecting with the body
• Safe touch
• Bodyscan
• Chacrawork
• Peter Levine
• Pat Ogden
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Reconnecting with the body/ Peter
Levine
• The goal of Self- Holding:
– To calm the nervous system
– Bring the Self back into the body
– Develop more body awareness
– Train one’s own nervous system to remember what
normal is like.
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Somatic experience/Peter Levine
• Self- holding
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Somatic experience/ Peter Levine
• Self hug
• Goal: To feel the body as container. To
develop our container.
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