Dissertation - Somatic Experiencing Treatment for Reduction of Symptoms of Depression and Anxiety in Homeless Adults

ASSESSING THE EFFICACY OF SOMATIC EXPERIENCING
FOR REDUCING SYMPTOMS OF ANXIETY AND DEPRESSSION
A Dissertation Presented to
the Faculty of John F. Kennedy University
PsyD Program
In Partial Fulfillment
of the Requirements for the Degree of
Doctor of Psychology
by
Michael C. Changaris
MAY 17th
, 2010

ii
© 2010 by Mike C. Changaris
All Rights Reserved

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ASSESSING THE EFFICACY OF SOMATIC EXPERIENCING
FOR REDUCING SYMPTOMS OF ANXIETY AND DEPRESSSION
This dissertation by Michael C. Changaris has been approved by the committee members,
who recommend that it be accepted by the faculty of John F. Kennedy University,
Pleasant Hill, California, in partial fulfillment of the requirements for the degree of
DOCTOR OF PSYCHOLOGY
_____________________________________________________
Peter Van Oot, PhD, Chair
_____________________________________________________
Sandra Mattar, PsyD, Reader
____________________________________
Tuesday, January 10, 2012

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TABLE OF CONTENTS
Page
Dedication............................................................................................................ v
Acknowledgments ............................................................................................... v
Abstract ............................................................................................................... vi
List of Tables ...................................................................................................... x
List of Figures ..................................................................................................... x
I. Introduction .................................................................................................. 1
II. Review of the Literature .............................................................................. 4
Somatic Experiencing (SE) ............................................................... 5
Resilience: Bouncing Back From Stress ........................................... 8
The Broaden and Build Hypothesis: Modeling Resilience ............... 11
Nature and Nurture: Adversity, Stress, and Resilience ........ 14
Adverse Life Events: Depression, Anxiety and Stress ..................... 15
Toward a Psychobiological Model of Resilience ............................. 16
Clinical Relevance of the Autonomic Model of Resilience .............. 19
The SE Model: A Psychobiological Model of Resilience ................ 22
Psychobiological Changes: The Role of the Body in the Mind ........ 27
The Psychobiological Roots of Dissociation .................................... 35
SE Model of Affect Dysregulation: Dissociation and Depression ... 41
Current Treatment Modalities: Trauma, Depression, and Anxiety ... 44
Current Treatments for Depression .................................... 44
Current Treatments for Anxiety ......................................... 45
Current Treatments for PTSD ............................................ 46

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Current Alternative Treatments ......................................... 47
The SE Model for the Treatment of Trauma, Depression, and Anxiety
............................................................................................................ 48
Homelessness: Stress and Systemic Oppression ............................... 50
Summary ........................................................................................... 53
III. Methods ....................................................................................................... 54
Overview ........................................................................................... 54
Participants ........................................................................................ 54
Recruitment ....................................................................................... 55
Instruments ........................................................................................ 56
Beck Depression Inventory-II (BAI-II) .............................. 56
State Trait Anxiety Inventory (STAI)................................. 57
Data Collection ................................................................................. 59
Data Analysis Plan ............................................................................ 58
Limitation and Assumptions.............................................................. 61
IV. Results .......................................................................................................... 62
Demographics ................................................................................... 62
Data Analysis .................................................................................... 64
Hypothesis 1 ...................................................................... 67
Hypothesis 2 ...................................................................... 69
Hypothesis 3 ...................................................................... 70
Hypothesis 4 ...................................................................... 71
Hypothesis 5 ...................................................................... 72

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Summary...................................................................................... 72
V. Discussion .................................................................................................... 74
Summary ........................................................................................... 74
Changes in Symptoms of Depression ............................................... 76
Changes in Symptoms of Anxiety .................................................... 79
Limitations ........................................................................................ 80
Directions for Future Research ......................................................... 82
References ..................................................................................................... 85
Appendix A ................................................................................................... 102
Appendix B .................................................................................................. 111

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DEDICATION
This dissertation is dedicated to all those who attempt to transform their suffering
in a gift for others and to Maureen Harrington whose support and love kept me working
steadily in both storms and sun. As well as to the Dream Team (Rebecca, Sara, Juliette,
and Satoko) who always made the impossible seem simple and who regularly attempted
to see if laughing to death were feasible.

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ACKNOWLEDGEMENTS
This dissertation would not have been possible without the generosity of many
people. I would like to acknowledge the many individuals who, while homeless, took the
time and energy to complete these forms openly. Your steadfastness in the face of
profound difficulties helped this researcher understand the true meaning of strength.
Special acknowledgement to the founders of the COTS SE clinic, Patricia Meadows, Lee
Wylie, and Deborah Boyar, for their constant support and dedication to this clinic. They
have been working at this project for years and their time is completely donated. I am
profoundly grateful to the staff at COTS, Lauren Darges, Glen Weaver, John Records,
Mike Johnson, Carrie Hess, and many others. I am deeply grateful for Dr. Mattar and Dr.
Van Oot for challenging me to work hard and for developing this project, nurturing it
through to completion. A special thanks to Dr. Carroll for always being willing to let me
drop by at a moment’s notice and helping me transform what seemed like an
overwhelming problem into a simple solution. Also, I acknowledge my family who
helped me financially, emotionally, and scientifically with this project. A deep debt of
gratitude for SE and the impact it has had on my life and the lives of many others. Also,
deep thanks you to Rocks and Clouds Zendo for giving me a place where the mind can
rest and open up to the vast possibilities present in each moment.

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ABSTRACT
Homelessness can be stressful and overwhelming. This study assessed the
efficacy of Somatic Experiencing (SE), a short-term resiliency based treatment, for
reducing anxiety (State Trait Anxiety Inventory, STAI) and depression (Beck Depression
Inventory, BDI-II) in homeless adults. A matched sample of homeless adults who
received SE sessions (M = 1.33, n = 18) were compared with controls (n = 18). State
anxiety scores were significantly reduced in the SE group (p = .031). Trending toward
symptom reduction, depression, and trait anxiety were not significantly reduced for the
SE group. Somatic and cognitive symptoms of depression were significantly reduced for
the SE group when controlling for number of sessions, and in a small sub sample who
completed the surveys five times. The number of individual sessions strongly covaried
with the degree of reduction of symptoms of depression. Further, more controlled studies
with larger subject samples are indicated.

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LIST OF TABLES
Page
Table 1. Demographic Information ................................................................... 111
Table 2. Therapeutic Participation .................................................................. 112
Table 3. Summary of Multivariate Statistics .................................................... 112
Table 4. Summary of Discriminant Statistics ................................................... 112
LIST OF FIGURES
Page
Figure 1. Total Score on the BDI-I: Group Means ........................................... 67
Figure 2. Multivariate Analysis of Total BDI-II Score
Controlling for Number of Sessions ................................................... 68
Figure 3. Multivariate Analysis State Score on the STAI .............................. 71
Figure 4. Change in Somatic Symptoms of Depressions
Including the Covariate of Number of Sessions ................................. 114
Figure 5. Cognitive Symptoms of Depression: Group Means........................... 115
Figure 6. Somatic Symptoms of Depression: Group Means.............................. 116
Figure 7. State Anxiety Symptoms: Group Means............................................ 117
Figure 8. Trait Anxiety Scores: Group Means................................................... 118

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CHAPTER I
INTRODUCTION
Becoming homeless can be an overwhelming life event. Added to that, homeless
adults are often exposed to significant life stress and frequently multiple traumatic events
(National Center for Family Homelessness, 2008). These events put people at risk for the
development of many mental health problems (Belle, 1990; Turner & Lloyd, 1995).
Some of the most common of these difficulties are depression, anxiety, and post-
traumatic stress disorder (PTSD) (Brewin, Andrews, & Valentine, 2000; Charney &
Manji, 2004). Psychological first-aid models are short-term treatments focused on
reducing the symptoms of PTSD or interrupting their development in the aftermath of an
extreme event (Weisæth, 2003). A psychological first-aid model might prove effective at
reducing the impact of the mental health sequelae of homelessness.
After hurricanes Katrina and Rita, a psychological first-aid program based on
Somatic Experiencing (SE) was shown to be effective at decreasing the impact of
symptoms of trauma for emergency-care providers (Leitch, Vanslyke, & Marisa, 2009). It
is possible that this SE based psychological first-aid model could also reduce or interrupt
the formation of symptoms of depression and anxiety in the aftermath of extreme events
(Weisæth, 2003).
Homelessness can be an extremely stressful event and can expose individuals to
multiple traumatic events. The SE based, psychological first-aid model for grounding
and stabilization could prove effective at reducing the impact of stressors in homeless
adults in a cost-effective, resource efficient manner. This study assessed the above
mentioned, SE-based, psychological first-aid model for its ability to reduce symptoms of

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anxiety and depression in homeless adults. Symptoms of anxiety and depression could
negatively impact the ability of homeless adults to navigate the complexities of the
shelter system (Crane, 1998). If a short-term, psychological first-aid model reduces the
impact of these symptoms, it could increase the ability of individuals who are homeless
to find work, engage with services, and obtain housing.
The SE model is, in essence, a psychobiological model of resilience, offering a
series of tools that work by increasing the resilience of psychological and biological
processes disrupted by overwhelming life events (Levine & Frederick, 1997). Through
experiencing small amounts of sympathetic activation (fight/flight) in a ‘titrated’ manner,
an associated reduction of a stress response occurs, by which practitioners can support an
individual’s capacity to rest, be socially engaged, and experience physical and emotional
safety in the presence of a range of stressors. Along with being a theoretical orientation,
the SE model offers a series of tools to work with the nervous system to reduce baseline
levels of stress, the intensity of stress reactions, and to normalize the threshold of cueing
for fight or flight activation. The SE model works with these innate resources to broaden
and build resilience to stressful events (Fredrickson, Tugade, Waugh, & Larkin, 2003).
Depression and anxiety often happen in the aftermath of overwhelming and
traumatic life events (Fullerton, Ursano, &Wang, 2004; Momartin, Silove,
Manicavasagar, & Steel, 2004; Silove, Sinnerbrink, Field, Manicavasagar, & Steel,
1997). A study of Bosnian refuges found that individuals who met the criteria for
depression were 9.5 times more likely to also meet the criteria for PTSD 7 months after
the traumatic event than those who did not (Momartin et al., 2004). Many individuals in
the homeless community have experienced multiple traumatic events. The National

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Center for Family Homelessness (2008) found that 92% of homeless mothers had been
assaulted or sexually abused. Symptoms of depression and anxiety subsequent to
traumatic events could significantly reduce homeless adults’ abilities to engage with
services effectively and to tolerate the many stressors of homelessness (Crane, 1998;
Silove et al., 1997).
SE is an integrative mind-body treatment for PTSD first developed in 1996 by Dr.
Peter Levine (Levine & Frederick, 1997). It conceptualizes both depression and anxiety
as symptoms generated by the dysregulation of the homeostatic range in the autonomic
nervous system (Foundation for Human Enrichment, 2007). To date, no studies assess
the SE model for the reduction of the symptoms of anxiety and depression. The current
study assessed whether, and to what degree, one to two SE sessions reduce the symptoms
of depression and anxiety in homeless adults. Exploring current research on the SE
model, resiliency theory, and the psychobiology of stress will help to contextualize the
data found in this study.

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CHAPTER II
REVIEW OF LITERATURE
Peter Levine created the SE model in 1998 in response to the fact that while
animals in the wild experience high amounts of stress, they are rarely traumatized. SE is
both a theoretical approach and a treatment modality that is grounded in the
psychobiology of stress and resilience. In the SE theory, resilience is understood as the
ability to bounce back after stressful events. The SE model incorporates aspects of
systematic desensitization while including several other aspects of trauma theory,
resiliency theory, and affect regulation. SE is a radical departure from traditional
psychological theories in three key ways: it is based on a psychobiological model of
resilience; it represents a shift from a purely cognitive model of affect regulation to a dual
model of both cognitive regulation and implicit affect regulation; and it is an integrative
approach that includes tools to treat the psychological and physiological aspects of
autonomic dysregulation (Foundation for Human Enrichment, 2007).
This literature review will explore the role of psychobiological resilience in the
genesis and treatment of depression and anxiety; the role of affect regulation and
cognitive processes in symptoms of depression and anxiety; and the clinical relevance of
an integrated mind-body approach to psychological health and recovery from
overwhelming events, depression, and anxiety. A brief overview of the current literature
on SE and a review of existing studies of the efficacy of the SE model are important to
understand this study.

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Somatic Experiencing (SE)
SE is a short-term, resiliency-based model designed to reduce symptoms of PTSD
(Levine & Frederick, 1997). It works through identifying existing areas of resilience
present in the client and builds on that resilience. In SE parlance, the practitioner tracks
autonomic changes in the client through watching working signs of their autonomic states
(e.g., skin tone, breath rate, muscle tension, etc.). Through ‘tracking’ the autonomic
reactions, the SE practitioner supports the client to attend better to moments of pleasure,
rest, and social engagement and to reduce levels of autonomic reactions (Foundation for
Human Enrichment, 2007). This and other techniques support the client to re-establish
and expand their innate resilience.
According to SE theory, the increased attention to these events, along with in-
session experiences of mastering tolerance for the experience of stress alters both the
client’s expectancies about stressful events and their ability to regulate stressful events.
This model has been measured for its ability to reduce symptoms of trauma and to
increase resiliency on a symptom checklist and resiliency checklist. However, no studies
have assessed this model for its efficacy at reducing symptoms of anxiety and depression.
To date, there are three studies on a psychological first aid model based on SE
designed to work with individuals in the immediate aftermath of a natural or manmade
disaster. Leitch (2007) studied the efficacy of a psychological-first aid model in
southeast Asian Tsunami survivors in Thailand. Svelman (2008) studied another
psychological first aid model in India while working with survivors of the Southeast
Asian Tsunami. Leitch et al. (2009) studied the effects of her psychological first-aid

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model for reducing the impact of trauma on care providers in the aftermath of hurricane
Katrina.
Svelman (2008) started a trauma support team for the disaster relief effort in India
called Trauma Vidia for survivors of the South East Asian Tsunami in 2004. In this
study, 150 individuals were given a 75-minute individual session and training in self-
regulation skills. Svelman found a significant reduction of symptoms immediately
following the session, at four weeks, and at an eight-month follow up. At the
eight-month follow up, 90% of individuals displayed a complete reduction of avoidance
and intrusion symptoms.
Using an SE based psychological first aid model called Trauma Resiliency Model
(TRM), Leitch et al. (2009) conducted a study for care providers who worked with
Catholic charities in the aftermath of hurricanes Katrina and Rita. In this study, 142
individuals were given between one and two psychological first-aid sessions.
Participants displayed a significant increase in resilience as measured by a resiliency
checklist. This same study also found significantly less severe symptoms than those of
the control group. However, both the control group and the experimental group had an
increase of both psychological and PTSD symptoms at a three to four month follow up.
Leitch (2007) also published a preliminary study on the efficacy of the TRM
program working with survivors of the Southern Asian tsunami in 2004. Fifty-five
participants were given a single treatment and were measured on symptoms of trauma on
a self-report checklist and clinical observation. A few days after the first session, 90% of
participants showed complete or partial improvement in reported symptoms. A few days
after the second session, 84% of participants exhibited complete or partial improvement

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in therapist-observed symptoms. These results should be interpreted with caution given
the small sample size and the lack of an equivalent control group.
The main difference between the psychological first-aid models and the full
treatment model of SE is that the psychological first-aid models focus primarily on
grounding and settling. Grounding is in essence bringing an individual in contact with
the here and now. Activation, anxiety, and stress are usually about events that are not
currently happening. Grounding orients the individual to current areas of safety in their
environment. Settling is the reduction of stress reactivity through a technique designed to
reduce current levels of stress. The goal of SE-based, psychological first-aid treatments
is to give the participants the felt-experience of reducing their stress levels and the tools
to continue to reduce their stress levels after the session.
The full treatment protocol of SE, on the other hand, focuses on a wide range of
elements of the traumatic event, including exploring triggers, working directly with the
event, and increasing mastery experiences in tolerating fight/flight reactions. The SE
paradigm, while teaching individuals tools for the regulation of stress, does not aim at
controlling symptoms. It is aimed at the individual experiencing the ability to witness
and function with a wide range of stressors.
SE techniques are directed at supporting individuals to attend to psychological,
physiological, emotional, and social resources that they currently already have access to
(Foundation for Human Enrichment, 2007). After the 9/11 terrorist attacks in New York,
individuals who had a higher number of positive emotions (joy, trust, hope, happiness,
serenity, and gratitude) in the days after the attack were less likely to develop symptoms
of PTSD than those who had less positive emotions (Fredrickson et al., 2003). The SE-

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based, psychological first-aid models work to increase positive experiences without
focusing on the overwhelming event (Foundation for Human Enrichment, 2007).
According to SE theory, this focus on reducing stress and increasing positive events
increases resilience in the aftermath of major life stressors. According to the SE model,
choices, habits, behaviors, and social contexts that could increase or decrease the ability
to bounce back after life stress and understanding these factors could shed some light on
the suppositions in the theory.
Resilience: Bouncing Back From Stress
“Nature has instilled in all animals, including humans, a nervous system capable
of restoring equilibrium. When self-regulating function is blocked or disturbed, trauma
symptoms develop” (Foundation for Human Enrichment, 2007, p. B1.4).
The term resiliency is a loosely defined heuristic that has come to indicate a
complex conglomeration of theoretical concepts (Luthar, 2003). In essence, resilience is
the ability to bounce back from significant life stressors. Models of resiliency often
incorporate both risk and resiliency factors. Compensatory models of resilience are those
in which the resilience factors mitigate the negative effect of risk factors (Ledogar &
Fleming, 2008). Protective models are models that highlight the ability of resiliency
factors to provide a buffer or to build a reserve that protects the individual against the
stressor or risk factors. Another model of risk and resilience is the challenge model. In
this model, having no risk at all leaves the individual without the mental resources to
solve life problems. In the challenge model if the risk factors are extreme enough, they
overwhelm the individual’s capacity to respond to the risk and to use the stressor for

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effective adaptation (Ledogar & Fleming, 2008). However, if individuals have enough
resources, they will grow stronger from meeting and mastering the challenge.
Risk factors are events or traits that increase the likelihood of negative outcomes
and can include the development of symptoms of a mental illness, early death, teen
pregnancy, smoking, risk-taking behaviors, and low ego strength (Edwards, Holden,
Anda, & Felitti, 2003). Resiliency factors are those life events, habits, or choices that
reduce the risk of aversive physical health or mental health outcomes (Edwards et al.,
2003). As stated before, resilience is often defined as the ability to bounce back or to
return quickly to a baseline of psychological and physical functioning after a stressful
event (Ledogar & Fleming, 2008; Luthar, 2003).
In the literature on resilience, there are often many possible confounds,
assumptions, and overlapping findings (Luthar & Cicchetti, 2000). However, a growing
body of data supports the idea that personal habits, life events, and emotional
competencies increase the ability to manage a wide range of stressors (Luthar &
Cicchetti, 2000). This section will provide a basic understanding of resilience, explore
the foundation of a psychobiological ‘stress model’ of resilience, and develop an
understanding of the clinical relevance of a psychobiological model of resilience.
Adverse life events, particularly in childhood, are key risk factors in the
development of multiple psychological and physiological disorders, including the
development of depression, anxiety, and PTSD (Edwards et al., 2003; Schore, 2002).
The development and severity of symptoms of depression and anxiety also increase in
direct correlation with the number of adverse childhood experiences (ACEs) (Felitti,
Anda, Nordenberg, Williamson, Spitz, & Edwards, 1998). The ACE study was an

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epidemiological study (n= 17,000) that assessed the correlation of ACEs and adult health,
mental health, and health-destructive behaviors. The study defined ACEs using nine
classes of events, including but not limited to, incarceration of a parent, physical abuse,
sexual abuse, and the death of a parent or sibling (Felitti et al, 1998). Just as the ACE
study found a direct linear relationship between the number of adverse events and the
severity of psychological symptoms, it is also possible that the number of protective
factors and ‘exposure’ to protective life events would provide insulation from life
stressors. As Luthar (2003) noted, there are traits that increase children’s resilience and
make them better able to adapt. Some of these factors have a significant genetic
component and the environment in which the child develops mediates many of these
factors.
Multiple studies have found that the number and quality of social relationships an
individual has is highly predictive of resilience in the face of stressful events (Luthar,
2003). Emotional dysregulation is the physiological and autonomic response to exposure
to extreme emotions that exceed the individual’s capacity to return to a baseline level of
function. Many forms of emotional dysregulation, including depression, anxiety,
elevated levels of aggression, negative attribution biases, and avoidance behavior, could
decrease an individual’s ability to find and maintain solid supportive relationships
(Eisenberg, Guthrie, Fabes, Reiser, Murphy, & Holgren, 1997); thus, reducing the
individual’s capacity to tolerate life stressors. It is also possible that unsupportive,
abusive, or neglectful relationships can exacerbate emotional dysregulation. A large
amount of risk factors for emotional dysregulation comes from destructive relationships.
Along with personal life events, factors affecting resiliency are likely culturally

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mediated (Ledogar & Fleming, 2008). It is clear that some of the factors that lead to
resilience are contextual while others are cultural. Luther (2003) discussed the impact of
contextual and cultural factors on resilience, highlighting the importance of building a
solid identity, and ironically, that navigating between the two worlds of dominant culture
and the individual’s culture of origin often increases resilience. A full model of
resilience would likely contain many levels of social, psychological, biological, and
behavioral functioning supporting a multi-modal and context-dependant model of
resilience. One of the major theories of resilience is the Broaden and Build Hypothesis.
The Broaden and Build Hypothesis: Modeling Resilience
A current theory of resilience is called the Broaden-and-Build hypothesis
(Fredrickson et al., 2003). This hypothesis matches several predictions in SE theory. It
is universalistic in its approach to resilience, pointing to the role of positive emotions and
their effect on stress reactivity for the development of increased resilience. It does not
highlight the cultural and contextual basis of resilience, and does not deny the possibility
of these factors playing a key role in resiliency. This theory could elucidate some key
aspects of SE theory.
Some theorists have found that positive or prosocial emotions help increase
resilience; among these are Bonnano (2008) who discusses the relationship between
adversity and resilience and Fredrickson (2000) who describes the role of positive
emotions as a protection against adversity.
Taking an evolutionary psychological approach, the Broaden-and-Build
hypothesis attempts to understand the role of different classes of emotions in human
evolution. Based on ethnological studies of animals, Fredrickson et al. (2003) based on

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ethnological studies of animal behavior, postulated that negative emotions (e.g., fear,
anger, or disgust) reduce the range of possible behavioral actions in order to increase the
efficiency of mobilizing a defensive response for short-term action and to limit one’s
ability to perform long range planning. Positive emotions (e.g., joy, serenity, and
gratitude) ‘broaden’ the amount of risk an individual will take, increase attempts at
creative solutions, increase the variation of behavioral choices, and increase social
engagement. Negative emotions are effective short-term adaptations to an immediate
stressor and are focused on removing the stressor, and positive emotions allow for the
‘building’ of psychological resilience, new skills, and effective group bonds for collective
actions.
Also according to Fredrickson et al. (2003), negative emotions have an immediate
purpose directed at short-term, high-energy solutions. Their purpose is self-protection,
the safety of a family or group, security of resources, and mobilization of an appropriate
defensive strategy. According to the Broaden-and-Build hypothesis, when under threat
animals and humans have a narrow range of choices in order to complete a defensive
strategy. This defensive strategy narrowly focuses the animal’s attention on the removal
of an immediate and profound threat. In this type of situation, one would not need to be
focused on yesterday or the details of the terrain. Threat situations require action.
Indeed, when individuals are under heightened amounts of stress, their bodies mobilize a
profound fight/flight reaction.
According to Frederickson et al. (2003), positive emotions, such as joy, serenity, and
gratitude, do not have the same function as negative emotions. Positive emotions do not
have an immediate survival demand to accomplish. Positive emotions support the growth

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of abilities over a longer time. Fredrickson et al. (2003) postulated that positive emotions
‘broaden’ one’s horizon and increase the ability to plan, think of alternate solutions, and
problem solve. Fredrickson Mancuso, Branigan, and Tugade (2000) posited that positive
emotions, over time, build up one’s psychological resilience to stress. Positive emotions
have been shown to reduce autonomic reactivity and to increase the rate of return to a
more ‘normal,’ functional range of autonomic response (Fredrickson et al., 2003). The
negative health and mental health effects of prolonged stress are well documented
(McEwen & Lasley, 2002; (Dube, Fairweather, Pearson, Felitti, Anda, & Croft, 2009).
In addition to the negative health outcomes associated with depression and
anxiety, there is a tendency toward increased numbers and duration of negative emotions
(Campbell, 2002; R. Sapolsky, personal communication, November 10, 2009).
Individuals who experience symptoms of depression display a tendency to discount,
ignore, or dis-attend to positive events. Anhedonia or loss of the ability to feel pleasure is
a key symptom of Major Depressive Disorder (MDD) (R. Sapolsky, personal
communication, November 10, 2009). Anhedonia and depression have been associated
with dysregulation of the stress hormone, cortisol (Dougherty, Klein, Olino, Dyson, &
Rose, 2009; R. Sapolsky, personal communication, November 10, 2009; Soninoa, Favab,
Belluardoa, Girellia, & Boscaro, 1993). Increased cortisol reactivity has been noted in
individuals with depression, anxiety, and PTSD (Heim & Nemeroff, 2000; Yehuda,
Teicher, Trestman, Levengood, & Siever, 1996).
According to the Broaden-and-Build hypothesis, the lack of ability to experience
positive emotions could significantly reduce one’s resilience in the face of life stressors
(Fredrickson et al., 2003). While some individuals have a genetically established level of

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stress hormone reactivity, life events also likely play a key role in the establishment of
one’s autonomic set point (Bartels, de Geus, Kirschbaum, Sluyter, & Boomsma, 2003;
Retie, 2009). Exploring the role of life experience, stress, and the autonomic nervous
system in increasing or decreasing resiliency could shed some light on the importance of
a psychobiological model of stress in the reduction of symptoms of depression and
anxiety.
Nature and Nurture: Adverse Life Events, Stress, and Resilience
The debate about the role of life-events in the genesis of psychological symptoms
and psychological disorders has raged for years (Weaver, 2007). Currently, most
theorists posit that psychological symptoms have genetic determinants, epigenetic risks
(factors that alter gene expression across during a single life span), and environmental
factors leading to their genesis (Weaver, 2007). To exemplify this, one study of monkeys
found that removing a child from its mother for multiple short periods (several days) lead
to profound alterations in its cortisol reactivity across the lifespan of the animal (Retie,
2009). Other studies have been able to breed mice with alterations in cortisol levels from
birth (Kotelevtsev, et al., 1997; Caspi et al., 2002). An often-quoted longitudinal study of
resilience in New Zealand found that a certain gene puts children at increased risk for
violent behavior (Kennedy, 2008). Individuals expressing this gene were seven times
more likely to be in jail for violence. However, this effect only occurred in individuals
exposed to violence in their youth.
This study will work from the assumption that there are genetic, epigenetic, and
environmental factors that influence the development of psychological symptoms (e.g.,
depression, anxiety and PTSD) and biological reactivity.

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Adverse life events: depression, anxiety and stress.
Herman (1997) stated that most, if not all individuals have a breaking point. A
breaking point is a point of intense stress beyond which the individual has a radical shift
in functioning and a change in autonomic set point. This can be one major event or a
series of events. Some studies have found that the amount and severity of exposure to
traumatic events relates to the development of and severity of PTSD symptoms (Foy,
Sipprelle, Rueger, & Carroll, 1994). Increased risk of depression and anxiety disorders
have also been noted subsequent to an exposure to life stressors (Edwards, et al., 2003).
In a study of ACEs, Felitti et al. (1998) researchers found that exposure to
multiple childhood traumas increased anxiety, depression, addiction, health destructive
behaviors, and the likelihood of an early death. As part of this epidemiological study of
the additive effects of multiple traumatic events, 17,000 middle class individuals were
assessed. ACEs were broken down into eight categories, ranging from physical abuse to
the incarceration of a family member. The number of events in each category was not
recorded. With the increase in class of traumatic events, there was a linear increase of
health destructive behaviors. To exemplify this, there was a 250% increase in the
likelihood that an individual will smoke if he or she had experienced six ACEs rather
than if they had experienced only one. For drinking, there was a 500% increase in
alcohol addiction. Finally, with intravenous drug use (heroin), there was a linear increase
of risk (4600%) ranging from zero to four ACEs. Thus, the relationship between
childhood adversity and adverse health risk is strong (Felitti et al., 1998). Felitti et al.
(1998) went on to say, “Clearly, we have shown that adverse childhood experiences are
common, destructive, and have an effect that often lasts for a lifetime. They are the most

16
important determinant of the health and well being of our nation” (p. 6).
Researchers have also observed a high correlation of attachment style with the
development of depression, and/or anxiety (Dieperink, Leskela, Thuras, & Engdahl,
2001; Williams & Riskind, 2004). This is not surprising a pattern of neglect, emotional
abuse, or physical aggression by a child’s primary caretaker define three of the four
attachment styles (Wallin, 2007). Felitti et al. (1998) stated that his original data did not
assess the effect of neglectful and negligent parenting on addiction and health destructive
behaviors.
ACEs have a strong correlation with multiple negative health and mental health
outcomes (Edwards et al., 2003). However, some individuals are still able to bounce
back after experiencing high numbers of these events (Luthar, 2003). The
psychobiological roots of resilience could clarify some ways that clinicians could support
the process of resilience.
Toward a Psychobiological Model of Resilience
According to Affect Regulation theory, as individuals exceed their level of
affective tolerance, their reactivity to stress becomes erratic, representing a fundamental
shift in their autonomic functioning (Levine & Frederick, 1997; Schore, 2008). One
study finds that in individuals with PTSD, there is a dysregulation in cortisol reactivity
even thought cortisol retains its daily pattern of highs and lows (Yehuda et al., 1996).
The same study finds that in individuals with depression, the cortisol system losses its
diurnal pattern, appearing to follow little observable cyclical pattern in its functioning.
As SE is a theory based in an affect regulation model, it makes suppositions that match
the above studies findings.

17
Indeed, positive emotions do reduce the amount of time it takes individuals to
return to their baseline of autonomic functioning (Fredrickson et al., 2003). The original
conceptualization of ‘homeostasis’ was, in essence, a regulatory range that maintains
optimal functioning (McEwen & Lasley, 2002). Exceeding that range can cause damage
to the organism. The main shift in thinking offered by this model of resilience is that an
individual’s resources, which include affect regulation skills, social relationships, and
access to what Fredrickson et al. (2003) calls positive emotions and behavioral choices,
can alter the homeostatic processes. This process of maintaining homeostasis by
physiological or behavioral adaptation is called allostasis. For some individuals, their
lack of external resources, limited internal skills, and implicit affect regulation makes
them vulnerable under stress to an increased autonomic reaction that exceeds their
system’s ability to cope (McEwen & Lasley, 2002).
Intensity of exposure and length of exposure to stress can create systemic
adaptation. McEwen and Lasley (2002) coined the term ‘allostatic load’ to describe the
drag on one’s ability to function created by chronically exceeding an individual’s
homeostatic tolerance for stress. The concept of allostatic load is central to the SE
model. Similar to McEwen and Lasley’s (2002) suppositions, according to the SE model,
as the allostatic load becomes significant enough or under the right conditions, there is a
fundamental adaptation in psychophysiology (Foundation for Human Enrichment, 2007).
Indeed alterations in stress reactivity and psychological processes have been noted in
individuals with depression, PTSD, and anxiety. Felitti et al. (1998) described behavioral
shifts similarly, when they stated, as noted above, that adverse events have been
transformed by psychosocial experience in to physical diseases and mental illness.

18
Exposure to traumatic events has a linear relationship with suicidality, changes in
autonomic functioning, depression, addiction, and early death (Felitti et al., 1998).
As previously discussed, several authors have concluded that the number of
positive events, coping styles, and behaviors can increase resilience. Many of these
insulating/resiliency factors could reasonably be hypothesized to increase what Tugade,
Fredrickson, and Barrett (2004) refer to as positive emotions or pro-social emotions.
Tugade and Fredrickson (2004) highlighted the relationship between positive emotion
and an increase in the speed of returning to a homeostatic range as measured by galvanic
skin response and other physiological indicators. McEwen and Lasley (2002)
emphasized the necessity for an individual to be able to mobilize an allostatic response
when under threat. Equally, important, however, is the ability to shift out of an allostatic
level of stress reaction and return to a baseline of functioning when the threat has passed.
Allostatic responses that do not return to a baseline over time cause a drag on both
mental and physical health (McEwen, & Lasley 2002). This matches the observations
found in the ACE study. According to Felitti et al. (1998), even 50 years after childhood
traumas, individuals will have enduring psychological and physiological stress that
impacts their functioning on many levels. In a psychobiological stress-based resiliency
model, resilience factors, including internal coping, beliefs, social relationships, and the
broader social context, increase the likelihood that an individual will have positive
emotions that reduce the time spent in allostatic response and return them more quickly to
their baseline homeostatic range.
It logically follows from the above information that a psychobiological model of
resilience would include the effects of social and psychological factors on the stress

19
response. Other authors have noted these factors are important to resilience when they
note that life events, habits, beliefs, and social setting all impact the individual’s ability to
respond to life stressors (Ledogar, & Fleming, 2008; Luthar, 2003; Wills, Sandy, Shinar,
& Yaeger, 1999). These factors then increase or decrease the individual’s ability to
tolerate a range of stressful events. Adding to this is the role of the individual’s genetic
and epigenetic determinants of stress reactivity (Bartels et al., 2003). Genetic and
epigenetic factors create the backdrop for the effects of the contextually based resiliency
factors, making an individual more or less prone to experiencing an allostatic load (Kloet,
Joëls, & Holsboer, 2005; Luthar, 2003). Contextual factors also increase or decrease the
possibility of an allostatic load.
Clinical Relevance of the Autonomic Model of Resilience
Understanding the role of the dysregulation of the autonomic nervous system
could have profound applications in clinical practice. It could inform the types of
interventions used in sessions, help create a biological model of mental health symptoms,
and inform how and when to apply interventions. To elucidate this possibility further, it
could be helpful to apply this model of affect regulation and resilience to several study
findings that may have relevance to clinical practice.
Positive emotions can be triggered by multiple modes (e.g., sensory modalities,
felt experience and thoughts) of human experience. The smell of an apple pie can evoke
a strong sense memory of comfort and safety. Comfort to the physical body, such as a
massage or kind supportive touch, can reduce cortisol levels and stress response (Field,
Hernandez-Reif, Diego, Schanberg, & Kuhn, 2005). In Dialectical Behavioral Therapy
(DBT), an empirically validated and highly effective treatment for borderline personality

20
disorder with a heavy focus on affect dysregulation, uses “soothing in the five senses”
(evoking relaxation response in any or all of the five senses) as a key tool for increasing
one’s ability to tolerate extreme levels of distress (Linehan, 1993).
One study of soldiers in combat found that those who have greater amounts of
positive affect are less likely to develop PTSD (Maguen et al., 2008). Similar to most
resiliency studies, this study did not take a multivariate approach, including or controlling
for the multiple events that could influence the development of resiliency to constructing
their study, and thus, there are many possible confounds to their findings.
From a psychobiological model of resilience, one might postulate that the
soldier’s tendency towards positive emotions likely increases the number of times that
they can evoke positive emotion in the aftermath of a terrible battle (Maguen et al.,
2008). It is possible that soldiers with a tendency toward positive affect will indeed have
flashes of memories and high amounts of autonomic reactivity in the aftermath of the
battle. For the soldier with this tendency, it is reasonable to assume that often as the flash
memory of the event is evoked, their tendency towards positive emotion primes positive
feelings, along with the intense fight or flight affect a positive emotion. It follow that the
positive emotion could then increase the speed of return to rest and provide what could be
considered an ‘inoculation’ against the effects of extreme stress.
This is what Fredrickson et al. (2003) found after 9/11. Individuals who had
higher numbers of what she called ‘positive emotions’ in the aftermath of 9/11 were less
likely to develop symptoms. Similarly, individuals who use cognitive strategies, such as
reframing, have a reduced likelihood of developing psychological symptoms (Bryant,
Marosszeky, Crooks, Baguley, & Gurka, 2000). It is plausible that the use of reframing

21
also primes what Fredrickson et al. (2003) calls positive emotions and speeds the return
to rest through the interplay between higher order cognitive systems and the
limbic/emotional cortex.
Another population that might be effected by this autonomic model of resilience
is individuals who are depressed. Individuals who have symptoms of depression tend
toward a negative selection bias about information and events in their lives (Gotlib,
Krasnoperova, Yue, & Joormann, 2004). This occurs at the neurological level, as well as
the psychological/ experiential level (Goldin, 2008). For example, an increased amount
of key cortical areas fire in individuals who display symptoms of depression when
looking at a sad face when compared with individuals who do not display symptoms of
depression (Goldin, 2008). There are alterations in the neurological system’s response to
both negative and positive information in individuals with a wide range of mental
disorders, including depression, anxiety, and PTSD (Armony, Corbo, Clément, & Brunet,
2005; Evans, Wright, Wedig, Gold, Pollack, & Rauch, 2007; Phillips, Drevetsb, Rauchc,
& Laned, 2003). Changing the number of negative thoughts and inaccurate negative self-
perceptions likely increases what Fredrikson (2000) calls positive emotions and is
theorized to be one of the main curative factors in cognitive behavioral therapy’s (CBT)
treatment for depression (Rey & Birmaher, 2009).
The finding of multiple resiliency studies, that social relationships are a very strong
resiliency factor, can be also understood through a psychobiological model of resilience.
King, King, Fairbank, Keane, and Adams (1998) found that the quality of one’s
relationships can be a significant source of stress or support after significant life stressors.
If individuals are able to seek help in supportive relationships, the relationships can

22
provide ‘scaffolding’ of their ability to regulate negative emotions and to evoke positive
ones. Social support behaviors have been noted to reduce the production of the stress
hormone cortisol in both men and women (Kirschbaum, Klauer, Filipp, & Hellhammer,
1995).
Social support is relevant for better health as seen in the chimpanzee populations
(De Waal, 1989; Fredrickson et al., 2003). It may be that the physical contact provides
soothing and thus decreased stress response. Also, chimpanzees who are in a higher
strata of the social system have less stress reactivity and less heart disease than their
lower status brethren (De Waal, 2000; Sapolsky, 2005). The higher status reduces the
exposure of the chimpanzee to the violent behavior of other chimpanzees, the ease with
which they gain social support, and access to vital resources, such as food.
The ability for an individual to have increased numbers of positive life experiences
could significantly reduce the impact of negative life experiences (Fredrickson et al.,
2003). This has strong implications for clinical practice. The clinician’s ability to
support their clients to develop a wider range of coping strategies, a strong social support
system, the ability to attend to positive life events, and build up the life habits that
increase resilience could help mitigate many of the negative effects of stress reactivity
and reduce the allostatic load on the client’s body and mind.
The SE Model: A Psychobiological Model of Resilience
SE, although designed as a treatment for PTSD, is in essence, a psychobiological
model of resilience (Levine & Frederick, 1997). It works with an individual’s inherent
resilience to broaden and build up the areas of their life affected by their resilience. SE
posits that when individuals’ autonomic reactions to a life-threatening event exceeds their

23
personal abilities to tolerate sympathetic arousal, they experience a fundamental shift in
their overall sensory gating of reactivity to stressors, baseline ‘tonic’ stress levels,
intensity of reactivity, and a conditioned association of an event with fight-or-flight
reactivity (Levine & Frederick, 1997). The SE model implies that the autonomic nervous
system can enter into positive feedback loops in either hyperarousal or hypoarousal
(Foundation for Human Enrichment, 2007).
Positive feedback loops occur when the action of the system causes other events
that retrigger the initial cause that then retriggers the events that triggers the initial cause
and so on (Foundation for Human Enrichment, 2007). The individual whose nervous
system enters a feedback loop in hyperarousal would experience exaggerated startle
response, anxiety, and increased aggression. The individual whose nervous system enters
a feedback loop in hypoarousal would experience a flattening of affect, depression,
lethargy, and dissociation. Supporting this supposition, a reduction in HRV (heart rate
variability) has been found to have a relationship with depression and heart disease.
HRV is a measure of the use of what Porges (2002) in his poly-vagal theory, calls the
freeze response mediated by the phylogenetically older parasympathetic system. In SE
theory, the maintenance of the freeze response through a positive feedback loop leads to
among other events, the above-mentioned symptoms, and alterations in gut motility and
appetite amongst others.
SE postulates that a resilient nervous system exhibits a regular oscillation between
manageable levels of sympathetic activation and a re-engagement of parasympathetic
tone (Foundation for Human Enrichment, 2007). A simple method used to assess the
resilience in an individual during SE therapy is to note how quickly that individual shifts

24
from a description of a horrific event to an explanatory belief or another expression of
positive emotion. For example, as an individual describes their experiences in a
detention camp in the Philippines during WWII, the clinician might listen to their story,
track physical signs of changes in arousal, and monitor how quickly the description of a
terrifying event is followed with an aspect of the event that helped them survive the
experience (Foundation for Human Enrichment, 2007).
Due to the prefrontal context and its relationship to the emotional cortex (e.g.,
limbic system, cingulate gyrus, insula, and the orbital medial prefrontal cortex) in
humans, individuals have the ability to trigger a full range of affective experiences
through the imagination of an event (Sapolsky, R., Personal communication). The ability
to replay stressful events in the mind can lead individuals who are depressed, anxious, or
traumatized to perseverate on negative events, stressors, or worries. To the body, there is
little difference in the thought, image, sensation, or trigger, cueing a stress reaction from
the actual life stressor (Foundation for Human Enrichment, 2007). From the perspective
of the SE model, persevarating on stressful events exposes one’s self to high amounts of
stress without the mitigating factor of adaptive mastery, re-engagement of
parasympathetic nervous system, relaxation response, and the ability to return to rest
(Foundation for Human Enrichment, 2007).
In the SE model, practitioners track changes in autonomic arousal and ask the
client to evoke a positive emotion in SE parlance; this is called resourcing. This, in turn,
leads to a “dis”-association between the stress reaction and the triggering event and a
quicker return to baseline arousal levels (Levine & Frederick, 1997). This class of
interventions is highly similar to traditional desensitization interventions. They are

25
different is two key ways. These are the clinical tracking of the changes in autonomic
reactivity and the range of tools with which to reduce the stress response. The clinician
tracking the changes in autonomic reactivity allows for subtle appropriate application of
resorting. The clinician is trained on how to use sensations, imagery, grounding
(orienting through the senses to the here and now, for example, noticing the clients
contact with the chair, breath, current sights, smells, and sounds in the environment),
thoughts, emotions, and behaviors to evoke a relaxation response.
One of the main goals of SE therapy is for clients to be able to expand their time
in what is called exploratory orienting response (Foundation for Human Enrichment,
2007). The exploratory orienting response is in essence what Porges (2002) calls the
social engagement system. It is the patterns of behavior evoked when an individual feels
safe, at rest, and competent to manage the demands of their life. Similar to how
Frederickson (2000) described the effects of what is called positive emotion, SE theory
postulates that when individuals are at rest, they will naturally be drawn to explore their
environment (Foundation for Human Enrichment, 2007).
To the SE practitioner, curiosity is the hallmark of the reduction of autonomic
arousal. Frederickson et al.’s (2003) broaden and build theory of positive emotions
supports this statement. The predictions of the poly-vagal theory all support this (Porges,
1995). Porges postulates that the social engagement system, including resting, digesting,
and experiences of safety in relationships, goes off line under heightened levels of stress
reactivity (Porges, 2002). As an individual begins to reduce her/his levels of sympathetic
activation, they return to rest, feel an experience of safety, and have increased levels of
pro-social behaviors.

26
The SE model postulates that because individuals in fight/flight are coping with
survival demands, they have limitations in their ability to learn from their actions, build
social support, be open to exploring multiple solutions to problems, and cope with
stressors (Foundation for Human Enrichment, 2007). Fredrickson et al.’s (2003)
Broaden-and-Build hypothesis supports the assumptions presented by the SE model. In
the Broaden-and-Build hypothesis, the function of negative emotion is to limit choices to
highly efficient survival responses. According to SE theory, limiting to survival
defensive strategies is highly effective in short-term life and death situations but is less
effective in non-life threatening situations (Foundation for Human Enrichment, 2007).
In the Broaden-and-Build hypothesis, positive emotions increase behavioral
complexity and curiosity in the individual. SE theory postulates that as individuals, we
learn the skill of resourcing (evoking positive emotion/ relaxation response), will return
from high levels of stress quicker, build resilience, and begin to be more curious about
our environment. The model also posits that individuals always have an inherent level of
resilience and that there are many times when no intervention is necessary at all
(Foundation for Human Enrichment, 2007). As an individual begins to have a more
‘implicit’ or automatic evocation of positive emotion, the clinician’s role is one of
supportive witness. They are less directive, occasionally helping to steer the session if the
individual’s reactivity exceeds his or her current regulatory capacity (Foundation for
Human Enrichment, 2007).
Another key theoretical implication of the SE model is that defensive or
protective emotions, such as disgust, anger, and fear, meet an important survival demand.
Each represents a self-protective strategy (Foundation for Human Enrichment, 2007). In

27
the SE model, the thwarting of a motor plan or defensive strategy often underlies the
development of symptoms of trauma, anxiety, and depression. The defensive response is
the excitation of a fight-or-flight reaction with the development of a motor plan to
execute the defensive strategy. If that pattern is interrupted, the system can become stuck
and inflexible in its response to stressors. One possible way that this pattern can become
stuck is if the individual is unable to complete the plan due to intensity of the threat. The
individual held hostage might, when they first saw the gun mobilize an escape plan. If
the individual cannot mobilize the defensive strategy, they may enter into a freeze
response. The freeze response shuts down the individual’s level of awareness. The
thwarting of this response can lead to avoidance behaviors when the individual needs to
mobilize a defensive response or the avoidance of the emotions that would drive the
thwarted defensive strategy (Foundation for Human Enrichment, 2007).
Individuals who do not have access to a full range of these defensive orienting
responses will use avoidant strategies, have a diminished ability to be assertive, and tend
to either have overly rigid personal boundaries or be unwilling to assert their needs
(Foundation for Human Enrichment, 2007). Having full access to defensive strategies
allows individuals quite naturally and simply to protect themselves. In the SE model, the
body plays a key role in both the clinician and client ability to track body movements,
somatic markers of emotions, and tools to work with the autonomic nervous system.
Thwarted defensive strategies mobilized during overwhelming life events are
hypothesized to lead to the development of psychological symptoms.

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Psychobiological Changes: The Role of the Body in the Mind
The body plays a large role in psychological processes. Understanding the top-
down and bottom-up psychological theories, a psychobiological model of dissociation,
and the clinical relevance of body-mind approaches to psychotherapy could shed some
light on the bodies roll in psychological processes. Damasio (1996), a prominent
neuropsychologist and researcher, is a theorist who has highlighted the role of the body in
psychological processes. Damasio (1996) also originated one of the newer conceptions
of emotions called the somatic marker hypothesis.
According to Damasio’s (1996) somatic marker hypothesis, internal signals from the
smooth muscles of the viscera and the propreaceptive and nociceptive systems form
patterns or clusters that the individual interprets as emotions. The patterns of experiences
are associated with emotions. These patterns of current events and past experiences form
what Gendlin (2007) refers to as the ‘felt-sense.’ The felt-sense is the integration of all of
the current sense information with past experiences and the expectancies that those
experiences create for the current situation. Previous emotional experiences, patterns of
coping, autonomic arousal, smooth muscle reaction, thoughts, and overall body tension
form what is known as the felt-sense. The felt-sense is the integrated experience of being
embodied, and combines all of the sensory input, self-awareness, and consciousness into
a seamless experience of the moment (Gendlin, 2007).
In his book Descartes Error, Demasio (1994) describes a lawyer who had a
disruption in his ability to read his body signals. The lawyer was not able to function,
and he lost job after job but not due to lack of intelligence or to his lack of knowledge

29
about the law. He had a significant deficit but it was not to his intellect. His deficit was
that he could not make decisions. He could not read his somatic cues. This left him with
pure logic on which to make a decision. His skill as a lawyer then allowed him to argue
intellectually all possible sides of any small decision. The small stress reactions or hints
of pleasure that guide most individual’s decisions were gone for him. The lack of
somatic cueing left him unable to figure out which one to choose from among all the
possibilities in his life.
Further research on economic decision-making supports the vital role of the right-
brained implicit markers or somatic cues in decision-making processes (Bechara &
Damasio, 2005). Clinically, the inability to read the internal signals of threat can often
lead individuals to miss cues for danger in the environment and thus expose themselves
to unsafe situations (Follette & Ruzek, 2006).
Kardiner (1941), an early investigator of trauma in veterans, described the role of
the body in the mind when he noted that all neurosis have their roots in physiology. The
reaction to a traumatic event is not simply psychological or biological, but an interplay
between the systems. van der Kolk (1997) described three significant physical changes in
stress reactivity: (a) chronic physiological autonomic arousal; (b) heightened response to
reminders of the traumatic event; and (c) hyperarousal in reaction to intense, but neutral
events (e.g., loud noises like clapping, singing, or cars backfiring). He went on to state,
“Exposure to extreme stress affects people at many levels of functioning: somatic,
emotional, cognitive, behavioral, and characterological” (p. 183).
Individuals with depression show profound changes in biological and
neurological functioning (Eaton, Armenian, Gallo, Pratt, & Ford, 1996; Evans et al.,

30
2007; Frerichs, Aneshensel, Yokopenic, & Clark, 1982; Phillips et al., 2003). Currently,
the most effective and empirically validated treatment to date for depression is CBT in
combination with antidepressant medication (Butlera, Chapman, Forman, & Beck, 2006;
Blackburn, Bishop, Glen, Whalley, & Christie, 1981). The antidepressant medications
alter many somatic symptoms of depression and the CBT alters the individual’s thoughts
that lead to maintaining depression. Depression is associated with dysregulation and
often increases in cortisol levels (Sheaa, Walsh, MacMillan, & Steinera, 2005) and with
alterations in the brain resting state. Increased aggression and self-aggression are noted
in individuals with symptoms of depression (Messera & Grossb, 1994).
As alluded to earlier, symptoms of depression have significant physiological
components to them. An increased stress response elevates cortisol levels, an inhibition
of peristalsis, and a lack of desire for food (Dinan, et al., 2006). Both elevated cortisol
and lack of desire for food is seen in individuals with depression (American Psychiatric
Association, 2000). These individuals may be using food to trigger the activation of
peristalsis, and thereby switching their nervous system from sympathetic to
parasympathetic (Saper, Chou, & Elmquist, 2002). Parasympathetic nervous system is
also known as ‘rest and digests’ because it stimulates gut motility and increases the likely
hood of sleep (Argur & Moore, 2006). Individuals with depression have also been noted
to display significant alterations in their dopamine system (Dunlop & Nemeroff, 2007),
with increased anhedonia and aviolition.
Anhedonia is loss of ability to feel pleasure and is associated with the
neurotransmitter dopamine and others (Willner, Muscat, & Papp, 1992). Cortisol, one of
the main stress hormones, has a profound effect on the dopamine system (Dunlop &

31
Nemeroff, 2007). In individuals with Cushing’s syndrome (an over active secretion of
cortisol), one of the main symptoms is depression (Soninoa et al., 1993). Depression,
Cushing’s syndrome, and PTSD also lead to a loss in hippocampal volume, due largely to
the combination of increased cortisol and disruptions to the dopamine system (Bourdeau,
Bard, Noël, Leclerc, Cordeau, & Bélair, 2002; van der Kolk, 1997).
In Cushing’s syndrome and depression, a reduction of excess cortisol secretion
results in not only reduced depression, but also in increased hippocampal volume
(Bourdeau et al., 2002; Starkman et al., 1999). Although trauma is not the only means to
alter the cortisol system, trauma and ACEs likely play a key role for many in the
neurochemical alterations that can lead to depression (McEwen, 2003; Penzal, Heim, &
Nemeroff, 2003). Depression and anxiety are highly comorbid with PTSD. As one study
notes, “when PTSD and depression occur together, they reflect a shared vulnerability
with similar predictive variables” (O’Donnell, Creamer, & Pattison, 2004, p. 1) This
study also states that there is a small subset of individuals whose development of
depression 3 months after the traumatic event was predicted by other variables.
Individuals with multiple types of psychological disorders display alterations in
their autonomic nervous system (Thompson, Berger, Phillips, Komesaroff, Purcell, &
McGorry, 2007; van der Kolk 1997; Watson & Mackin, 2006). Few psychotherapeutic
theories incorporate how to track autonomic signals of heightened stress reactivity or
dampened stress reactivity (Foundation for Human Enrichment, 2007). Although, some
desensitization techniques and mindfulness-based therapies, such as DBT, teach
individuals how to track, observe, and understand the somatic markers of emotion, this
appears to be the exception and not the rule (Linehan, 1993). In these interventions, the

32
clinician does not track the changes in stress reactivity but rather teaches the skills for the
client to track their reactions.
Most psychological theories focus on increasing insight (a higher cortical-based
cognitive process), changing cognitive appraisal, distorted thinking, narratives, and
behavior (Schore, 2008). Changing behavior, cognitive appraisal, and one’s narrative all
can and do reduce autonomic activation and reactivity to triggers (Foa & Rothbaum,
1998). However, an integrated treatment for the full range of human experiences would
need to address the multiple levels of changes that make up psychological symptoms,
including autonomic changes, cognitive changes, and functional neurobiological
adaptations (Schore, 2008).
According Porges’s (2002) theory of neuroception, the autonomic stress reactivity
informs the higher order cognitive processes about the level of safety in the current
environment. In a study of spending habits, a small amount of the chemical oxytocin (a
chemical mediator of social engagement) sprayed in the nose of a college student
increased their generosity, willingness to give away their money to strangers, and
willingness to accept a bad business deal. In this study, changes in the social engagement
system altered behavior and cognitive interpretations of the behaviors of others.
Addressing only the cognitive conscious declarative mediators of behavior could ignore
the implicit, autonomic, and gestalt based mediators of behavior.
According to Ogden and Minton’s (2000) sensory-motor psychotherapy, an
outgrowth of SE, there is two major types of therapeutic interventions: top-down and
bottom-up therapies. Top-down therapists use cognitive (left prefrontal cortex) or
declarative memory to affect emotional responses (right pre-frontal and sub-cortical

33
limbic system) (Ogden & Minton, 2000; Schore, 2003). In contrast, bottom-up therapists
work with sensory motor or body processing to effect changes in patterns of cognitions.
This is a reductionistic metaphor because the two systems are likely affecting each other
all the time, but it is useful for characterizing the two types of processes and addressing
the gaps in the more traditional psychotherapeutic approaches (Ogden & Minton, 2000).
Most psychotherapeutic interventions use a top-down approach (Schore, 2008).
These approaches attempt to change the dynamic relationship between the sub-cortical
and cortical regions of the brain by affecting higher aspects of human functioning, such
as declarative thought, conceptualization, planning, and executive functions (Schore,
2008). Through changes in thoughts, interpretations and insight, an individual’s
emotional reactions change.
In psychodynamic approaches, therapists seek to make the unconscious
conscious. Through being able to describe, in a declarative way, habitual patterns of
behavior and feelings, an individual is then able to make choices about his or her actions
(Schore, 2008). In traditional CBT, individuals are asked to identify the thoughts that
affect their feelings and lead to disruptions in behavior (Foa & Rothbaum, 1998).
Through changing their verbally based thoughts, they change their feelings. In both of
these theories, therapists work to change higher order cognitive processes, such as
thinking, to affect emotional responses. This is the hallmark of top-down therapy.
Although the ability to change emotional reactivity with higher cognitive functions is
well documented and undeniable, it is not the only way to effect psychological change
(Dunmore, Clark & Ehlers, 2001; Schore, 2003).

34
Bottom-up therapeutic interventions work with the emotional brain to change
patterns in both emotions and cognitions (Ogden & Minton, 2000). Traditional
psychotherapeutic approaches have ignored these therapeutic techniques in the past.
Cognitive-behavior therapists have incorporated many of these interventions into their
treatment models. Techniques, such as progressive muscle relaxation and signal breath,
are widely used in the treatment of anxiety disorders (Foa & Rothbaum, 1998). In effect,
these techniques reduce an individual’s level of fight-or-flight reaction and stimulate the
“relaxation response” (parasympathetic re-engagement) to affect anxiety levels through a
sensory motor intervention.
Winnicott was proposing a bottom-up process when he described creating a
holding environment (as cited in Wallin, 2007; Rodman, 2003). As the client experiences
the clinician as another individual who is able to tolerate her/his emotional needs, the
self-story about his or her emotional life changes. The change in the self-story,
cognitions, or insight subsequent to an experiential change is the essence of bottom-up
processing (Ogden & Minton, 2000). SE practitioners often report that as individuals
have a new experience of the triggering event, they begin to express changes in the
‘meaning’ they had constructed about it (Foundation for Human Enrichment, 2007).
The most successful psychotherapeutic treatments likely need to address changes
in both these levels of consciousness. Inaccurate and distorted thinking can severely
reduce an individual’s ability to function. Distorted thinking is, in essence, an inaccurate,
non-flexible, or context-irrelevant representation of the self, other future, or world
(Young, Klosko, & Weishaar, 2003). Individuals can also develop inaccurate perceptions
at levels of subcortical limbic implicit reactivity (Schore, 2003).

35
Another study highlighting the ability to have inaccurately trained subcortical
(bottom up or a.k.a. low road) processes compared individuals who had experienced
childhood trauma with a control group who had not (Goleman, 1995). Participants in this
study were shown images of facial expressions. These expressions changed slightly over
a sequence of 12 photos from fear to anger. People who had experienced no trauma were
likely to start seeing anger at about the sixth image or the middle of the sequence.
Individuals who had experienced trauma tended to start seeing anger in the faces much
sooner, closer to the third image. These individuals had an inaccurate perception of fear.
When they encountered fear, they saw anger (Goleman, 1995). One might assume that a
psychotherapist who attempts to address reactivity to anger without effectively changing
the patient’s perception of other people’s emotions could be omitting a significant aspect
of anger management.
Both top-down and bottom-up processes play a role in most psychological
theories. According to SE theory, dissociation is deeply involved in the development and
maintenance of psychological symptoms. An exploration of several theories of
dissociation could illuminate the possible role of dissociation in the creation of
psychological symptoms.
The Psychobiological Roots of Dissociation
Dissociation is another key low road (bottom-up) process. Bessel van der Kolk
(1997) noted that the ability to describe events verbally is often off line under extreme
stress. In a talk in 2006, he showed MRI slides of individuals who had experienced
trauma. These individuals displayed significantly less activation in the language areas of

36
the brain than individuals who had not experienced trauma. This points to the difficulty
in working with dissociative states through purely verbal means.
Dissociation has been associated with overwhelming life experiences since the
late 1800s (Schore, 2008). Schore (2008) notes models of dissociation have roots in
psychological and physiological processes. The DSM-IV (2000) characterizes
disassociation as a “disruption in the usually integrated functions of consciousness,
memory, identity, or perception” (p. 519). The 10th edition of The International
Classification of Diseases (ICD 10, 2007) describes dissociation as “a partial or complete
loss of normal integration between memories of the past, awareness of identity and
immediate sensations and control of body movements” (p. F44). Janet (1887) referred to
the changes in the state of autonomic overwhelm as what translates to a lowering of
mental level. This, in essence, is a reduction in an individual’s level of awareness
(Schore, 2008). Due to the growing understanding of the importance of dissociation in
psychological and biological processes, there has been a call for a more clear, specific,
and comprehensive definition of dissociation that lends itself to empirical research
(Prueter, Schultz-Venrath, & Rimpau, 2002).
Four major theories of the psychobiological roots of dissociation have been
formulated over the years (Schore, 2008). The first posits a continuum from mere
psychological absorption to the creation of alternate self-states (van der Kolk, McFarlane,
& Weisaeth, 1996). The second postulates that dissociation consists of two types of
experience: compartmentalization and detachment (Holmes, et al., 2005). The third is the
polyvagal theory, which is a psychobiological model of the role of dissociation in PTSD
and depression (Porges, 1995). The fourth stems from MRI studies comparing

37
individuals with a dissociative or ‘hypoactive type’ of PTSD and those with
‘hyperaroused type’ of PTSD (Lanius & Hopper, 2008).
Detachment involves alterations of perception, emotion, cognition, and behavior
(Lanius & Hopper, 2008; Vermetten, Dorahy, & Spiegel, 2007). These include
flashbacks, depersonalization, derealization, amnesia, fugue, confessional states and
attention deficits, motor weakness, sensory distortions, paralysis, tremors, shaking, and
convulsions (Lanius, & Hopper, 2008; Vermetten et al., 2007).
van der Kolk et al. (1996) described what he called the continuum theory of
dissociation as having three levels of dissociation: primary, secondary, and tertiary. In
addition, they characterized PTSD as a disordered ability to be in the here and now. For
individuals with PTSD, life has moved on, but the experience of the terrible life event
still plays on in the individual’s mind and physiology. The primary level of dissociation
is a disintegration of experience and current sense of self (van der Kolk, et al., 1996). An
individual may recall an event, but he or she does not experience the associated emotion.
The most pronounced form of primary dissociation is flash bulb memories that intrude
into the consciousness of individuals with PTSD (van der Kolk, et al., 1996). Secondary
dissociation is a splitting of the observing ego and the experiencing ego. Individuals may
see themselves as if from afar. They float above the traumatic event and ‘watch’ it
happen to them. Tertiary dissociation has been associated with a splintering of
personality. Entire self-states are compartmentalized, and distinct ego states are formed
(van der Kolk, et al., 1996). Although highly controversial, it is the
compartmentalization that is hypothesized to be the process of development of DID
(dissociative identity disorder).

38
A third model of dissociation is the polyvagal theory, postulated by Stephen
Porges (2002). This model is used the most in SE theory to explain the
psychophysiology that leads to multiple classes of psychological symptoms. The
traditional model of the autonomic nervous system (ANS) breaks it into two subsystems:
the sympathetic nervous system (SNS) and the parasympathetic nervous system. In
response to noticing several inconstancies in the predictions of this model, Porges and
colleagues developed the polyvagal theory (Doussard-Roosevelt & Porges, 1999). The
polyvagal theory hypothesizes that the PNS breaks down into two branches. One branch
is evolutionarily newer and consists of myelenated neurons that originate in the brainstem
in the ventral lateral area and from there, innervate the heart and other internal organs.
The second branch is the evolutionarily older branch, originating in the dorsal motor
nucleus of the brainstem (Doussard-Roosevelt & Porges, 1999). It is unmyelenated and
hypothesized to mediate the function of the freeze response in all animals from
invertebrates to humans.
In the traditional ANS model, when a reaction to a stressful event exceeds the
tonic (constant) inhibition of the sympathetic (fight-flight) activation by the
parasympathetic nervous system, the parasympathetic nervous system releases what
Porges calls the VVC or ventral vagal brake on SNS activation. This activation then
mobilizes a fight-or-flight response. As the threat is evaded, the level of SNS activation
is reduced, and the parasympathetic nervous system brake re-inhibits the firing of SNS
activation.
The poly-vagal theory adds one more layer to this paradigm (Doussard-Roosevelt
& Porges, 1999). In a low-level stressful event, the polyvagal theory would predict the

39
same outcomes as the traditional ANS model. However, in life-threatening situations, the
polyvagal theory predicts that first the myelenated VVC would be disengaged, allowing
for the engagement of the SNS, which, in turn, would mobilize a defensive response
(Doussard-Roosevelt & Porges, 1999). However, if the amount of activation were to
reach extreme levels, the dorsal motor nucleus of the vagus (DMNX) nerve would
function like the tilt on a pinball machine, invoking a tonic immobility response (TI) and
shutting down SNS and CNS activity (Doussard-Roosevelt & Porges, 1999).
In very low threat or safe environments, the VVC branch of the PNS allows for
what Porges termed ‘social engagement’ (Doussard-Roosevelt & Porges, 1999). Some
indications of social engagement are the inner ear tuning to the range of the human voice,
breathing’s becoming slow and smooth, and the individual growing curious about his or
her environment. These assumptions match the findings about positive emotions by
Fredrickson (2002). Fredrickson (2002) proposed that positive emotions create a
broadening of attention, more engagement with others, and a larger array of choices.
This stands in stark contrast to negative emotions, which narrow focus to the removal of a
threat (Fredrickson, 2002). Social engagement is an indicator of therapeutic success in
SE theory (Foundation for Human Enrichment, 2007). In essence, SE postulates that the
inability to return to social engagement and safety is the hallmark of the transformation in
the aftermath of a traumatic event.
Porges (2002) also coined the term ‘neuroception’ to describe the processes
through which humans assess their environment for a threat. It is hypothesized that the
activity of the all branches of the ANS function through the fast but fuzzy circuit of
implicit learning (bottom-up process) rather than the slower but more detailed process of

40
explicit learning (top-down process). He postulated that these systems are dispositional,
semi-conscious, and not explicitly consciously assessed. Through a process of implicit
associations, individuals consistently assess their environment for threat.
A fourth theory of dissociation and PTSD, proposed by Lanius and Hopper
(2008), is that there are functional differences in neuroanatomy between individuals who
develop a hyperarousal reactivity cluster and individuals who display dissociative
symptoms, such as avoidance, depersonalization, and derealization. In one meta-
analysis, 70% of individuals with PTSD showed a heightened autonomic response to a
PTSD script, while 30% showed no heightened arousal, but instead displayed a ‘blank
state’ and a reduction in their heart rate (Lanius & Hopper, 2008). Individuals with the
hyperarousal cluster (underactive prefrontal cortex, over active amygdala, overactive
insula, and underactive anterior cingulate gyrus) tended to show less activity in the
regions associated with emotion regulation. On the other hand, individuals with the
hypoarousal cluster (overactive prefrontal cortex, underactive amygdala, underactive
insula, and overactive anterior cingulate gyrus) showed heightened activation in these
same areas (Frewen & Lanius, 2006).
Lanius and Hopper (2008) postulated that individuals who react with hyperarousal
or hypoarousal experience a different array of brain activity. Hypoarousal is associated
with dissociative experiences. In an fMRI study, Lanius and Hopper (2008) found that
individuals with a primary dissociative tend toward increased activation in the ACC
(anterior cingulate cortex), medial prefrontal cortex, and superior/middle temporal lobes.
Hyperarousal is associated with reduced ACC, medial prefrontal, thalamus, and occipital
cortices (Lanius & Hopper, 2008). These findings fit well with the postulations of the SE

41
model, which predicts a type of PTSD with and a type who predominantly displays
hypoactivation.
The SE Model of Affect Dysregulation: Dissociation and Depression
The SE model of the genesis of psychological symptoms starts in a disruption in
the functional relationship between neurobiological systems. In a flexible nervous
system, one can experience a wide range of affect, stress, pleasure, and motivation
(Foundation for Human Enrichment, 2007). The SE model uses the physiology proposed
by Porges to describe the changes in the nervous system after an extreme event (Porges,
2002; Foundation for Human Enrichment, 2007). In an extreme event, the VVC brake is
inhibited and the SNS is aroused. As the SNS is aroused, often a motor system based
defensive strategy is initiated. This strategy is aided by the full force of the SNS’s ability
to mobilize the body. If the stress is extreme enough or it is too dangerous to continue
with the motor plan, the DMNX nerve inhibits sympathetic activation (Porges, 2002). At
this point, the system will often have entered a feedback loop and started to behave
rigidly and erratically. According to SE theory, this erratic behavior leads to the
development of symptoms (Levine & Frederick, 1997).
One study found that dissociative experiences after an overwhelming event are
highly associated with development of depression co-occurring with PTSD and
individuals with PTSD displayed dysregulation of the cortisol system but maintained a
diurnal pattern (night and day cycle). Consistent with the predictions of the SE model and
the poly-vagal theory, in individuals who have depression, the cortisol system behaves
highly erratically, losses its diurnal pattern, and behaves more chaotically than in
individuals with PTSD (Shea et al., 2005).

42
The freeze response mediated by the DMNX nerve in certain animals can be
maintained indefinitely with an injection of adrenalin (Hoagland, 1928). According to
the SE model, in a traumatized individual, their nervous system becomes primed to react
to stressors through collapse (e.g., DMNX mediated freeze response), and that collapse is
maintained by an incomplete defensive strategy coupled with the heightened activation of
fight-or-flight autonomic arousal (Foundation for Human Enrichment, 2007).
Proponents of SE postulate both the engagement of fight/flight system and the
dissociative DMNX mediated freeze can become a classically conditioned to response.
This response can then be generalized to other situations through what SE calls
‘coupling’ or what behaviorism would call classical conditioning (Foundation for Human
Enrichment, 2007). Fight/flight reactions can also be generalized to other situations. The
theory holds that as the individual begins to display avoidance behavior to fight-or-flight
affects, they constrict their range of behavior. The anticipation of the fear state due to
avoidance behaviors can also over generalize to other situations irrelevant to the original
avoidance behavior. At this point, people will often start to constrict their activities and
avoid events likely to trigger the affect experienced in the event (Foundation for Human
Enrichment, 2007).
In individuals who enter into a collapse or freeze state, heightened affect and
increasing cortisol could lead to the feedback loop, maintaining the freeze or collapse
state for long periods. In the feedback loop, the implicit bottom up processes lead the
autonomic nervous system to respond in a rigid and situationally irrelevant manor. As
this rigidity in the system is maintained, the entire system begins to behave erratically.
The smooth transitions between sympathetic activation and the re-engagement of the

43
parasympathetic nervous system stop. The nervous system can display a rigid tendency
to enter a feedback loop on either end of its homeostatic range. According to SE theory,
at some points this will increase stress reactivity and at others, will lead to reduced
muscle tone, flat affect, and depression (Foundation for Human Enrichment, 2007).
SE theory incorporates non-linear dynamics or complexity theory into the
foundation of the theory. According to complexity theory, most complex systems only
display linear behavior under very limited situations (Chamberlain & Butz, 1998). When
a system exceeds the amount of rate of change tolerated by the system, it bifurcates.
Bifurcation is a splitting of the simple linear system with a single or small range of
predictive outcomes into a non-linear range of functioning, with widely varied and
difficult-to-predict outcomes.
One could think of a linear system as a bowl that one drops a marble into. The
marble will role around the bowl but come to rest at the bottom of the bowl in only a
small number of possible places. In a non-linear system, as the marble travels down the
bowl, it begins to warp so that there is a bump in the bottom of the bowl. As the bowl
warps when the marble rolls down, it bounces and rolls, and can come to rest in a much
larger number of places in the bottom of the bowl. It could land anywhere in the loop
around the warped bump in the bottom of the bowl. Non-linear systems are predictive
but in a different manner from linear systems: they are predictive in patterns of changes
not in the prediction of a single outcome.
An oak tree is a good metaphor for this prediction of pattern but not for the
specifics. No two oak trees are exact replicas of each other but the similar patterns in the
leaves, thickness of trunk, and shapes of seeds allow even a casual observer to see

44
similarities through the differences between trees.
Applying bifurcation theory to the ANS in an extreme event would be as follows.
The cortisol system begins to behave erratically and starts to become ‘stuck’ in feedback
loops that maintain hypo-aroused or hyper-aroused states (Foundation for Human
Enrichment, 2007). This is how the SE model conceptualizes affect dysregulation. As
the system begins to behave erratically, it becomes stuck for sometime in hyperarousal
and then in hypoarousal. The system begins to loose its ability to transition smoothly
from one hyper-arousal to rest. As the system becomes more dysregulated for longer
periods, second order changes in the system give way to more complex alterations of
functional neurobiology and thereby inner experiences.
The SE model for treatment offers several specific predictions about what factors
lead to psychological change and how to implement psychological interventions
(Foundation for Human Enrichment, 2007). There are currently many other treatments
for symptoms of PTSD, depression, and anxiety. Exploring some of the current treatment
modalities for these symptoms and the SE model could help to put SE therapy into the
context of current psychological treatments.
Current Treatment Modalities: Trauma, Depression, and Anxiety
Current treatments for depression. The main treatments for depression are
antidepressant medication, CBT, and mindfulness-based therapies (Blackburn et al.,
1981; Morgan, 2003). Other less mainstream treatments have been ECT
(electroconvulsive therapy) (Persad, 1990), ablation of the anterior cingulate cortex
(Shields, Asaad, Eskandar, Jain, Cosgrove, & Flaherty, 2008), and brain stimulation of
the pre-motor area (Lozano, 2009), and these have been shown to reduce symptoms of

45
depression. CBT works with distorted cognitions to reduce symptoms of depression
(Powell, Abreu, de Oliveira, & Sudak, 2008). It reduces automatic negative thoughts,
distorted schemas, and teaches anxiety reduction skills. The main difference between
mindfulness-based techniques and CBTs is that in mindfulness-based techniques, the
individual simply watches their thoughts and bodily sensations. In this process, the
individual, through direct attention, will begin to disrupt inaccurate thinking and learn
mastery with their ability to tolerate a range of affects (Morgan, 2003). Antidepressant
medications work by affecting three main systems: the dopaminergic, the serotoninergic,
and the andernergic (Preston, O’Neal, and Talaga, 2006). These drugs are thought to
either re-regulate the balance of neurochemistry or replace missing chemicals.
Current treatments for anxiety.
The core treatments for anxiety are CBT, exposure therapy, mindfulness-based
stress reduction (MSBR), benzodiazepine medications (GABAnergic), beta-blockers,
buspar, and antidepressant medications (Barrett, Duffy, Dadds, & Rapee, 2001; Miller,
Fletcher, & Kabat-Zinn, 1998; Preston et al., 2006). There are multiple anxiety disorders,
ranging from panic disorders to obsessive-compulsive disorders (American Psychiatric
Association, 2000). There are multiple treatment models for each disorder.
MSBR has been well established in the literature as an effective tool for reducing
the effects of stress and for its cognitive, physical, and emotional sequel (Goldin, 2008).
It has been shown to have a low attrition rate, with some studies having 93% of the
participants remaining through the completion of the study compared with other types of
interventions. Along with the reduction of symptoms of stress and general anxiety
disorder (GAD), MSBR has been shown to reduce symptoms of irritable bowel syndrome

46
in people who participated in two 15-minute sessions daily. This treatment has stronger
effects for the reduction of relapse in depression than in the initial treatment of symptoms
(Goldin, 2008).
For treatment of anxiety CBT, behavioral therapy, exposure therapy, and
mindfulness-based techniques have all been shown to be effective (Barr & Arnow, 1998;
Borkovec & Costello, 1993; Miller et al., 1998). These techniques all involve either
exposure to anxiety in doses that start low and increase throughout the treatment or
exposure to anxiety in the presence of stress reduction skills, such as progressive muscle
relaxation. Pharmacological treatments of anxiety include benzodiazepines,
antidepressant medications, and buspar. Benzodiazepine drugs affect the GABAnergic
system (Preston et al., 2006). GABA is considered a primary global inhibitory
neurotransmitter and it reduces the overall potential for neurons to fire. These drugs are
safe and fast acting but do not reduce anxiety in the long-term; rather they tend to be
habit forming and produce tolerance over time.
Antidepressant medications can be anxiolytics (Preston et al., 2006), particularly
certain SSRI drugs and the more sedative tricycles. These drugs are slower acting, less
dependency producing but still typically require a maintenance dose to reduce symptoms
of anxiety. Buspar is in a class by itself. It is slower acting and non-dependency
producing; however, it also requires ongoing maintenance dosing to reduce anxiety.
Treatments for PTSD.
Since the inclusion of PTSD in the psychiatric diagnostic nosology in the 1980s, a
number of empirically evaluated treatments have been created (Follette & Ruzek, 2006).
These treatments fall into seven major categories: psychodynamic treatments; cognitive

47
behavioral treatments; eye movement desensitization and reprocessing (EMDR);
pharmacotherapy; relaxation training; mindfulness based treatments; and exposure
therapies. The literature is divided as to which treatment is the most effective. Some
studies point to CBT and some to EMDR as being the most effective for PTSD
(Davidson & Parker, 2001; Seidler & Wagner, 2006; van der Kolk et al., 2007).
Pharmacotherapy, although providing some positive results, is not as effective as either
CBT or EMDR at symptom reduction (Butlera et al., 2006; van der Kolk et al., 2007).
Current alternative treatments.
Several studies have stressed the effectiveness of yoga as either a treatment or an
adjunct treatment for PTSD, depression, and anxiety (Brown & Gerbarg, 2005). In the
aftermath of the 2004 tsunami, a one-week program of yoga was administered to
survivors (Telles, Naveen, & Dash, 2007). Prior to the treatment, these individuals had
reported sleep disturbances, increased sadness, and increased fear. This study also
measured heart and breathing rate. Improvement was observed in all areas. Heart rate
and breathing rate were noted to have improved significantly (Telles et al., 2007).
Yoga is a low-cost (one teacher can instruct 30 individuals at a time), low-risk
adjunct treatment. It has also shown some efficacy in treating depression, PTSD, anxiety,
and substance-abuse disorders (Brown & Gerbarg, 2005). Yoga includes multiple
relaxation techniques effective for the treatment of anxiety. Yoga itself mirrors
progressive muscle relaxation. Meditation has also been found to be effective at reducing
anxiety. Meditation has been used in many forms around the world to help increase
physical health, increase positive emotion, reduce depression, increase psychological well
being, and to reduce anxiety (Segal, Williams & Teasdale, 2002).

48
SE Model for the Treatment of Trauma, Depression, and Anxiety
One of the current trends in psychological theory is away from a purely cognitive
model of psychological change (Schore, 2003). Led by attachment psychology,
developments in neurobiology and better means to research social interactions, implicit
models of affect regulation have begun to emerge in psychological theory. Theorists like
Allan Schore, Dan Siegel, Daniel Stern, Antonio Damasio, Robert Sapolsky, and many
more have outlined the importance of subcortical limbic areas of the brain in
psychological change. While most psychological approaches have both high-road
(cognitive/declarative) and low-road (implicit) interventions, the most popular
approaches focus mainly on cognitive processes to change the subcortical systems
(Ogden & Minton, 2000).
SE theory is organized differently in that it focuses on changing the low-road
(bottom-up) processes to affect the high-road processes (Foundation for Human
Enrichment, 2007). Therefore, it does not rely on descriptions of an event, narratives
about personal history, or changing the clients thinking in order to change their feelings.
By tracking the felt experience of an event, including sensations, images, emotions, and
thoughts, the individual gains, at the implicit level, a new felt experience of the event.
This new felt-experience leads to new patterns of behaviors. The shift in felt-experience
also leads to what practitioners call shifts in meaning, as the higher-order cognitive
systems change their expectations about the outcome of events.
The SE model is a short-term treatment model designed to reduce affect
dysregulation subsequent to extreme stress (Foundation for Human Enrichment, 2007).
SE theory postulates that in extreme stress, feedback loops form in the ANS. These

Dissertation - Somatic Experiencing Treatment for Reduction of Symptoms of Depression and Anxiety in Homeless Adults

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