Understanding CBT vs. Somatic Psychotherapy
A common question when pursuing mental health treatment or looking for a therapist is simply, what kind of treatment do I need? Although there are multiple forms of therapy, they all tend to fall into one of the following major schools of thought: cognitive/ behavioral therapy, psychodynamic psychotherapy, and somatic psychotherapy. This article will specifically explore and expand upon what cognitive and somatic therapies are, and who is best served by each of these types of therapy.
CBT or cognitive behavioral therapy, is one of the most commonly used and evidence-based forms of behavioral therapy. As the name suggests, it is focused on changing one’s thoughts and behaviors. Essentially, by working to change your thoughts about a situation, you can influence different outcomes and behaviors. For example, a client may have a persistent negative belief that “nothing works out for them.” This belief could in turn lead to feelings and behaviors that result in negative outcomes, thus reinforcing a negative cycle.
The therapist would work with the client to challenge the unhelpful patterns of thinking and behavior, and help the client to create new, more helpful patterns of thinking and behaving. Importantly, CBT is considered to be a “talk therapy” (relying mostly on dialogue between counselor and client).
CBT: What Is It Good For?
CBT is a primary mode of treatment for a diverse range of conditions, but most commonly it is used to treat anxiety, depression, chronic pain, disordered eating and low self esteem, among other issues. However, cognitive behavioral therapy may not be the ideal mode of treatment for individuals who have experienced developmental or acute trauma, and those who have chronic or recurring illnesses. In these cases changing thought patterns may not be enough to adequately address the patterns, belief systems, and developmental or shock trauma latent in the nervous system.
CBT is recommended as a primary mode of treatment for a variety of individuals, and is used in a variety of therapeutic settings, including inpatient and outpatient, short term and long term treatment. CBT is considered to be an evidence- based form of treatment, (or evidenced-based practice), simply meaning that the form of therapy is one that is based on peer-reviewed scientific evidence. It is for this reason that cognitive behavioral therapy is often suggested as a primary mode of treatment, especially in settings where offering an evidence-based practice is required by the health care organization where the treatment is being offered.
A more recent outgrowth of CBT is a specific trauma-informed mode of practice. Trauma informed CBT (TF-CBT) is a form of CBT specifically designed for treating children and adolescents who have experienced trauma. Like CBT, it is considered to be an evidence-based practice. TF-CBT is a short term, structured model (it can be as brief as 8 sessions). Although it is aimed at children who have experienced trauma, the secondary aim is helping parents and caregivers better support their children, as well as manage their own distress.
CBT vs Somatic Psychotherapy
Both CBT and TF-CBT are very structured approaches to treatment, and while effective at helping clients set goals and challenging distorted thinking, it is not the most appropriate treatment for all clients. CBT may not be as effective in addressing larger or more deep seated or latent issues, such as developmental trauma or understanding one’s family of origin. Still, most therapists who are well trained in cognitive behavioral therapy are able to use these skills in a flexible and creative way that allows for individual variations. Additionally, individuals who don’t respond well to structure may respond better to a more fluid and intuitive approach to treatment. Finally, because CBT is considered a “top down” approach, it relies heavily on verbal expression and cognitive functioning. For individuals who have experienced trauma in a pre-verbal or non-verbal state, again, CBT will be an inadequate approach.
Somatic psychotherapy uses a “bottom up” rather than “top down” approach. CBT is a classic example of a “top down” mode of therapy, working with cognitions and the “thinking brain” to create change. Top down approaches generally involve the body and the nervous system very minimally, if at all. Somatic psychotherapy instead works from the “bottom up”– reducing stress and anxiety physiologically, through changing the autonomic nervous system and discharging trauma.
Just as there are multiple modalities of cognitive therapy, there are multiple approaches to somatic therapies as well. Some of the most common modalities that a psychotherapist can be trained in include Somatic ExperiencingTM, Sensorimotor Psychotherapy, and the Hakomi Method. Although specific interventions with each of these therapies vary, their overall approach is to work with the body and the nervous system to both heal trauma and to use the body itself as a resource. For example, in Somatic ExperiencingTM a practitioner may not ask you to talk much at all about the specific trauma you experienced, but instead will ask that you observe and “track” physical sensation in your body in the present moment and when you are recalling a specific trauma. One important underlying theory in somatic approaches to therapy is that the body’s memory of the trauma is more important than the cognitive memory. When the body holds the memory of the trauma, people can get stuck in chronic fight, flight, freeze responses in the body which cause a variety of physical, mental, and relational issues to occur.
Renowned trauma Therapist Bessel Van Der Kolk describe the experience as follows: “Traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from themselves.”
This is why somatic psychotherapy has great potential to help traumatized individuals more than a cognitive approach. By starting to listen to the signals their body gives them and slowly beginning to create a sense of internal safety, clients can heal internally from their trauma.
There are many different forms of somatic psychotherapy and somatic modalities that a psychotherapist can utilize in their practice. One example is a modality called Somatic ExperiencingTM (a trauma healing modality that some somatic psychotherapists are trained in). After a client has learned to resource themselves (build body awareness, and notice the experience of receiving goodness, both internally and externally), a practitioner will help them to “titrate” their experience as a way of increasing one’s “window of tolerance” (a term used to describe the zone of arousal in which a person is able to function most effectively). Titration exposes a person to a small, tolerable amount of distress, as a way of allowing their nervous system to tolerate reminders of their trauma, without becoming triggered or overwhelmed. During this time, the client will be asked to pay close attention to their body, sensations, images, emotions and memories that emerge as they are exposed to these trauma reminders.
Finally, practitioners will use “pendulation” to help guide clients from a state of resourcefulness and low activation to a state of high activation and arousal. Moving back and forth between these two states several times allows the discharge of energy which has been held in the client’s body and nervous system since the trauma occurred. When this energy is discharged, clients may experience anxiety, shaking, or tearfulness, among other responses. Eventually this discharge will dissipate and allow the integration of new patterns in the nervous system in which it becomes easier to return to a relaxed, non-aroused state more easily. The eventual goal of Somatic Experiencing is to bring “completion” by literally discharging the energy stored in the body and nervous system as a result of the trauma. Trauma held in the body that remains unresolved can result in PTSD, depression, phobias, IBS and other digestive issues, chronic pain, and autoimmune disorders. Resolution of trauma has the potential to help other systems of the body to heal as a result of releasing the energy that held the body in a constant state of activation (fight, flight or freeze).
Although not all somatic psychotherapists are trained in CBT or “talk therapy,” many practitioners are able to combine both “top down” and “bottom up” approaches to best help clients achieve their goals. Additionally, somatic approaches are appropriate even for individuals who may not have experienced a specific trauma. Even exposure to long term stress can negatively impact multiple systems (nervous, hormonal, neurotransmitter, attachment systems, etc) in the body. By learning to direct one’s attention to internal sensations and develop new experiences of mastery and self-regulation, healing from a variety of both psychological and physiological wounds is possible.
New York: Viking. Van der Kolk, Bessel A. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking, 2014.
Payne, P., Levine, P. A., & Crane-Godreau, M. A. (2015). Somatic experiencing: using interoception and proprioception as core elements of trauma therapy. Frontiers in psychology, 6, 93. doi:10.3389/fpsyg.2015.00093