Psychodynamic body therapy

1. Introduction

Version followed: Kirsti Monsen's psychodynamic body therapy (psykodynamisk kroppsterapi), the Norwegian/Scandinavian method that grew out of Norwegian psychomotor physiotherapy (NPMP; Braatøy and Bülow-Hansen) and Kirsti and Jon Monsen's affect-consciousness model. This guide follows it as tested in Monsen & Monsen (2000), as taught at Karolinska Institutet from 1990, and as Swedish practitioners describe it (Lima de Faria & Moberg, 1994). Where the PBT sources are silent, it uses the NPMP base method as described by Bunkan (2001) and Gretland (2009). Monsen's own monographs and the full 2000 paper are not drawn on [uncertain]. This entry is not "psychodynamic body therapy" as a generic label for body-oriented psychoanalytic work (e.g. Sletvold's character-analytic tradition), and it is not Ventegodt's "clinical holistic medicine" [source: Rosendahl et al. 2021; de Faria & Moberg 1994].

What it is. It is an individual treatment, usually delivered by a physiotherapist with added training in clinical psychology and psychodynamic method. Each session combines body treatment (whole-body massage, stretching grips, and movements integrated with breathing) with psychodynamically oriented conversation. It grew out of NPMP because physiotherapists needed more psychodynamic competence for patients with psychosomatic pain-and-tension conditions. Kirsti Monsen formulated it, and in Sweden it was introduced as a 40-credit postgraduate course at Karolinska Institutet in 1990 [source: de Faria & Moberg 1994]. In the controlled trial with chronic pain patients, it was delivered individually, with about 33 one-hour sessions over roughly nine months, against a waiting list [source: Rosendahl et al. 2021, describing Monsen & Monsen 2000].

How change happens (the school's theory). Psyche and soma are treated as one system. Feelings act on the body through the autonomic nervous system, the muscles and breathing. In this model, early trauma tends to leave muscular slackness and reduced breathing. Later strain tends to produce active defence: the person tightens muscles and holds the breath to keep back anxiety, shame, grief or anger, and over time this can settle into chronic pain and tension. The sources cite Reich's view that every state of muscular tension carries the history of how it arose; this is the school's theory, not established physiology. Change is held to come from three things: deeper body contact, and greater flexibility and stability of posture, which raise the patient's tolerance for consciously carrying experiences they would otherwise suppress; putting the affects beneath the tension into words and linking them to life history; and new learning, so the patient expresses themselves directly instead of through tension and symptoms. Monsen frames psychic and psychosomatic disorder as "vitality on wrong paths" (her phrase, given in Swedish as vitalitet på avvägar), and treatment aims to strengthen the patient's "healthy core" [source: de Faria & Moberg 1994; Gyllensten & Nilsson Ovesson 1994, summarising Monsen]. Affect consciousness covers awareness of affect, tolerance of affect activation, nonverbal expression and verbal expression. The trial reported that change came with greater emotional awareness and more realistic views of significant others [source: de Faria & Moberg 1994; Affect consciousness (Wikipedia); Ekerholt et al. 2014, citing Monsen & Monsen 2000].

2. Framework

The PBT sources describe no fixed, named phases. They describe a process that unfolds "on the patient's terms" (de Faria & Moberg's phrase, in Swedish på patientens villkor) and whose pace depends on burden, motivation, capacity for reflection and psychosocial situation [source: de Faria & Moberg 1994]. The staging below is assembled from the PBT and NPMP sources; the phase labels and transition criteria are [synthesis].

Format. Individual sessions of one hour, weekly. In NPMP the hour runs roughly 45 minutes of treatment, about 10 minutes of rest and about 5 minutes of closing; frequency is later reduced to monthly or less [source: Bunkan 2001]. In PBT each session combines body work and conversation [source: de Faria & Moberg 1994]. Even milder cases typically need 20–40 sessions [source: de Faria & Moberg 1994]; the trial gave about 33 sessions over about 9 months [source: Rosendahl et al. 2021]. With traumatised patients in NPMP alongside psychotherapy, courses of 1–2 years are reported [source: Ekerholt et al. 2014].

Phase A: Assessment and test treatment (sessions 1 to about 3). Goals: a body examination (posture, breathing, movement, muscle consistency and resources), a history, a judgement of motivation and of how much strain the patient can carry, and a test treatment to see how the body and the person respond. Hypotheses are discussed with the patient afterwards [source: Bunkan 2001; Gretland 2009]. Move on when: the patient's response to the test treatment is tolerable, a working agreement exists, and there are no exclusion findings (see 5.8) [synthesis].

Phase B: Confirmation, body contact and stability. Goals: an accepting, affirming climate. Massage gives an experience of the body and of a boundary from the surroundings ("a first step in building a sense of self" in the source's account). Stabilising movement work centres the joints and the trunk. For patients carrying a heavy psychosocial or physical load, this phase can be most of the treatment, with little exploration of feelings [source: de Faria & Moberg 1994; Ekerholt et al. 2014]. Move on when: the patient can lie, sit and stand without marked distress or dissociation, reports some felt body contact, and can say "stop" or "ouch" during touch [synthesis].

Phase C: Opening breath and flexibility; affects into words. Goals: stretches are added to the massage grips to stimulate breathing; movements develop soft, flexible coordination; and the therapist helps the patient express and name the emotions that surface and see them in relation to their life history and present relationships [source: de Faria & Moberg 1994; Bunkan 2001]. Move on when: the patient links bodily states to feelings and situations of their own accord, and emotional reactions in session settle within the session [synthesis].

Phase D: Integration, generalisation and tapering. Goals: the patient applies the links between symptoms and psychological factors in daily life, symptom-focused thinking decreases, and session frequency is reduced [source: de Faria & Moberg 1994; Bunkan 2001]. End when: self-regulation in daily life is reported and maintained across longer gaps between sessions [synthesis].

3. Guiding principles

The patient's pace, not the therapist's. Do not push the process; lasting relief is said to depend on this. In practice, let the patient's reactions set the next step and slow down whenever you are in doubt [source: de Faria & Moberg 1994].
Mind and body are treated together in every session. Never split a session into "physio" and "talk"; let the conversation arise from the body work and return to it [source: de Faria & Moberg 1994; Bunkan 2001].
The whole body is treated, not the symptom. Treat the whole body every time, even when the patient presents with neck pain [source: Bunkan 2001].
Breathing is the continuous guide for dosing. Watch the breath during every grip and movement and adjust to it [source: Bunkan 2001].
Dose to the patient's capacity. The patient should not release more feeling than they can carry, or in Bunkan's image, should have "legs to stand on and a back to carry" (Norwegian: bein å stå på og rygg til å bære). If something hurts, reduce at once and invite a sigh [source: Bunkan 2001].
Stability before opening. With distressed or traumatised patients, tone down relaxation and work on centring the trunk and the lower-body joints first [source: Ekerholt et al. 2014; de Faria & Moberg 1994].
Confirmation. Create a climate in which the patient feels seen and confirmed, and accept their experiences as valid, repeatedly and predictably [source: de Faria & Moberg 1994; Ekerholt et al. 2014].
Careful, sensitive touch. Touch is individually adjusted, and it can evoke memories of earlier abuse. Ask before touching, go slowly, and treat sensitive regions such as the pelvis with particular care in trauma [source: de Faria & Moberg 1994; Gretland 2009].
The patient's own voice and boundaries are part of the treatment. Encourage the patient to say "ouch", to move out of the grip and to state wishes [source: Gretland 2009].
Affect consciousness as the psychological target. Aim to raise the patient's awareness, tolerance, nonverbal expression and verbal expression of affect, one affect at a time [source: Affect consciousness (Wikipedia); Ekerholt et al. 2014].
Healthy core and vitality. Work from the patient's resources: symptoms are seen as vitality on wrong paths. Name strengths and initiatives as well as tensions [source: Gyllensten & Nilsson Ovesson 1994].
Self-reflection over interpretation. Reflect back and ask what the patient thinks themselves before offering your own reading [source: Bunkan 2001].
Don't feed pain-focus. Avoid dwelling on pain, which may increase somatisation; ask about experience and change instead [source: Bunkan 2001; de Faria & Moberg 1994].
Generalisation. Help the patient carry what they discover into daily life [source: de Faria & Moberg 1994].
Predictable frame. Hold the same room, time and structure, and keep a long-term relationship [source: Bunkan 2001; Ekerholt et al. 2014].
Competence and scope. Practise touch only with specific training and supervision, and within what your licence and jurisdiction allow. In the Scandinavian tradition PBT is a physiotherapist's specialisation; psychologists usually work in tandem with such a therapist [source: de Faria & Moberg 1994; Ekerholt et al. 2014; jurisdiction note: synthesis].

4. Intervention inventory

The PBT sources name these body components: whole-body massage, stretches added to the massage grips, movements integrated with breathing, and psychodynamically oriented conversation [source: de Faria & Moberg 1994]. The detailed grips, positions, dosing rules and examination come from the NPMP base method that PBT builds on [source: Bunkan 2001; Gretland 2009; Ekerholt et al. 2014]. No published manual giving exact grip sequences, durations or repetition counts is cited; where these are missing, the guide says so [uncertain]. Example language is illustrative unless quoted.

Touch-consent protocol (applies to every technique marked "touch"). The sources supply the following: touch is careful and individually dosed; touch can evoke memories of earlier abuse; sensitive areas such as the pelvis need caution in trauma; and the patient is encouraged to say "ouch", to step out of the therapist's grip and to state wishes [source: de Faria & Moberg 1994; Gretland 2009]. The following steps are added [synthesis]:

Explain what you will do, where your hands will go and why, before the first session that includes touch.
Ask for explicit consent, and ask again for each new region or new grip.
Offer a no-touch alternative: the movement or breathing work alone, the patient's own hand, or work through clothing or a blanket.
Agree what the patient wears, and use towels or blankets so that only the area being worked on is uncovered.
Agree a stop signal (a word or a raised hand), and confirm it is honoured at once without discussion.
Check in during the work (e.g. "Still all right?" (illustrative)) and afterwards.
Never touch the breasts, genitals or the area around the genitals; sexual or genital touch is never part of any technique.
Record consent in the notes.
Touch requires specific training, supervision and a check of what your licence and jurisdiction allow.

4.1 Opening check-in conversation

Purpose / when: Every session. It links the past week to today's body work and shows the patient's state, so you can dose the session [source: Bunkan 2001; Gretland 2009].
Steps:
1. Sit with the patient for a few minutes before any body work.
2. Ask openly how they are; NPMP's standard opening is "How are you?" (Norwegian: "Hvordan har du det?") [source: Bunkan 2001].
3. Ask about the week, pain, sleep, medication changes and any events. Gretland's example also covers menstruation [source: Gretland 2009].
4. Ask what the patient noticed in their body or feelings after the last session [synthesis].
5. Decide today's dose: with a heavier load, choose stabilising work (4.7) rather than opening work [synthesis].
Example language (illustrative): "How have you been since last time? Did anything from our last session stay with you, in your body or otherwise?"
Watch for: Long, symptom-centred accounts (gently widen to experience and situations). Signs of acute crisis or risk call for a risk assessment before any body work (see 5.9).

4.2 Body examination and test treatment

Purpose / when: At the start of treatment, and repeated later to track change. It maps posture, breathing, movement, muscle consistency and resources; gauges distress; and gives hypotheses that you discuss with the patient [source: Bunkan 2001; Gretland 2009; Ekerholt et al. 2014].
Steps:
1. Take a history: the symptoms and how long they have lasted, any trauma or violence, and any psychotic episodes. Bunkan stresses knowing about long-standing pain and earlier psychotic breakthroughs [source: Bunkan 2001].
2. Observe standing posture and body axes. Look at the alignment of feet, knees, pelvis, trunk and head; for example, flexed knees pushing the head forward [source: Bunkan 2001].
3. Observe breathing at rest: where it moves, whether it is held or controlled, and how freely it goes between abdomen and chest [source: Bunkan 2001; Ekerholt et al. 2014].
4. Observe movement: the patient does simple active movements while you note range, coordination and how the breath responds [source: Bunkan 2001].
5. Palpate muscle consistency (touch; consent protocol above). Note resistance to pressure and habitual unneeded contraction [source: Bunkan 2001].
6. Give a short test treatment: a little massage and movement. Watch whether the breath releases and whether the patient tolerates it [source: Bunkan 2001].
7. Note extreme findings: numbness, trembling, nausea, inability to lie supine or to feel parts of the body. These signal high distress and call for a gentler plan [source: Ekerholt et al. 2014].
8. Discuss your impressions with the patient as hypotheses, not verdicts, and agree aims [source: Gretland 2009].
Standardised options: NPMP has published examination instruments: the Global Physiotherapy Examination, the Resource-Oriented Body Examination and the Comprehensive Body Examination [source: Bunkan 2001]. These require training. Their items are not reproduced here.
Example language (illustrative): "I noticed your breath stays high in the chest and your shoulders stay up even lying down. That's an observation, not a diagnosis. Does that fit how you feel?"
Watch for: Large deviations from the norm on examination are, in NPMP, usually a reason not to treat, because of chronicity or the risk of psychotic breakthrough [source: Bunkan 2001] (see 5.8).

4.3 Positioning and comfort set-up

Purpose / when: Before massage and movement, every session. Gives safety and lets you vary the work [source: Gretland 2009].
Steps:
1. Choose a starting position. The standard NPMP positions are sitting on a stool, standing, long-sitting on a bench, lying prone and lying supine [source: Gretland 2009].
2. Support with pillows and cover with a blanket [source: Gretland 2009].
3. If the patient cannot lie supine, or becomes anxious lying down, start sitting or side-lying instead [synthesis; inability to lie supine is noted by Ekerholt et al. 2014].
4. Ask whether the position is comfortable, and whether the patient wants the door and the room arranged in a particular way [synthesis].
Example language (illustrative): "Would you rather start sitting or lying today? Tell me if you'd like another pillow or the blanket."
Watch for: Bracing, eyes fixed on the door, or the breath held when lying down. These are signs to change position.

4.4 Whole-body massage (touch)

Purpose / when: The main body treatment from the first phase onward. It gives an experience of the body and of the body's boundary against the surroundings, and is described as a possible first step in building a sense of self. It also loosens tension so that breathing can deepen [source: de Faria & Moberg 1994; Bunkan 2001].
Steps:
1. Run the consent protocol (above).
2. With the patient in a supported position (4.3), work over the whole body, not just the painful region [source: Bunkan 2001].
3. Use a sensitive hand, and adjust the pressure and tempo to the individual [source: de Faria & Moberg 1994]. NPMP massage is mostly experienced as pleasant [source: Bunkan 2001].
4. Watch the breath continuously. If a grip brings pain or holding of the breath, lighten it at once and invite a sigh or an out-breath [source: Bunkan 2001].
5. In NPMP, massage takes roughly half of the treatment time; the other half is movement [source: Bunkan 2001].
6. Pause for short exchanges about what the patient notices (4.10) [source: Gretland 2009].
7. Close the massage with a rest period (4.14).
Duration: The sources give no fixed duration or order of grips; this is [uncertain].
Example language (illustrative): "I'll start at your back and work down to your legs. Let me know if the pressure is too much or too little, and you can tell me to stop at any time."
Watch for: A deeper, spontaneous breath, warmth and softening suggest it is working. Holding the breath, flinching, going "far away" or sudden silence call for you to stop, re-orient and ask. Touch may evoke memories of abuse [source: de Faria & Moberg 1994; Ekerholt et al. 2014].
Contraindications for deeper grips [synthesis]: recent injury, surgery or fracture; skin disease; thrombosis or bleeding disorders; severe osteoporosis; local inflammation; acute fever. Check pregnancy and cardiovascular conditions with the referring doctor.

4.5 Stretching grips to stimulate breathing (touch)

Purpose / when: Added to massage once the patient tolerates it, typically after the initial confirmation phase. It stimulates breathing and reconnects breath with muscle [source: de Faria & Moberg 1994].
Steps:
1. Run the consent protocol, naming the region.
2. Combine gentle muscle stretches with the massage grips [source: de Faria & Moberg 1994].
3. Two named examples in the sources are a stretch of the epigastric muscles (below the breastbone) to stimulate breathing [source: Bunkan 2001], and stretching over the sacrum and back to promote low ("basal") breathing [source: Gretland 2009].
4. Keep the stretch gentle and follow the breath: let the patient breathe out as you release [synthesis].
5. Watch for the response NPMP values: a marked in-breath and a passive out-breath, possibly with a sigh or sound [source: Bunkan 2001].
Example language (illustrative): "I'm going to place my hand just under your ribs and give a slow, gentle stretch. Just let your breath do what it wants."
Watch for: Spontaneous yawning, sighing, laughter, tears or more saliva can follow as the body loosens. NPMP treats a full yawn as an important sign that cannot be produced by instruction [source: Bunkan 2001]. Do not push for it. Temporary visceral reactions (pressure at the diaphragm, urgency, changed secretions) can occur; tell the patient in advance and keep the referring doctor informed [source: Bunkan 2001].
Contraindications: respiratory illness, abdominal surgery or hernia, pregnancy, and cardiovascular disease without medical clearance [synthesis].

4.6 Breath guidance: passive out-breath and the invited sigh

Purpose / when: Throughout, as the dosing guide and as a direct aid to letting go. Relaxation work centres on passive respiration [source: Bunkan 2001; Ekerholt et al. 2014].
Steps:
1. Observe rather than instruct a breathing pattern; the breath is read as the body's running answer to the treatment [source: Bunkan 2001].
2. When a grip or movement brings pain or holding, reduce it and invite a sigh, then let the out-breath go passively [source: Bunkan 2001].
3. Do not instruct deep or forced breathing: the method seeks freer breath, not intensified breath [synthesis, consistent with Bunkan 2001].
4. With very distressed patients, give only small doses of attention to sensation (e.g. one breath, then talk) [source: Ekerholt et al. 2014].
Example language (illustrative): "Let a sigh come if it wants, and let the air just fall out."
Watch for: Dizziness or tingling suggests over-breathing; stop, return to normal breathing, and sit the patient up. Rising panic calls for orienting to the room and switching to stabilising work (4.7).

4.7 Stabilising movement work and grounding

Purpose / when: First-line work for heavily burdened, traumatised or highly distressed patients, and a base for everyone. It gives "bodily anchoring" that can steady emotional reactions [source: Ekerholt et al. 2014; de Faria & Moberg 1994].
Steps:
1. Tone down relaxation and massage. Work instead on centring the trunk and the lower-body joints (feet, knees, hips) [source: Ekerholt et al. 2014].
2. Use active movements that emphasise good centring in every joint and avoid habitual end-positions such as locked knees [source: Bunkan 2001].
3. In standing: help the patient find the feet under the body, soften the knees, let the pelvis and trunk settle over them, and notice the floor's support [synthesis built on Bunkan 2001's centring principle].
4. Train soft, flexible coordination in the legs and standing muscles [source: de Faria & Moberg 1994].
5. Staging: where examination findings are marked, aim for stability and body control. Where they are moderate, aim for flexibility, body awareness and breath retraining [source: Bunkan 2001].
Example language (illustrative): "Feel both feet. Let the knees be a little soft. Where do you feel the floor holding you?"
Watch for: The patient looks steadier and more present, the breath is calmer, and they can talk about difficult material while staying in contact. Collapsing posture or spacing out mean you should shorten the work, open the eyes and orient.

4.8 Movement integrated with breathing

Purpose / when: From the middle phase onward. It develops flexibility and deeper inhalation, and connects movement with breath [source: de Faria & Moberg 1994; Bunkan 2001].
Steps:
1. Choose gentle movements and stretches suited to the findings: rolling, bending and stretching in lying, sitting or standing positions [source: Gretland 2009; specific choice: synthesis].
2. Instruct the movement and repeat it until a bodily change appears: the breath, tone or warmth changes [source: Gretland 2009].
3. Then ask about the patient's experience (4.10) [source: Gretland 2009].
4. Keep the movement centred in the joints, and let the breath follow the movement rather than being forced to it [source: Bunkan 2001; synthesis].
Repetitions: The sources give no counts [uncertain].
Example language (illustrative): "Slowly lengthen the arm along the bench and let it come back. Again, a few times. What do you notice now?"
Watch for: The movement becomes softer, the breath reaches lower, the patient begins movements themselves. Jerky or rigid repetition means the movement is too large or too fast; scale it down.

4.9 Pain grip and "marking" (NPMP technique; use with great caution, touch)

Purpose / when: In NPMP, a brief, quickly fading pain stimulus shows the patient's habitual reaction (clenching the jaw, holding the breath, stiffening). The patient then learns to release the reaction, and later to move towards the stimulus and stretch instead of withdrawing, which NPMP calls marking and links to self-assertion [source: Bunkan 2001]. Whether PBT uses this grip routinely is not stated in the PBT sources [uncertain].
Steps:
1. Run the consent protocol, and explain explicitly that this grip is briefly uncomfortable.
2. Apply a brief pressure stimulus that fades quickly; the sources give no site or intensity [uncertain].
3. Observe the reaction.
4. NPMP regards a strong in-breath and an emotional sound on the out-breath as the "adequate" response. Encourage the patient to release the motor reaction, for example by moving away [source: Bunkan 2001].
5. Later in treatment, invite marking: the patient moves towards the pressure and stretches [source: Bunkan 2001].
Example language (illustrative): "This one may sting for a second. Notice what your body does. It's fine to say 'ouch' or pull away."
Watch for / risk: Omit it for anxious patients, people who have experienced violence, and anyone who reacts negatively [source: Bunkan 2001]. For trauma survivors, the safer equivalents of self-assertion are the boundary-setting work in 4.13 and stabilisation in 4.7 [synthesis].

4.10 Exploring bodily experience in words

Purpose / when: Woven through all the body work. It turns sensations into words, which is described as an early step towards emotional and cognitive integration [source: Ekerholt et al. 2014; Gretland 2009].
Steps:
1. After a change in breath, tone or movement, ask an open question; Gretland's is "How is it now?" (Norwegian: "Hvordan er det nå?") [source: Gretland 2009].
2. Offer a closed question built on your observation, to help a patient who has few words for the body [source: Gretland 2009].
3. Ask them to say more [source: Gretland 2009].
4. Use the patient's own metaphors and explore their meaning. Gretland's example is a painful muscle named the "crutch muscle" [source: Gretland 2009].
5. Reflect back, or ask what the patient thinks themselves (Norwegian: "Hva tror du selv?") [source: Bunkan 2001].
6. Keep the exchanges short and frequent, with only brief silences, so the patient stays an active participant [source: Gretland 2009].
Example language (illustrative): "Your breath went lower just then. Did you notice anything? ... If that tight spot could speak, what would it say?"
Watch for: The patient describes sensations more precisely and in more nuance. Constant talking that never touches feeling is a sign of intellectualising (see 5.4).

4.11 Affect identification and verbalisation (affect-consciousness work)

Purpose / when: From the middle phase onward, or earlier if feelings arise on their own. It helps the patient express the emotions beneath muscular tension and put them into words [source: de Faria & Moberg 1994]. It also builds affect consciousness: awareness of an affect, tolerance of its activation, nonverbal expression and verbal expression [source: Affect consciousness (Wikipedia); Ekerholt et al. 2014].
Steps:
1. When body work produces a shift (tears, a held breath, a clenched fist, warmth), pause and name the bodily event neutrally [synthesis].
2. Ask which feeling might be there. The affect-consciousness model distinguishes eleven categories: interest, joy, fear, anger, shame, contempt, disgust, sadness, envy/jealousy, guilt, and tenderness/care [source: Affect consciousness (Wikipedia)]. Help the patient tell apart the feelings that are near each other [synthesis].
3. Explore the four aspects in turn [synthesis built on the model's four aspects]:
  - Awareness: "Where do you notice it?"
  - Tolerance: "Can you stay with it for a few breaths?"
  - Nonverbal expression: what the face, voice and posture want to do.
  - Verbal expression: saying it in words to you.
4. Dose it. If the affect floods the patient, return to stabilising work (4.7) [source: Ekerholt et al. 2014; Bunkan 2001].
5. Accept and confirm whatever feeling appears [source: de Faria & Moberg 1994].
Example language (illustrative): "Your jaw tightened when you mentioned your father. If there's a feeling in that, what might it be: anger, sadness, something else? You don't need to be sure."
Watch for: The patient tolerates more feeling while staying present, and names feelings more precisely. Mounting shame calls for you to slow down and normalise.

4.12 Linking body and feeling to life history and present relationships

Purpose / when: Once affects can be named and tolerated. It helps the patient see present reactions in relation to their life history and understand them from a psychodynamic perspective, and it helps them form more realistic views of significant others, usually parents [source: de Faria & Moberg 1994].
Steps:
1. Ask when the patient has felt this bodily state or feeling before [synthesis].
2. Follow what they bring; do not hunt for trauma. NPMP-based supportive work explicitly aims at support and regulation rather than uncovering [source: Gretland 2009].
3. Offer tentative links between the tension, the feeling and situations, past and present, and invite the patient's own view [source: de Faria & Moberg 1994; Bunkan 2001].
4. Explore current relationships in which the pattern recurs [synthesis].
Example language (illustrative): "You've said your shoulders go up whenever you have to say no. I wonder whether saying no felt risky somewhere earlier in your life. What do you think?"
Watch for: The patient begins to make links themselves and gives more balanced accounts of key people. If memories fragment or intrude, stop linking and stabilise (see 5.3).

4.13 Boundary and self-assertion practice within touch

Purpose / when: From the first touch onward, and especially with patients whose boundaries have been violated. It restores self-respect and boundaries ("rehabilitation") and widens habitual patterns of reaction ("rehabituation") [source: Gretland 2009].
Steps:
1. Tell the patient explicitly that they may say "ouch", step out of your grip, ask for less or more, or ask to stop [source: Gretland 2009].
2. During touch, invite them to use this: "Show me with your body if you want my hand to move" (illustrative).
3. When they set a limit, comply at once and acknowledge the act of setting it [synthesis].
4. Talk afterwards about how it was to set a limit [synthesis].
Example language (illustrative): "You just moved your arm away. Good, that's exactly what I want you to feel free to do. What was that like?"
Watch for: Patients who never object may be complying (see 5.6).

4.14 Rest period and closing

Purpose / when: At the end of every session. It lets the effects settle and returns the patient to everyday functioning [source: Bunkan 2001; Gretland 2009].
Steps:
1. After body work, give a rest of about 10 minutes, lying under a blanket [source: Bunkan 2001].
2. Close in standing [source: Gretland 2009]: feet on the floor, eyes open, a few movements [synthesis].
3. Spend about 5 minutes closing in conversation [source: Bunkan 2001]: what the patient takes with them, anything unfinished, and how they will get home [synthesis].
4. Warn the patient of possible after-reactions (tiredness, emotions, temporary visceral reactions), and agree what to do if they occur [source: Bunkan 2001; synthesis].
Example language (illustrative): "Let's come to standing. Feel your feet. What will you take with you from today, and is there anything you need before you go?"
Watch for: A patient who is spacey, tearful or unsteady at the door needs more time to orient before leaving.

4.15 Generalisation to daily life

Purpose / when: Middle and late phases. It helps the patient recognise links between physical symptoms and psychological factors and use them in daily life [source: de Faria & Moberg 1994].
Steps:
1. Ask the patient to notice, between sessions, the moments when the familiar tension or holding of breath appears [synthesis].
2. Ask which feeling or situation went with it [synthesis].
3. Ask what they could do differently: soften the knees, let a sigh go, or say what they feel [synthesis].
4. Review it at the next check-in (4.1).
Note: No formal homework protocol was found in the sources [uncertain].
Example language (illustrative): "This week, just notice when your shoulders rise. What's happening at that moment? We'll look at it together next time."
Watch for: Less symptom-focused thinking, more self-confidence and fewer limits on daily life were reported in a PBT outpatient study [source: de Faria & Moberg 1994].

4.16 Supportive mode for heavily burdened patients

Purpose / when: For patients under high psychosocial or physical strain, or with low capacity for reflection, from the outset. It shifts the treatment to confirmation, body contact and stability, with little exploration of feelings [source: de Faria & Moberg 1994; Gretland 2009].
Steps:
1. Prioritise predictable sessions, gentle massage and stabilising work (4.4, 4.7) [source: de Faria & Moberg 1994; Ekerholt et al. 2014].
2. Keep the talk practical and validating [source: de Faria & Moberg 1994].
3. Omit pain grips and strong stretches [source: Bunkan 2001].
4. Review whether, and when, more exploratory work becomes possible [synthesis].
Example language (illustrative): "For now, we'll concentrate on helping your body feel a bit safer and steadier. We don't need to dig into anything."
Watch for: The patient is calmer and steadier and comes regularly. Do not mistake this mode for failure.

4.17 Affect Consciousness Interview (assessment option)

Purpose / when: At baseline and at follow-up, to map affect integration. Affect consciousness was a central concept in the PBT trial [source: Ekerholt et al. 2014, citing Monsen & Monsen 2000]. Whether the trial used the interview itself is not confirmed in the sources [uncertain].
What it is: A semi-structured interview developed in Oslo by Monsen and colleagues. It rates each of eleven affect categories on four aspects (awareness, tolerance, nonverbal and verbal expression) using nine-point scales [source: Affect consciousness (Wikipedia)].
Steps: Use it only after formal training. The items and scoring are not reproduced here.
Watch for: In open-ended therapy, low affect consciousness at the start predicted greater change, so a low score is not a reason to exclude the patient [source: Affect consciousness (Wikipedia)].

4.18 Coordination with a concurrent psychotherapist

Purpose / when: When the patient is also in psychotherapy (common when the body therapist is a physiotherapist). Concurrent, reciprocal therapies with regular meetings between the therapists are described for NPMP with dynamic psychotherapy [source: Ekerholt et al. 2014].
Steps:
1. Get the patient's written consent for the two therapists to communicate [synthesis].
2. Tell the patient when the therapists meet [source: Ekerholt et al. 2014].
3. Agree who handles crises [synthesis].
4. Check whether the patient can manage two therapists. If not, do not start the collaboration, or stop it [source: Ekerholt et al. 2014].
Example language (illustrative): "Your psychologist and I would like to meet now and then to coordinate. I'll always tell you when we have, and what we talked about."
Watch for: Splitting (one therapist idealised, the other devalued), or material shared in one setting being avoided in the other.

5. Handling problems

The PBT sources name only a few difficulties: suppressed feelings are hard to express; touch can evoke memories of abuse; treatment is long and depends on motivation and circumstances; and heavily burdened patients may manage only confirmation and stability [source: de Faria & Moberg 1994]. The NPMP sources add overdosing, dissociation, intellectualising, re-traumatisation and the burden of parallel therapy [source: Bunkan 2001; Ekerholt et al. 2014]. Everything else below is [synthesis].

5.1 Stuck: no change after many sessions

Expect slowness. Even milder cases typically need 20–40 sessions [source: de Faria & Moberg 1994].
Re-examine the body (4.2) and compare with baseline. Change may be showing in breath or posture before the patient reports it [synthesis].
Check whether you are over-focusing on pain; turn the conversation towards experience, feelings and situations [source: Bunkan 2001].
Check the dose. Too much opening can provoke new armouring, and too little gives no stimulus. Move one step towards stability or towards flexibility, according to the findings [source: Bunkan 2001; Ekerholt et al. 2014; synthesis].
Review the psychosocial load. If it is high, deliberately switch to supportive mode (4.16) [source: de Faria & Moberg 1994].
Take the case to supervision, and consider adding psychotherapy or a medical review [synthesis].

5.2 Resistance: tension, guardedness, "nothing happens in my body"

In this school's theory, muscular holding is itself the defence. Do not try to break it; work around it with gentle massage and movement, and make room for it [source: de Faria & Moberg 1994; Bunkan 2001].
Name what you see without demanding a feeling: "Your breath held there; nothing more needs to happen" (illustrative) [synthesis].
Respect a "no" to touch completely, and offer movement-only work [synthesis].
Ask about earlier experiences of being touched or examined, which may explain the guardedness [synthesis; touch-evoked memories noted by de Faria & Moberg 1994].

5.3 Overwhelm, flooding, dissociation

More attention to the body can frighten patients, and they may dissociate when asked to focus on their bodies or their history [source: Ekerholt et al. 2014].
Signs: a fixed gaze, a flat voice, numbness, trembling, nausea, slow responses, losing the thread [source: Ekerholt et al. 2014; synthesis].
Responses:
1. Stop the touch [synthesis].
2. Help the patient sit up, open the eyes and orient to the room, and use the voice and the patient's name [synthesis].
3. Do stabilising work: feet on the floor, centring (4.7) [source: Ekerholt et al. 2014].
4. Reduce the dose at the next session [source: Bunkan 2001].
Prevention: give only small doses of attention to sensation, and avoid relaxation-heavy work with highly distressed patients [source: Ekerholt et al. 2014]. Be careful near the pelvis and other sensitive areas when there is trauma [source: Gretland 2009].
Risk: re-traumatisation can produce stronger defensive armouring [source: Ekerholt et al. 2014]. If the patient has severe dissociation or an unstabilised trauma disorder, refer for trauma-focused stabilisation before or alongside body work [synthesis].

5.4 Intellectualising ("talking and talking")

This is described as a way of avoiding emotional engagement [source: Ekerholt et al. 2014].
Bring the patient back gently to the body: "Pause. What do you notice in your chest while you tell me this?" (illustrative) [synthesis].
Shorten the verbal exchanges and add more movement [synthesis].

5.5 Non-adherence: missed sessions, no practice between sessions

Treatment depends on motivation [source: de Faria & Moberg 1994].
Explore the missed sessions as possible over-dosing: did the last session stir too much? [synthesis]
Keep the frame predictable [source: Bunkan 2001].
Make between-session tasks smaller (4.15) [synthesis].

5.6 Compliance masquerading as cooperation

Patients with boundary injuries may endure touch without saying anything [synthesis; boundary work from Gretland 2009].
Watch the breath and the body rather than the words. Repeat the permission to say "ouch" or to move away (4.13) [source: Gretland 2009].
Ask directly after a session: "Was there anything you put up with today?" (illustrative) [synthesis].

5.7 Ruptures, transference and boundary problems

Touch intensifies transference: longing, dependency, fear, anger or erotic feelings can attach to the therapist [synthesis; body-based transference noted in Rosendahl et al. 2021].
Name and explore the rupture in words, take your share of responsibility (for example for a grip that went too far), and adjust [synthesis].
If sexualised feelings arise, keep firm boundaries: stop that kind of touch, discuss it in supervision, and keep the work verbal and movement-based [synthesis].
Keep the room, the clothing level and the touch regions fixed and documented [synthesis].
In parallel treatment, watch for splitting between the therapists, and stop the parallel work if the patient cannot manage it [source: Ekerholt et al. 2014].

5.8 Selection, contraindications and medical safety

From the NPMP source: large deviations from the norm on examination usually rule out treatment because of chronicity or the risk of psychotic breakthrough. Know any history of psychosis. Take extra caution with anxious patients and survivors of violence, and leave out the pain grip for them [source: Bunkan 2001].
Added screening [synthesis]: active psychosis; severe dissociation; active suicidality; recent trauma without stabilisation; acute medical conditions. For stretches and deeper grips, also check pregnancy, cardiovascular or respiratory illness, epilepsy, recent injury or surgery, and bleeding risk.
Get medical assessment of the pain or other symptoms before starting, and keep the referring doctor informed of temporary visceral reactions [source: Bunkan 2001].
PBT is not a treatment for physical disease. Unexplained or changing physical symptoms need medical review [synthesis].

5.9 Suicidality and acute crisis

If the check-in reveals hopelessness, self-harm or suicidal thoughts, pause the body work [synthesis].
Do a standard risk assessment: ideation, intent, plan, history, protective factors [synthesis].
Make a safety plan, and use lethal-means counselling (secure or remove means) [synthesis].
Involve the responsible clinician or physician if you are a physiotherapist, and follow local emergency pathways [synthesis].
Resume body work only once the patient is stable [synthesis].

5.10 Strong releases: crying, shaking, laughter, yawning

NPMP sees these as possible signs of loosening and does not induce them [source: Bunkan 2001].
Allow them, stay calm and present, and then help the patient put words to the experience (4.10–4.11) [source: de Faria & Moberg 1994; Bunkan 2001].
If a release escalates beyond what the patient can carry, switch to stabilisation (4.7) [source: Bunkan 2001; Ekerholt et al. 2014].

Sources

Sources:

Further reading (not drawn on) [uncertain]:

Monsen, J. T., & Monsen, K. (2000). Chronic pain and psychodynamic body therapy: A controlled outcome study. Psychotherapy, 37, 257–269. Known only through Rosendahl et al. 2021, Ekerholt et al. 2014 and de Faria & Moberg 1994.
Monsen, J. T., & Monsen, K. (1999). Affects and affect consciousness: A psychotherapy model integrating Silvan Tomkins' affect- and script theory within the framework of self psychology. In A. Goldberg (Ed.), Progress in Self Psychology, 15, 287–306. Analytic Press.
Monsen, J. T., Monsen, K., Solbakken, O. A., & Hansen, R. S. (2008). The Affect Consciousness Interview (ACI) and the Affect Consciousness Scales (ACS). University of Oslo.
Kirsti Monsen's own monograph(s) on psychodynamic body therapy, cited as references 11–12 in Gyllensten & Nilsson Ovesson 1994: not identified or drawn on.
Gretland, A. (2007). Den relasjonelle kroppen. The source of the case in Gretland 2009.

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