Somatic Therapy in Trauma Therapy

The Role of Somatic Therapies in Complex Trauma Treatment: A Review of Benefits, Evidence, and Future Directions

I. Understanding Complex Trauma and the Somatic Healing Paradigm

A. Defining Complex Trauma (C-PTSD): Beyond Single-Incident PTSD

Complex Post-Traumatic Stress Disorder (C-PTSD) describes the multifaceted consequences of prolonged, repeated interpersonal trauma, often originating in childhood or other situations where escape is difficult or impossible. Unlike single-incident Post-Traumatic Stress Disorder (PTSD), which can arise from an isolated traumatic event, C-PTSD encompasses a broader spectrum of psychological and physiological disturbances. The pervasive nature of complex trauma, frequently involving sustained abuse or neglect within interpersonal relationships, means that its impact extends beyond the fear-based responses typically associated with PTSD, deeply affecting an individual's development, sense of self, and ability to connect with others.

Key distinguishing features of C-PTSD, often referred to as Disturbances in Self-Organization (DSO), include significant difficulties in several core areas of functioning. Firstly, emotion regulation is commonly impaired, manifesting as intense or overwhelming emotional reactions to stressors, difficulty modulating anger, engaging in self-destructive behaviors as a means of coping, or experiencing emotional numbing and an inability to feel. Secondly, C-PTSD involves profound disturbances in self-concept. Individuals may harbor persistent feelings of shame, guilt, failure, and worthlessness, often internalizing the abuser's negative messages or blaming themselves for the trauma endured. This can lead to a deeply diminished and fragmented sense of self. Thirdly, interpersonal difficulties are a hallmark of C-PTSD. Survivors may struggle with forming and maintaining healthy relationships, experience profound issues with trust, withdraw socially, or feel a pervasive sense of isolation and alienation from others. Finally, dissociation is a common coping mechanism, where individuals may feel detached from their thoughts, feelings, body, memories, or the surrounding environment as a way to survive overwhelming experiences.

The International Classification of Diseases, 11th Revision (ICD-11), officially recognizes C-PTSD as a distinct diagnostic entity. According to the ICD-11, a diagnosis of C-PTSD requires the presence of core PTSD symptoms—namely re-experiencing the trauma in the present (e.g., flashbacks, nightmares), avoidance of traumatic reminders, and a persistent sense of current threat (e.g., hypervigilance, exaggerated startle response)—in addition to the three categories of DSO: problems in affect regulation, negative self-concept, and disturbances in relationships.

The distinction between PTSD and C-PTSD is not merely an academic exercise; it carries profound implications for treatment selection, therapeutic approach, and prognosis. The roots of C-PTSD in prolonged, often developmental, interpersonal trauma mean that the very systems designed for human connection, safety, and regulation—such as the nervous system and attachment patterns—can become fundamentally disrupted and sources of ongoing dysregulation and perceived threat. Consequently, therapeutic interventions for C-PTSD must often go beyond addressing fear conditioning, which is a primary focus in some PTSD treatments. They need to address these foundational disruptions in self-perception, emotional experience, relational capacity, and bodily integrity. This is where somatic therapies, which work directly with the embodied experience of trauma and its impact on the nervous system, are increasingly recognized for their potential contributions.

B. The Rationale for Somatic Intervention: The Body's Role in Trauma and Recovery

The rationale for employing somatic interventions in the treatment of complex trauma is grounded in the understanding of its profound neurobiological impact and the way traumatic experiences become lodged within the body. Complex trauma often leads to chronic dysregulation of the autonomic nervous system (ANS), manifesting as persistent states of hyperarousal (a dominant fight-or-flight response) or hypoarousal (a state of freeze, collapse, or shutdown).1 This dysregulation is not simply a psychological state but a physiological reality that affects an individual's capacity to feel safe, manage stress, and engage with the world. Polyvagal theory, developed by Stephen Porges, is frequently invoked in somatic circles to explain how traumatic experiences can shift the nervous system out of a state of social engagement (mediated by the ventral vagal complex) and into defensive states governed by the sympathetic nervous system or the dorsal vagal complex.4 Somatic therapies aim to restore ANS regulation, increase an individual's "window of tolerance" for distressing sensations and emotions, and thereby facilitate a return to a state of physiological and psychological equilibrium.2 The Shahri paper on Bioenergetic Analysis, for example, links developmental trauma to character structure and ANS dysregulation, referencing Polyvagal theory in its discussion of shame and physiological states.4 Similarly, Fisher's work on Sensorimotor Psychotherapy emphasizes modulating autonomic arousal and restoring states of calm as key therapeutic goals.2

Central to somatic approaches is the concept of embodied trauma: the understanding that trauma is not merely a memory or an emotional wound, but an experience that becomes deeply imprinted on the body.1 Traumatic experiences, especially those that are overwhelming or prolonged, can result in "stuck" survival energy, chronic muscular tension, fragmented sensory information, and deeply ingrained procedural memories (e.g., habitual postures, gestures, or movement patterns associated with defense).2 The body, in essence, "keeps the score" 7, and healing necessitates accessing, processing, and releasing these somatic imprints. For instance, Bioenergetic Analysis posits that trauma can lead to feelings of numbness, dissociation, and a profound disconnection from one's own body.3 The Kaplan dissertation on Body-Centred Psychotherapy (BcP) further elaborates this, conceptualizing trauma as energetic impulses that become frozen in the nervous system without discharge, with the body holding the entirety of its history.5

This understanding of embodied trauma underscores the limitations of purely cognitive approaches for complex trauma. While cognitive therapies offer valuable tools for restructuring thoughts and beliefs, they may be insufficient when traumatic memories are stored primarily non-verbally and procedurally within the body, effectively bypassing higher-level cognitive processing.5 Accessing and resolving these implicit, body-based memories often requires more than cognitive reframing or verbal narration. Individuals with complex trauma may also struggle with the cognitive demands of these therapies due to persistent dysregulation, dissociation, or difficulties with concentration and memory stemming from the trauma itself. As Corrigan and Hull noted, working memory and cognitive solution areas of the neocortex often fail to influence the sensorimotor sequences programmed by trauma.7 Similarly, Kaplan's work suggests that verbal dialogue is limited, and language itself can function as a defense.5

The emphasis on "bottom-up" processing in somatic therapies directly challenges the traditional "top-down" dominance in many psychotherapeutic models. This suggests a necessary paradigm shift towards recognizing that cognitive understanding alone is often insufficient for healing deeply embodied trauma. If trauma is fundamentally stored at a somatic and autonomic level, bypassing or impairing full neocortical processing, then therapeutic approaches that directly engage these subcortical and bodily systems become essential for comprehensive healing. The body's wisdom and its capacity for self-regulation must be engaged directly, not as an adjunct to cognitive work, but as a primary pathway to resolution. This does not negate the value of cognitive insights but suggests that for profound and lasting change in complex trauma, interventions must also address the physiological and sensory legacy of the traumatic experiences. True integration, therefore, likely requires a skillful blending of both bottom-up and top-down processing.

II. Core Principles and Mechanisms of Somatic Therapies in Complex Trauma Treatment

Somatic therapies operate on a distinct set of principles aimed at addressing the deeply embodied nature of complex trauma. These principles guide interventions that often differ significantly from traditional talk therapies, focusing on the body's innate capacity for healing and regulation.

A. Bottom-Up Processing: Accessing and Releasing Stored Trauma

A foundational principle of most somatic therapies is the emphasis on "bottom-up" processing.7 Unlike "top-down" approaches that primarily engage cognitive functions (thoughts, beliefs, narratives) to influence emotional and physiological states, bottom-up processing begins with the direct experience of the body. This involves attending to bodily sensations, movements, postures, and autonomic nervous system responses as primary sources of information and avenues for therapeutic change.5 The rationale is that traumatic experiences, particularly those that are overwhelming or occur pre-verbally, are encoded in subcortical brain regions (e.g., brainstem, limbic system) and manifest as physiological dysregulation and sensorimotor patterns, often before they are accessible to conscious thought or verbal articulation.5

Somatic Experiencing, for example, posits that trauma symptoms arise from a dysregulated nervous system due to incomplete biological survival responses, and therapy focuses on facilitating the completion of these responses through attention to bodily sensations. Sensorimotor Psychotherapy explicitly works with "procedurally learned patterns evoked by recollection," observing the client's emotional and bodily responses to understand how experiences have been encoded as non-verbal, implicit memories.2 The MDMA-assisted therapy framework also incorporates "bottom-up" approaches to directly target physiological and sensory aspects of PTSD.9 By prioritizing the "felt sense" and the body's innate wisdom, these therapies aim to access and process traumatic material that may be unavailable through purely cognitive or narrative means, thereby facilitating the release of stored traumatic energy and the restoration of self-regulatory capacities. This approach acknowledges that the body is not merely a passive recipient of traumatic imprints but an active participant in both the storage and, crucially, the resolution of trauma. Engaging the body's innate healing capacities through bottom-up processing is therefore seen as essential for comprehensive trauma recovery.

B. Developing Interoceptive Awareness and Body Literacy

A core component of somatic therapies is the cultivation of interoceptive awareness, which is the ability to sense, interpret, and consciously register internal bodily signals.2 For individuals who have experienced complex trauma, interoceptive pathways are often disrupted. They may be disconnected from their bodily sensations, experience their bodies as alien or unsafe, or misinterpret internal cues, leading to heightened anxiety or emotional dysregulation. Somatic practices such as body scanning, mindful tracking of sensations (e.g., temperature, tension, tingling, pressure), and learning to differentiate between various bodily states are employed to enhance this internal sensory acuity. This process of developing "body literacy" helps clients to better understand their own internal landscape, including the physiological manifestations of their trauma responses.

Sensorimotor Psychotherapy, for instance, emphasizes helping clients become mindful of the persistent physical, cognitive, and emotional responses evoked by trauma-related stimuli, fostering curiosity about how trauma has been encoded in the mind and body.2 Research on interoceptive awareness interventions, such as Trauma-Sensitive Yoga (TSY), has demonstrated improvements in emotional distress, psychological discomfort, and interoceptive awareness itself in vulnerable women with chronic posttraumatic stress symptomatology. One study highlighted that changes in body responsiveness partially mediated changes in anxiety and psychological discomfort. For individuals with complex trauma, who often experience their bodies as a source of threat or confusion, developing interoceptive awareness is a foundational step towards self-regulation, emotional differentiation, and re-establishing a sense of safety and ownership within their own skin. This improved internal connection can serve as a crucial mediator for enhanced emotional regulation and a reduction in dissociative symptoms. By learning to accurately read, tolerate, and make sense of internal sensations, individuals can begin to differentiate between past trauma-related bodily states and present-moment safety, thereby diminishing the intensity of trauma triggers and fostering a more integrated and coherent sense of self.

C. Restoring Nervous System Regulation and Expanding the Window of Tolerance

A primary goal of somatic therapies in complex trauma treatment is to restore regulation to the autonomic nervous system (ANS) and expand the individual's "window of tolerance".1 The window of tolerance refers to the optimal zone of arousal where an individual can effectively process information, respond to stressors, and engage in daily life without becoming overwhelmed (hyperaroused) or shut down (hypoaroused).2 Complex trauma often results in a narrowed window of tolerance, leaving individuals highly reactive to perceived threats and easily pushed into dysregulated states.

Somatic techniques are specifically designed to address this. Titration involves gently and gradually introducing small, manageable amounts of trauma-related arousal or distressing sensations into the client's awareness. This is done carefully to prevent re-traumatization and to allow the nervous system to process the activation without becoming overwhelmed. Pendulation is another key technique, which involves guiding the client to alternate between these small, activated states and states of resourcefulness, calm, or safety. By rhythmically moving between activation and deactivation, or between distress and resource, the nervous system learns that it can experience arousal and then return to a state of equilibrium. This process gradually increases the capacity to tolerate difficult sensations and emotions, effectively widening the window of tolerance. Somatic Experiencing explicitly aims to recalibrate the nervous system to reduce hyper- or hypoarousal, while Sensorimotor Psychotherapy focuses on modulating arousal and cultivating the capacity for optimal arousal.2 Successfully expanding this window is central to alleviating the core dysregulation characteristic of complex trauma. As the nervous system becomes more regulated and resilient, individuals are less likely to be hijacked by trauma triggers, leading to improved emotional stability, a greater sense of internal safety, and an enhanced capacity to be present and engaged in their lives and relationships.

D. Addressing Dissociation and Supporting Embodiment

Dissociation, a common and often pervasive consequence of complex trauma, involves a disruption in the normally integrated functions of consciousness, memory, identity, or perception of the environment and body. It serves as a protective mechanism during overwhelming experiences, allowing the individual to mentally escape unbearable realities. However, chronic dissociation can lead to a fragmented sense of self, feelings of unreality, memory gaps, and a profound disconnection from one's emotional and physical experiences. Somatic therapies directly address dissociation by working to restore a sense of embodiment—the experience of being present, alive, and connected within one's own body.2

These therapies gently guide clients to bring awareness back to their physical sensations, movements, and internal states in the present moment. This process helps to counteract the numbing, detachment, or out-of-body experiences characteristic of dissociation. Sensorimotor Psychotherapy, for example, focuses on how procedurally-learned responses contribute to dissociation and aims to reorganize these implicit, body-based memories to foster integration.2 Bioenergetic Analysis conceptualizes trauma as leading to a disconnection between mind and body, and views embodiment as the bridge to healing this fragmentation.3 Similarly, Body-Centred Psychotherapy, as described in the Kaplan dissertation, helps clients learn the "language of sensation" to resolve trauma and integrate sensory, affective, and cognitive aspects of the self, thereby fostering a more cohesive experience.5 By gradually and safely re-engaging with bodily experience, individuals can begin to tolerate and integrate sensations and emotions that were previously dissociated. This process is not merely about cognitively understanding the dissociation but involves a felt sense of re-inhabiting the body, leading to a more unified and present sense of self, which is crucial for healing from the fragmentation caused by complex trauma.

E. Completing Interrupted Defensive Responses and Reclaiming Agency

Many somatic approaches, notably Somatic Experiencing and Sensorimotor Psychotherapy, operate on the theoretical premise that trauma symptoms often stem from interrupted or incomplete biological defensive responses.1 When an individual faces an overwhelming threat and is unable to successfully execute a fight, flight, or effective freeze response, the immense survival energy mobilized for these actions can become "stuck" or "frozen" in the nervous system. This undischarged energy is believed to contribute to the ongoing physiological dysregulation and psychological distress seen in trauma survivors. Dr. Arielle Schwartz notes that the body holds not just the memory of what happened, but also the "memory of what wanted to happen"—the thwarted impulse for self-protection.

Somatic therapies provide a safe and supportive therapeutic environment where these incomplete defensive responses can be gently accessed, explored, and symbolically or through micro-movements, brought to a felt sense of completion.1 This is not about re-enacting the traumatic event itself, but rather about allowing the body to process and release the bound survival energy associated with the interrupted actions. For example, Sensorimotor Psychotherapy pays attention to "actions that wanted to happen," such as instinctive impulses to strike out, push away, or flee, which may have been abandoned during the trauma because they were impossible or would have worsened the situation. By mindfully exploring these impulses and allowing for their titrated expression (e.g., a subtle pushing movement with the hands, a tensing and releasing of leg muscles), the nervous system can achieve a physiological sense of resolution. This process can be profoundly empowering, as it helps to shift the individual's internal experience from one of helplessness and victimization to one of agency and restored capacity for self-protection. The discharge of this bound energy is often accompanied by physical sensations such as trembling, shaking, heat, or a sense of relief, indicating a recalibration of the nervous system.

III. Overview of Key Somatic Therapy Modalities for Complex Trauma

Several distinct somatic therapy modalities have been developed, each with its unique theoretical underpinnings and set of techniques, yet sharing a common focus on the body's role in healing trauma. This section provides an overview of some key approaches relevant to complex trauma treatment.

A. Somatic Experiencing (SE)

Theoretical Foundations and Key Techniques:

Somatic Experiencing (SE), developed by Dr. Peter Levine, is founded on the observation that wild animals, despite routine exposure to threat, rarely exhibit symptoms of trauma. Levine theorized that this resilience stems from their innate ability to discharge the high levels of energy mobilized for survival responses (fight, flight, freeze) once the threat has passed. Humans, however, can override these natural discharge mechanisms, leading to a dysregulated autonomic nervous system (ANS) and the retention of "stuck" survival energy, which manifests as trauma symptoms. SE, therefore, focuses on gently facilitating the release of this bound energy and restoring the ANS's capacity for self-regulation.1

Key techniques in SE include:

• Felt Sense: Guiding clients to develop interoceptive awareness by tracking subtle internal bodily sensations, images, emotions, and movements associated with the traumatic experience and with states of resource.

• Titration: Introducing small, manageable amounts of traumatic activation or sensation into the client's awareness to prevent overwhelm and allow for gradual processing.

• Pendulation: Helping clients rhythmically shift their attention between states of arousal or distress related to the trauma and states of calm, safety, or resourcefulness within the body. This helps build the nervous system's capacity to regulate arousal.

• Resourcing: Identifying and strengthening internal (e.g., a sense of strength, positive memories, calming bodily sensations) and external (e.g., supportive relationships, safe places) resources. These resources provide a foundation of stability and safety from which to explore traumatic material.8

• Discharge and Completion: Facilitating the natural physiological processes of discharging bound survival energy, which may manifest as involuntary movements like trembling, shaking, or changes in breath. This allows for the completion of interrupted defensive responses.

• Use of Touch: With informed consent, therapeutic touch can be used to support nervous system regulation, enhance body awareness, provide containment, or facilitate the release of physical tension.8

Reported Benefits for Complex Trauma:

SE aims to reduce PTSD symptoms, improve emotional resilience, enhance overall well-being, and recalibrate the nervous system by restoring its innate capacity for self-regulation. For complex trauma, SE can be particularly beneficial in addressing chronic nervous system dysregulation, dissociation (by gently re-connecting clients to their felt sense), and the somatic residue of incomplete survival responses.1 It is often helpful for individuals who feel "stuck" in their trauma or have found traditional talk therapies insufficient. The focus is not on reliving the trauma, but on safely processing the bodily sensations and survival energies associated with it.

Summary of Research Evidence (Efficacy, Outcomes, Limitations):

The evidence base for SE is growing, with preliminary studies suggesting its effectiveness for PTSD and related symptoms.1 A scoping review by Kuhfuß et al. (2021) found preliminary evidence for positive effects of SE on PTSD-related symptoms, affective and somatic symptoms, and measures of well-being in both traumatized and non-traumatized samples. Some studies, including RCTs, have reported significant reductions in PTSD symptoms, depression, anxiety, somatization, and fear of movement, alongside increases in resilience and quality of life. One study noted that 44.1% of participants no longer met PTSD diagnostic criteria after SE treatment.

However, the research field faces limitations.1 The Kuhfuß et al. (2021) review highlighted mixed overall study quality, a limited number of RCTs, a lack of adequate control groups in some studies, the use of self-developed symptom checklists instead of standardized measures, and heterogeneity in study samples and intervention protocols.8 Consequently, there is a strong call for more high-quality RCTs with standardized methodologies.8 Some critics have described SE as "largely unproven" or based on "New Age philosophy", though these criticisms often predate more recent research efforts. Potential risks include feeling overwhelmed or experiencing discomfort if the process is not carefully managed, and some individuals may perceive progress as slower compared to more cognitive methods.

The unique contribution of SE lies in its direct engagement with the physiological underpinnings of trauma. By focusing on the completion of thwarted survival responses at the level of the nervous system, SE offers a distinct pathway for individuals whose complex trauma is deeply embedded in autonomic dysregulation and incomplete motor patterns. This approach may address aspects of trauma that are not fully reached by interventions focusing primarily on cognitive restructuring or emotional catharsis without specific attention to somatic discharge and regulation.

B. Sensorimotor Psychotherapy (SP)

Theoretical Foundations and Key Techniques:

Sensorimotor Psychotherapy (SP), developed by Dr. Pat Ogden, is a body-oriented talking therapy that integrates cognitive and emotional approaches with direct attention to physical sensations and movement.2 It is built on the understanding that trauma, particularly developmental and attachment trauma, profoundly impacts the body and nervous system, leading to the development of habitual sensorimotor patterns, procedural memories, and dysregulated autonomic states.2 SP aims to help clients become aware of these patterns and develop new, more adaptive sensorimotor capacities.

Key techniques and principles include:

• Mindfulness and Dual Awareness: Clients are guided to mindfully observe their present-moment experience, including thoughts, emotions, and, crucially, bodily sensations (interoception), while simultaneously maintaining an awareness of the present therapeutic environment and relationship. This dual awareness helps prevent overwhelm and supports integration.2

• Tracking Somatic Indicators: The therapist and client collaboratively track somatic indicators of trauma, such as posture, gestures, breath patterns, muscle tension, and subtle movements, as these provide direct access to trauma-related information and procedural learning.2

• Working with Procedural Memory: SP directly addresses the habitual, automatic physical responses, movement tendencies, and implicit relational patterns that are learned and encoded non-verbally as a result of traumatic experiences.2

• Building Somatic Resources: Clients are helped to discover and cultivate bodily experiences of safety, calm, strength, and regulation. These somatic resources serve as anchors and support the capacity to process difficult material.

• Modulating Arousal and Expanding the Window of Tolerance: SP focuses on helping clients regulate states of hyperarousal (fight, flight) and hypoarousal (freeze, collapse, submission) and to widen their window of tolerance for affect and sensation.2

• Completing Defensive Actions ("Actions That Wanted to Happen"): A distinctive feature of SP is its attention to "actions that wanted to happen"—instinctive, self-protective physical responses that were thwarted or incomplete during the traumatic event(s). Therapy may involve exploring these impulses in a titrated and safe manner, allowing for their symbolic or micro-completion to restore a sense of agency.2

• Phase-Oriented Treatment: Treatment is typically structured in phases: 1) Stabilization and Symptom Reduction (focusing on safety, regulation, and resourcing); 2) Processing of Traumatic Memory (addressing specific memories and their sensorimotor components); and 3) Integration (focusing on personality integration and engaging more fully in life).

Reported Benefits for Complex Trauma:

SP is considered particularly effective for addressing the sequelae of developmental trauma and attachment disturbances.2 It aims to resolve affect dysregulation, dissociation, and the somatic symptoms of trauma by helping clients reorganize implicit memories, regulate their nervous system, and restore adaptive defensive actions.2 By increasing the window of tolerance and fostering a sense of safety within the body, SP helps individuals move beyond trauma-driven patterns and cultivate a more integrated and embodied sense of self.2

Summary of Research Evidence (Efficacy, Outcomes, Limitations):

The empirical research base for Sensorimotor Psychotherapy, while growing, is less extensive than that for modalities like EMDR or even SE. Preliminary evidence is promising. A literature review by Payne et al. (2015), though not directly provided, is often cited in relation to SP's efficacy. More directly, a pilot Randomized Controlled Trial (RCT) of the Trauma and the Body Group (TBG), a body-oriented group therapy adaptation of SP, involved 32 women with histories of childhood trauma. This study found significant improvements in body awareness, anxiety, and soothing receptivity in the treatment group compared to a waitlist control.12 Another small pilot study involving 20 weeks of SP group therapy for 10 women with childhood abuse histories reported reductions in trauma-related symptoms and significant improvements in body awareness, which were maintained at a six-month follow-up.13

Limitations in the current research include the preliminary nature of existing studies and the need for larger-scale RCTs to establish broader efficacy. The group therapy pilot study 13 did not find significant changes in somatic aspects of dissociation or receptivity to soothing, indicating areas for further investigation. As with other somatic therapies, potential drawbacks include the possibility of an initial worsening of symptoms as the focus on the body can reactivate traumatic memories, and the approach may not be suitable for individuals who are highly resistant to body-focused techniques or mindfulness.

The explicit focus of Sensorimotor Psychotherapy on "procedural memory" and "actions that wanted to happen" provides a direct therapeutic pathway to address the often non-verbal, action-oriented nature of traumatic encoding. This is particularly relevant for developmental trauma, where early adverse experiences shape implicit relational expectations, movement patterns, and physiological responses that may persist into adulthood, often outside of conscious awareness. By working with these embodied habits, SP can facilitate profound changes that purely cognitive or narrative-based therapies might not fully achieve.

C. Eye Movement Desensitization and Reprocessing (EMDR) with Somatic Focus

Integrating Somatic Awareness into EMDR:

Eye Movement Desensitization and Reprocessing (EMDR) is a structured, eight-phase psychotherapy approach initially developed by Francine Shapiro for the treatment of PTSD. It involves accessing traumatic memories while simultaneously engaging in bilateral stimulation (BLS), typically therapist-directed eye movements, but also auditory or tactile stimulation. The Adaptive Information Processing (AIP) model, which underpins EMDR, posits that trauma can cause memories to be inadequately processed and stored dysfunctionally, leading to PTSD symptoms when these memories are triggered. EMDR aims to facilitate the reprocessing of these memories, leading to a reduction in their vividness and emotional charge, and their integration into more adaptive memory networks.

Standard EMDR protocol inherently includes a somatic component, particularly in Phase 6: Body Scan. After the desensitization of a traumatic memory and the installation of a positive cognition, the client is asked to mentally scan their body for any residual tension or uncomfortable physical sensations while holding the target memory and positive belief in mind. If somatic distress is identified, further BLS is applied to process it.

For complex trauma (C-PTSD), standard EMDR protocols are often adapted to enhance safety and efficacy. These adaptations frequently involve an extended preparation phase (Phase 2), with a greater emphasis on somatic resourcing, affect regulation skill-building, and addressing dissociative symptoms before proceeding to memory reprocessing.9 There is an increased focus on tracking and integrating somatic experiences throughout all phases of treatment, not just in the body scan.

Somatic and Attachment Focused EMDR (S.A.F.E. EMDR) and Attachment-Focused EMDR (AF-EMDR):

Recognizing the unique challenges of C-PTSD, specialized adaptations like Somatic and Attachment Focused EMDR (S.A.F.E. EMDR), developed by Deborah Kennard, and Attachment-Focused EMDR (AF-EMDR), developed by Laurel Parnell, integrate principles from attachment theory and somatic psychology more explicitly into the EMDR framework.14

• These approaches emphasize the therapeutic relationship as a secure base and focus on repairing developmental deficits and attachment wounds that are often central to complex trauma.

• S.A.F.E. EMDR, for instance, helps clients understand their "Answer"—adaptive behaviors learned in childhood to maintain safety and connection with caregivers, which can later act as blocks to healing during EMDR. Significant time is spent building awareness of these patterns and developing somatic coping skills and resources before reprocessing.

• AF-EMDR similarly prioritizes extensive resourcing, including the installation of positive attachment figures and experiences, to help clients build the internal stability needed to process early relational trauma.

Reported Benefits for Complex Trauma:

EMDR is a strongly recommended, evidence-based treatment for PTSD. Somatically focused and attachment-informed adaptations aim to extend these benefits to individuals with C-PTSD by improving emotional regulation, enhancing body awareness, fostering a sense of safety during processing, and providing relief from physical symptoms associated with trauma.14 AF-EMDR is described as an affirming and nurturing approach, particularly for those with developmental deficits.

Summary of Research Evidence (Efficacy, Outcomes, Limitations for C-PTSD):

The efficacy of standard EMDR for PTSD is well-established through numerous RCTs and meta-analyses, showing large effect sizes in symptom reduction.

For EMDR in complex trauma and C-PTSD, the evidence is growing but presents a more nuanced picture.

• A systematic review by Bongaerts et al. (2018) found that EMDR was associated with reductions in PTSD symptoms, depression, and/or anxiety in both adults and children who had experienced complex childhood trauma, when compared to alternative therapies or control conditions. However, the review also noted significant heterogeneity across studies in terms of populations, treatment length, follow-up duration, comparison groups, and outcome measures, with one study having a high risk of bias.9

• A retrospective study by de Jongh et al. (2019) indicated that trauma-focused psychological therapy, including EMDR, effectively improved symptoms of CPTSD.15

• A prospective case series by Gurtner et al. (2024) involving 22 adolescents with histories of abuse and meeting ICD-11 criteria for CPTSD found that EMDR significantly decreased scores for PTSD, depression, anxiety, emotion dysregulation, and insomnia.

• Conversely, a systematic review and meta-analysis by Antuña-Camblor & Tejedor Hernández (2025) focusing on EMDR interventions in refugees and asylum seekers (populations often experiencing complex trauma) reported a non-significant effect of EMDR on PTSD symptoms at the end of the intervention period, though they cautioned that this finding should be interpreted with awareness of limitations due to the exclusion of other study designs.16 Other studies with refugee populations have shown positive outcomes.

Direct empirical outcome studies specifically evaluating S.A.F.E. EMDR or AF-EMDR for C-PTSD are scarce in the provided materials.14 Much of the support for these adaptations is theoretical, based on clinical expertise integrating standard EMDR with established principles from somatic psychology and attachment theory. The Korn & Leeds (2002) article proposed Resource Development and Installation (RDI), an EMDR-based protocol, for the stabilization phase of Complex PTSD treatment, presenting preliminary evidence from two single case studies that showed positive psychometric and behavioral outcomes.

Limitations of applying standard EMDR to C-PTSD include the risk that protocols may move too quickly, potentially leading to intense emotional or physical responses, re-traumatization, or increased dissociation, especially if clients lack sufficient internal resources or affect regulation skills. Inconsistent practitioner training and experience in handling complex trauma responses are also significant concerns. General research limitations include the lack of adequate control groups in some studies, variability in populations and outcome measures, and limited long-term follow-up data. For S.A.F.E. EMDR and AF-EMDR, the primary limitation is the current lack of specific large-scale outcome studies validating their unique contributions beyond the principles they integrate.

The development and application of somatic and attachment-focused adaptations within the EMDR framework signify a critical recognition that complex trauma requires more than the reprocessing of isolated memories. C-PTSD is often characterized by profound disruptions in nervous system regulation, a compromised sense of self, and deep relational wounds stemming from early developmental experiences. Standard EMDR, while highly effective for single-incident PTSD, may not adequately address these foundational deficits without significant modification. The integration of somatic resourcing, explicit attention to bodily states during processing, and a focus on repairing attachment deficits prior to and during memory work appear to be key enhancements for making EMDR safer, more tolerable, and ultimately more effective for the multifaceted challenges of complex trauma.

D. Hakomi Therapy

Theoretical Foundations and Key Principles:

Hakomi Therapy, developed by Ron Kurtz in the 1970s, is a mindfulness-centered somatic psychotherapy that draws from a rich tapestry of influences including general systems theory, body-centered therapies (like Reichian work and Bioenergetics), Gestalt therapy, psychomotor therapy, Feldenkrais, Ericksonian hypnosis, Focusing, NLP, Buddhism, and Taoism.5 It is an experiential approach that emphasizes the client's present moment experience as a gateway to understanding and transforming deeply held unconscious beliefs and patterns.

Core principles underpinning Hakomi include 6:

• Mindfulness: Cultivating a state of non-judgmental, present-moment awareness. Clients are guided to observe their internal experiences (thoughts, emotions, memories, bodily sensations) with curiosity.

• Nonviolence: A profound respect for the client's inner wisdom and defenses. The therapist supports and explores defenses rather than confronting or trying to break them down, creating a safe environment for organic unfolding.

• Mind-Body Holism: Recognizing the inseparable connection between mind and body. Bodily sensations, postures, and movements are seen as direct expressions of psychological states and pathways to unconscious material.

• Organicity: Trusting in the client's innate, self-healing intelligence and their natural impulse towards growth and wholeness. The therapist facilitates this organic process.

• Unity: Emphasizing the interconnectedness of all aspects of the self (thoughts, feelings, body, spirit) and the self's connection to the larger world, fostering integration.

• Loving Presence: A core state of the therapist characterized by compassion, attunement, acceptance, and mindful presence, which creates a safe and nurturing relational field essential for deep healing.

• Working with Core Material: Gently exploring and bringing to consciousness "core material"—formative experiences and the resulting emotional attitudes, memories, neural patterns, and beliefs that unconsciously organize a person's life and behavior.

• The "Missing Experience": A unique Hakomi intervention that involves co-creating and providing an individually-tailored experience that was needed but absent during childhood or past developmental stages. This aims to rewire neural pathways and reconsolidate implicit memories in a more nourishing way.

Application to Developmental and Relational Trauma:

Hakomi is explicitly described as a therapy that uses mindfulness and somatic interventions to heal attachment wounds and developmental trauma.6 Its gentle, non-invasive, and deeply relational approach, emphasizing safety, "loving presence," and the provision of "missing experiences," is considered particularly well-suited for individuals whose complex trauma stems from early relational wounding and unmet developmental needs.6 The focus on understanding and transforming core beliefs and character adaptations formed in response to difficult early circumstances directly addresses the legacy of developmental trauma. Furthermore, Hakomi's inherent "parts work"—recognizing and working with different self-states—aligns with effective treatment strategies for C-PTSD, where internal fragmentation is common.6

Summary of Research Evidence (Qualitative Data, Case Studies, Limitations):

Direct empirical research on Hakomi for complex trauma, particularly large-scale RCTs, is limited.6 The evidence base primarily consists of theoretical articles, dissertations, qualitative explorations, and case studies.

• The Kaplan dissertation (2006), which employed the Pragmatic Case Study Method to study Body-Centred Psychotherapy (with the therapist being a master Hakomi clinician and trainer), demonstrated substantial progress in three clients. Two of these clients showed statistically significant quantitative changes on standardized measures. This research highlighted the therapist's ability to tailor therapy to individual needs, combining verbal and somatic interventions, including the use of touch.5

• The Powers dissertation (2022) is a hermeneutic literature review arguing for Hakomi's suitability for treating anorexia nervosa, often linked with developmental trauma, based on its principles and alignment with trauma recovery concepts.6

Limitations of Hakomi include the scarcity of large-scale empirical outcome studies specifically validating its efficacy for complex trauma.6 Some criticisms suggest it can be a slow-moving therapy, may heighten client vulnerability, can be costly due to the need for weekly sessions with trained therapists, and might impact existing defense mechanisms. It has also been noted as not recommended for some patients with trauma histories, underscoring the need for careful assessment and therapist skill. The deeply experiential and relational nature of Hakomi makes it inherently challenging to standardize for traditional research protocols.6 Ethical considerations, particularly around dual relationships, require careful management by practitioners.

Hakomi's profound emphasis on "loving presence" and the co-creation of "missing experiences" within a mindful, body-aware state offers a therapeutic environment that directly addresses the core attachment wounds and unmet developmental needs often central to complex and developmental trauma. Its foundational principle of nonviolence towards defenses is particularly crucial for clients who have experienced relational violations and may approach therapy with significant distrust or fear of being overwhelmed or re-shamed. By fostering a deep internal study of how past experiences shape present-moment organization, Hakomi aims to gently unwind maladaptive patterns and cultivate more authentic and fulfilling ways of being.

E. Bioenergetic Analysis (BA)

Theoretical Foundations and Key Concepts:

Bioenergetic Analysis (BA), founded by Alexander Lowen and John Pierrakos, is a form of body-psychotherapy rooted in the work of Wilhelm Reich.3 It combines bodily, analytic, and relational work, based on an energetic understanding of the human being.

Key concepts include:

• Body-Mind Continuity: BA operates on the principle that the mind and body are functionally identical; thoughts, feelings, and behaviors are inextricably linked to physical processes and bodily states.

• Energy and Muscular Tension ("Character Armor"): Emotional blockages, unresolved conflicts, and traumatic experiences are believed to manifest as chronic muscular tensions that restrict the natural flow of energy in the body. These patterns of tension form what Reich termed "character armor," which are somatic defenses against overwhelming emotions and past hurts.4

• Grounding: A core concept in BA, grounding refers to the individual's energetic connection to the earth, to reality, and to their own body. Physical exercises are often used to help clients develop a stronger sense of being grounded, which enhances stability and self-awareness.

• Character Structure: BA utilizes a system of character structures (e.g., schizoid, oral, narcissistic, masochistic, rigid, and later, borderline) that describe how early developmental experiences, unmet needs, and trauma shape an individual's personality, bodily posture, and patterns of energetic expression.4

• Movement, Breathwork, and Expressive Techniques: Therapy often involves specific physical exercises, deep breathing techniques, expressive movements, and sometimes vocalizations to help clients become aware of, mobilize, and release chronic muscular tension and the suppressed emotions held within them. Therapeutic touch may also be used by some practitioners, with careful attention to boundaries and consent.

Application to Developmental Trauma and Embodied Defenses:

BA views character structure as a direct result of developmental trauma, where frustrated drives and adaptive responses to early environmental failures become ingrained in the body as "armor".4 This armor represents embodied defenses against overwhelming feelings and relational injuries. BA aims to address these deeply held patterns by:

• Helping clients become aware of their character armor and how it restricts their vitality and self-expression.

• Using physical exercises and breathwork to soften chronic muscular tensions and release blocked energy and emotions.

• Working through the developmental issues and relational wounds associated with each character structure.

• Fostering greater body awareness, emotional expression, and capacity for pleasure and intimacy. The Shahri paper (2014) provides a contemporary integrated model, linking Bioenergetic character structures to developmental trauma and incorporating insights from self-psychology and neuroscience to address "disorders of the self" often seen in complex trauma survivors.4

Summary of Research Evidence (Retrospective Studies, Case Reports, Limitations):

The evidence base for Bioenergetic Analysis includes systematic reviews of the broader field of Body Psychotherapy (which often encompasses BA), retrospective studies, theoretical papers, and case reports.34

• A systematic review and meta-analysis by Rosendahl et al. (2021) on Body Psychotherapy (BPT) indicated medium effects on primary outcomes like psychopathology and psychological distress.34

• The "Evidence Gap Map of Clinical Effectiveness of Bioenergetic Analysis" (CABSIN, 2022) compiled 56 studies, including 8 RCTs (though not all necessarily on trauma). It highlighted positive effects for various outcomes, including psychological stress, particularly through Trauma Release Exercises (TRE), which are considered exercises in Bioenergetic Analysis.38

• Homayoun Shahri's (2014) paper presents a detailed case study illustrating the application of an integrated BA approach to developmental trauma, reporting positive outcomes in terms of motivation, relational capacity, and responsibility.4

• A retrospective study by Ventling (2002), cited in Arnault & O'Halloran (2013), examined 149 former BA patients and found significant positive changes that were largely stable over time.

Limitations in the research include a relative scarcity of large-scale RCTs specifically investigating BA for complex or developmental trauma.35 Many existing studies are qualitative, theoretical, or case-based.38 The Evidence Gap Map noted that a significant portion of BA literature is "gray literature" (not peer-reviewed) and that the field has historically focused more on theoretical and qualitative studies than on EBM methodologies like RCTs.38 Some criticisms of BA have historically been associated with earlier, more aggressively expressive techniques, although contemporary BA practice is often described as more relational and attuned. Certain BA workshops may have contraindications for individuals with psychosis, pregnancy, epilepsy, or severe anger management issues, or high sensitivity to noise and screaming. The general sparseness of research evidence supporting BA is a frequently cited limitation.35

The concept of "character armor" within Bioenergetic Analysis offers a potent and tangible framework for understanding how chronic developmental stress and relational trauma become physically patterned and defended within the body. BA's active focus on releasing these somatic defenses through breath, movement, and energetic work provides a direct pathway to liberating suppressed life energy and emotional expression, which are often profoundly constricted in individuals with C-PTSD, thereby fostering greater vitality and authentic selfhood.

F. Other Relevant Somatic Approaches

While the modalities detailed above are prominent, the field of somatic therapy is broad and includes other approaches that share core principles of mind-body integration. Focusing, developed by Eugene Gendlin, emphasizes attending to the "felt sense"—a subtle, internal bodily awareness that carries implicit meaning about one's experiences. Dance/Movement Therapy (DMT) utilizes expressive movement as a primary mode of processing emotions, experiences, and relational patterns held in the body, and has been applied to trauma populations. Trauma Release Exercises (TRE), developed by David Berceli, involve a series of simple physical exercises designed to evoke neurogenic tremors, which are seen as the body's natural way of discharging tension and trauma stored in the muscles and nervous system.38 These and other body-centered practices contribute to the diverse landscape of somatic interventions for trauma.

The following table provides a comparative overview of the key somatic therapies discussed:

Table 1: Comparative Overview of Key Somatic Therapies for Complex Trauma

Modality

Founder(s)/Key Developers

Core Theoretical Principles for Complex Trauma

Key Techniques Used

Primary Focus for C-PTSD

Summary of Research Evidence for C-PTSD

Noted Limitations/Criticisms for C-PTSD Application

Somatic Experiencing (SE)

Peter Levine

Trauma as incomplete survival responses leading to ANS dysregulation; body's innate capacity to heal.

Felt sense, titration, pendulation, resourcing, discharge/completion of responses, touch (optional).

Restoring ANS self-regulation, completing survival responses, releasing trapped energy.

Preliminary evidence (some RCTs, case studies, reviews) suggests efficacy for PTSD symptoms, affect regulation. Kuhfuß et al. (2021) review found mixed study quality.

Limited RCTs, heterogeneity in studies, some criticisms of being "unproven" or "New Age." Potential for overwhelm if not paced well.

Sensorimotor Psychotherapy (SP)

Pat Ogden

Trauma impacts body, nervous system, procedural memory, and attachment patterns. Integrates cognitive/emotional work with body awareness.

Mindfulness, dual awareness, tracking somatic indicators, working with procedural memory, somatic resourcing, arousal modulation, completing defensive actions, phase-oriented treatment.

Resolving developmental/attachment trauma, affect dysregulation, dissociation, integrating implicit memories, restoring adaptive action.

Emerging evidence (pilot RCT of group adaptation, pilot studies) shows promise for trauma symptoms, body awareness, anxiety. Less extensive research than SE/EMDR.

Limited large-scale RCTs. Initial worsening of symptoms possible. May not suit those resistant to body focus.

Somatic EMDR (incl. S.A.F.E./AF-EMDR)

Francine Shapiro (EMDR); D. Kennard (S.A.F.E.), L. Parnell (AF-EMDR)

Standard EMDR's AIP model adapted for C-PTSD by integrating somatic awareness, attachment theory, and extensive resourcing.

Standard 8-phase EMDR with bilateral stimulation (BLS), enhanced body scan, somatic resourcing, attachment-focused interventions, addressing "The Answer" (S.A.F.E.).

Processing traumatic memories while managing dysregulation and addressing developmental/attachment deficits.

Strong evidence for EMDR in PTSD. Growing evidence for adapted EMDR in C-PTSD (systematic reviews, case series). S.A.F.E./AF-EMDR support is more theoretical/clinical.

Standard EMDR may be too intense/fast for C-PTSD without adaptation. Risk of retraumatization if not paced. Need for specialized C-PTSD training. Limited outcome studies on specific S.A.F.E./AF-EMDR protocols.

Hakomi Therapy

Ron Kurtz

Mindfulness-centered, experiential. Focus on healing attachment wounds and developmental trauma by accessing and transforming core unconscious material held in the body.

Mindfulness, nonviolence, mind-body holism, organicity, unity, loving presence, working with core material, providing "missing experiences," body reading, somatic experiments.

Healing attachment/developmental wounds, transforming core beliefs, integrating fragmented self-states, fostering self-acceptance and embodiment.

Primarily qualitative (dissertations, case studies, theoretical articles). Kaplan dissertation (BcP with Hakomi therapist) showed positive outcomes. Limited RCTs.

Scarcity of large-scale empirical studies. Can be slow-moving. Potential for vulnerability. Not recommended for some with trauma. Experiential nature hard to standardize.

Bioenergetic Analysis (BA)

Alexander Lowen, John Pierrakos (rooted in Wilhelm Reich)

Trauma and developmental issues create "character armor" (chronic muscular tension) restricting energy flow and emotional expression.

Grounding, breathwork, expressive movement, stress postures, character analysis, relational work, touch (variable).

Releasing character armor, freeing blocked energy and emotions, addressing developmental deficits reflected in character structure, restoring vitality.

Evidence from BPT reviews, retrospective studies, case reports (e.g., Shahri, Ventling). Evidence Gap Map shows some RCTs (not all trauma-specific).

Sparse RCTs for C-PTSD. Historical criticism of some older techniques. Need for more EBM-aligned research. Some contraindications for specific workshops.

IV. Synthesized Research Evidence: Efficacy, Outcomes, and Populations

The body of research examining somatic therapies for complex trauma is evolving, characterized by a mix of broader systematic reviews that group various body-oriented approaches and modality-specific studies that range from randomized controlled trials (RCTs) to qualitative case reports.

A. Systematic Reviews and Meta-Analyses on Somatic/Body-Oriented Therapies for Trauma

Several systematic reviews and meta-analyses provide a higher-level perspective on the efficacy of interventions that include somatic components for trauma. A notable review by Karatzias et al. (2020) examined psychological and pharmacological interventions for individuals exposed to complex traumatic events. This review found that trauma-focused psychological interventions, such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and EMDR, were generally effective in reducing PTSD symptoms. Importantly for the context of C-PTSD, phase-based psychological interventions—which often incorporate skills training that can include somatic regulation techniques—were identified as the most promising for addressing emotional dysregulation and interpersonal problems, key features of complex trauma.39

Another significant meta-analysis by Rosendahl et al. (2021) focused specifically on Body Psychotherapy (BPT), a category that often includes approaches like Bioenergetic Analysis. This review concluded that BPT demonstrated medium effects on primary outcomes such as psychopathology and psychological distress.34 While these reviews group diverse therapies, they suggest a general positive signal for approaches that attend to the body in trauma treatment.

Focusing on Somatic Experiencing (SE), a scoping review by Kuhfuß et al. (2021) indicated preliminary positive effects of SE on PTSD-related symptoms, as well as on affective and somatic symptoms and measures of well-being.8 However, this review also highlighted the mixed quality of existing studies and the need for more rigorous research.

A pattern emerges from these broader reviews: while the underlying principles of body-oriented work appear beneficial for trauma, and particularly for the multifaceted symptoms of C-PTSD, there is a critical need for more modality-specific, high-quality research. The general positive findings for "trauma-focused psychological interventions" or "body psychotherapy" support the rationale for somatic approaches, but the next step involves robustly demonstrating the specific efficacy of individual somatic modalities for the distinct challenges of complex trauma.

B. Evidence for Specific Symptoms of Complex Trauma (e.g., Affect Dysregulation, Dissociation, Relational Difficulties)

Somatic therapies, by their inherent focus on bodily experience and nervous system processes, are theoretically well-positioned to address the core Disturbances in Self-Organization (DSO) characteristic of C-PTSD.

• Affect Dysregulation: A central aim of many somatic therapies is to enhance interoceptive awareness and teach skills for nervous system regulation, directly targeting affect dysregulation.1 Techniques like pendulation and titration in SE and SP are designed to expand the window of tolerance, allowing individuals to manage intense emotions without becoming overwhelmed. The Karatzias et al. (2020) review found phase-based interventions, often incorporating such skills, to be promising for emotional dysregulation in complex trauma.

• Dissociation: Somatic approaches generally aim to reduce dissociation by fostering embodiment—a felt sense of connection to and presence within one's own body.2 By gently guiding attention to physical sensations and grounding individuals in the present moment, these therapies help to bridge the disconnections (from self, body, or environment) that define dissociation. Sensorimotor Psychotherapy, for instance, directly addresses how procedural learning contributes to dissociation and aims to reorganize these implicit patterns.2

• Relational Difficulties and Negative Self-Concept: Many somatic modalities, such as Hakomi, Sensorimotor Psychotherapy, and attachment-focused EMDR, explicitly address relational and attachment issues.2 The therapeutic relationship itself is often viewed as a key vehicle for healing early relational wounds. By working with embodied relational patterns and core beliefs about the self that are held in the body (e.g., character armor in Bioenergetic Analysis 4 or core material in Hakomi), these therapies can help to shift negative self-perceptions and improve interpersonal functioning.

The direct engagement with the physiological underpinnings of emotion, the felt sense of self, and embodied relational patterns makes somatic therapies particularly relevant for the DSO criteria of C-PTSD.

C. Effectiveness Across Different Populations with Complex Trauma

The effectiveness of trauma interventions can vary significantly based on the specific population and the nature of the traumatic experiences. The Karatzias et al. (2020) review, which included complex trauma subgroups such as veterans, childhood sexual abuse survivors, war-affected individuals, refugees, and domestic violence survivors, found that while TF-CBT and EMDR were generally superior to non-trauma-focused interventions, their effects were somewhat reduced in veteran and war-affected populations.39 This suggests that the type of trauma (e.g., combat versus interpersonal developmental trauma) and the associated sociocultural context can significantly influence treatment response.

Research on EMDR for refugee populations, who frequently experience complex trauma, has yielded mixed findings. While some studies report positive outcomes, a recent systematic review and meta-analysis by Antuña-Camblor & Tejedor Hernández (2025) found a non-significant effect of EMDR on PTSD symptoms at the end of the intervention period for refugees and asylum seekers, though with caveats about study heterogeneity.16 Conversely, a case series on EMDR for adolescents with histories of abuse and C-PTSD reported significant improvements across multiple symptom domains.

This variability underscores the importance of context-sensitive and culturally attuned therapeutic approaches. Somatic therapies, with their emphasis on the individual's unique embodied experience, may offer inherent flexibility. However, more research is needed to specifically evaluate the efficacy of different somatic modalities across diverse populations with complex trauma, taking into account cultural expressions of distress and healing.

V. Limitations, Criticisms, and Contraindications of Somatic Therapies for Complex Trauma

While somatic therapies offer promising avenues for healing complex trauma, it is crucial to acknowledge their limitations, the criticisms they face, and potential contraindications to ensure safe and effective application.

A. General Limitations of the Somatic Approach

One general limitation is that the scientific understanding of the precise mechanisms of action for some somatic therapies is still evolving, though neuroscience is increasingly providing support. A core challenge inherent in the somatic approach is that direct engagement with bodily sensations can be difficult or overwhelming for some individuals, particularly those with severe C-PTSD, profound body-based phobia, or significant dissociative responses.40 The very strength of these therapies—their focus on the body—can become a hurdle if not approached with exquisite attunement, careful pacing, and robust resourcing strategies. Without such precautions, there is a risk of inadvertently increasing distress or even re-traumatizing the client.

B. Modality-Specific Criticisms and Contraindications

Each somatic modality also faces specific criticisms and may have particular contraindications:

• Somatic Experiencing (SE): Has been criticized by some as "largely unproven" or based on "New Age philosophy," though these critiques often overlook more recent research efforts. Clients may sometimes feel overwhelmed or experience discomfort if the process is not carefully titrated, and some may perceive the progress as slower compared to more directive cognitive methods.

• Sensorimotor Psychotherapy (SP): As with SE, there is a potential for an initial worsening of symptoms as the focus on the body can reactivate traumatic memories. SP may not be suitable for all individuals, particularly those who are highly resistant to body awareness or mindfulness techniques. The research base, while growing, is still considered relatively new.

• EMDR for C-PTSD: Standard EMDR protocols, if applied rigidly without adaptation for complex trauma, may proceed too quickly for C-PTSD survivors. This can lead to intense emotional and physical responses, potential re-traumatization, or an increase in dissociative symptoms. Concerns also exist regarding inconsistent practitioner training and experience in managing the complexities of C-PTSD presentations within an EMDR framework.

• Hakomi Therapy: This approach can be slow-moving, which may not suit all clients or service delivery models. The deep exploration of core material can lead to heightened vulnerability. It has been suggested that Hakomi may not be recommended for some patients with histories of severe trauma, emphasizing the need for careful assessment. The experiential nature also makes it difficult to standardize for research.

• Bioenergetic Analysis (BA): Some BA workshops have specific contraindications, including for individuals with active psychosis, pregnancy, epilepsy, or severe, unmanaged anger issues, as well as high sensitivity to noise or intense emotional expression. Historically, BA has been associated by some critics with older, more aggressively expressive techniques, although modern BA is often described as more relational and attuned. A significant limitation remains the sparse body of rigorous research evidence supporting its efficacy, particularly from RCTs.35

A recurring theme in the criticisms of many somatic therapies is the perceived lack of a robust, traditional (RCT-heavy) evidence base and the potential for intense emotional or physiological experiences if the therapeutic process is not skillfully managed by a well-trained practitioner. This highlights a tension between the deeply experiential nature of these therapies and the demands of conventional research paradigms.

C. Potential Risks (e.g., Retraumatization, Misuse of Touch) and Ethical Considerations

The application of somatic therapies, especially with vulnerable populations like C-PTSD survivors, carries potential risks that necessitate stringent ethical considerations. Retraumatization is a significant concern if traumatic material is accessed too quickly, without adequate client resourcing, or in a dysregulating manner.40 The therapist's skill in pacing, titration, and maintaining a safe therapeutic container is paramount.

The use of touch, a component in some somatic therapies (e.g., SE, Hakomi, BA, SP), requires particular ethical sensitivity.41 While therapeutic touch can be profoundly healing and regulating for some, it can be triggering or harmful for others, especially those with histories of physical or sexual abuse. Absolute clarity regarding informed consent is essential: clients must understand the rationale for touch, what to expect, and have the unequivocal right to refuse or stop touch at any time without negative repercussions. Practitioners must have specialized training in trauma-informed touch, understanding cultural sensitivities, trauma responses, and maintaining impeccable professional boundaries to prevent misinterpretation or, worse, abusive touch.

Power dynamics are inherent in any therapeutic relationship but can be amplified in somatic work due to the vulnerability involved in accessing deep bodily experiences. Therapists must be acutely aware of this dynamic and use their influence responsibly. This underscores the critical importance of comprehensive therapist training, not only in the specific somatic modality but also in general trauma theory, ethics, countertransference management, and therapist self-awareness.5 The "personhood of the therapist"—their own level of embodiment, self-regulation, and awareness—becomes a crucial ethical instrument in facilitating safe and effective somatic work. Inadequate training or therapist self-awareness can lead to ethical breaches and harm, whereas well-trained, self-aware, and ethically grounded practitioners are better equipped to navigate the complexities of somatic trauma therapy and foster profound healing.

VI. Challenges and Future Directions in Researching Somatic Therapies for Complex Trauma

The empirical validation of somatic therapies for complex trauma is an area of active development, characterized by unique methodological challenges and a growing call for diverse research approaches.

A. Methodological Challenges in Studying Experiential and Body-Focused Interventions (Limitations of RCTs)

Randomized Controlled Trials (RCTs), often considered the "gold standard" in medical and psychological research, present significant limitations when applied to experiential and body-focused interventions for complex trauma.5

• Standardization vs. Individualization: Somatic therapies are often highly individualized and process-oriented, adapting to the client's unique moment-to-moment experience and nervous system responses.5 This contrasts with the RCT requirement for standardized, manualized interventions, making it difficult to capture the therapeutic artistry and attunement central to many somatic approaches.

• Blinding: It is nearly impossible to effectively blind participants or therapists in psychotherapy trials, particularly those involving distinct physical techniques or experiential components.42

• Capturing Holistic and Process-Based Changes: RCTs typically focus on quantifiable symptom reduction using standardized measures. They may fail to capture the more nuanced, holistic, and process-based changes often targeted by somatic therapies, such as increased body awareness, improved self-regulation, a greater sense of agency, or shifts in relational patterns.5

• Heterogeneity of Complex Trauma Presentations: C-PTSD is characterized by a wide range of symptoms and comorbidities, making it difficult to recruit homogenous samples for RCTs and often leading to exclusion criteria that limit generalizability to real-world clinical populations.7

• Ethical Concerns with Control Groups: For individuals suffering from severe complex trauma, assigning them to no-treatment or placebo control groups can raise ethical concerns, especially if effective interventions are believed to exist.7

• Measuring Non-Ordinary States and Self-Directed Healing: Therapies that work with non-ordinary states of consciousness or emphasize the client's "inner healing intelligence" (as discussed in the MDMA-assisted therapy framework, which has relevance for experiential therapies) pose challenges for traditional RCTs focused on observable behaviors or symptom checklists.9

There is a fundamental epistemological tension between the reductionist, positivist paradigm that often underpins traditional RCTs and the holistic, phenomenological, and systems-oriented paradigms that inform many somatic therapies. This is not merely a matter of refining RCT design but often questions whether RCTs alone can adequately capture the essence, mechanisms, and efficacy of these deeply experiential and relational approaches to healing complex trauma.

B. The Value of Alternative Research Methodologies (Qualitative Research, Case Studies, Pragmatic Trials, Practice-Based Evidence, Level 2/3 Evidence)

Given the limitations of RCTs for studying somatic and experiential therapies for complex trauma, there is a growing recognition of the value of alternative and complementary research methodologies.5

• Qualitative Research: Methodologies such as phenomenology, grounded theory, and hermeneutics are invaluable for capturing the lived experience of clients and therapists, understanding the therapeutic process in depth, and exploring meaning-making in trauma recovery.6 The Powers dissertation on Hakomi, for example, employed a hermeneutic literature review to explore its potential contributions.6

• Pragmatic Case Study Method (PCSM): Championed in the Kaplan dissertation for Body-Centred Psychotherapy, the PCSM combines in-depth qualitative analysis of individual cases with quantitative measures, focusing on real-world clinical practice and the individualized nature of treatment.5 This approach allows for the development of "microtheory" and a nuanced understanding of process-outcome links.

• Practice-Based Evidence (PBE): This approach values the evidence generated from actual clinical practice and client outcomes in real-world settings, rather than solely relying on evidence from controlled research environments.55 It acknowledges the wisdom embedded in clinical experience.

• Level 2/3 Evidence: As argued by Corrigan and Hull (cited in Fisher & Ogden, 2009), evidence from case-controlled trials (non-randomized), observational studies, and surveys (Level 2/3 evidence) is frequently accepted in medicine when RCTs are difficult to apply and should be valued for body-focused psychotherapies for complex trauma.7

• Naturalistic Data: Tracking patient attendance, dropout rates, and long-term functioning in routine clinical settings can provide valuable "naturalistic data" on the acceptability and effectiveness of therapies.7

The call for these alternative research methodologies reflects a broader shift towards an "evidence-informed practice" model. This model integrates the best available research evidence with clinical expertise, client values and preferences, and contextual factors. For complex, individualized conditions like C-PTSD and for therapies that are inherently relational and process-oriented, such a multifaceted approach to evidence is vital for building a clinically relevant and holistic understanding of what works, for whom, and under what conditions.

C. Identified Research Gaps and Priorities for Key Somatic Modalities

While each somatic modality has unique research needs, common themes emerge regarding gaps and priorities:

• Somatic Experiencing (SE): The Kuhfuß et al. (2021) scoping review called for more methodologically sound RCTs with adequate sample sizes, the development of standardized SE manuals to reduce intervention heterogeneity, comparative effectiveness studies, and investigations into the specific contributions of key SE factors like touch and resourcing. Research on the optimal number of sessions and combinability with other therapies was also prioritized.8

• Hakomi Therapy: The dissertations by Kaplan and Powers highlighted the scarcity of RCTs and the need for qualitative inquiry and systematic case studies (like the PCSM) to build an evidence base that honors Hakomi's experiential and relational nature.5

• Bioenergetic Analysis (BA): The Evidence Gap Map for BA pointed to a need for more studies published in peer-reviewed journals, greater use of evidence-based medicine methodologies (including RCTs), and better indexing of BA literature.38 Shahri's work suggests a focus on integrating neuroscience and addressing contemporary presentations of self-disorders.4

• Sensorimotor Psychotherapy (SP) and Somatic EMDR: While SP has some pilot data, and EMDR has a strong evidence base for PTSD, more research is needed specifically on SP for C-PTSD and on the efficacy of somatic and attachment-focused adaptations of EMDR for this population.

Across modalities, there is a clear desire to move beyond anecdotal evidence and small-scale studies towards more systematic investigation. This includes not only demonstrating efficacy but also elucidating the mechanisms of change (i.e., how these therapies work) and identifying optimal applications for specific C-PTSD populations and symptom clusters. This progression is essential for these therapies to gain wider acceptance and integration into mainstream mental health care for complex trauma.

D. Emerging Research, Innovative Approaches, and Expert Opinions (2024-2025 Insights)

The field of somatic trauma therapy is dynamic, with ongoing research and innovative approaches continually emerging. Recent expert opinions and preliminary findings from 2024-2025 suggest several key trends:

• Integration of Neuroplasticity and Neuroscience: There is a growing emphasis on integrating principles of neuroplasticity into somatic practices, using body-based exercises to target and rewire neural pathways associated with stress and trauma. Research leveraging neuroimaging techniques to understand the biological underpinnings of PTSD and treatment effects is also advancing, potentially leading to more precise, personalized interventions.60 Dr. Arielle Schwartz, for example, integrates neurobiological understanding with practical somatic tools.50

• Resilience-Informed Therapy: A significant shift is occurring towards "resilience-informed" somatic therapy, which moves beyond mere symptom reduction to foster post-traumatic growth, life satisfaction, and an enhanced sense of personal strength.50 Recent studies (e.g., a cited April 2025 study in the Journal of Traumatic Stress and a 2024 study in the Journal of Consulting and Clinical Psychology) suggest that resilience-focused techniques lead to better long-term outcomes and higher client satisfaction compared to traditional deficit-based models.

• Technological Innovations: Virtual Reality (VR) is being explored to create safe, controlled environments for graded exposure to traumatic memories within a somatic framework. Neurofeedback, another technology-assisted approach, shows promise in helping individuals learn to regulate brainwave patterns associated with PTSD symptoms, with some recent studies indicating improved symptom severity.

• Integration of Modalities: A notable trend is the increasing integration of somatic therapy principles with other established trauma treatments like EMDR and Internal Family Systems (IFS). This aims to provide a more holistic approach by combining body-based work with emotional processing and parts work. The MDMA-assisted therapy framework also explicitly integrates "top-down" and "bottom-up" approaches, including somatosensory processing.9

• Focus on Specific Somatic Techniques: Conferences and expert discussions are highlighting specific somatic techniques and their neurobiological rationales. Examples from the 2024 and 2025 Somatic Trauma Healing Summits include Gabor Maté discussing early environmental programming of stress patterns and methods for releasing traumatic immobilization; Nkem Ndefo on differentiating dysregulation from adaptive responses and using a "Resilience Toolkit"; and Manuela Mischke-Reeds on integrating movement into trauma therapy. Techniques like "Self-Havening Touch" and "Bilateral Movement" are also being explored for their roles in vagus nerve stimulation and neural integration.

• Ongoing Clinical Trials: Research activity continues, with clinical trials investigating various aspects of trauma treatment. For instance, the University of Queensland is establishing a C-PTSD biobank to better understand the biological drivers of the disorder and identify treatment targets, noting the challenges of applying standard EMDR to C-PTSD. Other ongoing trials are examining intensive trauma-focused therapy (TFT) for (Complex) PTSD and comparing different versions of EMDR (EMDR 2.0, Flash technique) for C-PTSD.

The future of somatic therapies for complex trauma appears to lie in this increased integration—with other therapeutic modalities, with evolving neuroscientific understanding, and with innovative technologies. There is a clear movement towards not only alleviating symptoms but also actively building resilience and fostering post-traumatic growth. This evolution necessitates flexible, personalized, and deeply embodied approaches to healing.

VII. Clinical Implications and Recommendations

The growing understanding of complex trauma and the potential of somatic therapies has significant implications for clinical practice, therapist training, and individuals seeking healing.

A. Integrating Somatic Principles into Complex Trauma Treatment

Clinicians working with complex trauma can enhance their practice by integrating core somatic principles, even if they are not fully certified in a specific somatic modality. A foundational element is adopting a phase-based approach to treatment, which is widely recommended for C-PTSD.43 This typically involves prioritizing stabilization and safety before directly processing traumatic memories.

Key somatic principles that can be woven into existing therapeutic frameworks include:

• Psychoeducation about the Nervous System: Helping clients understand the fight, flight, freeze responses and the concept of the window of tolerance can demystify their experiences and reduce self-blame.40

• Cultivating Body Awareness: Gently inviting clients to notice bodily sensations without judgment can be a starting point for reconnecting with dissociated parts of their experience. Simple practices like mindful body scans or noticing areas of tension or comfort can be introduced gradually.40

• Grounding and Centering Techniques: Teaching clients simple grounding techniques (e.g., feeling feet on the floor, noticing the support of a chair, orienting to the current environment) can help them manage moments of dysregulation and anchor themselves in the present.40

• Resourcing: Collaboratively identifying and strengthening internal and external resources—such as positive memories, felt senses of calm or strength, supportive relationships, or safe places—can build a foundation of stability.

• Titration and Pendulation: Even in talk therapy, the principle of approaching difficult material in small, manageable doses (titration) and helping clients move between challenging feelings and resources (pendulation) can prevent overwhelm.

• Tracking Nonverbal Cues: Paying attention to a client's posture, gestures, breath patterns, and vocal tone can provide valuable information about their internal state and guide interventions.40

Integrating these principles requires sensitivity to the client's pace and readiness, always prioritizing their sense of safety and control. Even without extensive training in a formal somatic modality, clinicians can significantly enrich their complex trauma work by becoming more attuned to the body's role in healing, thereby helping clients move beyond cognitive understanding to a more deeply felt and integrated recovery.

B. Considerations for Therapists (Training, Self-Awareness, Ethical Practice)

The effective and ethical application of somatic therapies for complex trauma places significant demands on the therapist. Specialized training in both complex trauma and specific somatic modalities is crucial.5 Generic clinical training is often insufficient to navigate the nuances of embodied trauma, dissociation, and nervous system dysregulation.

Equally important is therapist self-awareness and ongoing self-care. Working with complex trauma can be emotionally and physiologically taxing, increasing the risk of vicarious traumatization, compassion fatigue, and burnout.5 Therapists must cultivate their own somatic awareness, emotional regulation skills, and engage in practices that support their well-being. The therapist's own level of embodiment and presence significantly impacts the therapeutic container and their ability to co-regulate with clients.5 Managing countertransference effectively is also critical, especially given the intense relational dynamics often present in complex trauma work.

Ethical practice is paramount, particularly when interventions involve direct body focus or therapeutic touch.41 Key ethical considerations include:

• Informed Consent: Clients must be fully informed about the nature of somatic interventions, including the rationale, potential benefits, risks, and alternatives. Consent for any physical touch must be explicit, ongoing, and freely revocable at any time.

• Boundaries: Maintaining clear professional boundaries is essential to prevent exploitation or harm, especially given the vulnerability that somatic work can evoke.

• Competence: Therapists should only practice within the scope of their training and expertise, seeking supervision or consultation when needed.41

• Cultural Sensitivity: Recognizing that experiences and expressions of trauma, as well as comfort with bodily focus and touch, vary across cultures is vital.

Inadequate therapist training, poor self-awareness, or ethical lapses in somatic work can lead to re-traumatization or other harm.41 Conversely, well-trained, self-aware, and ethically attuned therapists are better positioned to create the safe, relational conditions necessary for profound healing from complex trauma.

C. Guidance for Clients Seeking Somatic Therapy

Clients seeking somatic therapy for complex trauma can take proactive steps to find appropriate and effective care:

• Seek Qualified Practitioners: It is important to look for therapists who have specialized training and certification in a recognized somatic therapy modality, as well as specific experience working with complex trauma. Professional organizations like the United States Association for Body Psychotherapy (USABP) or specific modality institutes (e.g., Somatic Experiencing International, Sensorimotor Psychotherapy Institute, Hakomi Institute, International Institute for Bioenergetic Analysis) may offer therapist directories.

• Inquire About Training and Approach: Clients should feel empowered to ask potential therapists about their training, their approach to complex trauma, how they integrate somatic work, and their experience with issues like dissociation or severe dysregulation.

• Prioritize Safety and Trust: The therapeutic relationship is fundamental. Clients should choose a therapist with whom they feel a sense of safety, trust, and comfort. It is important to trust one's intuition about the fit.

• Understand Informed Consent and Agency: Clients have the right to understand all aspects of the proposed therapy and to give explicit consent for any intervention, particularly those involving physical touch. They should know they can decline or stop any intervention at any time without needing to justify their decision. Therapy should be a collaborative process.

• Patience and Pacing: Healing from complex trauma is often a gradual process. Clients should be encouraged to be patient with themselves and to communicate with their therapist about the pacing of the work to ensure it feels manageable and not overwhelming.

By being informed consumers, clients can play an active role in finding a somatic therapist and therapeutic approach that best supports their journey towards healing and recovery from complex trauma.

VIII. Conclusion: The Evolving Landscape of Somatic Healing for Complex Trauma

Somatic therapies offer a vital and evolving paradigm for addressing the profound and often deeply embodied wounds of complex trauma. By recognizing that trauma is not merely a cognitive or emotional experience but one that leaves lasting imprints on the nervous system and physical being, these approaches provide pathways to healing that complement and, in some cases, may surpass the efficacy of traditional talk therapies alone for this population. The core principles of bottom-up processing, interoceptive awareness, nervous system regulation, addressing dissociation through embodiment, and completing interrupted defensive responses directly target the multifaceted symptomatology of C-PTSD, including disturbances in self-organization that often prove resistant to purely cognitive interventions. Modalities such as Somatic Experiencing, Sensorimotor Psychotherapy, somatically-focused EMDR, Hakomi Therapy, and Bioenergetic Analysis, each with their unique theoretical nuances and techniques, collectively contribute to a richer understanding of how to facilitate healing at the deepest levels of human experience.

The research evidence supporting specific somatic modalities for complex trauma is growing, with promising findings emerging from systematic reviews, pilot RCTs, qualitative studies, and extensive clinical reports. However, the field acknowledges the need for more rigorous, large-scale empirical investigation. Methodological challenges inherent in studying experiential, individualized, and body-focused interventions within the traditional RCT framework are significant. Consequently, there is an increasing call for diverse research methodologies—including pragmatic case studies, robust qualitative research, practice-based evidence, and well-designed Level 2/3 studies—to build a more comprehensive and clinically relevant evidence base. The integration of neuroscientific findings is also playing a crucial role in elucidating the mechanisms by which somatic therapies facilitate change.

Future directions point towards greater integration of somatic principles within broader trauma treatment frameworks, a continued focus on building resilience and fostering post-traumatic growth beyond mere symptom reduction, and the innovative use of adjunctive techniques and technologies to enhance embodied processing. The ethical application of these powerful therapies requires highly skilled, well-trained, and self-aware practitioners who can create the safety and attunement necessary for clients to navigate their internal landscapes.

Ultimately, the journey of somatic healing for complex trauma is about restoring a sense of wholeness, agency, and connection—to oneself, to others, and to life. As the field continues to evolve, driven by both clinical wisdom and scientific inquiry, somatic therapies hold the potential to significantly deepen our understanding of trauma's impact and expand the possibilities for profound and lasting recovery for those who have endured prolonged and severe adversity. The continued development and validation of these approaches are essential for unlocking the full potential of the body's innate wisdom in the healing of complex trauma.

Compiled Gemini AI 03.06.2025

Somatic Therapy in Edinburgh and Online

Stuart is a  Certified Traumatic Stress Clinician and has been practicing mind-body analysis and therapy since 1993. He is trained and certified in a number of therapies including Hakomi and various "informed" (competency level certification for professionals) in Sensorimotor and TIST therapies. He is also a certified Chi Gung practitioner (5th Dan Martial Artist) and complementary health practitioner with experience of using movement in somatic work. He is also a certified Mindfulness Clinician and Integrative Clinician. He practices online and at his clinic in Edinburgh.