The following talk was given by Margaret Landale in March 2002 as part of the Confer spring lecture series.
Our subject this evening is how to work effectively and short-term with psychosomatic or stress related disorders. I have decided to make this a practical talk based on my clinical work and experience.
My interest in short-term work is driven both by my own inquiry into how we can support clients to make positive and different choices in their lives and by the ever growing numbers of patients who are visiting their GPs with a range of complaints that appear to be as much to do with psychological health as with physical wellbeing - conditions such as depression, anxiety attacks and stress. In this context the demand for short-term approaches to psychotherapy has grown rapidly.
My aim in this talk is to illustrate how both our body and our imagination are powerful catalysts for recovery. Let's not forget that our bodies are designed by nature to be the ultimate survival experts. In our treatment oriented world we forget too easily that our body knows it's own medicine, that it is designed for healing. I have found this applies also to working with psychosomatic symptoms, indeed it seems at times that the symptoms themselves are the organisms attempt to reinstate balance, to discharge the underlying turmoil, to express physically what emotionally cannot be processed or released.
I will start with D's story. I have chosen this case study and two others which I will come to later, to illustrate what I consider to be the key principles and techniques of working short-term with psychosomatic symptoms.
D was 32 when she came to see me. She had been referred to me through her company's EAP and was suffering from severe dermatological problems which had started to develop over the past two years. Apart from eczema, her skin seemed to randomly erupt into rashes, blisters and infections. It particularly affected her face and chest. At the worst times she experienced unbearable itching and burning and she had tried all sorts of conventional and alternative treatments to relieve the symptoms including diet. However, any external treatment seemed only to aggravate her condition. By the time she came to see me, she had developed a range of obsessive behavior centered around her symptoms. She was particularly concerned about avoiding sunlight, or any form of warmth or heat. She could only have cooling showers and had developed a number of habits around keeping herself cool such as avoiding woolen jumpers, hot meals, hot drinks and cinemas or any public places which she felt were overheated. Because of the condition and her reaction to it D had become socially isolated and withdrawn. She was very ashamed of her appearance and was convinced that people were staring at her and were disgusted by her. She feared going out which meant "showing her face in public". This was of course particularly difficult for her at work. D was in middle management and felt ostracised by her colleagues. She felt that her staff were avoiding her, were disgusted by her and were talking behind her back. Her problems escalated further when she developed spouts of severe diarrhea and vomiting. Prior to the onset of all these problems D had been living an active social life, had lots of friends, a steady relationship of six years and a successful career. She felt that she had lost all of this because of her skin. She admitted that at times she was thinking of finishing herself off, that she had begun to lose hope that she would ever get better. She said during our first session: " I feel like my body is a fiery monster and I am trapped in it". D was strongly identified with her helplessness and felt persecuted and tortured by her own body. Her body and its army of symptoms had become her enemy, launching attack after attack. I have chosen D's case as it represents a typical picture of psychosomatic distress, a cluster of physical, emotional, behavioral and cognitive symptoms, often in conjunction with depression or anxiety disorder. Not to feel overwhelmed, powerless and deskilled, is the first challenge we meet as therapists. What on earth do we have to offer that would help relieve such distress? And in particular how do we work with such a patient when we may only have a few sessions to make an impact.
At this point in my work with D I felt exactly that.
Well, the first assistance that we can draw on is in the structure of the assessment process. Taking the patients personal history and the history of the presenting problem, often provides us with important clues. This sounds easy but it is of course not always straightforward and in Ds case the exploration of her history gave us no indication as to what might have brought on these severe symptoms. We could not detect any significant events either prior to the onset of her symptoms nor anything dramatic in her childhood. This suggested to me that the underlying emotional problems were held deep in the unconscious, which in my experience may either relate to a very early and pre-verbal conflict and/or to trauma.
Let's leave D here for a moment and look at a case of somatisation where there were obvious clues in the person's history. It is crucial during history taking to scan for possible trigger events or experiences. The emotional dissociation with these trigger experiences often prevents the client from making these links, even if they are as obvious as in Ray's case.
Ray was a 36 year old lawyer who had developed Asthma 4 years previous to coming to see me. He had needed hospitalisation several times during this period and it emerged during the history taking, that he had spent much of his childhood trying to mediate between his quarrelling parents. In the interview he said jokingly: "Well, at least it turned me into a good lawyer".
When I asked him to talk about his life before the onset of his asthma, he told me that he and his wife had decided to separate about a year prior to his first attack. On closer examination however, it emerged that his attack had been the same month as his divorce settlement. He had never made this link which is not uncommon. In fact he had felt relief about the separation from his wife as he did not want to end up in "the same quarrelling hell" as his parents. Further exploration, however, brought to light deeply held guilt feelings for not rescuing his parents and indeed his own marriage.
This is a good example of how suppressed or denied feelings re-emerge as physical symptoms. In Ray's case we were now able to make sense of his symptoms in the light of these experiences.
Whilst psychosomatic symptoms can be viewed as an expression of an underlying emotional conflict, they can also actively hide and cover the conflict, thus functioning as a defense. This means that any question which suggests too directly a link between life events and symptoms might get a defensive response, i.e. "nothing has happened that would have caused me to get this illness". So to phrase the questions as a general enquiry about what's been going on in our patient's life is crucial. Or as Brian Broom puts it: "My favorite way of approaching this is to ask: what has been the most important, or major, or difficult thing that has happened to you over the last two years (assuming that the patient's symptoms began eighteen months ago". Brian Broom, Somatic Illness And The Patient's Other Story, Free Association Books,1997, p.76.
In D's case things were more complicated, as no important or significant events surfaced during history taking. So I had to think of other ways in which I could get to the hidden meaning or dissociated emotional material. First of all I had to find out whether D was able or willing to search for the emotional components to her problem and whether she was prepared to actively engage with a process of such discovery.
* Was she able to comprehend that physical symptoms can have emotional causes?
* Was she prepared to make a substantial investment into regaining health, or, as is often the case, did she have too strong an investment in maintaining her symptoms.
These questions and the following assessment criteria have been very helpful to me over the years. I am in particular drawing here on Siffneous and his approach (STAPP - Short- Term Anxiety Provoking Psychotherapy):
* Client has ability to identify a chief complaint, to focus on problem.
* Above average intelligence and some psychological understanding.
* Ability for self-reflection and self-enquiry.
* Ability to think about their behavior, their emotional experience and how they might be responsible for the problem.
* Capacity to recognise and tolerate internal reality with it's wishes and conflicts and to distinguish it from external reality.
* Some capacity to recognise the existence of an unconscious mental life.
* Ability to recognise a psychological dimension to physical symptoms.
* Some degree of self-discipline.
* Some sign of success or achievement in some, even if limited areas of their life and some degree of self-esteem in relation to this.
* Motivation for change, rather than symptom relief.
* Evidence of a 'give and take' or meaningful relationship with another person during early childhood.
* Capacity to relate flexibly to the therapist and to experience and express some feelings.
* Capacity to tolerate challenge and confrontation and the resulting increased anxiety levels. Excluding factors for brief psychotherapy are:
* Fragile ego structure;
* severe self-destructive tendencies;
* serious suicide attempts;
* alcoholism or drug-addiction;
* long-term mental health problems;
* chronic phobic or obsessional symptoms;
Back to D. Ds assessment made it clear that she had the capacity to engage in short-term work and that she was indeed committed to finding the hidden cause for her problem. We identified for example that the vomiting and diarrhea prevented her from having to go to work and that she felt "empty and cool after she'd emptied her body". Usually before these episodes she would spend the night in great agitation and the 'getting ready for work' routine brought up the vomiting or diarrhea. Then, when she called in sick, she experienced a calm and tiredness which would let her rest and sleep. She was able to recognise that this was a defense against facing her problems at work and we discussed other and more productive ways in which she could calm herself. During the six sessions which followed we established a mindfulness and relaxation routine, which helped D to consciously observe her own sensations rather than feeling constantly overwhelmed by them. This helped her to manage her anxiety and the vomiting and diarrhea stopped. But I will expand on this a little more later.
I want to divert from the case study for a moment now and briefly talk about another element of short-term work, namely the therapeutic alliance.
What D and I had now entered is what I call a pragmatic alliance. This is crucial in short- term work, as we need the client to actively and pragmatically engage with and pursue their own process. Brief psychotherapy limits the psychotherapeutic relationship pretty much to working with the here and now transference. It is therefore important to engage the patient as a specialist in their own treatment. The emphasis is on the patient's internal relationship structure. The key questions here are - how does the patient relate to their problem, how are they are invested into their symptoms, do they feel powerless and how do they manage their condition. Equally we have to understand whether there are any benefits for the patient in maintaining the symptoms or whether they are frightened of getting better.
Once the client has gained some insight into these mechanisms we can begin to look at practical strategies to help them begin to respond differently to their symptoms. This also often helps to lower anxiety levels as it takes some pressure away from the focus that the symptoms must be alleviated completely. Helping the client to accept their symptoms and live with them releases pressure and, ironically, often indeed brings symptom relief. This also makes sense when we think of the defensive function that many symptoms have.
Educating the client about the psychological reality of psychosomatic symptoms in a down to earth language also plays a crucial part in forming this pragmatic alliance.
In D's case we established that just as her body was able to produce the diarrhea or vomiting as a way of coping with her anxiety of going out, it might also produce the eczema as an expression of an unconscious conflict or anxiety. That whilst she might have mentally forgotten what disturbed or troubled her, her body could have stored the experience away. That unresolved experience can lead to malfunction in the organism expressing itself through psychosomatic symptoms.
I therefore decided to work with the hypothesis that D's body was producing these symptoms as a form of memory.
This brings me onto the concept of embodied memory - again something that is central to this approach.
In her book "The Body Remembers" Babette Rothschild (a clinical psychologist and psychotherapist, specialising in working with PTSD) reflects: "In general, memory has to do with the recording, storage and recall of information perceived from the internal and external environments. All of the senses are integral to how the world is perceived. The brain processes perceptions and stores them as thoughts, emotions, images, sensations and behavioral impulses." Babette Rothschild, The Body Remembers, W.W. Norton &Co., 2000, p.26.
It is particularly the images and sensations which are being stored away, that I want to focus on now.
Since my training in Body Psychotherapy in the early eighties, I have had a deep fascination for the role the body can play in the psychotherapeutic process. As the body stores away experience, it is also possible to trigger the body into releasing these embodied and unconscious memories back into consciousness. But how can we access this unconscious material or memory via the body?
For many of us the body is a loaded object. It often carries shame and discomfort or on the other hand narcissistic over-identification. Approaching the body directly as was done in traditional body psychotherapy and aiming, for example, at cathartic release or abreaction of emotional process, is terrifying and too provocative for most people. Anxiety levels rise sharply in this kind of work and for most people with psychosomatic symptoms this increase is intolerable as they are already hyper-aroused.
A more indirect way of working with the body is required here. The body communicates in a different language to the rational mind. Body sensations or signals need to be translated into a language which the rational mind can understand. The translating function in this context is the person's imagination. A form of imaging I rely on heavily in my work with psychosomatic disorders is what I have come to call innate imaging.
Innate imaging is an ongoing mental process with sensory components. It is a form of unconscious or semiconscious thinking which underlies our rational (conscious) thinking. It refers to the inner sensory representation of experience. It arises from our senses and is triggered by our sensory perception. We can see this very clearly in trauma victims for example. A sound or smell or visual impression, unnoticed by the conscious mind, but sensually perceived can trigger flashbacks, anxiety or other physical symptoms. Sensory memory refers to the body storing away memory and experience. This can be accessed through innate imaging and in particular by applying innate imaging to the psychosomatic symptom.
We often think of imagery as visual, i.e. seeing pictures with our mind's eye and it is important to understand, that innate imaging, or sensory thinking as it is called in NLP, is triggered by and based in any of our senses. We tend to use our visual, auditory and kinesthetic senses above the olfactory and gustatory but that doesn't mean they are primary for everyone. Individual's sensory thinking or imaging tends to be based in their preferred sense or representational system to use another NLP term. Equally we can trigger sensory experiences through our thinking. Or as Joseph O'Connor and John Seymour put it: "When we think about what we see, hear and feel, we recreate these sights, sounds and feelings inwardly. We re-experience information in the sensory form in which we first perceived it. Sometimes we are aware of doing this, sometimes we are not.... So one way we think is consciously or unconsciously remembering the sights, sounds and smells we have experienced." (Joseph O'Connor, John Seymour, Introducing NLP, p26, Aquarian/Thorsons 1993).
To illustrate what we are talking about close your eyes, focus inward and think of a place where you feel safe and comfortable. Become aware of this place in ever increasing detail. Have a good look around and become aware of sounds or smells. You might feel like moving around, like touching things around you. Feel free to do so. Are you on your own or are there other people with you? Notice how you feel in your body, how does this place affect you both physically and emotionally?
Now open your eyes and take a moment to reflect on this experience. How did you perceive the place you arrived in? Or in other words which of your senses were engaged in your perception of it?
In conjuring up these impressions most people experience a change in their physical or emotional experience, like feeling more relaxed or calm. These changes would probably be different if I had suggested you focus on an unsafe, uncomfortable place. You might well have felt tense and uneasy.
Most of you of course will have imagined places you already know, as images tend to be personal and thus based on past experience. But most importantly, your images will have emerged spontaneously as a flow of associations, in other words innate imaging is a form of free association.
Let's now look at how to access innate images from within a symptom or sensation.
Close your eyes again and become aware of your body. Now notice different sensations in your body. It might be sensations of temperature like coldness or warmth, it might be a tingling, or a lightness or heaviness, it might be tension or discomfort. Let yourself be drawn to a particular sensation and explore this sensation with some curiosity. What colour is this sensation, what shape it is, notice any images, sounds, words or feelings which arise from it? You can make any of these impressions more vivid by exploring your image in ever greater detail.
Open your eyes and brainstorm these impressions on a piece of paper. Now look at the meaning of these associations, what do they tell you about yourself, what do they remind you of?
Okay ... this has, I hope, given you a personal experience of innate imagery and how it represents a form of free association. Let me now illustrate with a different case study how this technique can be applied in practice.
Nick came to see me because he was suffering from depression. Some way into the work he arrived for his session with a splitting headache. When I encouraged him to explore the headache (in a similar way to what you just did in the exercise), the following process unfolded: "My head aches... pain and ache... my body is light... my head is heavy... a heavy blackness, heavy and black as the night... no features... just heavy blackness... my body is so light it loses air... the blackness sucks out the air... I'm being squashed... can't see... no features... can't get away".
Nick fell silent at this point, a heavy silence which became palpable in the room. My instinct was to stay with the silence, both because he seemed deeply engaged in the experience of heaviness and also because this behavior differed dramatically from his usual verbal and rational manner. I used my counter- transferential experience of heaviness to stay engaged and it was from within this shared state that I ventured: "heavy and silent". With a voice deeper than his usual, he responded: "silent as the grave, I'm buried...they've buried me alive", his breathing changed, he seemed to be struggling for breath, his body signaled distress. "They have buried you alive," I repeat, slightly emphasising 'they'. "People in black, all are wearing black, staring down at me as the coffin goes down... I have to stay with him... he is taking me with him!..." short, panting breathing, and then he starts to sob uncontrolably which develops into a deep crying.
When he had calmed down enough we were able to talk about it. It was clear to Nick that he had re-experienced his father's funeral.
His father had died suddenly in an accident. The news had arrived at night, ripping him and his mother out of their sleep. His mother had been unable to cope with this sudden loss and had started to drink heavily and regularly brought different men home at night. He remembered lying awake at night, listening to the noisy sexual activity that went on in his mother's bedroom. This was the first time he had been able to release the grief and despair he had felt in the years after his father's death. He began to understand that a part of him had been buried with his father and that the active and happy little boy he had been had also died at that time. Over the coming sessions he grieved for this loss and began to understand how this experience had affected his life and relationships.
This example illustrates how surrendering into a sensation can trigger strong affective memory, how the body releases its stored and unresolved experience and allows an identification with old pain which can bring meaning to unconscious reactive patterns. It was crucial for me to follow Nick's emerging process closely, echoing his words and allowing my own instinctive perception of what was unfolding before me, but most of all trusting his body and imagination to navigate us through the material.
So how does innate imaging differ from guided imagery or visualization? Well there clearly are overlaps but the way I distinguish innate imagery is that it is a form of free association related specifically to stored body memory and expressed through a preferred representational system. In this respect it is directly linked with the clients unconscious and the images arise spontaneously and often without apparent structure. They are, however, typically symbolic as we saw in Nick's case, and can lead us directly to a deep-seated and often repressed memory or experience. In essence - and this is the core of the approach - it is the symbolic nature of psychosomatic symptoms which provides us with the clues that we are looking for and by using innate imagery we have a potent tool for recovery.
Let me just back this up with a couple of quotes. Jung's words about the potency of symbols are useful here. He said "A symbol should be understood as an intuitive idea that cannot yet be formulated in another or better way." Or as Dulles put it in 'Models Of Revelation', Gill and Macmillan, 1983,p.131.: " A symbol is a sign pregnant with a plenitude of meaning which is evoked rather than explicitly stated."
For us psychotherapists the question then is how to help evoke images, which are pregnant with meaning and, more importantly, how to recognise those images in the patients presentation of thoughts and association.
Let me go back to D now. In her presentation of her symptoms I had been looking for clues to identify those descriptions which might have a symbolic quality about them. I was looking to explore her preoccupation with heat and burning and in particular the potent image, which D had provided in our first session. She had said: "I feel like my body is a fiery monster and I am trapped in it".
Here is what happened in our third session:
D arrived for this session in a state of panic. Whilst her diarrhea and sickness had not occurred during the past week and she had felt less stressed by her work situation, her skin had become much more agitated. She had also developed a very painful tooth infection, which kept her awake at night.
She broke down crying almost immediately and talked about feeling trapped and hopeless and how she felt violated by her own skin. I took this as our cue and asked her what image came to mind about the D who felt trapped in her own skin. Her first response was defensive, a response which often indicates that we have indeed hit on something. She Said " I don't know, I' just want it all to stop, somebody give me a pill or something to make it all go away, it's ruining my life, makes me want to end it all, I just can't bear it any more!" Clearly this was aimed at me. There was a quality of helpless rage in her outpouring and I decided to interpret this in terms of here and now transference. I put to her that she felt let down by me, that I hadn't made the symptoms go away, that whilst she had been a good girl, doing her relaxation exercises and not been sick in the mornings, her skin had become worse, that I had joined the ranks of other helping professionals, not just unable to help her but seemingly making it worse.
She calmed down a little and said: "I know you mean well but I just don't see how we can find out what would help me."
It is often the case that we have to work through negative transference in order to maintain the practical alliance. D was of course disappointed that none of the treatments had worked and we had to recognise her feelings of hopelessness and anger.
After a few more exchanges along these lines I decided to try and direct her attention back to the symptoms she had brought to the session.
I said: "you spoke about feeling trapped in your own skin, how is that now?"
She responded: "I don't know, my tooth is hurting...."
I: "describe the pain to me".
D: (sounding slightly exasperated) "it's red, hot like somebody's put a red hot poker into my mouth, that's why I can't sleep at night, it keeps me awake, all I can think of is this pain and that it is hot and...you know it's really weird, but I believe somehow that the heat in my tooth brings up my eczema".
I: "heat is something that keeps coming up, what associations do you have with heat".
D: well... heat, hot, red, oven, sunburn, burning, trapped, being trapped.... can't get out...(signs of distress, tears welling up, and then in a very quiet breathless voice)....and flames, flames, flames burning skin... burning skin....". She covered her face, her body became rigid, her skin remarkably lost it's colour and I could see that she was holding her breath.
The symptoms I was witnessing confirmed to me that we might be dealing with surfacing traumatic material. The danger at this point is that the body simply reproduces the traumatic experience by going into panic and shock, thus making it impossible to bring into consciousness and integrate what happened. My challenge was to help embodied memory to surface without allowing her to collapse or go into shock. My first priority at this point was therefore to lower D's state of arousal.
I asked her to focus on her breathing and to go to her safe place.
Let me briefly explain about 'safe place'. The mindfulness/relaxation practice, we had established in the beginning of our work incorporated a defined image of a safe place. Babette Rothschild refers to this as an anchor, she says: "Basically an anchor is a concrete, observable resource (as opposed to an internalised resource like self-confidence). It is preferable that an anchor is chosen from the client's life so that the positive memories in both body and mind can be utilised. Examples include a person (grandmother, a special teacher, a spouse), an animal (favorite pet), a place (home, a site in nature), an object (a tree, a boat, a stone), an activity (hiking, swimming, gardening). A suitable anchor is one that gives the client a feeling (in body and emotion) of relief and well-being." Babette Rothschild, The Body Remembers, W.W.Norton & Company, p.93.
D's safe place was a particular village in Scotland where she had friends and had spent several happy holidays. The landscape and cool climate gave her strong associations of health and she was convinced that were she to live there, her symptoms would recede.
So I suggested she find herself in her safe place and I supported this with detailed description of this place in order to keep her innate imaging process going.
When I noticed her physically relaxing I suggested that she would now be able to project any images which came to her, onto a screen, that she could remain in her safe place whilst watching these images unfolding, that she could stop the image projection at any time.
D said: "It's all a bit blurry but I can see a cat, Patch, don't know why I am thinking of Patch, she was my Grandmother's cat, I used to stay with Gran at her farm during the holidays, I always gave Patch her bowl of milk."
I: "So you want to give Patch a bowl of milk?" D: "I have to go and see Pete, he milks the cows he has the milk, I try and find Pete, he must be in ...."
Here she breaks off and I notice again signs of rapidly increasing distress but this time there is a different quality to it. She is deeply absorbed inwardly, it seems clear to me that she is watching something unfolding internally, the distress signs don't suggest collapse, there is a palpable intensity about her. Then she covers her face with her hands and begins to cry.
What emerged when she had gathered herself enough was the story of an accident that D had witnessed. D remembered how when she was about five, she had stayed at her Grandmothers. She wanted to get the milk for Patch and headed towards a barn in which she was hoping to find Pete, a farm worker she had grown attached to and it was their little morning ritual for her to collect milk from him. She was hit by the noise and heat of a sudden explosion.
Luckily she was far enough away not to have been burnt herself but she saw Pete running out of the barn his clothes in flames. He was very badly burnt and died in hospital. She had buried this memory deep in her unconscious and we were only able to speculate what might have triggered her symptoms two years ago. The way these things work out, she might have just watched scenes of an explosion or fire on the TV.
We were now able to attach meaning to her symptoms and the remaining sessions were spent integrating her recovered memory.
Things are of course not always as straight forward as in the above cases but I have no doubt that there is enormous potential in involving the body in the psychotherapeutic process and I hope that this talk has given you some ideas as to how to access the hidden meaning of illness through body symptoms.
I'd like to finish off here with a quick summary of the practical skills that a therapist needs when using this approach which will complement the assessment guidelines we covered earlier ...
Remember that it's essential to establish and maintain a pragmatic alliance with the patient - that means we need to be able to engage them in their own recovery and work in a way that is far more directive than in long-term work. Typical techniques and skills that can help here are:
- working with symptoms and the presentation of disorders as symbolic and meaningful - having some understanding of the effects of trauma on the body and being familiar with some PTSD techniques - introducing and teaching mindfulness and relaxation exercises including breathing techniques - applying some cognitive behavioral techniques - using positive thinking or affirmations, - using creative techniques such as imagery, drawing and writing. - reading body language, especially the signs of arousal, closing down or distress and responding to it appropriately - working with the patient's defense, resistance or negative transference and being prepared to actively engage with the here and now transference - using imagination and having the courage to follow our intuition or instincts. - we also need to have at our disposal a few down to earth explanations or maps which can help the patient understand the inter-relatedness of body, mind and emotions. Imagine you would have to explain this to somebody in a pub who has never entertained any psychological ideas. This doesn't mean you have to patronise your client but it does mean talking to them in language that they can understand.
Finally this approach requires that we view body-mind-emotion as an interactive open system which has an innate capacity for integration and healing.
* Brian Broom, Somatic Illness, Free Association Books, 1997.
* Joyce McDougall, Theatres of the Body, Free Association Books, 1989.
* Babette Rothschild, The Body Remembers, Norton, 2000.
* Piero Ferrucci, What We May Be, Mandala, 1982.
* Joseph O'Connor &John Seymour, Introducing NLP, Aquarian/Thorsons
* Windy Dryden, Reason To Change, Brunner-Routledge, 2001.
* Mander, A psychodynamic Approach to Brief Therapy, Sage, 2000.
* Wiener/Sher, Counselling and Psychotherapy in Primary Health care, Macmillan.
* David Malan, The Frontier of Brief Psychotherapy, Plenum, 1976.
* Peter Sifneos, Short-Term Dynamic Psychotherapy: Evaluation and Technique, Plenum, 1987.
* Habib Davanloo, Intensive Short-Term Dynamic Psychotherapy: Selected Papers Of Habib Davanloo, Wiley, 2001.
Margaret Landale is an Integrative Psychotherapist, supervisor and trainer. She is also a member of the training committee at the Chiron Centre for Body Psychotherapy, London. She specialises in working with stress-related and psychosomatic disorders and has worked for several years in mental health, where she developed and ran a stress clinic offering short- term counselling and stress management programmes. Recently she has developed and runs courses in Brief Symptom-Focussed Psychotherapy for counsellors and psychotherapists. Her particular interest has been in the application of imaging techniques and their benefits to short- term psychotherapy. Her chapter on this subject has just been published in a book entitled 'Advances in Body Psychotherapy', published by Routledge, 2002.