From the Bottom Up: beginning with the body

Published on 4.15.24 at garyborjesson.substack.com

As a therapist I’ve said I’m often reminded of the phenomenon of flight distance in animals. This comes up in many ways. Here I tell a story about what I mean, that also illustrates what’s meant by working from the bottom up. While I always change identifying details of patients and our interactions, it’s paradoxical because in these notes we are exploring experiences that identify us all as human. For it’s not pathological to feel lonely, sad, mad, or scared, even crazy, anymore than it is to feel safe, connected, loving, and loved.

I won’t forget the drama that unfolded over three sessions. The first set things off by concluding in an unusual way: I ended it before the patient was ready. Usually, they made sure they were done before our time was up, but not this time. It was hard to interrupt their narrative, and I could see it pained them.

The next session they entered my office and, after milling nervously about, sat at the far end of the couch. Usually they sat in the chair across from mine. I said, “I see you’re not sitting in your usual place.” “Too close,” they said in a hushed voice. “What are you feeling?” I asked. “Scared.” “Oh, scared. Do you notice where you feel it in your body?” “My chest is tight and my stomach is jittery.” “That must not feel good.” “It doesn’t. I don’t know why that’s what I’m feeling, but it’s what I’m feeling.” I replied, “Um, I know how that is.”

I’ll pause here and make a distinction to give us context. It’s commonly said there are two basic directions therapeutic work goes: from the top down, or from the bottom up. (I can’t resist adding that there’s a third direction, which is out and back—the interpersonal dimension.) Most therapy sessions involve moving in both directions, but in this note I am focused on the “bottom-up” work, and have omitted the “top-down” parts. Roughly, “bottom up” means that we’re working from body to mind. We’re starting with our bodily experience and eventually moving “up” to our conscious feeling-and-thinking mind.

I’d have been inviting top-down work if I’d asked my patient why they felt scared, since this would have got them thinking—moving up into their head—where they already spend much of their time. Because this person was so often dissociated from their body, I followed my gut sense that their change in flight distance was an opportunity to help them stay with their somatic experience. So I focused on what my patient was feeling and where in their body they were feeling it; I avoided the other directions we might have gone: into what they were thinking, or into what might be going on between us.

From previous work they were familiar with, and had consented to, being prompted to go into their somatic experience. Bottom-up work means getting more comfortable in our bodies, and learning how to feel safe and grounded, even in the midst of strongly felt sensations and emotions. Instead of being overwhelmed by these, we can learn to tolerate and work with them. Even, finally, to see them for the invaluable signals they are—as pain, hunger, thirst, exhaustion, and all the emotions are bodily signals.

Speaking of signaling, I asked my patient whether there was anywhere else in the room they might feel even more safe. Maybe they could try out different places and see. They agreed to the experiment. First they stood up and then immediately sat back down again. “Feels better just to sit.” “Where does it feel better?” I asked. “I feel more relaxed when sitting, less jittery in my stomach and legs. I feel more settled.” After a minute they scooched down the couch, stopping midway, then said: “I feel more scared again, tense.” I replied, “So your body is telling you that’s close enough right now?” “Yeah. Maybe too close.” “Would you like to try taking a few deep breaths there, with long slow exhales, and see if that helps you feel more relaxed, more able to stay?”

By the end of the session they had gone from hovering by the door and sitting at the far end of the couch to scooching slowly down the couch until finally coming to rest at the end nearest me. During the hour, we explored their real-time somatic experience of feeling afraid. Whenever it felt overwhelming, we practiced breathing and self-soothing techniques to help them stay in their bodies and relax enough to bring their distress within the window of tolerance. Slowly but surely, they moved closer to me. At the beginning of the next session, they sat down in the chair across from me, as usual. This was a beautiful, tender reminder of how basic personal space is to feeling safe in the world.

In the next session we talked a little about the meaning of what happened. In other words, we worked our way up to the “top.” They started integrating their felt experience into their evolving story about who they are and how they handle ruptures and the distress they cause—like when your therapist ends a session while you’re in the middle of an intimate story.

I suggested in the last note that flight distance can be seen as a measure of how safe we feel. Roughly speaking, the safer we feel with others, the closer we let them come. In our fast-paced sedentary lives with our immersive technologies, being dissociated from our bodily experience is a common condition. This means we’re less likely to heed our body’s signals as to what’s going on and what we might need in order to feel safe—maybe by taking space—or how we might use skillful awareness and breathing to close the distance again and feel connected.