The Body Atom and psychosomatics

O Átomo Corporal e a psicossomática

El átomo corporal y la psicosomática

ABSTRACT

The authors of this article have created a unique technique based on their experience working with patients in both general hospital and private setting. The technique, called the Body Atom, is based on Moreno’s idea of the social atom and the theories developed by L’Institut de Psychosomatique Pierre Marty for understanding the origins and progression of psychosomatic diseases. The Body Atom was applied to hospitalized patients with cardiological diseases and patients with endometriosis in a private practice setting. Both groups responded positively to implementing the Body Atom, which helped them understand their personal experiences and relate them to their illnesses and body parts.

KEYWORDS
Body Atom; Psychosomatics; Monodrama; Clinical psychology

RESUMO

Os autores deste artigo criaram uma técnica exclusiva com base em sua experiência de trabalho com pacientes tanto em hospitais gerais quanto em ambientes privados. A técnica, denominada Átomo Corporal, baseia-se na ideia de Moreno do átomo social e nas teorias desenvolvidas pelo L’Institut de Psychosomatique Pierre Marty para compreender as origens e a progressão das doenças psicossomáticas. O Átomo Corporal foi aplicado a pacientes hospitalizados com doenças cardiovasculares e pacientes com endometriose em um consultório particular. Ambos os grupos responderam positivamente à implementação do Átomo Corporal, que os ajudou a entender suas experiências pessoais e relacioná-las com suas doenças e partes do corpo.

PALAVRAS-CHAVE
Átomo do Corporal; Psicossomática; Monodrama; Psicologia clínica

RESUMEN

Los autores de este artículo han creado una técnica única basada en su experiencia de trabajo con pacientes tanto en el ámbito hospitalario general como en el privado. La técnica, denominada el Átomo Corporal, se basa en la idea de Moreno del átomo social y en las teorías desarrolladas por L’Institut de Psychosomatique Pierre Marty (IPSO Pierre Marty) para comprender los orígenes y la progresión de las enfermedades psicosomáticas. El átomo corporal se aplicó a pacientes hospitalizados con enfermedades cardiovasculares y a pacientes con endometriosis en una consulta privada. Ambos grupos respondieron positivamente a la aplicación del Átomo Corporal, que les ayudó a comprender y relacionar sus experiencias personales con sus enfermedades y partes del cuerpo.

PALABRAS CLAVE
Átomo Corporal; Psicosomática; Monodrama; Psicología clínica

INTRODUCTION

Psychodrama

Psychodrama is a method that takes place in a group context and allows participants to explore difficulties, through role play and other action techniques, and utilize the process of awareness and reflection. The creator of psychodrama, Jacob Moreno, believes that dramatizing has a greater therapeutic effect than just talking (Moreno, 1946). Psychodrama helps the individual discover repressed feelings and emotions that get in the way of various situations. It gives a chance to develop potential and improve relationships with self and others.

The body is an essential tool in psychodrama. Through physical action and expression, people reach deeper levels of awareness and understanding and work through emotional and psychological challenges in a creative and supportive environment.

Bessel van der Kolk (2015) points out that play, improvisation, theater, and other experiential methods have many advantages in the treatment of psychological trauma. He repeatedly highlights the importance of intentional and meaningful action to loosen hard-to-carry emotions that seem to be “stuck” in the nonverbal and unconscious subcortical areas of the brain, in which they are inaccessible to the thinking and reasoning parts. His research confirms Moreno’s words: “The body remembers what the mind forgets.”

Psychodrama involves improvisation, creativity, role-playing, and other techniques and patterns of thinking that help a person to come out of the feeling of freezing when approaching a traumatic emotion. It provides a safe and secure space in which the individual can explore through action. The role play allows a different response and continuation, which in turn would lead to new responses and regulation in the nervous system.

Monodrama

Moreno seldom addressed the application of psychodrama in individual contexts, and he typically highlighted its limitations and recommended the incorporation of trained auxiliary egos during individual sessions (Figusch, 2019; Moreno, 1946). Figusch (2019, p. 11) notes: “Despite Moreno’s resistance to and lack of enthusiasm for one-to-one psychodrama, this approach has become part of the routine practice for psychodrama therapists globally.” Presently, practitioners frequently employ psychodrama in individual sessions, often without auxiliary egos. Given Moreno’s view that the dyad represents the smallest group, some argue that one-to-one psychodrama can be seen as another facet of Moreno’s group psychotherapy (Brito, 2019).

Various terms have been used to describe this approach, such as monodrama, bipersonal psychodrama, one-to-one psychodrama, psychodrama a deux, and individual psychodrama. Numerous contemporary authors, including Chesner (2019), Cukier (2008), Figusch (2019), Fonseca (2004), and Knittel (2009), have extensively explored this topic.

In a monodrama, the protagonist assumes all roles without any auxiliary participants, making use of only one role player. This method is commonly employed in individual therapy due to the absence of other participants (Blatner, 2000). Typically, other roles are represented using empty chairs. Gestalt therapy considers monodrama a fundamental technique (Blatner, 1996). Additionally known as bipersonal psychodrama or psychodrama a deux, it involves two individuals, the director, and the protagonist, in one-on-one sessions (Cukier, 2008; Knittel, 2009).

The expansion of the social atom

The social atom was invented by Jacob Levi Moreno. He suggests that the social atom starts to develop with the relationship between the child and the mother. Then, it begins to include the people who come into their lives and expand their surroundings (Moreno, 1941). It is used as a diagnostic and treatment tool and helps to learn more about the close interpersonal relationships of the individual. By exploring the social atom, participants can get new insights about their social relationships and identify areas of strength and support. They can develop strategies and mechanisms to improve their social connections. In addition, the social atom can give a deeper understanding of the factors that may be influencing the physical symptoms, and therefore one can develop strategies to deal with these issues.

Moreno (1941) also describes another type of atom–the cultural atom. It shows how the different roles relate to one another’s interpersonal reality. This also explains the feelings of attraction and repulsion in communication with others.

Many specialists started using the social atom in different ways and created tools for exploring various relationships. For example, the food atom (Caranbucci & Ciotola, 2013) explores the relationship that a person has with food, how close or distant they feel particular foods and what type of food is included or excluded from their menu. Together, the patient and the specialist can explore what motivates the food choices and which of them are labeled as “good” or “bad” choices. One of the main purposes is to reveal the metaphor of a patient’s relationship with food, self, and others.

The recovery support atom is usually used for exploring the relationship between a patient and their addictions. The goal is to identify which are the positive (supportive) and the negative influences that the individual has with their surroundings. It assists people in discerning which relationships to maintain, those that may require adjustment, and which ones to release. The goal is to achieve sustainable recovery. Although it targets addiction, the recovery support atom can be useful for patients seeking any kind of change (Salimbene & Sewell, 2023).

Another type of atom–named by the authors–the Body Atom¹, will be presented for the first time in this article. The Body Atom is designed to explore the connections between different parts of the body and how people perceive them. Further details regarding the construction of the Body Atom will be provided in the Method section.

Each of these atoms provides valuable information on how social, cultural, and other factors shape the experiences and behaviors of individuals, aiding in the development of strategies for growth and change.

Psychosomatics

In 1964, a World Health Organization expert committee noticed two different meanings of the term psychosomatic. The first referred to “the holistic view in medicine, a shift from a narrow focus on diseased organs and systems to an examination of the patient in his environment, both social and psychological” (World Health Organization, 1964). This aims to introduce a more humanistic, unified approach to the diagnosis and treatment of physical illness. At the same time, with the broadening of the concept comes the loss of its more specific meaning. The second and more limited use of the term restricts it to such diseases in which psychological factors are thought to play a special role. In her article, Bronstein (2011) talks about the paradox associated with these two different usages; for when the term is used to describe only certain diseases, it seems to undermine a unified approach to medicine. This paradox remains unresolved.

The term psychosomatic is widely used, although its definition is still not quite clear. Whitlock’s (1976) explanation of psychosomatic conditions as those “in which emotional influences play a significant role in genesis, recurrence, or potentiating” is interesting. This does not exclude the possibility of many other factors contributing to the development of a particular illness (genetic, physical, environmental, etc.).

Diseases do not appear and do not proceed uniformly. In many cases, their etiology is related to psychogenic factors. The emotional factor is a determinant that is entirely or partly unconscious. A person’s experiences are accompanied by functional changes or pathological disorders in the organs. Individual predispositions are likely to influence the development of a particular disease, and the constitutional features of the organism are also considered as a determining factor. Each of these theories has been criticized and reformed, but all have also contributed to the understanding of the relationship between the soma and the psyche. Psychosomatics or the treatment of psychosomatic illnesses offers a new approach to the sick person and, for this reason, belongs to the history of medicine.

The term psychosomatic first appeared in the 19th century. Its creator is believed to be the German psychiatrist Johann Heinroth, and Felix Deutsch is considered the first professor of psychosomatic medicine in the United States–around the 1940s. This new stream in medicine aimed to update and introduce the influence of psychological factors on physical diseases (Steinberg et al., 2013).

Addressing the psyche-soma dilemma, Freud (1910) provides a profound insight. Rather than a conflict between bodily desires and mental wishes, he suggests that contradictory forces may clash within a single somatic locus. In his 1910 essay, “The Psycho-Analytic View of Psychogenic Disturbance of Vision,” he introduces the notion of an organ serving two masters simultaneously, illuminating how such conflict imbues organic symptoms with significance. Hysterical conversion transforms the body into a language, with symptoms narrating an unconscious tale rooted in the erotic libido. Confronted with hysteria in clinical practice, Freud (1910) boldly disregards the taboo surrounding the psychological aspect of certain disorders. His approach underscores the fundamental role of sexuality–and, consequently, the body–in shaping the psyche.

Patients suffering from psychosomatic illnesses have been studied by many authors, mostly with a psychoanalytic orientation, and what they all confirm is the reduced ability of these individuals to process emotions. They have been described as people who are unaware of their emotions, cannot verbalize them, and have difficulty distinguishing and differentiating between anger and happiness (Nemiah, 1978). The most used term to describe this condition is alexithymia, literally translated as a lack of words for emotions (Sifneos, 1973). This concept evolved into “mechanical functioning” (Marty & De M’Uzan, 1963) characterized by a traumatized way of operating, often accompanied by a strong focus on physical sensations as a defense mechanism against internal turmoil.

While the concept of health in the context of psychosomatic equilibrium traces back to Hippocratic medicine, the foundation of the Paris Psychosomatic School is rooted in the discovery of the psychoanalytic method. According to Marillia Aisenstein (2006), the IPSO model of psychosomatics represents a logical evolution of psychoanalysis, arguably reaching its pinnacle.

Another pivotal concept within the framework of psychosomatic patients, as posited by the Paris school, is that of “essential depression.” This form of depression manifests not as conventional feelings of sadness or pain, but rather as a profound absence of desire, resulting in a pervasive sense of emptiness for the patients. These individuals grapple with regression, finding themselves unable to engage in mourning or achieve emotional catharsis. Consequently, this struggle often leads to the establishment of a tyrannical ego ideal and the potential disarray of both somatic and psychic functions.

Regression, or rather the inability to regress, holds significant importance in the clinical domain of psychosomatics. When patients are unable to regress, they fail to engage in processes of suffering or mourning, leading them to persist in their activities without acknowledging fatigue or the need for rest. This absence of regression often results in the replacement of the protective superego with a tyrannical ego ideal, and, in cases in which regression is unattainable, it gives way to disorganization. In the conceptualization of the human being as a psychosomatic unity, this disorganization can manifest as both somatic and psychic disorders.

In this model, instinctual drives originate from bodily excitations, serving to alleviate the tension they generate. However, when these excitations become excessive, the functional systems may become disorganized, overwhelming the mental apparatus and paving the way for somatization. The concepts of disorganization, fixation, and regression are central to this intricate and densely woven framework, which is challenging to succinctly articulate.

Early trauma, potentially occurring before the acquisition of language, can lead to various failures in psychic structuring. In such cases, individuals may develop character traits or attachments to narcissistic values in place of purely mental defenses. This often results in a recourse to somatic solutions, bypassing the process of psychic working through and leading to what some describe as an “acting-in in the body” (Aisenstein, 2006).

The therapist needs to consistently adapt and monitor the different levels of the patient’s mental functioning, all while considering the significant economic impact of the illness and its progression. Pierre Marty (1976) suggested a guiding principle that serves as a framework, illustrating the array of options within the therapist’s interpretive role, ranging “from maternal function to psychoanalysis.” This framework presents two perspectives: one involving the therapist’s maternal role, and the other one focusing on the interpretive aspect of classical psychoanalysis. The therapist’s maternal role involves an attitude deeply rooted in the psychoanalyst’s ability to identify with the patient, guiding their emotional movements and providing support. Its objective is to establish or restore a protective barrier against the patient’s emotional distress or, in cases of severe depression, to introduce sources of stimulation.

The therapeutic bond between therapist and patient holds significant importance, as it facilitates the patient’s emotional growth and adaptation. The psychoanalytic psychosomatic therapist’s work demands that they remain committed to the patient, even during challenging moments when the patient’s behaviors might be particularly demanding. This phase represents the most intricate aspect of the therapist-patient relationship, in which maintaining an analytical stance while supporting the therapeutic process is crucial. Once again, emphasis is placed on the diverse techniques therapists can employ, not limited to solely psychoanalytic methods. Marty (1976) suggests that psychodramatic techniques can also be effective in unraveling the patient’s defenses, provided that the therapist monitors the patient’s readiness and capacity.

Regarding the conclusion of therapy with such patients, there’s no one-size-fits-all approach. Termination can occur gradually or extend over an indefinite period. Detaching from the therapeutic relationship can prove challenging for patients, and, in some cases, it may even trigger regression and a return to severe symptoms. Therapists are advised to utilize their full range of skills and knowledge, continually adapting to the evolving dynamics and needs of the patient (Smadja, 2011).

Part of the materials used in the article are from one of the authors’ dissertation–Personality profiles of patients with cardiological and cardiosurgical interventions (Azis, 2022). It presents Violeta Azis’ continuous work in the hospital and explores the intricate realm of cardiac diseases and cardiac surgery, highlighting the involvement of clinical psychologist-psychotherapist in conducting diagnostic evaluations of personality traits relevant to treatment options and medical interventions. Additionally, it delves into the psychotherapeutic impacts associated with these assessments. The concepts for the relationship between personality and the specific development of the disease are explained and listed in four main groups, according to the understanding of the symptoms of the disease:

• Theories of the specific personality, according to which certain personality traits are predisposition to a disease. These theories are related to the names of Ernst Kretschmer, Flanders Dunbar, Hans Eysenck, Gordon Allport, Raymond Bernard Cattell, etc.;

• Theories of the specific model of response, in which the diverse emotional patterns and reactions of stress are transmitted transgenerationally through different organs. Each person has a specific pattern of stress response, with some being dominated by gastrointestinal reactions, and others by cardiovascular symptoms. The psychological theories of stress gradually evolved from the theory of emotion (James-Lange), the emergency theory (Cannon-Bard), to the theory of emotion (Schachter-Singer); Hans Selye’s theory of systemic stress based in physiology and psychobiology, and the psychological stress model developed by Lazarus;

• Theories of the specific conflict, according to which the ineffective resolution of internal unconscious conflict can become a symptom. These are the psychoanalytic theories, connected to the names of Sigmund Freud, Sandor Ferenczi, Georg Groddeck, Viktor Frankl, Schultz-Hencke, Franz Alexander, and other psychoanalysts;

• Theories of non-specificity. Central to the theories of non-specificity is the theory of alexithymia. Sifneos and his colleagues (Nemiah & Sifneos, 1970; Sifneos, 1973) are considered the first to define the term alexithymia–”no ability to read emotional life.” Pivotal to this concept is the understanding of the influence of psychological factors, namely the inability to express emotions, and feelings and recognize them in others. This condition is thought to be the result of a significant psycho-emotional deficit. Such patients are extremely literal; experience operational/mechanical thinking (pensée opératoire); and have reduced or no capacity for mentalization. This means that they are incapable of symbolization and are rarely in contact with their inner world.

PURPOSE

The authors’ purpose is to introduce their experience in working with individuals in private practice and patients in a general hospital via Body Atom. It also presents the new instrument and its implementation in different settings with two groups of patients–inpatients with cardiological diseases and patients with endometriosis–in a private office.

The study synthesizes some of the experiences of inpatients related to their feelings of powerlessness, vital threat, and isolation during their stay in the hospital. It traces a range of affective states provoked by vulnerability and lack of clear perspectives–on the one hand, because of impending heart surgery; and, on the other, for the group of patients with endometriosis, the questions of femininity and birth. Both groups encounter a sense of powerlessness regarding their bodies due to the unpredictability of the disease.

METHODS

The methods which are used in the present article are the technique of the Body Atom, monodrama, and psychodynamic approach. Both therapists use a psychodynamic model of thinking and monodrama as a combination of two methods. Psychodynamics serve as an explanatory model of patients’ psychological functioning, and the psychodramatic techniques provoke and facilitate patients’ spontaneity and creativity, which is critical for processing difficult content and the trauma of illness and its aftermath.

The Body Atom

The Body Atom is a unique technique coined by the authors in 2022. It gives opportunity for the investigation of relationships and analysis of strengths and weaknesses in the human body. This enables patients to consider the integration of their body and mind, to visualize and reconcile their sick and healthy parts, and to delve into the significance and comprehension of themselves.

The technique of the Body Atom underwent several iterations before reaching its final form. Initially, it was referred to as the Psychosomatic Atom, since many patients discussed the affected parts of their bodies, yet there was no specific medical explanation for their conditions. Usually, they could start their sessions with a prolonged narrative about their diseases or pain in the body. A lot of discussions were related to explanations of which parts of their body they don’t like and how this reflects on their life.

Later, during the sessions, patients were asked to think about their pain, illness, or body aversions, and draw all of them on a piece of paper, the same way it is done in a social atom. The patient will be in the center of the diagram, surrounded by diseases, pain, and parts of their body that they don’t like. If the pain is intense or if the patient thinks more often about this body part, they can draw a bigger circle. See an example in Fig. 1.

Figure 1
The psychosomatic atom.

This method offers an opportunity to explore and closely examine the relationship between the parts of the body causing pain and the underlying factors behind the symptoms. What is the body trying to say?

The next step in the development of the technique was to think about the healthy parts and organs in the body. Typically, patients discuss their pain and ailments, but overlook their moments of health. What is their health history? Which parts of their body they do like, and which ones do they perceive as healthy? If a patient feels a stronger connection to a particular body part, whether due to personal affinity or its significant impact on them, they may choose to draw a larger circle. The idea of the Health Atom was conceived and helped reinvent the positive aspects and feelings in the body (Fig. 2).

Figure 2
The Health atom.

Each atom shows different information and associations. Frequently, patients tend to compartmentalize their bodies, making it challenging to perceive it as a unified whole and examine its interconnectedness. Therefore, the technique further evolved to encourage viewing the body as an integrated system, as a cohesive unit. The authors illustrated the relationships in the whole body and named the technique the Body Atom. It encompasses all body parts associated with pain, diseases, health, preferences, and aversions (Fig. 3).

Figure 3
The Body atom.

Monodrama and psychodynamic approach

In the present study, monodrama was employed in conjunction with the Body Atom. Through psychological consulting and psychotherapy, patients can delve deeper into their relationship with their bodies. Following the completion of their Body Atom diagram, they spontaneously assumed different roles, leading to experiences of catharsis and a newfound perspective on their bodies. Utilizing techniques such as monodrama and the psychoanalytic model of the psychosomatics, patients can further explore their Body Atom, uncovering a sacred space for resolving unconscious conflicts and achieving integration. Additionally, psychological consulting and psychotherapy provide avenues for processing negative experiences and coping with difficult emotions.

PARTICIPANTS

The study included 37 patients–women, aged between 30 and 56 years old. Twenty of the patients suffered from cardiological diseases and had undergone various procedures or surgeries at the University Hospital “Lozenets,” Sofia, Bulgaria. Psychological consulting before intervention (two or three days prior) and after discharge from the hospital it is performed for a period between six months and two years.

The rest–17–were diagnosed with endometriosis and were patients from the free admission office. All the subjects had undergone long-term psychotherapeutic treatment. The authors selected the two groups of patients because they possessed sufficient interaction and experience to formulate hypotheses regarding certain behavioral patterns related to health. Additionally, they had ample observation of their experiences as patients, both in hospital settings and in private offices.

The clinical observations were conducted in the period from 2022 to the present. Psychological counseling and psychotherapy give opportunities for emotional stabilization and overcoming fears and tensions during hospitalization, as well as for achieving overall integrity and rehabilitation after discharge from the hospital.

Cardiological and cardiosurgical interventions play a crucial role in the health and survival of numerous patients, aiming to optimize their health status. Although patients are aware of the irrevocable nature of these interventions, they often experience them as traumatic events, leading to intense anxiety and tension in the preoperative period. The postoperative period is characterized by episodes of prolonged depression. Patients undergoing cardiological and cardiosurgical interventions experience various challenging psycho-emotional phases. Uncertainty about the outcome of the intervention, coupled with the pain associated with the procedures, exacerbates feelings of anxiety and confusion before and after treatment. Psychological counseling provides significant support for patients’ recovery and contributes to maintaining their emotional balance.

Given the fundamental role of the heart in maintaining bodily functions, patients may experience a profound sense of existential threat. They often struggle to symbolize and process their experiences, resorting to operational/mechanical thinking as a coping mechanism. This mental state, referred to as pensée opératoire (Marty & De M’Uzan, 1963), commonly manifests during the preoperative period and is associated with the phenomenon of alexithymia, in which patients have difficulty recognizing and differentiating their emotions. These psychological states align with the psychosomatic personality theory, and patients may also face challenges with associative abilities and organizing their thoughts concerning time (Krumova-Pesheva, 2017).

The other part of the patients in the study–17 women–are patients from the private practice in the psychological cabinet. They visited psychotherapy weekly for at least six months.

Endometriosis is a gynecological disease in which tissue like that of the uterine lining, the endometrium, spreads to different locations in the body, outside the uterus. Moreover, under the influence of the female hormonal cycle, these endometriotic foci grow and bleed every month. Endometriosis impairs ovarian reserve and reduces the number of eggs. It also creates immune problems that interfere with embryo implantation. At a later age, it can also manifest in long-bleeding pain and inability to perform daily activities (Nadezhda Women’s Health Hospital, 2022).

In our practice, when working with patients with endometriosis, we often encounter several aspects. Patients show difficulty in building close relationships and depending on others. Issues related to femininity are present and how patients try to explain what is happening to them. They report experiences related to gender injustice and “having something taken away from them” that they rightfully should have. A study from Yale School of Medicine (Azab, 2023) has shown that women with endometriosis experience depression, anxiety, and eating disorders, and, even when the chronic pain is regulated, still high levels of depression and anxiety are present. This means that probably there is a different mechanism that influences the women’s mental health (Azab, 2023).

RESULTS

In this study, several instruments were employed. The results are categorized into three phases, each with varying durations of psychotherapy continuation, ranging from three months to two years.

First phase: psychological counseling

Cardiovascular patients

The most common practice at “Lozenets” University Hospital is for patients to be referred to a clinical psychologist for consultation prior to surgery. This referral typically originates from the attending physician. Consultations take place either at the patient’s bedside or in the psychologist’s office within the hospital, depending on the patient’s condition. The participants in this study were characterized as individuals who, in both the initial interview and subsequent sessions, displayed limited capacity to identify, articulate, or elucidate their feelings and emotions. They seldom made connections between their bodily symptoms and emotional experiences. These patients often exhibited symptoms indicative of “essential depression,” as described by Marty and De M’Uzan (1963), characterized by feelings of emptiness and a complete lack of desire.

Patients with endometriosis

At the outset of the sessions, the patient articulates their reason for seeking psychotherapy. Patients with endometriosis begin to describe their symptoms and the pain they experience. As the sessions advanced, it became clear that we were engaging with a psychosomatic patient facing difficulties in mentalizing and demonstrating a predominant reliance on “operative thinking.” The patient struggles to integrate different aspects of their life with their emotions and challenges, leading the body to manifest its illnesses.

Second phase: Body Atom

The Body Atom technique was introduced to each patient at various stages of the therapeutic process. Some are in the early stages of psychotherapy, while others are engaged in long-term treatment. Similar to the social atom, the Body Atom serves a diagnostic function. The therapist assists the patient in drawing the diagram and allows them time to contemplate their entire body. For some patients, this proved to be a challenging task, occupying the entire session, while others found it easier. The therapist prompts them to consider all the parts of their body experiencing sickness or discomfort, alongside those they harbor negative feelings toward. Following this, patients are encouraged to reflect on the healthy parts of their body and identify which areas they appreciate. Interestingly, patients found it most challenging when encouraged to contemplate the parts of their body they liked. Depending on the session’s duration, the Body Atom exercise can either consume the entire session with drawing and reflection, or progress to the third phase.

Third phase: monodrama and psychodynamic approach

Depending on the time with some of the patients, monodrama or a vignette was applied during the session. The therapist instructed the patient to examine the Body Atom and endeavor to perceive it as a sculpture representing their strengths (healthy parts) and weaknesses (sick parts) in relation to their body, and, additionally, to view the illustrated parts as distinct roles. The patients were expressing their emotions and sharing surprising discoveries. They assumed various roles, creating sculptures representing the entire Body Atom, as well as the roles of their ailing and robust body parts. They were then encouraged to select a few roles that currently exert the most influence in their lives and engage with them monodramatically. Moreover, they were prompted to take on the role of an observer and propose advice to the protagonist, which, in this instance, was themselves.

For instance, one patient recognized a pattern of ailments predominantly on the left side of their body, prompting reflection on their tendency to rationalize rather than listen to their heart. Giving the space of communicating and connecting with the different parts of the body, the patients were able to reach a catharsis of integration. After the completion of several monodrama scenes and thorough exploration of diverse roles, our work is advancing with a profound insight into how the psyche and soma are intricately linked in the individual experience, particularly through the lens of psychosomatics.

DISCUSSION

The study’s findings suggest that patients tend to accept their illness with reason, but struggle to emotionally come to terms with its negative impact on their personalities. These patients use technical terms to describe their bodies without providing specific details or elements. This phenomenon is similar to the concept of “mechanical life/thinking” (pensée opératoire) as proposed by Pierre Marty and Michel De M’Uzan (1963), in which symbolization and fantasizing are either absent or blocked.

The first group of the study are patients with cardiovascular disease. Their illness can have a profound emotional impact, as they may experience a range of emotions, such as anxiety, depression, fear, and distress, especially following a diagnosis or during treatment. Below are listed some of their characteristics:

• Patients experience intense conflicts related to the process of acceptance of the disease and the unconscious psychic phenomena associated with it;

• Some of the leading emotional experiences are the sense of loss and emptiness, which can persist during the whole period of the psychotherapeutic work. The attitude towards the somatic illness contains multiple elements that can be summarized through the prism of the rational and the emotional. Accepting the illness in a psychological sense includes integrating these elements, and it defines the patient’s attitude toward the diagnosis and treatment (Krumova-Pesheva et al., 2011);

• Patients who suffer from heart disease have significantly reduced capacity for expressing and verbalizing emotions (Williams et al., 1985; Xia & Li, 2018). Based on this hypothesis and the researchers’ experience , the techniques of the Body Atom were implemented to explore deeply this tendency and to try to utilize expression. It is suggested that using the “line of disease” and the parts of their bodies that they consider strong and healthy, weak or dislike will show a broader picture of the psychosomatic world of these patients and provide the opportunity to not only identify but also verbalize, illustrate, observe, and work with their diseases, pains, as well as their strengths.

The other group in the study comprises patients with endometriosis. The disease adversely affects the quality of life of these women. They often experience severe physical pain, and psychological discomfort, and suppress their feelings. Women suffering from endometriosis:

• Often express difficulty in building intimate relationships and trusting men. They fear being misunderstood and hurt;

• Experience painful sexual intercourse and often share that they are very anxious and prefer to avoid intimacy;

• Sometimes have accompanying diseases associated with femininity–lumps in the breasts, other gynecological problems, etc.;

• Often experience injustice towards the other gender. They talk about discrimination and the need for equality. It’s interesting how being different from men is something that upsets and infuriates them. For most women, it is difficult to think and understand their femininity;

• Sometimes they find it hard to identify and express emotions and try to rationalize everything in their life;

• Express very high levels of anxiety, which reflects on their decision-making and spontaneity.

Applying the Body Atom concept revealed previously overlooked health concerns and facilitated a deeper understanding of the mind-body connection. Patients could visually map their illness history, linking emotions and memories, despite struggles in verbal expression, visual depiction aided in recognizing strengths amidst suffering, fostering a more empowered perspective.

Common characteristics were derived from the results of both patient groups:

• Experience extremely high levels of anxiety;

• Difficulties accepting their body image;

• High degree of emotional lability and tendency to avoid intimacy;

• Difficulty sharing with loved ones, and actively seeking support and help;

• Difficulty in expressing and stating desires;

• Difficulty in asserting personal boundaries.

When the Body Atom was applied to the patients from the cardiovascular clinic and patients with endometriosis, we observed:

• Additional organs or health concerns that were previously not considered emerged in the diagram of the Body Atom;

• By dint of the Body Atom, patients were able to identify and name the connections between organs (parts) in the body and formulate hypotheses about the relationship of emotions and experiences to their illness. They started recalling memories and events that preceded the beginning of the disease;

• Amidst the difficulties of verbalizing feelings and experiences, progress towards naming and linking was observed when depicting the Body Atom involving the “body” in addition to speech;

• Through the diagram, patients were able to illustrate the history of their illness as a process and development, both in physical and emotional aspects;

• Patients demonstrated the ability to identify the positive aspects of the body and, correspondingly, the capacities of the personality–in the direction of “I am not defined by pain and disease; I am an individual who experiences suffering, yet simultaneously possesses strengths.”

The Body Atom helps patients:

• See trends and connections between the disease and parts of the body, between unwanted emotions and illness, and observe their interaction using monodrama techniques;

• The model promotes awareness and integration and the relationship between the somatic and the psychic;

• Gives a possibility not only to talk about the problems, but also to “see” and visualize them on the Body Atom diagram;

• Enables patients to “dramatize” their disease and gain perspective from an external viewpoint;

• Raises the questions: who am I in relation to the illness? What do I possess–strengths, resilient organs, robust aspects of the body, and psyche; What do I lack–full health, etc. This helps the patients see a more detailed picture of their condition and explore different perspectives and explanations.

CONCLUSION

The Body Atom technique is a comprehensive way for individuals to understand their bodies, including both healthy and unhealthy parts. It allows patients to explore the relationships between their health and illness, and how these factors affect them psychologically. By using the Body Atom diagram, patients locate their diseases and comprehend their significance within the intrapsychic realm.

The study has shown that patients who have undergone cardiac interventions and surgeries are open to using the Body Atom technique. They may have concerns about the outcome of the surgery and the following recovery.

Similarly, patients with endometriosis can use the Body Atom technique to discover other diseases related to femininity and have concerns about sexual intercourse and future pregnancy.

Both groups can explore the history of their weaknesses and understand the questions related to physical pain and life continuation. By using the Body Atom technique, patients gain a better understanding of their bodies and how they can manage their health and emotional conditions.

• 1
  The creators of the Body Atom technique are Violeta Azis, PhD, and Alexandrina Milcheva, MA. Violeta is a doctor of clinical psychology and psychodrama therapist. She is the head of the Center for Psychological Help in Lozenets University Hospital (Sofia, Bulgaria). Dr. Azis has been working with patients with chronic and acute somatic illness, cardiovascular surgeries, and transplantations since 2010. Additionally, she conducts psychodrama groups, individual consulting and psychotherapy of adolescents and adults, as well as various trainings for organizations in private practice. Dr. Violeta Azis is honorary assistant professor at the master’s program of Clinical Psychology at Sofia University “St. Kliment Ohridski.” Alexandrina Milcheva has a Master degree in Clinical Psychology–Psychoanalytic Approach, and she is a certified psychodrama therapist. Alexandrina has working experience in the psychiatric ward at the Military Medical Academy (Sofia, Bulgaria), Clinic of Nervous Diseases at the University Hospital Alexandrovska, as a school psychologist with children with special needs, people affected by violence and more. Alexandrina works in her private practice individually and with groups using all kinds of tools through psychodrama, sociometry, and psychodynamic approach. Both therapists work with patients experiencing various forms of physical pain and illnesses, some of which lack a clear medical explanation and may be categorized as psychosomatic in terms of their psychological functioning.

ACKNOWLEDGEMENTS

Not applicable.

• FUNDING

  Not applicable.

DATA AVAILABILITY STATEMENT

All datasets were generated or analyzed in the current study.

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Edited by

Section editor: Oriana Hadler https://orcid.org/0000-0001-9736-2224

Publication Dates

• Publication in this collection
  23 Aug 2024
• Date of issue
  2024

History

• Received
  03 Jan 2024
• Accepted
  17 May 2024