Bioenergetics

Reich and the idea of muscular armour

Accounts written within the bioenergetic community trace the approach to Wilhelm Reich, an Austrian psychoanalyst who left Europe for the United States in 1939. Coffman and Bowden describe Reich as having noticed that clients resisted therapy through the body as well as through words, and as theorising that chronic muscular tension, which he called muscular armour, held back emotional impulses. These are the tradition's own descriptions of Reich's ideas, and they are theory, not measured findings.

Hilton, a former executive director of the International Institute for Bioenergetic Analysis (IIBA), writes that Reich taught a course at the New School for Social Research in New York from 1940 and that a small seminar group formed around it. She adds that Reich later described what he called orgone energy, which he believed to be a physical energy in all living matter. She notes that his later claims were widely dismissed at the time.

Lowen, Pierrakos and the institute

Alexander Lowen was born in 1910 and died in 2008. Hilton, who held office in the IIBA, writes that he joined Reich's weekly discussion group in 1940 and then became Reich's patient for about two and a half years. He studied medicine in Geneva from 1947 and met the physician John Pierrakos in 1953, and the two shared an office and worked on techniques together. Hilton dates the founding of the Institute for Bioenergetic Analysis to 1956.

Hilton writes that the institute became international after a congress at Waterville Valley, New Hampshire, in 1976, when by-laws were written, a board was elected and trainers were appointed. Lowen served as executive director until 1996. She reports that Lowen and Pierrakos separated in 1973 because Lowen could not accept Pierrakos's mysticism, and describes Pierrakos as seeing auras and orgone energy fields, an account given without independent support.

Later changes within the approach

Schroeter, a member of the IIBA faculty, describes a split in the late 1980s between a more orthodox, bodywork-centred East Coast style and a more relational West Coast style. In 1990 Lowen introduced a back-to-basics curriculum, and in 1999 trainers from several countries wrote a new curriculum meant to hold both traditional tenets and newer additions. She names attachment theory, self psychology, trauma work and polyvagal theory as later influences. Bowden, writing in 2001, lists a move away from catharsis, closer attention to the therapeutic relationship and use with post-traumatic stress as the main developments.

Where the sources differ

The accounts disagree on several details. Coffman gives about three years for Lowen's therapy with Reich and the late 1960s for the start of the IIBA. Hilton gives two and a half years, 1956 for the institute and 1976 for its international form, and Bowden gives 1942 to 1945 for the therapy. Coffman names Lowen's early colleague as William Waller and Hilton as William Walling. All three authors belong to the bioenergetic community, and no independent historian's biography was opened for this draft.

Names used within the approach

Coffman calls the method Bioenergetic Analysis and also Bioenergetic Therapy, and Bowden uses Bioenergetics for the same approach. Coffman says Lowen and his colleagues chose the name after what he calls Reich's discovery of bioenergy. He describes the method as a psychodynamic psychotherapy that works with body and mind, and places it among the psychoanalytic schools of body psychotherapy. He contrasts it with methods he calls singular somatic techniques, listing Feldenkrais, Rolfing and the Alexander technique. That comparison is his position as a trainer, and the sources do not test it.

Other meanings of bioenergetics and energy

Outside psychotherapy, bioenergetics is an established term in biochemistry. The US National Library of Medicine's MeSH vocabulary lists Bioenergetics as an entry term under Energy Metabolism, defined as the chemical reactions involved in the production and utilisation of various forms of energy in cells. That is a different subject from Lowen's approach, and findings from cell biochemistry do not bear on claims about bioenergetic analysis.

A third usage is biofield or energy medicine. A 2015 review of clinical studies of biofield therapies reports that the term biofield therapies was coined at a 1992 US National Institutes of Health conference and that the field has limited understanding of mechanisms within the biomedical framework. The bioenergetic sources reviewed describe energy as a concept for understanding aliveness and muscular holding, and describe talk and exercises, not a practitioner transmitting energy to a client. Bowden does write that people affect one another energetically, and that most psychotherapies do not use the concept. Studies of biofield therapies should not be read as evidence about bioenergetic analysis.

Vocabulary within the approach

Several terms recur in the sources. Muscular armour means chronic muscular tension that practitioners believe holds back emotional impulses. Character structure refers to developmentally derived patterns of holding, which Bowden says Reich and Lowen described using the diagnostic terms common in psychiatry at the time. In Coffman's account, grounding involves standing and feeling the feet, ankles and legs to make better contact with the ground. Bowden says the aim of some exercises was to bring energy down into the legs to restore grounding and natural assertion. Catharsis refers to the discharge of strong feeling. These are concepts of the tradition and not measured biomedical constructs.

Setting and exercises

Coffman describes sessions in which the therapist works through talk and through the body, sometimes asking a client to stand and attend to the feet, legs and breathing. He contrasts this with Freud's seating behind a reclining client and says Reich moved his chair beside the couch to observe the body. He lists active exercises intended, in the tradition's account, to change energy, increase respiration and promote expressive movement of the arms, legs, trunk and shoulders, and notes Lowen's design of a breathing stool to expand the chest. Bowden gives two examples of Lowen's preferred exercises: stretching backwards over the breathing stool, and lying down, kicking the mattress and shouting no.

Bowden and Schroeter describe adaptation to the client. Bowden says strongly expressive exercises were judged suitable only for clients whose main difficulties arose after about the age of three. For earlier difficulties, softer techniques were used, such as attention to breathing, stretching, looking, pushing or reaching, within a relational context. Schroeter says a client with a dismissive relational style may need a trusting relationship before any somatic work is introduced.

Touch and consent

Guest and Parker, both certified bioenergetic therapists, say that bioenergetic analysis counts touch among its approved interventions. They recommend written consent explaining how and why touch may be used, that it can evoke strong emotions and how to withdraw consent, followed by asking permission immediately before touching. They report that the standard consent form states there will be no contact with the breasts, genitals or sexually charged parts of the body. These are the authors' practice recommendations and a description of the tradition's standard, not an audited requirement.

The format used in the one controlled trial

In the inpatient trial published in 2006, bioenergetic exercises were added to a six-week inpatient psychotherapy programme. The review that summarised the trial describes them as twice weekly for 60 minutes. The comparison group received the same inpatient programme with gymnastic exercises in place of the bioenergetic ones. This format is not necessarily how private or outpatient sessions are delivered.

Aims described by practitioners

Bowden writes that a primary goal of the therapist is to help clients work through unresolved issues while experiencing increasing health and vitality, and that the approach has an explicit goal of fostering aliveness and a passion for life. Coffman says the approach is used to help solve psychological problems by attending to how psychological issues affect the body as well as the mind. Both describe a psychotherapy, not a treatment for physical disease. Aliveness and vitality are not defined as measurable outcomes in these sources.

In the tradition's account, chronic muscular holding is linked to emotional history, and releasing it is expected to bring emotions to the surface and, in Bowden's words, a greater sense of aliveness and energy. Hilton quotes Lowen as saying that a person entering therapy commits to life and to the body's feelings, not to a therapist for life. These are statements of purpose and not findings.

Conditions studied in trials

The only controlled trial of bioenergetic exercises identified studied chronic somatoform disorders, the trial's term, in Turkish immigrants receiving inpatient care in Germany. Its outcomes were symptom checklist scores and anger expression. The review of body psychotherapy as a group covered psychopathology and psychological distress across several diagnoses, including affective, somatoform and schizophrenia presentations. These studied uses are narrower than the range of aims practitioners describe.

A randomised trial of bioenergetic exercises

Nickel and colleagues randomised 128 Turkish immigrants with chronic somatoform disorders, treated as inpatients, to bioenergetic exercises (64) or gymnastic exercises (64) in addition to their inpatient psychotherapy over six weeks. In an intention-to-treat analysis, the bioenergetic group had significantly better results on most scales of the Symptom Checklist (SCL-90-R) and the State-Trait Anger Expression Inventory (STAXI), according to the abstract. The authors conclude that the exercises appear to improve somatisation, social insecurity, depressiveness, anxiety and hostility, and to increase spontaneous outward emotional expression.

The trial was published in 2006 and tested exercises added to a larger inpatient programme, in one clinical and cultural population, using symptom scales and an active comparison. Effect sizes, follow-up after the programme, blinding and adverse-event reporting were not verified from the full text for this draft. Its results should not be transferred to outpatient bioenergetic analysis, to other conditions or to other populations.

Reviews of body psychotherapy

Rosendahl, Sattel and Lahmann (2021) searched PubMed MEDLINE, PsycInfo and PSYNDEX (initial search 4 November 2018, hand search updated to 30 April 2021), screened 2,180 references and included 18 randomised trials with 1,297 patients. They defined body psychotherapy as treatment using psychological and bodily means equally. Pooled effects were medium: g = 0.56 (95% confidence interval 0.35 to 0.77) for psychopathology and g = 0.52 (0.27 to 0.78) for psychological distress.

Heterogeneity was substantial (I2 of 62% for psychopathology and 68% for distress). Effects were smaller when the control group followed a physical activity and for schizophrenia than for affective or somatoform presentations. Evidence for secondary outcomes was scarce, with improvement shown only for coping abilities, and funnel plots did not rule out bias. Only one of the 18 trials used bioenergetics, so the pooled estimates describe body psychotherapy broadly and do not establish the effect of bioenergetic analysis.

What the sources reviewed do not cover

No randomised trial of full bioenergetic analysis as an outpatient psychotherapy was identified. PubMed searches for this draft covered the phrases bioenergetic analysis, body psychotherapy and bioenergetic exercises, plus a search by the trial's lead author. The first was dominated by cell biochemistry and was not screened exhaustively, and no systematic review specific to bioenergetic analysis was found. Hilton reports that Lowen declined a suggestion to start a research project to prove his thesis, and Guest and Parker note that most somatic training programmes do not conduct quantitative research. Absence of studies is not evidence that the approach is ineffective.

Catharsis

Bowden writes that in the 1950s and 1960s bioenergetic analysis developed a reputation for emphasising catharsis, and that many bioenergetic therapists later moved away from it because expression alone did not change anything and could in fact be harmful. Schroeter notes that many in the trauma field oppose catharsis, regarding it as flooding and not healing, while a bioenergetic analyst, Klopstech, has written a defence of it. The sources reviewed give no outcome data to settle the disagreement.

Authority, theory and measurement

Schroeter describes Lowen as an authoritarian figure who had difficulty accepting new ideas, says some trainers were ostracised, and says women had to meet higher proofs of competence than men. She says the original method rested on a one-person model in which the therapist is the authority on what the client needs, and gives an example she calls a failed intervention. Bowden presents attention to the relationship as a later development. Bowden also acknowledges that most therapies do not include the energy concept and may question its existence, and the sources reviewed report no measurement of bio-energy. All of these accounts come from within the community, and no external critique was reviewed.

Emotional intensity and suitability

Bowden writes that strong expressive exercises were considered suitable only for clients with later-developing difficulties, and that for those with earlier difficulties strong expressive therapy was more likely to retraumatise, because they were less able to contain emotion safely. Schroeter says clients without a strong sense of self needed more relational support before somatic work succeeded, and describes a demonstration in which a client's hands shook and he appeared dissociated. These are practitioners' accounts and not data on how often harm occurs.

Touch, boundaries and consent

Guest and Parker list clients for whom touch needs careful consideration: those with poor boundaries or fear of engulfment, histories of childhood physical or sexual abuse, sexual assault or violence, post-traumatic stress from war or torture, erotic transference, cultural or religious prohibitions on touch, or a psychotic disorder. They state that touch is not contraindicated except in psychotic disorder, provided it is considered and the therapist is trained. They describe consent as something that can be withdrawn once given, so a person can ask what contact to expect and can ask for it to stop.

Evidence on harms and care boundaries

The 2021 review of body psychotherapy states that future studies should report data on safety, adverse events, acceptability and patients' preferences. The abstract of the 2006 bioenergetic exercise trial does not describe adverse-event reporting. The safety of bioenergetic analysis has therefore not been established by systematic data in the sources reviewed. Because the practice is described as psychotherapy, it is not a substitute for assessment or treatment of persistent or severe symptoms. New or worsening physical symptoms, thoughts of self-harm, or distress that becomes unmanageable during or after sessions warrant prompt professional assessment, and necessary care should not be delayed or replaced.

Training and professional context

Guest and Parker report that the IIBA curriculum integrates training in the use of touch throughout a four-year programme, and that most body-oriented training programmes are two to four years of postgraduate work. Hilton, a former chair of the IIBA ethics committee, reports that the institute had 55 societies in 17 countries at the time of her 2005 paper. No statutory regulation or training standard specific to the approach was found in the sources reviewed, requirements differ by country, and the sources do not say whether a given practitioner is also licensed in psychotherapy, psychology or medicine. A reader can ask a practitioner about licensing, training and supervision.