THE PSYCHOSOMATIC ARC IN THERAPY

The psychosomatic arc, based on an idea of Nossrat Peseschkian in 1988, was further developed by the author from 1994 on to visualize the process of body and mental symptoms caused by life events and microtraumatic situations of everyday life. A semi-structured psychosomatic treatment process is described by which to understand the function and language of psychosomatic symptoms more easily .


Introduction
To find out the subconscious and bodily functions of psychosomatic symptoms, it is helpful for clients and therapists to have an understandable model for the reasons for the suffering and the ways for possible treatment of psychosomatic disorders.In the following text the "psychosomatic arc" will be explained in its function as visualization of the mental and physical processes in the development of symptoms.As a student, I had been witnessed to an idea of Nossrat Peseschkian's, who in 1988 painted an arc on a flip chart in a post-graduate seminar in the training center for psychotherapy in Wiesbaden, Germany.He marked the life event at the beginning of an arc, followed by the first stress symptoms in the central nervous system with an affective reaction.Consecutively he named neurotransmitters in the second step that can cause reactions of anxiety, aggression or depression in the next step, followed by the hormones and the vegetative nerve system which induce functional disorders in a third step.Finally, the organic disorder at the end of the arc was marked as an end point in a fourth step.Fig. 1 shows how I noted it down as a student in 1988, and made a graphic in 1994 that shows this consecutive process: At that time, the neuro-immunological system had not yet been studied thoroughly enough to understand all of the regulatory circuits and neuromodulators.The idea of Nossrat Peseschkian's about the interaction of the systems just mentioned them as mediating dysfunctions or disorders in the body.I first published this arc in 1994 in a Bulgarian book "The Method of Positive Psychotherapy" (Peseschkian, 1994), and Nossrat Peseschkian used my graphic in German and English for slides in his lectures.

Discussion
Later, some more research was added to explain the reactions within the psychosomatic arc (Remmers, 2010& Boncheva, 2012).The starting point of any psycho-somatic activity is the experience of an event or a situation with our (preferred) senses.The focus of perception depends very much on the style of personality as a "filter of perception" and on the underlying life experience and the related individual reaction pattern.This information from the senses, specifically filtered by the individual value system and concepts, causes a reaction of the brain stem within less than 500 milliseconds, and simultaneously goes to the brain, where it is compared with earlier experiences and concepts.The brain stem causes affects and impulses related to the event, as in flight -fight -freeze schemes, resulting in patterns of fear -aggressiondissociation.The brain has the possibility to immediately "veto" these reactions during the first second.To think about the consequences needs more than a second, and the further comparison of the event with concepts and memories typical to that person, and even unique to her or him will cause either a conflict or calming down.Upcoming conflicts between needs and limits, between values and expectations, safety and threat can hereby influence the stress hormones and neuromodulators consecutively, see fig.If the observation of an event or consideration reveals any solution for the situation or conflict, or an understanding, meaningfulness, and manageability in coherence (Antonovsky, 1985;Antonovsky, 1987), the inner conflict can be solved, the affects and the mood will be balanced again.In the case when the situation with its affective and emotional consequences continues, neurotransmitters (neuromodulators) will be activated to cause an affection, a specific mooddepressive, aggressive, or anxious.A bodily reaction can be caused in mimic and skeletal tonus, in vegetative functions, as a conflict reaction related to stress mechanisms.If the conflict situation continues, the autonomous system can create a specific change in the functions of the organs, like somatoform autonomous dysfunctional disorders, as described in ICD and DSM.Within these organic reactions of the individual subconscious meanings seem to be already hidden as a pattern of possible bodily reactions, the suppressed "as if" reaction.This can be compared with what Alfred Adler had in mind with the "weak" organ that reactsand the body "talks" with the symptom, concerning the subconscious needs of the person as a psychodynamic understanding of psychosomatic reactions in a specific cultural environment.Here the comparison with language pictures starts to become interesting in therapy."What somebody can and may feel... in a given situation, towards certain people or things, depends on social norms and rules.It is thus historically variable and open to change."(Frevert).
In the case when the "stress" or the inner conflict, the challenging observation and its influence on this person's concepts continues it can become a "micro traumatic situation" (Peseschkian 1991) because of a continuing dissonance of perception and the formerly functioning old concepts.The neuro-immunological regulation system will change its activity using (more than 60) different neuropeptides or immunopeptides, like different kinds of interleukin (IL1, IL6) or the tumor necrosis factor, TNF.These peptides are transmitting information between different immune cells, between immune cells and neurons, and also between neurons., as shown in fig.3: Here we see the starting point of organic changes, as a low-immune activity in depression and grief.Consequently, organic diseases of depressive persons appear more often than in comparison to affective healthy persons.The opposite is overreacting, or a onesided strong immune reaction, so that highly active auto-immune processes might start destroying the person's own tissue -the auto-immune disease can start on a basis of genetic vulnerability or virus infections.This can influence many different kinds of organs as with thyroid -M.Basedow, Hashimoto or others, Diabetes type 1, ulcerative Colitis, Rheumatic diseases, M. Bechterew, Lupus Erythematosus.Lungs, skin or eyes can be affected, or all of them in a combination of genetic predisposition and environmental circumstances.The start of autoimmune activity can be influenced by the affective status (mood, temperament) of the person, bonding/attachment experiences, and life events (trauma and emotionally important events).

The Psychosomatic treatment process
Psychotherapy, starting with the therapist accepting the symptoms as a reason to suffer and influencing the life of the client, describing the feelings and body sensations of the client in relation to the actual and former experiences can build up a trustful therapeutic relation.An ongoing process of labilisation of old memories can change concepts of reactions in observed events, situations or feelings, see graphic 4: On the basis of an emotionally corrective therapeutic experience in an emotionally safe place A five-step process is used in the positive psychosomatic treatment, as developed by N. Peseschkian (1991) and his co-workers (Remmers, 2021).The actual life situation and way of suffering and the function of the disfunctionality of the symptoms can be discovered in the first step.The influence of the symptoms on everyday life can be discovered and understood as a function of the symptoms using the balance model, followed by understanding the values and value conflicts of the patient within the second step.In a third step, finding out the resources and actual coping strategies of the client becomes a basis for conflict solving, clearing or developing new patterns of interaction with the therapist in the fourth step, that includes understanding the inner conflict and basic conflicts causing the symptoms.Within the therapeutic alliance, it is possible to train patterns different from the former ones to create a new perspective.This therapeutic process causes hope, which begins as early as scheduling the appointment for therapy, later an understanding of the situation, symptom function and reactions.Positive psychotherapy works with differentiation of contents and subconscious concepts.So, the changed emotional atmosphere will change the immediate reactions of the brain stem (not earlier than from 6 weeks on) as a reorganization of the memories is needed.Brain stem parts help to memorize the new emotionally important encounters and events, as the ones with the therapists, sometimes similar to reparenting.
In Psychosomatic Disorders the function of the disease is an interesting key to understand the psychodynamic meaning."To solve a problem, we need to know first how to ask the question" (Cedric Villani 2013).So, we need a simple structure for a question to be understood by the patient and the specialist as well.
A first look at the four areas of life, representing the balance model, creates the question "What has changed since you have been having these symptoms?".Suffering and also the functions of the actual symptoms, the "positive interpretation" of the symptoms are a possible result of this approach as described by N. Peseschkian (1977Peseschkian ( , 1991)).In his psychodynamic textbook, S. Mentzos, a German psychiatrist, calls it the "functions of the disfunctionality" (Mentxos, 2010).The symptom can be seen as an expression of the organ, of the body in a language the patient does not understand.The vegetative or organ neurosis can be seen as a physiological side reaction of suppressed patterns of action and their emotional context which continue to go on becoming chronic symptoms: a "mute" pathophysiological fixation, concerning F. Alexander.

Body language of symptoms
Listening exactly to the language of the patient very often brings out the hidden, subconscious meaning of the symptom.Language pictures and sayings or proverbs sometimes open the door to the patient's fantasy.As a therapist, I try to discover the narratives in interaction with the client, try to find images, symbols or proverbs that fit the experienced situation.This lets us understand the way the patient suffers.By finding "images for the experience" (G.Rudolf 2004).In the everyday language, the connections between inner conflicts and symptoms often seem obvious: "my back is breaking" -when the responsibility is too heavy for a person; "it makes me want to vomit" -when aggression is suppressed; "it itches" -when something touches me in a figurative sense; "this is like a stone in my stomach" -in the conflict between adaptation, submission and one's own needs; "this gets under my skin" -in unconscious closeness-distance conflicts; "this makes my stomach ache" -like a primary school pupil who no longer wants to go to school with a stomach ache.
Therefore, the next question might be "what is this about?" to find out the contents of the problem, the inner conflict, the inner dilemma, to which the body reacts.From multicultural therapeutic interviews, positive psychotherapy recognized a list of typical capacities, called "actual capacities" because of their importance in the actual situation: "Secondary Capacities" as social norms on one side, "Primary capacities", on the other side, as primary needs, show the possible inner dilemma between internal needs and external expectations.These simple, understandable terms now become the basis on which to understand the inner value conflicts that finally cause the symptoms (in this case psychosomatic).Arno Remmers One of the most frequent difficulties in psychology, psychotherapy and medical treatment is to create a helpful therapeutic alliance with patients suffering from bodily complaints, and who often do not feel understood by the medical professionals when no physical reasons for these symptoms are found.To take all the symptoms very seriously, to understand them as a language of the patient's body, to accept all kinds of description and word pictures is an important door which opens toward a healing process.As in a goodenough anamnesis, the qualities of symptoms need to be found out until the patient gives feedback, that the therapist has really understood her or his individual experience.The way symptoms are expressed often show language pictures and subconscious meanings and values.Therapists can find language pictures, symbols or proverbs fitting the patient's experiences to come to a common sense of understanding the way the visitor has been suffering.A further comparison with the psychosomatic arc together with the client can demonstrate the influences of the event as such on the mind and body.The character of affects and moods of the client as an emotional expression of inner conflicts in the value systems and concepts can be visualized, as well as three consecutive psychosomatic levels of symptoms -affective reactions, vegetative functional disorders, organic disorders.

Fig. 3 .
Fig. 3. "Psychosomatic Arc": Immunomodulation (developed by the author) , a new kind of perception can begin.The different perception of the therapist helps to broaden the client's ISSN 2710-1460 WAPP 72 THE GLOBAL PSYCHOTHERAPIST.Volume 2. Number 1. January 2022 Arno perception.The old, dysfunctional perception can be seen in its former meaningfulness for situations experienced earlier.Mentalization of feelings will become possible with the help of the therapist by differentiating contents and concepts.Re-connotation of meanings and values and a positive interpretation of the body's symptoms, as formerly useful reactions, change the way of observing all this.