The contribution of Feldenkrais Method to mind-body medicine [Thesis ed.]

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THE CONTRIBUTION OF FELDENKRAIS METHOD TO MIND-BODY MEDICINE

A thesis presented to the Faculty of Saybrook University in partial fulfillment of the requirements for the degree of Master of Science (MS) in Mind-Body Medicine by Clifford Smyth

San Francisco, California May 2012

UMI Number: 1536829

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Approval of the Thesis

THE CONTRIBUTION OF FELDENKRAIS METHOD TO MIND-BODY MEDICINE

This thesis by Clifford Smyth has been approved by the committee members below, who recommend it be accepted by the faculty of Saybrook University in partial fulfillment of the requirements for the degree of Master of Science (MS) in Mind-Body Medicine

Thesis Committee: ___________________________________ Donald Moss, Ph.D., Chair

______________________ Date

___________________________________ Gabrielle Pelicci, Ph.D.

______________________ Date

ii Abstract

THE CONTRIBUTION OF FELDENKRAIS METHOD TO MIND-BODY MEDICINE Clifford Smyth Saybrook University

The Feldenkrais Method generates a range of healthful or salutogenic outcomes, yet its contribution to the field of mind-body medicine (MBM) remains largely unexamined.

The Feldenkrais Method is a form of somatic education offering both

practices and theoretical perspectives for an integrated mind-body approach. Research shows that the Feldenkrais Method produces outcomes on a range of functional, psychophysical, and psychosocial measures.

This thesis argues that the Feldenkrais

Method is an awareness practice of value for mind-body and integrative approaches to health. Possible mechanisms and dynamics of action of the Feldenkrais Method are presented. This thesis proposes that non- or preconscious intentionality and “know-how” can be an important aspect of healthy behavior. Somatics practices and somatic awareness can play an important role in creating an intentional arc toward health.

This study

supports the importance of research into the Feldenkrais Method in relation to MBM and health.

iii Table of Contents INTRODUCTION ........................................................................................................... 1 Purpose ........................................................................................................................... 1 Mind-Body Medicine (MBM) .......................................................................................... 3 Feldenkrais Method ......................................................................................................... 5 Uses and Applications .......................................................................................... 7 Somatics .......................................................................................................................... 8 Somatics Practices ................................................................................................ 9 Statement of the Problem and Research Questions ......................................................... 10 Methods ........................................................................................................................ 11 A Note on Levels of Description .................................................................................... 13 Interdisciplinary Nature of This Thesis ........................................................................... 14 BACKGROUND ........................................................................................................... 15 Emergence of Somatics Thinking and Practices .............................................................. 15 Influences on the Development of the Feldenkrais Method ............................................. 19 Philosophical and Scientific Context ............................................................................... 20 THE FELDENKRAIS METHOD .................................................................................. 24 The Aims of the Method ................................................................................................ 24 Moshe Feldenkrais’s Concepts of Health ........................................................................ 25 Modes of Practice .......................................................................................................... 26 Practices: Awareness Through Movement .......................................................... 26 Practices: Functional Integration......................................................................... 29 Some Key Concepts: Intention, Action, Function, and Self-Image .................................. 30 Intention............................................................................................................. 30 Function ............................................................................................................. 31 Action ................................................................................................................ 32 Self-Image .......................................................................................................... 33 THE FELDENKRAIS METHOD IN MBM AND CAM LITERATURE ....................... 37 Complementary and Alternative Medicine Literature ...................................................... 37 Mind-Body Programs..................................................................................................... 38 National Bodies ............................................................................................................. 38 Contradictory Findings ................................................................................................... 39 Discussion ..................................................................................................................... 39 FELDENKRAIS RESEARCH LITERATURE .............................................................. 42 Case Reports ................................................................................................................. 42 Intervention Studies ....................................................................................................... 44 Limitations of Studies to Date ........................................................................................ 44 Outcomes of Research Studies ....................................................................................... 50 Outcomes From Feldenkrais Method Research Studies in Relation to Pain.......... 50 Pain: Results From Pilot Studies ............................................................. 50 Pain: Results from Larger Scale Studies .................................................. 51 Pain: Qualitative Study............................................................................ 53

iv Outcomes From Feldenkrais Method Research Studies in Relation to Measures of Affective States .............................................................................. 55 Outcomes From Feldenkrais Method Research Studies in Relation to Body Awareness, Body Image, and Feelings About the Body ............................. 57 Body Awareness and Awareness of Movement ....................................... 58 Body Image and Self-Image in Relation to Feelings About the Body....................................................................................................... 60 Outcomes From Feldenkrais Method Research Studies in Relation to Movement, Motor Coordination, and Functional Activities ................................. 61 Posture and Movement ........................................................................... 62 Dexterity................................................................................................. 62 Balance, Mobility, Activity, and Gait ....................................................... 63 Patient Specific Functional Outcomes ..................................................... 64 Sleep ...................................................................................................... 64 Outcomes From Feldenkrais Method Research Studies in Relation to Measures of Quality of Life ................................................................................ 64 QOL: Outcomes From Pilot Studies ........................................................ 65 QOL: Outcomes From Larger Studies ..................................................... 65 Self-Efficacy....................................................................................................... 66 Retention of Participants and Participant Satisfaction.......................................... 67 Discussion ..................................................................................................................... 67 FELDENKRAIS METHOD’S CONTRIBUTION TO HEALTH ................................... 72 Results of Interviews with Key Informants ..................................................................... 72 Promoting Functional Improvements .................................................................. 72 Self-Education.................................................................................................... 73 Health as Ability or Competence......................................................................... 73 Attention as an Ability and the Value of Attending.............................................. 75 Refining the Self-Image ...................................................................................... 77 The Skill of Learning: Learning to Learn ............................................................ 78 Developmental Perspective ................................................................................. 78 TOWARD A FELDENKRAIS THEORY? .................................................................... 80 SOME POSSIBLE BIOLOGICAL BASES FOR IMPROVEMENT.............................. 82 Physical Level ................................................................................................................ 82 Neuromuscular Relationships ......................................................................................... 82 Muscular Sense .............................................................................................................. 83 Sensory Integration ........................................................................................................ 84 Feed-Forward and Prediction ......................................................................................... 84 Changing Systems Dynamics .......................................................................................... 85 A FRAMEWORK FOR FELDENKRAIS METHOD, SOMATICS, AND HEALTH ..... 87 Salutogenic Model of Health .......................................................................................... 87 The Nature of Somatically Grounded Learning............................................................... 89 Uses of Somatic Awareness ........................................................................................... 92 Bodily Meanings ............................................................................................................ 93

v A Possible Model of the Role of Somatics Practices in Mind-Body Health...................... 95 RESEARCH RECOMMENDATIONS .......................................................................... 99 Methodological and Epistemological Issues.................................................................... 99 What is Being Studied? ................................................................................................ 100 Phenomenological Approaches ......................................................................... 100 Overall Needs for Research Into the Feldenkrais Method ............................................ 102 Some Directions for Research Into the Contribution of the Feldenkrais Method to MBM and Health ..................................................................................................... 103 Outcomes Research .......................................................................................... 103 Research Into the Mechanisms and Dynamics of Action.................................... 104 Quantitative, Qualitative, and Mixed Measures Research.............................................. 106 Quantitative Approaches: Self-Report Measures ............................................... 106 Qualitative Approaches .................................................................................... 107 Mixed Methods Approaches ............................................................................. 108 Conclusion ................................................................................................................... 109 FELDENKRAIS, SOMATICS, AND MIND-BODY MEDICINE ............................... 110 Meaning and Action for Health .................................................................................... 110 A Place to Stand .......................................................................................................... 110 Afterword .................................................................................................................... 112 REFERENCES ............................................................................................................ 113 APPENDICES............................................................................................................. 135 A. The Feldenkrais Method .............................................................................. 135 B. Recruitment Letter for Key Informants......................................................... 139 C. Sample Interview Questions for Key Informants........................................... 141

1 Introduction This Master’s thesis explored the relationship between the Feldenkrais Method of Somatic Education (see Appendix A) and the field of mind-body medicine (MBM). A review of MBM and complementary and alternative medicine (CAM) literature reveals that Feldenkrais Method is poorly or inconsistently represented. A review of Feldenkrais Method research studies showed that, in addition to a range of functional outcomes for movement coordination, manual dexterity, balance and gait, Feldenkrais Method interventions also produce significant improvements for pain, affective states, self-efficacy, body awareness and body image, and a range of quality of life measures. This thesis includes historical and scientific background supporting the significance of somatics approaches in the development of healthful behaviors. Literature from other mind-body practices, theories of health behavior, neuroscience, and philosophy are drawn upon to explicate possible mechanisms and dynamics of action of the Feldenkrais Method. This literature, along with interviews with key informants, is used to create frameworks clarifying how Feldenkrais Method contributes to health. It is hoped that these frameworks may be of value to the development of MBM thinking and practice, especially in relation to conceptions of the body, and the role of bodily awareness and movementbased practices. The outcome of this study was to propose that further research into the Feldenkrais Method in relation to MBM and health is warranted, and to suggest approaches using qualitative, quantitative and mixed measures. Purpose When faced with the challenge of developing research into the application of the Feldenkrais Method to health, it became clear that, although there is now an extensive literature about the Feldenkrais Method, there is no consistent published theoretical

2 framework for the Method. In particular, there is no thorough explication of how Feldenkrais Method contributes to healthy outcomes. As a consequence, any empirical research into Feldenkrais and health faces challenges in identifying outcomes that are of significance to the Feldenkrais Method by its own description. While the development of a full theory of the mechanisms of action of the Feldenkrais Method is both scientifically and philosophically very challenging, and beyond the scope of this thesis, this study attempted to identify some key elements of how Feldenkrais Method contributes to improved health. There is a significant body of literature by the creator of the Method, Moshe Feldenkrais, and other authors identifying key ideas and the science underlying the Method, a substantial case literature, and a growing body of outcomes research. Much of the research in relation to health has been in the area of rehabilitation, and draws on conceptual frameworks from motor skill acquisition and postural control theories. However, the research shows that there are also significant outcomes in terms of pain, anxiety, depression, self-efficacy, and, quality of life measures. That is, the Feldenkrais Method creates functional, movement-related outcomes, but it also generates a range of broader outcomes, which suggest Feldenkrais does also contribute to overall health outcomes. This thesis argues that both functional outcomes and the development of a somatically-based healthful, or salutogenic1, know-how are valuable outcomes of Feldenkrais Method in relationship to health.

1

Salutogenic is a term developed by sociologist Aaron Antonovsky (1979, 1987) to describe factors, such as person’s behavioral orientation and sense of coherence in life, often shaped by social factors that contribute to health. His ideas are discussed at more length, and in relationship to Feldenkrais Method, in the section, A Framework for Feldenkrais Method, Somatics, and Health of this thesis. See also Duensing (2008) and Lindström and Eriksson (2005).

3 The Feldenkrais Method was conceived by its founder as a practice for selfdevelopment, especially of developing awareness through movement. As such, it will be argued that Feldenkrais Method can stand in relation to MBM in a similar way to other awareness practices, such as meditative practice. Such practices, which were created for the overall development of the human being, can be used to promote health and healthy ways of living. In this context, health is seen as an expression of the quality of human life and human potential, rather than just the absence of disease. This thesis argues that the Feldenkrais Method, although not a medical intervention in itself, can contribute effectively to health in the context of MBM. It should be considered for inclusion in MBM programs, and as part of integrative approaches to health care. In order to make this argument, and provide a context for future research, it is necessary that this thesis also presents possible frameworks for how the Feldenkrais Method contributes to health. These two themes are woven through the text, partly because it is in the ways that Feldenkrais Method contributes to health that make it a useful intervention in the context of MBM. The frameworks presented here may also be of value for conceptualizing the role of somatic thinking and somatics practices in MBM. To provide a context for the following discussion, descriptions of MBM, Feldenkrais Method, and somatics thinking and practices are provided next. Mind-Body Medicine (MBM) MBM is an approach to medical care that has developed in the last 25 years, especially as a way to respond to chronic and nonspecific conditions found in Western societies—and increasingly in countries dealing with rapid industrialization and urbanization. MBM often addresses conditions such as those associated with obesity, lack

4 of exercise, pollution, stress, posttraumatic conditions, and the effects of chronic conditions (e.g., asthma, cardio-vascular conditions, and chronic pain). Many people now also live with the sequelae of life-saving but noncurative treatments—symptoms that are not resolved by treatment, or that arise as a result of the treatment process itself. Moss (2003) pointed out that “the majority of primary care patients’ complaints lie in the twilight zone between body and mind, marked by overlapping psychosocial stress, physical discomfort, relationship conflicts, life-stage dissatisfaction, and unfulfilled aspirations” (p. 5). Moss (2003) wrote that MBM Includes a wide range of behavioral and life style interventions on an equal basis with traditional medical interventions. The patient in mind-body medicine is understood as a totality of body, mind, and spirit. Interventions are directed at each of these aspects of the person.…Mind-body medicine includes behavioral and psychosocial interventions among the first line of interventions. (pp. 3-4) Practices commonly used in MBM include biofeedback2, hypnosis3, guided imagery, meditation, relaxation techniques, breathing practices, and expressive activities (Center for Mind Body Medicine [CMBM], 2010; Goleman & Guerin, 1993; Moss, McGrady, Davies, & Wickramasekera, 2003). Health and wellness education and coaching,

2

The American Association of Applied Psychophysiology and Biofeedback (AAPB, 2008) describes biofeedback in this way: “Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately ‘feed back’ information to the user. The presentation of this information—often in conjunction with changes in thinking, emotions, and behavior—supports desired physiological changes. Over time, these changes can endure without continued use of an instrument” (para. 2) 3 Hypnosis can be seen as characterized by a state of absorption in a person’s internal state, often but not always, induced with physical or mental relaxation. In a hypnotic session, imagery or suggestions, including post-hypnotic suggestions are used to alter perception, mental and physical state and behavior. Hypnosis can be done with an operator or as self-hypnosis. It is often used in psychotherapy, for stress and pain management or for health behavior change—such as eating disorders and smoking cessation (American Association of Applied Psychophysiology and Biofeedback [AAPB], 2008; Yapko, 2003).

5 improvement in diet and exercise, massage, and practices such as Yoga and Qigong are often included as part of MBM programs or in integrative teams using MBM approaches (Gordon, 1996; Moss, 2003). Feldenkrais Method The Feldenkrais Method can be considered as a method of somatic education, learning based in lived experience of, and through, the body. Reflecting the double nature of the body, practicing this Method can lead to changes in the organization of one’s bodily systems of perception and action and subsequently, alterations in (a) one’s perception of one’s body, and (b) in one’s perception of self and the world. The emphasis in the Method is on improving one’s whole action, rather than just alterations to separate aspects of one’s thinking, emotional, or physical state. Through its practices, the Feldenkrais Method is designed to provide the experience of an improved sense of one’s body, greater motility, enhanced psychophysical function, and more effective action in the world, in one integrated process (Brand, 2001; Shafarman, 1997). The educational model is one of experiential learning (Jarvis, 2006; Kolb, 1983). Moshe Feldenkrais described his approach as promoting “organic learning”4, that is, learning that emphasizes the functioning of the organism, and he distinguishes it from intellectual, academic, or social learning (Feldenkrais, 1981, p. 29; Shafarman, 1997, p. 189). Feldenkrais is a method, in that it proceeds from observations about the actual

4

When referring to organic learning Feldenkrais may be suggesting a number of things: that organic learning is the kind of learning that happens through and with the whole organism, that is, it could be called “organismic” learning. He also may be suggesting that it is the kind of learning that arises from the nature of the organism similarly to how animals and humans learn when they are young. It is a kind of learning emergent from the dynamics of the growth and development of the organism. Feldenkrais (1981) distinguishes it from the more commonly understood forms of academic and social learning (see also Shafarman, 1997 and Alon, 1990).

6 functioning of the human organism in its environment, and from consistent ideas and principles (see Appendix A). This allows it to be applied in a large range of situations to improve human functioning. A key element of this Method involves the making of exploratory movements and re-directing attention (verbally or through touch) to the sensations associated with the actions generated. Conscious awareness of habits and tendencies within these patterns of action can contribute to integrating new functional abilities, to shifting habits of thought and belief, and to seeking out further opportunities for learning how to learn about oneself. Awareness can promote further curiosity about one’s life. Feldenkrais Method primarily makes use of precise sequences of movements and attention directed to the experience of movement to improve the qualities of action of the client or student, and to promote awareness. Particular emphasis is put on (a) enhancing spatial orientation and the spatial sense of the body; (b) timing and coordination of actions; and (c) the skeletal, as well as muscular, aspects of the experience of movement. Feldenkrais Method is taught and practiced in two primary modes: Awareness Through Movement and Functional Integration. The former is the class mode of the Method, where a teacher verbally suggests to the client or students movements to explore, especially regarding the directions and qualities of the movements, and directs attention to bodily experience arising from making the movement. In Functional Integration, for most of the session, the practitioner touches and moves the client, directing attention both through the touch and movement, and verbally. More detailed descriptions of these modes can be found in the section The Feldenkrais Method of this thesis. Uses and applications. Feldenkrais Method can be seen as a method of selfcultivation, in a similar way that meditation, Qigong, Yoga, martial arts, and some forms

7 of artistic endeavor can be used as approaches to personal and human development. Many individual clients or students use Feldenkrais Method in their lives to deal with pain and disability associated with illness, injury, or habits of self-use. However, many also come to a practitioner or a class in order to maintain improved self-use, physical flexibility, and comfort, as well as for stress reduction, creativity, and self-awareness. Feldenkrais Method is often used in medical settings as a particular approach—or as an adjunct—to physical rehabilitation. This is often done by dual-trained Feldenkrais practitioners, who are also physical or occupational therapists. In the United States, Feldenkrais Method has been used at hospitals and by health maintenance organizations in integrative medicine programs for chronic pain, cardiac rehabilitation, occupational injuries, anxiety, and eating disorders (Bowes & Smyth, 2002). Feldenkrais Method is also used to support the acquisition of physical skills, such as for athletes and performing artists. Feldenkrais Method is taught and practiced in many situations where one’s body is the instrument for performance, for example, with actors, dancers, singers, and instrumental musicians. The Feldenkrais Method is one of the somatics practices commonly in use today. Therefore, it is valuable to locate Feldenkrais Method in the historical and conceptual context of somatics and somatics practices. Also, the frameworks for understanding the contribution of Feldenkrais Method to health developed in this thesis may be of relevance to understanding the potential contribution of somatics to MBM. Somatics Thomas Hanna was a major thinker in the development of the field of somatics, publishing an early volume on the neglect of bodily experience in Western thought, and surveying those thinkers who did emphasize the importance of bodily experience (Hanna,

8 1970). At the same time as he was completing his training in the Feldenkrais Method, Thomas Hanna founded Somatics magazine and in its first issue coined the term “somatics” to refer to this field of study (Criswell, 2001; D. H. Johnson, 1995, 2005). Hanna’s idea was that somatics is the field concerned with the lived, experienced body. Rather than the medical definition of soma as the physical structure (anatomy and physiology), “the soma is process, that is, function…” (Criswell, 2001, p. 585). The soma is the first-person experience of an alive, bodily being-in-the-world. Even though somatics practitioners come from a range of disciplines (such as psychotherapy, dance, martial arts, manipulative therapy, Eastern spiritual practices), and draw on a variety of explanatory systems, the emphasis is on practices that bring forth the experience of the integration of mind and body, or the body-mind. This emphasis on practice is important. Criswell (2001) suggested that in MBM, at the level of practice, there may be commonality among approaches: “The Western approaches to mind/body medicine have much in common with Eastern disciplines. This commonality is created by the borrowing of techniques between cultures and by working with the natural tendencies of the body” (p. 586). In describing the field of somatics practices, Grossinger (1995) wrote, “Cohen emphasizes that the distinguishing features of the field of somatics…are ‘focus on body image, anatomy, sensory and kinesthetic education, and nonverbal language.’ I take this to mean the simultaneous priority of all five domains” (p. 204). Somatics practices. Somatics practices include somatic education (e.g., Sensory Awareness, Alexander Technique, Eutony, Feldenkrais Method, Middendorf Breath Work, Mind-Body Centering, Hanna Somatics, Continuum, the Sounder Sleep System), somatic body work (e.g., Rolfing, Hellerwork), somatic therapies or somatic psychotherapy (e.g., Rosen Method, Somatic Experiencing, Focusing, Rubenfeld Synergy,

9 Hakomi Method), somatic approaches in dance and expressive movement (LabanBartinieff, Authentic Movement), and somatic approaches to expressive arts therapy (such as the work of Anna Halprin and the Tamalpa Institute). It is beyond the scope of this thesis to provide definitions and descriptions of all these practices; however, the works of Grossinger (1995) and D. H. Johnson (1995, 2005) provide an excellent overview. It can be argued that Qigong, Tai Chi, and Yoga could be seen as somatics practices; however, practitioners of those approaches often do not locate these practices within the domain of somatics, but rather within the spiritual practice traditions in which they arose (Grossinger, 1995). Somatics practices emphasize—variously—the use of directed attention to bodily experience, movement, touch, and bodily manipulation, and attention to the breath, and combinations of these, as means of personal learning and development, and for health. How affective states are expressed in the body, as well as how bodily awareness and movement practices can alter those states, are fundamental understandings of somatics. Particularly important is that many somatics practices focus on attending to— metaphorically—listening to oneself and one’s bodily experience. That is, the locus of control is more with the client or participant, than the teacher or practitioner. To the extent that these practices are healing, the emphasis is on self-healing (Grossinger, 1995). A history of the development of somatic thinking and somatics practices, and of the Feldenkrais Method in this context, is included in the Background section of this study. Statement of the Problem and Research Questions The problem to research in this thesis arose from observing a number of phenomena:

10 1. That the case literature and anecdotal reports from students and clients of the Feldenkrais Method suggest outcomes that include many of the kinds of outcomes sought in MBM interventions and programs, such as: improved sleep, reduced pain and stress, enhanced breathing, improvements in mood, an increased self-efficacy with regard to health, and the adoption of more healthy behaviors. 2. That much of the research into the Feldenkrais Method to date has had an apparent focus on functional movement outcomes. 3. That the model of behavior change, adoption of salutogenic habits through an altered sense of self, arising from somatics interventions, such as the Feldenkrais Method, are of potential benefit to MBM theory and practice. The research questions for this thesis were as follows: 1. To what extent, and in what ways, can the Feldenkrais Method contribute to the field of MBM in terms of: • •

outcomes for patients, clients or participants, and the development of the field?

2. What unique contributions can Feldenkrais Method make to MBM? 3. In what ways are the ideas and practices of the Feldenkrais Method similar to or different from those of a variety of other practices in the field of MBM? 4. What common mechanisms of action may be involved in the effects of Feldenkrais Method and other mind-body practices? 5. What research has been conducted into the Feldenkrais Method and what research is needed to document and clarify its contribution to health and well being? In order to explore the implications for MBM it is necessary to triangulate this topic area by: (a) describing Feldenkrais practice and theory; (b) identifying the gaps or uneven coverage of the topic in the MBM and CAM literature; (c) reviewing the research into the Feldenkrais Method to date; (d) gathering the views of experts in the field; and (e) looking for conceptual connections between Feldenkrais theory and practice, MBM practices, and relevant scientific and philosophical frameworks.

11 The aim of this thesis was to identify how somatics approaches, and the Feldenkrais Method in particular contribute to health and therefore can make an important contribution of MBM. For example, on a theoretical level, this study emphasized the importance of bodily experience and awareness, of how changes in sensory-motor organization, of alterations in the bodily self-image, as well in movement and action are a vital part of health and healthy behaviors. Of particular importance is the understanding from somatics of the unity of mind and body in experience and action. Meaning that mind-body interventions are not seen dualistically as the mind-influencing-the-body, but that the mind-body is integrated—and that integration is vital to health. The model of health behavior change is one of somatically integrated action in the world, rather than a cognitive-behavioral one. On a practical level this thesis proposed that the integration of Feldenkrais practice as a whole, or aspects of Feldenkrais and other somatics practices, into MBM programs enhances outcomes. Of necessity then, this thesis focused on researching, explicating, and mapping this topic, rather than, for example, proving or disproving the efficacy of a particular intervention for a particular condition or population. Methods This thesis primarily made use of a literature search and review of the literature as the main research processes. Literature searched for was of three main kinds: (a) works on the history, theory, and practice of the Feldenkrais Method; (b) works on the Feldenkrais Method and somatics practices found in the MBM and CAM literature; and (c) Feldenkrais research studies. An extensive review of the literature in English was conducted using databases, including Academic Search Premier, Medline, Pubmed, Sage Journals Online, Science

12 Direct, ProQuest Research Library, and other public websites, such as Google Scholar, the National Institutes for Health (NIH, 2011) and the National Center for Complementary and Alternative Medicine (NCCAM, 2011b, 2011c). In addition to these sources, extensive use was made of a collection of research literature published by the Feldenkrais Educational Foundation of North America (FEFNA, 2001), and online bibliographies provided by the Australian Feldenkrais Guild (Wise & Connors, 2010), International Feldenkrais Federation (IFF, 2011), and the Feldenkrais Guild of North America (FGNA, n.d., “Research bibliography”). Further articles were found using the reference lists of articles located, and three scholars in this field (Buchanan, Hillier, and Ullmann) were contacted to identify further materials and obtain some of the research studies. There is a considerable literature of the Feldenkrais Method in other languages, especially research published in German, which this author is not able to access at this time. In addition to these research articles, books and articles on the history, theory, practice, and the scientific and philosophic foundations of the Feldenkrais Method were identified and consulted. Interviews were undertaken with three key informants. Institution Review Board application was made and approved for carrying out interviews with key informants. The recruitment letter for the key informants is attached as Appendix B, and the interview protocol is attached as Appendix C. These key informants are very experienced teachers of the Feldenkrais Method, all of whom studied with Feldenkrais himself, have been involved in training new practitioners, as well as researching and writing about the development of the Method (E. Beringer, personal communication, March 17, 2012; D. Leri, personal communication, March 14, 2012; R. Russell, personal communication, February 12, 2012).

13 A Note on Levels of Description As can be seen from the Introduction, as a system of somatics practice based in scientific ideas, the Feldenkrais Method presents particular challenges in terms of the level of description to be adopted. Any discussion of the Method requires at least some reference to several levels of discourse, without which vital parts of the Method’s approach would be missed. First, there is the level of the physics, physiology, and neurophysiology of movement and perception. Second, there is the level of the large-scale organization of the nervous system, and the brain in the body and the environment. This is a level where information theory, dynamic systems theory5, and the biology of cognition are relevant. Third, there is the level of description of function and action, of ability and competence, as well as learning theory. This would often be seen as the behavioral level in much of the medical literature. Various psychological constructs are relevant at this level. There is the level of human action in the context of society and culture, including language. Finally, Feldenkrais Method can be seen to be engaged with lifelong human development and learning. The following discussion will endeavor to address all these levels of discourse to some extent as part of describing the Feldenkrais Method and its relationship to human health.

5

Dynamic systems theory is a way of describing the behavior of complex systems composed of multiple, mutually interacting and influencing elements which may include multiple subsystems. Such systems may generate chaotic behaviors; however, they may also over time bring forth relatively stable patterns (or dynamic equilbria). The characteristics of dynamic systems are that they are self-organizing, that the behaviors are emergent from the relationships in the system, in contrast to top down command and control or rule-based models. Thelen and Smith (1994) wrote, “When systems self-organize…they ‘settle into’ one of a few modes of behavior (which themselves may be quite complex) that the system prefers over all other modes. In dynamic terminology this behavior mode is an attractor state, as the system – under certain conditions – has an affinity for that state” (Thelen & Smith, 1994, p. 56). Dynamic systems theory has been used to describe complex systems such as weather and climate patterns, chemical reactions, neural networks, and whole organisms. They have been applied to the study of the development of human behaviors, such as the coordination of movement (Thelen & Smith, 1994).

14 Interdisciplinary Nature of This Thesis As the field of MBM and somatics practices are interdisciplinary, diverse literatures are drawn upon in this thesis, including sources from somatics, psychology, dance, neuroscience, movement science, physical therapy, philosophy, physiology, sociology, medicine, and health sciences. Every attempt has been made to respect the domains of knowledge and conceptual frameworks therein. However, the aim of this thesis—to map a field of practice that could be viewed from all these perspectives—means that associated concepts and insights are brought into relationship while acknowledging that the underlying philosophical and scientific discourses are not necessarily integrated.

15 Background This section provides historical background on the emergence of the field of somatics and the Feldenkrais Method. It then explores some of the traditional views of the mind-body relationship and emerging models arising from phenomenological6, biological, and neuroscientific thought about the importance of bodily experience in consciousness and action. Emergence of Somatics Thinking and Practices In seeking to overcome many of the limitations of the traditional Western, biomedical or biotechnological model, and the mind-body dualism that underlies it, MBM has asserted the essential connection between mind and body. The early research on stress showed how mind, in the form of thinking and emotional responses, negatively impacted health in very serious ways (Selye, 1976). The early MBM movement drew on practices from Western culture such as hypnosis, and sought to develop its own approaches to using the mind to influence the body, such as Benson’s relaxation response (Benson, 1975) and Jacobson’s progressive relaxation (Jacobson, 1938). As the technology for measuring

6

Phenomenology is a philosophical movement whose ideas have been applied as a method research into psychology, consciousness, and the creation of knowledge, through a process of phenomenological reduction (Honderich, 1995). The emphasis is on the direct study of phenomena themselves through the idea and practice of “bracketing” as much as possible received conceptual understandings—a process referred to as “epoché.” “Phenomenology distinguishes sharply between perceptual properties on the one hand, and abstract qualities on the other” (Honderich, 1995, p. 659). The founder of philosophical phenomenology, Husserl, suggested this allowed the identification of the essences of particular phenomena on one hand, and the perceptual experience on the other. Later phenomenologists did not emphasize the idea of essences as strongly, focusing more on the possibility of describing experience from the bottom up, rather than experience framed by top down ideas or concepts (Varela, Thompson, & Rosch, 1993). Phenomenologists acknowledge that perceptual knowledge is always situated in some way in relation to a particular perspective (Blackburn, 2005; Honderich, 1995). As a philosophy, “Phenomenology…seeks to understand anything at all that can be experienced through the consciousness one has of what is ‘given’…from the perspective of the conscious person undergoing the experience” (Giorgi, 2009, p. 4).

16 physiological responses came to be used as a tool for altering responses, biofeedback was born. Other researchers and clinicians drew on Eastern meditation to create nonreligious and scientifically grounded practices, such as Luthe’s autogenic exercises7 and “clinically standardized meditation”8 (Lehrer & Carrington, 2003; Luthe & Schutz, 1969). In this frame, the body, as we usually conceive of it, could be seen as the location of disease and illness, to which the mind, as we usually conceive of it, could be applied to provide a cure. Criswell (2001) described these as dualistic approaches to MBM. At the same time there was a looking to the East, with an introduction of practices that make use of movement, bodily awareness, and meditation from China, Japan, India, and Tibet into MBM practice and programs (Gordon, 1996)9.. CAM also followed a similar pattern, including Western herbal medicine and homeopathy, but also turning toward Eastern whole systems approaches to medicine10. In popular thinking, at least, 7

In autogenics practice, a seated or lying client hears a number of repeated phrases suggesting changes in physiological states, such as muscular relaxation (e.g., using suggestions of relaxation and heaviness of the limbs) or circulation (e.g., using suggestions of warmth or coolness of parts of the body) (Lehrer & Carrington, 2003). Autogenics has been used to promote relaxation, but also in the treatment of a range of specific physical and psychological conditions (Luthe & Schultz, 1969). 8 Clinically Standard Meditation was developed to create a kind of meditation practice that could be used in medical settings. There is no use of spiritual or religious images or language. The protocol has the participant sitting in a quiet place and listening to audio recordings of the practice that involves speaking rhythmical mantras (repeated phrases) that use meaningless resonant sounds. The aim is to create a sense of physical and mental relaxation, and for the client to experience a mood of calmness (Lehrer & Carrington, 2003). 9 These practices include Yoga, Tai Chi Chuan and Buddhist meditation practices (such as Zen meditation or Vipassana meditation). These practices have in common that they were originally developed as part of integrated systems of practices for personal and spiritual cultivation. Health is seen, at least in part, as a result of living in ways that are consistent with the larger systems of belief, ethics, personal, and spiritual practices. 10 These Eastern whole systems approaches include Traditional Chinese medicine (which includes the practice of acupuncture), as well as Ayurvedic medicine from India and traditional Tibetan medicine. They are characterized by an integrated use of diet, herbs and supplements, movement practices, and forms of physical manipulation and massage, as well as other interventions. They use explanatory systems that link health to nature—including the concept that there are natural forms of energy or life force (often referred to as Chi, Qi, or Ki), the disruption of which can contribute to ill health (see also following footnote).

17 there was interest in the new (to the West) energetic explanatory systems and the role of spirituality in a healthy way of life11. Given this historical emphasis, other mind-body practices that developed in the West from the mid-19th century to the present have often been overlooked in MBM (Grossiner, 1995; D. H. Johnson, 2005). These practices, grounded in existential philosophy12 and the phenomenology of experience (Hanna, 1970), point toward the cultivation of awareness of bodily experience, improving action in the world, and exploring the relationships between the person and environment, as keys to transcending the mind-body split. Criswell (2001) proposed that this “non-dualistic approach [to mind/body medicine] begins with an understanding that we are already whole and that it is a return to or remembrance of wholeness inherent in mind/body practice” (p. 583). The creators of these practices drew on scientific ideas, including Darwinian evolution, and the emerging physiology, psychology, and neuroscience of movement and perception. They also built on European movement traditions such as “Gymnastik,” a form of integrated, expressive movement and awareness rather than mechanical exercise (D. H. Johnson, 1995, 2005). A number of somatics practices were developed that

11

The understanding of ideas such as Ki as having to do solely with subtle, but literal, energies is largely a Western understanding. It appears that a concept like Ki in Japan can have multiple meanings or is considered beyond our current understanding in many of the cultures in which these ideas originated (Nagatomo, 1992). Ozawa-De Silva (2002) suggested that while the understanding of Ki in Japanese culture is often translated as “spiritual energy,” it is primarily seen as a unifying force that can be found in nature, but “can also be understood as ‘atmosphere,’ ‘air,’ ‘feelings,’ ‘intention,’ ‘will,’ ‘mind,’ and ‘heart’” (p. 28). Ki can be maintained through many factors including diet, ethical intentions and behavior, and through practices such as meditation and martial arts (Nagatomo, 1992). 12 Existentialist ideas emphasize the subjective experience of the individual, rather than rational decision-making or institutional precepts, as the basis of meaning and judgment. The emphasis is on the individual identifying what constitutes authentic action for them, and making choices and commitments on that basis. The person’s actual mode of being-in-the-world is seen as the basis of real human existence, rather than an abstracted subject (Blackburn, 2005; Honderich, 1995).

18 emphasized the role of the body and bodily experience in learning about one’s self that could be done as stand-alone practices, or were integrated in psychotherapy and expressive arts practice. The Second World War both interrupted development of these approaches in their countries of origin, and gave an impetus to a diaspora that saw these approaches flourish in London and New York—where they particularly influenced dance and expressive arts. They also flourished in the San Francisco Bay Area, where these approaches became part of the emerging human potential movement 13 that was centered on Berkeley and Esalen in the 1960s and 1970s. Here the emphasis on bodily experience contributed to new psychological approaches such as Gestalt14 body-awareness exercises and the psychophysical exercises of Robert Masters and Jean Houston (Criswell, 2001; Masters & Houston, 1978; Moss & Shane, 1999; Reese, 2002). Influences on the Development of the Feldenkrais Method Like many mind-body practices, the development of the Feldenkrais Method was influenced by some traditional practices of Eastern origin. The notion of the “mind-and-

13

The human potential movement of the 1960s and 1970s in the United States and other countries was characterized by experimentation in modes of personal exploration for personal and social development. There was extensive use of group processes (encounter groups, T-groups), expressive processes such as poetry, movement and dance, imaginative processes, and so forth, to promote mental and physical health, individual learning or transformation, and the creation of new social forms. Many somatics practices gained interest at that time. Many of the practices from that time were incorporated into psychotherapy, coaching and organizational development, and formed the basis of some contemporary MBM practices (D. H. Johnson, 1995, 2005; Kolb, 1983; Leonard & Murphy, 2005). 14 “Gestalt therapy is a non-interpretive psychotherapy which emphasizes awareness and personal responsibility and adopts a holistic approach, giving equal emphasis to mind and body”. “Much of Gestalt therapy is a training in awareness, in improving the individual’s contact with himself and his environment” (Gregory, 1987, p. 291). Therapy sessions were often done in a group setting, attention to bodily sensations associated with emotions, movement, and vocalization were often included as part of the process. Fritz and Laura Perls were among the founders and most prominent practitioners in this approach (Gregory, 1987). Laura Perls developed somatic awareness exercises as part of gestalt practices. Robert Masters and Jean Houston collaborated with Moshe Feldenkrais and developed exercises for personal growth involving the use of directed

19 body” that Feldenkrais (1985, p. 152) proposed is consistent with, for example, nondualistic understandings of the body found in Japanese culture, and rooted in Buddhist meditation and Eastern martial arts practices (Nagatomo, 1992). This is probably reflective of his study and practice of Judo. In addition, Feldenkrais was steeped in the ideas and practices of Hassidic Judaism. Kaetz (2007) has written about the connections between the ideas of human development in the Hassidic tradition and the ideas underlying Feldenkrais conception of the Method. Feldenkrais (1972) himself wrote that some of these Jewish traditions “were more influenced by Zen and Raja Yoga than appears at first sight” (p. 30). However, in developing the Method, Feldenkrais eschewed explanations involving subtle energy systems and mystical symbolism, feeling they were unnecessary for creating, experiencing, or explaining improvement in one’s psychophysical organization. He strongly based his Method in his studies of physics, anatomy, physiology, neurology, and psychology (Feldenkrais, 1949, 1985). Finally, Feldenkrais had studied or was familiar with autosuggestion, hypnosis, and autogenics, Gurdjieff’s self-remembering practices, Jacobson’s progressive relaxation, the Alexander Technique, Eutony and other somatic awareness practices (Feldenkrais, 1964/2010c, 1972, 1988/2010b). Thus the Feldenkrais Method was grounded both in Feldenkrais’s study of science, his knowledge of various somatics practices and his experience of nondualist ideas embodied in the Eastern martial arts practice of Judo. In this way, Feldenkrais Method shares many of the historical sources of ideas and practices that are found in MBM. This

attention, imagery, and movement to develop self-awareness (Masters & Houston, 1978; Moss & Shane, 1999).

20 thesis suggests that the Feldenkrais Method also has a distinct approach and makes a unique contribution. Philosophical and Scientific Context This section explores historical, and emerging philosophical and scientific models for understanding the mind-body unity. This is critical for this thesis, as a deepened understanding of the intertwining of mind and body is useful in illuminating the human impact of somatics and somatic approaches such as the Feldenkrais Method. Historical views of the body include the Christian view of the body as the corpselike vehicle for a living spirit or the scientific view of the body as a biological machine inhabited by the ghost of mind (H. Jonas, 2001). H. Jonas (2001) suggested that the phenomenon of life itself provides the challenge to this kind of inherited dualistic thinking. He proposed that “the living organism,” in its existence, resists the dualisms of “self and world, inner and outer existence, mind and nature” (pp. 14-15) as well as mind and body. A number of thinkers propose that we experience ourselves as bodies and ourselves through our bodies, and the world through our bodily experience (Damasio, 2010; Merleau-Ponty, 1962, 1973). They suggest that our bodily experience is the ground for both our human understanding, and our being-in-the-world. Merleau-Ponty (1973), in his last work, wrote: Our body is a being of two leaves, from one side a thing among things, and otherwise what sees them and touches them; […] it unites these two properties within itself, and its double belongingness to the order of the “object” and the order of the “subject” reveals to us quite unexpected relations between the two orders. […] it teaches us that each calls for the other. …because the body belongs to the order of things, as the world is universal flesh. (p. 137) The mind-body relationship has been one of the predominant philosophical questions in human history. A growing literature combining existential philosophy,

21 phenomenological methods, and recent neuroscientific findings, suggests that mind and body are much more mutually influencing and dependent, more intertwined and interpenetrated, more co-arising and coordinated than either Christian, idealist, or materialist scientific dualist philosophies would suggest (H. Jonas, 2001). From the earliest days of psychophysiological research, for example, the development of the Progressive Relaxation practices of Jacobson (Jacobson, 1938; Jacobson, 1987; McGuigan, 1997), there has been strong evidence of the relationship between body and mind. There is now substantial research supporting the indivisible and vital connections of physical body and of action to sensation, perception, thought (e.g., remembering, imaging, conceptualizing, and other capacities) and affect (e.g., emotion, mood and “vitality affects”15) (Damasio, 2010; W. J. Freeman, 2000; Ginsburg, 2010; Sheets-Johnstone, 2009). Emotion and action are always already bodily, and are integral to the experience of self. These new approaches suggest that the exploration of the dynamic relationships among thought, emotion, motility, and the environment can provide new ways of thinking about the mind-body problem. That the concepts of bodily experience, intention, and action16 provide ways of thinking about human experience that transcend the old dualist

15

Vitality affects is a term used by Stern (2004) for affective qualities of experience such as “surging, fading away, fleeting, explosive, tentative, effortful” (p. 64). Stern (2004) suggested, “Vitality affects emerge as the moment unfolds…captured in terms such as accelerating, fading, exploding, unstable, tentative, forceful and so on” (p. 36). Sheets-Johnstone (2009) proposed four basic qualities of movement: “tensional, linear, amplitudinal, and projectional,” that are aspects of particular “corporeal tonicities” associated with emotion and action (pp. 205-210). 16 In this paper, movement designates the purely physical displacement of the body, whereas action refers to movement that is intentional and meaningful for the person whether the intention and meaning is conscious or reflective of the intentional arc of the person’s behavior. Action may also include speech acts. Gallese (2009) made the distinction between “bodily movements” as “simple physical events,” “motor acts” as “movements that are goal directed,” and suggested, “Actions are a specific subset of goal directed movements. These are a series of motor acts that are functionally integrated with a currently active representation of a goal-state as leading

22 conceptions (Damasio, 2010; Gallagher, 2005; W. J. Freeman & Nuñez, 1999; SheetsJohnstone, 2009; Thompson, 2007; Varela et al., 1993). For example, in the field of cognitive neuroscience, an “enactive” paradigm is gaining significant interest and support (M. Johnson, 2007; Noë, 2004; Stewart, Gapenne, & Di Paolo, 2010). Varela et al. (1993) wrote, We propose…the term enactive to emphasize the growing conviction that cognition is not the representation of a pregiven world by a pregiven mind but is rather the enactment of a world and a mind on the basis of a history of a variety of actions that a being in the world performs. (p. 9) This new approach provides some direction out of a dualist conception of a disembodied mind directing a material body. These authors explored how the relationships among environments, the organism, and meaning are based in the biological processes of life, including motility, function, and experience. The enactive paradigm proposes that cognition arises from our situated life in the world, which is always already grounded in bodily experience. In this view, cognition is dynamic, reflecting the autonomous organism’s continuous processes of sense-making essential for survival and development of its identity (Di Paolo, Rohde, & De Jaegher, 2010). As an example of the relationship between bodily experience and meaning, many of the deep metaphors, or image schemas, that provide the conceptual underpinnings of our thought arise from the bodily, physical, and spatial nature of human life, (e.g., up is good, down is bad, forward to the future, back to the past, he had a well grounded argument built on solid evidence; see also M. Johnson; 1987; Lakoff & Johnson, 1999). The concept of arise itself is already a physical and spatial metaphor.

to a reward” (p. 487). Gallese’s (2009) definition includes a “pre-linguistic and pre-theoretical” understanding of “representation” (p. 487).

23 On broad conceptual levels as well as on deeply personal ones, the body and its experiencing can be seen as a vehicle for the phenomena of life through us, a source of knowledge and meaning, and through our action, a fundamental way in which we extend ourselves to shape the world that also shapes us (Gendlin, 1978; M. Johnson, 2007; H. Jonas, 2001; Russon, 2003). H. Jonas (2001), discussing the concept of causality, provided a passionate summation of these ideas: The experience of living force, one’s own namely, in the acting of the body is the experiential basis for the abstractions of the general concepts of action and causation; and the “schematization” of directed bodily movement,…between the formality of the understanding and the dynamics of the real. Causality is thus… itself a basic experience. That experience has its seat in the effort I must make to overcome the resistance of worldly matter in my acting and to resist the impact of worldly matter upon myself. This happens through and with my body, with its extensive outwardness and its intensive inwardness at once, which are both genuine aspects of myself. And advancing from my body, nay, myself advancing bodily, I build up in the image of its basic experience the dynamic image of the world—the world of force and resistance, action and inertia, cause and effect. Thus causality is…the universal extrapolation from propriobodily prime experience into the whole of reality. It is rooted in just the point of actual, live “transcendence” of the self, the point where inwardness actively transcends itself into the outward and continues itself into it with its actions. This point is the intensive-extensive body in which the self exists, at once, for itself (intensive) and in the midst of the world (extensive). (pp. 22-23)

24 The Feldenkrais Method The Aims of the Method In developing the Method, Moshe Feldenkrais drew on his experience of the martial art of Judo. In Higher Judo (1952) he wrote, The essential aim of Judo is to teach, help, and forward adult maturity, which is an ideal state rarely reached, where a person is capable of dealing with the immediate present task before him [sic] without being hindered by earlier formed habits of thought or attitude. (p. xii) This view also underlies Feldenkrais’s aims for the Method he developed. He saw this capacity to alter one’s learned and habituated patterns of response to situations—“a change in the dynamics of our actions” (Feldenkrais, 1972, p. 10)—as essential for people to both achieve their goals and to move toward their human potential. His aim for the Method he created was to reinstate modes of action that were consistent with more optimal biological functioning, and not distorted by “the body pattern of anxiety” (Feldenkrais, 1949, p. 83) arising from the fears, insecurities, and other distortions that characterize a human’s long period of dependence through childhood and adolescence. Although Feldenkrais had clear ideas of what would be more ideal human functioning, his approach was pragmatic: To be of practical use, the mode of doing must not be an ideal, but expedient—one that can be normally used in our present-day society. It is useless to aspire to an idea of being better than everyone else. The main object is to form an attitude and a new set of responses that permit an even and poised application of oneself to the business of living and not create new terrain for conflict. Moreover, the new mode of action must perforce be adjusted to the present environment – even though everybody agrees that our social structure and education need radical improvement if they are to become suitable for a society of creative, evolving, mature adults. (Feldenkrais, 1985, p. 107) The Feldenkrais Method creates learning situations that lead to the alteration of patterns of action (and their components of movement, perception, autonomic responses,

25 sensation, thinking, emotion, and mood). Feldenkrais explains that using the “actionsystem as the point of attack for…improvement” comes from the understanding that: At any moment the whole system achieves a kind of general integration that the body will express at that moment.…A fundamental change in the motor basis within any single integration pattern will break up the cohesion of the whole and thereby leave thought and feeling without anchorage in the patterns of their established routines. In this condition it is much easier to effect changes in thinking and feeling, for the muscular part through which thinking and feeling reach our awareness has changed and no longer expresses the patterns previously familiar to us. Habit has lost its chief support, that of the muscles, and has become more amenable to change. (Feldenkrais, 1972, pp. 38-39) Moshe Feldenkrais’s Concepts of Health Feldenkrais discussed health in two principal ways. One was that “health is measured by the shock a person can take without his or her usual way of life being compromised” (Feldenkrais, 1979/2010d, p. 55); that is, a person’s ability to recover. He also talked about health being a person’s ability to live his or her “avowed” and “unavowed” dreams (Feldenkrais, 1979/2010d, p. 58; Feldenkrais, 1981)17. Avowed dreams, for Feldenkrais are one’s explict goals for one’s life. Feldenkrais described unavowed dreams as those that are intentions that one has for one’s life as a child or adolescent that are not acted on but remain active at some level in the person’s sense of themselves. Feldenkrais saw the kind of learning he advocated as promoting health in both these senses. He wrote, “Organic learning is essential—it can also be therapeutic in its essence” (Feldenkrais, 1981, p. 29). He felt that in many ways this kind of learning was

17

A similar concept of identifying long-held, if unacknowledged, desires to help clarify one’s motivations can be found in life coaching practice. A common question used for preparing a client for the coaching process might be worded, “What accomplishments must, in your opinion, occur during your lifetime so that you will consider your life to have been satisfying and well-lived – life with few or no regrets?” (Whitworth, Kimsey-House, & Sandahl, 1998, p. 184).

26 better than a simple cure delivered from an external source, as such learning provides the basis for recovering from the illness and injuries that are an inevitable aspect of life (Feldenkrais, 1981, 1977/2010a). “Improving the learning ability of the person is the real foundation of [good bodily organization] and therefore the foundation of good health of…the “body-and-mind” (Feldenkrais, 1985, p. 152). In this formulation, health could first be considered as having capacities for coping and resilience. Second, health is linked to human development. Both these concepts are considered in more detail below. Modes of Practice Practices: Awareness Through Movement. This is a verbally-directed mode where students are asked to explore making movements (actual or imagined) and to observe qualities that arise through the process, for example, changes in contact with the supporting surface (e.g., floor or chair), direction of parts of the body in relation to other parts of the body, the whole body in gravity and space, and qualities18 of the bodily experience of the movement. These may include the sense of muscular effort, smoothness of action, the initiation of the movement and what stops it from continuing further, what parts of the body are involved, and more. Shifting attention is also used to alter perception and heighten awareness. At the same time, students are asked to do only what is comfortable and pleasant, to use only the amount of effort necessary to make the movement, to move at a speed where they can continue to sense themselves, to make the movement smoothly without jumpiness, sudden stops, or changes in speed. Consistent

18

This emphasis on the qualities of action is an important aspect of Feldenkrais Method. While in philosophy and neuroscience there is intense debate about the significance of “qualia”— the unique, personal qualities of experience, Feldenkrais is an approach that explicitly makes use of these qualities of experience in order to alter it.

27 with the Weber-Fechner Principle19, as applied to the perception of muscular effort (Leri, 1997), reduction of effort allows for the student to sense smaller and smaller changes in the level of effort. This approach aims to reduce habitual, tonic muscular contraction. Apart from some movements that are intended to be ballistic, students are encouraged to make movements that are reversible—that can be stopped and reversed easily at any time. Attention is often directed to the breath, which is encouraged to be appropriate to the movement being performed, or as much as possible, undisturbed by the movement. Feldenkrais suggests that appropriate, unforced breathing is one of the measures of the quality of an action (Feldenkrais, 1981-1982). In Awareness Through Movement lessons there is often an element of problem solving as students deal with the question of how to achieve the movement while maintaining the suggested constraint—which may promote shifts in habitual ways of moving, acting, or thinking about their bodies. Constraints might be physical (e.g., keeping a particular relationship between body parts), about movement quality (e.g., moving smoothly), or mentally based (e.g., maintaining awareness of a particular image while moving). Students are encouraged to notice their affective responses, to the process, such as not knowing how to do something. Values emphasized in Awareness

19

Leri (1997) described the Weber-Fechner Principle (also the Weber-Fechner Law, or the Fechner-Weber Principle or Law) as, “An approximate psychological law relating the degree of response or sensation of a sense organ and the intensity of the stimulus” (para. 1). The law suggests that there is constant ratio for response in the sense organ as the level of the stimulus changes, which allows for the threshold for noticing such a change to be determined. In relation to perception of muscular effort, Weber and Fechner found a ratio of approximately between 20/1 and 40/1 in the conscious perception of an increase or decrease in the perception of effort. For example, when carrying as 20 kg item, someone will only notice an increase in effort if the weight is increased by 1 to 2 kg. Conversely if someone is making a muscular effort of 4 kg, then they can notice a reduction of effort of .1 to .2 of a kilogram. As practically applied in the Feldenkrais Method, a reduction in muscular effort when making a movement is thought to lead to greater sensitivity to changes in effort, and a greater ability to modulate the effort used.

28 Though Movement include being nonjudgmental toward oneself, one’s body, or movement, not to strive in way that affects the quality of the movement, and to accept one’s current levels of ability. Students are encouraged to move in ways that do not cause strain or pain, or increase any pain they may already have—and to rest whenever they want to. Thus selfcare is learned as part of the process. A student can learn how he or she can move without injuring him or herself or stimulating a pain response, which might involve moving less or with less effort, or moving in a new way. In these ways the emphasis is on the experience of the self-in-action—the how of how the person is moving—and on developing self-regulation in the process. The movement sequences are designed precisely. Lessons often break down whole movement patterns into parts and then reassemble them into new movement sequences. The lessons usually involve either novel or functional movement patterns as important ways to promote learning. Awareness Through Movement lessons address many human functions including breathing, standing, balancing, sitting, walking, jumping, running, lying, sleeping, turning, reaching, throwing, the use of the jaw and eyes, vision, and voice, and more. There are recordings and transcripts of over 1,000 lessons Feldenkrais taught in his lifetime, a large proportion of them uniquely constructed (Feldenkrais, 1994-2004). Feldenkrais Method could be considered a mode selfobservation while moving. It is a way of “understanding while doing” (Feldenkrais, 1972, p. ix). While movement and action are improved, the name Awareness Through Movement also reveals that Feldenkrais’s emphasis for this mode of learning is also on awareness. Awareness Through Movement can be done in a group class setting, with a teacher and a single student, with recordings, or from memory.

29 Practices: Functional Integration. Functional Integration involves the practitioner (teacher) working mostly manually and often nonverbally, but sometimes also verbally, with a client (student) on a one-on-one basis. The practitioner seeks to understand and connect with the client’s experience, as much as possible from the client’s perspective. It is a communicative, rather than instrumental or directive, model of learning (Edwards, Jones, & Hillier, 2006). Functional Integration follows the same principles as Awareness Through Movement and makes use of many of the same strategies. Usually, for much of the lesson, the practitioner is engaged in touching and moving the client. The practitioner touches the client in ways intended to convey a sense of support, and to provide sensory information about the state of the client’s body (such as, position, muscular tonus, and the movements of breathing). The practitioner is thinking of influencing the client’s nonconscious or preconscious perception of the body and movement, as well as conscious awareness. These conceptions of the mechanisms and dynamics of the Method will be discussed further below. Through moving the client, the practitioner aims to generate sensory information for the client about the qualities of his or her physical organization including, for example, the movement in particular joints, the smoothness or jerkiness of the movement, the ease or difficulty of moving a particular part of the body, the relationship between the part being touched and moved and other parts of the body, the capacity of the body for recoil, the relationship between movements of parts of the body with the whole body, movements of breathing, and fundamental relationships in the body with certain movement patterns, such as bending or rolling. The practitioner’s touching and moving the client is intended to convey the initial state of the person’s body and movement, and new possibilities for

30 movement, and to reinforce and integrate the sensations of those new possibilities for movement when they are achieved. Again, thinking of the Weber-Fechner Principle in relation to the perception of muscular effort, the practitioner may support muscular activity until there is a palpable reduction in that activity, with the aim of creating the possibility for the client to experience new qualities and range of movement, and develop new capacities to perceive levels of muscular contraction (Grossinger, 1995). The practitioner may also verbally direct the individual client in movement explorations similar to those in Awareness Through Movement lessons, and may assist the person with making such movements—and again, qualities such as direction, force, and effort may be communicated through the practitioner’s touch. They may also provide the client with self-observation practices or movement explorations to do between Functional Integration sessions. Feldenkrais (1981) described the experience of Functional Integration in this way: [In Functional Integration] the deepest kinesthetic sensations formed in early childhood are affected. The person withdraws from what happens in the outside world and is completely absorbed with attending to the internally occurring changes. The smoother eye movement, the rotation of the head, the change in pressure distribution on the soles of the feet, the reduction of intercostal tensions, the completion of the antigravitational muscular patterns for a clear feeling of vertical upright standing cannot occur without a complete change of neural functioning of the intentional or motor cortex and of the sensory one. The muscular tonus becomes more uniform and is lowered. A feeling of well-being prevails. The breathing becomes regular; the cheeks more colored. The eyes are brighter, wider, and moister and sparkle. At the end, one rubs one’s eyes as if awakening from a restful dream. (p. 144) Some Key Concepts: Intention, Action, Function, and Self-Image Intention. For Feldenkrais, intention did not involve only conscious thought-inlanguage, but was also revealed in one’s bodily dispositions and one’s actions. Intention, related not only to motivations toward discrete actions in the moment, but also to one’s

31 longer-term, often unconscious motivations. Feldenkrais saw that one of the important outcomes of the Method was to help people clarify their intentions. He felt it was very important for people to understand their organic, biological needs, and how biological drives and affective states influenced their action in the world. He argued that crossed motivations20 inhibited or distorted effective action, leading to, for example, hesitation, muscular tension, and ineffective expression. Function. For Feldenkrais, function could be viewed at both an individual level, and at the level of the species (Feldenkrais, 1993)21. He focused on the idea of improving function as a way to influence the organization of physical structure, in contrast to various tissue manipulative approaches. “Feldenkrais described function as the link between intention and action” (Ginsburg, 2010, p. 263). Taking a view similar to ecological psychologists, function involves those activities that promote “self-protection,” “selfmaintenance,” and “self-reproduction” (Feldenkrais, 1981, pp. 13-14). Function may include such things as feeding, grooming, elimination, and reproduction (Reed, 1996), all of which require self-movement (or in the case of people with disabilities, to live in a social environment that helps provide these things; Feldenkrais, 1981). As humans are social organisms, functioning also requires abilities for communication—such as speech, touch, facial, and bodily expression.

20

Crossed motivations, according to Feldenkrais, occur when the intention for action is not clear—perhaps because the original intention or learning was formed under too much pressure. Crossed motivation can lead to inability to act, hesitation, or lack of completion of an action. 21 Feldenkrais’s emphasis on function as means of improvement, as opposed to trying to directly influence physical structure, may have been influenced by his knowledge of the early neurologist Kurt Goldstein. Goldstein (1995) observed from his work with severely wounded World War I soldiers how his patients found ways to continue to function despite significant damage to their physical bodies.

32 Feldenkrais also used function to describe various ongoing behaviors that subserve or support these biological requirements, such as facing (orienting the teleceptors of eyes, ears, nose), breathing, standing, walking, turning, sitting, and eating, as well thinking22 or self-assertion. When considering a single function for an individual client Feldenkrais wrote that he: Visualized the information that must be gathered from the environment and the mechanisms that can handle it, then the body structure housing the intention to move, and, lastly, the tools that can realize that intention. Finally, I considered the integration of the data from the outside with the continuous changes of position of the body structures. (Feldenkrais, 1993, p. 19) Action. Feldenkrais saw action as having a central place in the expression of our lives in the world, as well as the location for making effective improvements. He believed that “mind, unconscious, and will,” and indeed all human functions “have no existence before action has taken place” (Feldenkrais, 1985, p. 67). In action, the whole self is involved; it is the way in which the self is experienced. In action both physical and mental aspects of human functioning are expressed. A central aim of the Method is to help people “learn a better mode of action” (Feldenkrais, 1985, p. 153). Action therefore brings together meaning, or intention, the bodily apparatus for perception and movement, in a specific environment and at a specific moment. Feldenkrais (1972) suggested that focusing on the movement component has a number of benefits in promoting improvement, noting that “the nervous system is occupied mainly 22

Feldenkrais (1972) saw that thinking could only be separated from moving, sensing and feeling in language. That is, that thinking is a function of the whole organism. Feldenkrais (1985) wrote: “the use and experience of the body are necessary to form mental functions. After the formation of a sufficient number of paths and patterns, the somatic support becomes less and less essential; we can think—that is, re-excite the formed patterns, regrouping them into new ones. This common experience of the gradual liberation of cerebral functions from somatic support, although perhaps not so clearly formulated, may provide the clue for the idea of a soul or a mind altogether free from material support” (p. 79).

33 with movement” (p. 33) and that movements “reflect the state of the nervous system” (p. 35). Also, that we have a rich experience of movement that allows us to “distinguish the quality of movement” (p. 34) often more easily than qualities of thinking or affective states. The vital and continuous activity of breathing is also a movement which both affects and provides observable information about oneself. Self-image. Feldenkrais proposed, “The behavior of human beings is firmly based in the self-image they have made for themselves” (Feldenkrais, 1988/2010b, p. 3). This self-image in seen as dynamic—constantly being updated on the basis of experience. Beringer (2010b) proposed that perhaps we should instead talk of “self-imaging” (p. 33). Feldenkrais argued that because we act in accordance with the self-image (Feldenkrais, 1972; 1988/2010b), developing a more complete image of the body in action can help improve function and realize intentions. Developing greater skill in sensing the musculospatial-temporal and kinesthetic aspects of one’s experience is vital to improving function and action. A primary role of the Feldenkrais teacher, then is to provide processes to fill these gaps in self-perception. Further describing this construct, Feldenkrais (1988/2010b) wrote: What is the self-image? I would argue that it is the body image; namely, it is the shape and the relationship of the bodily parts, which means the spatial and temporal relationships, as well as the kinesthetic feelings. Included with this are feelings and emotions and one's thoughts. All of these form an integrated whole. (p. 3) In some ways this concept is similar to the idea of “bodily dispositions” proposed by Merleau-Ponty (1962). It includes within it the idea of experience of body awareness, but also the concepts of body image and body schema. Body image as is often described as involving the subjective, experiential, affective, and socially and culturally influenced, image one has of one’s body. On the neurological level, it is proposed that this image is

34 subserved primarily by interoceptive mechanisms. The body schema is proposed as the nonconscious, physical, and neurophysiological image of the body in the nervous system, composed of information about bodily position and organization, and sub-served by proprioceptive mechanisms (Gallagher, 2005). Both these concepts, however, are the topic of considerable discussion and dispute (Bermudez, Marcel, & Eilan, 1995; LeGrande, 2011; Sheets-Johnstone, 2009; Shusterman, 2008). Indeed, there is currently considerable ongoing discussion, debate, and research into ideas related to the self-image, the body, and awareness amongst and between philosophers and neuroscientists (Gallese, 2011; Gallese & Sinigaglia, 2011; Knoblich, Elsner, Aschersleben, & Metzinger, 2003; LeGrande, 2007). Whether or not body image and body schema are sustainable constructs, the conscious and nonconscious perceptions of one’s body can include (a) the perception of the body in the environment and the spatiotemporal aspects of action; (b) the subjective-experiential aspects of bodily experience; and (c) the attitudes we take to our bodies and bodily experience—which are always already influenced by society, language, and culture. One of the ways Feldenkrais practice enhances bodily awareness is though scanning the body. A number of approaches in MBM make use of a body scan; it is the first practice used in the MBSR program, and Yoga Nidra is a body scanning practice in its own right (Miller, 2005; Saraswati, 1998). Feldenkrais Awareness Through Movement lessons, and sometimes Functional Integration, often make use of the body scan at the beginning and end of a lesson (Gutteridge, n.d.). The body scan in Feldenkrais practice generally has an emphasis on the relationship with the environment (gravity and space) as a way of accessing the experience of the body. There are also whole Feldenkrais lessons dedicated to exploring spaces and distances within the body (Feldenkrais, 1981-1982;

35 Stransky, 1987). Finally, through the use of directed attention Awareness Through Movement lessons involve attending to bodily sensation while moving throughout the lesson – as well as when resting. Feldenkrais proposed that the self-image is acquired through a long period of experience. As such it can provide a way of responding reliably to demands from the environment. It can also take on a quality of fixity that may prevent the emergence of new, more appropriate responses. Each person’s development tends to be uneven. Often, once a level of skill needed for basic functioning has been achieved, many people stop expanding their repertoire of ways of acting. Therefore the self-image is rarely complete (Feldenkrais, 1972; Rywerant, 1994). Through scanning the body in Feldenkrais lessons, one often discovers that there are areas or parts of the body that one is unable to bring to conscious attention (Feldenkrais, 1964/2010c). For example, the sense of the skeleton is often missing (Feldenkrais, 1988/2010b). Feldenkrais also gives the example that people are often unable to compare the size of one body part (e.g., the mouth) with another (e.g., the distance between thumb and index finger tips) with the eyes closed (Feldenkrais, 1972). Social and cultural factors impact this bodily self-image in important ways. Drawing on Feldenkrais’s idea, Hutchinson (1985) found that in a similar exercise, Western women commonly overestimated the width of their hips when using the distance between their hands as a measure. Feldenkrais was familiar with Shilder’s (1942) work on perception, and especially the relationship between self-image, body perception, and psychological conditions (Shilder, 1950). For example, how stress and anxiety or a history of trauma could be linked with the experience of dizziness and a sense of imbalance (Feldenkrais, 1981). Or,

36 for example, that the anticipation of difficulty leads to habitual shortening of the body, and conversely, how the sense of lengthening is associated both with well organized movement and an experience of ease (Feldenkrais, 1972). Feldenkrais also noted how the “emotional body image” (Feldenkrais, 1964/2010c; 1994-2004) is often involved in the experience of pain. The location and nature of pain sometimes has emotional meaning as part of the story of someone’s self-image, in addition to the contribution of any physical illness or injury to the pattern of pain (Feldenkrais, 1981). Feldenkrais (1981) suggested that pain reduced the self-image, and recent research supports the idea that pain leads to disturbance of body perception (Schwoebel, Friedman, Duda, & Coslett, 2001) and mental representations of movement (Lewis, Kersten, McCabe, McPherson, & Blake, 2007), which is reflected in altered cortical organization (Maihöfner, Handwerker, Nuendörfer, & Birklein, 2003). In a recent study, the use of a body scan was shown to reduce phantom limb pain for people post-amputation (MacIver, Lloyd, Kelly, Roberts, & Nurmikko, 2008). The next section is a review of how the Feldenkrais Method is reported in the MBM and complementary and alternative medicine literature and presents Feldenkrais research studies to date.

37 The Feldenkrais Method in MBM and CAM Literature Complementary and Alternative Medicine Literature Reviewing the literature for CAM or integrative medicine practices in general, and MBM in particular, reveals an inconsistent representation of the Feldenkrais Method and other somatics practices. Some of the most widely used textbooks and guides for clinicians do not address these methods and approaches at all. For example, L. Freeman’s (2001) Mosby’s Complementary and Alternative Medicine: A Research-Based Approach, discussed movement only in the context of exercise, and the only touch therapies described are energy-based approaches. Likewise, Moss, McGrady, Davies and Wickramasekera’s (2003) Handbook of Mind-Body Medicine for Primary Care does not provide significant coverage of somatics approaches, although there is mention of Yoga and Rolfing. It is possible that these texts reflect the relative paucity of research studies and of actual use of somatics practices in medical settings. Similarly, in the presentation of CAM and MBM to the public, somatics approaches are often omitted (for example, Goleman and Guerin’s 1993 Consumer Reports compilation Mind Body Medicine, the PBS television series by Bill Moyers in 1995 and subsequent book, Healing and the Mind and the 2008 publication, The Cure Within: A History of Mind-Body Medicine, by Harvard medical historian Anne Harrington). By contrast, another publication for the medical profession, Novey’s (2000) Clinician’s Complete Reference to Complementary and Alternative Medicine, includes descriptions of Feldenkrais Method and a range of somatics practices provided by professional practitioners of those approaches. A previous survey of CAM approaches, Grossinger’s (1995) Planet Medicine: Modalities, provides much detail about actual somatics modalities, whereas the recent review of integral approaches, Schlitz, Amorok,

38 and Micozzi’s (2005) Consciousness and Healing, includes a history of somatics by Don Hanlon Johnson (2005). Mind-Body Programs Some creators of MBM programs have clearly drawn on thinking from the field of somatics in the development of their work. This can be seen, for example, in the MindBody Skills program developed by James Gordon (1996) from the Center for Mind-Body Medicine (CMBM, 2010), and the Integral Transformative Program (ITP) developed by George Leonard and Michael Murphy (2005). Gordon (1996) wrote of his understanding that emotions and thoughts take on a physical reality in tight muscles, restricted movements, and physical dysfunction; and a conviction, based on experience, that working with and reeducating the physical structure can also profoundly alter the mental and emotional life. (p. 136) National Bodies Looking at the materials from the National Center for Complementary and Alternative Medicine (NCCAM) also shows that the inclusion of Feldenkrais Method and other somatics approaches is only recent and rather limited in scope. The National Center for Health Statistics (NCHS) only included Feldenkrais Method in its utilization surveys of CAM in 2007 (NCHS, 2008). However, in the NCCAM 2011-2015 Strategic Plan: Exploring the Science of Complementary and Alternative Medicine, Strategic Objective 1 is to “Advance research on mind and body interventions, practices and disciplines” (NCCAM, 2011a, p. 17). Feldenkrais Method, along with other somatics and MBM approaches, is listed as falling within the scope of this research priority. The NCCAM description of the Feldenkrais Method has a number of limitations. For example, the Feldenkrais Method is categorized and described as a “movement therapy” (NCCAM, 2011b, 2011c) whereas the Feldenkrais profession

39 considers it as a method of “somatic education” (FGNA, n.d., “Somatic education”). The NCCAM (2011b) description of the Method, “The intent is to help the person become more aware of how the body moves through space and to improve physical functioning” (“Feldenkrais,” para. 1) captures the emphasis on awareness, movement, and function. However, consistent with the arguments made here, this description does not address the potential for the Method in relation to other aspects of health and well-being. Contradictory Findings Finally, changes in how people experience their bodies may be an important outcome of CAM and MBM interventions. For example, in a study of unexpected outcomes, Hsu, BlueSpruce, Sherman, and Cherkin (2010) found that “increased body awareness” (p. 157) was among the top five benefits participants identified from programs involving acupuncture, massage, Yoga, chiropractic, Tai Chi, and Mindfulness-Based Stress Reduction. Whether improved bodily awareness is part of what makes these kinds of interventions effective, which is what proponents of somatics approaches would suggest, deserves further investigation (Mehling et al., 2011). The CAM and MBM literature reveals a number of contradictions: in some places Feldenkrais Method and other somatics practices are included and well described, in other places they are entirely missing. In yet other places they are inadequately described. On the other hand these practices have clearly been influential in the development of some MBM programs. Discussion The lack of recognition and the inadequacy of understanding of somatics practices in the CAM and MBM literature is somewhat surprising given the longevity of Western somatics approaches on the one hand and the frequent inclusion of approaches such as

40 Qigong, Tai Chi, and Yoga, on the other. Grossinger (1995) suggested that the central focus on the experiential dimension for the client or participant, rather than the expertise of the therapist or practitioner, may mean that there is a poor fit with the biomedical paradigm. Somatics practices, as healthful practices, are based in a model of self-care. Grossinger (1995) also suggested that the strong links between somatics practices and the human potential movement, with its emphasis on psyche and spirit, may have led to these practices being overlooked in their contribution to health—at least as narrowly defined as physical health. In addition, many somatics practitioners are deeply concerned about the risks of being involved in current biomedical systems, which are based in very different assumptions about human functioning and health, and which have a great deal of social and economic power. The structures and processes of biomedical practice may present difficulties for somatics practitioners to contribute effectively. This may have contributed to some separation between somatic practices and the medical world. The explanatory systems of practices like Qigong, Tai Chi, and Yoga are based in spiritual and energetic concepts that have an internal consistency, and while they are outside Western understandings, they can be understood as a wholly different worldview and are often adopted within integrative medicine as a whole system. Alternatively, somatics approaches challenge the Western dualist understandings of the body from within a Western paradigm. For example, the personal, internal experience of the patient has historically often been given little weight in medical practice, whereas it is central in somatics practice. As the physiological basis of relationship between the mind and body has come to be studied and better understood scientifically, there is greater potential for the inclusion of somatic perspectives in health care. The increasing scientific understanding of the

41 psycho-physiologicial mechanisms of stress and trauma, for example, help provide a basis for mind-body approaches in medicine (Moss, 2003). The difficulty providers of interventions based in the biomedical paradigm have when dealing with conditions such as obesity, stress, addictions, and the results of trauma, led to a call for the development of a biopsychosocial model of medicine, where social, emotional, and environmental, as well as biological factors, are taken into account (Engel, 1977). Gordon (1996) proposed that self-care should be the basis of primary care. Such shifts in understanding can provide the basis of greater inclusion of somatics practices in health care. There is clearly an argument for research that better describes somatics practices, starts to map their relationship to other MBM interventions, points toward their possible mechanisms of action, and identifies their contribution to health. Indeed, the NCCAM Strategic Plan (2011a) does identify the need for further research into the Feldenkrais Method in health care.

42 Feldenkrais Research Literature There is now a considerable literature documenting the practice and outcomes of the Feldenkrais Method. These studies represent the wide range of applications of the Feldenkrais Method in the promotion of health, including in rehabilitation, dealing with neurological conditions, illness, and injury, as well as effects on pain, affective states, motor coordination, body awareness, and body image. Two thorough descriptive reviews of the research literature (Ives & Shelley, 1998; Stephens, 2007) and one systematic review of randomized controlled trials (RCTs) (Ernst & Canter, 2005) have been published. Ives published an updated review as part of a theoretical article in 2003. Unfortunately all these reviews are somewhat out of date and do not include the many empirical studies published between 2005-2012. Additional reviews can be found in a number of other sources (Wildman, Stephens, & Aum, 2000; Stephens, 2001), and many of the research studies reviewed here. Case Reports Much of the early literature was in the form of narrative case studies (Ives & Shelley, 1998; Smyth, 2008), including Moshe Feldenkrais’s (1993) own book length study, the Case of Nora. Much of the case study literature was published in professional journals such as The Feldenkrais Journal (FGNA, 1984-2011), the International Feldenkrais Federation Journal (1996, 1997), and the IFF Academy Feldenkrais Research Journal (IFF, 2004-2008). Ives and Shelley (1998) identified case reports on “a diverse range of clinical improvements, including cases involving” (p. 78) for example, cerebral palsy, brain damage, psychological problems, hysterical paralysis, recovery of hand function and instrument playing, reduction of knee pain and stiffness, improvement of head and trunk mobility, recovery from whiplash injury, and improved range of motion.

43 This is just a small sample of the topics of published case studies, and only covers the studies published through 1987. Most of the studies are narratives written by practitioners, and are sometimes used to illustrate conceptual aspects of the practice of the Method (e.g., Beringer, 2010b), or even the process of a single lesson (Beringer, 1997), as well as to describe processes and outcomes with clients. Most do not use systematic approaches to qualitative research, such as drawing on multiple sources (e.g., a mix of practice notes, participant diaries and interviews, etc.; Ives & Shelley, 1998; Smyth, 2008). There have been some recent studies using systematic qualitative methods: (a) Öhmann, Aström, and Malmgren-Olsson’s (2011) study using a grounded theory23 approach and examining the use of Feldenkrais for chronic pain sufferers, and (b) Connors, Galea, Said, and Remedios’s (2010) textual analysis examining transcripts of Feldenkrais lessons for improving balance in relation to motor control theories. A number of case reports have been published in peer-reviewed journals outside of Feldenkrais professional publications. These include both individual cases and reports on Feldenkrais-based programs, such as (a) Ginsburg’s (1986) report on a program for people with spinal cord injury, (b) several reports of the use of Feldenkrais with people with low back pain (Kepner, Strohmeyer, & Elgelid, 2002; Lake, 1985; Segura & Ping, 1995), (c) Lyttle’s (1997) summary of Feldenkrais principles, (d) Stephens’s (2001) review of applications of the Feldenkrais method for musculoskeletal conditions, (e) O’Connor and Webb’s (2002) report on the use of Feldenkrais in palliative care, and (f)

23

Grounded theory is an approach to qualitative research that involves systematically working through the data gathered to find commonalities and groupings that make intrinsic sense. That is, using the data to generate theory, rather than organizing data based on existing theories, or the empirical approach of using data to prove or disprove a theory (Smith, Harré, & Van Langenhove, 1995).

44 Ann’s (2006) paper on work with patients with dementia. A couple of studies use single subject research designs, such as Schenkman et al.’s (1989) study of working with two Parkinsons’ patients, and Narula, Jackson, and Kulik’s (2001) study of a client with rheumatoid arthritis. Intervention Studies In preparing this literature review, 31 research studies published in peer-reviewed journals between 1977 and 2011 using Feldenkrais Method as an intervention were identified. Details of these studies were entered into a database for reference and analysis, along with three additional studies—one described in a funding grant acquittal (Hall et al., 2001), and two presented at professional meetings (Brand, 2001; Dean, Yuen, & Barrows, 2001). These studies will form the basis of this review of the Feldenkrais research literature. In addition, 13 Master’s projects or theses and Doctoral dissertations that use Feldenkrais Method as an intervention were also located and obtained (Brown, Finney, & Sarantakis, 1996; Bruce, 2003; Deig, 2001; Elgelid, 1999; Goldfarb, 1995; Haller, 1998; Ideberg & Werner, 2001; Murphy, 2011; Narula, 1993; Ofir, 1993; Phipps & Lopez, 2001; Shelhav-Silberbush, 1998; Ullmann, 2008). Additional theses and dissertations were identified, but could not be obtained before completion of this literature review. Limitations of Studies to Date Much of the research into outcomes from the application of Feldenkrais Method suffers from significant limitations. Many of the authors of the published studies characterize them as pilot studies, focused on proof of concept or testing the relevance of particular outcome measures. Again it can be seen that these studies cover a wide range of human functions and clinical conditions. However, this very heterogeneity of application means that there are only a small number of studies looking at the same

45 populations, conditions, or functions. This has been remedied in at least one area of research that of Feldenkrais-based balance programs in elderly populations, where there are now several studies showing positive results (Connors, Galea, & Said, 2011; Hall et al., 2001; Hillier, Porter, Jackson, & Petkov, 2010; Ullmann, Williams, Hussey, Durstine, & McClenaghan, 2008; Vrantsidis et al., 2009). Until recently, many studies have been with very small groups, reducing the statistical power of the results obtained. This also increases the probability of differences in baseline scores between intervention and control groups, making interpretation of the results difficult. Until some recent studies (Vrantsidis et al., 2009; Bitter, Hillier, & Civetta, 2011), many studies did not provide an analysis of the statistical power of the study size. Some of the earlier studies were not randomized, had inadequate randomization, or did not report adequately on randomization procedures or on dropouts from the study (Ernst & Canter, 2005). Again, more recent studies have attended more thoroughly and effectively to these issues. A normal intervention using the Feldenkrais Method would usually involve a number of sessions (Ernst & Canter, 2005) of at least one hour in duration. However, some early studies involved only a very small number of sessions (e.g., 1, 2 or 4; Kolt & McConville, 2000; Lowe et al., 2002), sometimes with sessions lasting only 30 minutes (Brown & Kegerreis, 1991; Chinn, Trujillo, Kegerreis, & Worrell, 1994; James, Kolt, McConville, & Bate, 1998; Smith, Kolt, & McConville, 2001). The implications of this can be seen when we consider that the study of treatment for hamstring length using a single, half-hour intervention (James et al., 1998) concluded that there was no change, whereas a more realistic 3-week long study involving initial instruction and home practice

46 (Stephens, Davidson, DeRosa, Kriz, & Saltzman, 2006) produced statistically significant changes. Even the longer-term studies identified here are, for example, for periods of only 8 to 10 weeks. However, studies of similar kinds of interventions are often conducted over even longer periods with populations such as those with MS and older adults (Kendall, Ekselius, Gerdle, Sören, & Bengtson, 2001). Clearly these limitations of study size and level of intervention are most likely attributable to the well-known limitations of funding and institutional support for research into mind-body practices, and CAM in general (Ernst & Canter, 2005). It is interesting to note that many of the research studies in English came from Australia and Sweden. These research studies also suffer from challenges associated with how to conceptualize what constitutes an appropriate study, the identification of appropriate phenomena to study, and appropriate instruments to measure outcomes (e.g., Kendall et al., 2001). This is especially true for a complex methodology like the Feldenkrais Method, which can be applied in a wide variety of ways and “can affect a variety of psychosocial, physical performance, and clinical improvements” (Ives & Shelley, 1998, p. 85). For example, Brown and Kegerreis’s (1991) electromyographic (EMG) study of trunk musculature raises the question of whether the study should be conceptualized as the activation or relaxation of particular muscular groups (e.g., the trunk flexors and extensors), or the action of flexing, or the function of bending? In addition, is surface EMG the most appropriate measure of these phenomena? Even if this were clear, there are different theoretical perspectives on the physiology of these movement phenomena that potentially confound the interpretation of the results in relation to the Feldenkrais Method.

47 Another methodological limitation is that most of these research studies make use of language-based self-report measures. However, many of the changes brought about by a somatic approach like the Feldenkrais Method may be either difficult to describe in language (Barrows, 2007), or may be inadequately captured by language-based assessment tools. A few of the studies identified lacked control groups. In addition, some used controls involving a similar intervention to Feldenkrais Method (Gutman, Herbert, & Brown, 1977; Hillier et al., 2010). This has the virtue of comparing the Feldenkrais intervention with a similar, perhaps more standard intervention, but lacks the contrast provided by the inclusion of a control group with no intervention or normal activity. Ernst and Canter (2005) in their systematic review of six randomized controlled trials used the Jadad scoring system. Overall the studies reviewed scored poorly. One key methodological question arising from such a review concerns the possibility of fully blinding studies using mind-body interventions. Full double blinding in these kinds of studies is almost impossible; however, the Jadad scoring system deducts one point on its five-point scale if a study is not double blinded. The identification of suitable controls or suitable sham interventions also presents considerable methodological challenges (Licciardone & Russo, 2006; Mehling, DiBlasi, & Hecht, 2005). In many cases involving mind-body interventions, participants are able to identify which is a sham intervention and which is not, thus making it difficult to blind these kinds of trials to the participants. Choosing a believable sham intervention that does not actually produce effects that might impact the study measures is a challenge (Bitter et al., 2011). In one study (S. K. Johnson, Frederick, Kaufman, & Mountjoy, 1999), which employed a crossover methodology, the sham intervention was delivered by the same practitioner as the actual

48 intervention. In the description of the sham, at least one practice (systematically moving around the client and lightly touching them) is sometimes used within the Feldenkrais Method itself (e.g., at the beginning of a lesson with someone in strong pain or experiencing trauma). This confusion calls into question the validity of the results for the sham and actual interventions. In addition, the authors indicated that the aim of the sham intervention was to control for effects of touch and attention by the practitioner. This suggests a certain conceptual orientation by the researchers, where for example, perhaps they considered only the manipulation and the manipulation sequences of the Feldenkrais Functional Integration lessons as of importance. However, in many mind-body approaches attention (including the shared attention of practitioner and client) and touch have come to be seen as active elements of a successful mind-body intervention, rather than only as potential confounds. This is especially true in the light of the recent discoveries of how the mirror neuron and other neurological systems sub-serve empathy and compassion (Decrety & Jackson, 2004) in health-promoting relationships. Interestingly, S. K. Johnson et al.’s (1999) paper includes no references for Feldenkrais Method theory or research. It is surprising that none of those who have written reviews of Feldenkrais research noticed such an omission. Finally, both Ives and Shelley (1998) and Ernst and Canter (2005), pointed to a number of methodological limitations in relation to data analysis, including the lack of rationale in some studies for the measures used and for the techniques of statistical analysis utilized. Unfortunately, over a third of the research studies identified here were published since 2003 (which is the cut-off date for Ernst and Canter’s review and the date of Ives’ second paper on this topic), so these most recent studies are not included in their analyses.

49 These reviews of research come with their own limitations. Ernst and Canter (2005) made a number of mistakes in their description of the Feldenkrais Method, for example, that the Feldenkrais Method “employs structured body movements where the position of the head is of particular importance” (p. 152), whereas, to the extent that Feldenkrais privileged any parts of the body in his work, both the organization of the pelvis, as well as the head and neck, are important foci of attention in Feldenkrais’s approach (Feldenkrais, 1949; Lyttle, 1997). Also, for example, for one of the six RCTs they reviewed, Ernst and Canter had only a copy of the abstract, rather than the full research report. Ives wrote from a movement science perspective, and indeed in his later paper (Ives, 2003), he clearly argued for a particular perspective on motor learning of which he is a proponent, and which differs from the emphasis on bodily awareness and kinesthesia that are part of the Feldenkrais approach (Buchanan & Ulrich, 2001). Many of the more recent Feldenkrais research studies have clearly addressed and corrected the methodological limitations identified by these reviewers (Bitter et al., 2011; Buchanan & Ulrich, 2001; Vrantsidis et al., 2009), and have produced higher-quality studies that deal with and report more explicitly on study size and statistical power, randomization and dropouts, and rationales for the measures and statistical procedures used. Ives and Shelley (1998) pointed out that Feldenkrais Method has “sound theoretical underpinnings [that] certainly add some reputability” to the claims of the Feldenkrais Method, and that it has been “discussed credibly in terms of neurophysiological processes, mind-body connectedness, motor control theory and pedagogy” (p. 77). Notwithstanding the limitations they identified, both Ives and Shelley (1998) and

50 Ernst and Canter (2005) believe that Feldenkrais Method deserves further research. Directions for research form the conclusion of this thesis, and some of the methodological challenges identified above are addressed there. Outcomes of Research Studies The research studies in this literature review present some clear outcomes in areas such as pain, affect, body awareness, sense of muscular effort, and self-image, functional outcomes and quality of life. An examination of these outcomes follows. Outcomes from Feldenkrais Method research studies in relation to pain. A number of Feldenkrais research studies used measures of pain experience, perception or impact as part of their outcome measures for interventions with particular populations, while several studies focused on the use of Feldenkrais Method for the alleviation of pain. Pain: Results from pilot studies. In a very small pilot study of 6 people with fibromyalgia, Dean et al. (2001) found a significant decrease in pain as measured by the Fibromyalgia Impact Assessment (FIA) questionnaire, as well as a reduction for several participants in the number of areas in the body in which they reported they were experiencing pain. In another pilot study (N = 22), Kendall et al. (2001) found that there was an overall, but not statistically significant, trend toward functional and symptomatic improvement with the Feldenkrais intervention group. Interestingly, participants reported in a treatment option questionnaire that, “they did not experience less pain, but they felt they had a better way of handling it” (Kendall et al., 2001, p. 32). In a study of Medicaid recipients with chronic pain at the Santa Barbara Regional Health Authority (SBRHA), a small group of 6 chronic pain patients engaged in an extensive Feldenkrais Awareness Through Movement program (Bearman & Shafarman, 1999). Participants began the program with high levels of pain, and the treatment group had histories involving a

51 significant level of trauma and socioeconomic disadvantage. Based on patient self-reports, both at postintervention and 12-month follow-up, considerable reductions in perceived levels of pain, and considerable increases in levels of function and activities of daily living (ADLs) were reported. The study also identified that in the year post intervention there was a significant decrease in the use of medical services and pharmaceuticals by study participants, with subsequent cost savings for the SBRHA. Pain: Results from larger scale studies. In a RCT involving 97 truck assembly plant workers with neck and shoulder complaints, Lundblad, Elert, and Gerdle (1999), measured outcomes for a Feldenkrais group and a physical therapy intervention group, as well as a control group. In a trial run over one year, intervention periods for the participating groups were 16 weeks, for 50 minutes per week. The Feldenkrais intervention involved 50% group Awareness Through Movement and 50% individual Functional Integration sessions. In the postintervention measures, the Feldenkrais group reported greater reductions in usual levels of pain in the previous 7 days using a visual analog scale (VAS), compared to the control and physiotherapy groups. These differences were statistically significant. In addition, the Feldenkrais group reported “the significant decrease in the prevalence of complaints from the neck and shoulders in the previous 7 days” (Lundblad et al., 1999, p. 189), whereas “the prevalence of neck complaints in the previous 7 days tended (nonsignificantly) to increase in the two other groups” (Lundblad et al., 1999, p. 189). The Feldenkrais group also reported a significant decrease in the impact of neck and shoulder complaints had on leisure time activities. In another 2001 study, Malmgren-Olsson, Bengt-Ake, and Amelius compared alterations in pain, psychological symptoms, and self-image for 71 patients with a range of nonspecific musculoskeletal disorders, in a program comparing Body Awareness Training

52 (BAT), Feldenkrais Method, and conventional physiotherapy, as well as a medical treatment as usual control group. Interventions lasted 20 hours over 10 weeks. Using the Swedish version of the West Haven Yale Multidimensional Pain Inventory (MPI) they found that all three intervention groups had a decrease in pain severity, interference of pain with daily life, and affective disorders associated with pain, and an increase in the control in their lives. In addition, a significant between-group difference was found in the life control index where the Feldenkrais group showed greater improvement than the treatment as usual group (Malmgren-Olsson et al., 2001). In an important study of outcomes from private practice, 11 Feldenkrais practitioners in Australia collected data on pain, quality of life, and functional outcomes for 33 of their clients (Connors, Pile, & Nichols, 2010). Participants seeking help for functional challenges attended Functional Integration sessions, and in some cases individual Awareness Through Movement sessions, for a period from 2.5 to 31 weeks (with a mean of 11.6 weeks), with an average frequency of one session every 2 weeks. The study showed reductions in pain, as well as improvements in quality of life and functional outcome measures. To collect pain-related data, the Patient Outcome Profile (POP) was used. There were statistically significant outcomes on the “current pain,” “affective index,” and the “physical index” (Connors, Pile et al., 2010, p. 448) of this profile. Based on research into the POP, clinically significant differences for the current pain item are 0.34, 0.85 and 1.35 for small, medium and large differences respectively. The clients in the current study had an improvement of 1.7 points, which can therefore be considered a large clinically significant difference. When only the patients who initially scored 3 or over on current pain at baseline were included the improvement of 3.14 points is well above the 1.35 points needed to be considered a large difference. (Connors, Pile et al., 2010, p. 449)

53 Taken together these three pilot studies and three outcome studies suggest that Feldenkrais-based interventions, using Awareness Through Movement, Functional Integration, or both, and carried out in a number of settings, can produce reductions in perception of pain and pain impact on participants’ lives. In addition, a number of measures were identified that would appear to detect alterations in reported pain in studies of this type. Pain: Qualitative study. Finally, a qualitative study of the use of Feldenkrais in the treatment of chronic pain was published by Öhmann et al. (2011). Back pain and neck pain were the most common complaints reported by this group. Participants experienced two Awareness Through Movement classes per week for 7 weeks. Data collection involved participant diary entries made during the intervention, and thematic interviews conducted 4 to 6 months after the end of the intervention. Data analysis involved using a grounded theory approach for the generation of themes and categories of responses from the qualitative material (Creswell, 2009; Smith et al., 1995). The diaries and interviews clearly indicated that participants experienced increased ability to move without pain. What is significant, in addition, is that these participants also described many of the mechanisms that practitioners of the Feldenkrais Method would claim contribute to pain reduction using Feldenkrais. In the key theme generated by the researchers, Feldenkrais was seen as “wholesome, but difficult”—in the sense some of the movement sequences were complex and participants were concerned whether they were doing them correctly, and that Feldenkrais required concentration and attention to not using too much effort in order to not generate pain (Öhmann et al., 2011, p. 157). In the category “more erect without effort” the authors identify a range of postural, movement, and functional improvements

54 identified by participants, including the sense of being able to stand comfortably on both feet, more stability in standing, comfort in the hanging of the arms, more space in the body to breathe, ease in walking, and more erect posture (Öhmann et al., 2011, p. 157). They also reported greater awareness of the body, which we will discuss further below. They reported “the feeling of reclaimed movement ability and freedom” (Öhmann el al., 2011, p. 159). Also consistent with Feldenkrais Method’s focus on people attending to sensory feedback from the body, they reported they were more prone to not make painful sacrifices to do particular activities, and were “more prone to ‘listen’ to the body and its restrictions” (Öhmann et al., 2011, p. 159). Pain has been defined as an unpleasant physical and affective experience for the sufferer (International Association for the Study of Pain [IASP], 2010). In the medical literature this is often assessed in terms of its sensory and affective dimensions. The results of the studies presented here suggest that Feldenkrais Method can contribute to the reduction in the experience of pain and its impact on people’s lives. While the sensory aspect of pain in the medical literature often focuses on the perception of the intensity of the pain, it seems possible that by altering the perception of the body as a whole, perception of pain may also be affected. Feldenkrais Method shares this approach with other mind-body approaches including, for example, meditation, hypnosis, and autogenics. The Feldenkrais Method brings with it another dimension: that of movement and action. Many, but not all, of the studies identified functional improvements along with reductions in pain experienced. This raises the question of what is the relationship between pain and function, and what mediating factors may be at work between these phenomena, and how these mediators may potentially act in both directions. In the next sections, other outcomes of these research studies will be explored. Outcomes that may also be

55 mechanisms of action, such as alterations in affect, bodily awareness, perception of effort, will be explored. Outcomes from Feldenkrais Method research studies in relation to measures of affective states. A number of Feldenkrais research studies have reported outcomes in relation to affective states24, including levels of psychological distress associated with particular conditions, as well as anxiety and depression. Malmgren-Olsson et al.’s (2001) study of people with nonspecific musculoskeletal conditions used the SCL–90—“a 90 item self-report symptom inventory designed to reflect the psychological symptom patterns of patients on a number of different sub-scales” (p. 82)—to measure psychological distress associated with these conditions. They found that Feldenkrais and Body Awareness Training (BAT) had higher effect sizes for improvements in the “global severity,” “state symptom” and “personality severity” psychological indices, compared to treatment as usual (physical therapy), and the control group, which had no improvement (MalmgrenOlsson et al., 2001, pp. 84-85). Similar results were found for the specific scales for anxiety, and depression sub-scales, with significant improvement in relation to somatization. Kerr, Kotynia, and Kolt (2002), using the state scale of the State-Trait Anxiety Inventory (STAI–S or STAI–Y1), found statistically significant reductions in state anxiety for university students who were new and returning to a Feldenkrais class, for a single

24

Affective states can include the named emotions (e.g., fear, joy, anger, disgust, etc.) that appeared to be universal to humans, and which arise rapidly and spontaneously (Ekman, 2007; Nathanson, 1992). There are also longer-term or ongoing affect states, often described as ‘moods’. Moods involve complex cognitive and evaluative, as well as physical and behavioral aspects. Anxiety and depression are common states in this category. Some authors also describe as moods, states such as hopefulness, acceptance, resignation, optimism, fatigue, vigor, hostility or confusion (Fletcher et al., 1992; Sieler, 2003, 2007). The concept of “vitality affects” (Stern, 2004) attempts

56 lesson—as well as at the halfway and completion points of a 10-week series of Awareness Through Movement classes. In a study (N = 147) of middle-aged women, Netz and Lidor (2003) examined the mood enhancing effects of aerobic exercise (aerobic dance, swimming) compared to mind-body awareness practices (Yoga, Feldenkrais), with a control group doing computer classes. Based on volunteer participation with adult students, levels of participation varied. However, the authors found that swimming, Yoga, and Feldenkrais all contributed to significant decreases in state anxiety on the STAI-S (STAI-Y1) scale. They theorized that the noncompetitive, rhythmical, and to some extent the self-paced and predictive nature of the movements, may be elements in common among these three interventions. In their study of 47 older adults, Ullmann and Williams (2011) identified a reduction in subclinical depressive symptoms. Using the Centers for Epidemiological Studies Depression scale (CES–D), they found that the 5-week, 15 sessions Awareness Through Movement program which they studied, led to decreases in the CES–D score from 11.24 to 7.76. The authors noted that physical exercise in general is associated with a reduction in depression. However, for many older adults over 65 years (as in this study) a more gentle approach such as Feldenkrais, may help with depression, while being better tolerated (Ullmann & Williams, 2011). Using a quantitative and qualitative research design, Löwe et al. (2002) reported on outcomes from four individual Functional Integration sessions—as compared with Progressive Muscle Relaxation (PMR) and standard medical treatment control groups—in a study of 60 patients immediately post myocardial infarction. The authors concluded,

to capture the nonspecific affective qualities related to qualities such as the speed, acceleration, or intensity of affective experiences.

57 The therapeutic doses were probably too small to have a significant effect on the self-rating methods, the qualitative patient statements support using the Feldenkrais method or PMR for particular cases in an acute medical setting and continued treatment during rehabilitation or on an outpatient basis. (Löwe et al., 2002, p. 179) Seventeen of the 20 patients in the Feldenkrais group reported that they felt subjectively better from the Feldenkrais treatment. Interestingly, when asked how they felt better or worse, these patients reported such things as “feeling more lighthearted,” “more relaxed,” “more easy going,” and that there had been “a positive effect” (Löwe et al., 2002, p. 187) on their mood from the Feldenkrais intervention. In their qualitative study, Öhmann et al. (2011), identify a range of other affective responses to the Feldenkrais program for people with chronic pain. They noted, for example, that the experience of “increased ability to move without pain” had “instilled hope and a sense of security and the effects were to a large extent still present at the time of the interviews” (Öhmann et al., 2011, p. 158), which was 4-6 months post-intervention. Another significant finding from this study was that participants reported increased ability to sense the physical correlates of their affective state (e.g., muscular tension in the face and jaw, “staring eyes”), and the feeling that consequently they were better able to regulate their emotional states (Öhmann et al., 2011, p. 158). Outcomes from Feldenkrais Method research studies in relation to body awareness, body image, and feelings about the body. As defined in contemporary literature on mind-body interventions in health, body awareness involves an attentional focus on an awareness of internal body sensations, it is “the subjective, phenomenological aspect of proprioception and interoception that enters conscious awareness, it is modifiable by mental processes including attention, interpretation, appraisal, beliefs, memories, conditioning, attitudes and affect” (Mehling et al., 2011, “Introduction”,

58 para. 2). Mehling et al.’s (2011) qualitative study reported that many of the mind-body practitioners who participated considered that, “body awareness is an inseparable aspect of embodied self-awareness realized in action and interaction with the environment and the world” (“Discussion”, para. 1). The historical shift in the understanding of this concept is also important to understanding this concept in relation to medicine. Mehling et al. (2009) noted: In the past, most research and clinical therapies were based on conceptual understanding of body awareness that focused on the negative aspects of heightened body awareness as it overlaps with hypochondriasis and somatization. As new research suggests the potential value of interoceptive awareness of subtle bodily sensations, the traditional view of body awareness is challenged to recognize complexity and ambiguity of this construct for psychosomatic research and therapies. (“Introduction”, para. 5) […] Diffuse, emotion–based hypervigilance seems to be maladaptive, whereas “concrete somatic monitoring” or “sensory discrimination” of the precise details of present–moment characteristics in physical sensations appear to be adaptive. (“Introduction,” para. 6) The construct of body image is usually taken to primarily involve subjective, qualitative experience of one’s body on an ongoing basis. A second aspect of this construct body image is often refers to the introjection of socially or culturally influenced or created bodies influenced by factors like gender, class, race, sexual identity, as well aspects of body image influenced, for example, by sports, medicine, fashion, or advertising. A third aspect is the spatial-temporal, nonconscious image of the bodily coordinates that provides a basis for movement—often also called the body schema. The nature of the body image and the extent to which it includes the body schema is subject to considerable debate. There is more discussion of this construct in the section A Framework for Feldenkrais Method, Somatics, and Health of this thesis.

59 Body awareness and awareness of movement. While the Feldenkrais Method emphasizes Awareness Through Movement, one artifact one would also expect from a Feldenkrais-based intervention would be greater awareness of the body, and greater or improved awareness of the body in movement. A number of participants in these studies reported increased body awareness (e.g., Dean et al., 2001). Kendall et al. (2001), in the pilot study with fibromyalgia patients, recorded on the Swedish Body Awareness Health Scale that 8/15 of Feldenkrais intervention group have improved awareness on the “centered/ground” subscale, whereas 10/15 had improved awareness on the “centered/breathing” subscale, both at 15-weeks and 6-months postintervention (Kendall et al., 2001, p. 32). Qualitative feedback from participants with MS in Stephens et al.’s (1999) study included reports from participants of sensing increased flexibility, reduced stiffness, and greater awareness of how they move. Likewise Öhmann et al.’s (2011) qualitative study of people with chronic pain gathered much data on people’s changed experience of their bodies. They report, for example, “a liberating feeling,” and that “relief from muscle tension and strained breathing” were among the positive outcomes (Öhmann et al., 2011, p. 158). People reported that they felt “more present in the body.” One particular aspect of the Feldenkrais Method, applying the Weber-Fechner Principle, is its emphasis on the reduction of muscular effort as a strategy for developing increased awareness of how much effort one is using, finding the appropriate level of effort for an activity, and as a way of becoming more aware of the body through greater sensitivity (Lyttle, 1997). Chin et al.’s (1994) study of functional reach by people with symptoms of shoulder and neck pain or discomfort, found statistically significant measures of perception of a reduction exertion after a single Feldenkrais lesson. Bitter et al. (2011)

60 found that participants had increased ability to respond to alterations in the weight of an experimental device (a “grip-lift manipulandum”—which requires alterations in perception of grip strength used), as well as an increased ability to respond to such changes more quickly. Paralleling these perceptual-motor responses, participants also reported that “the experimental hand ‘felt different’ to the non-experimental hand after intervention” (Bitter et al., 2011, p. 792), and reported “a reduction in perceived writing difficulty on the hand that received the intervention” (Bitter et al., 2011, p. 792). In both these cases a single, but targeted Awareness Through Movement lesson comprised the intervention. In Öhmann et al.’s (2011) qualitative study of people with chronic pain, participants reported an overall experience of reduced muscular tension, which they associated with greater ability to move more easily and a sense of bodily comfort, as well as experiencing less pain. Body image and self-image in relation to feelings about the body. Hutchison did early work on the impact of Feldenkrais on body image where she worked groups of women using guided imagery and elements of Awareness Though Movement lessons. The results of her study and work were published in her book, Transforming Body Image (Hutchinson, 1985). A measure of self-image, “the introject version of the Structural Analysis of Social Behavior (SASB)” (Malgren-Olsson et al., 2001, p. 83) which measures dimension of (self acceptance, self love and nourishing the self, or a negative responses of blaming, rejecting or ignoring the self), was used in Malmgren-Olsson et al.’s (2001) study of people with nonspecific musculoskeletal conditions. For three interventions (Feldenkrais, Body Awareness Training, and physiotherapy), “there was a certain positive development of self-image over time…and it was especially negative self-image that improved” (Malmgren–Olsson et al., 2001, p. 89).

61 The issues of self-image and acceptance of one’s body are addressed directly and in detail in Laumer, Bauer, Fichter, and Milz’s (2004) study of young women with eating disorders. The authors used a range of measures, including: the Body Cathexis Scale (BCS), Body Parts Satisfaction Scale (BPSS), the Questionnaire for Body Perception (Fragebogen zum Körpererleben [FKE]), Emotional Inventory (Emotionalitätsinventar [EMB-B]), and the Eating Disorder Inventory-2 (EDI). The Feldenkrais intervention group had significant improvements in satisfaction with various body parts (e.g., hips/thighs, buttocks, torso, and arms) which are often associated with dissatisfaction for people with eating disorders, as well as satisfaction with overall physical appearance and health. In addition, participants’ answers to questions revealed improvements in their experience of their own movement, and five other areas that revealed acceptance of one’s own body, such as responses to looking at oneself in the mirror, or feelings of immaturity, lack of enjoyment or discomfort in relation to their body (Laumer et al., 2004). There were also statistically significant outcomes for questions that revealed that the Feldenkrais group saw themselves as more spontaneous, free, and open, as well as less shy and “held in,” and less likely to feel overwhelmed than prior to the series of lessons. A reduction in fears associated with maturing, and a decreased wish to return to dependence, were also detected in the Feldenkrais group by the questionnaire responses. Laumer et al. (2004) suggested that these outcomes indicate “the development of a felt sense of self, selfconfidence and the general maturation of the whole personality” (Abstract). Outcomes from Feldenkrais Method research studies in relation to movement, motor coordination, and functional activities. As Feldenkrais Method emphasizes the possibility for improvement in one’s action and functioning in the world, a

62 number of studies revealed that Feldenkrais interventions generated a range of observable improvements in movement, often coupled with improved functional outcomes. Posture and movement. Quintero et al. conducted a study, published in 2009, which involved using Feldenkrais-based movement and play exercises for 3 hours per week for 10 weeks for children with bruxism. The 13 participants, compared to the control group of the same size, were shown to have observable improvement in the relationship between the upper cervical vertebrae and the cranium (as measured by an increase in CVA angle). In addition, 77% parents of the intervention group reported that the children had stopped grinding their teeth compared to 15.38% for the control group. In another study measuring changes in musculoskeletal organization, Stephens et al. (2006) reported statistically significant increases in the active muscle length of the hamstring muscles—in the study of physically active adults who were provided with a 30minute introduction and a three-week home practice period. Using knee extension as a measure of hamstring length, the mean change in knee extension the ATM group “was +7.04° compared with the control group change of +1.15°” (Stephens et al., 2006, p. 1645). Other interesting outcomes from this study were that there was a clear positive correlation between amount of practice and the amount of measured change in active hamstring length. In addition, the study asked participants about whether their experience of doing Awareness Through Movement was similar to that of stretching with 94% (17 of 18) participants experiencing the Feldenkrais lesson as clearly different from stretching. Dexterity. Bitter et al.’s (2011) study of whether Awareness Through Movement could affect manual dexterity involved a sham-relaxation control group, and two Feldenkrais–based intervention groups—one where the dominant hand was used and one with the nondominant hand was used. In addition to improvements in the ability to adjust

63 grip strength to changing demands with the dominant hand (as reported above), this group also improved in the speed and accuracy of performance with the Purdue Pegboard Test. Taken together, they presented significant improvements in dexterity. Balance, mobility, activity, and gait. Five studies with older adults – including both active and less active seniors – detected statistically significant improvements in selected measures of balance, activity and mobility. Here is a summary: 1. Hall et al.’s (2001) study (N = 59) used Feldenkrais, control, and Tai Chi groups. The Feldenkrais intervention was 32 hours, with an average attendance of 24 hours. Significant improvements were found in the Timed Up and Go (TUG) (sit-to-stand activity measure), Berg Balance Scale (BBS), and Frenchay Activities of Daily Living (FAI) measures. 2. Ullmann et al.’s (2008) study (N = 47) used a Feldenkrais group, with a waitlisted control. The Feldenkrais intervention was 15 hours over 5 weeks. Significant improvements were found in the Tandem Stance balance test, and Timed Up and Go (TUG) activity measure. 3. Vrantsidis et al.’s (2009) study (N = 55) used a Feldenkrais and control (normal activities) groups. The Feldenkrais intervention was 16 hours over 8 weeks. Significant improvements were found in gait speed. The Timed Up and Go (TUG) measure activity measure approached significance. 4. Hillier et al.’s (2010) study (N = 22) compared a Feldenkrais group and a generic balance program. The Feldenkrais intervention was 8 hours over 8 weeks. Significant improvements were found in the Functional Reach Test (FRT), and the Single Leg Stance (SLS) balance test. 5. Connors et al.’s (2011) study (N = 63) used a Feldenkrais and control (normal activities) groups. The Feldenkrais intervention was 16 hours over 8 weeks. Significant improvements were found in gait speed, and the Four Square Step Test (FSST; balance test). It should be noted that gait speed is not only an improvement in itself, but is taken as an indicator of balance and balance confidence. Similar to these results with older adults, Batson and Deutsch (2005) reported significant improvements with their four participants with post-stoke neurological deficits on the Berg Balance Scale (BBS) and the Dynamic Gait Index (DGI). Stephens,

64 DuShuttle, Hatcher, Schmunes, and Slanika (2001) study of six people with MS also had positive findings for improved balance using the 8-item Equiscale balance test developed for MS patients, and from computerized balance assessment. This measure showed improvement in movements around the center of pressure (COP) under the feet when their standing was experimentally perturbed. Buchanan and Vardaxis (2000) found similar improvements in COP as a measure of balance with healthy adults after a Feldenkrais intervention. Patient specific functional outcomes. At least two studies, Hillier et al.’s (2010) study of older adults, and Connors et al.’s (2011) study of clients of 11 Feldenkrais practitioners used the Patient Specific Functional Scale (PSFS), where patients designate functional areas in which they wish to improve. In both these studies, the Feldenkrais students or clients indicated statistically significant improvements on the PSFS. Sleep. A number of studies using self-report measures or qualitative participant feedback from interviews, indicated that participants reported improvements in sleep (Dean et al., 2001; Gutman et al., 1977; Öhmann et al., 2011). As would be predicted from the focus on function in Feldenkrais theory, these studies showed a range of functional improvements from the Feldenkrais interventions, including a number of complex functions such as dexterity, gait, and balance that involve high levels of coordination between body parts, and multiple sensory and motor systems. Outcomes from Feldenkrais Method research studies in relation to measures of quality of life. A number of studies reviewed here include qualitative reports of improvements of quality of life25. For example, in the earliest study reviewed here by

25

Quality of Life is a multidimensional construct used in such areas as economics, planning, and healthcare. Health related quality of life measures usually explore the physical,

65 Gutman et al. (1977), a greater proportion of the seniors in the Feldenkrais intervention group than the exercise and control groups, reported in follow-up interviews that their health was excellent, they worried less about their health, and had increased perceived energy levels. QOL: Outcomes from pilot studies. A number of Feldenkrais research studies made use of quality of life measures. In their small pilot study of Feldenkrais for fibromyalgia patients, Dean et al. (2001) saw improvements on the pain and fatigue scales of the Fibromyalgia Impact Assessment (FIA). In a similar preliminary study of four adults with chronic neurological deficits after stroke, Batson and Deutsch (2005) used the Stroke Impact Assessment (SIS), which showed improvements of between 20 and 45% on this scale for these patients post intervention. Stephens et al.’s (1999) study with four women suffering from MS used the “Incapacity Status and Environmental Status scales of the Minimum Record of Disability, the Fatigue Severity Scale, and the Index of Wellbeing” (p. 58). After 10 weekly Awareness Through Movement classes, participants showed averaged improvements of 5.55% on the Fatigue Severity Scale, 19.55% on the Index of Well-being, 31.9% on the Incapacity Status Scale. QOL: Outcomes from larger studies. Two studies used the Short Form 36 (SF36) quality of life scale along with measures of balance and other functional activities in older adults. The SF-36 measures health and functional status, including indices for a person’s physical function, physical role, bodily pain, vitality, general health, social

functional, psychological or affective, social, recreational or occupational dimensions of a person’s life as an indicator of the health status and its impact. Health-related quality of life measures can be generic or related to particular conditions. They use self-reported answers to questions which can be used to (a) assess the impact of a particular disease, (b) as indicators of prospects for recovery and rehabilitation, (c) to assess the impact of a particular intervention, or (d) in clinical or programmatic decision-making (Fitzpatrick et al., 1992; Fletcher et al., 1992).

66 function, mental health, and emotional role (Connors, Pile, et al., 2010; Hillier et al., 2010). Hall et al. (2001) reported statistically significant improvements in vitality and general health for the Feldenkrais and Tai Chi intervention groups, and for physical function for the Feldenkrais group, with no change for the control group on these indices. Hillier et al.’s (2010) proof of concept study of active older adults (N = 22) showed that both the generic balance education program and the Feldenkrais group showed statistically significant postintervention improvement on the SF-36. The Connors, Pile, et al. (2010) study of 48 clients of 11 Feldenkrais practitioners in private practice settings made use of the SF12v.2 survey—which is based on the SF-36, using a smaller number of questions, but the same indices. There were significant improvements in 6 of the 8 indices, and the other two changes approached significance (4.8 of the 5 points needed to rule out measurement error). The authors concluded that the SF12v.2 was a suitable and convenient measure for quality of life outcomes from Feldenkrais in this kind of setting. Self-efficacy. Only one study used a measure of self-efficacy. In Stephens et al. (2001) the Multiple Sclerosis Self-Efficacy measure was used. While the results did not reach significance, for the measures of (a) function, (b) control, and (c) overall selfefficacy, the Feldenkrais group declined 1.2% on the first score and increased 10.5% and 4.2% on the last two, while on these measures the control (education) group declined 5.3%, 0.8% and 3.2% respectively. An interesting result of this study, and many of the studies with older adults, was an increase in balance confidence (Connors et al., 2011; Ullmann et al., 2008; Vrantsidis et al., 2009). These studies used either the Falls Efficacy Scale (FES) or the Activities-Specific Balance Confidence (ABC) scale. Balance confidence is an interesting outcome measure, since it suggests that participants had a shift

67 in their evaluation or their sense of their ability to perform an important function. This could be seen as an improvement in self-efficacy in a particular area of life. Balance has significant implications for the quality of life for older adults, and people dealing with conditions like MS and post-stroke disability. Conceptually it points to the questions of Feldenkrais Method’s possible contribution to health in areas where functional activity interact with affective and cognitive assessments of one’s health status. Retention of participants and participant satisfaction. Most of the studies had high levels of participation, with few drop-outs from the Feldenkrais intervention groups. Many studies reported levels of participation in all sessions at 80 to 100% (e.g., Hillier et al., 2010; Ullmann & Williams, 2011; Varantsidis et al., 2009). Brand (2001) reported that when chair-based relaxation was replaced by Awareness Through Movement classes in a hospital-based, 12-week cardiovascular recovery program, drop-out rates reduced from 51% to 18%. Many study authors cited interview or questionnaire results reporting high levels of satisfaction by participants with the Feldenkrais interventions (e.g., Bearman & Shafarman, 1999; Gutman et al., 1977; Hall et al., 2001; Hillier et al, 2010; Lowe et al., 2002; Vrantsidis et al., 2009). Discussion This review of the literature showed effects of the Feldenkrais Method in areas that would be predicted by the theory of the Method itself. That is, while there were improvements in bodily organization (e.g., posture, active muscle length), there were also improvements in affective states, body awareness, and self-perceived body image, pain, quality of life, and complex functional outcomes such as dexterity, balance, and gait. Some of these areas in which outcomes were detected are themselves multidimensional

68 constructs. For example, quality of life as a concept, and the measures used in these studies, include physical, social, affective, and functional aspects of life. Pain as a concept includes sensory, affective, evaluative, and physical (e.g., muscle tension, movement) dimensions and the impact of pain on function. Pain, anxiety and depression, and issues around body awareness and body image are in areas in which other MBM interventions are frequently used. Clearly then, the Feldenkrais Method can contribute to all these areas. In addition, many of these Feldenkrais studies revealed that a number of functional outcomes were achieved at the same time. These research studies were carried out in a number of countries and a variety of settings, including private practice, community settings, community health centers and public clinics, in hospitals, and at universities. Participants were diverse in terms of age and activity levels, although perhaps less diverse in terms of race, ethnicity, and socioeconomic status. However, these data were only available for some of the studies. In studies where Feldenkrais interventions were compared with comparable interventions, outcomes for the Feldenkrais groups were overall equal to those of the other interventions, and often had stronger results on some measures. In the studies where the Feldenkrais intervention was compared to a control group with no intervention (activity as usual), the results for the Feldenkrais interventions often showed clear improvements on many measures compared to the controls. While Ives and Shelley (1998) put forward the proposition that Feldenkrais interventions need to show themselves superior to standard treatments, it could rather be argued that questions of the acceptability of the intervention must also be assessed on criteria such as: (a) the cost effectiveness (e.g., see Bearman & Shafarman’s pilot study, 1999), (b) whether the intervention best fits with the client or patient’s needs (e.g., for people with movement

69 challenges, Feldenkrais may be more suitable than other possible interventions, see Stephens et al., 2001; and Ullmann & Williams, 2011), or (c) consistent with the principles of evidence based practice, whether the intervention accords with the client or patient’s values and preferences (W. B. Jonas, Walach, & Coulter, 2007). These studies showed that outcomes of Feldenkrais interventions were able to be detected by objective measurements of such things as balance and grip strength, by the use of self-report measures and tools covering a wide range of human perception and behavior, as well as qualitative tools such as diaries and interviews. In most cases longer interventions, using a number of sessions similar to that seen in Feldenkrais private practice and integrative medicine programs, produced more substantial outcomes. This also suggests that there are dose effects with the Feldenkrais Method, and that should be taken into account with future studies. While it might seem obvious, studies where the intervention was targeted in relation to the measures seemed to produce clearer results. This is an important methodological question for a Method, like Feldenkrais, which sometimes produces changes or improvements in unexpected areas, and predicts by its own theory that improvements are generalizable. Studies like Connors, Pile, et al. (2010) provided an interesting approach to this where the Patient Specific Functional Scale (PSFS) allowed for targeted outcomes to be measured, while the pain and quality of life measures allowed for assessment of more diverse and multidimensional outcomes. This methodological issue needs to continue to be addressed in future studies. In many studies the Feldenkrais intervention groups showed improvement in a broad range of measures in comparison to controls, but in many cases these did not reach statistical significance suggesting overall small improvements in a broad range of the phenomena measured. Results both within and between studies revealed a number of

70 confounds. Measures that the authors expected would produce positive outcomes in some cases did not. Some measures used in one study produced results showing improvement, while in another study there was no significant improvement detected by the same measure even in studies with similar populations. The methodological question then arises as to whether these results are related to the efficacy of the Feldenkrais Method, the nature of the study design, or the population studied, the measures used, or some other factor. The inclusion of qualitative interviews as part of the research studies identified here, and especially Öhmann et al.’s (2011) qualitative study, is important. The qualitative data show a consistent trend for participants to value their experience of Feldenkrais for contributing to: (a) an “improved mental outlook” (Stephens et al., 1999, p. 61), (b) improved ability to cope or a sense that they can improve their situation (Kendall et al., 2001; Öhmann et al., 2011; Stephens et al., 1999), and (c) a greater sense of health and well-being (Gutman et al., 1977; Lowe et al., 2002). Some of these reports come from studies that did not find statistically significant improvements from the measures used. This raises questions about the research design, especially the level of the intervention, as well as the sensitivity and suitability of the measures. A number of the authors of these studies recommend that more qualitative studies are needed given the questions about the suitability of the measures (Ernst & Cantor, 2005; S. K. Johnson et al., 1999; Kendall et al., 2001). An important part of future research into the Feldenkrais Method will be creating greater clarity about the phenomena being studied in order to help understand both the outcomes and mechanisms of Feldenkrais-based interventions (Stephens, 2007). Another major conceptual and methodological challenge will be to discover if it is possible to identify the interactions between the kinds of factors (e.g., body awareness, function, self-image, quality of life) identified by the research so far.

71 Overall this literature review reveals that the Feldenkrais-based interventions contribute to health and well-being. The challenge is how to conceptualize the Feldenkrais Method’s contribution to health and how to best study this question.

72 Feldenkais Method’s Contribution to Health Results of Interviews with Key Informants What kind of system can generate these kinds of diverse outcomes in these areas of affect, such as anxiety and depression, body image and self-image, pain, perceived quality of life, as well as in posture, movement, and function? An argument will not be made here about how Feldenkrais Method works. Apart from being an enormous task, it would take us into largely unresolved areas in neuroscience and philosophy (R. Russell, personal communication, February 12, 2012). Instead, ideas about what could be taken into consideration will be presented as part of the aim of this thesis to describe and map Feldenkrais Method in relation to MBM, and to make suggestions for future research. To do this it is necessary to present some conceptual frameworks. This report first presents a framework from Feldenkrais practice itself, explores the goals and intended outcomes in more depth, and reports the perspectives from the three key informants—E. Beringer, R. Russell, and D. Leri—interviewed for this thesis. Promoting functional improvements. The primary goal of the Feldenkrais Method is to enhance a person’s functioning and action consonant with their intentions and their potential in a very broad sense. The goals of the Feldenkrais Method can be seen in terms of two different scopes and timescales within the development of people’s lives. One where the Method helps people deal with more immediate functional difficulties, such as nonproductive habits, lack of confidence in one’s capacities, injury, pain, and disability, which provide barriers to more optimal functioning for the individual. Writing of his task working with a client, Feldenkrais (1981) noted: I have to communicate something which may help a person who is in trouble, or wishes to change his aches and pains, was born with… cerebral palsy, or has been injured, or is acquired by the habits which are self-directed (feeling inadequate) and

73 self-destructive (feeling unworthy). I wish to convey something which may help the person to reorganize the acting of his self through the body with self-direction to make life easier, simpler, or even more pleasant and aesthetically satisfying. (p. 149) Self-education. Feldenkrais also saw the Method as a means of self-education, or self-learning (Bruce, 2003). He drew the distinction between our (a) biological heritage, (b) the education provided by society, and (c) self-education which he saw as a vital need in human development (Feldenkrais, 1972). His focus was on developing self-knowledge, not just in the form of insight, but also as improving ability in the carrying out of our lives. One of his aims was to reduce the compulsive character of action, and help people to change how they respond to stimuli. To help them have choice in their action. Increasing the capacity to alter how one responds to one’s environment, also has the potential to allow the person to alter the environment to meet their needs in a more effective way (Feldenkrais, 1985). Health as ability or competence. In many ways the Feldenkrais Method can be seen as a model of ability; of competence. Feldenkrais’s books and articles are replete with the language of competence: talking about skill, know-how, and the ability to function effectively, and take action. Boni and Lozno (2007) defined competence as, “a complex operational capacity resulting from the integration, mobilization, and disposition of a set of capacities and abilities (of a cognitive, affective, psychomotor or social order) and of knowledge (declarative knowledge) used in an efficient manner in certain situations (p. 822). A simpler description that is used by the Feldenkrais profession is, “Competency is the ability to mobilize and focus the resources necessary to act successfully in a given situation” (IFF, 2006, p. 7). In Feldenkrais developing “sensory-motor competence” is a primary focus (Goldfarb, 2004, “Interview”, para. 8).

74 All the key informants spoke about health as an active process that can draw on abilities developed though Feldenkrais practice especially the ability to generate choices in the ways they move, and the ways they think and feel about their health. E. Beringer is interested in, How do people shift over from passively having health care, kind of, done to them, to [where] they take responsibility? Responsibility to a lot of people means going on the Internet and educating themselves. That’s all good, and that is a way of taking responsibility. But there’s a shift where people actually are more embodied and are able to get the signal from themselves about what they should be eating, when they should be resting, what kinds of exercises they should do, when it’s time to get up from the computer. […] When the kinesthetic world becomes more alive and people become more awake to their lived experience, then I see there’s a process that starts where people can become healthier. I think that Feldenkrais does have a pathway for that, a process of entering into the life of the body and being able to make sense of that. You present a pathway for that. (personal communication, March 17, 2012) E. Beringer suggested that by making things simpler, by reducing the stimulation and variables in lessons, “people can learn to make kinesthetic distinctions and have more choices” (personal communication, March 17, 2012). The ability to make distinctions in their experience carries over to their health and the rest of their lives. Describing, for example, clients dealing with pain, E. Beringer suggested, So many people who are dealing with chronic pain situations… by the time they come for private sessions, often they’ve exhausted what they can do on their own. They’re a little stuck. That stuckness manifests both physically and mentally in their ability to think about their situation. (personal communication, March 17, 2012) After Feldenkrais sessions, It may be that their [underlying] physical situation hasn’t necessarily got better, but they are much better because now they have more choices. They can listen to themselves better, they understand better about generating options, and therefore they create less pain. They get themselves into the situations that create pain much less, so they can go about their lives. (E. Beringer, personal communication, March 17, 2012)

75 This is consistent with Lowe et al.’s (2002) finding that even if participants did not have less pain, they felt that they had new ways of coping with it. Of particular importance in Feldenkrais Method is developing the ability to separate the observing self from any idea of correcting. This shifts the relationship with the body and the self from a focus on “the right way of doing things” and can create a sense of “spaciousness” and “playfulness” in the learning (E. Beringer, personal communication, March 17, 2012). Removing the judgment allows people to develop the capacity for self-observation that provides a basis for altering their own actions. Attention as an ability and the value of attending. Feldenkais lessons can develop a range of abilities to (a) direct attention to different sensations in the body and in relation to the environment; (b) to shift attention from one experience to another; (c) to focus attention on particular experiences; (d) to diffuse attention though the body, and toward the body in the environment; and (f) the environment itself. All three key informants mentioned the value of Feldenkrais for learning, in everyday activity, how to quiet the “noise…of extra effort, things not working together, biomechanical stresses” and “start to have a simpler experience of themselves” (E. Beringer, personal communication, March 17, 2012). Attending is a key ability developed through Feldenkrais practice. Russell (2004, personal communication, February 12, 2012) compared Feldenkrais practices as similar to the phenomenological practice of epoché, which is a process of intentionally putting aside cognitive and emotional conceptualizations—to the extent that it is possible—and attending to the experience at hand. Talking about Awareness Through Movement lessons, R. Russell explored the experience and possible neurological basis of such attention:

76 I think there is something built into the neurology of doing the lessons that gets you there. It’s not visible most of the time because most people are concentrating on what are the steps of the lesson. I think the first step is to ask you to basically do what the phenomenologists calls epoché,…to suspend your belief. To actually stop your intention of making up for things, and trying to be better, to stop it.…To really use your brains, literally your prefrontal cortex, to interfere with your emotional drive to try to fix yourself because you believe that you’re not good enough.…The prefrontal cortex is the only thing that can get you to do that. It can get your limbic system to [say], “Oh, they want me to stop being upset, stop being excited, stop being off balance, stop pumping the sympathetic, they’re telling me [from] upstairs to wait a minute. And they’re the boss.” So I get to wait. Then you can actually pay attention. The idea is to stop being so fearful in the middle of a lesson that you’re not going to do it right. Because that’s just a habit. “What happens if I just don’t do all that habitual emoting, and actually just pay attention?” Then our attention is, I think, transformative. It changes the way our whole brain works… I think that’s the point at which, when you can do that … you have one of those wonderful days when it all just clicks into place and you’re lying there and going, “Wow. I didn’t know I could sense that much detail and so clearly, in an instant, about what I’m doing.” (R. Russell, personal communication, February 12, 2012) This emphasis on nonstriving in Feldenkrais lessons can promote the ability to let go of habitual ways of trying and let new experiences arise. Focusing attention on bodily sensations quiets habitual cognitive and affective activity. Feldenkrais (1988/2010b) had experienced a “stopping” exercise – pausing to notice what is happening in the present at predetermined or random times – developed by Gurdjieff for the process he called “self remembering” (Goleman, 1988, p. 92). His experience with Gurdjieff’s practice, and study of other meditative traditions, may have influenced the creation of Feldenkrais classes (Feldenkrais, 1972). Interestingly R. Russell’s (personal communication, February 12, 2012) description is very similar to the definition of mindfulness meditation as the “intentional cultivation of present-moment, non-judgmental awareness” (p. 230) proposed by KabatZinn (2000). All key informants recognized that there is significant similarity between Feldenkrais and other mind-body practices in developing and using attentional abilities

77 (Fogel, 2009). At the same time, Feldenkrais lessons are somewhat unique. As they involve movement they provide the opportunity to work with one’s habitual attitude to oneself and one’s body “while doing,” or “while trying to do.” Refining the self-image. All key informants emphasized the importance of the idea of the Feldenkrais student being able to refine their self-image. D. Leri (personal communication, March 14, 2012) and R. Russell (personal communication, February 12, 2012) both emphasized the idea of creating greater invariance26 in the part of the selfimage engaged with sensing the precise organization and location of the body (the idea of the body schema). D. Leri (personal communication, March 14, 2012) particularly referenced a series of Awareness Through Movement lessons known as the “primary image” lessons27 that make use of the image of the “five cardinal lines” of the body as a way of precisely clarifying the shape, size, and direction the parts of the body, and the body as a whole. These informants emphasized that having this more precise image of the body allowed people to quickly sense disruptions and deviations in the organization of the body, including those arising with emotional states, which may be part of less healthy

26

Various authors have proposed that one of the functions of the nervous system is to create perceptual invariance, which allows us to interact with an object in a consistent way, even if the object is encountered in different conditions, for example, different orientations, different lighting conditions, etc. For example, a book appears as a book to us when seen from across the room lying on a table, of close up standing on a shelf. Knowing that it is a book then affords picking it up, reading the spine for the title or opening it regardless of the specifics of the particular book. In the case of Feldenkrais Method, the suggestion is that having greater invariance in the self-image, body image or body schema can allow for one to respond more consistently and effectively in changing circumstances (Ginsburg, 2010). 27 Feldenkrais (1981-1982, 1994-2004) taught a series of primary image lessons using the image of five cardinal lines of the body (the line of the spine—including the head, the lines of the arms and the lines of the legs) as a way to sense the size and direction of these parts of the body, and the body as a whole, and to sense spatial relationships within the body. He referred to the primary image as a concise image of the body. These lessons can help students notice small alterations in the organization of the body with reference to changes in their sense of the image, well as for students to experience some of the fundamental properties of movement (Feldenkrais, 1972).

78 functioning. A more precise, inclusive, and stable internal body image could provide the basis for effectively dealing with the instabilities of life and the environment, helping to prevent injury and deal with illness. The skill of learning: Learning to learn. Feldenkrais (1981) was concerned to help people not only to learn, but also to become self-directed learners: to learn the art of learning. Such learning can then be applied to any function and situation. All the key informants mentioned that Feldenkrais lessons provided the opportunity for students to develop and generalize the learning skills within lessons, and drew attention to Bateson’s (1972) ideas of the multiple levels of learning. For example, to be able to attend to how one attends (Goldfarb, 2004; D. Leri, personal communication, March 14, 2012). They suggested that knowing how to shift attention and what to pay attention to was a generalizable ability that allowed Feldenkrais students to continue to learn in ways that could be healthy. Developmental perspective. All the key informants saw the value of Feldenkrais for health though the perspective of human development – from infancy through life. E. Beringer (personal communication, March 17, 2012) noted that Feldenkrais Method was similar to Judo (before it became a sport) and Aikido as they all involve the idea of what is described in Japanese as a Do—a path. R. Russell (personal communication, February 12, 2012) explained his perspective in this way: For me it’s become really obvious [that] health [is a] question of the developmental line over your life. The question “What is health?” has got to be put in the context of how does a person’s life span unfold? What’s the driver of development? That’s where all Esther Thelen’s work became really interesting… “Oh so this is how children make sense of themselves, so they can make sense of the world”. So you look at a person’s life span – you go from birth to death: how did they learn to be competent and what is health in relation to your ability to live in the world? I think that’s the only context that the Feldenkrais theory makes any sense. Everything else is a piece. Like, you can fix your back and you can throw

79 the ball farther… but what difference does it make to the person’s sense of, “Oh, that’s me.” It’s a question, first of all, of being effective at what you want to do. But the next question is, how come you want to do that? You could be really good at something that isn’t healthy.…That’s a personal developmental question: “Who am I as a person?” How did I become like that? Who can I become? That’s where the question of what does health mean—within that series of questions – is really interesting. Because the “What can I become?” question has nothing to do with repairing things. In a similar vein, D. Leri (personal communication, March 14, 2012) suggested: I think on some level [a person] may not have any inkling of what that vision, what your avowed or unavowed dream, is. But [you can start to] live your life with the direction of your life, of your life, rather than somebody else’s direction. I think that’s the thing, just taking a path that you lay down yourself.

80 Toward a Feldenkrais Theory? While these three key informants, grounded in the practice of the Method, emphasized similar aspects of the practice, in his lifetime, Feldenkrais himself did not write a comprehensive theory of the Method. Delman (1993) suggested: “Moshe [Feldenkrais] had a system but he did not really have the language to envelop that system. The work went much further than his language, which is based on his own education and life” (“Interview,” para. 18). A number of theoretical frameworks for describing the Method have been proposed drawing on: •

Information theory and cybernetic concepts from Wiener (1948) and others (Rywerant, 1983; Goldfarb, 1995);

•

The ecological psychology of thinkers such as Bateson (1972) and Reed (1996);

•

Thelen and Smith’s (1994) application of dynamic systems theory to human development and action (Buchanan & Ulrich, 2001, 2003; Reese, 2012);

•

The biology of cognition and the idea of “autopoesis”28 developed by Maturana and Varela (1987), Thompson (2007) and others.

Further, phenomenological, and particularly neurophenomenological perspectives (e.g., Varela et al., 1993) have been referenced in conceptualizing the Feldenkrais Method. Ginsburg (1999, 2003, 2010) and Russell (2004) both draw on a combination of these theories to support their framing of the Feldenkrais work. Recent discussion within the Feldenkrais field has also drawn on perspectives from child development, focusing on relational aspects, and dynamic models (Fogel, 1993; Stern, 2000; Thelen & Smith, 1994). Within the philosophy of aesthetics, Shusterman (2008) has drawn on somatics practice 28

Autopoesis means literally self-creating. Maturana and Varela (1987) proposed that this is a key characteristic of biological systems, and is an aspect of these systems—a single celled organism through to the development of human cognition.

81 and the idea of mindfulness to explore the idea of body consciousness and proposed a field of “somaesthetics.” Some of these perspectives will be drawn upon in the discussion that follows.

82 Some Possible Biological Bases for Improvement How might the kinds of improvements in health, and in health enhancing behavior, be supported and subserved by the biological systems the body? Physical Level On the level of the physical body, over use, under use or inefficient use can contribute to a range of conditions, including (a) inflammation, (b) muscle strain or hypertrophy, (b) damage to cartilage, disks, tendons, (c) infusion of muscles and joints with fibrous tissue, (d) changes in hormonal balance and immune function, as well as other conditions (Wildman et al., 2000). More efficient and balanced movements can reduce the risk of injury—wear and tear—and other consequences of chronic conditions. Neuromuscular Relationships Feldenkrais lessons have the potential to introduce a variety of changes in the neuromuscular and perceptual systems. Taking just one idea from Feldenkrais practice that of reducing muscular effort as an example, it could be theorized that the use of small, slow, and unforced movements may lead to the muscle spindles (extrafusal fibers) responding to the decreased demand by allowing a lengthening of the muscles (Ginsburg, 2003). Likewise, alternating movements of agonists and antagonists (e.g., the front and then the back of body; the flexors and extensors) may lead to a greater resting length in both sets of muscles (Masi & Hannon, 2008). The evoking of synergistic muscular patterns (e.g., how the respiratory diaphragm, transversus abdominus, multifidi, and pelvic floor muscles work together; see Sapsford, 2004) may lead to a more even tonus in those muscles or in other muscles which were substituting for their inactivity. An increased ability to allow gravitational and compressive forces to pass through the skeleton may lead to improvement in tonic contractions along the spine. As yet, there is not sufficient

83 research into these phenomena in relation to the Feldenkrais Method, or indeed in relation to many somatic or exercise systems. Such measures could be part of future research efforts. Even then how can we conceptualize the kinds of alterations in complex functions identified in the Feldenkrais research to date? This “bottom up” information – transmitted and organized in the brain stem and cerebellum – are part of the “primary senses of oneself” (S. du Lac, personal communication, February 12, 2012) and are of great importance to one’s self image in action. Muscular Sense On the basis of the volume of the tissues in the human body, the musculo-skeletal system is the largest organ system in the body. To a large extent, the felt-sense of one’s body is a muscular sense (Bakal, 1999; Feldenkrais, 1972). Ginsburg (2010) quoted neuroscientist Karl Pribram, who suggested that the motor cortex could be seen as “a sensory cortex for action” (p. 264). In MBM there is often an emphasis on the role of the autonomic nervous system, and the smooth muscle it regulates, as a primary mechanism of physiological change. Likewise there is an emphasis on how activities that can be considered of the mind or mental can affect these systems (e.g., meditation, guided imagery, hypnosis). However, it is clear that the state of the striated, skeletal muscles, largely regulated by the somatic nervous system, also has a profound effect on the state of the organism, consciousness, and health. In addition, the autonomic nervous system is involved with the skeletal musculature. Emotions and moods associated with, for example, fear, anxiety, curiosity, or joy, can all affect the initiation, speed, strength, direction, and smoothness of bodily movements (Sheets-Johnstone, 2009). The autonomic nervous system affects the levels of arousal of the whole organism (Feldenkrais, 1949). Muscle spindles, which provide

84 feedback on the extent of the contraction of the muscle fibers and operate in the maintenance of levels of background muscular tonus—or tonic contraction (Carpenter, 1996), have recently been shown to be innervated from the autonomic nervous system. Muscle spindles, associated with muscular over-activation and pain were shown to be responsive to stress conditions, and their level of activation is reflective of stress-prone psychological traits (Gevirtz, 2006; McNulty, Gevirtz, Hubbard, & Berkoff, 1994). The importance in the Feldenkrais Method to sense the skeleton has already been identified in this study. Taken together the muscular and skeletal senses of the body are important aspects of bodily organization and awareness. Sensory Integration Recent neuroscientific research shows that some brain regions bring together sensory information about the state of the musculature, with information, for example about temperature, itch, and pain, as part of the interoceptive assessment of the state of the body or self (Craig, 2002, 2009). It is increasingly clear that there is a high level of sensory integration within the nervous system, not just including the traditional five senses associated with exteroception, but also interoception, proprioception, and vestibular function that contribute to the sense of bodily organization and movement. The function of this sensory integration is not only to sense the body and the world after the fact, but also to provide the vital ability for the organism to anticipate and predict the consequences of its actions (Berthoz, 2000; W. J. Freeman, 2000; Llinás, 2002). Feed-Forward and Prediction One possible neurological mechanism underlying improvements in action from a Feldenkrais intervention is the role of preafferent corollary discharges, and the creation of an efference copy of motor commands that signal to the sensory parts of the nervous

85 system the nature of intended action (Carpenter, 1996; W. J. Freeman, 2000; Rywerant, 2008). This mechanism for the anticipation of an action allows for the sensory monitoring of the movement in the nervous system, and can provide a basis for changes if the sensation generated by movement does not match the efferent information. Potentially, increasing the accuracy of this feed-forward and feedback loop can assist new, improved patterns of action to become effective new motor habits. Through this loop the association of pain or difficulty with a particular movement can be interrupted and supplanted (Rywerant, 2008). On another level, neuroscientists like Gallese and Sinigaglia (2011) and philosophers like Petit (1999) proposed that this anticipatory capacity of the motor system is a major factor in the bodily basis of self-awareness. They suggest that the bodily sense of self is grounded “as a manifold of action possibilities” (Gallese, 2011; Gallese & Sinigaglia, 2011, p. 117). Changing Systems Dynamics Feldenkrais emphasized a change in the dynamics of the person seen as a whole system (Gilman & Yaruss, 2000). Using an analogy common in dynamic systems theory, he suggested a problematic habitual pattern “can be likened to a groove into which the person sinks” and which will persist unless “some special force” makes him or her shift (Feldenkrais as cited in Buchanan & Ulrich, 2003). Buchanan and Ulrich (2001, 2003) proposed that Feldenkrais Method uses a number of strategies to create a perturbation in the person’s action systems that can lead a state shift in the system. For example, changes in one of the multiple subsystems—the perceptual or motor systems, the body itself or the nervous system itself, or in the environment—can create a shift in the dynamics of the whole system. Buchanan and Ulrich (2001) theorized that the creation of comfort and

86 pleasure and of ease and efficiency in Feldenkrais lessons can serve to reinforce emergent and new sensory motor patterns, which can then act as an attractor basin for new patterns of action (Thelen & Smith, 1994). One valuable concept here is that of coherence (Berthoz, 2000). Feldenkrais suggested that the role of the nervous system is to “make order out of chaos” (Feldenkrais as cited in Ginsburg, 2010, p. 254) or as Varela put it, “A brain is a system so constructed as to create a stable reality” (Varela as cited in Ginsburg, 2010, p. 254). Feldenkrais lessons can be seen as creating the possibility of new synergistic relationships between nervous system, body, and environment to create a new homeostatic state (Feldenkrais, 1977/2010a) based in a new pattern of bodily organization. Ginsburg (2010) suggested, “An infant or person recognizes the coherence of an act and the necessary synergies. It also has value. It feels right. We call the process of creation here self-organization” (p. 137).

87 A Framework for Feldenkrais Method, Somatics, and Health Salutogenic Model of Health Before considering further how Feldenkrais Method contributes to health, and in that context its contributions to MBM, it may be useful consider a model of health and health improvement that seems to have some consonance with Feldenkrais thinking. The salutogenic model of health, proposed by Antonovsky (1979, 1987), is consistent in many ways with the Feldenkrais approach. Antonovsky (1979) proposed that rather than seeing health and illness as dichotomous, that we should consider there is a continuum from “disease” to “health-ease” (pp. 194-195). Illness and injury and other sources of tension, which disrupt homeostasis, are to be expected in the course of life. Therefore the question is about coping with such tension, rather than its elimination. In constrast to life being homeostatic, Antonovsky (1987) suggested that “dynamic heterostasis” is perhaps a more appropriate description of the actuality. Feldenkrais (1979/2010d, 1981) also acknowledged that challenges to health and well-being are inevitable, and the issue is to build one’s ability to respond effectively. Antonovsky (1979), quoting Wertheimer, emphasized that health is about “doing rather than undergoing” (p. 140). Like Antonovsky, Feldenkrais Method embraces an active view of health. Feldenkrais’s first conception of health—that it involves one’s ability to recover—is consistent with Antonovsky’s concern with how someone can return to his or her former place (or even improve their position) on the disease–health-ease spectrum. They both reject the idea of looking for a single etiology of a disease state, and instead consider the whole person in the context of their life (Antonovsky, 1987). Antonovsky suggested that whether a person perceives tension as a stressor, or as a meaningful challenge, is reflective of a healthy orientation. Feldenkrais wanted to help

88 people deal with strong stimuli, and with strong emotions, and not be debilitated by them (Feldenkrais, 1981). He sought to help people learn how to direct physical and other forces to which they are subject (Feldenkrais, 1964/2010c). Like Feldenkrais, Antonovsky (1987) saw that a healthy person could introduce order and meaning into their life, and have choice—including flexibility in choosing which resources to mobilize. While Antonovsky’s (1979) model comes from his sociological work, and by his own account is very cognitive, it is highly congruent with Feldenkrais’s approach. The sensory-motor competencies and somatic knowledge generated by Feldenkrais practice could be considered as kinds of “generalized resistance resources” (pp. 194-195) within Antonovsky’s29 (1979) schema. Antonovsky considered Bandura’s social cognition theory, in which Bandura (1977) proposed the concept of self-efficacy, as being consistent with a salutogenic approach. Self-efficacy is a model of behavior change where “expectations of personal efficacy” is a key aspect of “coping behavior” (Bandura, 1977, p. 191). Self-efficacy has been shown to be an important factor determining outcomes in a range of health behavior change, from dealing with phobias and addictions, to adopting health promoting activities (O’Leary, 1985; Strecher, DeVellis, Becker, & Rosenstock, 1986). Research has also shown that self-efficacy can be enhanced. While this model, like salutogenesis, is quite cognitive in its conception, there are some key elements, which are relevant to a somatic learning approach. Bandura (1977) and those who applied his work to health promotion

29

Antonovsky himself favored social-level solutions to health improvement, and was concerned with solutions that shifted complete responsibility to the individual (Bakal, 1999). While Feldenkrais developed this system of somatic awareness, he did not see the outcomes as creating necessarily quiescent and purely introspective people, but people who could use their awareness to take more effective action in the world; a world which he readily acknowledged was clearly in need of improvement (Feldenkrais, 1981).

89 (Strecher et al., 1986), propose that one of the key sources of information from which someone derives a sense of self-efficacy, is their experience of success in performance. Awareness Through Movement lessons provide a concrete opportunity at success in altering, for example, the felt qualities of movement and the body, or of having less pain (E. Beringer, personal communication, March 17, 2012; Öhmann et al., 2011). Feldenkrais suggested that change needs an experiential basis; that “the benefit cannot be imagined until the improvement is sensed” (Feldenkrais, 1964/2010c). The Feldenkrais practitioner creates a sense of safety and manages the level of challenge to maximize the experience of success (Ginsburg, 2010), for example, by focusing on the means of making a movement rather on than a goal (Feldenkrais, 1964/2010c). Consistent with this approach, the self-efficacy model (Bandura, 1977; Strecher et al., 1986) also posits that if new behaviors are attempted with too high a level of arousal, success and the development of the sense of self-efficacy can be undermined. Feldenkrais (1972, 1985) suggested that the ideal state for learning is where one is not too relaxed and not too aroused; where there is good sympathetic-parasympathetic balance. This ability to shift to greater autonomic balance through using Feldenkrais lessons is an empowering aspect of the work (Öhmann et al., 2011). In contrast to many mind-body approaches, with Feldenkrais Method, “The aim is not complete relaxation, but healthy, powerful, easy and pleasurable exertion” (Feldenkrais, 1964/2010c). To find the right level of arousal and kind of organization for successful and comfortable action, may provide a basis of a sense of self-efficacy. The Nature of Somatically Grounded Learning One question about the approach to health as discussed here is the role of awareness. This immediately raises the many possible uses of terms like awareness and

90 consciousness in different scientific, philosophical, cultural, and practice traditions. One problem is that such words tend to imbue these concepts with a thing-like quality, as if they were fixed states. The kind of somatic learning discussed here emphasizes how consciousness and awareness are processes. Ginsburg (1999) suggested that we should perhaps use the term “consciousnessing” (p. 79). Another challenge is that historically consciousness has been conceived of, and written about, in terms of human language capacity (Gregory, 1987, p. 164). It is clear from this discussion that much of, and perhaps most, of the changes in function and action engendered by the Feldenkrais Method occur at an unconscious or nonconscious level of human organization. Clearly the observable changes in dexterity (Bitter et al., 2011), and balance and gait (Hillier et al., 2010, Ullmann et al., 2008; Vrantsidis et al., 2009), described here do not only arise from conscious processes linguistically directed, or even verbally reportable, by the person making the action. Nor are we looking for all functions to be carried out consciously. One of the historical arguments against somatic introspection is the concern that it would interfere with effective “automatic” functioning (Shusterman, 2008). Using the familiar steps of learning model, in each iteration a person may go from (a) “unconscious incompetence,” to (b) “conscious incompetence,” to (c) “conscious competence,” and finally to (d) “unconscious competence” (Claxton, 2007, p. 34). Claxton (2007) suggested changes occurring directly in the nonconscious processes in the nervous system may allow one to go directly from unconscious incompetence to unconscious competence. This is a question that needs discussion and research in relation to the Feldenkrais Method. While there are clearly shifts in the whole pattern of mobilization as a result of Feldenkrais lessons,

91 conscious processes are also important during different stages of learning, and at different times when accessing that learning. Ginsburg (1999) suggested, “all human action requires an integration or conscious and non-conscious activity, and also requires immense and complex organization” (p. 81). For Ginsburg (2010), learning and the integration of learning are not conscious processes, yet “the process depends on conscious processes in feeling and detecting changes” (p. 185). Conscious direction of attention and initiation of movements are also essential components of Feldenkrais classes. “Conscious awareness,” also described as the “reflective consciousness” (LeGrande, 2007) gives us access to our “mental states, cognitions, emotions, and motives” (Khilstrom, 2012, para. 1). Awareness, in this context, might be considered as related to the contents of the conscious process. In everyday usage, what one is “conscious of” or “aware of.” However, the concept of awareness needs also to include the process for accessing those contents. A number of philosophers also suggest that there is a possibility “that the basic forms of bodily awareness are non- (or pre-) reflective in nature” (Gallese & Sinigaglia, 2011, p. 123). They suggest that there is “pre-reflective self-consciousness” that is grounded in bodily experience (LeGrande, 2007, p. 1). These two conceptions of awareness need to be identified in our descriptions of these phenomena, therefore, the need to use an apparently redundant formulation like conscious awareness. Another implication of this discussion is that there is a host of nonconscious or unconscious processes which subserve conscious awareness. The concept of nonconscious or unconscious used here is not the old Freudian one of repressed emotional material, especially of a traumatic or sexual nature. Feldenkrais suggested rather that, Freud left out the “manipulative” unconscious (1973/2010f, p. 198). New views propose

92 an unconscious that encompasses procedural memories and tacit or implicit knowledge. It includes one’s sensory-motor competencies. It provides the substrate for the ways in which we make rapid, perceptually-based judgments of situations and people. Khilstrom (1987) proposed the term “cognitive unconscious” for this new understanding, whereas Wilson (2002) suggested the “adaptive unconscious.” Implied in the forgoing description of Feldenkrais practice is the possibility that initially unconscious or nonconscious experience can be brought to consciousness and become the contents of our conscious awareness. These newly available feelings can then be available to inform one’s movement toward health. Grossinger (1995) proposed, “What is not felt, axiomatically cannot be changed” (p. 265). Even the kind of conscious knowledge generated through a somatics practice may have more a quality of being “acquainted with” or “in touch with” a particular, concrete “fact, thing, constellation, structure or person” (Pelz, 1974, p. 83) in a way that acknowledges the tentativeness or partialness of such knowledge, rather than the kind of knowledge associated with a generalized scientific certitude. Uses of Somatic Awareness In his 1999 book, Bakal noted that 19th century authors talked about the idea of bodily or somatic awareness as a “a state of inner touch” (p. 9). He suggested that this kind of awareness can provide vital experiential information on the health status of our bodies—allowing us to detect the early onset of conditions, such as headache. This creates the possibility of altering one’s actions to reduce the stressor, and interrupt the pattern on onset. Learning when to rest to avoid the onset or worsening of pain is a useful skill – one that is taught by Feldenkrais practitioners with their clients and experienced in Feldenkrais classes (O’Connor & Webb, 2002). The early signs of pain are often not pain

93 itself, but muscular tightness or fatigue, or other often nondescribable sensations. Öhmann et al.’s (2011) qualitative study of people with chronic pain supports the value of Feldenkrais for helping people develop the awareness and perhaps the confidence to “listen to the body and its restrictions” (p. 159) and deciding to make “no more sacrifices” (p. 159) that engender unnecessary pain. Levin (2005) suggested that various culturally understood bodies have been constituted by Western medicine throughout its history. The: (a) “rational body,” (b) “anatomical body,” (c) “physiological body,” (d) “biochemical body of cells and molecules”, (e) “psychosomatic body,” (f) “body of psychoneuroimmunology,” and finally, (g) the body of “experienced meaning,” the “body of lived experience” (pp. 99-102). He suggested that with increased understanding of the relationships among mind, body, and the environment, medicine potentially has the conceptual tools to enter into a discourse that connects the patients’ experienced meaning of their bodies as they cope with the kinds of conditions and states of the body dealt with in medical treatment and research. Progress, he suggested, is not just dependent on medical science. Levin (2005) elaborated: However, it must be noted that medicine’s success in making such correlations does not depend only on advances in medical knowledge. It also depends on patients’ ability to fine-tune their embodied awareness, their sensitivity to processes of bodily experiencing, and the skillfulness in carrying those processes forward into more articulate, more discriminating meanings. For many centuries, Western culture has denied recognition of this ability and consequently made it very difficult for people to enjoy contacting and working with their bodies’ felt meanings […], the intricate meanings carried by the bodies in co-responsiveness to particular situations and circumstances. (p. 101) Bodily Meanings In developing the psychophysical process called “focusing,” psychologist and philosopher Eugene Gendlin (1978) proposed the idea of the felt-sense. The focusing

94 process involves attending to the emergent felt-sense of and in the body, and waiting for personal meanings associated with that felt-sense to arise. One is encouraged to gently “tap” and “sit with” the material that arises (Gendlin, 1962, 1996). The concept of felt-sense has entered more common usage and it has some value here. The development of greater somatic awareness may allow one to have a clearer sense of how affective states and evaluations feel in the body—as the key informants for this study suggested. It might be possible for people to develop a bodily felt-sense of which things, actions, and situations are healthful for them, and which are not. Perhaps, even to be able to access an overall felt-sense of health and vitality (E. Beringer, personal communication, March 17, 2012). Lakoff and Johnson proposed that many of the deep metaphors or image schemas in our language are based in the body and the experience of bodily movement in space (M. Johnson, 1987, 2007). While this model is proposed to work at a cultural-linguistic level, it may also be that one can connect to a metaphorical level of meaning through bodily experience. M. Johnson (2007) proposed that to find “immanent or embodied meaning, you must look more deeply into aspects of experience that lie beneath the words and sentences. You must look at the felt qualities, images, feelings, and emotions that ground our more abstract structures of meaning” (p. 17). That is, not meaning in the simple dualist sense, for example, “I have back pain because I am angry,” or “I am angry because I have back pain.” Instead, finding a feltsense of what it is like to be one’s self with the experience of back pain, and then on that basis to explore senses of one’s self, for example, as strong or weak, capable or incapacitated, flexible or less flexible, angry or calm, moving too much or moving too little, or moving in a particular way.

95 Feldenkrais (1981-1982) suggested that one of the things he was seeking ways to make abstract ideas concrete. It seems that it may be possible to have a bodily experience of both the direct and conceptual meanings of an idea such as, “to breathe easy” (D. Leri, personal communication, March 14, 2012). Through Feldenkrais lessons, students have the chance to develop a felt-sense of concepts, such as balance (E. Beringer, personal communication, March 17, 2012), support, ease, comfort, calm, rest, or resilience. People get to experience self-compassion (Neff, 2003; Neff, Kirkpatrick, & Rude, 2007) and come to “trust” their bodies (Öhmann et al., 2011), as they “look after themselves” in a Feldenkrais lesson. Students get to practice self-care (Gordon, 1996), at least for the duration of their class, and feel what it is like. The constructs of feeling and feelings are potentially important in this discussion. Although often taken to mean only emotions, or only sensations, feelings can also be considered to include sensory or perceptual, evaluative or attitudinal, as well as affective aspects which may be a vital part of motivation (Blackburn, 2005; Honderich, 1995). Feldenkrais (1972) proposed, “Our self-image consists of four components that are involved in every action: movement, sensation, feeling, and thought” (p. 10) which can only be separated in language, and not in actuality. Feelings can also have an aspect of skill or competence. We can develop the ability for “feeling feelings” (Rothfield, 2008, “Title”) or to “feel for the feeling” (“Prolegomena,” para. 3) as dancer and philosopher Rothfield (2008) expressed it. A Possible Model of the Role of Somatics Practices in Mind-Body Health Returning to the importance of intention and action, some phenomenological thinkers have proposed the concept of bodily intentionality, which may provide an important conceptual link in developing a model for how somatic experiences and somatic

96 learning contributes to health. Merleau-Ponty (1962) proposed bodily intentionality as a phenomenon, where, on a preconscious level the body organizes itself in relation to perceptual objects of interest, thus allowing for the perception of the thing in a way that is meaningful for the organism. It thus creates an intentional arc between the self and the object. Likewise, on a preconscious level, the body prepares itself for action consistent with what is of value to the organism and while making use of the affordances30 in the environment (Dreyfus, 1996; Merleau-Ponty, 1962; Nagatomo, 1992). In everyday understanding, one assumes that intention requires conscious thought. W. J. Freeman (2000) reminds us of an earlier meaning of intention, still found in biological and medical science, of intentionality as a phenomenon where “humans and other animals act in accordance with their own growth and maturation” (p. 8). He also reviewed the evidence of research from Libert and others, which shows neurological activity occurring prior to conscious awareness of the intention to act. From this and other evidence he concluded, “Most intentional behaviors occur without the need for awareness, so intentionality operates before awareness and consciousness, up to a point” (Freeman, 2000, p. 10). It is not that conscious-thought-in-language is not important; it is just that a large portion of our action is in response to our biological needs, and occurs in ways consistent with our experience and learning in our environment. Dreyfus (1986, 1996) described Merleau-Ponty’s concept of the intentional arc, a nonrepresentational model that suggests that most of our actions arise from dispositions to act in certain ways consistent with experience and learning. The intentional arc reflects the relationship

30

The concept of affordances comes from ecological psychology, and it describes features of an environment that allow for a certain kind of behavior or action. A common example is “chairs afford sitting.” Elements of society, language and culture also can be seen as affordances for human actions (Reed, 1996).

97 between our environment and the skills we have developed though our functioning in the world. Much of our behavior represents our skillful coping in the world. It is the deportment of the body and a set of increasingly refined bodily dispositions (Dreyfus, 1986, 1991) that allows one to be more effective—to achieve maximum grip—in our action in the world (Dreyfus, 1986, p. 1). Through “repeated cycles of action and perception” (W. J. Freeman, 2000, p. 120) we create an equilibrium between the world and ourselves. To shift the direction of the intentional arc requires that the person’s current patterns of motor intentionality must be shifted (Dreyfus, 1996). Using concepts from dynamic systems theory, Dreyfus suggested that new attractors can be created within the person’s experience. The experience of pain or disease often provides the disequilibrium needed to begin the process of altering action patterns. However, pain or disease can often propel people into dysfunctional and unskillful coping patterns. Feldenkrais Method may provide another way to perturb such patterns and supplant them with more functional and skilled responses to stress, illness, and injury. Somatic learning creates the opportunity for new feedback within the intentional arc, between the bodily self and the environment. Historically, models of change in individuals’ health behaviors involved conscious rational or rational-emotional approaches, including the provision of information on illness, disease, and healthful behavior, attempts to change attitudes and beliefs, planning and taking decisions for conscious, deliberate action (Baranowski, Cullen, Nicklas, Thompson & Baranowski, 2003). One of the great challenges is how people’s nonconscious or noncoherent behaviors undermine conscious intentions for self-improvement (Leri, 2008). This model suggests the possibility that salutogenic, or healthful, behavior, could be seen as a form of know-how (Dreyfus, 1991). A person with a more salutogenic

98 orientation is more likely to make use of affordances in their environment that promote health. The experience of success in becoming healthier bends the arc even more toward health; often healthier people are more likely to show up at health fairs than unhealthy people. How can we help people make a full-bodied shift toward health? Somatics practices add another dimension to health improvement. They provide the experience of improved well-being that can act to shift a person’s action and being-inthe-world. To directly experience bodily ease, comfort, and well-being, along with selfefficacy in the altering of emotional and bodily states, can have a profound effect on one’s motivation to positive action for one’s health.

99 Research Recommendations Methodological and Epistemological Issues The nature of the Feldenkrais Method presents a number of methodological and epistemological challenges. As a complex system, the question arises as to, “What is being measured?” Within the Method that are the two modes—Awareness Through Movement and Functional Integration—and a wide variety of concepts and strategies are used, functional themes addressed, as well as lesson structures, techniques for classes, and touch and handling with individual clients. In addition, Feldenkrais seems to generate a diverse range of effects or outcomes in a number of domains. It produces a number of functional outcomes in discrete areas, but to what extent do they contribute to overall health, and in what ways? There has been a certain indeterminacy of effects and outcomes associated with application of the Feldenkrais Method. This may be partly because Feldenkrais is not a prescription or a standardized protocol (Feldenkrais, 1977/2010a). The individual practitioner responds to the uniqueness of the client as that uniqueness expresses itself moment-to-moment in the course of the lesson. In Awareness Through Movement the movement and attention sequences and foci, the language and imagery, and the teacher’s voice all provide a framework to guide the student. However, how movements are actually made, how attention is actually directed, what is sensed and perceived, even how the person rests, will be unique to the person and the situation. “Individuals may have very different responses and improve in different ways through the same lesson” (Stephens, 2007, “Outcomes,” para. 4). A Feldenkrais clients’ or students’ personal experience of movement, action, and their body and sense of self are important mechanisms or variables and outcomes. The

100 question arises about the value of the standard approaches of empirical science, particularly when only measurable data coming from a third person relationship with the phenomena are seen as value (Ginsburg, 2008). Finally, research using language-based reports and measures may not capture the true nature and benefits of an approach like Feldenkrais (Barrows, 2007; Ginsburg, 2008). The person, the nervous system, and human movement have the characteristics of complex dynamical systems. However, while this is a powerful explanatory tool, dynamic systems theory creates very significant challenges in terms of research. The nonlinear dynamics proposed suggest that all components of the system can simultaneously affect all others, and even a small phenomenon within the system can have significant impact on its dynamics (Thelen & Smith, 1994). In terms of research, this makes it very hard to determine which are dependent and independent variables. What is influencing what? What is a mechanism and what is an outcome, or are these kinds of linear descriptions of little use (Ginsburg, 2008)? Dynamic systems theory also predicts that sometimes there may be incremental changes in a system, and sometimes sudden shifts in the whole system’s dynamics occur. This could go some way to help account for the dramatic changes reported in the case literature (Buchanan & Ulrich, 2001) and at the same time explain some unevenness of outcome data from Feldenkrais research studies. Research using measurement tools may need to be sensitive to outlying data and account for ways in which it might be represented as significant, rather than a statistical aberration (Ginsburg, 2008). What is Being Studied? Phenomenological approaches. A first question is what are the phenomena being studied? There is clearly a need for phenomenological research into the experience and

101 outcomes of the Feldenkrais Method (Ginsburg, 1999). Particularly, how do people experience Feldenkrais as contributing to health and well-being. Practitioners of the Method have written a majority of the detailed, descriptive reports. There is a need for finding ways to bracket the assumptions and explanatory frameworks of the Method to come to understand better what is experienced (Bentz & Shapiro, 1998; Giorgi, 2009; Van Manen, 1990). As reported above, R. Russell (personal communication, February 12, 2102) suggested that by taking time out from everyday activity, by directing attention to sensory and motor experience, Feldenkrais classes have some of the characteristics of the phenomenological epoché. In a special issue of the Journal of Consciousness Studies edited by Varela and Shear (1999b), many authors advocate for the use of first-person experience in the study of consciousness, including bodily experience. However there is considerable discussion and debate on the nature of the experiential data, how they are gathered and their significance (Schwitzgebel, 2011; Varela & Shear, 1999a). Based on his anthropological research, Stoller (1989, 1997) suggested that there are some experiences that can only be studied by doing them. While acknowledging the limitations of language, there may be ways to involve trained observers in research processes to create both first and second person accounts. Particular methods of documentation could include the use of interviews, journals, and other forms of writing and reflection. Also, documentation using audio or video could be utilized and possibly related to first and second person reports (Fogel, 2007; Joly, 2004). The observer may be the practitioner, creating a useful contrast between what is intended and theorized on the one hand, and experienced by the client or student on the other. In this way, the role of the practitioner-researcher can be included and valued within an explicit, systematic approach (Bentz & Shapiro, 1998; Ives & Shelley, 1998; Jarvis, 1999). Reviewing

102 documentation with participants and dialogue between participants or participant observers, and teachers about the process could add another layer of qualitative data. This is the kind of qualitative participatory and collaborative experiential research advocated by Reason and Rowan (Reason, 1988; Reason & Rowan, 1981). This use of first and second person data, along with documentation, could potentially create a rich data set, which could then be used for thick description of the experience of Feldenkrais and health, or a grounded theory approach to generating theoretical constructs. One problem arises, which has been encountered in research into meditation, that the experiential reports, and of course the nature of the experience itself, of neophytes and those of experienced students or practitioners of meditation are often quite different (Varela & Shear, 1999a). Phenomenological research may need to involve both people with little knowledge or experience of Feldenkrais Method, as well as of experienced students and practitioners. Another approach would be to do a kind of crossover study where, for example, experienced meditation practitioners, who developed a certain level of sensitivity to their own experience, participate in a Feldenkrais intervention, and experienced Feldenkrais students participate in a meditation intervention. Overall Needs for Research Into the Feldenkrais Method Clearly there is a significant need for much more research into the Feldenkrais Method. This could include more research into other areas of application than health, such as in other learning contexts, in skill acquisition for performance, and other domains. In his 2007 literature review and outline for future research, Stephens looked at the areas of existing Feldenkrais research into (a) chronic pain, especially low back pain; (b) people with neurological conditions; (c) mobility and balance with healthy older adults; (d) cardiovascular conditions, and (e) anxiety, emotional self-image, and other

103 psychological needs. He proposed that there is a need to further investigate outcomes in these areas, for example, to try to determine what is the most appropriate intervention in terms of intensity and duration. He noted although there is a body of research in relation to outcomes developing, there needs to be more research undertaken in terms of the proposed mechanisms of action and the theory of the Feldenkrais Method (Stephens, 2007). Browne (2007) also supported further outcome research, but suggested there are limitations of a “black box model” where Feldenkrais is studied as an undifferentiated intervention, in comparison to other interventions. He proposed that for credibility in the area of healthcare, there is a need to investigate and explicate the possible ways in which Feldenkrais contributes to the observed outcomes. Browne (2007) and Stephens (2007) noted that there is increasing acceptance of the importance of variability (Harbourne & Stergiou, 2009) and individualized approaches in both clinical practice and research in an area like physical therapy. The research environment may thus be becoming more supportive of the kinds of varied and individualized intervention characteristic of the Feldenkrais Method. In relation to health, some functional outcomes can be seen as positive health benefits in themselves (e.g., a reduction in pain). At another level, a phenomenon like reduction in pain, may be a mechanism for improvements in general health and well-being (e.g., improvements in functional activity that can then contribute to strength, cardiovascular benefits, weight loss, improved sleep, and positive affect). Some Directions for Research Into the Contribution of the Feldenkrais Method to MBM and Health Outcomes research. More outcomes research needs to be undertaken, looking at the application of Feldenkrais for populations with particular health challenges and needs.

104 As a starting point it is important that future outcome studies have appropriate controls, and be of a sufficient size to create valid results within the research paradigm being used (Stephens, 2007). Studies comparing treatment as usual with Feldenkrais plus treatment as usual would be useful. The questions of appropriate placebo controls or whether valid sham interventions can be found also needs to be addressed in future research. It would be valuable to do Feldenkrais research studies for the kinds of groups and conditions for which MBM is often helpful—people dealing with stress, the effects of trauma, chronic pain, anxiety and depression, those dealing with addiction, or those who have difficulties in establishing more healthful behaviors. Outcomes research projects could involve looking at Feldenkrais as a standalone intervention or in combination with other mind-body practices. One interesting option would be to include Feldenkrais as an addition to an existing MBM program, such as the Mind-Body Skills Program from the CMBM (2010) and observe if this impacts outcomes. Research into the mechanisms and dynamics of action. The research presented here suggests a number of ways in which the Feldenkrais Method may contribute to healthful improvements for people. Possible physical mechanisms suggested include changes in muscular organization, bodily coordination, neuromuscular relationships, and the overall state of the nervous system (e.g., ability to achieve appropriate sympathetic– parasympathetic balance in response to current demands). Also shown were changes in function and action—what would usually be called the behavioral level—improvements in sensory-motor abilities, in changes in conscious awareness of the body in action, as well as a shift in the overall disposition toward healthful or salutogenic possibilities. This is clearly a huge research challenge, but it seems possible that some of it may be done in conjunction with other approaches to MBM. The somatic orientation

105 presented here may also provide a possible framework for thinking about aspects of MBM practice. Feldenkrais utilizes mechanisms for health improvement that underlie approaches such as meditation and biofeedback (sensory awareness, the organization of attention, nonjudgmental attitude and letting happen), and hypnosis and autogenics (suggestions for qualities of somatic experience). This also might be a useful framework for conceptualizing and researching other somatics practices (e.g., Alexander Technique, Mind-Body Centering, Middendorf Breath Work, the Sounder Sleep System) in relation to MBM. Traditional mind-body practices that involve movement, such as Yoga, Qigong, and Tai Chi may be able to be studied using similar tools as those suggested here. For example, Chow and Tsang (2007), theorizing about Qigong as a form of mindful exercise within a biopsychosocial model, proposed various mechanisms of action including, (a) self-efficacy, (b) shifting the internal locus of control, (c) attentional abilities, and (d) the role of amines (cortisol) and endorphins. Programs of complementary and comparative research may be valuable and more viable. Research into specific factors predicted as significant by Feldenkrais, could involve investigating changes in muscular length at rest and in activity, as well as the perception of effort (Stephens, 2007). Surface EMG or ultrasound, for example, could be used to observe levels of muscular activation. Functional magnetic resonance imaging (fMRI) has been used to detect changes in the paraspinal muscles pre- and postintervention in studying the effects of osteopathic manipulation (Clark, Walkowski, Conatser, Eland, & Howell, 2009). Although functional MRI imaging of brain activation measured by regional cerebral blood flow (rCBF) does not tolerate movement of the head, it may be possible to measure effects of Feldenkrais lessons done with only the hands or tongue (Stephens, 2007). Perhaps fMRI imaging studies examining the effects on patterns of

106 neural activation associated with imagined movements or chronic pain could be measured in pre- and post-studies of Awareness Through Movement or Functional Integration interventions. The research outcomes presented here and the Feldenkrais theory both suggest alterations in autonomic functioning and breathing, along with increases in positive affect as outcomes from Feldenkrais lessons. Heart Rate Variability (HRV)31 could provide a good way to measure these kinds of changes (Henley, Ivins, Mills, Wen, & Benjamin, 2008; Shaffer & Moss, 2006). Finally, biomarkers of, for example, stress and pain experience (cortisol, beta endorphins, and selected hormones) could be measured pre- and postintervention (Degenhardt et al., 2007; Stephens, 2007). Quantitative, Qualitative, and Mixed Measures Research Quantitative approaches: Self-report measures. The Feldenkrais research studies described here identified a number of quantitative self-report measures that seem to have validity for identifying outcomes (e.g., Connors, Pile, et al., 2010) in areas of pain, quality of life, affect, balance confidence, self-efficacy, body image. Additional self-report measures could also be utilized in relation to the possible mechanisms and dynamics of action of the Feldenkrais Method suggested here. For example, there are scales for body awareness (Mehling et al., 2009), self-compassion (Neff et al., 2007), coherence (a 31

Heart Rate Variability (HRV): Shaffer and Moss (2006) stated, “Heart rate is constantly changing, based on factors as diverse as exertion, blood pressure changed, negative emotions, and respiration. The variability of heart rate is measured in a number of ways, such as the statistical variability of the interbeat interval (the length of time between each heart beat)” (p. 5). Heart rate and HRV are phenomena of the relationships between the sympathetic and parasympathetic branches of the autonomic nervous system (ANS). The sinoatrial (SA) and atrioventricular (AV) control the action of the heart. Heath rate and variability in heart rate are produced by the relationship between the activation of these two nodes. Greater coherence in HRV has been associated with slowing of respiration, positive emotions, reduced sympathetic and increased parasympathetic activation, and therefore can be a measure of autonomic changes as a result of an intervention.

107 salutogenic scale; Lindström & Eriksson, 2005), and resilience (Davydov, Stewart, Richie, & Chaudieu, 2010), which may be relevant to Feldenkrais and health. Delman (2007) suggested that there may be additional measures of human development (e.g., open mindedness, problem solving, mental flexibility) that may also be relevant. If Feldenkrais does contribute to the adoption of a more healthful or salutogenic orientation and behaviors (Duensing, 2008) overall, then studies with longer term followup or longitudinal studies will be needed. Reports on the adoption of health promoting behaviors and health outcomes could be used. Qualitative approaches. Öhmann et al.’s (2011) study of Feldenkrais for people with chronic pain shows the value of qualitative research approaches. It provides concrete detail about the actual experience of doing Feldenkrais, and the benefits for the participants, and most importantly, the specifics of improvement in sensory-motor skills, attitudes, and health promoting behavior in the participants own words rather than in terms of Feldenkrais theory. For example, how participants chose to look after themselves, to not continue with activities that were painful or when they were fatigued, to listen to their bodies to notice their affective state through their sense of muscular tension. The grounded theory approach used by Öhmann et al. (2011) allowed for new constructs that can then be used for comparison with those from the Feldenkrais Method, or other theoretical perspectives (Connors, Galea, et al., 2010). Textual analysis is another qualitative approach that could yield useful research. For example, Connors, Galea, et al. (2010) analyzed recordings of Feldenkrais lessons used in a Feldenkrais balance program with older adults, which provided material for a comparison of the content of the lessons with current motor skill acquisition and postural control theories finding considerable congruence. Wright (2000) analyzed the transcript

108 of part of a Feldenkrais lesson and compared it with one from a conventional high school gymnastics class, as part of an exploration of how language may be involved in the creation of particular culturally constituted bodies. Reese (1984) identified a number of theoretical and practical similarities between Eriksonian hypnosis and the Feldenkrais Method. Yapko (2011) used textual analysis effectively to compare hypnosis and mindfulness meditation practice. Such an approach may be useful to identify similarities and differences between Feldenkrais Method and hypnosis, and indeed other practices in MBM. There is now considerable literature on how to analyze qualitative data from journals and reflective writing exercises, interviews, practice notes, case descriptions, records of participant observation, dialogues, and so on (Smith et al., 1995). Mixed methods approaches. Using a mixture of methods (Creswell, 2009) can be particularly useful in studying approaches for which the subjective experience of the participants is an important part of the phenomena being studied. It allows for the correlation and comparison of experiential data with what is detected by empirical, third person data collection. Single or multiple case research designs, for example, can allow the presentation of both qualitative and quantitative (e.g., self-report and/or behavioral measures) organized around interventions with individuals (Smyth, 2008; Stephens, 2004; Yin, 1994). Of particular value might be a combination of objective measures, for example, of neurophysiological changes, with first person experiential accounts. This is the kind of neurophenomenological approach advocated by Varela and his colleagues for the study of meditative experience (Ginsburg, 1999, 2008, 2010). Combinations of fMRI results have been used with participant self-reports in the study of hypnosis and pain (e.g., Derbyshire, Whalley, & Oakley, 2009). Ginsburg (1999) suggested, “We cannot have a separate

109 understanding of the brain or consciousness without understanding experiencing, without accounting for the details of the phenomenology of lived experience” (p. 91). It would be very useful to conduct a study, for example, of the use of Feldenkrais with people with low back pain, using some combination of ultrasound or blood biomarkers, self-report measures of pain, functional activity and quality of life measures, qualitative data from interviews or journals of the experience of the program, and textual analysis of the features of the lessons taught. Conclusion There is an enormous amount of research needed and work to do. There may be considerable value in joint research efforts looking at Feldenkrais Method and other modalities in the context of MBM. Dialogue is needed between practitioners in the somatics and MBM fields, and also between practitioners and scientists. Schacker (2004) suggested, “[Feldenkrais] practice is to some extent already multidisciplinary and manyvoiced because we are dealing with living human beings who cannot be fitted into the limitations and fragmentations of separate disciplines. Thus we need many dialog partners” (“Dialogue is many-voiced,” para. 1).

110 Feldenkrais, Somatics, and Mind-Body Medicine Meaning and Action for Health Somatics practices allow people to access bodily meanings associated with health and at the same time shift their habitual action-in-the world toward a more salutogenic direction. This new model for somatics in health supports an enlarged significance for changing bodily habits and patterns through somatics practices. In this sense, every somatics intervention is not just a mechanical change in physical behavior, but also a change in behavior in the new broadened sense. Every change in bodily habits also creates transformations throughout the domain we traditionally know as mental—in emotions, expectations, and attitudes. Somatics interventions are thus always mind-body interventions. A Place to Stand Feldenkrais Method is a somatically-based awareness practice (Delman, 2006; Goldfarb, 2004), which has a high level of applicability to functional challenges, especially for people with neurological conditions, experiencing pain, and dealing with impairments due to poor self use, illness, injury and pain. It is clearly not, by its own description and practice, a medical model. Instead, it may be applied in medical and health–promotion contexts, especially if considered in the context of a biopsychosocial model of medicine (Engel, 1977). In this model, the physical, affective, relational, and environmental factors that impact upon health are considered. A disease is not seen in terms of a single etiology, nor do the outcomes of intervention seem to be a simple cure. Instead the concern is with how to promote ongoing health. In addition, this model proposes that it is vital for the client or patient to be active in his or her own health improvement, in partnership with professional providers. Certainly the Feldenkrais Method engages the person in all these

111 domains: the physical body in movement, the affective and meaningful aspects of healthy functioning and action, while including the importance of environment (including some areas not often considered, such as gravity and space, but also the social and cultural aspects of the body-in-action). In the context of the biopsychosocial model, a somatic approach like Feldenkrais can make an important contribution both for an individuals’ health, and to mind-body or integrative medicine programs (Bowes & Smyth, 2002). One way to think about Feldenkrais Method would be that it could stand in relation to medicine in a similar way to the Mindfulness-Based Stress Reduction (MBSR) program. Drawing on Buddhist meditation practice of mindfulness, Kabat-Zinn (1990, 2000, 2005a), Santorelli (1999) and their colleagues created a program32 to make the benefits of these practices available to people dealing with, for example pain, stress, disability, and terminal conditions, without the spiritual and ritual aspects of Buddhist practice. On his thinking about the role of MBSR and health, Kabat-Zinn (2000) wrote: When we begin to pay attention and cultivate awareness, our view of the world changes and we begin to navigate in ways that are highly adaptive, highly supportive of healing, of health, and live a healthier way of being, not only in one’s own body but in the world. We do that through the choices we make, to taking responsibility for ourselves to whatever degree is possible. (p. 239) Feldenkrais Method can stand as an awareness practice in its own right that people can pursue for their own growth and development. Feldenkrais Method is also used as a 32

In the literature, MBSR is consistently described as “meditation,” without any further clarification. For many people, the use of the term meditation would suggest only mental practices that do not involve bodily awareness or physical movement. However the three core practices in MBSR involve sitting meditation, but also a body scan and mindful Yoga (Kabat-Zinn, 2000). In the sitting meditation attention is often directed to the sensations of bodily contact with support surfaces, or the skin with the air, and walking meditation is also frequently practiced. Based in the “First Foundation of Mindfulness,” which involves mindfulness of the body (Hanh, 1990; KabatZinn, 2000), it could be argued that MBSR includes a significant element of somatically based practice.

112 complementary to conventional medical practice and as part of the MBM programs. It is useful for many people as a way of maintaining their health and well-being, with both functional and overall salutogenic outcomes. Consistent with the research findings presented here, it is also particularly useful when working with individuals and populations of people dealing with significant functional movement challenges. It may also be particularly useful in those populations where clients or patients perceive their conditions to be primarily caused by physical injury or illness. In addition, Feldenkrais Method may provide another dimension to MBM programs, where the practices used have been or are mostly mental (e.g., cognitive or imaginative). For people or groups resistant to practices such as sitting meditation or guided imagery, Feldenkrais may provide different, more active ways of developing skill in attention to bodily sensation and feeling. Feldenkrais Method provides many of the experiences and competencies that can form the basis of a capacity for self-care (Gordon 1996). Finally, then, Feldenkrais Method can be seen as a mind-body intervention for health in its own right. Afterword In his history of traditional and complementary medicine Grossinger (1995) wrote, The Feldenkrais Method is thus much more than just the method of Moshe Feldenkrais. It is the primary method of Western (and possibly human) sensorymotor education. As such, it is at the beginning of its historical development, and it’s possible uses and ramifications of limitless. Its ultimate success would be a planet–wide reorientation to the fact that we all need to learn new habits in order to make a more functional society. Then, long after people know the name “Feldenkrais”, each generation could set about inventing its own appropriate lessons. (p. 267) Moshe Feldenkrais (1981), in the last book he wrote, suggested, “The feeling of being alive relates to the awareness of growing to be oneself” (p. 96).

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135 Appendix A The Feldenkrais Method The Feldenkrais Method is described briefly below. The aims of the Method, concepts of health, and other key concepts are described in detail in the section The Feldenkrais Method of this thesis. These descriptions are based on Feldenkrais’s books (1949, 1952, 1972, 1981, 1985, 1993), the published collection of Feldenkrais’s papers and interviews (Beringer, 2010a), new introductions to two of Feldenkrais’s books (Ginsburg, 2005; Reese, 2002), popular books by Alon (1990) and Shafarman (1997), and theoretical perspectives from Ginsburg (2010), Rywerant (1983, 2000) and Shusterman (2008), along with the various journal articles about Feldenkrais practice identified in the text. The terms Feldenkrais Method, Awareness Through Movement, and Functional Integration are service marked terms of the Feldenkrais Guild of North America. In keeping with academic conventions, they will not be service marked in the text as would be required in nonacademic use. In recognition that these phrases are formal terms referring to specific practices within the Method, and to the Method as a whole, capitalization of all the words in each term has been retained. This Method is based on observations of a number of key aspects of human anatomy, physiology, and psychology, including: (a) That there is an integration of human functions in action. That moving, sensing, thinking, and feeling cannot be separated, except in language. For example, that sensing almost always involves some kind of movement, and that thinking (conceptualizing, remembering, calculating, speaking) and affective states (emotions, moods) are always based in current bodily states, and previous bodily

136 experience (Feldenkrais, 1949, 1972). (b) That underlying this functional integration is the very high level of sensory, perceptual, emotional or affective, autonomic and motor integration within the human nervous system (Feldenkrais, 1949). (c) That sensory processes include not only exteroception of the world and objects (through vision, hearing, touch, smell and taste), but also as interoception of processes of digestion, circulation (e.g., pulse and for some people, blood pressure), as well as: perception of the state of the body (such as orientation responses, overall muscular tonus, levels of alertness and arousal, pain, itch, and temperature), and its movement including: i.

the sense of effort from stretch receptors in the skin, tendons, and muscles;

ii. the sense of pressure—the haptic sense, the sense of the location of parts of the body—proprioception; iii. the sense of movement through space from optic-flow; iv. the senses of acceleration and deceleration and balance, provided by the vestibular apparatus of the inner ear combined with visual, haptic and proprioceptive information; and finally v. anticipation of muscular effort from preefferent or corollary discharge from the premotor areas of the brain and feedback based on actual contraction of the muscle fibers (Feldenkrais, 1949, 1985; Berthoz, 2000, W. J. Freeman, 2000; Craig, 2002, 2006; Llinás, 2002; Proske & Gandevia, 2009; Rywerant, 2008). (d) That human beings have significant capacities to learn new patterns of

137 action. Although not scientifically proven in Feldenkrais’s time, we now see that this observation is reflected in the processes altering and improving neural connectivity (neural plasticity; Doidge, 2007) and neuronal growth (neurogenesis; Doidge, 2007). (e) That the human being has the characteristics of a dynamical system (or a system of many dynamical systems). Potentially every aspect of human functioning effects other functional systems and the whole person, and change in one can effect a shift in state and a new integration (Buchanan & Ulrich, 2001; Feldenkrais, 1972; Thelen & Smith, 1994). As a consequence, while the overall outcomes of practicing the Feldenkrais Method are quite consistent, the results of a particular intervention are often emergent from the process. They are also somewhat dependent on the participants’ and teachers’ expectations, intentions, and perceptions, as the student and teacher also form a temporary system. (f) That the human being is always already embedded in an environment that includes gravity, the surfaces on which the body rests and in relation to which one moves, space, objects (including tools), society and culture (including language). (Feldenkrais, 1949, 1972) (g) That movement can be improved by attuning bodily organization to make better use of the anatomical structure of the body and its behavior as a physical entity, including for example, i.

directing force effectively through the skeleton;

ii. using the minimum amount of effort to achieve a task; iii. balancing the use of the musculature so that unnecessary muscular contractions are not working against or inhibiting other muscles;

138 iv. distribution of work through the system—so that the appropriate muscles, connective tissues, and bones generate, transmit or receive the appropriate forces. All these can lead to the conservation of energy and reducing mechanical damage and inflammation in tissues (Feldenkrais, 1949, 1985). (h) That attunement between a person’s conscious or nonconscious intentionality and the functioning of their body can lead to more ideal action.

139 Appendix B Recruitment Letter for Key Informants Cliff Smyth [address] [email] [phone] Dear ________, I am writing to you to invite your participation to assist me with my studies for my Master of Science in Mind-Body Medicine at Saybrook University’s College of Mind-Body Medicine. The title of this Master’s thesis is: “The contribution of the Feldenkrais Method to MindBody Medicine.” The purpose of this study is to research the relationship between the Feldenkrais Method and mind-body medicine in order to uncover and articulate the historical, theoretical, and practical overlaps and linkages of this particular method of somatic practice on one hand, and the developing field of mind-body medicine on the other. The research methods will include: a literature review, interviews with key informants like yourself, outlining of concepts identifying areas of overlap and difference between Feldenkrais Method and mind-body medicine ideas and practices, and identifying the unique contribution Feldenkrais Method can make to mind-body medicine, health and well being. The outcome will be a Master’s thesis containing recommendations for further research. This thesis is being supervised by Don Moss, PhD (Committee Chair and Chair of the College of Mind-Body Medicine, Saybrook University), and Gabrielle Pelicci, PhD (Committee member and adjunct faculty at the College of Mind-Body Medicine, Saybrook University). I am seeking to interview a small number of key informants, like yourself, who are longterm, experienced teachers of the Feldenkrais Method with the aim of clarifying a number of pivotal ideas from Moshe Feldenkrais’ writings and teachings, and reflect on the practice of the Feldenkrias Method in relation to mind-body practices and health – drawing on your study and experience of teaching the Feldenkrais Method. A list of sample interview questions is attached. It is anticipated the interview will take 60 to 90 minutes. It will be by telephone or in person, and will be recorded. Any directly quoted material will be attributed to you. I will send you for approval any direct quotations from you that I plan to use in the final Master’s thesis. This might take a small additional amount of your time. Sending the quotations to you for approval however does not guarantee that any particular quotation will be used in the final report.

140 I hope you will be able to assist me in this study. I would be pleased to answer any questions. I will be in touch again soon to see if you are willing to do this interview with me, after which I will send you the Informed Consent form and set up a time to conduct the interview. Sincerely, Cliff Smyth

141 Appendix C Sample Interview Questions for Key Informants •

What are the unique contribution(s) Feldenkrais Method has to offer to human health, well being and development?

•

From your practice and study of the Feldenkrais Method, what is your understanding of health? Does Feldenkrais Method contribute to health, as you understand it? How does Feldenkrais Method contribute to health?

•

In what ways does Feldenkrais Method differ from the current, Western (biomedical) model of medicine?

•

What is your understanding of self-efficacy and does practicing Feldenkrais Method contribute to a sense of self-efficacy? What are your thoughts on how practicing Feldenkrais Method contributes to a sense of self-efficacy?

•

What are the most important concepts that underlie the Feldenkrais Method/practice?

•

What role, if any, do awareness, attention, imagination, absorption, suggestion, values, and/or self-regulation play in the practice and effectiveness of the Feldenkrais Method?

•

From your practice and study of the Feldenkrais Method, what is your understanding of ‘mind-body relationship(s)’ or the ‘unity of the mind/body’?

•

Have you experienced, studied, or practiced other mind-body or somatic approaches (e.g., meditation, hypnosis, autosuggestion, autogenics, guided imagery, martial arts, Yoga, etc.) What is the nature of your experience, study or practice? What is your understanding of any similarities or differences between the Feldenkrais Method and these other approaches?

•

What is your understanding of this [X] concept from Feldenkrais’ writing and teaching, or your practice of the Method. (e.g., self image compared with body image, etc?). [The precise nature of this question will develop during the thesis process with the literature search and review and from previous interviews conducted.]

•

Where in Feldenkrais’ writings or documented teachings can I find this [X] idea or this [X] quotation?

•

Do you know where I could locate this [X] research study?