INTRODUCTION
The connection between emotions and the body is an interesting topic for many mental health clinicians and researchers [1]. Recently, a new perspective that conceptualizes the mind as an embodied component, as opposed to an individual entity separate from the body, has been emerging in the field of cognitive neuroscience [2,3]. From that perspective, mind function cannot be understood without consideration of physical experiences and surrounding environments. Furthermore, to recognize emotions and understand their meanings, it is necessary to be aware of body sensations and movements [4,5].
From that background, a concept that has recently emerged to link the body and emotions is interoception. Interoception is narrowly defined as awareness of internal bodily signals, such as heartbeat, breath, thirst, hunger, and pain [6,7]. In the broad sense, interoception goes beyond bodily sensation representations to include how individuals interpret and react to those sensations [8].
Interoceptive awareness involves noticing and acknowledging internal body sensations, emotional states, and movements and appraising those stimuli [7,9]. Therefore, interoception plays a role in emotional regulation and behavior because distressing stimuli generally signal a need to return to a homeostatic state [10,11]. Dysfunction of interoceptive processing has been postulated as a biomarker for numerous affective states [12,13]. Individuals with affective disorders such as depression and anxiety are particularly prone to abnormalities in interoceptive processes, which could contribute to illness development, clinical symptom severity, or disease progression [14-16]. Severalempirical studies have indicated that disturbed interoceptive processing occurs in depression and anxiety disorders [16-18].
Therefore, interventions that improve interoceptive awareness could be helpful for emotion regulation. Accordingly, various types of body-based interventions are being developed to improve emotion regulation [19-21]. Several techniques based on somatics are attracting attention as interventions that can improve interoceptive awareness and related emotion regulation. Somatics is a field of body work and movement studies that emphasizes internal perception and experience [22]. It includes yoga, Tai Chi, Feldenkrais, and the Alexander technique. Soma, which is used in various forms of movement-based therapy, specifically focuses on “the body as perceived from within” instead of “the body and movements as externally observed by others.” [23] Recently, a new perspective has emerged that views somatic-based techniques as mindful movement [24]. From that perspective, somatic techniques are conceptualized as movement-based contemplative practices [25]. Like mindfulness meditation, the non-judgmental recognition of body sensations and adjustments to them can improve interoceptive awareness and emotion regulation. Somatic-based movement can help individuals with emotional dysregulation learn mindfulness. As a form of contemplative movement, somatics can enhance body awareness, enabling attention and observation to an individual’s senses and re-integrating inner awareness to create meaning [26]. These processes can lead to self-compassion [27-30]. Several previous studies have suggested that somatic movement practices such as yoga can enhance emotion regulation including body awareness and self-compassion. However, studies on the psychological effects of techniques based on somatics are insufficient, particularly how somatic-based techniques affect the emotion regulation process and the underlying mechanisms of those effects. To identify the clinical effects of the somatic technique, it is essential to apply existing somatic techniques in a treatment program that is easy to apply clinically.
Therefore, a clinically applicable somatic-based program, the Soma experiencing motion (Soma e-motion) program, was developed to improve participants’ emotion regulation ability. The Soma e-motion program integrates several existing somatic techniques, Feldenkrais, yoga, and other soma movements, for individuals with emotion dysregulation [31]. This program was designed to help participants become non-judgmentally aware of the various sensations coming from their bodies while they perform relatively easy and simple movements under the guidance of a therapist using non-directive, friendly language.
This study qualitatively and quantitatively analyzed the efficacy of the Soma e-motion program in clinical and non-clinical individuals. Because no previous study has examined the efficacy of a program integrating somatic techniques, we conducted in-depth interviews with the program participants to explore the psychological and physical changes experienced. In addition, we hypothesized that the Soma e-motion program, which has characteristics of contemplative movements, would effectively enhance interoceptive awareness and self-compassion, and we quantitatively analyzed our results to test that hypothesis.
METHODS
Participants
We recruited participants for clinical and non-clinical groups. The clinical group contained patients diagnosed with and receiving treatment for depression and anxiety disorders at the department of psychiatry of a general hospital. Patients were recruited through the recommendation of their psychiatrist and advertisements posted in outpatient clinics. The non-clinical group contained students taking a psychology class at a university. All participants received a detailed explanation of the study process and provided written consent to participate. We enrolled 22 participants in the study. Three participants in the clinical group dropped out during the intervention, and no one dropped out of the non-clinical group. The three who dropped out refused to continue participating in the program because it was difficult for them to adapt to the group setting.
The final sample contained 19 participants (mean age=51.40, standard deviation [SD]=13.00; 73.68% female). The clinical sample of novices to somatic techniques (n=9, mean age=42.90, SD=13.30) received their self-report questionnaires from the department of psychiatry in the hospital. The non-clinical sample of novices to somatic techniques (n=10, mean age=59.00, SD=6.42) received their questionnaires from a graduate student at the university. This study was approved by the Institutional Review Board of Incheon St Mary’s Hospital, College of Medicine, The Catholic University of Korea (No. XC19OEDI0068).
Procedure
In this study, four sessions of Soma e-motion program were conducted for the participants. At the end of the program, the participants were interviewed by clinicians and completed another set of questionnaires. Participants also completed demographic questions, the Korean Multidimensional Assessment of Interoceptive Awareness (K-MAIA), and the Korean version of the Self-Compassion Scale (K-SCS).
Our study involved one psychiatrist and one psychologist with previous psychotherapy experience. Clinicians received group supervision and peer supervision. The in-depth interviews were conducted offline and online about the experience of the participants in the Soma e-motion program from December 2019 to April 2020, and each interview took 20-30 minutes.
For qualitative analyses, one psychologist and one psychiatrist analyzed the data using verbatim records. The psychologist who performed the major qualitative analysis has a PhD. in public health and works as an assistant professor at the department of meditation psychology in a university. In addition, she has conducted numerous in-depth interviews and published qualitative research papers. The data obtained through the interviews were examined by extracting common content and discerning main categories using consensual qualitative research. Based on the first analysis, the psychiatrist responsible for this study reviewed the categories and contents, and then the researchers discussed their opinions and adjusted the content accordingly. The research and review process were conducted by two researchers (MS Lee, HJ Huh) from twice to third times, and only final consensus opinions were analyzed.
Soma e-motion program
The Soma e-motion program was designed to help participants attend to their own bodies and become aware of their personal states of mind connected to their bodies. The detailed protocol for the Soma e-motion program was described in a previous article [31]. The Soma e-motion program is composed of easy and comfortable movements because many participants have a low tolerance to pain or uncomfortable sensations. Furthermore, considering that participants might easily become tense in an unfamiliar setting, the program uses movements common in daily life such as sitting, standing, and walking. This protocol consists of four 60-minute sessions and is based on body scans, breath training, and soma movements. The body scan focuses attention on the body part that touches the floor and helps stabilize the body and mind through grounding. In the breathing exercise, participants notice when and how they breathe, move, and relax. During the program, participants practice self-regulation and choose the power and speed of each movement [32].
The first session focuses on exploring the length of the spine and width of the back using pelvic movements, and the second session explores physical tension and breathing patterns using eye movements. The third session explores the lateral parts of the body using tilting movements. The fourth session explores the tension and relaxation of moving body parts using respiration and one’s hands (Table 1).
Based on clinician guidance, participants gradually learn to perceive their inner sensations in more detail by performing intentional body movements. Through this process, participants learn to select and regulate their movements based on their own comfort.
Measures
K-MAIA
To measure body awareness, we used the K-MAIA by Gim et al. [33] who revised and validated the MAIA developed by Mehling et al. [34]. The K-MAIA contains 32 questions divided into six subfactors: noticing, acceptance, attention regulation, mind-body connection awareness, return to the body, and trusting. This measure uses a 7-point Likert scale, and the total score ranges from 0 to 192 points. In Gim et al. [33] study, the Cronbach’s α value of the K-MAIA was 0.94. In the present study, the Cronbach’s α value was 0.92.
K-SCS
To measure self-compassion, we used the K-SCS, developed based on Neff ’s [35] SCS, revised by Kim et al. [36], and validated by Lee and Lee [37]. The K-SCS contains 26 questions answered on a 5-point Likert scale that ranges from “almost never (1 point)” to “almost always (5 points).” The total score ranges from 26 to 130 points. The K-SCS is divided into six subscales self-kindness, common humanity, mindfulness, self-judgement, isolation, and over-identification. In Neff ’s study [35], the Cronbach’s α value of the SCS was 0.92. In the present study, the Cronbach’s α value was 0.89.
RESULTS
Analysis of pre-post differences in the K-MAIA
The total K-MAIA score of the non-clinical group improved from 121.30 in the pre-session to 150.00 in the post-session, a statistically significant difference (z=-2.805, p<0.01). However, in the clinical group, the total score improved from 97.89 to 104.56, which was not a significant difference (z=-0.652, p>0.05). In subfactor analysis, the non-clinical group significantly improved in noticing (z=-2.670, p<0.01), attention regulation (z=-2.706, p<0.01), mind-body connection awareness (z=-2.437, p<0.05), return to body (z=-2.451, p<0.05), and trust (z=-2.694, p<0.01). In the clinical group, on the other hand, the scores of all subfactors improved in the post-session compared with the pre-session, but none of the differences was statistically significant (Table 2).
Analysis of pre-post differences in the K-SCS
The total K-SCS score of the non-clinical group improved from 92.10 in the pre-session to 104.90 in the post-session, a statistically significant difference (z=-2.191, p<0.05). However, in the clinical group, the pre- and post-session scores were both 69.56 (z=-0.178, p>0.05). In the subfactor analysis, the non-clinical group showed statistically significant differences in self-judgement (z=-2.081, p<0.05) and over-identification (z=-1.997, p<0.05). In the clinical group, on the other hand, the scores for common humanity, mindfulness, and isolation all improved in the post-session compared with the pre-session, but none of the differences was statistically significant (Table 3).
Qualitative analysis
When we analyzed the contents of the interviews, we were able to divide the main characteristics of participants’ Soma e-motion experiences into five dimensions: psychological and emotional, physical, cognitive, behavioral, and difficulty and hope to improve. Across the dimensions, we derived 18 upper categories, 58 subcategories, and 131 semantic contents.
Psychological and emotional dimension
In the psychological and emotional dimension, we derived two upper categories, eight subcategories, and 28 semantic contents. The upper categories were “experiencing positive emotions” and “resolving negative emotions.”
The subcategories were “felt relaxation and comfort,” “wanted to stay withone’s emotion,” “felt joy and gratitude,” “experienced the mind’s rest and space,” “freedom from pain and suffering,” “mitigating lethargy,” “reduced frustration,” and “reduced anxiety symptoms” (Supplementary Table 1 in the online-only Data Supplement).
The main contents of the physical dimensions experienced by the participants through Soma e-motion program were as follows:
• “I felt more supple and comfortable. Even small movements brought a lot of relaxation, which felt good.” (Participant A)
• “With ordinary fitness activities I would compare my body’s movements to others and sometimes feel relatively deprived and discouraged, but I liked this somatic program because I only need to progress up to where my body allows movement and observe the possibilities of my own body.” (Participant F)
• “Through investigating my anxiety symptoms and feeling and identifying the level of such symptoms in this program, I think I made a great discovery that I can now measure the extent of my anxiety to a certain degree.” (Participant P)
Physical dimension
In the physical dimension, we derived seven upper categories, 21 subcategories, and 48 semantic contents. The upper categories were “awareness of movement in each body part,” “detected subtle sensations,” “awareness of body balance,” “activation of the body,” “experienced physiological phenomena,” “mitigation of pain,” and “changes in body temperature.” The subcategories were “felt changes in the spine,” “noticed movement of rib cage,” “felt movements of scapula and pelvis,” “increased space between eyebrows,” “felt subtle sensation of various muscles,” “felt vivid bodily sensations,” “experienced body vibration,” “alignment of the body,” “noticed differences between left and right side of body,” “awareness of imbalance in body,” “stimulated blood circulation,” “flexibility,” “increased metabolism,” “urge to release intestinal gas,” “belching,” “activation of salivary glands,” “reduced shoulder pain,” “reduced pain in the arm,” “relieved muscle pain,” “sweating profusely,” and “felt warm energy” (Supplementary Table 2 in the online-only Data Supplement).
The main contents of the physical dimensions experienced by the participants through Soma e-motion program were as follows:
• “While the last time my sensations were centered on the spine, this time I sensed delicate movements in the rib cage. As I contracted and stretched my body, I felt movements in not only my spine but also the rib bones and pelvis, and I also sensed them together when raising and lowering my arms.” (Participant I)
• “Prior to the program I had a lot of chills in my body and poor blood circulation. But upon soma movements, it felt like warm energy was flowing to previously blocked, icy areas. Through a variety of movements, it felt as if the warmth in my body were expanding. I definitely felt my body was getting warm.” (Participant E)
• “As I felt the movement of the muscle delicately, I experienced the mystery of the body. Also, as I moved my muscles delicately, my body alignment and posture improved.” (Participant K)
• “At first, I didn’t know how to conduct the movements, so I put a lot of effort on finding the correct movement. But as I investigated the movements of my spine, I think I found my own way of alignment.” (Participant D)
• “There was a lot more saliva being created in my mouth than usual. I think the movements throughout the body stimulated the secretion of saliva.” (Participant C)
Cognitive dimension
In the cognitive dimension, we derived five upper categories, 16 subcategories, and 27 semantic contents. The upper categories were “awareness and perception of the body,” “understood and focused on oneself,” “increased concentration,” “improved understanding of somatics,” and “expected internal growth.”
The subcategories were “perceived need of balance,” “perceived body sensation,” “systematically utilized the body,” “ability to respond to physical symptoms,” “discovered self-connected with the body,” “learned to regulate body and mind,” “immersed in the movements,” “concentrated on the breath,” “increased curiosity about somatics,” “became comfortable with non-directive approach,” “noticed differences with other interventions,” “made effort to understand somatics,” “benefitted from moving slowly,” “mentioned benefits of using music,” “expected positive change,” and “intended to utilize as resource” (Supplementary Table 3 in the online-only Data Supplement).
The main contents of the physical dimensions experienced by the participants through Soma e-motion program were as follows:
• “At first, I was obtuse and oblivious to the movements of my body. Gradually I realized I was feeling my own bodily sensations.” (Participant H)
• “I reminded myself about grounding techniques and the feeling of comfort and discovered how I can respond when my breathing gets out of control.” (Participant S)
• “I realized that focusing on the body could result in regulating negative emotions. I learned that I could investigate my own emotions or states in different ways than with language.” (Participant H)
• “I now look forward to seeing a lot of changes in my life if I repeatedly and regularly practice noticing my sensations and staying in the present.” (Participant O)
Behavioral dimension
In the behavioral dimension, we derived one upper category, four subcategories, and 14 semantic contents. The upper categories were “changes in daily life.”
The subcategories were “benefitted sleep,” “attempted to incorporate somatics in daily routine,” “applied somatics in public transit,” and “formed habit” (Supplementary Table 4 in the online-only Data Supplement).
The main contents of the physical dimensions experienced by the participants through Soma e-motion program were as follows:
• “When I couldn’t fall asleep, I tried the movements, and they helped me sleep.” (Participant R)
• “I didn’t do too much of it in my daily life, but when I had some free time, or when I felt anxious, I tried the movements to find a little peace of mind.” (Participant K)
• “I tried concentrating on the pelvis in situations where noises were amplified and sounded violent, and even small movements of people felt aggressive. I felt comfort from grounding and could sense every single bone in the lumbar vertebrae. This gave a refreshing feeling of air passing through the gap between each bone, and I was able to endure four more stops by focusing on that feeling. This was my first and last successful experience outside the hospital setting.” (Participant N)
Aspects participants found challenging and needs improvement
In the aspects participants found challenging and needs improvement, we derived two upper categories, nine subcategories, and 14 semantic contents. The upper categories were appeals for “reported physical/psychological difficulties” and “suggested improvements to program organization.”
The sub-categories were “difficulty concentrating,” “felt despair,” “difficulty breathing,” “difficulty in eye movement,” “felt challenging,” “felt pain,” “difficult to tell apart movement,” “dissatisfied with number of sessions,” and “dissatisfied with environment” (Supplementary Table 5 in the online-only Data Supplement).
The main contents of the physical dimensions experienced by the participants through Soma e-motion program were as follows:
• “I had difficulty in focusing on my breathing. I was filled with feelings of loss, shame, anxiety, and fear, so I couldn’t recall the contents of the program due to dissociation - this was disappointing to me.” (Participant O)
• “Perhaps due to my older age, I felt pain in the back of my thighs and lower back when doing one of the standing motions, when we slightly bent the knees and immediately straightened them.” (Participant K)
• “I would like the program a bit longer. It feels like a short time to allow the body to get familiarized with the movements or the sensations.” (Participant N)
DISCUSSION
In this study, we aimed to understand the effects of the Soma e-motion program on the body awareness and self-compassion of novices to somatic practices. To our knowledge, this study is the first study to evaluate the feasibility of using the Soma e-motion program to improve body awareness and self-compassion.
In the total K-MAIA score, the non-clinical group showed a statistically significant difference (z=-2.805, p<0.01). But the clinical group did not (z=-0.652, p>0.05). Our results are consistent with a previous study [38] that a mindfulness-based intervention focusing on body awareness improved interoception relative to the control group. Additionally, the current study is similar to thepriorstudy [39] that yoga positively affected sensory awareness and interoception and increases parasympathetic activity. A recent study also suggested that mindfulness moderates the relationship between behavior and body awareness [40]. Body awareness is the phenomenological and subjective aspects of interoception and proprioception mediated by mental processes such as attention, appraisal, beliefs, conditioning, affect, and attitudes [41]. Similar to our findings, body awareness has been described as a key element and mechanism that can provide mental health benefits [41]. As previously mentioned, our protocol aimed to increase body awareness by allowing participants to experience openness, acceptance, and non-judgmental mindfulness [41]. Our findings indicate that body awareness during movement is a significant determinant of emotional wellbeing. In our qualitative findings, participants described shifts in their awareness of negative emotions and physical sensations, emotion regulation and self-care, engagement in self-regulation, and integration of their minds. Taken together, our results suggest that individuals who experience their bodily sensations as trustworthy and their bodies as safe might report greater body awareness than those who do not [38]. Better understanding the mechanisms between mental health and the processes of bodily sensations deserve continued investigation. Future studies should consider using a longer intervention period or booster sessions for the clinical group.
In the total K-SCS score, the non-clinical group showed a statistically significant difference (z=-2.191, p<0.05). But the clinical group did not (z=-0.178, p>0.05). The present result is similar to previous research [42] that underlined the importance of a self-compassion intervention in improving self-management behaviors and physical health. In addition, our findings are in close agreement with a previous study [29] that found that 47 nursing college students significantly improved their levels of self-compassion and mindfulness after experiencing yoga. As recent studies [42-45] showed, somatic experiences can help individuals expand what they may be feeling and their awareness of their bodies and minds. In the present study, Soma emotion allowed participants to observe their inner experiences in the moment. Guiding them to observe their emotions and thoughts as they occur in the present moment could influence self-compassion [43]. Inparticular, previous studies [45-47] showed that self-compassion is related to psychological well-being, better quality of life, and decreased depression and anxiety. Self-compassion means offering non-judgmental empathy to one’s inadequacies, shortcomings, and suffering, so that one’s experience can be perceived as part of a broader human experience [46]. Furthermore, self-compassion generated through somatic movement could reassure participants that their experience is safe [43]. Our qualitative data show that better understanding of the underlying influences of self-compassion allowed participants to describe their particular phenomenological experiences. As reported in this study, novices experienced mind-body awareness and self-compassion more adaptively after completing Soma e-motion.
Despite offering qualitative and quantitative analyses of changes in the psychological, emotional, physical, cognitive, and behavioral dimensions that occurred after participants completed the Soma e-motion program, this study has some limitations that should be noted. First, we analyzed small clinical and community samples. Further studies should use larger randomized samples in various settings. Second, this study performed crosssectional analyses, therefore, long-term follow-up with participants was infeasible. Third, qualitative responses and self-report measures reflect only personal reports. Thus, additional studies with observational designs are needed to triangulate the effects of self-reporting. Fourth, future research should establish the mechanism of action by which the Soma e-motion program affects the brain and confirm its applicability in clinical settings.
In conclusion, our results showed that the Soma e-motion program improved body awareness and self-compassion in the non-clinical group unfamiliar with somatic therapy. The body awareness and self-compassion offered by Soma e-motion program could produce resilience in dealing with psychological difficulties in daily life of non-clinical group. However, the Soma e-motion program showed no significant changes in body awareness or self-compassion in the clinical group. Nevertheless, the qualitative analysis indicated that the Soma e-motion program reduced anxiety symptoms and improved the emotional control of the clinical group participants. The current findings support the importance of further study of the intervention in both clinical and non-clinical populations.
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