Body, Movement and Dance in Psychotherapy

An International Journal for Theory, Research and Practice

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Chronic fatigue phenomena – somatic and

relational perspectives

Tom Warnecke

To cite this article: Tom Warnecke (2017) Chronic fatigue phenomena – somatic and
relational perspectives, Body, Movement and Dance in Psychotherapy, 12:4, 269-283, DOI:
10.1080/17432979.2017.1385536

To link to this article: https://doi.org/10.1080/17432979.2017.1385536

Published online: 09 Oct 2017.

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Body, Movement and Dance in Psychotherapy, 2017
VOL. 12, NO. 4, 269–283
https://doi.org/10.1080/17432979.2017.1385536

Chronic fatigue phenomena – somatic and relational

perspectives
Tom Warnecke
Re-Vision – Counselling and Psychotherapy from a Soulful Perspective, London, UK

ABSTRACT
This paper aims to develop therapeutic perspectives on relational and somatic
phenomena but also difference and diversity dynamics associated with chronic
fatigue as a presenting issue. In common with other complex and severe conditions,
chronic fatigue will often appear as a single issue dominating the therapeutic
space, a dynamic that may easily obscure sight of the person. The author reviews
contemporary literature and considers dynamics associated with chronic fatigue
phenomena commonly encountered in the therapeutic relationship. Autonomic
nervous and sensory-motor systems also appear crucial for developing better
understanding of, and sensitivity for, working with chronic fatigue phenomena.

ARTICLE HISTORY  Received 26 April 2017; Accepted 25 September 2017

KEYWORDS  Chronic fatigue; somatic; relational; ME; CFS; predisposing factors

Introduction
Understanding of the chronic fatigue (CF) spectrum remains sketchy and cli-
ents coping with CF present with a complex range of symptoms. These share
similarities but also present significant variations and their meaning remains
uncertain. The aim of this article is to take stock and review phenomenological
and empirical insights gained in psychotherapy and supervision practice1 in
conjunction with available literature.
In this paper, the term CF is employed as an umbrella descriptor for the
spectrum of CF as a presenting issue in psychotherapy rather than as a diag-
nostic term. CF describes a spectrum of severe, disabling and persistent fatigue
which will not improve with rest and lack patho-physiological explanations,
such as cancer or other severe illness for example. CF is commonly diagnosed
as myalgic encephalopathy (ME) or as ‘chronic fatigue syndrome’ (CFS), though

CONTACT  Tom Warnecke  info@integralbody.co.uk

© 2017 Informa UK Limited, trading as Taylor & Francis Group
270   T. WARNECKE

definitions of these terms vary geographically. Several other diagnostic terms

such as fibromyalgia also include CF clusters.
CF phenomena are commonly associated with the immune system but
nature, aetiology and causes remain uncertain. Some recent criteria for exam-
ple define ME as a heterogeneous disorder with a common set of symptoms
that often either follows a viral infection, a period of stress, or both combined
(Bansal, Bradley, Bishop, Kiani, & Ford, 2012). In addition to fatigue, reported
CF symptoms may also include muscular or skeletal pain, pains suggestive of
fibromyalgia, difficulties to regulate skin temperature, sleep disturbances, light
or noise sensitivity, headaches, impairments in short term memory and concen-
tration, or slow mental and emotional processing. CF phenomena can vary from
mild to moderate to severe when mobility may be seriously compromised and
simple basic tasks become major obstacles.
CF was initially a controversial diagnosis which unfortunately also led to
hard-to-erase descriptions of ‘mass hysteria’ or ‘yuppie flu’ in general culture.
A number of common biological variations have been identified in tests and
became associated with the CF spectrum but such developments have not led
to clinical treatments. As such, even physicians fully supportive of CF patients
can apparently offer little more than tests, supplements to compensate iden-
tified deficiencies, and nutritional advise. The absence of established medical
treatments feeds into ‘all in the mind’ myths furiously contested by CF patient
groups and contrary to a broad consensus that ME or CFS are not synonymous
with depression or other psychiatric illnesses (Carruthers et al., 2003).
In 2007, the UK National Institute for Health and Care Excellence (NICE) rec-
ommended cognitive behaviour therapy (CBT) and ‘Graded Exercise Therapy’
(GET) treatment, a decision criticised by ME/CFS patient groups who argue
that exercise therapy may be harmful, unlike simple ‘pacing’ techniques pre-
ferred by many patients. A patient survey (ME Association, 2015) concluded
that CBT has little impact on CF and 74% of participants reported that GET
made their symptoms worse. In the UK, some private CF clinics provide good
quality clinical support with normalising patients’ bewildering CF experiences,
introducing them to concepts and techniques that facilitate pacing, or help
develop awareness of emotions. They also teach self-help techniques such as
‘Emotional Freedom Technique’ (EFT) tapping, or encourage patients to seek
psychotherapeutic support.

Chronic fatigue as a presenting issue in psychotherapy

One of the most striking and consistent features is how CF introduces a polaris-
ing edge of biological – psychological dualism to the therapeutic relationship.
In some ways, this feels as if the ‘nature versus nurture’ divide was still raging
in its heyday. For many clients, there seems to be a significant charge riding on
whether their physicians and psychotherapists believe that CF is a medical/
 BODY, MOVEMENT AND DANCE IN PSYCHOTHERAPY   271

biological condition. Even in a well-established therapeutic alliance, such bio-

logical – psychological polarisation remains close at hand and may reappear
when triggered by a minor misunderstanding for example. Naturally, psycho-
therapists should wonder whether CF signals, at least in part, a patients ‘other
story’ as Broom’s metaphor (2007) aptly (though not in a CF context) portrays
the symptomatic body. Or consider Dethlefsen and Dahlke’s (2002) model of
symptomatic bodied escalation, whereas shock or trauma that cannot be pro-
cessed by the individual through emotional or cognitive higher order systems
for whatever reason, may metabolise along a psychobiological spectrum, as for
example, medically unexplained symptoms. However, while such biological –
psychological polarisation dynamics often have defensive aspects, at their core,
CF polarisation dynamics commonly appear to relate to injuries rather than
presenting maladaptive responses.
A second fairly consistent feature of CF is how clients do not feel seen or heard
by others which may well relate to the CF polarisation phenomena and this
shall be returned to later. Not surprisingly, both these dynamics make a ‘bumpy
ride’ more likely as a relationship stereotype than, for example, some idealised
or attachment bonding in the therapeutic relationship. Quite remarkably, the
‘bumpy ride’ stereotype is also widely recognised by physicians who describe
CF therapeutic relationships as mutually dissatisfactory (Stein, Stormorken, &
Karlsson, 2013). Factual or perceived disagreements include the validity and
severity of ME/CFS, the causes and/or best management of ME/CFS and frustra-
tions about lack of improvements, with both patients and physicians frequently
feeling unheard by the other (patients about their symptoms or fears and cli-
nicians about their therapeutic role and/or expertise). Stein and colleagues
observe that ‘[…] the problem is the medical encounter, the interaction between
the doctor and the patient, and not just the patient themselves’ (2013, p. 2), and
there is evidence that such patient grievances are not imagined. A Belgian study
with 177 participating patients concluded that 64% had received a psychologi-
cal/psychiatric diagnosis from their GP as an explanation for CF symptoms (Van
Hoof, 2009).

Correlated or concomitant presenting phenomena

A number of correlated phenomena are common with clients who present with
CF:

• Anxieties fuelled by past experiences of dismissive responses to CF but also

from previous medical and/or psychological treatments that aggravated CF;
• Anxieties or fears that psychotherapeutic interventions may instigate set-
backs or relapses;
• Social anxieties and compliance anxieties (e.g. anxieties about saying ‘no’);
272   T. WARNECKE

• Autonomic nervous system (ANS) imbalances, frequent hyperarousal and

freeze responses (e.g. anxiety and fear) that impact cognitive processing
and concentration (e.g. ‘mind fog’ or ‘I cannot think straight’)
• Numbing, e.g. difficulties to recognise and articulate somatosensory
experiences;
• Difficulties to recognise and identify affective and emotional states;
• Diminished sensori-affective self-experience or sense of self and impaired
sense of motor effort impacting self-regulation capacities.

Predisposing and precipitating factors

Broom (2007), an immunologist, psychiatrist and body-psychotherapist, sees
similarities between reoccurring CF relapse episodes and the perpetuating
dynamics of severe trauma and Post Traumatic Stress Disorder (PTSD), when the
organism responds to stressful triggers as if a trauma was reoccurring. Similarly
to such trauma dynamics, CF appears like a pattern of symptoms that initially
developed during an initiating event, for example a viral infection or a severe
stress response, which subsequently becomes perpetuated when revived by
stress or by particular cues. However unlike trauma, Broom associates CF phe-
nomena with predisposing factors that precipitate the initiating event.
There seems broad acceptance in literature (Broom, 2007; Pheby & Saffron,
2009; Shomon, 2007) that a variety of predisposing factors play a role in devel-
oping CF. Empirical evidence from testimony and clinical observations likewise
suggests that psychological-emotional personality patterns such as ‘being
driven’, ‘high achiever’, ‘wanting to please’, ‘frightened of conflict’, ‘out of touch
with their own negative feelings’ or indeed express such feelings, struggling to
say ‘no’, or fears of disappointing others are common among clients presenting
with CF. Glandular fever, which scores high as a risk factor, and a number of
biological circumstances such as weaknesses of the immune system, detox and
diet/lifestyle factors have also been identified as potential predisposing factors.
However, there seems to be little recognition of how predisposing factors
may combine and thus potentially amplify each other. Dynamics such as high
achieving and fears of disappointing others may interfere with accepting the
slow pace and time required for a full recovery from illness for instance. One
client developed glandular fever during our work together and was explicitly
warned by a GP about being at CF risk. This client did in fact struggle with
over-achieving and fears of disappointing others and we spend almost a year
grappling with these during a prolonged glandular fever recovery. There is also
scant recognition for social anxieties and compliance anxieties phenomena.
Every single CF client I have worked with presented with high anxieties about,
and often quite irrational fantasies of, the supposed dire consequences of saying
 BODY, MOVEMENT AND DANCE IN PSYCHOTHERAPY   273

‘no’ or of disappointing and not living up to the (often imagined) expectations

of others.

Correlated or concomitant somatic presenting phenomena

Autonomic nervous system (ANS) and sensory-motor system operate conjointly
and complimentary across the hypo- and hyper-arousal spectrum and appear
central to CF as a presenting issue. However, with CF polarisation dynamics
in mind, I want to briefly review definitions of ‘psychosomatic’. This term, and
particularly so in Anglo-Saxon culture, is often perceived to suggest or imply
some kind of causal relationship between psychological/emotional and somatic
phenomena. Tim Adams for example, reviewing O’Sullivan’s controversial book
in the Observer (2015), describes psychosomatic illness as ‘[…] the experience
of physical symptoms brought about by emotional states’, a factually wrong but
unfortunately common misconception. In contrast, the field of psychosomatic or
biopsychosocial medicine is a discipline concerned with correlations rather than
causation. More specifically, ‘[…] the study of the correlations of psychologic
and social phenomena with physiologic functions, normal or pathologic, and of
the interplay of biologic and psychosocial factors in the development, course,
and outcome of diseases’ (Lipowski, 1984, p. 167). Biopsychosocial medicine
maintains that psyche and soma cannot be isolated for practical or theoretical
purposes and instead offers systemic models where multiple biological, psy-
chological and social factors are seen as interlinked.

Autonomic nervous system and sensory-motor system

Shomon (2007) suggests Dysautonomia, an imbalance in the autonomic nerv-
ous system (ANS), as a possible root for CF phenomena but there can be little
doubt that the ANS is central to CF. Of particular relevance are Porges (2007)
Neuroception and Polyvagal conceptions. Neuroception is thought to register
to both danger and safety signals received below levels of conscious awareness
and respond with initiating corresponding vagal nervous system activity. Porges
characterises the Polyvagal regulatory potential as ‘immobilisation without fear’
(2004, p. 21). In contrast, CF could be described as immobilisation with fear.
Porges (personal communication, May 14, 2017) links Fibromyalgia and CF with
sub-diaphragmatic ‘shutdown’ responses facilitated by the unmyelinated Vagal
system – also termed the ‘parasympathetic hyperarousal and freeze response’.
Neuroception ordinarily relies on nervous system safety cues to turn off ANS
survival responses. CF may indicate ANS defences that are inadequately modu-
lated by safety cues to allow sufficient intervals for recovery. Danger and safety
signals may also get distorted or misread.
CF phenomena also appear fuelled by ANS hyper-arousal fight-flight dynam-
ics. ANS fight-flight-freeze defences become activated in situations when we
274   T. WARNECKE

may fear or experience threats to both our physiological and our psychological
integrity, including any adaptive compensatory aspects of the latter. Fight-flight-
freeze dynamics narrow our consciousness and affect perception or cognition
as well as our sensorymotor systems with rapidly diminishing somatosensory
experience, a numbing dynamic seeking to protect the person from overload.
Such narrowing of consciousness occurs in two ways, both relevant to CF phe-
nomena. Unmyelinated vagus shutdown responses facilitate parasympathetic
nervous system suppression which inhibit perception and reflective processing
and may extend to partial loss of consciousness or blackouts. The intrinsically
polarising (life or death) mobilisation-accelerating dynamics of the sympathetic
nervous system on the other hand, impair capacities for multidimensional psy-
chological-emotional perception and processing of events (also described as
‘reflective function’ or ‘mentalization’) by taking a person into a realm of polar-
ised, sympathetic hyperarousal driven, black and white either-or perceptions
(Uvnäs-Moberg, 2006).
Narrowing of consciousness, numbing, freeze and sympathetic hyperarousal
states are all commonly observed with CF. With one client, our conversations
often felt as if I was communicating with someone located deep down in a
tunnel or an open well. Clients themselves have used descriptive terms such as
‘being buried alive’ or ‘trapped’ alongside expressions like ‘brain fog’ or ‘cannot
think straight’ to communicate their cognitive impairment experiences. In every
CF account I have heard or read, the initial onset of CF is described as a traumatic
shock irrespective of past histories of traumatic disturbances.
Ferenczi already argued at the 1932 International Psycho-Analytic Congress,
that ‘there is neither shock nor fright without some trace of splitting of per-
sonality’ (1955/1980, p. 229). Fragmentation, cognitive-affective unlinking, and
dissociation are inherent in our species psychobiology and powerfully populate
our unconscious. The concept of dissociation can be traced back to the work
of Pierre Janet (1889) who also pioneered ideas that mental and physiological
manifestations activate conjointly. Janet understood dissociations as adaptively
altered states of consciousness arising from excessive or inappropriate physical
responses to manage overwhelming or unbearable experiences (Schore, 2009).
Janet also thought that such physical responses might include what we would
describe today as hypo-responses or hypo-arousal, a deficiency of psychological
energy that could impair a person’s abilities to bind together all their mental
functions into an organised unity. This takes us into the realm of kinaesthetic
and sensory-motor dynamics.
The sensory-motor system consists of two parts, the gamma and the alpha
system. While each has its own principles of organisation, distinct muscle cells
and neural pathways, both operate complimentary. Much of kinaesthetic activity
is termed proprioceptive, sensory-motor self-organisation and experience just
below the consciousness threshold, and crucial for monitoring our bodies in
time and space but also for organising localised feedback loops necessary to
 BODY, MOVEMENT AND DANCE IN PSYCHOTHERAPY   275

fine tune specific motor efforts. This aspect of proprioception appears of par-
ticular relevance to CF phenomena. Kinaesthetic activity depends critically on
local gamma muscle spindle tensions which are organised along a continuum
ranging from hypo to hyper tension or tone. Both hyper and hypo tension dis-
rupt and emaciate the ability of muscle spindles, the sensory-motor system’s
sense organs, to feel themselves, and thus facilitate proprioception sufficiently
(Warnecke, 2003). Muscle spindle tone constitutes a central aspect of affective
and emotional psychobiology. Alpha and gamma motor systems may also jointly
metabolise conflicting and contradictory impulses or activities (Boadella, 1992)
and profoundly shape a person’s bodied self-experience, be that emotionally
or physiologically. The kinaesthetic ‘sensory-motor music’ phenomena vividly
described by Sacks (1984) which facilitated his recovery from a functional paral-
ysis is a good example.
Muscle spindle hyper or hypo tension may operate localised and context spe-
cific as dissociative numbing or affect the person more generally as an aspect of
their procedural organisation, i.e. our body’s psycho-physiological organisation
in space as fundamental to our sense of self, manifesting for example as general
anxiety, low confidence or self-esteem. Clients presenting with CF will typically
struggle not only with hypo-arousal (collapse) phenomena but also with con-
necting to some kinaesthetically rooted sense of self or to bodied experience
of activities which indicates diminished kinaesthetic and ‘sense of effort’ (Juhan,
1987, p. 278) sensory-motor organisation. Clients recovering from CF typically
struggle with awareness and monitoring of movement efforts for the purpose of
pacing. They often rely on mental monitoring to compensate for this handicap.
The author has argued (in press) that somatosensory anchoring and the ‘calm
and connect system’ (Uvnäs-Moberg, Arn, & Magnusson, 2005, p. 60) play an
essential part in enabling psychological-emotional processing of events or stim-
uli. More specifically, for affective, pre-verbal and pre-symbolic experience to
become transformed into emotional experience and thus into intentional states
of mind that are available for regulation and reflection. This seems to be a key
issue for clients struggling with CF phenomena. The usefulness of amplifying
somatosensory experience with for example EFT tapping to manage both local-
ised hypo- and hyper-arousal and tension is widely recognised and appears to
be an important tool to help identify or track affective and emotional responses.

‘Tired but wired’ – hyper activity, anxiety and stress

On first sight, the term ‘hyper’ and conceptions that portray an organism
responding to severe threat appearing in CF literature may seem surprising.
Such conceptions range from a ‘hyper-reactive immune system’ (Parks, 2012, p.
47) to ‘allostatic load’ (McEwen, 2000, p. 108) which refers to damaging effects of
sustained high stress conditions. Arroll (2013, p. 506) also proposes a model of
‘allostasic overload’ in her ‘maladaptive stress disorder’ conception to investigate
276   T. WARNECKE

CF phenomena whereas Wyller, Eriksen, and Malterud (2009) propose a concept

of sustained arousal dynamics that affect immune system and cognition. Stress
precipitates emotional strain and anxiety, but also fear and helplessness when
extreme and is a key contributing factor in a number of complex conditions. CF
is no exception. In one study (Salit, 1997), 85% of CFS patients reported stressful
events during the year preceding the initial CF phenomena compared to 6%
of the control group. Based on clinical observation, psychological-emotional
overwhelm and fragility appear common among clients presenting with CF who,
in Reichian terminology, typically display underdeveloped armouring and thus
commonly become overwhelmed by stimuli and affect. Similarly, clients recov-
ering from CF typically learn to develop somatosensory anchoring or bodied
container functions (Holm Brantbjerg & Stepath, 2007; Warnecke, in press) and
to pace themselves to function within their psychological and physiological
means. It may well turn out that such learning is integral to CF recovery. As
such, there is good probability that CF phenomena are fuelled by both hypo
and hyper tensions.
While CF appears traumatic in itself, predisposing traumatic disturbances
should not be discounted either. Benton (2006) describes how he came to recog-
nise fear and hyperactive vigilance reoccurring in response to an earlier assault
as a precipitating CF factor. He learned to utilise ‘Reverse Therapy’ techniques to
explore and make sense of his symptoms. Prolonged states of fear that remain
unrecognised may burn a person’s resources and could be likened to running
an engine consistently at top capacity. Actively deepening exhalation appears
to be an effective way for working with ANS hyperarousal. One client concur-
rently improved somatosensory anchoring and kinaesthetic awareness when
she developed a pattern of spontaneously deepening exhalation upon arrival
for her sessions. This also instigated frequent yawning throughout the sessions
which continued for over a year. Yawning typically signals a shift towards ‘calm
and connect’ responses. For instance, borrowing a Bodynamics metaphor, when
the organism ‘lands’ (Holm Brantbjerg & Stepath, 2007) after a period of ANS
hyperarousal or prior to sleep.

Chronic fatigue and Autism – difference and diversity aspects

A noteworthy number of features commonly presented by clients struggling
with CF are reminiscent of the Autism spectrum. Possible connections or links
between CF and Autism are a subject of discussion on CF patient forums but
have yet to be investigated at depth by researchers. It may also be significant
that Autism has typically been a male diagnosis whereas a majority of diagnosed
CF patients are female. Recognition of Autism among women is improving with
better understanding of the condition and especially among those who are bet-
ter able to mask Autism clusters (Carpenter, 2017). The following is a selection
 BODY, MOVEMENT AND DANCE IN PSYCHOTHERAPY   277

of Autism attributes (Carpenter, 2017) reminiscent of features commonly asso-

ciated with CF:

• High levels of near permanent anxieties;

• Sensitivities to noise or smells, or other sensory hypersensitivities;
• Difficulties in coping with change;
• Difficulties in developing some distinct (bodied) sense of identity;
• Food intolerances;
• Stress reducing and sensory comfort behaviours (e.g. earplugs, stress ball,
favourite pen);
• Difficulties in processing and retaining information (risk of overwhelm/
overload);
• Importance of ‘pacing’ (risk of overload);
• Catatonic-like symptoms – increased passivity, slowness, difficulties to ini-
tiate and complete actions;
• Impaired imagination (i.e. flexibility of thought);
• Choice can be overwhelming;
• Difficulties to identify specific feelings when aware of being emotionally
impacted;
• Social anxieties (e.g. ‘I’m constantly thinking about what others are think-
ing of me’), lack of social intuition compensated by intellectually shaped
social roles;
• Alexithymia – irrespective of ‘cognitive empathy’ and ‘reading other peo-
ple’ skill levels, individuals score poorly at noticing their own emotions,
unless obvious and require good time to process or answer questions about
feelings.

Considering the above similarities between some CF clusters and some Autism
clusters, it is not intended here to propose a direct link between CF and Autism,
be that from diagnostic, aetiology or phenomenological perspectives. However,
the potential of any such connection appears too significant to be ignored in the
psychotherapeutic context. Autism features cannot be defined as maladaptive
responses or appear open to therapeutic change. There is a good possibility that
the same might said about some CF clusters. Another similarity is how both CF
and Autism clusters overlap with presenting phenomena of other conditions
and are being misdiagnosed with some frequency, for example as mental health
issues. Yet another parallel is how CF and Autism both may introduce biological
– psychological dualism and polarisation in the consulting room.
Perhaps most importantly, such potential difference and diversity dynamics
makes it imperative to also consider CF with bodied intersubjectivity or inter-
corporeity (Gallese, 2009) perspectives in mind. As clinicians, we are confronted
with a client’s psychobiology in some ways acting and behaving profoundly
different to our own and moreover, different from our culturally shared bodied
experience within the demographic majority. We currently do not know how
278   T. WARNECKE

difference may affect the mirror neuron system abilities to reliably read one
another’s expressions or intentions. As therapists, we often struggle to attune
to, enter into, or projectively identify with the psychobiological inner worlds
of both chronically fatigued and autistic clients which may in turn give rise to
feelings of inadequacy or vulnerability. Mainstream psychotherapy has a poor
track record of working with difference and diversity. This is probably not helped
when practitioners may feel bodily out of tune or even inadequate with such
clients, for example the intellectually disabled (Corbett, 2015), or with sexual
minority clients, when for decades therapists enacted their countertransference
by interpreting sexual orientation as the cause of their clients’ persecution and
social exclusion symptoms (Warnecke, 2013).
Misinterpreting CF phenomena as ‘mental health problems’ could become
a serious ethical concern if there were indeed difference and diversity aspects
linked to some CF phenomena. Difference and diversity considerations are also
relevant in the context of therapist’s adaptive practice. I heard one account of
a client spending eighteen month in complete silence while an analyst waited
for the client to open the session which the client, presenting with Autism, was
unable to do. The analyst appeared unable to adapt the clinical approach to
allow for difference, which left the client with no alternative but to end therapy
eventually. This is reminiscent of CF clients’ accounts of therapists’ inabilities to
constructively work with CF complexity which may for example require sched-
uling sessions at a particular time of day, with less frequency, or pausing during
a relapse.

Discussion
This article does not suggest that CF is brought about by emotional or psy-
chological problems. To the author’s knowledge there is no evidence in either
clinical practice or the research literature to support such a link.
CF poses major psychological-emotional challenges and there may be pre-ex-
isting or perhaps predisposing psychological-emotional issues. CF often seems
like a dominating monolith in the therapeutic relationship which might easily
obscure the sight of the person. From a relational perspective, this may indicate
a dynamic of something profoundly meaningful being unseen or unheard by
significant others but perhaps also by clients themselves. CF severely dimin-
ishes a person’s mastery of the world, their independence, and their personal
and professional lives. Add the absence of explanations and treatments, fears
of something serious being missed, and the person finds themselves in a pro-
found state of uncertainty. Daily life provides a steady stream of inescapable
reminders of an uncertain future. Another common aspect of polarisation relates
to how CF is being met by the therapist and what it awakens in the therapist,
which may contribute to clients not feeling seen and heard. The pace of chron-
ically fatigued clients in the therapeutic relationship can be agonisingly slow
 BODY, MOVEMENT AND DANCE IN PSYCHOTHERAPY   279

and therapists may polarise to the low energy CF states with high energy or
over-active responses (Holm Brantbjerg, personal communication, May 7 2017).
CF appears simultaneously a visceral and a symbolic state of existential fra-
gility and vulnerability. From observation, common ‘not feeling heard’ or ‘seen’
complaints may seek to communicate a host of grievances such as:

• anxieties that something essential about CF is being missed or not

responded to by physicians and therapists;
• past traumatic experiences with physicians, therapists and others in
response to CF phenomena;
• existential and psychobiological vulnerabilities or fragility that impact a
client’s capacities for psychological-emotional processing, reflective func-
tions and articulation;
• bodied, visceral and symbolic fragility and vulnerabilities may also connect
to early relational traumatic disturbances;
• some difference and diversity dimension, some unseen/unacknowledged
dimension or aspects of CF, or stressful condition contributing to CF, which
is not open to therapeutic change.

Considering the predisposing and precipitating conception, we may also ask

whether a viral infection (or any other initiating event) may have been the pro-
verbial straw that broke the camel’s back. Broom (2007) notes that such triggers
often arrive at a time when the essential structure of a life is already precariously
poised. We cannot ignore the possibility that psychic fragility or vulnerability
may pre-date the onset of CF phenomena as one of the predisposing factors.
Client’s presenting with CF phenomena will commonly display habitual patterns
of being overstretched or overburdened and struggle with social and compli-
ance anxieties and related internal conflicts. While bearing these possibilities in
mind, it seems equally important to acknowledge that any psychological-emo-
tional problems may pre-exist, coexist or arise in the context of living with CF.
That said, traumatic disturbances are common in any demographic sample
from all sections of society and clients presenting with CF are no exception. CF cli-
ents struggle (in the author’s experience) with, for example, attachment trauma,
traumatic narcissism, or inter-generationally transmitted trauma. Furthermore,
CF diminishes, and in some instances radically so, a client’s mastery of their world
which is traumatic and undermines confidence and self-esteem. Some clients
may present traumatising previous therapeutic encounters which may include
assumed or implied causal assumptions about CF. While such interpretations are
best avoided for valid reasons, therapists nonetheless cannot ignore possibilities
of, in the wake of severe disturbances, a client’s psychobiology acting as if a
previous disturbance is either continuing or repeatedly reoccurring.
Some aspects of CF phenomena may include a client’s untold ‘other story’ but
I would expect that if this were the case, the nature of such disturbances would
be quite intricate and far from obvious. Not dissimilar perhaps from grappling
280   T. WARNECKE

with bodied aspects of inter-generationally transmitted trauma. Baum (2013)

offered the metaphor of a vinyl record stuck in a groove that impedes the mean-
ing-making of the vinyl record as a whole for such repetitive bodied experiences.
Polyvagal dynamics and the continuum of immobilisation with or without fear
for example may potentially carry multiple layers of soma and meaning.
Jackson (2000, p. 153) lists four key components essential for coping with
CF and recovery which are in keeping with the psychotherapeutic endeavour:

• Accept the diagnosis;

• Adapt your lifestyle;
• Adjust your priorities;
• Acknowledge your limits.

They stay clear of the causation trap while facilitating in-depth review of psy-
chological-emotional patterns, for example any compliance anxieties about
the real or imagined expectations of others, and invite making meaning of CF
phenomena. Arroll and Howard (2013) describe CF recovery as a process of
rebuilding that involves identity change and new post-traumatic development.
Bodied phenomena and experience are central to CF and the benefits of bod-
ied interventions such as breathing and muscle relaxation techniques or mas-
sage and movement therapies are well acknowledged in CF literature (Parks,
2012). Body and dance movement psychotherapies are well suited to connect
psychological-emotional and somatic CF dimensions. Clients will often arrive
with various self-help interventions such as EFT tapping and some awareness
of psyche-soma connections. One client, for example, in the author’s practice
observed ‘When I feel stuck I want to move, walk around – moving helps me to
get back into a sense of flow’.
Sacks (1984) observed that recovery is not a gradual process but rather a
series of dramatic steps, each inconceivable until it occurs. While some CF clients
may make good recoveries or at least within a few years, for others it can be a
much more prolonged period and relapses are common. It also appears that
vulnerabilities will often remain even after full recovery. Such vulnerabilities
include high susceptibility to stress and relatively low resilience levels to the
inevitable variables and problems encountered in life. Recovery may necessitate
learning how such vulnerabilities may be mitigated through careful monitoring
of stress and rest periods, maintaining sufficient blood sugar levels, or ensuing
good water consumption prior to any strenuous physical activity.
Holding the diversity of CF phenomena as well as the above noted difference
and diversity concerns in mind, CF should not warrant any specific ‘treatment’
or deviation from contemporary psychotherapy practice. Similarly to all demo-
graphic client groups, any recovery of vitality and motility will be folded into
a client’s psychotherapeutic process and we should not expect to identify any
single factor in a client’s process necessary to, or particularly enabling, their
recovery. As with all complex conditions, meaning making will be central to
 BODY, MOVEMENT AND DANCE IN PSYCHOTHERAPY   281

recovery and such meaning will be deeply personal and unique to the individ-
ual. Whatever changes in outlook, values, or lifestyle a client may pursue, they
will emerge from discovering insights, making connections, and developing
understanding of mental, emotional and behaviour patterns prior to and at the
time of developing CF. This may seem surprising in the context of therapeutic
relationships dominated by a powerful and hard to bear single issue. But as with
other single issues, the challenge for the therapist is to avoid becoming trapped
together with the client by the single issue. Good clinical practice requires us
to keep an open mind about any presenting issues and allow for other, and
perhaps multiple, meanings to emerge in the client’s process.

Note
1. 
Due to high sensitivities and vulnerabilities amongst clients presenting with CF
and often unique CF features and narratives, no case vignettes are included in
the article.

Disclosure statement
No potential conflict of interest was reported by the author.

Notes on contributor

Tom Warnecke (PgDip, ECP) is a relational body psychotherapist, artist, writer and faculty
staff member at ‘Re-Vision’ in London. He teaches internationally, facilitates small and
large group events, and developed a relational-somatic approach to borderline dynamics.
His publications include a number of book chapters and journal articles and the book
‘The Psyche in the Modern World – Psychotherapy and Society’ (Karnac 2015). He is
a webcast editor for www.psychotherapyexcellence.com, a member of the Executive
Board of the European Association for Psychotherapy (EAP) and a past Vice chair of the
UK Council for Psychotherapy (UKCP).

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