{"id":1875,"date":"2026-10-06T05:52:36","date_gmt":"2026-10-06T05:52:36","guid":{"rendered":"https:\/\/sideproject.media\/?p=1875"},"modified":"2026-10-06T05:52:36","modified_gmt":"2026-10-06T05:52:36","slug":"dristas-article","status":"publish","type":"post","link":"https:\/\/sideproject.media\/es\/dristas-article\/","title":{"rendered":"The Acceptability of Somatic Therapy for PTSD Among Patients at an Urban Safety Net Primary Care Clinic"},"content":{"rendered":"\n

Abstract<\/h2>\n\n\n\n

Background<\/h3>\n\n\n\n

Posttraumatic stress disorder (PTSD) has higher prevalence in safety net settings, which also face structural barriers to the use of gold-standard, exposure-focused treatments. Somatic therapies (STs) are used to treat PTSD with a focus on sensations. STs may be a culturally relevant option not requiring exposure. They have not been rigorously studied.<\/p>\n\n\n\n

Objective<\/h3>\n\n\n\n

Assess the acceptability of ST for patients with PTSD and staff in a safety net setting.<\/p>\n\n\n\n

Methods<\/h3>\n\n\n\n

We conducted a qualitative study with interviews of patients and staff in a general internal medicine clinic within an urban safety net health system. Patients were eligible if they were seen between October 1st<\/sup>, 2022 and October 31st<\/sup>, 2023, had PTSD in their chart, had one past trauma-related visit with any psychotherapist, and were English-speaking. Staff were eligible if working in a patient-facing role for 6 months in primary care or integrated behavioral health. Transcripts were analyzed using the Consensual Qualitative Research approach.<\/p>\n\n\n\n

Results<\/h3>\n\n\n\n

The 14 patients interviewed were diverse in terms of race and traumatic exposures, and most had a chronic pain condition. Childhood sexual abuse was the most common traumatic exposure disclosed. Analysis yielded five major themes: the somatic experience of PTSD, patient perspectives on exposure-based therapy, past experiences with mind and body practices, patient mind and body beliefs, and acceptability of ST. ST was congruent with many patients\u2019 lived experiences and their beliefs about mental health. Challenges faced in seeking care for PTSD, including negative past therapy experiences and poor access, promoted openness to ST.<\/p>\n\n\n\n

Conclusion<\/h3>\n\n\n\n

Patients with PTSD and staff found ST acceptable. Further work is needed to develop somatic interventions for PTSD.<\/p>\n\n\n\n

Introduction<\/h2>\n\n\n\n

Posttraumatic stress disorder (PTSD) prevalence in the United States ranges from 4.7% to 6.1% in the general population.1<\/a><\/sup> PTSD prevalence in safety net care settings is as high as 23%,2<\/a><\/sup> and it is associated with increased all-cause mortality.3<\/a>,4<\/a><\/sup><\/p>\n\n\n\n

Evidence-based treatments (EBTs) for PTSD include medications and psychotherapy, particularly cognitive processing therapy (CPT) and prolonged exposure (PE).5<\/a>,6<\/a><\/sup> CPT and PE are associated with moderate reductions in PTSD symptoms when patient successfully receive an adequate number of sessions, typically eight.7<\/a><\/sup> CPT and PE may not be compatible with safety net settings which face workforce shortages and may lack the necessary resources.8<\/a>,9<\/a><\/sup> People of color are seen disproportionately at safety net institutions, yet are underrepresented in the literature on these EBTs.10<\/a><\/sup> The minority stress model suggests that increased exposure to violence or trauma in this setting makes this omission particularly grave.11<\/a><\/sup> Exposure therapies are also not tolerated by all persons with PTSD,12<\/a><\/sup> and avoidance of traumatic memories is a barrier to therapy.13<\/a><\/sup> Since these are the principle EBTs in addition to medications, a large focus of health services research in PTSD is to improve implementation and uptake.14<\/a>,15<\/a><\/sup> Somatic therapy (ST) may be a treatment option for patients who do not tolerate exposure-based treatments, or those whose most debilitating PTSD symptoms are somatic symptoms, since STs engage somatic symptoms and other sensory experiences.<\/p>\n\n\n\n

STs are a subcategory of mind and body therapies used to treat trauma and PTSD. Their true uptake, efficacy, and acceptability have not been thoroughly or rigorously studied, and there are few mentions of them in peer-reviewed literature. However, media accounts describe STs as increasingly popular.16<\/a><\/sup> STs emphasize interoception (sensing and interpreting signals from within the body), proprioception (sensing and interpreting body position), and kinesthesis (sensing and interpreting body movement). They include sensorimotor psychotherapy17<\/a><\/sup> and Somatic Experiencing\u00ae (SE\u2122).18<\/a><\/sup> While cognitive behavioral approaches to trauma treatment aim to modify \u201cautomatic thoughts\u201d and underlying beliefs,19<\/a><\/sup> somatic therapists support patients to \u201ctrack\u201d pleasant and unpleasant sensations within their window of tolerance. Those sensations are the primary entry point for intervention, and the practitioner helps the patient to actively notice them (ie, interoception) before<\/em> engaging the meaning or emotions which may be attached to the sensations.17<\/a><\/sup> STs also frequently incorporate practices seen in other mind and body practices such as visualization, mindful noticing of one\u2019s environment, active grieving, or supportive grounding exercises or \u201cresources.\u201d<\/p>\n\n\n\n

Some have argued that somatic therapy can \u201cfill a gap\u201d in the treatment landscape.18<\/a><\/sup> However, research on somatic therapies and the integration of somatic approaches into other forms of therapy is relatively sparse, and there is no consensus on which therapy practices fall in this category. We know of no studies of the acceptability of STs.<\/p>\n\n\n\n

Our aim for this study was to understand the acceptability of STs for PTSD delivered in primary care. We conducted a qualitative study of a diverse group of patients with PTSD and clinical staff at a large safety net primary care clinic.<\/p>\n\n\n\n

Methods<\/h2>\n\n\n\n

Setting<\/h3>\n\n\n\n

This study was conducted in a General Internal Medicine (GIM) clinic within Boston Medical Center (BMC), a large safety net health system. The clinic features colocation of a broad interdisciplinary clinical team who provide comprehensive adult primary care. Integrated Behavioral Health (IBH) is a service which integrates psychiatry, psychology, and clinical social work into clinic operations. The majority of patients are low-income and on Medicaid, and the population is racially and ethnically diverse. Patients behavioral health needs are high: many face complex psychosocial stressors. Clinical data has shown that 23% of BMC GIM patients meet criteria for PTSD.2<\/a><\/sup> This research was approved by the Boston Medical Center and Boston University Medical Campus Institutional Review Board.<\/p>\n\n\n\n

Participants and Recruitment<\/h3>\n\n\n\n

Participants were patients receiving primary care at GIM from October 1st, 2022 to October 31st, 2023 and GIM staff. Patient participants met the following eligibility criteria: (1) had a primary care appointment at GIM during the above period, (2) had at least one past visit with a psychologist, psychiatrist, or other behavioral health clinician for PTSD or trauma treatment, (3) were English-speaking, and (4) were 18 years of age or older. A list of potentially eligible patient participants was generated from electronic health records. Patient participants were recruited through an opt-out letter or by telephone recruitment conducted by the first author. Additional recruitment letters were sent to younger patients and Hispanic patients, who were initially underrepresented among patients who consented. Staff participants met the following eligibility criteria: (1) providing care to patients in GIM for at least 6 months, and (2) practicing in GIM, Integrated Behavioral Health (IBH), or Psychiatry. Staff participants were recruited through email listservs.<\/p>\n\n\n\n

Research Team<\/h3>\n\n\n\n

The research team included an internal medicine physician with training in SE\u2122, a type of ST (Author 1), a psychologist specializing in trauma therapy (Author 2), and an internal medicine physician with expertise in the implementation of mind and body therapies in primary care (Author 3). Interviews were conducted by A1, data analysis and interpretation were completed by A1 and A2. All team members provide care to the population from which patient participants were recruited, but not to the specific participants.<\/p>\n\n\n\n

Interviews<\/h3>\n\n\n\n

Qualitative interviews occurred between June 1st and August 31st, 2023 and were conducted by A1. Interviews were conducted and audio recorded using HIPAA compliant and encrypted Zoom software. Participants decided whether to be on camera, no personal identifiers were recorded, and transcripts were de-identified for analysis. Transcripts were saved on a HIPAA compliant and encrypted server only accessible to the study team. Patient interviews lasted approximately 1 h. The 18-question interview guide elicited patient\u2019s past experiences with trauma therapy, physical PTSD symptoms, beliefs about the relationship between mind and body, exposure to mind and body practices, and their responses to a short description of ST (Supplement 1<\/a>). Staff Interviews were conducted in 90-minute focus groups with three to five participants. The 27-question staff interview guide focused on their experiences diagnosing and treating PTSD, physical symptoms of PTSD, and patient experiences with psychotherapy (Supplement 2<\/a>). It included the same description of ST presented to patients.<\/p>\n\n\n\n

Data Analysis<\/h3>\n\n\n\n

Preliminary analysis followed rapid coding procedure20<\/a><\/sup> consistent with conventional content analysis where data is continuously compared throughout the data collection process.21<\/a><\/sup> The team met regularly to construct themes and reach consensus on prototype subthemes and domains, iteratively returning to transcripts in order to resolve discrepancies. The conduct of interviews and the analysis were conducted according to the principles of Consensual Qualitative Research (CQR). CQR is a phenomenological approach commonly used in the psychology literature,22<\/a><\/sup> and is well suited to the study\u2019s focus on inner experiences, attitudes, and beliefs. While interviews guides helped achieve a degree of uniformity across interviews, CQR views the co-creation of meaning between the researcher and participant as a natural and inevitable aspect of qualitative research. Richness of data is achieved through probing follow up questions which invite participants to describe their inner experience. Saturation was defined on the basis of novel codes generated. Data collection stopped when no new information for a theme was identified.23<\/a><\/sup> We used NVivo Version 1.7.1 for analysis. Patient and staff interviews were analyzed separately. The study was conducted following the Standards for Reporting Qualitative Research.24<\/a><\/sup> (Supplement 3<\/a>)<\/p>\n\n\n\n

Results<\/h2>\n\n\n\n

Patients<\/h3>\n\n\n\n

Of 14 patient participants, nine were female (Table 1<\/a>). Ten patients identified as Black, of which one also identified as Hispanic, three identified as white, and one identified as Asian. Median age was 61 (IQR 55, 67). All but one participant disclosed at least one traumatic exposure without prompting, and the majority of these were DSM-5 criterion A exposures. Some reported experiences (see Table 1<\/a>), such as incarceration and homelessness, were potentially traumatic but not identified as traumatic exposures by participants. Childhood sexual abuse was the most common traumatic exposure affecting 6 of 14 participants, followed by other undisclosed traumas (5 of 14) and witnessed death (4 of 14). Thirteen of 14 participants had a chronic pain condition listed in their chart, and 7 of 14 had one of the ten recognized chronic overlapping pain conditions.25<\/a><\/sup>Table 1<\/strong>. Patient Participant Characteristics<\/p>\n\n\n\n

Age, median (IQR)<\/td>61 (55, 67)<\/td><\/tr>
Gender<\/td><\/tr>
\u2003Female<\/td>9 (64)<\/td><\/tr>
\u2003Male<\/td>5 (36)<\/td><\/tr>
Self-identified race<\/td><\/tr>
\u2003Black<\/td>10 (71)<\/td><\/tr>
\u2003White<\/td>3 (21)<\/td><\/tr>
\u2003Asian<\/td>1(7)<\/td><\/tr>
Self-identified ethnicity<\/td><\/tr>
\u2003Non-Hispanic<\/td>13 (13)<\/td><\/tr>
\u2003Hispanic<\/td>1 (7)<\/td><\/tr>
Traumatic exposure<\/td><\/tr>
\u2003Childhood sexual abuse<\/td>6 (43)<\/td><\/tr>
\u2003Other undisclosed trauma<\/td>5 (36)<\/td><\/tr>
\u2003Witnessed death<\/td>4 (29)<\/td><\/tr>
\u2003Incarceration<\/td>3 (21)<\/td><\/tr>
\u2003Violent assault or gunshot wound<\/td>3 (21)<\/td><\/tr>
\u2003Accident<\/td>1 (7)<\/td><\/tr>
\u2003Family member killed<\/td>1 (7)<\/td><\/tr>
\u2003Homelessness<\/td>1 (7)<\/td><\/tr>
\u2003Severe childhood neglect<\/td>1 (7)<\/td><\/tr>
\u2003Suicide loss<\/td>1 (7)<\/td><\/tr>
Chronic pain in chart<\/td><\/tr>
\u2003Any chronic pain condition<\/td>13 (93)<\/td><\/tr>
\u2003Any chronic overlapping pain condition (COPC)<\/td>7 (50)<\/td><\/tr>
\u20032+ COPCs<\/td>4 (29)<\/td><\/tr>
\u20033+ COPCs<\/td>1 (7)<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

IQR, interquartile range; COPC, chronic overlapping pain condition.<\/p>\n\n\n\n

Analysis of patient interviews yielded five major themes: the somatic experience of PTSD, patient perspectives on exposure-based therapy, past experiences with mind and body practices, patient mind and body beliefs, and acceptability of ST. (Figure 1<\/a>)<\/p>\n\n\n\n

\"\"
Figure 1<\/strong>. Conceptual Model for the Acceptability of Somatic Therapy for Patients With PTSD<\/figcaption><\/figure>\n\n\n\n

The Somatic Experience of PTSD<\/h3>\n\n\n\n

Thirteen of 14 participants described responses to trauma-related triggers or perceived threats in terms of their somatic symptoms. Among these, six emphasized symptoms related to the \u201cfight or flight\u201d response and autonomic pathophysiology, such as palpitations, diaphoresis, or dizziness26<\/a><\/sup>: \u201cI\u2019ll start sweating really heavy and I\u2019m dizzy and [\u2026] It usually comes on like a smell, something that I smell, just all of a sudden brings me back to that place.\u201d<\/em><\/p>\n\n\n\n

Patients also described the body as a site for emotional states, often using images or other metaphors to do so. One patient described a somatic response to a trauma-related trigger including tears and physical arousal: \u201cAll [my friend] knew was I started crying, and then I explained it to her…I held it in for over 40 years, you know. So, that\u2019s what triggered it, and then I had to tell her what happened. I was ready to go on a warpath. I was ready to fight.<\/em>\u201d<\/p>\n\n\n\n

Two patients described their somatic symptoms as the most severe and distressing manifestations of their PTSD. One tied his somatic symptoms directly to a body-based trauma narrative: \u201cThat [trauma] lived with me my whole childhood. The nightmares, the sleep, the worry about my parents, the fear of them dying.<\/em>\u201d<\/p>\n\n\n\n

Patients also expressed various ideas about the relationship between their experiences of physical pain and trauma-related stress. Stress was commonly experienced as a factor exacerbating pain, but one patient described an inverse relationship in which anger-related \u201cadrenaline\u201d desensitized her to pain: \u201cWhen I calm down, that\u2019s when I feel all the pain.<\/em>\u201d Patient beliefs about PTSD and pain are further discussed below.<\/p>\n\n\n\n

Patient Perspectives on Exposure-Based Therapy<\/h2>\n\n\n\n

Most participants believed that revisitation of traumatic memories is important and worthwhile. Many also described challenges associated with it, such as this patient\u2019s experience with written exposure therapy: \u201cI wrote down, like about three pages of stuff that I could think about and all that came back to me and that was pretty difficult to do.\u201d<\/em> This patient rarely engaged with such intense exposures, even though it was an important experience for him. Another patient described a sense of empowerment related to group therapy involving exposure: \u201c…After [group therapy], I didn\u2019t care, because I want my story to be heard, because I felt like, after that, I could help somebody<\/em>.\u201d<\/p>\n\n\n\n

Two patients felt very strongly that exposure-based therapy is not for everyone. One patient was overwhelmed by current and ongoing stressors. His goal for therapy was to manage current stressors rather than past traumas: \u201cWhat I think what I find is helpful is – what\u2019s on my mind right now. Where am I right now?<\/em>\u201d Another patient described her desire not to engage with the trauma memory: \u201cI know the act in and of itself was bad, but there\u2019s something else there and I don\u2019t want to remember. I don\u2019t need to because I know how I felt. So I don\u2019t want to go there\u2026\u201d<\/em><\/p>\n\n\n\n

Domain 3 \u2013 Past Experience With Mind and Body Practices<\/h3>\n\n\n\n

While most participants had no formal experience with ST, they were exposed to components of it in other contexts. Participants had experiences with tai chi, reiki, Buddhist chanting, breathing exercises, mindfulness, meditation, spiritual direction, and massage. Some patients engaged in these activities for general wellness, while in others cases, they were recommended or performed by a psychotherapist, or independently pursued to address trauma symptoms. One participant described an experience with reiki performed by a therapist as a transformative form of sensation-based exposure therapy: \u201cIt actually brought me to actually remember the smell, remember the feel of what took place.<\/em>\u201d It left him \u201cfeeling better.\u201d<\/em> Similarly, one patient who engaged in (longstanding spiritual direction practice) felt that the description of ST provided resonated strongly with her positive experiences in spiritual direction, which she found after many negative and stigmatizing experiences in therapy and healthcare more broadly. She describes how this practice helped her attune to and manage the embodied rather than cognitive aspects of trauma and PTSD:<\/p>\n\n\n\n

\u201cI\u2019ve always thought about this thing about \u2018the feeling,\u2019 how the body feels. I know that when I start getting really depressed, my body just feels so heavy and when I start getting that heaviness, I know that this is the beginning of something. And so I\u2019ve learned now it\u2019s like not run to shop — not go do anything else but to sit with it and let it come forth and now with the groups that I have, I know which person that I wanted to have like a really more intense conversation who, amongst the people that I\u2019m with that I can call on.\u201d<\/p>\n\n\n\n

She went on to describe the de-emphasis on cognitive processes: \u201cThe [spiritual direction approach] is of a spiritual nature more than an intellectual [approach]<\/em>.\u201d Though participants had substantial exposure to mind and body practices outside the healthcare system, many (7) participants said their psychotherapy was always \u201ctalk therapy.\u201d These experiences were generally described in positive terms, but rarely incorporated mind and body practices. One participant underlined this distinction after hearing about the theory of ST: \u201cSee, everything else feels like talk, talk, talk, and talk, talk, talk, talk.\u201d<\/em> She believed that ST would be effective for her: \u201cI think that it would be [effective for me], because what\u2019s going on right now ain\u2019t doing nothing.\u201d<\/em><\/p>\n\n\n\n

Domain 4 \u2013 Patient Mind and Body Beliefs<\/h3>\n\n\n\n

Patient beliefs about the mind and body had many different influences. A prominent influence was the experience of PTSD and pain, including the dismissal of pain complaints by medical professionals. A participant with a history of pelvic inflammatory disease said her pain was initially misdiagnosed as \u201cpsychosomatic\u201d pain: \u201c[\u2026] as a Black woman going in for medical treatment it\u2019s like, \u2018It\u2019s all in your head.\u2019\u201d<\/em><\/p>\n\n\n\n

For some patients, their pain symptoms were a separate matter from their PTSD, and stated so explicitly: \u201cYeah, the pain is physical. The PTSD is emotional.<\/em>\u201d For other patients, PTSD, stress, and pain were connected:<\/p>\n\n\n\n

\u201cBecause when I\u2019m upset and I\u2019m crying and I\u2019m going back thinking about all the, the tragedies and things that I\u2019ve been through and stuff, it has my blood pressure high. I have inflammation in my body. I have osteoarthritis so the inflammation goes in my body. My knee swells up, my hand swells up. I had two surgeries on both of my hands. I had carpel tunnel and arthritis surgery. So everything affected my physical. Whatever was going on in my brain, it was affecting, definitely affecting my physical.\u201d<\/p>\n\n\n\n

The majority of patients articulated some belief that PTSD affects both the mind and the body, and that their illness experiences reflect this. These beliefs often translated into a belief in the effectiveness of mind and body interventions generally, and interest in ST specifically. This was one patient\u2019s immediate response to the description of ST:<\/p>\n\n\n\n

\u201cIt [ST] is giving words to what it is that I\u2019ve been thinking and feeling and trying to understand\u2026 I know that there\u2019s so many people that will not go in for talk therapy, for psychotherapy, for psychoanalysis. I know that they will not and it\u2019s how I deal with people a lot is to really talk with them about what they\u2019re feeling…because I make that distinction…between — \u2018I feel happy,\u2019 and feeling like \u2018I\u2019m feeling like inside, something just not right.\u2019 Those are two different \u2018feelings\u2019 to me and this [ST] sounds like it is something that can make that distinction.\u201d<\/p>\n\n\n\n

Domain 5 \u2013 Acceptability of Somatic Therapy<\/h3>\n\n\n\n

All participants were open to trying ST, but with varying degrees of enthusiasm. Some were eager to try it, while others expressed openness to new therapies in general. One participant\u2019s openness to trying an unfamiliar therapy was tied to a sense of desperation, having tried many medications and therapies: \u201cI think some of it [ST] could help…Sometimes I just want to feel better and sometimes a lot of the things that I have tried, they don\u2019t work and I get frustrated because it\u2019s been so long…I don\u2019t want to just feel good just for the day, the next couple of days. I want to kind of find something that works for me without having bad thoughts or feelings.<\/em>\u201d Two participants with relatively muted interest became more enthusiastic with follow up discussion \u2013 this included additional information about the neurobiology of trauma, and examples of questions a somatic therapist might ask to elicit therapeutic interoception.<\/p>\n\n\n\n

Staff<\/h3>\n\n\n\n

Staff participants in 3 focus groups included 2 medical assistants, 2 general internists, 1 family nurse practitioner, 1 nurse, 1 patient navigator, 1 clinical pharmacist, 1 clinical social worker, 2 psychiatrists, and 1 clinical psychologist. Analysis of staff interviews yielded 4 major themes: staff perspectives on available PTSD treatments, staff experiences treating trauma and PTSD, structural challenges to PTSD treatment, and staff perspectives on ST. (Figure 2<\/a>)<\/p>\n\n\n\n

\"\"
Figure 2<\/strong>. Conceptual Model for Clinical Staff Perspectives on Somatic Therapy for PTSD<\/figcaption><\/figure>\n\n\n\n

Domain 1 \u2013 Staff Perspectives on Available PTSD Treatments<\/h3>\n\n\n\n

Staff participants across social work, psychiatry, and psychology disciplines used a variety of techniques in their therapy practice. While they incorporate some mindfulness techniques, they reported an emphasis on cognitive therapy in their training: \u201c[I\u2019m] primarily psychodynamically trained. And then we all learn CBT in a formal sense.<\/em>\u201d However, these practitioners viewed ST and exposure-based therapy as not mutually exclusive, stating that the body is often a site of trauma: \u201cExposure to just feeling their body again and in a slow careful way and experiencing their body again.<\/em>\u201d<\/p>\n\n\n\n

IBH providers shared a critical view of PTSD as a diagnostic category, citing its creation as a byproduct of the Vietnam War, its limited applicability for patients \u201cin an environment of chronic trauma,\u201d and the underdiagnosis of complex PTSD and other trauma-related syndromes. This was connected for some to a diagnostic approach for trauma accounting for a variety of psychological and somatic symptoms, rather than a \u201crigid diagnostic model\u201d which may not reflect patient circumstances.<\/p>\n\n\n\n

Multiple staff described how cultural and historical factors shape the use of mind and body interventions for trauma. In many cases this was related to cultural fit and stigma. For example, one internist argued that ST and other mind and body therapies resemble some Central American healing practices: \u201cthese are practices that are somewhat similar, they have other names.<\/em>\u201d<\/p>\n\n\n\n

Domain 2 \u2013 Staff Experiences Treating Trauma and PTSD<\/h3>\n\n\n\n

Trauma informed care was an important concept for all participants. Medical assistants in particular described the importance of de-escalation and other aspects of trauma informed care – they are often the first staff bringing up mental health in a visit through routine screenings.<\/p>\n\n\n\n

Staff across disciplines described primary care as a setting with opportunities and challenges in diagnosing and treating PTSD. The relationships built into primary care enable disclosure of traumatic experiences and access to appropriate services. Primary care providers and staff of ancillary services like clinical pharmacy consultations, the nursing triage line, and patient navigation had at times directed patients to IBH services. An IBH social worker said that this a common pathway by which trauma is initially disclosed prior to a PTSD diagnosis.<\/p>\n\n\n\n

Many providers noted experience with patients with PTSD and comorbid chronic pain. Two primary care internists shared a strong sense that these patients suffered because their care for these conditions is fragmented: \u201cThe notes that I see, they\u2019re like, \u2018Oh, they\u2019re doing well on their [psychiatric] medications, they\u2019re fine.\u2019 Nothing else to do. And every time they come to see me, it\u2019s like, \u2018I\u2019m not doing well, I\u2019m feeling very anxious, very depressed and my pain is worse.<\/em>\u2019\u201d<\/p>\n\n\n\n

Domain 3 \u2013 Structural Challenges to PTSD Treatment<\/h3>\n\n\n\n

The collection of clinical services offered by the psych department allowed for a nuanced discussion of PTSD presentation across care settings. Some providers suspected that PTSD is underdiagnosed in primary care. This was complicated by a sense that complex PTSD (which is part of the ICD11, but not the DSM-5) is a prevalent condition in this clinical environment. However, these distinctions are rarely made in primary care. The circumstances of diagnosis are further complicated by administrative barriers to social supports for vulnerable patients such as refugees. Staff thus shared a sense that the questions around PTSD epidemiology extend beyond the precision of prevalence estimates.<\/p>\n\n\n\n

Stigma and other cultural factors created barriers for primary care providers in meeting the needs of the population they serve. Two providers described patients who were able to discuss trauma and related issues only with them because of trust built over years and additional effort by those clinicians. The unavailability of language concordant therapists was emphasized as a major hindrance to care: \u201cI cannot imagine having therapy with an interpreter. I can\u2019t imagine that. I know some people try to do that, but I think it\u2019s just very hard. So my patients tell me, \u2018If there\u2019s no Spanish speaking therapist, just don\u2019t refer me. I\u2019m not going to have therapy with an interpreter.<\/em>\u2019\u201d Many staff noted poor access to mental healthcare in general, suspecting that related harms are especially severe in the safety net setting.<\/p>\n\n\n\n

All staff emphasized the importance of the therapeutic relationships, and felt it was particularly important not to rush conversations about PTSD. While continuity was felt to be important in both primary care and psychotherapy relationships, turnover of psychotherapists was brought up as a particularly common and severe hindrance to the care of PTSD patients.<\/p>\n\n\n\n

Domain 4 \u2013 Staff Perspectives on Somatic Therapy<\/h3>\n\n\n\n

Staff generally were supportive of ST based on the description provided or, for some, their prior experience. One psychiatrist noted: \u201cSo often we\u2019re overly cognitively oriented, and we don\u2019t pay attention to emotional and physical states\u2026.I love the idea of doing therapy modalities that focus more on just paying attention to your body.<\/em>\u201d Others were drawn to the idea of therapy not requiring exposure, and also believed that ST could address some point of connection between trauma and chronic diseases, particularly chronic pain. The main concerns raised related to resources including time, staffing, and space \u2013 factors which constrain the care currently received by their PTSD patients.<\/p>\n\n\n\n

Discussion<\/h2>\n\n\n\n

Patients with PTSD at a safety net primary care clinic with diverse trauma exposures described interlocked psychological and somatic symptoms of PTSD. Their beliefs about the mind and the body reflect these experiences and are expressed through their personal narratives. They actively seek a variety of treatments, and are generally open to trying ST. This is in part because they have faced stigma, long waitlists, therapist turnover, and at times, therapy which does not reflect their worldview or the full extent of their symptoms \u2013 previously documented phenomena.8<\/a>–10<\/a><\/sup> Multidisciplinary staff in this setting struggle to provide the best care to their patients with trauma, noting system-level limitations which correspond with local patient experiences and published literature.13<\/a><\/sup><\/p>\n\n\n\n

McFarlane and Graham argue that PTSD is a somatic disorder and that somatic symptoms should be included in its diagnostic criteria.27<\/a><\/sup> In their latent class analysis of veterans with severe trauma symptoms, distinctions between three somatic symptom classes were predicted by lifetime trauma exposure, suggesting the possibility of different somatic phenotypes. The embrace of a mind and body perspective by patients with PTSD is well-aligned with this analysis.<\/p>\n\n\n\n

ST may differ from traditional exposure-based therapies in two key ways: it does not require the retrieval of traumatic memories, and it stimulates the sensory nervous system, the site of somatic symptoms. Primary care clinicians noted significant limitations in the treatment of comorbid PTSD and chronic pain, which was common among the patients interviewed. Primary care settings with integrated behavioral health may be an ideal setting for developing and testing somatic or other mind and body interventions tailored for PTSD patients with a high burden of somatic symptoms or pain.<\/p>\n\n\n\n

Patients with PTSD are diverse in terms of their exposure to trauma and its effects, and there is a substantial literature critiquing the limitations of EBTs given this diversity.28<\/a><\/sup> Improving the care of patients with PTSD will require both improved implementation and availability of current treatments and support for established and novel mind and body approaches. A key challenge to overcome in further translational research on STs is a lack of consensus on their key distinguishing features. Ogden et al17<\/a><\/sup> explicitly describe the procedures which distinguish the somatic approach of sensorimotor psychotherapy from cognitive and exposure-based approaches. However, mindfulness-based approaches, which are effective for PTSD,29<\/a><\/sup> and trauma-informed pain treatments such as emotional awareness and expression therapy30<\/a>,31<\/a><\/sup> may also have points of overlap. Patients with PTSD will benefit from further work to distinguish key components of these techniques and define clinical scenarios in which they are most beneficial. This will require piloting ST interventions using replicable protocols.<\/p>\n\n\n\n

Our study has several limitations. We interviewed patients actively engaged in primary care and with identified PTSD \u2013 our findings may not apply to patients exposed to trauma with subclinical or undiagnosed PTSD or those not engaged in care. Refugees are a large proportion of the PTSD population, and they were not represented in our study. Interviews were only conducted in English. Finally, patients were asked for their thoughts on ST after learning about it, but not getting to experience it. There is a risk that patients would be biased in favor of the technique through the educational process. This was mitigated with a simple description of the relative lack of ST research. It was also mitigated by inviting and validating perspectives which don\u2019t necessarily support its use, such as the perspective of the participant quoted above who described PTSD as strictly \u201cemotional\u201d and separate from their physical pain symptoms. Along with the CQR approach, this helped assure that a range of perspectives were elicited from the relatively small number of participants.<\/p>\n\n\n\n

This study confirms that ST, and a mind and body approach to PTSD more broadly, is acceptable and perhaps culturally relevant to diverse patients with PTSD in an urban safety net setting. Findings encourage broader interdisciplinary efforts to characterize the burden of somatic symptoms and chronic pain among patients with PTSD, define testable somatic interventions, and measure their efficacy in PTSD.<\/p>\n\n\n\n

Ethical Considerations<\/h2>\n\n\n\n

This research was approved by the Boston Medical Center and Boston University Medical Campus Institutional Review Board.<\/p>\n\n\n\n

Consent to Participate<\/h2>\n\n\n\n

Participants provided verbal consent to participate prior to interviews and focus groups.<\/p>\n\n\n\n

Consent for Publication<\/h2>\n\n\n\n

Verbal consent included consent to publish anonymized quotations from interviews and focus groups<\/p>\n\n\n\n

Declaration of Conflicting Interests<\/h2>\n\n\n\n

The authors declared no potential conflicts of interest with respect to the research, authorship, and\/or publication of this article.<\/p>\n\n\n\n

Funding<\/h2>\n\n\n\n

The authors disclosed receipt of the following financial support for the research, authorship, and\/or publication of this article: This work was supported by a grant from the National Center for Complementary and Integrative Health K24AT011561 [identifiable funding information provided with submission]<\/p>\n\n\n\n

ORCID iDs<\/h2>\n\n\n\n

Karim Sariahmed https:\/\/orcid.org\/0000-0002-1522-5267<\/a><\/p>\n\n\n\n

Natalia Morone https:\/\/orcid.org\/0000-0002-8405-5396<\/a><\/p>\n\n\n\n

Data availability statement<\/h2>\n\n\n\n

Data is not available for sharing for patient privacy.*<\/a><\/p>\n\n\n\n

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Biographies<\/h2>\n\n\n\n

Karim Sariahmed<\/strong>, MD, MS, Section of General Internal Medicine Boston University Chobanian & Avedisian School of Medicine Boston Medical Center Boston, USA.<\/p>\n\n\n\n

Nuha Alshabani<\/strong>, PhD, Department of Psychiatry Boston University Chobanian & Avedisian School of Medicine Boston Medical Center Boston, USA.<\/p>\n\n\n\n

Natalia Morone<\/strong>, MD, MS, Section of General Internal Medicine Boston University Chobanian & Avedisian School of Medicine Boston Medical Center Boston, USA.<\/p>\n\n\n\n

Supplementary Material<\/h2>\n\n\n\n

Please find the following supplemental material available below.<\/p>\n\n\n\n

For Open Access articles published under a Creative Commons License<\/a>, all supplemental material carries the same license as the article it is associated with.<\/p>\n\n\n\n

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.<\/p>\n\n\n\n