Using Polyvagal Theory in Clinical Settings
In last month’s post, I explained the basic concepts of the Polyvagal Theory, a theory proposed by Stephen Porges that describes how the mammalian autonomic nervous system evolved to keep us safe and alive. In short, the Polyvagal Theory states that:
“When challenged, the regulation of the autonomic nervous system sequentially degrades to older circuits as an adaptive attempt to survive.” -Stephen Porges, The Pocket Guide to the Polyvagal Theory, p. 64
This means that when we sense danger, our sympathetic nervous system takes over and we go into fight-or-flight mode. If our fight-or-flight defenses don’t make us feel safe, the sympathetic nervous system can become inhibited as our ancient, reptilian defense mechanisms take over. These defense mechanisms immobilize us and can make us faint.
When people experience chronic stress or trauma, their nervous system can get stuck in fight-or-flight mode or in a state of immobilization. This can result in high blood pressure, elevated levels of stress hormones, anxiety, insomnia, a range of psychological problems including dissociation, avoidance, and the inability to communicate, and physiological issues involving the organs of the body.
The bidirectionality of the vagus nerve is central to Polyvagal Theory. The vagal nerve fibers that control parasympathetic function of the organs and motor function of the mouth, pharynx, and larynx only make up about 20% of the fibers in the vagus nerve. The other 80% of vagal nerve fibers are afferent, meaning that they send sensory information from the organs back to the brain.
So, not only does our brain function affect our organs, but the function of our organs affects our brain. Malfunctioning organs send feedback to the nervous system about their state, and the nervous system may conclude that we are in a state of danger because our organs are not functioning correctly. This can be a vicious cycle from which it is difficult to escape. Polyvagal Theory emphasizes the importance of addressing these physiological issues in order to help people overcome the effects of trauma.
Challenges in education and healthcare
“In the Western world, we tend to place higher value on thoughts than on feelings. Parenting and educational strategies are targeted toward expanding and enhancing cognitive processes while inhibiting bodily feelings and impulses to move.” -Stephen Porges, The Pocket Guide to the Polyvagal Theory, p. 33
In school and at home, the focus tends to be on improving our cognitive abilities rather than our interoception—the sensations we feel in our bodies. Many adults are detached from their bodily sensations, and have difficulty slowing down their mental processes long enough to focus on their internal sensations. For some people, paying attention to their internal bodily sensations feels so foreign that it is unsettling and uncomfortable. Sadly, the result of ignoring our bodies’ signals is that we develop chronic injuries and health conditions over time.
Another issue that Porges describes is that with increased use of computers and tablets in schools, children’s social engagement systems are not being used. The social engagement system is a network of motor pathways that allow us to send facial expressions and bodily cues to other people. When we interact with screens all day instead of other humans, our social engagement system doesn’t get developed—which can lead to problems with communication and mental health over time.
Lastly, Porges points out an important problem with how medications are prescribed. Many medications have been proven to have benefits in the short-term, yet they are prescribed for long-term use—when positive results for long-term use have not been proven. In fact, many medications that are beneficial in the short-term are detrimental when used long-term.
The nervous system is plastic, meaning that it adapts to the input it receives. Any medication that affects nervous system function will result in the nervous system adapting to it over time. For example, if a medication supplies the brain with a neurotransmitter, then the brain will gradually adapt by producing less and less of this neurotransmitter. The result is that the problem gets worse, and we need to take increasing dosages of the medication in order to achieve the same effects.
The importance of feeling safe
In last month’s post, I described how we sense danger and why it’s so important to correctly sense danger and avoid getting stuck in the state of immobilization. Feeling safe is one of our most primitive needs; if we’re not safe, we don’t survive. As Porges writes, “Deficits in feeling safe form the core biobehavioral feature that leads to mental and physical illness. It is my sincere hope that furthering an understanding of our need to feel safe will lead to new social, educational, and clinical strategies.”
Therapies for people who have experienced trauma must create an environment in which the patient feels safe. Feeling safe is a critical part of trauma therapy—Porges describes that for trauma sufferers, feeling safe is actually a neural exercise. A safe environment may be different for each patient based on their life experiences. It is important for the therapist to find out if there are specific triggers, such as loud noises, physical touch, or other sensory cues, that cause their patient to feel unsafe.
Seeing oneself as a hero instead of a victim
People who suffer long-lasting effects of trauma often believe that their brain and body reacted in a way that is wrong or bad. They may feel embarrassed or angry about the way they instinctively reacted during the traumatic incident or how they failed to return to normal afterward.
Porges has found that one of the most important parts of trauma therapy is explaining to patients that during their traumatic incident, their nervous system did what it had to do to keep them safe and alive. This may have included immobilizing or dissociating in order to prevent them from being hurt or killed. Their nervous system knew that if they had fought, they might be dead. Their nervous system did what it had to in order to survive.
When patients can reframe how they think about their reaction, they can learn to respect how their brain and body dealt with the situation. They can begin to see themselves as heroes instead of victims. If patients can celebrate their instinctive survival mechanisms, they can move out of the state of immobilization.
Applying Polyvagal Theory in therapy
Since Polyvagal Theory is relatively new—Porges first presented the theory in 1994—therapies that intentionally apply Polyvagal Theory are somewhat rare. Porges hopes that an understanding of Polyvagal Theory will help clinicians be aware that their patient’s physiological state may largely determine their behavior, and that their behavior may not change until they work with their physiological state. He also hopes that the theory will lead to more “neural exercises” that can regulate autonomic nervous system function.
“The Polyvagal Theory restructures clinical disorders as difficulties in neural regulation of specific circuits associated with turning off defensive strategies and enabling social engagement to spontaneously occur. This perspective departs from traditional learning models that assume that atypical behaviors are learned and can be modified through treatments informed by learning theory that focus on association, extinction, and habituation.” Stephen Porges, The Pocket Guide to the Polyvagal Theory, p. 45
Porges describes why desensitization treatments typically don’t work: because they don’t take into account the physiological state of the patient. Exposure to cues of trauma may result in increasing “sensitivity to stimuli associated with a traumatic event.” Porges argues that instead of triggering defense systems with exposure, it is more effective to down-regulate defense systems through top-down influences—such as therapies involving listening, music, play, and the body.
When we talk to babies and animals, we instinctively raise our pitch and modulate our voice, meaning that we vary the tones we use—the opposite of speaking in a deep, monotone voice. Have you ever wondered why we do this? It’s because highly modulated vocalizations engage the middle ear muscles, which then send feedback to the brain, engaging the social engagement system. When the social engagement system is functioning well, we feel safe. Porges says that “Listening is a portal to trigger the entire social engagement system.”
Prosody (rhythm and sound in voice) signals our physiological state to others—it tells them that we are safe to come to. And if we’re stressed, scared, or angry, it is communicated to others through our tone of voice as well.
Porges developed the Listening Project Protocol (LPP), which uses a computer to exaggerate the modulations of female vocal music. Listening to these altered vocalizations exercises the neural regulation of the middle ear muscles. The middle ear muscles send feedback to the nervous system letting it know that the environment is safe, and this stimulates the entire social engagement system and adjusts the vagal regulation of the heart.
Studies that Porges has carried out show that about half of people with auditory hypersensitivities can be cured using LPP. And as their social engagement behaviors improve, vagal regulation of their autonomic state increases as well. These results suggest that using LPP as an intervention can reduce defensive behaviors. When this approach is used with children, they exhibit less oppositional behavior, are less reactive and defensive, and become better able to learn and socialize.
Music therapy regulates vagus nerve function in two primary ways: by stimulating the middle ear muscles (when listening) and by forcing a long, slow exhale of breath (when singing). If you’re singing in a group, then you’re stimulating your vagus nerve in a third way—by using your social engagement system.
When we inhale, our heart rate increases. But when we exhale, the vagus nerve sends an inhibitory signal to our heart’s pacemaker that slows our heart rate. Since singing requires a longer exhalation than inhalation, the overall effect is that heart rate is slowed, bringing us into a calm physiological state. We can use this technique of exhaling for longer than we inhale anytime we want to calm ourselves down. Porges notes that this type of breathing is used in some yoga practices, which is one reason why yoga can help to regulate vagus nerve function.
Porges has recommendations on how to use music in a clinical setting: get rid of low-frequency sounds in the office, use prosodic voice, and don’t force eye contact if the patient is gaze-averting. The patient will make eye contact with the therapist when they feel comfortable.
Working with the Social Engagement System in therapy
‘Play is functionally a neural exercise of using the social engagement system, a uniquely mammalian system, to down-regulate our fight/flight behaviors, to be able to contain and “socialize” this defensive system.’ -Stephen Porges, The Pocket Guide to the Polyvagal Theory, p. 82
In play, reciprocal social interaction regulates our sympathetic nervous system. This is why play therapy is important for people whose pathology is the result of not feeling safe, as well as for people who have issues with social engagement. Social interaction (involving face-to-face interaction or vocal interaction) makes us feel safe, which then reduces the over-reaction of the sympathetic nervous system.
Porges says that his professional focus is on how co-regulation with humans and other mammals is a biological imperative and allows us to feel safe. Play, and any comfortable, appropriate interaction with another human or mammal, can make us feel safe and regulate our defense mechanisms, which are typically out of our conscious control.
Porges sees trauma therapy clearly moving toward more body-centered therapies. He believes that in the future, use of pharmaceuticals in trauma treatment will be greatly reduced.
Trauma and chronic stress can affect the physical body in countless ways, including elevated levels of stress hormones, increased heart rate, a weakened immune system, digestive issues, malfunctioning organs, insomnia, muscle tension, and pain. Working with the body can allow us to access functions of the nervous system that cannot be reached or retrained through cognitive therapy alone.
Yoga is the only movement practice that Porges specifically suggests, and it is due to the long exhale involved in pranayama breathing. He would likely be in favor of somatic movement because of its emphasis on diaphragmatic breathing, and because pandiculation naturally relaxes the nervous system. I would also guess that Porges would be in favor of playing team sports (or doing any group physical activity) because it engages the social engagement system.
While research on the vagus nerve is still in its infancy, many types of movement—from slow, mindful movement like yoga and Tai Chi to vigorous, aerobic exercise like running—have been shown to reduce stress. Whether this happens primarily by involving the vagus nerve or by other means as well, the end result is a reduction in stress, which is always a good thing. The most important thing is to find types of movement that you enjoy and that feel good for your body and mind.
The Pain Relief Secret: How to Retrain Your Nervous System, Heal Your Body, and Overcome Chronic Pain by Sarah Warren, CSE
Somatics: Reawakening the Mind’s Control of Movement, Flexibility and Health by Thomas Hanna