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Polyvagal-informed trauma therapy: An overview

by Debbie Hegarty

The impact the Covid-19 pandemic is having on our society is astonishing and bewildering, forcing us to adapt to our environment in an unprecedented way. The World Health Organisation (WHO), as well as public health officials, has been guiding governments in how to respond to the spread of the virus until a vaccine is discovered. For months, international governments have been implementing social distancing, lockdown and quarantine policies. Uncertainty is ubiquitous, during an epoch of rapid change for civilisation. Rich (2019) stated that in 2019, 1,490 jurisdictions in 30 countries made climate emergency declarations. The climate emergency movement is calling for governments to increase dramatically their pledges to reduce deforestation, cut carbon emissions and decrease dependence on fossil fuels. Trends such as uncertainty in citizen voting suggest a need for radical political reform. Technological developments, such as quantum computing and artificial intelligence, are displacing workers in a time when work tends to be non-unionised, insecure and unprotected (Rich, 2019). According to the International Organisation for Migration (IOM) Report 2020, the number of stateless persons globally in 2018 was 3.9 million, with the number of forcibly displaced persons due to violence and conflict reaching 41.3 million, “the highest number on record since the Internal Displacement Monitory Centre began monitoring in 1998” (McAuliffe and Khadria, 2019: 3). De Haas et al. (2016) note that global migrants and refugees are often seeking asylum in countries where protectionist policies, nationalistic traits, xenophobic attitudes and anti-Semitic movements are surging. Authoritarian governments and right- wing populism undermine our democratic institutions such as human rights, the rule of law, free markets and free press. In addition, social media increasingly influences our political systems.

It is a time of adversity, uncertainty and for some members of our communities, a time of deprivation. Humanistic and integrative psychotherapists want to help and are already aware that our expertise, skills, and knowledge facilitate clients in adapting and adjusting as we move deeper into the 21st century. Primarily the emphasis in this paper is on how therapists can work with survivors of adversity using a polyvagal-informed approach. An attempt will be made to make sense of how adversity in childhood contributes to how adolescents and adults respond to stress throughout their lifespan. I will proceed from this introduction to a summary of the ACE (Adverse Childhood Experiences) Study, continuing to an overview of the three organising principles of Polyvagal Theory as conceptualised by Stephen Porges, and finally, to the conclusion.

The ACE study

Childhood trauma haunts people into adulthood.

(Mulcahy, 2018)

In 1998 Felitti et al. published the findings of the Adverse Childhood Experiences (ACE) Study and they found that there was a “strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and the multiple risk factors for several of the leading causes of death in adults” (Felitti et al., 1998: 258). Fundamentally, the study presents substantial data establishing a correlation between children exposed to threat and deprivation and the risk of adults acquiring addictions, chronic diseases and suffering premature death.

Adverse environmental experiences in childhood—such as exposure to violence, abuse, neglect, separation from caregivers, and chronic poverty—have powerful and lasting influences on children’s development.

(McLaughlin et al., 2019: 279)

According to Roelofs and Spinhoven (2007), survivors of childhood trauma and deprivation often present to medical centres and emergency services with comorbidity symptoms and Medically Unexplained Symptoms (MUS). The ACE Study was conducted in the United States by Kaiser Permanente and the Centre for Disease Control and Prevention (Anda et al., 2006). Felitti et al. (1998: 245) state that “13,494 adults who completed a standardised medical evaluation at a large Health Maintenance Organisation (HMO)” were invited to take part in the study. A ten-item scale named the Adversity in Childhood Experience Questionnaire (ACE-Q) was used to obtain information. Of those invited, 70.5% (9,508) agreed to take part, answering questions related to abusive acts of commission and omission, as well as household challenges where family members experienced substance abuse issues, mental health problems, suicide, divorce and/or imprisonment (Anda et al., 2006). Felitti et al. (1998) stated that two thirds of the respondents reported at least one Adverse Childhood Experience (ACE), one in five reported three or more ACEs and one in 16 reported four or more. A high ACE score was linked to ischemic heart disease, liver disease, obesity, alcoholism, drug addiction and early death.

Subsequent studies have examined the negative impact childhood adversity has on adolescent and adult mental health and academic achievement (Evans et al., 2013; Green et al., 2010; Kessler et al., 2010; McLaughlin et al., 2012). Finally, a more recent study conducted by McLaughlin et al. (2019) concludes that “reduced volume and altered function in frontoparietal regions were observed consistently in children exposed to deprivation, but not children exposed to threat” (McLaughlin et al., 2019: 277). Ultimately, the findings advanced from all the research studies consulted for this paper are consistent in stating that adversity in childhood contributes to how adolescents and adults respond to stress throughout their lifespan. How can therapists work with survivors of adversity using a polyvagal-informed approach? In order to answer this question, I will present an outline of the three organising principles that are at the heart of polyvagal theory:

1. Hierarchy
2. Neuroception
3. Co-regulation

The first organising principle – Hierarchy – studies the evolution of the autonomic nervous system (ANS). According to Levine (2015), the ANS is designed to preserve life and plays a crucial role in controlling and modulating behaviour. How your brain and body interprets the outside world and internalises it can be ascribed to the ANS. The ANS is a networking system that communicates back and forth between the brain and the body. Afferent (meaning toward) neural pathways communicate around 80% of our sensory signals from the body to the brain to be decoded, while efferent (motor) neural pathways carry approximately 20% of the same signals away from the brain towards the working muscles. The nervous system is a conduit, meaning that in order to know what is happening, we need to know where the signal originates (Karemarker, 2017).

The ANS regulates the digestive system, the bladder and urethra, the lower airways, cardiac muscles, lacrimal glands, the adrenal medulla, as well as sweating and shivering. The ANS forms neural pathways, some of which are myelinated and others are not. A key player in the body and brain’s interpretation of, and response to, social experiences is the vagus nerve. Porges (2011) explains that virtually all vertebrates have an unmyelinated vagus but only mammals possess a myelinated vagus originating in an area of the brainstem that regulates the muscles of the face and head. Myelinated vagal nerves are sheathed in a fatty coating that allows impulses to travel more swiftly along its length.

ANS responses allow us to react quickly without thinking because time spent thinking and planning might slow us down and impede our escape in times of threat. Traditionally neuroscientists understood that the ANS was made up of two main divisions, the parasympathetic and sympathetic nervous systems. Both systems are involuntary, physiological and sequentially interdependent with accompanying and opposing functions, behaviours, feelings and interpretations (Levine, 2015).

1. According to Porges (2009) the dorsal vagal branch of the parasympathetic nervous system is the unmyelinated branch of the ANS and inhibits involuntary physiological responses. Evolutionary studies of the ANS (its phylogenetic tree) characterise dorsal vagal pathways as the oldest and most primitive component of the autonomic nervous system, detected in early vertebrate creatures about 600 million years ago. In mammals, it communicates primarily with organs below the diaphragm (the gut and intestine), and adjusts the body’s stress response in an immobilised (hypoarousal) or death feigning, freeze response.

2. The sympathetic nervous system activates involuntary physiological responses. It has been categorised phylogenetically as the “next [stage] in evolutionary development” (Levine, 2012: 98). It emerged from reptiles approximately 400 million years ago. It mobilises the flight/fight (hyperarousal) response to sudden stress in co-ordination with the hypothalamus-adrenal-pituitary (HPA) axis.

Porges (1995) conceptualised polyvagal theory (‘poly’ meaning more than one) when his research discovered a third system in the autonomic system, and a second branch of the parasympathetic nervous system that is not detectable in reptiles.

3. The parasympathetic ventral vagal system is the myelinated branch of the 10th cranial nerve that originates in the brainstem region during the final 3 months in utero and the first year of life. According to Porges (2001) this parasympathetic ventral vagus system is unique to mammals and phylogenetically evolved around 200 million years ago. This neural system “shows its greatest refinement in primates, where it mediates complex social and attachment behaviours” (Levine, 2012: 15) to include mobilisation without fear. It primarily regulates organs above the diaphragm (heart and lungs). It originates in a brainstem area that is involved in the regulation of the muscles of the head and face and, thus, integrates bodily feelings into facial expressions, head gestures, and vocal intonation. The brainstem area controlling this vagal pathway is also known as the ventral vagal complex (VVC).

Figure 1: Created by Debbie Hegarty

The second organising principle – Neuroception – was conceptualised by Porges (2003, 2004) and describes our ability to intuitively evaluate risk, regulate physiological states and inhibit automatic defence systems. Dorsal and vagal responses to sudden stress are automatic and “allow us to remain in contact with others or will cause us to disconnect from social engagement” (Prendiville, 2017: 11). Siegel (2010) states that “the brain continually monitors the external and internal environment for signs of danger in a process called neuroception” (Siegel, 2010: 21). Under stress, human beings, primates and mammals try to engage the social engagement system first and when this does not produce safety, a fight or flight response is activated. When fight or flight is not possible, the dorsal system gets activated and enables a death-feigning reflex response. Normally individuals can bounce between sympathetic and parasympathetic states accordingly. Trauma survivors can get stuck in a shutdown/freeze state (dissociative). It is imperative when working with trauma that therapists neuroceptively detect indicators of sudden stress or fear in clients. Polyvagal-informed therapists need to find a way to signal to clients with a trauma history that everything is going to be okay. As Siegel points out: “presence depends upon a sense of safety” (2010: 21).

In addition, when danger is detected “we cannot activate what Porges calls the social engagement system” (Siegel, 2010: 23). A polyvagal-informed therapist prioritises safety and practises the skill of presence, watching out for signs and symptoms of re-traumatisation in the client when working through trauma.

Porges (2011) states it is not what we say to clients but how we say it. Two or more people come together and physiological cues are sent out interpersonally. If one person in the relationship is stuck in a trauma response they will avoid gazing into the eyes of the other and stiffen when a hug is offered. Neuroceptively people detect the intonation of the voice which is an indicator of one’s physiological state. Low intonation in people and in the background, sound like predator sounds to the hypervigilant survivor of trauma. See below a table depicting the signs and symptoms to watch out when working through trauma with clients. Please note that signs are visible, symptoms are less visible (although they can be detected neuroceptively).

Figure 2 created by Debbie Hegarty

Co-regulation: The transformative power of feeling safe
The third organising principle – co-regulation – is crucial in establishing safety and social bonds between the child and their caregiver, as well as the client and their therapist. Social bonds are sequential, ultimately moving towards connectedness, co-regulation and proximity with others and rely on familiarity and expectancy (Carter, 2017). What this looks like in practice is:

  • Compassionate eye contact.
  • Prosody of vocal tone (neither pitched too high or too low). Intonation of the voice is an indicator of one’s physiological state. The physics of a mammal’s middle ear is detached with overlapping frequencies. This allows for safety detection. Middle ear muscles in trauma survivors tire easily from too much stimulation (Carter, 2017).
  • Upper facial muscle tone that is expressive rather than frozen.
  • Appropriate use of touch (ensure the client leads on this type of contact).
  • Maintain a stance that is encouraging, welcoming and curious about the existential internal world of the client.
  • Attenuate extraneous, intrusive low-grade frequency background sounds in your work space with survivors. Low frequency sounds are predator sounds to a victim.

In addition to establishing safety and social bonding using presence and co-regulation, and revising false and unhelpful personal narratives relating to the traumatic experience or experiences, the polyvagal-informed therapist needs to encourage direct awareness and mastery over intrusive and disowned bodily sensations and feelings using here-and now breathing techniques. Jerath et al. (2019) confirm that vagal activity measured by heart rate variability (HRV) is at its highest, and heart rate variability (HRV) is at its lowest, when we are exhaling. Heart rate refers to the number of heartbeats per minute and HRV refers to the fluctuation in the time intervals between heartbeats (McCraty and Shaffer, 2015). The most soothing way to breathe is to inhale for five seconds and exhale for five seconds a couple of times together. Every time you exhale, your vagus nerve releases acetylcholine into your heart. Acetylcholine acts as a tranquiliser that slows down HR and increases HRV. The goal is to improve vagal tone. Some other practices to improve vagal tone in the therapeutic space are laughing, singing, humming and chanting together. Outside the therapy room vagal tone can be improved by practising yoga, splashing cold water on your face, having a cold shower and swimming in a lake, river or sea (Carter, 2017).

Awareness and mastery over disowned and denied bodily sensations and feelings using breathing techniques expands the regulatory boundaries of the “window of tolerance” (Siegel, 2012: 281), ensuring the client’s “autonomic arousal is within a tolerable range” (Wallin, 2007: 297) so that recalling and retelling the story of the abuse doesn’t re-traumatise the client. The ultimate goal in working with trauma is facilitating the development, healing, integration and repair of the disowned, dissociated parts (Siegel, 2010).

What therapists meet in clients who survive trauma typically are individuals who tried to solve the problem by creating another problem. Survivors tend to use their higher brain structures in the aftermath of trauma (specifically the cerebral cortex and the limbic system) to create a speculative narrative that makes sense of the cause (the source of the triggers) and the effect (the overwhelming and enduring feelings of shame and helplessness). The feelings are always real but the narrative identifying the source of the triggers is frequently misleading. For example: Client J experienced incest during her childhood. Her abuser was a trusted person in her immediate family. In adolescence and adulthood Client J increasingly used avoidance and social withdrawal to manage shame and mistrust in relationships. She disrespected her body and used self-injurious and addictive behaviours as a strategy for self-regulation and to numb unwanted, painful memories, bodily sensations, and feelings of powerlessness, helplessness, disgust, guilt, shame and rage. Her experience of abuse was real, as were the accompanying memories, bodily sensations and feelings. What was not real was the personal narrative that Client J constructed after the abuse to try and make sense of what happened. Instead of directing her rage outward at her abuser and the world for the injustice of what happened to her, she deflected it back on herself. Rather than blame her abuser, Client J blamed herself for just letting it happen to her. By covering up the abuse, feelings of guilt, shame and self-loathing persevered into her adolescence and adulthood. Client J disowned a part of herself. Because the trauma from her past was unresolved, whenever she saw, heard or smelled something reminiscent of the original abuse she unwittingly made contact with the unresolved, denied and disowned memories, bodily sensations and feelings and became overwhelmed. Her ability to tolerate these sensations and feelings was not sufficiently developed to regulate herself and this added to the personal narrative that she was the problem. Consequently, she found it hard to accept or trust herself fully. Accordingly, she found it difficult to accept or trust others fully.

Relationships heal and regulate. It is the quality of the relationship that matters. As already said, the findings from the research studies are consistent in stating that adversity in childhood negatively impacts responses to sudden stress throughout the lifespan. How can therapists work with survivors of adversity using a polyvagal-informed approach? In order to answer this question, I first outlined the three organising principles that underlie polyvagal theory. The overarching aims of the polyvagal-informed therapist is in facilitating clients in developing mastery over their intrusive symptoms and activating their spontaneous social engagement system by communicating safety in a way that is neuroceptively detected by the client. Implicitly, or indeed explicitly, the therapist communicates: ‘Everything is going to be okay’. Key objectives are facilitating the client in developing a personal narrative that is compassionate, working through the unresolved trauma, expanding the window of tolerance and integrating disowned, depersonalised and dissociated parts.

Collectively our society is crying out for change. Because of your counselling and psychotherapy qualifications and training, you are a change agent and you can make a difference to someone’s experience of this world by holding, maintaining and modelling a hopeful rather than a fatalistic stance. Counsellors and psychotherapists are in an advantageous position in becoming part of a social movement that moves away from hostility, towards a fusion of cultures, and away from indefensible practices in the name of progress towards sustainable living. We have the recipe, we have the ingredients…can we bake the cake?

Debbie Hegarty (MIAHIP, SIAHIP) is a former member of An Garda Síochána. She began her studies with a degree in social sciences, initially working in adult mental health. She also provided short-term counselling for the NCS. She has a particular interest in relational psychotherapy and has specialised training in working with trauma, PTSD and dissociation. Debbie has a longstanding association with IAHIP having spent time on both the Governing Body and on the editorial board of this journal. She is currently an IACP Core Trainer and Module Leader on the BSc in Counselling and Psychotherapy (Cork Counselling Services Training Institute).

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