Polyvagal Theory for Mental Health Care: Applying the Work of Deb Dana in Therapy

“Safety is not the absence of threat, it is the presence of connection.” — Gabor Maté

For providers of behavioral health care, it’s very important that the people we serve feel safe around us.

The process of therapy requires vulnerability from those in care, and vulnerability is difficult or impossible unless a client feels safe opening up to their therapist. Without this sense of safety and trust, the therapist won’t be able to make the emotional connection needed to help the consumer succeed in therapy.

Therefore, one of the provider’s chief duties is to make the individual feel safe and comfortable to engage in treatment. But how can we do this? There are many strategies that may work, but at Cummins, we prefer a trauma-informed approach to care that incorporates the developing science of polyvagal theory.

In fact, we have recently begun training our providers on the work of Deb Dana, LCSW, who has pioneered work in applying Dr. Stephen W. Porges’ ground-breaking polyvagal theory to therapy practice with clients. Deb Dana has written several books describing clinical strategies and techniques that further apply this foundational understanding, including The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation.

We’re very excited to be incorporating Deb Dana’s techniques using polyvagal theory into our own clinical practices! In this blog post, we’ll provide a brief synopsis of polyvagal theory and preview how it can serve as a framework for mental health care.

Deb Dana, LCSW, author of The Polyvagal Theory in Practice

The Bodily Response to Danger

At some point in your life, you’ve probably had the experience of feeling unsafe.

If you think back to one of those instances, you’ll remember some interesting physiological symptoms. First, at the moment you detected danger in your environment, there’s a chance you might have frozen in place. Perhaps it was only for a second or two, or perhaps it was for longer than that. During those few moments, you made a rapid and instinctual assessment of the threat at hand without moving or speaking.

Then came the rush of adrenaline. Your body entered a state of high alert as your senses sharpened on the source of danger. Depending on the situation, you made a gut decision to either move away from the danger as quickly as possible, or, if you were threatened by a person or animal, to confront the aggressor in order to end the threat of danger. And then you did so, almost without conscious thought about it.

When you reflect back on the event today, you can probably understand it in its greater context. Using the logical part of your brain, you can surmise whether or not the perceived threat was a legitimate threat to your well-being, and you can judge whether you acted reasonably or unreasonably in the heat of the moment. You might even have some idea of how you wish you had reacted instead. But at the time of the incident, it would have been nearly impossible to have these kinds of thoughts.

Why is this so? Polyvagal theory offers an answer.

Polyvagal Theory: Linking Physiology and Cognition

As human beings, our cognition is closely linked to our physiology, and our physiology is closely linked to our perceptions of danger and safety. Polyvagal theory states that the presence or absence of a perceived threat activates different parts of our brain and autonomic nervous system (ANS), which produces different physiological states.

When we feel calm and safe, we are operating in what polyvagal theory calls the Engagement State. This state is associated with higher-level cognitive processes, social interaction, and emotions like joy, compassion, curiosity and mindfulness. When we’re in the Engagement State, the ventral vagus nerve and associated ventral vagal complex of the ANS are activated.

If we perceive a threat in our environment, our ANS may shift into the Mobilization State. In this state, our sympathetic nervous system is activated, which prepares the body to move in response to the threat. The Mobilization State may trigger “fight or flight” behaviors, and it is associated with emotions like anger, fear, anxiety and panic. Importantly, higher-level reasoning and social engagement are extremely difficult when in this state.

Finally, if the perceived threat is so great that we feel unable to counteract it, our dorsal vagus nerve and dorsal vagal complex may become activated, triggering the Collapse State. In this state, we might feel ashamed, hopeless, disassociated, depressed or even suicidal. At lower levels of dorsal vagal activation, we may also exhibit freezing behavior, which can occur when a sense of danger comes on very strongly and abruptly. While temporary, “defensive” freezing behavior can be useful for surviving dangerous situations, prolonged dorsal vagal activation is especially dangerous to our mental and emotional well-being.

The 3 Organizing Principles of Polyvagal Theory

In addition to the three physiological states described above, polyvagal theory proposes three key principles that explain how our bodies shift between them. They are:

1. Hierarchy

The three states of polyvagal theory are always activated in a specific order, without skipping any state. As our level of arousal and perceived danger increases, we move from the Engagement State (ventral vagal activation) to the Mobilization State (sympathetic nervous system activation), and then, if arousal continues, to the Collapse State (dorsal vagal activation). As arousal and perceived danger decrease, we move from the Collapse State to the Mobilization State, and if we are sufficiently calmed, then to the Engagement State.

It should be noted that arousal can happen very quickly, such as when someone who is calm jumps to freezing behavior in response to an abrupt threat. However, this is the one notable exception. In most cases, an individual does not move from a state of calmness and connection (Engagement State) to a state of numbness and hopelessness (Collapse State), or vice versa, without first passing through the state of frustration or anxiety (Mobilization State).

2. Neuroception

Neuroception is the premise that our nervous system can and does take in outside information and respond to that information. Importantly, this process happens without our conscious awareness.

Neuroception stands in contrast to perception, which is our capacity for consciously interpreting the world around us. While perception is moderated by conscious thought, neuroception is not. Neuroception explains how a person, object or environment that subconsciously reminds us of danger can create changes in our autonomic nervous system, even if we consciously know the person, place or thing does not pose a threat to us.

3. Co-Regulation

As our bodies and bodily systems mature throughout our lives, our autonomic nervous system develops the ability to self-regulate. For example, once it is sufficiently developed, our ANS can “learn” to transition out of heightened states of arousal on its own. However, this development process begins with co-regulation, which involves mirroring or mimicking the behaviors and arousal states of others.

Co-regulation can be seen commonly among young children, such as when an upset child is soothed by a parent or caregiver. Through neuroception, the child’s ANS responds to the calming cues given off by the parent and successfully de-escalates its own arousal level. Although co-regulation becomes less critical as self-regulation skills develop, it remains a useful principle to leverage in situations such as therapy and counseling.

Applying Polyvagal Theory to Clinical Practice

So, what exactly does all of this have to do with providing mental health care?

For individuals receiving care, seeking and receiving mental health services can be a challenging experience. For starters, a person who is seeking services may feel a variety of difficult emotions, such as uncertainty, anxiety, fear, or shame. What’s more, the therapeutic process may elicit upsetting thoughts and feelings as the consumer works through whatever issues they are seeking help for.

In some circumstances, these difficult emotions—perhaps coupled with traumatic memories or certain features of the treatment environment—may cause a person to feel unsafe, triggering an ANS response. If this happens, they will be temporarily “locked out” of the cognitive processes associated with the Engagement State, which are necessary for productive participation in treatment.

As care providers, we can use our understanding of polyvagal theory to help prevent this from happening. Although this is a nuanced process, Deb Dana’s framework poses three essential elements of practice:

1. Context

Some people seeking services may feel unsafe if they do not fully understand what is happening in treatment and why it is happening. For this reason, providers should demystify the process by consistently explaining what will be done, why it will be done, and how it will be done in the context of our brain and our nervous system. This will reduce the chance that the individual’s ANS will detect a perceived threat via neuroception.

2. Choice

Individuals may also be prone to feeling unsafe if they believe they don’t have any control over their treatment. This can create the feeling of being trapped within treatment, which may trigger ANS arousal. To prevent this, providers should ask their clients what they would prefer to do or offer multiple choices whenever possible. This will help the individual feel safe in the knowledge that they are in control.

3. Connection

As we mentioned above, the emotional tolls of treatment may cause some distress for the person receiving services. To prevent or counteract this, providers must constantly monitor their own emotional state and strive to remain in the Engagement State of the ANS. Doing so will assist the consumer in staying or becoming calm via the principle of co-regulation.

Robb Enlow, LCSW, Cummins’ Chief Clinical Officer, explains:

“Part of what any therapist, nurse, teacher, or communicator has to do with other people is co-regulate. If you’re in an ugly frozen state, and the person you’re communicating with is in an ugly frozen state, that’s not a pretty conversation. In fact, sometimes we see that clinically. The parents are frustrated and triggered, the child is screaming and triggered, and neither one of them are communicating effectively with each other. They’re both frozen or very ‘fight or flight,’ and it’s just not working for them. The idea is we get them regulated to the ventral vagal state, or the social engagement state. When people are truly in the social engagement state, that’s when your brain is able to do miraculous things. When you calm down those cover ups, those protective, defensive parts, the rest of your brain is able to access creative, curious things that you’re just not able to access when you’re not in that state.“

At Cummins, we are always working to provide the most effective care possible for the people we serve. Part of this means training our providers in new and promising clinical practices. (In fact, continuous learning is one of our core organizational values!)

To this end, we’re thrilled to be incorporating polyvagal theory and the work of clinician Deb Dana into our standards of care. We believe it will further improve the knowledge base and therapeutic effectiveness of our care providers, which will in turn result in better outcomes for our consumers. And this, after all, is our most important goal.

If you are interested in advancing your career with a position at Cummins Behavioral Health, we encourage you to visit our employment page. We are always looking for talented and passionate people to join our team!

Wellness for Care Providers: Nurturing the Personal Self

Let’s face the facts: working in the caring professions—such as health care, education, emergency services, criminal justice, and social work—is often stressful. On top of attending to the people they serve, care providers must also make time to manage their own health and wellness.

In previous entries in our “Wellness for Care Providers” series, we’ve discussed:

We’re now ready to discuss the concept of the personal self and personal self-care. Whereas the professional self is the part of a person that identifies with and is nourished by their work, the personal self is the part of a person that’s concerned with everything outside of work. It is who we are on a day-to-day basis when we’re left to do as we please.

There are actually many different dimensions to the personal self, such as the emotional self, the playful self, and the solitary self, to name just a few. Good personal self-care is about properly nurturing each dimension of the personal self; if any one dimension receives insufficient care, we may begin to feel unhappy, stressed, aimless, or otherwise unwell.

In this post, we’ll break down the various dimensions of the personal self and provide some instruction for nurturing each one. We’ll once again be guided by insights and advice from Ciera Jackson, our Professional Development Specialist here at Cummins.

Ciera Jackson, MSW, LCSW, Professional Development Specialist at Cummins Behavioral Health

10 Dimensions of the Personal Self

Here at Cummins, we use a model of the personal self inspired by the book The Resilient Practitioner: Burnout Prevention and Self-Care Strategies for Counselors, Therapists, Teachers, and Health Professionals by Thomas Skovholt and Michelle Trotter-Mathison. This model divides the personal self into a dozen different sub-selves.

Today, we will discuss 10 of them in detail:

1. The Emotional Self

Humans are emotional beings at our core. The emotional self is the part of us that needs to feel and express our emotions in order to be at peace. If we keep emotions bottled up for too long, our emotional self will suffer.

The emotional self can be nurtured in a variety of ways. “Some people might journal. Some people might have a good cry everyday,” Ciera suggests. Others might use art as a way of expressing their emotions. One of the easiest things you can do is simply speak with friends or family members about emotions that may be troubling you.

Attending therapy is also a great way to nurture the emotional self—even for people who are therapists themselves. In fact, studies show that 86% of psychologists who prescribed therapy to their clients found therapy to be helpful for themselves, as well.

“How many people who are in the field ‘take their own medicine’?” Ciera asks. “A lot of people wonder, ‘If I admit I’m a clinician who goes to therapy, does that make me lesser? Does that mean something negative for me?’ And no, it doesn’t. I tell people that I go to therapy. I do it because I need check-ins, I need accountability, I need perspective.”

2. The Financial Self

Whether we like it or not, we have to admit that money is an important part of life. If you have poor money skills, are financially unassertive, and tend to have a consuming nature, then you will eventually experience financial stress. For practitioners, this will make it harder to form empathetic connections with clients and remain focused on meeting their needs.

“My grandma always used to say, ‘Have some money for a rainy day,’ “ Ciera says. “Rainy days come. It’s bound to happen, whether it’s unexpected car expenses, house expenses, health concerns, or whatever it is. And if you don’t have anything in savings, that tends to be stressful.”

For these reasons, it’s crucial to develop your financial literacy, and preferably to live a little below your means. “It’s important to have that financial self-care, even if it’s just, ‘For each paycheck, I’m going to send a certain amount to a savings account, so that if I don’t see it, I don’t touch it,’ “ Ciera adds.

3. The Humorous Self

Just about everyone likes to laugh. In fact, laughter has been proven to carry surprising health benefits, such as improving immune system functioning and helping to prevent heart disease. In a study of psychologists regarding coping strategies, maintaining a sense of humor was also the #3 career-sustaining behavior. It’s important to laugh, have fun, and be playful regularly in your life and even in your work.

Ciera shares an example from her own life: “When I first started in the field, I was working with families involved in DCS. I don’t know if I really knew what I was getting myself into. But I would go home every day for six months straight and watch The Nutty Professor and laugh like I had never seen the movie in my life. That was my thing.”

If possible, it can be helpful to use humor at your place of work, as well. Joking around with your co-workers (in appropriate moments) can be a great way to bond, form friendships, and relieve stress in a communal way.

4. The Loving Self

Affection is a powerful source of professional vitality. The loving self is the part of us that needs to express affection and receive affection from other people.

“If all you have is work, then that’s not a flourishing reality for you,” Ciera explains. “That’s not something that is going to be long-lasting, because eventually you’ll burn out. I know some people tend to be ‘workaholics’, but you have to look forward to something other than work.”

We all need to have people or things that we care about outside of our work. These might be family, friends, pets, a mentor or mentee, and so on. These relationships can nourish the loving self by providing it with the affection it needs.

Of course, maintaining relationships outside of work also requires us to make them a priority whenever possible. “How good are you at spending time with the people outside of work? Do you make them a priority?” Ciera asks. “You have to ask yourself, ‘Do the people who are closest to me always deserve my leftovers?’ And work on getting better at not giving them your leftovers, but giving them some of the best parts of you.”

5. The Nutritious Self

It has been said that “Happiness is a steady rhythm of blood glucose.” While this might not be an absolute truth, it is nevertheless true that our bodies and minds need fuel to be healthy. This is where the nutritious self comes in.

Good nutrition can be complicated and may look different from person to person. However, there are many rules of thumb that can be helpful for most people. For starters, it’s generally a good idea to eat plenty of fruits and vegetables and limit your consumption of fats, sugars, and processed foods. Drinking plenty of water is also essential, so you should drink whenever you feel thirsty, and limit dehydrating beverages like coffee, tea, soda, and alcohol. Breakfast is also an important meal not to skip, as it jumpstarts your metabolism and provides fuel for your body to begin the day.

Above all else, it’s important to develop a long-term perspective with regard to eating habits. “Do what is sustainable for you,” Ciera suggests. “If you’re going to change eating habits, make sure they’re sustainable eating habits for you. That way you’re doing something that is not just going to get you quick results, but long-lasting results.”

6. The Playful Self

Even the most serious people—and those who perform the most serious work—need to have fun from time to time. After all, the world of play helps make the world of work possible. The playful self is the part of us that needs to be silly and light-hearted sometimes.

“I think sometimes when we get to be adults, and especially in this field, we can become so serious, or so focused on what it is that we’re doing, or drained, that we’re just like, ‘I don’t have time for anything else except my work,’ “ Ciera says. Playfulness, like humor, is an important counterbalance to stress and anxiety.

Once again, there are many different ways someone can nurture their playful self, and the best methods for you will be those that align with your interests. Many people enjoy games of various types, whether they are card games, board games, video games, or games based in physical activity. Another common example is attending festivals or partaking in amusement park rides.

“You don’t have to spend money to have fun,” Ciera adds. “You can just get creative. Channel your inner child.”

7. The Priority-Setting Self

Most of us feel like we always have too many things on our “to do” list. When we don’t have enough time to finish everything, we are liable to feel overwhelmed and over-extended.

Ciera says, “Sometimes we start so many things at once that, for some people, they don’t get anything done, and for other people, they feel like they have to get everything done. That stresses them out, and then if they’re stressed, they can become snappy, and that can stress out other people around them, or make other people around them uncomfortable. And it just makes the whole atmosphere unpleasant.”

To satisfy the priority-setting self, we need to learn to do the most important things first and leave the rest for later. Ask yourself: What has deadlines? What’s more time sensitive? What’s more urgent? Put a star or asterisk next to those tasks, and put aside the rest until you have time for them.

8. The Relaxation/Stress-Reduction Self

As care providers, our work can be stressful and hectic. This is to be somewhat expected, but it can’t be sustained forever. Our relaxation and stress-reduction self demands that we also make time for peace and serenity.

“You have to practice de-stressing, period,” Ciera says. “You can’t carry the weight of the world on your shoulders. Everything is not within your control. You can do what you can do, and after that, it’s up to your client, it’s up to your family, it’s up to your boss, or whoever. Do what you can do, and then let it go.”

Everyone has their own methods of relaxing and de-stressing, but activities like meditation, mindfulness, yoga, and relaxation training work for many people and have been proven to reduce instances of high blood pressure, heart disease, depression, cancer, arthritis, and gastrointestinal disorders.

It’s worth mentioning that stress-reduction activities are not always easy to maintain. “Sometimes it takes practice, and I’m not saying it will be a day of practice. Sometimes it takes weeks, months, or even years to get to that point of giving yourself permission to just be,” Ciera says.

9. The Solitary Self

People are social animals. We all enjoy talking to and spending time with other people (especially if we like those people). But we each also have a solitary self that needs to be alone every once in a while.

Solitude means removing yourself from the known channels of life. It means unplugging from the electronics and being at one with yourself. It means getting away from the noise in order to refill yourself.

Although we all require solitude sometimes, it comes easier for some than for others. “A lot of people struggle with this because it means being alone,” Ciera explains. “Some people really enjoy being by themselves and have no problem with this at all. For other people, it’s like the worst thing ever.”

If you’re someone who hates to be alone, know that it’s alright to embrace solitude in baby steps. Ciera says, “It’s OK to start small if you do struggle with this. It can be 5 minutes of just saying, ‘I’m going to unplug for 5 minutes and just do nothing.’ “

10. The Spiritual or Religious Self

The spiritual or religious self is the part of us that seeks connection to something larger than ourselves. An active spiritual or religious life is important for many people because it gives meaning to the “big questions” of life. Are people basically good or evil? Is there an afterlife? What moral rules should govern your life?

Nurturing the spiritual or religious self can also help practitioners find meaning and purpose in their work. When the things we do every day are in service of a greater purpose—whatever that purpose may be for us—then we are more likely to find our work personally relevant and important. We’re also more likely to believe that we’re living a fulfilling life.

In essence, spirituality and religion provide codes for us to live by and give greater context to our actions. “For a lot of people, spirituality or religion is important to them because it just helps govern their day-to-day,” Ciera says.

Self-Care Action Plan Step #4: Assessing Your Personal Self-Care

Now that we’ve reviewed the various dimensions of the self, let’s discuss how to assess your personal self-care for your Self-Care Action Plan.

You can begin by considering: How well am I nurturing each part of myself? What am I specifically doing to nurture each part of myself?

Next, make a list of the 10 dimensions of the self we discussed above. Next to each dimension, write down specific activities you are currently doing to nurture that part of yourself. If you can’t think of any, leave that space blank. Then, give yourself a rating from 0–6 for how well you are currently nurturing each dimension of the self, with 0 being not at all and 6 being very well.

Once you’ve done this for all 10 dimensions, write down your three strongest and three weakest areas of personal self-care. This will give you a better understanding about which parts of yourself are most nurtured and which parts you most need to focus on in the future.

Every one of us is a complex, multifaceted individual. Our individual identities, or “who we are” as people, are layered in several important ways. At a high level, we all possess a professional self and a personal self, but even the personal self can be subdivided into multiple smaller selves that make up our identity. In order to be fully well, all of these sub-selves must be regularly nourished and maintained. Only then can we feel content, fulfilled, and inspired to do our best work as practitioners.

We hope this article helped you discover some dimensions of yourself you might have never thought about before—and gave you some ideas for how to better sustain them. In Part 5 of our series on Wellness for Care Providers, we’ll dive into one final dimension of the self that we skipped today: the physical self. Until next time!