“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.
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.
