The Importance of Polyvagal Theory for Mental Health Care Clinicians

Polyvagal theory provides a neural foundation for an integrated brain-body medicine that deeply informs the patient-clinicians relationship and leads to insights on how to treat trauma-related mental and physical health challenges.

On Friday, December 16, at the Evolution of Psychotherapy in Orlando, polyvagal theory pioneer Stephen W. Porges, PhD, Distinguished University Scientist and founding director of the Traumatic Stress Research Consortium, Indiana University, presented his session titled “Polyvagal Theory: A Science of Safety,” before an audience of mental health care professionals.

Ahead of his presentation, Dr. Porges spoke with Psych Congress Network to discuss the relevance of polyvagal theory to psychiatric care, key clinical pearls, and how the theory can help to inform patient diagnoses and treatment.

Keep up with the latest insights from the Evolution of Psychotherapy 2022 in our meeting newsroom.

Stephen W. Porges, PhD, is Distinguished University Scientist at Indiana University where he is the founding director of the Traumatic Stress Research Consortium. He is Professor of Psychiatry at the University of North Carolina, and Professor Emeritus at both the University of Illinois at Chicago and the University of Maryland. He served as president of the Society for Psychophysiological Research and the Federation of Associations in Behavioral & Brain Sciences and is a former recipient of a National Institute of Mental Health Research Scientist Development Award.

He has published more than 400 peer-reviewed papers across several disciplines including anesthesiology, biomedical engineering, critical care medicine, ergonomics, exercise physiology, gerontology, neurology, neuroscience, obstetrics, pediatrics, psychiatry, psychology, psychometrics, space medicine, and substance abuse. He is the author of The Polyvagal Theory: Neurophysiological foundations of Emotions, Attachment, Communication, and Self-regulation (Norton, 2011), The Pocket Guide to the Polyvagal Theory: The Transformative Power of Feeling Safe, (Norton, 2017) , Polyvagal Safety: Attachment, Communication, Self-Regulation (Norton, 2021), and co-editor of Clinical Applications of the Polyvagal Theory: The Emergence of Polyvagal-Informed Therapies (Norton, 2018). He is the creator of a music-based intervention, the Safe and Sound Protocol ™ , which currently is used by more than 2000 therapists to improve spontaneous social engagement, to reduce hearing sensitivities, and to improve language processing, state regulation, and spontaneous social engagement. He is a cofounder of the Polyvagal Institute (polyvagalinstitute.org).

Read the transcript

Brionna Mendoza, Associate Digital Editor, Psych Congress Network: Hello, Psych Congress family. I'm Brionna Mendoza, one of your Associate Digital Editors. Today I have the pleasure of talking with Dr. Stephen Porges in advance of his presentation at the Evolution of Psychotherapy. Thank you so much for joining us today, Dr Porges. Could you please introduce yourself for our audience?

Stephen W. Porges, PhD: Well, I'm Stephen Porges. First of all, it's a pleasure to be interviewed prior to the conference. I actually look forward to seeing many of you at the conference. Oh, I should tell you who I am. I am the founder or creator of the polyvagal theory. I am a professor of psychiatry at the University of North Carolina, and the Founding Director of the Traumatic Stress Research Consortium in the Kinsey Institute at Indiana University. And I'm Professor Emeritus at the University of Illinois at Chicago Medical School Department of Psychiatry, and at the University of Maryland in College Park as well.

Mendoza, PCN: Wonderful. Thank you again for taking the time to speak with us today. So let's dive right in. Could you please summarize polyvagal theory and explain its relevance for psychiatrists' clinical practice?

Dr. Porges: I will try. As most people have heard that question asked of me, my response is almost a knee jerk. It's the least-liked question because it could go on for days, and I don't really want to do it. So let's basically come to the major point of what the theory is from a clinician's point of view. It's really to understand that the physiological state, the autonomic state, is a mediator of behavior in the therapeutic setting. What that means is that the physiological state of your client and the physiological state that you are in influences the progress that you will make in a therapeutic setting.

The other part I want you to really think about and take home is that when you feel safe, or when your clients feel safe, it's really their autonomic nervous system telling their conscious brain that everything is functioning well. They're supporting homeostasis, meaning health, growth, and restoration. But when their physiology gets disrupted, it's in a state of defense or they, in a sense, don't feel good, or they have gut feelings. Basically their body's under a state of threat and their ability now to interact in the world changes.

So polyvagal theory is really this theory that emphasizes both a bottom-up impact of our body on our conscious brain, and the influence of memories and associations that influence our body. And all this interaction is occurring really in the lower part of the brain called the brain stem. And often going through, in a bidirectional way, through this major nerve called the vagus, thus the term polyvagal. And so basically we have a surveillance system that is monitoring our body, sending signals to the brain, the brain interprets it, and sometimes we detect cues in the world. And now our brain interprets those cues and shifts our physiological state.

The bottom line here is polyvagal theory emphasizes the importance of physiological state as a mediator of not only our actual behaviors, but our feelings and our thoughts.

Mendoza, PCN: Wonderful. Thank you for sharing that with us. Now, you'll be focusing on polyvagal theory, of course, at the conference. So what would you say are the three most important takeaways from your session on this topic?

Dr. Porges: Okay. If I were to extract from what my talks will be and came up with three principles, the first one is that if there is a balance in our life, the balance is really going to be biased towards our foundational survival circuits. This takes precedence, it takes control over our intentional behavior. So we can have wonderful thoughts of a glorious, intentional, rational behavior, but when we get hit with certain cues that trigger our physiology, that's going to take control. And so we use the term, people acting out. But basically our physiology, when it gets into certain states, states of defense, the portal to engage a person in a co-regulatory dialogue is going to be extraordinarily limited and very biased. And I think that therapists need to understand that. They have to totally respect the fact that when a person is activated or destabilized, telling them to calm down or telling a person who's depressed not to be depressed is not very effective, because the physiology is taking control.

What we need to think about as therapists and as human beings, is how can we clearly talk to our bodies? Now, when we are parents of very young infants, that's what we're doing. The words don't mean anything, but the way we speak to our infants is everything. The way we talk to our dogs and cats and horses with intonation of voice, we're conveying trust and love to them. And their bodies respond appropriately, or at least usually. But if we tell them, come on, just sit still. Come on, do this, it doesn't really work because we're conveying our own physiological reactions in the intonation of our voice. So that's the first part.

The other part, which is very much related to that, is both the client and the therapist are functionally broadcasting their own physiological states to each other. And they're doing that through gesture, through voice, and through facial expressivity. Polyvagal theory literally explains how the muscles in the face are linked to the nerve, the vagus, as it regulates the heart. And that we have this wonderful circuit that's involved with ingestion, suck, swallow, breathe, and vocalize. But it also is our social engagement system. It's what we use to engage, and even, we ingest food as part of our engagement.

So remember that we are broadcasting our physiological state. And when our physiological state is being broadcasted as being in a state of threat, those signals become signals of threat to the client, where the client is sending signals to the therapist of being in a state of threat. And now the therapist can either say, whoa, I'm now really feeling that in my body. Maybe it's time to just take a deep breath. Maybe we should both get up, walk, and shake it out and mobilize a little. As opposed to building a narrative of literally justification of why you don't like the client or why the client doesn't like you. So the issue is don't make an interpretation. Be respectful of your bodily reactions and your client’s.

So the real part here is our nervous system is very sophisticated to make decisions of signals of safety and trust, but those decisions may not be valid. And the issue is when we have those physiological reactions, they're going to occur through a process that I call neuroception, which is extraordinarily rapid and occurs outside of our conscious intention, but our bodily feelings we become aware of. And now we have this gap. We have feelings, and we're trying to figure out where they come from. And that becomes these complex narratives.

So polyvagal theory really emphasizes the fact, respect the feelings. They're real. They're coming through another neural mechanism called interoception. And that's good because our body is really a surveillance system that's monitoring what's happening to our organs. But it doesn't mean that the intentionality of the other person has been aggressive at you.

Mendoza, PCN: Wow. There are a lot of implications here in terms of the patient-doctor relationship. So thank you.

Dr. Porges: Or child-parent, or spouse, or all of them. We tend to misinterpret other people's behaviors and we try to make a narrative that makes us feel—I use the term—moral veneer. We want to feel that we're ethical person so we can dislike the persons who are doing bad things. But what if the bad things are really survival circuits just being triggered? Okay?

Mendoza, PCN: Yeah. So let's dive into some of the other practical applications. What are some of the psychiatric diagnoses that polyvagal theory helps to further explain?

Dr. Porges: Well, the issue of using psychiatric diagnosis has always been a bit problematic because there's been a dependence, or at least an expectation, that there would be a neurophysiological substrate. And I, as a laboratory scientist, at various times in my career we were literally tasked with identifying the physiological substrate of different types of disorders. The irony of that task is that virtually every psychiatric disorder has a common set of core features, and those core features are that of an autonomic nervous system that has shifted from being calm to being in a state of threat.

The consequences of that are, in polyvagal terms, the dampening of the social engagement system. Flat facial affect. Hyper-sensitivities, especially to sounds. The intonation of voice is lost. So people talk in a monotone, or very loud and booming, and they don't have the inflection of the voice, which is conveying their physiological state. So what we're seeing is a lot of features across many diagnosis that are really a projection, or that broadcasting of the client's physiological state. And it's not necessarily the diagnosis, it's a common feature.

And polyvagal theory says, what would happen if you could downregulate those--let's use the term aversive,or at least those idiosyncratic reactions that are disruptive in social interactions. What if the person's physiology would get calmer? Can then you as a therapist do your work more efficiently? Can you engage the client in a more meaningful therapeutic interaction?

Mendoza, PCN: And how would you say that clinicians can most effectively utilize polyvagal theory to inform their treatment plans?

Dr. Porges: Well, to inform treatment, you start with basically the base level condition that if you have a treatment plan, it has a lot of information. The information is being conveyed to the client. The client has to process that information. And frequently, that information has to do with processing one's own bodily feelings, especially if you move into the world of trauma. Now, the ability to monitor one's own bodily feelings is a function of your physiological state. If you're in a state of defense, forget it. Your body's numbed, which happens to be a feature of some of these diagnostic categories.

So enabling the body to give up its defenses, to give up hypervigilance, to give up its hypersensitivity so that it can now engage in the processing of information. And it's not just information as a quantitative index, it's information on an interpersonal level, meaning feeling safe enough to trust another person. Which is, qualitatively, a different type of information.

Mendoza, PCN: So to return to the topic of the patient-clinician relationship, what implications does polyvagal theory have for maintaining that dynamic?

Dr. Porges: Well, the important point here is that both the client as well as the therapist are broadcasting their physiological state. And that physiological state is going to have reciprocal reactions. Now, we like to use this positive term, like co-regulation, where the mother hugs the baby and the baby conforms to the mother's hug. But that's the metaphor of a symmetrical, reciprocal relationship. Therapy is not a symmetrical, reciprocal relationship, or at least not all the time, or at least most of the time.

So it means that the therapist has to be able to understand to the therapist's own interoception of their bodily reactions, to the client's behaviors, intonation of voice, gestures, not to, in a sense, create a narrative of what that client is doing. The client is really, in a sense, responding that there's a degree of threat to be exposed to, in a sense, to trust their client doesn't want to be vulnerable. The nervous systems of others don't want to be vulnerable. And if a person is going into therapy, many of them have adversity histories. And what adversity history does is primes the nervous system to be biased not to be available, to be defensive. So you're really dealing with an organism that is really going to be defensive.

Now, the question is, are therapists, in a sense, consciously aware that they're stepping into that mine field, literally? And can they modulate their own physiological state not to overreact? Take a deep breath, move, but not develop a narrative that ends up aggressing at their own clients.

Mendoza, PCN: Great. That's definitely ... I can see some points there that our audience will find very useful in their own practices. Now, what can misconceptions about polyvagal theory, if any, would you like to address?

Dr. Porges: Well, the first one that I would like to address is that people think of it as a bottom-up theory. It's neither a bottom-up nor top-down theory. It's a theory that basically says the body and the brain talk to each other. It's a dialectic. And this interaction between our intentional or conscious brain and our bodily functions, actually the interaction is in the brain stem, the most primitive part of the brain. But it's getting signals from higher level areas into that brain stem and signals from visceral organs. And so it's this mixture.

So what is often a problem is that if you start trying to explain that it's both, people get a little bit concerned because they see people as being somatic-oriented or cognitively-oriented. Polyvagal theory is functionally brain-body integrated. So it's respectful of all these different, I'm going to use the word technologies, of therapeutic intervention, which all have the same goal. And the goal from a polyvagal perspective is to optimize the neural regulation of the autonomic nervous system ... or what therapists would say, behavioral state. To enable the behavioral state of your clients to be more regulated. Not to be hyper-reactive, not to be oppositional, but literally, to be a good witness, a good interactor, and in polyvagal terminology, the goal is to be an adequate co-regulator of others.

Mendoza, PCN: Any final thoughts on the topic of polyvagal theory that you'd like to share with our audience before we wrap up?

Dr. Porges: The take home message of what I want the audience to really get is that when we interact with others and we are in a calm state and welcoming to others, that we're clearly broadcasting cues of safety to them, it enables the other person's nervous system to reciprocate. To move into that space of accessibility, to be in contact with another. Remember, in the world of trauma, the greatest fear of a person who has had an adversity history is accessibility. It's a fear, but they're in therapy for one primary reason. They want to have a relationship.

So they have the visualization, they have the expectation, they have the dream of feeling safe enough with another to be held in their arms, but their body is actually programmed to be in a defensive state. It's locked into defense. So we want to leave this, the workshop and the keynote, with a feeling, an optimistic feeling that there are portals to engage that physiological feelings of accessibility without triggering vulnerability, that can be manipulated in a positive way through therapy. And they become, what I call, neural exercises that build resilience.

Mendoza, PCN: Well, this has been most informative, Dr. Porges. Thank you so much for your time today. And we wish you all the best for your session.

Dr. Porges: Well, thank you.