SELF-REGULATION AND SOCIAL ENGAGEMENT
Stephen W. Porges and Ruth Buczynski
HEART RATE VARIABILITY AND SELF-REGULATION: WHAT’S THE RELATIONSHIP?
Dr. Buczynski: We hear how our unconscious functions—heart rate, respiration—are vaguely related to social relationships such as trust and intimacy. If they are, they would have a huge impact on treatment—our treatment of anxiety, depression, trauma, and even our treatment of autism.
But it’s not just that the nervous system influences our interaction with others. The reverse is also true; our interactions with others influence the nervous system. Stephen, you’ve observed that people who have some stability in their heart rate and people who are more able to self-regulate seem to be different, in terms of how they respond to trauma and other experiences, than people who don’t have stability in their heart rate and can’t self-regulate it.
Dr. Porges: The ability to observe heart rate patterns is literally a portal to watch how our nervous system is regulating our bodies. When the pattern of heart rate is showing nice periodic oscillations, it’s basically telling us that we’re in a good state; it’s reflecting a homeostatic system that is regulating well.
When this system is challenged, the neural feedback—from the periphery, from our viscera, from our heart—to our brain, changes, and is reflected in the vagal regulation of the heart. The vagal regulation of the heart is dynamically reflected in the amplitude of a periodic component embedded in heart rate variability known as respiratory sinus arrhythmia.
Rather than talking about physiological correlates of psychological experiences, think of physiological responses more as a dynamic window of the nervous system’s ability to adjust to various challenges and how our body is reflecting those adjustments.
THE ORGANIZING PRINCIPLES OF POLYVAGAL THEORY
Dr. Buczynski: Your theory provides the organizing principles behind the observation, and I would say that you are tying together some pretty disparate fields, scientific fields and treatment fields. What are your thoughts on that?
Dr. Porges: This has been a lifelong journey to basically understand how our physiology was related to our mental and behavioral states. It has been a wonderful experience, since I have been able to use my research and profession to explore ideas about how our nervous system functions—really how we function in a complex environment.
The concepts underlying the Polyvagal Theory are relatively basic, but they were elusive. They were elusive for decades if not centuries. They were uncovered by a shift in orientation and an attempt to understand nervous system responses to challenges from an evolutionary perspective and to see shifts in physiology and behavior as adaptive strategies linked to survival. For mammals, the adaptive strategies functionally are a recapitulation of our phylogenetic history. It follows how the neural regulation of the autonomic nervous system shifted during vertebrate evolution, especially as mammals emerged from ancient extinct reptiles.
Dr. Buczynski: This evolution is not just the biological evolution, but the genetic evolution.
Dr. Porges: Yes. The systems changed and provided mammals, which we are, with various adaptive functions. So the real issue in understanding the Polyvagal Theory is to realize that humans, being mammals, need other mammals, other humans, to interact with to survive.
The important aspect is really the ability to reciprocally interact, to reciprocally regulate each other’s physiological state, and basically create relationships to enable individuals to feel safe.
If we see this as a theme through all aspects of human development and even aging, then concepts like attachment start to make sense, as do concepts like intimacy, love, and friendship. But then again, concepts like bullying and having problems with individuals or spousal conflict also start to make sense. Oppositional behavior in the classroom starts making sense. Basically, our nervous system craves reciprocal interaction to enable state regulation to feel safe. And disruptions to this ability to have reciprocal interactions become a feature of dysfunctional development.
Now, that being said, people have thought that’s behavioral, not physiological. But the Polyvagal Theory informs us that it is physiological, and that the neural pathways of social support and social behavior are shared with the neural pathways that support health, growth, and restoration. They are the same pathways. Mind–body and brain–body sciences are not correlative; they’re the same thing from different perspectives.
Dr. Buczynski: I want to get you to repeat that: The neural pathways are shared.
Dr. Porges: There are neural pathways of social support. Again, within areas of social psychology and behavioral medicine, people are very interested in how friendships or being near others helps the progression of health or recovery from injury, disease, and other disruptive experiences.
This has been treated as if it were just an issue of—we’ll give people social support. That’s not the real issue; the real issue is that appropriate social interactions are actually using the same neural pathways that support health, growth, and restoration. When a sick person is moved into an environment where that person doesn’t feel safe, you’re doing something harmful, not helpful. So, the bottom line is the understanding that the human nervous system, like other mammalian species, is on a quest, and the quest is for safety, and we use others to help us feel safe.
HOW WE USE OTHERS TO FEEL SAFE
Dr. Buczynski: There is some research from maybe three or four years ago where they were looking at failing-practice physicians, and they recruited a whole bunch of people who were sick and randomly assigned them. Half got a warm connection and empathic listening to their symptoms; the other half got status quo medical treatment with no warmth and kindness. They found that the people who got the warmth and kindness recovered from the flu faster.
Dr. Porges: This makes physiological sense, and it’s missing from our understanding of health care.
Dr. Buczynski: Why does it make physiological sense?
Dr. Porges: It makes sense because of the impact of social behavior on physiological state—the state of our autonomic nervous system. The cues from the safe individual enable the sick or compromised person not to be in defensive states. When we are in a defensive state, then we are using metabolic resources to defend. It’s not merely that we can’t be creative or loving when we’re scared; we can’t heal.
The neural pathway for healing overlaps with the neural pathway for social engagement. To be more specific, this is a vagal pathway that conveys information from the brain to the periphery. It is signaling safety to your body and calming you down.
If the higher-order parts of our nervous system detect risk or danger, then this vagal calming response is retracted and we become prepared for fight/flight behaviors. This occurs through an older phylogenetic circuit, the sympathetic nervous system, that enables defense to occur through mobilization.
Polyvagal Theory informs us that the phylogenetically newest vagal circuit is available only when the body detects features of safety. In addition to calming our visceral state, this circuit enables the face to work; our face can be expressive and our voice can be prosodic. When these features are projected from others, our body calms and our voice and face express positive affect.
Our temporal cortex reads this information as it is projected in the voice and face of others. This area of the brain detects biological movement and reflexively interprets intentionality. If you put a hand over the back of the head of a strange dog, what will happen? The dog may snap at you and attempt to bite you. If you put your hand down in front of the dog, the dog will sniff the hand and interpret your movement as a neutral engagement behavior and not get defensive. The temporal cortex contributes to the interpretation of facial expressivity, intonation, and gesture. This interpretative process leads to a ‘neural’ decision that is not cognitive as to whether the features of the engagement are safe or dangerous.
Dr. Buczynski: What about people who don’t have the ability to read those?
Dr. Porges: Polyvagal Theory informs us that the inability to read these cues is a function of physiological state. Functionally, if a person is mobilized and in a defensive state, it will be difficult for them to detect cues of safety. If a person is “shut down” or dissociated, it will be almost impossible for them to detect cues of safety.
I want to expand this answer and discuss why the Polyvagal Theory evolved. Scientists have understood that there are fight/flight systems and they understood that there are calming systems, but they didn’t understand that the calming system, involving the highly evolved mammalian vagus, was linked to the neural regulation of the muscles of the face and head. That’s an important contribution by the Polyvagal Theory, and it’s also important to understand that the autonomic nervous system predictably reacts as a hierarchy in which the uniquely mammalian vagal system could dampen the sympathetic nervous system. But what was missing or minimized in the literature, was an ancient and old defensive system of shutting down—death feigning—just as the mouse responds in the jaws of the cat.
Through our education and culture, we have been structured to think that humans have only one defense system, a system that increases mobilization and is expressed as fight/flight behaviors. Even our vocabulary limits our ability to understand defense, and we frequently use the word “stress” when our body is in a highly mobilized state of defense.
How do traumatized individuals describe their reactions? If you are stressed, your heart is beating rapidly and you feel tense. But these features are not always described by individuals who have experienced trauma and abuse. When survivors of trauma are interviewed, they often describe their personal experiences to the trauma and abuse as shutting down, losing muscle tone, losing consciousness, and dissociating.
Often when they described these features to their clinicians, the clinicians assumed that the client experience the trauma in a state of stress characterized by activation of the sympathetic nervous system and the associated fight/flight behaviors. This mismatch between the client’s experience and the therapist’s interpretation can disrupt the therapeutic experience with the client feeling that the therapist was not listening or understanding the client’s personal narrative. This is why people who have experienced severe abuse and trauma often have difficulty explaining their experiences. They have a problem because clinicians, friends, and family often don’t have the concept of an immobilization defensive system in their vocabulary.
When we talk about psychobiological treatments or we talk about basic models of stress and fear, people ask, “Are you studying fear?” I say, “Do you mean fear as in when we run away? Or fear as in when we pass out?”
We use psychological constructs, and those psychological constructs do not map well into biological adaptive responses. The reason that I am talking with you now is that people within the trauma field found that the Polyvagal Theory explained several important features of their clients. Before the Polyvagal Theory, they had no explanation of some the features their clients reported.
I was shocked that my ideas, which started with the explanation of bradycardia and apnea in babies, could be translated into the human experience of abuse and trauma. I am pleased that clinicians and clients are using Polyvagal Theory to validate personal narratives of how the body responds to trauma in a heroic manner. They are learning that their body responded in an adaptive way that enabled them to survive.
THREE SYSTEMS INFLUENCE HOW WE RESPOND TO THE WORLD
From my perspective, one of the major contributions of the Polyvagal Theory is the articulation that there are three components of the autonomic nervous system that are hierarchically organized to respond sequentially to challenges.
When we are in safe environments, we efficiently detect cues. We instantaneously process facial expressions, gestures, and vocal prosody. We need to emphasize the importance of a safe environment as a facilitator of these abilities. Sitting in an enclosed environment as we both are—you are in a room with four walls and a door and I’m in a room with four walls and a door—neither of us is concerned about what is happening behind us, and we are not turning our gaze from each other to check for a potential unknown and unsuspected danger. If we were conducting this interview in an open area, our nervous systems would constantly want to look behind us; we would want to identify potential risks.
But there are no risks in our rooms. We have created within our society environments that are defined as safe, because they have a certain amount of structure and predictability. We know that our nervous system wants this; we know that if we can use face-to-face interactions, we can diffuse many misinterpretations of events. Thus, face-to-face interactions are often very helpful in dampening and resolving conflict, especially if the interactions occur in a safe environment.
We also know that our sympathetic nervous system is really not a bad thing. We appreciate it as an enabler of movement, alertness, and exuberance. But if it is used primarily as a defense system, we become dangerous to others and ourselves. When our autonomic state is overwhelmed by our sympathetic nervous system, we in a sense become skittish. We’ll aggressively hit others, and we’ll misinterpret others’ cues. Polyvagal Theory informs us that when the sympathetic nervous system is unrestrained by the myelinated (mammalian) vagal circuit, it becomes a defense system that can disrupt attempts to interact.
But there is another defense system, and that system is the shutdown system, which also has adaptive functions. It raises pain thresholds. It enables an individual to experience horrendous exposure to abuse and not consciously feel it and, thus, to survive.
But there are consequences of that survival strategy. Although mammals evolved to rapidly shift between the social engagement safe state and mobilization associated with activation of the sympathetic nervous system, we did not evolve to shift efficiently between shutting down and mobilization and between shutting down and social engagement.
If you think in terms of people who have been abused, their active defenses, if they can recruit them, are to flail out at people or try to escape from where they are. It is useful to think in terms of a response hierarchy, with each circuit having an adaptive function—each circuit having a useful purpose.
There is a problem when we use the immobilization circuit for defense, since our nervous system doesn’t have an efficient pathway to get out of it. Many people are in therapy because they can’t get out of the immobilization circuit.
THE VAGAL PARADOX
The vagus nerve is involved in shutting down (e.g., fainting, bradycardia, apnea), but it also is involved in social engagement and calming. Actually, the functions of the vagus nerve are paradoxical. The Polyvagal Theory was the product of trying to resolve this paradox.
How can these two processes occur via the same nerve? Can we speculate that this represents when too much of a good thing is bad? This speculation did not make sense to me because of observations in my research with human newborns. I observed bradycardia only in the absence of background heart rate variability. This was perplexing since both the bradycardia and heart rate variability were assumed to be mediated through vagal pathways.
Without robust heart rate variability patterns, bradycardia occurred. This observation sent me into an intellectual quandary. In a sense, being a scientist is a wonderful profession not because of what we know, but because of what we don’t know. Science is driven by questions, and questions can be structured into testable hypotheses.
In this case, the paradoxical functions of the vagus were understood by studying the evolutionary changes in how neural regulation of the heart, or more specifically how the function of the vagus, changed as vertebrates evolved. It is an interesting story, and, as research continues in several fields, the story is still developing. One might think the study of evolutionary changes in the neural systems regulating autonomic function would put someone to sleep, but it’s exciting to identify neural changes in the phylogenetic transition from the primitive, now-extinct reptiles to mammals. Our ancient common ancestor probably had an autonomic nervous system similar to a turtle. What is the primary defense system of a turtle? Shutting down and even retracting the head!
Mammals inherited this ancient neural shutdown system. It’s embedded in our nervous system. We don’t use it often, and when we do, it has several risks. As mammals, we need lots of oxygen, so slowing our heart rate and stopping our breathing is not a good thing. However, if mobilization doesn’t get us out of danger, our nervous system may automatically switch to this system.
The issue, again, is to understand that the physiological circuits or states we may experience are not voluntarily selected. Our nervous system is evaluating this on an unconscious level. I use the term neuroception to respect the role our nervous system has in reflexively evaluating features of risk in the environment.
If you start feeling comfortable with me and my voice has positive prosodic features; my gestures are inviting; I’m not yelling at you; I’m not talking in a deep tone of voice; I’m not lecturing you or forcing you to accept information. If I follow this sequence, you’re going to start listening better and you’re going to calm down. If I talk like most university professors, your eyes will start rolling up, and you’ll lose interest and say that I made a good decision not to become a clinician!
We understand that when we spend more time with ideas and interacting with objects and not people, our ability to relate and interact with people may change. I will bridge these thoughts in a moment. But first, I want to emphasize that Polyvagal Theory uses evolution as an organizing principle to decipher and understand the neurophysiological circuits that regulate biobehavioral state.
Phylogenetically earlier vertebrates had only an unmyelinated vagus, which is a less efficient regulator of physiological state than a myelinated vagus. This unmyelinated vagal circuit provided ancient vertebrates with an ability to defend by immobilizing, which meant reducing metabolic demands, reducing oxygen demands, and reducing food demands.
As vertebrates evolved, a spinal sympathetic nervous system emerged in bony fish. This system supported movement, including the coordinated movement among groups, such as schools of fish. When highly activated, this mobilization system becomes a defense system and inhibits the immobilization circuit.
As mammals evolved, there were changes in the vagus. Mammals have a vagal pathway that differs from their evolutionary ancestors. This new vagal circuit had the capacity to dampen the sympathetic nervous system. By actively inhibiting the sympathetic nervous system, the mammalian vagus could down-regulate fight/flight defenses sufficiently to enable social engagement behaviors to spontaneously occur while optimizing metabolic resources and homeostatic processes. When we are social and are engaged, we are reducing metabolic demands to facilitate health, growth, and restoration.
There is another important issue. When the calming vagus emerged in mammals, the area of the brainstem that regulated the newer myelinated vagus was linked to the brainstem areas that controlled the muscles of the face and head. This brainstem area controls our ability to listen through middle ear muscles, our ability to articulate through the laryngeal-pharyngeal muscles, and our ability to express emotion and intention through the face.
As a clinical psychologist, when you look at clients’ faces and listen to their voices, you are inferring information about their physiological state because the face and heart are wired together in the brainstem. Again, an important clinical observation, especially in treating individuals with trauma, is the covariation of an emotionally flat upper face with a voice that lacks prosody. When these features occur, the client may also have difficulties understanding human voice in background sound while being hypersensitive to background noises.
When we listen to intonation—prosodic features of voice—we are reading the other person’s physiological state. If the physiological state is calm, it is reflected in a melodic voice, and listening to that voice calms us down. Another way of thinking about the relation between vocalizations and listening is to understand that long before there was syntax or language in mammals, there were vocalizations, and vocalizations were an important component of social interaction. Vocalizations convey to conspecifics—members of the same species—whether that individual is dangerous or safe to come close to.
THE VAGUS: A CONDUIT OF MOTOR AND SENSORY PATHWAYS
Dr. Buczynski: Is the vagus nerve a family of nerves or a neural pathway that originates in several areas of the brainstem?
Dr. Porges: There are two ways of looking at this. You can ask the question: Where does the vagus nerve come from? Or you can ask: Where does the vagus nerve go to?
The vagal motor fibers going from the brain to the visceral organs and vagal sensory fibers coming to the brainstem are located in different areas, although they exit the brain in a common nerve that functions more as a conduit. Think of the vagus as a conduit, a cable with lots of fibers in it. The vagus is not merely a motor nerve, meaning that it comes from the brain to the viscera; it’s also a sensory nerve, going from the viscera up to the brain.
Now you have the neural pathways to explain many of the mind–body, body–mind, or brain–body, body–brain relationships. Eighty percent of the fibers in the vagus are sensory. Only approximately one in six of the motor fibers are myelinated. The few myelinated vagal motor fibers are profoundly important in providing the primary vagal motor input to the organs above the diaphragm. Most of the unmyelinated vagal pathways regulate organs below the diaphragm.
There are three vagal pathways, consisting of sensory fibers and two types of motor fibers—motor fibers traveling through the unmyelinated vagus going primarily below the diaphragm (i.e., subdiaphragrmatic vagus) to organs such as the gut, and motor fibers through the myelinated vagus going primarily above the diaphragm (i.e, supradiaphragmatic vagus) to organs such as the heart. In the brainstem the sensory fibers terminate in an area known as nucleus of the solitary track, the myelinated vagal motor pathways originate primarily in the nucleus ambiguus, and the unmyelinated vagal motor pathways originate primarily in the dorsal nucleus of the vagus.
To link these pathways to clinical features, think about the health and behavioral problems of your clients. They may have gut and gastric problems, which may be the product of the unmyelinated vagus being recruited as an immobilization defense system. Subdiaphragmatic problems can also occur when the individual uses the mobilized fight/flight defense system chronically. When this occurs, the activated sympathetic nervous system dampens the ability of the unmyelinated vagus to support homeostatic functions including digestion.
Dr. Buczynski: Polyvagal hierarchy states that there are different zones of arousal affected by trauma. Is that correct?
Dr. Porges: The theory functionally states that if you are confronted with a challenge, based on evolution, the most recent part of your nervous system will attempt to negotiate safety by using the face and vocalizations. If that doesn’t work, the social engagement system will be withdrawn including the vagal inhibition on the heart (i.e., vagal brake), which would increase heart rate to promote mobilization in anticipation of defending with fight/flight behaviors. If that doesn’t work, then you’re going to ramp up the sympathetic nervous system for fight/flight.
If you can’t escape or fight, then you may reflexively shut down. This is a feature of many trauma narratives, especially with small children and other situations in which there is a size differential or if the survivor is confronted with an assailant with a weapon.
Basically, signals of risk may be translated by different neural circuits into different physiological states and behaviors. These variations in responses to a common signal or event leads to one the most difficult problems in treating trauma. Trauma treatment and diagnosis have been focused and biased on the event and not on understanding that an individual’s response to the event is the critical feature.
THE CONNECTION BETWEEN TRAUMA AND SOCIAL ENGAGEMENT
The critical point is that if people go into a state of immobilization with fear, they are using a very ancient neural circuit. Through evolution, the human nervous system has been modified, and these modifications appear to hamper the ability to easily transition out of the immobilization-with-fear state back to a safety state characterized by spontaneous social engagement behaviors.
When stuck in states that do not promote social interaction and a sense of safety, individuals develop complex narratives of why they don’t want to socially interact and why they don’t trust others. There narratives provide an interpretation of their visceral physiological feelings. Their nervous system is detecting risk when there is no real risk, and their narrative provides their justification for not being loving, trusting, and spontaneously engaging.
When this occurs, how do you get a person out of that loop of defense and justification? How do you recruit the social engagement system and inhibit both the sympathetic mobilization fight/flight state and enable the person to come out of the dangerous immobilization shutdown state? In response to this question, insights from the Polyvagal Theory are moving into the clinical world.
From the Polyvagal perspective, first the client needs to negotiate and navigate in any environment to experience a physiological state of safety. Often it has to do with the proximity to the therapist. In a sense, the client with a trauma history may react to the therapist as dangerous. The clinician needs to empower the client to navigate and negotiate in both physical and psychological space until the client feels safe. Once the client feels safe, there will be a concomitant shift in the client’s physiological state. When this occurs, spontaneous engagement behaviors will emerge with changes in voice and facial affect.
I suggest two points to clinicians. First, empower the client to negotiate safety. Second, understand the principles of neuroception that enable us to understand that the nervous system, in safe environments, will respond to certain features differently than it will in dangerous situations.
Since noisy environments that contain low-frequency sounds are triggers of predator to our nervous system, removing low-frequency sounds and background noise will optimize the healing potential of the clinical space. It is important for the clinical space to be relatively quiet. Many clients with a trauma history are extremely uncomfortable in public places. Often they don’t want to go to restaurants or movie theaters. When they walk in shopping malls, they feel threatened and overwhelmed by sounds, vibrations, and proximity to others. The low-frequency sounds and vibrations from the escalators bother them. If we know this, why don’t we create environments where they will feel safer?
Once the client feels safe, the therapeutic strategy may proceed efficiently. But how would we trigger the social engagement system to ensure that the client is feeling safe? Some options are wired into our nervous system. For example, listening to the prosodic features of sound, such as listening to vocal music even without another person, may make us feel safer.
HOW MUSIC CUES VAGAL REGULATION
Listening to vocal music was part of an intervention that I developed. The Listening Project Protocol (see Chapter 2) was initially implemented with autistic individuals. The intervention exercises the neural regulation of the middle ear muscles by exaggerating the processing intonation of voice, and that feeds back as a cue to a nervous system that they are in a safe place, which changes that vagal regulation of the heart.
Dr. Buczynski: What do you do in the music project?
Dr. Porges: I computer-alter vocal music. Vocal music, especially female vocal music, uses intonation without low frequencies. The computer processing of the vocal music emphasizes and functionally amplifies the modulations. This is equivalent to exaggerating prosody, which would efficiently trigger the neural circuit that detects and responds to prosodic voices.
The intervention was theoretically designed to trigger the neural circuits that detect prosody, which trigger descending neural pathways that would increase the neural tone to the middle ear muscles to dampen background sounds and improve the ability to understand human voices. Since the brainstem areas regulating the middle ear muscles are also involved in regulating facial expressivity, prosodic vocalizations, and vagal influences to the heart, the listening intervention was designed to stimulate the integrated social engagement system.
For 15 years, I had a plausible hypothesis, derived from the Polyvagal Theory, that linked the neural regulation of middle ear structures to hyperacusis and auditory processing. Specifically, I hypothesized that shifts in the neural regulation of middle ear muscles would deterministically shift the transfer function of middle ear structures providing a plausible mechanism explaining why auditory hypersensitivity covaried with difficulties in the processing of human speech. However, although the Listening Project Protocol reduced both auditory hypersensitivities and improved auditory processing, there was no device or test available to measure the transfer function of the middle ear and test this hypothesis. This problem was solved by my former graduate student, Greg Lewis. By 2011, Greg Lewis had finished his PhD research in my laboratory, in which he developed a device that measured the transfer function to middle ear structures. It was a concept that was missing from speech and hearing sciences. We call the device the Middle Ear Sound Absorption System, or MESAS (Porges & Lewis, 2011).
Now we are able to objectively evaluate which sounds pass into the brain or are bouncing off the eardrum. MESAS (see Chapter 2) documents whether people are absorbing human voice through their eardrum or whether these sounds are being masked by absorbing the low-frequency sounds that our nervous system interprets as predator sounds. Visualize the eardrum as a kettledrum. When the skin on the kettledrum is tightened, the pitch goes up, meaning that higher frequencies are selectively absorbed and lower frequencies are not.
MESAS provides an objective measure of auditory hypersensitivity. We have tested MESAS with several children with a diagnosis of autism. We also have tested others with a history of trauma, who frequently report auditory hypersensitivities. In preliminary research, we documented that the absorption in the frequency band of the human voice was diminished, especially in the frequency band of the second and third formants of human voice. Formants are concentrations of acoustic energy at specific frequencies that correspond to resonance frequencies of the vocal tract. People with auditory hyperacusis absorb more of the low frequencies, while the higher-order formants that enable us to distinguish various vocal sounds are distorted. The ability to process these higher-order formants contributes to an ability to distinguish consonants and to process the ends of words.
We tested several of our participants before and after the Listening Project Protocol. In a subset of these participants, middle ear transfer function was normalized. This meant that in some of our participants we were able to rehabilitate the neural regulation of the middle ear muscles. MESAS provided documentation of a change in the sound absorption curve, meaning that more of the frequencies associated with human speech were absorbed. Before these observations, clinicians assumed that hyperacusis and difficulties in auditory processing were determined by neural circuits located in the cortex. They did not understand the role of the middle ear structures as a filter nor its role in the social engagement system, which linked auditory processing and hyperacusis to difficulties in behavioral state regulation and other features of the social engagement system.
About 50 percent of the participants in our Listening Project Protocol studies, who entered the study with auditory hypersensitivities, no longer had auditory hypersensitivities after the intervention (Porges et al., 2014). Most of this subset of participants also had improved social engagement behaviors. In another study, we documented that the improved social engagement behaviors were paralleled by an increase in vagal regulation of autonomic state, supporting the plausible hypothesis that changing autonomic state with the intervention functionally changes the neural platform for social engagement behaviors, reducing defensive behaviors (Porges et al., 2013).
Dr. Buczynski: How about music therapy? Does that have any effect?
Dr. Porges: Yes. There are two parts of music therapy that would be very helpful to many individuals. The issue with music therapy is that the mechanisms through which it works are not understood. Although there are positive reports, there is no real strong theory of why or how it works. However, the Polyvagal Theory with its linkage to the middle-ear muscles and linkage to laryngeal and pharyngeal muscles, which are involved in singing, could be used to explain how it works and why it would be beneficial.
When people sing, they control their breath. The process of singing requires expanding the duration of exhalation. During the exhalation phase of breathing, there is an increase in the effectiveness of the myelinated vagal efferent pathways on the heart. This explains how singing or playing a wind instrument would contribute to a calmer physiological state and provide greater access to the social engagement system.
Singing is more than just exhaling. What else do you do when you sing? You listen and this increases the neural tone of your middle ear muscles. What else do you do? You utilize the neural regulation of your laryngeal and pharyngeal muscles. What else do you do? You utilize the muscles of your mouth and face through the facial and trigeminal nerves.
If you sing with a group, then you’re social referencing—you’re engaging others. So singing, especially singing in a group, is an amazing neural exercise of the social engagement system.
Playing a wind instrument is very similar and involves listening, exhaling, and engaging whoever is leading or conducting the music.
Pranayama yoga is another strategy that employs similar processes. Pranayama yoga, functionally, is yoga of the social engagement system—yoga of breath and of the striated muscles of the face and head.
SOCIAL ENGAGEMENT SIGNALS: SELF-REGULATION VERSUS “HAVING NO CLUE”
Dr. Buczynski: Awhile back, we were talking about why some people need those social engagement signals and other people just have no clue—as if it’s a foreign language and they’ve just immigrated to a foreign country.
Dr. Porges:. Let’s start off by forgetting that we have all these complex diagnostic categories. If we use diagnostic categories, we end up describing comorbidities and using other terms that are not helpful in understanding the underlying functions and processes.
Let’s create a very simple model of human behavior. Let’s rank people based on their ability to co-regulate with other individuals along a continuum. This is really what you’re saying: Some people don’t have a clue about other people’s features, and what it’s telling you is that their ability to co-regulate their physiological state is really not good with other people.
Now, let’s create another dimension. Let’s ask about people who self-regulate with objects. Remember that in our contemporary society, technologies for social communication are literally being pushed on us by people who are challenged in terms of their own social communication skills and their ability to co-regulate with others. We label this new technology social networking. We use computers. We text with a smartphone. In a sense, we are stripping the essence of human interactions, direct face-to-face experiences, from human interactions. We’re moving from a synchronous interactive strategy to an asynchronous one in which we leave messages and look at people later. We are allowing the world to be organized based upon principles of individuals who have difficulty regulating their biobehavioral state in the presence of others but who may regulate well with objects.
In a very global clinical perspective, many of the disorders that therapists are actively requested to treat are about difficulties regulating state with others. When individuals have difficulty regulating state with others or co-regulating, they adaptively gravitate to regulating state with objects.
Sometimes these tendencies lead to clinical labels. Whether it is labeled autism or social anxieties doesn’t really matter. What we know is that these individuals’ nervous systems are not enable to engage in reciprocal social interactions. It is rare for them to feel safe with people and get into that, beneficial physiological states that enable social behavior to support health, growth, and restoration. For these people, social behavior is disruptive and not supportive. Individuals may self-select into two different groups that are categorized by either regulating through social interaction or through the use of objects.
A secondary problem is the impact of these two strategies on the education and the socialization of children. Changes in education are moving away from face-to-face interactions. Schools now are putting iPads in the hands of preschoolers and elementary school children. I was watching a recent newscast of a school in which iPads were being used in elementary school. The school officials were extremely proud of this decision to embrace this technology. When the camera scanned the classroom, the children were looking at the iPads and not looking at each other or at the teacher.
What does this really mean? It means that the nervous system is not having the opportunity to exercise the neural regulatory circuits associated with social engagement behaviors. Without opportunities to exercise these neural circuits, children will not develop the natural capacity to self-regulate and regulate with others when challenged.
Another important point here is what happens to the school systems. Under the pressure in our cognitive-centric, cortical-centric world, we are bombarded an increasing amount of information without understanding that our nervous system needs to be in a physiological state regulated by the myelinated vagus to process information sufficiently to generate new bold ideas, to be creative, and to experience positive social behavior. Rather than enabling these expansive and positive attributes of the nervous system with group behaviors requiring co-regulation such as singing in a choir, playing a musical instrument in an orchestra, or physically playing with another during recess—all opportunities to exercise the social engagement system and the myelinated vagal pathway—we misinterpret these opportunities for neural exercise as distracters from the opportunity to sit longer in the classroom. The students get more information, of course, but the information is not being efficiently processed, and oppositional behaviors are popping up. It’s a naive view of the educational process and human development.
I think this line of inquiry should lead to questions about early experience, the consequences of those early experiences, and how early experiences may lead to other risk factors. We should approach these questions from neural, developmental, and even exercise models. For example, if we don’t use specific neural circuits in regulating behavior and physiology, they will not develop well. It doesn’t mean that we are so pessimistic that we can’t recruit them later; it means that because we haven’t recruited them early, there are going to be consequences.
RECRUITING NEURAL REGULATION
Dr. Buczynski: How do we help someone who hasn’t recruited them learn how to recruit them?
Dr. Porges: The first thing, of course, is the context of safety. I was going to say depending upon the age of the client, but actually, regardless of age, the first thing is to convey to the client that they did not do anything wrong. As soon as we ask a client to change, the client often interprets this to mean that they did something wrong. Once this “critical” feedback is processed by the nervous system, the nervous system might switch into a state of defense, which will make it more difficult for the client to understand and maintain a calm state. So, there’s a total paradox between how our nervous system functions and how we raise our children, teach our students, and treat our clients.
If we want individuals to feel safe, we don’t accuse them of doing something wrong or bad. We explain to them how their body responded, how their responses are adaptive, how we need to appreciate this adaptive feature, and how the client needs to understand that this adaptive feature is flexible and can change in different contexts. Then we can use our wonderfully creative and integrative brain to develop a narrative that treats our atypical behaviors not as bad, but as understandable in terms of adaptive functions that may often be heroic.
HOW ATTACHMENT THEORY CONNECTS TO ADAPTIVE FUNCTION
Dr. Buczynski: How does attachment connect to the Polyvagal Theory?
Dr. Porges: This is a frequently asked question and the answer is partially linked to Sue Carter’s research. Sue is both my colleague and wife. Sue discovered the relationship between oxytocin and social bonding. For several years, I would say that the study of social behavior, including social bonding and attachment, was her research area and not mine. She developed her ideas about social bonding by observing and conducting research with the prairie vole, a small rodent with very interesting social behavior, including pair-bonding for life and a parenting style in which father and mother share in the care of their offspring. The vole is quite an amazing animal.
The prairie vole has a high level of oxytocin, and for the past few years, we’ve been doing research together in which we measure in the vole vagal regulation of the heart. This small mammal, weighing approximately 50 grams, has vagal regulation of the heart at levels very similar to humans, which is very atypical for rodents and small mammals.
Since I started to collaborate with Sue, I have started to feel more comfortable discussing social behavior, including the area of attachment. But as we started to collaborate, I realized that an important setting condition leading to attachment was missing in the attachment literature. Missing is what I called the preamble to attachment, and the preamble to attachment is dependent on the signals of safety. I felt that one couldn’t discuss issues of attachment without discussing safety and the features of social engagement. From my perspective, the social engagement system with the myelinated vagal pathway provides the neural platform upon which attachment processes can occur. It’s a hierarchy. First safety, then healthy attachment would naturally follow.
Sue and I having been working on a concept that we call the neural love code. The love code has two parts: Phase one is social engagement, which uses cuse of safety via engagement behaviors to negociate proximity. Phase two deals with physical contact and intimacy. To articulate this as a code would mean that if the two processes do not occur in the right order, there would be problems associated with attachment and bonding.
I think, from a clinical perspective, that people bonding to each other without feeling safe with each other can be one of the driving forces for couples to come to therapy. The point I am emphasizing is that attachment should not be discussed on any level, whether it is theoretical or practical, without a thorough understanding of the setting—the conditions of safety and social engagement.
MAKING HOSPITALS MORE PSYCHOLOGICALLY SAFE
Dr. Buczynski: I want to ask you about hospitals and making hospitals more psychologically safe. Hospitalization is a time when we would hope that our facilities and the way we organize them would enhance healing processes and the immune system functioning. But I’m not sure that we are the best at that because we’re focusing so much on other things.
Dr. Porges: I think this is an important question, and of course the answer is that very little effort has gone into this. Those of us who have been hospitalized can tell you the situation of being awakened every hour, dressed in a revealing gown, and the chronic noises that provide a continuous signal to your body to get out of the hospital because the hospital is not safe.
The issue has a lot to do with who organizes hospitals and sets their agenda. What are the goals of hospitals and their staffs? They are there to deliver health services to patients and to protect staff from being sued for malpractice. Within this agenda, health surveillance and cleanliness are prioritized. Other issues such as social support tend not to be treated as important, which is tragic.
When we are admitted into a hospital, our nervous system functionally informs us with cues that trigger thoughts consistent with the narrative: “I’m going into a physical situation where I cannot protect myself. I want to be assured that I’m in safe, loving hands.” Unfortunately, most patients do not feel safe in hospitals.
I think it is really tragic, because there are so many well trained and loving clinicians in medical and allied health areas who could create a different type of clinical setting for people going into hospitals.
Rather than being overwhelmed with documents to sign that release the hospital from legal responsibilities—because you can’t get the service unless you sign—why not have someone who functions like a concierge for your body to help you navigate through the hospital? This person could take you to the hospital and take the burden of hypervigilance from you. With these burdens and uncertainties removed, your body could be a willing collaborator with the medical treatments instead of frightened and locked in a state of defense.
The issue, as we discussed very early in the interview, is that if you’re frightened and if you’re scared, you’re not going to heal efficiently. If we know this, why don’t we do whatever we can to make people feel safe?
We need to realize that as human beings, we require reciprocity and feeling safe.
Dr. Buczynski: Before we close, I just wanted to ask you, Stephen, what’s next for you?
Dr. Porges: I think of myself as a mature scientist who has done some interesting research, and I intend to do many more new interesting things. I intend to continue working to translate my basic research into clinical practice. For example, rather than thinking that medical treatments can only be surgical or pharmaceutical, we will be developing interventions that recruit the neural circuits that support health, growth, and restoration.