Lisa Find Love

Clinical Applications of the Polyvagal Theory is another work in the Norton series on interpersonal neurobiology.

I have come to believe that at least three theories are indispensable in learning and understanding how and why we behave the way we do — attribution theory, attachment theory, and our underlying physiology of safety, called the polyvagal theory.

The polyvagal theory was developed by Stephen Porges and presented to the Society for Psychophysiological Research in 1994. The theory takes into account how our autonomic nervous system is constantly working to keep us safe. Very simply, the components are our parasympathetic system (“rest and digest”), the mammalian ventral vagal system (positive social engagement), sympathetic system (“fight or flight”), and the reptilian dorsal vagal (freeze, faint, shut down, dissociate). These all work together to give us an ongoing sense of our surroundings and how to react, what Porges calls our neuroception.

The polyvagal theory is essential knowledge for everyone who works as a therapist, but familiarity with the theory can benefit us no matter what our profession because it deepens our understanding of what is going on with us in the moment. As the theory points out, our neuroception leads to how we perceive, and our perception gives rise to how we live our story.

In his presentation in 1994, Porges emphasized how “mammals had evolved in a harsh environment in which survival was dependent on their ability to down regulate states of defense with states of safety and trust, states that supported cooperative behavior and health.”  This means our natural state is to be on red alert, but our “vagal brake” helps slow our heart rate and move to cooperation, safety and rest and digest — when we sense the conditions are okay for that. Porges gives an excellent overview of the theory at the beginning of the book.

While the theory was not initially developed for use in behavioral health, it has become a centerpiece, particularly in trauma treatment and mindfulness. As Pat Ogden writes in the book, “At its core, polyvagal theory is about love, and identifies the physiology behind it.” Connectedness and safety are the heart of the therapeutic process. Our core, as we learn in practices such as yoga, taijiquan and qigong, is our heart, our breath, and the vascular feedback loop.

The contributors to this book offer a wide range of the applications for polyvagal theory. Bessel van der Kolk discusses his submission to APA’s DSM committee for a developmental trauma diagnosis based on research from various sites that included over 20,000 children. The proposal was rejected. As van der Kolk points out, in the DSM we are left with a variety of “so-called diagnoses” that “capture some aspects of developmental trauma, while none of them provide a clue about what has really gone wrong, nor do they offer any suggestions about what can be done to help patients who have them.” Here, the polyvagal theory has been invaluable for treating developmental trauma.

Applications of the theory include working with traumatized children, people with a fear of flying, pediatric medical trauma presenting as Asperger’s, grief, dance and movement therapy, energy psychology, poetry and PTSD, doctor-patient relationships (you can read this chapter here), nursing, and more.

I was particularly interested in applications for the ICU and for veterinary practices. My father once spent the better part of almost two years in an ICU, and it is a very difficult place to feel safe. And for animals, something as simple as changing the surface of the examining table can have a big impact on how a companion animal reacts at the vet’s office. There are also especially moving and thoughtful chapters by co-editor Deb Dana on the stroke recovery of her husband and by Liza Morton on her congenital heart condition and the impact on her life, with each story telling how polyvagal theory helped with coping.

I highly recommend this book for professionals and the general public alike.  I think those who consider themselves political leaders could especially benefit. I also think about the impact the theory would have when applied to things like economic game theory. It is for anyone who is interested in the underlying physiology on how we come to view the world and how we come to act as we do. We are all on some level seeking connection and safety. We mammals have evolved as social beings, and we truly are all in this together.

Clinical Applications of the Polyvagal Theory: The Emergence of Polyvagal-Informed Therapies
W.W. Norton & Company, June 2018
Hardcover, 464 pages

from Psych Central http://bit.ly/2UK408L

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How do we handle aggression and anger in children? It is a question that has evaded parents, teachers, and child therapists alike.

Often when faced with aggressive behaviors, caregivers tend to focus solely on those behaviors and miss the important messages — and even adaptive strategies — they confer. Conversely, many fear that by allowing the child to express her frustration, we open the door for future combative behavior.

Yet according to Lisa Dion, one of the most important components in helping a child learn to handle her aggression is a child therapist. In her new book, Aggression in Play Therapy: A Neurobiological Approach for Integrating Intensity, Dion draws on the important underlying neurobiological actors that drive aggression to show how, when we mindfully join with the child and offer them a safe space to express their aggression, we offer them the greatest lesson of all: that in their aggression can also be deep healing.

Dion explains, “We live in a culture that teaches children that aggression is wrong. So much of the education on aggression that children receive at school and in their homes is behavior based. In my opinion, we are missing the child inside the behavior.”

Aggression is a behavior, but it is also an attempt on the part of the child to integrate traumatic memory and sensation — and the consequent activation of the sympathetic nervous system — and find a way to regulate themselves.

However, a child learning to regulate themselves in play therapy requires a therapist who doesn’t avoid intensity in play and instead knows how to be with the experience — and themselves — offering the child a model of self-regulation.

“It is also my opinion that many play therapists don’t understand how to manage the intensity of their own bodies so that they don’t develop signs of compassion fatigue or burnout,” writes Dion.

In many ways, play therapy is the perfect place for aggression to be expressed, and Dion notes that when aggressive urges are suppressed in play therapy, children are often forced to express and explore them outside of the playroom.

She writes, “What we suppress, we eventually express. At minimum, children grow up learning not to understand and trust their instincts and impulses, which over time can lead to a disconnected relationships with their bodies.”

One result can be internalized shame, which creates not just confusion, but relational disconnection.

“I am asking you to make the shift from seeing aggression as bad and needing to ‘do something to’ the child to learning how to be with the child,” writes Dion.

To accomplish this, Dion offers six keys: therapists must become external regulators to help modulate the intensity in the playroom; interventions must encourage children to become mindful of the thoughts, feelings, and sensations in their bodies; therapists must model for children how to stay connected to themselves in the midst of intensity; therapists must be authentic and congruent to promote feelings of safety; boundaries must be set when there is a genuine safety concern; and therapists must create a neuroception of safety if emotional flooding occurs to help children get back into their windows of tolerance.

While many events can initiate a threat response, there is one that is especially insidious. Dion writes, “‘Shoulds’ and ‘unmet expectations’ are perceived as a danger to our sense of self…. The number one thing that will block your ability to facilitate children through their aggression are the messages in your head about what you think you ‘should’ or ‘shouldn’t’ do in the moment.”

Moving toward intense and emotional states is how we develop emotional resiliency. When the therapist can act as an external regulator, by offering mindful awareness, they can help children learn to find their own regulation and stay connected to themselves in the process.

“Becoming a play therapist is not just a commitment to the children we work with but also a commitment to ourselves and our ongoing personal growth,” writes Dion.

Therapists must be willing to feel what is happening in their own bodies without suppressing or becoming consumed by the experience, and they must work through their own fears and past experiences related to aggression.

“If we can’t hold our own discomfort, we will have a hard time holding the child’s,” Dion explains.

By spending time in their own bodies, widening their window of tolerance and offering what is known as a “ventral embrace,” therapists offer a rich interpersonal experience to their clients where their nervous systems flow into and back out of synchrony many times.

By attuning to their bodies, feeling — not thinking — their way through play therapy, increasing their window of tolerance and confronting their own beliefs about aggression, modeling regulation and authenticity, remaining mindfully aware and understanding play therapy as a shared experience, therapists will be able to offer the child a space not just to express and explore aggression, but also find profound growth and transformation.

Aggression in Play Therapy would be helpful for every child therapist. Dion does a brilliant job of integrating mindful awareness, polyvagal theory, and a neurobiological understanding of aggression into a comprehensive, thoughtful, and much needed guide for handling aggression in play therapy.

Aggression in Play Therapy: A Neurobiological Approach for Integrating Intensity
W.W. Norton & Company, November 2018
Hardcover, 288 pages

from Psych Central http://bit.ly/2MM1LyM