As we all learned in school, we have two options in the face of perceived danger: fight or flight. But that was before neuroscientist Stephen Porges, author of The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation, undertook his research into the relationship between human physiology and social engagement.
Porges’s work—which noted researcher Paul Ekman called “a truly revolutionary perspective on human nature”—dramatically broadens our understanding of the sympathetic and parasympathetic systems, and explains how our bodies and brains interact with one another to regulate our physiological states. However, what may be more pertinent to therapists is the extent to which our autonomic nervous systems influence long-term issues with intimacy and trust. In the interview that follows, Porges offers some research-based insights into how therapists can more effectively convey safety to clients and clarifies the evolutionary roots of anxiety, depression, and trauma.
RH: Can you explain your Polyvagal Theory in simple terms?
Porges: It’s hard to make it simple, but let’s try by starting with what we’ve all learned about the autonomic nervous system. It’s a pair of antagonistic systems: the sympathetic supports mobilization, and the parasympathetic supports immobilization, usually associated with relaxation, growth, and restoration. In the past, we tended to believe that stress responses were, in general, vested within the sympathetic nervous system’s capacity to support fight-or-flight behaviors. But there’s another defense system, unrelated to the sympathetic nervous system and dependent on the parasympathetic nervous system. The mechanisms and adaptive function of this defense system are impossible to understand from the paired antagonism model. The parasympathetic defense response is mediated through a vagal circuit producing a behavioral shutdown such as fainting or, from a clinical perspective, dissociation. This defense system doesn’t fit within the fight-or-flight model. Nor does it fit within the view that the vagus, the major nerve in the parasympathetic nervous system, mediates calmness and induces resilience and health.
RH: Your work suggests that our autonomic systems are better thought of as hierarchical, rather than competing.
Porges: Right. The vertebrate autonomic nervous system has changed through stages of evolution, and the human autonomic nervous system shares several of these autonomic circuits with more ancient vertebrates. Functionally, our autonomic nervous system is composed of three phylogenetically organized subsystems. We utilize our newest systems first, and when they don’t work, we recruit older ones. In terms of evolution, the newest autonomic circuit is a uniquely mammalian vagal circuit, which inhibits the heart rate by placing a tonic inhibition on the heart’s pacemaker. This circuit also inhibits sympathetic activity. The brainstem areas controlling this neural pathway coordinate the nerves controlling the muscles in the face and head. So people are literally showing their heart on their face. That’s because humans are social beings who have to convey to one another that we’re safe to come close to, to hug, and in some cases, to have sex with. To convey this message of safety, we utilize the newest vagal circuit to down-regulate our sympathetic defenses and present cues of safety when it’s appropriate. While the face is a crucial vehicle for this, the voice also plays an important role in conveying a physiological state of calm. If the voice has a higher-pitched frequency, it’s saying, “Don’t come near me.”
The thing to bear in mind is that the vagal circuit is both expressive and receptive. That’s why you feel calmer when I use a soothing, prosodic voice. When the vagal circuit is working, our middle-ear muscles change our capacity to hear predators or low-frequency sounds. Middle-ear muscles, similar to the muscles of the face, are regulated by the brainstem area that controls the mammalian vagal circuit. Typically, when there’s something in the environment that threatens us, we turn off the vagal circuit, because it inhibits our ability to mobilize: it gets in the way of moving to fight or to flee.
RH: That’s because it’s the vagal system that makes us freeze, right?
Porges: Yes, but there are two vagal systems. The root of the Polyvagal Theory is the recognition that in the absence of the ability to fight or flee, the body’s only effective defense is to immobilize and shut down. This can be observed as fainting or nausea, both features of an ancient vagal circuit that reptiles use for defense. However, unlike the uniquely mammalian vagal pathway, these vagal pathways are unmyelinated, and are only effective as a defense system when the newer circuits, including the sympathetic nervous system, are no longer available for interaction and defense. Our reptilian ancestor was similar to a turtle, and the primary defense for a turtle is to immobilize, inhibit breathing, and lower metabolic demands. Although immobilization may be effective for reptiles, it can be life-threatening for mammals, and for humans it can lead to states of dissociation. The Polyvagal Theory provides a way of seeing how the organization of our nervous system can shape our understanding of clinical disorders and issues, enabling us to see symptoms like dissociation not as bad behaviors, but as adaptive reactions to cues in the environment that trigger our physiological responses to perceived dangers.
Think about it this way. When you want to calm a person down, you smile and talk to them in a soothing way. The nervous system detects these cues and down-regulates or inhibits the sympathetic nervous system. But when the sympathetic nervous system is activated as a defense system, it turns off all those social-engagement behaviors. Clinicians are aware of that. But what they often don’t understand is the role of the vagal system in shutting down as a defensive strategy in response to a life threat. When someone is immobilized, held down, or abused, the vagal system is triggered, and they may disassociate or pass out—or perhaps drop dead or defecate. It’s an adaptive response.
I often talk about immobilization with fear and contrast it to immobilization without fear. The mouse in the jaws of a cat is immobilized with fear. The mouse isn’t voluntarily playing dead; it’s fainted. But someone in the embrace of a lover, parent, child, or friend is immobilized without fear.
RH: We might call that stillness, or peace.
Porges: Right, you’re still, but you’re being present. For reptiles and more primitive vertebrates, the primary defense system was to disappear—to immobilize, stop breathing, and look like you’re dead. For mammals, immobilization is a risky business. We have to be selective about whom we can feel still, calm, and comfortable with.
Many clients have difficulty feeling comfortable in the arms of another. They can’t immobilize without fear. If you go through their clinical histories, you’ll find that many were severely abused and had experiences of being forcedly held down. These experiences of forced immobilization trigger fear responses and shutting down. Those who survive these experiences don’t want to be immobilized and find it difficult to be held and calmed, even by people who are trying to be helpful. This response is often expressed as anxiety and a need to keep moving, which is a functional defense to a fear of immobilization. Often individuals with a history of immobilization with fear will adaptively become anxious and go into panic states to avoid this immobilization state. This is a problem many therapists see in their practices.
RH: What are the practical implications of Polyvagal Theory for clinical work?
Porges: It heightens our appreciation of the role of creating safety in therapy. For example, our bodies, physiologically, are extraordinarily sensitive to low-frequency sounds. We, like other mammals, interpret these low-frequency sounds as predatory. If your clinical office is bombarded with sounds from ventilation systems, elevators, or traffic sounds, your client’s physiology is going to be in this more hypervigilant defense mode. Likewise, if you sit some people in the middle of the room away from a wall, they may become hypervigilant and concerned with what’s going on behind them. If we’re not safe, we’re going to assume that neutral faces are angry faces. We’re going to assume the worst because that’s what our nervous system tells us to do. As vertebrates evolved into mammals, they had to interact with other mammals for survival. They needed to detect the social cues and identify when it was safe to be with another mammal. Thus, vocalizations in social contexts are less about syntax and language and more about the intonation conveying emotional state. Again, this is critical in therapy because the intonation of voice conveys more information about the physiology of the client than the syntax.
RH: In other words, how you’re saying something means more than what you’re saying.
Porges: Absolutely. When you were an undergraduate, what were the lectures that put you to sleep? Was it the college professor who was off in space, who basically read from notes and had no prosodic features and no engagement? Social communication has little to do with syntax and a lot to do with intonation, gestures, and a cluster of behaviors we would call biological movement. The face is moving along with the voice and hand gestures. The behavioral features trigger areas of our brain outside the realm of consciousness and change our physiology, enabling us to feel closer and safer with another. Good therapy and good social relations, good parenting, good teaching, it’s all about the same thing—how do you turn off defensiveness? When you turn defense systems off, you have accessibility to different cortical areas for more profound understanding, learning, and skill development.
Ryan Howes, PhD, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs for “In Therapy” at Psychology Today. Contact: firstname.lastname@example.org; website: www.ryanhowes.net.
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Q: One of my European colleagues is excited about “mentalization” and Mentalization-Based Treatment. What is it?
A: Mentalization refers to the mind’s innate capacity to make sense of social experiences and implicitly know how to respond to them. Think about the following examples. You arrive home and say, “Hi” as you open the door. Your partner says, “Hi” back. Without a second thought, you’re aware of the tension in his voice that suggests he’s had a hard day. Or after a meeting with an old friend, you experience an uneasy feeling. Reflecting on your time together, you realize that you’re feeling bad because your friend takes a superior attitude with you.
Mentalization enables us to understand the intention or purpose behind other people’s behavior from their tone of voice, facial expression, and body posture. Therefore, when someone comes toward us wearing a grimace and hunched shoulders, we “get” that he or she is upset and perhaps angry. We instinctively recognize that mental states—thoughts, feelings, beliefs, or attitudes—underlie almost all behaviors.
This concept was introduced into the clinical literature by Peter Fonagy of the Anna Freud Centre in London in the 1990s. In a series of papers, including “Thinking about Thinking” in 1991 and “Playing with Reality” with Mary Target in 1996, he explored the theory of mind’s central role in the development of a sense of self. Drawing on clinical studies of borderline personality disorder and violent behavior, he argued that the failure to read and get the implicit meaning of another’s actions led to the loss of impulse control, an unstable sense of self, and problematic relationships. In the last 20 years, the mentalization model of mind has gone from being an obscure aspect of Attachment Theory to the centerpiece of Mentalization-Based Treatment (MBT) for borderline personality disorder. It’s now being integrated into treatments for addiction, trauma, eating disorders, and other conditions. But how does it work?
While mentalization fosters an empathic awareness of the moods and mindsets of others, it also enables us to know what our own states of mind and body mean. Our brain–minds assemble information about the state of our body, the input of our senses, and our associative memories to grasp our own intentionality. We mentalize explicitly by reflecting on experiences, conscious narratives, and empathic communication with others. Our “social brains” have evolved over the eons to become highly specialized in “reading” others’ minds, and our own. Menninger Clinic psychologist and mentalization expert Jon Allen and colleagues believe that mentalization is at the heart of emotional and social intelligence, and is central to all interpersonal experience.
Fonagy asserts that mentalization represents the epitome of human cognitive evolution and is the foundation of all effective psychotherapy. In fact, research has shown that when people lose their ability to mentalize their experience—usually in the context of high affect and threats to emotional security—they have a hard time making sense of other people’s behavior and their own. They become reactive, impulsive, and self-centered, and lack perspective.
Fonagy’s early work examined the development of borderline personality disorder. He found that people who became borderline had fragile mentalizing capacities and were vulnerable to breakdown in close interpersonal situations. The research also revealed that these people had often grown up in families that inhibited mentalization skills. In abusive families, for instance, high levels of frightening feelings overwhelm and shut down children’s capacity to think about what’s happening. In addition, children may avoid reflecting on their parents’ intentions, since it could be terrifying to understand their confusing and, at times, hateful feelings toward them.
These findings dovetail with similar data generated by the Adult Attachment Interview, developed by psychological researcher Mary Main. She found that individuals who are able to reflect on their relationships with their parents with perspective and understanding were likelier to be secure in their attachments to others and have securely attached children.
Rather than being an entirely new form of treatment, mentalization-based therapy contributes to our understanding of what happens in many different approaches. Fonagy argues that achieving more stable and robust mentalization constitutes success in most treatments because it enables people to regulate their own moods more effectively and think coherently about themselves and what they want. By focusing on mentalization as a skill, therapists help clients understand more of the connection between how they feel, what they want, and how they act by themselves or with others.
Mentalization encourages a nonjudgmental attitude of curiosity, inquisitiveness, and open-mindedness toward the client’s subjectivity. Rather than assuming a role of expert, the therapist adopts a “not-knowing” stance, founded in the belief that we come to know what it’s like for another by inquiry, not by assumptions or formulations or by explaining clients to themselves. It’s a here-and-now, process-oriented approach. The therapist encourages the client to think about his or her experience, the goal being to learn to “think about feeling, and feel about thinking.” The therapist guides the client to step back and take perspective on their experience together in therapy: “Yes, that’s one possible meaning; what are others?” “How do you imagine it looks from my point of view?” He or she listens to the client’s narrative and seeks to explore the aspects that are being neglected.
Some critics have wondered what’s gained in using the term mentalization as opposed to empathy, psychological mindedness or affect awareness. Some find Daniel Siegel’s idea of mindsight a friendlier term referring to many of the same functions. But in my own practice, a focus on mentalization has deepened my understanding of the balance between affect and cognition and the need to integrate these aspects of experience. Of course, we all know, theoretically, that the therapeutic connection is at the heart of all good therapy, but understanding the moment-to-moment processes of mentalization can deepen a therapist’s understanding of just how shifts in the relationship can lead to lasting therapeutic change.
Steven Krugman, Ph.D., is a psychotherapist in Boston. He teaches about Attachment Theory and interpersonal neuroscience, and is on the faculty of the Psychoanalytic Family and Couples Institute of New England. Contact: firstname.lastname@example.org. Tell us what you think about this article by e-mail at email@example.com.
Explore with renowned clinician Dan Siegel how applying the latest advances in the neuroscience of child development to clinical practice can have practical implications for parents and families. You’ll discover how therapists can help parents raise calmer, happier children by teaching kids to think and listen before reacting, shifting their emotional states through physical activities, and paying attention to their left brain story-telling.
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