So how do these findings apply in the context of psychotherapy?
Doidge: It turns out that learned nonuse also happens when a certain kind of a psychological process gets you to engage in one behavior, cognitive operation, or kind of interaction and not another. Thus, your knowledge of the thing you’re not doing, or the side of yourself you’re not exercising, can atrophy, especially if it’s a psychological defense. Just having an insight into the defense isn’t sufficient. A good psychotherapist has to be attuned to the developmental issue a person is facing because, if the learned nonuse goes far back, the person can be almost infantile in that area of functioning.
Another important principle for therapists to understand in applying neuroplasticity in the therapy room is what I call the plastic paradox. We know that neurons that fire together wire together. If you do something that’s good for you, the circuitry will fire faster, stronger, and more clearly. Over time, it’ll take up more cortical real estate and become your default circuitry in some situations, but it’s also true that if you do something that’s bad for you, the same thing happens, so neuroplasticity explains bad habits, addictions, and patterns that we can’t easily break.
When I explain this to patients, I tell them neuroplasticity is like snow. The first time you go skiing down a mountain with fresh snow on it, you can take almost any path you want, as long as there aren’t any trees or rocks in your way, but if you had a good run the first time, the next run tends to be very close to that one. Eventually, if you keep it up, you’ll develop tracks in the snow that become harder and harder to get out of.
The plastic paradox accounts for both our flexibility when we choose to do something for the first time as well as our symptomatic rigidity. Each time we respond to a trigger in a particular way, we actually deepen the neural circuitry supporting it. Each time you do the thing that’s bad for you, like go into another relationship with someone who treats you in a demeaning way, you’re going to deepen that pattern.
So what has your understanding of neuroplasticity taught you as a therapist about changing habit patterns?
Doidge: Sometimes I think it’s good for therapists to do with their clients what Taub does with his neurological patients. If a client has a behavior that’s not serving her well right now and another one that’s underdeveloped, you need to put a kind of a cast on that problematic habitual behavior and help her exercise the one that’s harder to do. But first she has to understand that it’s possible and have a sense of how much effort is going to be required. She also has to know that she needs to pay attention while she’s engaging in the new behavior or thought pattern, because the best and the quickest way to get neuroplastic change is by paying close attention. I’ve seen people defeat bad habits, severe anxiety-disorder issues, and obsessive-compulsive disorder by understanding that they can drive brain change in a positive direction using their own minds.
Of course, I don’t believe that the discovery of neuroplasticity somehow replaces all of our other therapeutic skills. Nevertheless, the understanding of neuroplasticity makes you realize that talk therapy is more than just talk. In fact, the right kind of therapeutic talk can be seen as just as much of a biological intervention as medication. When you get people to focus on their key issues, those parts of the brain that are involved in the conflicts or difficulties are being triggered as they talk about them. As psychoanalyst and psychiatrist Susan Vaughan has said, psychotherapy is like microsurgery, in that we’re getting precisely at the circuitry required to make change.
For that reason, I think hypnosis, which can help people to pay sustained attention to different aspects of their own functioning, is good for taking people out of automatized behavior. Be it with smoking or a problematic way of thinking about themselves, hypnosis can be effective at quickly getting people past the circuitry that supports bad habits and creating new paths into another kind of circuitry or mental set.
As a therapist, I use my understanding of the plastic paradox to make sure that in each of my sessions, in so far as it’s possible, neither I nor my patient are making their problem worse.
Where do you see the next great advances in psychotherapy coming from?
Doidge: I think a lot of the newer methods in our field—approaches like recent developments in hypnosis, hypnoanalysis, brainspotting, and eye movement desensitization and reprocessing—are good at helping people get into different states quickly. When that happens, rather than reinforcing the problem or inadvertently retraumatizing people, it’s amazing how fast certain aspects of change can occur. But we need to bear in mind that the brain isn’t a machine and can’t be changed by just moving a couple of wires around. Neuroplasticity teaches that change is still something we need to grow into.
Stephen Porges on Signaling Safety
Can you give a nontechnical explanation of Polyvagal Theory and why it matters to therapists?
Stephen Porges: Polyvagal Theory begins with the recognition that mammals come into the world needing other mammals to take care of them and interact with them. So we have to convey to each other that we’re safe to come close to, and we have to utilize others to help us self-regulate. When we come into the world, we have to functionally trick the nervous systems of our parents into saying, “This baby is cute; I want to take care of this child.” Throughout life, we have to continue to functionally trigger the nervous system of others in our species into saying, “I’m safe and it’s OK for me to hug you, to have sex with you, and to reproduce with you.” What makes human civilization possible is our ability in the appropriate context to present the cues of safety to each other to down-regulate defensiveness and, thus, make further interaction possible.
The face and the intonation of the voice are critical vehicles for conveying our physiological state to each other so that we can determine whether we present a threat. If a person’s voice is prosodic, it’s conveying to others that their physiological state is calm. But if a person’s voice is higher in pitch with a narrow frequency, it’s saying, “Don’t come near me.” Why would you feel calmer when I use a prosodic voice? Because it triggers brain structures that engage our middle ear muscles, and increases the tone of the myelinated vagus. The little middle ear muscles shift the sensitivity of our hearing to human voices and functionally tune out low-frequency sounds that signal the possibility of a predator being present. Of course, if we live in a dangerous environment, we want to remain vigilant of low-frequency sounds. In fact, many children who live in dangerous environments have a nervous system adapted to detect predators, rather than speech, and have language delays.
I coined the term neuroception to describe our automatic, unconscious ability to detect risk in the environment. Usually, we’re not cognitively aware of why we’re reacting one way and not another. We respond emotionally to people and situations and then try to figure out why we’re responding in that way. It’s as if we each have our own TSA agent in us. If we tighten up and pull away when a person attempts to give us a hug, it’s like our personal TSA agent is saying, “I’m not taking any chances: no one’s getting on board this plane.” In fact, that’s really what social engagement is about: the evaluation of safety through proximity.
Why do you think so many therapists have gotten so interested in your work?
Porges: Polyvagal Theory shows us how social interactions facilitate both mental and physical health in a way that’s often ignored in the mental health field. Currently, there’s a great emphasis on the manualization of treatment procedures without conveying the central aspect of what makes treatment work: helping the client feel safe with the therapist.
I think what first caught the attention of therapists was that the theory provided an explanation of shutting down as a defensive strategy to life threat. If you’re immobilized, held down, and abused, you may dissociate or pass out. It’s like the mouse playing dead in the jaws of a cat. Does the mouse want to immobilize? There’s no choice; it’s a reflex. And humans behave in this way, too. This gave trauma therapists, in particular, new insight into the terrifying experiences and subsequent reflexes that their clients had long been telling them about. When that ancient evolutionary defense system of freezing and going numb is put to use, it’s not easy to stop it.
Before Polyvagal Theory, there was the idea that, because they’d experienced a stressful event, every trauma survivor should be in a high state of sympathetic activation. So the trauma world was locked into trying to define the effects of trauma and abuse through looking at only a part of the human nervous system. And when certain patients came in numb and frozen or dissociated, their therapists were often confused.
So at the practical level, what difference does Polyvagal Theory make for psychotherapists?
Porges: It enables therapists to work more closely with clients to make the treatment environment safer. For example, there’s a video by Pat Ogden, the developer of Sensorimotor Psychotherapy, manipulating a client’s sense of neuroception by adjusting her own proximity to the client. Pat moves her chair away from the client while continually asking if the client feels more comfortable. Pat has a large office, and when she moved her chair approximately 20 feet from the client, the client requested that she come closer. By adjusting the degree of physical distance between the client and the therapist, the client could recalibrate her nervous system and feel in control, and even start to smile and laugh. Pat’s work is centered on modulating states of safety for optimal functioning, and this understanding of neurophysiology comes out of Polyvagal Theory.
What does Polyvagal Theory tell us about what makes a good psychotherapist?
Porges: I’m often asked, “Why don’t you develop a school of therapy based on Polyvagal Theory?” But the point is that some of the participants who are busy taking notes at my workshops may not have the interpersonal sensitivity and style that enables them to convey safety to clients. They simply may not have a command of the subtle nonverbal features that make master clinicians effective. From my viewpoint, it doesn’t matter what a therapist’s degree is in or what his or her theoretical model is. Effective therapists are defined by their ability to interact functionally: above all, they know how to make another person feel safe.
Part of it has to do with calling attention to processes of communication that are often ignored in clinical training. For example, there’s the intonation of the voice, which has its roots in our evolutionary history as mammals, as we discussed earlier. Tone of voice and the acoustic properties of sounds are important. If the acoustic stimulation contains certain frequencies, we tend to feel safe. For example, we tend to feel safe and our social behavior is facilitated when we listen to the acoustic frequencies that characterize a mother’s lullaby, the melody in Mozart’s symphonies, and many folk songs, especially those using melodic female voices. We need to understand the powerful emotional influence the acoustic environment exerts on us. Our industrial world is dominated by low-frequency sounds, which our nervous system interprets as meaning that a predator is present.
From this perspective, the therapeutic process is less dependent on the words or the therapeutic method being used and more dependent on behavioral cues, gestures, and how things are said. I’m not sure that beyond a certain point we can train clinicians to be more effective therapists if they don’t naturally have the basic skills to create safety in the consulting room. In fact, I think there are many people drawn to the therapy trade who probably shouldn’t be in it. They’re not safe enough themselves to convey safety to others.