Polyvagal Theory, Trauma and Neuroscience of the Mind – Dr. Stephen Porges – HPP 101

SPEAKERS
Dr. Steven Porges, Keith Kurlander, Dr. Will Van Derveer

Dr. Steven Porges 00:00
So polyvagal theory is functionally a brain body science. And it really emphasizes the bidirectionality of information from the organs to the brainstem, and from the brainstem to the organs. And so you don’t have any separation of mind or brain function from bodily organ function.

Keith Kurlander 00:21
Thank you for joining us for the higher practice podcast. I’m Keith Kurlander with Dr. Will Van Derveer. And this is the podcast where we explore what it takes to achieve optimal mental health. Welcome back. Today, we’re going to take a deep dive into polyvagal theory with Dr. Steven Porges. If you haven’t really explored polyvagal theory, it’s really changed the way we think about trauma and understanding the nervous system’s role in the way in which we process traumatic events, psychologically traumatic events, and how that information translates into the nervous system and how it then causes many different responses in our physiology, our biology, our chemistry, and also in a sort of two way street with our cognitive processes in our mind and emotions and the ways in which that interaction takes place. So Dr. Porges, really has been a massive influence on, you know, what we’ve seen in the last 20 years around our understanding of trauma and where we’re headed, and how to work with trauma, and the clinical application of the neuroscience that he theorized and really started to unpack and unfold. And he’s also done a lot with other applied techniques with sound and ways in which we can really heal ourselves with sensory overwhelm. Dr. Steven Porges is a distinguished University scientist at Indiana University where he’s the founding director of the traumatic stress Research Consortium. He’s a 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 has published more than 300 peer reviewed papers across several disciplines, including anesthesiology, biomedical engineering, critical care medicine, ergonomics, exercise physiology, gerontology, neurology, neuroscience, obstetrics, pediatrics, psychiatry, psychology, psychometric space medicine and substance abuse. In 1994, he proposed the polyvagal theory, a theory that links the evolution of the mammalian autonomic nervous system to social behavior, and emphasizes the importance of physiological states in the expression of behavioral problems in psychiatric disorders, theories leading to innovative treatments based on insights into the mechanisms, meanings and symptoms observed in several behavioral psychiatric and physical disorders.

Dr. Will Van Derveer 03:02
Dr. Steven Porges, welcome to the show.

Dr. Steven Porges 03:04
Well, thank you very much for inviting me. Looking forward to it.

Dr. Will Van Derveer 03:07
I’ve been looking forward to this conversation for a long time. I’m such a huge fan of your work. And it’s really an honor to get to spend some time with you and ask you some burning questions we’ve had for a long time

Dr. Steven Porges 03:16
Fire away.

Dr. Will Van Derveer 03:18
Well, so our audience is mostly therapists, psychiatrists, mental health providers in general, and for those in the audience who haven’t heard about the polyvagal theory, we thought we would just ask you to give a summary and kind of introduction walking us through the basics of physiology and implications in regards to presentation,

Dr. Steven Porges 03:40
We have to think of what we come on the planet with. And since our toolkits are, functionally, our neurophysiology. Our nervous system is especially in polyvagal theory, that neural regulation of our visceral organs through the autonomic nervous system, and this is really organs in the body in a brain structure in the brainstem regulating those organs. So polyvagal theory is functionally a brain body science. And it really emphasizes the bidirectionality of information from the organs to the brainstem, and from the brainstem to the organs. And so you don’t have any separation of mind or brain function from bodily organ function. So within the world, of course, in psychiatry, people talk about comorbidities. Polyvagal theory really says expressions of the same system in different ways. And you often find disorders in the gut like irritable bowel syndrome, being co morbid with trauma, you often see gastric and GI problems with anxiety disorders, and we tend not to understand that we’re talking about a physiological system that has reacted to threat and that reaction is predictable. So polyvagal theory really emphasizes and describes the evolutionary journey that in a social reptilian species transition into social mammals. So how did this occur? Well, it occurred with changes in how the autonomic nervous system was regulated because social mammals had a ternal threat response. And it had to do that rapidly. So they had to be able to detect cues of safety. And those cues of safety were adaptive and reflexively downregulated our defenses, so just visualize a mother talking to her baby or singing or using a hyper prosonic voice with intonation versus someone saying the same words. But now in a monotone, our bodies respond very differently. In a sense, we have the template for what are cues of safety and modulation of voices, one of those facial expressiveness, another gesture, they’re part of a system that was this social engagement system, which was the neural regulation of the strike muscles of the face and head. But that system in mammals became connected in the brainstem with a uniquely mammalian vagal pathway to the heart, which basically down regulate threat and send signals to the sub diaphragmatic areas for body, do your job, don’t react to threat. So when our bodies go into states of threat, we’re not getting the signal to the lower part of our body saying do your job. So in terrick system is a big flag. But the real issue, if we want to really strip it away, there are two things I would like you to to take away from this. One is through evolution, social behavior, or interaction with another is functionally elevated to a neuromodulator. Since it is literally a neural stimulation, it’s not social behavior. Haha, that’s fine. Don’t waste my time. We’re dealing with hard sciences or neurophysiology. But in mammals, social behavior is a neural modulator, it’s elevated. There’s this interaction in the body between social behavior and physiological regulation shift states, that’s the first thing to take away in the sense get a grip onto because it’s so powerful. It means that social interaction or social prescribing, which is now words that are used in psychiatry, is really a powerful neuro stimulation metaphor. It’s a neuro stimulation, ternal threat systems, and to optimize systems of homeostasis. So it’s homeostasis in the mental world in the mental and homeostasis in the organ world. So they’re intertwined. So that’s it says, to understand that evolutionary trajectory that we have this toolkit that detects threat and shifts our physiology, we detect safety, which is the gift we detect safety, and that turns off our threat. And so we start to recognize that physiological state that we’re in. Is this intervening variable, powerful concept, it’s in between the external world that we’re responding to in our own responses. Based on that physiological state, your responses will be biased towards being defensive or being welcoming and accessible. And if we instance ask people how they feel, and they have a language to describe feelings, you find out that for many people, a much bigger life is all about suppressing feelings, becoming numb to their body, and from a neuro physiological model that’s trying to go hear feedback loops. And guess what you see in the medical metaphors of this are manifestations, you see the feedback loops are malfunctioning. That’s when you see disease being expressed. So I’m sorry, I kind of rambled on for a while. But the emphasis is really, sociology is sociality is a neuromodulator. Our physiological state is the intervening variable between how what’s going on in the world and our reactions. But our physiological state becomes a portal of intervention to change the biases.

Dr. Will Van Derveer 08:36
Well, that was an incredibly pithy overview of a very complex system. And I can understand, I guess, I’m guessing that you probably don’t love that question, because you’re probably all the time. Can you summarize this?

Dr. Steven Porges 08:49
Well, it’s worse than that. I don’t know where I’ll go with it. So what you heard was the first time I scripted it that way, so it’s not a reflex for me, because if I get scripted, then why do podcasts? Why do we draft this? What’s the benefit to me? I’m not enjoying it. As I said, social behaviors, that neural moderator, I want to

Dr. Will Van Derveer 09:10
Thank you. I’m curious, just a little bit deeper down the rabbit hole of neurophysiology around the dorsal vagal which as I understand is more of the reptilian,

Dr. Steven Porges 09:20
we have to be careful in essence, compartmentalizing. So the major part of this ventral because that’s the part of the brainstem dorsal or ventral, where the cells of origin of this pathway come from. So it goes into a conduit that we call the Vagus. The Vagus is a tube with pathways and unfortunately in the popular press, the Vagus is being treated as if it makes decisions, it has executive function, you want to hack it, you want to tame it. It’s a conduit. It’s a cable with pathways coming from these two different actually three areas because it’s two that are motor and then it goes to one that is sensory and it’s functioning at 80 percent of the fibers for sensory, so it’s your surveillance system of your body. And you have to think of it as this major regulator of your organs. And we have the dorsal. Now back to your issue of dorsal and ventral the original Vagus invertebrates is dorsal. And then through evolution in the transition primarily in the transition from reptiles to mammals is a migration of cells of origin of the Vagus of the cardio inhibitory fibers of the Vagus, that move to this ventral area that regulates the muscles, the face and head. And if you look at it, now, we think, Why, what was the adaptive function of this movement, and you start realizing it that our social behavior now became intertwined with the regulation of our cardiovascular system, and so has the capacity to down regulate threat reactions. And it was the sense evolutionarily prioritized, meaning that there’s a hierarchy and this is not polyvagal in originality goes back to John healing. Jackson was a neurologist at the turn of the 20th century. And what he was saying is that when you get brain damage, older circuits start expressing cells, and he called that firm dissolution. And I took that concept dissolution, modified it for polyvagal theory and said under challenges that are damaged, we basically go through older evolutionary stages, so we lose that newer ventral circuit. And next one that came in the fourth one was our sympathetic spinal sympathetics. And when so when we sense lose our accessibility and we become vulnerable, we become defensive, which means we become mobilized initially to fight or flee, you see that in psychiatry is anxiety, tightly wrapped people here to build the inability to sit still high risk behavior, you see the whole portfolio coming out, and you also with that will get symptoms like tactical hypersensitivity in auditory hypersensitivity, and the auditory hypersensitivity is because the neuro regulation of the muscles of the face of head includes the middle ear muscles, and when they’re tense with the neural tone, they damped out background sounds. But if you’re under threat, what do you want to hear to survive? Low Frequency predator sound, so everything becomes adaptive, and not pathologized. And then the oldest circuit is when the sympathetics no longer get you into a safe place, you shut down with that old dorsal circuit when recruited in defense, but the sympathetic and dorsal we don’t want recruited defense, we want the sense contained in a sense of safety. And that’s where that ventral Vagus creates the boundaries that enable the sympathetics to be fine. So we play, we don’t fight or flee, we’re playful, we move and we smile, and we play with others. And when we immobilize, we’re not shutting down, we’re having moments of intimacy and trust in other people’s arms. So the ventral Vagus is I use the terms I started to introduce these terms. In an interview, I didn’t have to figure out what I meant by, you know, saying like, this seems like interesting. I said, the ventral Vagus as both a cheerleader and a choreographer, the choreographer is clear that it keeps it within certain boundaries, these other systems, the cheerleader is that we become accessible, we become mobilized, we expand life becomes meaningful.

Keith Kurlander 13:17
I like this so far, let’s expand on this concept of down regulating threats. So if we think about sort of an individual, let’s say that we would say is more highly traumatized, a lot of PTSD, and how do you describe polyvagal theory and this neuromodulator and downregulating threat? Are you saying that the person who is traumatized, all that’s happening is that their ability to down regulate the threat is impaired?

Dr. Steven Porges 13:50
Well, we want to be careful and using words like impaired we would say their capacity to detect threats is enhanced. You see, if you flip it around, it’s like a body that’s been injured, isn’t going to go back to the same place to be injured again, and with many individuals who suffer from trauma is a violation of trust, and safety with another person, which is what is the result to create the traumatic event. And so you find that with people with trauma histories, if their bodies start to relax, start to become accessible, they immediately react to that vulnerability, and get highly anxious, mobilized and be stabilized because they don’t want to be there. So even though on the conscious, intentional level, they want to be there. The body says No way. I know what that will do to me. And it says you have this, I would say for most association or disparity between our different intentionality is the intention of a body nervous system to stay safe and alive and an intention of our narrative, our cognitive view of what is to be human, to be safe in the arms of another.

Keith Kurlander 14:56
Maybe you can kind of expand more on how the social engagement system detects safety versus threat? What’s actually happening there?

Dr. Steven Porges 15:06
Well, let’s say that the social engagement system is really downstream. So it’s really structured from the neuroanatomy. And it’s the neuroanatomy of certain pathways that evolved to regulate structures linked to the Incas, Gill arches integration already in the brainstem, that the muscles, the face, the muscles, the larynx, the muscles, the pharynx, and the muscles of the middle ear, all part of the same system. And it’s a system of incense ingestion with the newborn baby. And it’s also a system that is later modified and used as our primary social engagement one. So in the world of some of the psychiatric disorders, you’ll see eating as a disorder. But if you see it from the lens of polyvagal theory, eating disorders are valiant attempts to utilize the social engagement system to really engage it to calm down. So it’s the sucking, swallowing, ingestion, that is calming chewing gum, these are strategies to come down. So you were really wondering, how’s it detected that detections are actually at a higher level in the brain, because they’re dealing with detection systems. And the issue is where the brain and I’ve been very interested in this process that I labeled neuro ception, which was the nervous systems detection of risk in the environment. And it had when I started to come up with the construct I was playing around with, like, emotional perception. And then I realized, if I dropped the word perception in the dialogue, I’m in trouble, because people will start blaming themselves for not perceiving because we think of perception as having a cognitive or at least a degree of awareness. If we don’t we think we can learn to be more perceptive. So I want to give the agency to the nervous system without awareness, so called neuro ception. And I think the important part is to say the nervous system evolved to detect threats. And the part is overt a bit nervous systems detect threat or have a nervous system, or neuro ception of threat. But mammals have this unique neuro ception of safety. And when we see that we realize that removal of threat is different than detecting safety. And then we start understanding the politics of the world we live in, which doesn’t make any distinction between cues of safety or removing a threat. We think that arming people with guns removes the threat and will be safe. I’m not saying that the removal threat is bad. I’m saying our nervous system is not satisfied that it wants something else, it wants its cues of safety, it really craves that. So if we start asking questions like where is the brain where this occurs, I initially start to think that errors in the temporal cortex were important, because they detect features of face familiarity. And so it is that areas of the temporal cortex are going to detect features of intentionality. And that’s going to now go downstream to the brainstem say, based on intentionality, I better shift my physiological state from accessibility to defensiveness.

Keith Kurlander 18:10
On a very basic level is the brain interpreting a pain versus a pleasure, and it’s saying pleasure is safe and pain is threat? Is that not even a good contract to talk about?

Dr. Steven Porges 18:23
Listen, everything’s interesting to think about. And I was pulled into a group of pain physicians and psychologists who were interested in polyvagal theory, and I had not thought much about pain in general. And what they were trying to tell me is that when they started to apply principles of polyvagal theory, their clients became pain free. And it took me a while to really, not a while, it took me a couple hours of interacting with them. And then I got the aha moment. And I said, of course, because pain is a cue of threat like you’re describing. Physical pain is a cue of threat. So that means your body’s in the state of defense, if you are in pain. So some of these insightful people decided that if this were true, they could do techniques like breathing and social interaction and group psychotherapy, and their clients became pain free. So it says the clients were now able to regulate state through another mechanism. And that mechanism shifted state to them into a state, which was incompatible with being in pain. So going back to your question, I don’t think the word is really pleasure. See, we start getting into reward systems. I think it’s more linked to our biological imperative. What does our species need to survive? The species needs to be safe in proximity to another. That’s our history. And once we’re that way, we have cooperation, we have creativity, we have in essence, the ability to solve problems through cooperation. Yet our society is so contradictory to this biological imperative. It’s always the individual that is fostered, yet our bodies like to feel safe in the arms of another we want to trust. And you know, we end up with these, I think false narratives of love. It’s a rough world out there, our bodies want to feel safe with others.

Dr. Will Van Derveer 20:16
This question might feel really off the wall, but I’m going to go forward anyway. I’ve always wondered, you know, humans clearly are social primates, and no argument there. chimps are social primates, lots of monkeys are social primates. Is there something different about an orangutan that wants to live in the forest by itself and come and mate with another orangutan and then go back to the forest? Do we know anything about why that animal is not that social?

Dr. Steven Porges 20:41
If you were interviewing my wife, and you probably should, my wife is Sue Carter, who discovered the relationship between oxytocin and social behavior. And so she would probably go from a molecular model and start saying different degrees of oxytocin. They need, it says, to be by themselves, at least for a while. But remember, even solitary primates are solitary mammals that have a period of dependency, a maternal dependency, in which they have to be taken care of. So there are different stages here. And part of the problem I find with our understanding of human development, and educational model is that we basically want self regulation too early. And the sequence is that if we have access to good co-regulation, good parenting, the system, the neural systems of regulation, develop naturally, and then the person can have the capacity to be self regulated. And we tend to get all this big stuff. We see it as smothering and all these others, but we have to think in terms of neural exercises of getting regulation to the system. Often in my talks, I show a picture of kittens playing. And I reflect on the picture because I saw these types of pictures when I was in graduate school. And then you say, Oh, the kittens are learning, they’re fighting skills. And now with the lens of the polyvagal theory, I’d look at this guy, he got off wrong, the claws are retracted, they don’t break skin, they don’t bite hard. They are learning skills of self regulation. So they’re learning to regulate their bodily states through play, which is different from aggression. Play is movement in a safe environment. And these animals are learning that neural exercise that gives them this tremendous range of regulation.

Dr. Will Van Derveer 22:39
So if a person had a difficult attachment period, let’s say they’re biased in regards to what they’re expecting in a social engagement, they tend more toward defensiveness, they have this touch aversion or exaggerated, startle, they have trauma. And there’s just, it seems to me and I’m curious, I’m sure you’ve thought about this a lot with the vagal nuclei in the brainstem. Are we talking about different tonality?

Dr. Steven Porges 23:07
Well, I think I know where you’re going. You are, I think, asking about reversibility. Or sense a is a destiny a temperamental let’s start off by saying whatever I talk about scribe optimistic narrative, because it’s really focused not on neuroplasticity, which is the other part of your I think assumption is based upon state changes with the potential of shifting state and the neuro flexibility rapidly being recovered and growing. So we have to understand that there are state changes, especially in the world of trauma, we buy into the fact that the person can be jovial interacted and seen real buffer on one day, then a traumatic event happens, the person can’t even walk both legs steps can’t be near another person can’t be touched. So we know their massive state changes that can down regulate the system. And we know that it’s not neurogenesis, it’s not going on. It’s a reorganization or returning. And the question now is, can you recover? And you know, we talked before about your practices in somatic experiences. Somatic Experiencing takes the role that you can reawaken those circuits. But you have to do the titration or pendulum as they would say, because the and I think I understand that now from a different level, the reason you have to is that cues of safety become cues of trauma. So the person has to be their body and has to be comfortable with feeling accessible. And so I’m extremely optimistic. So, but let’s clarify part of your point because you want to get into the notion of tonality. And when we talk about the Vagus, no longer being able to downregulate threat reactions. What do we really mean by that? Well, there are two things that we would find in the person’s warning. On the profile, one would be the measurement of cardiac fatal tone, which can be extracted from heart rate variability measures. And that is really, really a very powerful and accurate index coming out of that area of the brainstem. So if you have more respiratory sinus arrhythmia and more changes with breathing, you have more cardiac vagal tone, but I started to work on another metric. And this metric I call vaguely efficiency. It was not only how much apparent people tone Do you have, but how effective it is in regulating your heart rate. So with a well tuned, typical neural, diverse person, but a typical person, you find if you’re not in the state of fight flight, your heart rate is primarily being regulated by moving the vehicle brake on and off. You’re basically using that ventral Vagus vehicle tone and you retract, the heart rate goes up, you walk around and you sit down and now your heart rate comes back down to a vago recovery. But now I start to find people whose heart rate patterns were unrelated to their heart rate variability regulation, and it was always the same thing. Symptoms in the medical world of dysautonomia, and they are such a person. I’ll give you a few examples. So we can start off with where I discovered this. I discovered it initially looking at newborns showing that in different sleep states they had different coupling or different degli efficiency. Then I moved to what happens when an adult drinks alcohol. Well, the vagal efficiency drops make sense now. Then I did a study on prematurity and showed that it developed, you could see it developing. Then we did a study with Ehlers Danlos’ Syndrome, which is a hypermobility syndrome. I thought it was rare, but you see it manifested in many clinics, including gastroenterology clinics, where we found out that 50% of the adolescents in this pediatric gi clinic would fit the diagnosis of eds. Ehlers danlos. Most of them were not even diagnosed. So by doing the testing, they had very poor Daigo regulation of vehicle efficiency, and even though they overlapped in terms of gastric pain, functional abdominal disorders, with those without it vaguely efficiency was significantly lower than the others. And with Ehlers danlos, when the common theme that comes out is disordered knowmia. And it’s often misdiagnosed. But what we’re really trying to say is there’s a physiological, neural physiological component of the symptomatology. So if you had and then in a normal study with people with mild trauma history, it’s not PTSD, they had significantly lower vaguely efficiency. Now, I’ll pose that within a medical model. Because what is the vagal efficiency telling you, it’s telling you about the effectiveness of a feedback loop that the Vagus is involved in that regulates mobilization, it regulates heart rate, to get you into different places, you need to regulate heart rate to move. So what we’re saying is that the feedback loops are depressing. Now, what does that mean? In general, if it’s a marker for general autonomic feedback loops, then it is dysautonomia, because what it really means is your feedback loops are not efficiently working, you’ll end up getting end organ disorders. And this is the fallacy or the vulnerability or weakness in medicine, it’s end organ focused disease is located in the organ, the neuro regulation of that organ is irrelevant. But if you think about it, the neuro regulation, this deficit has to precede the end organ damage. So what you’re seeing here with this type of measure is most likely the antecedent of will end up as Endor damage. So the optimistic part that I’m still dealing with, can you reverse that? And can you now re-engage through what I call neural exercises to reconnect or recover the system into a more efficient system?

Dr. Will Van Derveer 29:06
Oh, thank you for that. I’m just in my head, it’s spinning, thinking about all the ways that this is relevant to the patients that I see. And also my own life, my own experience of having quite a few aces in my ace score, and then dealing with kind of watching my blood sugar kind of dance on the edge of what’s happening in the end organ there. Excessive sympathetic tone in my system.

Dr. Steven Porges 29:34
Yeah. So from a polyvagal perspective, aces are important, but it’s not the real issue. The real issue is the impact of the aces on the neural-regulation of the autonomic nervous system. So even though you’re upping the risks of a returned autonomic nervous system, it’s not asking those questions. So I feel that aces is a good start. But the next start is the lease survey questionnaires on a physiological response. We developed the scale, it’s on my web page. It’s called a body perception questionnaire. And it really asks people through subjective ratings of their own internal responses. And it’s organized. So above the diaphragm and below the diaphragm. And we’re finding this to be very powerful in our survey research model, because if you take that aces, we were using childhood trauma questionnaires, and then we developed our own adversity index, it does predict, those predict lots of things. But if you measure also, the subjective measure of the autonomic nervous system accounts for virtually all the predictive variants of those traumatic indices. So it’s a pathway that results in a returned autonomic nervous system. So reflecting it on your own personal experience, your ace scores probably had an impact on retuning your autonomic nervous system. Now with that information, it starts to lead you into portals of intervention, more likely than just say, Oh, you’ve been traumatized, you have risk for all these things. It says, Well, you have a trauma history that has left its footprint on your nervous system. And your nervous system is now very well positioned to be defensive. But this is the baggage that comes with that defensive mode. So it’s not an anger at your body, it’s an understanding that your body is really primed to fight off a predator when there may not be one. And that’s your job now to re educate the body. And that’s an instance, I believe what was seen was all about somatic experience is functionally every educational model. In fact, virtually all the effective trauma models are all about welcoming the individual back into their body in their journeys of re embodiment. So we start connecting our feedback loops again,

Keith Kurlander 31:56
I think you mostly just answered this, maybe you’ll say it a little differently here. When doing a proper assessment on the degree of trauma someone might be experiencing is, are you saying that like you would, maybe you would do your childhood history you would do maybe this questionnaire you have, aces to come to a formulation, that’s not necessarily just like, okay, let’s check off the symptom list.

Dr. Steven Porges 32:20
No. Let me first make a strong statement. I’m not a therapist, okay, so you can take whatever I say in any way you want. But there are people who have developed intervention strategies based on polyvagal theory that have been very effective dealing with people with trauma, and one is Deb Dana. And she’s a remarkable therapist. She never talks with our clients about their trauma history. She talks about their physiological or subjective feelings of their body. So her therapeutic strategy is for people to be comfortable in their body and to experience the range of feelings and then the emergence of that skill set, or that regulatory capacity enables them to move on or in a sense to deal with life in a more resilient way.

Keith Kurlander 33:05
So we’re also speaking to sort of philosophy of how to speak about their experiences and conditions. And I hear something destigmatizing when we just let’s just talk about the physiological response.

Dr. Steven Porges 33:19
Your feelings. It’s all about your feelings. Let’s understand your body. Let’s take that psycho educational journey together, where we learned about your body now you feel. Let’s explore you. Now there’s something you brought up, which I think is extremely important to discuss. And that is when someone suffers or survives, as soon as the more positive terminology, survives trauma. They often don’t want to talk about their trauma, because in talking about it, they see reactions in others, and they feel that they’re hurting others. So it’s a really complicated space to be in to be supportive, empathic, compassionate, and just allow a person to talk about their own feelings and experiences. And I think, as a mental health provider world, we haven’t spent enough time developing a skill set to be witnesses, it’s just to listen, to be present and to listen, you start hearing from different, say, threads or of therapies. And when people go to therapeutic presence, people come up with terminologies that they’re really saying. This is what’s helping the most, where I’m in, I’m present, I become a co regulator, because I’m not evaluating the other person’s experience.

Dr. Will Van Derveer 34:34
Yeah, it’s especially lacking this skill set you’re talking about in the medical community. We’re not taught to do that in medical school. And I think there’s a lot to be said about making the choice or we were talking about medical education a little bit before we got on this call about how do we actually help physicians to sit with the uncertainty of emotional states that are unfamiliar or discomforting for them even to sit with in the service of co-regulating?

Dr. Steven Porges 35:03
Yeah, so the first thing is, okay, and this is something that you’re going to acknowledge immediately, is that most physicians are under time pressure. Most physicians are being evaluated by their patient lower than the amount of time, whatever. They’re run by MBAs, this is what I’ve been told that the whole medical profession has been corrupted from the compassion perspective by the financial drive to basically make money through medicine. So the issue is, if the physician is under a state of threat, they’re projecting that to their clients. They’re not going to be accessible, and they’re not going to be supportive. So you now have this really a contradiction about the intentionality of wanting to be helpful and not being allowed to be helpful. And I’ve heard from many people of my generation who are so frustrated with the medical profession now that they’re just running out the door. And these are very senior established people, because they feel they can’t practice medicine anymore.

Dr. Will Van Derveer 36:05
Right, we see that a lot. And the physicians and nurse practitioners that we interact with are not feeling great about their careers, because they’re not getting to do the healing work that they set out to do.

Dr. Steven Porges 36:17
I started to work with a healthcare company, preliminary, we were developing a proposal, it didn’t really didn’t go anywhere. But it was to create what I called polyvagal informed navigators, which would be a person who was guardian or the navigator for the client. And so you didn’t have to change the whole system, you just have to make sure that someone was with the client to help them navigate and who was understood the principles of polyvagal theory with how you engage the person affects their physiology is extra bias in life, their awareness of other and if you want people to be healthy, you better treat them nicely.

Keith Kurlander 36:54
Let’s talk a little bit about some of the technology so to speak, that you’re developed over time for interventions to work with this system that we’re talking about here. And I know a little bit not much about the sound and the safe and sound protocol. I want to say a little bit about the starting point.

Dr. Steven Porges 37:12
Sure. And actually, it fits in well with your interest in neuro ception. Or where did the signals come from? So if we looked at the mother, their baby, she’s using this prosonic voice. Do you look at virtually any pet owner who has a dog or a cat? How do they talk to the dogs and their cats, they’re using hyper prosonic intonation of voice. And if they have a dog, if they don’t do that the dog will detect that they might think they did something wrong in the huddle down on the floor and may urinate on the floor, feeling that they’re being disciplined or so the point is that we’re sensitive to babies. We’re sensitive to our pets, are we sensitive to each other? And the answer’s no, to that babies are babies, pets or pets. But somehow when we interact with people, it’s not how I say this is actually the word syntax is that how sound is presented. So I decided I would develop a system that would recruit the social engagement system through the portal of acoustic stimulation, in a way that functions as if it were an acoustic driven vehicle nerve stimulator, that would calm people and make their bodies accessible. Now, in general, this works extraordinarily well with most people, especially children who are on the spectrum. So we see children on a spectrum, we don’t know if they’re autistic or not, we know that they have hypersensitivity, social withdrawal, but we don’t know if it’s a true disease, or their body’s in a state of constant threat. So if you can turn off the threat, what happens to the features is a cognitive disorder that can be worked with or adjusted with, but even if it can’t be the quality of life, this whole subset of the population can be improved if state regulation isn’t a problem. If you talk to teachers, you ask them the question, what’s the major problem in your classroom, it’s going to be state regulation. And behavioral technologies don’t work. But the safe and sound principle enhances state regulation in many, many high probability of a hit. Now the interesting part was, since I talked so much in the world of mental health, especially in trauma, the trauma world embraced the safe and sound protocol. And this is where we learned so much, because for many, it was very, very helpful. They were coming back saying, well, life’s different. My husband now looks at me differently. It was really all these wonderful things that I understand why life is one you know, it’s really beautiful. But then you get these counter indications where people would become stabilized by and it took a few of those cases for me to truly understand what was going on, what was going on the cues of safety were triggers of vulnerability. So it’s like listening as my body becomes like this. Now, the cues of this visceral opening, become cues that I can get hurt, as Suddenly, I can’t sit in the chair anymore, and I’ll be stabilized. And so all through insightful trauma informed therapists, they start to build a model of intervention that has some of the similarities with se is titrated. And they use the feedback through for psycho educational discussion. What are you feeling in your body, and what you start learning is that the trauma history resulted in total numbness or dissociation of their cognitive worlds when their body and now their body was talking to them. And it was talking too fast. And it was scaring them, literally scaring them. And so you had to incense work with them at a very slow level. And there are several people who are somatic experienced trained SCP providers who have been trained with the SSP and they say that it accelerates Somatic Experiencing treatment, the modest one was six months, but people were saying more than a year is changing the platform that they’re working with. And then many other somatic oriented therapies, were also saying, it’s changing the state of the person before they actually get to work. So we’re trying to do some pilot work to see if a psychotherapy even more traditional psychotherapy benefits by a few minutes of listening to the safe and sound protocol before the therapy. But it’s not just listening for a few minutes. It’s talking about your feelings while listening. So it’s again this journey of re embodiment. So the answer is this intervention was designed because our neurophysiology in this evolution, evolutionary change from a social reptiles to social mammals resulted in our middle ear bones breaking off so it sounds so esoteric for when those middle ear bones broke off enabled, humans are not just humans, mammals, to hear acoustic sounds in frequency bands, that reptiles could hear higher frequency, air, airborne sounds, and then middle ear muscles that regulate these little bones were all about social communication was about cooperation, communication, of the species to talk to itself conspecifics in a dangerous world. So I started to label what it called a band of perceptual advantage that when we’re safe, we can hear or process listen might be a better word, we can process acoustic information as a frequency band. But when our bodies in the states are a threat, we can’t even detect what’s there, we hear low frequency sounds. And this is frequently observed in the trauma survivors and other mental health issues including autism, low frequency sounds resulting in the hyperacusis. But the processing of speech is very difficult. They can’t clearly extract speech from background sound. So it’s that social engagement system. And when you modulate those, those get that system working, it’s being regulated in the brainstem in the same area that regulates the ventral Vagus. So you start seeing this whole array of changes, including changes in gut function. In fact, we have a clinical trial going on now with Ehlers danlos, to see if we can decouple the gut problems from the disorder by giving cues of safety. From a medical perspective, we’ve finished a feasibility pilot study of one individual with Parkinson’s, and we’re putting it together to show the videos in the acoustic processing of that person’s voice. And it had a remarkable effect. It was slow, and I couldn’t go through the normal protocol, which is one hour a day for five days. It took several weeks to go through it. But there are remarkable changes in recruiting systems that were assumed to be dysfunctional. And I think the model this is what I’ve been writing about recently, is that many of the diseases or disorders that we think include these hypersensitivities, that these hypersensitivities are not part of the disease, they’re part of a response to having the disease, they’re part of a threat reaction, their part, even in cases of inflammation, our body reacts to this. And the question is, our body hasn’t got the signal to say that it is necessary to react anymore. The safe and sound protocol is really saying you don’t have to react to those things. So I think the future this is really we’re getting to this optimistic pitch, that if we really think about disorders, that we start to notice that so much of medicine and medical problems whether we talk about mental health or comorbidities that are manifested in the body, they all tend to be the syndrome, of which that social engagement system has turned off the ventral Vagus isn’t working. The sympathetic is over reactive, and often oscillates with a dorsal Vagus going into shutting down or into a diarrhea constipation oscillating model. It’s because they’re not being constrained by the safety signals coming from the ventral Vagus. Now if we get the system on what happens it doesn’t necessarily cure the disease. It just redefines what the disease is and the upside of this, It changes the quality of life for so many people?

Keith Kurlander 45:03
Do you feel like technology is really going to be a major component of dealing with this issue?

Dr. Steven Porges 45:10
I think the technology is not as high tech as one might think that once you understand the principles of what is the signal that our bodies want to hear, the next question is what are the signals that we can use to document that the body has responded so requires signal processing, and autonomic responses all which are available, and we’re trying to optimize the packaging of that, so users can see it happening in real time. I was part of a team that invented a camera that measures physiology from a distance, and hopefully will be embedded into something like a webcam. So as a therapist, you could watch the autonomic responses of your client, and see if the vagal system was coming on board, they use that in the psycho educational part of replaying it with your client, where they can see their body reacting, and then come more in body. So the question is, the development of the stimulation model is there, we’re learning more about how it can be delivered. The second part is, we can measure the impact because the polyvagal theory comes with it as a theory of how to measure it. So it measures its function through that ventral vagal system. And we now have portals and we describe a presbytery science route. And now vehicle efficiency. And I’m sure there’ll be more variables over time. But just with those two, we’ll see a lot happening.

Dr. Will Van Derveer 46:37
Speaking of webcams in the world of pandemic and social isolation and two dimensional teletherapy, what would you suggest to the providers in the audience are doing like us right now are on zoom and are not having the social engagement in 3d with their clients right now, in terms of supporting them for I would say, optimizing their vehicle fitness? Well,

Dr. Steven Porges 47:00
There are a couple parts and I’m listening a lot to what I hear from providers all around the world. And that is for some of them. First providers perspectives, they think that it’s working real well on zoom. And part of it is the feedback they’re getting from individuals, especially those who have trauma histories, that the person with the trauma history is safer in their own home. They don’t have to go out to the clinic, they want to be in the outside world. And if they’re uncomfortable, if the therapist’s eye gaze is too much for them, they ask the therapist to turn the camera off for a while. So there’s an agency and that’s working well for that group. Before the therapists some of them, I got two different types of information. One was, it’s great. That was exhausting. Because when the exhausting part was telling me that maybe as therapists, they weren’t always as engaged as they thought they were with their clients. And so now they’re focused, and they realize that they’re not there. Present the client, the client is going to attack them, because they’re now saying cameras on me. So you get this kind of reversal for me not being a therapist, but getting webinars and these podcasts. I find that it’s not the same as the metaphor we use having a cup of coffee at Starbucks, which would be really nice, but it’s better than nothing. And my body seems to like it. I hurt my back about a year ago, I twisted it as a really excruciating pain. But I used to do webinars, and some of them were full day webinars, I was paint free while interacting. Now when I was done, I was in excruciating pain. But it meant to me, even in my own little pilot study, that the social engagement system was working while I was online. And so it became my life. It’s become all of our lives. Now. The question for me, and it’s probably for you and everyone else is how do we go back into the world that we came from? And again, this becomes very polyvagal to me, because my autonomic nervous system is somewhat returned. So when I go out and I’ve been vaccinated since the end of June, end of January, I can go out and often go to Costco, so it was overwhelming. And the issue is, the presence of others bothers me. I’m a social being and I’ve turned down all my invitations for 2022 already. I’m not ready. I’m not I don’t feel comfortable being part of me. The brain wants to give hugs and be around people that the body says, This is predictable. We’re in now. It’s a return. I think we have a lot to go through and our colleagues and friends who survived the virus, who got infected and survived their lives are also challenged because there’s remnants in their system. Some of the consequences include a returned autonomic nervous system, so long haul COVID is another one of these were called to back disorders of autonomic retuning and we have to give the body another clue. And things like Lyme disease, they’re all chronic, the types of disorders that are probably coming to your clinic. These are disorders without a clear disease model. But they’re real, because the autonomic nervous system is in that state of threat. So if they read get redefined by saying you’re stuck in a state of threat, don’t tell a person they’re stuck in a state of threat. But you see it as that and your nervous system needs to develop more plasticity, more flexibility. And that means it has to start internalizing cues of safety.

Dr. Will Van Derveer 50:47
It certainly is more palatable to me to be told that you’re stuck in a state of threat, then it’s all in your head, for example, which is what I think that’s criminal. So

Dr. Steven Porges 50:55
I wrote a foreword for a book on Ehlers danlos. And to pray for it, I decided I must read the book. So I read a 560 page book is a sad story of these were state of the art physicians working passionately in this area, and many of them had the diagnosis and you start seeing common features. So it’s a collagen disorder, at least hypothetically. However, trauma tends to be the cue that sets it off. So you now start seeing these trauma and dysautonomia. So you start seeing what I’m talking about as part of these disorders. The body has this vulnerability, suddenly, drama cubs, it gets stuck in this autonomic state. And this whole cluster of symptoms, including anxiety, gut problems, all of these things in pain start really, really coming out. And many of these individuals have been told by physicians that nothing’s wrong with them. Right, right.

Dr. Will Van Derveer 51:54
Yeah, it’s what we were taught to say when we didn’t understand what was Yeah,

Dr. Steven Porges 51:57
yeah, it’s such an exploitation of a group of people. And the word like medically unexplained symptoms. I never even heard that term until a few years ago. And that term is really a firm that says, this is an area where polyvagal theory is useful. And in fact, it’s an area in which many practitioners are using the safe and sound protocol with great success. So cues of safety, change those, that symptomatology of the systems, because those symptoms are related to the body being in a state of defense.

Keith Kurlander 52:30
Well, let’s go to our last question. We asked the same question to everyone. If you had a billboard that every human would see once in their life with a paragraph on it, what would you tell them?

Dr. Steven Porges 52:42
Well, I would tell them to listen to their body and respect what it’s telling them. And we have different words when you say something like honor your body or, or have self compassion, but it’s really saying your body’s trying to tell you something, listen to your body and develop a vocabulary to understand what that body’s telling you. And that’s what I view as part of my job is to give that vocabulary to science and to the medical profession.

Keith Kurlander 53:07
Thanks so much for being on the show and everything you’re doing.

Dr. Steven Porges 53:12
Thank you for inviting me. It’s been a joy.

Keith Kurlander 53:16
Well, it’s nice to meet you. We look forward to connecting with you again on the next episode of the higher practice Podcast, where we explore what it takes to achieve optimal mental health.