Read the Q&A from our event An Afternoon with Dr. Stephen Porges, held in May 2021.
As a pharmacist, I am particularly curious about any interactions – or synergies – that might’ve been researched so far between pharmacological modalities and SSP? Particularly in areas other than autism, such as depression or anxiety. Or are there studies in depression/anxiety comparing SSP to pharmacotherapy, such as SSRIs?
It’s a great question, and unfortunately, there’s no research in the area. My view is that if medication could support enhanced neural regulation, you’d see much more synergy between pharmaceuticals and SSP. I think the question has multiple layers to it, asking, ”if you use a drug for anxiety, will it enable SSP to be more effective?” The answer is that no one’s tested this yet, and no ones done the research.
In general, the Covid-19 pandemic has contributed to the mental health crisis, particularly in teens. How could Polyvagal-Informed therapies be more widely utilized to more effectively address the ongoing mental/emotional health pandemic?
The Polyvagal informed therapies provide a narrative to explain what the pandemic is doing to people. In essence, putting their physiology into a state of threat. Then you start seeing the emerging properties, which would be reactivity, anxiety, lack of co-regulation and lack of interpersonal accessibility. You can see the narrative playing out, and the therapists who are Polyvagal informed see that and they move into discussions of the portal of treatment from a Polyvagal perspective. The portal of treatment is the physiological state. First, comes the body and then you can start dealing with the other issues. SSP is one of those portals-it functions through a portal of calming the body. What SSP providers have witnessed and parents and teachers have observed, is that once you calm the Autonomic Nervous System (ANS) you start seeing more prosocial behavior spontaneously emerging.
Is there an intersection between polyvagal theory and the reprocessing of memories that is advocated through EMDR?
I wouldn’t draw that overlap but I would certainly say that reprocessing and memories will be affected by the physiological state that you’re in. So, if you’re in a calm physiological state the memories tend to be biased more positively and if you’re in a threat physiological state memories will be seen as more aggressive, more biased, more negative. It may function the same way with EMDR. EMDR therapists working with SSP may functionally shift the physiological state of their clients, and then the memories lose some of their listening power because the body is now in a state of much greater resilience.
Have the people in your Ehlers-Danlos Syndrome VNS study experienced improvements in their hypermobility and collagen integrity? I know you were hoping it would help with comorbidities, but I and a number of others have greatly improved or completely resolved our connective tissue disorders using brain retraining techniques. Even for classical EDS. I wonder if VNS could have a similar effect.
The project is about to be launched – it’s gone through IRB, we’re now putting it on clinicaltrials.gov, and we are going to be delivering the SSP to people who have Ehlers-Danlos Syndrome, hypermobility subtype, and who also have GI problems. It’s being run through Medical College of Wisconsin, through their pediatric GI clinic.
There’s an interesting theory that’s being tested in this project, and the theory is that the SSP can down-regulate, or shift autonomic state and literally decouple some of the symptoms that have been associated with Ehlers Danlos Syndrome, including gastric problems – not take away EDS but in a sense decouple some of the symptoms. This is similar to how we have been working with autistic individuals. SSP shifts the hypersensitivities, and it may not shift their cognitive and social functioning. It may shift them, but it may not. So the question is ‘can you pull apart the symptoms that are truly part of the core syndrome from those that are a reaction to having the disorder?’
Since EDS is quite an interesting disorder, the question really is “does the intervention reverse some of that atypical collagen feature?” And the answer is, we don’t know, and it may be unlikely but it may most likely reduce the other symptoms, which would be symptoms of dysautonomia and autonomic function, or atypical autonomic function. I was recently asked to write a preface for a book on EDS that was being written by people at the forefront of research around the world. When I read the whole book I learned a few important things. One is: that the onset of the manifestations of the disorder that gets a person into the clinic is often trauma-related. People may have the features but they’re not really suffering until a traumatic event. Traumatic events become a trigger and following that trigger an important expression of the disorder is dysautonomia, ANS Atypical Function. So the question is ‘can you rehabilitate autonomic function with the SSP?’ and that’s what we’re starting the project for. It will be launched in a few weeks and then we hope to see some positive findings.
How would you describe the SSP to a person who has never heard of it before?
I would use two points of discussion. I would say that physiological state influences how we behave and react to the world and the other part is that realize that even in very early life our nervous system is tuned to down-regulate threat reactions with prosodic intonation of vocalizations – I would direct them to visualize a crying baby and a mother talking to her baby, or singing to her baby. Then I would go on to say that the SSP is really the extraction of acoustic cues, or the term I use is distilled essence of trust in acoustic cues. So in a sense, our nervous system, like the nervous system of a baby, and even the nervous systems of other mammals, find it very difficult not to calm down when we listen to a prosodic voice. Think about how you talk to your baby or talk to your pet – you’re using this melodic voice, so the intonation is what’s doing the calming, not your words. Words become almost irrelevant, but the intonation – remember dogs and cats really don’t have a large vocabulary but they understand your intentions, based on the vocalizations. So our nervous system comes into this world with a template for certain intonations and those intonations to our nervous system say, ”you’re safe” and that’s what SSP is delivering.
The use of the SSP has evolved significantly over time. Does this surprise you on how it was initially planned when doing your research and then when it was officially launched in 2017, to where we are now?
On a personal level, I’m startled. I have a history as being an academic, a laboratory scientist, and scientists have dreams and they also have frustrations. So their frustration really is ‘are any of their ideas going to get outside of the laboratory’, and most of us don’t believe they ever will and we hope that after our death that someone might discover it. When I first discovered the SSP as a research protocol I was startled by its effectiveness. I didn’t have a clue about how to bring it into the real world. I thought, in my mind, I’d open listening clinics but I had no skill set and I had no experience with that and I basically piddled with projects, trying to do it within my own laboratory. Then, Randall and Karen, Randall Redfield, who you probably know was the former CEO of iLs, and Karen came to visit me when I was in Chapelville, and we got along well. As any academic scientist, we all have a streak of paranoia-that is we don’t want our ideas misused. So I was very cautious, especially in the world of children with disabilities like being on the spectrum, and I did not want my ideas to be misused or hurt people. I really felt that I could trust Randall and Karen and look at what they’ve done. They brought it out and it’s without a doubt a major part of Unyte and growing because people use it and are learning how to use it – and I’m learning from them. We’re learning how powerful it is and how it can be used to make people’s lives better. There was really a choice point that occurred. One was the initial research that I did – which was really with adults and kids on the spectrum. But the groups that I talk to most frequently are trauma-informed therapists. The trauma-informed therapist immediately saw the possibility and that created more possibilities for SSP. It created an entirely different community, a community of people with different clinical histories. We had to learn how cues of safety to a person who has survived trauma may at certain times act as if they’re cues of threat because people who have survived severe trauma will have often been traumatized when they were in a state of trust and safety or thought they were.
Their nervous system gets functionally retuned to being defensive. So we started to learn that the delivery of the SSP in the world of trauma had to be titrated. It had to be delivered with people who had an appreciation of the experiences of someone who survived trauma.
Back to the initial question, yes, I, I sit back and I smile. I sit back and in the mornings, when I get emails, unsolicited emails from people telling me that their lives have changed, it puts a smile on my face. I feel that this wonderful gift—that an idea that percolated through my mind in my laboratory—has been able to reduce the burden of suffering for so many artists makes you feel like a validated human being. So the bottom line is I tend to be very excited by the impact that it’s having.
I have two question streams: (1) as a parent about polyvagal theory and dysautonomia – what are the effects of polyvagal theory-based therapies on dysautonomia? – and (2) as a practitioner who works in schools. How can I use this to work with children ages five through 12?
Dysautonomia is a catch-all term. It’s really saying that your neuro-regulation of the autonomic nervous system isn’t working right. Unfortunately, most of the tests are relatively simple. Their posture shifts changes, meaning that our internal medicine or cardiology or organ-based internal medicine has few tools to deal with neuro-regulation of those organs. When they can’t find a disorder in the organ, they start saying it’s in the regulation but they don’t have tools to measure it. Polyvagal informed strategies really start to ask questions on a different level. They ask questions about the neuro regulation of the organ. The part of that is it implies that many of the features of dysautonomia could be altered if you had functionally sufficient neural exercises of the feedback loops that have resulted in the dysfunctional system.
So it takes an optimistic model, really our nervous system is doing whatever it can. But what it’s really telling us is that it’s reacting to a world as if the world is threatening. And when we act to the world as threatening, the neural regulation of our organs is suppressed, and becomes more dormant. I’ll give you a Star Trek metaphor, we’re using it to defend and not to regulate our system. So we shift the energy from feedback loops of homeostatic function to defending externally to the body. We see people anxious, in mobilized states, and polyvagal informed therapies for dysautonomia would really focus on, can you calm the body? As you calm the body you take the body out of defense, meaning out of a sympathetic mobilization reaction. You enhance the feedback loops through the parasympathetic, through the vagus, which is really part of our internal surveillance system.
It’s based on an optimistic principle that if you calm the body, the feedback loops will become more accessible. And the second part is, can you develop exercises to optimize those feedback loops? And there are a lot of exercises, including SSP that are out there. I don’t know if anyone on this call is a yoga therapist, but yoga is another portal for exercising. Many of the feedback loops within our body, within the autonomic nervous system. And I think we will start to explore more and more of this over time.
As a practitioner, how could I use polyvagal theory to teach kids about downregulation and so forth and especially kids ages five through 12?
The first thing is we’d have to really put the word ‘teach’ in parentheses because if we’re dealing in a world of teaching, you start thinking that behaviorally we can through intentionality, control these systems. The first part of a polyvagal informed model is that much of our behavior and our feelings are not determined by our intentions. They’re turned by how our body’s reacting in the world. So the first phase is really a psychoeducational journey of feeling one’s own body. As people feel their own body, the next step is can you develop certain regulatory exercises? Let’s say posture shifts or smiling, not smiling, inhaling, not inhaling playing a wind instrument or a recorder. Essentially, shifting your physiological state, and then having that psychoeducational journey of describing how did you feel? So now you’re teaching people to become more observant, more observant of their body.
And this is, remember, so much of our society and all our institutions. It’s all about not responding to how you feel, which is ‘let’s get over it’. Since being treated as a cognitive organism, without respect to the body’s feelings and over time, the body either gives up or, or wins. So you can’t sit still because the body says you’ve got to get out of there. If you’re involved in school systems, you see kids who become hyperactive oppositional, but they’re really telling you their physiological state can’t be regulated by their own intentions. The body wants to jump out. So in that situation, combinations of interaction with faces and words and movement are helpful. For children who can’t sit still, you can get them started on this journey of co-regulation through group movements. We used to call it dance or play. Other mammals can teach us – we can watch how they play and how its reciprocity defines play. When you shift into the state of defense, even in play, you lose reciprocity and people get hurt. The answer is we learn principles about our physiological state that are critical. We learn to be aware of that physiological state. We learn to honor it. Then we learn a toolkit of how to move ourselves into different states.
Hi, Dr. Porges, I’m a huge fan of your work. I’m a trauma therapist in Austin, Texas, and I actually worked to train organizations all over the state and trauma-informed care. We’ve been weaving in polyvagal theory and your insights into our work to hopefully have a huge impact in Texas. I’m very interested in some of the research that’s coming out on psychedelic-supported therapies with MDMA and psilocybin for PTSD and depression. I was curious to hear your thoughts on those results and the relationship between what we’re seeing now.
I think part of what’s happening is that it’s very consistent with the medical use of fusing pharmaceuticals. It’s just a different pharmaceutical and the issue is it may be helpful, but it’s a metaphorical strategy that if I do this, I take this, then I’ll be different. I had an interesting discussion with someone about a week ago who had a Kundalini experience from a drug. I can’t remember his history. I asked him, did he train for it? Meaning, was he prepared for this massive transformational experience? And I actually ask the same thing with psychedelics. Have the people been trained to deal with these massive transitions that may occur? In a sense, we’re on a journey of perceiving the world differently. It can either be catastrophically disruptive or welcomed. I also have very close friends who are involved in research on this, and of course, as researchers, they wanted to try it as well to see what the experience was.
One of them was a very well-known therapist who had a horrible experience because he was reliving his client’s traumas during his experience. He’s a very strong advocate for doing this because in the world, especially in psychiatry specifically, they have seen major transformations that have occurred. My bias is really that I’m an observer and I feel that the psychoeducational journey is important before doing this type of work, as well as the educational journey after that experience. Essentially, you’re teaching people to understand their neurophysiological experiences and to be more welcoming of them. I would rather see strategies of neural exercising and expanding the range of physiological state regulation before a massive transformative experience like psychedelics. It doesn’t mean that the psychedelics don’t have a place, but I would like to see the client made more resourceful with psycho-education and perhaps some form of a neural exercise model.
Do you believe that the size of the amygdala can be altered through various impacts?
Yes, I think we have to think in terms of neuroanatomy. The hippocampus can change the amygdala, the insula—the morphology of brain structures can be affected by our experiences. Once we acknowledge that we stop thinking of certain sizes of areas of the brain as being the causal feature. So your question really revolves around the important issue: are the brain differences causal, or are they consequences? And in many ways, they can be both. So my view, and again, I think a very optimistic viewpoint is that for many aspects of our nervous system, it will find its home media will become more optimized or normalized when cues of threat are removed from the environment. When the nervous system understands that it’s so long grass to defend.
Would support possibly the pullover relation between the size of the amygdala and the neurophysiological response to the individual.
I would say that if you’ve experienced chronic threats or disruptions in your life, you might have anatomical differences that would relate to that cumulative effect. But I’m also saying that’s not destiny. I’m saying that the system could potentially normalize itself as your nervous system gets more prepared, not to be defensive, but to be accessible. So it’s like saying, we can image brains and we can see differences, but functionally, what does that really mean? We have observable behaviors and we know the person has been under a lot of threat showing this is not really saying this is the cause of their defensive reaction. It’s like saying it re-tuned the structures to support defense. And now the optimistic perspective is can we re-tune the system to support social interaction, relationships and safety?