The information presented in this case study was submitted by the identified provider and reviewed by the Unyte Clinical Team. Modifications to the text have been made solely for the purpose of enhancing comprehension and clarity for the reader’s benefit, and were carefully applied while ensuring the accuracy and integrity of the original submission. Unyte Health makes every effort to use updated terms and inclusive language, this case study retains the author’s original descriptions to be most sensitive to the client’s identity and preferences.
About the Provider
This case study was submitted by a Unyte Health Social Impact Grant recipient. The intention of this grant is to equip individual providers whose practice is primarily dedicated to serving clients who are economically under-resourced with unlimited SSP access for 12 months. We are grateful to these providers for their invaluable work towards our combined mission to create a safer world for all people. You can learn more about this grant here.
Name: Barbara Wade
Disciplines/credentials: Social worker, certified Emotionally Focused Therapy (EFT) practitioner, Somatic Experiencing Practitioner (SEP)
Modalities: Safe and Sound Protocol (SSP), Somatic Experiencing, emotionally focused couples therapy, Internal Family Systems (IFS)
Client Background
Name: Hope (pseudonym)
Age and Gender: 40-year-old woman
Program Delivered: Safe and Sound Protocol (SSP)Core (Hours 1-5); Connect (Hours 1-4); Balance (Hour 1)
Hope presented with severe anxiety, insomnia, dysregulated heart rate and difficulty with mental focus, and described herself as disconnected and numb. She described feeling a sense of a “hamster wheel in her head,” and found that the “noise in her head” kept her from sleeping. She was disturbed by her dysregulated heart rate, frequently experiencing highs of over 200 beats per minute. She had also been diagnosed with an autoimmune condition, ankylosing spondylitis, had physical pain and suffered from fatigue.
Hope had difficulty with mental focus. She would go fetch something from another room and forget why she was there. She felt unfocused in conversations, alienated from people and overwhelmed if significant others confided in her, unable to offer regulation to others. She felt she could not reengage in teaching again, which was something she had loved. She said it had been her identity and that it really helped her to have her career after her divorce as a resource, but now it was lost. She did not feel secure anywhere and was tired most of the time. Although her mind seemed to be racing, she felt numb and disconnected from herself and the world.
Hope had come to therapy following the traumatic loss of her business. She was a remedial teacher and used to love it, but reported that she did not know if she even wanted to be a teacher anymore. She was very sad about losing her love for her job. After the loss of her business, Hope moved in with her parents. The atmosphere in the home was tense; her parents had experienced marital tension for several years. She had little emotional support, although practical help was there. She had no income and was desperate for help.
Before losing her business, Hope had been married to a person who suffered from untreated bipolar disorder. She stayed in the relationship until the situation became unbearable in 2013, at which time they divorced. Provider Barbara Wade saw her for therapy at this time for about three months, prior to the loss of her business. Hope was unable to work for a year after the divorce, after which time she worked at two different schools.
After the divorce and during the three months of therapy, she revealed to Barbara how much she wanted to start her own school for children who needed extra support and individual attention. She finally realized her dream and started a small, private learner-centered school. The school grew rapidly and was a big success.
Sadly, against her gut feeling, she took in a partner when she started the school. There was a conflict between her and the colleague that was ugly, personal and intense. Hope gave up the school as a result, and the colleague continued with the little school that Hope had started. She tried really hard to keep teaching privately in a different location; however, the loss of her dream, emotional tension and financial strain took its toll. Her health took a strain and she came to see Barbara for therapy a second time.
When she came for therapy this time around, she was suffering from major hip pain. She had already undergone two hip surgeries following her ankylosing spondylitis diagnosis.
A matter of great concern was that her heart rate was very elevated, at times reaching 209 beats per minute. She wore an Apple Watch and monitored her heart rate consistently. She noticed her heart rate was affected by stress; it was almost always over 90 beats per minute and it was not uncommon for it to reach 200. Her medical doctor and homeopath had put this down to anxiety.
Hope was suffering from sadness and anxiety and felt unable to function. She had lost her dream and direction in life, while also under a huge financial strain. She felt isolated and lost.
Implementation of the Safe and Sound Protocol (SSP)
The SSP was delivered in person. Before delivering the SSP, Barbara spent time on psychoeducation. She explained Polyvagal Theory and the principles on which the SSP works. They mapped Hope’s nervous system on the polyvagal ladder. She was very enthusiastic and readily understood the concepts, especially in light of her experience as a remedial teacher. She also went home and did her own research. She felt safe trying the program when she understood the theoretical basis.
Hope completed the Unyte intake assessment in great detail. She scored 19 on the resourcing section and 12 on the client experience section, with an overall score of 31. Barbara believed her nervous system to be very sensitive. She also felt that she did not really have appropriate emotional support at home should she become dysregulated, which informed Barbara’s decision to deliver SSP Core in person.
Before beginning SSP Core, Hope began with eight days of SSP Connect. She listened for half an hour at a time and the first session was done in person. Barbara discovered that Hope really loved classical music and played the cello, so she really enjoyed and responded well to the [classical playlist]. She continued at home for a week at night. She was free to contact Barbara at any time and they met once in person during the eight days. From the outset, there was a significant improvement in her ability to sleep.
SSP Connect was a very helpful way of introducing her nervous system to the SSP and assessing the impact of listening in her nervous system, especially as Barbara believed her nervous system to be sensitive and easily dysregulated.
Following hour four of SSP Connect, they began using SSP Core although she still used SSP Connect when she wanted to at night, as the unfiltered music helped her get to sleep. Hope again completed assessments before they began SSP Core.
They met once a week for 90 minutes. Hope listened to SSP Core for 30 minutes each session and used the remaining time to share any personal struggles or experiences. At other times, she listened for 30 minutes and spent another 30 processing the session. She frequently colored while listening or sat quietly.
During the first hour of SSP Core, Hope began to cry but indicated that she could be with the tears. Afterwards, she reported the weeping to be a release that she appreciated. She was relieved to have Barbara with her as a regulating presence as she allowed the emotion to emerge and remained present.
At hour three of SSP Core, Hope noticed a change in her heart rate. It dropped from 158 on the Saturday to 90 on Tuesday. She noted that her mind was not racing. She reported a big shift to a sense of calm. She had been able to stop working for an hour and rest when she needed it, something she could not do previously. She noted she was not as easily triggered and felt more empathy when among others.
After the first 30 minutes of hour four of SSP Core, Hope reported there was less weight on her chest — that it felt more open. She noted her anxiety was less consuming. Because the first 30 minutes of hour four were so helpful, she attempted doing the last 30 minutes of listening at home. She felt fine during listening, but that night she experienced nightmares and intense feelings of fear and distress. The next day she felt very angry, irritable and anxious.
She came for a session that day and was actually happy to be in touch with her emotion of anger and noticed she was not disconnected from her feelings. For the first time, she expressed how intensely angry she was with people who had harmed her. It was very helpful to relate this to the polyvagal ladder.
At first glance, it may have seemed that she was in a sympathetic state, but in fact she identified her state as being ventral — she was angry, but present, aware and regulated. She was not in a disconnected defense state, and was able to verbalize and process the experience in a clear, articulate and contained way with Barbara. They worked with the anger and Hope felt intense relief, highlighting the value of having a therapist present. They paused the SSP Core for three days, and Hope used SSP Connect during the pause to integrate what she experienced. After the three-day pause, she sensed she was ready to move to hour five of SSP Core.
After the first 30 minutes of hour five, Hope commented she could regulate her activities more, was able to relax and felt she was “living in the present.” She was able to notice and name her state, and identify triggers and glimmers. She was also better able to shift states using the somatic regulating activities Barbara showed her, such as resourcing, movement, touch and breath, as needed.
Response
Hope felt present and focused after completing the SSP. She reported clarity of thought and was able to regulate her activities, to stop and rest, even if there was work to do. She was less exhausted and shut down, allowing her to be able to do her gym exercises.
There was a dramatic reduction in her level of pain and her heart rate became more even; her Apple Watch showed that her heart rate stays mainly below 100 beats per minute in normal activities now.
Another significant change was that Hope could talk about her traumatic experiences without reliving them. She also noticed that she could talk to friends about her ex-husband without only mentioning the bad experiences; some of the good memories had returned as well. Even when she did speak about the traumatic times, she did not find herself re-experiencing the trauma.
Her pre- and post-assessment scores are shown below:
| Assessment | Pre-SSP | Post-SSP |
| GAD-7 (General Anxiety Disorder) | 18 | 5 |
| PHQ-9 (Patient Health Questionnaire) | 26 | 7 |
| PCL-5 (PTSD Checklist For DSM-5) | 68 | 40 |
| BPQ (Body Perception Questionnaire) | 121 | 76 |
| NPSS (Neuroception of Psychological Safety Scale) | 70 | 113 |
Below is an assessment analysis by Susanna Coss, Unyte Health’s Research and Training Associate:
Notably, Hope’s scores on the GAD-7 and PHQ-9 both moved from a clinical to non-clinical level following SSP Core listening, signifying a significant reduction in symptoms of anxiety and depression. Additionally, the increase in her NPSS score is indicative of stronger feelings of psychological safety following SSP.
Discussion
Barbara shared that she felt great compassion for Hope from the beginning. Since she had previously seen Hope after her divorce, she knew about Hope’s dream of starting the school and how much the loss had impacted her.
“I was surprised that Hope reported that much of the distress related to her marriage and divorce had been resolved and settled,” Barbara said. “We never addressed these issues overtly at all during the course of the SSP.”
Hope had also suffered greatly because of what others had done. There was a sense of attunement between Hope and Barbara because of a shared interest in the nervous system, albeit from different perspectives.
When Hope started the SSP, she kept saying, “Wow! This is powerful!”, giving Barbara sense that she would respond well. Barbara experienced a sense of resonance with the client, sharing, “It was fun working with her, with her bubbly enthusiasm and natural humor, which was refreshing to me as quite a serious person. I felt very calm in the sessions. On one occasion, I canceled because I had a tooth problem and I knew I could not be a regulating presence.”
Hope shared that friends asked her what she was doing because she “looked different,” even asking if she “had changed her hair or something.” She shared that she was becoming more focused, efficient and rested. She felt safe for the first time in 13 years.
“The SSP works on a passive pathway. Recall on the part of the client is not needed. It is different because of the impact on the autonomic nervous system, creating a sense of safety. Hope was able to process difficult emotions because she felt calm. She felt contained in the presence of a regulated and regulating person. She commented that she needed a regulated person with her and that it would not have been the same had she listened in the presence of her mother, for example. This again substantiated the importance of a well-regulated provider. I do not think she would have been as regulated at home as she was in my office, which is very peaceful,” Barabra said.
Hope appreciated how much she could process without needing to recall the story. She quickly discovered that the power of the program lay in regulating her autonomic state rather than recounting the story itself. Hope noted that she could remember traumas without reliving them. The difference was in the sense of safety.
Barbara noted that the pace of the intervention is important. Hope was able to cope with half an hour a day without being overwhelmed. On hour four, when she listened to an hour, it was too much and was triggering later on in the night. Barbara stated she would not do that again.
“We were able to slow the pace and take a break to allow her nervous system to settle and integrate. The power of the program lies in experiencing regulation and safety. Hope also showed me that she needed my presence to remain regulated, although I was just a quiet presence,” Barbara said. “After the session, she liked to verbalize what the experience was like and at the start of each session, she liked to notice and name any changes and impact from the previous day. She needed someone who ‘got her’ to talk to and she got very excited about what she observed. She showed joy as she emerged from her shutdown state.”
Since then, Hope’s cardiologist confirmed that her dysregulated heart rate was due to anxiety, and her homeopath said her inflammation has decreased. Hope’s financial problems are unresolved and although her future is uncertain, she is coping with the stress of this. She still lives in a tense atmosphere at home, but is managing to regulate her nervous system despite the ongoing stress.
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