How Polyvagal Theory Helps Us Understand the Effectiveness of Theraplay 

Originally published in the The Theraplay® Institute Newsletter of  Winter 2016

Sandra Lindaman, MA, MSW, Training Advisor, The Theraplay Institute

Stephen Porges, PhD, author of The Polyvagal Theory, will speak on “The Transformative Power of Feeling Safe” at the 2016 7th International Theraplay Conference. During the past year several of us from TTI have studied and consulted with Dr. Porges about the Theraplay model and potential Theraplay research. This article is an introduction to Polyvagal Theory concepts and their link to Theraplay practice.

Polyvagal Theory (PVT) links the mechanisms underlying feelings of safety, social interaction and healthy development. An understanding of PVT adds to our knowledge of how Theraplay interactions work to help children feel safe enough in relationships to develop in healthy ways. In Theraplay treatment we see clinical changes that indicate that our clients feel safer, for example:

•  been silent, fearful and sometimes “frozen” at school for 1.5 years and only talks at home. A 5 year old girl who experienced severe medical trauma during her first three years has 

After two Theraplay sessions, she makes grunting sounds at holiday gatherings of extended family. After three Theraplay sessions her teacher reports that she is more interactive and responsive to her peers, makes sounds when working by herself, silently laughs at things her classmates say and seems very happy to be at school.

• A child was adopted from a South American orphanage at nine months following severe deprivation and probable abuse. As a baby she seemed miserable and was aggressive to her parents. Now 5 years old and described as smart, verbal, controlling, and frequently wildly dysregulated, she often is clearly in a state of “fight or flight”. She volunteers in her third session that Theraplay made her want to cry less. She later reports, “I don’t know how it works but playing makes my mind feel calmer.”(Booth & Lindaman, 2010, p. 82)

We have understood that Theraplay’s Structure dimension of order, predictability and regulation contribute to safety. PVT shows us that the way Theraplay therapists Engage their clients and Theraplay’s unique sequencing of engagement, play and Nurture also play a significant role in the client’s sense of safety.

Theraplay Through a Polyvagal Theory Lens

When we examine Theraplay through a Polyvagal Theory lens, we see:

•The way that Theraplay therapists use their warm expressive faces and melodic voices so similar to “parentese” to  Engage clients provides the very cues that children seek to detect safety in their environments. Thus it creates the  environment in which the child feels safe enough in proximity to allow for interpersonal healthy connectedness.  The use of the voice, face and proximity is the essence of the dimension of Nurture, which allows for down  regulation of arousal while staying in connection.

•The physically active but interpersonal face to face play used in Theraplay combines safety cues with up regulating  the state of arousal. With this, it increases the scope of feeling safe in proximity to others and thus the scope of   arousal that can be tolerated without falling into a fight-or-fight state. 

•The combination and sequencing of social engagement, play and the down regulation of arousal by nurturing care   represent three physiological states which are seen in the optimal, cyclical changes in arousal.

•For the above reasons, PVT affirms the use of Theraplay for children and adults with trauma while informing our  trauma modifications of the model.

A Simple, Familiar Theraplay Sequence with an Elegant, Complex Agenda

The Theraplay Therapist sits face to face across from a child on the floor and, with a smile and widened eyes, places a soft stuffed toy on her own head. She extends her hands palms up toward the child and nods, inviting the child to do the same, placing her hands below the child’s hands. In a melodic voice the therapist says, “One, two three...” and then tilts her head forward so the toy drops into their hands with a soft plop. The therapist exclaims, “Wow, we caught it!” The child laughs and eagerly says “My turn!!”After several rounds of dropping the toy into each other’s hands, the therapist looks carefully at the child’s hands, saying, “My goodness, what great hands you have—they’re warm (feels briefly), they have 1-2-3-4-5 fingers (touches each finger lightly), and look, (leans forward, points) there is a special freckle on your thumb! Mom, I’ll bet you knew all about that freckle; now it’s your turn, sit right here....”

Trained Theraplay therapists in sixty countries including many cultures engage children in activities similar to the above example with parents and children in offices, homes and schools, as well as in orphanages, refugee camps, community centers, shelters, preschools and well-baby clinics. As illustrated by the first two examples, the children and parents often “do better” quickly, which they may describe as feeling calmer, physically closer, more emotionally connected, and happier.

We have understood the mechanism for these improvements in this way: Theraplay stimulates deep areas of the emotional brain of the child and parent through establishing security and organization (Structure), activating attachment experiences of synchrony, attunement, repair, intersubjectivity, delight and joy (Engagement), soothing and caring (Nurture), and encouraging growth and development with the parent’s help (Challenge). In addition to having new, positive parent-child experiences, which shift the inner working models of both parties in a positive direction, parents also are helped to think about and reflect on the Theraplay experience. Polyvagal Theory adds an understanding of the mechanisms of safety to the foundation of our work.

In (PVT) terms, the therapist in the vignette above is using her Social Engagement System (SES) of contingent, in the moment, warm facial expression, melodic voice and welcoming body posture to activate the child’s Social Engagement System and create an unconscious sense, or “neuroception,” of safety. Through her SES the therapist signals that this interaction is play and not aggression; in fact, it is joyful. Additionally, the proximity, brief touch, partnership and support shows the child that this adult helps him. The interest, delight, pleasure and caring contact triggers positive chemical changes in the brain. Through the sequencing of social engagement, play and care, the Theraplay therapist co-regulates a process of neural arousal and connection which supports the child’s mental and physical health.

Polyvagal Theory in Brief

TThe specifics of Polyvagal Theory can be complex but there are key aspects of it that we are quite familiar with as human beings, as trauma informed therapists and as Theraplay practitioners.

• “We as mammals have a social engagement system that evolved to employ cues from face-to-face interactions to efficiently calm our physiological state and shift our fight/flight behaviors to trusting relationships.” (Porges, 2015, p. 4) The following summary is derived from the references cited below:

We humans are always unconsciously looking for features of safety in our environment to calm our brain’s threat-defense system. Porges created the word “neuroception” for this automatic detection of risk in the environment; it occurs without our awareness and is distinct from perception or sensation. We seek cues in the faces and voices of others and can be calmed by those cues. In this calm/optimal state we can be socially engaged, play, rest and be physically close to others. In this state we can access our higher level brain structures and our highest level of functioning. When we detect a sufficient threat of danger, we leave this state and go into sympathetic hyper arousal or fight/flight. If that state doesn’t work and we experience life threat, we go into a state of parasympathetic hypo arousal or freeze.

We share the latter two states of hyper and hypo arousal with ancient reptiles. Only mammals have the ability to be calmed by social cues. This is made possible by the development of a second branch of the vagus nerve (the “smart” ventral vagus) that ultimately controls the heart and lungs. Within the brain, the vagus makes connections with nerves that innervate the muscles of the face, head and middle ear. This “face-heart connection” means that there are mutual interactions between the influence of the vagus nerve on the heart and the neural regulation of the muscles of face and head. These face and head muscles control gaze, facial expression, ingestion of food, head gesture, prosody and picking out human voices via the muscles of the middle ear. The connection makes it possible to signal our physiological state with changes in our face and voice. And, in turn, enables another’s facial expression and voice to calm our physiological state.

Our use of safety cues from the face and voice of another is not a learned behavior but an evolutionary adaptation of mammals that begins in the infant-caregiver relationship. This neurophysiological experience of felt safety is the foundation of the attachment process. More about this later!

“Play” is a combination of sympathetic arousal and down regulation to a calmer state via face to face social engagement cues. If the social engagement cues are absent, the interaction is experienced as aggression.

Porges identifies five basic physiological states as described above: social engagement, play, being close to another without fear (as in cuddling, hugging, sleeping with another), hyper arousal into fight/flight, and hypo arousal into immobilization with fear or freeze. These physiological states are a fundamental part of emotion and mood, not simply correlates of emotion.

All humans experience the processes described above. People with past traumatic experiences may be triggered into defensive states of flight/flight/freeze more easily than those without past trauma. They may “neurocept” danger when there is none in the environment, or they may not detect danger when it actually exists.

Being safe is not the equivalent of removing threat. Porges points out that it is common to attempt to reassure children that they are “safe” through visible displays of law and order or punishing people who make them feel unsafe. However, our nervous systems really crave the active presentation of features of safety via the Social Engagement System and that these features “can promote development and foster resilience” (2015, p. 115).

All treatments should incorporate the concept of neuroception at their base to figure out how safe a person feels before attempting to change behavior. Feeling safe has a transformative power in the direction of health and should be a goal of therapy.

PVT and Attachment Theory

We have used attachment theory and the model of the parent-infant relationship as the prototype for Theraplay treatment since its beginning, heeding Bowlby’s advice: “the pattern of interaction adopted by the mother of a secure infant provides an excellent model for the pattern of therapeutic intervention....” (1988, p. 126). Here we have Porges’ neurophysiological description of that early process: (bolding re: outcomes is mine)

• “... the interactions with the mother also serve as neural exercises that enable social cues of safety, emanating  from the mother, to regulate the infant’s physiology and behavioural state. As the infant calms, cues from the  infant calm the mother. These bidirectional and reciprocal interactions strengthen the social bonds between mother  and infant and foster a capacity to co-regulate. These features of co-regulation between mother and infant form the  prototype for social relationships through the child’s lifespan. Functionally, the experiences of the infant in the  mother–infant relationship provide opportunities for neural exercises to strengthen pathways that will enable social  behavior to regulate physiological state.

•If these neural pathways are adequately exercised, the ability to co-regulate with another is optimized.

•If these neural pathways are inadequately exercised, or the opportunities to co-regulate with the mother are  disrupted or unreliable, then as the child matures the ability to co- regulate with another is at risk.”( Porges,  2015, p. 116).

•“Even with removal of danger cues, the Social Engagement System may remain dormant unless it is appropriately  stimulated with safety cues.” (ibid. p. 120)

In Summary

We know that our child and parent clients typically have difficulty co-regulating with each other and with others in their worlds; some seem to have ‘dormant’ social engagement systems. Polyvagal Theory helps us understand the mechanism behind the fact that many of our clients fundamentally do not feel safe. PVT also shows us that Theraplay has a specific role in safety creation via social engagement, play and nurture. I invite Theraplay practitioners to consider these aspects of PVT in their own work. Please bring your observations and questions for Dr. Porges to the Theraplay Conference.

References

Booth, P.B. & Lindaman, S. “Theory and Research that Inform the Core Concepts of Theraplay” in Booth, P.B. & Jernberg, A.M. (2010). Theraplay (3rd Edition). Jossey-Bass.

Bowlby, J. A secure base. Parent-child attachment and healthy human development. NY: Basic Books, 1988

Porges, S. W. . (2015). “Making the World Safe for our Children: Down-regulating Defence and Up-regulating Social Engagement to ‘Optimise’ the Human Experience.” Children Australia, 40, pp 114-123 doi:10.1017/cha.2015.12

Porges, S. W. (2015). “Play as neural exercise: Insights from the Polyvagal Theory”. In D. Pearce-McCall (Ed.), The Power of Play for Mind Brain Health, (pp. 3-7). Available from http://mindgains.org/

Geller, S. M. & Porges, S.W. (2014) “Therapeutic Presence: Neurophysiological mechanisms mediating feeling safe in therapeutic relationships” in Journal of Psychotherapy Integration Vol 24, 3, 178-192.

Porges, S. W. (2013). “A Neural Love Code: The Body’s Need to Engage and Bond.” DVD Seminar. www.pesi.com. Porges, S.W.. 2011. The Polyvagal Theory. Norton.

My thanks to Phyllis Booth, MA and Jukka Mäkelä, MD for their wisdom, support and editorial suggestions.

 

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