What is Polyvagal Theory?

Clinical therapists, in their efforts to understand the “why” of certain behaviors, have been asking about Polyvagal Theory.  You probably know more than you think about this, but have not put all the pieces together. This is something we as pediatric occupational therapy providers need to be able to answer questions when our occupational therapy clients ask!

According to the Polyvagal Institute, “Polyvagal Theory is a way of understanding how our nervous system responds to different situations, like stress, danger, or safety. It was developed by Dr. Stephen Porges, a neuroscientist and psychologist, in 1994. In simple terms, Polyvagal Theory helps us understand how our body and brain work together to respond to stressors that are a part of everyday life as well as experiences that are more significant, such as trauma.”

A lot of the information presented on this topic is hard to decipher from a clinical perspective.  While I find medicine fascinating, it is difficult to understand all the scientific terminology related to Polyvagal theory. 

At first glance, this article popped up: “The Polyvagal theory describes an autonomic nervous system that is influenced by the central nervous system, sensitive to afferent influences, characterized by an adaptive reactivity dependent on the phylogeny of the neural circuits, and interactive with source nuclei in the brainstem regulating the striated muscles of the face and head”.

In this post we will learn the nuts and bolts of this theory, but more importantly, how it correlates to the learners we work with. When I read descriptions like the ones above, I try and imagine talking to a teacher or new parent using this definition.  While I, as an experienced pediatric occupational therapist, might sound smart, I am not likely to have others “buy in” to therapy if they can not understand what we are doing. 

POLYVAGAL THEORY IN LAYPERSON’S TERMS

Now that you have clinical definitions in your toolbox, what does Polyvagal theory actually mean?  Polyvagal theory breaks down the function of the vagus nerve and its’ connection with the rest of the body. 

The vagus nerve is a large nerve that goes from the base of the brain to the gut, connecting the brain to the body. The vagus nerve plays a key role in regulating our heart rate, breathing, and digestion, as well as our emotional state.

The theory suggests that the central nervous system (made up of the brain and spinal cord) has three branches:

1. Fight or flight is the first branch.  This is activated when we are in a threatening or dangerous situation.  In polyvagal theory this is termed “mobilization,” and is the body’s way of preparing to fight a threat, or run away from it.
2. The second branch is the “collapse” response. Our body feels powerless to respond and will often shut down, or become unresponsive to stimuli in the surroundings.  In Polyvagal theory this is called “immobilization.”  You might have referred to it as shut down or freeze state.
3. The third response state is the “social engagement” response (termed ‘ventral vagal’ in the Theory), which is activated when we feel safe and connected to others. This is when we are relaxed and open to social interaction, and is communicated in our eyes, facial expressions, and tone of voice.  This branch is referred to as the “relaxed” state.

All three of these branches are controlled by different parts of our nervous system, but are managed by the vagus nerve.  Polyvagal theory suggests that by being able to understand these different branches or response states, we can better manage our own health and wellness, and understand the behavior of others (including empathy).

NEUROCEPTION AND POLYVAGAL THEORY

Here is where things get tricky.  If our systems worked correctly 100% of the time, we would not be over or under-responding to stimuli. 

The autonomic nervous system has a build in monitoring system that interprets information about risk through sensors in the body (neuroception).  These sensors determine danger, without involving the thinking parts of our brain.  Autonomic can be thought of as “automatic”. Neuroception scans people, our body, and the environment for cues of safety or danger. The nervous system reflexively shifts to manage the situation for a survival response. 

• A neurotypical system with a great sense of resilience will have greater cues detecting safety, whereas a less resilient person’s system will lean toward detecting threat.
• When in a calm state, the nervous system is less likely to activate the fight or flight response.
• If our neuroception or feedback monitoring system is faulty, it sends a signal of danger when we are actually safe, or signals safety when we are in danger.
• Some people find themselves in a constant state of hypervigilance, just waiting for a threat.
• Hypervigilant people may seek out risky behaviors to keep their body in this state of arousal.

Polyvagal theory and sensory processing

Polyvagal theory sounds a lot like regulation, arousal level, and sensory processing. When we understand the polyvagal theory, it is easier to see that sensory processing is a function (or dysfunction) of the vagus nerve.

What kind of people come to mind when you think about polyvagal theory and sensory processing?

• People with anxiety disorders – often in a constant state of high alert, easily triggered, sensitive, and “jumpy.”  I think I gasp 50 times a day.
• Autism spectrum – classically linked to arousal level difficulties, behavioral responses, and over/under reactions to stimuli.
• Depression – sometimes people with depression miss signals around them, or may exaggerate their responses.
• Sensory seekers – the risk takers often do not have the same feedback mechanism to alert them to possible danger.
• Sensory avoiders – these people are often overly fearful of stimuli or events around them. 

Each of these challenges have some aspect of sensory dysregulation.

HOW CAN I APPLY POLYVAGAL THEORY TO EVERYDAY LIFE?

• Recognize your response to stress and anxiety. Even if we do not realize that our brain has detected danger, there is an automatic reaction. A lot of it is self reflection skills. Pay attention to your nervous system activation and what that looks/feels like, or interoception skills (increased heart rate, breathing, blood pressure, sweating, flushing). Learn to recognize these responses in the people you work with. I have many children whose pupils dilate, or ears turn bright red when overstimulated.
• Practice or teach self-regulation. This is the ability to manage your response to stressors. We often teach this through deep breathing, deep pressure, gentle touch, quiet words, yoga, meditation, or other calming activities.
• Build social connections – according to Polyvagal theory, building social connections can help us feel safe and secure. This can help reduce stress responses.
• Identify triggers – learn what makes you (or your clients) feel unsafe or in danger.  Learn to work through or avoid certain triggers.  We do a lot of work on this with sensory therapy.  My book, Seeing your Home and Community with Sensory Eyes is full of chapters that describe typical daily triggers and responses.
• Seek professional support. If you feel you are struggling with your mental or emotional health, or your responses to stimuli are not typical, an occupational therapist or mental health professional that understands the vagus nerve and self-regulation can help.

Basically, having an understanding of the tools available can be used along with a stop and think strategy to help us interact in the environment and stressors around us.

HOW CAN I USE POLYVAGAL THEORY IN HEALTHCARE OR SCHOOLS?

The most efficient treatment aims at uncovering the cause or “why” our learners do certain things. We do not just put band aids over a gaping wound.  This is a temporary fix, that does not lead to long term results.

• Understanding that the responses we see are an autonomic or uncontrolled response to stimuli, can help you accept your learner’s responses differently. This can lead to better informed quality of care.  Example: understanding that you were hit or bitten because your kiddo was responding to something we were asking them to do, rather than being naughty, goes a long way.
• Trauma informed care – learning about Polyvagal theory helps with trauma informed care building trust, safety, and empowerment. A child (or adult) who feels safe around you is more likely to step out of their comfort zone and keep trying.
• Mind body interventions – teach relaxation techniques as part of your treatment plan.  Words are often not enough to calm an overactive state. Empower your learners to take control of their body and nervous system
• Pain management- understanding the role of the vagus nerve can help understand the response (or over/under response) to pain to treat your patients more effectively.
• Caregiver/client relationship – when you show that you understand what a person is going through, it builds trust and a willingness to go through the healing treatment process.

Polyvagal therapy

Polyvagal therapy can be talk-based therapy, or sensory based therapy to help reprogram the central and autonomic nervous systems.  It can involve yoga, meditation, and mindfulness.

Immersion therapy aims to slowly surround the person with the stimuli that is triggering, helping their body have a more appropriate response to it.  Slowly working with sounds, smells, or textures, can help desensitize the ANS response.  The key is to do this slowly, while watching for bodily responses.

Desensitization is similar to immersion – the body is slowly desensitized or accustomed to certain stimuli. This may be through slowly working from something easy to tolerate, to more difficult input.  Example: when working with textures you may start at dry beans, then dry noodles, rice, sand, playdough, putty, all the way to shaving cream. 

Dialectical Behavioral Therapy (DBT) is a type of talk therapy. “Dialectical” means combining opposite ideas. DBT focuses on helping people accept the reality of their lives and their behaviors, as well as helping them learn to change their lives, including their unhelpful behaviors.

Journaling can help understand and manage emotions. The OT Toolbox has many resources to get you started journaling and self-monitoring.

Vagus Nerve Exercises

Vagus nerve exercises are another tool in your therapy toolbox to support self regulation and co-regulation. There are specific exercises you can do that target the vagus nerve to get out of that fight/flight/fright/freeze zone. I like to use these vagus nerve exercises in Simon Says games, brain breaks, and other activities in OT sessions. Check out our relaxation breathing post for why breathing helps.

• Deep breathing- Breathe in through your nose with short breaths for four counts. Then Hold your breath for 7 seconds. Then slowly breathe out for 8 seconds. Repeat this a few times.
• Arm hugs- Wrap your arms around your upper arms and place them just below the deltoids. Gently give yourself a hug and breathe in and out.
• Tap your collar bones with both hands. Place your right hand on your left collarbone and your left hand on your right collar bone. Tap your fingers one at a time.
• Place one hand on your chest and the other on the back of your neck. Breathe in and out deeply.
• Arm taps– Place the palm of your hand on the opposite shoulder with both hands. Gently pat up and down both arms at the same time.
• Neck turn and look– Sit with your shoulders back. Gently look over your right shoulder and look as far to the right as you can with both eyes. Hold that position and gently breathe in and out. You will feel a release of pressure in your chest and a sigh. Then repeat on the opposite side.
• Eye gaze up– Bend your neck to one side by placing your left ear toward your left shoulder. Look up toward the ceiling with your eyes. Hold that position as you breathe in gently. You will feel a slight release of pressure in your chest and a sigh of breath. Then repeat on the other side. Hold that position until you feel the sigh.
• Hum! This is a simple way to focus on breath work. I also saw a meme recently that said you can’t think about ruminating thoughts at the same time as you are humming. This is a good way to stop stressing or anxiety thoughts.
• Gargle– This is another simple way to stimulate the vagus nerve. Bonus is that it’s a life skill that some of our kids need too.
• Meditation and mindfulness– This is another life skill that kids and adults need throughout life, so now is a good time to work on this with kids and teens.

POLYVAGAL THEORY BEST TREATMENT IDEAS

During my career, I have found the best treatment has been understanding my learners. Once I take a step back and show them that I understand their fears, pain, and objections, I can create a bond of trust that begins the healing process. While I do not like getting hit/bitten/slapped, or chasing a kid down the hallway, I do not get angry about it. I understand their response is often out of their control, and they usually do not have the language to be able to express themselves.

This has taught me much patience in working with people who struggle. As a highly sensitive person myself, polyvagal theory gives me grace to understand that I am a work in progress. Sometimes my body has a mind of its’ own, and I have to practice what I preach.

Victoria Wood, OTR/L is a contributor to The OT Toolbox and has been providing Occupational Therapy treatment in pediatrics for more than 25 years. She has practiced in hospital settings (inpatient, outpatient, NICU, PICU), school systems, and outpatient clinics in several states. She has treated hundreds of children with various sensory processing dysfunction in the areas of behavior, gross/fine motor skills, social skills and self-care. Ms. Wood has also been a featured speaker at seminars, webinars, and school staff development training. She is the author of Seeing your Home and Community with Sensory Eyes.