Presentation on theme: ": POLYVAGAL SOLUTIONS TO TRAUMA AND PAIN: Ericksonian Pathways"— Presentation transcript:
1 : POLYVAGAL SOLUTIONS TO TRAUMA AND PAIN: Ericksonian Pathways Maggie Phillips, Ph.D. USAMaggiePhillipsphd.com:
2 Workshop Objectives:Participants will identify 3 branches of the polyvagal system and their functions.Observe and practice tools to turn on socialengagement & ventral vagal circuits.Learn strategies to help clients move out of fear/immobility connected to SA and DV circuits.Practice two Ericksonian strategies to help heal trauma and pain by regulating polyvagal function.
3 The “A” and the Four F’s of Trauma Arrest (increased vigilance, scanning)Flight: try first to escapeFight (if we are prevented from escape)Freeze (“scared stiff”) and fold (collapse into helplessness)Trauma occurs when we are intensely frightened and perceive we are trapped. We freeze in paralysis or fold/collapse in helplessnesscopyright Maggie Phillips, Ph.D.
4 Pain is linked to 5 Types of Trauma Trauma may have caused the pain through accident, injury, disease, natural disaster, other overwhelming events, or the accumulation of “little t” trauma.Persistent emotional and physical pain becomes traumatizing in itself.Unresolved trauma that predates the pain can help to trigger the current pain problem: ex: traumatizing illness, surgeries & hospitalizations, car accidents
5 5 Types of Trauma Linked to Pain Early childhood trauma, including perinatal/postnatal/birth trauma, attachment problems, emotional/physical/sexual abuse, neglect and loss can create distress which can set the stage for later emotional and physical pain.Insecure attachment, such as disorganized, avoidant, and ambivalent attachment experiences can become barriers to trusting the body, developing reliable self-regulation and self-soothing, and trusting professionals to help.
6 Neurobiology of Pain: The Brain Pain messages arrive first at the thalamus for sorting and switching.The thalamus forwards these to 3 areas: the somatosensory cortex (physical sensation), the limbic system (emotional pain), and the frontal cortex (thinking region)So there are always 3 components of pain: physical, emotional, and belief &/or intention.
7 Polyvagal TheoryResearched by Dr. Stephen Porges, Research Professor at UNCThe polyvagal theory is based on evolutionThat which contributes to human survival and reproduction is valuable, and will be passed along genetically to the next generation
8 Polyvagal Theory Proposes: That two functionally separate tracks evolved within the vagus nerve to regulate activation. Both inhibit behavior within the parasym. system:Old Vagus (DV – Dorsal vagal)New Vagus (NV – Ventral vagal complex or Nucleus Ambiguus)
9 Vagus: 10th Cranial Nerve The vagus nerve (wanderingfrom Latin) is your body’s longestnerve, starting in your brain andwinding through many important organsystems in the body. It’s a primary componentof the autonomic nervous system.Old vagus dates from the reptilian era. It elicits immobilization behaviors under threat—DV. New vagus (VV) is linked to social communication and self-soothing.
10 3 Polyvagal, Hierarchical Circuits Most primitive is DV shared with all vertebrates: immobiliz as defense. Very ancient circuit.Mobilization system--S/A—fight/flight. As long as we keep moving, we’re not vulnerable to shut down and freeze. However when chronic, creates disease and is devastating for social engagement as we can’t co-regulate.Newest VV circuit evolved with mammals. Links all the muscles that control face & head—vocaliz, listening, facial cues, prosodic vocalization, and connected to down regulation of the heart.
13 The Polyvagal System: A Blueprint for Pain and Healing Steven Porges’ polyvagal theory (1995) helps us to understand the interplay between the sympathetic and parasympathetic branches of the nervous system with creation & maintenance of pain.1) The ventral vagal social engagement system is “in charge” during nonthreatening situations. It helps us engage with the environment and helps us relate to others. It also helps to regulate the sympathetic system and keeps us in a “window of tolerance.”
14 The Polyvagal System: A Blueprint for Pain and Healing 2) During times of traumatic threat, the ventral vagal system is overridden by the sympathetic system activation, which mobilizes survival responses (fight and flight). The “alarm” is sounded by the amygdala and the hypothalamus turns on a cascade of chemicals, including cortisol, epinephrine, and adrenaline, which help to mobilize energy to meet the threat.Activation of the sympathetic system results in increased blood flow to body’s muscles, decreased flow to the brain cortex, & increased vigilance. These reactions maximize our chances for survival.
15 The Polyvagal System…3. If both the ventral vagal social activation system and the fight/flight response do not match the threat, then the dorsal vagal system is turned on. This is the most primitive system and is triggered by lack of oxygen in tissues and muscles. It turns on the immobility response displayed by the possum as “fake death.” The immobility response shuts down many functions of the body leading to decrease in heart rate and respiration and accompanied by numbness. Although this immobility protects survival, it can be lethal over a long time period, leading to heart and breathing problems, among other medical disorders.
19 Understanding Absent Social Engagement/VV responses The newest vagus has myelinated pathways and is connected to cranial nerves that control facial expression and vocalizationIf someone’s face is flat with no facial expression, little muscle tone, drooping eyelids, and averted gaze, neural regulation of the face may be “off-line”We no longer would say “sit still” or criticize restlessness because the neural system that regulates both bodily state and face muscles may be off-line.We no longer say “Why aren’t you smiling?” or “Look at me when I’m talking.” Teaching eye contact when neural regulation is off-line is NOT helpful because the spontaneous eye gaze may be turned off.
20 Top-Down & Bottom-Up Interventions for Pain: Framework for Protocols Teach breathing methods to regulate reptilian brain response and develop the skills for self-regulation (dorsal vagal)Rebalance & regulate sympathetic(fight/flight) by teaching awareness of and working with pendulum rhythms (DV&Sympathetic/Adrenal). Repair attachment trauma through the therapy relationship (Ventral Vegal).Resolve internal attachment and relational conflicts through ego-state therapy (ventral vagal)***Teach multiple methods to help “thaw” the freeze/immobility response, balance fight/flight, assist with self-regulation, and enhance relational experience (all 3 brains & nervous systems)
21 Importance of Self-Regulation When traumatic disregulation occurs over time, somato-affective experience can become extremely intense, leaving the traumatized person stuck in fight, flight, or freeze response outside the window of toleranceRenegotiating trauma involves completing autonomic patterns and exchanging active, intentional defenses for passive ones in order to achieve homeostasis in the CNS, which then produces new internal responses.
22 CIRCLE BREATHING FOR SELF-REGULATION Circular breathing (a): If there is more discomfort on one side of the body, imagine that you can breathe in up the more comfortable side, feel the breath crossing over and then breathe out down the less comfortable side. Modify by adding several breaths if needed to focus on particular areas of pain; start with feet & legs.(b): Breathe in from the base of the pelvis and follow the flow of breath up the middle of the body to the face and then back down again. Continue until the breath cycle feels like a circle.
23 CIRCLE BREATHING FOR SELF REGULATION C) Breathe in from the pelvis up the midline of the body to the face and/or up to the top of the head. Then breathe out down the back of the head and spine to the tailbone.Alternatively, breathe out down through the shoulders and arms.D) Imagine your breath as a magnet; as you breathe in up one side of the body or up the middle, self-suggest what positive sensations you are picking up and what you are letting go of as you breathe out
24 Other Simple Breathing Practices “Just One Breath”: Ask the client to take one breath without changing anything. What is different?Porges: Out breath twice as long as the inhalation,dropping the diaphragm: Count in: 1-2; out: [7-8]. Start with what is easy and then expand. If it helps, place hands on your diaphragm and press down gentlyCalming breath: Breathe in: “Safe and secure;”breathe out: “relaxed and ready”
25 Ericksonian Pathway #1: Getting to “Yes” To teach breathing or any other technique, it must be offered as a meaningful way to engage with the self instead of as a mechanical practice.“What if there was a simple way to reduce your pain right now? Would you be interested in learning about it?”“You are already aware of your conscious beliefs about pain. Did you know that your unconscious has a more creative wisdom that can be discovered by connecting with your body? Are you curious about learning more?”
26 The Ventral VagusThis circuit mediates the actions of sympathetic and parasympathetic functions of the ANS.The VV helps us orient to connectionand safety and literally creates thewarmth in our smiles or a sparkle inour eyes.
27 The Ventral VagusPorges notes that not only can high activation be connected with fight/flight; when we are safe, it contributes to excitement and play.When we are safe, the parasympathetic is linked with relaxation and facilitates bonding and intimacy. When we are feeling unsafe, the same low activation system is linked to collapse, dissociation, & despair.
28 The Newest Vagus: VV Social Engagement For calming; DV & S/A for defenseNeuroception is the term for how we use “feature detectors” to identify external safety & calm our- selves down.Nervous system detects safety through voice prosody (rhythm, speed, pitch, & emphasis).Traumatized people have difficulty making eye contact but they cannot turn off their ability to interpret voice qualities.If we process cues= safety, muscles of our faces loosen and become spontaneously engagingWe can rapidly distinguish between false smiles and real, spontaneous smiles
30 How Do We Turn On the VV and Safety? The calming effect of breathing is amplified when we exhale and dampened when we inhale.According to Porges, longer duration of exhale is linked with perceiving surroundings as safer and more positive.Muscle tension is reduced during slower exhale.Visceral pain is reduced during slower exhalations.When you teach someone to exhale longer and more slowly, make sure it is truly relaxing to the client.
31 Shift into VV through Ego-State Therapy EST is an ongoing relational therapy, which differs from NLP, gestalt, psycho-synthesis, and other “parts” models. The therapist attends simultaneously to 4 ongoing relationship dimensions:Alliance between therapist and client (first and foremost);Alliances between therapist and ego states;Alliance between client and ego states; andAlliances of ego states with one another.Maggie Phillips copyright 2015
32 Why Work with Ego States? One way of expanding the ventral vagal circuitResolve inner conflicts and related symptoms that have not responded to other approachesNecessary when working with complex PTSD, dissociative disorders, DIDBrings greater self-cohesion and personality integrationWorking with the inner family of self can generate changes in external relationshipsEmphasize last 2 pointsMaggie Phillips copyright 2015
33 Rapid, Strategic Ways of Finding ES Ask what the client knows about the part that…Ask other states for helpUse ideomotor or ideosensory signalsBridge from micromovements to statesOften very helpful to activate ego states that are connected:To the origin of the conditionTo the maintenance of the conditionTo the healing and solution of theproblem or symptomMaggie Phillips copyright 2015
34 Ericksonian Pathway #2: The Power of Words and Suggestion: Magic of WE Emphasize the “we” of healingWhat can we do to make things better for you?How much more creative energy do you think we can mobilize together vs. when you deal with pain alone?This is a big challenge for US. Do you think we’re ready?
35 Sympathetic/Adrenal and Pain S/A evolved from reptilian timesMobilizing fight/flight but also involved with bracing, holding, protecting and flexingIf we are threatened repeatedly, but don’t mobilize/express/complete/discharge, defensive energy builds and builds with negative results.Huge muscle tension, heart pumping, blood vessels constrict in extremities, hands, feet, belly (we are less likely to bleed to death)When someone is hyperactivated chronically in the SA system, we don’t regulate without preparation.Pain is related to trauma that has gotten locked in the system and not released
36 SA System and PainSystemic lockdown could lead to conditions like fibromyalgiaMust identify bracing and holding patterns and perpetual arousal patternsWhen these are regulated, pain will decreaseThe challenge is to find a portal into these patterns and to work with the whole system rather than specific symptoms
37 SA System and PainWorking with movement is important to help complete incomplete movements that are locked in the nervous system.Notice micro-movements and encourage clients to be curious and allow them to continue.Encourage rhythmic movement: “Go ahead and move just a little bit; now pause and breathe; move just a little more; pause and breathe.Psychoeducation is also hugely important—let clients know why you are asking them to do a particular task or assume a particular focus.
38 Interpreting the Language of Sensation When you ask clients to describe sensations related to emotional or physical pain, you will get clues about where they are stuck in the polyvagal system.If they use words like stabbing, burning, shooting, frightening, alarming…the pain is more likely to be related to the Sympathetic/Adrenal circuit.If they say that they don’t feel much of anything or are numb, dissociated, etc., they are likely caught in the Dorsal Vagal circuit.And, if they describe pain as attacking them, they are likely connected to the Ventral Vagal circuit and the S/A.
39 SA System and Pain: SE Tools Pendulation and titration are basic SE toolsWhen people sense the rhythm of expand and contract, they begin organically to shift into the flowWhen we teach pendulation we have to “prime the pump” by having clients sense into the pain and then focus on a body area that feels different.Eventually they get deep enough into the trauma vortex that they experience trembling and shaking, which is part of downregulation. Pain, like any other sensate pattern, has to go through its own cycles into settling and then into an easy deep breath of relief.
40 Benefits of Pendulation Helps us with embodimentHelps us to be a neutral observerHelps to develop self-connection—a portal to social engagementHelps us know we (and the world) contain goodness as well as sufferingHelps us identify resourcesHelps us open to & receive inner & outer resourcesHelps us learn self-regulationEmpowers us to manage our own symptomsReveals a flexible nervous system
41 The Art & Science of Pendulation Oscillation approaches help usregulate our sensory experiences.Pendulation, coined by Peter Levine, utilizes the pendulum rhythms of the nervous system to rebalance and restore.Alternating between areas of overactivation and underactivation helps to shift from imbalance & disregulation to homeostasis and present time awareness.It is also helpful at times to pendulate between 2 counter vortex resource areas for strengthening OR between 2 traumatized areas for release.
42 Pendulation & Breathing for Self-Regulation Practice Somatic Experiencing methods to regulate pendulum rhythms related to trauma:1) Explore the pain, fear, or symptom2) Scale the problem (1-10) in intensity3) Explore symptoms in the body and describe/name the sensations4) Find the part of the body that feels or seems farthest away from the symptom (eg. body safe place or area of expansion)5) Guide the client back and forth with their inner focus to form a connection between the two areas
43 Using Pendulation & Breathing for Self-Regulation 6) Add the breath to help this process along…(ex. Inhale: notice the positive/neutral somatic place; Exhale: notice symptom or pain). Complete 3-4 cycles7) You may want to add circular breathing. Imagine your breath moving up the side of the body that is most comfortable (resourced) and down and out the side that is less comfortable.Do this for several breath cycles8) What do you notice? What do you feel?9) Take some time and experiment10) Debrief and discuss how you can use this.
44 Ericksonian Pathway #3: Focus on RHYTHM Rhythm is the basis of how the nervous system operatesHelp clients connect with natural rhythms of breathing, movement, sensation and with specific reptilian brainstem rhythms that create daily rhythms that are soothingIdentify what natural rhythms create momentum toward comfort and away from pain. Practice effective chaining.
45 Containing S/A through VV Therapist’s own presence is important—do your own self-regulationIt’s especially essential that you self-regulate when the client cannot self-regulateThe prosodic voice is hugely importantSimple touch on the upper arm or shoulder or “foot to foot” with a firm, easy touch can be helpful. Ask the client where and whether he/she would like contact.
46 Dorsal VagusThe primary role of the DV in humans is to regulate the visceral organs below the diaphragm.It originates in the brain stem area called the dorsal nucleus of the vagus.Most of the nerve fibers of the vagus are efferent, meaning coming down from the brain. 80% of those go to the DV and only a few go to the VV.The role of afferent fibers are sensory pathways that go back to the brain.The VV fibers are linked with face and affect while DV fibers are linked to the subdiaphragm area.
47 DV—S/A—VV: Who’s in Charge? If the VV is in charge, then the S/A will work in a more regulatory way, promoting healthy blood flow and other healthy functioning.If the VV is “offline,” the S/A moves into defense, breathing moves into the chest & is shallow, the DV is the only defense left and it shuts down the organism to change.
48 DV—S/A—VV RhythmsThe vagal afferents that come from the gut and diaphragm help modulate pain. The task is to stimulate them so that they are optimally available.Many people float between DV & S/A. DV interacts with a spinal pathway used in nociception, processing of harmful stimuli. This disrupts blood pressure-vasovagal sympatheticsyncope. 3 syndromes: chronic fatigue, fibromyalgia, & blood pressure regulation problems (fainting and falling). All DV. If the person attempts to regulate from DV, they cannot immobilize without fear, which further maintains freeze.
49 How to Stimulate Vagal Afferents Vibrating a sound from the diaphragm—”voo”—”ahhh” long sigh…also releases jawSing, vocalize, or chant especially in higher range—create prosodyMany of the powerful afferents are in the diaphragm so pushing the diaphragm down & extending the duration of exhalation increases the VV flow, which triggers the DV & sympathetics to go back into homeostasis.
50 Shifting out of the DV shutdown The shift from acute to chronic pain largely happens through bracing, constricting, & holding patterns that aren’t released. This then creates more pain.More pain itself causes more bracing and more sympathetic activation. Eventually this leads to shutdown and release of many opioids in dissociation.To get out of shut down, we activate the VV through the therapist’s presence, voluntary belly or abdominal breathing, creating a “now” state. Can also walk or move together with clients to help them come into the now.Impt. to honor the defense system being used, and help the client make the change gradually.Remember, pain and trauma do NOT resolve in shutdown. Clients must come out of shutdown to be energetically accessible to different experience.
51 Autonomic BalanceIf VV is functioning well, then you have AB between the sympathetic and DVsense of well-being.Must keep the DV & S/A out of defensive roles.Then the person can connect with feelings of well-being & expansion and shift back and forth with pain (pendulation).Other types of movement can contribute, such as rocking. The key is rhythm. Standing on ½ of an exercise ball while holding on for support with the therapist there brings safety and trust. This changes an activity into a neural exercise of growth vs. a shutting down defensive reaction
52 The Pain Trap: S/A & DV •The brain responds to threat by activating primitive brain structures like the brain stem and amygdala. • If there is a perception of danger that is threatening, the brain turns on the fear response. • Once the fear response is activated, the body begins to brace to protect against threat (ex. arms come up to protect the head). • Bracing can trigger chronic constriction and chronic pain if not released. • Eventually we brace against the pain itself which creates more constriction and pain. • As this continues we can collapse into helplessness or freeze.
53 The pain trap deepens in complexity because certain areas of the brain like the frontal lobes essential to observation, language, and perspective are turned off •Threatfearbracingconstrictionpain collapse • If this vicious cycle is not interrupted, many serious problems occur, including chronic pain. • One powerful intervention is to use curiosity to help interrupt the fear response • We can also learn to keep a soft, mindful focus on sensations so that we learn the felt sense instead of defaulting to the DV shutdown/dissociation. • And we can activate the VV to downregulate both S/A & DV through breathing, vocalizing, & positive attachment experience
54 Ericksonian Pathway #4: Utilization 1) When helping a client out of the freeze, use what is currently working best to shift the client toward mobility, movement, and momentum, and even enjoyment. 2) Playing and listening to music, online games, engaging hobbies, or even very short walks that feel comfortable and energizing. 3) Gradually and slowly you can help the client increase the baseline or watch for times when they are beginning to do so.
55 Teleclasses/Webinars in Mindbody Healing, Trauma, & Pain Books by Maggie Phillips: Freedom from Pain (2012) with Peter Levine Reversing Chronic Pain (2007) Finding the Energy to Heal (2000) Healing the Divided Self (1995)Maggie Phillips, Ph.D.(510)Teleclasses/Webinars in Mindbody Healing, Trauma, & PainCD Program on Hypnosis & Pain