FEATURED WORKSHOPS for 2016: 

October 22, 2016 
 
July 16, 2016



Polyvagal Theory and its Implications for Group Therapy

An interview of Phil Flores, Ph.D. by Bob Fredrick, LCSW

How did you first become interested in polyvagal theory? Am I right in assuming that it had something to do with your long-term interest in attachment theory?
You are absolutely correct, Bob. Attachment has become more biologically than psychologically inspired theoretically because of a conceptual revolution that has evolved over the last twenty years, which synthesizes the best ideas of attachment theory and the neurosciences. However, despite the valuable empirical evidence provided by a vast array of discoveries in neurosciences, a lack of practical applicability to clinical practice has been sorely missing. For instance, van der Kolk (2009) observed that an understanding of the neuro-physiology of the brain alone does not provide the information necessary for translating this knowledge into relevant clinical practice. Polyvagal theory, with its innovative and paradigm-shifting perspective on the neuro-circuitry and biophysical mechanisms underlying attachment behavior, has been the one primary theory that clearly describes how the new evidence from the neurosciences can be translated to practical clinical application, especially for group psychotherapy.
Could you give us a brief primer on polyvagal theory? What are the main tenets of the theory?
Let’s use an everyday example of a chance encounter between two people that might help explain polyvagal theory. It’s been a stressful day at work and you decide after you get home that a relaxing walk in your neighborhood in the evening might help you unwind. The streets and sidewalks are quiet, peaceful and uninhabited. You notice in the distance that a man is walking towards you. As you get closer, you recognize him as someone who lives just around the corner from you. He smiles and greets you with a friendly hello. You exchange pleasantries for a few minutes. He makes a humorous comment and you share a moment of laughter together before finishing your walk. You arrive back home feeling calm and relaxed. From a polyvagal perspective, two things have occurred on a biophysical level that would explain the shift in your emotional state.
First, a primitive part of our brain, without cognitive awareness, immediately activates something called neuroception — a biophysical process that operates automatically, without conscious effort to detect threat or safety in our environment. Neuroception reflexively shifts our autonomic nervous system to either defuse or ignite the neurobiological defense mechanisms of fight/flight/freeze (the stress response) depending on whether the environment or a person is detected as threatening or safe. Turning off the autonomic nervous system and its activation of the stress response is absolutely necessary before states of calmness and the restoration of healthy homeostasis can occur if a person is stressed, injured or suffering from an illness. The human nervous system provides two paths for triggering the neural mechanisms of neuroception that are necessary for the down regulating of fight/flight arousal states.
One path is passive and involves contextual features like a pleasant, quiet, safe environment, which is why people enjoy a walk in nature and camping. The other path is active, requiring conscious voluntary interpersonal behaviors with a safe, sensitive and emotionally responsive person. A pleasant conversation with a good friend (or a therapist) will stimulate a series of neural mechanisms connected to something called the Social Engagement System. Once the Social Engagement System is activated, it stimulates specific neural platforms of the vagal system that automatically change physiological state. (This is one explanation of why psychotherapy is helpful).
If neuroception detects that another person is safe, our vagus system will allow our social engagement system to come online, making pleasant social intercourse possible. Because our vagus system is connected to our cranial nerves, vocal cords and the muscles of our face, our facial expressions will immediately relax, permitting smiles, prosody of speech and other non-threatening pro-social activation of the head and the shoulders to occur. This will usually potentiate a reciprocal response from the other person. Each person in the exchange will feel pleasantly regulated emotionally by the other, causing the autonomic arousal system to go off line, reducing the stress response. Evolution designed our vagus system so that it is neuro-physiologically impossible for our autonomic nervous system and our social engagement system to be activated at the same time. These are two mutually exclusive events. We can either be in the social engagement mode or we can be in the fight/flight (angry or frightened) mode.
In this example, the pleasant stroll in a safe familiar environment combined with a pleasing enjoyable encounter with a friendly recognizable acquaintance has primed a person’s physiological state of stress to be shifted to a psychological state of calmness. Now let’s change the scenario.  You are still walking in your neighborhood at night and the streets are still quiet and uninhabited. However, this time an unfamiliar banged up pickup truck with a cracked windshield suddenly speeds around the corner and screeches to a halt about a hundred yards in front of you. Two men get out of the truck, point in your direction and start walking slowly towards you. You don’t recognize them and their blank faces fail to convey their intentionality. They stop five feet in front of you, blocking your passage and glare at you. Your heart begins to pound rapidly, your breathing becomes short and fast and the muscles in your body tighten. The sympathetic branch of your autonomic nervous system has kicked in, preparing your body to either fight or flee. Your vagus system reacts automatically to the neuroception of threat or danger, and provides you with a hierarchy of biologically determined responses. When confronting danger, the newest and less primitive part of our vagus system will try to negotiate with the threatening person by using facial expressions, vocalizations and language. You may offer a smile and speak in a friendly tone saying something like, “It’s a wonderful night for a walk, isn’t it?” You may then politely add, “Excuse me”, as you attempt to pass them. If they continue to block your way, you may then snarl or growl at them (as most mammals do when they feel threatened),”Get the hell out of my way!” If this fails, fight or flight mobilization kicks in. You either run or you strike out at them. In extreme cases when fight or flight are impossible because there are two of them, they are bigger than you or one of them pulls out a gun, the oldest and most primitive part of our vagus system (the freeze response) gets activated. You could become immobilized, dissociate or even faint when there is no avenue open for escape and the situation is life threatening. This often happens to someone who is trapped, raped, tortured or caught in the middle of deadly combat during war.
The human nervous system, similar to that of other mammals, evolved not solely to promote survival in safe environments but also to support survival in dangerous and life-threatening contexts. To accomplish this adaptive flexibility, the human nervous system retained two primitive neural circuits to regulate defensive strategies (i.e., fight-flight and death-feigning behaviors). It is important to note that social behavior, social communication, and visceral homeostasis are incompatible with the neurophysiological states and behaviors promoted by the two neural circuits that support defense strategies. Thus, via evolution, the human nervous system retains three neural circuits, which are in a phylogenetically organized hierarchy. In this hierarchy of adaptive responses, the newest circuit is used first; if that circuit fails to provide safety, the older circuits are recruited sequentially.
It would seem that polyvagal theory would give us a new biological perspective on how we as group leaders help create safety in the group. Could you comment on this? What other implications does polyvagal theory have for group psychotherapy?
Anytime a group therapist circles eight to ten chairs in a room, he or she is intuitively applying one of the most essential principles of polyvagal theory that is critical for effective group treatment. In order to develop a social bond, individuals have to be in close proximity to each other. It also helps if the chairs are positioned in a grouping that permits all group members to have face to face contact with each other because it is the muscles and cranial nerves of the head (eye gaze, smiles, prosodic vocalizations, etc.) and neural pathways of the face that serve as portals to the neural platforms responsible for the activation of the vagal system, neuroception, and stimulation of the social engagement system. If the group leader provides safety and predictability, especially at the beginning of a new group, it will be impossible for group members to NOT become attached to each other. We cannot help ourselves but become connected interpersonally whenever safety, familiarity and proximity are provided. Turning on a person’s social engagement system makes it practically impossible for the defensive operations (fight/flight/freeze) of the autonomic nervous system to come online. Promoting a preference for implicit emotional communication over explicit cognitive communication will only help lubricate this process. Just by the simple act of encircling chairs in a way that promotes proximity and face-to-face interpersonal emotional engagement in a predictably safe environment, the modifications of the neural mechanisms responsible for the emotional regulation of each group member’s nervous system has already begun.
Polyvagal Theory seems on the one hand to be rather deterministic – ” our biology is our biology.”  On the other hand I sense that Stephen Porges holds much hope in our ability to socially engage and move away from more restrictive responses such as fight flight. Could you comment on this?
At the risk of oversimplifying polyvagal theory, after cohesion and safety is established at the beginning of a group, there are just four primary principles that guide its recommendations for enhancing successful group treatment.
  1. Provide and sustain a delicate balance between safety and enrichment in the group environment.
  2. Activate each member’s Social Engagement System.
  3.  Become familiar with the concept of neuroception and understand that neuroception is not a one-dimensional construct. It involves a complex array of multiple functions. Neuroception is also reflective of an acquired aptitude for accurately reading emotional and visceral signals (feelings) from one’s own body. Not only is neuroception allowing our bodies to tell us when we are threatened or safe, it also provides us a subtle array of other signals about our visceral states. Our body, thanks to neuroception, is always communicating with us.
  4. Group leaders need to pay more attention to the increased use of interventions that promote both the activation of the social vagus (vagal brake) and the dampening of unwarranted sympathetic arousal. As with any authentic relationship, group members need to feel that the group is safe enough for members to challenge or disagree with each other and the group leader without the threat of violence or abandonment.

Applications for Group therapy: If each of these four principles are employed in concert to guide clinical interventions during group treatment, then three essential outcomes will naturally emerge as a consequence of exercising the neural platforms necessary for: 1.) Improving affect regulation (both explicit and implicit); 2. ) Enhancing affect recognition and refining emotional literacy; 3.) Correcting faulty neuroception and, 4.) Expanding relational capacities by increasing acuity in reading social cues and non-verbal implicit communication. Before we can hope that our group members will have any semblance of understanding what their emotions and their bodily-based visceral feelings are communicating to them, we must help them recognize and identify their emotions as they are synchronously occurring in the group.  We must assist them in becoming aware of their visceral signals (feelings) instead of numbing them out, dissociating, becoming frightened by them, or acting them out. Within this approach, the capacity for establishing and maintaining close, emotionally satisfying and pleasurable interpersonal relationships lies at the heart of successful treatment and psychological and physical well-being.

Group Therapy as a Neural Exercise: Polyvagal theory introduced the concept of vagal tone as a physiological construct to help explain individual differences in the expression and regulation of emotion. As an organizing construct, vagal tone can also be a useful metaphor for helping describe the efficiency of the vagus system in integrating central, autonomic, and psychological components of emotion. Think of good vagal tone as a metaphor similar to good muscle tone. Polyvagal theory provides tantalizing evidence that our brain and its associated neural-systems, like the rest of our body, can be altered intentionally. Just as a good aerobics class and a “workout” at a gym can alter our biceps and our abdominal muscles, so a properly conducted psychotherapy group can provide a ‘workout” of our social engagement system — an exercise crucial for improving vagal tone in much the same manner that physical exercise improves our muscle tone. The more we exercise the social engagement system, the stronger our vagal tone becomes. While good vagal tone is a natural developmental outcome for securely attached individuals, insecurely attached individuals usually have a deficiency in vagal tone resulting in a reduced capacity for affect regulation and interpersonal regulation through the establishment of mutually satisfying relationships. Vagal tone is a physiological mechanism that gets “hardwired” into the CNS and is an essential physiological process that greatly enhances affect regulation and successfully managing relationships.

What is unique about polyvagal theory is that it indicates the way to improve vagal tone is best accomplished outside of the realm of verbal symbolic narratives (explicit communication like cognitive or interpretive interventions), which are usually emphasized in most therapies. Polyvagal theory focuses on the realm of procedural implicit communication, much of which involves body language and nonverbal communication — how things are said, rather than what is said. Polyvagal theory also highlights the use of neuroception (increase awareness of internal bodily based responses) in this approach. Many competent therapists are already intuitively doing much of this with their utilization of emotional attunement, etc. What is unique about polyvagal theory is that it translates the abstract neurobiological components of this process so that it can make this intuitive process less ambiguous while also allowing group leaders to take advantage of a different type of evidence based treatment approach to guide their application of group treatment.
Bob Fredrick, LCSW, BCD is a member of the AGPS Board Education Committee.
Phil Flores will be presenting a workshop on Polyvagal Theory and Attachment on August 19th at the Anxiety and Stress Management Institute.

The Ethics of Group Psychotherapy

An interview of Tom Stone, Ph.D. by Hank Fallon, Ph.D.

 

In your opinion what is the most important idea or concept about ethics that clinicians need to keep in mind as they practice?
 
The APA has the 5 Guiding Principles that are aspirational in nature and all five of them provide excellent guidance. The one that, in my view, captures the essence of the other four is the one we all know: “Do no harm” (Beneficence and Nonmaleficence). This principle puts everything we do in perspective in the sense that we put the people in our care first! We think first and foremost of what they need from us for effective care and treatment. To do so, we are called to examine our motives about what we decide to do for those who entrust us with their care. We are called to know what effective care and treatment is for difficulties brought to us. This principle also requires us to take care of our own emotional and physical health so that our clinical judgments are not impaired by poor self-care. Finally, at the core of our clinical approach is that, no matter what our interventions are, we do so with empathy and thoughtfulness. If we are truly empathic and thoughtful, we will take the time and the energy to be thoughtful and caring about what we choose to do for those in our care.

How do you see ethics issues related to group therapy as being similar and/or different to those for individual therapy?

 
This, of course, is a rather complicated question. Since I prefer to think of our work as ethical clinical care (the two as one), I think of how we structure our psychotherapeutic practices in accordance with our values and commitments in order to facilitate good care whether in group or individual therapy. Individual and group psychotherapy each require some similar and different practices in terms of both how we structure the time and space of the psychotherapeutic action. For instance, when I am seeing someone individually, I have a confidentiality agreement that primarily encompasses just the two of us. In group therapy, confidentiality is enforceable by me with each group members, but not between the group members. In group work, part of our clinical ethical role is to facilitate and cultivate a group experience that engenders safety and trust so that the members will feel secure in their desire to be known and get to know each other. A more simple way of putting this is that in individual therapy we are concerned about the one;and in group, we are concerned about the many. There are a multitude of ways in which the ethics of individual have additional nuances in group work and would require a very long answer to cover everything.
You have presented ethics workshops for a number of years. What has changed the most over that time and how do you view those changes?
 
There are several changes that have occurred over the last 15 years. Eleanor Komet and I got involved in the ethics of group when HIPAA arrived on the scene. Everyone was more or less terrified of meeting the regulatory demands for fear that the federal government was going to be scrutinizing their practices. We were struck by how ethics workshops were mostly about the do’s and the don’ts. We felt that principle-driven clinicians, who were well-informed of the guidelines, would generally make the right decisions. HIPAA, as the years went on became less of a concern, but then there is always something to take its place.
There are two areas of ethical clinical practice that are impacting all modalities of practice. One is tele-health and the other is diversity. The emergence of the Internet and then the arrival of smart phones/iPads has created a connection between people that seems beyond belief. And it is reality and we are in the middle of figuring out what it means both from a cultural perspective as well as a psychological one. Of course, we have to make sense out of the ethical complexities, of which there are many, created by it. Diversity has become of such import that it is now a designated continuing education requirement on its own in many states. As our world has become more globalized, our survival depends on embracing the differences that we are discovering through the plethora of avenues in which people are expressing the wide variety of human experience. There is a value system that informs our various disciplines about how we are called to conduct our ethical clinical practices. What our disciplines are asking of us from an organizational perspective can be a challenge to our personal value systems. As group psychotherapists we have no choice but to meet the challenges of diversity by the very fact that we have more than one person in our groups.

 

Hank Fallon, PhD, CGP, FAGPA is a member of the AGPS Board Education Committee.

Thom Stone and Phil Flores will present our Summer ethics workshop “Clinical and Ethical Complexities: A Group Dialogue About Our Values, Beliefs, and Therapeutic Action” on July 16th at Oglethorpe University.

 Interested in learning more? Join us at our fall workshop with Martyn Whittingham on October 22nd.

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