In an Unspoken Voice

by Peter A Levine

  Nervous systems are tuned to assess potential risk in the environment—an unconscious evaluative process that Porges calls “neuroception.”‡ If one perceives the environment to be safe, one’s social engagement system inhibits the more primitive limbic and brain stem structures that control fight or flight. After being moderately startled, you might, for example be calmed by another person—as when a mother says to her child, “It’s ok; that was only the wind blowing.”

  Generally, when threatened or upset, one first looks to others, wishing to engage their faces and voices and to communicate one’s feelings to secure collective safety. These are called attachment behavior. Attachment is virtually the only defense young children have, as they cannot usually protect themselves by fighting or fleeing. Attachment for security is a general mammalian and primate survival strategy against predation. By dealing with threat in quantity, the individual is less likely to be “picked off.” In addition, if someone in your own group is threatening you, you may first try to “make nice” before resorting to fighting or fleeing.

  Simplified Block Diagram of the Polyvagal Components

  Figure 6.1

  However, when “pro-social” behaviors do not resolve the threatening situation, a less evolved system is engaged. We mobilize our fight-or-flight response. Finally, in this “hierarchy of default”—when neither of the more recently acquired systems (social engagement or fight/flight) resolves the situation, or when death appears imminent—the last-ditch system is engaged. This most primitive system, which governs immobility, shutdown and dissociation, takes over and hijacks all survival efforts.§

  Figure 6.2a This figure shows which part of the body is affected by each of the evolutionary subsystems.

  The concept of default hierarchies—first described by the preeminent neurologist of the later nineteenth century, Hughlings Jackson60—remains a fundamental principle of neurology‖ and is a primary assumption in Porges’s theory. Basically, Jackson observed that when the brain is injured or stressed, it reverts to a less refined, evolutionarily more primitive level of functioning. If there is subsequent recovery, this regression will reverse, returning the individual to the more refined functions. This is an example of “bottom-up processing,” so important in trauma therapy.

  Evolutionary Roots

  Figure 6.2b This shows the neural control of the three phylogenetic systems: primitive vagus, sympathetic/adrenal and “smart” (mammalian) vagus.

  The more primitive the operative system, the more power it has to take over the overall function of the organism. It does this by inhibiting the more recent and more refined neurological subsystems, effectively preventing them from functioning. In particular, the immobilization system all but completely suppresses the social engagement/attachment system. When you are “scared to death,” you have few resources left to orchestrate the complex behaviors that mediate attachment and calming; social engagement is essentially hijacked. The sympathetic nervous system also blocks the social engagement system, but not as completely as does the immobilization system (the most primitive of the three defenses).

  Polyvagal Theory: Phylogenetic Stages of Nervous Control

  Figure 6.2c This summarizes the phylogenetic stages of the sympathetic and polyvagal systems.

  Immobility and hyperarousal are, as I have explained, organismic responses to threat and prolonged stress. When they are operative, danger (in the case of fight or flight) and doom (with immobility) are what an individual perceives—regardless of the reality of the external situation. The human nervous system does not readily discriminate between a potential source of danger in the environment, such as an abruptly moving shadow, or distress about a situation long past.a Where the distress is generated internally (by muscles and viscera), one experiences an obsessive pressure to locate the source of threat or (when that’s not possible) to manufacture one as a way of explaining to oneself that there is an identifiable source of threat.

  Highly traumatized and chronically neglected or abused individuals are dominated by the immobilization/shutdown system. On the other hand, acutely traumatized people (often by a single recent event and without a history of repeated trauma, neglect or abuse) are generally dominated by the sympathetic fight/flight system. They tend to suffer from flashbacks and racing hearts, while the chronically traumatized individuals generally show no change or even a decrease in heart rate. These sufferers tend to be plagued with dissociative symptoms, including frequent spacyness, unreality, depersonalization, and various somatic and health complaints. Somatic symptoms include gastrointestinal problems, migraines, some forms of asthma, persistent pain, chronic fatigue, and general disengagement from life.

  Polyvagal Theory: Emergent “Emotion” Subsystems

  Figure 6.2d This shows the effect the phylogenetic systems have in either increasing (+ sign) or decreasing (- sign) the activity of the various organ systems.

  In some exciting research, the brain activity of people suffering from posttraumatic stress disorder (PTSD) was recorded by functional magnetic resonance imaging (fMRI) while they were read a “traumatic script,” which was a graphic and detailed description of someone’s serious trauma (such as an accident or rape).61 The fMRI, scanning the location and the intensity of brain activity, portrayed them as a rainbow of colors.b So, for example, blue (cold) colors indicated a relative reduction in brain activity, while red (hot) colors might indicate an increase. The distress of the volunteers was intensified by the fact that their heads were immobilized, confined in a noisy clanging metal basket. In these studies, at least 30% of the subjects exhibited a decrease in activity of the insula and the cingulate cortex. The PTSD of these volunteers was characterized by dissociation and (vagal) immobility. On the other hand, about 70% of the subjects studied suffered primarily from the simpler symptoms of sympathetic hyperarousal and showed a dramatic increase in the activity of these same areas.62 The insula and the cingulate are the parts of the brain that receive sensory information from receptors inside the body (interoception) and form the basis of what we feel and know as our very identity.63 Underactivity portrays dissociation, while overactivity is associated with sympathetic arousal.

  In my long clinical experience, I found that many (perhaps even a majority of) persons exhibit some symptoms of both systems. The expression of symptoms appears to depend on a variety of factors, including the type and severity of a person’s trauma, the age at which it occurred, and which traumatic patterns and content were activated during treatment. There are also most likely constitutional and gender factors at play as well. In addition, these symptom constellations tend to change over time and even within a single session.c Most important, treatment must be approached differently according to which of these three systems is activated during sessions and which lie dormant.

  To effectively guide the processes of healing and transformation in their clients, therapists must be able to perceive and track the physiological footprints and expressions of these organismic systems. Since each of the hierarchical polyvagal systems has its own unique pattern of autonomic and muscular expressions, therapists need to perceive these indicators—skin color, breathing, postural signs and facial expressions—in order to determine the stage (immobilization, hyperarousal or social engagement) their clients are in and when they are transitioning to another.

  As we saw with Nancy in Chapter 2, a patient can undergo a wild roller-coaster ride between the three evolutionary subsystems, which demand parallel changes in strategy.d When, for example, the individual is in sympathetic hyperarousal, the therapist can observe a tightening of the muscles in the front of the neck (particularly the anterior scalenes, the sternocleidomastoids and the upper shoulder muscles), a stiffened posture, a general jumpiness, darting eyes, an increase in heart rate (which can be seen in the carotid artery in the front of the neck), dilation (widening) of the pupils, choppy rapid breathing and coldness in the hands, which may appear bluish particularly at the finger tips, as well as pale skin and cold
sweat in the hands and forehead. On the other hand, a person going into shutdown often collapses (as though slumping in the diaphragm) and has fixed or spaced-out eyes, markedly reduced breathing, an abrupt slowing and feebleness of heart rate, and a constriction of the pupils. In addition, the skin often turns a pasty, sickly white or even gray. And, finally, the person who is socially engaged has a resting heart rate in the low to mid-seventies, relaxed full breathing, pleasantly warm hands and a mild to moderate pupil aperture. Therapists are rarely trained to make such observations (though they can get a little coaching from watching episodes of the TV series Lie to Me).

  Of the three primary instinctual defense systems, the immobility state is controlled by the most primitive of the physiological subsystems. This neural system (mediated by the unmyelinated portion of the vagus nerve) controls energy conservation and is triggered only when a person perceives that death is imminent64—whether from outside, in the form of a mortal threat, or when the threat originates internally, as from illness or serious injury.e Both of these challenges require that one hold still and conserve one’s vital energy. When this most archaic system dominates, one does not move; one barely breathes; one’s voice is choked off; and one is too scared to cry. One remains motionless in preparation for either death or cellular restitution.

  This last-ditch immobilization system is meant to function acutely and only for brief periods. When chronically activated, humans become trapped in the gray limbo of nonexistence, where one is neither really living nor actually dying. A therapist’s first job in reaching such shut-down clients is to help them mobilize their energy: to help them, first, to become aware of their physiological paralysis and shutdown in a way that normalizes it, and to shift toward (sympathetic) mobilization. The next step is to gently guide a client through the sudden defensive/self-protective activation that underlies the sympathetic state and back to equilibrium, to the here-and-now and a reengagement in life.

  Generally, as a client begins to exit the freeze state, the second most primitive system (sympathetic arousal) engages in preparation for fight or flight. Recall how Nancy went from sympathetic arousal (her heart rate shooting up wildly) to helpless terror and then abruptly to shutdown (her heart rate dropping precipitately), and then finally to mobilization and discharge when she activated her running muscles and escaped from the image of the tiger. The important therapeutic task in the sympathetic/mobilization phase is to ensure that a client contains these intense arousal sensations without becoming overwhelmed (I described this process in Chapter 5). In this way, they are experienced as intense but manageable waves of energy, as well as sensations associated with aggression and self-protection. These sensory experiences include vibration, tingling, and waves of heat and cold (I described both of these phenomena in Chapter 1 and in my report on Nancy in Chapter 2).

  When one is able to ride the sometimes bucking bronco of one’s arousal sensations through, and begin to befriend them in a slow and steady way, one is gradually able to discharge the energy that had been channeled into hyperarousal symptoms. This initial stage and foundational piece of the self-regulation pie, and the basic ingredient for restoring equilibrium, is what brought both Nancy and me out of limbo and back to life. Only after this point of intervention does the social engagement system, the third evolutionary subsystem, begin to come back online. An individual who has been able to move out of immobility, and then through sympathetic arousal, begins to experience a restorative and deepening calm. Along with these sensations of OK-ness and goodness, an urge, even a hunger, for face-to-face contact emerges.f Because that yearning may have been painfully unmet during critical periods of infancy, childhood and adolescence (or may have been associated with shame, invasion and abuse), many traumatized individuals also need particular guidance to negotiate this intimacy barrier. This therapeutic guidance can occur only when it becomes physiologically possible to access the social engagement system—that is, when the nervous system is no longer hijacked by the immobilization and the hyperarousal systems.

  The intentional use of a mental or physical health practitioner’s own intact heartfelt human expression can be profoundly therapeutic. In spite of the raw dominance of the vagal immobilization and sympathetic arousal systems in suppressing social engagement, the power of human contact to help change another’s internal physiological state (through face-to-face engagement and appropriate touch) should not be underestimated. Thus, as I discussed in Chapter 1, the pediatrician with the kindly face who sat by my side after my auto accident gave me the glimmer of hope I needed at that exact moment in order to go on.

  The gentle power of the human face to soothe the “savage beast” is portrayed in a film with the revealing title Cast Away. Tom Hanks plays the lead character, Chuck Noland, who is marooned on a remote, uninhabited island as the sole survivor of an airplane crash. Also washed ashore is some of the plane’s cargo, which includes a white volleyball printed with the Wilson brand name. He aptly names the ball “Wilson” and offhandedly adopts it as his mascot.g To his surprise, it begins to take on a life of its own, becoming the confidant for Noland’s innermost thoughts. One day, in a fit of impotent rage, Noland throws the ball into the sea, but then—realizing how deeply he has become attached to Wilson—he dives in to retrieve it. Back on the beach, he affectionately draws childlike facial features65 (eyes, mouth and nose) on the round volleyball.h Wilson now becomes his most intimate companion, sharing his troubled thoughts, deepest yearnings and anguished feelings of loneliness and despair, as well as his joyful triumphs. Noland’s bonding with Wilson is eerily reminiscent of the ethologist Konrad Lorenz’s orphan ducklings and their powerful attachment (imprinting) to a white ball after their mother was removed from their life shortly after their hatching.66 Once they were permanently bonded to the ball as their surrogate mother, they preferred it even to a live, soft, feathery mother duck.

  Finally, Hanks’s character realizes that the island is apparently outside of any shipping lanes and that he will never be rescued if he remains on it. In his ill-fated attempt to leave on a raft he has made, Wilson is swept away during a fierce storm, and Hanks is inconsolable in his grief.

  Face-to-face, soul-to-soul contact is a buffer against the raging seas of inner turmoil. It is what helps you calm any emotional turbulence. So, in spite of the vast primal power of the immobilizing and hyperarousal systems, therapists should recognize the power of facial recognition and social engagement in calming their clients, and in meeting people’s deepest emotional needs and motivating many behaviors, both conscious and unconscious. Lest I leave you in the lurch, Noland, at death’s door, is finally rescued. Upon returning home he takes all of the surviving packages and, traveling across the country, delivers them to their rightful owners. Yes, that’s right: face-to-face.

  Deprived of face contact (and even a person who is blind from birth uses his or her hands to “see” other faces), we are (like Hanks’s character) cast away, adrift from our deepest needs and sense of purpose in life. Most of us would go insane without some kind of face-to-face contact. Along with facial recognition, the sound, intonation and rhythm of the human voice (prosody) have an equally calming effect. Even with clients who cannot tolerate face-to-face contact, the sound of the therapist’s voice—like the mother’s cooing to her infant—can be deeply soothing and enveloping.

  In a revealing commentary, Dr. Horvitz, a leading computer scientist, recently demonstrated his voice-based system, which asks patients about their symptoms and responds with empathy.67 When a mother said that her child was having diarrhea, the animated face on the screen said, in a supportive tone, “Oh, no; sorry to hear that.” This simple acknowledgment put the woman at ease and helped her to interact with the program in a secure and empowered manner. One physician told Horvitz that “it was wonderful that the system responded to human emotion … I have no time for that.” Perhaps this computer system is the equivalent of Chuck Noland’s volleyball. Its programmed “empathy” was certainly hel
pful but a meager substitute for the real thing. It is a depressing commentary on the growing alienation of our postmodern, twenty-four-hour texting culture. While so many of our young keep in touch with dozens of people every hour in cyber-relationships, authentic face-to-face engagement is clearly on an apocalyptic wane. How sad and disturbing that the physician believed he didn’t have the minuscule time for such basic and salutary human communication—contact that would help humanize them both. If practiced regularly, it might even help both patient and physician stave off Alzheimer’s or other forms of dementia.68

  Why Therapy Fails

  Many traumatized individuals, and especially those who have been chronically traumatized, live in a world with little or no emotional support, making them even more vulnerable. After a devastating event—be it violence, rape, surgery, war or an automobile accident—or in the aftermath of a childhood of protracted neglect and abuse, traumatized individuals, even those who share a residence with a friend, family member or intimate partner, tend to isolate themselves. Alternatively, they cling desperately to other people in the hope that they will somehow help and protect them. Either way, they are bereft of the real intimacy—the salubrious climate of belonging—that we all crave and need in order to thrive. Traumatized individuals are, at the same time, terrified of intimacy and shun it. So either way, avoidant or clinging, they are unable to maintain the balanced, stable and nurturing affiliations we all need, the egalitarian bond characterized by the Jewish theologian Martin Buber as the “I-thou” relationship.69