ISSUE
                       QUICK BYTES
     49 TRAUMA NETWORK FOR CHILDREN
                               Part 2: Polyvagal Theory 
                            Brought to you by the PTSS team (KKH)  •  May 2021
     (This article is the second in a three-part series about Polyvagal theory and its clinical applications in trauma intervention.)
    In the last Quickbytes article, we introduced the polyvagal theory and the three tiered response to
    threat, whichwasrepresentedbythepolyvagalladder.Thetoprungoftheladderrepresentstheventral
    vagussystem(socialengagementstate),followedbythesympatheticnervoussystem(mobilisedstate),
    and lastly the dorsal vagus system (immobilised state). In trauma therapy, we can help clients move
    upward on the polyvagal ladder, i.e. from immobilised and mobilised states back to the social
    engagementstate.Thisprocessinvolves:
    1. Creating safety for clients
   Creating safety for clients can help activate their ventral vagus systems. Consistent
   activation of the ventral vagus system helps efficiently apply the “vagal brake” on the
   other two nervous systems. It is akin to controlling the movement of a car, by knowing
   when to release the brake (entering mobilised state), step on the brake (returning to
   social engagement state) without stalling the car (immobilised state). Creating safety
   therefore allows clients to manage their stress responses sufficiently to socially engage
   withothersinameaningfulwayagain.
   Somewaystocreateasafeenvironmentforclients:
                    Making sure that the physical                         For therapists to notice their
                    environmentisrelatively quiet, as                     own vocal patterns and facial
                    noisy environments often contain                      expressions,  and how that
                    lower-frequency sounds that may                       might influence the client’s
                    trigger the dorsal vagal systems                      responsesandcommunication
                    in clients with traumahistories
    2. Bottom-up approaches
    Once safety has been introduced, bottom-up approaches can be used to help shift clients out of their
    immobilised and mobilised states. This approach emphasizes on starting therapy with the lower brain
    regions, such as the limbic system and the brain stem, which are responsible for emotions, reflex actions,
    andautonomicresponsesessentialforsurvival.Itacknowledgesthatthebody(bottom)reactsfirstbefore
    theconsciousmind(top)does,inresponsetothreatsinthesurroundings.
    The bottom-up approach to trauma therapy involves increasing one’s interoceptive
    awareness, that is the way of perceiving and attending to one’s internal experience.
    Havinginteroceptiveawarenessisabout:
    a)  Recognisinginformationcominginfromthesenses
    b)  Tuningintochangesinbodilysensations,and
    c)  Eventuallyintegratingallofthatinformationwithemotionsandthoughts
    Bottom-upregulationstrategiescaninclude:
     •   Listening to vocal music sung by                        •   Given that the ventral vagus nerve
         females (as the female voice                                travels between the vocal cords and
         typically has more intonation                               the middle ear, humming a song
         with higher frequencies). This                              can generate rhythmic vibrations in
         may help relax the dorsal vagal                             the vocal cords, that may stimulate
         system and stimulate the social                             theventralvagussystem.
         engagementsystem
    •   Engaging in rhythmic movements                            •   Slow, diaphragmatic 
        has been found to activate ventral                            breathing helps 
        vagus system, such as walking,                                increase heart rate 
        sitting in a rocking chair, moving and                        variability while 
        tracing an “infinity” ∞ sign using an                         reduces sympathetic 
        outstretched arm(s), playing on a                             nervous activity
        swing,bouncingonagymball
       •   Progressive muscle                                  •   Increasing the length of exhalations
           relaxation exercises can                                when engaging in deep breathing 
           also increase                                           exercises can increase ventral vagal 
           interoceptive awareness                                 activation
       •   Adding an                                       •   Engaging in light body 
           intentional sigh in                                 stretches encourages 
           exhalations may                                     interoceptive awareness, by 
           help reduce dorsal                                  practising becoming attuned 
           vagal activation                                    to changes in body sensations
    Tohelptraumasurvivors heal from their traumatic experiences, feeling safe within their bodies and their
    physicalenvironmentsisoneofthetwowaystoregulatetheirnervoussystemsandaidtheirrecovery.The
    nextarticleinthisserieswillexplorethesecondway,thatisthetop-downapproachtotraumatherapy.
    References:
    •  Brickel, R. E. (2019). Why a bottom-up approach to trauma therapy is so powerful. 
       https://brickelandassociates.com/bottom-up-approach-to-trauma/
    •  Dana, D. (2020). Polyvagal Exercises for Safety and Connection. W. W. Norton & Company
    •  Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, 
       and Self-regulation.. W. W. Norton & Company
    •  Wagner, D. (2016). Polyvagal theory in practice. https://ct.counseling.org/2016/06/polyvagal-theory-practice/
               The Trauma Network for Children (TNC) programme is a joint collaboration
               between KK Women’s and Children’s Hospital (KKH) and Temasek
               Foundation. It aims to enhance the capability of the Singapore community
               in providing psychosocial support to children, youth and their families after
               crises or traumatic events.