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The Advantages of Combining EMDR with Schema Therapy and Polyvagal Therapy for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

EMDR and Brain Functioning

EMDR is a treatment method used to eliminate the negative impacts of traumatic memory quickly and effectively. EMDR is a neurobiological intervention that makes use of eye movements to facilitate a physiological impact on brain functioning which creates permanent emotional and cognitive change in an individual when thinking about or visualizing a traumatic memory.

Recent studies on brain scans of individuals indicate that traumatic experience and traumatic recall negatively impact brain functioning and that EMDR corrects it. Specifically, during trauma a part of the brain called the amygdala, which controls many of our emotions and is responsible for autonomic responses associated with fear and fear conditioning, becomes over activated and this creates an impasse between itself and the hippocampus. The hippocampus plays an important role in the consolidation of information from short term memory to long term memory and spatial memory which is responsible for recording information about one’s environment and spatial orientation.

It is recognized that this impasse between the hippocampus and the amygdala creates symptoms found in generalized anxiety, panic attacks and posttraumatic stress disorder. During EMDR, this impasse is corrected as eye movements will both enlarge and activate the hippocampus so it can receive the overwhelming amount of information from the amygdala and then sort it. The hippocampus then completes the proper brain processing by sending information to the anterior cingulate cortex, which is involved in aspects such as attention, decision making, reward anticipation, ethics, morality, impulse control and emotion. The impact of opening this impasse and restoring proper brain functioning means that a negative memory, once too overwhelming to manage, is put into the proper context of time and space, has affective and cognitive aspects of the memory merged, is viewed with more rational thought, reason and control and exists in a clear distinction between the past and the present.

EMDR and the Two Primary Positive Treatment Reactions

During EMDR treatment, which is administered by a psychotherapist, a client responds to the neurobiological process described above and experiences two primary reactions to a traumatic memory. First, there is a distancing from the memory that includes an elimination of the negative emotional reactions related to the trauma. Second, the client experiences an increased level of rational perception related to the memory. This increased rational thinking is called Adaptive Information Processing (AIP). AIP is the result of successful EMDR reprocessing and allows the client to hold a more rational view of personal safety, personal responsibility and personal choice while visualizing or discussing a traumatic memory. AIP also allows the client to hold an accurate positive self-perception or cognition while visualizing the trauma. This assists the client in problem solving how he or she would react, or prefer to react, differently in a similar situation. Repeating the EMDR procedure over a series of planned interventions targeting traumatic memories relieves the person of the negative impacts the memories have created. Due to its neurobiological quality, the changes from successful EMDR reprocessing are permanent and generates dramatic symptom reduction across the spectrum of most all mental health diagnosis.

What Is Schema Therapy?

Schema Therapy is a branch of Cognitive Therapy that was developed by Jeffrey Young PhD and includes several different psychotherapeutic interventions including Behavioral, Gestalt, Psychoanalytic and Relational Therapies. Schema Therapy argues that if individuals are abused or neglected as children, they may develop “maladaptive schemas”. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. Maladaptive schemas (known as schemas) can be defined as self-defeating emotional and cognitive patterns that begin in early childhood and continue throughout life. The goal of Schema Therapy is to eliminate the schema(s) by recognizing and challenging it and replacing it with more effective behaviors.

Schema Recognition

The first step in Schema Therapy is schema recognition or evaluating if an individual has any schemas. This can be done in several ways. First, individuals can read “Reinventing Your Life” by Jeffrey Young PhD and complete a brief set of questions on each schema listed throughout the book. This will illustrate both the existence and intensity of the schema. Second, in a therapeutic setting, an individual can complete a questionnaire which will identify the presence of certain schemas as well as their intensity. After a schema is recognized, the person can read schema descriptions, provided in the book or by the therapist. These descriptions can bring clarity and definition to emotional and relational hardship.

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years, the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic exercises assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety.

Polyvagal Theory and The Perception of Safety and Danger

Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate. It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations.

The Three States of the Autonomic Nervous System

Polyvagal Theory argues that people are regularly moving through three different autonomic states throughout their daily lives. This movement is caused by reactions to life events and the attempt to survive emotionally or physically, to restore oneself, or connect with others. These three states are the ventral vagal state (safe and social), the sympathetic state (mobilized for fight or flight) and the dorsal vagal state (immobilized and collapsed). Each state is managed by a specific set of nerves and each state serves a specific set of biological and social needs.

1.Ventral Vagal State – The ventral vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The ventral vagal state, also known as the “safe and social state”, is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other two defensive autonomic states listed below. Being in a safe situation and then actively looking for and seeing safety will activate the ventral vagal state. The activation of the ventral vagal state facilitates self-regulation and eliminates unnecessary defensive thoughts, feelings and behaviors. In a relational sense, people in the ventral vagal state feel safe which leads to a sense of connection, trust, comfort, restoration and happiness. It is best that individuals solve relational problem(s) in the ventral vagal state. If they do not, they will switch involuntarily to the sympathetic state and attempt to solve their problem(s).

2.The Sympathetic State – The sympathetic state is a physical, emotional and cognitive experience facilitated by a set of nerves coming from the center of the spine and connecting to various organs. This set of nerves alerts and activates people when they detect danger and prepares the body to act. The sympathetic state, also known as “mobilized for fight or flight state”, moves through various levels of intensity measured by both the level of fear experienced and the related amount of physical and mental energy that is given to deal with the event. When someone is in this state, they are pulled out of the ventral vagal state, lose the benefits of feeling safe and begin to disconnect from people. Relationally it is a state of conflict and fear. Clinically the sympathetic state parallels anxiety, anger, posttraumatic stress, relational discord, obsessions and cognitive distortions leading to self-questioning. Physical symptoms include headaches, high blood pressure, heart disease and joint pain. If the problem or event is not solved in the sympathetic state, the person will then involuntarily activate the next state which is the dorsal vagal state.

3.The Dorsal Vagal State – The dorsal vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves that extend from the Vegas Nerve to the organs located below the diaphragm. When the dorsal vagal state, also known as “the immobilized and collapsed state”, is activated an individual will shut down. Often this will follow the overwhelm of energy and fear caused by the sympathetic state. This overwhelm can be physical, emotional, or cognitive. The body will grow cold, weak, slow and lacking in energy. Socially the individual feels disconnected from others. Clinically this state triggers symptoms of depression, dissociation, performance anxiety, paranoia and cognitive distortions leading to challenged self-concept. Physical symptoms consist of low blood pressure, immune system disorders, stomach problems, obesity, fibromyalgia and irritable bowel syndrome.

The Vagal Brake and The Window of Tolerance

The vagal brake is a term created by Stephen Porges PhD to describe the process of stopping physiological reactivity to life events that lead either to the sympathetic or dorsal vagal defensive state. It is important that individuals accurately read the level of both safety and danger in life events to not overuse a defensive state position. People who have a history of trauma and nonacute trauma found in PTSD and Complex PTDS have histories where it was necessary to maintain states of high defense. However, in different life settings, or in adulthood, the level of threat generally is less and the need for a defensive state is less. An unnecessary overactivation of a defense state will create emotional, physical and cognitive overwhelm and a relational management style that is ineffective. The activation of the vagal brake, at the right time, will ease a defense reaction and leave the individual in a position to self-regulate and return to a ventral vagal state of safety. The development of an accurate vagal brake response can be done by polyvagal exercises as well as by the reprocessing of traumatic memory through the EMDR protocol. These interventions are central to the treatment of Complex PTDS.

The window of tolerance is a clinical term used to describe the parameters of one’s state of non-defense. It is necessary to recognize one’s own window of tolerance since it will determine what are manageable tasks, thoughts, memories, relationships and topics in and out of therapy. Thus, the awareness of one’s window of tolerance will assist in self-regulation and with creating the most likely positive results from the use of internal resources and therapeutic suggestions. A goal of treatment is for the client’s window of tolerance to increase over time so one can actively problem solve needed topics of change while maintaining a ventral vagal state position. As this relates to the vagal brake, the window of tolerance will expand as one can more quickly use their vagal brake to inhibit defense response, maintain a state of safety and “tolerate” life events. The window of tolerance is expanded by Polyvagal exercises and EMDR since both will decrease the automatic activations of unnecessary defensive states.

What is Coregulation?

Coregulation is the moment to moment act of managing a relationship to self-regulate. Coregulation is based on attachment theory which argues that the regulation of a child doesn’t simply come from the “good enough” behavior of the parent but is a process by which the child feels calm in reaction to the parent’s self-regulation which is in response to the child’s initial signs of self-soothing. In relationships, coregulation is the processes of keeping a relationship safe in an effort of bring oneself to state of regulation. In Polyvagal terms, the individual has an awareness of both their window of tolerance and sensitivity to their vagal brake and will use methods to manage the relationship to remain in or return to a ventral vagal state. This often requires the need to defuse the defensive states of sympathetic defense and dorsal vagal defense that occur both in oneself, but also in others. Often individuals with a history of abuse or neglect leading to PTSD or Complex PTSD have a history of strained and conflictual relationships and do not have a background of guided experience leading to self-regulation through relational management.

The Polyvagal Hybrid States

Polyvagal Theory argues that the three states of the autonomic nervous system listed above, the ventral vagal, sympathetic, and dorsal vagal states, are not mutually exclusive nor antagonistic but rather comingle and coexist to create a full spectrum of cognitive, relational, behavioral and emotional experiences. These coactivated states are called “hybrid states” states. There are two hybrid states which are the combined ventral vagal and sympathetic state and the combined ventral vagal and dorsal vagal state. Polyvagal hybrid states represent how polyvagal awareness and creative application can facilitate the process of using internal client resources for self-regulation and solving problems. For more information on this topic and useful exercises see “Polyvagal Hybrid States and Complex Posttraumatic Stress Disorder” by author.

The Advantages of Combining EMDR and Schema Therapy

As stated, EMDR is a powerful and effective intervention for eliminating the negative impacts of traumatic memory. Clients with a history of multiple traumas leading to complex Posttraumatic Stress Disorder often exhibit complications beyond PTSD symptoms which require added interventions to the EMDR Protocol. Schema Therapy assessments allow a client and therapist to categorize the effects of trauma into various schemas. This categorization facilitates memory identification needed in EMDR treatment as it directs the client and therapist to specific causal events. Also, Schema Therapy has several exercises which are like the EMDR Protocol. These similarities allow for daily exercises which strengthen progress made through EMDR work. See specific advantages listed below.

1.Decreased Dissociation – Combining EMDR and Schema Therapy creates a solution to the problem of seeing and experiencing dissociation as an uncontrolled state of psychological dysfunction by reframing dissociation as a reasonable movable state created by triggers which can be controlled through EMDR reprocessing. Following the identification of individual schema reactions, clients can identify the triggers to these reactions and use EMDR to reprocess triggers.

2.Decreased Self-Abuse – Combining EMDR and Schema Therapy creates a solution to the problem of self-abuse by recognizing self-abusive behavior a reaction to a dysfunctional schema “Punitive Parent Mode”. After a client recognizes the existence of this mode, they can track its development and triggers and reprocess them using the standard EMDR protocol.

3.Managed Addiction – Combining EMDR and Schema Therapy creates a solution to the problem of addiction by recognizing addiction as a schema coping mechanism of avoidance. Clients can identify schemas that trigger the desire to avoid and EMDR can be used to both reprocess the negative memories contributing to the schema and to reprocesses the “pleasure state” using the EMDR Addiction Protocol.

4.Increased Personal Narrative – Combining EMDR and Schema Therapy creates a solution to the problem of flashbacks by decreasing negative emotional trigger arousal while assisting the client to use the descriptive language of schema identification rather than visualizations to deal with trauma. After a client identifies their individual schema reactions, they can use EMDR on the traumatic memories that created PTSD symptoms and schemas. Following, the client can use schema descriptions to accurately verbalize the schema’s development.

5.Productive Imagery – Combining EMDR and Schema Therapy creates a solution to the problem of daily of self-management struggles by providing effective visualizations to use during EMDR reprocessing as well as outside of therapy sessions. The cognitive exercises of Schema Therapy are like those used in EMDR protocols. Following successful EMDR sessions, clients can continue to apply their positive changes to daily events through Schema exercises.

6.Effective Memory Targets – Combining EMDR and Schema Therapy creates a solution to the problem of memory avoidance by quickly and accurately providing EMDR target memories for reprocessing that will bring the greatest amount of change. Following the recognition of individual schemas, clients can use this information to explain their development. These developmental topics can be used as EMDR memory targets for effective change.

7.Ending Self-Blame – Combining EMDR and Schema Therapy creates a solution to the problem of self-blame by creating workable reframes of personal responsibility and self-forgiveness through recognition of the schema’s necessary and reasonable beginnings. EMDR reprocessing will eliminate the cognitive hardship of irrational self-blame. Schema Therapy exercises can assist clients in using these changes in daily struggles with self-blame.

8.Decreeased Overwhelm – Combining EMDR and Schema Therapy creates a solution to the problem of emotional overwhelm caused by triggers. Solutions are facilitated by EMDR reprocessing which decreases emotional reactivity and with Schema Therapy which provides daily exercises to elicit strength and solution.

The Advantages of Combining EMDR and Polyvagal Therapy

Polyvagal Therapy is based on neurobiological theory and allows for a unique and powerful articulation of the impacts of safety and danger. This is of importance for someone who has a history of repeated trauma since dangerous or threatening situations may cause over or under reactivity in these clients. Increased recognition of states of defense and safety facilities one’s ability to self-regulate both when alone and when in contact with another. EMDR reprocessing of traumatic memory makes this process easier and more feasible since the reprocessing of memory decreases emotional reactivity and cognitive decline. See specific advantages listed below.

1.Decreased Dissociation – Combining EMDR and Polyvagal Therapy creates a solution to the problem of dissociation by reframing and treating dissociation as an expected, involuntary reaction to traumatic triggers that can be changed through decreasing defense through EMDR reprocessing. After a client identifies the subjective feelings of the various Polyvagal defensive states, they can use this awareness to identify triggers leading to defense and dissociation. EMDR can then be used to decrease those triggers.

2.Increased Personal Narrative – Combining EMDR and Polyvagal Therapy creates a solution to the problem of flashback imagery by helping clients use language and trigger identification instead of visualizations to deal with traumatic memory. After a client increases their awareness of shifting through Polyvagal states of defense, they can verbally explain this reaction as well as its development.

3.Ending Hyperarousal – Combining EMDR and Polyvagal Therapy creates a solution to the problem of hyperarousal found in Posttraumatic Stress Disorder by assisting the client in recognizing triggers that activate defensive states leading to hyperarousal. Clients can increase awareness of hyperarousal by doing “Polyvagal Mapping” and identifying triggers of arousal and the activation of safety states. EMDR can be used to reprocess triggers as well as initial memories associated with triggers.

4.Increased Self-Awareness – Combining EMDR and Polyvagal Therapy creates a solution to the problem of trigger vulnerability by allowing the client to track states of defense and safety and provides the capacity to shift the state of defense at will. After a client identifies their movement between Polyvagal defense states they can notice environmental triggers causing the shifts and reprocesses triggers using EMDR.

5.Danger Management – Combining EMDR and Polyvagal Therapy creates a solution to the problem of psychological numbing by recognizing and problem solving social and situational times of danger. This can be done by actively noticing and tracking subjective experiences of safe and dangerous situations through Polyvagal exercises. Clients can use this awareness to problem solve change and use EMDR to eliminate triggers which might cause an irrational perception of danger.

6.Relational Management – Combining EMDR and Polyvagal Therapy creates a solution to the problem of behavioral reactivity to relational conflict by maintaining self-regulation through the management of conflict levels in relationships. This can be done by using state defense awareness to plan necessary times of relational change and management. Change can be facilitated by relational management strategies such as boundary management, the use of validation and demands for reciprocity.

7.Proper Physical and Emotional Activation – Combining EMDR and Polyvagal Therapy creates a solution to the relational problem of over and under activation of defensive states by assisting clients in learning manageable levels of safety and energy. This change can be facilitated by tracking the subjective experience of defensive state shifts, tracking the levels of safety and energy in each state and problem solving ways to decrease danger and energy levels through rules, cooperation, game metaphors and using EMDR positive interjection imagery.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Societ y by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience for Self-Regulation and Resilience by Sullivan, Erb, Schmalzi, Moonaz, Tylor, and Porges from Frontiers in Human Neuroscience February 2018.

Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures by Francine Shapiro PhD (2001)

EMDR as an Integrative Psychotherapy Approach: Experts from Diverse Orientations Explore the Paradigm Prism Edited by Francine Shapiro PhD (2002)

Getting Past Your Past: Take Control of Your Life with Self Help Techniques from EMDR Therapy by Francine Shapiro PhD (2012)  

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)

Exercises for EMDR Tracking and Communucation

1. Tracking EMDR Results

After each EMDR session the individual should notice and list the impacts of their work. The results of EMDR are immediate. Here are some of the most commonly noticed changes from a successful EMDR session.

  1. A decrease in anxiety and an increased feeling of relaxation.
  2. A sudden decease in presenting symptoms of anxiety, depression and PTSD.
  3. An increase in positive beliefs about self and a decrease in negative self thoughts.
  4. An increase in the belief that the future will be good.
  5. An awareness that the targeted memory is no longer thought about or bothersome.
  6. A decrease in negative body sensations that occur during times of stress.
  7. A decrease in negative emotions that had been triggered by reminders of traumatic memory.
  8. An increased ability to problem solve in relationships.
  9. An increase in the ability to be objective about self, others, the future and the past.
  10. A feeling that a weight or heaviness has been lifted.
  11. An increase in quality sleep.

2. Imago Listening Exercise

Imago Communication is a technique developed for marital therapy with the primary goal of developing relational intimacy. Proper Imago Communication will allow for the speaker to relate current relational conflicts to childhood experiences and emotions.

Mirroring –Mirroring is simply a repeat of what was heard by the speaker.

         So you are saying…Is there more…let me make sure I have it all…

Validation –Validation is a statement that the speaker’s perspective is reasonable. Validation is not necessarily agreeing with the speaker, however.

        That makes sense because…Can you help me understand?

Empathy – Empathy is the act of putting oneself in the position of the speaker and imagining how it would feel to experience their position.

       I can imagine you feel…

3. Finding your Imago – Complete the sections A-E then refer to the sentence below.

  1. List the bad qualities of your mother and father.
  2. List the good qualities of your mother and father
  3. Complete the sentence – “What I wanted and needed most as a child was…”
  4. List good memories of your childhood and how you responded emotionally.
  5. List the disappointments of your childhood and how you responded behaviorally.

Complete the sentence below using the corresponding answers from the statements above. This sentence will give you a description of what you look for in a partner.

I am trying to find a person who is (A) to always be (B) so I can get (C) and feel (D). I stop myself from getting this sometimes by (E).

4. Cognitive Exercise

The goal of the cognitive exercise is to better understand negative thoughts and change related patterns and behaviors.

The exercise is divided into four parts. The exercise should be written.

  1. Identify a situation that causes an emotional change such as feeling anxious or depressed.
  2. List the negative self belief that accompanies the change in mood. Use the sentence “I am _______” and fill in the blank. Examples are “I am bad”, “I am worthless”, “I am not good enough”. Also write the negative emotion and body sensations that are felt from the negative emotion.
  3. List the Cognitive Rebuttal – In other words what is the self perception you want to believe. It is usually the opposite of the negative belief. Again use the frame sentence “I am_________”. Examples may be “I am good”, “I am important” or “I am ok”. After this is listed then write as evidenced by… and fill in. Such as “I am good as evidenced by my daily respect and concern for my coworkers”.
  4. Reread the positive Cognitive Rebuttal and the rational evidence for this description and then list the appropriate behavioral reaction. Follow through with the behavior.

5. Journal Exercise

The purpose of the journal exercise is to experience, track and increase awareness of emotions. This exercise helps to decrease symptoms and increases assertive communication. Journal writing should be done daily and can include any emotion from the day good or bad. Journal writing should follow very specific language. First, start with –

I feel________  because _______. For example “I feel angry because you forgot about me.”

After using this exercise for 3-4 weeks, change it to a more detailed version. Think about a specific situation and follow the suggestions below.

  1. I think…..
  2. I feel…
  3. I want…

For example “I think you are more concerned about your own schedule. I feel hurt by your inconsiderate behavior and I want you to include me in your planning.”

Schema Mode Therapy for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

What Is Schema Therapy?

Schema Therapy is a branch of Cognitive Therapy that was developed by Jeffrey Young PhD and includes several different psychotherapeutic interventions including Behavioral, Gestalt, Psychoanalytic and Relational Therapies. Schema Therapy argues that if individuals are abused or neglected as children, they may develop “maladaptive schemas”. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Stress Disorder.  Maladaptive schemas (known as schemas) can be defined as self-defeating emotional and cognitive patterns that begin in early childhood and continue throughout life. The goal of Schema Therapy is to eliminate the schema(s) by recognizing and challenging it and replacing it with more effective behaviors. One of the ways to accomplish this goal is through schema mode work.

Schema Modes

Schema modes can be defined as moment to moment emotional states and their related behaviors that all individuals use to manage life events. Often a life event will trigger a schema and then the person will switch their behavior and thought process to a maladaptive mode.  Schema modes can be adaptive or maladaptive and the goal of Shema Mode Therapy is to recognize maladaptive modes and replace them with adaptive modes.

Modes are measured by both their level of rigidity and intensity. For people who are responding to life events in a healthy way, their responses tend to be flexible and not ridged. The flexibility between changing modes during a healthy reaction is spontaneous and the individual can switch from one mode to the next as well as easily recall their thoughts, feelings and actions when shifting from one mode to the next.

Also, an adaptive reaction to a life event consists of a reasonable level of intensity. While some events in life are extreme and have major emotionally reactions, others are not extreme. The quality of healthy mode reactivity is rational and parallels the intensity of the event.

Unhealthy behavior is more ridged in quality. For example, one might quickly switch from a healthy adult mode to a more childlike mode and the intensity of the child mode will take over the person. Thus, the person appears to lose control over their behavior as well as the stability of identity. These sudden mode switches impact the sense of cognitive, emotive and behavioral maintenance and the overwhelm of the mode causes difficulty recalling healthy mode experiences. This is shown in its most extreme forms in states of dissociation which schema therapists would describe as a process of extreme mode switching and reactivity.

Also, an unhealthy reaction to a negative life event consists of an unreasonable level of reactivity to that event. Thus, if a person switches to an unhealthy mode they might appear to overreact to situations that are minor, or they might appear to have extraordinarily little or no reaction to life events that are overwhelming or critical.

Schema Mode Categories and the Nine Schema Modes

Schema Therapy defines nine schema modes as the basis for mode behavior. In a sense, all these modes are universal. In other words, all people tend to embrace each mode. Again, the concerns have to do with the person’s level of rigidity and/or intensity when in the mode. The nine schema modes fall into three categories. Below is a description of each category followed by a detailed description of each mode within that category. A description of the healthy adult mode is included.

Child Modes – Child modes are characterized by childlike feelings, thoughts and behaviors. The impact of a child mode can be mild yet in extreme forms the person might give the mode an identity. This, according to Schema Therapy, is the foundation for the switching and extreme reactivity found in Dissociative Identity Disorder.

1.  The Vulnerable Child Mode – The individual in a vulnerable child mode will experience dysphoric, anxious and sad feelings when triggered by a life event or memory. Other emotions might include loneliness, isolation, overwhelm, self-questioning, neediness, helplessness, hopeless, abandonment, fragility, weakness and oppression. The behavior of the vulnerable child depends on which dysfunctional coping mode they use to manage their reactions.

2. The Angry Child Mode – The individual in an angry child mode is fueled by feelings of victimization and bitterness which then leads to pessimism, jealousy and rage. The individual often feels unsupported and may have urges to yell, scream, throw or break things or injure themselves or others. Often a trigger for the switch to an angry child mode is the sense that one’s needs are not being met.

3. The Impulsive or Undisciplined Child Mode – The individual in an impulsive or undisciplined mode acts on their desires of “at the moment” needs. The individual generally acts impulsively and in a selfish and/or uncontrolled manner. The person has a desire to get his or her own way and has difficulty delaying short-term gratification. Emotionally the person feels anger, rage, frustration and impatience when these desires or impulses are not met. The person generally appears to be “spoiled”.

4.The Happy Child Mode – The individual in the happy child mode feels at peace because their core emotional needs are being met. Generally, the person experiences love, validation, safety and connection. The person thinks they are special, lovable, important and strong.

Dysfunctional Coping Modes – Dysfunctional coping modes are used to prevent emotional distress but end up reinforcing or perpetuating the schema. These coping modes parallel the core emotional, cognitive and physical reactivity seen in fight, flight or freeze behaviors referred to in schema language as overcompensation, avoidance and surrender, respectively.

1.  The Overcompensator Mode – The individual in the overcompensator mode will adopt a coping style to counteract feelings of defectiveness or feelings related to not getting their emotional needs met. The individual appears inordinately grandiose, aggressive, dominant, competitive, arrogant, haughty, condescending, devaluing, controlling, rebellious, manipulative, exploitative, attention-seeking and status-seeking. The individual in this mode perpetuates their schema patterns since they actively deny the schema’s existence.

2. The Detached Protector Mode – The individual in the detached projector mode cuts themself off from their own needs and feelings and presents with an overall appearance of avoidance. The person will detach emotionally from others and reject outside assistance. The person appears to be withdrawn, distracted, disconnected, depersonalized, empty, bored or aloof. The individual may compulsively and excessively pursue distracting, self-soothing, or self-stimulating activities. The individual in this mode perpetuates their schema patterns since they cut themselves off from problem recognition.

3. The Compliant Surrenderer Mode – The individual in the compliant surrenderer mode typically acts in a passive, submissive, approval-seeking or self-deprecating way to avoid conflict or rejection. Individuals in this mode will tolerate abuse and mistreatment and will not express their own needs. The individual in this mode perpetuates their schema patterns since they are avoiding effective problem-solving.

Dysfunctional Parent Modes – Dysfunctional parent modesare internalizations of critical, demanding, or harsh parental voices. When someone is in this set of modes they will take on and own the messages taught to them through abusive behavior and will act as if the message is real and appropriate. Although this is described as a “parent” mode, the negative abuse messages can come from anybody including teachers, religious leaders, siblings, relatives or peers.  

1.The Punitive Parent Mode – The individual in the punitive parent mode generally believes that they deserve punishment and blame. Often the person will be self-abusive shown by self-mutilation, anorexic behavior, bulimic behavior, self-sabotage, self-loathing, self-blame, self-criticism and suicidal thoughts and behaviors.  The individual will present with a tone that is harsh, unforgiving and critical. Relative to norms and rules there is a preoccupation with the style of rule enforcement rather than rule appropriateness.

2.The Demanding Mode – The individual in the demanding parent mode is preoccupied with perfectionism, achievement, order, status and efficiency. The individual will appear irritated, anxious, demanding and/or emotionless. There is a tendency for the person to devalue both spontaneity and emotional expression. Relative to norms and rules there is an emphasis on the act of meeting high standards rather than on the style of implementation or the general effectiveness of meeting a particular purpose.

Healthy Adult

The Healthy Adult Mode – The individual in the healthy adult mode presents as being comfortable in their decisions, problem-solving, impulses, ambitions, limitations and relationships. The individual acts in a way that is responsible, thoughtful, participatory and self-nurturing. Relationally the person can maintain presence without a preoccupation for the past or future. Schema Therapy concentrates on the role of the adult mode to use its resources as a method of self-parenting when other modes have taken control.

Schema Mode Treatment

Schema Therapy emphasizes the role of five primary steps for useful mode work. Generally, these steps are taken within the context of treatment, but benefits can also come by doing the exercises alone. The end goal of these initial five exercises is to be able to do schema problem solving as defined in the next section. List your answers.

1.Schema Mode Identification – The first step is schema mode identification. This involves learning about the different schema modes and identifying the most common modes used including both negative and positive modes. Read the schema mode descriptions and with an understanding of their characteristics begin to list the modes that are most often used.

2.Origin and Adaptive Use – The second step is recognizing the schema mode’s origin and adaptive use. The origin of the schema mode typically comes from the family of origin, usually a parent. However, it could also include other significant figures from youth. Following this, begin to think about how it was helpful or adaptive for use as a child to survive but as an adult, is ineffective.

3.Triggers Identification – The third step is trigger identification and involves the recognition of the most common life events that initiates mode switches. It can be helpful to think about sudden shifts in mood or an awareness of others’ change in reaction to behavior.

4.Mode Advantages and Disadvantages – The fourth step is recognizing the advantages and disadvantages of the mode. This can be done by putting oneself at a distance from the behaviors and evaluating its negative and positive impacts on social, emotional and physical being as well as its general impacts on life. The recognition of mode advantages and disadvantages is an important part of the process of self-parenting.

5.Self-Parenting – The fifth step is self-parenting. Generally, this involves the processes of seeing and adapting the use of both the Happy Child Mode and the Healthy Adult Mode. Change occurs as one uses these healthy modes to nurture or redirect unhealthy modes. This can be done by the imagery of changed behavior or the imagery of seeing oneself in a healthy mode providing safety or direction to an unhealthy mode.    

Schema Mode Problem Solving

With the initial exercises completed one is a better position to coordinate and use the learning on a day to day basis. The goal is to use the understandings and growing awareness from the previous exercises and apply them to daily relational and emotional challenges perpetuated by the modes(s).

Completing the framework sentence below will allow for spontaneous change and the elimination of unhealthy schema modes. The goal is to get to the point of being able to do the exercise automatically in real life settings.

Use the framework sentence below to talk, write or think through a challenging life situation. 

I feel (emotion) in (this part of my body) and the emotion was caused by (causal event). This event has triggered my (mode) which was taught to me by (family of origin influence). This mode reaction has caused me to exaggerate or overreact by (behavior). The mode may have been helpful when I was (age or situation) but today it is ineffective because of (disadvantages). Although my schema causes me to believe that I am (negative self-belief) I am (rational positive self-belief) as evidenced by (supporting evidence). Although I would like to do (negative behavior) instead I will do (positive behavior).

Resources

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Challenging Problems by Judith Beck (2005)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)

Polyvagal Mapping for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years, the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic exercises assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety. One of those exercises is called Polyvagal Mapping which is a process of describing or “mapping” one’s individual experience while in various states of the autonomic nervous system.

Polyvagal Theory and the Perception of Safety and Danger

Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate. It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations. The exercise of Polyvagal Mapping will assist individuals to better recognize how life experiences of safety and danger impact them physically, cognitively, emotionally and relationally and create workable solutions for change and decrease unhealthy reactivity.

Before beginning the exercise of “Polyvagal Profile Maps” it is important to understand the three states of the Autonomic Nervous System.

The Three States of the Autonomic Nervous System

Polyvagal Theory argues that people are regularly moving through three different autonomic states throughout their daily lives. This movement is caused by reactions to life events and the attempt to survive emotionally or physically, to restore oneself, or connect with others. These three states are the ventral vagal state (safe and social), the sympathetic state (mobilized for fight or flight) and the dorsal vagal state (immobilized and collapsed). Each state is managed by a specific set of nerves and each state serves a specific set of biological and social needs.

1.Ventral Vagal State – The ventral vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The ventral vagal state, also known as the “safe and social state”, is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other two defensive autonomic states listed below. Being in a safe situation and then actively looking for and seeing safety will activate the ventral vagal state. The activation of the ventral vagal state facilitates self-regulation and eliminates unnecessary defensive thoughts, feelings and behaviors. In a relational sense, people in the ventral vagal state feel safe which leads to a sense of connection, trust, comfort, restoration and happiness. It is best that individuals solve relational problem(s) in the ventral vagal state. If they do not, they will switch involuntarily to the sympathetic state and attempt to solve their problem(s).

2.The Sympathetic State – The sympathetic state is a physical, emotional and cognitive experience facilitated by a set of nerves coming from the center of the spine and connecting to various organs. This set of nerves alerts and activates people when they detect danger and prepares the body to act. The sympathetic state, also known as “mobilized for fight or flight state”, moves through various levels of intensity measured by both the level of fear experienced and the related amount of physical and mental energy that is given to deal with the event. When someone is in this state, they are pulled out of the ventral vagal state, lose the benefits of feeling safe and begin to disconnect from people. Relationally it is a state of conflict and fear. Clinically the sympathetic state parallels anxiety, anger, posttraumatic stress, relational discord, obsessions and cognitive distortions leading to self-questioning. Physical symptoms include headaches, high blood pressure, heart disease and joint pain. If the problem or event is not solved in the sympathetic state, the person will then involuntarily activate the next state which is the dorsal vagal state.

3.The Dorsal Vagal State – The dorsal vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves that extend from the Vegas Nerve to the organs located below the diaphragm. When the dorsal vagal state, also known as “the immobilized and collapsed state”, is activated an individual will shut down. Often this will follow the overwhelm of energy and fear caused by the sympathetic state. This overwhelm can be physical, emotional, or cognitive. The body will grow cold, weak, slow and lacking in energy. Socially the individual feels disconnected from others. Clinically this state triggers symptoms of depression, dissociation, performance anxiety, paranoia and cognitive distortions leading to challenged self-concept. Physical symptoms consist of low blood pressure, immune system disorders, stomach problems, obesity, fibromyalgia and irritable bowel syndrome.

Directions for Completing Polyvagal Profile Maps

The Polyvagal Profile Maps consist of three different maps. These are The Personal Profile Map, The Triggers and Glimmers Map and The Regulating Resources Map. The personal profile map and the triggers and glimmers map are exercises to increase self-awareness while the regulating resource map is used to create solutions for managing situations and relationships that are threatening or dangerous.

Personal Profile Map

The purpose of the Personal Profile Map is to increase the awareness of both the time, intensity, triggers and control of the ventral vagal (safe and social), sympathetic (mobilized for fight or flight) and dorsal vagal (immobilized and collapsed). To do this, divide a piece of paper into three sections (one for each state) and for each state complete the following questions.

  1. When I am in this state, I think the world is…?
  2. When I am in this state, I think I am…?
  3. What emotions do I feel in this state?
  4. What physical sensations do I feel in this state?
  5. How does this state impact how I hear, smell and see things or people?
  6. How does this state impact my relationship to sleep, substances, food and others?
  7. How does this state impact my needs?
  8. What does this state cause me to do or want to do?

The completed map should assist you in understanding what it is like to experience each state. At times it will be difficult to describe how each state feels since movement from one state to the next is automatic and not always recognizable. However, the more often you do the exercise the better you will be at recognizing when you shift states as well as their level of intensity.

Triggers and Glimmers Map

The purpose of The Triggers and Glimmers Map is to assist you in recognizing what event and what types of events cause you to change from one state to the next.

Triggers are cues of danger that bring someone into sympathetic and dorsal vagal states. A trigger can happen at any time and can be significant or seemingly insignificant. All triggers have the quality of being a threat that creates a survival response. Triggers cause harm when they overwhelm someone’s internal resources making someone release too much energy to resolve the event. This trigger then takes one out of social connection.

Glimmers are cues of safety and bring someone into a ventral vagal state. Glimmers can be spontaneous but are generally purposeful. Glimmers have the quality of allowing one to safely connect with others in a way that is relaxing, regulating and diminishes the survival mode or desire to disconnect. Glimmers can come when alone or when with others. It is important to keep in mind that a glimmer can be very brief such as “A smile from my favorite store clerk” and that recognizing these brief moments can allow one to build on something that is significant and helpful.

Each trigger or glimmer is a recognizable event. Again, divide a piece of paper into three sections (one for each state) and list the triggers for sympathetic and dorsal vagal as well as the glimmers for the ventral vagal.

Regulating Resources Map

The purpose of the Regulating Resources Map is to assist you in indentifying and using individual strengths, creativity and the information from the previous two maps to move out of negative states and maintain a positive state.

The Regulating Resources Map illustrates that this improvement can be done alone or with others. Additionally, it illustrates the power of one’s own resources and highlights what additional skills might be needed.

Again, divide a piece of paper into three sections. For the ventral vagal state answer the question “What can I do by myself and with others to stay in this state?” For the sympathetic and dorsal vagal state answer the question “What can I do by myself and with others to get out of this state?” For each state list 3-5 ideas.

This exercise will assist in increasing the understanding of the level of reactivity to situations that are or appear to be safe or dangerous. Also, it will then assist in creating reasonable reactions to those situations. This exercise will require some repetition before it becomes automatic. However, in time, and with some effort, one should be able to do the exercise in real life events naturally.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Society by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Polyvagal Journal Writing for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic exercises assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety. One of those exercises is called “Polyvagal Journal Writing” which is a process of articulating the day to day experience of being in various states of the autonomic nervous system and how to decrease defensive states for increased restoration and problem solving.

Polyvagal Theory and the Perception of Safety and Danger

Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate. It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations. The exercise of Polyvagal Journal Writing will assist individuals to better recognize how life experiences and anticipated life experiences can impact them physically, cognitively, emotionally and relationally.

Before beginning the exercise of “Polyvagal Journal Writing” it is important to understand specific topics in Polyvagal Theory that are impacted by this exercise. These topics are The Three States of the Autonomic Nervous System, The Vagal Brake and The Window of Tolerance.

The Three States of the Autonomic Nervous System

Polyvagal Theory argues that people are regularly moving through three different autonomic states throughout their daily lives. This movement is caused by reactions to life events and the attempt to survive emotionally or physically, to restore oneself, or connect with others. These three states are the ventral vagal state (safe and social), the sympathetic state (mobilized for fight or flight) and the dorsal vagal state (immobilized and collapsed). Each state is managed by a specific set of nerves and each state serves a specific set of biological and social needs. An initial goal of Polyvagal Therapy is the tracking and awareness of these states.

1.Ventral Vagal State – The ventral vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The ventral vagal state, also known as the “safe and social state”, is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other two defensive autonomic states listed below. Being in a safe situation and then actively looking for and seeing safety will activate the ventral vagal state. The activation of the ventral vagal state facilitates self-regulation and eliminates unnecessary defensive thoughts, feelings and behaviors. In a relational sense, people in the ventral vagal state feel safe which leads to a sense of connection, trust, comfort, restoration and happiness. It is best that individuals solve relational problem(s) in the ventral vagal state. If they do not, they will switch involuntarily to the sympathetic state and attempt to solve their problem(s).

2.The Sympathetic State – The sympathetic state is a physical, emotional and cognitive experience facilitated by a set of nerves coming from the center of the spine and connecting to various organs. This set of nerves alerts and activates people when they detect danger and prepares the body to act. The sympathetic state, also known as “mobilized for fight or flight state”, moves through various levels of intensity measured by both the level of fear experienced and the related amount of physical and mental energy that is given to deal with the event. When someone is in this state, they are pulled out of the ventral vagal state, lose the benefits of feeling safe and begin to disconnect from people. Relationally it is a state of conflict and fear. Clinically the sympathetic state parallels anxiety, anger, posttraumatic stress, relational discord, obsessions and cognitive distortions leading to self-questioning. Physical symptoms include headaches, high blood pressure, heart disease and joint pain. If the problem or event is not solved in the sympathetic state, the person will then involuntarily activate the next state which is the dorsal vagal state.

3.The Dorsal Vagal State – The dorsal vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves that extend from the Vegas Nerve to the organs located below the diaphragm. When the dorsal vagal state, also known as “the immobilized and collapsed state”, is activated an individual will shut down. Often this will follow the overwhelm of energy and fear caused by the sympathetic state. This overwhelm can be physical, emotional, or cognitive. The body will grow cold, weak, slow and lacking in energy. Socially the individual feels disconnected from others. Clinically this state triggers symptoms of depression, dissociation, performance anxiety, paranoia and cognitive distortions leading to challenged self-concept. Physical symptoms consist of low blood pressure, immune system disorders, stomach problems, obesity, fibromyalgia and irritable bowel syndrome.

The Vagal Brake and The Window of Tolerance

The vagal brake is a term created by Stephen Porges PhD to describe the process of stopping physiological reactivity to life events that lead either to the sympathetic or dorsal vagal defensive state. It is important that individuals accurately read the level of both safety and danger in life events to not overuse a defensive state position. People who have a history of trauma and nonacute trauma found in PTSD and Complex PTDS have histories where it was necessary to maintain states of high defense. However, in different life settings, or in adulthood, the level of threat generally is less and the need for a defensive state is less. An unnecessary overactivation of a defense state will create emotional, physical and cognitive overwhelm and a relational management style that is ineffective. The activation of the vagal brake, at the right time, will ease a defense reaction and leave the individual in a position to self-regulate and return to a ventral vagal state of safety. The development of an accurate vagal brake response can be done by polyvagal exercises described in this article and others and is a central focus in the treatment of Complex PTDS.

The window of tolerance is a clinical term used to describe the parameters of one’s state of non-defense. It is necessary to recognize one’s own window of tolerance since it will determine what are manageable tasks, thoughts, memories, relationships and topics in and out of therapy. Thus, the awareness of one’s window of tolerance will assist in self-regulation and with creating the most likely positive results from the use of internal resources and therapeutic suggestions. A goal of treatment is for the client’s window of tolerance to increase over time so one can actively problem solve needed topics of change while maintaining a ventral vagal state position. As this relates to the vagal brake, the window of tolerance will expand as one can more quickly use their vagal brake to inhibit defense response, maintain a state of safety and “tolerate” life events. The window of tolerance is expanded by this exercise and other Polyvagal exercises. It also is expanded by other treatment models notably Schema Therapy and Eye Movement Desensitization and Reprocessing.

Directions for Completing Polyvagal Journal Writing

The purpose of Polyvagal Journal Writing is to assist one in recognizing both the intensity and triggers of the ventral vagal, sympathetic and dorsal vagal state experience. This is done through daily writing and addressing these three topics, State Calculation, State Reflections and State Anticipations. This exercise can be done alone. However, it is used most effectively if one has first completed the exercises listed in the article “Polyvagal Mapping for Complex Posttraumatic Stress Disorder”. See directives below for completion.

State Calculation

State Calculation is the process of measuring the intensity of the ventral vagal, sympathetic and dorsal vagal states as they occur. Since each state is different, each requires different measurement considerations. These calculations will be used in the State Reflections and State Anticipation exercises.

1. Ventral Vagal – To measure a ventral vagal state, consider the level of safety experienced in the thoughts, emotions, body sensations and relational connectedness of the state. To do this, pick a number between 0 and 10 with 0 being a nonexistent sense of safety and 10 being safety as high as can be imagined. Write this number when the exercise requires it. In most all cases the number will be above 4, since a low number response would indicate being in a defensive state.

2. Sympathetic State – To measure the sympathetic (mobilized) state, consider both the level of energy and fear when in the state. First, when evaluating energy levels, consider the energy spent on relational topics such as a verbal confrontation or a physical fight or threat. Also consider the energy put into a cognitive topic such as challenged self-perception leading to preoccupation of self-worth or performance. Second, evaluate the subjective experience of fear and measure it. For both fear and energy sensations, calculate the level by providing a number between 0 and 10 with 0 being nonexistent and 10 being as high as imaginable. List these numbers as the exercise requires it.

3. Dorsal Vagal – To measure the dorsal vagal (immobilized) state, consider both the level of shut down and fear when in this state. First, the level of shut down might be experienced as pulling away from people, feeling flat, feeling nonexistent, feeling disconnected or having depressed cognitions or an inability to recall recent events. Second, evaluate the subjective experience of fear in these experiences and calculate it. Again, use a number between 0 and 10 with 0 being nonexistent and 10 being as high as imaginable. List these numbers as the exercise requires it.

The State Reflection Exercise

The State Reflection Exercise involves reviewing an entire day, then labeling and measuring the current and past states. The exercise should be done daily. This exercise increases the awareness of state influence and increases the capacity of the vagal break in social and individual settings. Follow these directives.

1. Evaluate the current state – Pick a general time at the end of the day for the journal writing exercise. Using a journal or computer, list the current state experienced, whether that state be ventral vagal, sympathetic or dorsal vagal. Calculate the level of the state using the state calculation directions.

2. List significant events – Next, think chronologically through the day making a mental note of the events throughout the day. Ask if these events increased, decreased, triggered or maintained the previous a state. List all the events chronologically and their accompanied state. Reflect on the intensity of each state experience and complete a state calculation on each event.

3. Determine the level of rational response – Review what has been written and ask if the current state is a rational holistic response to the collective state experiences of the day. If it is rational, it means there is a sensitivity and recall to both the immediate and holistic impacts of life events. If not, it means an event(s) was not recalled or there is a disconnect with the impacts of immediate state experience or the impacts of collective state experiences or both. If this is the case, reevaluate the exercise starting with a rethinking of the day’s events and their level of intensity. Following this, ask if an event is missing from recall. If so, include and measure it and continue until the current state seems to be a rational position.

The State Anticipation Exercise

The State Anticipation Exercise involves the processes of looking ahead to future events and calculating their possible impacts on state experience. This exercise will assist with the development of the window of tolerance since it increases the understanding of the impacts of future events and creates methods of problem solving to decrease reactivity.

1. List future events – Following the state reflection exercise, continue journal writing and list planned future events such as the tasks of the next day. Imagine each event and begin to anticipate if the event will cause fear, heightened mobilization or shutdown. Based on this information, imagine what state the event might trigger weather it be ventral vagal, sympathetic or dorsal vagal. List each event.

2.Calculate state intensity – After listing each event, use the state calculation method to calculate its intensity considering fear, energy and shut down levels.

3. Do a holistic calculation – Based on the calculations of step two, evaluate how the combination of events might impact the entire day and consider the possible end state position.

4. Problem solve for window of tolerance capacity – If it is anticipated that the following day’s events lead to a defensive state, then go through each event and evaluate how to decrease fear, energy or shut down in each event. List the answers.

5. Imagine success – Image successfully decreasing the anticipated fear, energy or shutdown reactions, recalculate state positions and consider how these changes would impact the state position of the end of the day.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Society by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Polyvagal Hybrid States and Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years, the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic exercises assisting people with self-regulation, relational management, and an articulation of the subjective experiences of danger and safety. One of those exercises is recognizing and activating Polyvagal hybrid states.

Polyvagal Theory and the Perception of Safety and Danger

Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive, and relational hardship if their perception of those safe or dangerous situations is inaccurate. It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety, or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments, or allow verbal, physical or emotional boundary violations.

The Three States of the Autonomic Nervous System

Polyvagal Theory argues that people are regularly moving through three different autonomic states throughout their daily lives. This movement is caused by reactions to life events and the attempt to survive emotionally or physically, to restore oneself, or connect with others. These three states are the ventral vagal state (safe and social), the sympathetic state (mobilized for fight or flight) and the dorsal vagal state (immobilized and collapsed). Each state is managed by a specific set of nerves and each state serves a specific set of biological and social needs.

1.Ventral Vagal State – The ventral vagal state is a physical, emotional, and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The ventral vagal state, also known as the “safe and social state”, is responsible for detecting, accepting, evaluating, and reciprocating states of social safety. Also, it regulates the other two defensive autonomic states listed below. Being in a safe situation and then actively looking for and seeing safety will activate the ventral vagal state. The activation of the ventral vagal state facilitates self-regulation and eliminates unnecessary defensive thoughts, feelings and behaviors. In a relational sense, people in the ventral vagal state feel safe which leads to a sense of connection, trust, comfort, restoration and happiness. It is best that individuals solve relational problem(s) in the ventral vagal state. If they do not, they will switch involuntarily to the sympathetic state and attempt to solve their problem(s).

2.The Sympathetic State – The sympathetic state is a physical, emotional, and cognitive experience facilitated by a set of nerves coming from the center of the spine and connecting to various organs. This set of nerves alerts and activates people when they detect danger and prepares the body to act. The sympathetic state, also known as “mobilized for fight or flight state”, moves through various levels of intensity measured by both the level of fear experienced and the related amount of physical and mental energy that is given to deal with the event. When someone is in this state, they are pulled out of the ventral vagal state, lose the benefits of feeling safe and begin to disconnect from people. Relationally it is a state of conflict and fear. Clinically the sympathetic state parallels anxiety, anger, posttraumatic stress, relational discord, obsessions and cognitive distortions leading to self-questioning. Physical symptoms include headaches, high blood pressure, heart disease and joint pain. If the problem or event is not solved in the sympathetic state, the person will then involuntarily activate the next state which is the dorsal vagal state.

3.The Dorsal Vagal State – The dorsal vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves that extend from the Vegas Nerve to the organs located below the diaphragm. When the dorsal vagal state, also known as “the immobilized and collapsed state”, is activated an individual will shut down. Often this will follow the overwhelm of energy and fear caused by the sympathetic state. This overwhelm can be physical, emotional, or cognitive. The body will grow cold, weak, slow and lacking in energy. Socially the individual feels disconnected from others. Clinically this state triggers symptoms of depression, dissociation, performance anxiety, paranoia and cognitive distortions leading to challenged self-concept. Physical symptoms consist of low blood pressure, immune system disorders, stomach problems, obesity, fibromyalgia and irritable bowel syndrome.

The Vagal Brake and The Window of Tolerance

The vagal brake is a term created by Stephen Porges PhD to describe the process of stopping physiological reactivity to life events that lead either to the sympathetic or dorsal vagal defensive states. It is important that individuals accurately read the level of both safety and danger in life events in order to not overuse a defensive state position. People who have a history of trauma and nonacute trauma found in PTSD and Complex PTDS have histories where it was necessary to maintain states of high defense. However, in different life settings, or in adulthood, the level of threat generally is less and the need for a defensive state is less. An unnecessary overactivation of a defense state will create emotional, physical, and cognitive overwhelm and a relational management style that is ineffective. The activation of the vagal brake, at the right time, will ease a defense reaction and leave the individual in a position to self-regulate and return to a ventral vagal state of safety. The development of an accurate vagal brake response can be done by polyvagal exercises described in this article and others and is a central focus in the treatment of Complex PTDS.

The window of tolerance is a clinical term used to describe the parameters of one’s state of non-defense. It is necessary to recognize one’s own window of tolerance since it will determine what are manageable tasks, thoughts, memories, relationships and topics in and out of therapy. Thus, the awareness of one’s window of tolerance will assist in self-regulation and with creating the most likely positive results from the use of internal resources and therapeutic suggestions. A goal of treatment is for the client’s window of tolerance to increase over time so one can actively problem solve needed topics of change while maintaining a ventral vagal state position. As this relates to the vagal brake, the window of tolerance will expand as one can more quickly use their vagal brake to inhibit defense response, maintain a state of safety and “tolerate” life events. The window of tolerance is expanded by this exercise and other Polyvagal exercises. It also is expanded by other treatment modes notably Schema Therapy and Eye Movement Desensitization and Reprocessing.

Polyvagal Theory and Coregulation

Coregulation is the moment to moment act of managing a relationship to self-regulate. Coregulation is based on attachment theory which argues that the regulation of a child doesn’t only come from the “good enough” behavior of the parent, but is a processes by which the child feels calm in reaction to the parent’s self-regulation which is in response to the child’s initial signs of self-soothing. In relationships, coregulation is the individual act of keeping a relationship safe in an effort of bring oneself to state of regulation. In Polyvagal terms, the individual has an awareness of both their window of tolerance and sensitivity to their vagal brake and will use methods to manage the relationship in order to remain in or return to a ventral vagal state. This often requires the need to defuse the defensive states of sympathetic defense and dorsal vagal defense that occur both in oneself, but also in others. Often individuals with a history of abuse or neglect leading to PTSD or Complex PTSD have a past of strained and conflictual relationships which did not provide examples of problem solving leading to self-regulation and relational management.

The Polyvagal Hybrid States

Polyvagal theory argues that the three states of the autonomic nervous system listed above, the ventral vagal, sympathetic, and dorsal vagal states, are not mutually exclusive nor antagonistic but rather comingle and coexist to create a full spectrum of cognitive, relational, behavioral and emotional experiences. These coactivated states are called “hybrid states”. There are two hybrid states which are the combined ventral vagal and sympathetic state and the combined ventral vagal and dorsal vagal state. The activation of these states facilitates the process of the vagal brake, an expanded window of tolerance and a heightened capacity for coregulation.

The Ventral Vagal and Sympathetic Hybrid State

The coactivation of the ventral vagal and sympathetic states enables the experience of safety combined with mobilization. Because of the safety of the ventral vagal state it allows for mobilization without fear. This is an example of the development of the expanded window of tolerance discussed above. Examples of this hybrid state include movement, play, competition quick thinking, creativity and productivity. For utilizing the benefits of this coactivation, consider these points.

1. This hybrid state decreases fear while maintaining mobilization – The clinical benefit of this hybrid state can be best understood by noting that it is a process of using the safe and social engagement system (ventral vagal) to decrease the experience of fear found in the sympathetic state while holding the advantages of physical mobilization.

2. This hybrid state uses the power of play – Play is a useful metaphor for understanding the clinical benefits of this hybrid state. During sympathetic defense, the body is activated to prepare for mobilization to attend to a confrontation. However, when using the ventral vagal state an individual can maintain connection, safety and cooperation while still being mobilized. This maintenance is facilitated by the safe and social engagement system that activates noncombative communication, useful vocal tone, warm facial expression, proper structure, and rules of cooperation. These qualities can be seen in play activities such as sports, competitive activities in all areas, relational teasing, mutual sharing of fun events and group musical performance. Applying this understanding to a broad set of relational tasks will assist an individual in creatively rethinking conflict situations to have less fear and increase the capacity for connection and resolve.

3. This hybrid state assists in problem solving – If an individual has a background of abuse, it is possible that their perception of danger is high even in safe environments since defensive states had been a requirement for survival. This perception of danger leads to mobilization with fear and this pattern is often a part of PTSD or Complex PTSD symptomology. The function of this hybrid state allows an individual to decrease defense by utilizing some of the concepts described in play. For example, an individual can approach a conflictual discussion or relationship and apply the stated measures of safety like rules of cooperation, proper structure, useful vocal tone and warm facial expression to decrease fear, increase safety and increase problem solving. Since this process involves two people, the use of “play” facilitates coregulation allowing people with Complex PTSD to use a hybrid template to manage relationships and self-regulate. This process can first be done by imagery. For more information on this see “Combining EMDR and Polyvagal Therapy for Complex Posttraumatic Stress Disorder” by the author.

4. This hybrid state can be practiced alone – Mind body work such as yoga and meditation are excellent methods of practicing this hybrid sate when alone. Yoga and meditation allow for the activation of the body while meditation and mindful breathing anchor the person in safety, connection and calm. Additionally, other activities can activate this hybrid state. For example, activities such as dance, play, artistic expression and writing are methods which initiate the subjective experience of safety combined with mobilization. An advantage of these practices is that they can be done alone and provide a foreshadow to success in relationships.

The Ventral Vagal and Dorsal Vagal Hybrid State

The coactivation of the ventral vagal state and the dorsal vagal state facilitates a state of safe immobilization. Because of the safety of the ventral vagal state it allows for immobilization without fear. Rather than initiating the shutdown defense of dorsal vagal activation, safety is introduced through the social engagement system so one can remain connected with another person while being immobilized. This connection is considered a necessary part of intimacy, conception, childbirth, nursing and attachment. For utilizing the benefits of this coactivation, consider these points.

1. This hybrid state decreases fear while maintaining mobilization – The clinical benefit of this hybrid state can be best understood by noting that it is a process of using the safe and social engagement system (ventral vagal) to decrease the experience of fear found in the dorsal vagal state while maintaining its quality of immobilization.

2. This hybrid state creates safe immobilization through play. The metaphor of play is again helpful in illustrating the benefits of this hybrid state’s coactivation. Play consists of a playful manner, rules, cooperation, gentle contact and prosodic vocalizations. This “play method” of connection decreases states of defense. If an individual has a history of abuse, neglect or longstanding exposure to conflict, they likely have patterns of defense from fearful situations. This leads to an activation of a sympathetic fight or flight state and then to a necessary shut down. As one moves into adulthood or less threatening environments, the need to defend and shut down is not needed. However, the autonomic nervous system is tuned to respond in the same way. The metaphor of play can assist one to put together a concept of behavioral methods leading to this hybrid state. The individual can remain connected while immobilized by utilizing a playful manner, gentle contact and soothing vocalizations and thus short circuit the activation of defense. This hybrid activation is an example of expanding one’s window of tolerance since one has expanded their “working space” of resolve, restoration and resilience.

3.This hybrid state creates safety through reciprocity – For most all people, immobilization is considered a vulnerable posture and the inhibition of fear in social settings is necessary for restoration, safety and survival. This hybrid state represents these stated qualities and can be activated by the social processes of reciprocity. Reciprocity is best seen as a consistent exchange between two people. Relationally, it is the act of hearing and meeting needs of another across a wide range of human expectations while also stating and receiving those same types of needs. This act of reciprocity creates an atmosphere of trust.

4. This hybrid state fosters physical health – The activation of this hybrid state may have long term benefits on the regulation of body organs by providing a method of supporting homeostasis. This hybrid activation individually is a process of self-soothing which can be physically beneficial and, within a social context, leads to a process of self-regulation through the management of real or potential threat existing in relationships. Related to Complex PTSD, this coactivation supports the concepts of self-regulation and a decrease in the negative physical impacts of ongoing states of defense, isolation and conflict.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Societ y by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience for Self-Regulation and Resilience by Sullivan, Erb, Schmalzi, Moonaz, Tylor, and Porges from Frontiers in Human Neuroscience February 2018.

Polyvagal Coregulation for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic exercises assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety.

Polyvagal Theory and The Perception of Safety and Danger

Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate. It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations.

The Three States of the Autonomic Nervous System

Polyvagal Theory argues that people are regularly moving through three different autonomic states throughout their daily lives. This movement is caused by reactions to life events and the attempt to survive emotionally or physically, to restore oneself, or connect with others. These three states are the ventral vagal state (safe and social), the sympathetic state (mobilized for fight or flight) and the dorsal vagal state (immobilized and collapsed). Each state is managed by a specific set of nerves and each state serves a specific set of biological and social needs.

1.Ventral Vagal State – The ventral vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The ventral vagal state, also known as the “safe and social state”, is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other two defensive autonomic states listed below. Being in a safe situation and then actively looking for and seeing safety will activate the ventral vagal state. The activation of the ventral vagal state facilitates self-regulation and eliminates unnecessary defensive thoughts, feelings and behaviors. In a relational sense, people in the ventral vagal state feel safe which leads to a sense of connection, trust, comfort, restoration and happiness. It is best that individuals solve relational problem(s) in the ventral vagal state. If they do not, they will switch involuntarily to the sympathetic state and attempt to solve their problem(s).

2.The Sympathetic State – The sympathetic state is a physical, emotional and cognitive experience facilitated by a set of nerves coming from the center of the spine and connecting to various organs. This set of nerves alerts and activates people when they detect danger and prepares the body to act. The sympathetic state, also known as “mobilized for fight or flight state”, moves through various levels of intensity measured by both the level of fear experienced and the related amount of physical and mental energy that is given to deal with the event. When someone is in this state, they are pulled out of the ventral vagal state, lose the benefits of feeling safe and begin to disconnect from people. Relationally it is a state of conflict and fear. Clinically the sympathetic state parallels anxiety, anger, posttraumatic stress, relational discord, obsessions and cognitive distortions leading to self-questioning. Physical symptoms include headaches, high blood pressure, heart disease and joint pain. If the problem or event is not solved in the sympathetic state, the person will then involuntarily activate the next state which is the dorsal vagal state.

3.The Dorsal Vagal State – The dorsal vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves that extend from the Vegas Nerve to the organs located below the diaphragm. When the dorsal vagal state, also known as “the immobilized and collapsed state”, is activated an individual will shut down. Often this will follow the overwhelm of energy and fear caused by the sympathetic state. This overwhelm can be physical, emotional, or cognitive. The body will grow cold, weak, slow and lacking in energy. Socially the individual feels disconnected from others. Clinically this state triggers symptoms of depression, dissociation, performance anxiety, paranoia and cognitive distortions leading to challenged self-concept. Physical symptoms consist of low blood pressure, immune system disorders, stomach problems, obesity, fibromyalgia and irritable bowel syndrome.

The Vagal Brake and The Window of Tolerance

The vagal brake is a term created by Stephen Porges PhD to describe the process of stopping physiological reactivity to life events that lead either to the sympathetic or dorsal vagal defensive state. It is important that individuals accurately read the level of both safety and danger in life events in order to not overuse a defensive state position. People who have a history of trauma and nonacute trauma found in PTSD and Complex PTDS have histories where it was necessary to maintain states of high defense. However, in different life settings, or in adulthood, the level of threat generally is less and the need for a defensive state is less. An unnecessary overactivation of a defense state will create emotional, physical and cognitive overwhelm and a relational management style that is ineffective. The activation of the vagal brake, at the right time, will ease a defense reaction and leave the individual in a position to self-regulate and return to a ventral vagal state of safety. The development of an accurate vagal brake response can be done by polyvagal exercises described in this article and others and is a central focus in the treatment of Complex PTDS.

The Window of Tolerance is a clinical term used to describe the parameters of one’s state of non-defense. It is necessary to recognize one’s own window of tolerance since it will determine what are manageable tasks, thoughts, memories, relationships and topics in and out of therapy. Thus, the awareness of one’s window of tolerance will assist in self-regulation and with creating the most likely positive results from the use of internal resources and therapeutic suggestions. A goal of treatment is for the client’s window of tolerance to increase over time so one can actively problem solve needed topics of change while maintaining a ventral vagal state position. As this relates to the vagal brake, the window of tolerance will expand as one can more quickly use their vagal brake to inhibit defense response, maintain a state of safety and “tolerate” life events.

What is Coregulation?

Coregulation is the moment to moment act of managing a relationship to self-regulate. Coregulation is based on attachment theory which argues that the regulation of a child doesn’t only come from the “good enough” behavior of the parent, but is a processes by which the child feels calm in reaction to the parent’s self-regulation which is in response to the child’s initial signs of self-soothing. In relationships, coregulation is the individual act of keeping a relationship safe in an effort of bring oneself to state of regulation. In Polyvagal terms, the individual has an awareness of both their window of tolerance and sensitivity to their vagal brake and will use methods to manage the relationship to remain in or return to a ventral vagal state. This often requires the need to defuse the defensive states of sympathetic defense and dorsal vagal defense that occur both in oneself, but also in others. Often individuals with a history of abuse or neglect leading to PTSD or Complex PTSD have a past of strained and conflictual relationships which did not provide examples of problem solving leading to self-regulation and relational management. This article explains the six steps needed to coregulate a relationship. They are Calculating Safety in Relationships, Evaluating Boundary Management, Evaluating Communication Skills, Reciprocity and Validation.

Calculating Safety in Relationships

The first part of coregulation is calculating relational safety. This involves the processes of looking at specific relational topics and measuring the level of safety experienced within the relationship. See the directives below.

1. List broad topics – Using a piece of paper or a computer, list the seven broad categories found in relationships that are stated below. These categories are communication, work, play, physical intimacy, emotional intimacy, spiritual connectedness and daily activities.

2. Rank the relationship – Choose any relationship and review a general pattern of safety and connection that is experienced in each category. For each category give it a ranking between 0 and 10 with 0 being nonexistent and 10 being as high as imaginable.

3. Review danger – Review any numbers below 5 or 6. Ask why the number is low considering experiences of safety and connection. Evaluate if this topic represents times of ventral vagal safety or defense.

4. Review safety – Review numbers above 6. Consider what is being done by both people in the relationship to create safety. Consider if it parallels times of ventral vagal safety.

5. Evaluate methods of change – Looking at all the answers, consider if the relationship falls within the window of tolerance and if the vagal brake can be applied during times of conflict. Determine if topics with lower rankings can be improved.

Maintain Boundary Management

Coregulation is the moment to moment act of managing a relationship for the purpose of self-regulation. Setting boundaries allows one to manage the negative influences of a relationship and to keep those influences at a distance as needed. Boundary management involves creating visible or invisible lines between oneself and another and can change over time. The typical categories of boundary consideration are verbal, emotional, sexual, physical and mental. In polyvagal terms, one creates boundaries to decrease and eliminate states of defense or potential states of defense. In order to do this, the person needs to be sensitive to their ability to manage their own vagal brake as well as to sense and predict if the level of danger in the relationship will fall outside of their window of tolerance. Consider if applying boundaries to conflictual issues in the topics ranked low in the safety calculation brings more safety.

Use Effective Communication Skills

If someone feels safe enough to allow another person in their space (boundaries) there needs to be an ongoing method to manage the other person to ward off aggression and conflict. Throughout the act of coregulation, communication skills empower an individual to maintain a consistent atmosphere of safety so they can thrive. In polyvagal terms this means one is managing another person well enough that they can ward off defensive states, maintain safety and stay self-regulated. In addition to assertion skills, some of the most valuable communication skills are, knowing your rights, knowing ways to manage criticism, using assertive listening and recognizing the qualities of fair fighting. For a detailed explanation of these skills see “Messages: The Communication Skills Book” by Fanning, McKay and Davis.

Demand Reciprocity

Individuals require a sense of belonging and without it one will move into defensive states like the sympathetic or dorsal vagal states. Reciprocity means “returning the same way” and reciprocity generates an ongoing sense of belonging and safety. In relationships this can be described as the consistent give and take of hearing, expressing, meeting and receiving needs. Ideally, the meeting of needs is equally balanced with an ongoing exchange of physical, emotional and practical provision that is not coerced. In polyvagal terms, reciprocity is a central part of the ventral vagal state and will increase one’s window of tolerance within that specific relationship. Relative to coregulation, reciprocity is a relational process leading to feelings of trust which is the foundation for relational safety.

Use Validation

When two people are in conflict, they will both attack the other and defend themselves. This cyclical process causes two people to perpetuate a process of anger, disconnection and poor problem solving. Validation is a relational strategy that ends the cycle of attack and counterattack. Validation is a diffusion technique and perhaps one of the fastest ways to end a verbal conflict.

Validation means communicating to another person an understanding of their current experience. Validation is actively trying to understand and empathize with another person to make sense of their position. Validating messages can be formed by using phrases such as “ That makes sense because…” or “That makes sense because as I know you…” Validation is not necessarily agreeing with another person but rather seeing things from their point of view to the extent that it makes sense.

Here are four things you can expect from successful validation

  1. Validation will disarm the other person – The continuation of conflict requires that both people be involved. The act of validation stops the counter attacking posture and leaves hostility to be useless.
  2. Validation opens the way for communication – As validation happens and hostility and defensiveness diminish, it allows each person to focus on the root of the problem and discuss it for resolve.
  3. Validation soothes negative arousal – Relational conflict creates a defensive sympathetic response. If someone expects conflict they will defend. If someone is in conflict they will defend. If one validates then the usefulness of arousal disappears.
  4. Validation builds trust – If a person takes an active role to validate another it sends a message that the relationship is important and deserving of consistent effort. This active role creates safety as others trust the other’s commitment.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Society by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

“Messages: The Communication Skills Book” by Fanning, McKay and Davis (2009)

Mindfulness for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW, ACSW

Mindfulness is the act of intentionally living with awareness in the current moment and striving for its benefits of decreased stress and increased happiness, mind control and emotional regulation.

Often when people are not mindful, they are focusing on both the past and the future. This can cause difficulty since focusing on the future can lead to a fear of future events. Also, focusing on the past can lead to negative emotions if one is thinking about past trauma or past events leading to negative thoughts about oneself. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder.

Mindfulness allows someone to focus on the past, present and future with control so that thoughts and feelings don’t become overwhelming.

Mindfulness is not a quick fix for stress or suffering. Although the benefits can be experienced quickly, the best and most long-lasting impacts come from keeping a routine of practice.

Mindfulness skills are those conscious acts that increase one’s ability to be mindful in a large variety of contexts in life. The following is a list of five things that can be done to be mindful.

Five Things to Do to Be Mindful

1. Mindful Breathing 

The practice of mindful breathing serves two purposes. First, it causes a physical reaction that relaxes the body and the mind. Second, it provides a beginning point for being mindful and focusing on the moment. Mindful Breathing is the central exercise for mindfulness and is extremely beneficial for self-regulation even if done apart from any other exercises. Follow these steps.

  1. Breath through your nose and fill your lungs with air. While doing this be sure that your stomach is moving more than your chest.
  2. Think about your body from head to toe and notice where in your body you feel relaxation. Continue for at least ten minutes. Keep your breathing smooth and regular.
  3. Develop mindfulness and staying in the present moment by focusing only on your breathing. Also, be aware of the physical sensation of air moving through your nose and to your lungs. Notice the pauses between breaths. If you become distracted and think about something else, simply return to focusing on your breathing.  For a good and extended training use Jon Kabat – Zinn’s audio training called “Guided Mindfulness Meditation: Body Scan Meditation”.

2. Observe and Describe Things That Are External

Observing is the act of purposefully noticing the reaction of our senses in the current moment. The power of observing comes from the fact that it requires one to step back from an object and notice it from a distance.

Describing is the act of tracking an observation. It involves labeling something or putting words to experience. Describing mindfully requires one to focus only on the facts without judgment. Thus, one should describe only the who, what, when, where and how of an observation.

The second step in mindfulness is to observe and describe things that are external using one of the five senses. Thus, one can observe and describe a smell, a physical sensation, a taste, a sound or a sight. Also, all observations and descriptions are of things that are external and not internal such as thoughts, feelings or memories.

Begin this step by picking things to observe and describe. Observe and describe one thing at a time and consciously stay in the moment. Pick a variety of things to observe in order to individually use all or most of the five senses. Keep from using judgment.

3. Observe and Describe Things that are Internal

Observing and describing things that are internal is usually more difficult than observing and describing things that are external. However, the practice of mindfulness makes this task more tangible.

Use the skill of observing and describing to observe, label and describe an emotion. Notice the emotion and hold onto it for a period then let it go. Emotions are things that exist in the current moment and are meant to be experienced as well as completed. Don’t judge the emotion but observe and describe only the facts or consequences of the emotion.

Use the skill of observing and describing to observe, label and describe a thought. Thoughts are a part of our daily existence and direct us to reason. Next, challenge this by observing and describing a thought of yourself that is negative. Perhaps this is a negative self belief such as “I am bad”, “I am not good enough” or “I am damaged”. Observe and describe this negative thought about yourself then let it go. Negative thoughts cause the most trouble for someone when they go unrecognized. Their power deceases when they are recognized and challenged through replacing them with rational positive thoughts or pushing them away.

Next observe and describe a memory. Challenge this process by picking a negative memory. Again observe, describe and let it go. Do not judge it or yourself but describe only the facts.

The most common topics for internal observation and description are thoughts, feelings, memories and body sensations. The most difficult topics for observation and describing are any of the above topics that are negative.

4. Create Expanded Awareness by Combining Mindful Breathing, Observations and Descriptions

As stated, mindfulness is the act of intentionally living with awareness in the current moment and striving for its benefits of decreased stress and increased happiness, mind control and emotional regulation. The skill of mindfulness is increased through the act of expanding awareness. Expanding awareness consists of the movement from one present focus to another within a controlled set of time. Basically, it is the combined use of the skills presented above. Here are some examples.

Begin mindful breathing until feeling relaxed and focused. Then observe and describe something external. When completed return to mindful breathing.

Begin mindful breathing until relaxed and focused then observe and describe a thought and return to breathing. If it is a negative self thought use the concepts described before of replacing the negative thought or pushing it away. When completed, return to mindful breathing.

Use this method in various combinations including mindful breathing, thoughts, feelings, body sensations, memories and external observations. It can be done in any combination. However, there are some suggestions to consider.

  1. Use mindful breathing in most all combinations when possible.
  2. Begin expanding awareness by using external observations before internal observations.
  3. Begin by using smaller combinations such as only two combinations.
  4. After practicing expanded awareness on more basic topics include negative thoughts, feelings and memories. These are more difficult to process and resolve yet they also provide the greatest benefit of change.

The overall impact of mindfulness practice is an increased ability to stay in the moment and not be pulled into the negative consequences of distracting or overwhelming thoughts of the past or future. Also, it should lead to a resolve and control of present negative thoughts, feelings, memories and body sensations that lead to problems in relationships, behavior, performance and many problems in mental health.

Practice expanded awareness daily doing three sets of ten minutes each. People will vary in their need so you may prefer to do it more or less than this. Set aside a time to practice so you can concentrate on the results. Also, begin to then use in your daily activities.

5. Participation

Another mindfulness skill is the practice of participation. Mindfulness can be increased by thoughtfully considering how you approach social activities. Living in the moment when involved with people requires a certain level of letting go of typical routines and responses to actively participate in things around you.

Practice participation by joining an activity and going with the flow. Open to the direction and norms that are being established by others involved in the activity. Allow yourself to stretch your norms and step into something new. Practice by being involved in activities of school, church, sports or general activities of having fun.

Participation does not have to be done all the time but a skill that is practiced to the extent that it helps to be more naturally mindful in social contexts.

After practicing these five skills above begin to use the list of three things below to increase the quality of mindfulness skills.

Three Ways to Increase the Quality of Being Mindful

1. Strive for Nonjudgmental Observations and Descriptions

The act of judgment is costly to one’s well-being and initiates thoughts and feelings that make it difficult to remain in the present. It is a problem when someone is thinking judgmentally about themselves. Striving for nonjudgment is a skill that needs to be used during the tasks of observation and describing. To keep a nonjudgmental attitude, follow these suggestions.

  1. Focus on the facts of what you are observing and keep from evaluating it as good or bad.
  2. Remain especially aware of judgment when acknowledging your own thoughts, feelings and values. Keep from interpretations and opinions of yourself and others.
  3. Don’t compare yourself or others.
  4. Decease judgmental thoughts by counting them and writing them down as well as observing your judgmental posture, facial expressions and tone.

2. Do What Is Effective

When people get preoccupied by past experience or upcoming anxieties they tend to react irrationally and solve problems poorly. For example, if someone has a history of limited validation by family or peers their memories of these times might compel them to want to appear as right in their views or disagreements. A ridged posture in relationships is destructive and not effective. Another example of ineffective behavior is avoidance. If someone has a history of helplessness or verbal abuse their memories of these events might cause them to approach problems by avoiding them or seeing them as too big to solve. Mindfulness practice helps someone to live in the present. That skill combined with attention to being effective allows someone to better solve their problems. For doing what is effective follow these ideas.

  1. Know your goals for a situation and do what is needed to achieve them.
  2. Focus on what works to solve a problem. Don’t let emotions interfere.
  3. Follow the rules. Rules generally keep people on a track of possibilities and methods for solving a problem.
  4. Do what is needed for the situation rather than what might be seen as fair, comfortable or desirable.
  5. Ask yourself “Am I trying to be effective or am I trying to be right”?

3. Approach Tasks One-Mindfully

When someone is living in a mindful way it means they are letting go of the distractions that keep them from being in the moment. This can be increased by thoughtfully evaluating and changing how tasks are approached.

If you have many tasks to accomplish, do only one thing at a time and keep your focus on that task. If you begin multitasking, then stop and return to doing one task. Apply this routine to the hard tasks at work and home as well as positive things like eating, talking with friends and having fun.

Holding It All Together Using Wise Mind

Practicing Wise Mind consists of a daily approach to thoughts, feelings, decisions and values that keeps from extremes in thinking and behavior. Extremes in thinking and behavior are generally irrational and are not productive for problem solving or emotional health and are influenced by past hardships, anxiety about upcoming events, negative thoughts and self beliefs and poor regulation of emotion. Mindfulness helps people stay in the present and the practice of Wise Mind is another skill to make this happen. Wise Mind can be seen as an acceptance and synthesis of the opposites or extremes in a situation in an effort to consciously recognize them to remain balanced. Here are some examples.

1. Keep an even balance between Thoughts and Feelings

If someone is not in touch with their emotions, it leaves them vulnerable to unsafe situations since they are not aware of the negative emotional reactions that bad situations can bring. On the other hand, people who are overly emotional tend to make poor decisions since intellect is hard to access if emotions are running high. Keeping a balance between thoughts and feelings requires that we recognize and manage emotions while combining them with reason so we can make good decisions and solve problems.

2. Balance Doing Behavior with Existing

The extremes of workaholic behavior and laziness or avoidance are ineffective, and the hardships of their results are destructive. Balancing these two extremes allows for being able to do what is needed to get things done and solve problems while also remaining able to experience, as needed, the uniqueness of each moment.

3. Balance Desire for Change with Accepting Things as They Are

Some things in life cannot be changed and attempts to change an impossible situation are both tiring and useless. Also, being too quick to accept things as they are can create helplessness. A balance of these two things allows for an ongoing desire to change things while also being willing to accept things as they are in the moment.

4. Balance Self Denial with Self Indulgence

A life of self denial requires the avoidance of need while self indulgence is a preoccupation with future need. Both extremes are ineffective for maintaining a happy life. Create a balance of these extremes by consciously satisfying the senses while also practicing moderation.

Resources

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Full Catastrophe Living by Jon Kabat – Zinn (2013)

Wherever You Go There You Are by Jon Kabat – Zinn (2005)

Guided Mindfulness Meditation; Four Practice CDs. Series One by Jon Kabat – Zinn

The DBT Skills Training: Handouts and Worksheets by Marsha Linehan PhD

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Society by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

The Anxiety and Phobia Workbook by Edmond Bourne (2015)

EMDR for Complex Posttraumatic Stress Disorder and Depression

By Jeff Dwarshuis LMSW ACSW

EMDR (Eye Movement Desensitization and Reprocessing) is a highly effective treatment for eliminating the negative impacts of traumatic memory.  Created as a treatment for Posttraumatic Stress Disorder, EMDR also is used with dramatic speed and effectiveness for depression. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder.

Depression

Depression can be mild or severe with symptoms that include sleep disturbance, weight gain or weight loss, difficulty concentrating, low motivation, low self esteem, suicidal thoughts, gestures or plan, feelings of worthlessness and frequent thoughts of death. The causes of depression are complex and range from chemical imbalances to unhealthy communication patterns, repressed memories and negative thought patterns. Treatment for depression may include medication, emotive processing, problem solving and Cognitive Therapy.

EMDR

EMDR is a neurobiological treatment that uses eye movements to eliminate the negative impacts of bad memories. Clients using EMDR follow a strict protocol that includes the identification of a disturbing memory and an evaluation of the negative feelings, body sensations and disturbing self beliefs (cognitions) that result when the memory is remembered. Reprocessing the memory happens as the client imagines the memory and then moves their eyes back and forth as facilitated by the therapist. The eye movements create an intense relaxation response which parallels the deep sleep experienced following REM sleep. The negative memory treated in therapy, like all negative memories, requires for its existence the collective involvement of a negative feeling, negative cognition, and a related negative body sensation. If one of these stated elements disappears then all elements will disappear, and the bad memory no longer creates a negative reaction. In therapy, because the client is using eye movements while imagining the negative memory and is experiencing intense relaxation at the same time, the negative impacts disappear all together. Generally, a negative memory can be identified and reprocessed successfully in one session.

Cognitive Therapy

Cognitive Therapy is a treatment intervention that changes a person’s thought patterns and cognitions. Studies have shown that people who are depressed have negative thought patterns called “distortions” and negative self beliefs called “negative cognitions”. Both distortions and negative cognitions can be recognized by questionnaires. In Cognitive Therapy, symptom reduction is said to occur as one teaches themselves to think more positively.

EMDR, Cognitive Measures and “Closing the Gap”

The EMDR Protocol, combined with Cognitive Therapy questionnaires, creates a very fast and effective method of treatment for depression. For example, after the client completes the questionnaire, the therapist collects a list of the client’s most negative cognitions. Then, related to each one of these negative cognitions, the therapist asks the client “When did you start believing this negative self belief and how did you learn it?” Almost always the client will refer to memories of relational conflict with their parents. Also, it is common that the client mentions memories of childhood loss or trauma experienced in school. Following this, the therapist and client use this information to create a list of all the negative experiences leading to negative cognitions and then treat each of these memories using the EMDR Protocol explained above. The client follows the EMDR treatment, eliminates the negative impacts of these childhood memories and no longer has the negative cognition contributing to depression. This is a dramatic change for the client as it is nearly impossible for a depressed person to realistically see themselves accomplishing all that they are able to based on their abilities. In general terms, before therapy the client has a gap between what they can do and what they believe they can do. The EMDR intervention eliminates the gap between perceived inabilities and realistic potential. This change of perception is shocking, comforting and euphoric often putting the client in a position of well-being not felt since their early childhood.

The treatment of depression using EMDR is an intense and highly effective method of therapy that permanently changes negative self-beliefs leading to depression and Complex Posttraumatic Stress Disorder. Also, the length of therapy is much less often taking 50%-75% less time than traditional therapy.

Resources

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Challenging Problems by Judith Beck (2005)

Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures by Francine Shapiro PhD (2001)

Getting Past Your Past: Take Control of Your Life with Self Help Techniques from EMDR Therapy by Francine Shapiro PhD (2012)  

EMDR for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

When Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francine Shapiro in 1989 it was used as a method of treatment for Posttraumatic Stress Disorder (PTSD). EMDR dramatically reduced or eliminated the negative impacts of traumatic memory leading to PTDS. Today it is recognized as the treatment of choice for PTSD and thousands of people have benefited from its use.

Since that time, researchers and therapists have expanded the use of EMDR to include several other mental health diagnoses besides PTSD. It was discovered that not only did EMDR eliminate the impacts of acute memories leading to PTDS, but it also eliminated the negative impacts and irrational self perceptions caused by bad memories and bad experiences in general.

This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder.

With this discovery, EMDR treatment could be applied to depression, anxiety, relational problems, performance problems or any problem or mental health diagnosis that was caused by negative life experiences. Due to the complexities of many of these problems, treatment needed to include other suggestions besides EMDR Therapy such as cognitive therapy, psychoeducational reading or communication exercises.

The Two Primary Responses

When using EMDR it is important that the therapist be able to predict how EMDR will impact a client. Having this understanding, the therapist can determine if other treatment suggestions are necessary.

With each EMDR session there are two primary responses by the client. First, the client experiences a distancing from the negative memory and a decrease in related negative emotions, body reactions and negative cognitions that accompany the memory.  These changes are permanent, and the therapist can expect the client be able to discuss, investigate, and revisit any part of the negative experience with an objective view.  Also, the decrease in negative reaction quickly eliminates PTSD symptoms as well as related symptoms of depression and anxiety.

The second distinct response to EMDR is Accelerated Information Processing (AIP). AIP is best described as a fast cognitive restructuring of the irrational thoughts that occur with the recall of negative memory. During EMDR the client has an acceleration of reasonable thoughts, perceptions and considerations related to the event and sees the memory (and sometimes related memories) in a reasonable, rational manner.

AIP is what allows the traumatized war veteran, who once felt helpless during memory recall, to say “I did the best I could and I am a good soldier” and the sexual assault victim who experiences intrusive flashbacks to say “It is over and I am OK”.

AIP is found to work also on future pictures that cause negative reactions such as performance topics, workplace assignments, athletic competitions or personal assertions. AIP, in these cases, allows the client to look ahead to the future performance picture with a rational and reasonable perspective on their ability to successfully complete the task.

The distancing from traumatic memory and AIP are both an expected result of each successful EMDR session. Knowing that these responses occur allows the therapist to predict how a client will think, feel and act after EMDR is completed and this can aid the therapist in considering other client needs.

The Best Expected Level

In addition to knowing the responses to EMDR, it is also helpful to know that EMDR will bring a client to what is known as their “best expected level”. For example, a client who was abused at a young age may have carried negative memories and related complications for a lifetime. EMDR will bring this person to their “best expected level” which means all symptoms and negative physical, emotional and cognitive reactions should be reduced or eliminated. The client is likely to feel better than they ever have felt before. However, if that person was raised in an environment of conflict, they may not have the skills to communicate their needs or their progress. For this client the treatment plan would require added suggestions for communication skills. A similar client may experience all the benefits listed above. However, if that client has a history of neglect, the client may not be able to explain their internal changes. This client would benefit from cognitive therapy exercises designed to help one pay attention to specific changes in thoughts and feelings. In general, EMDR will bring someone to their “best expected level” but will not teach things that have not been learned. Recognizing this specific quality of EMDR, the therapist and client can address additional needs and the treatment objectives can be suggested as necessary.

Therapeutic Considerations

EMDR is a highly effective method of treatment for most all mental health diagnoses and can be used often. Clients who use EMDR complete treatment more quickly than traditional therapy (3-4 times more quickly) and are in a better position to not have to return to therapy.

Many therapists will find that Integrated EMDR is different from traditional therapy. With EMDR, the therapist acts as a “technical manager” over a treatment process and offers little feedback or interpretation. In this way, the therapist’s role is diminished and there is more reliance on a treatment method and client participation. Also, therapists traditionally make suggestions and interpretations to clients. However, with EMDR and the impact of AIP, the best interpretations are done by the client. Therapeutic interpretations are best done during times of review.

Also, the process of evaluation for positive change in Integrated EMDR can be difficult. Often the client experiences a dramatic shift in their life. However, since EMDR will bring someone to their “best expected level” the client experiences life as they should and at times will not recognize the differences. Successful EMDR is comparable to the person who has felt the pain of a sore foot for weeks and wakes one morning with no pain and not recognizing that anything is different. EMDR is the same. Often the client is unaware of changes until the therapist reviews symptoms and cognitive self-beliefs.

Resources

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Challenging Problems by Judith Beck (2005)

The Trauma Model – A Solution to the Problem of Comorbidity in by Colin Ross MD (2000)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Society by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures by Francine Shapiro PhD (2001)

EMDR as an Integrative Psychotherapy Approach: Experts from Diverse Orientations Explore the Paradigm Prism Edited by Francine Shapiro PhD (2002)

Getting Past Your Past: Take Control of Your Life with Self Help Techniques from EMDR Therapy by Francine Shapiro PhD (2012)