Introduction to Porges and the Social Brain
" Being able to feel safe with other people is probably the single most important aspect of mental health, safe connections are fundamental to meaningful and satisfying lives. Numerous studies of disaster response around the globe have shown that social support is the most powerful protection against becoming overwhelmed by stress and trauma."
Bessel Van der Kolk
In this series of posts I want to explore the connection between the mind and the body through bringing insight from research that I think really demystifies some of the natural healing methods developed over millennia by our ancestors. What better way to start this topic, which has been like opening one immensely large can of worms for me, than to look at the work of Stephen Porges on the fascinating vagus nerve!! This nerve, which Darwin dubbed the "pneumogastric nerve" is, in effect, a portal between our emotions and our physical being. It signals information from the brain to the body and from the body to the brain like a continuous neural ping pong match. The vagus nerve brings much of the sensation of our viscera into our awareness, just think of your "gut feelings" or a "heartbreaking moment" and you will recognise the potency that this stimulus can deliver. About 80% of vagus nerve activity is signals from the body to the brain, effectively making the vagus our internal CCTV system that relays all the raw data of our internal sensory experience up to our brains. Importantly though, this information isn't always processed cognitively, i.e brought into our awareness. This is what Porges has dubbed "neuroception" and is basically our subconscious neural feed that alters our moods, feelings and ultimately determines the physiological state of the nervous system. This theory, which forms the bulk of this article, stresses the importance of our need for safety. It shows how we are constantly on a largely sub-conscious level, assessing the environment for signs of safety or danger. It gives us a biological understanding of how the subtle changes in facial expression and voice tone alter our moods and how when we can't defend ourselves verbally or vocally it throws us into more primal animal like states that profoundly change our perception of the world around us.
Porges theory explains to us how we have three inbuilt survival mechanisms that are distinct physiological states. These have developed in levels of sophistication throughout our evolution.
Social engagement system
The most recent of our physiological survival states is what Porges calls the social engagement system and forms a branch of our "parasympathetic nervous system" (PNS). This is the part of our evolutionary struggle for survival that enables us to better love and to be loved. Human's have developed a type of social intelligence that enables us to regognise safety or threat in our environment. We observe the subtle cues of others body language, expressions, voice tone and posture to discern others intentions, whilst at the same time, we respond to our own physical and emotional states by exhibiting the same external changes. An example of this so aptly displayed right in front of me as I slurp a cup of tea writing this blog on a monday morning is a Mum going to toilet leaving small girl with Daddy in cafe. Small child reacts by instantly starting to cry leaving Dad desperately trying to pick up the pieces and prevent the disruption to fellow cafe dwellers by telling the child to be quiet. As small girl doesn't relent in her instinctual cry for the safety of her mothers arms the fathers voice deepens into a more assertive, monotonous and low tone as he tells her "there is no reason to cry". This really starts to set her off and soon everyone in the cafe is starting to get a bit unsettled by the young girls screaming just as mummy comes out the loo open armed and nestling child in bosom talking in a high pitched prosody as child settles down and continues developing her still primitive social engagement mode as we all relax back into our Monday morning routine. What the innocent lack of social inhibition and cognitive reasoning displayed by this small child exemplifies so perfectly is how we are subconsciously picking up on cues implicit to our survival.
If you have, what has been termed by Porges ever growing fan club as "good vagal tone" then you will be able to understand social cues and react to them smoothly and succinctly. You will observe and recognise the subtle cues of others body language, facial expressions, vocal tone and posture in order to discern their intentions and you will respond with your own appropriate external changes in expression, voice etc.
Top-down/Bottom Up regulatory system
When we observe safe social cues then our vagus puts on the brakes to our breathing and heartbeat, slowing them down and making us feel more relaxed and calm. Importantly though, not all the signals of this system are from the brain to the body (top down), we can also modulate our mood and feelings through vagal pathways from body to brain (bottom up). If we use slow breathing, such as pranayama or various qigong techniques that focus on the exhalation, it slows down our heartbeat, stimulating our social engagement system and sending messages to the brain that we are safe and relaxed. Singing and chanting are also particularly good at achieving this as it causes us to exhale for a longer duration of time than we inhale, which alone activates our PNS but is also reinforced by a physical vibration of the laryngeal nerves at the brain stem that in turn stimulates stimulates our vagus. How many cultures have singing and chanting as a means to greater social unity and a pathway to relaxation. Pretty smart really!
Scientists had already demonstrated a two-way connection between our facial expressions and moods by putting a pencil into a group of research participant's mouth's, in effect forcing a smile, and then testing their reactions to a series of cartoons compared to a control group. Low and behold, those who were forced into a smile would respond with more positive emotional responses than those who weren't. Studies to back up this bi-directional body- brain business is research done into the more recent trend of inducing localised paralysis via injection of poisonous neurotoxin's into the striated muscles of the face, or as it is otherwise known, botox. One of the more common botox injections is into the muscle on our foreheads that causes us to frown. This study scanned the brains of women whilst they imitated pictures of sad and angry emotions before and after botox. Both before and afterwards, when imitating angry expressions, the women displayed more activity in the amygdala region of the brain (an almond shaped structure of the brain that has been shown to register particularly negative emotions such as anger and fear). But after botox there was less activity in the left amygdala, indicating that the inability to change the structure of the muscles, skin and connective tissue alters the level of the brains processing of emotions. The study also showed that despite no change in amygdala activation in response to sad facial expressions the brain did show changes in areas associated with emotional processing of touch signals.
The studies on botox have spawned a series of ideas and articles that suggest that if we "botox ourselves up" we can treat our depression and anxiety. Another victory for the pill-popping quick fix society? I don't think so... In my opinion, I find the idea of not being able to fully express and cognitively process emotions a very disconcerting idea. Recognising the body's role in modulating our sub-conscious emotional picture only to then isolate a negative affective link and remove the connection leaving us free of it's burden seems really short-sighted to me. These emotions form an important part of our biological quest for safety and are implicit in our connection to the world. What if the ability to express fear and anger is actually sometimes a good thing? This disconnect of mind to body is akin to the pharmaceutical approach to mental disorders, being that if you can nullify the activation of primal responses to negative emotional stimuli by, in effect subduing our mind and nervous system, then we can have better emotional stability. Whilst drugs are an indispensable tool and one that allows many people most afflicted by the harshness of their internal world a foothold in a functional and positively meaningful existence, at what cost does it have? If by, in effect, severing our brain-body connection or at least quitening it, we can dampen the hyper-arousal to negative life experience then what about the connection to positive life experience? Could this effect our ability to feel subtle feelings of love, compassion and happiness? Instead of pathologising our body's signals to our brain, maybe we can befriend them. Begin to explore how we can work with the inner experience of ourselves with insight from the new advances in science and also the mind-body based traditions that have over many centuries cultivated this connection. We are in an exciting point in the history of medicine where we now are beginning to recognise the value of mind-body based interventions but yet our society is so centred around this "quick fix" paradigm or brainwashed by the sacred gold standard of evidenced based medicine that many don't embrace it. The idea that we can just take a pill and it will go away is much more convenient to us than having to spend time and effort on the arduous path to enlightened states of being. To be honest, I don't blame people. It is the society we live in and we have all committed a lot to it.
Where would I possibly find enough leather
With which to cover the surface of the earth?
But (just) leather on the soles of my shoes
Is equivalent to covering the earth with it
Likewise it is not possible for me
To restrain the external course of things
But should I restrain this mind of mine
What would be the need to restrain all else?
It has been a pleasure to spend two months as part of the project living and working with the people of Sipadol and Bhaktapur.
In retrospect my role as a healthcare practitioner here has often been more one of a sports therapist and a personal trainer than I had envisaged. What constitutes the daily grind over here would be seen more as an athletic pursuit in the UK. All through the day you see the village women in their colourful saris and flimsy flip flops bobbing up and down along the near vertical paths through the valley with a giant pile of logs in a basket hanging from their heads.
Sometimes I would ask the patients if their pain was better and would get the reply "a little bit" or often just "no". Initially this would leave me feeling a bit deflated; however, later I started asking how the farm work was going and would get responses like "Oh yes I could harvest a lot more potatoes yesterday"! At this point the penny dropped. It became clear to me that my job was about keeping these folks at the top of their game. The only difference between these hard-grafting subsistence farmers in the steep slopes of the Himalayan foothills and professional athletes is that here the physical exertion comes out of pure necessity. If the potatoes aren't harvested the family will get less food on the table. It would become an ongoing joke in the clinic as I would ask them not to carry too much weight on their heads or stop harvesting the wheat when their back starts to ache and the very next day they would come in saying "it was better before I was working and then...".
This said, they would still keep turning up in the morning and with our palms joined together in prayer position we would respectfully "namaste" and then begin our session.
From this point my focus shifted to how to make my treatments last. I started applying sports tape to take the strain off an inflamed achilles or plantar fascia when negotiating the steep trails around the village, I used herbal pastes, compresses and liniments that patients could go away with, I would have mini revelations whilst going for walks in the hills, my quads in full engagement stepping down unforgivably steep paths thinking, "So this is why everyone has knee pain here… Right! So how can I apply this knowledge in the clinic?" To have the time and space to commit to adapting my skills and techniques to the people I was working with was an invaluable opportunity and one which began to pay off in the smiles and waves I would receive around the village.
The most challenging difficulty, which is by no means unique to Nepal but was quite common, is getting people to really connect with what is going on inside their bodies during a session. Many people will have pushed through their chronic pain for so many years that they would not be able to accurately determine where they had their problems. Often they might just point vaguely at their legs, back, neck, arms, head, or all of the above and then just say "dhukksa'" or "pain" in Nepali. The danger of this I felt at times was becoming too focussed on chasing pain. I wanted to avoid the tendency to just stick needles in where it hurts (a frequent request). This could verge on becoming a sort of "cathartic pain exorcism" which I don't find to be of much use to anyone.
This is not a matter of intellect or cultural nuance but, I would suggest, is the strange and elusive nature of chronic pain and suffering itself. Its insidious and pervasive presence makes a transition at some point from being an interference in one’s life to an unwelcome part of life. This process, at the physical level, involves a lot of neural adaptation that amplifies the intensity of the signal and increases our reactivity to it, whilst at the same time obscuring the specific and the detail.
On the other side you have the emotional and mental adaptation to pain. It is not compatible with our existence and perception of self so we ignore it, block it out and often, in effect, disconnect a part of ourselves from our kinaesthetic body map. Invariably you see these mechanisms outliving their usefulness and becoming a part of people’s existence at great cost. I am interested in interrupting the cycle, opening up to other sensations or conflicting signals. In Nepal, like anywhere, people fight chronic pain every day. It is a big part of my job to bring them from fighting it to managing it. If one doesn't feel what is going on, how does one change it?
The level of commitment on behalf of the patients to attend so regularly, which was so important to the treatment outcomes, was only made possible by the very low cost service that is provided by the acupuncture relief project and its sister NGO run by the esteemed Ayurvedic doctor, Sarita Shrestha. In a society where many people, through fears of unaffordable hospital bills, are more likely to visit their pharmacy for a relatively indiscriminate handful of drugs than see a doctor, the work done here is worth so much more. It is more than just the acupuncture, massage, moxa or cupping itself. It also extends its roots far deeper into the community. It is a place where people can become informed, aware and proactive about their health as well as providing a safe and constructive place to share the burden of their pain with one another. In the aftermath of the devastating earthquake that touched so many here this is all the more important. From providing treatment and basic healthcare advice to giving shelter and basic sanitation in hours of need, I believe this grass-roots community work to be at the heart of good healthcare.
* King Curd is the name given to the deliciously sweet yoghurt that the Bhaktapur district is famous for.