Polyvagal Neurobollocks Q&A: The End of the Yellow Brick Road

Polyvagal drama finale. I will make it short and sweat. Pinky promise.

OK, I still owe you that Q&A. Before I cut to the chase, a few opening statements, as to my motivation, domain of expertise and what is the aim here.

I shall try to keep the polemic tone to the minimum and turn the information and epistemic benefit to the maximum. I want to reiterate that I don’t like critiquing for the sake of critiquing. My mission, as I see it, has always been and remains very simple: to do my bit in trying to bring neuroscience into psychotherapy and to do that well. My gut feeling is that the potential for the synergy is huge, and mostly untapped for now. But for this to happen, we need to get hold of some pseudoneuroscience to start with. Yet, this space, I have come to realise, is populated, and to a shocking degree, with pseudoscience and neurobollocks.

My way to say it is that neurobollocks is hogging the lane. Then, after my previous post, a fairy came to me and told me that there is a technical expression for this: opportunity cost. Opportunity cost is the cost of missing out on other options once we are set with one specific option. If that option is a scientific dead-end, it only stands to reason the opportunity cost is only going to be higher.

Now, let me get one thing straight first: not all therapy needs to be supported by neuroscience (thanks god for that). But if an approach claims to be rooted in neuroscience or physiology, it is not enough simply to dazzle us with a profuse use of neuro or physio babble. It needs to have something to show for - in the form of active neuroscientists and the body of research supporting it. As I show in my previous piece, that just is not the case with PVT.

Whether theories such as the polyvagal theory should still be recommended and used despite the fact that they are pseudoscientific just because some might be finding them clinically useful is not for me to say or decide.

I do however believe that the clinicians should first receive accurate information about it. This includes being made fully aware of the fact that these theories have no scientific backing and are as such de facto pseudoscience. And then, they can decide for themselves whether they want to keep using it. I should add that to say that this is not how things play out at present, would be an understatement.

For more of the context of what polyvagal theory is and the different ways it was debunked over time, please refer to my post Polyvagal Neurobollocks. For general intro to neurobollocks see here.

Now, I hopefully have set the stage with these opening statements, I will keep it short and sweet.

Over time, I have received a number of questions regarding polyvagal theory (this theory has an extraordinary power of cathexis in psychotherapy community). I value all interactions with my fellow therapists and I know all questions come from a place of genuine curiosity. I was able to compile them into following categories:

1. Why doesn’t all the evidence around the sympathetic and parasympathetic nervous system not provide the evidence for polyvagal theory?

2. If there is no evidence for polyvagal theory, why are we interested in the vagus nerve stimulation and regulation?

3. So what if the science is bogus, not all therapy needs to be supported by neuroscience.

4. The science of polyvagal theory is still under scrutiny, so I am keeping an open mind.

5. I know polyvagal theory is controversial but…

6. If so many clinicians find it useful, there’s got to be something to it, right?

7. I know it is not true, but it is a useful metaphor (the metaphor card).

Let’s dig in.

Isn’t the Evidence Around the Sympathetic And Parasympathetic Systems Evidence For Polyvagal Theory?

Polyvagal theory explicitly challenges the sympathetic/parasympathetic ANS set up, proposing an alternative system (with three autonomic states). Therefore, any evidence concerning the autonomic nervous system, that is the sympathetic and parasympathetic systems, and mental health pertains to the use of the ANS in psychotherapy, not to polyvagal theory.

There exists today a growing body of evidence on the ways dynamics of parasympathetic and sympathetic activation both affect and serve as indicators of aspects of mental well-being, resilience and emotions in general ( for example see here, here, here , here and here). This evidence does not align with nor support polyvagal claims and, in many respects, directly contradicts them.

As a reminder, the main claims of PVT from psychotherapy perspective are the existence of three autonomic states defined on the basis of vagus anatomy, strict evolutionary and behavioural hierarchy between those states and that humans sociality/happiness/contentment are only compatible in one of those states, which is all neurobollocks (see my previous piece).

Developing the ANS literacy, based on actual science, is an extremely useful instrument in therapy. I would recommend it to everyone, especially those who work with presentations such as anxiety, stress, burnout and trauma. (I am preparing a separate post on the use of the ANS in psychotherapy where I will provide an extensive list of relevant references.)

If there is no evidence for polyvagal theory, why are we interested in the vagus nerve stimulation and regulation?

Like in the case of ANS, the polyvagal theory does not own a monopoly or exclusive privilege to include the vagus nerve in the conversation about mental health nor it the mention of the vagus nerve implies that people are referring back to this theory.

In fact, some of the scientists who were the first to warn about the lack of robust scientific evidence and credibility behind polyvagal theory specialise in the physiology of the vagus nerve. This is because they understand the intricacies of the more technical claims made by the polyvagal theory, and it is precisely because they understand them that they recognise it as bollocks.

The vagus nerve and its role, on the other hand, are currently in the centre of thriving research efforts to better define its role in interoception and wellbeing and the ways it can be used to improve it (some of it might go against our intuition though, for some popular accounts see here, here and link with emotions see here).

It is, however, unclear whether manual manipulation of the vagus nerve can produce any such effects, as clinical trials have focused on electronic stimulation of the vagus nerve (to my knowledge?).

So what if the science is bogus, not all therapy needs to be supported by neuroscience.

Does all therapy need to be supported by neuroscience and have neuroscience evidence? Of course not (thankfully).

As I say in the intro, if an approach claims to be supported by neuroscience however, then it only stands to reason to require existence of bona fide science behind it. That means that it and the body of work that includes active neuroscientists supporting it. If that is not the case, then the neuroscience claim to fame cannot be made (otherwise it is deceptive advertising).

So to summarise, it is OK for therapy to have nothing to do with scientific reality but then it cannot claim to be supported by neuroscience. I talk about this more here and here.

The science of polyvagal theory is still under scrutiny, so I am keeping an open mind.

The jury is NOT still out on polyvagal theory. Polyvagal theory is a thing only in parallel universe of psychotherapy and wellness speak, not in science. I think as therapists, we really need to wake up to that reality.

The tenets of polyvagal theory have been debunked time and time again by leading scientists from respective fields (see here for neuroanatomy, here for evolutionary, here for claims about human sociality, here for physiology).

Furthermore, there is no active neuroscientists or physiologist who supports it in any way, shape or form.

Let me reiterate some key common-sense elements that make this theory incompatible with the scientific consensus today:

1. Explains complex human emotions, reactions and behaviours by automatic reactions from the brainstem and midbrain (the autonomic states). This types of oversimplifications is a hallmark of neurobollocks.

2. This theory leans extensively on the idea of ‘ladder of nature’: the outdated idea that humans are the pinnacle of evolution.

3. Makes simplistic and inaccurate claims about the nature of human sociality (we are only social when we are in one autonomic state)

4. Promotes ideas of nervous system mystique (one remains ‘stuck’ in one autonomic state akin to a nervous system ‘curse’)

Additionally, how scientific theory ‘fights back’ when challenged? It provides more evidence. Some notable examples of this are attachment theory or the theory of constructed emotions. When challenged they did what bona fide science does: provide a wealth of evidence. More extraordinary the claim, more extraordinary evidence needs to be.

In the case of polyvagal theory none of that has happened. Despite considerable amount of time (30 years) and huge resources generated, we are still waiting for that evidence.

I know polyvagal theory is controversial but…

This depends on your definition of controversial. However, this specific argument is employed to give the benefit of the doubt to PVT. Benefit of the doubt principle is great, but only when there is doubt.

To me, to say that something is controversial means that there is a dispute among scientists as to the validity of a certain theory or hypothesis, and therefore the scientific consensus cannot be reached. That, to me, constitutes the definition of controversy. As explained in the answer to the previous question, there is no divergent opinions when it comes to polyvagal theory in scientific community. I think they are pretty unanimous to say that it is bollocks.

If so many clinicians find it useful, there’s got to be something to it, right?

Appeal is NOT the proof of anything. If I received £1 for everything that people deeply felt and believed to be true throughout history, only for the tide to turn later and a new belief to take its place, I would quickly become a millionaire.

Yet, I frequently hear the argument that the polyvagal theory must be tapping into some deep clinical truth, otherwise it would not be so resonant with clinicians. It is a compelling argument, but really shaky in its roots.

To buttress my case further, let me take you to a little trip down the therapy memory lane.

Do you remember the doctrine of the therapist as a “blank screen”? It is a traditional psychodynamic approach in which the therapist reveals nothing about themselves, maintains a poker face, avoids reacting emotionally or even offering a friendly smile, and withholds empathy, warmth or comfort, or any indication that they are in fact human, in order to create what is supposedly a neutral space for the client to project their feelings and experiences onto the therapist. Just writing about it gives me the creeps. For many decades it was both thought and taught to be the only way to be a good therapist. In other words, therapists were essentially encouraged to go out of their way to avoid forming a therapeutic relationship. Today we know that the therapeutic relationship accounts for a considerable part of therapeutic effectiveness.

Second example. Did you know that the attachment theory used to be the pariah of developmental theories? At the time of its inception, the dominant theory was that of Object relations which had a very different view on the importance of the emotional and physical proximity between infants and caregivers emphasising the ‘internal fantasies’ of the infant rather than the dyadic emotional and physical interdependence between the child and the caregiver. But the tide has changed. A good account of how John Bowlby was shunned by the object relations establishment for his ‘shocking’ theory that the relationship quality really counts, see here.

How about Freud’s the famous theory of Oedipus complex? When faced with a growing number of accounts of sexual abuse and trespassing by parental figures coming from his patients that he was seeing for ‘neuroses’ or other issues they were experiencing, Freud concluded that the children couldn’t have been telling the truth but instead were ‘fantasising’ about having these sexual relationships with their caregivers - giving rise to the famous 'Oedipus complex’ (king Oedipus falls in love with his mother). Therapists bought into it and it became the dominant therapeutic framework to understand mental health disorders (and accounts of childhood sexual trauma and abuse) for many, many decades - using elaborate intellectualisation to dismiss the harrowing accounts of abuse and downgrade them to the status of “repressed fantasies”. How the tide has indeed turned. Thankfully. Big time. For an in depth account see here.

I think I have made my case: that something enjoys approval of clinicians or becomes a dominant narrative at a given time tells us nothing about whether it reflects a deep clinical truth. All it means is that these ideas, through a mixture of factors including the zeitgeist and to a significant degree, social engineering and the creation of a consensus of opinion that often has little to do with science and is frequently driven by charismatic figures, have managed to spread and take hold. I should add that science is by no means immune to this process, although it is somewhat better safeguarded against it through layers of empirical and epistemic accountability.

After this historical detour back to the initial question: the fact that people embrace polyvagal theory today and that they feel it confirms their clinical intuition, means strictly nothing as to its validity. As I showcased above, history gives us a clear lesson on that.

I know it is not true, but it is a useful metaphor (The metaphor card).

“I know it is not true, but it is an useful metaphor”. This is the argument I hear from clinicians time and time again. At this moment, I would like to unpack the idea of a metaphor. So what is a metaphor?

metaphor noun

An expression that describes a person, object, or situation by referring to something else with similar characteristics, typically to create a vivid image or comparison.

Here are some popular metaphors:

“Life is a journey” - here the life is compared to the act of traveling

“Ideas taking roots” - here we are comparing spreading of an idea with a process of growth of a tree or a plant

To be sure, psychotherapy has an illustrious history of using metaphors beautifully. Let’s look into some of them:

The image of an iceberg for the conscious and the unconscious mind, from Freudian psychology. Here the physical object of an iceberg and its position as it floats in the water is used to describe the analogous structure of the human psyche, according to Freud.

The inner child. This is another powerful metaphor used in psychotherapy - of course it is not a literal child in us, but rather a part of us that is an earlier and sometimes vulnerable self.

But when it comes to polyvagal theory, I don’t see where is the metaphor (the metaphoric image). In fact, the polyvagal theory is the opposite of metaphoric, it is actually quite literal (if erroneous) description of the anatomy and evolutionary history of the vagus nerve and the supposed effects on mental states, mental life and life in general, that ensue from it. Therefore, I cannot accept the metaphor: PVT is by its nature not metaphorical.

The Bottom Line

With this I am wrapping this season of polyvagal drama. I suppose the only remaining question is why this thing has become so popular?

I think the answer might actually be pretty simple and can be compressed in four elements: focus on ANS, dangling neuroscience authority (seductive allure of neuroscience explanations), seductive allure of oversimplified explanations, filling the gap that was there for the taking.

Let me expand.

First, and to give credit where credit is due, the polyvagal theory places attention on the autonomic nervous system and the bodily markers of mental health, which have been conspicuously absent from the dominant psychotherapy theories of the past. Although it does so on the basis of incorrect premises, the simple fact that it brings focus to the body and to autonomic states explains, in my view, many of its perceived benefits, even if those benefits don’t come from the polyvagal theory itself (it is kind of a baby and bathwater situation).

Second, it offers a simple, albeit inaccurate and misleading, solution to the complex questions of human emotions, mental states and sociality. It trades on the seductive allure of simplicity, and it draws on the intuitively appealing idea of a ‘ladder of nature’ that places human characteristics at the pinnacle of evolution of life.

Third, it dangles the neuroscience authority that it does not have into our face, and that is something we almost always fall for (seductive allure of neuroscience explanations).

Finally, there is no good alternative - and please loop back here to the idea of opportunity cost and my previous piece where I say that theories such as the PVT are essentially hogging the lane for other approaches to emerge.

Of course, there might be other reasons at play, belonging to the domains of power, politics, allegiance effect and the ways in which consensus, status and prestige are created within what is now increasingly referred to as an ‘industrial complex’. However, I shall leave that chapter to be written by someone who is more fluent and competent in performing that specific level of analysis.

I will simply say that, after careful consideration, I cannot see how this speculative theory is compatible with the scientific consensus today. I can’t help but wonder what other clinicians would decide if they were given a transparent information about the (lack of) science behind polyvagal theory?

For my part, I know I can’t endorse what essentially amounts to pseudoscience to be used in the name of neuroscience and psychotherapy integration. For me it is the end of that yellow brick road.

I am hoping that I have answered some of your questions. Sorry I can’t drink Kool-Aid, I really wish I could. As always, thank you for reading 🙏.

In the next Neuroscience&Psychotherapy Lab 🧫 piece, I will share some ideas on what we CAN do when we use the ANS in therapy, when this is useful and some hands-on tips I use in my therapy work.