Introduction

The world is becoming more complex through cumulative exposure to global crises, rapid technological change, social disconnection, economic instability, and persistent systemic inequities, all of which place sustained demands on individuals’ nervous systems (McEwen & Stellar, 1993; McEwen, 2007). Chronic exposure to these stressors contributes to cumulative stress and increased allostatic load, resulting in prolonged activation of survival states, reduced access to regulation, and compromised physical and mental health (Danese & McEwen, 2012; McEwen, 2007). This rising physiological burden manifests as anxiety, exhaustion, hypervigilance, emotional numbing, and relational withdrawal, evidencing the need for effective interventions that foster emotional regulation and well-being (McEwen & Gianaros, 2011). This paper is rooted in an ongoing dialogue between the authors who have drawn upon Polyvagal Theory (PVT) (Dana, 2018, 2021; Porges, 2011, 2017) to inform their practices and address these complexities.

PVT aligns with expressive arts therapies (EXATs), is embedded in the creative process, and assists in shifting autonomic states through deliberate behaviours and observations. While the autonomic nervous system (ANS) is often perceived as operating beyond conscious awareness, it responds to intentional actions in predictable patterns. Simple creative acts, such as gliding a paintbrush across a canvas, moving one’s body through space, or singing a tune, stimulate the vagus nerve, increasing vagal tone. This increase in vagal tone fosters grounding, self-connection, social engagement, safety, and emotional regulation (Dana, 2018, 2021; Gray, 2017; Haeyen, 2024; Porges, 2011, 2017; Richardson et al., 2024; Williamson, 2021).

In moments of heightened stress and dysregulation, engaging with the arts provides a bridge to self-regulation and a deeper connection with others (Dana, 2018; Porges, 2017). This paper uses the case of Eva to demonstrate how EXATs, grounded in PVT, can access the ventral vagal state to promote emotional resilience, regulation, and connection (Dana, 2021; Porges, 2011). Through Eva’s journey, we aim to illustrate the vital role EXATs play in supporting individuals navigating the complexities of modern life and cultivating a sense of safety and balance.

Literature review

Polyvagal Theory in practice

PVT proposes a hierarchical organisation of the ANS, shaped by evolution, that continuously evaluates safety and threat through neuroception and shifts physiological states accordingly (Porges, 1995, 2011, 2017). Rather than having a simple on-off stress response, the nervous system moves through adaptive state changes that support survival, connection, and self-regulation (Dana, 2018; Porges, 2011). This framework reframes behaviour, emotion, and relational patterns as state-dependent autonomic responses rather than conscious choices alone (Dana, 2021; Porges, 2017).

Porges (2022) describes PVT as a “science of safety”, emphasising that physiological safety is foundational for health, learning, creativity, and social connection. In this view, the nervous system’s core task is not only to avoid danger, but to detect and prioritise cues of safety that support trust, co-regulation, and relational engagement, positioning safety as an active biological process rather than the passive absence of threat.

The ANS governs physiological processes outside conscious awareness, such as heart rate and breathing, and continually organises toward protection and balance (Porges, 1995, 2011). Within PVT, shifts between autonomic states are shaped by neuroception, co-regulation, and the social engagement system (Dana, 2018, 2021; Porges, 2017; van der Kolk, 2014). Bringing these concepts into the therapeutic space can help clinicians frame symptoms as state-dependent responses and strengthen conditions for safety and engagement.

From a polyvagal lens, safety is not primarily a cognitive belief, but a lived neurophysiological condition that emerges when the nervous system detects sufficient cues of connection, predictability, and care. As neuroception registers “no threat”, the body can gradually shift toward ventral vagal regulation, allowing social engagement, curiosity, creativity, and more flexible emotional regulation to unfold (Dana, 2018, 2021; Porges, 2011, 2017). In this sense, safety is not defined by the absence of danger alone, but is experienced as a felt sense of calm, connection, and embodied presence. This experience of safety is conveyed and sustained through the social engagement system – facial expression, vocal prosody, eye contact, gesture, and rhythm, which can soften defensive states and support a physiology of connection that enables healing and the safe exploration of emotionally challenging material (Dana, 2018; Porges, 2017, 2022).

Furthermore, PVT emphasises vagal pathways in organising autonomic states, with the vagus nerve extending from the brainstem into the face, heart, and viscera. The ANS responds to internal and external stimuli in three predictable patterns: (1) ventral vagal state, characterised by regulation and social engagement; (2) sympathetic mobilisation, associated with fight or flight responses; and (3) dorsal vagal immobilisation, associated with collapse or shutdown (Porges, 1995, 2011). Clinically, treatment often aims to increase access to ventral vagal regulation while expanding the capacity to move flexibly among states. When faced with a threat or fear of death, the ventral vagal complex (VVC) downshifts and sympathetic mobilisation may result in increased heart rate, oxygen intake, muscle tension, digestive inhibition, increased blood flow to the extremities, and pupil dilation (Porges, 1995, 2011).

The sympathetic nervous system’s fight, flight, freeze, and appease responses are adaptive survival mechanisms rather than pathological reactions, reflecting the nervous system’s biologically organised attempt to preserve life under threat (Levine, 2010; van der Kolk, 2014). From a trauma-informed perspective, psychoeducation that frames these autonomic responses as protective adaptations can reduce shame and foster self-compassion by reframing trauma symptoms as survival strategies rather than personal failures (Dana, 2018; Levine, 2010). Such understanding supports a more integrated and compassionate relationship with clients’ physiological trauma responses.

There are also instances far outside the window of tolerance (Siegel, 1999), in which sympathetic mobilisation is insufficient and dorsal vagal shutdown predominates, which can manifest in reduced heart rate and oxygen intake, fainting, dissociation, and disengagement (Porges, 1995, 2011). Persistent sympathetic activation can contribute to compromised immune functioning, gastrointestinal syndromes, fibromyalgia, inability to relax, anxiety disorders, and chronic hyperarousal; it may also precipitate a shift into dorsal vagal shutdown. Persistent dorsal vagal activation may contribute to disconnection from self and others, depressive disorders, flat affect, chronic fatigue syndrome, and emotional numbness.

A central polyvagal concept is that intentional engagement of the central nervous system can influence autonomic regulation, bridging disconnection toward healing (Dana, 2018). In this paper, multisensory EXATs are conceptualised as a safe, socially engaged pathway for intentionally supporting such shifts toward regulation.

Expressive arts therapies and the Polyvagal Theory in practice

Malchiodi (2020, p.136) has found that “EXATs emphasise gesture, intonation, rhythm, visual, tactile, and proprioceptive experiences” and “have the potential to help individuals both sense safety and feel more secure with others and their environments”. Thus, autonomic stimulation and awareness can occur by using art, music, writing, play, drama, or dance. The creative process is proposed to shift vagal tone through rhythmic, bilateral, and multisensory stimulation that synchronises breath, movement, vocalisation, and sensory input, thereby activating the ventral vagal pathways associated with social engagement and regulation (Dana, 2018; Malchiodi, 2020; Porges, 2011, 2017). These patterned sensory-motor experiences facilitate bottom-up nervous-system regulation by integrating brainstem, limbic, and cortical networks, reducing threat responses and increasing parasympathetic flexibility (Kossak, 2015; van der Kolk, 2014). Over time, repeated creative engagement strengthens neural pathways that support emotional regulation, interoception, and relational safety, contributing to sustained increases in vagal tone (Dana, 2021; Gray, 2017). Furthermore, breath work, chanting, humming, singing, drumming, creating music, and dancing can all increase vagal tone, which improves physical and mental health (Gray, 2017; Haeyen, 2024; Malchiodi, 2020; Richardson et al., 2024; van der Kolk, 2014; Williamson, 2021).

From a polyvagal lens, repetition, consistency, pace, and length of the therapeutic intervention function together as a primary regulator of the nervous system by creating predictability and cues of safety that support ventral vagal access (Dana, 2018, 2021; Porges, 2017). For instance, slow, gentle, and repetitive movements in art-making (Hedlund-Nelson, 2020) allow the nervous system to remain within the window of tolerance, while gradually increasing capacity for regulation through embodied rhythm and bilateral engagement (Siegel, 1999). Elbrecht (2018), Malchiodi (2020), and Tripp (2007, 2016, 2022) similarly describe repetition as a core therapeutic mechanism that fosters neural integration, stabilises affect, and supports autonomic regulation through patterned sensory-motor experience.

The aforementioned literature clarifies how the EXATs inherently allow for social engagement to occur in connection to safety, which is needed to access creativity (Diamond & Lanskey, 2024; Malchiodi, 2020). They are multisensory, engage the kinaesthetic, have rhythm and repetition, increase access to regulation, may increase activation to access healing, and create a safe connection to the self, body, and others. The EXATs can allow for a safe exploration of memories connected to sympathetic and dorsal states, and bridge connection to the ventral vagal. Furthermore, the EXATs can enhance attunement to self, other, and art product, as a means to bring individuals together and allow for empathic connection (Dana, 2018; Eckhaus & Hedlund-Nelson, 2024; Kossak, 2015). Specific EXAT modalities and their connection to the polyvagal states are outlined below.

Dance/movement therapy

Dance is an active process that includes reciprocal movements that allow for connection to regulation and feelings of safety (Devereaux, 2017). Specific movement sequences of the body are in direct connection to the autonomic states. For instance, movements that are circular in fashion are connected to the ventral vagal state, fast or sharp movements are connected with the sympathetic state, and slow and strenuous movements are connected with the dorsal vagal state. Activating mirror neurons (Berrol, 2006) through the mirroring of movements can engage automatic resonance and kinesthetic empathy (Chace, 1975), increase attunement, and allow a clinician to more fully embody another and understand movement sequences. Simple changes in posture can increase vagal tone, and using props such as a physio ball or rocking chair can actively engage the body, stimulate the vagus nerve, and increase access to regulation (Dana, 2018; Gray, 2017; Williamson, 2021).

Art therapy

In art therapy, materials function as sensory experiences that interact with an individual’s nervous-system regulation capacity and window of tolerance (Siegel, 1999, 2012). Individuals with wider windows may experience tactile or fluid materials such as paint, clay, or wet collage as engaging and regulating, while those with narrower windows of tolerance, particularly trauma survivors, may experience these materials as overwhelming due to sensory intensity, unpredictability, or reduced control. More structured materials such as coloured pencils, markers, geometric collage, or guided drawing may support stabilisation and titrated engagement. This variability reflects longstanding art therapy understanding that media properties influence emotional regulation, symbolic expression, and perceived safety (Hinz, 2009; Moon, 2010). Art therapy scholars have increasingly integrated polyvagal-informed and somatic frameworks to explain how material properties, therapist attunement, and relational safety contribute to autonomic regulation during the creative process (King, 2016; Malchiodi, 2020), underscoring the importance of intentional material selection and pacing within trauma-informed art therapy practice.

Music therapy

“The polyvagal theory focuses on the modulation of frequencies that define the intonations associated with both vocal music and acoustic features of vocalizations that convey information about content and intent” (Devereaux, 2017, p.37). Music provides a calming effect that induces a felt sense of safety. Misto (2016) has used breath, singing, musical scales and rhythm to connect with the ventral vagal and induce feelings of calmness. For instance, emotional stuck points or barriers were transformed into energy that increased vagal tone, connection to creativity, and regulation. Misto noted that the use of song allows for interpersonal co-regulation through engagement of the voice, facial muscles, and tones picked up by ear.

Play therapy

Play is vital to development and can continue to shape the brain into adulthood. Play is a safe way to increase vagal tone and access healing. It allows one to pendulate between activating states and calmer states. It engages both the sympathetic and ventral vagal states (Porges, 2009), allowing individuals to engage with regulation more readily in stressful situations. A polyvagal play experience can be created through the use of attunement, body and movement, objects, social engagement, imagination, storytelling, and creativity (Dana, 2018; Richardson et. al., 2024). Moreover, play nourishes a sense of safety when feeling levels of activation and fosters regulating connection (Kestly, 2016). Thus, the various modalities of the EXATs can increase access to regulation and safety; however, a crucial element of their facilitation is the presence of the clinician.

EXAT clinician’s presence

The presence of the expressive art therapist during the therapeutic session is essential and can increase safety, co-regulation, and access to social engagement. The therapist can activate the social-engagement system through tone of voice, modulation of eye contact, or facial expressions. Environmental shifts such as pleasing objects and images to view, lamps or natural lighting, soft items to touch, and quiet music can aid in connection to social engagement, regulation, and the ventral vagal (Erkkilä & Samaritter, 2023; Geller & Greenberg, 2023; Hass-Cohen, 2016).

In summation, human beings are wired for connection and protection; it is an instinctual, reflexive need that lies deep in the viscera of the soul (Devereaux, 2017). Porges (2011, p.2) had a “vision that monitoring physiological state would be a helpful guide to the therapist during the clinical interaction” and aid in connecting to others (PESI Publishing & Media, 2013). As illustrated, the EXATs naturally connect with the polyvagal states and can weave in and out of levels of activation safely to connect with balance, healing, and regulation. Consistent with Levine’s foundational work on pendulation and somatic processing, healing occurs through the nervous system’s capacity to rhythmically move between states of activation and settling, rather than remaining in a fixed state of regulation or safety (Levine, 1997, 2010, 2015). From both a polyvagal and a somatic perspective, therapeutic change involves cultivating awareness of internal states and gently training the body to tolerate and move through sympathetic, dorsal, and ventral vagal patterns within the window of tolerance (Levine, 1997, 2010; Siegel, 1999). This oscillation between arousal and restoration builds nervous-system flexibility, expands the window of tolerance, and supports trauma resolution by discharging survival energy and restoring self-regulation (Levine, 1997, 2010, 2015).

To further illustrate the use of the EXATs through the lens of PVT in practice, Eva’s case study is outlined below. All identifying information in the case has been altered to maintain confidentiality and anonymity.

EXAT polyvagal case-study: Eva

The case study described here took place over approximately 18 months and consisted of weekly 50-minute individual psychotherapy sessions. The treatment integrated EXATs within a relational, body-oriented psychotherapeutic framework informed by PVT. The case vignette highlights selected moments from the therapeutic process that illustrate shifts in autonomic regulation through embodied and creative interventions. Written informed consent for the incorporation of recreations of the patient’s artwork and the sharing of her therapeutic process in this publication was obtained. All artworks were recreated by the author to protect anonymity.

“I want to work on my lack of confidence and low self-esteem,” said Eva, a woman in her 30s, at the beginning of our first session. Eva was a talented, bright, Caucasian woman from a middle-class family. “You know, two brothers, good parents… normal people.” While well-liked by her peers, she harboured a constant feeling of loneliness and not fitting in. Eva confessed to being easily triggered in loud or “too vibrant” social interactions and frequently feeling scrutinised, resulting in her withdrawal or silence. All the while, internally, she was in turmoil with fear and anxiety.

As our connection deepened, Eva began to reveal more about herself. She shared that she avoided confrontation, feared being abandoned by friends if she asserted herself, and felt ashamed of her own needs. Several months into our sessions, Eva arrived flustered after a bitter fight with her father over an errand. “He wanted me to do something for him, and for the first time, I said I had other plans that I couldn’t cancel.” It was a significant moment as Eva asserted herself, rather than simply trying to please others. After the argument, her father refused to speak with her. I observed the tremor in her voice, a familiar sign of anxiety. Her fists were clenched. We transitioned to bodywork, incorporating grounding and breath exercises, initiating with diaphragmatic breathing to promote a parasympathetic response. Slowly adding slight humming and gentle motion, Eva’s body gradually became more present, and the shivering lessened. We proceeded by gently moving the extremities to release muscle tension and eventually transitioned to a mirroring of movements. At that point, Eva’s breath changed, and she softly smiled: “It felt like I was shaking something off, like I could finally breathe again.” Psychoeducation regarding PVT was woven into the process in an experiential and relational manner to name states of safety, activation, and regulation as they emerged in the body, which led us to make sense of what had transpired in connection to the intensity of her emotions.

Six months into treatment, Eva demonstrated progress in recognising when she was triggered and dysregulated. Although she could now anchor herself during moments of anxiety, she continued to suffer from somatic symptoms such as lack of sleep and poor digestion. “It’s like I can’t eat anything before and after an exam, and even afterward everything hurts.” During one session, Eva arrived anxious due to an approaching final exam. “I can’t study at all. Nothing works. I sit in front of my computer and then I see two hours passed and I did absolutely nothing; I don’t even know what I was thinking about.” Through grounding and breathing exercises, Eva recalled how she used to sit alone in her room during high-school exams. At that time, two of her close friends severed ties with her without explanation. Eva was deeply hurt; she struggled to concentrate, sometimes crying herself to sleep while maintaining a brave face in front of her parents, who expected her to excel. At this juncture, I suggested a live portrayal exercise (Medley, 2021), wherein Eva embodied both her present self and her teenage self while standing in two different places in the room. Thinking of the teenager she was while sitting in her room, the posture of her head and body sensations, Eva’s gestures changed as she embodied her teenage self. Tears ran down her face while telling the story of heartbreak and loneliness. As she physically moved back and forth between her adult self and teenage self, Eva’s posture and emotions shifted, ultimately leading to a sense of liberation and a fresh perspective on her past and present experiences. Eva texted me later that week, stating, “I’m still impacted by our last session. I was finally able to study. It’s weird how it was suddenly easy.”

As our therapeutic process deepened, Eva became more in touch with her emotions, describing triggering states akin to feeling like being pulled underwater. At that time, Eva reported a slight improvement in her sleep and that she was finding more enjoyment in social settings. During a subsequent session, Eva arrived uncharacteristically agitated, loudly recounting a recent fight with her boyfriend. She oscillated between feelings of fear and assertiveness, recognising her right to hold her own opinions.

After some grounding exercises, incorporating art into the session provided Eva with a creative outlet for expression. Eva engaged in bilateral art-making using pastels, crossing two lines with different colors and textures, which facilitated a somatosensory integration process, helping her to process dysregulated emotional states.