Healthcare specific adjustments - personal practice

Polyvagal theory, introduced by Stephen Porges, explains how our autonomic nervous system responds to perceived safety or threat. When applied to PDA, this perspective can help health and social care providers recognise and respond to anxiety cues more effectively, providing the right support at the right time.

1. Ventral Vagal (Green Zone): This ‘safe and social’ state is where people can engage meaningfully, reflect on information, and cooperate in care. For PDAers, achieving this state often requires a calm environment, empathetic communication, and minimal pressure.

2. Sympathetic Activation (Fight or Flight): Under threat, energy surges-leading to agitation or avoidance. A small request can feel monumental. If a PDAer shows distress or irritability, it may indicate sympathetic activation, and professionals should adjust demands, slow the pace, and offer reassurance.

3. Dorsal Vagal (Freeze, Fawn, or Shutdown): When stress is overwhelming, some PDAers may ‘shut down,’ become non-communicative, or appear passive. They may seem indifferent, but in fact are too anxious to engage. Here, reducing demands and offering choices without pressure is critical.

This aligns with Dan Siegel’s Window of Tolerance model, where an individual’s capacity for coping shrinks when anxiety spikes. Polyvagal theory shows how, moment by moment, the nervous system scans for safety or threat-affecting cooperation, communication, and willingness to attempt tasks.

Things that might be helpful in your daily practice:

• Observing autonomic states:
  Recognising signs of fight/flight (restlessness, tension, agitation) or freeze (minimal response, seeming ‘shutdown’). Tailoring interventions-reducing pressure, pausing demanding tasks, offering an exit strategy.
• Co-regulation:
  Using a warm tone of voice, relaxed body language, and genuine empathy. An anxious professional often escalates a PDAer’s anxiety, while a calm manner can help restore safety.
• Incremental Demands:
  Offering small steps or breaking procedures into manageable chunks. This prevents rapid shifts into fight/flight/freeze.
• Environment and Relationships:
  A supportive environment, combined with validating relationships, can expand a PDAer’s ‘window of tolerance.’

This will give you the information you need to judge when you should be backing off and when reintroducing tasks is appropriate.

It is natural to assume people want to be “healthy” or “safe,” yet these concepts may not motivate someone with a PDA profile. Instead, consider motivations tied to a person’s special interests, immediate goals, or personal values by:

• Asking about interests and goals:
  A PDAer might be more invested in building the strength to climb stairs for a favourite view or developing stamina for a specific activity than in meeting conventional health targets.
• Avoiding generic health language:
  Messaging like “This will keep you safe” or “You need this to be well” can sound hollow if they don’t align with the person’s current priorities.
• Linking interventions to tangible outcomes:
  If treatment enables them to practise their special interest or pursue a particular objective (e.g., running a marathon, painting, or exploring the outdoors), highlight that connection.
• Collaborating on motivation:
  Explore ways to incorporate the individual’s passions into appointments or care routines. For instance, discussing how improved mobility might allow more time for a beloved hobby can be more compelling than a vague mention of “better health.”

By aligning care with personally relevant goals, professionals reduce the sense of imposed demands and create a shared purpose that the PDAer can genuinely support. This shift from abstract health imperatives to tangible, interest-based motivations often help lower anxiety and fosters more cooperative engagement.

Many PDAers justifiably fear interactions with professionals because of past negative experiences or the inherent demands placed upon them-such as enduring painful treatments or fearing life-altering decisions made by others. This anxiety is not necessarily irrational; it may be entirely logical when viewed from their perspective.

For phobias or fears considered irrational, a structured exposure approach is considered the standard of care and can sometimes reduce anxiety-provided there is genuine consent, a gradual plan, and a motivation to overcome the fear. However, PDAers in healthcare or social care contexts often experience anxiety grounded in real potential distress: uncomfortable procedures, invasive tests, or perceived threats to autonomy – this means exposure is unlikely to be effective.

If professionals push exposure without addressing the individual’s actual safety concerns-especially when they are already outside their ‘window of tolerance’-this can escalate fear and even cause trauma. More affective approaches might be:

• Acknowledging the reality of the fear: Validating that healthcare procedures can be painful or that social services have authority. Recognizing the legitimacy of worry can defuse tension.
• Offering transparency: Clearly explaining what might happen during treatments or meetings and allow plenty of time for processing.
• Collaborative planning: Involving the PDA individual (and their family, if relevant) in deciding how to approach appointments. This can include scheduling at quieter times or splitting longer procedures into multiple shorter visits.
• Use alternatives to direct exposure: Instead of focusing on ‘fixing’ the fear, professionals can reduce triggers-for example, by providing less intrusive spaces to wait in or use coping tools (e.g., headphones, fidget items).
• Offering choice where possible: Reinforce the idea that they have some measure of control. This could be choosing how to enter a building or where to sit. Such small but significant decisions can prevent meltdown or withdrawal.

In essence, while exposure-based strategies often target ‘unfounded’ phobias, fear of healthcare or social care interventions may be perfectly rational for PDAers. By reframing the goal from “fixing the fear” to “respecting legitimate anxieties and accommodating them,” professionals can create safer, more effective environments for assessment, treatment, and ongoing support.

PDAers may find structured treatment regimens, strict timetables, or lengthy consent processes especially demanding. Their avoidance often stems from anxiety over perceived loss of control or an inability to process choices quickly. Professionals can better support them by:

• Explaining why demands exist:
  For time-sensitive interventions-like fast-progressing cancers or urgent social care measures-clarify that this urgency isn’t arbitrary. Emphasize the clinical or legal rationale, citing the ‘higher power’ driving the timeline. For example, “I know you’d prefer more time to decide between chemotherapy and radiotherapy. However, if we wait beyond next Monday, the tumour may grow beyond the stage where these options are as effective.”
• Providing options and evidence:
  Even if there are narrow timeframes, present any viable alternatives and associated evidence. For instance, “You can choose between an in-home care assistant starting tomorrow or waiting until next week-but here’s the risk factor increase if we delay.” This level of transparency can lessen anxiety by clarifying that the constraints are grounded in external facts, not arbitrary demands.
• Offering a shared decision approach:
  Where possible, co-create a plan within the available window. Rather than imposing, invite them to discuss how to make the process feel safer or more manageable-e.g., scheduling partial sessions, enlisting a trusted advocate, or enabling short breaks.
• Acknowledge the loss of flexibility:
  Express empathy for their wish to reflect on big decisions. Recognize that not being able to offer extended thinking time can be distressing. Explaining constraints candidly- “I wish we had more leeway, but we must prioritize your immediate safety due to the legislation around significant harm”-helps them grasp the logic behind swift action.
• Validate anxiety:
  Affirm that fear around rushed processes are understandable. By showing you respect their perspective, you can reinforce that the external urgency arises from clinical or legal frameworks, not from a desire to override their autonomy.

Even limited choices, clearly explained, reduce feelings of being ‘forced’ into compliance and help sustain trust-particularly when lifesaving or legally mandated interventions are at stake.

Research in paediatric wards found that when nurses and clinicians use coregulation techniques-speaking softly, reflecting a child’s feelings, using comforting touch-children show reduced procedural anxiety and improved cooperation (Tiedeman, M. E., & Clatworthy, S. 1990).

Co-regulation involves matching and supporting a PDAer’s emotional state, so they feel safe enough to engage. It goes beyond simply providing information, requiring the practitioner to tune in, respond empathically, and help the individual return to their ‘window of tolerance.’ This is especially relevant during potentially stressful healthcare encounters.

Empathic, attuned communication from staff has been linked to better patient satisfaction, greater trust, and improved adherence to treatment. In social care contexts (e.g., disability teams, safeguarding, mental health support), workers often co-regulate by validating distress, allowing time for emotional processing, and gently guiding service users through complex decisions or transitions. (Menschner, C., & Maul, A. 2016).

Practical ways to implement this in your work might include:

1. Commenting on observed cues: Noticing small signs of anxiety or restlessness (e.g., fidgeting, pacing). A neutral statement like, “I see you might be feeling unsettled-would it help to take a moment?” acknowledges their discomfort without imposing a demand.

2.Encouraging stimming: If a PDAer uses hand flapping, rocking, or another form of stimming for self-regulation, reassure them that it’s acceptable. Clinicians or social workers can also model relaxed posture or gentle movements to signal calm.

3. Sharing interests: Actively asking about the individual’s hobbies or passions before or during appointments. Take time to learn enough about these topics to engage authentically-this can lower anxiety and shift the dynamic away from “formal authority” toward mutual respect.

4. Modelling calm and curiosity: Slowing your speech, breathing evenly, and showing genuine curiosity in their perspective. Overly formal or rushed demeanours can elevate stress for a PDAer. A calm, compassionate presence signals that they have space to express themselves.

5. Offering verbal reassurance: Using soothing tones: “It is okay to say if this is too much right now.” This type of gentle permission helps a PDAer feel they have real choice, reducing the sense of confrontation or hierarchy.

Proactive co-regulation encourages collaboration over compliance, helps diffuse escalating tension, and ultimately builds trust. By openly observing and validating emotional cues, encouraging stimming, and learning about personal interests, professionals can create conditions where a PDAer feels comfortable enough to engage in care decisions.