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Trauma stabilization through polyvagal theory and DBT

By Kirby Reutter September 14, 2021

From my perspective, polyvagal theory has thus far provided us with the best working model of how trauma affects the brain and the body. According to this model, trauma has an impact on both branches of the autonomic nervous system (sympathetic and parasympathetic), which includes both branches of the parasympathetic nervous system (ventral and dorsal). 

The sympathetic branch of the nervous system is associated with physical and emotional acceleration (such as increased fear, anger, breathing and heart rate); in the case of danger, this means “fight or flight.” In contrast, the parasympathetic branch of the nervous system is associated with physical and emotional deceleration. More specifically, the ventral branch of the parasympathetic nervous system is associated with social engagement, while the dorsal branch is responsible for “rest and digest” functions and, in the case of extreme threat, “freeze.” Freeze occurs when the organism either mentally dissociates or, in even more extreme cases, faints.

When presented with danger, the various branches of the autonomic nervous system are affected in a specific order. The first branch to be affected is the ventral sub-branch of the parasympathetic nervous system, which is responsible for social engagement. In other words, when presented with threat, functions related to social connectivity — laughter, smiling, empathy, attunement, the ability to provide validation — go offline. If the danger persists, the next branch to be affected is the sympathetic nervous system, which results in fight or flight. When neither fight nor flight can mitigate the threat, the dorsal sub-branch of the parasympathetic nervous system is activated, resulting in freeze (some sort of either mental or physical collapse, such as dissociating or fainting). The following actions summarize this sequence:

  1. Danger is sensed.
  2. Social engagement goes offline (ventral parasympathetic nervous system).
  3. Danger persists.
  4. Fight or flight is triggered (sympathetic nervous system).
  5. Danger cannot be mitigated through fight or flight.
  6. Freeze response activates (dorsal parasympathetic nervous system). 

The two pedals

Think of the sympathetic nervous system as the accelerator and the parasympathetic nervous system as the brakes. As we drive down the highway, we need both of these functions. If the drive is smooth, sometimes we will gently accelerate and sometimes we will gently brake. The same process applies to our physical, mental and emotional functioning. If the “drive” is smooth, our mind and body enjoys a gentle oscillation between accelerating and braking. 

This is even reflected in our heart rhythm. A healthy rhythm is indicated by a consistent repetition of fast/slow, fast/slow, fast/slow. The reason for this gentle pendulation is so that the entire organism, at a moment’s notice, can either further accelerate or further break, as needed. A heartbeat that is either consistently fast or consistently slow or irregularly fast/slow is not a healthy rhythm because these circulation styles cannot allow for the gentle oscillation between accelerating and braking that is required for a smooth ride.

Let’s return to our driving analogy. If you are driving down the highway and a truck carelessly swerves right in front of you, you will probably have all of the reactions represented by the polyvagal theory: You may swear and flash various fingers (social engagement goes offline), you may suddenly accelerate, or you may slam on the breaks. But after the danger is averted, you will most likely return to your baseline of gently oscillating between accelerating/braking as needed — until the next threat again requires more extreme action.  

Now let’s assume you have experienced so many roadside perils that you decide never to let down your guard. You are poised at every moment to yell and scream at other drivers, unpredictably accelerate and unpredictably brake. If you are really frazzled, you may even attempt to accelerate and brake simultaneously. Over time, this becomes your new default driving style, regardless of the driving conditions: cuss everyone out, suddenly accelerate, suddenly brake. (You may have noticed that in some major cities, this sort of driving is common.) Do you see how this will lead to a wild ride? Even if the driving conditions would otherwise have been relatively smooth, they won’t be anymore. And even if no danger would otherwise have been present, now there is. You are off to the races …

A breakdown in dialectics

This driving metaphor describes what happens to people who have experienced chronic trauma: too much accelerating, too much braking, and loss of social engagement to boot. This leads to a vast variety of responses that are either “too much” or “too little,” resulting in a host of life complications. This tendency toward too much or too little especially affects the following domains:

  • Awareness
  • Thoughts 
  • Emotions 
  • Reactions 
  • Relationships 

For each of these domains, it is possible to have either too much (overuse of the accelerator, or sympathetic nervous system) or too little (overuse of the brake, or parasympathetic nervous system). Too much awareness leads to hypervigilance, whereas too little leads to dissociation. Too much thinking leads to obsessive rumination, whereas too little leads to impulsive decision-making. Too much emotional stimulation leads to overwhelm, whereas too little leads to numbness. Too much reactivity leads to even more crises, whereas too little leads to paralysis. Even relationships can be either too much or too little, resulting in either overdependence or under-dependence on others.  

In short, trauma results in all of the following possibilities: over-awareness versus under-awareness; overthinking versus under-thinking; overemoting versus under-emoting; overreacting versus underreacting; and over-relating versus under-relating. Because both the sympathetic and parasympathetic nervous systems have been hijacked, the driver is constantly over-accelerating and over-braking in each of these domains — and often doing both at the same time.

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Restoring balance 

Dialectical behavior therapy (DBT), which was developed by Marsha Linehan, is all about reconciling “dialectical dilemmas” (binary extremes resulting in dysfunction) by teaching specific behavioral skills to forge a “middle path” between those extremes. In particular, DBT teaches the following five skill sets: mindfulness, distress tolerance, emotion regulation, dialectical thinking and interpersonal effectiveness. These skill sets teach the middle path between each of the dialectical dilemmas mentioned in the previous section.

As long as clients are existing and operating at these extremes, it is extremely difficult for them to do even basic counseling — much less trauma work and much less life. That is why DBT as a treatment model is entirely skills focused. DBT teaches the foundational skills one needs to optimize counseling, stabilize for trauma work and then thrive in life — “building a life worth living,” in the words of Linehan. Among dozens of skills that could be highlighted, I would like to present five simple acronyms to help clients find — or forge — each of these middle paths.

The RAIN dance: One path to mindfulness 

Mindfulness, by definition, is always a combination of both awareness and acceptance. The RAIN dance helps clients increase both awareness and acceptance of intense emotions and other triggers in a highly practical and applied manner. RAIN stands for Recognize, Allow, Inquire and Nurture.  

The purpose of this acronym is to help clients know precisely how to apply mindfulness in a real-life situation. Let’s suppose you want to help a client become more mindful of their anger. First, teach your client to recognize their anger — and especially where they notice it in their bodies (e.g., clenched jaw). Next, teach your client to allow their anger (instead of judging or resisting it, which will make it only more difficult to manage in the long run.). Then, teach your client to inquire about their anger — with curiosity, empathy and maybe even humor. (Fear and anger are neurologically incompatible with empathy, curiosity, and humor.) Finally, teach your client to engage in some sort of nurturing (i.e., self-soothing) behavior to release the anger in an appropriate manner (such as taking a long walk through the woods). The emotional energy will need to become appropriately discharged, especially if the intense emotion has resulted from a fight-or-flight response; otherwise, this energy will simply become frozen — and then continue to resurface when triggered. 

The basic idea behind this skill is simple: Learn to “dance” with your emotions rather than avoiding, resisting, suppressing or judging them.  

TIP the balance: One path to distress tolerance 

DBT distress tolerance is all about learning to cope in the moment without making it worse. It is about replacing impulsive, addictive, risky or self-injurious behaviors (in other words, any behavior that leads to even more of a crisis orientation) with more-effective coping strategies.  

One of my favorite distress tolerance skills has to do with finding ways to TIP the balance. Because there is such a direct and obvious mind-body connection, often the quickest way to shift your mood is to quickly shift something in your body. If you can “tip” your body chemistry, you can also “tip” the balance on your emotions. There are three ways to quickly TIP your body chemistry: Temperature, Intense exercise and Paced breathing/Paired muscle relaxation (this refers to tensing your muscles as you inhale and relaxing your muscles as you exhale). 

Although each of these techniques is effective on its own, they can be even more effective when done together. For example, one way I personally TIP the balance in my own life is by riding my bicycle. This activity helps me to quickly change my body temperature, involves intense physical exercise, and helps me synchronize my respiration (inhale/exhale) with my musculation (tense/relax) through the cyclical nature of pedaling.

Sow your SEEDS: One path to emotion regulation

Whereas distress tolerance refers to short-term coping in the moment, emotion regulation refers to a long-term lifestyle change that will ultimately support much healthier emotionality. When I teach emotion regulation skills to clients, I use an extended garden analogy. For example, if you want to have a healthy garden of flowers, would it make any sense to scream and swear at the flowers? Ignore the flowers? Shame the flowers? Coerce or manipulate the flowers? Of course not. Your flowers do not need to be controlled — they need to be cultivated. 

The same concept applies to our emotions. Instead of trying to control them, we need to care for them — like beautiful, delicate flowers. (By the way, it makes me cringe every time that I hear therapists — and even DBT practitioners, no less — paraphrase emotion regulation as “controlling your emotions.”) There are several things you need to do to care for a real garden: plant the right seeds, do some weeding, check the soil, continue to care for the garden even when you feel like giving up, and fertilize. Each of these activities represents a specific way to care for our emotions as well. Here, I will simply introduce the first one: You need to plant the right SEEDS.  

Planting the right SEEDS refers to five ways of taking care of your physical body: Symptoms, Eating, Exercise, Drugs and Sleep. If you want to have a healthy garden of emotions, you will need to plant each of these seeds by addressing physical symptoms, finding healthy eating patterns, getting moderate exercise, monitoring which drugs enter your body, and getting adequate sleep. After helping my clients develop a specific plan for each of these “seeds,” I often have them provide me with a quick SEEDS report at the beginning of each session, as part of their weekly check-in. 

Working the TOM: One path to dialectical thinking  

Dialectical thinking is all about letting go of the extremes, learning to think more in the middle, learning to be more flexible with your cognitions, learning to see things from someone else’s perspective, learning to see things from multiple perspectives in your own head, and learning to update your beliefs when presented with new information.  

When I teach dialectical thinking to clients, I use a very simple process: We work the TOM, which stands for Thought, Opposite and Middle. First, we identify the original problematic thought. Next, we identify the complete opposite extreme of that cognition. Finally, we brainstorm a possible belief somewhere more in the middle.  

Let’s assume a client has the original problematic thought of “I am not good at anything.” The complete opposite extreme would be: “I have never once made a mistake. I am absolutely flawless. I am the most competent human specimen that has ever existed.” And something more in the middle might be: “There are some things I am OK at, but there are also lots of things that I need to work on.”  

The purpose of this exercise is to help clients quickly identify a cognition that is most likely much more accurate than the original belief. Clients may not always be able to come up with a middle thought on their own, so it is completely fine to help them at first. Eventually, however, it is better if clients can generate their own middle thoughts because whatever they produce will inherently be more believable than whatever you come up with. Even if the client insists they do not believe the middle thought that they generated, chances are that part of them does — because those words came from their mind. Regardless, your job is not to try to convince your client that the middle thought is more accurate; it is simply to plant the seed for that thought and then let it germinate on its own.
In fact, the more the client wrestles with the middle thought, the more they are thinking about it, therefore reinforcing the new cognition.  

DEAR Adult: One path to interpersonal effectiveness 

Whereas all the other skills mentioned so far are about self-regulation, interpersonal effectiveness inherently involves both the self and someone else. Therefore, interpersonal effectiveness inherently subsumes the other skill sets. After all, you can’t possibly deal with another person if you can’t even deal with yourself yet. 

Here, I would like to introduce perhaps the most comprehensive of the interpersonal effectiveness skills: DEAR Adult. D stands for Describe: First, describe the situation that needs to be addressed. State only the facts, and truly focus on the situation, not the person. Next, Express how you feel about the situation. Use “I feel” statements. Once again, truly express how you feel about the situation, not the person. Sometimes it can be helpful to use a “float back” and express how you have felt about similar situations previously so that both you and the other person understand that there might be more history beyond the current situation. If you want to be especially dialectical, also use this E to Empathize with the other person’s perspective.  

Now you are ready to move on to A, which stands for Assert. When asserting, use “I need” statements. In particular, explain what you need in positive terms, not negative ones; explain precisely what you need the other person to do, not what they should stop doing. If you want to be even more dialectical, also use the A to Appreciate the other person’s perspective and even Apologize for your role in this situation.  

R stands for Reinforce. You want to end on a positive, upbeat note by reinforcing both your request and the relationship itself. In my opinion, the best way to reinforce both is to explain how what you are requesting is a win-win proposition. You simply want what is best for both parties. Therefore, you are willing to further negotiate and compromise as necessary.  

Finally, you want to do all of this using the Adult Voice, which is the dialectic (the middle ground) between the Parent Voice (yell, lecture, berate) and the Child Voice (whine, pout, throw a tantrum). The Adult Voice is when you communicate in a manner that is calm, composed and collected.

Summary 

Ongoing trauma results in overstimulation of both the sympathetic and parasympathetic nervous systems (accelerator and brake), resulting in a variety of responses that are either “too much” or “too little.” The five skill sets taught in DBT help restore the balance between these extremes by providing a middle path, which includes reactivation of the social engagement system. That’s why when I am explaining DBT to my clients, I usually dispense with clinical jargon and simply refer to this model as “developing balance therapy.” In this article, I have briefly introduced five skills (among legion) as examples of these middle paths: RAIN dance as a form of mindfulness; TIP the balance as a form of distress tolerance; sow your SEEDS as a form of emotion regulation; work the TOM as a form of dialectical thinking; and DEAR Adult as a form of interpersonal effectiveness. 

To be clear, DBT was not designed to resolve the original trauma. Myriad models have been developed for trauma processing. Some models focus more on verbal processing and are generally referred to as “top-down models.” Other models focus more on somatic processing and are generally referred to as “bottom-up models.” Some clients prefer verbal forms of processing, some clients prefer somatic forms of processing, and most clients can benefit from both, so it is not necessary (in my opinion) to engage in endless debate or pointless turf wars on this point. My recommendation is simple: Be trained in at least one form of trauma processing that is mostly top-down and at least one form of trauma processing that is mostly bottom-up — and become proficient in both. (Another dialectical dilemma resolved.) 

However, no form of trauma processing can be completely effective when the individual is actively in crisis, experiencing ongoing danger or constantly dysregulated. That’s where DBT comes in. DBT (which I like to call “developing balance therapy”) provides the necessary skill set to help individuals sufficiently stabilize or self-regulate in order to then proceed with deeper trauma work.  

If you would like to learn more about how to use trauma-focused DBT with a variety of trauma-based disorders, I recommend the following resources to get started:  

  • The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder by Kirby Reutter, 2019
  • “DBT for Trauma and PTSD” (DBT Expert Interview series at psychotherapyacademy.org/dbt-interviews)
  • Survival Packet: Treatment Guide for Individual, Group, and Family Counseling by Kirby Reutter, 2019
  • “The Journey From Mars: Brain Development and Trauma” webinar (youtube.com/watch?v=WSFqHS_axOc)

 

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Kirby Reutter is a bilingual clinical psychologist and licensed mental health counselor who contracts with the Department of Homeland Security to provide mental health services for international asylum seekers. He has provided four trainings for the U.S. military, is a TED speaker and is the author of The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder. Contact him at Kirby.reutter@gatewaywoods.org or through his website at drkirbyreutter.com.

 

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Polyvagal theory in practice

By Dee Wagner June 27, 2016

Picturing brain chemistry can be something like picturing a hurricane. Although we can imagine bad weather, it is difficult to imagine changing that weather. But Stephen Porges’ polyvagal theory gives counselors a useful picture of the nervous system that can guide us in our efforts Branding-Images_chemistryto help clients.

Porges’ polyvagal theory developed out of his experiments with the vagus nerve. The vagus nerve serves the parasympathetic nervous system, which is the calming aspect of our nervous system mechanics. The parasympathetic part of the autonomic nervous system balances the sympathetic active part, but in much more nuanced ways than we understood before polyvagal theory.

Our three-part nervous system

Before polyvagal theory, our nervous system was pictured as a two-part antagonistic system, with more activation signaling less calming and more calming signaling less activation. Polyvagal theory identifies a third type of nervous system response that Porges calls the social engagement system, a playful mixture of activation and calming that operates out of unique nerve influence.

The social engagement system helps us navigate relationships. Helping our clients shift into use of their social engagement system allows them to become more flexible in their coping styles.

The two other parts of our nervous system function to help us manage life-threatening situations. Most counselors are already familiar with the two defense mechanisms triggered by these two parts of the nervous system: sympathetic fight-or-flight and parasympathetic shutdown, sometimes called freeze-or-faint. Use of our social engagement system, on the other hand, requires a sense of safety.

Polyvagal theory helps us understand that both branches of the vagus nerve calm the body, but they do so in different ways. Shutdown, or freeze-or-faint, occurs through the dorsal branch of the vagus nerve. This reaction can feel like the fatigued muscles and lightheadedness of a bad flu. When the dorsal vagal nerve shuts down the body, it can move us into immobility or dissociation. In addition to affecting the heart and lungs, the dorsal branch affects body functioning below the diaphragm and is involved in digestive issues.

The ventral branch of the vagal nerve affects body functioning above the diaphragm. This is the branch that serves the social engagement system. The ventral vagal nerve dampens the body’s regularly active state. Picture controlling a horse as you ride it back to the stable. You would continue to pull back on and release the reins in nuanced ways to ensure that the horse maintains an appropriate speed. Likewise, the ventral vagal nerve allows activation in a nuanced way, thus offering a different quality than sympathetic activation.

Ventral vagal release into activity takes milliseconds, whereas sympathetic activation takes seconds and involves various chemical reactions that are akin to losing the horse’s reins. In addition, once the fight-or-flight chemical reactions have begun, it can take our bodies 10–20 minutes to return to our pre-fight/pre-flight state. Ventral vagal release into activity does not involve these sorts of chemical reactions. Therefore, we can make quicker adjustments between activation and calming, similar to what we can do when we use the reins to control the horse.

If you go to a dog park, you will see certain dogs that are afraid. They exhibit fight-or-flight behaviors. Other dogs will signal a wish to play. This signaling often takes the form that we humans hijacked for the downward-facing-dog pose in yoga. When a dog gives this signal, it cues a level of arousal that can be intense. However, this playful energy has a very different spirit than the intensity of fight-or-flight behaviors. This playful spirit characterizes the social engagement system. When we experience our environment as safe, we operate from our social engagement system.

Trauma’s effect on nervous system response

If we have unresolved trauma in our past, we may live in a version of perpetual fight-or-flight. We may be able to channel this fight-or-flight anxiety into activities such as cleaning the house, raking the leaves or working out at the gym, but these activities will have a different feel than they would if they were done with social engagement biology (think “Whistle While You Work”).

For some trauma survivors, no activity successfully channels their fight-or-flight sensations. As a result, they feel trapped and their bodies shut down. These clients may live in a version of perpetual shutdown.

Peter Levine, a longtime friend and colleague of Porges, has studied the shutdown response through animal observations and bodywork with clients. In Waking the Tiger: Healing Trauma, he explains that emerging from shutdown requires a shudder or shake to discharge suspended fight-or-flight energy. In a life-threatening situation, if we have shutdown and an opportunity for active survival presents itself, we can wake ourselves up. As counselors, we might recognize this shift from shutdown to fight-or-flight in a client’s move from depression into anxiety.

But how can we help our clients move into their social engagement biology? If clients live in a more dissociative, depressed, shutdown manner, we must help them shift temporarily into fight-or-flight. As clients experience fight-or-flight intensity, we must then help them find a sense of safety. When they can sense that they are safe, they can shift into their social engagement system.

The body-awareness techniques that are part of cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) can help clients move out of dissociative, shutdown responses by encouraging them to become more embodied. When clients are more present in their bodies and better able to attend to momentary muscular tension, they can wake up from a shutdown response. As clients activate out of shutdown and shift toward fight-or-flight sensations, the thought-restructuring techniques that are also part of CBT and DBT can teach clients to evaluate their safety more accurately. Reflective listening techniques can help clients feel a connection with their counselors. This makes it possible for these clients to feel safe enough to shift into social engagement biology.

Specific aspects of ventral vagal nerve functioning

Porges chose the name social engagement system because the ventral vagal nerve affects the middle ear, which filters out background noises to make it easier to hear the human voice. It also affects facial muscles and thus the ability to make communicative facial expressions. Finally, it affects the larynx and thus vocal tone and vocal patterning, helping humans create sounds that soothe one another.

Since publishing The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation in 2011, Porges has studied the use of sound modulation to hierarchytrain middle-ear muscles. Clients with poor social engagement system functioning may have inner ear difficulties that make it hard for them to receive soothing from others’ voices. As counselors, we can be conscious of our vocal patterns and facial expressions and curious about the effects those aspects of our communication have on our clients.

Based on his understanding of the effects of the vagus nerve, Porges notes that extending exhales longer than inhales for a period of time activates the parasympathetic nervous system. Porges was a clarinet player in his youth and remembers the effect of the breath patterns required to play that instrument.

As a dance therapist, I am aware that extending exhales helps clients who are stuck in forms of fight-or-flight response to move into a sense of safety. For clients stuck in some form of shutdown, I have found that conscious breath work can stir the fight-or-flight response. When this occurs, the fight-or-flight energy needs to be discharged through movement for clients to find a sense of safety. For instance, these clients might need to run in place or punch a pillow. The hierarchy of defense system functioning explains these therapeutic techniques.

Respiratory sinus arrhythmia is a good index of ventral vagal functioning. This means we now have methods to study the effectiveness of body therapies and expressive arts therapies.

Polyvagal theory in my practice

What follows is an example of how I used polyvagal theory with a client who experienced medical trauma during her birth.

The client, whom I have been seeing for some time, described feeling very sleepy and acknowledged having difficulty getting to our session on this day. Her psychiatrist had prescribed her Zoloft as a way of treating anxiety stirred by the birth of her daughter’s first child. The client and I had previously normalized her anxiety as a trauma response.

During the years before coming to see me, this client had attempted suicide, which resulted in medical procedures that added to her trauma. Through our work, she has come to understand that the panic attacks she has when in contained situations are also trauma responses. She has lived much of her life in perpetual fight-or-flight response mode.

On this day, she was relieved to be less emotional, but she feared the tiredness that accompanied Zoloft’s help in calming her fight-or-flight sensations. I saw this fear of the tiredness as a fear of dorsal vagal shutdown. We discussed the possibility that this tiredness could allow her a new kind of activation. I asked if she would like to do some expressive art that would allow gentle, expressive movement. She shuddered, naming her preference for things that were less subjective.

We talked about the existence of a kind of aliveness that still feels safe. We talked about the possibility of existing in a playful place in which there is no right and wrong, only preference. We acknowledged that since her birth, she and her parents had feared that her health would fail again. This environment in which she had grown up had supported nervous system functioning designed for life-threatening situations. With the Zoloft calming her fight-or-flight activation, I suggested that perhaps she could explore some calmer, more playful kinds of subjective experiences.

“It feels like you are trying to create a different me,” she responded. I acknowledged that it might sound as if I were thinking she could be someone she wasn’t. But I explained that what I was actually suggesting was the possibility that she could be herself in a different way.

The client told me she had a new book on grandparenting that contained a chapter on play. She said she would consider reading it. At the same time, she said that she might not be able to tolerate the Zoloft and might have to get off of it. Regardless, the idea of this different, more playful way of being has been introduced to her and, for a moment or two, experienced.

Getting the picture

As counselors armed with polyvagal theory, we can picture defense mechanism hierarchy. We can recognize shifts from fight-or-flight to shutdown when clients feel trapped. We can also recognize the movement from shutdown into fight-or-flight that offers a possible shift into social engagement biology if and when the client can gain a sense of safety.

Before polyvagal theory, most counselors could probably recognize fight-or-flight and shutdown behaviors. They could probably sense a difference between defense responses designed for life-threatening situations and responses that characterize what Porges calls the social engagement system. Polyvagal theory deepens that awareness with the knowledge that playful arousal and restorative surrender have a unique nervous system influence.

Most counselors appreciate brain science but may find it difficult to picture how to use the information. Thanks to polyvagal theory’s clarification of the role of the ventral branch of the vagus nerve, we now have a map to guide us.

 

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Dee Wagner has worked as a licensed professional counselor and board-certified dance therapist at The Link Counseling Center in Atlanta for 22 years.
Her book/workbook Naked Online: A DoZen Ways to Grow From Internet Dating helps clients use their online dating experiences to shift from attachment trauma to social engagement system functioning. Contact her at mdeewag@gmail.com.

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