How can we help people to tolerate uncomfortable sensations?
Lessons learned from a Haunted House
Occupational Therapists often work with clients who are experiencing an inability to tolerate certain sensory stimuli.
Our clients might only be able to wear particular kinds of clothing, they may eat a limited range of textures or temperatures, or they might startle to sounds or get overwhelmed by noise more easily than the average person. These kinds of defensive overresponding to sensations can limit their ability to participate in life.
In therapy the goal is often to increase tolerance for sensory stimuli.
What does that mean, and how do we do that effectively, while also honoring the nervous system?
It is important to first understand that sensory defensiveness (an “adverse reactions to a non-noxious stimuli” as defined by Pat and Julia Wilbarger) is a central nervous system dysfunction of regulation that results in sensory modulation challenges. It is not a dysfunction of the peripheral receptors.*
In other words: it is not that their skin or their ears are too sensitive, it is that their dysregulation has turned up their reactivity.
When our central nervous system gets highly activated, the sensory circuitry in our brain and body becomes sensitized, which can result in overresponding.** This is true for all of us.
To imagine what a highly activated nervous system would feel like, we can think of being in a haunted house.
If it is comfortable for you, stop reading now and try to imagine yourself walking through a haunted house. You are in the dark. There are loud, unexpected noises, and spooky sights. Imagine yourself approaching a doorway, glowing with smoke, knowing something is likely to jump out at you as soon as you step into the next room. See if you can pause and notice how your body would feel in that situation.
I imagine that your heart would be beating fast, your breath would probably be short and shallow or you might be holding it, you might be sweating or feel clammy, and your muscles would probably be tight; ready to jump or run away in every moment.
Your nervous system would likely be more activated in that haunted house than it would be walking in your safe neighborhood on a beautiful day.
Now imagine a cool, sunny afternoon under blue skies with birds singing and trees changing colors. On your sunny afternoon walk, in a safe and familiar environment, it is likely that your heart would beat slower, your breath would be even and deeper, and your muscles would be more relaxed. A leaf could fall and brush your arm and you are likely to notice it, brush it off, and move on quickly. Even if a bug landed on you, you could probably brush off the bug and keep walking, if you have a neurotypical nervous system. You could tolerate those sensations with minimal distress.
In the haunted house, a light touch is likely to send your nervous system into bigger protective reactions. You might jump, scream, or run, and your posture would likely change as you try to protect yourself from the noxious stimulus. This is a protective mechanism that is built into us.
In situations when our body is perceiving danger, our sensory systems automatically dial up their sensitivity for the purposes of keeping us safe.
The danger doesn’t have to be real. Most of us know that we are going to come out of the other side of the haunted house in just a few minutes with no harm having come to us. It is the perception of danger that increases our nervous system activation and changes our reactivity to sensory stimuli.
The circuitry in the lower parts of our brain (brainstem, midbrain, and limbic (emotional) structures) take over when we perceive that we are not safe. The resulting behavior is often referred to as “fight or flight”. It includes automatically turning up our sensitivity to noise, touch, and peripheral vision, as well as increasing our heart rate and getting our muscles ready to move. To survive.
Cognitive strategies are often not effective for changing reactivity because our brain is biased towards keeping us safe.
That rules out using cognitive strategies as an effective way of reducing nervous system activation. We just aren’t built to work that way.
Another technique that is sometimes used in an attempt to increase tolerance is exposure to the noxious stimuli.
I offer the example of the haunted house because it is helpful to imagine what we would do in that situation to alleviate the discomfort of the person that is overreacting to sensations. We would not take a person who was overwhelmed and continue exposing them to light tickling touch and loud noises in hopes that they would become less sensitive. We would get them OUT of the haunted house and find ways to help them calm their nervous system.
In a nervous system that is overwhelmed we should not be subjecting them to experiences of feeling things, with the goal of increasing their tolerance for sensation. Rather, we want to find ways to reduce the overwhelm of the nervous system, which will result in their system being less sensitive, and more able to tolerate.
When I am treating a child who is responding defensively to sensory inputs I am measuring the effectiveness of interventions by tracking increased tolerance, but I would never intervene by offering noxious sensation and asking them to tolerate it. It is a subtle difference that is super important!
For a dysregulated person with a typical nervous system, leaving the haunted house and being comforted by a trusted friend or adult will likely result in a more regulated state and decreased sensory sensitivity.
For individuals with sensory defensiveness, that dysregulated state of the nervous system is happening in everyday life. They are often in a state of sympathetic nervous system activation. They are always ready to respond to a threat.
Their defensive responding to sensory stimulation can be better or worse from moment to moment, depending on other factors that contribute to regulation (like sleep, blood sugar, physical activity, connection with people who help us feel safe etc), but it won’t totally go away until the dysregulation of the nervous system is addressed.
To increase tolerance for sensory inputs we must use our mind to zoom out to see the whole person and address all of the factors that are affecting their regulation.
For our kids that means doing things to support their regulation from the bottom-up.
Reducing expectations and stressors is where I would likely start. The work of Stuart Shanker helps us to understand of the responsibility of adults to first reduce the stressors on a child before expecting them to grow their ability to self-regulate.
In their STEPP-SI course, occupational therapists Tracy Stackhouse, Julia Wilbarger, and Sharon Trunell present the idea that we must be able to attain a state of regulation and maintain that state of regulation before we can challenge our capacity to regulate. Often adults challenge a child’s regulation by raising the expectations for self-regulation, when the child is not yet able to attain a state of regulation in the current circumstances.
A regulated state is necessary for working towards expanding tolerance. Reducing stressors is typically going to be the best first step in helping a person to feel more regulated.
Otherwise, we are just asking people to mask the way that their body feels, and that has many physical and mental health repercussions.
After reducing stressors we need to find ways to support the nervous system. Using the principles of sensory integrative processing, as originated by occupational therapist Jean Ayers, we can support neurophysiological shifts that can occur as a result of offering specific sensory inputs.
Proprioceptive input (from the muscles and joints), deep pressure touch, sucking, chewing, rhythmic movement and sounds are all inputs that are typically calming for the nervous system. An occupational therapist trained in sensory integration (SI) has advanced training in using these kinds of sensory experiences to shift the nervous system towards feeling more regulated. But it is never one size fits all.
Finding a match for a particular nervous system involves looking at not only the type of sensory input, but the frequency, intensity, duration, and predictability of the stimulus needed to help a particular person’s system to be more adaptable.
For many children who are experiencing sensory defensiveness, there are challenges with not only their sensory processing, but also with their basic motor capacities.
Jean Ayers said “One of the more difficult tasks of the therapist is to recognize not only the existence, but more importantly, the significance of slightly disordered postural mechanisms.” Ayres (1972), p. 77.
Disordered postural and breath mechanisms have far reaching consequences that often underly challenges with regulation.
To support regulation we need to consider the quality of the child’s breath support, the mobility of their ribcage, and their ability to coordinate nasal breathing and the suck swallow breathe synchrony. We need to assess and remediate the movement patterns they use, their postural control, the alignment of their diaphragm and their pelvic floor, and their core strength. All of these are basic motor capacities that underly regulation.
Most importantly, these interventions must be done within a connected relationship that helps the child to feel safe. When we perceive that we are safe, it changes the way our nervous system functions. It allows us to be more adaptable.
But safety is a perception. We cannot force someone to feel safe. Instead, we have to offer safety by reducing stressors and using sensory, motor and relationship strategies.
We must also learn to read the signs of the nervous system that tell us whether a child is feeling safe or unsafe:
When we can learn to read a person’s signals of felt safety and regulation, and we offer the supports (sensory, relational, and motor system supports) in a way that matches their needs, over time we can create a shift in their regulation.
The person with a neurotypical nervous system who gets overwhelmed in the haunted house can eventually feel regulated again, and their sensory responsivity will return to their normal. Similarly, if we can help the person who struggles with sensory modulation to feel regulated, their sensory responsivity can decrease, allowing them to tolerate sensations that were once overwhelming.
By addressing the foundations of regulation in a way that respects a person’s nervous system, we can decrease defensive responding and allow for increased tolerance.
It is not an easy task to treat sensory defensiveness, but our clients need us to know the science that leads to effective intervention. When we respect the way their nervous system is responding, and help to bring them comfort, we enable them to participate more fully in their life. Ultimately, that should always be our goal.
Resources:
Self-Reg by Stuart Shanker
STEPP-SI course by Tracy Stackhouse and Dave Jereb (available soon)
Sensory Integration and Learning Disorders. Ayres A. J. (1972). Los Angeles, CA, Western Psychological Services.
MORE course by Patti Oetter and Eileen Richter (assessment and treatment of motor, oral, respiratory, and postural skills)
Sensory Integration Theory and Practice (3rd edition) by Anita Bundy and Shelly Lane
*There are some situations, such as a child with a history of ear infections, where the muscles of the middle ear that are responsible for contracting to dampen sound are not working properly, and in these cases it may be necessary to work on peripheral structures in addition to addressing the autonomic nervous system functioning.
**When our central nervous system gets highly activated and our sensory circuitry becomes sensitized it can also result in our system shutting down to avoid the noxious stimuli, resulting in what appears to be underresponding. It is imperative that therapists recognize when a client is experiencing this level of overwhelm in order to provide appropriate intervention.