Psychiatry & Psychotherapy Podcast - Affective Neuroscience in Psychotherapy with Francis Stevens, Ph.D.

Episode Date: February 18, 2022

On this week's episode, Dr. Puder interviews Francis Stevens, Ph.D., a clinical psychologist and author of the new book, Affective Neuroscience in Psychotherapy: A Clinician's Guide for Working With Emotions. Dr. Stevens trained as a therapist under cognitive behavioral and psychodynamic theories, as well as completing a postdoctoral degree in neuroscience. The lack of emphasis on emotion in these two approaches led Dr. Stevens to begin research on the neurobiological basis of emotion and to ultimately compile this book. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. our welcome back to the podcast i am joined today with dr francis stevens he is a phd-level psychologist he did some further a further fellowship post-back work in neuroscience and he has written a book called affective neuroscience in psychotherapy a clinician's guide for working with emotions

and i'm excited to have you on yeah i'm excited to have you on yeah i'm excited to be here. I always love talking about psychology, talking about this book. Yeah. So this is, so the basic gist of the book is a focus in psychotherapy on emotion. Yes. And six steps, helping a client through this process, emotional awareness, mindfulness, so becoming aware of your emotions, emotional validation, so validating your client's emotions, helping a client develop self-compassion. Step three, step four is understanding the nature of emotion. So not just kind of like distracting away from the meaning of the potential, why they're having this emotion. And then moving in step five to emotional regulation, coping with emotion. And finally,

in step six, affect, reconsolidation. And so big picture, kind of like, I like to start out with that, just kind of let my audience know what they're in for. So you're kind of your central drive is emotion. And I'm curious as a neuroscientist, it seems like it's a very cognitive field, you know, your postback in neuroscience. It seems like you kind of came in to a world that was heavy in, you know, CBT,

cognitive behavioral therapy. There was a big focus on thoughts. You did like a year of psychodynamic stuff, focus on insight, and then you kind of like had this turning point. Tell me about that turning point and when you kind of realized emotion was more important for you to focus on.

Yeah, so like in my master's degree, like many people have training kind of behavioral therapy and my PhD was more kind of psychodynamicly focused. But both of these kind of treatment approaches really focus on cognitions. Like with psychodynamic, David's at insight,

trying to understand your childhood and that makes a change. and, you know, with behavioral therapy, it's changing your cognition, which is supposed to make you feel better. And I found that nearly these approaches were quite, were kind of lacking, were that effective. You know, psychotherapy is effective, but if you look at the studies, the effect size is actually quite low. So I kind of did like a deep dive into the neuroscience and really trying to understand like what's going on in the brain. You know, if we really look at kind of like the basics of the brain and try to, you know, boil it down, our limbic system, our cerebellum,

and kind of the basic parts of our brain are very much based in emotion. And so emotion drives a lot of our thoughts and behavior. And if we look at the psychological research and I just wrote a paper kind of reexamining like this idea, does cognition really change emotion? Or can we change emotion with itself? And so I think we need to kind of shift our interventions

in psychotherapy from less like, okay, let's think about the problem differently to let's deal with emotion. directly itself. And I found as a practicing psychologist, when I do that, my outcomes for patients are much better. And so I didn't set out to write a book. I wasn't like, oh, I want to write this. I was like, this is something that's really important. And I really want to get the word out there. And I can explain it through affective neuroscience how much, how important emotion is. Okay. So you're like seeing clients and you're starting to think through like there's something

I'm missing. Yeah, I would be like trying to reappraise the cognition or think about it this way. And they'd be like, yeah, I mean, I know I'm not supposed to hate myself, but I do. And I'm like, hmm, yeah, well, I guess you do know, but you still hate yourself. And then sometimes you're like, well, you know, I know why I hate myself. It's because my parents invalidated me and, you know, treated me horrible. But I still don't like myself. And it's like, yeah, so what do we do now?

And I find myself kind of getting that stuck point several times with patients. It's like they know what their problem is. They know that their thinking is maladaptive or, you know, that their thinking is not aligned with how they feel, but they still can't change those feelings. Okay. So you're sitting with these clients. They're feeling stuck.

They have this knowledge, but no emotional insight into kind of like how they can change this. And so you're in this like quandary. And so you kind of are trying to reassess like, what am I, what do I need to focus on? Was it a journey for yourself as well? It was, yeah. Definitely like in my own training and, you know, I feel like even sometimes,

and I mentioned in the book, like I may have kind of shamed clients in some ways to be like, well, how come, you know, if you think this way, can't you just tell yourself to feel differently or, you know, shouldn't that because that's the ABC model, that's the way it should work? And I realized that, you know, we can have all sorts of insight.

We can understand ourselves, but we can still be, you know, depressed or neurotic. I always talk about Woody Allen. I mean, that guy's been in therapy for years, right? It's still very neurotic, you know, not addressing the emotion, has all this cognition, understands why he behaves the way he does, you know, has great insight, is unable to change how he actually feels. Well, I'm sure Woody Allen, after hearing this, will reach out. out to you and you can work the next 10 years. Yeah, yeah, yeah. Come to see me. And,

no, okay, coming back to like your frustration towards yourself, having said some of these things, your patients experience shame, you recognize your patients experiencing shame. And you're like, oh, shoot, that's not. Yeah, this isn't working out. That's not working. And so you're kind of going back to the drawing board in your mind. on what could be a better way of approaching these things, what would you say to that earlier version of yourself to when in the midst of that frustration having... Well, that there's another way, right?

Like, I had just kind of taken on a lot of these theories of psychotherapy kind of carte blanche, right? Like, this is just what you're supposed to do without thinking like, wait a minute, there might be a better way here. And then, you know, through training and, you know, kind of reading about some people like Leslie Greenberg and Diane Fochia that kind of do more emotion and focus therapies and things like that, I started saying, oh, there's kind of a different approach to this. And my internship was more interpersonally focused.

So I was like, oh, this seems to be like have a different effect. You're like when you just kind of join the clients with their feeling, it seems to be helpful. But I'm a very kind of analytical person. And I'm like, well, I want to understand exactly. how this works, not just like we sit there with our patients and we feel, we talk about our feelings we feel better. Like, what is the mechanism behind us? And so then we start looking at the neural science behind you, like memory consolidation, which has been, you know, really

identified in the rodent population, now being applied to human population. You can see how the brain changes, how the wiring changes when you pay our emotions. Okay. Yeah, so you yourself were very cognitive. You would... Yeah, I'm a very cognitive. Like, yeah, I'm not a, I was never a touchy feeling person till I kind of discovered this. Oh, man, as you say that, you have this, like, an expression of, like, emotions were not something that you, like, enjoyed sitting with, maybe. Oh, yeah, I think for myself, I was never good at sitting with emotions.

I was kind of always trying to, like, all right, what's the plan here? Like, what am I going to do? And, you know, only through really understanding the science of it, I think that's helped me sit with, understand, be more self-compassive to my emotions, because I'm saying, oh, this is actually what works. It's not just like foo-y-gooey or whatever you want to call. At first, you felt like it was fooey-goory. I want like a science explanation, right?

I want to understand why is it that, you know, because it's counterintuitive for most people, right? Like, I'm sad. Why would I want to talk about my sadness? Like, that seems counterintuitive. Like it doesn't feel good. And so I want to understand. well, what is that? And so, you know, what I tell people is like, you know, everybody, you know, gets upset, you know,

they have someone dies, you feel sad. But what happens is, is like, you don't want to deal with that sadness. You put a lid on it, but you're still sad. Now you're in kind of a dissidence. You're fighting yourself. It's suffering, study Buddhism. So what we, as therapists, you know, to get lit off that, allow ourselves to have our feeling, accept it.

And when we accept it, deal with it, it passes no longer in that state of tension, which results in depression, anxiety, psychopathology. Okay. So, yeah, so you yourself kind of had to grow personally to do, to kind of make this shift in your mind. You started out kind of thinking you were going to save the world with these, you know, CBT, kind of like, okay, I'm just, if I can just help them think their way out of it, it just kind of like roadblock after roadblock. And so you're kind of going through this like phase shift. did you have any like mentors or guides in the midst of that? Sure.

I mean, I had a lot of, you know, I've been to therapy myself. I've had great supervisors. I've done all sorts of different things. And that's all help me in different ways. It's hard, you know, to point out one person there. I mean, I remember I had Dagmire Kaufman as a supervisor at the University of Rochester and really saying, hey, let's look at this differently. And then I'm like, you know, it's kind of interesting.

So you pair that with like my next. supervisor, which was Catherine Tabor at the VA in Southern North Carolina, who's more like the neuroscientist and putting those two together, that's kind of the affect of neuroscience piece. So how do we put this emotion in the context, which can understand it? So yeah, I mean, just doing all these different experiences, like I trained at the Boston Institute for Cycotherapy and learning all about that, you see all these different perspectives, then you're able to kind of put it together in a way that makes sense. And I think the kind of the overreacted thing is the emotion.

Yeah. Yeah. And so with the emotion and with that journey, how much more were you able to access your own emotions in session maybe or when someone else was having an emotion in session? Like have you, do you feel like you can feel their emotions differently than you used to be able to? Yeah. I think I have a better distinction between what my. emotions are and maybe what the patient's emotions are because, you know, as I've been able to sit with

and recognize and understand my feelings better, then I'm able to kind of make this distinction between, you know, what might be my feelings, you know, or what might be a feeling from the past and what might be coming from the patient. Okay. So one story I like to talk about is I usually read the VA and I had people with guys who come in the road rage, you know, they drive someone off the road, some little lady pulls out in front of them and they want to run them off the road. And so how it was anger and they would often blame their anger. They're like, oh, I just got to give it my anger. My anger is the problem.

I don't like it. You know, I just need to be less angry. I'll be fine. But if I can get them talking, you know, we found out this anger's been within a long time. It's not just this one incident. You know, that they're angry from things to happen to childhood. And if you can go to,

doing things in wars they want to do. And so they had a good reason to be angry. And what happens if someone pulls out in front of you, we all get a little bit angry, right? It activates us all, you know, it's upsetting. But it would activate this whole kind of wells spring, all this anger for them. And so they would go into a rage. And we're a rage, of course,

you want to run the person off the road. But all this anger was not about the woman that pulled out in front of them. It was all their anger from the past. So for me, training in this and learning about this, I start to understand, okay, where is this like my past emotions that's coming in to play, you know, that maybe it's like, oh, patient criticizes me and I don't like me criticized, so I'm upset and then I'm getting mad at the patient. It's like, no, that's me. Like, that's all about me. It's my feeling. You know, it's nothing to do with them. So I'm able to sort that out. And so when I work with the veterans, it was to see, like, that anger is not germane to the current situation. That anger from the past. You know, we need to treat that differently.

We don't want to go after the person. And so then you start to understand where your feelings come from. Like, oh, that's from the past. That's actually, you know, someone's in the environment is causing that. Yeah. Yeah. Yeah. I like how you talk about emotion is an adaptive thing, even if it seems maladaptive presently, like it served an adaptive role or serves an adaptive role. Yeah, so anger is like an adaptive thing when someone crosses your boundaries.

Again, with these veterans, what happened was they never had, they were to utilize or access their anger. They felt powerless in those situations when they were in the military or as a child. And so they just kind of held on to that anger. Now, at the moment, the anger was adaptive because it was like saying, this isn't okay.

But now the anger is kind of maladaptive because it's coming out towards this person on the, that pulled out of the front of the street. And so the emotion itself is adaptive, but when it's misattributed to a different situation, you can sometimes kind of over-respond or have an exaggerated response because of that emotion. So you have to be able to kind of identify where the emotion's coming from to deal with it effectively. Yeah. Okay. Yeah. Yeah, I like, I like your focus on empathy, validation, validating their emotion. So like, let's say that one person was like, I hate myself.

And I know it's because of my childhood and I don't know how to stop hating myself. Like what would be the validation? What would be the empathy you would have for them in that moment now? Yeah. So it's a really tricky thing that goes on here because I think there's a lot of impetus and clinicians to be like, okay, like, get rid of that thought. Like, or like, oh, you know, it's wrong to hate yourself. Don't do that.

And so then they're like, oh, but that's how I feel, and they feel shame around that. What I've worked with patients that have had problems like this, that hate is usually an adaptive mechanism. So, for example, say, you know, kids that were traumatized as children, right? You know, maybe they were abused or something, right? They don't have any control in that environment because they're kids. But a way to control that is to take ownership of that. So it's like, oh, if I don't spell the milk again, I won't get abused. Or if I do this differently, I won't be abused, right?

So they try to control that by hating part of themselves. They hate the part of themselves that's been abused or makes a mistake, and they can get rid of that, then they can control the environment so they won't be abused again. So that self-hate serves a very adaptive function there, which is to get rid of the part of you that's causing the abuse. Well, it's a delusion. It's not real, right, because the child's not causing you abuse. The adult is, but at that young age, you don't realize that. So you end up blaming yourself. And when you work with that,

You don't want to be like, oh, what's a matter? Don't hate yourself. Don't do that. Don't beat yourself up because it's like, but this is what I've done for so much. It's been adapted. You want to empathize with them, help them understand that,

oh, that was an adaptive response then. But it's not helpful now. We want to let go of that response. We want to love ourselves. We want to love that part of that self-hate to say, hey, you know, you're okay. Like what you went through wasn't okay. You know, you're fine.

You don't have to hate yourself. And when they can do that, then you can see a shift. I think it's like to love all of themselves and not have this bifurcation here. Yeah, yeah, I think I like to see where dissociation fits into it. And I think there's something about shame. In the extreme sense, you get different personalities. You get totally dead to a dentist order.

No, I mean, I'm a little bit hesitant to think of it as like a different personalities. But what I'm talking about is like, let's say that trauma happened to that kid. And when they're feeling that shame, it's like, okay, they can either attack back. which gets them in more pain or puts them at more risk, or they can just kind of go numb, dissociate, disconnect from reality. And in the midst of that dissociation, I often see that shame so prevalent. But the dissociation I see as like the adaptive mechanism

to basically protect themselves from getting hurt worse. You know, like if someone's, yeah, something's horrible, it's happening to someone, it's like, so they take that that anger as being dissociated or like push down or and then kind of directed at themselves because it's most adaptive to so that i don't know that's i see it a little bit differently than how you've heard but i think we're on the same page with what you would do with it is to empathize or to hey it's it's adaptive to do that in that situation yeah often that part that self-hate gets cut off right you don't want to have it gets associated from

So it got me hard for people they even recognize that that's part of them. The feelings seem to come out of nowhere. The anger. Yeah. Yeah, the anger will be intense. And sometimes it comes out at the therapist because you're the safest person in the room. Sure. So sometimes that anger gets pointed at me, which I'm actually enthusiastic when that happens because at least it's not being dissociated.

Yeah, yeah. Yeah, so it's like a good step. also what you said so you're okay so you jumped from like the emotional awareness becoming aware of the anger emotional validation step two validating your anger's real so sometimes when they have that anger towards you right then they feel guilty they're like oh my god I shouldn't have done that my anger is so bad it's like no that anger's real let's validate that now maybe it's not a good idea to yell at me but like let's honor and validate that anger that you feel right because that's that's how you the emotional validation.

Does self-compassion? Go through that again? Like, what is, in your mind, being compassionate towards yourself? So compassion involves, like, being with your emotions. I think, like, if you break down the Latin,

it's, like, calm is with and pat-thai is something emotion. But it's like to be able to be like, you know what, it's okay for me to be sad. It's okay for me to be angry. Like, I'm human. Like, I'm going to suffer. I want to have struggles.

Like, it's okay for me. to have these feelings. I can be kind to them. Yeah, I have self-hate. I don't like that, but that's what it is. Let's be kind to it. Let's not get mad at ourselves for hating ourselves. That makes it worse.

That draws us further away from ourselves. Yeah, I like that. It's kind of like the emotional validation that we have for them gets internalized. So they believe it. Yeah, yeah. And when you can start doing that, these are the steps. Then you can start to really care for those feelings that are so difficult to care for. And then understanding the nature of emotion.

So then kind of like them understanding the cause. And you talk about not distracting or doing necessarily like a mindfulness activity to decrease the intensity of the anger that they might feel but to like more understand it. Is that what you would say? All of these things kind of work in flux. You're always, as a therapist, you're always want to get like a moderate level of brows. that's to be most effective. So if people are dissociated, you want to activate feelings.

You want to ask them about themselves. You want to help them feel their feelings. People are overwhelmed. You want to do like coping mechanisms like deep breathing, you know, count to 10, slow down. Because if they're overwhelmed, they're not going to be able to integrate and process these emotions. So you need to always want to go for that moderate level awareness. And you may have to do one intervention, the other depending upon where the patient's at. Okay.

Yeah, that makes sense. you mentioned in the book you often will say to a patient you can't change your feeling you can only change how you respond to your feelings tell me about that line yeah so a lot of people

I think with this kind of therapy is like oh if I just think differently I should really change my feelings and you can change about how maybe you take things personal or how you look at a situation but if you feel depressed or you feel angry you can't change that feeling and just make it go away

so you can't change your feelings but you can change how you respond to your feelings, which is like, okay, I don't have to act out with my anger or I can be kind to my depression. How we respond to it is going to then subsequently change what happens next with the emotion. You know, it's going to feel safer to express. It's going to be able to work through it. So then you're able to move towards like a memory reconsolidation or you're able to actually work to change the emotion when you can allow yourself to have it and be okay with it. Okay. Yeah. So this kind of comes back to that. You talk about how memory changes every time you access the memory.

That's where the research is pointing, that we never seem to have the same memory twice. Right. So, okay, so would you say that the goal is to change the memories over time? Do you think that's like the mechanism for what is... Yeah, I don't like the term memory of reconsolidation, so I've been calling it affect reconciliation,

because as therapists, we're not really trying to change the memory so much, We're trying to change the emotional nature of it. So it's not like, oh, let's forget your trauma or change the memory of your trauma. We want that to stay the same. What we want to do is to change the memory where something that's overwhelming is okay or something, me being worthless, now I can experience a sense of worth. Yeah, I'm working with this one client right now, and it's like the memory is moving from dissociation to anger.

and so in the dreams she's standing up for herself in ways that she wasn't before so before she would take a more passive acquiescing role to the person who traumatized her in dreams now she's yelling at the person standing up against people it's still distressing for her

it's like I want this to be gone I want this person to be purged out of my mind which she's entitled to but it's I see it as a great movement forward. It's like the memory, in the memory, the way that the memory is represented in the brain, which is now being represented in dreams, in different ways with different facets, but it's being represented in dreams. It's like that there's a movement into a different style of emotion, right? Yeah. It almost makes me think that like Elizabeth Kubler-Ross stages of

death and dying, where you have to kind of go through these emotional stages before you can finally get to acceptance and be. past, you know, your past trauma or whatever major life event you went through. Yeah. Yeah, I see that. I see numbness, disconnection, moving through anger, disgust. The first step to like denial, right? It's like, yeah, you know, this didn't happen.

And then maybe you start feeling angry. Yeah, I would put, yeah, denial and dissociation. It's like, it's like more of the defense mechanisms that sort of keep it from your conscious awareness, right? And even, you know, as... That's where your patient started. The patients started there. I think that when you first tell family members about trauma that may have happened to you when you were young,

they also start there too, which is disorienting to clients. Yeah, yeah. Like to, when the family members deny that that took place, oh, that couldn't have taken place. It's like, yeah, it took place because, but it's hard for you to consciously bear witness to that because it's so distressing. I think that's the defense mechanism we all have,

is that our first response over here, something overwhelming is to deny that that's the reality. Yeah, yeah. And then, okay, so let's see, I really liked the practical solutions to emotions that you talk about. For example, anger, you talk about how forgiveness is a practical solution. Can you tell me a little bit about what forgiveness is or how you bring that up with clients or what that means?

I've done an episode on forgiveness, but I think it's always good to hear someone's sort of own journey with what that means. Forgiveness and self-forgiveness. And I want to talk about both of them. Forgiveness means to forgive, which means to give back, right? So if someone hurts you and you're angry, you know, ideally, you want to give that anger back to them. That's their hurt.

They did that to you. Like, you don't have to suffer. You should forgive it. Give that back to them. Like, that's their problem. That's their hurt. You don't deserve to hold on to that. And when you can recognize.

recognize your anger. Remember, your patient can start to accept her anger more. She can start to forgive her parents who ever hurt her and give that back to them. That's not her fault. She did nothing wrong. That was about them. But oftentimes, sometimes even with forgiveness comes self-forgiveness because sometimes patients, like maybe your patient blames themselves or they feel responsible or they said I should have done something different. So that involves self-forgiveness, which means you want to give back that, you know, shame or that anger. You know, I messed up. I was, I did something bad when I was. I was, I did something bad when I younger, I want to give that back to my old self. I want to forgive that. But that's harder to

do because it requires kind of a second step, which is to really engage in self-forgiveness, you have to change as a person. Because that shame there, that guilt, which is about behavior, is a way to keep your behavior in check. If I feel shame about, you know, like my drinking, okay, that's going to keep me from drinking more, which is ostensibly a good thing. But then I'm carry on this burden of shame, which doesn't feel good. So I really want to forgive myself. I have to say, okay, I'm a different person now. I don't need to drink to cope with my emotions. I have a better way to handle things. And then I can really forgive my shame because I don't need to use that shame anymore to regulate or control my behavior, control what I am. So we can change as people,

we can recognize why we made the mistakes we did, why that occurred. Then we can let go of that guilt, shame, anger, sadness, whatever we have, that's our old self because it won't happen again. Yeah, I look at a lot of the forgiveness literature. I look at like Enright. I don't know if you've read any of Enright's forgiveness literature. He's like the, he's written all these books on it. And so I think it's, I've never heard that you, you just are giving it back to the person. I think of forgiveness as like you are doing it for yourself because it, you know, you realize like. Yeah, it's for you It's most beneficial for you to let this go in a way. You know, whether you're, you're not saying that the thing was right.

You're saying, actually, no, this was very wrong. What happened to me was wrong. A lot of people get messed up when they think that forgiving is just saying that, oh, it's okay. I'm okay with you doing that. No, what you did was really wrong. There's, you know, spiritual forgiveness and there's like secular forgiveness. So there's like different practices. Every spiritual tradition has forgiveness as part of, they've written about it.

So I think it's an important thing to look at across the spiritual traditions and sort of see how it's been an important thing because we all don't want to just get stuck in the cycle of bitterness and anger chronically. Yeah, that could happen when we don't forgive. Yeah. So, yeah, it's a journey. and I think I have empathy for people who have a hard time forgiving because it's very difficult. I think you kind of put your finger on it when you said oftentimes I think when people forgive, they assume that that means that the behavior is okay or that I'm saying that that's fine, which is not it.

You know, it's not, you know, justifying what they did. Forgiveness is all about for you and it's letting go of your pain because you don't deserve it. You didn't do anything wrong. Yeah. you know um so when i went through psychodynamic training i my main supervisor dr tar was very focused on emotions actually he came out of more of i think he kind of went through a journey like you said like it there was a very sort of analytic cognition time frame but then with the inner subjectivists and friends alexander the corrective emotional experience my so this guy was

actually taught by friends alexander oh okay so a lot of therapists saying that memory reconsolidation, which I just talked about, is very similar to what they would refer to, is that corrective emotional experience. That those are actually kind of the same thing. So the way that I understand the mechanism of change is the therapist and the therapist's connection with the individual is so pertinent to that. So I think that's where I would like kind of see where your thoughts were, if they're different than that. I think the focus on emotion gets you to the connection. But I think the experience of the patient not feeling shame from you, feeling your acceptance, I don't think it can happen in a vacuum.

Like I think if someone's listening to this, like, oh, I'm just going to do these steps on myself. Like, I don't think that's going to work very well. I tend to agree with you. I think there's a lot of implicit processes that we don't necessarily articulate or have the words for. You know, when a baby's born, you pick up a baby's born, you pick up. that baby, you look at that baby, that baby's crying. What you often do is you like, you kind of

like match their expression and then you're kind of like, it's okay too. You know, then you kind of smile and hold them, right? So what you're doing is you're joining them, you're validating their feeling, and then you're kind of regulating it by saying it's okay. And I think we do that nonverbally with our patients all the time. Is they're like, oh man, like, wow, you're really angry. Like we're expressing that, maybe even a little exaggerating. Whoa, that sounds awful. And then we're like, but it's okay. Breathe or all right. And then so we're kind of like mirroring them, matching them in some ways.

And that really helps them learn to express and regulate their emotion in an implicit process. That's pretty hard to just put into words in a book of how you do that, right? Right. So these implicit right brain to right brain, often attachment type of things. And so, like, I think with the anger, I don't know if I would say to a patient, though, it's all right. I would say you're entitled to be angry. And I would be okay. I mean, just like you're saying, like with the emotional validation, just sitting there and just being like, let's like, what does that feel like in your chest?

Yeah. Let's be angry. that tightness. Tell me what that tightness would say. I found like there's some links between your approach and schema therapy. I don't know if you've dug much into schema therapy, but it's kind of like an offshoot of CBT, like the people who felt like CBT wasn't working, so they developed like schema therapy to deal with these more like emotional processes. And they go back to the memory and they like they enter into the person's so they you know like let's say a person was driving and they got angry they might say to the person when was a time in the past that you felt similar and then oh this

memory of when I was a kid and this happened right and it's like okay that's the memory then they go and they look at the emotions they they try to enter into it with the person in like kind of a corrective emotional experience way so it's kind of similar to what you were saying I don't know if you've had any reflections on how you would differentiate your line of thinking and schemo therapy, it's okay if you don't. But it seems like you both, you're kind of joining the patient, right? Like you're validating what they're feeling, you know, which is kind of like similar to the process.

I don't think you're aware of it. You're validating it, maybe having some compassion more like, wow, it's hard to feel that way, regulating it in some ways where it's like, okay, we can feel that way and be all right. and then maybe trying to work with it. Like, all right. Can we feel that anger and also allow ourselves to be calm? Maybe we need to set a boundary with that anger. Maybe we need to forgive someone with that anger.

What do we want to do with it? Right. It's like, yeah, the anger often will lead to a visceral desire for a boundary, right? Or visceral desire for having a voice in a situation. Yeah. What about like emotionally focused therapy? You mentioned it, you mentioned how it has some influence on you, kind of like this focus of emotions.

Like is it, how is that different? How is that similar from your processing of how things work? Yeah, so it's very similar in that, you know, the focus on emotion and not kind of behavior or cognitions or insight like some other therapies. What I might say is different about my approach is that it kind of like outlines the steps a little bit more. and so you can kind of like see a little bit more kind of how to go through it. And it kind of provides some specific intervention. So emotion focus is kind of its own thing where you could be like a cognitive behavioral

therapist or whatever and kind of integrate some of the techniques that I'm kind of presenting. And emotion is all about kind of being able to express that emotion and have it. But it doesn't really talk through like the more kind of specifics, especially say the neuroscience of like, well, why do we want to match the emotion? When do we want to maybe set a boundary of forgiveness or utilize that emotion? And that, you know, I think it's probably just kind of like another building block on tops of all these like ways to do therapy. Yeah. Yeah. What do you think of the, these studies that look at like common factors, right? So it's like it's not necessarily a modality that makes a difference.

Oh, that totally fits in line with what I've been talking about because these studies are saying, well, the interventions don't matter so much, but the interventions are like cognitive reappraisal, you know, some sort of like insight. The common factor is like the therapeutic alliance, right? It's like the empathy. And these things are like kind of what I'm talking about in the book. And so these common factors, I think, are actually a lot of them are, actually really good therapeutic techniques.

They're just not identified as such because we tend to think of therapy techniques in cognitive behavioral terms. Yeah. Yeah. So I had Stephen Hayes on my podcast talking about acceptance commitment therapy. And then I was like trying to do an intro for it. So I was like looking at like, okay, how does it compare to, you know, CBT? And pretty equivalent for depression.

And I was a little bit like, okay, I. I'm missing some study here. And so my buddy who's like, he's a psychiatrist, he sent me this meta-analysis, you know, where it's like it's better, right? And so I looked at all the individual studies and I see the same thing over and over again. It's like, you know, I put this in my...

Go ahead. So I think mindfulness is a great therapeutic technique, right? It allows you to be aware of your emotions, which is the first step we talked about. It allows you to kind of have your emotions, but separate from them, like what emotions part of me, but it's not all of me.

But nowhere in there are you changing the emotion like you are with an intervention like memory consolidation or forgiveness. Yeah, I like how you differentiate those two things. Because I think a lot of people take mindfulness to the full extent of just continuing to disconnect from all desire, emotions. Now, mindfulness is... And you're not human, right? Of course you're going to be hurt.

You get traumatized. Of course it's going to traumatize you, right? It's ridiculous. The way that I practice mindfulness is actually through rowing. I go rowing every morning and I really focus in on each stroke. And while I'm focusing on the stroke, I have past traumas come to my mind of rowing races that I lost or, you know, times that coaches yelled at me. I was in like one of the most, I was in one of the top three programs with the coach with the most national championship. So every day it was just like, today we're here to win.

a national championship, right? So nothing was ever good enough. So a lot of internal critique, right? So I'm rowing now and I'm having a very different, I'm trying to get to a very different place where I can just like enjoy it, right? Yeah. And focus on each stroke. And then you have all these sort of self-critical thoughts that come into my mind and then I just try to like refocus it on the stroke. But maybe I need to do some more deeper emotional work on that as well. Well, if you were to take that example, I think that's a great way not to have those self-critical thoughts take over, right? That this is part of me.

It's not all of me, right, to recognize that. But it doesn't change the self-critical thoughts. To really change that, you'd have to kind of go back, have that thought and say, okay, I've been told them a piece of garbage, but I know I'm not a piece of garbage and repair that emotional experience to be like, you know what? like I can love myself in that moment. When you do that,

then you can have that memory without feeling so bad. Yeah. Yeah. Yeah. Yeah, I'm starting, temperature's getting a little hotter in here somehow. That's good.

Okay, so, yeah, I like, I like your initial chapters going through some of the science of it. There was one study that talked about autonomic changes in decision making. and I'll link this on my website, if you guys are curious, my research. I've said a lot of studies. Yep. Remember that one.

Oh, man. Yip 2020. And so it was looking at how emotional intelligence moderates the association between physiological measures of somatic markers and risk taking. Oh, okay. And so one thing that it seemed to me is that are we, when we're looking at like autonomic nervous system arousal, skin conductance. Are we looking at emotion or are we looking at autonomic arousal? Like are those the same

or different things for you? Oh my gosh. This is a great question. It was very insightful. I think that's a debate, right? And so if you look at people like yak Panskep, they're going to say like the arousal, the initial symptom, that's an emotion. You look at people like Lisa Feldman Barrett's going to say, no, an emotion is after, later. There's a cognition involved. You thought about it. it feels like this, right? So I think this is like an unexplored question that there's no good answer to, even if you look in the science, that like, what is arousal? Is that an emotion itself?

Or is that just a physiological response that then yields an emotion or feeling later? So a lot of this stuff, like that is based upon this like shaky bridge study where, you know, people went across the shaky bridge and they were aroused and then they misattributed that and they liked the Confederate or they didn't like it depending upon if they were able to attribute that arousal of something else, right? And one time they say, oh, well, their thinking is that they like this person. And so some people interpret that to support this kind of ABC that your cognition changes your feeling model.

And some people say, no, the arousal itself is the initial thing that's driving the thinking, and that the arousal precedes that. And as I look into this, it's like, nobody knows. It's a hodgepodge. You look in the brain, the cognitions, and the motions, they're all kind of entangled. Yes, and, right? Yeah. Yes, and probably more.

You know, I think it's like, sometimes when I think about the brain, like, you have a great chapter where you sort of summarize, like, here's all the different brain circuits. and I'm, you know, I've heard this stuff. And I think there's some interesting research where they look at like, like here's these brains that are lighting up and the correlation is like point two or point three or, you know, associated with depression or, you know.

But then I think like how many neurons do we have in the brain again and how many connections does the average neuron have? Like some have like 40,000 connections. Like, so you have like 10 billion neurons, some with 40,000 connections. Like, how do you, like, are we oversimplifying things? Like, are we... Probably.

Are we trying to grasp and try to make sense of this thing? And I think it's good that we do that. Like, I love looking at the... I love reading that stuff. But then I ask myself this question, like, like, okay, my brain can hold three to five things at a time, right? Working memory. Yeah.

So we have these brain loops that were like three, three to five things. But like, some of our neurons have 40,000 connections. Does that ever like the complexity of it? If you're asking,

do we oversimplify things? I think the answer is yes. I think whenever time we try to take something and put it into an analytical framework, you're always losing something. Do I think that's a bad thing? I would say not necessarily

because if that can form us to have better treatment, you know, to understand the brain better, to advance science, then it has value. Now, what we have to be careful of is recognizing that there is an oversimplication. We might be missing things. And to always be willing to kind of go back and question some of the assumptions and

axioms we base these ideas upon. Yeah. Okay. So arousal autonomic nervous system, here's what my sense is. Okay. So when I initially have someone talk about something right away, even before they say words, they flash a micro expression of emotion. Okay.

So as, for example, today, as we're talking, the moment you talk about this patient and you said something that made them feel shame, even before you told me that story, you flashed anger on your face. Oh, cool. You can look back at the video later and watch this. And so I knew there was something frustrating,

some anger. Now, I think if I got you to talk about that for a couple minutes, your autonomic nervous system arousal may go up and you may feel with that a little bit more of that fight and flight, right? That sort of like activation. But if it's too much, like you're saying, like we have to moderate the levels and you might go into dissociation.

So I see kind of, you know, the polyvagal theory, I think it has some issues, but overall I like the idea of like we have this very parasympathetic rest and relaxation state. We have this fight and flight state, which is like our hands are maybe a little bit cold. And some people that I meet, they're like chronically in this state. and we have to figure out how to get them into that more parasympathetic state.

And then I meet some people who are more in the dissociative state, you know, which is like more areas of the brain are shut down. And so I think when you talk about we need to moderate the intensity of the affect, it's like we don't want people to be dissociating, you know, in our office, at least for too long, like maybe initially as the memory was brought up. But then I'm looking for where's the emotion, right? because the emotion pulls them out of that dissociation because they dissociated away from the emotion.

So that's my like a thought of that process. You can pick it apart based on your research. There's a lot of those research supporting that you want to be in that moderate level of arousal where you don't want the person over the arousal. I mean, there's tons of psychotherapy interventions for coping with emotion and ways to do that. That's very well established.

And then, you know, you also don't want them to dissociate. So you have to bring them online. But you've got to be careful because sometimes when you activate that feeling, they get overwhelmed. So it's always kind of this balance. I wrote an article called affect reconciliation and affect regulation. It's organizing principles. And it's all about like being able to kind of activate emotion,

but then also be able to regulate it to it at the same time. Yes. Yes. I like, if you don't get to the emotion, I think, especially in people who are like a little bit more, OCPD, you know, obsessive, compulsive personality sort of, they may intellectualize away from the emotion. They may rationalize away from the emotion. They may have like, it's the intellectualizing, the rationalizing are different than how you talk about understanding the nature of the emotion

because it's like there's an aspect of denial in it or distracting away from it. So it's more of, they're not in that emotional awareness space yet, which a lot of medical, students actually have more of that OCPD because it's very adaptive for their, it's very adaptive for their journey to be. The medical school is very competitive, all that, yeah. It's high conscientiousness, right? Yeah. So I was thinking about that as well as when you were talking about when I was reading your book.

And I appreciate the rigor, the scientific rigor, the citations. I love, love, love a book with like 50 citations after every chapter. It just makes me excited. One thing I like about this book, I'll give it my plug, is like, I think it can be read at different levels. If you are not a neuroscientist, but you're starting out as a therapist, you can read it and still get stuff. But if you want to come back to it and you have an understanding of neuroscience, you can

read it and dig into the citations and really start, okay, what is the, what are the mechanisms behind here? What's going on? And so it's a book, I think, that can be appreciated on different levels of terms of just how to apply some of these techniques, you know, how it might fit into how we think about psychotherapy and other modalities. And then also like, well, what's the neuroscience? What's the hardcore science behind this that's driving why this might work?

Right. And I think in your journey and your hero's journey, it kind of was coming to a place of that initial like, okay, there's something else that I'm missing. There's a rigidity that I'm operating out of. And then I think that your intellectual journey through this material that you've presented here allowed you to sit in those emotions and not be and not and not have a sort of revulsion towards them or like I just want to get rid of these things but can I can I participate and be present with someone else's emotions yeah there's kind of a short autobiographical part in

beginning of the book because I really want to explain like why am I doing it this way what is like what's the meaning for me in this approach yeah yeah all right well I I appreciate your time coming on here, and I think we'll have more discussions in the future if there's articles that come out that are crucial articles for psychotherapy. Sure, I love talking about this sort of stuff, and you seem very intelligent and know what you're talking about, so it's just nice to talk to you.

Yeah, and we'll have to convince you to learn micro-expression because I feel like it's just so powerful to see the emotions, and then to know that that person flashed that emotion, I didn't flash the emotion. So I've read Paul Ekman's book and I checked out your page with a micro-expression, and I've knew this before, I'm horrible at it. This is not my foretank. Most people are.

And I love to get better at it and learn more about it. But like you told me I flash anger and maybe you flash micro-expressions during this. I didn't catch any of them. I'm sure I did. I didn't catch any of them because that's very difficult for me. Sometimes my clients will be like, you're staring at me. I'm like, yeah, I kind of have to pick up the emotion because it's not a natural thing for me. Well, just even attempting to pick up the emotion, you'll pick up more emotion and you'll empathize more.

There's a study that looked at that. They had people trying to focus on the videos of emotion versus the video, what they were wearing, and they mimicked the videos they were watching of emotion more if they were trying to focus on the emotion. And these are not trained experts. So even your focus on emotion will lead to you mimicking. and by mimicking, I mean, you flashing a micro-expression closer to what the person actually had as an emotion. So even your focus on emotion, I think, is allowing you to better connect with people. Oh, I definitely think I've improved, but it's just not something that comes natural to me.

Micro expression doesn't come natural. No, and it doesn't come natural how to use it, and that's where I feel like I've added to the field. And maybe I need your help writing up an article because you're much, better writer than I am, but basically the use of the micro-expression to empathize with the people and connect with them, because if I just tell someone, and I'm sorry I told you, and I imagine it stimulates shame or like something like that, knowing that I read your emotion. I didn't intend it to be that way, right? But it's like if I'm in session with someone, I don't point out like, oh, I saw your expression of anger. I more empathize with it and validate it, you know, because

because you're entitled to feel frustrated that you were like, amongst, like, wanting to improve your abilities, and then you were able to find a way through it, you know, cognitively. You kind of worked out that intellectual puzzle. So I appreciate it. I think that's how I had to do it. It wasn't going to come to me in a more natural sense. Yeah.

And you had some good guides, both in the authors and in the mentors and in the mentors you had. so and it's led to you putting out a good piece of material so i appreciate that oh great well hey we'll have to leave it there for today and i will talk to you soon sure yeah let's be in touch