Psychiatry & Psychotherapy Podcast - How to Fix Emotional Detachment

Episode Date: June 30, 2018

Do you ever feel out of touch with your emotions? Or have you ever felt like you had to hide your real emotions? When people do that—emotionally detach—they develop what therapists call "incongruence." Most therapy is actually centered around getting patients back in touch with their emotions. On this week's podcast, Ginger Simonton and I talk about the different methods we use to help our patients develop and maintain healthy emotional congruence. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join David on Instagram: dr.davidpuder Twitter: @DavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Okay, so welcome back to the podcast. I am here today with Ginger Simon Teng. a PhD candidate, mother of five, and I was just talking to one of our former patients today.

And I said, who did you most connect with in the men program? And the patient said, Ginger. And so Ginger is on this program because she is a truly excellent therapist. And, you know, not, I think a lot of times you'll, on podcast, they'll interview people over it in books and stuff. And that's great. We'll do that. But I think it's also really good to interview people who are unknown because they're just good therapists doing good work.

And I have the chance to run a program. And Ginger is a part of that. It's a program for people with medical issues and psychiatric issues. And so, you know, I'll show up one day or a couple days a week and see the patients once a week. But she's in the trenches there three, four days a week with the patients, seeing them, seeing their families. And I really appreciate that. So, Ginger, welcome to the show. Thank you.

Thank you, Dr. Peter. It's good to be with you. So today I want to zoom in on what it means to be congruent. And I think that this episode will be helpful for both providers, a psychiatrist or therapist, and I think it'll also be helpful for people. Okay? I agree. Just human beings who are curious on how to develop,

emotionally and psychologically. So what does it mean to be congruent? I think when we're working in mental health, to be congruent means that we allow our patients and opportunity to have an internal voice and an external language where the two are in parallel with one another. So what I mean by saying that's a lot like Virginus Seteer

talks about congruence, wherein the body has a language, and then we have a verbal language. So our goal is to make sure that the language, the experience that's being held physiologically, mirrors what's, you know, the verbal language, verbal is the process. So if a patient is feeling sad inside their body and feeling physiological symptoms of sadness, that they're able to match those physiological symptoms with a language that is indicative of sadness. Okay, so it's when your insides match your outsides.

Exactly. So the core of someone's like sort of sensations in their body are in parallel with what they're saying? Correct. So if, you know, our society, we're socially constructed to provide inaccurate information for one another all the time. So if I saw you at the market, you would, and I asked you how you were doing, you would probably tell me fine, good, something close to that, whether or not you are really feeling good or not inside of your physical body becomes an afterthought. But the point of congruence, especially in therapy, is to allow a person an opportunity to take what's happening inside of their physical body and give that language that matches. So if I am experiencing sadness in my body, that I have a capacity in a safe space to express that,

emotional process to my therapist or to hopefully then a loved one, someone with whom I have a secure attachment, that I'm able to be accurate in those places. So what are some of the common issues? So social construction, right? We're sort of from a young age taught how to be polite and how to be, you know, navigate, you know, not always being 100% truthful with how we are. What are some other issues that get in the way of people being congruent, common issues? Safety. I mean, safety can be a big one. If we were raised in an environment in our family of origin or our family constellation where there was childhood maltreatment, then being able to express emotionality in a proper way would have never been safe. And so we learned from an

early age that expressing emotionality is not safe because number one, maybe someone doesn't care, maybe two people can't handle it or three, there's just not anybody listening on the other side. So we learn through trauma, through unsafe experiences,

I think when we're children, that congruence isn't allowed. I also believe that there tends to be a major disconnect within at least our Western population between the mind and the body. And so many people don't even know what's happening within their physiological self.

They don't even know how to give it language until we establish with them a mind-body connection that helps them to create a language between their physiological personhood and then language to be able to express that and move it off the body. Yeah, one of the things that occurs to me is like psychological defenses, right?

Precisely. Like you're experiencing an emotion and you did like unconsciously choose to deny that it's there or like suppress it or push it down and instead you put on this or we put on this like sort of fake happy face or um you know just a blank face so any other thoughts on common issues how about common issues with men um specifically are you know are men that come into the program like naturally congruent or how are they natural? predisposed.

I'm really grateful that you asked about the gender difference because it's very fascinating how men present therapeutically, particularly in a group setting because, you know, the natural tendency is to filter information and to have a facade, which is the antithesis of being congruent as having a facade. Males tend to come into the program much more guarded than females because males are typically not socially constructed, not gendered to be able to have an authentic experience. So if we look at males across the board, you can pretty much guarantee that men are typically allowed to be angry because that's allowed in a male culture. They're allowed to be angry.

They're allowed to be quiet. But as far as like experiencing a wide range of emotions, that can be muted and dependent upon the family of origin and the culture, the level of, of, of, mutedness varies. So we tend to see men coming in really struggling to put language to their lived experience, really struggling to give language to their emotional regulatory process. And I just saw a patient this morning actually, and it took a while to actually bring him to a congruent place. And then even once they'll work with them to bring him to a congruent place where his body and his language mirrored one another, he still reverted. back very rapidly and put up a very guarded exterior.

So that's what we see frequently. Yeah, I think at first, because I was big into Myersburg early on and like the difference between thinkers and feelers. Right. But then one thing that I realized was that a lot of men come off as a thinker because they've an underdeveloped feeler. And that's kind of what we're talking about. It's like they they know how to pretend almost to look like a thinker.

to not relate in emotion, but we all, we all have a bodily emotional experience. And I think it's only through being a psychiatrist, being in psychotherapy myself for years, that I've felt more able to access that even. Yeah, so for you, for men, it's like that. Okay, how about women? What are the common distinctions for women? Are there any differences? are there, what emotions are allowed, what aren't allowed?

I think oftentimes, you know, this discussion falls along gendered lines. So where women are taught to have communion-based traits and men are taught to have agentic type of traits, women are comfortable to exhibit communion-based traits, nurturing, gentleness, kindness. And then the flip side of that would be like a mild or gentle sorrow, sadness. those types of what we would consider to be communion or could be considered feminine traits are all acceptable in group therapy. Wherein we run into a problem is if we have, say, a patient who has struggled with severe

sexual abuse, physical abuse, perhaps a multitude of childhood maltreatments, they have a difficult time becoming angry at the perpetrator because anger is an emotion that is not typically acceptable for females. And so you'll want to get a female, say, angry at a mother righteously for abandonment or for methamphetamine use, which we've experienced so recently, Dr. Peter and I, is patients who have had some substance abuse parents in their family of origin. And with righteous reasons to get angry and yet struggling to defend and struggling to find excuses for their loved ones because we're not really given a voice to feel frustrated or angry. Yeah.

Yeah. What about, um, we deal with a lot of people with like physical pain. Right. Physical pain is in like, you know, they're diagnosed fibromyalgia, irritable bowel, chronic fatigue, TMJ, chronic headaches. What do you notice with them and any issues that are unique to that sort of population and becoming congruent? I think that's an absolutely excellent question. It alludes to a lot of the work that we're doing in the room and that I know you're following up in your own therapeutic space.

And that's that oftentimes when we have physical, biological physical issues that are comorbid with mental health issues, it becomes very difficult for the patient to bifurcate or parse out what part of their experience is actually physical pain and what part of their experience is actually physical pain and what part of their experience is emotional pain. And so what we'll do is have the patient start to chart like, if I ask them, what is your pain today? They may say their physical pain is a seven. The reality is probably that their physical pain is closer to like a three or a four, but their emotional pain makes up the difference. So we start them tracking. Okay, so maybe today you have physical pain out of seven, how much of that number seven are you willing to give to

emotional pain? Are you willing to give even 0.5, even one, even a two, how much can you possibly transfer over to emotional pain? And that begins the process of becoming congruent and getting this off the body. Like that's always the primary goal is the talking is important, but moving it off the body and getting this lived experience into language and getting the pain off the body and the emotional process off the body, I think that's where it becomes, the work becomes so rich. I love that. I love that. Getting the pain off the body. It's kind of as if the body bears the bird and the body carries the score. You know, there's lots of different ways of saying that. Of emotional trauma, of, you know, emotions that are unprocessed.

And how do we get them to put that into words in a way that actually resonates with the core of their being? Yeah. That's the vital part of congruence, I think, is to give them an opportunity to move it from their inner subjective experience to the external world and then look at it and hopefully recreate a meaning around it because the fundamental piece of this is to stop. the internalization of pain and externalize it. So we can move it off of the body. You said the body keeps the score, does a beautiful job of talking about that process of understanding how the body is holding trauma, you know, that's such a deep level. Yeah.

So, okay, so you're trying to help someone become congruent. How do you do that through art? Well, art is a beautiful way to aid in the process of congruence because it bypasses the frontal lobe. And so when we have somebody coming in that's really having a difficult time getting in touch with their body, making a mind-body connection, then if we allow them to engage in an art-based process, it gets some of their experience, you know, onto the canvas. And then we can deconstruct it and process it afterwards as. a group or individually, then I can use that art piece in therapy with the family and the couple outside of the peer group. So essentially what we get captured on the canvas is always pure and unadulterated because the art, if it's, you know, the art is always coming from a pure place

within the body. And if I can't get anything else, I can always start there and find something within the art that's accurate. Once I find one piece of an experience that's accurate, I can begin to scaffold. So if I just have something about a person that I see, like, if they break cover for just long enough for me to see inside for a second, then I can scaffold and start to build. It's just, they just have to break cover for long enough for me to get like one way in. I love that. And you're really good at that. Thank you. Yeah, I was thinking about my son. We had we had gone to a coffee shop and he had done this. I'd take water pastels and I kind of draw a little sketch for him and then he paints it.

And this morning he was finishing it. And then he took a green marker and he crossed it out like multiple times, just scribbled on top of it. And I was just like, oh, it was like this really beautiful picture of a cat. Oh, you showed me the picture on, yeah. And I'll post this on Instagram actually. So you guys can take a look at this. But the thing that I'm realizing now as you're talking is that's totally a representation of what happened this morning.

We have a brand new cat, a little kitten, and the kitten bit him pretty bad. And he was like really upset at the cat. And so he takes his green marker on the cat's face, you know, and like smears it around. And to me at the time, like I didn't get it, like why he was like so upset, you know, and it was a difficult morning. but there you go, a two-year-old, right? Living out has lived experience an authentic way through art. Oh, beautifully said. I love that analogy. Yeah, you're right.

What, specifically with the art, what kind of surprises have you had in the past when people do pictures? Any pictures come to your mind that really were like, oh, okay, wow, this is what's going on? Well, I think you asked because we had this big moment. you and I this week where we were deconstructing a patient's artwork. And so we were blessed to share in that experience together. When art is a patient's congruent space for processing information, their art is so rich. And you and I have a patient right now that we're blessed to work with. And her art is absolutely stunning and that she felt that her inner child was deceased. And we had decided that that wasn't possible because there was enough hope living inside of her to bring her into an intensive outpatient program. And so she was able to recreate the inner child through art in a beautiful and moving way.

The fascinating part about her art was that it called into question whether or not she, you know, how much of her experience ever was devoted to childhood because she painted her inner child as like a much older woman. And then she, of course, went back and constructed hope as a part of that process. So, you know, you and I were able to glean so much just from seeing how she viewed her lack of childhood. Yeah, that was, gosh, maybe I'll ask her if I can post that anonymously. It was very beautiful. Because it was, it's like, wow, that's like, it's not only like really beautifully done, like a piece of art, but it's just like really, deep and frightening as well. That being the core of her being feeling dead inside, but then feeling like a kind of a

glimmer of light. And, you know, this is someone who really wants to get through this and she's doing the hard work and doing therapy is hard work at that level. And, you know, there's really good reasons why people feel that bad and it's legitimate. and she's entitled to feel that way. And I think she's doing the work and she's starting to talk about it. And that's brave. That's really brave.

It's very brave, particularly when you're coming from, like, the way that I view in her child work is so pure and her capacity to be resilient in the face of polyvictimization, multiple traumas from never really knowing a secure attachment. her capacity to at least show us how she interpreted her inner child was profound. I still think we can push in a little bit more on the hope aspects of the painting and probably get a little bit clearer picture of who the inner child is without the core belief being there around the depression and the darkness. Yeah.

So I don't use the terminology inner child very much. And there may be other people who don't kind of see where that's coming from. Can you define what that means and kind of put that into other words? Maybe that would help me make sense. Inner Child is a word that I use frequently. I'm very surprised that I've come to use it so often because being an MFT, it wasn't something that I learned a lot about in college even. But I think because in our program, Dr. Peter and I do so much work with individuals who have suffered

such an extent amount of trauma. Of course, we know that early childhood experiences translate to poor physical and mental health outcomes, and so our room is filled with people who have early childhood trauma. I think of the inner child as that little part of yourself that the God of your understanding created that's untouched and immune from the atrocities, perhaps, that have been put upon us. And so from a spiritual perspective, I guess I say, see it as like the core of who we are, who we would have been without the damage, the things that happened to us in childhood. So when we're working with patients, the inner child becomes vital

because we want to go back and try to cultivate like a secure attachment with that inner child so that we could reparent ourselves. And that's the goal is for the patient to be able to go back and realize that they can show up for themselves. even those tender parts of themselves in a way that's going to be consistent and respected and nurturing and gentle and that they can give that to themselves on an intrinsic level. So I guess it's kind of an externalization of sorts. Yeah. So the authentic self, the real self, which has been highly protected through the midst of trauma.

and I would say that this is the like when we talk about congruent, we're talking about living out of this space and maybe not in all contexts because honestly it's probably not a good idea if someone's super unsafe to be that way. So not in all context, but in some contexts of life. So how do we help them sort of feel

into that, that sort of strength, right? That part of them, that is the most authentic and the most protected in other ways. So are you saying, like, how do we give them an opportunity to step into that? I think that's the bigger question of becoming congruent. I don't know if you would state it differently. No, I have to completely agree with you. I think that teaching a patient to be able to step into that, like new way of being and own that requires going back, helping them to feel secure and safe.

We do that in the peer group. I will do that with my patients to make sure that they have a safe base, a safe person to work with. So a lot of the work that we're doing in the room is safety-based, forming deep attachments so that the patient's physiology is able to, perhaps for the first time, understand what secure attachment feels like because many of our patients have no context physiologically for how secure attachment manifests within the body. So we want to make sure that within the mend room that they have the capacity to experience

secure attachment within the context of their physical body. Once they get that feeling, that feeling is this new experience into the body. body that they've not had before. So sometimes the patients and I will joke, and the men team will joke that it's like if you've only ever had blue skittles, it's like someone give you a red skittal. And it's introducing like a new state of being into the physical body. And that typically feels so good for the embodied brain that the patient wants more of that. And so what we do is just guide them into a place where they can have more of that.

And then as they get more, their body becomes accustomed to what health feels like. And that's how come the mend model has been successful in improving biopsychosocial outcomes, health-related quality of life, is because we've been able to reduce stress in the body by creating these healthier ways of being that subsequently improve health. Yeah, yeah, I think it's really good. And I think, so intense valve patient programs usually meet three days a week, three hours a day. Partial programs meet seven hours a day, five days a week starting out. And a lot of them have one hour of process time.

And what we do differently is we have like the whole time is process time, which can be like really emotionally exhausting for some patients. do you find that that level of exhaustion ever gets in the way of doing becoming containing or no continuing to be congruent? No, I like it. I think that the important part is to, we do consider each of the hours process, but to make sure that not each of the hours is an intensive process for each patient. So I usually work my patients pretty hard in IOP for the first and second hour. And then for the third hour, we kind of pull back a little bit and wrap up and enjoy the peer group support. Maybe we'll listen to music and chat and make small talk because those are still important parts of them learning how to socialize in a healthy context.

But yes, long-term processing is not always healthy for a patient. So learning how to break it with art, with projects, particularly for partial patients, their day is long. with snacks and lunch and I think all of those things do help make sure that the patient's ego strength is able to stay intact over the duration of the treatment day. It is definitely the role and responsibility of the clinician to control the timing and temperature in the room and to make sure that the patients are able to withstand the level of rigor that's being doled out. Yeah.

Yeah, that's good. Okay, so you have someone in the group who is able to, to be congruent in the group with other people other than yourself. So they meet one-on-one with the other patients and can be congruent. And they're connecting. And that connection is pleasurable. And that is very powerful. But what happens when you send them back into the world, back into their family structure?

What happens then? Well, that's, of course, like the million-dollar question. I like to think of men, hopefully, as being highly systemic. I know myself, I'm constantly doing family sessions, couple sessions. I just met this morning with a couple, just had another phone interview session before you and I met because involving the family system is critical to ensuring post-post outcomes that we want to make sure that we're able to establish for our client's health. And so we're doing that through the sessions, through making sure that we have systemic buy-in.

And the other thing is making sure that we're testing them when they come back. So if I see them on a Monday or Tuesday, then I'll test the quantity, quality, and duration of their stress response over certain issues to see if they are being able to withstand the rigors of home life. And if they're not, then I need to do more work to make sure that I'm reducing the meanings that they have about themselves that are not healthy that are actually enhanced. illness activity. And so it's just a matter of monitoring stress on the body and making sure that the family is being supportive. So let me put this into my language and you tell me if

you agree. So what I've seen is that when we're able to do family work, when we're able to bring the family in and we basically what I sense is that the family, they learn how to get the connection between themselves. So it's not like they're dependent for this level of connection on you. So they can get this connection from their spouse or from some of their family. Whereas, and that's like really super healthy. Right. That's the ultimate goal. So like I tell my patients all the time is when they first come, all they have to do is make it to the front door. Like I will take care of the rest. Even on their worst date. I just want them to get to the front door of Dr. Peter and I's building.

And then I can take care of the rest and he can help facilitate on his end. And so the men team is carrying a tremendous amount of the load at the onset. I want the patient, their body to feel secure with me. I want their body to be in a place of comfortable homeostasis so that they can start to begin to understand what trust and security and safety actually means. And then after they become more comfortable within the program, then they begin to take over more ownership of their therapeutic experience. And so, you know, when they first come, they think, oh, I could never be without, you know, Ginger or Sean, my colleague, or Jesse.

I could never be without Dr. Puter. And okay, I can understand that. But come about when they get to phase, like phase three, they're ready. They know. They know. know that they don't need us. And then by phase four, according to the mend model, when they actually graduate, they don't need us at all. They're completely ready to move on. The process happens so gradually for patients, I don't necessarily think that they're consciously aware that their initial need for us has titrated down to where they're actually ready to function in the wild without us. In the wild. So I want to put some like some teeth to this because what happens, for a while I kind of launched my own program and through, you know, the birth of my second child,

I kind of decided to shut it down. And I was dealing with psychosomatic patients. Like, we, for the time we had men dealing more with like the medical patients, like diabetes, cancer, stuff like that. But what I think the program missed from the current model that we're talking about is this family therapy. And the family therapy, really, I mean, I don't, I don't think we're paid for this. I think that's kind of like the unique part is like the therapists here are like, like yourself are so passionate about what we do that we're like, hey, let's just do it, you know?

And what I saw happening, because I follow these patients after men for years is the ones that the families were not worked with, they go back to their family and their husband or family structure wants to keep them ill. And that may come off really abruptly odd to say, you know, to someone who hasn't really thought about this. But the family is rigid and wants to keep them like they were and shame. And, you know, they try to share congruently and the family just shuts them down and over and over again. Speak to that a little bit.

Well, unfortunately, that is very accurate. As human beings, we like homeostasis. We like to keep things the same. Illness brings a lot of things into relational dynamics that controls power. It controls closest and distance. So it's not uncommon for our patient's family systems to have something to gain out of the patient remaining in their old way of being and maintaining the homeostatic pattern that they've been accustomed to for years. When we don't have the family system on board, it's very difficult for the patient. patient to maintain because of the pull of the family to bring them back into that feedback loop.

Let me put some, like, details on a common dynamic I see so we can move it out of the theory just so people can understand this, maybe on a different level. What I see is, like, you'll have a child and parents, and the parents are, like, in rough waters, they're about to go through a divorce. A child gets ill. all of a sudden, family is peaceful again, right? Family's focused on the person getting ill. So what happens when the parents start arguing again?

The kid goes ill again, over and over again, right? So, you know, I've seen this where it's like the family will get stuck in this pattern. And no matter how much therapy the kid gets, if the parents are still behaving in this way and giving attention to when the child is ill and not connect, you know, having a very sort of tremultuous sort of relationship, that the dynamic continues. Clearly, yes. And the interesting part, so yes, Mendez's Pedes, and that's something that presents itself regularly in Peds, for you and I doing adult work, I think about like Salvador Manuchin when he talks about Alice in Wonderland and she eats the cake where she grows and gets big.

So the trick in family therapy is to make sure that when the patient begins to grow, that the house grows at the same rate as Alice. Because if I grow a patient larger than what the house can't support, then clearly the patient is faced with two choices, both being very difficult. One, return to illness or two, make a change to the family system. And this is something that has presented itself in our work on more than one occasion where we've, you know, if someone's in a marriage, they entered into a marriage. you know, from a broken place.

And so the marriage is unhealthy. And then we heal one of the partners. And then it's just like the Alice in Wonderland paradigm, right, where all of a sudden now Alice is outgrown the house and we have to make a decision. So tracking that, monitoring that, trying to make sure that we get the family on board can also mean. Providing a lot of couple work, a lot of family work. And if they're still resistant, then we have to hope. that the patient is differentiated enough to be able to sustain after they leave.

Yeah, and just to be clear, I mean, I can't think of very many cases where divorces occur while the patient is in the program. Like, I can't think of one case off the top of my head. But I'm sure it's happened just because statistically people get divorced. I was also thinking back to my in my analytic training. One of the supervisors talked about how often when one of the members of a couple went through analysis, it really created a strain on the relationship because they psychologically matured and the other person stayed the same. The key thing I want to connect with here, though, is in the family,

dynamic, how do we help the couple, help the family connect outside of illness, okay? So the illness may be something that's helped them connect in the past, but I think what we really try to figure out is like, how do we help this family connect in a healthy way? Right. So that's, you know, moving them away from having an illness-based attachment into having a secure and healthy attachment. So define illness-based attachment. So an illness-based attachment is where within their relationship, there isn't a secure attachment based on my real self connecting with your real self and us creating safety therein. What happens is all of the communication, all of the experiences of the relationship are being funneled through illness. So it's sort of like

Bowenian, right, where if we have a triangle between husband, wife, and illness, then everything's being routed through illness. Instead of people being in love with one another, they begin to connect and join through the illness process. An example would be a patient, an elderly lady patient that we had recently. And this patient was so incredibly dedicated to wellness, but her relationship with her husband was completely centered around going to the doctor, going to the pharmacy, where else would they? going to the hospital, multiple appointments.

And so when I asked her originally, how are things with you and your husband, her comment back was wonderful. He takes me to the doctor, the pharmacy, the hospital. I said, but what does he do for you as a woman? And it was sort of like, oh, but no, he does all these things for me. And so the hope by uncovering the illness attachment is connecting people back to their real self. and away from illness. One of the things I appreciate is how you guys have the room introduce themselves.

And I'll hear, you know, at first they introduce themselves as, you know, hi, I'm Joe, and I have diabetes and heart disease, and I'm on my deathbed and things are out of control. And, you know, it's like all of the bad things that they're going through, all of their illnesses are like the first thing that they put out there. And then you guys will say, okay, now I want you to go around the room. and I want you to identify yourself as who you are. And who you are like as a unique individual, you know?

So I am David and I am creative and I'm passionate about my children and, you know, like that, right? Any comments on that process or what you've seen there? I think that process becomes really rich when we start to look at it. We can do it on the whiteboard, do like a large exercise where we will deconstruct the illness narrative and look at the illness attachment that's that's there with it. So what happens is people get so lost in illness that they truly forget who they are outside of it, especially when you're talking about multimorbidities. They're managing so many illnesses at one time. And so what we'll do is go around the room then and have like everybody in the peer group

make a comment as to what that patient is without illness. And so, So we'll write it all out on the board. So let's say the patient's name is John, then we would say around the peer group, you know, what do you know about John that's like character related, that's, you know, something good about them that's not illness. And we'll list it all out on the board and say, okay, so these are all the things that make up John. And these are all the things that illness says about John. And these are all the beautiful things that are about John.

The reality is John may have been stuck in illness for so long that he has forgotten all of those core parts of who he is. I love that too because it's like that positive interpersonal feedback. You're having the other people in the room tell him, right? And it's not just you. It's not just relying on you telling him. And people notice things, you know, and people can think of things that they're grateful for

and things that they've, you know, things that they've seen. So that's really cool. I really like that. Okay, how do you help people body scan? Do you do that? Body scan. Body scan to become congruent? You mean like interception?

Yeah, interception. Define interception. I'm probably not the best person. I like to think of interception as like establishing a mind-body connection. And the way I start to do that is by helping patients, first of all, to understand that they have a body. Because typically, I think as, especially in our current culture, we are very disconnect. from our physical body. So the idea of checking in with our physical body as a roadmap of our experiences

is something very, very rare. And so we start to establish, connect them, like their embodied brain, if we want to think about Dr. Sagle, but connect their brain and their body together. And that begins by first bringing consciousness to it because people are like, why are you asking me about my body? Right, right. And that's their first reaction. It's like, what? You're asking about my body.

Like, why would you do that? I'm here for psychotherapy. And so when we have the opportunity to say, no, what is your body feeling in this moment? And the most beautiful process happens because when a patient begins to experience congruency, it means that they're able to work in real time, which means that their body's, their emotional regulatory system is completely accessible. So if their body is feeling something that may be really really, to like a trauma memory, something from their family of origin, then I can say, how does your body feel? And the patient may say my body feels clammy and hot,

and my heart is beating quickly and, you know, et cetera. And then my next question is, and so what emotion do you want to tie to that physiological process? Yeah. And the patient may say shame. And then I want to ask a follow-up question to that, which is where the real work, exists and they want to say, when is the last time that you remember your body feeling that way?

So I won't accept an answer because you and I are working with an adult population. I won't accept an answer to say like three months ago at Walmart or something like that. No, I want to push into the family of origin or at least close to the illness, close to the time of trauma, and know what memory that bodily sensation attaches to. So if they say my body feels clammy, hot, sweaty, I associate that with shame. The earliest time I remember feeling that was perhaps, you know, when my mother, this was a recent one, when my father was beating my mother, you know, in my childhood. Yeah.

Yeah. From that place, we're able to look at the meaning that that trauma has associated to it. And once we know the meaning, then we're able to start the process of creating second in order to change. Okay, so, like, what do you mean by meaning? So, like, in that sort of moment, when that person went back to that domestic violence sort of going on, what meaning was, so you have the bodily sensation, you have them in the memory.

Do you ask them, like, what meaning or what are you asking them to get to the meaning? So once they're deconstructing the trauma, verbalizing the trauma, then my goal is to see how they made meaning of that experience internally. So as human beings were meaning-making creatures, we're always making meaning of experiences. And so especially during key developmental periods in childhood. So if things are happening during these key developmental periods of brain formation during childhood, I want to know, okay, so mom and dad are having this terrible domestic violence-related argument

what does that say about you? And the patient may say, it said that they didn't love me. And so my next question is, if it says that they didn't love you, what does that say about you? And they might say it means that I'm unlovable, which allows me to understand that from that moment, their inner child made, because they're children at that point, from that moment a paradigm was created in their brain, a meaning-making experience was created within their brain that has probably underscored, undergirded their socio-relationships from that time on to a degree because they had, they believed that they were not lovable. And now they're with us, you know, however many

years later, still struggling in the face of this construct that they're not lovable. That is, that's good. That I'm just like really excited to learn to hear this all again. Yeah, it's so fascinating. We are passionate. You know, treatment team has not always been this glorious. And as I'm sitting here, I'm remembering back to the early days of working with the team. And because we talk about,

we talk about illness narratives. Right. Right. And at first, like, you know, I knew how to give good empathy, right? And I was trained kind of in a more, you know, just give empathy, empathize with pretty much everything comes your way. And so what that would do sometimes is it would derail what was going on in the room. And because I would co-author, unbeknownst to me, and set the patient back a little bit because I would co-author some of the illness.

Any examples of that come to your mind off the top of your head? And it could be not me. It could be like another treatment physician because we see this actually happen like when they go back to their, you know, ultra-specialist, you know. Someone has like some rare zebra illness. They go to their super specialist and their super specialist tells them like, absolutely you have this illness, you know? And like, I don't know what that doctor's talking about, like feelings, you know.

Or that's not exactly what I would do, but, you know, any kind of thoughts about how providers, how psychiatrists could potentially co-author an illness narrative? I think that happens probably frequently, particularly within our traditional medical model, because physicians are trained to treat, and that's what their hope is to do, is to ameliorate symptomology. And so that's the hope. I don't know that, you know, men as created within like a psychosocial, I would venture to say biopsychosocial framework, which hasn't fully taken off within the traditional medical system. A big part of our work is then is realizing the connection between stress and the body and realizing how the body can actually heal itself. It's easy for a physician

to co-author a patient's inaccurate meanings if they go to the doctor and the doctor wants to, say, prescribe medication that the patient doesn't need or give a lot of language to illness or pathology that perhaps could otherwise be medicated by the patient. So if we take like you and I deal a lot with PNES seizures or pseudo-non-epileptic seizures. And, you know, that's something that the patient with proper therapy can most oftentimes correct. And so otherwise a physician may give energy to those places and give energy to these illnesses that a patient could potentially ameliorate on their own.

Yeah. So I think that, you know, thinking about a lot of people practice. in the community where there are not good access to therapists, it's unfortunate, you know, because a lot of people's issues that they come in with are therapy-related. You know, I was just reading statistics and, you know, the amount of prescribing of medications has gone up, but for those people who are on medications, proportionally, there's a decrease in therapy. So it's something like 30%, and I'll put the exact, well, it's already on my website.

30% of people who are taking medications are in therapy, where I think it should be like, you know, mostly people are in therapy and the severely ill, you know, need medications. But unfortunately, we don't have the sort of caliber, and I'm blessed to have good therapists that I can, you know, do this with, which allows me to decrease medications, actually. A lot of the time, a lot of the time patients come in on, I don't know, six or seven medications, believe it or not. And by the time they're done, you know, it's decreased significantly and can continue to decrease it. I see a lot of these patients long term.

And a lot of them, you know, do really well long term. So they can essentially decrease medications. Yeah, any thoughts on how medications can interrupt the process of being congruent? Have you seen that? both drugs of abuse and psychological medications. I definitely think that that has the potential. When you said seven to eight medications, that's completely accurate. When patients first come to us, it's not uncommon for them to be taking between 20 to 33 pills a day.

And so... Not all. And all sorts of different medical issues. All sorts of different medications for assortment of different issues, different physical and mental health issues, yes. But that's the level of medication that we're actually seeing. And I think that it's been great because you and I share a common philosophy around like let's titrate down as much as we possibly can to allow the patient to be in a congruent state because the primary goal of a men therapist is to access the patient's emotional regulatory system.

If there's so much medication on board that that becomes an impossibility, then my work is very, very difficult. So oftentimes if we have patients that are using substances, Dr. Peter will work with our nurse to make sure that they're able to stop using substances that we provide treatment options to help them to stop using substances. If it's like illegal drugs, street drugs, we see marijuana now, possibly more than before. And so it's still impossible for me to do psychotherapy.

on somebody who is high, you know, for lack of a better word. And then, so we have to get control of that. As far as the psychotropic medication or the pain medication, which you're so good at getting the patients relieved of, when we get some of these other meds off the table, then the patient's emotional process becomes accessible to me. I like to think of depression as not necessarily, not necessarily, an emotional process, but actually the process of being devoid of emotions, like completely numb from emotions.

And so our patients are very used to depression and the numbness, the void that comes with depression. But our goal is to help them to start to feel a range of emotional processes, including sadness, sorrow, anger, frustration, and then, of course, the more positive if we want to say emotions, but we need to get through the medication block to be able to access those painful emotions that are going to allow the body to heal. Yeah, and I have about, I think, four episodes up prior on Sensorium. And that's really what I'm looking at when they come in.

I'm looking at how do I optimize their brain function so that they can best succeed in the psychotherapy process. And, you know, I do not blame patients for where they're at. I mean, people who smoke marijuana, people who use drugs, I think often they're doing the best they can. Now there are some people who use drugs and enjoy it and that's just like, that's their thing. But I'm talking about people who are struggling from trauma, from other stuff, and it's like being on drugs allows them to cope with the realities. What I find is that once they get in a group and they're committed and they believe in the process, then you can start to take them

off of stuff. And, you know, first goes the benzos, any anticholinergic medications. If they're on opiates, we'll reduce the doses. And, you know, very slowly, sequentially, once a week, you know, a lot slower than you would do in a detox center. And sometimes we get a person to a place where we're like, okay, they need to go to detox because they're on huge doses of opiates and, you know, benzos. And it's just easier to have them go for the weekend, you know, four or five days detox and then come back to the program. But what we found is that you have to build the connection before this happens. Like I can't do this to someone who's just a pure outpatient. who I see once a month. You know, if they're not in really good psychotherapy, if they have a good psychotherapist, like a once a week or twice a week, they can often do this.

But what, I mean, this is like, like really helpful to have a treatment team that's, they're there, a couple days, you know, three, five days a week. Because in that context, they can, they can process the emotions in ways that allow them to not need the medications to blunt it or need alcohol or need marijuana to blunt those emotions.

No, I completely agree with you what you're saying about taking the meds away or the marijuana substances away. First of all, we have to have something to replace it with because that could be their primary coping skill. Right. And it's obviously helping them to. numb out, given that they're in the first category of population that you described as far as people who are struggling with trauma and trying to kind of numb that process, then we can't just

take it away and leave them with nothing because that leaves them vulnerable and exposed. And at that point, it could be dangerous for the patient. So we want to make sure that they're completely bought into the program, completely bought into myself, my co-therapists are students and Dr. Peter so that they know that we have, we have have 100% support them, that we are completely on board with them and that they're already learning healthier ways of being so that it's kind of a get, like sort of watching an adjustment, right? So they're giving up the maladaptive coping skills as they're gaining adaptive coping skills and it's kind of leveling out from the maladaptive to the adaptive, kind of in a continuum,

perhaps? Yeah, I like to think of it as like, okay, what are you getting out of your substances that you really want, oh, I'm getting peace or I'm able to sleep at night. How would you like to do that without the substance? How would you like to learn how to find peace in your body? And I get it. Like a lot of people, like, they bury so much of their psychological burdens in their body. They just don't feel comfortable in their body anymore.

Like a lot of the patients who come in are like, where do you feel no pain? It's not where do you feel pain because they'll describe almost everywhere in their body. It's like, where do you feel no pain? okay in your face right there on the top of your head okay well that's that's the place or like on your chin that's like the one place in your body that you don't feel pain okay let the shower hit there in the morning and just wake up to your body at least some part of your body not feeling pain you know or like um yeah anyways that's just kind of me rambling about how how much suffering there is and and you know it's real pain people people feel

pain, psychological pain and physical pain in the same brain circuits. They feel it in the same areas of the brain when it's chronic. And so, you know, emotions, pain, one and the same thing. Is it all in your head? Is pain, is the pain all in your head in the sense that it's all psychological? No, I think you're feeling it physically. It's actually physically being represented. But can you get it out congruently? Yes, I think so. And, you know, some people, have physical pain. You know, they had a surgery. They had 10 surgeries.

And I've seen some of these patients detox and actually have less pain off of medications after a good, you know, stent in partial, which is really freaking amazing. Yeah, I couldn't agree more. I love what you were saying about the body just being the conduit of all of these painful experiences. think about the work that you and I do and the patients that we see and how burdened their physical

body is by emotional and physical pain. And it's interesting because we were having a conversation about like the SES and different demographics of our patients in a meeting and a men team meeting a while back. And I was explaining to some of our other team members who don't work in adult as much that it's difficult for us to even tell who has a higher or low SES or anything like that in our program because everybody's body's showing up the same burdened by illness. And that seems to be something that's been pervasive across just about every single one of our patients is that their physical body feels burdened by illness and the internalization of illness meanings and inaccurate meanings and painful traumas.

So yeah, I couldn't agree with you more. Yeah, so socioeconomic status, you know, the super wealthy that come to the program and the super poor, you know, people on many, many Medicare, both of those extends, their bodies show up in the same way. Sometimes they, you know, like if super, you know, like wealthy people will find a certain cocktail of medications and the super poor may find a very similar. cocktail of medications, but street ones, but they're the same thing, right? I mean, so it's like psychological issues affect both populations. Yeah, I agree with you. I'm glad that you said that actually because it really validates what I had thought to be accurate, you and I have never talked about the SES and cultural underpinnings

of our patient load before. So thank you for sharing your thoughts on that. I appreciate that it validates what I experience. all the time, which is that it doesn't really seem to matter when illness and trauma are on board, then we seem to shake out in the same way for each side of the scale. Yeah. Well, I've been really blessed to work with you, Ginger, and I'm glad you've stuck in around and continue to be devoted to our patients.

And, yeah, any other final thoughts you want to throw out there? I too feel richly blessed to participate with you and the men team. My colleagues, as we're able to, I think that the men, what resonates with me the most is I think our work moves towards the overall mission, right, which is I think we are working to make a man whole. I think that we are working to alleviate stress in the body and improve health-related quality of life. And what I love about our team is that, you know, we've demonstrated outcomes that support that, that we can feel excited and proud about. But I think the larger issue at hand is the reality that there are many models out there that demonstrate that they can provide relief for psychosocial issues associated with childhood trauma. What makes our work rich and unique is that we're able to say through our outcome measures that we're able to reduce physical, mental, and sociolational issues for individuals who are struggling in the face of childhood maltreatment

and the manifestation of that within the physical body. And I think for that we're richly blessed. Yeah, I'm going to put a link in the show notes to the Mend Manual and to my website where I'll put some more details on this stuff. and if any of you have any questions, go ahead and post a comment on what I will link. And I hope that we can continue this dialogue, Ginger. Yes. And I'm sure I'll have you back on to zoom in on one other aspect of just psychology and helping people develop wisdom and empathy for the patients they treat.

Oh, I love that. That would be wonderful. Thank you. All right.