Psychiatry & Psychotherapy Podcast - Therapeutic Alliance Part 5: Emotion

Episode Date: October 3, 2019

People often think of emotions as ethereal, complicated depths that are difficult to explore. They are actually adaptive physical reactions to stimuli. There are a few main categories, and as we will discover, they are concrete, identifiable, and usually in a healthy therapeutic alliance, they can be discussed and even when emotions are painful to express or come with shame or linked with traumatic memories, can be disarmed and understood.  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 CMEE 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. Welcome back to the podcast. Today, I am excited to continue the Therapeutic Alliance series. And this is a series that really got birthed from my relationship with one of my mentors, Dr. Tar. Dr. Tar and I, he's kind of in his generativity phase of Ericksonian stages. And we have been co-teaching a class on Therapeutic Alliance since I started as an attending here at Loma Linda. And this class is for first years, psychiatry residents.

and so far I've put out four of the Therapeutical Alliance series. This one will stand alone. If you haven't listened to those, you can listen to this one and then go back and listen to those. But I really hope from this series that you understand how to connect with patients and connect with maybe more difficult to connect with patients and with people who maybe have a more of an anxious or avoidance. or disorganized attachment style, and also how to navigate maybe ruptures if they occur and how to build that therapeutic alliance early on.

And, you know, this is so important for us in psychiatry and in psychotherapy, right? So whether we're doing med management or we're just going to be an inpatient or a consultant liaison doctor or a child adolescent psychiatrist, developing an effective therapeutic alliance will help you help the patient. And I really think, you know, we talk about burnout a lot in medical education. And one of the things that I think decreases burnout the most for me is when I do connect

with a patient and I can feel that connection. Sometimes it's warmth in my chest. Sometimes it's just a feeling of contentment and sometimes it's a feeling of pleasure. And I can feel that throughout the day as I connect with different patients. And it's a very satisfying sort of experience, even in the midst of talking about some of the most dark and depressing and, you know, really difficult things to talk about. If you can find a way to connect,

then it brings something else into that moment, into that moment of trauma. And that's why I think the therapeutic alliance really does continue to shine throughout all of the research that's been done on it. Study after study, hundreds of studies on therapeutic alliance, and just the foundational importance of it. And I would say almost, you know, therapeutic alliance alone is enough to be helpful.

So a lot of times we get sort of obsessive about specific techniques or specific theories. And what I try to convince the residents of is something called therapist, effect. And I really went into that in depth in the empathy episode. But just briefly, what that is, is that there's different studies that show that across modalities, there are commonalities that are centered in the therapist. And so some therapists have better outcomes than other therapists. And some therapists have worse outcomes. And one of the things that I think is modulating that is the ability to develop a therapeutic alliance, empathy, develop safety, psychological safety, so that the patient feels like they can give feedback to you.

So here we go into part five of therapeutic alliance, and this is going to be on emotion. And, you know, there are problems that patients come in with that relate to being able to control affect, right? So maybe they have issues with management of, you know, the highs and the lows. And, you know, a lot of patients will say, they'll come in with anger,

or anxiety or depression. But when you start to listen more to the story, it's moments where they get shut down or they feel emotionally not contained or they feel distant or lonely from other people. And so although maybe they're not coming in with those descriptors, and especially if they've been in the psychiatry system for a while, sometimes they're given names and labels.

And I almost try to get away from that. Like, what do you mean you're depressed or what do you mean you're anxious? Like describe what is going on. So there's failures of affect management, sort of controlling the ups and the downs or the ability to regulate. And, you know, as an infant, we learn how to understand, label, regulate, and tolerate emotional responses. And if a child doesn't, they oscillate between,

emotional inhibition, you know, it could be shame or shut down or dissociation and extreme mobility where they're, you know, angry or irritable or, you know, unable to control the strength of the affects that they have. So as infants, you know, how does one slowly learn to develop the language of emotions and regulate those things? And a lot of times it comes from connection with an adult, right, an adult, putting words to the emotions. You know, I hear you really sad, I hear you really sad, I hear you're really sad, I hear you're really upset. You are very upset. You are very upset. So I always start with labeling what's going on with my kids and then, you know, move into other aspects of helping them draw meaning in what's going on. So sometimes there's an early

loss that kids have that creates a neurobiological sensitivity and vulnerability that predisposes is future stress to induce depression and, you know, sort of not have that ability to contain. And there's epigenetic phenomenon that go on and, you know, with the HPA access system and, you know, how stress is contained is changed. So what I mean by epigenetics is that, you know, environmental stuff from early life will change the expression of different genes in the body. and, you know, attachment experiences really shape early organization of that brain, especially the right brain, which is the neurobiological core of the human unconscious,

of the human unconscious. And so attachment really shapes a lot of those representations that are later difficult to catabolize or difficult to make sense of or organize, you know, so that organizing, regulating type of stuff, can be more difficult if those early attachments aren't there. So what are some of the big ideas? The big ideas is that the therapist, patient interaction may change how the patient feels and the world will be perceived differently.

So how I think therapy takes place is a patient forms an attachment with the therapist. And that attachment is actually a powerful means of, how the patient will benefit from therapy. And as then the patient discusses distressing things in their life, they're pulling out these folders of information and these memories, right? And there's all these like papers in there and lots of, sometimes it's very disorganized, sometimes there's a lot of anger or sadness or disgust or revulsion or, you know,

and then they're opening that up and they're discussing that. And some of those emotions, those negative emotions, get catabolized through that process of bringing them out, right? And then now the therapist gets inserted back into that folder, that attachment relationship with that person. And through that attachment, the patient will not feel as lonely in some of those memories. And so some memories, like if a patient felt very alone growing up, they may not have hundreds of different folders for that feeling of aloneness.

maybe that'll be one big folder that comes up over and over again. And as therapists, I think we should be patient with the process that, you know, this may take time. It may take a lot of time to make the patient feel less alone and less isolated. And the memories may be disorganized. I saw a really cool cartoon of a patient talking and above them is that little bubble thing of their words. And instead it's like yarn and it's just a mess. and then the therapist has a bubble and it's like the yarn is moving from the patient

over to the therapist and it's getting organized into a nice spool of threat. That would be the ideal, right, of what kind of the process of therapy does is it helps sort of take those disregulated emotions and those memories and helps them, the therapist helps them make sense of them,

helps them organize them, and helps insert new emotions. largely, I believe, coming from the connection that takes place in the therapy that then gets inserted into that folder and then put back into the memory. And what I've found is that patients will come in with, you know, dreams and fantasies and different aspects of their day in which, you know, you can tell what is still disorganized because the dreams and the fantasies or the fleeting thoughts sort of give you that indicator, you know, because there's parts of the memory that are like leaking out. And once the distress is, you know, once that, that folder is

taken out enough and maybe the memories are organized enough and there's that connection that gets inserted into there, now the patient is coming back and they don't report those nightmares. They don't report those distressing sort of intrusive thoughts. Okay. So I feel like I should define what is an emotion or what is a feeling. Because a lot of people, you know, they'll say like, I feel like you don't understand, okay, or something like that. Well, the feeling of not feeling understood, there's a thought there. The thought is, I'm not understood, but there's the feeling maybe not even completely put out there, right?

The feeling might be sadness or it might be anger. So sometimes feelings can be a little bit difficult for people to put a finger on, you know, are like, I feel tired. Well, fatigue, it could be a drop in censorium. It could be a feeling of tiredness could be, you know, that maybe they feel anger, but then it's just easier for them to have a defense against the anger. So that could become like, okay, I'm just going to sleep instead. So what is the feeling underneath?

And that can be difficult to sometimes to get to initially. So emotions and feelings are built from reactions that promote. survival or well-being of the person. For example, Kohut said, awareness of the self is minimal unless self is threatened. So it's this thought that a lot of times emotions are sort of these inborn functions to solve automatically without logical reasoning many of the basic problems of life. So we're either approaching things when we want pleasure or maybe with

drawing when we have anger, fear, or disgust, maybe we're off external agents or a physical injury or danger or disease and maybe that's, you know, anger is sort of overcoming those things or maybe fear is telling us to move away from those things or disgust is telling us to spit out those things that could harm us. And sometimes we have arousal or increased activity versus calming or, calming or decreased activity as part of that, right? Sometimes it's like, it's like better to become more sort of alive. And sometimes our body says, no, it's better to kind of more shut down. But a lot of those things are like adaptive mechanisms for preservation of ourselves and our loved

ones. Sometimes we move into a place of cooperation, sometimes of competition. A lot of times that's, once again, adaptive in order to protect ourselves or our family or our loved ones. And we can also have immune system activators or deactivators based on emotions. So each emotion has like a different profile on how like it will boost the immune system or deactivate the immune system. So and I think people are slightly different in this as well. Emotions will last longer amounts of time for some people, shorter amounts of time for other people. Like some people know like exactly how long they're going to be angry once they start to get angry. Yeah, I'm angry for like three days, they'll say. I'm angry for one hour or I'm angry for five minutes and then I'm just done. So, you know, emotions play out in

our body. They influence us. They influence our biology. They light up different areas of the brain. And it's not simple. Like when you actually get into like the MRI scans, it's not like the emotions light up just one little area of the brain. It's like quite a few places the brain light up in different emotions. The metabolism changes based on our emotions. Endorphins change. inflammation changes. So some emotions can increase inflammation markers like TNF Alpha and IL, 6 and 12. And emotions are movement towards actions. So they're moving us sometimes into an action, either to withdraw or to move towards. And I like to think of emotions as solving problems, right, that they're not good or bad. Sometimes, you know, we think of anger as always bad or

shame is always bad but maybe like there's an adaptive mechanism and so maybe we don't have to judge them and maybe we can release that judgment and just look at the logic and see what they're doing be curious about them and you know fornegie said the whole of childhood development is is to be towards the enhancement of self-regulation and so there's some early you know he was a mentalization guy and so he's he's thinking that a lot of is actually towards learning how to self-regulate better. And I see it in my own kids. My three-year-old does not self-regulate as well as my five-year-old.

And my five-year-old did not self-regulate as well when she was three. And so a lot of the repetition on what we're doing and how we raise our kids really does help them learn how to self-regulate over time. So I'm not solving all of my daughters or my son's issues. Sometimes I'm going like, oh, okay. Okay, you feel upset. I wonder, I wonder what, I wonder what your options are, you know, here's two options. What would you like? I really like the parenting style where you give a couple options. So you say, you know, I want to watch TV. No, you know, that's a good desire. It's a, it's a desire that you have to watch TV. You know, right now we're going to be doing either

story time or we're going to go to bed. Which one would you rather do? And it's usually story time. So the essential task in the first year of human life is the creation of a secure attachment. And in the next Therapeutic Alliance episode, I will go into this in depth. So we're trying to create this attachment between us, the infant and the caregiver. And in order to enter into communication with the mother, there has to be a level of attunement. And there's these shifts that go on back and forth. between the mother and the infant. And there's this kind of diad that forms,

this co-regulation of emotion, where the mother is co-regulating the infants developing central nervous system and autonomic nervous system. And there's actually quite a bit of research in this field that's really beautiful. There's this sort of affect synchrony that can go on between, for example,

four-month-old and a mother. that is going to predict whether the child has a secure attachment or, you know, an insecure attachment, an avoidant or an anxious attachment or disorganized attachment. So those are the three different types of insecure attachments. And you can watch this and you can videotape these infants. And Beatrice Beebe did this work. It's one of my favorite researchers in the field here. She was able to predict at one year what type of attachment style would go on.

just from watching these four-month-old children interact with their mother. And when the child had sort of a mirroring, or the mother had a mirroring of the child, and the child would smile, the mother would smile, the child would move their arm to touch the mother's face. The mother would lean forward to be touched. The child would then lean away and want some space. The mother would take the hint and move back and let the child have some space.

That was secure attachment. The insecure attachment was, when the mother was not noticing the cues and not really responding in a synchronous way. And so there's this affect synchrony that occurs or does not occur. And on fMRI, adult attachment activates the right inferior frontal cortex, which is also involved in control processes,

and emotional regulation. And so a lot of relational experiences are encoded in the unconscious internal working models in the right brain. So what that means is that that sort of that right inferior frontal cortex that attachment activates encodes these sort of patterns of how we're going to relate or how we're going to maintain connection. And a lot of the work that we do is with patients who don't really have a lot of this going on. So their way of connecting is more troubled. Maybe it's harder for them to gain secure feelings of connection with other people.

Maybe they, you know, put, adults are interesting because it's like you have this basic machinery of like I don't feel like I can connect or feel secure. and now then you put a bunch of verbal stuff on top of it to try to make sense of it. And so a lot of the narratives that come out of people with anxious or disorganized attachment is trying to make sense of these unconscious internal working models that right brain to make sense of it. And I'm sorry if this is a little bit theoretical. But basically what I'm saying is that, it's like our intelligence is commenting,

and our left brain and our verbal centers is commenting on and trying to make sense of this, but it may be difficult to make sense of because there might not be the right understanding of what's going on. And so it can be very organizing to a person to sort of start to receive empathy for their emotions, but maybe the narratives are also,

looked at in terms of the cognitive distortions, you know, like, is there all or nothing thinking, black and white thinking, over generalization, jumping to conclusions, predicting the future? You know, a lot of this goes on in the words that we create to make sense of our situations, which may not be fully accurate. So the self-organization of the developing brain occurs in the context of a relationship with another self, another brain. That was Shore, Alan Shore, who's written a lot about early infant attachment and this type of co-regulation.

And so the self-organization of the developing brain, so how the brain is starting to organize, occurs in the context of a relationship with another self, another brain. And so that's the necessity of actually a human relationship in the healing process. Okay, so a lot of people who find themselves looking for those self-help books need to find a relationship to find the solution, right? There's certain people that when I meet them, I say what I think is going to really help you long term is finding a really good therapist and maybe spending one to two years in therapy. and for some people that they may not see the big picture. The picture that I'm seeing is that they may not have had this sort of self-organizing experience. And so the therapy is really what is going to be helpful for them.

And I was specifically comment on people with maybe a borderline personality disorder. If you look at the long-term outcome studies for them in mentalization-based therapy, in transference focus therapy, in dialectical behavioral therapy. It was all long-term therapy. I mean, we're talking about a year or two years of therapy and then some decent follow-up that really made the difference in these people's lives.

I mean, in mentalization, you're talking about almost 80% of the people no longer being criteria for borderline persia disorder, no longer experiencing suicidal, you know, suicidal thoughts all the time. And so my thought on borderline precise order specifically is that there is often a start to the child's life of more of a thwarted ability to attach or connect, whether it was a mismatch, a mis pairing of the infant to the mother or

the infant to the father and or some trauma early on or, you know, mom and dad were using drugs or alcohol or, you know, neglect or role reversal where the infant is put. into the adult picture even at a very, very young age. So when these things happen, sometimes the brain itself doesn't really learn how to regulate its own emotions, its own thoughts. And so you have things like DBT, which has a lot of, you know,

how do we learn how to regulate our affects? How do we learn how to create some behaviors around the chaotic affects? But in the midst of DBT, like true DBT, is that you have your therapist phone number and you can call them. And they help you when you're feeling disregulated maybe or you're feeling disconnected.

So it's that attachment that's there that's so important. And True DBT also has weekly process groups where the therapist process some of the more difficult situations so that they themselves can then continue to be caring and continue to be maternal to these patients. And then you have like mentalization-based therapy, which is largely learning how to understand and read your own emotions and your own experiences

and also the experience of other people around you, which are different. And then transference-focused therapy, of course, is really focusing it on the relationship with you and the therapist and the importance of that relationship. And, you know, at the center of all these things is, of course, the therapeutic alliance. And the commonality between them is probably the therapeutic alliance

and the ability to focus on emotions and help continue to be in relationship for a long enough time for some internalization of some of the necessary attachment stuff that wasn't happening earlier on. Okay. So a little bit of evidence to support my ideas. There was some split-brain patients

that had a... a cut between their right and their left hemisphere, basically, either for various reasons. People will have this issue, but it's where their right brain doesn't talk to their left brain, except maybe if it goes down to the brainstem or below, you know, but it's not like they're going back and forth like they normally do. So these patients are interesting because you can have them read words with one side of the brain. And so, for example, you can get the left hemisphere to read something or see a picture of something and describe it.

And let's say they see a picture of a demon. And they'll say, I'm looking at a picture of a demon and it's bad. And then you tell the right hemisphere to look at the same picture of that demon, and the right hemisphere of the brain was unable to say what it was, however it could say if it was good or bad.

So, for example, seeing this picture of the demon, would say bad, whereas seeing a picture of the mother, a mother, it would say good. And somehow the emotional significance of the picture leaked across. Okay. And so there's this emotional processing that takes place outside of awareness. It's an unconscious sort of representation of what's going on. Here's another example in those studies. when instructing the right hemisphere to wave,

the patient would wave, but when asked why they were waving, they would make something up. Like, oh, someone was waving at me. And when the right hemisphere was told to laugh and then asked why they were laughing, the left hemisphere would make something up, like, oh, you guys are so funny.

Or it's like, it just says laugh out loud, you know? So I think these studies, these split-brain patient studies in particular show how there is this sort of encoding of good and bad. It's largely unconscious. It's largely out of verbal awareness. And it's on that right side of the brain. Okay. So a little quote by one of my favorite authors, Antonio DeMasio, he said, emotions are practical action programs that work to solve problems often before we become conscious of it. These processes are at work continually in pilots, leaders of expeditions, parents, and all of us. So there's these sort of emotions are these

practical action programs that work to self-problems. Okay, here's a quote from my mentor about emotions. The most intense affects make us the most vulnerable. In failures to be understood, we feel disconnected. This may induce profound shame. Shame precedes rage. Moments of disconnection are inevitable, how does the patient learn to tolerate such vulnerability? So that is a good little transition to our next part, which will be, you know, what is our focus? So we know we want to focus on emotions. We know we want to start to be aware of them. So we focus on emotions. So we focus on emotions in order to grow and strengthen the therapeutic alliance because it's that sort of right brain to right brain experience. It's that implicit attachment regulatory function,

which is necessary for growth of the individual. And so the empathic therapist's capacity to regulate a patient's arousal state is really important. And it's sometimes actually, I think what separates like a good therapist for a patient and a not so good therapist. So there's these effectively charged moments of transference and countertransference where, you know, the patient is starting to believe some things about the therapist that may be because of previous relationships that the patient had with their mother or their father or, you know, and then you have your own reaction to the patient. So you can have very strong reactions just either they're trying. transference or you can have strong reactions to just something about them that maybe triggers yourself

your own transference, which is kind of lumped into how we understand countertransference as well. So within all of that going on in the session, you are working on regulating yourself, your own affect, and then you're also empathizing with the patient's distress and you're seeing things from their perspective. And so this takes some skill. and it's something we can grow in, we can start to notice a patient's affect. And we can do that, I think, in two main ways. One is to observe it visually.

So maybe it's their body movement, their posture, their gestures, their facial expressions, their prosody. And the other way is through our own sort of experience in the room, like our mirror neuron experience, our experience of like, okay, I'm watching them, I'm starting to feel this way. So that also gives us a bit of information. And I think if we take both of those and compare and contrast them

and then use that to be curious and seek to understand the other person, that's where the magic really happens. So that's why I care so much about training people in like microexpression and how to observe body language. So in my like, for example, my polyvagal episode on shutdown, I talked about how to observe when someone is shutting me. down when they're when they're dissociating their their eyes may kind of space out a little bit. They may slump a little bit. Their voice may get a little bit and it's harder to get the

voice out. You know, it's hard to get words out when someone's dissociated versus, you know, if someone's in more of a fight and flight place where their, their words are more staccato and they're trying to, you know, it's more mechanical maybe or it's more forced or maybe they're moving in a more animated way or they're closed off, they're, you know, using their hands to guard their vital organs. And so that's one thing is like starting to notice body language. And then the other thing is to start to notice that the emotions flash on the face. And, and then using this information, along with our sort of mirror neuron experience of what's going on, we start try to help the patient put names, body sensations, describe body sensations, and look at the

potential meanings of emotions. And I actually really enjoy this type of work. It makes me really excited when a patient starts to maybe move from a place of intellectualizing what's going on in them, you know, rationalizing. So, you know, sometimes people will feel flash anger on their face and then immediately, you know, maybe they're a little bit more obsessive, OCPD, they'll start to intellectualize. It's very common actually with doctors and professionals and highly trained people where, you know, intellectualization is a higher form of defense, so it's a good form of defense. But still, if we can move a little bit more back into the emotion and, you know, see that that defense is adaptive, but, you know, let's be curious a little

bit about what that emotion meant underneath or what the goal of that emotion was. And if we can get to the exploration of that, it's in my mind a lot of fun. So what are the different flashes of emotion or the main categories that I'm looking at? So I really dive into this in my microexpression series, part one, two, and three of my microexpression. And I created an app called a motion connection only for iPhone or iPad. There is a version coming out that I will have for the computer. And if you are in my, if you've checked out my resource library, you get email updates. So when that gets out, there'll be an email update. So one of the emotions is joy or happiness. And, you know, people know when people are smiling, right? It's the cheeks pull up. There's a little bit of

crow's feet on the side of the lateral sides of the eye the eyes contract um the lips move up bilaterally and symmetrically and they move down bilaterally and symmetrically afterwards and um smiles are very symmetrical and so it's both sides of the face and you know when people are happy when people are feeling this joy there's there's this sort of positive feeling in the body there may be a and feeling grounded. People want to move towards, embrace. Maybe they desire others to be blessed, give random acts of kindness. You know, happiness is something that gets evoked a lot in watching funny videos. And I think, you know, a lot of people who are trying to sort of evoke that emotion, spend hours on YouTube watching funny videos. And that's why funny videos on Instagram and YouTube,

who are so popular. So that's happiness. And I think what's important to note about happiness is there's gotta be the contraction of the eyes and it has to be bilateral. And so the contract, you know, smile with your eyes is sometimes something, sometimes photographers will say. And, you know, that sort of Cheshire cat smile,

the psychopath smile, where there's no smiling with the eyes, the lip smile, it sometimes is a little bit off-putting. and actually Gottman showed that it predicted months of future separation when they looked at it and newly married couples. So joy and happiness is one of them. The next one I will talk about is anger, frustration. You know, a lot of people don't like the word anger, so I often use the word frustration.

It's a short tightening of the eyelids, the eyebrows moving down and together, the lips pressing together. there's sometimes showing of the teeth like a snarl. There's a tightening of the eyelids and the eyebrows. But if it's an extended tightening, then that sometimes is concentration. So usually this is just a very short flash of emotion. And the main reason I think people get angry is to move past an obstacle. So there's a goal and then there's an obstacle. And there's always a goal that precedes the obstacle, right?

Or you wouldn't get angry. If you had no goals, you probably would be angry. angry less. So once you start caring about something, then it's like you start getting angry when you're thwarted and getting that. And, you know, anger often is, you know, a good thing to protect yourself or to protect your family or protect those you love. And usually people will only attack when they feel no escape is possible, either physically or psychologically. So we want to notice when there's when there's anger and we want to kind of seek to understand like where the patient might feel

thwarted, where they feel there's an obstacle that's, that's difficult to overcome. You know, people who are chronically angry, it's like they have these great goals that maybe they weren't able to achieve or accomplish or maybe there's a huge sort of ongoing thwartedness that they feel from some previous relationship. And, you know, how do. do you help someone once you see the anger? Well, I think sometimes just even telling them that it's

adaptive makes a lot of sense. Like, hey, it makes sense that you would feel angry about this because you really wanted that and it makes sense. I do this with my kids. It helps them calm down. So, you know, I hear that you really want that right now. You really want that. And it's hard, it's hard to tolerate not being able to have that when your sibling has it. And I want them to try to put that to words as well if possible. Can you describe that? So sometimes when the anger is very, very large, I want them to put words to it.

Because remember, words activates that left side of the brain, and we want the left side and the right side to be both active if possible. And if they can tell me their goal, then we can sometimes strategize how to get their goal and accomplish their goal. Maybe it's not in their timetable. They want it now.

but maybe it isn't. You know, maybe it's like, okay, can we set a timer and you can get that in five minutes? Okay. So the next one is sadness. There is a heavy feeling in the chest. Sometimes decreased limb activity. The inner eyebrows are rising and the outer eyelids are drooping. Probably when the inner eyebrows rise, there isn't usually tension in the middle.

So there isn't like a crease in the middle. of those eyebrows. They're just moving up, the inner parts of the eyebrows. And there's sometimes pulling down of the lip corners. So there's like a pout or the chin moving up slightly. And, you know, what is the purpose of sadness? So I think inside out the movie, Pixar, had a couple great scenes where sadness saves the day. And early on one, I won't ruin the whole movie for you if you haven't watched it you should watch it she she's a little girl and she loses this hockey shot and she starts to cry and then her family sees the tears and they come around her and then she feels the warmth of her family and it's like ah you know it's like it's like the sadness

pulled people in to comfort me right and so a lot of times when people feel sadness though they didn't really get that sort of draw of people to them to comfort them early on. So sometimes it can be hard for people to experience sadness or with sadness come shame, you know, because maybe early on they were told that they shouldn't be sad, you know? I don't think it's ever helpful to tell a kid like you shouldn't feel sad or you shouldn't feel angry. Like it's like, well, they just do. And it's like, okay, what is the message? I would be more apt to talk about the message

of what the emotion is telling them. So that brings us to shame. Shame is kind of similar to sadness, but I think it's worthy to talk about it in and of itself because also there's changes in the body posture. So the eyes look down, the hands cover the face. The mouth is puffed out with the lateral part of the lips downturned. The arms cover the body.

the body slumps over. And your face may feel flushed with warmth. You may feel a punch to your stomach. You may feel rotten or dirty. You may feel like I am bad or inadequate. There can be a loss of body energy, a feeling of your body collapsing. You may have this desire to cover and to hide. Do not do.

Refrain, forbid, remorse, atone, stop. And shame really shuts up. people down. It's like this little kid that's excited about, you know, this new achievement he's been able to do and he wants to show his parents. And when he shows his parents, his parents don't react with happiness. They react with something else. Maybe disappointment or fear or anger. And so the kid just feels slumps down and like just shame is what they experience. You know, like, oh, I'm bad. And shame, you know, unfortunately, shame is there whenever trauma is there. So it's, it's like in the room, you know, and I tell,

I tell the people I train in psychotherapy, like, guys, like if you're not seeing the shame, you're just not seeing it's there, it's going to be there. People feel shame and seeing mental health professionals. I know what that felt like early on when I, when I was thinking about making the call, I had the number for a couple months, looking at the number, looking at the number,

wanting to call the number. And, um, I just couldn't actually pull myself to call. You know, it was the shame of like, what would people think if I saw a therapist? What would, you know, so people are coming in to their sessions with this early on.

It's hard to, it's hard to witness a trauma experience that a patient's had without some aspect of shame being there. I'm convinced that shame and shut down and trauma kind of go together. It's like shame is the shadow or something. So that's shame.

Disgust. So disgust is a feeling of being queasy, wanting to vomit, feeling a desire to gag, and there's this wrinkling around the nose. The upper lip rises, which is unique to discuss. And the eyebrows move down, down and together, similar to anger. It kind of looks exactly like anger to me, except for this upper lip rising and the wrinkling around the nose. and disgust, you know, says to us, move away, spit it out, get away from it. This is morally bad. This is reprehensible.

When partners feel disgust towards the other partners, it's a very difficult affect to tolerate and make sense of. And had a patient recently just tell me about, you know, some of the childhood stuff that went on. And then they talked about their spouse and they flash disgust. and I said it's hard when you have some of these things from your past kind of weighing down the current situations and it kind of makes you feel revulsed towards your spouse in this moment and it's hard to make sense of because there's other influences from your past

kind of bleeding into this situation making you want to vomit it out. I sometimes use visceral words like that, and the patient felt very heard and understood. Now, if you use visceral words like that and they disagree with you, then allow them to disagree and have them correct you

and tell you more accurate ways of representing it. So that's discussed. Fear is sometimes felt as like a weight on the chest, constricture around the neck, you know, like someone's choking you, butterflies in your stomach, and the upper eyelids are rising high and together.

So there's some tension as the eyebrows are rising high in the middle. There's tension in the middle and the eyelids are rising too. So the eyebrows and eyelids are rising, there's tension between the eyebrows and the mouth is moving horizontally. So the mouth moving horizontally

is rapid, along with the other aspects of this. And the purpose of fear is to preserve and maintain life, freeze to analyze a situation, fear that you might be hurt or a loved one might be hurt. It's sometimes preparing to run to attack or the fear that precedes puffing up to look more dangerous. I see a lot of puffing up.

We say fight and flight, but I would actually add puff up to that because I feel like a lot of a lot of people kind of puff up to look stronger than maybe they are to kind of ward off threats, right? So I'm going to just leave surprise in my notes

that will be in my resource library for this episode. All of this will go in the resource library. And if you haven't been there yet, there's probably about 100 to 200 resources for you there. All of my episodes have notes, blogs, PDFs are all there for you to download, share. Please share them freely. I'm more than happy for you to get the word out and to help educate other people. And however you can utilize my resources to do that, I'm happy for you. And so the next one I'm going to talk about

is pride. So pride or smug contempt was how it was called in the research initially, but I really think contempt has some negative connotations. I've seen pride a lot when people are talking about what their kids are doing in sports or what their kids are doing in school and they're happy about it. They put up a one-sided smile. So I don't think it's always a negative sort of contemptuous thing. It's one side of the face rising faster than the other side, like in a smile, like a one-sided smile, or it comes down slower than the other side. So that's pride. And sometimes, you know, when someone's experiencing pride about something, you know, I try to get excited with them about what they're excited about.

So, yeah, it makes a lot of sense that you would feel some pride over that because, you know, it's really cool that your kid's able to do that. Initially, you know, in the sort of the writing of Paul Ekman when they were describing these micro expressions and some of these authors, they didn't emphasize pain. But pain actually, so sometimes, for example, Paul Ekman will talk. about how like if showing pictures of circumcision elicited disgust in people across all nations. And when when I had these videos of circumcision and I was getting people to evoke different emotions and such, one of the emotions that came up didn't quite look like disgust because the

mouth didn't, the upper lip didn't go up. It actually the mouth stretched, stretched horizontally. So when I looked at this more, you know, there's the emotion of pain. When pain is on the face, you know, the brows, the eyebrows go lower and down and together, similar to anger or disgust. The nose wrinkles, similar to disgust.

The eyelids tightened. But the mouth stretches horizontally, which is unique. It kind of looks more like, you know, if it was just stretching horizontally, that would be fear. But in this case, it stretches horizontally and it's pain.

So pain, you know, can be flashed on the face. And what I'm talking about is more like physical pain, right? But people can flash this when talking about emotional content, which is something that I've observed over the last couple years. And something empathic you can say to them is something simple like, this is very painful. What you're going through right now is a very painful thing. And that just resonates with people.

And once again, what is the purpose of doing this? When you can feel into another person's experience, like that creates connection. And when you feel that sort of connection, you feel that pull in your heart to another person. And, you know, spontaneous smiles come up. And there's a mirroring of emotion. And sometimes the body language, people, you know, they kind of lean towards each other. And sometimes you talk about we, like it's no longer an I that's describing something. It's a we that are experiencing something together.

So all of this, all of this is really. really for connection. You know, a lot of the micro-expression research, if you look at it, it talks about like trying to decipher if someone's lying or telling the truth. And, you know, once in a while I use that. I was, let me tell you, it was a situation that I used that. Just I was at the car dealership and it was, they gave me a price for the car. And I went and got a cashier's check for it.

And I came back. And then they said there was a mix-up and that I would have to pay them money or I couldn't have the car and I was I was pretty angry I was I felt morally um like just bad like I've maybe I was picking up their mirror neurons of what was morally going on in them but then I also felt like you know like the guy who we drove the car together and everything he was a really I felt he was a really nice guy I felt he was very congruent I didn't get that sort of used car salesman vibe from him like like like that he was He was like just about the sale, you know.

And so I ask him, I'm like, look, like, how do you feel about this? And he's like, oh, I'm pissed. I'm pissed. I can't believe they did this to you. And he flashed a micro expression of anger when he said that. So I do think that he was congruently angry for me over this experience. And that helped me. It helped me pull through it.

The other guys, I think, were kind of more of the sharks. and when I asked them and I was observing their micro expressions, I didn't see much at all. It was more like they were very flat-faced, and it was more like psychopathic. Okay, I had some trouble over that, guys. I felt dissociated for a little bit. I needed to ground myself.

I had to discuss it with a couple different people afterwards. I felt horrible. And you know what? I think at the end of the day, if you're listening to this and you're in sales or something like that, and you're just trying to be able to connect with people for the reason of what, for your own gain. Like, I just feel like you're missing the point

because when I know this is what I explained to the guy that I felt like was a good guy that was kind of the guy showing me the car and everything. I said, you look, look, like in the end of the day, like if you continue to violate people's, like, if you do moral things that are bad over and over again, like for your own gain, people will feel that. people pick that up people in a mere neuron way register that you know people will feel your

intentions and the history of your intentions as well and so it's so important to actually do what's in someone's best interest like if you're if you're a psychiatrist really guard yourself against your bias or your self-interest or your um like the things that you know like are helpful for you but maybe not as helpful for the patient. Really guard yourself against that. And I think in general we do. And other people who are not professionals are, you know, I see them on Instagram.

They're just trying to sell their supplements or their, you know, blah, blah, blah. It's like they're trying so hard to get that sale. And everything around it is sometimes more convoluted and tricky. But I think in this field, we need to try to remain as, closely as we can to the evidence. And we're presenting the evidence in a persuasive way so that people will get what they deserve, which is emotional health and wellness. Okay, there's my little side rant.

Dr. Osoria, who was on my prior podcast on, she listened to me today, and she gave me some empathy. And she was like, oh, my gosh, it's horrible, that's horrible. Thank you, Dr. Osoria. That's a shout out to Dr. Osoria. to that episode on it's geriatric psychiatry if you haven't listened to that one. So now I want to get into more of the practical side of what do we say. So it's impossible not to feel a bit into their feeling if we're paying attention. If we're monitoring their emotions,

you know, research has shown that you will mimic their emotions. If they flash anger, you may flash some emotion. If they flash sadness, you're more likely to flash sadness. And that mirroring of emotion is important. It's important to feel that connection for the person. But we also want to, of course, put that to words and to regulate our own self in the midst of maybe hearing a very distressing story. So grounding ourself, not allowing ourselves to be flooded with emotion. If you're early on and someone's talking about something traumatic and you get pulled into a kind of a more dissociated traumatic state, you know, getting good supervision for that is so, so, so important. because learning how to tolerate those traumatic states, I think is what really creates a good therapist

because we don't want to avoid or be complicit in avoiding them. We don't want to join their defenses. We want to actually be able to get to what is really going on. So if we don't know why they're feeling a certain way, then we may ask more questions. We may get them to deepen our understanding of what's going on. So you see a flash of anger and you don't understand it. Don't say to them, I saw a flash of anger, I don't understand it.

That will elicit more anger towards you for telling them maybe that they're feeling something that they don't feel like they're feeling. Instead, get them to talk more about it. You saw the anger, you know something's emotionally salient there. Now, kind of dive into it a little bit more. And once you can reiterate to them that you understand a bit of what they're going through, people will feel heard and understood and that will be pleasurable. When someone feels hurt and understood, it's pleasurable.

When I told Dr. Osori of this situation and she repeated things back and she kind of joined with me like, oh, I hate when that sort of thing happens. I hate shopping for cars. I can't do it. I just can't do it. When she said stuff like that to me, it made me feel like someone understood me. Someone heard me. I kind of left like feeling better, you know, more pleasure.

And so when you notice that they feel more pleasure, you're doing something right. So you may say something like you are entitled to your emotions. We will put them to words. We will not necessarily act on them. So if a person is feeling desire or anger or they want to harm someone, putting it to words doesn't necessarily do the damage that the action would. we would rather have them non-judgmentally put things to words, and that's important. So what does your emotion want to accomplish?

So maybe I don't put it that directly, but maybe a little bit more indirectly. Like, if your emotion could do something, what do you think it would want to do? Or what do you think is helpful about having this emotion? what does your emotion say if it could say something? And maybe it's not emotion, maybe it's that tightness in your chest. What would that tightness in your chest say if it could say something? What would you feel, gosh,

what would that choking sensation say if it could say something? And maybe it would say something like run away or something like that. And if you're a somatic therapist, maybe you have them move their feet up and down and feel like, what that feels like to move their feet up and down just a little bit, you know, start to get their body doing what their emotions are telling them to do. So shame. What do we do with shame?

Sometimes I think normalizing shame is a good place to start. I can understand why talking about this must be difficult. Perhaps as you talk about this, you feel like it's difficult to talk about, and that would make sense to me, you know? So can we find the adaptive function of any emotion? you know, specifically for shame, let's say someone's switching to you as their doctor and they feel like it's hard to talk, you know, and it's the first appointment. You say, you know, I hear switching to a new doctor is hard. And I think it is a common experience. I think it's

adaptive to be hesitant at first in what you share. We are just meeting, you know? So of course, of course it makes sense to have a little bit of hesitancy. So putting to words the adaptive function, you know, like there is stranger anxiety. You know, it's good to not tell a stranger everything about yourself. Maybe that's protective, right? So the hesitancy to share that that's normal. So of course we're concerned about this embarrassment that they may feel like this self-consciousness or this apprehension of talking about something.

Maybe talking about it reduces a sense of self-esteem. It's like it doesn't put them in the best light, right? Most people want to present the best parts of themselves or put themselves in the best light. So that sharing might be difficult. And we want to anticipate that sharing actually might elicit this feeling of shame. So we may say things like when you feel uncomfortable in thinking about something or avoiding topic, it will be valuable for us to become aware of your hesitation.

So sometimes we preemptively start to talk about how shame might occur and then how it's important to actually start to put words to it, to put words to the hesitation. Of course, it's hard to share with me something that you feel disappointed or discourage. about, what undesirable feelings might you have if you were to talk about it? So it's hard to talk about things that people feel disappointed or discouraged about. And, you know, what feelings might be there if someone did talk about it? Okay. There are some things that we would much rather not bring into the open. And we can really learn a lot about ourselves

and about what makes us feel distressed about ourselves. So learning to start to sort of put some of those words about what distresses ourselves or what's distressing about ourselves to put some of those things to words. So we're talking about shame and we're talking about how to decrease someone's shame. sometimes patients wonder if they will say something that disappoints you.

And so we can normalize that. We can say it is natural to wonder if I will be disappointed in you. I had a patient who was very anxious who came in. And it was that feeling that she was going to say something wrong or disappoint me in some way. And once I empathized with the distress that she would fear that in some way she could say something that would disappoint me or that would be too heavy for me

her anxiety went away. So revealing this, putting ourselves out there is often difficult. Do we ever really want to say aloud all the things that we think about and feel? Probably not, you know? But at the same time,

learning and putting words to how difficult it is to talk about it can be one step in that direction. So sometimes when I'm in the partial and I have a patient and sort of pull them out a group, and they'll talk about how it's difficult to talk about something. And instead of having them talk about what is difficult to talk about, I'll empathize with how difficult it is to talk about some things and how maybe that's what they should share with the group. And they go back and they share that with the group. and then when they receive warmth from the group for, you know, yeah, of course,

it's really hard to talk about some things. Then they feel maybe more open to talk about some things. So I'm going to leave it there for today. And I'm going to put the rest of these notes in the resource library. Go through a little bit of anger and sadness and disgust and fear and some different approaches to that and a little bit more on shame. And I really want to thank you guys. I feel a lot of gratification from doing this, actually.

I get a lot of messages from some of the listeners, and it's really meaningful to hear from you. I've been responding to most messages of when people log into the resource library. They'll leave a little message. I'll try to respond to most of those. And so, you know, in going to get this in the resource library, you leave me a message.

I will try to answer it the best I can. So I really like hearing about who's listening, where they're at, what they're into, what they would like more of, and what's been meaningful. If you feel like you've made any changes to the way that you're practicing, if you feel like you're better able to connect with patients, I love that stuff.

Because at the end of the day, and I get a lot of people asking me, like, why are you doing this? Why are you spending so much time doing this? at the end of the day, what really brings meaning to me is to think about providers being able to provide better care

to more patients. You know, I'm only one provider. I can only see one person at a time. And so for me, education is really about the multiplier effect. Like, if you can get a little bit better at connecting with people, that will impact thousands of people's lives. And that's what gets me excited

is thinking about one person, in the middle of, you know, Nebraska, who maybe feels alone in their practice and who all of a sudden now can gain some skills, maybe gain a little bit of ability, improved ability to connect with people. And through that, you know, provide better care

and feel more satisfaction in the work they do a little bit less burned out. And, you know, we support the podcast through Patreon. We support the podcast through, the CME signups. So if you haven't done that yet, I am soon going to get some mugs for anyone who signs up at the $5 level. So if you do that, I will retrospectively give you a coffee mug and send that to you. And it's going to be like the highest quality coffee mug with our logo on it. So anyone who signs up for $5 will get that. And, you know, if I could get even a quarter of the

listeners to sign up for that $5 a month thing, I could devote more time to this. So that's my goal is eventually to devote, you know, time that's not a way, you know, not my evening time. If I could devote some of my time to this every week, that would be awesome. And I would really enjoy that. So thank you guys for your support and have a great day.