Sunday, April 22, 2012

Teaching a Little Guy to Recognize Emotion

Here on this rainy lazy Sunday in NYC, I was drinking my usual morning green tea and thinking about the cases I've seen of alexithymia - or the inability to recognize emotions - in children.  What do we do about alexithymia?  Well, definitely the usual stuff like playing games like emotion charades where we have to guess what emotions / feelings we're acting out, practice problems solving / acting out solutions to various conflicts, etc.  But what else?

Here's a made up case to illustrate my thoughts:

Let's say that I'd been treating a 8 year old boy with alexithymia with the usual techniques until one day his mother asked to talk to me womano-a-womano.  She says that he doesn't understand important feelings she has about a specific family situation and takes the opportunity to tell me about her emotions.  So I go into session and directly discuss what mom might be feeling in these tough family scenarios.  The boy is surprised to learn how she might be feeling and feels a bit badly about his behavior.  Then we discuss what he can do differently in the future that takes his mothers emotions into consideration.  During the next week's session, mother reports that the boy was appropriately attentive to her from the moment they left therapy and throughout the entire week.

Now, even though our hypothetical session - that is a hybrid of multiple sessions with various patients - apparently produced the most effective behavior change outside of session, it was probably the most (mildly) aversive session we ever had.  Compared to past sessions where I have been teaching through games, this was no walk in the park.

During a game like emotional charades, the emotions remain impressionistic by nature. So where do we go from there? Sure this may be a good starting point and we also spend some time discussing issues that are upsetting outside of the session, but what about evoking real emotion in session?

By discussing the feelings that his mom might have, a little light bulb went off in his head.  He first reported feeling sad, but after some pressing, he also reported feeling a little bit guilty about his lack of attentiveness to his mother. After all, we are talking about a very kind child, here.

Notably, those emotions of sadness and guilt were freshly created as a direct result of newly learned content in the session. These emotions were not re-conjured from past events outside of session, nor impressionistic. Something to think about.

Because this session was mildly aversive though, my concern for next week was that he would not want to come back. After all, in his mind, we typically just play games. (Sure, these techniques can produce some change, but it is my opinion that they remain surface.)

Flying in the face of my nagging worry, this little guy was actually quite eager to return to session the following week. I suppose that I'll never be sure as to why. We can only speculate that perhaps it was because of a long standing therapeutic rapport and a learning history that coming to therapy is fun. A second option is that he did not experience the sadness and guilt intensely enough for it to deter him longer term.

But what about the results of Walter Mischel's studies?  We know some children can appreciate something more aversive & meaningful in the long-term, but not a barrel of laughs in the short term. 

Maybe this little guy appreciated learning something new and subsequently having his environment change.  After all, mom did say things were much better at home following that session.

Who knows?

To summarize, there are three ways of dealing with emotion in session:
1) evoking then processing new emotion in session as a result of new information / insight
2) rehashing previously felt emotion
3) creating impressionistic expressions of emotions

Maybe #1 is preferable.  Something to think about.

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