Uses and Abuses of Interoception
Public and professional awareness of interoception has followed a familiar path, and is currently at the stage where people are selling all sorts of products (including research) by slapping “interoception” on the cover as a buzzword. Those packages all tend to suffer from the same sorts of problems:
- They are accompanied by a whole lot of baseless talk pretending to explain why Evidence-Based Practice is useless, or even harmful (where that straw argument will be burned elsewhere).
- They rely instead on anecdotes, including frequent references to testimonials (i.e., “My friend said this,” “My client said that,” and so on).⇲
- They fail to be open about the following limitation: only people who are by nature physiologically sensitive to their internal senses can learn to engage with them, and no amount of training can bring someone to become sensitive if they are physiologically insensitive.⇲
- They include strategies for improving communication, even when (a) that is outside their scope of practice, and (b) the program is not developed with any meaningful involvement with an SLP.
As a prominent example of misinformation that is marbled into an otherwise valuable program, I’m going to take a particular look at Kelly Mahler’s products. This is not going to be an attack on Mahler the person, or on the people who find her to be inspirational. Like some other therapies, there is material worth recognizing as valuable (which should be salvaged), but there are also some distinct quackery-style flaws that obstruct informed participation in health care decisions (which should be corrected).
Once again: people who chose to publicly represent a product that affects the well-being of other people, are subject to public review and responsible for the consequences.
Mahler’s Interoception Products
Executive Brief: Mahler brings up some very good points (e.g., be trauma informed, promote sensory safety, imagine yourself wearing a student’s sensory array), but they are made in the context of (a) some significant inaccuracies associated with (b) a lack of evidentiary support. The good points could certainly be better understood in special education programs (in order to be heeded). The bad points should just as certainly be better understood (in order to be avoided), where that likelihood improves in proportion to one’s exposure to a solid research base.
Full Text: In general, I’d like to promote an appeal to Mahler’s programs in special education classrooms (such as presented in the likes of “Modern Emotion Regulation”). Mahler not only lists a number of insightful indictments of her working environment (which we want to avoid recreating), but she also highlights such needs as being trauma informed and practicing sensory safety (which is supported as people learn about interoception).
This program has its best chance of success if we discuss it, because while some of it looks great (and does have demonstrable value), other parts of it only look great, and present a nontrivial risk of harm unless:
- some SLPs ground those good portions in practicable therapeutic techniques; and
- we require more of Mahler than her largely anecdotal foundation.
That would include Mahler changing the frankly self-serving, ingenuous, wide-eyed campaign that she wages against EBP, which is not just dangerous in a professional training, but it’s also super annoying (to me).⇲
Mahler’s Steps Have Value
Mahler suggests that we help people to follow a series of steps (to quote her words):
- Body: notice body signals
- Emotion: connect signals to meaning⇲
- Action: regulate with an action that promotes internal comfort & health
The first step is missing at least one crucial clarification. The second step is waaay complicated in real life (as opposed to the gloss in Mahler), and needs meaningful SLP involvement in order to have a viable chance of success (beyond luck or coincidence). The third step I don’t have anything of significance to comment about; that is to say, it seems like a great thing to do, and it is not squarely in my scope, which are good reasons for me to just keep my yap shut about that part.
Might as well take them in step order.
(Step 1) Body: notice body signals
Mahler should have been a whole lot clearer about what her training can help people to accomplish. She fails to mention that the effectiveness of her product is ultimately limited by a person’s physiological/anatomical nature. She is either ignorant of that fact, or she failed to mention it (or some other options that haven’t occurred to me).
Yes, people in general can learn to become more aware of their internal states, and many do just that. And it can be helpful to become more aware of the way in which your behavior (including communication) is affected by what you are experiencing internally. And some people who receive therapy might well benefit from this heightened awareness as well.
But awareness relies on one’s base sensitivity. Some people are sensitive to some of those states in ways that others are not, so they differ in what there is to be aware of in the first place. If you can’t physiologically experience those signals at all, then you can’t become more aware of them, no matter whose training you attend, or how much you pay for their product. Neither can people receive the benefit of awareness therapy if they don’t already have this going on inside (i.e., something about which to be aware).
That goes for other types of sensitivity as well. I’ve got a number of examples if anyone wants them.
Tetrachromats would be just one such. Finding out that someone had tetrachromatic vision would be helpful for informing decisions, and for having a better understanding of how that person might want to be understood to be like; nonetheless, a person who is not a tetrachromat can’t be trained/taught to sense the additional colors (or then be more aware).
So, if you don’t have the anatomical/physiological underpinning, then there is no training that you can attend that will make that type of interoceptive experience actually available to you.
Speculatively, some such sensations could be medically simulated, and that kind of simulation might be valuable to some people; that is to say, it might help them to experience what other people feel who don’t need that medical induction.
Nonetheless, Mahler should be more forthcoming in order to ensure that her trainees are adequately supported in making informed decisions.
(Step 2) Emotion: connect signals to meaning
There is value here: “Teach the student to understand what the signals mean.”
Do step 2.
But Mahler doesn’t say how.
Not with a chance of success beyond coincidence, anyway.
Why? Because she doesn’t seem to understand what’s really going on in this area.
When she talks about communication improvements, she contends that:
A: Emotions are physically felt inside.
B: Interoceptive events are physically felt inside.
A + B: Improved interoception awareness (and then regulation) might generalize to emotions.
The notion of “communication” comes in with the speculation that this might help with an ability to put names to emotions.⇲
To get there, she evidently just went with something that made sense to her, like this…
First, get a student to associate the following two things together (for example), which represents a case of homeostatic interoception:
- the common overlap of internal sensations associated with each need to void a full bladder
- an awareness of the need to void a full bladder
So far, so good. Next, use improved awareness of that association to help support improved regulation around voiding.
Yay! You’ve reinvented potty training! Pat yourself on the po-po!⇲
Second (and last), extend that familiarity with the potty training process to scaffold the student into successfully associating these two things (for example), which represents a case of affective interoception:
- the common overlap of internal sensations associated with each experience of anxiety
- an awareness of the experience of this specific emotion cluster (without forcing the “anxiety” name onto it)
Finally, use improved awareness of this association to help support improved regulation around anxiety.
That second part is so commonly understood to be difficult, and as not having any clearly effective therapeutic approach, that Mahler’s program is specifically designed to provide a solution (which is a laudable intent): get the student to become so familiar with potty training (homeostatic interoception) that they will start to grasp the connection between specific sets of bodily feelings and certain emotions (affective interoception).
Her assertion of effectiveness relies on the authority of “common sense”: if you can improve a person’s regulation of their homeostatic systems, then that should naturally transfer to the affective systems, by virtue of nothing more than the fact that they are both things that are happening inside the body.
Yes, they are both things that people commonly use the word “feel” to describe.
However, that mere synonymy does not make them sufficiently the same kind of thing for students to be able to make the leap.
The sensation of your bladder doorbell ringing is directly tied to that specific organ system. While there are probably exceptions, typically you won’t experience it as a burning tightness diffused across your chest and a fear that you’re dying of a heart attack. Hunger is similar, which is another Mahler example: your stomach is a specific organ that growls. If instead your whole body flushed with heat when you were hungry, then aside from that being a very wasteful messaging system, there would be nothing body-specific to tell you, “Put something in here (through the mouth end of your stomach hole).”
There is no similarly encapsulated sensation that would be your anxiety doorbell ringing. It is diffused across several systems, and it is not associated with a biological cause-and-effect system like the one that is designed to explicitly tie together (a) the sensation of the need to void with (b) the physical sense of relief upon voiding (and the quieting of the doorbell).
That’s why there is no real explanation of how to do Step 2 in this way; instead, there is valuable guidance on how to better imagine what a given student is experiencing, and being able to meet them where they are. When you’ve done that, then you are in a much better position to figure out what they might be feeling inside affectively, so that you can support them effectively.⇲
In transdisciplinary coordination with SLPs, this could be really cool.⇲ And it wouldn’t need the “homeostasis ≈ affection” inaccuracy.
So, why did Mahler decide to rely on her domain ignorance instead of an SLP’s collaboration? Why all the anecdotes about what someone-or-other told her, or what she’s seen someone else do, and throwing shade on EBP?
I don’t know about Mahler in specific, but when packaging a product, it does save time when a quack skips the development step of eliciting skilled collaboration, or including objective evidence. It ignores Guideline #1, and doesn’t get as far as Guideline #2.
There is also no downside for the quack if they don’t get caught, so they make sure to target audiences who know even less than they do. Merely sounding like an authority works well enough to sell a product when it is buried in an otherwise informed presentation.
Without regard to her intent, the consequence still exists of her just making something up (instead of becoming informed), whether she recognized her insufficiency or not.
The moderating factor here is that some SLPs also believe wrong stuff, like the whole “delayed echolalia” and GLP thing, so even had she significantly involved an SLP, that is no guarantee of their getting it right either; in fact, even ASHA wrongly supports these errors. Regardless:
- the approach to meeting the student where they are would be improved with the influence of experienced SLP techniques; and
- the ubiquity of a myth is not an excuse for relying on one’s own lack of experience, instead of at least relying on the ignorance of an expert in the appropriate field.
Crucially, Guideline #2 should help to lower the risk of being misled by a misguided expert.
Case in point: according to G2, all she had to do was to ask me, or someone like me, namely someone who could point out where she had gotten it wrong. There are distinct disadvantages to having your fortress patrolled by fans, one of which is that they believe that they are protecting you from harm, when more typically, they are guarding you against the truth.⇲
In any event, the consequence is this: A product that fails in an intermediate step will ultimately fail before the end. I don’t want that to happen with the good parts of Mahler’s work. So how can SLPs help a student to “connect signals to meaning”?
To begin with, SLPs support a substantial array of available forms. As discussed earlier, the symbolic links between forms and conceptual structures are crucial to communication (broadly, essentially defining words), and sensory signals play a role in the development of forms.
That’s one huge reason that we promote sensory lifestyles (formerly known as “sensory diets”) for our students, namely to help ensure that their inventory of sensory experiences is not so impoverished as to limit the emergence of these links, which would in turn hinder their communication and language. We want to avoid that unnecessary limit.
Then, in terms of conceptual structures, how can we help a student change their conceptions (i.e., their encyclopedic knowledge) to blend (a) this new sensory experience (where they are newly aware of a sensation that they have the physiological ability to feel) with (b) their existing conception of a certain emotion?
What if they experience sensory integration challenges, and we’ve just added more sensory information to the existing pot?
And what if their existing experience (and conception) of that emotion is nothing like the one that is canonically shared among the members of their community? What if it only exists in an entirely rudimentary form, if at all (essentially)?
As SLPs, we have some good ideas about where to start, in conjunction with the support of other specialists.
None of this really exists in Mahler.
Now here’s an interesting question (to me): can interoception help someone with their segmentation challenges; that is to say, can Mahler’s therapy help a ~GLP, as long as they are already physiologically sensitive to their interoception?
And here’s the equally crucial answer: maybe.
Maybe there is an interoceptive cue associated with auditory spectrotemporal features that would help the segment boundaries in the time-stream to be perceived, and maybe we will find that the research eventually extends to include visuomanual cues in signed language. What is it that you hear in speech, or maybe see in signing, that you might associate with an interoceptive sensation?
Pressure is one possibility, which would contribute to meaning of thunder.
It is important to get this figured out because having a firm Step 2 is crucial if you’re going to have a Step 3. It cannot be hand-wavy, otherwise you ascend into comedy, as follows…
It’s much like the Syndey Harris cartoon, where one scientist is saying, “I think that you should be more explicit here in step two” (where the other scientist has written on the chalkboard, “Then a miracle occurs.”)⇲
Or maybe it’s more like Steve Martin’s SNL monologue, “You say… ‘Steve… how can I be a millionaire... and never pay taxes?’ First... get a million dollars.”⇲
Or maybe it’s like any number of other things that sound like great ideas, but the trainer never tells you how it’s actually going to be done.
(Step 3) Action: regulate with an action that promotes internal comfort & health
Yes. Do that thing.
Becoming (and then remaining) trauma informed is one of Mahler’s very good points, as is her related one about promoting sensory safety, and trying to experience some of what the student feels by closely, personally inhabiting their environment.
The supporting details are subdivided by a list of abuses that she continues to witness in her environments; in fact, it seems clear that this is why Mahler is such a strong proponent for changing the environments within which she works, and thank goodness that she does, because what she describes as typical there is an awful mess:
- Comfort is withheld in order to elicit compliance;
- Students get all of the way beyond age 21 without anyone evaluating their need for AAC;
- Cognition-grounded therapies are implemented in an unexamined fashion without regard to the cognitive space within which a given person resides;
- Students are subjected to “Theory of Mind” goals (i.e., their awareness of “other” minds) before they have substantial access to a theory of their own mind (i.e., their experience of their sense of self);
- Aversion/Exposure therapy is applied to students who do not have access to a neurology that has a hope of being able to dampen responsively;
- Lived-Experience Informed Practice (LEIP) is “colliding” with Evidence-Based Practice (instead of their being coordinated); and, in general,
- The people with whom she works still prefer to rely on a deficit-based mindset.
All of those things are horrid. They absolutely need to be changed in her environment, and wherever else they occur.
I try not to escalate over thoughts/feelings about balancing (a) the time that it takes for change and (b) wanting to eliminate the related suffering right the hell now.⇲
Comfort and Compliance
To use Mahler’s words from the making of this good point, I’d like to believe that “felt comfort” is not often treated as “coddling” or “reinforcing negative behavior,” but I see it happen even with people who feel that they are well intentioned.
I’d like to think that we would no more knowingly withhold comfort than we would medication or nutrition or bathrooming or any need:
It’s one thing when we apply training to address this issue, and it not only requires several coats, but periodic reapplication.
It’s another thing when we’re not even noticing the various insidious manifestations of this practice, and fail to address it.
It’s an even worse thing when it has become entrenched as part of our standard practice in an unexamined way.
It’s that “knowingly” bit that is too soft in parts of many programs.
And there is the issue of “food” that could use some discussion. In the same manner that a golf pro might clarify if I were to use the generic word “club” (i.e., telling me that a particular tool is a mashie, niblick, mashie-niblick, nine iron, or whatever), SLPs don’t use the word “food” in a generic sense; for example, there isn’t an abuse inherent in using some sort of entertaining edible treats as reinforcement tools.
However, we don’t conflate that sort of exchange to include all other types of “food.” We aren’t supposed to use this compliant exchange with meals, or with any other nutrition (of substance), but we know some of our students can find it difficult to distinguish the likes of snack time from a meal.
While snacks/treats are not needed for nutrition (i.e., they are only wanted, desired, or whatever), such positive reinforcers might be needed for learning.
Similarly, if a student had some type of food that was needed for sensory regulation, or other necessary comfort, then we would not make them perform to gain access.
Question: So when do we introduce such typical communicative exchanges as polite pleasantries in exchange for being handed food (such as requiring a student to say/sign “please”)?
Answer: It depends. This ties in with Mahler cautioning against training people with autism to “pass.”
Mahler’s anecdote refers to a student outside of Life Skills, and I don’t have nearly as much experience there. In our Life Skills program, we actively engage in appeals to communication alternatives and augmentations starting at a very early age (ideally from kindergarten).
Don’t apply cognition-based therapies in any sort of one-size-fits-all manner, but rather take the student’s personal cognitive profile into account (just as we similarly tailor other types of therapeutic approaches).
In our program, we have that understanding, anyway.
Support a person’s development of their own mind (i.e., their experience of what it means to them to be like them… their sense of self) before you try implementing any expansion towards their understanding that minds exist in other people.⇲
Don’t appeal to helplessly inescapable misery as a negative reinforcer. (Just temporarily inescapable misery, as above.)
Types of Practice
Mahler’s anecdote about EBP messing up an individual’s medical care is deceptive, especially as associated with the plug for LEIP. The truth is that LEIP and EBP are the best of friends (when neither is abused). I have more to say about this in another editorial.
Ideally, we look at a student’s strengths/challenges in regard to various events that we would like them to experience across a set of their typical environments. This is a SEPT analysis (i.e., a less directive variation of SETT).
Summing Up this Bit on Mahler’s Concerns
While special education programs will always have room to grow, and Mahler’s work environment sounds grotesque, I haven’t (broadly) noticed the people who support the Life Skills program at Lane ESD to be suffering from knowingly engaging in the abusive perspectives identified by Mahler;⇲ however, I do notice that even when we put in a lot of time and effort to route a path away from these bad things, and towards better alternatives, we still see some shit happening. But (again broadly) it does not represent our unexamined standard.
We do need to be much better about differentially diagnosing students who (a) are associated with some sort of autism-like cognition and (b) those who are intensely affected by the experience of trauma (re: the talk that Randall Phelps has given). We have many students who are receiving therapy related to autism who instead should have their trauma recognized. We are working on this.
I might well be wrong about the following (and other stuff, of course), and I welcome corrections, but it is consistent with my current understanding…
Our students don’t receive an evaluation (through the school, anyway) regarding whether they need the involvement of a mental health professional. Behavior outside of school that elicits that sort of attention, and that sometimes identifies a student as needing something more akin to psychiatric care, is not used when that same behavior occurs at school; instead, they get sent to a more restrictive educational environment, but currently without the mental health support that they need.
I think that part of that was because we got used to relying on the expertise of one of our autism/behavior specialists who was a licensed psychologist, and he has since retired. We do have people who are working to address this fragility in our program.
While we have to adapt Mahler to align with Life Skills, that is a typical need for us. It helps us to gauge where we are with (a) old-ish stuff (like the medieval practices that Mahler lists), and (b) new-ish stuff like approaches to interoception.