I occasionally think how backwards it is that we go to school to learn math, reading, and science but we didn’t take classes on feelings or relationships, things that will impact us for the rest of our lives. Many of my patients struggle with identifying and expressing feelings. Often, they grew up learning that certain emotions were “bad,” and they received little to no help from their parents in educating them about affect management. Nowadays, many children are learning in school and at home essential skills to help them identify and regulate their feelings, something of which most adults today could definitely make use.

When working with patients who need help developing a language for their emotions, I encourage them to begin with what I label “primary feelings,” akin to primary colors. They start by learning the basic emotions of anger, sadness, happiness, and fear. Or as some therapists say, “Mad, sad, glad, and scared.” These are the red, blue, and yellow of feelings. If we put each of these feelings on a scale from 1 to 10, with 1 being the mildest degree of the emotion and 10 being the most intense, we can start to differentiate the varying degrees of an emotion. For example, if we have a scale for anger, we put “angry” in the middle at 5. Along the anger scale, we can put feelings such as irritated and annoyed at the low end of the scale - around 2 or 3 - and a feeling such as enraged at a 10, on the high end of the scale. These feelings all are different forms of anger, just to varying intensities of this emotion. On the “happy” scale, with “happy” a 5, we might label a 1 or 2 “satisfied” or “content,” while a 9 or 10 might be “ecstatic” or “exuberant.” Additionally, some feelings are a combination of primary ones. For instance, “hurt” might be a combination of sad and angry. “Surprised” may be a mixture of fear and happiness. When we peruse lists of feelings, we start to see how most labels for feelings can be either a degree of a primary feeling and/or a combination of multiple primary feelings.

The other skill that most patients need help with is differentiating feelings from thoughts and behaviors. If we stick with the core emotion of anger, then anger is the feeling, while slapping is a behavior used to express this feeling, and “I hate you” is a thought that is attached to this core feeling. Most people confuse these and think that “getting angry” is the same as hitting and screaming. We have choice about which behaviors we want to employ to express a feeling; even when it feels “out of control,” we can choose not to hit or scream. We do not have choice about the feeling itself. Feelings are neither good nor bad, they simply “are,” the same way thirst and hunger simply are physiological states. People rarely judge themselves for being thirsty but people often judge themselves for being angry or sad. We cannot choose if we are angry or not, but we can choose how we respond to that anger.

Much of my work with patients around feelings is to educate them about the differences between thoughts, behaviors, and emotions and to help them learn that emotions are not something “bad” they need to run from. I can help them learn various healthy and effective ways to express feelings, in contrast to unhealthy, maladaptive expressions of emotions they may have learned up until now. Most importantly, I help my patients learn that feelings are not something they need to avoid at all costs, but rather essential parts of being human.

In recent years I have begun implementing meditation practice during the first ten minutes of a session with some of my patients. The choice whether to meditate or not is always at the discretion of the patient. The purpose of such practice is to help bring awareness to one’s internal world in the present moment. This encompasses improving one’s attunement to emotions and physical sensations that can be detected in the body. I have found that many people are initially uncomfortable being with themselves in the here-and-now, and thus they flee being in the present and resort to living in the past or future, allowing their thoughts to distract them from what is right before them.

Most people do not need my help accessing their thoughts; they can fairly readily identify what they are thinking. It can be a different matter when they are trying to identify what they are feeling. When an emotion is intensely felt, it is likelier that the individual will notice it and be able to describe it. One is more apt to recognize that she is enraged than to recognize that she is mildly annoyed. But if we believe that all people have thoughts, feelings, and physical sensations at every moment, whether we are aware of it or not, then we can begin to see how difficult it can be for many people to access feelings when felt to a lesser degree. This concept that people have thoughts, feelings, and physical sensations at every moment is similar to breathing. Once an individual is encouraged to focus on his breathing, he usually can do so easily. We are all breathing at every moment but often we are not paying attention to our breathing. The same applies for thoughts, feelings, and physical sensations. Some people may find identifying and accessing physical sensations challenging. Still more may struggle to identify and stay with their feelings. Trauma survivors in particular may struggle in this way, given that one of the ways they learned to cope with the trauma they experienced was to numb themselves and dissociate from their internal world. This serves a protective function. As adults many of these individuals have difficulty knowing what they are experiencing when it comes to emotions and physical sensations.

Meditation seems to assist people in building their awareness of what is happening internally. Furthermore, it can help people learn to stay in the present moment and tolerate inhabiting their own internal world without feeling threatened by unpleasant emotions. I’ve witnessed people who initially had trouble sitting still because they were so anxious learn to relax into a ten minute meditation practice and open themselves up to the present. With most patients we start and end the meditation practice with four deep breathing inhalations and exhalations. This seems to help people relax and prepare themselves for the meditation. During the meditation itself, patients are instructed to focus on something simple, such as their breath, that they can keep returning to when their minds start to wander. They simply can notice and be curious about the thought that distracted them and then return to their breathing. With some patients, it is preferred to scan the body from head to toe during the meditation as a way to tune into what is happening internally. By conducting a body scan, one might become aware of tension and other physical sensations that are being held in various body parts. Another option is to draw one’s awareness to the sounds around them, both near and far. I invite my patients to focus on their breathing or to do a body scan, however, because these are ways to increase awareness of one’s internal space, whereas sound brings the individual to something that exists outside of them. Over time, most patients tell me that they have found that the meditation helps them be more aware of what is going on inside them, both with emotions and with physical sensations, and these skills can transfer to the their lives apart from the meditation. For the purpose of developing these skills during psychotherapy, I find that the term “awareness building” rather than “meditation” may be a better fit. People can get confused by what is meant by meditation practice. When we agree that we are working on improving their awareness of their feelings and body sensations, they can best understand how such practice can be of value to them. After the ten minutes, I find it useful to briefly discuss how the patient experienced the exercise and what she became aware of during the time. I also attend to whether starting with this practice has a positive shift for the remainder of the session and can help the patient feel more present and connected to me while engaged in the therapeutic endeavor.

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