Interoception Is a Sense Few Understand

For example, like as an occupational therapist, like I was trained to assume to understand the emotions of my clients and label their emotions because that's going to help them understand how they're feeling. And what we're finding is that assuming to understand someone else's inner experience is really um very derailing. That's Dr. Kelly Mahler, an occupational therapist and professor at Elizabethtown University.

that allows us to feel our own bodies. What happens when the biological signals for hunger, pain, or even emotions are processed differently? And how can we better support neurodivergent individuals in feeling their feelings without imposing neuronormative standards? I'm Emily Kirchhamorris. A conversation with Dr. Kelly Mahler is up next on episode 313. Yeah.

So many late-diagnosed adults were missed not because there were no signs of being neurodivergent, but because those signs didn't match what people expected to see. Maybe they were bright, maybe they were compliant. Maybe they were anxious or perfectionistic or working twice as hard just to hold everything together.

From a mental health perspective, that matters because when neurodivergence goes unrecognized, people often build an understanding of themselves around failure, inadequacy, or being too much. Then they arrive in therapy carrying As clinicians, we need frameworks that help us see beyond stereotypes so we can better understand burnout, masking, internalized stigma, and the emotional complexity that often comes with late identification.

That's exactly what our May 1st CE training for mental health clinicians is all about. It's approved for one and a half APA and NBCC continuing education hours. But if you can't attend live, you can still get the continuing education credits through the recorded independent study version. You can head over to neurodiversity.university for more info or just click the link in the show notes. Okay, Kelly Mahler is here next. Hard to remember things. And then when you have it.

You know, that's also still remembering to do things whatever is impacting you and your executive functions. Not that they're the same, but in some ways they really hit you in similar ways. And when you mash them together, it's almost like exponentially or more. Very much.

Whether again it's from you finding out something that you feel like you should have known long ago or someone dying, emotional regulation with many of us with ADHD can be hard to really control it and manage it. And so it can just crushed together in like a tidal wave. That's episode 289, Adult Diagnosed ADHD, grieving what might have been. Find it wherever you get your podcasts.

We are very excited to chat with Dr. Kelly Mahler today about interoception. Kelly is an occupational therapist and the go-to person when it comes to understanding interoception. So thank you so much for being here. Thanks Emily. I'm so excited to be here today. So I when I provide professional development to educators I often talk about sensory needs. And when I start off, I always ask people how many sensory systems we have.

And overwhelmingly, very few people realize that there are more than the five that we learned about in elementary school, which is always amazing to me because I think if we're really in this neurodiversity community, we just talk about it so much. But it hasn't filtered down. So in addition to the vestibular and the proprioceptive systems, which we're not going to talk about too much today, the one that is of particular interest to you is interoception.

So I want to dive right in and why don't we just explain what interoception is and why we should all care about it. Yeah, I think it's a great place to start. So as you mentioned, introsception is our eighth sense. So we, you know, we nicknamed it the eighth sensory system. And

Um, it really is our sense of um our inner experience, our inner world, our bodies, like so how do our bodies feel? So introsception helps us to notice internal sensation, like Um, maybe it's the feeling of like our heart racing or maybe our stomach feeling empty or growling or a full bladder or tense muscles or hot sweaty skin or a pounding head or relaxed eyes, like all of these body sensations we come to notice and connect to through this sense of introsception.

Um, and we are learning that being connected to these internal sensations is oh so important because they provide really important clues to like what our body needs. um, for health, for regulation, um, and also provides important clues to our emotions. So it helps us to know when we're hungry or when we're thirsty or when we're getting overwhelmed.

One of my clients that I worked with at one point in time was autistic and very insightful about things and this may have even really been I don't know, this was a while ago when I think I was probably still even learning about interoception because really it's not People haven't been talking about it for a really long time. You know, it's a much more recent um conversation piece. But what she was describing to me was basically, by the time I notice that my stomach hurts, it really hurts.

And I can't tell if it's hurting because I'm hungry, I'm going to be sick, I'm anxious, or I have to go to the bathroom. So she would have to literally go through a list in her head and think, okay, when was the last time I ate?

Do I feel like I'm gonna be sick? When was the last time I went to the bathroom to try to deduce what was happening by the time she finally noticed that sensation? And I thought that that was such an amazing depiction of what that hyposensitivity specifically is where she just didn't have as much awareness about those sensations.

Yeah, that's an amazing insight. And I I can't wrap my head around that experience of having an intense inner sensation that um some of my clients explain it as it almost seemingly comes out of nowhere and all of a sudden you're having this like extremely di uncomfortable sensation. And then you have to go cognitively through and work your way through to figure out how to meet your body's needs. Um, it can be really, really complicated and overwhelming.

So hyper and hyposensitivity are part of the diagnostic criteria for autism. So that's one population where we see these differences quite a bit in processing that interoceptive sense. What are some of the ways that we might see this really impacting their day-to-day life? I mean, we mentioned a few, but what are some others?

It can impact a lot of different areas. Um, so toileting is a big one. We get a lot of questions about toileting, and this is for children and adults. Many adults are experiencing interception.

um disconnect that affect their toileting habits and it's just not something that's talked about because there's a lot of shame around it. Yeah. Um so if you think about toileting, for most people It's a sensation coming from their body that lets them know like, ugh, like I have to get to a toilet one time.

Um, so it's not just limited to toileting, like feeding and eating um is really impacted by introsception, like noticing when we're hungry, noticing when we're full, noticing when we're thirsty.

body temperature, like noticing if we're getting overheated or um if we're really cold. Like I have a lot of clients that could their parents explain like they could go outside and like really cold winter weather with just, you know, nothing and with no shoes and socks on and seemingly not notice the cold in their body.

And so there's just a so many um other areas. I could keep going if you want. Like pain is another really big one. Like I had a client that c that walked around on a broken femur for three days before knowing it was anyone knew it was broken. And we're talking a lot about a muted inner experiences, but we also should mention there's a lot of people that have intense interceptive experiences where they notice so many different sensations happening inside their body at once and they

many times describe it as like overwhelming, chaotic. Like they don't know which signal is important to pay attention to at the time. So it can still lead to a lot of confusion um in daily life. Like some of my clients, they might just be going to the bathroom like very, very frequently'cause they feel that little sensation of the bat the bladder feeling and they're like, Oh, I gotta go, gotta go, gotta go.

Or they're very sensitive to feeling cold or hot or thirsty or hungry, you know. So so many different experiences. But then I also want to mention the like what scientists call like affective emotion. So that's like being able to understand when we're getting overwhelmed or anxious or excited or um feeling safe. And those are all coming from our interceptive sensations as well.

I wanna kind of follow up on a couple of those things that you mentioned because I do find them so interesting. So starting with the toileting one, I can think of the variety of sensations that have to occur. in order to know like when you need to use the restroom. But additionally, I have talked to people and and worked with clients who

sometimes view the toileting issue as like a discipline issue or like, oh, they just don't want to stop what they're doing. So they're not going to go use the restroom. But then on top of that, sometimes let's say they have, you know, a small accident and they have, you know, wetness, but maybe they're not really aware of that sensation either, to even really know that that they need to go change or do whatever.

I think what we find is that then sometimes the social implications of it are interpreted differently as well. So then maybe the motivation to change perhaps isn't really there because I remember talking to a kiddo who we were kind of doing some perspective taking and I was kind of trying to say, Well, what do you think, you know, if somebody else

noticed, would that be okay? Would you feel, you know, nervous or embarrassed or whatever? And he goes, I wouldn't care because he doesn't understand how other people are gonna react to him, which it's just hard then, I think to find what the neurodiversity affirming ways are to support that because it's one of the things that we really have to work through, obviously. Definitely. And you know, my curiosity with that kid, I mean I don't know him at all, but um

You know, I'm wondering if just that years of learning that that toileting demand was so hard for his body and what he could handle, is that his defense mechanism? Like I don't care. But really, so deeply rooted sources of shame. um that so many people report from having

um, you know, all of these external demands that their body just is having a really hard time cooperating with and and and and meeting. Um, so and and interception is such a hidden um a hidden like process that if someone is really, you know, if they're experiencing a muted or an intense inner experience,

Um, up until recently, that really went unspoken, misunderstood, mislabeled and pathologized really, but it from a different point of view, like no one really getting deep enough to understand what was happening. Mm-hmm.

It's complicated and you have to have tough conver I don't want to say tough conversations. You have to have uncomfortable conversations sometimes, but hopefully the people have the people who they trust, their parents, you know, a therapist or you know, whoever that might be, where you can kind of talk about those things in judgment-free zones in order to kind of help them figure out the tools that might really work.

Absolutely. And I think one of the biggest parts of like the whole interception science and the work we're doing that we hear from so many people is that.

It just feels so validating that someone gets curious enough to ask you about your inner experience. That when you share your inner experience, they believe you. They say, Oh my gosh, like wow, like thank you for sharing, even if it's something against what someone else might expect. And I think that is like One of the biggest parts of this work.

when you talk about that curiosity and talking about it, I've also noticed so many people don't even realize that their experiences might be different. Because we don't talk about it. We use a lot of euphemisms. We use a lot of, you know, metaphors for different things without really explaining What some of those are.

Yes, absolutely. You don't realize that your inner experience is different than someone else. So why even talk about it? Right?'Cause you're just assuming that it's the same and I mean that's that same thing is so true like For example, like as an occupational therapist, like I was trained to assume to understand the emotions of my clients and label their emotions because that's going to help them understand how they're feeling.

And what we're finding is that assuming to understand someone else's inner experience is really um very derailing to many people because when we assume to understand and I'm like, oh, it looks like you're frustrated right now. If I'm assuming then I am very at high risk of being dead wrong. And so then I am labeling their experience and assuming that to think I know what's going on.

And that just complicates their own personal experience because they're like, well, Kelly keeps saying I'm frustrated. I don't think I'm frustrated, but why are all these people saying this? And then it just leads to even more inner confusion.

So talking about hunger specifically and eating, I I am curious, is there a connection between like ARFID, which is it's like avoidant Restricted food. Food intake disorder, maybe? Maybe We'll put it in the show notes. And so is there a connection with interoception and and RFID? Well, there's no formal research studies saying, but I can tell you from lots of reports of lived experience that there is a lot of connections there from the way certain foods and textures and smells and temperatures

make your body feel like that's intrusive in nature. Also if you just get to the core of like noticing when you're hungry and thirsty and all of that, like that's your motivation to eat. And also if you're really stressed around mealtime, the natural body's reaction is to shut off those hunger and thirst and our body's cues. So that motivation to eat, if it's a highly stressful mealtime experience.

um is going to go out the window. Um so there's a lot of connections there. And um I'm actually working with an autistic nutritionist right now and putting together some more information about that because it needs to be talked about a lot more. Yeah. Yeah, that's fascinating because it's like I haven't seen a lot out there about it, which is why I wanted to ask, because to me it makes logical sense that there's so much of a connection there. But we talk so much about

Feeling our feelings. And a lot of people don't even realize that we say that, but what we're we're literally talking about feeling the sensations of emotions in our bodies. So can you talk a little bit more than we have already about the connection between interoception and emotional regulation? Interception is, I think, shifting uh the whole emotion world big time. For so long it was such a cognitive process. We thought like emotions were

coming from like our brain and our thoughts and we forgot about this entire thing down below our head, call it our body. And um And so yeah, what th all this really cool research is showing is that emotions arise from our body, from these introspections. And first you have to be really clear on how you feel in order to know what to do.

to be able to regulate your body. So if we want to be working on emotion regulation, we need to start with the body, start helping someone become more connected to those internal sensations. And that's quite a big shift. Uh a at least it is for me as an OT in the way I was trained twenty years ago. I was using a lot of cognitive behavioral therapy techniques and

I always felt like something was missing, but I had no idea what it was until I learned about interception and it makes a lot of sense. And it doesn't mean that those cognitive approaches are wrong. It just means that we need to rewind a little bit and start with the body and help someone. to begin to notice and understand those interceptive sensations and what they mean uniquely from them. We cannot teach someone else what an emotion feels like because it is different for each one of us.

We can't teach someone that anger is when your fists get tight and your skin gets hot because that is um different for every single one of us. And there's a lot of really cool interception research coming out saying there's no single footprint of an emotion. And So it has to get back to that curiosity piece that we were talking about, right? And helping each person um get curious about their body and discover those internal sensations and what they mean uniquely for them.

Can you talk a little bit about Alexithymia?

Yes. That's a really good question, Emily. Um so alexithymia just translates to difficulty identifying and describing your emotions. Alexithymia to me is kind of like a surface term. Like it just tells you, okay, like this is what's going on with a person, but it doesn't tell us why. Like why are they having difficulty identifying and describing their emotions? Um, but the interception field is thankfully um s expanding in this area and showing that Alexithymia, like the underlying reason why.

Um, someone might be a lexithymic is due to an interception disconnect, whether it's that muted inner experience that we talked about, or even that intense inner experience, where they're just having a hard time using those internal sensations as clues to how they're feeling. It's so interesting how so many of these things get misinterpreted.

For example, a person, it doesn't matter what age, who experiences some of that alexithymia might really have a difficult time labeling and talking about their emotions. But when somebody asks How are you feeling or what you know what's happening? And you don't get a response. That is often interpreted as rudeness, defiance, when really it's like they really maybe can't make that connection. Or, and I'm curious about your thoughts about this.

You mentioned earlier about how sometimes finally when those sensations are experienced, when they finally come to the surface, they're very intense. those sensations might be building, but if you're not aware of them, we often see kind of explosive behavior. Would you connect those two things, like that poor awareness or integration of interoception, and then that leading up to that big overwhelm as it finally comes to the surface?

Yeah, that can definitely be a um connection for many people. And I've had clients tell me that you know, they're just missing those like quieter signals, like letting them know when something is brewing or like something is just starting to get off. And then all of a sudden this meltdown, this shutdown just comes out of like

the it it just seems to be like this big surprise. Like they didn't know it was coming and all of a sudden they're in the midst of a meltdown and a shutdown. And I mean at that point it It's nearly impossible. I don't want to say completely, but it's really hard to self-regulate. You're probably going to be relying on hopefully a safe person in your world to help you to co-regulate.

What are your thoughts about helping people build their interoceptive awareness. I mean, it feels like it's something that's so hardwired that gut instinct might be to rely solely on accommodations in the environment. But I'm I'm wondering if there are some ways that people can actually improve that interoceptive sense. Yeah, I mean accommodations is definitely one of the things that we might offer someone. Um, so for example, an accommodation like for maybe an adult that

um, isn't noticing like those sensations of hunger or even thirst or toiling, whatever it is for them, um, to set a timer on their on their smartphone. And then it'll just remind them to like, you know, like go to the bathroom or eat or whatever it is. But we always want to work towards building that interceptive awareness if that if it's meaningful to that person because there is so much hope in this space.

The research is so clear that interception is highly changeable. Um, so it's highly changeable towards like, I guess, the more positive, like where you're more connected to your body. But we also do know that interception can be significantly changed. um where we might be derailed from our bodies like through trauma or through um different compliance based behavioral interventions that condition us to not listen to our body.

So whenever possible, we want to offer those interceptive awareness support so that someone can um become better acquainted with their body, their own, you know, unique inner world. um and understand that so that they can take care of their bodies in a more proactive way.

It's interesting that you mentioned this piece about being conditioned not to listen to our bodies. So I have a professional consultation group that I meet with once a month and we met yesterday actually. And that actually came up in our conversation about how Schools, it's like you go to the bathroom when your teacher takes you to the bathroom, you get up and move when it's time to get up and move. I mean we are trained from such a young age not to listen to what our bodies are telling us.

And it's no wonder so many of us don't really respond to our feelings as in our emotions in ways that are as productive or or healthy as they could be. let alone people who process that information differently.

Absolutely. I mean, those IA extremes, like whether you have a muted or an intense inner experience, are not exclusive to neurodivergent people. It is just across the board for many people and culturally we are conditioned to ignore our body. Listening to our body is weak. It's not allowed. And even when we're getting I think we're getting a little bit better at the messaging on self care and listen to your body and, you know, kind of body mindfulness and all that stuff. But

Even when we take time to listen, you know, the I think sometimes for people I hear that those voices creep in, like, will I be considered weak if I ask for a break? You know, like it's all of these things. Um, so we are undoing like cultural conditioning. Um, but it like you said, it starts from such a young age. And even I've had educators talk about um how even their own jobs

um, do not allow them to listen to their bodies. They are only allowed to go to the bathroom at ten fifty five AM when their ch when their students are like, you know, out at recess or you know what I mean? So It's really, really hard that we're we're just up against an entire system. But like I said, there still is so much hope.

We've talked, I feel like, a lot, and I feel like this is where we often notice a lot of these things is maybe more with the hyposensitive side of interoception. Is there a a converse? Like what what might that be like if somebody is hypersensitive to their interoceptive sensations? Yeah, I'm so glad you asked this because I do think it's not something that is as widely talked about as the muted side of things.

What we're learning is I mean, that first of all there are a lot of people that have an intense inner experience. They're feeling so much on the inside of their body. And um the cool thing about it, which is really interesting to me and it actually surprised me. is that the interception based activities that we're offering are the exact same activities are working for people that have a muted inner experience, but also for those people that have an intense inner experience. And

You know, really what we're trying to do with the core of our work is to help people just start to notice and understand their body sensations. And the reason I think that's working for the intense feelers. Um, and this is what they're sharing, is that we're helping them to be able to spread their attention to their entire body, where they don't get stuck just on one or two signals, which is very co a common report we hear.

Um, we help them to become their inner world becomes more predictable with all this practice of noticing because um, you know, if something's not predictable, you're not understanding what's going on. Many times those sensations become even more heightened because you're just worried about them. Of course, you don't know what's happening in your body. And so when we begin to be give that predictability, that understanding around their bodies being working on spreading their attention out.

uh they're having some really awesome outcomes. Do you think that individuals who experience psychosomatic headaches or stomach aches? related to their anxiety. Like a lot of times people will say, Oh, that you're just imagining it. Like you're not really sick. You're fine. But the way I often interpret that is it's that more intense experience. Would you agree with that or am I off face?

No, I definitely agree with you. Okay. Yeah. And I know there's a whole lot of people, maybe even some of your listeners, agreeing with you too. Uh, there's so much accidental gaslighting in this space and you know, someone like going to the doctor and like they're feeling all these symptoms and maybe the medical provider can't find any like medical reason why they should be having all of these symptoms, but Um interception's not taught in medical school. Like they're not

You know, and it doesn't mean that um those those sensations that experience is not there. And so they they leave those medical appointments having their inner experience, you know, not validated and they're wondering like what's wrong with me. Maybe it is in my head, you know, what all these people are are saying about me, but I definitely think a lot of those heightened psychosomatic symptoms can be due to those uh that intense inner experience.

Do we notice differences in interoception with other types of neurodivergent diagnoses? I mean, we talk a lot about autism. Is there research about where that might also impact individuals? Yeah. Uh well there's some literature coming out of the ADHD space, um saying that a lot of ADHDers um experience these IA extremes. Um

And there's a lot of information coming out of the mental health field that almost every single mental health diagnosis that exists has been connected to some form of an interception extreme, which that's pretty profound um findings. In fact, The National Institute of Health in the US has declared interception as a research domain of priority. Wow. And they're they're actually this is a fun fact, Emily. I'm so excited about this. But the National Institute of Health.

is hosting their second annual um conference on in interoception in November. So I mean this is like interception is gaining a lot of attention. Um like we don't know enough about like You know, like I'm curious, like, you know, are these interception extremes like leading to the mental health like like anxiety disorders or depression or is it the depression, the anxiety, whatever it is leading to the IA extremes? Like I kind of probably I feel like they're probably

like a parallel development together, but we don't know. Um, and I I do think some people are born into this world with like genuine interception differences. And then some people experience They their just their life experience derails their interceptive world. Um, so there's just so much to learn in this space. And I'm sorry if I got off on a really excited tangent there, but I I don't remember your original question.

No, you answered it perfectly, like recognizing that I feel like the neurodiversity community in general focuses quite a bit on the autistic experience, which I think is valuable and important and everything, but I also want to make sure that we aren't leaving those other things out. And it sounds like we recognize that there's a connection with all of those things. Yeah. And just our daily lives.

Absolutely. And I know there's a lot of PDAers that are teaching me a lot about their intrusive world and how internal sensations can be perceived as a demand, which we know then in turn sets off a whole cascade of a, you know, stress response. Like

My body's like saying I need to eat, but that's a demand on me, you know. So it's just like so much to learn. I mean, I know there's a lot of research going on right now in the eating disorder world too, and looking at introspens as a pivotal aspect of healing and recovery.

So let's just briefly talk about some accommodations. So you mentioned earlier, like for example, somebody could set some alarms on their phone to try to make sure that they're trying to use the restroom at certain intervals or whatever. Are there other accommodations that you find really helpful either at school or at home that might really help?

Yeah, one of my most favorite accommodations is to set up a schedule of proactive feel-good breaks. I feel like we wait way too long or more reactive, especially like I'm a school-based therapist. We tend to wait until the students getting dysregulated and then let's offer a break. So getting better at embedding those proactive breaks.

throughout the day. So not really relying on a person needing to recognize that feeling in their body, like, oh, like I think I need a break right now. They're just they're just happening. They're proactively embedded in their day where they can take some time to do whatever it is that helps their body to feel good. And I should say that

If you are experiencing interception extremes, it also can be really hard to identify what makes your body feel good. Um and it's a really cool part of our work. Like sometimes, like I just was assessing a teenage boy um a few weeks ago and I asked him, like, well, what kinds of things do you enjoy?

And he's like, video games. I'm like, all right, cool. And and I was like and then I said, like, well, what other things like make you feel good? And he's like, That's it, video games. And I'm like, Okay.

So I mean I that's a awesome answer, but if you're dysregulated and you're trying to play video games and it's not working and you have no other idea of what helps to promote, you know, that regulation and comfort in your body, you're stuck. And so For him, like we really want to help him expand that repertoire and help him connect with those things that make his body feel good.

Um, so that's one of my most favorite accommodations are those proactive um breaks because that's quite a paradigm shift for a lot of the systems I work in. Kelly, I know that we could talk about this all day, but as we wrap up, um, it brings me to our final question. So if you were talking directly to a young person who's having some struggles in their daily life based on their sensory differences, whether they're interoceptive or perhaps otherwise.

What would you say to them? What is it that you would really just want them to hear? That's a great question. Um, well, I would want them to know that they're first they're not alone. And um sometimes my clients feel like they're all alone in their experience and Um and I also want them to know that I deeply am curious about their inner world and I want to learn

And I I know a lot of my clients find that to be extremely validating too and I want to ask questions and and learn what their experience is. Um so yeah, I would want them to know they're not alone and that they're is definitely valid. Yeah. Thanks, Emily. What does it feel like in your body when you're angry? How about Or calm. The next time you experience an emotion, ask yourself. Did you know

Thought process first. Mindfulness sometimes gets a bad rap as something that is kind of the But when you really understand how closely linked the mind, body, and emotions are, it's So much more taking that pause and finding a way to regulate our bodies and emotions through our sensations. Sometimes people may be skeptics, especially our neurodivergent kids. Difference, not only in our ability to self-regulate, but also with building self-understanding and ultimately self-compassion.

I'm Emily Kircher Morris. I'll see you next time on the Neurodiversity Podcast.

For more information about our guest, Kelly Mahler, there are links in the show notes. If you're a mental health professional, we're presenting another CE training on May 1st. It's 90 minutes and designed so you can better understand burnout, masking, internalized stigma, and the emotional complexity that often comes with late identification.

It's approved for 1.5 APA and NBCC approved CE hours, and it's live on May 1st, but you can get access to the recorded independent study version and get those credits after the live event. Head over to neurodiversity.university for more info or just click the link in the show notes.

Our host is Emily Kircher Morris. Corey Orik is our office coordinator and assistant producer. Hannah Hadike Swift is the program coordinator. Andy Kahn is our chief clinical advisor. Amanda Morin is our hub co-facilitator. I'm the executive producer Dave Morris, for all of us. Thank you for listening, and we'll see you next time. This is a service of the Neurodiversity Alliance.