#85: OT and Interoception with Kelly Mahler

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Learn more about our guest: Kelly Mahler OTD, OTR/L

Interoception is having a moment.

The skyrocketing popularity of the “8th sense” likely stems from its effectiveness in putting words to the importance of deep and personal sensations—like hunger, fatigue, raised heart rate, and pain.

But while these sensations seem universal, in reality there are vast differences with how—and to what degree—we each experience the components of interoception.

What’s especially interesting is how these differences relate to emotional regulation.

We are still in the early stages of this research, but early stage studies seem to be showing that interoceptive awareness can be improved. And, this improvement may possibly correlate with improved emotional regulation—even in individuals who are not explicitly working on emotional regulation.

In this 1 hour CEU course, we’ll look at a school based program that does just that: improves interoception and emotional regulation.

:white_check_mark: Agenda

Intro and breakdown of journal article

Discussion on practical implications for OTs

  • 00:13:15 How Kelly became interested in interoception
  • 00:17:05 How the Interoception Curriculum came to be
  • 00:22:59 Article impressions
  • 00:26:13 How Kelly currently describes interoception?
  • 00:31:31 How does interoception fit into a strengths based approach?
  • 00:36:09 What settings is the interoception curriculum being used in?
  • 00:41:01 What does it take incorporate the curriculum into schools?
  • 00:45:11 What is one potent interocpention intervention for all OTs?
  • 00:51:26 Where does Kelly hope to see interoception in 5 years?

:white_check_mark: Supplemental Resources

Free Resources from Kelly:

Supporting Research and Journal Articles

:white_check_mark: Article Review

Read Full Text: An Interoception- Based Intervention for Improving Emotional Regulation in Children in a Special Education Classroom: Feasibility Study (There is a fee to purchase this full article, but we thought it was important to cover nevertheless.)
Journal: Occupational Therapy In Health Care
Year Published: 2024

Interoception is having a moment.

The skyrocketing popularity of the “8th sense” likely stems from its effectiveness in putting words to the importance of deep and personal sensations—like hunger, fatigue, raised heart rate, and pain.

But while these sensations seem universal, in reality there are vast differences with how—and to what degree—we each experience the components of interoception.

What’s especially interesting is how these differences relate to emotional regulation.

We are still in the early stages of this research, but early stage studies seem to be showing that interoceptive awareness can be improved. And, this improvement may possibly correlate with improved emotional regulation—even in individuals who are not explicitly working on emotional regulation.

Here, we’ll look at research involving a school-based program that led to improvements in both interoceptive awareness and emotional regulation.

Then, next week on the podcast, we will welcome Kelly Mahler OTD, OTR/L—the lead author of this paper and one of the pioneering researchers on practical implications of interoception for OTs and other health professionals.

What is interoception?

Interoception is a network of senses that support the detection, interpretation, and reaction to internal sensations.

This is the mechanism behind self-awareness of sensations like:
:grimacing: Pain
:hot_face: Body temperature
:nauseated_face: Hunger or fullness
:cup_with_straw:Thirst
:zap: Sexual arousal
:face_vomiting: Illness
:poop: Need for urination/defecation
:sleeping: Need for sleep

Interoception and Emotional Regulation

The detection and interpretation of physiological changes—especially increases in intensity—is key to successful emotional regulation.

The inverse is also true: when people are unable to notice or interpret their interoceptive body signals, they miss crucial cues for successfully understanding and regulating their emotions.

In a previous study, Kelly and her fellow authors explained this difference in interoceptive awareness as it relates to autistic children, who may experience alexithymia—a.k.a. difficulty with identifying feelings, and more specifically, identifying and describing emotions. Researchers approximate that one in 10 people can experience alexithymia, and the rate is even higher in people who are neurodivergent, have experienced trauma, and/or have a mental health diagnosis.

Please tune into the podcast for a more nuanced discussion on how Kelly now uses—and doesn’t use—language like alexithymia.

Emotional Regulation in Schools

In a school environment, emotional dysregulation can lead to outward behaviors like outbursts, aggression, refusals, self-injury, and impulsivity.

Historically, these outward behaviors have been addressed with behavior-based interventions. But, the authors of this paper argue that these interventions do not address the underlying challenges (one of which may be a difference in interoception).

In fact, behavior-based interventions may teach children to further ignore their internal feelings and instead focus only on behaviors—even when those behaviors do not match their internal experience.

Given our expanded understanding of how interoception impacts emotional regulation, interoception-based interventions may be a more effective option.

Initial small-scale studies support this hypothesis, including:

However, both of these studies were small and limited only to autistic children, which leads us to this paper…

Intent of the Research

The purpose of this study was to determine if there were changes in interoceptive awareness and emotional regulation following interoception intervention in a special education classroom of students with several diagnoses.

Methods

This study used a one-group pre-test/post-test design to compare scores on measures of interoception and emotional regulation.

Participants

9 students (ages 11–14) in a middle school special education classroom participated in the study. Consent was obtained from both the students and their parents.

Outcome Measures

To measure interoceptive awareness, the authors used an adapted version of the Interoceptive Awareness Interview. This self-report is a sub-assessment of the:

Emotional regulation was assessed using the Emotional Regulation Index, a teacher report that is a sub-test of the:

The Intervention

Participants engaged in one 30-minute session per week for 7 weeks. All 7 modules were conducted within the participants’ special education classroom and co-led by the same therapists.

The weekly topics were based on the Interoception Curriculum:

Week 1: Hands/fingers and feet/toes
Week 2: Ears and voice
Week 3: Mouth and stomach
Week 4: Eyes and nose
Week 5: Heart and lungs
Week 6: Brain
Week 7: Skin and muscles

Participants began each session by reviewing and brainstorming interoceptive words related to the body part. Here’s an example:

832×1032 193 KB

Next, participants completed a series of activities designed to evoke interoception sensations related to the body part. These activities gave participants practice with noticing and describing sensations:

770×1026 145 KB

Additionally, a Body Check Chart iPad app was introduced during the first session. Participants used the app:

  • following in-session activities, and
  • at least two other times per school day.

The app prompted the participant to:

  • focus on a specific body part,
  • notice how it felt in the moment, and
  • select a matching descriptor term.

Results

Statistically significant improvements were observed in the Interoceptive Awareness Interview AND the Emotional Regulation Index.

Discussion

This was the first study of its kind to find that interoceptive awareness and emotional regulation can be improved in children in a mixed-diagnosis special education setting through the use of the Interoceptive Curriculum.

It is interesting to note that during the weekly intervention sessions, the OTs did not discuss emotions or emotional regulation. While the transferability of this research is limited—and more rigorous designs are needed—the current study does provide preliminary evidence that interoception interventions focused on noticing and understanding sensations may implicitly lead to greater emotional awareness and regulation.

:white_check_mark: Review %open%

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Please share any other feedback below! Including, ideas for future programming, and most importantly, how you feel this podcast will impact your practice!

1 Like
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Looking forward to the podcast. This is a particularly interesting topic to me, and learning how to help our clients with interoception awareness has been a bit of a struggle. Excited to hear how others are navigating the topic, and gain some ideas!

2 Likes
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Yay to Kelly, et al! I have one of her books and it has been so useful in my practice! And now, a study with middle-school students is so encouraging! Within my practice, many of my clients (ages 8-17,) miss critical information bc they have challenges noticing & interpreting their unique interoceptive sensations. In addition, the term “alexithymia,” is new to me.
It is encouraging that this small study showed some promising results. I look forward to attending this podcast
Renee Owens

1 Like
5

I hear this, @brandy!! The topic also felt nebulous to me! I think this is what makes @kelly46’s work so remarkable, is her ability to make this so actionable.

(I can also say that I just wrapped an upcoming podcast with a program director at NYC public school and interoception was top of mind for her- so this definitely feels like the thing we should be thinking about!)

6

@kelly46, my next podcast is on social emotional learning interventions. Specifically the Path Program in NYC which strives to make SEL culturally responsive and strengths-based. (And, the program director brought up the importance of interoception in their approach.)

I’m curious how you see interoception awareness fitting into this larger umbrella?

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Thank you for this article , waiting for more information about this topic and how sensory regulation can make change in patients life .

2 Likes
8

After reading this article I’ve realized that failure in interpreting interoceptive sensations can be a limitation to occupational performance and sometimes prevent the person from being independent. for example if a person can’t tell if he is in pain or not I can’t expect them to be in charge of their medication, also a child who can’t tell if his bladder is full or not can’t be expected to be independent in toileting.
this is a very important aspect to address, looking forward to the podcast.

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Hi Sarah,

Love the mission of the PATH program! How important! Interoception is the neurobiological foundation of social-emotional learning, yet it is missing from most (if not all) SEL curricula available. Except for the Interoception Curriculum which is the only SEL curricula that I know if that goes deep enough into interoception.

Don’t get me wrong. The SEL push is essential in our country! But we are often way too far ahead in the skills that are targeted. Many students are not ready to identify/regulate their emotions, consider the feelings of others, etc when they don’t have a firm foundation in their body…understanding their own personal body signals and what their body uniquely needs for regulation. So, in a nutshell, yes please to SEL (especially when it is culturally sensitive!), but wayyyy more interoception at the start.

PS it is not enough interoception to have students simply label a body outline of how they imagine their body feeling when angry, anxious, excited, etc. To do this activity or similar surface level work and say “we did interoception”, now on with the show. Interoception work can take some time, especially if we want to be individualized, culturally sensitive, trauma informed, neuro-affirming and effective.

Hope this helps!

Take care :blush:, Kelly

2 Likes
10

I have been using this those handouts in my sessions and they are so helpful! Interoception is hard to teach and hard for my kids to understand so anything to make it fun is so helpful. Looking forward to listening to the podcast.

1 Like
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While reading this article I was encouraged by the method of implementation within the study. Using the Descriptor Menu and the Focus Area Experiments incorporated multimodal learning. I also appreciated that this study acknowledged that feelings of various body parts can be perceived differently among individuals. I would love to see further research in this area to determine the level of transferability and if it had any impact on the development of social interactions among students.

12

This was an informative and efficient podcast! I learned more details about interoception and about additional resources and I will be using some of Kelly’s suggestions within my practice

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13

INFORMATIVE and EFFICIENT! Those words speak right to my podcast host heart! :slight_smile: I’m so glad it was helpful!

14

Thank you for this podcast. It gave me so much food for thought! I am thinking of ways to address interoception and emotional regulation in an “individualized, culturally sensitive, trauma informed, neuro-affirming, and effective,” way in my work with adults in an outpatient partial hospitalization and intensive outpatient therapy program (primarily group therapy). I am excited to explore and integrate more of Kelly Mahler’s work!

2 Likes
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I’m so glad you found this helpful, @kathryn3! Our new podcast on OT and Emotional Disability, really showcases how interoception and emotional regulation can be addressed in a comprehensive-classroom wide program.

(@kelly46, if you have a chance to listen to this latest podcast, I would also be curious what you think of it!)

16

This was a really interesting podcast. As a person who become hangry very frequently I learnt to read my emotional state (also with the help of my partner) to understand what is wrong with my body. Therefore, having experienced this first hand myself I agree with Kelly’s argument that certain interventions focusing on learning about one’s problem area or strength to achieve the ultimate outcome in this case an improved sense of self is the right way how to provide intervention. As OT practitioners we need to be mindful when to use task oriented and when to use bottom up approaches.

Increasing my knowledge about interoception was always great! Will surely look into the Interoception curriculum course.

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So great to hear from you, @mattcil! I love that this research is making its way to Malta!

I also seem to get low-blood sugar easily and even as 38 year old am still trying to learn my body’s signs that this is happening- before it gets really bad! There are so many interoceptive skills like this that I wish I had learned when I was younger - and I’m excited for OTs to bring this knowledge to their clients!

We are setting them up for success for years to come, if they can master these skills!

18

I have worked with individuals in the past who had no idea how they feel. The information provided on interoception offers me a place to start. Thank you for this valuable information.

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I’m so glad you found this helpful! I’ve definitely begun to think of this episode as one of the most foundational courses we did in 2024! It feels like so many things come back to interoception, and this is an area OTs are uniquely poised to help with.

20

What a wonderful course, Kelly and Sarah! I learned so much and am looking forward to previewing a bit of the curriculum and reviewing the articles more.

1 Like