The Default Management of Emotions in Medicine

As physicians, we encounter many interesting situations and can experience a variety of emotions. Most of us have learned over strategies to dealing with those even if we haven't explicitly thought through what they are.

1. Distancing from the situation. That can be helpful to allow space and time to emotionally regulate and regroup. However, as the physician, that's not always safe or appropriate. 

2. Distancing from emotions. We can just call this emotional regulation in the moment. It serves the purpose of staying focused in emergencies, maintaining professionalism in clinical situations, and successfully navigating situations within power differentials.

Immediate regulation can happen by default either because we are so hyperalert to the emergent situation we don't notice emotions or because it's a learned response over years of being in the training environment.

Sometimes, though even with years of practice, our sympathetic response goes on overdrive and we need grounding or centering techniques to take care of the immediate situation. "Take your own pulse first..."

This can take the form of a couple of deep breaths, focusing on exhalation longer than inhalation, to help activate the parasympathetic system to balance the fight/flight. Or it can take the form of focusing on the breath or any of your senses for just a few seconds. The tuning into sensations, such as rubbing your fingers together tyring to feel the fingerprint ridges or listening to for sounds that are near and then that are distant,  brings us into the present moment to bring a bit of calm and focus. That's because much of the anxiety and stress lives just outside the present, in the immediate future or past. (Shirzad Charmaine's book Positive Intelligence has some excellent techniques). 

The Challenge of Emotions in Medicine

While emotional regulation is essential in the moment, unresolved or unprocessed emotions can build up and lead to negative consequences over time. 

Cy Wakeman, a drama researcher with a therapist lens, once addressed an audience of physicians I was in. She said something along the lines of  'Look therapists and physicians all get Lesson 1 - You have to emotionally regulate in the moments of stressful patient situations. However, it seems like physicians didn't get Lesson 2 that therapists get. You have to deal with those emotions at somepoint!"

So that's the challenge. Which ones, where, when, and how?

Let's look at the typical options of dealing with emotions - other than adaptive responding: 

The Four Ways to Respond to an Emotion

1. React – As covered previously, emotions drive actions. Responding to an emotion is normal and often functional. However, reacting to an emotion  - Yelling when angry, quitting when disgruntled, or making an excuse or blaming when embarrassed, are examples of reacting - often impulsively. This is when "The emotion has you, rather than you have an emotion," as Ann Deaton from Lodestar Trauma Coaching says it. We often end up regretting our actions from reacting. 
2. Resist -- White-knuckling through the emotion, suppressing feelings - like holding a beach ball underwater, isn't effective for the longterm. Will-power is finite. Eventually, that ball bursts back up in the air getting everyone soaked. A great descriptor of what happens when we ignore emotions comes from Brooke Castillo from The Life Coach School. It's like a toddler, pullling on your pants leg trying to get your attention. They will get louder and more animated, until you give them attention and listen. 
3. Avoid – comes in 2 forms:
   1. Ignore - you can become good at just ignoring your emotions. The downside, as Brené Brown teaches, is that you cannot selectively ignore emotions. You will dull the pleasant along with the unpleasant. Just like an aperature on a camera - if you open it up to fully to feel the good, you fully experience the unpleasant. And if you shrink the aperature, you feel less emotions overall.
   2. Numb - or buffer emotions,  through overeating, overdrinking, excess gaming, social media, or even things like excessive cleaning. Not that there is anything inherently wrong with any of those, but when we do them to avoid unpleasant emotions, they are often to our dedriment as well. 
4. Allow & Process – Recognizing, naming, and metabolizing the emotion to let it pass naturally. 

So, what they heck does it really mean to process an emotion?

This is a great question. I hadn't ever even heard the term, let alone understand what it meant until one day as core faculty, my BH team recommended that we allow a resident to grow in her ability to "sit" with her emotions. And that, "She was lacking the skill to process them." Hmmm, well - I honestly didn't really know what the heck they were talking about, but nodded my head thinking I should know this - when did I miss it?

Eventually, though observing how they talked with that resident and more fully in my coach training program several years later, I learned what that meant and the actual practical steps.  

How to Process an Emotion

1. First Tune In  You have to intentionally become aware of your emotions. This takes practice, intentionality and patience to notice them earllier. But it becomes easier. Emotional self-awareness is a skill. 
2. Name the Emotion This is called Affect Labeling. It's just simply putting a name to the somatic sensation. Physicians, like most people, have a fairly limited vocabulary around feelings. Using a list of feeling words can help with affect-labeling, which alone can reduce emotional intensity by disarming the amydala - that threat detection center we all have. Use a resource such as the Feeling Wheel, Mood Meter app for your phone, or if you want to really dig deep - Brené Brown's Atlas of the Heart. Accuracy in the label of the emotion is more effective. And keep in mind to not label yourself but the feeling. I'm feeling embarassement, not I'm embarassed. You are not your emotion and by recongizing it's a feeling you're experiencing, it creates some objective distance. (I like to add, "and that's okay" when I name that I'm feeling someway to help decrease the common self-judgment of any given emotion.)
3. Allow It to Be Present  Instead of avoiding, lean into the feeling.  They are just sensations in the body. We willingly experience emotions when reading books, watching movies, or riding roller coasters (even unpleasant ones)—why not allow them in real life? You've survived everyone of your unpleasant emotions. 
4. Stay Focused on the Somatic  We feel emotions in our body - feelings. Just like butterflies in our stomachs when you're nervous. Intentionally focus your brain on the somatic sensations. Where do you feel the emotion? Chest, stomach, head? Run it through your HPI questions. Does it feel heavy, tight, fluttery? Is it moving, or still? Is it fast or slow? Fast emotions can be excited or scared. Slow emotions can be depressed or content. Observing, as the compassionate, objective observer - without judgment,  the sensation rather than reacting helps it dissipate naturally. "And, so this is what shocked, feels like to me. Interesting." 
5. Let It Pass. As you keep your attention on the bodily part of the emotion, the sensation eases and resolves. Usually within 15 seconds to 2 minutes. Recognizing and allowing them without judgment can help them move through. If new thoughts arise, refocus on the body instead of fueling the feeling with additional narratives. Emotions often come in waves, especially grief. Nothing has gone wrong, recognize, allow, name, tune in to the body, allow it to run its course again. 

But what if the emotion doesn't ease?  

There are couple of things to consider if that happens and a couple of additional things to try.

1. Can we just be honest and say, sometimes the emotions are so intense we need an immediate emotional release? This can be done in a healthy way - choosing time and location to be alone or away from anyone that is not prepared to see you in that state. Having a good cry or screaming into a pillow or in your car - can be the intial step to processing. (Dr. Edith Eger, a holocaust survivor and pscyhologist, talks about her personal experience with this and her client's experience in her books The Gift and The Choice.) You just want to be sure to reflect afterwords and continue the process of processing. This isn't the right approach for everyone or for every intense emotion - you'll want to see how it affects you. 
2. Are you judging the emotion or yourself for having it - that will hinder the process. Remind yourself you are human and will have the full human experience. 
3. Are you allowing more thoughts about the situation to continue thereby distracting your focus from the body? Those thoughts are fuel to the emotional fire. Just notice when they happen - let them go as you tune back in to the somatic sensations.
4. Is the emotion a go-to "indulgent" emotion - worry, overwhelm, confusion - these are often some of the emotions that become familiar and comfortable even though they're unpleasant. These don't always need processing - you need to acknowledge they're there. Allow it to be there without any additional attention. Elizabeth Gilbert writes about her anxiety this way (my paraphrase): It's coming along for the ride whereever I go. So I just tell it, I know you're coming just take the back seat. I'm still driving. You can have a voice but you can't have vote on where I steer. Brooke Castillo talks about it as like it's just an object coming with you - like a purse or a backpack. But it doesn't have to be the star of the show.
5. Can you find a way to close the stress cycle regularly: Stress isn’t a one-time event with a single reaction. It has phases:
   External Stressor --> Internal appraisal - senses, insula, --> amygdala’s emotional processing --> Physiologic response – hypothalamus and pituitary --> sympathetic response -->
   Internalization - full awareness, physiological response (tachy, sweaty, GI)  --> aware of discomfort of stress -->
   Coping mechanism – actions taken in response to discomfort (positive and maladaptive types). 
   By demonstrating to your system that you are safe, it allows a reset to the system. The Nagoski sisters in their book on burnout highlighted seven things shown to close the cycle and signal your brain and threat detection system you are safe:
   

   Phyisical Exercise. Focused breathing exercises. Postitive social interactions. Gunuine laughter. A Hug. A good cry. Creative expression.

6. It may be that you are need professional help. You are human. Physicians often neglect their own mental health for a variety of reasons, tuning in late to the need is just one factor. I like to encourage all physicians to have their own doctor that they could bring this up to for referral to therapist. Take your own PHQ9 or GAD7  periodically - what would you tell a patient with that score? Line that up for yourself. If in crisis, call 988 or the physician/medical student support line (this is staffed by volunteer psychiatrists from across the country so is may not as immediate) 1-888-409-0141

    

The 50/50 of the Human Experience

Life is a balance of pleasant and unpleasant emotions. If we expect only positivity, we’ll constantly resist reality (which is a losing battle!). And when we react, resist, or avoid emotions we actually shift the balance of negative consequences and experiences to favor the negative side of things. 

You can also see the unpleasant emotions as data. If you feel anger, ask yourself: Is this signaling a crossed boundary or is it a clue to something else? If so, what action do you want to take? Emotions as data can help guide our next steps.

Disappointment, frustration, and sadness are normal parts of life - parts of the full human experience. The key is to let them exist without fear or avoidance. And remember from last week's blog: Madeleine L'Engle's quote "Joy is not the same thing as pleasure. Indeed, it partakes of difficulties, sadness, sorrow." These are not mutually exclusive.

Final Thoughts

Coping isn’t just about external tools—it’s about embracing emotions without fear. By allowing feelings to be present, noticing them in the body, and letting them pass naturally, we reduce suffering and build emotional resilience. After all, you've survived 100% of your emotions to date. 

Reflection Question: What emotion have you been resisting lately, and how could you become the compassionate, objective observer of it and metabolize it instead?

I'd love to know what you discover! 

Have a joy-filled, emotion-embracing and metabolizing type-of-week!  Tonya

If you're looking to have an external coach involved in your residency program, reach out to discuss options. 

TLDR
- Processing emotions is essential for healthy coping.
- Avoiding, resisting, or reacting to emotions can have negative consequences.
- Allowing and processing emotions helps regulate them effectively.
- Naming emotions, accepting their presence, and noticing physical sensations can ease their intensity.
- This approach promotes healthier emotional responses and forward movement.