Using Microexpressions to Understand the Unconscious

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham

This PDF is a supplement to the podcast “Psychiatry & Psychotherapy” found on iTunes, Stitcher, Overcast, Google Play, or on the website PsychiatryPodcast.com

The last two weeks, we’ve covered using Microexpressions to Make Microconnections and the Microexpressions of Fear, Surprise, Disgust and Creating Connection. We discussed what microexpressions are, and what each of the different emotions are, and how they look on the face.

Learning about microexpressions develops a deeper connection with others—whether in therapy, or just in everyday relationships.

Microexpressions are tiny facial movements that give us cues to what someone is feeling. Their eyebrows might twitch down for a moment to display anger. Or the sides of their mouth might stretch horizontally to show they are afraid.

Our goal as therapists is to understand what emotion our patients are feeling, and to develop our empathy towards them through understanding the reason behind that emotion. Understanding microexpressions can lead to micromoments of connection by developing a greater closeness between you and your patient.

Microexpressions happen out of our awareness, and can be great cues to what someone is unconsciously feeling.

Using microexpressions to understand the unconscious

Identity We are always picking up on some level of people’s microexpressions, whether we are trained in it or not. Many people intrinsically understand what others feel. This understanding can become our social mirror as we are growing up.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham If we have an ability to make people smile when we are children, we may try to reinforce that reaction from others by building our interactions around humor. Then we are known as the “funny” one. These cues people give us can become a part of our identity.

One of my patients had a slight facial deformity. She noticed, and internalized, the messaging that she was “disgusting” to look at, based on other people’s facial expressions when they saw her. That led to deep feelings of disgust about herself. She often showed a microexpression of disgust on her face when she was talking about herself. Over time spent in therapy, she was able to create her values, her beliefs, and determine that as a human, she was more than her deformity.

Internalizing people’s microexpressions as feedback about ourselves can be helpful or harmful. When we learn more about microexpressions, we are able to develop techniques to delve deeper into people’s reactions and understand that those reactions are often not about us, but about the other person’s experience.

Through understanding microexpressions, we learn that we do not need to take every reaction and internalize it as part of our identity, either positive or negative. With our patients, seeing microexpressions as they talk about themselves can help us uncover deep seated beliefs—whether it’s disgust, arrogance, or any number of other emotions.

Object relations Object relations is a theory about how we internalize early attachment figures and then subsequently understand future in relationships. For example, if we have a tense relationship with our father, and then we might expect or recreate tense relationships with our male teachers, male boss, and male therapist, as a way to make sense of the world.

We most often create these emotions towards early developmental relationships, then paint our beliefs about them on others throughout our lives, unless we deal with our feelings towards those people, and begin to be able to distinguish and differentiate, i.e., “not all authority figures are evil.”

In therapy, microexpressions can be helpful to unearth some of these emotions. The relationship between a therapist and a patient can represent, to the patient, many different relationships. Being a safe person for them to discuss their feelings with is the most important part of therapy.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham Reading microexpressions can help me understand the emotions still present that the patient feels towards early attachment figures. These may come out as they discuss a current issue, and then express a strong emotion. If you focus in on the part of the story where the emotion was present, then they might start eventually talking about early attachment figures like their emotionally distant dad or angry mother. The microexpression allows us to know where to focus in, and listen closely in their story. They are not only important to pay attention to when it comes to how a patient feels about others, but also how they feel about us. Knowing how they feel about us, as their doctors, helps to be able to identify what are overarching, negative early life experiences and how we can help them work through those feelings so that they can live more present and thriving in the present.

Dreams As therapists, listening to dreams can give you a great glimpse into your patient’s inner emotional life. Studies show that memories more easily develop around negative emotions, and those negative moments can form points of organization for our memory. They found that PET scans showed that the parts of the brain that store our memories are also the ones activated during REM sleep.

Dreams usually demonstrate what’s most emotionally relevant to work on during psychotherapy. As patients are telling me their dreams, they will show microexpressions while reporting the narrative of the dream. Subsequently through discussing the dream, they can talk about emotions and desires they might not have consciously allowed themself to have.

For example, if a patient is feeling trapped in a job or relationship, she may have a dream she is trapped in a box, or stuck underwater. She will be able to express her emotions during the description of the dream—her fear, anger, surprise, disgust. She may not be ready to talk about her relationship or job, but she can unearth the unconscious emotions of the dream and feel comfortable talking about that. In the end, her thoughts will go to areas of her life where she feels stuck, and then suddenly realize what the dream might mean.

As psychotherapy progresses and the person unpacks their emotions, the dreams change to be more positive. When a patient feels supported and heard, and psychologically safe, they begin to unpack deeper, unconscious emotions they once only felt in dreams.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham

Psychological Defense People experience psychological defense as a way of creating an alternative, safe reality for themselves. It’s an adaptive way to defend against their feelings, their reality, and the state of their mental health. Psychological defense is largely an unconscious, adaptive process.

Sometimes a patient will have a thought that is too distressing to pay attention to. Their brain will then send what we call “signal anxiety,” or a message that this thought, emotion, or desire must be suppressed from consciousness. Subsequently they might have a psychological defense act as a way to adaptively defend against these thoughts. For example, they might suppress a thought to later deal with, deny that it happened, or go wash the car to get their mind off of it.

Another example, where microexpressions will help, is if a patient says they aren’t angry at a person. They may believe that, or may try to believe that. Maybe that person harmed them in a huge way. Prior to saying, “I’m not angry,” their face may have flashed a microexpression of anger, letting you know that perhaps they are denying what is truly going on.

The best thing to know here, is that psychological defenses are there for adaptive reasons, and the patient needs to feel safe enough to have them soften. If you empathize with the distress that comes with the defense you will be helping them get to what is under it.

Warnings about using microexpressions in therapy

Miscategorization When I first started learning about microexpressions, I would tell people, “When you told that story, you flashed an expression of anger.” Then the patient would be angry at me for assuming they were angry. Maybe the patient hadn’t even had the chance to process on their own that they were, in fact, angry. Or maybe I was just wrong about what I was assuming! Either way, I didn’t give them the space to find their own emotions.

It’s important to allow people to mine their own feelings, and even discover the meaning behind the feeling. If they are telling a story and show a microexpression of anger, be curious about their feelings in that moment. Ask them to draw out the emotion and describe it. Be gentle with your word choices.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham

The danger is when we are wrong about what we think someone is feeling, but we aren’t accurate, and we assume we are still correct.

Emotional contagion As we learn about microexpressions, we see that there are hundreds of them being expressed in any one-hour therapy session. It can be overwhelming if we take responsibility for another person’s emotional life. It’s important to know the difference between their feelings and our own feelings, so we don’t own their emotions.

When I first started in my psychiatry rounds in medical school, I didn’t understand emotional contagion. I began to feel depressed after different conversations with suicidal patients. After talking to several mentors about it, I realized I was internalizing my patients’ emotions, and having issues with self/other distinction. There emotions were contagiously experienced in my head and I had little defenses against feeling overwhelmed.

Now, before I go into any therapy session with a patient, I take an emotional gauge of myself. I see how I’m feeling, what my natural, resting emotional state is. When I enter the therapy session, I am able to categorize what is additional to my experience—sadness, anxiety, joy, fear, as the other persons, not mine. I am also able to deeper empathize with their feelings because I am not in a confused emotional state.

When we delve too deeply, become so emotionally distressed with our patients, it inhibits our ability to offer insight, reflect, or therapeutically influence the other person. Feeling deeply can be a tool in therapy for developing connection, but make sure you have healthy boundaries, too.

Being able to understand the patient and their reality can also help us own our own reaction to them. Maybe the patient reminds us of someone we know, and we are putting negative feelings on them.

Rushing the process Maybe you repeatedly notice anger on your patient’s face during conversations about their father. Here’s the catch—maybe they don’t know they are angry at their father yet. If you rush that revelation, you are taking away their emotional experience of uncovering their feelings.

Letting someone use their words, and not forcing word choice, is important. If they say “frustration” and not anger, you should also say “frustration” and not the word anger. Allow them to have their own process.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham

Allow feedback People are the experts of their own inner world. Microexpressions, though incredibly helpful, only give us hints. They do not give us a perfect map of someone’s entire emotional experience.

When you express curiosity about what someone is feeling, allow them to correct you if you offer specific word choices or suggestions. Ask them to clarify, and accept their explanations about what they were feeling.

Learn about microexpressions

It is helpful, when used correctly, to learn about microexpressions and use that knowledge to develop micromoments of connection.

To learn more about microexpressions, download the Emotion Connection IOS app.

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Using Microexpression to Understand the Unconscious ● mirror neuron system = responsible for internalizing how others feel about us (Sue et al., 2007). ● E.g. a patient with a nose deformity experienced several people’s reactions of disgust towards her, eventually thought all people were focused on her, and began to think of herself as irrelevant, disgusting and repulsive anger, and afterwards, she did not flash disgust when talking about her face.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham

Dream analysis and the effect of therapy ● 1987 Mishkin and Appenzeller = dreams link affects and memory processing. ● Reiser = memory is organized around nodal points of intense emotion that expand into networks over time. ○ collected data on the dreaming brain using PET-studies; same limbic and paralimbic areas involved in linking affect and memory are also activated during REM sleep. ○ Dreams are not random; Sensory perceptors encode emotionally meaningful life experiences into memory. These encoded memories then recur in dreams. ● Disturbing dreams can change with psychotherapy ○ psychotherapy is a process of changing the encoding conditions of a patient’s memory => distressing dreams decrease in frequency and/or intensity as conflicts are resolved. ○ Supported by Fishermann’s project

tailored dream-words extracted during dream analysis interviews as stimuli for fMRI scanning of individual patients, found differences in brain activation patterns over the course of 1 year of therapy. activity @ precuneus and left parietal lobe disappeared; dream content that had been previously distressing to the patient lost its significance secondary to psychotherapy (Fischmann, 2016).

Using Microexpression to Understand Psychological Defense ● we defend ourselves psychologically against things that increase our anxiety (Vaillant,1992). ● You can watch microexpressions to see original emotion followed by defense emotion ○ E.g. moment of disgust towards a spouse, followed by a reaction formation, in which the patient may comment on the positive things they do for the spouse. ■ Disgust towards someone we are supposed to love is a very strong conflicted feeling & if this tension is intolerable we automatically attempt to suppress it.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham

Use of Microexpression to Improve Therapeutic Alliance ● microexpression training is correlated to increased empathy on both the Jefferson and CARE scales (Hojat et al., 2011; Riess et al., 2012) ○ increased understanding of the patient’s experience (cognitive empathy), maximization of mirror neuron inner mimicry (affective empathy), improved therapeutic dialogue (compassionate empathy) by gaging the accuracy of our assessments and how our verbal responses are being received. Enhancing self/other distinction can enable the provider to remain more emotionally engaged during the appointment. ● difficult to assess therapeutic alliance ○ questionnaires are insufficient d/t subjectivity and inability to differentiate specific aspects (Merten et al., 2005) ○ physicians and physicians in training have been found to be inaccurate judges of their own performance and ability in this regard (Blanch-Hartigan, 2011; Davis et al., 2006). ○ Video analysis of such encounters using FACS allows for objective measure of therapeutic alliance by measuring the microexpressions ■ complimentary microexpressions are associated with better therapeutic outcomes ■ relative frequency of an expression of a single affect is associated with poor therapeutic outcomes (Darwiche et al., 2008; Merten et al., 2005)

Use of microexpression in object relations ● We internalize aspects of our primary caregivers, or those close to us throughout our life, into internalized parts of ourselves that psychotherapists refer to as “objects.” ● internal object = emotion we felt towards the other, and emotion that they felt towards us. ○ A patient’s internal objects will be comprised of unresolved feelings, feelings that were never satisfactorily expressed, or feelings that were expressed but led to non-desired outcomes. ● In childhoods, if certain emotions are not sufficiently mirrored back through empathy, then a child will not learn to understand that particular emotion.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham ○ E.g. If every time a child was angry they were subsequently punished or ignored, they may learn to suppress anger into their unconscious and potentially experience it in their body as tension or physical sickness. ● E.g. patient had a large amount of disgust towards her father for various events that happened in her childhood, and when she talked about him, she would flash microexpressions of disgust. At first, these microexpressions came out when she talked about other men. As therapy progressed I noticed her also doing this towards her father, which raised suspicion that her narrative was that all men were evil may have started with her father. It was only after untangling and empathizing with her distress from that experience that the narrative started to soften and shift to where she could appreciate increased complexity, and identify that not all men were disgusting.

Use of microexpression to decrease countertransference ● we will feel a patient’s emotions via effect of mirror neurons and our automatic mimicry response ● As a professional it is our goal to feel other people's emotions to the point that we can empathize cognitively and affectively, but not become emotionally flooded or fall into an enactment, as both impair our ability to reflect on the patient's experience or therapeutically influence the patient through our own mirror neuron responses. ○ need to be constantly identifying the patient's’ emotions, our own emotions, and our experience of the patient.

Warnings about using microexpression in therapy ● Don’t verbally point out observations, saying things like, “I see you have an expression of anger when you talk about that.” ○ the patient will then become angry at you for telling them that they feel something that they think they do not. ● Dont misattribute the reason the patient is feeling a certain emotion. ● If a patient’s displayed emotion and verbal content of their emotional description are discongruent they may not have conscious awareness of the emotion, or you may have misread the emotion if your skills are entry-level. ● Do allow the patient the freedom to correct you.

Episode 17: Microexpressions to Make Microconnections Part 3 David Puder, M.D., Ariana Cunningham ● Do offer normalizing statements for the emotions you presume they are experiencing to encourage expression of them, but no matter the case ● Do let the patient be the expert of their own internal experience ● Do allow your curiosity and compassion to guide you in its incorporation into your clinical practice.

Conclusion ● Microexpressions offer a unique stepping stone into the realm of empathic understanding. ● Create moments of microconnection through acknowledging and empathically mirroring emotions others express. ● Training to increase microexpression detection is efficacious, and that this skill is correlated to improved empathy, degree of patient-physician alliance, and clinical outcomes. ● This is applicable within psychotherapy in terms of understanding the patient’s unconscious, psychological defense, and object relations. ● The providers themselves stand to benefit as well, in regards to having a tool for decreasing countertransference and distress. Finally, use this new skill cautiously at first, allowing the patient to correct you and inform you of their own experience.

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