Think about it: How many of your clients come to you because they want their bodies to feel better? The answer is almost certainly all of them. And which of their five senses would they use to perceive this “feeling better”? Our clients seek out massage and manual therapy because they want a change they can perceive using their body sense. And yet as practitioners, it’s common for us to think about our work in terms of things other than our clients’ basic body sense: We think about anatomy and pathology, mechanisms and methods, energy, ethics, entrepreneurship, etc.

But from another point of view, the ultimate test of our effectiveness rests on our ability to help shift our clients’ body sense for the better. Simply put, the main question related to our skill as practitioners is, “Can we help our clients feel better?” Everything else is a means to that end. Since it’s a feeling we want to shift, what if we thought more about working with “feeling” itself? How can we get even better at that?

Interoception

The body sense (conventionally but inexactly known as the sense of touch) has several overlapping aspects, including proprioception (position and movement), tactile exteroception (the sense of touch proper), and interoception, which in its contemporary usage is the term for the perception of sensations from inside the body.¹

Interoception is the key domain in which our body feels either good or bad.

The first step is often to help our clients simply get in touch with their own interoceptive body sense. On one hand, this is no small thing. Despite being the first sense to develop in utero, the body sense—in spite of its potential richness and variety—is often said to be the most ignored, overwhelmed, or cut off of our five senses.

On the other hand, helping our clients refine and reconnect with their bodies is not as hard or complex as it might seem. Asking simple questions is often enough.

Asking Questions

Questions can be powerful therapeutic interventions in and of themselves. The best questions invite the client to reflect, look within, and learn something new in the process of answering them. Here are three everyday questions you probably already ask, but when you think of them as ways to switch on the “feel better” aspect of our clients’ interoception, they become important therapeutic tools in their own right.

Are You Comfortable?

This seemingly routine question can be a powerful interoception jump-starter. Interoception is the result of signals and predictive processes that converge in the brain’s insular cortex, or insula (Image 1).² This region of the brain links sensory experience with its emotional or affective valence, which is the pleasantness or unpleasantness assigned to a particular sensation.³ Asking about comfort can be thought of as asking your client to “turn on” their insular cortex in order to investigate whether they’re actually comfortable.

Of course, we can scaffold this process a bit by asking in a way that evokes more than just a polite “I’m fine” response. For example, “Check in with your body. Is there a change we can make to help you be even more comfortable now? Let’s take the time to get it right.” When a client is in pain, or at all anxious, this attending to the insula helps reset its valence to a receptive state.

As well as helping assign pleasantness/unpleasantness to an experience, the insula is thought to be involved in our sense of self and our bodily self-awareness.⁴ So this simple insula-activating question not only helps tune your client’s insula to a valence of “pleasant,” but could also assist in tuning up overall self-awareness (the key to self-care) as well.

How’s the Pressure?

Like the “Are you comfortable” question above, checking in about your work’s pressure, pace, etc. helps keep the client’s insula online and involved in your session. Asking about pressure also communicates interpersonal connection, attention, and care, which further predisposes the insula toward a “pleasant” valence.

By letting your client know they have control of the pressure, for example, this question can help head off any tendency to ignore their own body sense. Asking this question can also open a simple alignment conversation around the right amount of pressure. Clients often assume that more intensity will be more effective; sometimes, more intensity is indeed more satisfying, but the key factor in helping the brain renegotiate a pain response, for example, is shifting the pleasantness/unpleasantness valence the insula assigns to the sensory experience. In other words, the pressure has to feel good to do good.

What Happens if You Relax Into That?

So many of massage and bodywork’s beneficial effects spring to their power to help our brain reassess its protective reactions to our body’s sensations. The insula assigns pleasantness or unpleasantness (including painfulness) to a given sensation by making a prediction—based largely on input from other parts of the brain, rather than from the body—about context, memories, and associations.

The strength of the immediate sensory signal itself plays a much smaller role in the insula’s assessment than its prediction about that sensation. This is related to how painfulness, for example, is often not proportionate to tissue injury: Hitting your finger and seeing blood evokes a much stronger pain response than a blow of the same force with no visible bleeding. The difference is the visual input (seeing blood) into the brain’s assessment of painfulness.

Inviting your client to actively soften into a stroke, sensation, sore spot, etc. aims to help shift the insula’s protective prediction into a present-moment-based experience of the sensory signals themselves. The reaction gets teased out from the sensation, and sensations themselves are almost always easier to bear than our reactions to them.

Relaxing into experience could be thought of as the essential act that helps shift the insula’s “unpleasant” assessment. Framing this as an invitation or inquiry (“What happens if?”) rather than as an imperative (“Relax into it, now. Relax harder!”) is more likely to evoke willingness, of course; and such invitations also invite curiosity, as well as stimulate the insula’s self-awareness capabilities. Our client’s nervous system learns from the act of trying to answer the question—whether the answer is “It gets a little easier” or “That’s hard,” the question has helped exercise the “self-awareness muscle” of the insula.

Whose Interoception is It, Anyway?

As practitioners, we are constantly “getting a feel” for our client’s interoceptive experience. We can feel tissue qualities with our tactile sense, but we “feel” the client’s interoception with our own body’s response to the client’s nonverbal signals and cues. This happens mostly below the level of our conscious awareness, but skilled practitioners commonly use their own empathetic interoceptive sense, along with their tactile sensitivity, to great effect in their work. Our instincts and intuitions about where to work, what pressure, or which direction to use are largely informed by our own interoceptive sense.

However, those intuitive gleanings that may be amazing to the client (“How did you know to work there? That’s right where I feel it!”) are our body’s responses, and shouldn’t be confused for the client’s perceptions. Our client’s perceptions are sure to be different from ours given their unique history, associations, and make-up. We want our work to align with our client’s body sense, not just our own. Of course, the surest way to find out about the client’s actual inner experience is simply to ask a question.

Sensing Is Therapeutic

Our clients typically just want to feel better. Ironically, the hidden key to feeling better is often just “feeling, better”: that is, simply refining the interoceptive, inner-sensation function of the body sense.⁵ It’s easy to overlook the fact that just feeling our bodily sensations and letting them register in our awareness is often therapeutic in its own right.

Mindfulness-based approaches, trauma resolution methods, and many other somatic therapies build on this basic practice of refining awareness of inner sensation.⁶ This is because sensation is the basic building block of much of our experience, emotion, and behavior. Accordingly, the insula is involved in a vast range of functions in addition to what’s been mentioned so far. A partial list of those includes mediating fear and anxiety, compassion and empathy, taste, motor control, cognitive functioning, and interpersonal experience. Interestingly, the insula is also active when listening to music, laughing, and crying.

A common theme in these seemingly unrelated functions might be simply the pleasant or unpleasant assessment of bodily experience. As bodyworkers, we have the benefit of the body being our very scope of practice and therapeutic focus. Asking questions about interoception is an effective way to help change the insula’s mind about its assessments, help shift a painful body experience, and perhaps help shift so much more.

In this article, I’ve given examples of interoceptive questions to use while your client is on your treatment table. Off-the-table questions about interoception are also essential to our work, such as when assessing pain. I hope to explore specific questions for that context in a future column.

Notes

1. Sahib S. Khalsa and Rachel C. Lapidus, “Can Interoception Improve the Pragmatic Search for Biomarkers in Psychiatry?,” Frontiers in Psychiatry 7 (July 2016): 121, https://doi.org/10.3389/fpsyt.2016.00121.

2. Nadine Gogolla, “The Insular Cortex,” Current Biology 27, no. 12 (June 2017): R580–86, https://doi.org/10.1016/j.cub.2017.05.010.

3. Lisa Feldman Barrett, How Emotions are Made: The Secret Life of the Brain (Boston, MA: Houghton Mifflin Harcourt, 2017).

4. Nadine Gogolla, “The Insular Cortex.”

5. Thanks are due to Zenki Christian Dillo Roshi for “feel better by feeling better.”

6. Cynthia J. Price and Carole Hooven, “Interoceptive Awareness Skills for Emotion Regulation: Theory and Approach of Mindful Awareness in Body-Oriented Therapy (MABT),” Frontiers in Psychology 9 (May 2018): 798, https://doi.org/10.3389/fpsyg.2018.00798.