Welcome back to the Healing Pain Podcast with Kelly Mahler OTD, OTR/L
In this episode, we’re exploring the concept of interoception, and how it impacts both physical and mental well-being. Interoception can be defined as one sense of their internal state of the body. This is a full-body sensory experience that has both a conscious as well as a subconscious or semi-conscious layer to it. As practitioners, we’re able to train the sense just as we would train balance or proprioception. Interoception includes the brain’s processing of signals relayed up from the body into specific sub-regions of the brain, such as the brainstem, the insula and the somatosensory cortex. This felt a sense of our body, its organs, and all of our physiologic processes allow for specific, as well as subtle or nuanced representation of our emotional and physical state.
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Interoception: How Awareness Of One’s Body Affects Physical And Mental Wellbeing With Kelly Mahler OTD, OTR/L
Interoception is important for maintaining homeostasis in the body. It improves one’s self-awareness or body awareness. It’s a critical component of mindfulness training, especially when you’re working with body-based conditions, such as reversing chronic pain or releasing trauma. Both have important ties to interoceptive processing. Training interoception, which we can also term as this eighth sense, is often left out of both physical and mental health treatment for chronic pain.
Joining us to speak about interoception is Occupational Therapist Kelly Mahler. She an Occupational Therapist, serving school-aged children and adults and is a winner of multiple awards, including the 2020 American Occupational Therapy Association Emerging & Innovative Practice Award. Kelly is a principal investigator in several research projects pertaining to interoception, self-regulation, trauma, and autism. In this episode, we’ll further define interoception, how it can be used in clinical practice and how interoception has an influence on chronic pain and other chronic disease conditions. Without further ado, let’s learn about this eighth sense of interception and let’s meet Dr. Kelly Mahler.
Kelly, thanks for joining me for this episode.
Thanks, Joe. I’m so excited to have this conversation with you.
Me too, I’m excited to talk about interoception. It may be a new term for some people, it may be a term that they’re starting to learn about and understand how it interacts with chronic pain, pediatrics, general health and well-being, physical health and mental health. I know you’ve done work in this area. I’ve looked at your website and it’s incredible. Everyone can go check her website out at Kelly-Mahler.com. Everyone can go there and check it out. Tell me, as an OT, how did you become interested in interoception way back when?
I thought interoception was a toileting thing. I had no idea how impactful interoception was. It was through writing a book with a friend of mine. We were writing a book about sensory processing in general. I said to her, “Let’s add this information about this newest sense, interoception.” She loved it. Through that process of writing that book, I went deep into the interoception literature. There wasn’t a lot at the time but it blew my mind how vast of an influence this sense has on all of our lives.
Through publishing that book and starting talking on the topic, people were hungry for more information. That is an interoception pun that we’ll explain later, but interoception allows us to feel many feelings in our body like hunger, pain, thirst and all of our affective emotions, frustration and anxiety. It was a journey that naturally happened. It has taken me personally on a rollercoaster of self-improvement, but also professionally.
You mentioned there that you were doing research and you found this new sense. Most people think that as humans, we have five senses. Talk to us about the senses between the five that we traditionally know and identify, and interoception, which as you mentioned, is the eighth sense. What are the two in between and why don’t we talk about the other three more?
We’re getting better at talking about the other three, but they are lesser-known. We have our proprioceptive sense and that’s our sense of where our muscles and joints are and how our body parts are located in space. We have the sense of vestibular and that is our sense of movement and balance. We have interoception, which is the eighth sense. It is the newest sense on the block. It was defined back in the 1900s but largely ignored by the scientific community until Dr. Bud Craig, a brilliant neuroscientist.
He was able to give a lot more definition and weight behind the sense we call interoception. He did incredible work in his lab. Since 2002, when Dr. Craig published his first paper on interoception, the neuroscience field has caught on fire. It is one of the hottest topics in neuroscience. It’s starting to trickle over into medicine and the trickle is even slower as it makes its way into practical application, in PT, OT and so forth.
You would think as PTs and OTs especially, there are certain skills that we help people with. Activities of daily living, in general, are a sensory experience in a lot of ways. You would think we would be a little more interested in this topic, maybe even doing the research ourselves as PTs and OTs because it’s squarely within our wheelhouse to be assessing and training aspects of interoception. Tell me in your own words, how do you define interoception from a more scientific perspective and then how you would explain it to a patient or a client you’re working with?
Interoception has a lot of many different aspects. The biggest job interoception has is helping us to be consciously aware of how our body is feeling, noticing our inner body signals like a racing heart, tense muscles, neck pain, a growling stomach or a full bladder. Those body signals provide us with important clues to our emotional experience. How are we feeling at that moment? Our body provides us with these clues to help us to be able to understand exactly how we’re feeling because we live in a society that does not put a lot of emphasis on paying attention to how our body is feeling. Many of us have a disconnect with our interoceptive system, which can have profound impacts on many different aspects of life.
When you say our society doesn’t put an emphasis on what’s happening in our body, it resonates with me because when you work in musculoskeletal medicine, there’s definitely a segment of the population, certain diagnoses, where you almost get this sense. It wasn’t apparent to me early on in practice. It became apparent over the decade that, “This person doesn’t have a sense of what’s happening in their body, both on a proprioceptive level as well as on interoceptive level,” those two things as everything works together. If we’re not living in a body, where are we living?
We need to help our clients to live more in their bodies. We have to do so in safe ways because there’s a lot of times and reasons why people are not living in their bodies and we have to always be trauma-informed and, etc., but finding safe ways to get our clients back in their bodies if they so choose to is so important.
In essence, what we’re saying is our culture places a lot of emphasis on thoughts, thinking and living in the mind, cognition and to a lesser extent, language, and those are all important, but the other component is this interoception that you’re talking about.
I think even beyond that. Our society has marked it as perhaps a weakness if we slow down and listen to what our body is telling us. We are encouraged and conditioned to push through, take care of other people’s needs before our own, and have successful careers at no stop or whatever it is. How many people push through until they have a serious medical condition? If they reflect back, many people report, “I had some clues coming from my body and I ignored them.” Many times it’s looked at as a weakness to listen and honor what your body’s saying.
We’re talking about becoming aware of the signals that our body is sending us. You mentioned when we don’t, when we lack this awareness, there’s this idea of pushing through. Pushing through resonates with me on a lot of levels, but let’s put that into some real-life situations. If someone decides to change their diet in a healthy way, but they still experience hunger or craving, do people push through or ignore gastrointestinal sensations. Is that part of interoception?
That is part of interoception. It’s those gastrointestinal sensations like the growling stomach or whatever it is for you. I guess it depends on the diet. I know there’s a huge field called intuitive eating and that’s tuning in and noticing how your body feels. The message that is coming from your body is actual hunger and need for fuel. Is it boredom? Is it something else and tuning in and getting fine-tuned with what and how your body is feeling and then eating based on that information? I don’t think many interoception practitioners would say you should ignore those hunger signals for the sake of losing weight. I think that has some counterintuitive long-term effects.
Being aware of signals of satiety is an important component of interoception, let’s say.
I’m guilty. How many people have chatted through a bag of potato chips, not even paying attention to what they’re eating?
Most people are aware, or many people are aware of what it is to feel hungry. There’s almost like an emptiness in your stomach. One of the things we could work toward interoceptively is realizing as you’re eating that bag of potato chips, instead of eating the entire bag, maybe at the halfway point, you start to realize, “There’s this sense of fullness or stretch in my stomach. That’s telling me that my stomach is full.” Therefore, it can connect more to the idea or the sensation of satiety.
It’s a great example of how we can use our interoceptive signals for health benefits.
How do you use it with children? I know you’ve done some work in pediatrics. Where does interoception come importantly with helping children thrive?
We talked about how interception is an everyone thing, but my passion as an OT has been to support neurodivergent clients, clients that are autistic, have ADHD, anxiety disorders, etc. We find that a lot of people with those diagnoses and conditions struggle with noticing and understanding their interoceptive signals. They might not notice or understand that feeling of the growling stomach or that empty stomach you mentioned. They might rely on their caregivers to remind them to eat or not notice the signs of building overwhelm. All of a sudden, they’re in a full meltdown relying on their caregivers to step in and to help support their needs. My work is all about helping each client discover their own inner sensations and understand what they mean for them. It’s not us coming in and telling them how we think they should feel. It’s us helping them to discover how they feel in their own unique experience.
You’re talking about a situation of potentially sensory overload that might happen.
Many times, my clients don’t notice those subtle signals saying, “Something’s a little off right now.” All of a sudden, it’s this big interoception surprise, and they’re at the most intense emotional level and they’re in a meltdown or shut down. That can be hard if that’s your only clue that something’s off when you get to that intense point. That can be hard because you can’t use rational thought. You’re not going to be like, “What coping strategies should I pick out right now that my psychologist taught me?” It doesn’t work that way. We’re trying to help them to tune in and use their body signals as clues to their emotions.
It helps with assessing the incoming sensory data, let’s say, and then what do we do with that sensory data to a certain extent.
That is exactly what it’s all about.
When we’re talking about interoception, is there a certain part of the nervous system? I know people like to dive into the autonomic, the somatic, the enteric, the central or is it all a component of interoception?
That depends on which neuroscientist to ask. To me, I look at interoception globally. There is an implicit side of interoception of that sense that’s happening beneath our level of consciousness. It is our foundation of homeostasis. Interoception is monitoring all of the tissues, organs and everything in our body, monitoring the condition of our body. When there’s an imbalance detected, interoception helps to catch that imbalance and helps our brain and body restore that inner balance, whether it’s releasing more glucose or adjusting the pH levels in our body or whatever it is. I look at it more globally. Interoception is this general sense of homeostasis, whether it’s unconscious homeostasis happening beneath our level of consciousness or it’s that conscious side when we notice our body feels cold and we actively do something to restore that balance in our body.
It’s the entire organism is the way you like to look at it?
Otherwise, you wind up and we segment things out, which becomes problematic. I want to touch on the subconscious aspect of interoception, as you mentioned. We mentioned an awareness of your body and hunger, but you’re also talking about an important subconscious aspect of interoception. If we were aware of all of this sensory information coming into our body at every moment every day, what would that mean?
That would be an overwhelming place to be noticing e single change that’s happening in our body, to be striving for that place of homeostasis. I do have clients who do over feel many sensations that many of us might not feel. I’ve had a client that every time he ate a meal, he could feel it digesting the whole way through his digestive tract. That’s not an experience that many of us have on a daily basis, but for him, he was experiencing that.
Some people have a small element of that over-responsive to their internal signals, and too much interoception is not necessarily a good thing. It still results in an overwhelming experience. He wasn’t able to use his body signals as reliable clues to his emotional experience, which then limited his ability to take that next step in helping to care for his body’s needs.
We can learn how to modulate this in a way that’s healthy. There are signals that are to remain subconscious because throughout the day. I don’t necessarily want to think about my blood sugar levels or my heart beating, but then there are times when my heart does start to race that I want to be aware of that sensation and then start to figure out, “Is this low blood sugar?” The reason why my heart’s racing is this anxiety because I have a pending project or is this something worse? Obviously, I’m having a heart attack, so to speak. Those are all important ways for us to look at interoception and try to conceptualize it as far as the conscious and the subconscious. Where does chronic pain come into interoception in your world in your view?
That’s still something that’s of debate among researchers. For me, it doesn’t fit nicely into this definition, but we talked about how some people can be over-responsive to their internal interoceptive signals and other people can be under-responsive to have a completely different experience. I know that for pain, it is the same way. Some of my clients completely miss vital pain signals. I’ve had clients who have walked around on a broken femur for three days versus some of my other clients who present with being over-responsive to the feelings in their body. It’s almost to a painful place and they have chronic pain somatic symptoms. I don’t think it fits nicely in that definition, but it’s giving a bit of a framework that maybe you and I could talk about a little bit more.
It’s part of the pain experience, let’s say.
Interoception is why we feel pain.
When we talk about embodied cognition, the idea is that my thoughts are embodied. The thoughts I have, have a sensation in my body and I respond to those. Does that fit into the interoceptive/chronic pain category or helping us understand the connection between Interoception and chronic pain?
I definitely think it could. The sensations coming from our bodies do affect how we perceive and think about the world and our bodies. We have what is called interoceptive predictions. From the time we’re born, our bodies start to mark how our body responds to everything we’re experiencing. Is that experience making our bodies feel comfortable? Is it making our bodies feel uncomfortable? Those responses in the body are stored. We rely upon those interoception memories or predictions to guide our future behaviors. It’s our instinct or intuition, “This makes me feel uncomfortable or this makes me uncomfortable.”
What some researchers are starting to talk about in chronic pain is that the stored interoceptive predictions become, “Part of my body or my whole body is painful.” That becomes that person’s stored interoceptive prediction. I don’t know if I took that the way you wanted it to go. I do a lot of work with clients who have trauma as well and it’s all about how we update the stored predictions and help you have a more comfortable feeling in your body and update the fact that your body can be a comfortable place to be.
It led me right to another question. You’re mentioning these interoceptive stored memories. Are these interoceptive stored memories in our higher cortex or are these memories stored somewhere more lower? Do we know or is this a little bit still controversial?
Everything in the Interoception is controversial right now. It’s a field in its infancy and we’ve learned. We definitely know that there is an interoception system. No one is disagreeing with that but how it works exactly, we’ve learned a lot. I would say that the people that are talking a lot about Interoception predictions talk about it in almost a sequential, hierarchical way of your brain processing it.
Hierarchal is bottom-up.
If something is against what we have stored, it could reach higher levels of our brain and those predictions can be updated.
It’s not a fact. It’s a prediction. That’s important and I know even that is controversial, but the idea of chronic pain, since there is no actual physical threat happening. If I have chronic lower back pain, it’s not like someone is taking a knife and jabbing me in the lower back. Let’s say my body that way, we don’t pinpoint any part of the nervous system or any other organ. My body, in essence, is predicting that this is a dangerous situation for me and therefore it turns on pain. For someone with chronic lower back pain, it may be that picking up a bowling ball at a bowling alley, which weighs 5 pounds is an interoceptive sign or somehow there’s an interoceptive of a prediction of pain, that something is dangerous.
I like your question about facts. It is a fact for that person. Based on our outsider view, there is no actual danger, but there is a real threat to that person’s interoceptive system.
It’s a perceived danger. I know you’ve read a lot of research. I would love to hear your personal opinion on this. Do you think we always need or are the higher centers of the brain needed or are they that critical with regard to Interoception or is a lot happening through the spinothalamic systems through the spinal cord, through maybe even the midbrain lower parts of the brain that are important that we might not need to have to put focus on the upper higher levels, higher centers of the brain?
For so long, I was a cognitive-based therapist. I was doing lots of Cognitive Behavioral Therapy. Through all of the interoception research and all of the work I’ve been doing, I definitely 100%, 1,000% believe that body-based work is essential first before we can even or if we ever even need to get to that cognitive rational part of the brain in our therapies. Still, the body is where we need to start.
This is a message that I’ve been trying to send more and more because I’ve done a lot of work around psychologically informed therapies, which are important in the world of chronic pain, things like CBT, Mindfulness and ACT. Implore and I’m always encouraging therapists, particularly PTs. Although now I talk to a lot of mental health professionals about this as well. Cognitive Behavioral Therapies, as an umbrella term, have informed a lot of what we do and they’re important. Specifically, when we look at two conditions specifically that we see as PTs and OTs, are chronic pain and chronic trauma, that they are embodied conditions.
If we’re working chin-up, which pain neuroscience education has left us in the world of a chin-up perspective. We need to give people knowledge, to give people education, change their thoughts, and change their beliefs. If we do that, it’s all going to be okay. Once you spend time in the interoceptive literature, the way you have, and you’ve done work researching and building out products and programs, you see that we’re not just the head. We’re not just the brain. The idea of this top-down bottom-up is silly. All of this is one contiguous system in many ways, but you can’t leave the body out of a body-based problem.
Absolutely not. You’re forgetting 90% of the entire body. If you’re chin up, you’re missing the source. I had a client that said something to me and it stuck with me. Maybe it’ll stick with one or two of your readers. She said that Cognitive Behavioral Therapy is great, but it’s like giving her a DVD without making sure her DVD players are working first. I thought that that was so profound because she was getting all of this talk, cognitive-based therapy and nobody was helping her with the whole body piece. It wasn’t until she started doing interoception work that she started to have profound gains in her life. This was a woman in her 50s that have has been through every single therapy out there. It was life-changing for her.
This is where I’ve seen professionals take mindfulness in a direction where I’m like, “You’re losing a critical piece of mindfulness.” If you look at mindfulness as a top-down cognitive intervention, which the psychology world has pulled mindfulness into the cognitive realm. Mindfulness-based cognitive therapy took traditional CBT and putting a mindfulness aspect into it. It’s important, again, in the context of chronic pain and working with patients with body-based conditions, is mindfulness should turn your attention in a nonjudgmental aware way to all the interoceptive processes that you’re talking about.
I guess it depends on how you define mindfulness. I am with all body mindfulness and noticing how your body is feeling in the present moment in a nonjudgmental way. There are other forms of mindfulness, whether you’re mindfully aware of something in your environment, but that’s not necessarily helping you tune into your body. In fact, it’s helping you tune out of your body even more.
What you said is subtle. I don’t know how many people would pick up on that. Maybe review that again, how that is and why that is.
This is a simplified view, but mindfulness again, there’s outer and inner mindfulness in my categories in my brain. The outer mindfulness is mindfully paying attention to something outside of your body, whether it’s being present and aware of the noises in your environment or the smell in your environment. There’s also inner body mindfulness, paying attention to how your body is feeling in the present moment. If you’re only focused on that outer mindfulness, you’re essentially pulling the mind even further away from the body. A mix of both is helpful, especially if we want to help people to be tuning in to their interoceptive systeme need to be focused on the body-based mindfulness, the inner mindfulness.
When you’re training mindfulness or when you’re instructing people with mindfulness, you can orient them toward stimuli in the environment, for example, and everyone can do this with us at home. Right now, pay attention to two things that you hear. One, maybe the sound of my voice and take a moment to notice one other thing that you might hear. You can also say, for example, take a moment now to notice two things that you see and notice them and name them. I might say Kelly and the rim of my glasses. Those are two things that I can see. Those are environmental awarenes.
You mentioned a more internal awareness that fits into interoception. Take a minute and scan your right thigh. The front of your thigh from the top of your hip down to your kneecap and as you’re scanning, notice if you feel any sensation there and notice you could feel temperature there. It fits well on to interoception, right?
This is the third one I’m curious about. I want to get your feedback on it as the expert on interoception. What if I say, “I’d like you to turn your awareness now to thoughts and notice the name, the first thought that comes up.” They might say, “Thirsty. I’m thirsty. That’s my thought.” How does that relate to interoception?
To me, thoughts are at that cognitive level again, but that high-level cerebral cortex of our brain and I try to always bring it back to the body, especially when we’re starting interoception-based work and noticing, checking in with how your body is feeling and trying to keep the thoughts out of it, which is hard to do. It’s sticking to the body at first.
Let’s take that one step further. If I say, “Take a moment to notice one thought,” and someone says, “Traffic.” I say, “As you’re noticing that thought, what emotion do you connect to that?” They say, “Anger.” How does that relate to interoception?
Our body signals are clues to our emotions. Perhaps they’re remembering that when they were in traffic, maybe in a subconscious way, they’re remembering how their body feels in that body. These body sensations are informed. If they were feeling angry at that moment, that would be how interoception would be at play. I like to work in real moments, present-day moments, and noticing how your body feels right now in this moment. Starting to help someone to use how their body feels in that moment as clued to their emotional experience rather than working on pulling out contrive situations if that makes sense.
I talk about real learning and artificial learning. We’re good at artificial learning. “Tell me about how your body feels when you’re stressed.” That’s artificial learning to me or labeling a body outline and telling me what you notice when you’re in pain or angry. I would rather work in the natural, real learning context and where my work is all about. Evoking sensation in your body in a safe, playful way. Noticing how your body feels in that moment or in that activity. Real context-based learning.
Although in that example, when I said anger, my question for you and how this relates interoception is anger, which we identify as an emotion. Is that a cognitive appraisal or is that more of an interoceptive body appraisal?
I don’t know. It’s a little of both maybe. It is a body appraisal. You’re appraising what your body sensations mean.
When you say anger, people may feel heat, let’s say, in their neck or cheeks. They may feel sweaty palms and tension in their shoulders. All those are more interoceptive signals. Does it require that it is filtered up into the brain to have this cognitive evaluation of anger? Sometimes people confuse sensations. Sometimes excitement can be confused for anxiety, feelings of excitement, right?
When you started teaching interoception to PTs and OTs, where’s the one place that they get stuck in the beginning?
They can’t put down their cognitive strategy.
It’s a lot of things we spoke about.
I guess it depends on what practice setting you’re in, but a lot of the people I’m speaking to in the pediatric world, they’re also behavioral-based and compliance-based, which could apply to adults too. We live in a compliance-driven world, where we don’t listen to what our body needs. Instead, we try to comply with whether it’s rules or demands. We ignore what our body is telling us we need in order to comply with whatever it is, whether it’s pleasing other people or the whole nine yards.
In the pediatric field, in many of our dysregulated learners, the foundation of what they’re struggling with is understanding their interoceptive experience, but yet they’re subjected to these compliance-based behavior models like, “Do what I say. If you do what I say, then you’re going to get a reward or reinforced or you won’t get in trouble.” They’re continually conditioned to ignore what it is their body is telling them they need.
Maybe they need to wiggle and learn and move to learn, but the school is saying, “You need to sit still or you’re going to clip down on this chart.” The thing that they need to develop that inner understanding is being squashed by these compliance-driven models. That is helping people shift away from that and getting to a place where we’re empowering all of our clients with a better self-understanding through interoception.
That must change the whole dynamic for a kid who‘s struggling in school.
It shifts the narrative completely. It shifts it from you’re this kid behaving badly on purpose to a place where you’re confused with your inner experience and we can empower you with that self-understanding.
Becoming more aware of your inner experience helps you relate differently to what that experience is. That’s how I said before like, “You can confuse excitement with anxiety.” This goes back to what you initially said, how you discovered this toileting, for example. Even that can be confused as anxiety. If you have an urge, that can be confused as anxiety. It takes me back to when I’m in school. When I think about some of the mainstream kids I went to school with, some of the things they struggled with and how people perceived it versus how it is.
We misperceived many of our clients, young and old. I don’t think we put enough emphasis on trying to get to the deep whys, their inner experience. We assume and I don’t think this is coming from malicious intent. We assume that people have the same exact experience that we do, so we put that on them. What we’re finding is that’s not the case at all. Many times, we’re missing important pieces of our client.
Everything that you’re teaching here with this work with regard to interoception, whether it’s with adults or children almost no matter what diagnosis it is, you’re helping people to feel safe again in their body and safe again with their own personal experience.
That is the goal and my hope for all of this.
This is why your work is so important. As I read through your website, I’m like, “This is all about helping people feel safe in their bodies.” It’s hard to do that if you’re using a top-down approach. We have to work through the entire body, all parts of the nervous system, as we help our patients feel safe, empowered and then they can go out and do the things they want to do.
It brings it back to that whole mindfulness piece that you’re asking. I see this mindfulness craze and it’s like, “Mindfulness for everybody.” We don’t stop to think. People don’t have a safe relationship with their bodies. When we’re inviting someone to participate in mindfulness, many people are not taking that into consideration. We need to be careful in thinking about that safety aspect that you’re mentioning.
How do you titrate mindfulness and how do you approach mindfulness because some people might do better working with the environment first and then going into their bodies? Some people might do better working in their minds than moving into their bodies. For some people, it’s the opposite. That’s where the skill comes in with mindfulness rather than just like, “Take deep breaths and relax. Once that happens, everything is okay,” which we know once you start using mindfulness, that’s not how it works.
Everyone can find more information out about Kelly’s work on her website, Kelly-Mahler.com. It’s an incredible website with lots of information there, tools, tips and educational pieces that you can pick up on. Kelly, I want to thank you for joining us on the show and working through all the nitty-gritty of interoception. It’s important and I’m excited about your work. Come back when you have some more updates for us.
I’d love to. Thanks for having me, Joe.
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About Kelly Mahler
Kelly Mahler OTD, OTR/L, earned a Doctorate in Occupational Therapy from Misericordia University, Dallas, PA. She has been an occupational therapist for 19 years, serving school-aged children and adults. Kelly is winner of multiple awards, including the 2020 American Occupational Therapy Association Emerging and Innovative Practice Award & a Mom’s Choice Gold Medal. She is an adjunct faculty member at Elizabethtown College, Elizabethtown, PA as well as at Misericordia University, Dallas, PA. Kelly is a co-principal investigator in several research projects pertaining to topics such as interoception, self-regulation, trauma & autism. Kelly is an international speaker and presents frequently on topics related to the ten resources she has authored including The Interoception Curriculum: A Step-by-Step Framework for Developing Mindful Self-Regulation–used in over 30 countries world wide.
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