Dr. Ezra Cowan - Unveiling Misophonia Therapy Insights

Adeel [0:01]: Welcome to the Misophonia Podcast. This is episode 23, season 6. My name's Adeel Ahmad, and I have Misophonia. This week it was my pleasure to speak with Dr. Ezra Cowan. Dr. Cowan is pretty well known in the Misophonia community as a researcher and therapist focusing on Misophonia, as well as OCD and other conditions. We talked about how he got interested in Misophonia, especially since he doesn't have it himself. He explains extensively his model for what misophonia is, and then he describes how he developed his therapy, known as EASE, Experiential Acceptance and Stimulus Engagement. You can learn more at his website, which I'll have in the show notes, ocdmiso.com. He's got a lot to say, so please let me know what you think. You can join the discussion on Instagram or Facebook at Misophonia Podcast. And you know you can always reach me by email at hello at misophoniapodcast.com. Another reminder, just leave a quick rating or review wherever you listen to this show. If you're enjoying it, it helps reach more listeners. And as I mentioned on Instagram briefly, transcripts of all episodes are finally coming any day now. I found a way to get them affordably. They won't be perfect, but they won't be totally machine-generated. And this is partly thanks to all the incredible ongoing support from our Patreon supporters. If you feel like contributing financially, you can read about the various levels at patreon.com slash misophonia podcast. All right, now here's my conversation with Dr. Ezra Cowan. Dr. Ezra Cowan, very good to finally get to talk to you. Welcome to the program.

Dr [1:44]: Thank you for having me. It's a pleasure being here.

Adeel [1:47]: So, yeah, just to kick it off, I usually just kind of like to ask people kind of where you're located, what you do. And I will have, you know, introed you before this, but I would love to hear your own words.

Dr [1:58]: Sure. So I live in North Jersey, kind of close to Manhattan, the big city. and um i'm a clinical psychologist so my focus my background training is mainly in the world of psychology understanding how the mind works how emotions and behavior all kind of coincide and how people kind of we try to understand how people what makes people tick uh in that world and um that that's kind of my whole ever since i was a young kid i've always just tried to understand why just this question like why do people do what they do and that question kind of leads me till this very day i constantly ask this question and i I also asked that question with misophonia. And I think some interesting answers or potential answers or ideas emerged. So we could talk about that. I'm sure we'll get to those.

Adeel [3:01]: Yeah, we'll talk about misophonia. Cool. And oh yeah, speaking of misophonia, so you don't have misophonia yourself, but you treat a lot of people who have misophonia.

Dr [3:11]: Correct. I fell, I would say almost like fell, almost by chance. Nothing's chance, but I kind of stumbled on it. And I slowly got to learn about the world of misophonia and really appreciate the amount of pain and suffering that someone with misophonia has. I don't have to tell you and many of your listeners. And I actually, to be honest, I did a lot of research on it. I really got to get a sense of the amount of pain and suffering and the loneliness from listening to your show, Adeel. I would say that that's where just hearing the personal accounts, just the everyday life, it's sort of like there's the academic side, there's the... There's the numbers, there's what people are reporting on self-report measures and all that stuff. But then there's just the individual stories that really gave me a much richer picture.

Adeel [4:25]: Yeah, I kind of started it because I wanted to get past the or go beyond the rants that you just see on Facebook and get that richer view. So I'm glad you noticed that. And yeah, so... I mean, I'm curious how in your in your practice, how did you did you notice people were coming in with misplaced symptoms? Because, you know, you probably were doing others. You're treating other other conditions before. I think OCD. Right. I'm curious how that how that kind of like started for you.

Dr [4:53]: Yeah, it's a great question. So, yeah, my background is kind of in the world of of OCD treatment. So I guess a short a description of the evolution of my training and then how I entered into the world of misophonia in particular. I started to specialize in OCD or obsessive compulsive disorder in early on in my graduate school. So I have a doctorate in psychology and we have to do a lot of sort of uh what we call externships it's sort of like a essentially an internship and so my internships basically were all focused to some degree on ocd there and so i was also at the same time doing my dissertation on ocd um and i was like totally immersed in this world called obsessive compulsive disorder and trying to understand it on a, on a very kind of really breaking it down to its pieces and basic elements as it were, and to comprehend it. And as I mentioned before, we try to make sense, try to understand it. And that's usually how we could then arrive at a treatment. Once you understand what's going on, then the therapy kind of naturally flows in that. So I, there's already a therapy for, for, for ERP. It's kind of, When you have a deeper understanding, then the therapy itself could become a little bit more effective because all the nuances also make sense and you could respond to the nuances in a more meaningful.

Adeel [6:40]: Other corner cases. And yeah.

Dr [6:42]: And and so that was sort of what drove me there to just get to that world. And then. I it started to then I realized that everyone, almost every single person with OCD had something, what we would term some perfectionistic tendencies. So I started to ask myself, well, what is this thing called perfectionism? And I tried to then understand the bolts and pieces of that. And I started to go deep, just like, what is this? Why do people have all or nothing thinking? Why do we engage in this type of, why are people kind of... holding himself back from becoming their awesome self when you know fear of failure etc where's all this coming from and so i started to really question the the bring these types of questions to my mind and do a lot of research and i wouldn't rest until i each question i had had some type of compelling answer and so i was my my dissertation was really understanding the relationship between ocd and perfectionism that's that was the that connection and one day at home my uh my wife says have you ever heard of something called misophonia and i said i i said actually i might have heard of it i it once came up in a supervision like we were in a group supervision and someone mentioned something about it um it sounded a little familiar but i never you know sort of like you see a lot of things and you don't pay attention to it and So I said, I think, and she said, there's this article, someone wrote an article about their experience with misophonia. And so I read it and it was, it kind of opened my eyes. And to be honest, I was sort of like, I didn't understand it. I didn't, um, like it was, it was just confusing to me. And I was, and I kind of just left it at that. But I had this feel, walking away from that, I just had this feeling of there seemed to be some type of psychological part and that psychological part tasted, and it's hard for me to use the word beyond tasted, but almost tasted like some of the patterns I've seen in perfectionism. That's all my brain told me. And so... One day I just, I put that, filed that in the back of my mind. And one day I decided to just do a little research. And sure, I opened this article by an individual named Schroeder, Dr. Schroeder from, I believe, Amsterdam. And he has a big misophonia research team out there. And he published a paper in 2013, which I believe was, if not the first, one of the first psychiatric, psychological-oriented papers on misophonia. And he looked at, among the many things that he looked at, what were some of the variables, like the psychological personality variables. And he found that it was a small group of people, it was 42 people in the study. Half of them reported that they have what's called obsessive-compulsive personality tendencies some of them even what we call like a disorder meaning those tendencies we get in their life which is essentially if we want to know what that is it's sort of the the the psychiatric fancy way of saying perfectionistic and kind of inflexible having a hard time with things being outside the way someone understands the world so that that was all that was mentioned there And so I found that that kind of picked my interest in the sense that there was someone who looked at this and found that there was a potential relationship between misophonia, whether what came first, did the misophonia come first, did the perfection, these are all kind of questions that were up in the air. And when that, that really, that study was the one that gave me a little bit of a sense of like grounding to, start looking into it further that i that maybe there is something for me to look into here from a psychological perspective and that led to um i had a break at one point like a winter break And I had two weeks off, and I literally just plunged myself into the world of literature and misophonia, into just trying to read on everything, both sort of formal academic studies and just anything that's online. And that's when I found you. You were starting, I think you were pretty early at that point. And I was driving to, I would be driving, doing my commute and I'd be listening to Adeel and his friends and just like getting, and so it was sort of a part of my research experience. And so that's kind of how it started.

Adeel [12:00]: Cool. Okay. Yeah. No, thanks for giving that background. And yeah, I was looking at your website again and you cited a statistic where like you said like and there was a a study where 97 of people um with misophonia had like clinical perfectionism and i thought that seems like a lot i don't know i've never heard of that before but i looked it up and it's yeah it's it's very it's very true and it wasn't a small study it was a major study so i thought that was interesting that was that was news to me i felt kind of embarrassed not knowing that but uh so since then misophonia is now a major part of i guess your um your, your practice. Do you want to talk about, I guess, well, we should also at some point, I'm sure we'll talk about ease. Do you want to talk about kind of after you did your research, how long did it take for you to maybe develop some, some compelling treatments and we'll get into what some of those might be.

Dr [12:54]: Yeah. So it's interesting. It's kind of like still a journey. It's still an, I'm always like, I, You know, it's always refining, always trying to make things better. And so in terms of when I felt like I had something that made sense, that made... I would say the whole... It took probably two years till... It was like the first year... and a half was just trying to develop a conceptualization, an understanding that made sense that you could see if you told the story to someone, they would say, oh, OK, I can hear that. That probably took a year and a half. And and then once once we once I had and we could talk about what that sort of the model, the psychological model of of misophonia, once there was an understanding, then the therapy tends to flow rather quickly, relative quicker to the understanding. At the same time, it turned out to be more complex than I anticipated. And then it's kind of, you have the concept and then there's implementing the concept and that requires a lot of refining and rethinking and broadening and broadening the conceptualization itself. So that's usually how... that's pretty typical in the world of psychology. And I would say even beyond that, you sort of have a concept and you try to implement it and then you kind of get the feedback of the world that says, you know, hey, this works, this doesn't.

Adeel [14:45]: So maybe do you want to start? Yeah, go ahead. Thanks for laying out the roadmap for that. Do you want to maybe talk about your concept for Misophonia and how you explain it?

Dr [14:57]: Sure, yeah. It's a great question. I feel humbled to share it on this platform. So the way I would begin how to understand misophonia, I'll try to skip a lot of the academic psychobabble and the jargon. I'll try to share it the way I share with anyone I work with, really. We all have stories about the world. That's the way our mind works. We are born into a certain family and our family shares with us their views and some of those views we take in, some of them we develop from outside. And we kind of develop an idea, a story about the world. Like a good person is supposed to... Be responsible, make a living, and do their thing. Just be a good person, smile, and that's being good. Another person would say being good involves going far places and helping people. That's what it means. That's the story of what being a good person is. We all share stories about the world. And so with misophonia, there's also what I call the misophonia story. And it goes something like this. When people will stop making certain sounds that really bother me, that are really painful to me, then I will be better. Now, I'm curious, what do you think of that story, Adeel, as I said that?

Adeel [16:46]: Oh, if people will stop making noises, I'll feel better. That story?

Dr [16:51]: Yeah. Would you agree with that?

Adeel [16:56]: Does that feel accurate to you? Yes, for when I'm in a moment.

Dr [17:02]: In the moment, exactly. Yeah.

Adeel [17:04]: when i'm in the moment um i and i'll get to this later i'm very curious where those stories come from because i feel like there's a there's there's treating things in the moment and then there's maybe treating the root um yeah so but yeah but yeah for that sentence

Dr [17:22]: So, yeah, exactly. Where did that where did that story come from? That's a great that's a great question. So I think we're we're kind of looking at it right now. There's this there's this I think when someone come comes into therapy or when someone's getting triggered. We find someone, it makes sense. When this trigger goes away, I will be comfortable. I would be able to not worry about getting clobbered by these tights. I don't have to worry. I can be comfortable. And there's nothing intrinsically wrong with that idea up until... there's a kind of there's another phenomenon like the the the let's just call it the phenomenon that triggers let's say whatever the trigger i'm not gonna i'm not gonna give examples here uh you know your triggers yeah um those those triggers aren't have historically have not have been around and so that suggests that they're probably going to continue in other words i had a professor that that said uh dr brandwein he always said the best predictor of future behavior is past behavior in other words if we want to kind of make a conservative assumption of what things are going to be look like in the future it's probably the way things work So in other words, we could all hold ideas and hopes about how we hope things are going to be. And because also we really don't want to be hurt. At the same time, that hope or that idea that triggers can go away is something that clashes with what's likely going to unfold. And so this is kind of like what, one beginning point of understanding like there's a lot of there's a there's a clash between how I'm expecting things to flow and how things tend to be gone and how things are going to unfold. And so what I it brings up a lot of a lot an intense amount of frustration, an intense amount of pain and. And it's very disappointing when the triggers continue to happen. Now, we could say logically, I know that they're going to go away. But for some reason, logic, the logic doesn't tend to have an input in this situation. Like we can't we can't I can't like if I were to say this right now to everyone and say, look, you know, the triggers are going to go away, are not going to go away. That doesn't have any impact on how triggering it is. I might know that intellectually, but it doesn't have an impact emotionally. And so that relates to what we would call a sense of we don't want to be hurt. So inherently with the desire to not be hurt, that comes with a hope, which kind of hope and expectation are really in the world of psychology are kind of the same. that the triggers will go away. So we don't want to be hurt. In other words, if we were to put a different angle at this, we could say a different story. And the story could go like this. There are people around me that do things that I really don't like. However, it's especially people that are close to me that I have the highest expectation that they won't hurt me. they are, unfortunately, they're not going to, this behavior is not going anywhere. That's sort of just, you know, and I hate, I don't like saying this in like a, in a, in just like a matter of fact way, but it kind of, that just from a phenomenological place, that's what seems to be happening. And what would you be left with if we can't change? If we were to see this as something that's never going to go away? then that would be very sad, that would be very, feel very hopeless. And I tell people, you know, this sense of this feeling of hopelessness, this sadness, it's actually, usually we don't think of hopelessness as like a good thing, but sometimes in order for us to move on from something very painful, it involves going through a dark tunnel. And the dark tunnel, could lead to something brighter. At the same time, it is very painful when people around us are doing something that is so, so painful to me and I can't get it to change. And so if we could establish that and again, how that's done, we'll talk about how that's done. If we could establish that they're not changing and then then that means that now if I'm the one being hurt, if I'm the one being triggered, I'm stuck with getting hurt. And so then I can begin to focus on what I could do, which is focusing on the pain that's inside of me. Because now I'm not looking to change what's out there. And so there's really, in this sense, this kind of leads to the therapy itself, which is really there's two steps to the therapy. And before I talk about the therapy, I want to clarify, because I think sometimes it's This seems to kind of, it doesn't explain certain aspects of misophonia, especially like the intensity and the overwhelming aspect of like, why is my brain so latched on to the sound? And why does it like hijack my entire nervous system? And so I often explain that when we hear a sound that makes us uncomfortable, the tendency would be to not want to notice it. So if I hear a sound I don't want to hear, it's like... I would want to ignore it. I would want to move away. If it really bothers me, I definitely want to not notice it. So the, the problem is that there's something called the white bear phenomenon. Have you ever heard of the white bear phenomenon? I read it on your website yet. Okay. So if you, if you, um, uh, I'll share, I'll share with the, uh, with the, with the audience. Um, if, if, like, if I were to ask everyone listening, like, don't think of a white bear. And I'm guessing most of you thought of the way that's just the way we end up thinking about we don't want to think about. Now, this is true for sounds also. If I try not to notice a sound, it's just like it's like a not fear part of the brain. Like, why does the brain have to do that? It's just it's this is the way everyone seems to be wired. And it kind of makes sense in the sense that we notice the things we don't want to notice. Let me clarify that. In order to not notice something, you have to think about that thing that you don't want to notice. So it just keeps on bringing it back in a loop to your awareness. And so if I'm trying to not notice the sound, then I'll be more aware of the sound. And it will be stuck with me. Now, there's another effect that, When I'm trying to, when I'm trying to, that's one piece. Unfortunately, there's like another piece called the zoom-in effect, the zoom-in effect, which means that if, in the same way that if I were to be studying for a final, let's say, for a test, and I really want to be fully focused, I'm giving my full attention, it's almost like I'm losing track of everything around me besides for the material that I'm trying to focus on. The same is true with sounds that i'm trying to not notice the brain doesn't distinguish between the things that you do want to notice and don't want to notice it just says it just says notice and then it says notice even more and then it says notice even more more more and it keeps and it sort of becomes like a that the brain just attends it it thinks that it's doing what it's supposed to be doing which is just to attend what the mind is being told to attend to even though we're telling it not to attend to that so it becomes it's almost like taking headphones putting on on on really really high quality headphones and putting the volume all the way to the max and taking a microphone and putting it to the trigger that we don't want to notice or the site if in the case of a site mesokinesia And it becomes just sort of becomes the only thing that the brain is attending to in a certain sense. And so that from to me could at least partially explain why it's so that some of the overwhelming factor, because it's sort of we're told it's like to the exclusion of everything else. All that's being focused on is this one trigger. So that to me, a lot of the very, very difficult parts of misophonia, I believe, are kind of secondary effects. They're secondary effects to the initial of trying to not be present with a sound that's uncomfortable. So why exactly are people bothered by sounds in the first place? I think what I've found is that there are many reasons, meaning there are different types of contributors. I don't think each person has the same exact conditions. For example, there is one piece with the perfectionism that we saw, which basically means that when people have perfectionism, when there's some type of pain points. In other words, like... we the the symptoms of perfectionism are well known the the the the need to have things a certain way the all or nothing thinking um if it's not like this then i'm not okay with it at all um fear of failure different they're different we could list different symptoms in terms of what at the at the uh core of it at least how how it um it could be understood. One perspective is that when we don't feel comfortable, we become more extreme. So we become a little bit more inflexible. Like, hey, do you mind if I'm taking a knife and poking you with it? Like, yeah, I do mind about that. That bothers me. Could I do it a little bit? No, not at all. We don't become flexible when we're being hurt. So When when something when if for some reason the sound is it kind of touches someone's pain point to a degree. Now, that's something that could happen. And I'll explain how. But if it does, then then we become more inflexible about the sound. So like the sound could become more bothersome and less acceptable. And like worse, whereas one person might say, OK, it's not a big deal. Like whatever. It's annoying sound, but there's nothing I could do about it. someone who it's already it's kind of touching a pain point then it's sort of like no i can't have this and what would be an example of a pain there could be many things and i don't want like there no one on this planet is free of of pain like everyone has their their package as they say um but i'll just give an example let's say someone has like a helicopter mom or or dad It's not just moms that are helicopter, that could be helicoptering. But there's a feeling of like, I don't have space. And so then in that environment where I already feel like I don't have space, if I'm noticing a sound. and that sound makes me, it kind of brings up that same feeling to some degree, I'm going to try to move away from that sound because it also brings up a feeling that I'm already having in my life that's already a pain point. That's just one example. So I think the perfectionistic part that we're seeing in the research this is this is just like explaining what when we talk about perfectionism all perfectionism means is that there's something in a person's life that they're they don't want to feel and they're responding to the world in a way that they're protecting themselves from that so they want to do well on a test because not doing all tells not doing well on a test will make them feel vulnerable to to some type of pain that they've already had for example

Adeel [30:20]: Right. Some kind of pain point that they already have. So, yeah, I guess I think people might be curious, like, where did that come from? And is it worth addressing that as well as, you know, how to accept a sound? Like, is that part is addressing the is addressing that the root pain point part of the part of the.

Dr [30:40]: Great question. So the answer is, is ultimately, yes. I'm glad that's such a good question. Ultimately, yes. And I'll get to the therapy in a second, and I think that I'll show you how I mean by that. So the pain point, that's one way, that kind of is connected to the broad perfectionism. But there are other factors that could relate to contributing the rise for in the first place of developing misophonia. Meaning if someone has perfectionism, it doesn't mean that they'll develop misophonia. However, like certain risk factors, let's call it, that could contribute, I believe, is let's say someone, um someone lives in a house where someone does um have manners that are kind of deviate from the norm um and and and you know it's not as i say it's not just in the mind uh i think that that could create a risk if someone is is an incredibly loud breather for example i apologize for using a certain uh but but this is i think that that does have an impact um again it's not the whole story but i think it's a we call it a risk factor someone um and um just for for for example if someone goes through a recent change where someone used to uh not make a certain sound and then they started then they can become aware of sounds and even if that sound goes away that that like sudden uh new sound came like i'll just give an example i think uh if there was someone who told me that they uh a sibling got um braces or some type of orthodontic procedure and the way that that the sibling was eating changed and that change was very uncomfortable because it was it was just a new type of sound that wasn't there before And then even though that went away eventually, once the mind becomes aware of it, it's hard to become unaware of it. And so then it started to generalize. So that's another example.

Adeel [33:03]: So is this maybe related to, maybe that example related to rigidity, if somebody is predisposed to being extra, have rigidity, whatever that definition is, when they see something that deviates from that, is that part of your model in terms of like when it could develop? something outside of their expectation.

Dr [33:23]: Exactly. Exactly. It's it's it's there's there's a sense of like, I think that things should you know, this is the way someone should eat and and it's not being done. So I'm I'm expecting that to change. That's part of it. At the same time, I think it's important to realize that that. on a on a perhaps in a deeper level the perfectionism emerges from already emerges from a general sense of like i'm i'm already i already have something that hurts inside to some degree because everyone has something um and And that sound is is kind of rubbing against that. So, like, I don't like the way you eat. Maybe it's because of a it seems like a rule, a steadfast rule about how I expect things to be. But often that rule, why things I why I expect it to be that way. And it's hard for me to be flexible about it is because of how I already how I feel inside. And so and.

Adeel [34:28]: yeah so that would that would definitely uh play a role and yeah and you said something earlier maybe related to that it was that uh uh misophones um yeah we feel like you when you ask me like um you know you wish some i wish something a noise would would stop when i'm when i'm in the moment um but you also said that uh we hope that um in the future triggers won't happen but i but i don't i don't know have you talked to anyone who's told you that they actually realistically expect sounds to stop in the future because i don't know that i i certainly don't expect sounds to stop in the future i'm looking for ways to um you know heal my misophonia but i'm curious where that um observation came from yeah it's a great it's a great question so it it's i think on uh there we're kind of looking at the at

Dr [35:23]: at the the gap called that from of what we believe on a kind of just like our typical kind of uh this is i believe logically and then there's the emotional part of the what i would call kind of the hope that that almost like the hope that this would stop and that you really find more in the moment Like when, when there's a trigger, like, like can't like, and you could find this with the types of thoughts that someone has, like, can't you just eat a little quieter, for example, like just there, there, there, there, it's just instinctual. Um, and, um, in other words, like what I find is that there's, there's, um, and, and I guess we could talk about like, this is going to start bleeding into the, into the, into the therapy itself. Um, It's not uncommon for us to have almost like conflicting beliefs in the same moment. In other words, I could know that this is not going to go away and at the same time have a certain hope that it will go away. And that's not a contradiction in terms of the existence of those two in the mind. It's entirely possible for someone to have those two. And I think it's coming, it's not coming, I think we're, I find that individuals in misophonia tend to be on the brighter side. It's not coming from like, you know, a logical conclusion per se. It's coming from the desire to not be hurt. So everyone has a deep desire to not feel hurt anymore. So naturally there's, the mind sees the way out or hopes the way out is the mind hopes that there's a way out and then naturally the mind says well if people were to stop chewing that would be a way out of this out of the situation if people would stop doing the triggers that bother me um and And it's kind of like, I call it like a little bit of a twilight zone in the sense that a person knows and doesn't know, is aware, has this one belief that I know that it's not going to go away. And then it's like emotionally, there's a sense of hope that, and I call that hope toxic hope, because it's a hope that really holds us back from healing. And let me talk about what healing could look like. the the way the mind that it's really a two step there's there's two steps um and i'll i'll start with kind of describing what a a therapy looks like for not misophonia and i think it will be useful as a launching pad to kind of go into how it looks like so for let's say someone is dealing with a lot of anxiety anxious distress and they were to go to a therapist. There's many, there's different ways people treat it. One of the kind of the cut, the frontline ways today that a lot of people are treating anxiety, difficult emotions, is using what's called an acceptance-based approach, which is basically taking the following, this is what the conversation looks like. you're experiencing a lot of anxiety, and I'm hearing that you're in a very difficult state, and it's painful for me to see that. And the hard part is that some of these emotions, they're kind of like part of us. We have positive things. We also have painful parts, and we can't really get rid of these emotions. They're not something that we can get rid of. So let's learn how to feel them. Let's learn how to experience them. In other words, it's not about feeling good. It's about being good at feeling. And so we could do exercises together and we could practice. how to learn to deal with those difficult feelings. And we can learn how to experience those. In other words, how to make peace with difficult feelings. And this actually, and the research, there's tons of research on this. This is incredibly effective in learning how to just move on from difficult emotions. In other words, I might feel pain, but I'm okay with my pain. I've made, in a sense, another way of putting it is I'm at peace with my pain. And so I'm not thinking about it. Oh, I feel sad. Okay, I feel sad today. It's okay. I don't need to escape. This is where I'm at. Trying to move out of this, trying to fight that is only going to create suffering. It's only going to make me even more depressed and feel like I have less control over my life and more desperate. So another way is just to kind of pull back and be, okay, this is where I'm at right now. And that's okay. And there's a lot of nuances with that, but that's sort of the big picture. So with misophonia, there's a step before that that needs to be taken. And that's related to the idea that the solution for this really painful problem called misophonia is outside of me. If I believe on any level whatsoever that the solution is outside of me, then I'm going to continue to wait for that solution to emerge before I even start thinking about dealing with painful emotions. In other words, we're not willing to deal with a difficult situation unless we really have to. And so painful feelings is we... We just don't like to feel bad. I don't know about you, Adeel, but I don't like feeling negative emotions. I'm sure many of the listeners could... Would agree. It's not fun to feel uncomfortable. There's many industries all all based on just pain relief. Bad. Yeah. Or pain relief, too. I think I think the term out there, even in the business world, for like marketing different products is like what's, you know, solving a pain point. In other words, like every everything is is there to like some someone has a problem, like a discomfort of sorts. And this is going to alleviate that that. At the core, we just don't like being uncomfortable. And we can learn how to deal with that if we feel there's nothing else that we could do. Unless we think that there's something that could be done to solve the problem. if we think there's something that can be done to solve the problem, then we'll take that step first. We're not going to start saying, all right, let me just sit kumbaya with my feelings over here and while there seems to be this button I can press and everything will go away. And so with misophonia, it's kind of like what we want to do is to recognize all the ways that my mind entertains as possible ways to feel like this could change, like the sound could change or the sound could go away. And this involves, in order to create this type of conditions that the situation's not going to change, we need to look at all the different variables that contribute and give rise to the sense that I could get away from these sounds. And so that involves thinking about how the source of the trigger could go away. That involves thinking about how I could get away and all the different ways that go with that. And that also involves, and this is an interesting one, And yet, I think this is another kind of, I would call it, risk factor that I find in misophonia, where we have this certain expectation of our own body of how we're supposed to feel. There are different types of... um uh ways that it perfectionism uh emerges that ways that it it um how it affects people is it it could be so many different ways one way is how a person feels like i shouldn't be feeling this emotion the very interesting thing that we do like i have an emotion and i could look at it and be like this should not be happening this emotion is is not supposed to exist inside of me which is which isn't which is an interesting way phenomenon that where we do this and yet we do this all the time and so if i feel like like i'm already getting triggered I'm already uncomfortable. And now I'm telling myself I shouldn't be triggered by this sound. That's creating a whole new level of like distress on myself, pressure that like somehow I'm violating the norms of humanity that I'm feeling the way I'm feeling. And so and it creates a lot of distress. And so the third piece is also recognizing that the way I'm responding right now is not changing in the moment right now. Like this is kind of how I'm reacting right now. So it's not expecting It's recognizing the person's not changing, recognizing that I'm not leaving, I'm not doing anything to escape the situation, and that the way that I respond right now is the way I respond. So everything is kind of put in its place. Nothing is moving. Nothing is changing. That's the concept. Now, the therapy is packaged in a way that it's to build up that... belief system emotional belief system let's call it in a consistent way and it takes quite a while because the brain the way i the way i see it is there's been one conversation going in the mind for the most part which is how the mind has been thinking until now regarding the misophonia if we're introducing a new way of thinking about it it's kind of like you have you're you have a very like the dominant voice is the old way and if a new voice is being introduced it's still like a small little voice being overshadowed by like you know you imagine you have like a thousand people at a protest and then there's one person on the other side protesting something else it's kind of hard to hear what that one person is saying. It's sort of overwhelmed. And so the idea is to reinforce the idea time and time again, to put ourselves into situations in a very sort of slow but consistent buildup to challenge ourselves to start thinking in this type of way and acting in this way. and and that's something that's in our realm of choices we have that ability that's something that that's accessible to us it's not easy and and that's why i usually start this using more imaginal techniques i say let's just try to imagine the the trigger and see what see what what's happening in your mind and body and we'll take it from there and then we start to introduce The different way we create a new dialogue in the mind. This I can't take this. Well, I see you can't take this. And yet this is not going to go away. Like it has to go away. Well, I understand a lot of validation. We validate ourselves. We validate the heck out of ourselves because we're in so much pain. We need that feeling of like it's OK to feel overwhelmed. But we always need to end with an and it's not going to change. Now, that sounds. painful and yet like we were saying before it's actually it's it's that it's it's kind of like a bitter medicine in a sense we we need that we need to be told that the one one i use a little bit of an extreme example to bring out this point because sometimes we can understand like a more uh nuanced point when it's in in the in the extreme aspect Imagine someone loses, let's say, let's call someone John. John loses his dog, Parker. And John is devastated. Parker was everything to John. And John has a friend named Jack. And Jack comes over to John and says, you know what, John, I see you're really sad. I don't like seeing you sad. Parker's going to come back one day. Parker, it will be okay. And so we would tell that friend, that's not helpful. That's probably not going to happen. And it's okay for John to mourn, to feel sad over Parker because that's what it is. It's kind of like there's a finality to it. And that creates a pathway for healing, for moving on. In a certain sense, we're kind of putting ourselves in a path to begin thinking in that way like this is this is the way it the mind is going to be put no it can't be it can't be we're going back and being like i know i know it's so painful and this is just the way this that they're even though it looks like they might change they're probably not going to change And regarding like the I use a metaphor sometimes to kind of bring out the idea of how people tend to change, because sometimes we see like, oh, I sometimes X. Let's say let's say my sister triggers me. So my sister, Maggie, is one time I saw that she could change. And so she could change. And so we could I always liken people to a guitar. You take a guitar string and you pluck it. It makes a little sound and might move a little bit, but then it kind of goes back to where it was before. And people are like that. I know this might sound like kind of a little bit pessimistic, a cynical view of humanity, but for the most part, people kind of... If we think about people in their lifespan, for the grand majority of people's personality and tendencies, they, for the most part, kind of stick to overall where they are. And then when they do change, the change is slow and gradual. In fact, when we see someone change very quickly, very fast, usually we start to wonder, like, how long is this going to last? And or is this healthy? Right. So that's usually the types of questions that we ask when someone has a radical change. So it's kind of like. We want to always go, we have to be creative about this in terms of how to speak back to our mind regarding all these counterpoints that it says. It's going to say a lot of counterpoints and we're going to constantly bring us back to this is just the way it is. And we also, we need to, for when we start doing the therapy and beginning to do live exercise, I call them, it involves... commitment for a certain amount of time that right now I am choosing to act in a way as if leaving is not an option at all. So I'm starting to get a taste of what it's like to be stuck and I and they're not changing. I'm not leaving. The way I respond is the way I respond. That's just I'm starting to learn how to what's called accept the situation for what it is. That's step one. So I'm kind of and that involves a lot of building up. Another metaphor that I use is imagine you were tasked to fill up a tub of water, a big tub. You're in the basement. The tub's on the third floor, and you were given a mouthwash cup. It's like two ounces. It says, I want you to fill up the tub on the third floor with the sink in the basement. So fill up water, run upstairs, put it in the tub, go back downstairs again. after after a hundred times if i look in the tub it's gonna be pretty disappointing right it's like i'm panting and and yet still it's like it and it's kind of like that like we're it's it's a very slow process with a little but then once we put ourselves on this track after some time we start to begin to think differently we begin to respond differently the conversation becomes different in the mind so that's step one step two is now that i'm beginning to let go of what's going on out there. I don't see any hope for change there. And it's also important to realize that we want to learn to sit with those. To mourn that loss, that's part of it is like, yes, this does feel sad. It feels like a sense of helplessness. Like I thought that something could change and that's a loss and that's okay. We could process that together. That is painful. And then we do what's called the U-turn, which I spell Y-O-U, U-turn. We turn to you and we focus on the individual because now that we've let go of out there, we're going to focus inward. And that step, I specifically created a step for that because it's a conscious effort. It sort of requires like a decision, like, okay, I'm letting go of out there and I'm moving inward into my body. Have you ever had that experience where something was a problem and all of a sudden you're like, oh, wait, I'm contributing to what's going on here. Sort of like that aha moment of like... I'm also part of this. I was looking out there. Now it's also inward. That type of experience, it requires a conscious effort. And so it's like a decision. And then the last step is called experiential acceptance, which is learning how to experience. difficult emotions. And only once we've gone through the first step could we then show up to the learning to deal with painful emotions. And that's something that is very hard and yet we're very capable. I actually find that the first step is in a sense more difficult than the second step. It is hard for people to deal with painful emotions. It's harder for people to let go. of the idea that there's no solution for the change outside of me. Once a person realizes nothing to do, there is a certain ease of learning how to deal with painful emotions, if taught how. So once a person is taught how to deal with painful emotions without resisting the emotions, and there are a lot of nuanced ways that we do try to resist our own emotions, we can learn how to let go and let go of control of our own emotions and to experience the emotions as they are. we become free people because I'm not fighting anything. I'm not fighting out there and I'm not fighting my own internal world. Does that mean that I'm not bothered by sounds? Does that mean that sounds don't bother me? Not necessarily. However, I'm not spending time thinking about it and I'm not spending time getting stuck on it. So my mind is, I'm not worrying about it. And when I do feel uncomfortable, I'm able to move on from it and forget about it. And so that's how that process works. So that's kind of the therapy in a, I wouldn't say nutshell.

Adeel [55:23]: I gave a little- Yeah, no, that was good. No, thanks for going through that and the rationale and the background behind it. And that first step, you mentioned dialogue at a couple of points. Is there like a kind of a script or playbook or decision tree that you give the person to kind of think through or do you give them some general- Is there a character that they, I'm just curious kind of like what they think about when they're going through that.

Dr [55:51]: So there are some like useful tools that I try to use to help with that. Like, for example, I'll say like, let's try to imagine the person, whoever the trigger is, let's try to imagine that person in a year from now doing the same exact thing. And then I'll say, okay, think about that for a minute. Now let's think about that they'll be doing the same exact thing in two years. And then I just like slowly try to like build it up to just to help impress, to make it, make it a little less abstract. That's just one type of tool that we could use. And that kind of helps with the dialogue in the mind. There is no, there's no one structured way because people have different ways, like what their mind is telling them is different. But for the most part, I, it's kind of like a, teaching them how to respond. So like, for example, in a therapy session, I would have the client share what their mind is saying. What is going through your mind? And let's respond to that. And then, so it's kind of, it's more like choosing, teaching how to respond to each line that the brain says in the moment. When we're doing an exercise, we're engaging in the trigger and responding to the thought in a way that's consistent with the philosophy that we're trying to impress on the mind. And then I have them practice that every day in between sessions. Um, so it's kind of becoming like, it's, it's just like sort of that example of, of running up and down with, with the cup. Like it's just, it's, it's a, it's just a lot of repetition, a lot of repetition and, and also upping the difficulty as, as it, uh, as, as, as we go through it.

Adeel [57:51]: Gotcha. Yeah. And then, but going back, that's interesting. The, uh, um, asking them if. um in a year if they're going to still hear the sound or two years because going back to my original um well one of my um points earlier i think and you and you and you said that you know we have often two conflicting thoughts in our hands at the same time a lot of us know that some of these sounds are not going to go away we know that uh going back to that another analogy um that past uh the past is the predictor of the future we kind of know that logically um i guess you know if somebody's looking what do you say to people who are who are thinking that and say well i already know that so how are you going to help me kind of thing

Dr [58:34]: right so it's it's kind of like in the moment when they're when they're saying like ah it could be just like i can't handle this right so it could be like logically the the in between living in between it it's the it's not necessarily only knowing that um that like whether or not we know if the person is going to change or not, like we might know that the person is not going to change. But we also haven't made like the next step, which is like and this this is not something that I could get away from. In other words, like there's nothing that like it's almost like the brain could hold the idea that they're not going to change and. also like i somehow would be able to get away from this and that but that idea that idea that i could somehow get away from this is not a logical idea it's coming from i just don't want to be hurt so it sort of like becomes a default like the default um doctrine in the mind is like i can't take this and we and the if when we examine like why like okay you can't take this and but like what could we do about it like and it doesn't seem like there's what like we could We could we could escape from it temporarily. That's true. And that reinforces the sense that this is something that we could escape. So it's it's not necessarily like the belief, the like a sort of a clear like this is the story I have and this is how how I think things will change. It's kind of it's more on an emotional sense of like, I, I need to get I need to get away from this. And we're saying, like, but how how are we going to get away from this? And we kind of think about, well, there is no like i i guess the only way is to just be find a comfort zone which where i just want to feel normal and not triggered which is which makes total sense and when we take away that as well then that also takes away from the sense of there's no there's like nothing could change the situation so then we're kind of forced in this we're kind of forcing ourselves if we're if if we're willing to then deal with with the with the feelings themselves because i've i've i've developed the sense that nothing there's nothing out there that i could i i can't get away from this at all so you're you're right i think to your point it's it's it's not a um it's usually not like a clear sometimes it is sometimes it's just like uh there is what we would call like just like a straightforward belief system that this is something that could be changed. I actually find that to be pretty common pretty often that that individuals, there's a certain expectation that especially when someone is does kind of. Again, I don't think there's objective measures, but when someone does deviate somewhat from the norm of how someone, how people, you know, I don't want to use examples here, but there's, and that's the hard part. That's kind of, how do we learn to live with difficult people, right? So the way to think about... Like, on one hand, I mean, we do this on our relationships also. Like, someone is always late. Why can't you come on time? You know, like, it's just try to think about the hour, plan accordingly, and yet the person comes late again. So it looks like the person, like, there's this characteristic in the person. It looks like it's sort of a low-hanging fruit that we can get it to change, and yet it still keeps on eluding us.

Adeel [62:16]: and so it's sort of realizing that that's not really a low-hanging fruit it's actually kind of built in in a very deep way to how the person it's a manifestation of how the person thinks and feels right uh and maybe related to like um you know having conflicting thoughts at the same time but also your i think part of your the dialogue in your therapy um kind of made me think of uh like parts work in like ifs internal family systems um And I'm wondering if any of that informs this? Is that voice that's the illogical voice that's afraid of something, is that maybe a part that comes from the past? Or is it a part of you that's not necessarily broken, but is trying to warn you of something that is not a danger anymore? Or is that not in the scope of what you're trying to do here?

Dr [63:09]: No, Adeel, you're... I've been reading some stuff. You're educated. I'm loving these questions. This is great. Short answer is yes. I think IFS is a wonderful contribution to the world of psychology. world of mental health the idea of thinking about a person having different parts to them and realizing that they're all kind of part of one's makeup and to learn how to live with all parts of us um is uh just to kind of uh uh that that's in a short what i i mean i ifs is a very broad area but for the most part like people have painful parts We have good parts and we have parts that we don't like so much. And so this actually goes back to your question before about like, do we deal with that, the pain point? And the answer is yes. When we're doing the final step, the experiential acceptance or the second step of the therapy. What we often find is that's where we're going. Whatever feelings are there, they're going to present themselves. They're kind of they're there. So a big part of that step is teaching people to learn like these. Number one, these reactions. and the different types of feelings that are showing up inside. It's not just frustration. It's not just anger. There's often anxiety and there's often pain beneath. And that's kind of learning how to realize that that's part of you and that's okay. And so when we learn to make peace with all parts of us, whatever parts are being activated, That's what we're learning to kind of learn to live with. And so in that regard, it's very much, I would say, like IFS. I definitely draw. I don't have a strong background in IFS. It's sort of like... A lot of the therapies, when it gets deeper, when you get deeper into the therapies, you find there's a lot of overlap between the two. And I find IFS does a great job languaging the parts aspect, like realizing that this is just a part of you and it's okay to learn how to experience it. And specifically in the context of misophonia, we're only going to really learn to be okay with that part of us if we realize that there's no solution for it outside of us.

Adeel [65:47]: um and which includes um any form of avoidance trying to move away from the sound because then we're gonna we it kind of it impresses upon the mind that i could i could uh get away from this part of me gotcha and then when um let's say you someone's done uh gone through this therapy and treatment with you um like a year or two later are there like ongoing work that they do is there different ways that they when they're sitting in at dinner or whatever um is there like a um a way to think about sounds that's kind of more permanent or is this is your is your third do you find um after you know when somebody's completed your work with you that they can go out in the world and they're kind of like not noticing sounds and they don't have to think about it anymore

Dr [66:35]: It's a great question. What I find is that after, I would say a typical course of this therapy is between six months and a year. after by the time we're we're getting like towards the end of the therapy one of the positive indicators that i find is that the that way of thinking is much more instinctual so it's kind of like oh i don't like that but like there's nothing like moving through those steps in a more of a rapid instinctual way and and and being able to like again it's like like how do how do we you know we working with like an unpleasant co-worker who has like an uh like a little bit of a intense unpleasant let's just say like a personality that's hard to get along with like we could make peace with that it's still not necessarily pleasant being around that individual but we're not we just kind of like realize like this is just what it is the same the same is true here it's kind of like okay I don't like this and this is just the situation and it's not getting stuck on it it's just and and so the mind is not thinking about it the mind is and so sometimes what I do find and this is what I what I when I when I finish work when I conclude working with someone they know that when someone's very stressed out they're going to be more triggered um that's just and and it's not like just like we are more we get more easily frustrated from things that wouldn't bother us on on a regular day when we're more stressed out from something we're probably going to be more sensitive to sound and therefore it might require more of an f conscious effort to work through the sound so that's when usually that's when the work would be a little bit more conscious And it will require more of like kind of working through the steps. But but that's not that's just for life. Like, you know, it's kind of like once the brain learns about something, it's hard. The brain doesn't unlearn it. So the things that stress us out, usually they we could learn how to deal with them. But when we're very stressed out, they're still going to bother us. That that's and that's true for almost all forms of anxiety.

Adeel [69:00]: Gotcha. Okay, cool. I know we're running over an hour here. This has been a really interesting discussion. Maybe just a couple other questions that we can, I would love to get your kind of like final thoughts and stuff. But for someone who, are there certain types of, you know, obviously Misfun is pretty wide in terms of like types of triggers or types of people. Anything that I guess, if somebody was thinking about approaching you? Is there a type of misophonia or type of person that responds better to your therapies?

Dr [69:34]: So I would say I find that I think that there is, well, first of all, If someone's going through a lot of different things in their life, like they're already like their plate is like really full, is like brimming with like just stress from different parts of their life. I don't think that's the best time because we are putting ourselves out of the comfort zone. Like that's what's happening. And so it's important for someone to be in a place where they feel settled. They feel like they have, for the most part, their their life in order and this is just this is something that's important for them um it's it's also i would say all a person needs to succeed and this is this has been the recipe for success is that they want to go into the therapy in other words like if someone is is is dragging into therapy they are they are not going to succeed because they they're inherent you can't force willingness and a lot of this is willingness to experience to change how we think and feel about things and and and that's hard so if someone's being like you could you could physically drag someone to a therapy room but you can't physically force someone to be willing in their mind how to deal with their own uh their own world and so would say that that that that's all it requires is overall i would say being in a in a in a reasonably stable place in terms of just like life uh um and for each person that's different um so you you kind of have to know yourself um and and just a willingness like a commitment to being like look i i'm i wanna i I want to take this and I'll go with the – and I would say another piece, it's a good – now that you brought it up, it's kind of that example of like with the bathtub and filling up the bathtub. if we're looking to fill up the bathtub if we want to see that bathtub filled already so to speak we're going to be it's just going to be a very disappointing process it's it's sort of it's a commitment to the process itself to the just doing it time and time again it's like it's like it's like training you know it's like we're not going to see that six pack right away um and and if every time we look we're going to be disappointed because it takes time So it's a commitment to the process itself.

Adeel [72:15]: Gotcha.

Dr [72:16]: Okay. Interesting.

Adeel [72:18]: Yeah. Well, Ezra, it's been great to have you. Any kind of final, well, I'll see links and everything to your website and all that stuff. Anything else you want to share? Any new research that you've got coming out or findings or, yeah, closing thoughts for our listeners?

Dr [72:38]: um i mean i think that that we're living in my i just want to um this is my my sense from what i see um in my kind of like little world uh that that that and and it's been it's really uh humbling experience to be uh an ally to the the world of of individuals suffering from misophonia or as you as you call misophones yeah there's no there's no i think accepted word but i think yeah yeah uh and it it you know it's sort of like i you at you know five years ago you would have mentioned the word misophonia i would say uh but you know here here here here we are and it's it's uh it's an absolute um It's really humbling. And I think that I just want to share with all the listeners that I really, really believe that I know it's hard. People have been hurt by having hope and, you know, for getting better because there's just been so many disappointments in this. And we are at a very, in my opinion, we're seeing there's an explosion of interest in the world. There could always be more. And I have seen in my own eyes that there is hope and people could move on from misophonia. And I believe we're at the... at the beginning of the healing era for misophonia. And I believe it's only going to get better from here. So I just went into that note.

Adeel [74:22]: Thank you, Dr. Cowan, again. That was a long one, but it was great to really go deep into his thinking behind misophonia and his therapies. If you liked this episode, don't forget to leave a quick review or just hit the five stars wherever you listen to this podcast. You can hit me up by email at hellomissiphoniapodcast.com or go to the website, missiphoniapodcast.com. It's even easier to just send a message on Instagram at Missiphonia Podcast. Follow there or Facebook at Missiphonia Podcast. Twitter, we're Missiphonia Show. Support the show by visiting the Patreon at patreon.com slash missiphoniapodcast. Theme music is always by Moby. And until next week, wishing you peace and quiet.

Unknown Speaker [75:34]: Thank you.