I ask one to smile and he says he can't. I pause, allowing the silence to grow pregnant, then nod my head with a whimsical smile and ask, "C,mon. You can't smile?" I knit my brow, perplexed. "Do you have a neurological deficit?
No? Then you don't want to smile?"
My patients appear annoyed, as though they were about to say, "Leave me alone. I don't want to smile." But they do want to smile. My little pre-schooler acts the same way when he's miffed. I joke with him and he flickers between laughing, smirking and frowning. The patients are stuck in old patterns of inhibition that prevent them from opening up to good feelings when they want to.
It's so common for people to be uncomfortable expressing their feelings. John Perry describes how anorgasmic women are comfortable having orgasms masturbating with their legs closed, but become anxious when they spread their legs.
He teaches them to masturbate with their legs spread so they become comfortable with the position.
Here's how I work with smile resisting patients: I suggest, "You do want to smile, don't you? Let me show you how."
At that point, I demonstrate an exagerated smile. Or I'll tell a joke or threaten tickling (if it's a group.) So far, this effort has never failed. Every patient smiles and usually laughs spontaneously. Part of the reason my little trick works is because there are two nerve pathways which control the smile and other facial expressions. The upper nerve pathway is connected to the gray matter motor cortex of our brain. When we decide we want to smile and think "smile," then the motor cortex activates our smile via the upper nerve pathway. Stroke patients with damage to their motor cortex lose the ability to voluntarily turn on a smile, though some smile rehabilitation physical therapy can help.
But even after a stroke, patients with the lower smile pathway still intact will reflexively smile in response to something funny or ticklish, because the lower pathway is connected to the lower part of the brain, where emotions are mediated and where the stress and emotion mediating sympathetic nervous system is controlled. I get my patients to smile and laugh by bypassing their voluntarily or subconsciously disconnected upper smile pathway. I've tickled their lower smile pathway into activation by turning on synthetic smiles that activate the PE physiological response pattern, allowing them to feel the real thing.