Do you ever go home at the end of the day feeling wiped out? How often do you finish a treatment session with a client and feel drained? Do you have a boss or co-worker that you dread interacting with and feel like you need to “put on a happy face” when around them?

The drain that accompanies “putting on a face” at work is known as emotional labor. The sense of effort that one applies to meet an expected expression of emotion is real, and if not done properly, can be costly to an individual and the organization.

Emotion management is the process by which we regulate our emotions to meet the social demands of the moment. We do it with patients, co-workers, and with people in nearly all social interactions. The truth is it takes energy to engage with people. But how can we turn off the drama drain and refill our own capacity to meaningfully engage with patients? Let’s start by diving into our circuitry.

We are wired to connect

As social animals, our nervous system and brain are configured to connect with other people. Matt Lieberman, a social scientist and author of Social: Why Our Brains Are Wired to Connect, explains that, because of the critical importance of relationships, we have brain circuitry that allows us to “feel” what others are feeling (the mirror system) and create a story about why they are feeling that way (mentalizing). To truly understand emotional labor and patient engagement we must understand these basics of human engagement.

The mirror neuron system lets us feel others by replicating or mirroring the emotional expression of others. For example, when we see someone smile, we have an automatic tendency to replicate the action. In most face-to-face communication we “feel” the other’s emotional stance through simulation in our own nervous systems. Whereas the mentalizing system allows us to create a theory about why someone is feeling or behaving in a certain way. We use these systems all the time to navigate the complexities of social interactions and our relationships.

The fundamentals of emotional labor

The concept of emotional work was first introduced by A.R. Hochshild (1983, p. 7 of The Managed Heart) who defined it as “the management of emotion to create a publicly observable facial and body display.” The term emotional work has been used to describe emotional management within personal interactions.

Emotional labor, however, applies specifically to work where individual and team performance can be impacted by the emotional health of the organization. Morris and Feldman (1996) define emotional labor as “the effort, planning, and control needed to express organizationally desired emotions during interpersonal transactions.”

Work environments—especially in healthcare—have expectations that employees present themselves with an open and cheerful disposition. Patients prefer to experience people who are cheerful and welcoming when greeted at the front desk. They want therapists who are emotionally available, empathetic, encouraging, positive, and enthusiastic about their work.

Emotional “acting”

In the event that an employee does not actually feel these things, they will instead attempt to meet these expectations by managing their emotions or “acting.” They will regulate their emotions in one of two ways: surface acting or deep acting.

Surface acting is regulating the expression of emotions. For example, a therapist may try to suppress the emotion of working with a “difficult patient,” one who is chronically late or not compliant, with surface acting or emotion suppression techniques. Rather than outwardly expressing frustration, they work to present a calm, neutral facial expression in front of the patient.

Deep acting is a process of changing an emotion by changing how one views the situation. Rather than suppressing the expression of the emotion, they change the emotion by cognitively reframing or reappraising the situation. A deep-acting technique requires the capacity to think differently about the difficult patient. I often coached clients to be “curious, not furious,” by being mindful of any challenges the patient might be facing.

Emotional alignment at work

Therapists and clinic leaders are beginning to recognize the tremendous value of having an atmosphere of positive emotion in the workplace. Even patients value the “good feeling,” as the atmosphere in the clinic can have a direct impact on patient satisfaction and subsequent clinical outcomes.

But what happens if there is a gap between what’s emotionally expected and an individual’s actual emotional experience? Excessive emotional labor in healthcare providers can lead to depression and create a proverbial “drama drain.” There is clear evidence that suppression of emotion is unhealthy. While we often choose to “fake it” with colleagues or patients, the cost of doing so too often is significant and a major contributor to burnout.

Healthy organizations are characterized by the degree of alignment between the authentic feelings of individual employees and the expected emotional expression of the organization. When aligned, performance increases in almost every key performance indicator: employee satisfaction, patient satisfaction, clinical outcomes, etc.

How to repair misalignment

Step 1: Identify gaps.

The easiest way to identify a gap is to see it in the numbers. Regularly ask your employees for feedback on the work environment at your organization, whether through anonymous surveys, annual reviews with managers, or whatever works for your team. Successful business leaders are increasingly conducting quantitative and qualitative measures of their culture. However, getting honest feedback first requires a culture that values psychological safety and where employees feel safe to express their true feelings.

Step 2: Create a culture of connection.

High-performing teams create a culture of connection by providing clear ways for employees to connect with each other and their managers. There is a range of ways to accomplish this.

One example is the recently crowned NCAA Football national champions, the Georgia Bulldogs, who worked with a sports psychologist to implement “skull sessions.” During the sessions, players would explore their “why” and other topics to define their personal motivation and the team’s DNA. This approach may not work with your clinical team, but there are a variety of ways to explore connection and ensure emotional alignment across a team in a way that decreases the negative effects of emotional labor.

Step 3: Nurture your team’s emotional performance.

We can decrease the weight of emotional labor by teaching relationship-centered skills. While most of our continuing education dollars are spent on the technical skills of being a therapist, successful organizations are recognizing the value of learning “soft skills” that raise the “emotional performance” of an individual and organization. More than just communication skills, they include emotion regulation, interpersonal emotion regulation, empathy, awareness, and resilience.

Alignment clears the drain

Emotions are an essential part of the work experience. Our nervous systems are designed with emotion systems that inform us and connect us. Individual and organizational success depends upon an environment where employees and patients “feel” a positive, encouraging, and compassionate atmosphere. And the degree to which an individual must “labor” to express these emotions is an indicator of the overall health of an organization.


About the author: John Woolf, PT, MS, ATC is a Ph.D. candidate in performance psychology. As CEO of Patient Success Systems, he consults with leaders and teaches Relationship-Centered Care™ to healthcare organizations.


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