A l e x i t h y m i a a n d Psychotherapy* H E N R Y

K R Y S T A L , M . D . t | East Lansing,

Michigan

Alexithymia represents a disturbance in affective and cognitive function which overlaps diagnostic categories. Emotions are not differentiated, and are poorly verbalized. Imagination related to drive fulfillment is limited. These and other problems seriously interfere with the patients' capacity to benefit from dynamic, uncovering or ''anxiety-producing" psychotherapy. In order to consider possible remediation of the problem, we must explore the nature and causes of this disturbance. INTRODUCTION O v e r t h e last 15 years, t h e r e has b e e n a n a c c u m u l a t i o n o f studies a n d o b s e r v a t i o n s o f a n affective a n d c o g n i t i v e d i s t u r b a n c e w h i c h S i f n e o s has c a l l e d " a l e x i t h y m i a . " T h i s c o n d i t i o n o v e r l a p s d i a g n o s t i c categories. I t occurs c o m m o n l y i n p s y c h o s o m a t i c p a t i e n t s , - i n s u b s t a n c e - d e p e n d e n t p a t i e n t s , a n d i n severe p o s t t r a u m a t i c states. 1

2

4,5

3

6

T h e o c c u r r e n c e o f a l e x i t h y m i c characteristics i n a p a t i e n t ' s m e n t a l l i f e creates serious l i m i t a t i o n s as t o his capacity t o u t i l i z e p s y c h o a n a l y t i c p s y c h o t h e r a p y , t h u s p r e c l u d i n g o r g r e a t l y d i m i n i s h i n g t h e chances o f success w i t h i t . I n t h i s a r t i c l e , I w i l l r e v i e w t h e n a t u r e o f t h e d i f f i c u l t i e s one encounters a n d consider the possibility o f m o d i f y i n g the t h e r a p e u t i c t e c h n i q u e s i n o r d e r t o i m p r o v e t h e i r effectiveness w i t h these p a t i e n t s . A L E X I T H Y M I A : A D E S C R I P T I O N AND

DEFINITION

A l e x i t h y m i c i n d i v i d u a l s have d i s t u r b a n c e s i n : (1) a f f e c t i v e f u n c t i o n s ; (2) c o g n i t i v e f u n c t i o n s ; a n d (3) t h e n a t u r e o f t h e i r self- a n d o b j e c t representations: 1. Affective disturbance: T h e m o s t c o n s p i c u o u s p r o b l e m is t h e i m p a i r m e n t o f these p a t i e n t s i n t h e r e c o g n i t i o n a n d u t i l i z a t i o n o f e m o t i o n s as signals t o themselves. T h e y a r e u n a b l e t o d i s t i n g u i s h b e t w e e n o n e e m o t i o n a n d a n o t h e r , a n d , i n f a c t , e x p e r i e n c e u n d i f f e r e n t i a t e d affect responses. Since specific e m o t i o n s such as a n x i e t y o r d e p r e s s i o n o f t e n * P r e s e n t e d at t h e F o u r t e e n t h N a t i o n a l Scientific M e e t i n g o f the A s s o c i a t i o n f o r t h e A d v a n c e m e n t o f P s y c h o t h e r a p y , A t l a n t a , G e o r g i a o n M a y 7, 1 9 7 8 . * T h i s p r o j e c t w a s s u p p o r t e d i n p a r t by f u n d s f r o m N I H B i o m e d i c a l R e s e a r c h S u p p o r t G r a n t o f the M i c h i g a n State U n i v e r s i t y C o l l e g e o f O s t e o p a t h i c M e d i c i n e G R S 7 1 - 0 6 7 1 . f P r o f e s s o r o f P s y c h i a t r y , D e p a r t m e n t o f P s y c h i a t r y , M i c h i g a n State U n i v e r s i t y . Mailing address: 7 0 2 N o r t h l a n d M e d i c a l B u i l d i n g , S o u t h f i e l d , M I 4 8 0 7 5 . A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol.

17

X X X I I I , No.

1, J a n u a r y

1979.

18

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

f a i l t o m a n i f e s t themselves, t h e p a t i e n t s o f t e n c a n n o t t e l l w h e t h e r t h e y a r e sad, t i r e d , h u n g r y o r i l l .

Occasionally

some become aware o f a

v a g u e p h y s i c a l distress i n s i t u a t i o n s w h e r e a n e m o t i o n a l r e s p o n s e w o u l d be e x p e c t e d , o t h e r s t e n d t o o v e r l o o k e v e n p h y s i o l o g i c a l aspects o f e m o t i o n s s u c h as p a l p i t a t i o n s o r "queasiness i n t h e s t o m a c h . "

Alexithymic

i n d i v i d u a l s generally are unable to p u t t h e i r emotions i n t o w o r d s , a n d o f t e n a r e n o t a w a r e o f t h e i r a f f e c t i v e responses e v e n i n s i t u a t i o n s w h i c h o n e w o u l d e x p e c t t o be v e r y d i s t u r b i n g t o t h e m . W h e n a l e x i t h y m i c p a t i e n t s d o m e n t i o n h a v i n g a f e e l i n g a n d are q u e s t i o n e d a b o u t i t , t h e y a r e g e n e r a l l y n o t able t o d e s c r i b e w h a t t h e y are experiencing.

S c r u t i n y reveals t h a t , l i k e t h e c o l o r - b l i n d p e r s o n ,

they

have b e c o m e a w a r e o f t h e i r d e f i c i e n c y a n d h a v e l e a r n e d t o p i c k u p clues by w h i c h t h e y i n f e r w h a t t h e y c a n n o t d i s c e r n .

However, like the color-

b l i n d , t h e y are m i s s i n g a q u a l i t y i n t h e i r e x p e r i e n c e . W h a t emotions

t h e y c a n e x p e r i e n c e i n t o t a l i t y varies

considerably,

b u t t h e r e is u s u a l l y a " g r e y a r e a " o f vagueness a n d c o n f u s i o n i n w h i c h t h e affects r e m a i n u n d i f f e r e n t i a t e d a n d u n v e r b a l i z a b l e .

These patients

a r e u n e a s y a b o u t t h e i r a f f e c t i v e d i s t u r b a n c e b u t t h e i r r e c o g n i t i o n o f i t is vague.

O n l y w h e n questioned do they become clearly aware that they

are n o t able t o d e s c r i b e t h e i r e m o t i o n s a w a r e o f p h y s i c a l sensations.

a n d t h a t at best t h e y b e c o m e

A m o n g the psychosomatic patients i n this

g r o u p , t h e r e a p p e a r s t o be a g r e a t e r t e n d e n c y t o a l a c k o f awareness o f autonomic

nervous

system

responses associated w i t h

r e s p o n s e is o f t e n a c c o m p a n i e d b y g r e a t s t o i c i s m .

affects.

This

A m o n g the substance-

d e p e n d e n t p a t i e n t s t h i s p a t t e r n is less c o m m o n — i n s t e a d ,

t h e r e is a n a l -

m o s t h y p o c h o n d r i a c a l f e a r o f t h e p h y s i o l o g i c a l aspects o f e m o t i o n s a n d an inclination to block

them.

Patients i n b o t h g r o u p s m a y s h o w a

d i m i n u t i o n o f m i m e t i c a n d e x p r e s s i v e m o v e m e n t s o f t h e face a n d b o d y w i t h a r e s u l t i n g stone-face e x p r e s s i o n a n d w o o d e n stiffness o f p o s t u r e . The

final

characteristic p a t t e r n involves s u d d e n outbursts o f w h a t

a r e a s s u m e d t o be s t r o n g e m o t i o n s : a b r u p t l y as t h e y s t a r t .

f o r i n s t a n c e rages w h i c h cease as

T h e subject is n o t q u i t e s u r e w h e t h e r h e r e a l l y

feels w h a t he seems t o be e x p r e s s i n g , a n d o f t e n confesses t h a t h e d i d i t " f o r s h o w " t o c o n v i n c e h i m s e l f t h a t he f e l t s o m e t h i n g , o r t h a t h e g o t " c a r r i e d away w i t h his o w n o r a t o r y . " marked

i n those

patients

in whom

T h i s c h a r a c t e r i s t i c is especially "addictive"

patterns are

more

s i g n i f i c a n t ; t h e y t e n d t o b e h a v e as i f t h e y s u d d e n l y s w i t c h e d t o a n o t h e r personality—eventually they abandon it w i t h equally startling dispatch. 2. Cognitive disturbance: B e s i d e t h e p a t i e n t s ' i n c a p a c i t y t o v e r b a l i z e their emotions

a n d t o d e s c r i b e t h e i r sensations i n r e s p e c t t o

responses, t h e r e is a b r o a d e r p r o b l e m as w e l l .

affective

These patients, w h o are

o f t e n f u n c t i o n i n g v e r y successfully i n t h e i r w o r k seem t o be

"super-

adjusted to reality."

superb

G e t t i n g past t h e s u p e r f i c i a l i m p r e s s i o n o f

19

ALEXITHYMIA AND PSYCHOTHERAPY

f u n c t i o n i n g , o n e discovers a s t e r i l i t y a n d m o n o t o n y o f ideas a n d severe impoverishment of their imagination.

T h e patient's t h o u g h t s t u r n o u t

t o be c o m p o s e d o f t r i v i a l details o f t h e i r e v e r y d a y l i f e , a n d t h e y seem t o be d e v o i d o f t h e capacity t o get b e y o n d t h e i r m u n d a n e

preoccupations.

T h i s c h a r a c t e r i s t i c c o g n i t i v e style has b e e n c a l l e d " p e n s é e o p é r a t o i r e " b y Marty and deM'Uzan,

7

i m p l y i n g t h a t " o p e r a t i v e t h i n k i n g " takes o v e r at

the expense o f the symbolic or imaginative type.

These patients show a

m a r k e d i m p a i r m e n t i n t h e i r c a p a c i t y f o r c r e a t i v i t y , especially i n r e g a r d to d r i v e g r a t i f i c a t i o n fantasy. S i m i l a r l y absent a r e wishes o r d r i v e s . " poor;

flat

8

T h e i r use o f s y m b o l s is e q u a l l y l i m i t e d .

"thoughts

relating to inner attitudes,

As d e M ' U z a n

9

feelings,

p u t s i t : " T h e p a t i e n t ' s l a n g u a g e is

a n d banal, glued to the present a n d only p r o d u c i n g

facts

stated c h r o n o l o g i c a l l y . " ( p g . 4 6 2 ) As an example

o f their problems

i n t h e c o g n i t i v e s p h e r e is t h e

d i f f i c u l t y they have i n w o r k i n g w i t h dreams i n psychotherapy. patients

report

manifest

dreams

contents

only

rarely, and

are characterized

when

These

they recall one

by exceptional

simplicity.

d r e a m s a r e u s u a l l y l i m i t e d t o a f e w s i m p l e sentences.

its The

W h e n asked to

associate t o e l e m e n t s o f t h e d r e a m , t h e p a t i e n t s a r e c o m p l e t e l y u n a b l e t o d o so.

When

dream.

This

alexithymia.

p r e s s e d , t h e y o b l i g e by f u r n i s h i n g m o r e details o f t h e characteristic

response

represents

a r e l i a b l e test

for

I t i l l u s t r a t e s these i n d i v i d u a l s d i m i n i s h e d a b i l i t y t o f o r m

fantasies a n d t h a t t h e i r associations a r e , as N e m i a h a n d Sifneos s a i d : "Stimulus bound rather than drive determined." 3. Self-

and

object representation:

8

( p . 159)

Associated

with

the

dead-pan

e x p r e s s i o n , r i g i d stance, a n d " o p e r a t i v e t h i n k i n g " o n e finds a n u n u s u a l detachment

f r o m e x t e r n a l objects, as w e l l as f r o m " a n y t r u l y alive i n -

ternal object r e p r e s e n t a t i o n . "

1 0

( p . 445)

T h e patients show little affec-

tionate interest i n the therapist, a n d treat an interviewer w i t h cool detachment

and

indifference.

Such

p a t i e n t s ' attentiveness

selves, i n c l u d i n g t h e i r b o d y a n d h e a l t h is e q u a l l y p o o r .

to their

They

often

s h o w gross n e g l e c t o f t h e i r w e l f a r e a n d i m p a i r m e n t i n t h e i r capacity f o r self-care.

11

McDougall

w h i c h characterizes

1 0

c o m m e n t s o n the q u a l i t y o f stony deadness

these p a t i e n t s ' a t t i t u d e t o t h e m s e l v e s as w e l l as t h e

w o r l d at l a r g e a n d t h a t i t is a f o r m o f n u m b n e s s d e s i g n e d t o b l o c k p a i n by b e c o m i n g a "lonely i s l a n d . " rock.

" O n e w a y o u t is t o t u r n o n e s e l f i n t o a

T h u s m a n y psychosomatic patients continue o n t h e i r u n w a v e r i n g

t i g h t r o p e , i g n o r i n g t h e b o d y ' s signs a n d t h e m i n d ' s distress

signals."

( p . 458) ALEXITHYMIA AND

PSYCHOTHERAPY

I n discussing a p a t i e n t w h o h a d a peptic ulcer a n d h y p e r t e n s i o n , w h o a f t e r a c o r o n a r y t h r o m b o s i s b e c a m e obese, a n d w h o s h o w e d n o f e e l i n g s

20

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

or involvement w i t h people, Sifneos therapy,

which

requires

1 2

said: " p s y c h o d y n a m i c

a patient to interact emotionally

psychowith

his

t h e r a p i s t is, i n m y o p i n i o n , c o n t r a i n d i c a t e d f o r s u c h i n d i v i d u a l s , because w h a t a p p e a r s as d e n i a l o f e m o t i o n s , is a n absence o f f e e l i n g s . t r e a t m e n t tends to lead to f r u s t r a t i o n .

Such a

I n m y patient, i t may have aggra-

v a t e d his p e p t i c u l c e r o r f u r t h e r e l e v a t e d his b l o o d p r e s s u r e .

I t is also

possible t h a t i t m i g h t give rise t o a n o t h e r h e a r t a t t a c k i n t h e f u t u r e . " ( p . 154) I d i s a g r e e w i t h t h e absolute c o n t r a i n d i c a t i o n as s t a t e d b y Sifneos. I w i l l t r y to show i n this article that w i t h certain modifications, alexithymic individuals

can

benefit

from

psychotherapy.

Additionally,

since

a l e x i t h y m i c characteristics a r e w i d e l y p r e v a l e n t a m o n g p a t i e n t s w h e n we treat for

p r i m a r i l y neurotic or characterological

problems,

we

must

l e a r n h o w t o d e a l w i t h t h e n e g a t i v e e f f e c t w h i c h t h i s p r o b l e m has o n t h e outcome o f treatment i n general.

L e t us t h e n c o n s i d e r s o m e o f t h e

p r o b l e m s w h i c h h a v e t o be f a c e d : 1. The nature of the transference: A l e x i t h y m i c p a t i e n t s o f t e n s h o w a n aloofness b o r d e r i n g o n i n d i f f e r e n c e ; n o t c o n t e m p t o r a n g r y r e j e c t i o n , but virtual failure to interact emotionally w i t h the therapist.

This, of

c o u r s e , is t y p i c a l o f t h e w a y t h e y r e l a t e t o e v e r y o n e a r o u n d t h e m . emotions

are h a r d l y available f o r o b j e c t - c h o i c e o r h u m a n

Their

relatedness.

I n t h e sense t h a t t h i s r e a c t i o n r e p r e s e n t s t h e i r c h a r a c t e r i s t i c p a t t e r n o f o b j e c t - e x p e c t a t i o n s a n d r e l a t e d n e s s , t h i s is a t y p e o f t r a n s f e r e n c e .

The

p a t i e n t s " g i v e us a t r y " w i t h o u t m u c h h o p e o r e v e n d o u b t r e g i s t e r i n g . These low-intensity expectations forestall the emergence o f a felt e m o tion o f disappointment or resentment.

T h e l i m i t a t i o n i n t h e i r capacity

o f i m a g i n a t i o n prevents the elaboration o f lively transference as e n c o u n t e r e d

i n other patients.

fantasies

These patients do f o r m , however,

c e r t a i n types o f t r a n s f e r e n c e s w h i c h p e r m i t us t o o b s e r v e t h e n a t u r e o f t h e i r self- a n d o b j e c t - r e p r e s e n t a t i o n s .

I n t r a n s f e r e n c e , t h e y assume t h e

p a t i e n t r o l e a n d e x p e c t us t o c u r e t h e i r p r o b l e m s o n t h e m e d i c a l m o d e l o f transaction.

T h i s r e s p o n s e shows a c e r t a i n l i t e r a l n e s s a n d lack o f

imagination, and it probably contributes to Sifneos' a r e best l e f t t o t h e c a r e o f a n i n t e r n i s t .

1 3

feeling that they

A n examination o f this attitude

o n t h e p a r t o f t h e p a t i e n t shows t h a t i t is a t r a n s f e r e n c e o f t h e r e c e p t i v e infantile frame of m i n d . O n l y i n c o n f r o n t i n g t h e i r o r a l a n d narcissistic o r i e n t a t i o n w h i c h i n cludes a "deficiency t h e o r y " o f t h e i r p r o b l e m s , crepancy i n t h e i r affective posture. t h e sense t h a t w e see i t i n t h e n e u r o t i c .

1 1

d o we d i s c o v e r t h e d i s -

T h i s aloofness is n o t d e f e n s i v e i n I t represents an emotional p r o b -

l e m so e n t r e n c h e d a n d p r o f o u n d t h a t i t a p p e a r s as i f these p a t i e n t s w e r e t r u l y "affectless."

However, i f we were to measure all o f t h e i r physio-

l o g i c a l responses, w e w o u l d d i s c o v e r " e x p r e s s i v e " aspects o f

emotion

ALEXITHYMIA AND PSYCHOTHERAPY

present.

21

T h u s we a r e d e a l i n g w i t h a n u n i q u e d i s t u r b a n c e w h i c h w i l l r e -

q u i r e specialized p s y c h o t h e r a p e u t i c Taylor

1 4

approaches.

has d e s c r i b e d t h e d i f f i c u l t a n d p a i n f u l c o u n t e r t r a n s f e r e n c e

r e a c t i o n s w h i c h , n o d o u b t , c o n t r i b u t e t o t h e u n p o p u l a r i t y o f these k i n d s o f patients.

H e related experiencing "boredom which w h e n indulged

leads t o a s l i g h t d i s s o c i a t i o n a n d [ h i s ] d r i f t i n g o f f i n t o m i x e d sadistic a n d e r o t i c fantasies. S o m e t i m e s [ h e ] e x p e r i e n c e d i n t e n s e f e e l i n g s o f d e s p a i r a n d helplessness w h i c h p e r s i s t e d b e y o n d t h e t h e r a p y h o u r a n d o f t e n i n t o t h e w e e k e n d . " ( p . 144)

T a y l o r d e m o n s t r a t e s t h a t these c o u n t e r -

t r a n s f e r e n c e r e a c t i o n s c a n be u t i l i z e d p a r t i c u l a r l y i n those p a t i e n t s i n w h o m t h e i r i n a b i l i t y t o v e r b a l i z e t h e i r e m o t i o n s (especially

aggressive

ones)

choice

have

a

defensive

element.

Thus,

as

usual, the

of

p s y c h o t h e r a p y strategies w i l l be g u i d e d b y t h e t h e r a p i s t ' s u n d e r s t a n d i n g o f t h e u n c o n s c i o u s aspect o f t h e t r a n s f e r e n c e s a n d c o u n t e r t r a n s f e r e n c e s w h i c h w i l l s u p p l y t h e m i s s i n g c o g n i t i v e aspects o f a f f e c t . 2. Affective problems: T h e p a t i e n t s w h o d o n o t e x p e r i e n c e t h e c o g n i tive aspects o f t h e i r e m o t i o n s s i m u l t a n e o u s l y w i t h t h e e x p r e s s i v e aspects f a i l t o o b t a i n a sense o f aliveness a n d c o n v i c t i o n a b o u t t h e i r o b j e c t r e l a tions.

Since t h e y d o n o t h a v e a f f e c t i v e signals t o g u i d e t h e m i n t h e

choices, t h e y have t o d e p e n d o n r e a s o n i n g . A t t e m p t s at s e l f - o b s e r v a t i o n e n d u p i n " m a y b e " o r " I a l m o s t f e e l " o r " i t is as i f " w i t h o u t g e n u i n e c o n viction or experience.

A s l o n g as t h i s s i t u a t i o n persists, i t is m o s t u n -

l i k e l y t h a t s u c h a p a t i e n t w i l l be able t o u t i l i z e his e m o t i o n s as signals t o himself.

N e i t h e r can he experience the psychotherapeutic

discoveries

w i t h a n i n t e n s i t y o f passion f o r w h i c h h e l o n g s , a n d w h i c h is necessary t o a c c o m p l i s h a c h a n g e i n t h e n a t u r e o f his psychic r e a l i t y . H o w e v e r , as S i f n e o s

12

p o i n t e d o u t as psychotherapy puts the patients in

positions which would otherwise evoke an emotional reaction, it produced an increment in the physiological aspects of emotions.

T h i s m e a n s t h a t i n psy-

c h o s o m a t i c p a t i e n t s t h e illness is l i k e l y t o get w o r s e .

Also, predictably,

t h e i n t e n s i f i c a t i o n o f t h e a f f e c t - r e l a t e d v i s c e r a l a n d s o m a t i c responses i n the individuals p r o n e to addictive mechanisms, m i g h t drive t h e m to the use o f d r u g s t o b l o c k these sensations. A n o t h e r aspect o f t h e a f f e c t i v e d i s t u r b a n c e w h i c h m i l i t a t e s a g a i n s t the

success

of

psychoanalytic

psychotherapy

with

the

p a t i e n t s is t h e i m p a i r m e n t i n t h e i r capacity f o r m o u r n i n g .

alexithymic Although

t h e i r e m o t i o n a l a t t a c h m e n t t o objects is g r e a t l y i m p o v e r i s h e d i t is n o t possible f o r t h e m t o r e n o u n c e t h e i n f a n t i l e v i e w o f t h e m s e l v e s a n d o f t h e i r l o v e objects, unless t h e y f i r s t b e c o m e able t o g r i e v e e f f e c t i v e l y .

In

a v e r y c o n c r e t e w a y , t h e a l e x i t h y m i c state m a y be v i e w e d as a s t a l e m a t e i n w h i c h t h e i n d i v i d u a l s r e t r e a t t o a w o r l d o f s h a d o w s , y e t c l i n g t o these stubbornly. T h i s b r i n g s m e to the question o f w h e t h e r some modifications o f

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

22

t e c h n i q u e a r e possible t o m a k e p s y c h o t h e r a p y h e l p f u l a n d u s e f u l t o t h e a l e x i t h y m i c , o r d o we have t o give u p o n a l l t h e p a t i e n t s w h o s h o w those characteristics?

H o w e v e r , b e f o r e w e can c o n s i d e r t h i s q u e s t i o n , we have

t o search f o r a t h e o r y o f t h i s c o n d i t i o n w h i c h w o u l d give us a r a t i o n a l e for exploratory modifications i n treatment approaches. THEORETICAL FORMULATIONS A c o u p l e o f o r g a n i c defects have b e e n p o s t u l a t e d t o e x p l a i n t h e cognitive a n d affective problems i n a l e x i t h y m i a . H o p p e that

there

is

hemispheric

a

"functional commisurotomy,"

blocking.

" I t causes

an

i.e.

1 5

a

has p r o p o s e d strong

impoverishment

of

inter-

dreams,

fantasies, a n d s y m b o l s , as w e l l as a h y p e r c a t h e x i s o f g e s t a l t — a n d b o d y r e p r e s e n t a t i o n s i n t h e r i g h t h e m i s p h e r e w h i c h n o l o n g e r c a n be v e r balized.

A r e s o m a t i z a t i o n o f a f f e c t is t h e e n d r e s u l t . " ( p . 240)

Nemiah

1 6

has c a r e f u l l y d i s t i n g u i s h e d t h e d i s t u r b a n c e s o f a l e x i t h y m i a

f r o m denial and isolation.

H e p o i n t e d out that the coincidence o f the

affective a n d cognitive disturbance i n the p o p u l a t i o n o f psychosomatic p a t i e n t s was a d i s t i n c t a n d separate p i c t u r e w h i c h d i d n o t r e s p o n d psychotherapeutic efforts. in

the

compulsive

components

are

patients are

clearly

to

I t s h o u l d be stressed t h a t t h e affects i s o l a t e d differentiated, and

verbalized,

i n contrast

to

their the

cognitive

alexithymic

patients. N e m i a h p u r s u e d an idea o f M a c L e a n ' s

about the possibility o f

1 7

b l o c k i n g o f impulses f r o m the "visceral" (or "emotional") b r a i n to the cortex.

E l a b o r a t i n g this p o s s i b i l i t y , N e m i a h

alexithymia represents

1 6

advanced

the view that

" t h e o b v e r s e o f s c h i z o p h r e n i a " ( p . 145)

The

locus o f t h e d i s t u r b a n c e is t h o u g h t t o be t h e p a l e o s t r i a t a l d o p a m i n e r g i c tracts. from

S o m e h o w , t h e y excessively d a m p e n ( o r f a i l t o a m p l i f y ) i m p u l s e s t h e l i m b i c system t o t h e c o r t e x .

Since b o t h o f these possible

defects c o u l d be f u n c t i o n a l , these t h e o r i e s d o n o t p r e c l u d e o u r search f o r p s y c h o d y n a m i c causes o f t h e p r o b l e m .

T h i s v i e w is c o m p a t i b l e w i t h

t h e t h e o r y t h a t t h e r e is a p r i m a r y o r i n b o r n , o r g a n i c a l l y based f o r m , as w e l l as a s e c o n d a r y o r a c q u i r e d f o r m o f a l e x i t h y m i a w h i c h is s u p p o r t e d by studies o n t w i n s . our

1 8

psychodynamic

I t is t h e a c q u i r e d f o r m t h a t w o u l d be r e l a t e d t o considerations

both

in regard

to etiology

and

chances o f i m p r o v e m e n t . T h e Paris g r o u p o f psychoanalysts w h o have s t u d i e d p s y c h o s o m a t i c p r o b l e m s f o r years has c o n t r i b u t e d m a n y ideas w h i c h n o t o n l y s h e d l i g h t o n a l e x i t h y m i a b u t w i l l also h a v e a n i m p o r t a n t i m p a c t o n p s y c h o a n a l y t i c theory.

McDougall

these ideas.

1 0

has f o r m u l a t e d s o m e o f t h e m o s t c h a l l e n g i n g o f

She sees t h e basic d i s t u r b a n c e i n d e c a t h e x i s

of benign

r e p r e s e n t a t i o n o f t h e m a t e r n a l l o v e o b j e c t , as w e l l as one's o w n b o d y . " T h u s i n s t i n c t u a l i m p u l s e s , w h e t h e r aggressive o r l i b i d i n a l , r u n t h e r i s k

23

ALEXITHYMIA AND PSYCHOTHERAPY

o f n o t g a i n i n g representation i n the early f r a g m e n t e d elements o f ' f a n tasy,' w h i c h m i g h t be s u p p o s e d t o a c c o m p a n y i n s t i n c t u a l i m p u l s e s , are t h u s n o t s t o r e d i n ways w h i c h a l l o w t h e m t o evolve i n t o t h e m a t e r i a l o f n e u r o t i c f a n t a s y c o n s t r u c t i o n . " ( p . 454) McDougall's

1 0

e x p l a n a t i o n f o r t h e f a i l u r e o f these p a t i e n t s t o d e v e l o p

some f u n c t i o n s — s u c h as t h e capacity t o t a k e care o f t h e m s e l v e s is t h a t t h e y h a v e f a i l e d t o f o r m s y m b o l i c o b j e c t r e p r e s e n t a t i o n s o r w h a t we w o u l d r e f e r t o as " b e n i g n i n t r o j e c t s . "

She e x p l a i n s t h e a d d i c t i v e p r o b -

lems o f these p a t i e n t s as a t t e m p t s "to make substitute objects in the external world do duty for symbolic ones which are absent or damaged in the inner psychic world" ( p . 4 4 9 , M c D o u g a l l ' s italics).

As f o r the affective a n d cognitive

p r o b l e m , she e x p l a i n s : Instead o f some f o r m o f psychic management o f disturbing affects or unwelcome knowledge or fantasies, the ego may achieve complete destruction o f the representations or feelings concerned, so that these are not registered. T h e result then may be a super-adaptation to external reality, a robot-like adjustment to inner and outer pressure which short-circuits the w o r l d o f the imaginary. This "pseudo-normality" is a widespread character trait and may well be a danger sign p o i n t i n g to the eventuality o f psychosomatic symptoms, (p. 444, McDougall's italics). M c D o u g a l l ' s v i e w o f these p a t i e n t s can be s u m m e d u p i n t h e w a y she c h a r a c t e r i z e d t h r e e o f h e r p a t i e n t s : " A l t h o u g h p h y s i c a l s e p a r a t i o n was a c h i e v e d , t h e r e was a f u n d a m e n t a l lack o f a n y i d e n t i f i c a t i o n w i t h a ' c a r e t a k i n g m o t h e r ' " (p. 456).

T h e failure o f introjection o f the maternal

object representation w o u l d , a c c o r d i n g to this way o f t h i n k i n g , result i n a n absence o r d e f e c t i n a f f e c t i v e a n d s e l f - c a r i n g f u n c t i o n s .

Recently, 1 1 1

have t a k e n issue w i t h t h e " d e f i c i e n c y " h y p o t h e s i s r e g a r d i n g t h e " m i s s i n g functions"

in

these

patients.

While

r e p o r t i n g that

psychosomatic

patients a n d substance-dependent i n d i v i d u a l s s u f f e r e d f r o m a serious i m p a i r m e n t i n t h e i r capacity t o t a k e care o f t h e m s e l v e s , I d i d n o t v i e w t h i s as a d e f i c i e n c y

i n functions.

R a t h e r , I saw t h i s p a r t o f t h e i r

d i f f i c u l t y as c o n s i s t i n g o f a d i s t o r t i o n i n t h e i r s e l f - r e p r e s e n t a t i o n r e s u l t i n g i n a n a t t r i b u t i o n o f self-caring, soothing a n d affective functions to the p r i m a l object-representation.

T h i s impoverishment o f the enliven-

i n g r e s o u r c e s o f t h e self c o n s t i t u t e s a n i n h i b i t i o n i n w h i c h t h e m a t e r n a l o b j e c t r e p r e s e n t a t i o n is r i g i d l y " w a l l e d o f f , " as i t w e r e , a n d t h e exercise o f s e l f - c o m f o r t i n g a n d m o t h e r i n g f u n c t i o n s is p r o s c r i b e d f o r t h e subject. T h e r e s u l t o f t h i s e a r l y i n h i b i t i o n is n o t o n l y a l i f e - l o n g p r o b l e m i n selfcare, b u t because o f its e a r l y o n s e t , a n a r r e s t i n a n u m b e r o f s p h e r e s o f development. I c a n n o t p u r s u e t h e details o f t h i s aspect o f t h e p r o b l e m at p r e s e n t — rather,

I want to

highlight my

regression i n r e g a r d to affect.

view

that alexithymia represents

a

I have postulated that emotions evolve

24

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

o u t o f t w o basic r e a c t i o n p a t t e r n s o f a f f e c t p r e c u r s o r s .

O u t o f the

distress r e s p o n s e e v o l v e t h e p a i n f u l o r " e m e r g e n c y " affects.

O u t o f the

p a t t e r n o f t r a n q u i l i t y e v o l v e t h e p l e a s u r a b l e " w e l f a r e " affects.

The

d e v e l o p m e n t a l l i n e s o f e m o t i o n s consist i n a f f e c t d i f f e r e n t i a t i o n , v e r balization and desomatization. past, 1 9

2 1

I h a v e r e v i e w e d these processes i n t h e

a n d o n l y t h e b r i e f e s t s u m m a r y is possible h e r e .

T h e process

o f v e r b a l i z a t i o n a n d s i m u l t a n e o u s d e s o m a t i z a t i o n o f e m o t i o n s is o n e o f t h e m a j o r d e v e l o p m e n t a l processes w h i c h takes place o r i g i n a l l y i n t h e context o f the m o t h e r a n d child interaction. Early, the child identifies w i t h the m o t h e r i n r e g a r d to affective behavior patterns.

A s t h e process

c o n t i n u e s , a n d especially i n l a t e n c y w h e n t h e r e is c o n t i n u i n g p r o g r e s s toward differentiation, verbalization and desomatization o f t h e y b e c o m e i n c r e a s i n g l y u s e f u l as signals t o one's self. process t h e r e is a d e v e l o p m e n t During

adolescence, these

emotions,

A l o n g w i t h this

o f the capacity f o r affect

tolerance.

t w o aspects o f a f f e c t d e v e l o p m e n t

2 2

come

together a n d enable the adolescent to develop a capacity f o r m o u r n i n g , w h i c h m a k e s i t possible f o r h i m t o give u p t h e a t t a c h m e n t t o t h e i n f a n t i l e self- a n d o b j e c t - r e p r e s e n t a t i o n s . The

connection

between

23

the

developmental

s y m p t o m s o f a l e x i t h y m i a is s e l f - e v i d e n t . ferentiated

nor

verbalized, however,

process a n d

some

E m o t i o n s w h i c h are n o t d i f -

a r e also n o t c o n d u c i v e

to the

g e n e r a l process o f r e f l e c t i v e self-awareness a n d m o t i v a t i o n f o r l y r i c i s m i n language development.

I n s t e a d o f b e c o m i n g a c q u a i n t e d w i t h one's

f e e l i n g s , desires a n d fantasies, o n e is p u s h e d t o w a r d " e x t e r n a l r e a l i t y " as the major preoccupation.

T h e i n t r a p s y c h i c v o i d is filled w i t h p r e o c c u -

p a t i o n w i t h t h e d e t a i l s so c h a r a c t e r i s t i c o f t h e " p e n s é e o p é r a t o i r e . " E v e r y s e l f - r e p r e s e n t a t i o n a n d o b j e c t - r e p r e s e n t a t i o n is b u t a r e c o r d o f the perceptions o f the self a n d / o r object a n d the affective change w h i c h accompanied it.

W h e r e t h e a f f e c t i v e p a t t e r n r e m a i n e d m o s t l y somatic

a n d u n d i f f e r e n t i a t e d , i t fails t o s u p p l y " c o l o r " t o t h e e x p e r i e n c e

and

m e m o r y , a n d i t r e g i s t e r s o b j e c t - r e p r e s e n t a t i o n i n "shades o f g r e y " w i t h its c h a r a c t e r i s t i c " d e a d n e s s " a n d u n i n v o l v e m e n t . enon

accounts

for

the

peculiar

unemotional

transference shown by the a l e x i t h y m i c patients.

T h e same p h e n o m responses

in

the

Instead o f feelings, the

patients experience some reaction i n the sphere o f the b o d y c o n t r o l l e d b y t h e a u t o n o m i c n e r v o u s system.

T h a t is n o t l o v e .

Most importantly however, the phenomena "all or n o t h i n g " phenomena. feelings some o f the t i m e . psychosomatic

o f a l e x i t h y m i a are not

M o s t p a t i e n t s a r e able t o e x p e r i e n c e s o m e C o n v e r s e l y , a l e x i t h y m i a is n o t r e s e r v e d f o r

or addictive patients.

I n p o i n t o f fact, b o t h psychoso-

m a t i c a n d a d d i c t i v e m e c h a n i s m s a r e t o be f o u n d t o s o m e e x t e n t i n v i r tually every n e u r o t i c p a t i e n t .

1 0

E v e n psychosomatic, addictive o r post-

ALEXITHYMIA AND

PSYCHOTHERAPY

25

t r a u m a t i c p a t i e n t s v a r y a g r e a t d e a l as t o t h e severity a n d consistency o f their

alexithymic

characteristics.

Within

the

function

of

a typical

a l e x i t h y m i c i n d i v i d u a l t h e r e is a c o n s i d e r a b l e v a r i a t i o n as t o t h e c a p a c i t y t o v e r b a l i z e , i d e n t i f y a n d d e s c r i b e e m o t i o n s , a n d i n his c a p a c i t y f o r a f f e c tively e x p e r i e n c e d object- a n d

self-representations.

A l l o f these p o i n t s i n d i c a t e t h a t we are d e a l i n g w i t h a r e g r e s s i o n i n the affective-cognitive rest o f t h e p i c t u r e . regression.

f u n c t i o n , a n d that this regression produces the W e t h e r e f o r e h a v e t o l o o k f o r t h e causes o f t h i s

T h i s b r i n g s m e t o t h e q u e s t i o n o f t h e r e l a t i o n s h i p o f psychic

trauma and alexithymia. I have previously

pointed

out 2 0

2 2

t h a t i f we d e f i n e t r a u m a as a n

o v e r w h e l m i n g e m o t i o n a l experience, t h e n we have to d i s t i n g u i s h t w o f o r m s o f i t : a n i n f a n t i l e t y p e a n d a n a d u l t catastrophic t y p e .

2 1

W h i l e the

t w o f o r m s o f t r a u m a h a v e a v a r i e t y o f d i f f e r i n g characteristics a n d a f t e r effects, t h e y b o t h cause a l e x i t h y m i a . * A f t e r t h e i n f a n t i l e f o r m o f psychic t r a u m a , t h e r e is a n a r r e s t i n a f f e c t d e v e l o p m e n t ; a f t e r a d u l t catastrophic t r a u m a t h e r e is a r e g r e s s i o n i n affective f u n c t i o n .

P e r h a p s h e r e w e h a v e t h e first c l u e t o t h e v a r i a t i o n i n

the severity o f alexithymic s y m p t o m s .

Regressions a r e , o f c o u r s e , m o r e

spotty, i r r e g u l a r , f l u c t u a t i n g a n d reversible.

However, in both posttrau-

m a t i c states t h e r e is a fear o f affects, a n d a n i n c l i n a t i o n t o b l o c k t h e m , o r to fail to integrate t h e m .

T h e r e s u l t is a t e n d e n c y t o p s y c h o s o m a t i c o r

addictive mechanisms. I M P L I C A T I O N FOR

SPECIAL TECHNIQUES

A l e x i t h y m i c characteristics are w i d e s p r e a d a m o n g p a t i e n t s w h o m we take i n t o psychoanalysis a n d p s y c h o t h e r a p y f o r n e u r o t i c a n d c h a r a c terological

problems.

The

existence

of

such

ways

of

functioning

seriously d i m i n i s h e s t h e success o f a l l o f o u r p s y c h o t h e r a p e u t i c e f f o r t s and methods. them

must

However

R e c o g n i z i n g a l e x i t h y m i c characteristics a n d d e a l i n g w i t h

become

with

some

part of

the consideration

patients,

dependent and posttraumatic

such

as

most

patients, the a t t e n t i o n to this

p r o b l e m m u s t be t h e first o r d e r o f business. d e p e n d e n t patients we f o u n d

4

o f e v e r y single psychosomatic,

case. drug-

affective

I n w o r k i n g w i t h substance

t h a t a p r e p a r a t o r y phase o f t h e t r e a t m e n t

was necessary, i n o r d e r t o m a k e t h e t h e r a p y h e l p f u l r a t h e r t h a n m o r e * I n t h e a b o v e p u b l i c a t i o n I h a v e d e f i n e d c a t a s t r o p h i c t r a u m a as t h e f u l l t r a u m a t i c process i n w h i c h the subjective evaluation o f the d a n g e r situation ( " e x t e r n a l " or " i n t e r n a l " ) d e t e r m i n e s t h a t t h e p e r i l is i n e s c a p a b l e . T h e r e follows a surrender to t h e d a n g e r i n w h i c h t h e affect c h a n g e s f r o m a n x i e t y to t h e " c a t a t o n o i d r e a c t i o n . " T h e t r a u m a t i c p r o c e s s i n volves b l o c k i n g o f e m o t i o n s , a n d c o n s t r i c t i o n o f c o g n i t i o n a n d m a y t e r m i n a t e i n p s y c h o g e n i c d e a t h . I f d e a t h is p r e v e n t e d , s e v e r e a f t e r e f f e c t s o f t h e t r a u m a i t s e l f m u s t f o l l o w , s u c h as a l e x i t h y m i a , a n h e d o n i a , a n d c o n t i n u a t i o n o f c o g n i t i v e c o n s t r i c t i o n .

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

26 d i s t u r b i n g to the patients.

W h i l e d e a l i n g w i t h a l e x i t h y m i a is a slow a n d

o f t e n d i s a p p o i n t i n g e n d e a v o r , s o m e p r o g r e s s c a n be m a d e t o h e l p t h e patients handle t h e i r emotions to t h e i r advantage, a n d to p r o m o t e differentiation and verbalization. The

affect

2 2

f i r s t task is t o h e l p t h e p a t i e n t t o o b s e r v e t h e n a t u r e o f his

alexithymic

disturbances.

p a t i e n t s have l o n g b e e n

The

very observation

i n g a n d o f t e n have c o m p o u n d e d t h e i r p r o b l e m s explain

their peculiarities.

avoiding responses.

any

exposure

is h e l p f u l as these

p u z z l e d a n d f r i g h t e n e d b y t h e i r ways o f r e a c t -

to

by t h e i r a t t e m p t s t o

S o m e p a t i e n t s have d e v e l o p e d ways situations w h i c h

might trigger

of

affective

T h u s , a l e x i t h y m i a is s o m e t i m e s s h e l t e r e d by a n i s o l a t e d ,

alienated or t h i n g - o r i e n t e d lifestyle.

T h e patients have to u n d e r s t a n d

i n w h a t w a y t h e i r e m o t i o n s are n o t l i k e o t h e r p e o p l e s ' a n d have t o s t a r t l e a r n i n g h o w t o c o n t e n d w i t h h a v i n g p h y s i o l o g i c a l r e a c t i o n s a n d sensat i o n s i n place o f f e e l i n g s . T h e s e c o n d task is h e l p i n g t h e p a t i e n t s t o d e v e l o p a f f e c t

tolerance.

H e l p i n g a patient w i t h affect tolerance involves observing w i t h h i m the w a y he e x p e r i e n c e s his e m o t i o n s a n d reacts t o h a v i n g t h e m .

Frequently

p a t i e n t s a r e f e a r f u l o f t h e i r affects o r r e s p o n d w i t h a n g e r o r s h a m e t o h a v i n g t h e m , thus b e c o m i n g involved i n circular patterns w h i c h aggravate a n d perpetuate the p r o b l e m .

T h u s , f o r instance, patients suf-

f e r i n g f r o m d e p r e s s i o n a r r i v e at o u r offices at t h e e n d o f a v i c i o u s c i r c l e i n w h i c h t h e i r r e a c t i o n t o having t h e e m o t i o n has m a d e i t w o r s e t o t h e p o i n t t h a t i t is e x p e r i e n c e d as a n " i l l n e s s . "

T h e patients n e e d to reac-

q u a i n t t h e m s e l v e s w i t h t h e i r e m o t i o n s as u s e f u l signals t o t h e m s e l v e s r a t h e r t h a n d a n g e r o u s d e m o n i c forces w h i c h possess t h e m .

As the

p a t i e n t s b e g i n t o r e c o g n i z e t h e i r e m o t i o n s as signals t o t h e m s e l v e s w h i c h a r e self-limited in duration and intensity t h e y h a v e t o be h e l p e d t o d i s c o v e r the maladaptive p a t t e r n a n d theories w h i c h they have h e l d u p to that point.

For instance, the widely h e l d " e x c r e t o r y "

views o f affects

as

substances t o be e l i m i n a t e d s h a r e d b y m a n y p a t i e n t s a n d t h e r a p i s t s o f t e n c o n t r i b u t e to the difficulties i n h a n d l i n g the e m o t i o n s .

2 0

T h e patients

n e e d t o be a w a r e t h a t t h e m e t a p h o r s o f r i d d a n c e d e r i v e d f r o m a n a l analogies d o n o t r e p r e s e n t r e a l i t y , a n d t h a t w h a t t h e y n e e d t o d o is n o t t o " e x p r e s s " t h e i r e m o t i o n s b u t t o observe t h e m . A m a j o r p r o b l e m f o r s o m e p a t i e n t s stems f r o m t h e i r h a v i n g l e a r n e d i n t h e i r c h i l d h o o d that t h e i r emotions were the only means to c o m m u n i cate w i t h t h e i r p a r e n t s a n d t o c o n t r o l t h e m .

I n other

words—their

parents r e s p o n d e d to n o t h i n g except t h e i r t e m p e r t a n t r u m s , o r affective e q u i v a l e n t s s u c h as a s t h m a attacks. S u c h p a t i e n t s e x p e c t t o c o n t r o l t h e whole w o r l d w i t h their emotional outbursts.

I t is t h i s p a t t e r n o f b e -

h a v i o r w h i c h gives t h e m t h e " d o u b l e p e r s o n a l i t y " n o t e d a b o v e .

When

ALEXITHYMIA AND PSYCHOTHERAPY

27

t h e y have a r a g e — t h e y s t a n d back, as i t w e r e , a n d l e t i t " w o r k " o n t h e i r objects.

W h e n we ask t h e p a t i e n t s t o give u p t h i s b e h a v i o r p a t t e r n we

are a s k i n g t h e m t o r e n o u n c e f o r m a t i v e years.

t h e o n l y t h i n g t h a t was e f f e c t i v e i n t h e

T h e y d r e a d t h a t i f t h e y give u p t h i s m e a n s o f c o n t r o l -

l i n g t h e i r love objects ( a n d by t r a n s f e r e n c e — f a t e ) t h e n t h e y w i l l be h e l p less.

T h e d a n g e r o f helplessness is v e r y g r e a t t o t h e m because t h e y are

l i v i n g i n t h e d r e a d e x p e c t a t i o n o f t h e r e t u r n o f t h e i r psychic t r a u m a . T h e s e a n d o t h e r fantasies w h i c h p e r p e t u a t e t h e m a l a d a p t i v e p a t t e r n s have t o be d i s c o v e r e d a n d i n t e r p r e t e d . F o r i n s t a n c e , a n o t h e r f a n t a s y i n c o r p o r a t e d i n d i s t u r b a n c e s o f a f f e c t h a n d l i n g is t h a t e m o t i o n s

"belong

t o , " o r e m a n a t e f r o m t h e object, a n d t h a t t h e subject is n o t p e r m i t t e d t o control t h e m .

1 1

I t is o n l y a f t e r r e m o v i n g a l l these blocks a n d p r o h i b i t i o n s a g a i n s t t h e o w n i n g u p t o one's o w n e m o t i o n s t h a t t h e p a t i e n t m a y f e e l f r e e p r o c e e d w i t h t h e n e x t task: t o g r a d u a l l y v e r b a l i z e his e m o t i o n s .

to

I n this

task t h e t h e r a p i s t p e r f o r m s a f u n c t i o n w h i c h c h i l d analysts a n d p a r e n t s t a k e f o r g r a n t e d — h e l p i n g t h e p a t i e n t t o find w o r d s t o d e s c r i b e feelings.

o b s e r v a t i o n is also c u l t i v a t e d . terpret,

organize,

Kligerman regressed

their

A s t h e y p r a c t i c e t h i s process t h e i r capacity f o r r e f l e c t i v e self-

2 4

and

T h e task is t o h e l p t h e p a t i e n t t o i n -

recognize

put it: "One

his

own

feelings.

22

Hence,

o f t e n has t o h e l p p a t i e n t s w h o

are

as very

t o u n d e r s t a n d what t h e y are f e e l i n g a n d t o give i t a n a m e . "

(p. 6 4 0 ) T h e process o f h e l p i n g t h e p a t i e n t t o r e c o g n i z e a n d v e r b a l i z e t h e i r e m o t i o n s is a slow a n d t e d i o u s o n e .

O n e has t o c o n s t a n t l y go o v e r t h e

p a t i e n t ' s s t a t e m e n t s t o see w h a t h e has e x p e r i e n c e d

at t h e t i m e o f a n

e v e n t , at t h e same t i m e w a t c h i n g f o r his a f f e c t i v e r e a c t i o n s w h i l e he is r e lating it.

O n c e t h e t h e r a p i s t is a w a r e o f t h e n e e d t o h e l p d i s c o v e r t h e

m e a n i n g o f the patient's a f f e c t s — a n d t h r o u g h it their n a t u r e , he will find

a v a r i e t y o f clues.

A m o n g these, h o w e v e r , t h e r e w i l l be a n u n -

d e r u t i l i z a t i o n (because o f u n a v a i l a b i l i t y ) o f t h e t w o m o s t f a m i l i a r a n d d e sirable arenas

o f psychoanalytic

dreams a n d transference. same c o g n i t i v e

and

and psychotherapeutic

observation:

I f we take a b r o a d view we discover that the

affective

problems

which interfere with

these

p a t i e n t ' s p e r f o r m a n c e i n analysis also r a k e h a v o c w i t h t h e i r c u r r e n t o b ject relations.

P a r t l y o u t o f t h e necessity t o h e l p p a t i e n t s d i s c e r n t h e

nuances o f t h e i r i n t e r a c t i o n o f w h i c h they are oblivious, (they d o n ' t even k n o w w h a t they are missing) a n d p a r t l y d u e to the need to d e m o n s t r a t e to t h e m t h e p r i m i t i v e f o r e r u n n e r o f a f f e c t i v e responses, o n e has t o m a k e observations, comments, elucidations a n d confrontations r e g a r d i n g the patients' " o u t s i d e " object experiences.

G r a d u a l l y , i t m a y b e c o m e possi-

ble t o s h i f t e m p h a s i s , a n d b e g i n t o m a k e d i r e c t t r a n s f e r e n c e i n t e r p r e t a -

28

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

tions.

E v e n i n these p a t i e n t s ' c u r r e n t o b j e c t r e l a t i o n s o n e m u s t n o t

presume

t h a t t h e y a r e a w a r e o f a n y , e v e n m o s t basic a n d

" h u m a n " feelings a n d perceptions.

common

T h e r e is a g r e a t d e a l o f v a r i a t i o n i n

this respect w i t h u n p r e d i c t a b l e lacunae c o m i n g i n t o view.

Even when

t h e p a t i e n t s d e s c r i b e a g i v e n f e e l i n g , r e l a t i o n s h i p o r e x p e r i e n c e , o n e has t o reserve j u d g m e n t w h e t h e r he t r u l y feels i t , o r w h e t h e r h e relates w h a t h e " f i g u r e d o u t , " o r was t o l d he should be e x p e r i e n c i n g .

The following

is a b r i e f i l l u s t r a t i o n : CASE M r . A . entered analytic therapy because o f neurotic and characterological problems, but he t u r n e d out to have asthma as well. He d i d not complain o f it, however, and defended its allergic nature w i t h considerable zeal. T h e following material is derived f r o m a single therapy session. T h e patient related that on the previous day he was supposed to have l u n c h w i t h his wife, but to his surprise, she backed out. I n the evening she was i n a bad m o o d ; irritable and "bitchy." Most o f the evening he felt that he w o u l d j u s t ignore her angry behavior, and it would j u s t stop. However, on several occasions i n the course o f the evening, he experienced i n a passive and unemotional way, flashes o f thoughts that he ought to j u s t walk out, leave her, and never come back. I n regard to these events, M r . A . had characteristically ignored the significant antecedents. He had called i n the m o r n i n g and t o l d his wife that he had asked two other people to j o i n them for l u n c h . As we talked about the reasons why his wife had objected to the intrusion I had to b r i n g to his attention that this was not an ordinary l u n c h date. T h e previous night his wife had questioned h i m about whether he was having an a f f a i r — w h i c h he dismissed by refusing to even discuss it. T h e invitation to l u n c h t h e n , was related to these serious marital problems, i n addition, the couple was also i n the process o f m a k i n g some other major decisions. Unlike neurotic patients, this man has very little empathy for other people, and that is why he could not imagine (1) why his wife decided not to j o i n h i m for l u n c h ; (2) why she was still angry i n the evening and (3) that she may still be angry, jealous, and so on about the possibility o f his infidelity. I n a d d i t i o n , the affective response provides f u r t h e r opportunities to explore a n u m b e r o f the aspects o f the self- and object representations. Why couldn't he have j u s t spoken u p and expressed his distress, or better yet, f o u n d out what his wife was upset about? I t is this k i n d o f an inquiry that leads one to discover the "evil"-object representation, the "helpless" self-representation, and the reflection o f a number o f other significant fantasies behind the cognitive aspects o f the affect. T h e idea o f " w a l k i n g o u t " reflected a pattern o f this patient i n dealing with his passive yearnings w i t h o u t o w n i n g u p to t h e m , but by getting his objects to take actions, which he experienced helplessly. He acted out the " w a l k i n g away" repeatedly but was unable to renounce the infantile object- and self-representations, or accomplish separation on an emotional plane. T h e above v i g n e t t e i n v o l v e s t h e i d e n t i f i c a t i o n o f a f f e c t i v e responses,

ALEXITHYMIA AND PSYCHOTHERAPY

29

t h e c o g n i t i v e aspects o f t h e a f f e c t a n d t h e n a t u r e o f self- a n d o b j e c t representations.

O f t e n i t is also necessary t o p i c k u p clues f r o m t h e

p a t i e n t s ' p h y s i c a l state t o establish t h e existence o f a n e m o t i o n a l reaction.

T h e reconstruction o f the cognitive elements o f the e m o t i o n ,

n a m e l y , t h e m e a n i n g o f t h e e m o t i o n , o r t h e " s t o r y b e h i n d i t " has t o be q u i t e e x t e n s i v e a n d s h o u l d be p u r s u e d i n greatest possible d e t a i l .

I t is i n

this process o f w o r k i n g w i t h v e r b a l i z a t i o n o f affects t h a t o n e observes progress

t o w a r d affect

differentiation and

desomatization.

At

the

same t i m e , o b s e r v a t i o n can be m a d e as t o psychic s t r u c t u r e s a n d p a r t i c u l a r l y t h e o f t e n associated d i s t u r b a n c e s i n s e l f - r e p r e s e n t a t i o n a n d i n h i b i tion

i n self-care

functions.

I n contrast

to neurotic

p a t i e n t s , i t is

necessary t o d e a l w i t h t h e a l e x i t h y m i c ' s " i n s e n s i t i v i t y " t o t h e f e e l i n g s a n d reactions o f o t h e r people a r o u n d t h e m .

Because o f t h e i r

problems,

t h e y h a v e n o t d e v e l o p e d a c a p a c i t y f o r e m p a t h y w h i c h creates problems

for

them.

patient's perceptions

Thus

dealing with

serious

the misjudgments i n the

a n d b e h a v i o r w i t h t h e i r objects is a necessary

p s y c h o t h e r a p e u t i c task, b u t also becomes o n e o f t h e arenas i n w h i c h affective f u n c t i o n evolves. T h e s e d y s f u n c t i o n s r e q u i r e f u r t h e r s t u d y , as m a n y q u e s t i o n s n e e d t o be e x p l o r e d r e g a r d i n g t h e a l e x i t h y m i c c h a r a c t e r i s t i c s s h o w n b y m a n y patients.

W h i l e a l e x i t h y m i a r e p r e s e n t s a serious a n d w i d e s p r e a d h i n -

d r a n c e t o t h e p s y c h o t h e r a p e u t i c process, i t s h o u l d n o t , i n m y o p i n i o n , be considered an insuperable barrier to i t .

R a t h e r t h a n give u p o n these

i n d i v i d u a l s , we s h o u l d s t u d y t h e i r p r o b l e m s a n d t h e r e b y e n r i c h t h e t h e o r y a n d technique o f psychoanalytic psychotherapy. SUMMARY T h e t w o c a r d i n a l signs a n d p r o b l e m s o f a l e x i t h y m i a a r e : (1) affective: e m o t i o n s are u n d i f f e r e n t i a t e d , m o s t l y s o m a t i c a n d p o o r l y v e r b a l i z e d . A f f e c t s a r e n o t u t i l i z a b l e as signals t o o n e s e l f , a n d p a t i e n t s c a n n o t t e l l h o w they feel.

T h e " e x p r e s s i v e , " i.e., p h y s i o l o g i c a l aspects o f e m o t i o n s

m a n i f e s t themselves nesses.

as t r o u b l e s o m e

sensations

or psychosomatic

ill-

(2) Cognitive: T h e t h i n k i n g is " o p e r a t i v e , " d e p r i v e d o f d r i v e i m -

p l e m e n t a t i o n , a n d g r a t i f i c a t i o n - d i r e c t e d f a n t a s y a n d is d o m i n a t e d by banal, chronologically o r i e n t e d "facts." F r o m these t w o d i s t u r b a n c e s f o l l o w o t h e r p r o b l e m s , m o s t l y i n t h e area o f d e a l i n g w i t h objects b u t also i n r e g a r d t o self-care. f o l l o w s also a severe i m p a i r m e n t t o u t i l i z i n g d y n a m i c

There

psychotherapy.

I n fact, p s y c h o a n a l y t i c o r a n y " a n x i e t y - p r o v o k i n g " p s y c h o t h e r a p y m a y p r o d u c e l i f e - e n d a n g e r i n g relapses i n b o t h p s y c h o s o m a t i c a n d a d d i c t i v e patients.

O u r a t t e m p t s t o a v o i d these p e r i l s b y s h u n n i n g these t w o

n o s o l o g i c a l categories m u s t f a i l because v i r t u a l l y a l l p a t i e n t s h a v e s o m e

30

AMERICAN JOURNAL

psychosomatic or

addictive tendencies.

OF

PSYCHOTHERAPY

I n addition,

another

large

g r o u p o f a l e x i t h y m i c p a t i e n t s r e p r e s e n t sequelae o f c a t a s t r o p h i c psychic trauma. I t is essential, t h e r e f o r e , t o l o o k o u t f o r a l e x i t h y m i c c h a r a c t e r i s t i c s i n any patient.

W h e n a l e x i t h y m i a is d i s c o v e r e d , s o m e m o d i f i c a t i o n o f t h e

d i f f i c u l t i e s can be a c h i e v e d by w o r k i n g w i t h t h e p a t i e n t s to i m p r o v e t h e i r affect tolerance, a n d to h e l p t h e m to verbalize (and desomatize) their emotions. REFERENCES 1. S i f n e o s , P. E .

C l i n i c a l O b s e r v a t i o n s o n S o m e Patients S u f f e r i n g f r o m a V a r i e t y o f P s y Proc.

chosomatic Diseases.

7th Eur.

Conf. on Psychosomatic

Research,

Karger, Basel,

1967. 2.

Marty, P., d e M ' U z a n , M . a n d D a v i d , C . Universitaires, Paris,

3.

N e m i a h , J . C . a n d Sifneos, P. E . I n Modern

Disorders.

L'investigation psychosomatique.

Presses

1963. Affect a n d Fantasy i n Patients with Psychosomatic

Trends

in Psychosomatic

Medicine-2.

Hill, O. W.,

E d . But¬

terworth, L o n d o n , pp: 2 6 - 3 4 . 4.

Krystal, H . and Raskin, H .

5.

Krystal, H . Quart.

6.

Suppl. 3 6 : 5 3 ,

Krystal, H . zation.

7.

11.

T r a u m a : Consideration o f Severity a n d C h r o n i c i t y .

Psychother.

deM'Uzan, M.

Psychosom.,

Traumati-

1971.

Psychoan.,

27:suppl.

Psychosomatic Illness: A Problem of C o m m u n i c a -

18:154-0,1970. Int. Rev.

Psychoanal.,

T h e Psychosoma a n d Psychoanalytic Process.

Int. Rev.

Psychoanal.,

1974.

Krystal, H .

S e l f - R e p r e s e n t a t i o n a n d the Capacity for S e l f - C a r e . Vol. V I , International Universities Press, New Y o r k ,

S i f n e o s , P. E .

I n The Annual

of

1978.

A Reconsideration of Psychodynamic Mechanisms in Psychosomatic

Formation in View of

chosom., 2 4 : 1 5 1 ,

Psychother.

Recent Clinical Observations.

Psy-

1974.

Problems of Psychotherapy o f Patients with A l e x i t h y m i c Characteristics a n d Physical Disease.

14.

Rev. Franc.

A n a l y t i c a l P r o c e s s a n d the N o t i o n o f t h e P a s t .

McDougall, J .

Symptom 13.

I n : Psychic

1974.

Psychoanalysis, 12.

L a pensée opératoire.

N e m i a h , J . C . a n d S i f n e o s , P. E .

1:437,

Psych.

1963.

1:461-6, 10.

1970.

1962.

M a r t y , P. a n d d e M ' U z a n , M .

tion. 9.

W a y n e State U n i v . P r e s s , D e t r o i t ,

Krystal, H . a n d N i e d e r l a n d , W . E d s . : Little, B r o w n , Boston,

1345-6, 8.

Drug Dependence.

T h e S t u d y o f W i t h d r a w a l f r o m N a r c o t i c s as a State o f S t r e s s .

Taylor, G. J .

Psychother.

Psychosom.,

26:68,

1975.

A l e x i t h y m i a a n d the C o u n t e r - T r a n s f e r e n c e .

Psychother.

Psychosom.,

28:141-7,1977 S p l i t B r a i n s a n d P s y c h o a n a l y s i s . Psychoanal

15.

Hoppe, K. D.

16.

Nemiah, J . C. Psychosom.,

17.

11:338, 18.

26:140,

M a c L e a n , P. D .

Psychother.

1975.

Psychosomatic Disease a n d the " V i s c e r a l B r a i n . "

Heiberg, A. and Heiberg, A. Krystal, H .

1977.

Psychosom.

Med.,

1949.

chosom. 2 8 : 2 2 1 - 2 2 5 , 19.

Q., 4 6 : 2 2 0 ,

D e n i a l Revisited: Reflections on Psychosomatic T h e o r y .

Alexithymia—An Inherited Trait?

Psychother.

Psy-

1977.

T h e G e n e t i c D e v e l o p m e n t of Affects a n d Affect R e g r e s s i o n .

nual of Psychoananalysis.,

I n The

An-

V o l 2, P o l l o c k , G e o r g e H . a n d E d i t o r i a l C o m m i t t e e o f T h e

ALEX I T H YMIA AND Chicago York

I n s t i t u t e for P s y c h o a n a l y s i s ,

Aspects of Affect T h e o r y .

21.

T r a u m a a n d Affects. Affect

Tolerance.

Wolfenstein,

M.

How

Bull. Menninger

Clin.,

41:1-26,

New

1977.

InPsychoanal. Study Child, 3 3 : 8 1 - 1 1 6 , I n The

Universities Press, New Y o r k , 23.

E d s . International Universities Press,

1974.

20. 22.

31

PSYCHOTHERAPY

Annual

of Psychoanalysis.,

Vol

1978. 3,

International

1975.

Is Mourning

Possible?

Psychoanal.

Study

Child,

21:92-96,

J . Am.

Psychoanal

1966. 24.

Panel.

Psychoanalytic T h e o r y of Affects.

Assoc. 1 6 : 6 3 8 ,

1968.

Lofgren, L . B. reporter.