You may wonder what is the significance of knowing this: is my spouse / boss / colleague / friend / sibling someone who happens to be alexithymic? Someone who has literally no feelings?
We are not all the same. In fact we are often blind to the people we live with, to their personality and character traits, because we live within our own personality biases. Without psychotherapeutic work, we are often not aware of the fact that we see and feel the world differently from the people around us. That we also have a tendency to assume that the other person understands us and vice versa.
Alexithymia is not uncommon. It is assumed that about 10% of the population is alexithymic. With awareness through psychotherapy, one may get to realize that one is or had been living with persons who are unable to identify and describe emotions in the self. This condition is seen as dysfunctional because it leaves the person un-empathic, and the people around the sufferers often get hurt.
Alexithyma proves to be prominent in a number of clinical disorders (e.g., somatoform disorders, panic disorders, depression with dominance of vital and somatic symptoms, posttraumatic stress disorder [PTSD], and eating disorders). Extent of Alexithymia is also significant to outcome in the treatment of these disorders.
Psychological questionnaires used to measure Alexithymia include: Observer Alexithymia Scale (Haviland et.al, 2001) and the the Bermond-Vorst Alexithymia Questionnaire (Vorst et.al, 2001).
Haviland, M. G., Warren, W. L., Riggs, M. L., & Gallacher, M. (2001). Psychometric properties of the Observer Alexithymia Scale in a clinical sample. Journal of Personality Assessment, 77(1), 176-186.
Helmes, E., McNeill, P. D., Holden, R. R., & Jackson, C. (2008). The construct of alexithymia: Associations with defense mechanisms. Journal of clinical psychology, 64(3), 318-331.
Vorst, H. C., & Bermond, B. (2001). Validity and reliability of the Bermond–Vorst alexithymia questionnaire. Personality and individual differences, 30(3), 413-434.
Quiz: How to Identify Alexithymia in a Person
Note: this is a basic quiz and not to be used as diagnosis of yourself or the other person. If you suspect that the condition affects your psycho-social functioning, please consult a mental health professional.
This case study is an abstract from a therapeutic work. It is a demonstration how a recall of the client’s favorite novel as a teenager develops into a psychotherapeutic session that is meaningful to the clients identification of himself. This is a technique usually used for working with dreams in Gestalt therapy, in which the client plays the parts (makes projections) of his dream. In this case it is not the dream, but the novel.
Case study: CL’s Novel
CL works in a publishing company. He reports having problems with procrastination. Although quite successful at his job, he struggles making datelines. He finds himself delaying getting things done till the last minute, which sees himself sitting up till early hours of the morning smoking cigarettes. This is an excerpt of a Gestalt Therapy Session. Throughout this article, the principles of Gestalt Therapy adopted in this session are also explained in this color.
NC: Now can you bring to mind a moment in which the word “procrastination” feels familiar?
CL: (Contemplates…) Yes. I had to write a short article for the company’s blog. It was in morning, I took out the PC, but then I did instead some online shopping.
NC: Stay with the feeling of the moment before you switch to online shopping.
“Staying with the feeling” is an approach in GT where the narrative (which is usually an intellectual process) is embodied into experience.
CL: I feel anxious.
NC: This familiar to you?… stay with it. Can you remember a time in your childhood when you felt something like this?
CL: In school. It was Math, and I had homework. The teacher wasn’t pleased, I made mistakes I did not understand…
This narrative goes on, and we talked about anxiety about what he considered “small criticism”. This recall of the past is a “free association”. The experienced client knows how to take memories or images that pop up in the moment and vocalize them. Sometimes these associations do not seem to make sense at the moment, but these usually do.
NC: Stay with this anxiety again… much earlier… maybe at home…
CL: Nothing special, really, I am just having a picture of a dirty bicycle. I was 8 or 9, it is my bicycle. I was supposed to clean it, but I didn’t want to do it.
NC: You had to do it, but you do not want to do it now?
CL had used the present tense, and I felt it is a good thing, so I followed with the present tense. This is a good opportunity to work with past experiences as if it were in the present. Actually this is how we live, with occurrences of our past popping up in the present.
NC: What would you rather have done?
CL: Read a book.
NC: Have you a book in mind?
CL: Yes. (mentioned a title of a book).
NC: Where would you go to read this book?
CL: In my bedroom.
NC: How does it feel to be in your bedroom reading this book?
CL: Relaxed, comfortable… safe.
Notice that he said “safe”. It seems to correlate with the “anxiety” behind the procrastination. This is an indication that sitting in the room, and reading that book is a way out of anxiety. At this point I could have gone back to the anxiety, and tried to work on it. My interest of the moment, however, took me to the curiosity about the book (which I will explain later why). This is working in the here-and-now. The therapist is following her own feelings of curiosity, and being present. This means that we may, at this juncture abandon trying to sort the problem of procrastination. In Gestalt, we work on what is present. The present is always changing. We do not try to force goals into the present or force the client to concentrate or dwell on issues that are not there at the moment.
NC: The title of this book got my interest, I have not heard of it before.
CL: (laughs). It is a very old novel. German novel about German brothers coming back from the 2nd World War, and the Russians came.
NC: You mentioned this book was comforting to you, a 9 year old.
CL: for some reason, yes.
The backstory here is, like many of his generation, CL’s estranged father was a soldier in the German NS. CL himself is a liberal (kind of left-wing writer). This information in background, now got my interest to this book preference CL as a child. The background is very important to the Gestalt therapist because we are interested in the foreground. The foreground is made clearer only when the background is complete.
NC: Tell me about the book…
CL: (laughs, a little more shakily. He goes to his phone, and searches this book on an online site. Makes some association:)
NC: What comes to mind…
CL: Two scenes. This guy talks to his buddy in prison about the time he was taken from his home by the Russians. He was in the garden of his parent’s home, and his mother had baked a cake. Then they came to take him away. (laughs) He tells his buddy that he wished now that he had taken the cake along with him. The other scene is that he tells his buddy, “now I hope the Americans come, and gets rid of the Russians, so that they can free us”).
CL, has made associations again. This I found to be interesting. The scenes have irony and are a bit funny. Freud in his writings, “Der Witz und seine Beziehung zum Unbewußten” or “Jokes and Their Relation to the Unconscious” , tell us that there is significant repressed unconscious material in jokes. We’ll see how this plays out…
NC: Could you play out the scene? Try. You are this guy talking to your buddy in prison. Say “I am in the garden of my parents, and my mother had baked a cake…”
Unlike psychoanalysis, where the therapist takes on the task of analyzing the joke for the client, in Gestalt Therapy, the client tells us his/her version of the story. This method is usually used in Dream analysis (or dream work) in Gestalt therapy. The client is invited to take a role in his dream (or in this case, story). His task is to talk in the first person. By this time, there was actually resistance on the part of the client. There were points in the session when CL started to intellectualizing, either by stepping out of the scene, or to make judgment of the scene, even though he was quite agreeable to doing this experiment of playing the part of the characters in his associations. Playing part in associations and dreams is usually uncomfortable for many people because they feel awkward, or they do not trust what they say or feel in this kind of work. My experience is that the client is seldom ever wrong in this sense.
CL: I am in the garden of my home. My parents are there. Mother has baked a cake.
NC: Tell me about the cake.
CL: Delicious. She baked it often.
NC: then what happened.
CL: Soldiers came to the gate, and took me away. Then I am in the prison talking…
NC: Slow down. What happened as they took you away…
CL: That is not in the book.
NC: They are at the gate, they ask you to come with them.
NC: What’s going on.
CL: I feel scared, I suppose.
NC: I can imagine.
CL: In I am not sure if I would ever come back.
NC: Yes. Now, come back here with me. Have you an understanding what is going on with this character in prison as told his buddy that he should have taken the cake along?
CL: He is scared, he wished his mother was there, he’s afraid he would never see her again.
NC: Would you like to work on the next scene?
NC: I am in prison and I hope…?
CL: I am in prison, I tell my buddy, I hope that the Americans come soon and drop bombs on the Russians.
NC: What is the purpose of that?
CL: to save us.
CL: We are trapped in prison.
NC: What does it mean to be in prison?
This part took a bit of time. We stayed with it together… Staying with the client’s pause is good point of contact. Contact is a very essential part of Gestalt therapy. It usually comes when the client touches something emotionally significant, and when the therapist is able to give support.
CL: No freedom… I am in danger… I am guilty… I feel hopeless… I feel helpless…
NC: in prison, no freedom, in danger, guilty…
The client, in his association, has come to contact with some deep feelings. These are unconscious until now. We can ask “what are you feeling guilty about…?”, but this might lead the client to intellectualizing. The cleaner path is to bring the client back to the present situation, the here-and-now.
NC: Tell me about what’s happening now. You being here with me now, we are talking now…
NC: are you in danger?
CL: no. I am safe.
CL: No… not hopeless nor helpless. (Takes a deep breath.)
Note that this is a condensed version of the dialogue. CL had a bit of difficulty with the associations at first, and this is normal. Why we worked these scenes is because they were freely associated, and my guess was that they had significance. The other clue that this was significant was the resistance of the client along the way of this experiment.
At the end of the dialogue, CL took a really deep breath reflexively. He looked calm, and said “I feel good”. “Fine,” I said, and we ended there.
This short session demonstrated a closing of a gestalt. The client had anxiety-related procrastination issues, and that led to a memory. This memory led to a group of unconscious feelings, which took solace is a kind of joke or wit, or an entitled way of thinking “I hope the Americans bombs the Russians..” These were also not fully owned by the client, since he attributes it to a story book. However, the client was really interested in the experiment, because he realized, too, that there was some kind of association between this story and his relationship to his father. The beauty of Gestalt therapy is that we help the client come to his own meanings and understanding through his experiencing and embodiment of the experience. The therapist’s work here was that of supporting, and not of prying.
In the following sessions we discussed this dialogue again in relation to CL’s relationship to his parents. There was even clearer understanding to the cultural significance of “jokes” or “making light” in tough situations. Also, there was a discussion about how we deal with anxiety and fear.
The rest of the associations with regards to this dialogue, I’ll leave it to you, the reader.
Kets de Vries gives a very detailed psychoanalytic account of a case study of an entrepreneur he names Nr. X. This case study illustrates how the inner and private life of the leader have significant effect on the performance of the leader. As the leader gets older, it is not unlikely that unresolved inner problems from childhood affect many areas of the individuals life, including his/her relationships and health.
Reason for Seeking Psychotherapy
Client: Mr. X, a 44 – year – old. Youngest of 6 siblings (2 brothers, 3 sisters). Occupation: Entrepreneur. Family Life: 21 years married but recently separated, 4 children.
Events leading to therapy request:
Mr X. had thrown his wife out of the house.
her increasing need for more independence had become a bone of contention.
He complained about her lack of caring and suspected that she was emotionally involved with a younger man working at the office (she worked in his company).
He is strongly annoyed that his children had taken the side of his wife.
History of depressive episodes (but not thought of as serious as now).
Has now feelings of worthlessness. No life prospects.
Fears losing his mind.
Problems at work due to wife’s (and young colleague’s) departure.
Worries about the company health. Fears of bankruptcy / humiliation as result.
Feels paralyzed at work. Not able to function. Feeling painful going to the office.
Psychosomatic complaints: nightmares, sleep problems, severe headaches which affects eyesight. Temporary loss of vision. Diarrhea and nausea. Impotence.
Mr. X’s thoughts about his father: a salesman / entrepreneur. Often away from home due to work. Remembered as a boisterous man who laughed a lot and brought him presents from his frequent business trips. Felt that he was his father’s favorite. When he was seven years old, his father became bedridden. Having his father in the house gave the boy the opportunity to spend more time with him. He began to feel close to his father. When he was 98 years old, his father died in a mental institution. This event was to Mr. X shrouded in secrecy. Mr. X is suspicious of the fact that his mother and elder sisters transferred his father to the mental hospital, thinking it was unnecessary and that it caused his death. He had tried a number of times to find out what had really happened, but had not been able to uncover the truth. The whole incident seemed to have been suppressed as a dangerous family secret. Mr. X suspected that his father had committed suicide which, given his family’s religious orientation, would explain the secrecy around the incident.
Mr. X’s recollection about his mother: Described as a very controlling, overprecise, critical woman who constantly worried about money and the future. After the death of his father she struggled maintaining the family also with coping financially. He felt that she saw everything in a
negative light. She never made a positive comment. Nothing he did was
ever good enough. He also described her as a perfectionist. He had never
been able to live up to her standards.
Mr. X’s recollection about his childhood life: Apart from the death of his father,his childhood was described as uneventful and quite happy. He felt proud of the fact that he had been something of a rebel as an adolescent.
Relationships with women:
Attitude to work: He used to be enthusiastic about his company, now feels it is too complicated and wants to give it away. Similar feelings about possessions.
Depression: feeling pessimistic, life is a sacrifice, fear of being alone. Feeling completely deserted due to wife’s departure from his life. According to Mr. X, he once used to have everything. Now things were different; his health had been ruined; his life was in a shambles. He felt worthless. He wondered what had kept him so busy at work in the past.
“He revealed that throughout his childhood he had been scared of losing control. He was reluctant, for example, to fight with other children for fear that he would lose control and kill someone.
Denial of inner reality and flight into external reality through work had
become a way of life. His defensive structure, however, of escaping into
action — ‘ the manic defense ’ (Klein, 1948) — no longer seemed to work.”
Dramatic mood swings, an all – or – nothing attitude. Very little was needed to push him in one direction or the other.
Repressed Emotions & Inner Reality
Denial of feelings of depression through unrealistic optimism, laughter, humor, frantic activity, and excessive control had always been an important element in maintaining Mr. X ’ s psychic equilibrium.
Attempts to fight his depressive state by eliminating negative thoughts. Turns to self-help books in order to improve ability to repress depressive reality.
This point of a person, and this happens often with people who are functioning and try to excel in aspects of their life through forcing themselves into change. i.e. When I feel hurt/stressed/sad/angry (any “negative” feelings), I try to escape by pushing myself to do better, to think positive. This works, but only very temporary. The breakdown that comes is usually catastrophic and very difficult to overcome. In Gestalt psychotherapy, there the paradoxical theory of change (Biesser, 1970).
Unfolding through Therapy
As Mr. X worked his way through therapy he was able to admit to himself several things that was repressed:
that his childhood was not so happy as he made it out to be. He realized his urge to think positive and believe positive (unlike how he sees his mother, as a pessimist). He realized how he was treated “like a baby” (which also means not being respected, and made to feel small), feelings of envy of his brother for the role of he man of the house.
He remembers using complaints of physical ailments to get attention, and being sensitive to children crying.
Was able to acknowledge his father’s darker side. That his father had beaten his children, stifle his behavior, strict rule enforcing.
His Oedipal memories.
His identification with his father’s tendency to be fake, hiding feelings.
He was able to grieve his father’s passing (which he had not the change to due to secrecy)
He comes to terms with his anger towards his mother, and also (as a child) feared that his other would die. He had fantasies that he might kill his mother when sleepwalking. His feeling of being unwanted by her, and wanting to prove to her that he was “worth it” to have as a child, and to admire him.
All emotions of aggression, guilt, grieve that accompanied these unfoldings.
Relationship with Women
Given the kind of relationship Mr. X had with his mother, it came
as no surprise that he perceived women as dangerous, over-controlling,
not really to be trusted.
Mr. X would divide women into two split categories, the easy and the proper. He had always been fascinated by prostitutes (and still was), but the fascination was accompanied by fear. Prostitutes were tempting but they could also be infected with diseases. He recalled an incident when he visited a prostitute. He felt that he had not treated her like other men. He had not taken advantage of her; he had gained her admiration.
As a young adult he had had many short relationships with women, treating them rather callously, usually dropping them when they became too clingy. He disliked feeling ‘ choked. ’
Dreams and Projections
He felt threatened by women. His dreams illustrated the role women played in his inner life. In many of his dreams, phallic women, portrayed as women with guns, would appear and lie on top of him, having intercourse while putting him in a passive position. He would wake up, frightened, feeling smothered. In other dreams, however, women would admire him from a distance. He described one dream in which he was persecuted by a number of large bees who kept striking at him. They were almost impossible to brush off. He associated this imagery with all the women he had dealt with in this life. Women could cling and sting, but also give honey. They could repel but also give pleasure. Gradually, however, dreams emerged in which he became more assertive with women, not taking such a passive role. Most importantly, in these dreams the degree of anxiety he had previously experienced was missing.
Being in Control
Starting and managing an enterprise had multiple meanings to Mr. X. It signified much more than a means of making a living. He had found out early in life, while employed by a German company, that working for others was too stifling.
These are projections, and much is known to be related to projections he has of his mother being controlling and having secretly done away with his father. Again identification with the father, being the victim of another’s control.
To be independent, to be in control, meant to be free from mother. His inability to work for other people (who would tell him what to do) made him decide to start on his own as his father had done before him. That was the only way to get some power, and no longer be subjected to the whims of others.
Transference of control and being controlled was reported to exist in therapy sessions.
What becomes apparent is his entrepreneurial mindset and work style slowly made sense to him, as his way of dealing with past traumas. It is his way of closing gestalts, and finishing unfinished business. This unfortunately leaves the real unfinished business open, and the only way that a person can live in inner peace is to work constantly. It is like filling water in a pot full of holes.
Mr. X also worked through other personality traits that developed as a result of being himself, basically. He was able to realize his meed for admiration, tendency for grandiose and depressive moods (bipolar disorder, perhaps), competitiveness, self-defeating behaviors,.
With the newly owned awareness and re-experiencing of past traumas, and the re-integration of his repressed emotions, Mr. X was reported to have slowly managed to get back to work, work with less stress, welcome his wife back into his life.
The process in which the patient manages to make positive changes to his life is through sitting through and experiencing what is there. What is in his real memories, his real childhood experiences. This is only possible with the accompaniment of a therapist, who is trained to support the client through the process. This process is very tedious and painful. The client has spent almost all his life trying to make changes by pushing his un-bearable realities to the unconscious. To not feel, to forget.
This is what it the paradoxical theory of change is about. When we try to elicit changes, in Mr. X case, when he tries to think positive, push himself to success, and try to do everything he can to overcome painful experiences, all he has achieved is a mountain of disappointments and stress. It is only through not changing. in just sitting in therapy and looking at all these childhood experiences, did his life really begin to change.
Beisser, A. (1970). The paradoxical theory of change. Gestalt therapy now, 77-80.
Klein, M. (1948). A contribution to the theory of anxiety and guilt. The International Journal of Psycho-Analysis, 29, 114.
Kets de Vries, M. (2009). Reflections on character and leadership.
Notice that this question starts not with the “what” but with the “who”. How psychotherapy works is unlike in other medical fields, in which the doctor does the healing “work” while the patient lies restfully and tries to recuperate from his symptoms. In psychotherapy the therapists functions to support the patient in his/her efforts to alleviate his/her own symptoms.
The beauty of a successful outcome in psychotherapy is that it happens, it is permanent, and it leads the patient to a far better quality of life.
This means that the patient’s input is essential to the outcome. It is the skill of the therapist to lead the patient to this engagement. There are many techniques that can be employed, and hence many kind of therapies. However these methods are essentially means to guide the patient towards the motivation and awareness of him/herself. The ultimate work happens when there is contact between the client to him/herself and to the therapist. This contact takes effort on the part of the therapist to nurture, and when it happens, the patient feels a “shift” in his/herself. This shift is an indication the something internal has changed.
This may sound abstract, and it is. Psychotherapy is a craft and a skill learned. To be a psychotherapeutic client with successful outcome is also learnt. The beauty of a successful outcome in psychotherapy is that it happens, it is permanent, and it leads the patient to a far better quality of life.
That is the goal of therapy: to relieve psychological or somatic symptoms through dialogue and contact. A patient suffering debilitating panic attacks, for example, slowly learns the psychological process and childhood experiences behind these attacks. The therapist supports him/her into contacting his/her unconscious activity and past emotions and unmet needs. In receiving this contact, the therapist works with the client through these experiences. The client is then able to make meaning of these experiences and learns to find resources to deal with pending situations.
So, who is psychotherapy for? It is for anyone who needs clarity in his/her life. He/she does not need to be “sick” or “dysfunctional” to start therapy. In actuality, it is better (and also cost-effective) to enter therapy as a healthy, stressed out, panicky individual, than to wait till the stress becomes too overwhelming.