Stijn Vanheule, Paul Verhaeghe “In search of a framework for the treatment of alexithymia.” Psychology and psychotherapy. 2010
From 1949 onwards, Lacan developed his theory on the mirror stage, wherein the other plays a central role (Lacan, 2006). In short, his starting-point is that human development starts with an experience of organic disturbance and discord. The infant lacks sensory and motor coordination and is moved by needs and impulses it cannot control. In Lacan’s interpretation, the ego comes into being as a reaction against this troubling state. The basis of it is the identification with a body image, which is acquired by identifying with the image of the other. Given its roots in images, this type of identification is called imaginary. The body image offers the infant an opportunity to see itself as a unity, and thus to achieve self-mastery. In the mirror stage, the image of the other serves as a basis for creating a self-image, which indicates that the actual presence of the other is important for creating this experience of unity (for a more detailed account of Lacan’s theory on the mirror stage and identity formation, download an article by Verhaeghe)
On the other hand, Lacan emphasizes that the role of the other is not limited to its function as an image. Via the other the infant is introduced to language and culture, or in what Lacan calls the symbolic order. His basic idea is that by means of language and narration, names are given to the child, its inner life, and the surrounding world. Along this way, the child builds mental representations of itself and the world, and assumes (sub-)cultural ideas and rules on human functioning. By means of the symbolic order discourses are imposed onto reality, as a result of which the child’s internal and the external world start to be comprehensible and controllable.
Lacan, J. (2006). “The mirror stage as formative of the function of the I.” In B. Fink (Trans.), Ecrits, The first complete Edition in English (pp. 75–81). New York: Norton. (Original work published 1949).
In our therapeutic approach, we assume that crucial subjectively touching and painful experiences overwhelm the alexithymic actual-neurotic patient. These experiences are ‘unmentalized’, meaning that they have not properly been named by means of language, and have not been incorporated into an autobiographical account. The goal of the treatment is tomentalize these painful experiences by helping the patient to gradually name them. The condition for this process is the installation of a containing therapeutic relationship.
In working with actual-neurotic alexithymic patients, we suggest a three-step logic. The basic idea is that during the process of therapy mental representations of difficult situations in patients’ lives need to be constructed by
(1) putting into words the chain of events that makes up the difficult situation;
(2) making the patient’s appraisal of the difficult situation explicit; and
(3) addressing affective responses and discussing the patient’s way of dealing with the difficult situation.
These three steps reflect principles that should be integrated in therapy. In practice, these three steps necessarily get intermingled, and we advise against considering them in terms of a protocol or in terms of therapeutic phases. The therapist shouldfirst start by asking the patient about his actual life and by exploring what goes wrong, with the idea of creating a conversation. Practically speaking, such a conversation focuses on the concrete situations the patient presents as important and difficult (trouble at home, an incident with a colleague . . . ).
In addressing these events, the therapist primarily strives to elicit a factual account that is coherent with the patient’s story. The aim is to construct the chain of events that makes up specific difficulties, and to create an elementary narrative about these difficulties. To construct such narrative, the therapist converses with the patient: many open questions are asked, summaries of what has been said are frequently given, and a relaxed atmosphere is established. It is important that the therapist strives to articulate the difficult situation in the patient’s own terms; explicitly recognizes the patient’s trouble in dealing with the situation; and invites him/her to further investigate this problem in therapy. Therapy itself is defined as a place for the investigation of difficulties in life.
Clinical vignette
The following clinical vignette illustrates both our conceptual model and the practica-bility of our therapeutic principles. Emma is a 45-year-old woman currently in therapy with the first author. She was urged to start psychotherapy by her general practitioner for her reported familial problems, depression, dipsomania, and somatizing reactions to The treatment of alexithymia distress. Therapy with Emma began in May 2008 and she underwent 60 sessions by April 2010.
The main transition that took place during the therapy was that Emma’s affective responses became a topic of reflection. A problem that came to the fore during the diagnostic sessions was Emma’s apparent confusion about her feelings – ‘when I feel bad, I don’t know what to do, I don’t know whether I feel sad or angry’ – and her intolerance towards manifestations of affects – ‘I don’t have time to stand still; things have to go on’. Specific events in her family life proved to affect her intensely, yet Emma’s typical reaction was to flee, to one of the two jobs she is efficiently combining; to her time-consuming hobby; or to drinking in her bedroom.
A slip of the tongue that occurred during the third session was most illustrative of this; Emma said ‘I always drink away my feelings’, instead of ‘I always push away may feelings’. Emma’s intolerance towards affective experiences also manifested during the initial diagnostic sessions.
Attempts by the therapist to talk about her problems with family members and her reactions to these problems provoked irritation, and were each time blocked by a tirade about the weakness of her husband or the unstable temperament of her daughter.
During therapy this affect intolerance was addressed by applying our three-step logic. First, we focused on letting her articulate specific events that she qualified as difficult. Typically, these events were interpersonal situations. The therapist invited her to describe these in detail by asking a number of questions: what did she do, what did others do, what does she think about her own actions, and about others’ actions. Most often, events from the past week were discussed. In the process of therapy, this type of reflection first proved to be successful in relation to work-related problems. Such problems were never mentioned during the diagnostic sessions, yet, early in therapy a conflict with a colleague and a manager at work took place. The colleague took a decision that Emma was harmed by and the manager took her colleague’s side. This infuriated her. At work, she ran away in tears and in therapy both were called all sorts of names. In therapy, the problem was dissected in detail, which made clear that Emma felt offended by the fact that her colleague burdened her with extra work, and meanwhile succeeded to impress the manager for her exceptional devotion to work. As therapy progressed more sensitive conflicts were discussed, like romantic difficulties and problems in dealing with her daughter.
In Emma’s case, addressing work-related problems first seemed to pave the way for effectively addressing family-related problems. During the sessions, Emma was often bothered by the specific events that were discussed, but she did not refuse this type of reflection. Her spontaneous tendency to quickly switch away from these events was explicitly countered by the therapist who picked up the same situation over and again during the session, and invited her to investigate in detail exactly what happened. Along this way, a mental representation of the difficult event was constructed, and gradually a pattern of reflecting on other mental representations during the therapeutic sessions was installed. The sessions thus became a place of constructing detailed mental representations of difficult situations. The therapist thereby tried to incarnate the principle of putting into words as clearly as possible what was difficult for Emma.
In the second step, after constructing the chain of events, Emma was invited to indicate why exactly she thought she, or the others involved in the situation were acting correctly or not. Much time was devoted to elaborating detailed appraisals of various situations. For example, by recounting the difficult situation with her colleague and manager several times, Emma began to realize that she herself partly paved the way for her colleague to take advantage of her: Emma frequently took on tasks that her colleague should have actually fulfilled, which made her realize that she was in fact partly responsible for the problem.
This conclusion was only obtained due to the therapist’s ‘deliberate non-understanding’ of the situation and his surprised questioning on the nature of her problems. This gave rise to an exploration of the problem from different angles.
In the third step, efforts were made to adequately name Emma’s experience of distress, and attention was paid to her way of dealing with it. Her spontaneous fleeing reactions were discussed and alternative ways of reacting to troubling events were explored. Emma gradually came to mentally represent her inner affective world. In terms of her work-related problem Emma began to recognize her own sadness and shame about her submissive attitude; she was not only angry about the colleague’s and the manager’s way of dealing with her, but also about her own attitude. Following our three-step logic was not always easy. The two moments of rupture in this therapy in fact took place when events that were very painful to Emma were discussed.
A first rupture took place during a period that was most difficult with her daughter. Emma wanted a psychiatric intervention for her daughter, but the therapist expressed disapproval. This infuriated Emma and she terminated the session. Telephone calls were not answered, and the therapist left a message, inviting her to continue therapy. After 4 weeks, she called back. Her daughter was not referred to a psychiatric service; she herself felt bad and eventually wanted to discuss the situation in therapy. Upon her return to therapy, Emma was invited to discuss her own reactions to the painful situation she ran away from. The discussions followed our three-step logic, and explored Emma’s way of dealing with tension and distress in relation to the therapist’s interventions. These discussions were difficult to the patient, but are important in terms of enhancing her capacity to tolerate conflict. During the discussions, she often burst out in nervous laughter, and showed non-verbal signs of disdain. The therapist addressed these and asked her what she was expressing. Along this way, she came to recognize her anger, helplessness, hopes, and sorrow, starting from which broader family-related problems were explored.
Conclusion
Inspired by Freud’s theory on actual neurosis, we consider alexithymia as a difficulty in processing and regulating affective arousal by means of mental representations. It is a marker of two underlying processes: problems in developing accounts of one’s own experiences of arousal, due to which arousal remains present as bodily distress; and a failure to make use of interpersonal relationships and communication with others for managing distress.
We suggest that psychotherapy with alexithymic patients should address both processes. Starting from Lacanian theory, we think that therapy should largely focus on naming and verbally articulating specific problematic events in patients’ lives. By means of language, experiences can be shared and situated in relation to culturally prevailing ideas and practices. From psychoanalytic attachment theory, we retain the idea that mirroring is a tool that is at the therapist’s disposal in addressing the patient’s distressing experience of arousal.
Based on these theoretical reflections, we suggest focusing therapy with alexithymic actual-neurotic patients on specific distressing events in their lives, starting from which a three-step logic can be deployed. The basic idea is that during the process of therapy mental representations of difficult situations in patients’ lives need to be constructed by (1) putting into words the chain of events that makes up the difficult situation; (2) making the patient’s appraisal of the difficult situation explicit; and (3) addressing affective responses and discussing the patient’s way of dealing with the difficult situation.
The case of Emma highlights how this logic can be implemented practically, and indicates that this approach works well. Both an intermediate assessment of alexithymia and the therapist’s own observations suggested that with this three-step logic Emma was able to construct mental representations of the distressing situations in her life and her affective reactions to them. These therapeutic sessions functioned as a place where mental representations could be constructed, and where a habit of building mental representations in relation to distressing events was gradually installed.