Skills-based Treatment for Alexithymia: An Exploratory Case Series

Mataji Kennedy and John Franklin

Macquarie University, Australia

This paper describes a skills-based intervention for the treatment of alexithymia. The intervention incorporates components to address the following three areas: the relationship between alexithymia and early life experiences, identifying feelings and expressing feelings. The efficacy of the intervention was explored using three individual case studies extending over 1624 weekly 1-hour sessions. A number of questionnaires were administered at five time intervals. The results suggest that the treatment was effective in reducing alexithymia within the three individuals and in helping them to clarify, identify and describe their feelings. Following treatment the participants were less ambivalent about expressing their feelings and more attentive to their emotional states. The results were generally maintained at a 1-year follow-up for two of the three cases.

lexithymia is a psychiatric term meaning lack of words for emotion (Sifneos, 1967) and it is a relatively recent term, having been coined in the late 1960s. The newness of the concept is reflected in the small number of well-validated assessment instruments in the area (Stephenson, 1996; Taylor, 1984) and the lack of research studies exploring the efficacy of treatment interventions. Alexithymia is characterised by the following:
(a) difficulty describing feelings; (b) difficulty distinguishing between feelings and the bodily sensations that accompany emotional arousal; (c) lack of introspection; (d) social conformity; and (e) impoverished fantasy life and poor dream recall (Taylor, 1994, p. 64).

Alexithymia is an important clinical concept. Research suggests that in a normal population more than 8% of men and 12 % of women fall within the alexithymic range (Blanchard, Arena, & Pallmeyer, 1981). These rates are higher within other populations: Mendelson (1982) found 47% of chronic pain patients were alexithymic and research suggests it maybe an underlying issue associated with a range of

problems such as eating disorders (Barth,1994), substance abuse, posttraumatic stress disorder and depression (Taylor, 1984). Alexithymia may be linked to illness behaviour and increased mortality rates (Lumley, Tomakowsky, & Torosian, 1997), as an ability to identify and express emotion may act as a protective factor against physical and mental ill health. A lack of emotional awareness impacts greatly on an individuals quality of life and is a major impediment to a persons ability to successfully connect with others and to have close and meaningful relationships. Many therapeutic interventions assume individuals have ready access to their emotions and when this is not the case therapy may be difficult, or even unsuccessful, and the chance of relapse heightened. Addressing alexithymic issues as a separate part of treatment, or before or after other treatments, may have important implications for symptom reduction, success of therapy and relapse prevention. A review of the literature suggests that treatment interventions for alexithymia fall within a range of orientations but there are three

Address for correspondence: Mataji Kennedy, Department of Psychology, Macquarie University, NSW 2109, Australia. Email: matajik@hotmail.com

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main types: psychodynamic therapies, cognitive-behavioural and skills-based therapies, and experiential therapies. There is very little research exploring the efficacy of these interventions, making conclusions about the responsiveness of alexithymia to treatment a difficult task. The goal of psychodynamic therapies in the treatment of alexithymia is to enhance patient insight and to explore defense mechanisms that hamper the individuals ability to identify and express emotion. Sifneos (1983), Krystal (1988) and McDougall (1982) use a psychodynamic approach in the treatment of alexithymia. The psychodynamic model views the role of early developmental experiences as important in the etiology of alexithymia; these include traumatic experiences or interactions between the caregiver and the child. Cognitive-behavioural and skills-based therapies teach the patient specific skills to identify and express emotion. Levant (1995, 1998) uses a skills-based approach in the treatment of men with what he calls normative male alexithymia. Linehan (1993) and DonaldsonPressman and Pressman (1997) describe treatment techniques for use with individuals who have difficulty identifying and expressing emotion. Neither of these treatments were specifically designed for the treatment of alexithymia per se, but nevertheless provide valuable techniques that could be used with these individuals. These types of treatments highlight the importance of the role of the family and the socialisation process in the development of alexithymia. Experiential therapies are concerned with the clients current situation and are less concerned with linking early learning experiences or the discussion of unconscious material to the presenting issue. The goal of these types of therapies is to stimulate experiential processing rather than directly changing the patients cognitions or behaviour (Greenberg, Rice, & Elliot, 1983). Shear, Cloitre, and Heckelman (1995) describe the use of an emotion-focused treatment in helping panic disordered people identify, understand and express emotional reactions. The emotion-focused treatment is not specifically designed to treat alexithymia but

provides techniques that could be used to treat the condition. Each of these three perspectives provides a different view of the etiology and philosophy for treatment with respect to alexithymia. There does, however, seem to be some synergy across the content of therapy and techniques used in each of these treatments. In particular, each of the therapies seems to cover one or all of the following areas: Exploring the relationship between alexithymia and early life experiences including rules within the family of origin for expressing emotion. Identifying feelings. This includes the ability to differentiate and label emotion and to understand why feelings occur in certain situations. The validation of the clients emotional experiences is also important. Expressing feelings. This includes validation of the clients right to express emotion. Therapy assists in the development of skills to verbalise emotions and manage emotional expression. The purpose of the current paper was to: Develop a skills-based intervention for the treatment of alexithymia. The intervention was an integration of techniques from the work of Donaldson-Pressman and Pressman (1997), Levant (1995) and Linehan (1993) and incorporated components to address the three areas of (a) the relationship between alexithymia and early life experiences, (b) identifying feelings and (c) expressing feelings. Evaluate the efficacy of the intervention via three individual case studies. It was hypothesised that the skills-based intervention would enhance the individuals ability to identify and describe their emotional experiences. The study would also provide important information regarding the responsiveness of alexithymia to treatment and, in particular, to a skills-based intervention.

Method
The study utilised an experimental single case design because such designs tend to be

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more appropriate to clinical practice as alterations are made based on client needs (Galassi & Gersh, 1991).

what emotion I am feeling and It is difficult for me to find the right words for my feelings. APRQ. The APRQ (Krystal, Giller, & Cicchetti, 1986), is a non-self report interviewer administered questionnaire designed to prompt verbal expression of emotion. The APRQ has significant face validity, inter-rater reliability, and is correlated with other measures of alexithymia. It has also been found to distinguish between psychiatric subject samples on the alexithymia construct (Krystal, 1988; Legorreta, Bull, & Kiely, 1988), although further work is needed to clarify its properties. The APRQ consists of 17 questions each rated as 1 for a non-alexithymic response and 0 for an alexithymic response, therefore lower scores on this measure indicate higher levels of alexithymia. It includes items such as: How would you feel if someone called you a thief? AEQ. The AEQ was developed by King and Emmons (1990) to measure the level of ambivalence associated with emotional expression. The AEQ consists of 28 self-report questions worded to reflect the ambivalent nature of expressing a range of positive and negative emotions (e.g., I try to suppress my anger, but I would like other people to know how I feel). Respondents rate each item on a 15 scale, with higher scores being associated with higher ambivalence. Preliminary studies suggest the reliability and validity of the AEQ to be sound (King & Emmons, 1990). CWM. The CWM was developed for the purposes of this study and consists of four questions. Each question relates to a characteristic of alexithymia as defined by Kleinberg (1996, p. 76): an inability to identify, differentiate, manage and articulate their own emotions. The first question relates to the ability to identify somatic type symptoms that may be related to emotion; the second question relates to the ability to identify and differentiate specific emotions; the third question relates to the ability to manage the expression of emotion in a constructive way; and the fourth question relates to the ability to find the right words to express emotion. Each question is rated on a 1 to 5 scale with higher scores being related to lower levels

Participants
The three participants selected for the study originally presented with anxiety disorders at the Macquarie University Clinic where they received treatment for the anxiety symptoms. Clients were asked to complete a package of questionnaires (see Measures section) and on the basis of the results of the Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994) were rated as alexithymic or borderline alexithymic. Following the initial course of treatment, participants were invited to receive ongoing treatment and participate in the current study.

Measures
Seven questionnaires were used in the current study and were administered at five time intervals: beginning of baseline, beginning of treatment, end of treatment, 1-month follow-up and at 12-month follow-up. The questionnaires used in the study were: Toronto Alexithymia Scale (TAS-20), Alexithymia Provoked Response Questionnaire (APRQ), Ambivalence over Emotional Expression Questionnaire (AEQ), Client Weekly Measure (CWM), Trait Meta Mood Scale (TMMS), Emotions Profile Index (EPI) and the Symptom Checklist-90-R (SCL90-R). The CWM was also administered weekly throughout the treatment phase. TAS-20. The TAS-20 (Bagby et al., 1994) appears to be the most valid self-rating scale for alexithymia and has been used extensively in a wide range of clinical research. The TAS-20 is an internally consistent measure of traits related to alexithymia. The three factors of the scale are: difficulty identifying feelings, difficulty describing feelings and externally orientated thinking. The TAS-20 consists of 20 self-report questions; each item is rated on a 5-point scale with higher scores indicating alexithymic tendencies. Studies investigating the validity and reliability of the TAS-20 have found it to be a psychometrically sound measure (Bagby et al., 1994; Bagby, Taylor, & Parker 1994). It includes items such as: I am often confused about

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of alexithymia. Items include: Over the last week, if you felt upset, how able were you to identify the exact emotion or emotions you were experiencing? TMMS. Salovey, Mayer, Goldman, Turvey, and Palfai (1995) designed the TMMS to measure an individuals ability to attend to their moods and emotions, discriminate clearly among them and regulate them (p. 128). The three scales of the TMMS are Attention to Feelings, Clarity of Feelings and Mood Repair. The TMMS consists of 48 self-report questions; each item is rated on a 5-point scale. The higher the score on each of the three subscales the higher the individuals tendency to display these characteristics. Items include: I dont usually care much about what Im feeling. The reliability and validity of the TMMS has been explored in a number of studies and found to be sound (Salovey et al., 1995). It has been used in a number of clinical studies (e.g., Goldman, Kraemer, & Salovey, 1996). EPI. Plutchik (1960) developed the EPI, which is a personality style test based on the postulate that there are eight basic or primary emotion dimensions: fear, anger, joy, sadness, acceptance, disgust, expectancy and surprise. All other emotions are said to be a mixture or synthesis of the basic emotion dimensions. It consists of 62-forced choice item word pairs that require the test taker to choose one item in a pair of words. It is composed of 12 trait terms that are combined into pairs. The scoring is based on the emotion implied by the trait term (e.g., shyness implies fear and quarrelsome implies anger). The EPI has been normed across a number of populations including normal and psychiatric groups and reliability and validity data suggests it is a sound measure. The EPI has been used in a number of clinical studies (e.g., Catipovic, Ilakovac, Durjancek, & Amidzic, 1996; Uherik, 1983). SCL-90-R. The SCL-90-R (Derogatis, 1979) was used in the current study to measure the amount of psychological distress and to measure the symptoms associated with a number of psychological disorders. It was included as part of the measurement battery in order to determine the impact, if any, of the current

intervention on global psychological functioning. The SCL-90-R consists of 90 questions rated on a 4 point scale and higher scores indicate higher incidences of clinical symptoms. The SCL-90-R has nine clinical scales: somatisation (SOM), obsessive-compulsive (OC), interpersonal sensitivity (IS), depression (DEP), anxiety (ANX), hostility (HOS), phobic anxiety (PHOB), paranoid ideation (PAR) and psychoticism (PSY). There are also two global measures, the Global Severity Index (GSI) and the Positive Symptom Distress Index (PSDI).

Data Analyses
The data was examined both graphically and with the aid of an approximate test based on the mean and standard deviation of the baseline and pretreatment measures. If the scores of the posttreatment measures were different from the mean of the baseline and pretreatment measures by greater than two standard deviations (either higher or lower), the graph was examined for a possible effect. When the standard deviation of the baseline and pretreatment measures was zero, the analysis was confined to inspection of the graph. The Client Weekly Measure was analysed differently as it was administered on a weekly basis. The weekly data was analysed via linear and quadratic regression and by inspection of the graphs. Because for one of the subjects, Case 2, the values were auto-correlated (values of the Durbin-Watson statistic departing from 2; Neter, Wasserman, & Kutner, 1985), the significance tests were not reported, and r-square values were used to evaluate the goodness of fit.

Treatment Procedure
The treatment phase lasted 1624 weeks. Prior to treatment there was a 4-week baseline period and after treatment there was a 4-week followup period. The treatment phase consisted of 1624 weekly 1-hour therapy sessions. Treatment covered five main areas: assessment of alexithymia, identifying possible antecedants of alexithymia and emotional expression, identifying feelings, expressing feelings and practice at identifying

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and expressing emotion. The following is an abbreviated outline of the treatment. Assessment of alexithymia. This involved an assessment of the clients emotional issues and their ability to experience and express a range of emotions (Levant, 1998). The assessment involved understanding the clients ability to differentiate discrete emotions from somatic sensations. Clients were assessed for their awareness and expression of vulnerable emotions such as worry, fear, anxiety, sadness, dejection, hurt, abandonment, caring/connection emotions such as concern, caring and love. The clients awareness of anger type emotions and the intensity to which they are experienced were explored. Also explored was the clients ability to experience emotions at a range of intensities and their awareness of mixed emotions and ability to tolerate emotional ambiguity. Identifying antecedants. This involved understanding past and current relationships with family members and the rules within the family of origin for experiencing and expressing emotion. The therapist discussed with the client the current research in the area that suggests familial issues are a predictor of alexithymia. Discussion focused on the clients limitations in their ability to understand and express emotions and how these limitations came about, drawing on information collected from the assessment phase. Homework during this phase included writing diary notes on rules within their family of origin for expressing emotion. Identifying feelings. This involved a discussion of the process of recognising and experiencing feelings. A major part of this was validating the clients right to experience emotion and helping the client to self-validate emotional experiences. This included a discussion of what feelings are and why they are important. The therapist helped the client acknowledge that they actually do experience feelings and observes and helped label the clients emotions, body sensations, facial expressions and identifies undifferentiated affects into discreet emotions (Linehan, 1993). By doing so the therapist helped patients to develop skills in identifying and analysing their own emotional experiences.

Homework exercises included listing a range of feelings, developing an emotional vocabulary and keeping a feeling journal to identify and label feelings and related physical sensations (Donaldson-Pressman & Pressman, 1997), making the connection between situations, thoughts, interpretations, emotion and behaviour. Expressing feelings. This involved discussing the clients right to express feelings and validating that feelings are important and useful to understand and express within their life. This was discussed because, it is easier for the individual to express emotion once they recognise that they experience it. The therapist continually encouraged the client to put their feelings into words within the therapy sessions. Homework exercises and techniques used within this phase include self-expression skills and I statements. Practice. Practice occurred throughout phases 3 and 4 but was most concentrated towards the end of therapy. During this phase the client was asked to bring to session situations during the week where they had experienced an emotional reaction. Clients were asked to record the issue in their feeling journal. The therapist helped the client to explore the context, physical sensations, themes and cognitions associated with the emotional reaction and to put the emotions into words.

Results Case 1 Nathan

Participant. Nathan was a 39-year-old male who presented at the clinic with generalised anxiety disorder (GAD). He initially received treatment for his GAD and then received 24 weekly treatment sessions as part of the current study. He presented with difficulty in decision-making in most areas of his life and a tendency to intellectualise issues. Nathan also had difficulty in connecting with others on an emotional level and had had a series of unsuccessful relationships. He had difficulty in identifying his emotional needs and appeared unaware of his emotional self. Nathan was not able to use emotional information in his decision-making.

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An assessment of his emotional issues suggested he had a fear of experiencing or expressing anger and difficulty with vulnerable emotions such as hurt, rejection or abandonment. He said it was easier for him to show his feelings through action such as giving someone a hug rather than putting his feelings into words. Feelings that were a mixture of positive and negative emotions were particularly difficult for him to identify and he said that emotions needed to be at the high end of the intensity spectrum before he could acknowledge them. Nathan described his family life as one where he was often fearful of his father losing his temper. His father was a strong disciplinarian and he recalls being fined as a child for showing anger. He said feelings were not talked about within the family and there was a sense that there had to be a justifiable reason for experiencing and expressing any emotion.

Results and Discussion

The results suggest Nathans level of alexithymia dropped following treatment as he became more able to identify and describe his feelings and his focus moved from an externally orientated to internally orientated thinking style. This is reflected in the TAS-20 and APRQ results (see Table 1). The TAS-20 indicated a reduction in the total score and on the difficulty identifying feelings, difficulty describing feelings and externally orientated thinking subscales, these results were maintained at follow-up. The APRQ increased following treatment and this was maintained at follow up. Nathan became more attentive to his emotional states and more emotionally expressive. The TMMS showed an increase on the Attention to Mood and Clarity in the Discrimination of Feelings subscales at end of treatment and at follow-up. The AEQ decreased following treatment and this was maintained at follow-up. Results on the CWM suggest that both the linear and quadratic regression models were statistically significant ( p < .01), although the Quadratic model was a better fit as indicated by the r-square of 0.371 (see Table 1). The regression line suggests (see Figure 1) that results on

the CWM showed an upward trend or improvement over the course of therapy. The questionnaire results were supported by the experience within therapy where he was able to experiment with expressing his feelings to others close to him and was rewarded with a positive response from these people. He became more able to experience and identify a range of emotions within the sessions, at times being able to cry and present feelings of vulnerability without a sense of shame. Nathan was able to identify feelings of anger at varying levels of intensity and to express anger appropriately without fear of anger damaging the relationship. Results on the SCL-90-R and the EPI at baseline/pretreatment suggested he had a tendency to choose the most socially desirable option or present himself as well-integrated and unemotional (Plutchik & Kellerman, 1983; Derogatis, 1979). This tendency decreased somewhat following treatment. This is reflected in results on the EPI following treatment which suggest he was less likely to describe himself as gregarious and trustful. The impact of treatment on his global level of psychological functioning was minimal as his results on the SCL-90-R suggest there was only modest change on the GSI at follow-up.

Case 2 Mary
Participant
Mary was a 58-year-old woman who presented to the clinic with panic disorder with agoraphobia and generalised anxiety disorder. She received treatment for these conditions and was then referred for treatment as part of the current study. Treatment consisted of 16 weekly sessions. She said she felt her emotional self was hidden behind an impenetrable barrier and she had always had difficulty sharing her feelings with those close to her. Mary said she kept herself on an even keel emotionally and would not allow herself to experience negative feelings. An assessment of her emotional issues suggests she would only express her feelings if they were very intense. Mary was unable to identify her own emotions or the emotions of others. She said it was very rare for her to experience anger and if she did she was more likely

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CASE 1 F/Up 1 mth 33 10 8 15 56 30 13 2.32 3.89 7 61 34 43 98 39 20 93 26 16 14 36 94 79 33 35 83 8 63 5 3.43 16 34 34 87 21 99 10 25 75 4 52 37 20 88 88 48 40 76 14 8 59 86 59 44 90 55 10 66 62 16 4 6 1.96 4.36 3.48 55 39 19 35 19 27 54 32 22 50 33 23 57 23 26 52 33 20 3.76 13 57 19 7 88 75 74 80 55 21 59 36 19 12 29 8 6 15 71 26 18 27 49 13 11 25 49 16 15 18 58 16 16 26 57 16 14 27 52 20 20 12 44 15 14 15 65 37 22 3.64 3.25 12 F/Up 1 yr Baseline* PostTrx F/Up F/Up 1 mth 1 yr Baseline* PostTrx F/Up F/Up 1 mth 1 yr CASE 2 CASE 3

TABLE 1

Results for Cases 1, 2 and 3

Measure Sub-scales

Baseline* PostTrx

MATAJI KENNEDY AND JOHN FRANKLIN

TAS-20 Total Identify Describe Ext Thinking

59 21 19 19

29 10 7 12

57 23 18 16
64 32 18 3.75 15

TMMS Attention Clarity Repair

50 24 16

74 37 16

AEQ

2.82

2.11

APRQ

11

16

SCL-90-R (T score) GSI

41

42

60
34 20 77 59 44 93 26 49

64
54 20 65 59 35 33 60 84

64
18 5 77 92 11 48 78 20

EPI (Percentiles) TRUST DYSC TIMID DEPRESS DISTRUST CONTROL AGGRESS GREGAR

90 12 93 27 25 68 6 67

82 2 91 62 41 68 10 59

74 3 94 45 33 81 4 45

TABLE 1 is continued over the page

Note: * Baseline scores were calculated by taking the mean of the baseline and pre-treatment scores. Scores in bold indicates those scores where movement was in the predicted direction (either 2 SD higher or lower than baseline or inspection of the graph showed an effect) Scores in italics are those scores that have moved but not in the predicted direction. Scores that are in normal type are scores where no change occurred.

TABLE 1 continued CASE 1 F/Up 1 mth F/Up 1 yr Baseline* PostTrx F/Up F/Up 1 mth 1 yr Baseline* PostTrx F/Up F/Up 1 mth 1 yr CASE 2 CASE 3

Measure Sub-scales

Baseline* PostTrx

CWM Linear Regression TOTAL

r-square = 0.392, p < .01

r-square = 0.422, p < .01 (sig tests are questionable due to autocorrelation) r-square = 0.423, p < .05 (sig tests are questionable due to autocorrelation)

r-square = .015, p >.05

Quadratic Regression TOTAL

r-square = 0.397, p < .01

r-square = .220, p > .05

Note: * Baseline scores were calculated by taking the mean of the baseline and pre-treatment scores. Scores in bold indicates those scores where movement was in the predicted direction (either 2 SD higher or lower than baseline or inspection of the graph showed an effect) Scores in italics are those scores that have moved but not in the predicted direction. Scores that are in normal type are scores where no change occurred.

SKILLS-BASED TREATMENT FOR ALEXITHYMIA: AN EXPLORATORY CASE SERIES

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FIGURE 1 Client weekly measure scores; Case 1.

to leave the situation rather than expressing it. Feelings of vulnerability were also difficult such as worry, abandonment and sadness. She was not able to cry in front of others. Mary was adopted as a baby and recalled that her adopted parents were not emotionally available to her and were busy with work the majority of the time. One of her early memories was losing her nanny who she was very close to at age 4. At this stage she said she believed her emotions became frozen and she felt very alone and terrified. Emotions were not spoken about within her family and she could not recall being cuddled or held as a child. Mary had a series of losses within her life and she had learnt not to make demands upon others or ask for what she needed for fear of driving people away.

Results and Discussion

The results suggest the level of alexithymia dropped following treatment and this was maintained somewhat at follow-up. She was better able to identify her feelings and became more attentive to her emotional states. This was reflected in her results on the TAS-20 (see Table 1), where the total score and the subscales of difficulty identifying feelings and difficulty describing feelings decreased following treatment. At follow-up, only the results on the difficulty identifying feelings subscale

was maintained at a reasonable level, although the results on the other subscales and the total score continued to show a decrease when compared to baseline/pre-treatment. Results on the APRQ were unchanged at end of treatment but showed an increase at follow-up. Results on the TMMS suggest an increase on the Attention to Mood and Clarity in the Discrimination of Feelings subscales at the end of treatment although only the Attention to Mood was maintained at follow-up. Mary also became less ambivalent about expressing her emotion and her levels of negative emotionality, in particular depression dropped. The AEQ decreased following treatment and was maintained at follow-up. The EPI showed a decrease on the Depressed dimension and no change on the other dimensions with the exception of the Timid and Aggressive dimensions which increased at follow up. There is some indication, however, that describing and expressing her feelings to others continued to be difficult. This is reflected in the TAS-20 subscale of difficulty describing feelings which remained unchanged at follow-up. Within the therapy sessions, she initially had great difficulty recognising her emotional reactions and labelling them. It would take her 4 hours to do a homework exercise that would take others 30 minutes to complete. Through the course of

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FIGURE 2 Client weekly measure scores; Case 2.

treatment she became more able to pinpoint what she was feeling and express it. She began to discuss her feelings using rich analogies and was aware of and able to interpret the emotional content of her dreams. She said she felt excitement and joy about knowing more about herself and becoming connected with her real self. Results on the CWM suggest that both the linear and quadratic regression models were a reasonable fit for the data as indicated by the r -square values (see Table 1). Significance values for these models must be considered with caution due to the auto-correlation of the data; however, examination of the graph (see Figure 2) suggests the CWM results showed an upward trend or improvement over the course of therapy. The impact of treatment on Marys global level of psychological functioning was minimal as suggested by her results on the SCL-90-R; the GSI measure remained unchanged following treatment and at follow up.

Case 3 Colleen
Participant
Colleen was a 49-year-old woman who originally presented at the clinic with panic disorder with agoraphobia where she received treatment to deal with the anxiety and panic symptoms.

After this she became involved in the current study and was seen for 16 weekly therapy sessions. Colleen had a 28-year history of alcohol abuse but had been sober for the last 6 years and had difficulty both identifying what she was feeling and expressing these feelings in words. Previously she had used the alcohol to suppress her emotions and found that since ceasing to drink, her emotions at times overwhelmed her. She questioned her right to have emotions or to express what she was feeling. An assessment of Colleens emotional issues suggested she had difficulty expressing a range of emotions including anger, caring emotions such as love or vulnerable emotions such as sadness. She would tend to bottle the emotion up and try to hide it from others. Often she felt uncomfortable about having strong feelings of any kind and felt that her emotions were inappropriate. Colleen said she felt most comfortable when her emotions were in the middle range of the spectrum, if an emotion was too intense this was a frightening experience. She said she sometimes was aware of feeling something but she was not sure how to identify the feeling. Colleen said she believed her emotions were apparent in her voice tone and others became aware of what she was feeling before she did.

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Colleen described her home environment as a child as one where she was not allowed to express her feelings. Both her parents were alcoholic and would become volatile if she or her siblings were to express opinions or make requests. She could not recall being hugged or kissed as a child and remembered that the relationship between her parents was bitter and angry. The way she learned to survive within the family was to become the people-pleaser or the agreeable one who would help others out but not make demands. Colleen had difficulty making a list of emotions and those she could label tended to be negative emotions such as sadness, guilt or anger. She was unaware of physical sensations or cognitions related to her emotions.

Results and Discussion

The TAS-20 results suggest treatment was effective in helping Colleen identify and describe her feelings (see Table 1). The total score, the difficulty identifying feelings and the difficulty describing feelings subscales decreased following treatment; however, these gains were not maintained at the 1-year follow-up. Colleens thinking style remained externally rather than internally orientated as reflected in her results on the externally orientated thinking subscale which increased following treatment and

remained high at follow-up. Following treatment she was able to pay more attention to her emotions and be less ambivalent about expressing her emotions as indicated by her results on the TMMS which showed an increase on the subscales of Attention to Mood and Clarity in the Discrimination of Feelings. However, at follow-up only the Attention to Mood scale remained high. Additionally, her AEQ results changed minimally at follow-up. During the follow-up interview Colleen said she had a difficult time since therapy ceased and that she felt she had not been able to deal well with the difficulties on her own. The results at the 1-year follow-up suggest she may have reverted to her previous coping style despite her encouraging gains at the end of therapy. Colleens original presentation was more complex when compared to the other cases due to the combination of anxiety and substance abuse issues and it is unclear how this may have impacted on her ability to maintain progress. The experience from therapy qualitatively supports the questionnaire results at post treatment. During the course of treatment Colleen became more able to identify her emotions and also to express what she was feeling in words. She began to do this with people close to her and revealed intimate aspects of herself to them. She experimented with asking others for what

FIGURE 3 Client weekly measure scores; Case 3.

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she wanted. Colleen practised reframing her negative thoughts and found she was able to have some control over her negative emotions. However, she had difficulty maintaining and using those skills at follow-up. Results on the CWM indicate that neither the linear nor quadratic regression models were statistically significant. Examination of the graph (see Figure 3) indicates an inconclusive pattern of results. The results were relatively high at the beginning of treatment, deteriorated over the course of treatment and then returned to a high level at the end of treatment. The SCL-90-R results suggest that treatment actually had a negative effect on her global level of psychological functioning as the GSI measure increased following treatment and at follow-up. It may be that she was more aware and able to identify her emotions and bodily sensations as a result of treatment and this was reflected in increased SCL-90-R results.

Conclusion
Overall, the posttreatment results suggest that the skills-based treatment was successful in reducing alexithymia and in helping the three participants to clarify, identify and describe their feelings. Following treatment the participants were less ambivalent about expressing their feelings and more attentive of their emotional states. These results were generally maintained at a 1-year follow-up for two of the three cases but not for the third case. The results are supportive of the hypothesis that alexithymic individuals tend to be more ambivalent about expressing emotion. In addition, an inability to identify and clarify emotion appears to be associated with an ambivalence about expressing it. This study suggests that this situation appears to be reversible through treatment. In general, it appears that the results on the TAS-20, TMMS, AEQ and the APRQ showed results in the expected direction. These are the questionnaires and measures that research has most closely linked to the alexithymia construct. The CWM results are less definitive, Colleen showed no change following treatment on this measure. Nathan and Mary showed improvement over the course of treatment to a

moderate degree as suggested by the linear and quadratic regression r-square values. The CWM was developed specifically for this study and has not been psychometrically validated; therefore there is no certainty that the CWM measures the alexithymia construct as hoped. The treatment appeared to have a variable impact on some of the dimensions. The Externally Orientated Thinking Scale of the TAS-20 went up following treatment for Colleen, down for Nathan and did not change for Mary. This is inconsistent with the results on the TMMS scale of Attention to Mood which showed increased results for all cases following treatment and at follow-up. Perhaps the treatment enhances an individuals ability to focus specifically on their mood states but it does not impact on their tendency to focus on their inner psychological state in general. Research suggests the Externally Orientated Thinking Scale of the TAS-20 is negatively correlated with emotional empathy (Davies, Stankov, & Roberts, 1998). The current treatment tended to focus on reading emotions within the self and was less focused on recognising emotions in others. Perhaps incorporating skills for emotional empathy in the treatment would improve the participants ability to be internally rather than externally orientated. Inconsistencies in results were also apparent in the treatments impact on the Mood Repair scale of the TMMS. This scale measures a participants perceived ability to repair negative moods and maintain positive moods. Research suggests that alexithymics tend to have high levels of negative emotion and low levels of positive emotion (Taylor, 1994). This is supported by results on the EPI for Colleen and Mary at pretreatment. Both clients tended to have higher levels of negative emotions such as timid, depressed and distrust and lower levels of positive emotions such as trust and gregariousness. If alexithymics have difficulty with positive emotions and tend to mostly experience negative emotions, repairing their moods would be a difficult task. The posttreatment results of the EPI suggest there were inconsistent results associated with each participants ability to experience positive and negative emotion. More research is required to understand the relationship between alexithymia and the mood repair

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dimension. It may be that therapy needs to incorporate specific skills for helping alexithymics to experience positive emotions, repair negative moods and maintain positive moods. The effect of treatment on the participants global level of psychological functioning was mixed. Colleen showed an overall increase on the SCL-90-R, which could be interpreted as an increased awareness and ability to identify emotions and bodily sensations as a result of treatment. This is not supported, however, by the results of Nathan and Mary who showed no change. Perhaps there is not a relationship between alexithymia and general psychological functioning as measured by the SCL-90-R. This is an issue that requires further research. In conclusion, it seems the skills-based intervention had positive effects on reducing alexithymia in these participants and enhancing their ability to identify and describe emotions. The durability of these results over the longer term needs more investigation. Due to the exploratory nature of the study, it is difficult to make generalisations based on the results. More research is required into the efficacy of the intervention with a larger sample and other patient groups. The three participants in the study presented with anxiety related disorders and it would be useful in future research to explore the effectiveness of the treatment with individuals presenting with other disorders. Future research could also explore the application of the treatment to a group therapy format, and the value of developing a supplementary client workbook.

Editor Note
Manuscript Received: 8/8/02 Accepted: 17/3/03

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