What is Alexithymia?

Introduction

Alexithymia is a personality trait characterised by the subclinical inability to identify and describe emotions experienced by one’s self.

The core characteristic of alexithymia is marked dysfunction in emotional awareness, social attachment, and interpersonal relation. Furthermore, people with high levels of alexithymia can have difficulty distinguishing and appreciating the emotions of others, which is thought to lead to non-empathic and ineffective emotional responses.

High levels of alexithymia occur in approximately 10% of the population and can occur with a number of psychiatric conditions as well as any neurodevelopmental disorder. Difficulty with recognising and talking about their emotions appears at subclinical levels in men who conform to western cultural notions of masculinity (such as thinking that sadness is a feminine emotion). This is called normative male alexithymia by some researchers. However, both alexithymia itself and its association with traditionally masculine norms are consistent across genders.

Lexicology

The term alexithymia was coined by psychotherapists John Case Nemiah and Peter Sifneos in 1973. The word comes from Greek: ἀ- (a-, ‘not’, privative prefix, alpha privative) + λέξις (léxis, ‘words’) + θῡμός (thȳmós, ‘heart’ or ’emotions’ or ‘seat of speech’) (cf. dyslexia), literally meaning “no words for emotions”.

Another etymology: Greek: Αλεξιθυμία ἀλέξω (to ward off) + θῡμός. Means to push away emotions, feelings

Nonmedical terms describing similar conditions include emotionless and impassive. People with the condition are called alexithymics or alexithymiacs.

Classification

Alexithymia is considered to be a personality trait that places affected individuals at risk for other medical and psychiatric disorders while reducing the likelihood that these individuals will respond to conventional treatments for the other conditions. Alexithymia is not classified as a mental disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. It is a dimensional personality trait that varies in intensity from person to person. A person’s alexithymia score can be measured with questionnaires such as the Toronto Alexithymia Scale (TAS-20), the Perth Alexithymia Questionnaire (PAQ), the Bermond-Vorst Alexithymia Questionnaire (BVAQ), the Levels of Emotional Awareness Scale (LEAS), the Online Alexithymia Questionnaire (OAQ-G2), the Toronto Structured Interview for Alexithymia (TSIA), or the Observer Alexithymia Scale (OAS). It is distinct from the psychiatric personality disorders, such as antisocial personality disorder.

Traditionally, alexithymia has been conceptually defined by four components:

  • Difficulty identifying feelings (DIF).
  • Difficulty describing feelings to other people (DDF).
  • A stimulus-bound, externally oriented thinking style (EOT).
  • Constricted imaginal processes (IMP),

However, there is some ongoing disagreement in the field about the definition of alexithymia. When measured in empirical studies, constricted imaginal processes are often found not to statistically cohere with the other components of alexithymia. Such findings have led to debate in the field about whether IMP is indeed a component of alexithymia. For example, in 2017, Preece and colleagues introduced the attention-appraisal model of alexithymia, where they suggested that IMP be removed from the definition and that alexithymia be conceptually composed only of DIF, DDF, and EOT, as each of these three are specific to deficits in emotion processing. In practice, since the constricted imaginal processes items were removed from earlier versions of the TAS-20 in the 1990s, the most used alexithymia assessment tools (and consequently most alexithymia research studies) have only assessed the construct in terms of DIF, DDF, and EOT.

Studies (using measures of alexithymia assessing DIF, DDF, and EOT) have reported that the prevalence rate of high alexithymia is less than 10% of the population. A less common finding suggests that there may be a higher prevalence of alexithymia amongst males than females, which may be accounted for by difficulties some males have with “describing feelings”, but not by difficulties in “identifying feelings” in which males and females show similar abilities.

Psychologist R. Michael Bagby and psychiatrist Graeme J. Taylor have argued that the alexithymia construct is inversely related to the concepts of psychological mindedness and emotional intelligence and there is “strong empirical support for alexithymia being a stable personality trait rather than just a consequence of psychological distress”.

Signs and Symptoms

Typical deficiencies may include problems identifying, processing, describing, and working with one’s own feelings, often marked by a lack of understanding of the feelings of others; difficulty distinguishing between feelings and the bodily sensations of emotional arousal; confusion of physical sensations often associated with emotions; few dreams or fantasies due to restricted imagination; and concrete, realistic, logical thinking, often to the exclusion of emotional responses to problems. Those who have alexithymia also report very logical and realistic dreams, such as going to the store or eating a meal. Clinical experience suggests it is the structural features of dreams more than the ability to recall them that best characterises alexithymia.

Some alexithymic individuals may appear to contradict the above-mentioned characteristics because they can experience chronic dysphoria or manifest outbursts of crying or rage. However, questioning usually reveals that they are quite incapable of describing their feelings or appear confused by questions inquiring about specifics of feelings.

According to Henry Krystal, individuals exhibiting alexithymia think in an operative way and may appear to be super-adjusted to reality. In psychotherapy, however, a cognitive disturbance becomes apparent as patients tend to recount trivial, chronologically ordered actions, reactions, and events of daily life with monotonous detail. In general, these individuals can, but not always, seem oriented toward things and even treat themselves as robots. These problems seriously limit their responsiveness to psychoanalytic psychotherapy; psychosomatic illness or substance abuse is frequently exacerbated should these individuals enter psychotherapy.

A common misconception about alexithymia is that affected individuals are totally unable to express emotions verbally and that they may even fail to acknowledge that they experience emotions. Even before coining the term, Sifneos (1967) noted patients often mentioned things like anxiety or depression. The distinguishing factor was their inability to elaborate beyond a few limited adjectives such as “happy” or “unhappy” when describing these feelings. The core issue is that people with alexithymia have poorly differentiated emotions limiting their ability to distinguish and describe them to others. This contributes to the sense of emotional detachment from themselves and difficulty connecting with others, making alexithymia negatively associated with life satisfaction even when depression and other confounding factors are controlled for.

Associated Conditions

Alexithymia frequently co-occurs with other disorders. Research indicates that alexithymia overlaps with autism spectrum disorders (ASD). In a 2004 study using the TAS-20, 85% of the adults with ASD fell into the “impaired” category and almost half fell into the “severely impaired” category; in contrast, among the adult control population only 17% were “impaired”, none “severely impaired”. Fitzgerald & Bellgrove pointed out that, “Like alexithymia, Asperger’s syndrome is also characterised by core disturbances in speech and language and social relationships”. Hill & Berthoz agreed with Fitzgerald & Bellgrove (2006) and in response stated that “there is some form of overlap between alexithymia and ASDs”. They also pointed to studies that revealed impaired theory of mind skill in alexithymia, neuroanatomical evidence pointing to a shared aetiology and similar social skills deficits. The exact nature of the overlap is uncertain. Alexithymic traits in ASD may be linked to clinical depression or anxiety; the mediating factors are unknown and it is possible that alexithymia predisposes to anxiety. On the other hand, while the total alexithymia score as well as the difficulty in identifying feelings and externally oriented thinking factors are found to be significantly associated with ADHD, and while the total alexithymia score, the difficulty in identifying feelings, and the difficulty in describing feelings factors are also significantly associated with symptoms of hyperactivity/impulsivity, there is no significant relationship between alexithymia and inattentiveness symptom.

There are many more psychiatric disorders that overlap with alexithymia. One study found that 41% of US veterans of the Vietnam War with post-traumatic stress disorder (PTSD) were alexithymic. Another study found higher levels of alexithymia among Holocaust survivors with PTSD compared to those without. Higher levels of alexithymia among mothers with interpersonal violence-related PTSD were found in one study to have proportionally less caregiving sensitivity. This latter study suggested that when treating adult PTSD patients who are parents, alexithymia should be assessed and addressed also with attention to the parent-child relationship and the child’s social-emotional development.

Single study prevalence findings for other disorders include 63% in anorexia nervosa, 56% in bulimia, 45% to 50% in major depressive disorder, 34% in panic disorder, 28% in social phobia, and 50% in substance abusers. Alexithymia is also exhibited by a large proportion of individuals with acquired brain injuries such as stroke or traumatic brain injury.

Alexithymia is correlated with certain personality disorders, particularly schizoid, avoidant, dependent and schizotypal, substance use disorders, some anxiety disorders and sexual disorders as well as certain physical illnesses, such as hypertension, inflammatory bowel disease and functional dyspepsia. Alexithymia is further linked with disorders such as migraine headaches, lower back pain, irritable bowel syndrome, asthma, nausea, allergies and fibromyalgia.

An inability to modulate emotions is a possibility in explaining why some people with alexithymia are prone to discharge tension arising from unpleasant emotional states through impulsive acts or compulsive behaviours such as binge eating, substance abuse, perverse sexual behaviour or anorexia nervosa. The failure to regulate emotions cognitively might result in prolonged elevations of the autonomic nervous system (ANS) and neuroendocrine systems, which can lead to somatic diseases. People with alexithymia also show a limited ability to experience positive emotions leading Krystal (1988) and Sifneos (1987) to describe many of these individuals as anhedonic.

Alexisomia is a clinical concept that refers to the difficulty in the awareness and expression of somatic, or bodily, sensations. The concept was first proposed in 1979 by Dr. Yujiro Ikemi when he observed characteristics of both alexithymia and alexisomia in patients with psychosomatic diseases.

Causes

It is unclear what causes alexithymia, though several theories have been proposed.

Early studies showed evidence that there may be an interhemispheric transfer deficit among people with alexithymia; that is, the emotional information from the right hemisphere of the brain is not being properly transferred to the language regions in the left hemisphere, as can be caused by a decreased corpus callosum, often present in psychiatric patients who have suffered severe childhood abuse. A neuropsychological study in 1997 indicated that alexithymia may be due to a disturbance to the right hemisphere of the brain, which is largely responsible for processing emotions. In addition, another neuropsychological model suggests that alexithymia may be related to a dysfunction of the anterior cingulate cortex. These studies have some shortcomings, however, and the empirical evidence about the neural mechanisms behind alexithymia remains inconclusive.

French psychoanalyst Joyce McDougall objected to the strong focus by clinicians on neurophysiological explanations at the expense of psychological ones for the genesis and operation of alexithymia, and introduced the alternative term “disaffectation” to stand for psychogenic alexithymia. For McDougall, the disaffected individual had at some point “experienced overwhelming emotion that threatened to attack their sense of integrity and identity”, to which they applied psychological defences to pulverise and eject all emotional representations from consciousness. A similar line of interpretation has been taken up using the methods of phenomenology. McDougall has also noted that all infants are born unable to identify, organize, and speak about their emotional experiences (the word infans is from the Latin “not speaking”), and are “by reason of their immaturity inevitably alexithymic”. Based on this fact McDougall proposed in 1985 that the alexithymic part of an adult personality could be “an extremely arrested and infantile psychic structure”. The first language of an infant is nonverbal facial expressions. The parent’s emotional state is important for determining how any child might develop. Neglect or indifference to varying changes in a child’s facial expressions without proper feedback can promote an invalidation of the facial expressions manifested by the child. The parent’s ability to reflect self-awareness to the child is another important factor. If the adult is incapable of recognising and distinguishing emotional expressions in the child, it can influence the child’s capacity to understand emotional expressions.

Molecular genetic research into alexithymia remains minimal, but promising candidates have been identified from studies examining connections between certain genes and alexithymia among those with psychiatric conditions as well as the general population. A study recruiting a test population of Japanese males found higher scores on the Toronto Alexithymia Scale among those with the 5-HTTLPR homozygous long (L) allele. The 5-HTTLPR region on the serotonin transporter gene influences the transcription of the serotonin transporter that removes serotonin from the synaptic cleft, and is well studied for its association with numerous psychiatric disorders. Another study examining the 5-HT1A receptor, a receptor that binds serotonin, found higher levels of alexithymia among those with the G allele of the Rs6295 polymorphism within the HTR1A gene. Also, a study examining alexithymia in subjects with obsessive-compulsive disorder found higher alexithymia levels associated with the Val/Val allele of the Rs4680 polymorphism in the gene that encodes Catechol-O-methyltransferase (COMT), an enzyme which degrades catecholamine neurotransmitters such as dopamine. These links are tentative, and further research will be needed to clarify how these genes relate to the neurological anomalies found in the brains of people with alexithymia.

Although there is evidence for the role of environmental and neurological factors, the role and influence of genetic factors for developing alexithymia is still unclear. A single large scale Danish study suggested that genetic factors contributed noticeably to the development of alexithymia. However, such twin studies are controversial, as they suffer from the “equal environments assumption” and the “heritability” estimates in no way correspond to actual DNA structures. Traumatic brain injury is also implicated in the development of alexithymia, and those with traumatic brain injury are six times more likely to exhibit alexithymia.

In Relationships

Alexithymia can create interpersonal problems because these individuals tend to avoid emotionally close relationships, or if they do form relationships with others they usually position themselves as either dependent, dominant, or impersonal, “such that the relationship remains superficial”. Inadequate “differentiation” between self and others by alexithymic individuals has also been observed. Their difficulty in processing interpersonal connections often develops where the person lacks a romantic partner.

In a study, a large group of alexithymic individuals completed the 64-item Inventory of Interpersonal Problems (IIP-64) which found that “two interpersonal problems are significantly and stably related to alexithymia: cold/distant and non-assertive social functioning. All other IIP-64 subscales were not significantly related to alexithymia.”

Chaotic interpersonal relations have also been observed by Sifneos. Due to the inherent difficulties identifying and describing emotional states in self and others, alexithymia also negatively affects relationship satisfaction between couples.

In a 2008 study alexithymia was found to be correlated with impaired understanding and demonstration of relational affection, and that this impairment contributes to poorer mental health, poorer relational well-being, and lowered relationship quality. Individuals high on the alexithymia spectrum also report less distress at seeing others in pain and behave less altruistically toward others.

Some individuals working for organisations in which control of emotions is the norm might show alexithymic-like behaviour but not be alexithymic. However, over time the lack of self-expressions can become routine and they may find it harder to identify with others.

Treatment

Generally speaking, approaches to treating alexithymia are still in their infancy, with not many proven treatment options available.

In 2002, Kennedy and Franklin found that a skills-based intervention is an effective method for treating alexithymia. Kennedy and Franklin’s treatment plan involved giving the participants a series of questionnaires, psychodynamic therapies, cognitive-behavioural and skills-based therapies, and experiential therapies. After treatment, they found that participants were generally less ambivalent about expressing their emotion feelings and more attentive to their emotional states.

In 2017, based on their attention-appraisal model of alexithymia, Preece and colleagues recommended that alexithymia treatment should target trying to improve the developmental level of people’s emotion schemas and reduce people’s use of experiential avoidance of emotions as an emotion regulation strategy (i.e. the mechanisms hypothesized to underlie alexithymia difficulties in the attention-appraisal model of alexithymia).

In 2018, Löf, Clinton, Kaldo, and Rydén found that mentalisation-based treatment is also an effective method for treating alexithymia. Mentalisation is the ability to understand the mental state of oneself or others that underlies overt behaviour, and mentalisation-based treatment helps patients separate their own thoughts and feelings from those around them. This treatment is relational, and it focuses on gaining a better understanding and use of mentalising skills. The researchers found that all of the patients’ symptoms including alexithymia significantly improved, and the treatment promoted affect tolerance and the ability to think flexibly while expressing intense affect rather than impulsive behaviour.

A significant issue impacting alexithymia treatment is that alexithymia has comorbidity with other disorders. Mendelson’s 1982 study showed that alexithymia frequently presented in people with undiagnosed chronic pain. Participants in Kennedy and Franklin’s study all had anxiety disorders in conjunction with alexithymia, while those in Löf et al. were diagnosed with both alexithymia and borderline personality disorder. All these comorbidity issues complicate treatment because it is difficult to examine people who exclusively have alexithymia.

What is Parallel Process?

Introduction

Parallel process is a phenomenon noted between therapist and supervisor, whereby the therapist recreates, or parallels, the client’s problems by way of relating to the supervisor.

The individual’s transference and the therapist’s countertransference thus re-appear in the mirror of the therapist/supervisor relationship.

Background

Attention to parallel process first emerged in the nineteen-fifties (1950s). The process was termed reflection by Harold Searles in 1955, and two years later T. Hora (1957) first used the actual term parallel process – emphasising that it was rooted in an unconscious identification with the client/patient which could extend to tone of voice and behaviour. The supervisee thus enacts the central problem of the therapy in the supervision, potentially opening up a process of containment and solution, first by the supervisor and then by the therapist.

Alternatively, the supervisor’s own countertransference may be activated in the parallel process, to be reflected in turn between supervisor and consultant, or back into the original patient/helper dyad. Even then, however, careful examination of the material may still illuminate the original therapeutic difficulty, as reflected in the parallel situation.

What is Relational Disorder?

Introduction

According to Michael First of the Diagnostic and Statistical Manual of Mental Disorders Version 5 (DSM-5) working committee the focus of a relational disorder, in contrast to other DSM-IV disorders, “is on the relationship rather than on any one individual in the relationship”.

Relational disorders involve two or more individuals and a disordered “juncture”, whereas typical Axis I psychopathology describes a disorder at the individual level. An additional criterion for a relational disorder is that the disorder cannot be due solely to a problem in one member of the relationship, but requires pathological interaction from each of the individuals involved in the relationship.

For example, if a parent is withdrawn from one child but not another, the dysfunction could be attributed to a relational disorder. In contrast, if a parent is withdrawn from both children, the dysfunction may be more appropriately attributable to a disorder at the individual level.

First states that “relational disorders share many elements in common with other disorders: there are distinctive features for classification; they can cause clinically significant impairment; there are recognizable clinical courses and patterns of comorbidity; they respond to specific treatments; and they can be prevented with early interventions. Specific tasks in a proposed research agenda: develop assessment modules; determine the clinical utility of relational disorders; determine the role of relational disorders in the aetiology and maintenance of individual disorders; and consider aspects of relational disorders that might be modulated by individual disorders.”

The proposed new diagnosis defines a relational disorder as “persistent and painful patterns of feelings, behaviors, and perceptions” among two or more people in an important personal relationship, such a husband and wife, or a parent and children.

According to psychiatrist Darrel Regier, MD, some psychiatrists and other therapists involved in couples and marital counselling have recommended that the new diagnosis be considered for possible incorporation into the DSM IV.

Brief History

The idea of a psychology of relational disorders is far from new. According to Adam Blatner, MD, some of the early psychoanalysts alluded to it more or less directly, and the history of marital couple therapy began with a few pioneers in 1930s. J.L. Moreno, the inventor of psychodrama and a major pioneer of group psychotherapy and social psychology, noted the idea that relationships could be “sick” even if the people involved were otherwise “healthy,” and even vice versa: Otherwise “sick” people could find themselves in a mutually supportive and “healthy” relationship.

Moreno’s ideas may have influenced some of the pioneers of family therapy, but also there were developments in general science, namely, cybernetic theory, developed in the mid-1940s, and noting the nature of circularity and feedback in complex systems. By the 1950s, the idea that relationships themselves could be problematic became quite apparent. So, diagnostically, in the sense not of naming a disease or disorder, but just helping people think through what was really going on, the idea of relational disorder was nothing new.

Types

The majority of research on relational disorders concerns three relationship systems:

  • Adult children and their parents;
  • Minor children and their parents; and
  • The marital relationship.

There is also an increasing body of research on problems in dyadic gay relationships and on problematic sibling relationships.

Marital

Marital disorders are divided into “Marital Conflict Disorder Without Violence” and “Marital Abuse Disorder (Marital Conflict Disorder With Violence).” Couples with marital disorders sometimes come to clinical attention because the couple recognise long-standing dissatisfaction with their marriage and come to the clinician on their own initiative or are referred by a health care professional. Secondly, there is serious violence in the marriage which is “usually the husband battering the wife”. In these cases the emergency room or a legal authority often is the first to notify the clinician.

Most importantly, marital violence “is a major risk factor for serious injury and even death and women in violent marriages are at much greater risk of being seriously injured or killed” (National Advisory Council on Violence Against Women 2000). The authors of this study add that “There is current considerable controversy over whether male-to-female marital violence is best regarded as a reflection of male psychopathology and control or whether there is an empirical base and clinical utility for conceptualizing these patterns as relational.”

Recommendations for clinicians making a diagnosis of “Marital Relational Disorder” should include the assessment of actual or “potential” male violence as regularly as they assess the potential for suicide in depressed patients. Further, “clinicians should not relax their vigilance after a battered wife leaves her husband, because some data suggest that the period immediately following a marital separation is the period of greatest risk for the women.

Many men will stalk and batter their wives in an effort to get them to return or punish them for leaving. Initial assessments of the potential for violence in a marriage can be supplemented by standardised interviews and questionnaires, which have been reliable and valid aids in exploring marital violence more systematically.

The authors conclude with what they call “very recent information” on the course of violent marriages which suggests that “over time a husband’s battering may abate somewhat, but perhaps because he has successfully intimidated his wife.”

The risk of violence remains strong in a marriage in which it has been a feature in the past. Thus, treatment is essential here; the clinician cannot just wait and watch. The most urgent clinical priority is the protection of the wife because she is the one most frequently at risk, and clinicians must be aware that supporting assertiveness by a battered wife may lead to more beatings or even death.

In some cases, men are abuse victims of their wives; there is not exclusively male-on-female physical violence, although this is more common than female-on-male violence.

Parent-Child Abuse

Research on parent-child abuse bears similarities to that on marital violence, with the defining characteristic of the disorder being physical aggression by a parent toward a child. The disorder is frequently concealed by parent and child, but may come to the attention of the clinician in several ways, from emergency room medical staff to reports from child protection services.

Some features of abusive parent–child relationships that serve as a starting point for classification include:

  • The parent is physically aggressive with a child, often producing physical injury;
  • Parent-child interaction is coercive, and parents are quick to react to provocations with aggressive responses, and children often reciprocate aggression;
  • Parents do not respond effectively to positive or prosocial behaviour in the child;
  • Parents do not engage in discussion about emotions;
  • Parent engages in deficient play behaviour, ignores the child, rarely initiates play, and does little teaching;
  • Children are insecurely attached and, where mothers have a history of physical abuse, show distinctive patterns of disorganised attachment; and
  • Parents relationship shows coercive marital interaction patterns.

Defining the relational aspects of these disorders can have important consequences. For example, in the case of early appearing feeding disorders, attention to relational problems may help delineate different types of clinical problems within an otherwise broad category. In the case of conduct disorder, the relational problems may be so central to the maintenance, if not the aetiology, of the disorder that effective treatment may be impossible without recognising and delineating it.

What is Relational Psychoanalysis?

Introduction

Relational psychoanalysis is a school of psychoanalysis in the United States that emphasizes the role of real and imagined relationships with others in mental disorder and psychotherapy. ‘Relational psychoanalysis is a relatively new and evolving school of psychoanalytic thought considered by its founders to represent a “paradigm shift” in psychoanalysis’.

Relational psychoanalysis began in the 1980s as an attempt to integrate interpersonal psychoanalysis’s emphasis on the detailed exploration of interpersonal interactions with British object relations theory’s ideas about the psychological importance of internalised relationships with other people. Relationalists argue that personality emerges from the matrix of early formative relationships with parents and other figures. Philosophically, relational psychoanalysis is closely allied with social constructionism.

Drives versus Relationships

An important difference between relational theory and traditional psychoanalytic thought is in its theory of motivation, which would ‘assign primary importance to real interpersonal relations, rather than to instinctual drives’. Freudian theory, with a few exceptions, proposes that human beings are motivated by sexual and aggressive drives. These drives are biologically rooted and innate. They are ultimately not shaped by experience.

Relationalists, on the other hand, argue that the primary motivation of the psyche is to be in relationships with others. As a consequence early relationships, usually with primary caregivers, shape one’s expectations about the way in which one’s needs are met. Therefore, desires and urges cannot be separated from the relational contexts in which they arise; motivation is then seen as being determined by the systemic interaction of a person and his or her relational world. Individuals attempt to re-create these early learned relationships in ongoing relationships that may have little or nothing to do with those early relationships. This re-creation of relational patterns serves to satisfy the individuals’ needs in a way that conforms with what they learned as infants. This re-creation is called an enactment.

Techniques

When treating patients, relational psychoanalysts stress a mixture of waiting and authentic spontaneity. Some relationally oriented psychoanalysts eschew the traditional Freudian emphasis on interpretation and free association, instead emphasising the importance of creating a lively, genuine relationship with the patient. However, many others place a great deal of importance on the Winnicottian concept of “holding” and are far more restrained in their approach, generally giving weight to well formulated interpretations made at what seems to be the proper time. Overall, relational analysts feel that psychotherapy works best when the therapist focuses on establishing a healing relationship with the patient, in addition to focusing on facilitating insight. They believe that in doing so, therapists break patients out of the repetitive patterns of relating to others that they believe maintain psychopathology. Noteworthy too is ‘the emphasis relational psychoanalysis places on the mutual construction of meaning in the analytic relationship’.

Authors

Stephen A. Mitchell has been described as the “most influential relational psychoanalyst”. His 1983 book, co-written with Jay Greenberg and called Object Relations in Psychoanalytic Theory is considered to be the first major work of relational psychoanalysis. Prior work especially by Sabina Spielrein in the 1910s to 1930s is often cited, particularly by Adrienne Harris and others who connect feminism with the field, but as part of the prior Freud/Jung/Spielrein tradition.

Other important relational authors include Neil Altman, Lewis Aron, Hugo Bleichmar, Philip Bromberg, Nancy Chodorow, Susan Coates, Jody Davies, Emmanuel Ghent, Adrienne Harris, Irwin Hirsch, Irwin Z. Hoffman, Karen Maroda, Stuart Pizer, Owen Renik, Ramón Riera, Daniel Schechter, Joyce Slochower, Martha Stark, Ruth Stein, Donnel Stern, Robert Stolorow, Jeremy D. Safran and Jessica Benjamin – the latter pursuing the ‘goal of creating a genuinely feminist and philosophically informed relational psychoanalysis’. A significant historian and philosophical contributor is Philip Cushman.

Criticisms

Psychoanalyst and philosopher Jon Mills has offered a number of substantial criticisms of the relational movement. Mills evidently thinks this “paradigm shift” to relational psychoanalysis is not exclusively due to theoretical differences with classical psychoanalysis but also arises from a certain group mentality and set of interests: “Relational psychoanalysis is an American phenomenon, with a politically powerful and advantageous group of members advocating for conceptual and technical reform” from a professional psychologist group perspective: “most identified relational analysts are psychologists, as are the founding professionals associated with initiating the relational movement”.

From a theoretical perspective, Mills appears to doubt that relational psychoanalysis is as radically new as it is touted to be. In its emphasis on the developmental importance of other people, according to Mills, “relational theory is merely stating the obvious” – picking up on “a point that Freud made explicit throughout his theoretical corpus, which becomes further emphasized more significantly by early object relations therapists through to contemporary self psychologists.” Mills also criticizes the diminishing or even the loss of the significance of the unconscious in relational psychoanalysis, a point he brings up in various parts of his book Conundrums.

Psychoanalyst and historian Henry Zvi Lothane has also criticised some of the central ideas of relational psychoanalysis, from both historical and psychoanalytic perspectives. Historically, Lothane believes relational theorists overstate the non-relational aspects of Freud as ignore its relational aspects. Lothane maintains that, though Freud’s theory of disorder is “monadic,” i.e. focused more or less exclusively on the individual, Freud’s psychoanalytic method and theory of clinical practice is consistently dyadic or relational. From a theoretical perspective, Lothane has criticised the term “relational” in favour of Harry Stack Sullivan’s term “interpersonal”. Lothane developed his concepts of “reciprocal free association” as well as “dramatology” as ways of understanding the interpersonal or relational dimension of psychoanalysis.

Psychoanalyst and philosopher Aner Govrin examines the heavy price psychoanalysis paid for adopting postmodernism as their preferred epistemology. He posits that only analysts who thought they “know the truth,” created classical, interpersonal, self-psychology, ego psychology, Kleinian, Bionian, Fairbairnian, Winiccottian and other schools of thought. While the relational tradition had made extraordinary and positive contributions to psychoanalysis, and its postmodern epistemology is indeed moderate, as a political movement the American relational tradition had unwanted psychological and sociological effects on psychoanalysis. This led to a severe decline in the positive image of knowledge that is crucial for the building of new theories. Led by the relational movement, but influenced by a much broader movement in western philosophy and culture, this impact has greatly influenced international psychoanalysis. It has led not only to the disparagement of the school era but also to the devaluation of any attempt to know the truth.

Adopting a more sympathetic line of criticism, Robin S. Brown suggests that while relational thinking has done much to challenge psychoanalytic dogmatism, excessively emphasizing the formative role of social relations can culminate in its own form of authoritarianism. Brown contends that the relational shift has insufficiently addressed the role of first principles, and that this tendency might be challenged by engaging analytical psychology.

Book: Therapy with a Map: A Cognitive Analytic Approach to Helping Relationships

Book Title:

Therapy with a Map: A Cognitive Analytic Approach to Helping Relationships.

Author(s): Steve Potter.

Year: 2020.

Edition: First (1st).

Publisher: Luminate.

Type(s): Paperback and Kindle.

Synopsis:

A therapeutic relationship is a web of interactions, tasks and processes in space and time. It is not easy to stay aware of the relationship in the thick of talking and trying to help someone; but doing so boosts flexibility and enables deeper formulation. A therapist who can attend not only to a specific therapeutic model, but also to relational factors underlying all therapy, has a far greater chance of enabling change.

Therapy with a Map sets out a therapeutic process of talking accompanied by visual conversation maps set down in real time on paper. Like all maps, these help us to find our way, notice when we are lost, track our route and survey the wider landscape. The book uses mapping to introduce the tools and concepts of Cognitive Analytic Therapy (CAT), along with other relational, conversational and narrative approaches. By mapping patterns of thinking and relating, therapists can help clients to develop self-understanding, solve problems, and take away a freer, more self-aware relationship with themselves in the world.

What is the Karpman Drama Triangle?

Introduction

The drama triangle is a social model of human interaction – the triangle maps a type of destructive interaction that can occur among people in conflict.

The drama triangle model is a tool used in psychotherapy, specifically transactional analysis.

The triangle of actors in the drama are oppressors, victims and rescuers.

The Theory

Stephen Karpman used triangles to map conflicted or drama-intense relationship transactions. The Karpman Drama Triangle models the connection between personal responsibility and power in conflicts, and the destructive and shifting roles people play. He defined three roles in the conflict; Persecutor, Rescuer (the one up positions) and Victim (one down position). Karpman placed these three roles on an inverted triangle and referred to them as being the three aspects, or faces of drama.

  • The Victim:
    • The Victim in this model is not intended to represent an actual victim, but rather someone feeling or acting like one.
    • The Victim’s stance is “Poor me!”
    • The Victim feels victimised, oppressed, helpless, hopeless, powerless, ashamed, and seems unable to make decisions, solve problems, take pleasure in life, or achieve insight.
    • The Victim, if not being persecuted, will seek out a Persecutor and also a Rescuer who will save the day but also perpetuate the Victim’s negative feelings.
  • The Rescuer:
    • The rescuer’s line is “Let me help you.”
    • A classic enabler, the Rescuer feels guilty if they do not go to the rescue.
    • Yet their rescuing has negative effects: It keeps the Victim dependent and does not allow the Victim permission to fail and experience the consequences of their choices.
    • The rewards derived from this rescue role are that the focus is taken off of the rescuer.
    • When they focus their energy on someone else, it enables them to ignore their own anxiety and issues.
    • This rescue role is also pivotal because their actual primary interest is really an avoidance of their own problems disguised as concern for the victim’s needs.
  • The Persecutor:
    • A.k.a. Villain.
    • The Persecutor insists, “It’s all your fault.”
    • The Persecutor is controlling, blaming, critical, oppressive, angry, authoritarian, rigid, and superior.

Initially, a drama triangle arises when a person takes on the role of a victim or persecutor. This person then feels the need to enlist other players into the conflict. As often happens, a rescuer is encouraged to enter the situation. These enlisted players take on roles of their own that are not static, and therefore various scenarios can occur. The victim might turn on the rescuer, for example, while the rescuer then switches to persecution.

The reason that the situation persist is that each participant has their (frequently unconscious) psychological wishes/needs met without having to acknowledge the broader dysfunction or harm done in the situation as a whole. Each participant is acting upon their own selfish needs, rather than acting in a genuinely responsible or altruistic manner. Any character might “ordinarily come on like a plaintive victim; it is now clear that the one can switch into the role of Persecutor providing it is ‘accidental’ and the one apologises for it”.

The motivations of the rescuer are the least obvious. In the terms of the triangle, the rescuer has a mixed or covert motive and benefits egoically in some way from being “the one who rescues”. The rescuer has a surface motive of resolving the problem and appears to make great efforts to solve it, but also has a hidden motive to not succeed, or to succeed in a way in which they benefit. They may get a self-esteem boost, for example, or receive respected rescue status, or derive enjoyment by having someone depend on them and trust them and act in a way that ostensibly seems to be trying to help, but at a deeper level plays upon the victim in order to continue getting a payoff.

The relationship between the victim and the rescuer may be one of co-dependency. The rescuer keeps the victim dependent by encouraging their victimhood. The victim gets their needs met by having the rescuer take care of them.

Participants generally tend to have a primary or habitual role (victim, rescuer, persecutor) when they enter into drama triangles. Participants first learn their habitual role in their family of origin. Even though participants each have a role with which they most identify, once on the triangle, participants rotate through all the three positions.

Each triangle has a “payoff” for those playing it. The “antithesis” of a drama triangle lies in discovering how to deprive the actors of their payoff.

Use

Through popular usage and the work of Karpman and others, Karpman’s triangle has been adapted for use in structural analysis and transactional analysis.

Historical Context

Family Therapy Movement

After World War II, therapists observed that while many battle-torn veteran patients readjusted well after returning to their families, some patients did not; some even regressed when they returned to their home environment. Researchers felt that they needed an explanation for this and began to explore the dynamics of family life – and thus began the family therapy movement. Prior to this time, psychiatrists and psychoanalysts focused on the patient’s already-developed psyche and downplayed outside detractors. Intrinsic factors were addressed and extrinsic reactions were considered as emanating from forces within the person.

Transactions Analysis

In the 1950s, Eric Berne developed transactional analysis, a method for studying interactions between individuals. This approach was profoundly different than that of Freud. While Freud relied on asking patients about themselves, Berne felt that a therapist could learn by observing what was communicated (words, body language, facial expressions) in a transaction. So instead of directly asking the patient questions, Berne would frequently observe the patient in a group setting, noting all of the transactions that occurred between the patient and other individuals.

Triangles/Triangulation

The theory of triangulation was originally published in 1966 by Murray Bowen as one of eight parts of Bowen’s family systems theory. Murray Bowen, a pioneer in family systems theory, began his early work with schizophrenics at the Menninger Clinic, from 1946 to 1954. Triangulation is the “process whereby a two-party relationship that is experiencing tension will naturally involve third parties to reduce tension”. Simply put, when people find themselves in conflict with another person, they will reach out to a third person. The resulting triangle is more comfortable as it can hold much more tension because the tension is being shifted around three people instead of two.

Bowen studied the dyad of the mother and her schizophrenic child while he had them both living in a research unit at the Menninger clinic. Bowen then moved to the National Institute of Mental Health (NIMH), where he resided from 1954 to 1959. At the NIMH Bowen extended his hypothesis to include the father-mother-child triad. Bowen considered differentiation and triangles the crux of his theory, Bowen Family Systems Theory. Bowen intentionally used the word triangle rather than triad. In Bowen Family Systems Theory, the triangle is an essential part of the relationship.

Couples left to their own resources oscillate between closeness and distance. Two people having this imbalance often have difficulty resolving it by themselves. To stabilise the relationship, the couple often seek the aid of a third party to help re-establish closeness. A triangle is the smallest possible relationship system that can restore balance in a time of stress. The third person assumes an outside position. In periods of stress, the outside position is the most comfortable and desired position. The inside position is plagued by anxiety, along with its emotional closeness. The outsider serves to preserve the inside couple’s relationship. Bowen noted that not all triangles are constructive – some are destructive.

Pathological/Perverse Triangles

In 1968, Nathan Ackerman conceptualised a destructive triangle. Ackerman stated “we observe certain constellations of family interactions which we have epitomised as the pattern of family interdependence, roles those of destroyer or persecutor, the victim of the scapegoating attack, and the family healer or the family doctor. Ackerman also recognise the pattern of attack, defence, and counterattack, as shifting roles.

Karpman Triangle and Eric Berne

In 1968, Stephen Karpman, who had an interest in acting and was a member of the Screen Actors Guild, chose “drama triangle” rather than “conflict triangle” as, here, the Victim in his model is not intended to represent an actual victim, but rather someone feeling or acting like one. He first published his theory in an article entitled “Fairy Tales and Script Drama Analysis”. His article, in part, examined the fairy tale “Little Red Riding Hood” to illustrate its points. Karpman was, at the time, a recent graduate of Duke University School of Medicine and was doing post post-graduate studies under Berne. Berne, who founded the field transactional analysis, encouraged Karpman to publish what Berne referred to as “Karpman’s triangle”. Karpman’s article was published in 1968. In 1972, Karpman received the Eric Berne Memorial Scientific Award for the work.

Transactional Analysis

Eric Berne, a Canadian-born psychiatrist, created the theory of transactional analysis, in the middle of the 20th century, as a way of explaining human behaviour. Berne’s theory of transactional analysis was based on the ideas of Freud but was distinctly different. Freudian psychotherapists focused on talk therapy as a way of gaining insight to their patients’ personalities. Berne believed that insight could be better discovered by analysing patients’ social transactions.

Games in transactional analysis refers to a series of transactions that is complementary (reciprocal), ulterior, and proceeds towards a predictable outcome. In this context, the Karpman Drama Triangle is a “game”.

Games are often characterised by a switch in roles of players towards the end. The number of players may vary. Games in this sense are devices used (often unconsciously) by people to create a circumstance where they can justifiably feel certain resulting feelings (such as anger or superiority) or justifiably take or avoid taking certain actions where their own inner wishes differ from societal expectations. They are always a substitute for a more genuine and full adult emotion and response which would be more appropriate. Three quantitative variables are often useful to consider for games:

  • Flexibility:
    • “The ability of the players to change the currency of the game (that is, the tools they use to play it).
    • “Some games…can be played properly with only one kind of currency, while others, such as exhibitionistic games, are more flexible”, so that players may shift from words, to money, to parts of the body.
  • Tenacity:
    • “Some people give up their games easily, others are more persistent”, referring to the way people stick to their games and their resistance to breaking with them.
  • Intensity:
    • “Some people play their games in a relaxed way, others are more tense and aggressive.
    • Games so played are known as easy and hard games, respectively”, the latter being played in a tense and aggressive way.

The consequences of games may vary from small paybacks to paybacks built up over a long period to a major level. Based on the degree of acceptability and potential harm, games are classified into three categories, representing first degree games, second degree games, and third degree games:

  • Socially acceptable.
  • Undesirable but not irreversibly damaging.
  • May result in drastic harm.

The Karpman triangle was an adaptation of a model that was originally conceived to analyse the play-action pass and the draw play in American football and later adapted as a way to analyse movie scripts. Karpman is reported to have doodled thirty or more diagram types before settling on the triangle. Karpman credits the movie Valley of the Dolls as being a testbed for refining the model into what Berne coined as the Karpman Drama Triangle.

Karpman now has many variables of the Karpman triangle in his fully developed theory, besides role switches. These include space switches (private-public, open-closed, near-far) which precede, cause, or follow role switches, and script velocity (number of role switches in a given unit of time). These include the Question Mark triangle, False Perception triangle, Double Bind triangle, The Indecision triangle, the Vicious Cycle triangle, Trapping triangle, Escape triangle, Triangles of Oppression, and Triangles of Liberation, Switching in the triangle, and the Alcoholic Family triangle.

While transactional analysis is the method for studying interactions between individuals, one researcher postulates that drama-based leaders can instil an organisational culture of drama. Persecutors are more likely to be in leadership positions and a persecutor culture goes hand in hand with cutthroat competition, fear, blaming, manipulation, high turnover and an increased risk of lawsuits. There are also victim cultures which can lead to low morale and low engagement as well as an avoidance of conflict, and rescuer cultures which can be characterised as having a high dependence on the leader, low initiative and low innovation.

Therapeutic Models

The Winner’s Triangle was published by Acey Choy in 1990 as a therapeutic model for showing patients how to alter social transactions when entering a triangle at any of the three entry points. Choy recommends that anyone feeling like a victim think more in terms of being vulnerable and caring, that anyone cast as a persecutor adopt an assertive posture, and anyone recruited to be a rescuer should react by being “caring”.

  • Vulnerable: A victim should be encouraged to accept their vulnerability, problem solve, and be more self-aware.
  • Assertive: A persecutor should be encouraged to ask for what they want, be assertive, but not be punishing.
  • Caring: A rescuer should be encouraged to show concern and be caring, but not over-reach and problem solve for others.

The Power of TED, first published in 2009, recommends that the “victim” adopt the alternative role of creator, view the persecutor as a challenger, and enlist a coach instead of a rescuer.

  • Creator:
    • Victims are encouraged to be outcome-oriented as opposed to problem-oriented and take responsibility for choosing their response to life challenges.
    • They should focus on resolving “dynamic tension” (the difference between current reality and the envisioned goal or outcome) by taking incremental steps toward the outcomes he or she is trying to achieve.
  • Challenger:
    • A victim is encouraged to see a persecutor as a person (or situation) that forces the creator to clarify his or her needs, and focus on their learning and growth.
  • Coach:
    • A rescuer should be encouraged to ask questions that are intended to help the individual to make informed choices.
    • The key difference between a rescuer and a coach is that the coach sees the creator as capable of making choices and of solving his or her own problems.
    • A coach asks questions that enable the creator to see the possibilities for positive action, and to focus on what he or she does want instead of what he or she does not want.

Book: Anxiety – Overcome It and Live Without Fear

Book Title:

Anxiety – Overcome It and Live Without Fear.

Author(s): Sonali Gupta.

Year: 2020.

Edition: First (1st).

Publisher: HarperCollins.

Type(s): Paperback and Kindle.

Synopsis:

Do you know the difference between anxiety and stress? What can you do when you have a panic attack? How do you know when it is time to get help?

Anxiety is a mental health crisis that has gripped over three crore Indians. In Anxiety: Overcome It and Live without Fear, clinical psychologist Sonali Gupta delves into the condition, using case studies to identify how anxiety can be triggered at work, in relationships, and by social media. Gupta shares a unique glimpse into this mental health condition in India, especially among Gen Z and millennials.

Recommending strategies and techniques for anxiety-prone readers, this book will help you confront your fears and take control of your life.

Book: Acceptance And Commitment Therapy For Dummies

Book Title:

Acceptance And Commitment Therapy For Dummies.

Author(s): Freddy Jackson Brown and Duncan Gillard.

Year: 2016.

Edition: First (1st).

Publisher: Wiley.

Type(s): Paperback.

Synopsis:

Do you want to change your relationship with painful thoughts and feelings that are holding you back from making changes to improve your life?

In this book, you will discover how to identify negative and unhealthy modes of thinking and apply Acceptance and Commitment Therapy (ACT) principles throughout your day-to-day life, creating a healthier, richer and more meaningful existence with yourself and others.

What is the Evidence for the Effectiveness of Psychological Interventions for Adults with Anti-Social Personality Disorder?

Research Paper Title

Psychological interventions for antisocial personality disorder.

Background

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

Therefore the purpose of this review was to evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

Methods

The researchers searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. They also searched reference lists and contacted study authors to identify studies.

Selection criteria concisted of randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

Data collection and analysis consisted of standard methodological procedures expected by Cochrane.

Results

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called ‘standard Maintenance'(SM) in some studies).

Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants.

Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks).

Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention.

One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence).

One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. ‘Driving whilst intoxicated’ programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months.

Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19).

The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants’ level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU.

Psychosocial risk management (PSRM; ‘Resettle’) versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

Conclusions

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour.

Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Reference

Gibbon, S., Khalifa, N.R., Cheung, N.H-Y., Vollm, B.A. & McCarthy, L. (2020) Psychological interventions for antisocial personality disorder. The Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD007668.pub3.