Tag: Social Attachment

An Overview of Normalisation

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Introduction

“The normalization principle means making available to all people with disabilities patterns of life and conditions of everyday living which are as close as possible to the regular circumstances and ways of life or society.” (Nirje, 1982).

Normalisation is a rigorous theory of human services that can be applied to disability services. Normalisation theory arose in the early 1970s, towards the end of the institutionalisation period in the US; it is one of the strongest and long lasting integration theories for people with severe disabilities.

Definition

Normalisation involves the acceptance of some people with disabilities, with their disabilities, offering them the same conditions as are offered to other citizens. It involves an awareness of the normal rhythm of life – including the normal rhythm of a day, a week, a year, and the life-cycle itself (e.g. celebration of holidays; workday and weekends). It involves the normal conditions of life – housing, schooling, employment, exercise, recreation and freedom of choice previously denied to individuals with severe, profound, or significant disabilities.

Wolf Wolfensberger’s definition is based on a concept of cultural normativeness: “Utilization of a means which are as culturally normative as possible, in order to establish and/or maintain personal behaviours and characteristics that are as culturally normative as possible.” Thus, for example, “medical procedures” such as shock treatment or restraints, are not just punitive, but also not “culturally normative” in society. His principle is based upon social and physical integration, which later became popularised, implemented and studied in services as community integration encompassing areas from work to recreation and living arrangement.

Theoretical Foundations

This theory includes “the dignity of risk”, rather than an emphasis on “protection” and is based upon the concept of integration in community life. The theory is one of the first to examine comprehensively both the individual and the service systems, similar to theories of human ecology which were competitive in the same period.

The theory undergirds the deinstitutionalisation and community integration movements, and forms the legal basis for affirming rights to education, work, community living, medical care and citizenship. In addition, self-determination theory could not develop without this conceptual academic base to build upon and critique.

The theory of social role valorisation is closely related to the principle of normalisation having been developed with normalisation as a foundation. This theory retains most aspects of normalisation concentrating on socially valued roles and means, in socially valued contexts to achieve integration and other core quality of life values.

Brief History

The principle of normalisation was developed in Scandinavia during the sixties and articulated by Bengt Nirje of the Swedish Association for Retarded Children with the US human service system a product of Wolf Wolfensberger formulation of normalisation and evaluations of the early 1970s. According to the history taught in the 1970s, although the “exact origins are not clear”, the names Bank-Mikkelson (who moved the principle to Danish law), Grunewald, and Nirje from Scandinavia (later Ministry of Community and Social Services in Toronto, Canada) are associated with early work on this principle. Wolfensberger is credited with authoring the first textbook as a “well-known scholar, leader, and scientist” and Rutherford H. (Rud) Turnbull III reports that integration principles are incorporated in US laws.

Academe

The principle was developed and taught at the university level and in field education during the seventies, especially by Wolf Wolfensberger of the United States, one of the first clinical psychologists in the field of mental retardation, through the support of Canada and the National Institute on Mental Retardation (NIMR) and Syracuse University in New York State. PASS and PASSING marked the quantification of service evaluations based on normalisation, and in 1991 a report was issued on the quality of institutional and community programmes in the US and Canada based on a sample of 213 programmes in the US, Canada and the United Kingdom.

Significance in Structuring Service Systems

Normalisation has had a significant effect on the way services for people with disabilities have been structured throughout the UK, Europe, especially Scandinavia, North America, Israel, Australasia (e.g. New Zealand) and increasingly, other parts of the world. It has led to a new conceptualisation of disability as not simply being a medical issue (the medical model which saw the person as indistinguishable from the disorder, though Wolfensberger continued to use the term into the 2000s, but as a social situation as described in social role valorisation.

Government reports began from the 1970s to reflect this changing view of disability (Wolfensberger uses the term devalued people), e.g. the NSW Anti-Discrimination Board report of 1981 made recommendations on:

“the rights of people with intellectual handicaps to receive appropriate services, to assert their rights to independent living so far as this is possible, and to pursue the principle of normalization.”

The New York State Quality of Care Commission also recommended education based upon principles of normalisation and social role valorisation addressing “deep-seated negative beliefs of and about people with disabilities”. Wolfensberger’s work was part of a major systems reform in the US and Europe of how individuals with disabilities would be served, resulting in the growth in community services in support of homes, families and community living.

Critical Ideology of Human Services

Normalisation is often described in articles and education texts that reflect deinstitutionalisation, family care or community living as the ideology of human services. Its roots are European-American, and as discussed in education fields in the 1990s, reflect a traditional gender relationship-position (Racino, 2000), among similar diversity critiques of the period (i.e. multiculturalism). Normalisation has undergone extensive reviews and critiques, thus increasing its stature through the decades often equating it with school mainstreaming, life success and normalisation, and deinstitutionalisation.

In Contemporary Society

In the United States, large public institutions housing adults with developmental disabilities began to be phased out as a primary means of delivering services in the early 1970s and the statistics have been documented until the present day (2015) by David Braddock and his colleagues. As early as the late 1960s, the normalisation principle was described to change the pattern of residential services, as exposes occurred in the US and reform initiatives began in Europe. These proposed changes were described in the leading text by the President’s Committee on Mental Retardation (PCMR) titled: “Changing Patterns in Residential Services for the Mentally Retarded” with leaders Burton Blatt, Wolf Wolfensberger, Bengt Nirje, Bank-Mikkelson, Jack Tizard, Seymour Sarason, Gunnar Dybwad, Karl Gruenwald, Robert Kugel, and lesser known colleagues Earl Butterfield, Robert E. Cooke, David Norris, H. Michael Klaber, and Lloyd Dunn.

Deinstitutionalisation and Community Development

The impetus for this mass deinstitutionalisation was typically complaints of systematic abuse of the patients by staff and others responsible for the care and treatment of this traditionally vulnerable population with media and political exposes and hearings. These complaints, accompanied by judicial oversight and legislative reform, resulted in major changes in the education of personnel and the development of principles for conversion models from institutions to communities, known later as the community paradigms. In many states the recent process of deinstitutionalisation has taken 10–15 years due to a lack of community supports in place to assist individuals in achieving the greatest degree of independence and community integration as possible. Yet, many early recommendations from 1969 still hold such as financial aid to keep children at home, establishment of foster care services, leisure and recreation, and opportunities for adults to leave home and attain employment (Bank-Mikkelsen, p.234-236, in Kugel & Wolfensberger, 1969).

Community Supports and Community Integration

A significant obstacle in developing community supports has been ignorance and resistance on the part of “typically developed” community members who have been taught by contemporary culture that “those people” are somehow fundamentally different and flawed and it is in everyone’s best interest if they are removed from society (this developing out of 19th Century ideas about health, morality, and contagion). Part of the normalization process has been returning people to the community and supporting them in attaining as “normal” as life as possible, but another part has been broadening the category of “normal” (sometimes taught as “regular” in community integration, or below as “typical”) to include all human beings. In part, the word “normal” continues to be used in contrast to “abnormal”, a term also for differentness or out of the norm or accepted routine (e.g. middle class).

Contemporary Services and Workforces

In 2015, public views and attitudes continue to be critical both because personnel are sought from the broader society for fields such as mental health and contemporary community services continue to include models such as the international “emblem of the group home” for individuals with significant disabilities moving to the community. Today, the US direct support workforce, associated with the University of Minnesota, School of Education, Institute on Community Integration can trace its roots to a normalisation base which reflected their own education and training at the next generation levels.

People with disabilities are not to be viewed as sick, ill, abnormal, subhuman, or unformed, but as people who require significant supports in certain (but not all) areas of their life from daily routines in the home to participation in local community life. With this comes an understanding that all people require supports at certain times or in certain areas of their life, but that most people acquire these supports informally or through socially acceptable avenues. The key issue of support typically comes down to productivity and self-sufficiency, two values that are central to society’s definition of self-worth. If we as a society were able to broaden this concept of self-worth perhaps fewer people would be labelled as “disabled.”

Contemporary Views on Disability

During the mid to late 20th century, people with disabilities were met with fear, stigma, and pity. Their opportunities for a full productive life were minimal at best and often emphasis was placed more on personal characterises that could be enhanced so the attention was taken from their disability. Linkowski developed the Acceptance of Disability Scale (ADS) during this time to help measure a person’s struggle to accept disability. He developed the ADS to reflect the value change process associated with the acceptance of loss theory. In contrast to later trends, the current trend shows great improvement in the quality of life for those with disabilities. Sociopolitical definitions of disability, the independent living movement, improved media and social messages, observation and consideration of situational and environmental barriers, passage of the Americans with Disabilities Act of 1990 have all come together to help a person with disability define their acceptance of what living with a disability means.

Bogdan and Taylor’s (1993) acceptance of sociology, which states that a person need not be defined by personal characterises alone, has become influential in helping persons with disabilities to refuse to accept exclusion from mainstream society. According to some disability scholars, disabilities are created by oppressive relations with society, this has been called the social creationist view of disability. In this view, it is important to grasp the difference between physical impairment and disability. In the article The Mountain written by Eli Clare, Michael Oliver defines impairment as lacking part of or all of a limb, or having a defective limb, organism or mechanism of the body and the societal construct of disability; Oliver defines disability as the disadvantage or restriction of activity caused by a contemporary social organisation which takes no or little account of people who have physical (and/or cognitive/developmental/mental) impairments and thus excludes them from the mainstream of society. In society, language helps to construct reality, for instance, societies way of defining disability which implies that a disabled person lacks a certain ability, or possibility, that could contribute to her personal well-being and enable her to be a contributing member of society versus abilities and possibilities that are considered to be good and useful.

Personal Wounds, Quality of Life and Social Role Valorisation

However, the perspective of Wolfensberger, who served as associated faculty with the Rehabilitation Research and Training Centre on Community Integration (despite concerns of federal funds), is that people he has known in institutions have “suffered deep wounds”. This view, reflected in his early overheads of PASS ratings, is similar to other literature that has reflected the need for hope in situations where aspirations and expectations for quality of life had previously been very low (e.g. brain injury, independent living). Normalisation advocates were among the first to develop models of residential services, and to support contemporary practices in recognising families and supporting employment. Wolfensberger himself found the new term social role valorisation to better convey his theories (and his German Professorial temperament, family life and beliefs) than the constant “misunderstandings” of the term normalisation!

Related Theories and Development

Related theories on integration in the subsequent decades have been termed community integration, self-determination or empowerment theory, support and empowerment paradigms, community building, functional-competency, family support, often not independent living (supportive living),and in 2015, the principle of inclusion which also has roots in service fields in the 1980s.

Misconceptions

Normalisation is so common in the fields of disability, especially intellectual and developmental disabilities, that articles will critique normalisation without ever referencing one of three international leaders: Wolfensberger, Nirje, and Bank Mikkelson or any of the women educators (e.g. Wolfensberger’s Susan Thomas; Syracuse University colleagues Taylor, Biklen or Bogdan; established women academics (e.g. Sari Biklen); or emerging women academics, Traustadottir, Shoultz or Racino in national research and education centres (e.g. Hillyer, 1993). In particular, this may be because Racino (with Taylor) leads an international field on community integration, a neighbouring related concept to the principle of normalisation, and was pleased to have Dr. Wolf Wolfensberger among Centre Associates. Thus it is important to discuss common misconceptions about the principle of normalisation and its implications among the provider-academic sectors:

a) Normalisation does not mean making people normal – forcing them to conform to societal norms.

Wolfensberger himself, in 1980, suggested “Normalizing measures can be offered in some circumstances, and imposed in others.” This view is not accepted by most people in the field, including Nirje. Advocates emphasize that the environment, not the person, is what is normalized, or as known for decades a person-environment interaction.

Normalization is very complex theoretically, and Wolf Wolfensberger’s educators explain his positions such as the conservatism corollary, deviancy unmaking, the developmental model (see below) and social competency, and relevance of social imagery, among others.

b) Normalisation does not support “dumping” people into the community or into schools without support.

Normalisation has been blamed for the closure of services (such as institutions) leading to a lack of support for children and adults with disabilities. Indeed, normalisation personnel are often affiliated with human rights groups. Normalisation is not deinstitutionalisation, though institutions have been found to not “pass” in service evaluations and to be the subject of exposes. Normalisation was described early as alternative special education by leaders of the deinstitutionalisation movement.

However support services which facilitate normal life opportunities for people with disabilities – such as special education services, housing support, employment support and advocacy – are not incompatible with normalization, although some particular services (such as special schools) may actually detract from rather than enhance normal living bearing in mind the concept of normal ‘rhythms’ of life.

c) Normalisation supports community integration, but the principles vary significantly on matters such as gender and disability with community integration directly tackling services in the context of race, ethnicity, class, income and gender.

Some misconceptions and confusions about normalisation are removed by understanding a context for this principle. There has been a general belief that ‘special’ people are best served if society keeps them apart, puts them together with ‘their own kind, and keep them occupied. The principle of normalisation is intended to refute this idea, rather than to deal with subtlety around the question of ‘what is normal?’ The principle of normalisation is congruent in many of its features with “community integration” and has been described by educators as supporting early mainstreaming in community life.

d) Normalisation supports adult services by age range, not “mental age”, and appropriate services across the lifespan.

Arguments about choice and individuality, in connection with normalisation, should also take into account whether society, perhaps through paid support staff, has encouraged them into certain behaviours. For example, in referring to normalisation, a discussion about an adult’s choice to carry a doll with them must be influenced by a recognition that they have previously been encouraged in childish behaviours, and that society currently expects them to behave childishly. Most people who find normalisation to be a useful principle would hope to find a middle way – in this case, an adult’s interest in dolls being valued, but with them being actively encouraged to express it in an age-appropriate way (e.g. viewing museums and doll collections), with awareness of gender in toy selection (e.g. see cars and motorsports), and discouraged from behaving childishly and thus accorded the rights and routines only of a “perpetual child”. However, the principle of normalisation is intended also to refer to the means by which a person is supported, so that (in this example) any encouragement or discouragement offered in a patronising or directive manner is itself seen to be inappropriate.

e) Normalisation is a set of values, and early on (1970s) was validated through quantitative measures (PASS, PASSING).

Normalisation principles were designed to be measured and ranked on all aspects through the development of measures related to homes, facilities, programmes, location (i.e. community development), service activities, and life routines, among others. These service evaluations have been used for training community services personnel, both in institutions and in the community.

Normalisation as the basis for education of community personnel in Great Britain is reflected in a 1990s reader, highlighting Wolf Wolfensberger’s moral concerns as a Christian, right activist, side-by-side (“How to Function with Personal Model Coherency in a Dysfunctional (Human Service) World”) with the common form of normalisation training for evaluations of programmes. Community educators and leaders in Great Britain and the US of different political persuasions include John O’Brien and Connie Lyle O’Brien, Paul Williams and Alan Tyne, Guy Caruso and Joe Osborn, Jim Mansell and Linda Ward, among many others.

References

Nirje, B. (1982) The basis and logic of the normalisatioprinciple, Bengt Nirje, Sixth International Congress of IASSMD, Toronto.

What is Social Connection?

Published on by Andrew Marshall1 Comment

Introduction

Social connection is the experience of feeling close and connected to others. It involves feeling loved, cared for, and valued, and forms the basis of interpersonal relationships.

“Connection is the energy that exists between people when they feel seen, heard and valued; when they can give and receive without judgement; and when they derive sustenance and strength from the relationship.” Brené Brown, Professor of social work at the University of Houston.

Increasingly, social connection is understood as a core human need, and the desire to connect as a fundamental drive. It is crucial to development; without it, social animals experience distress and face severe developmental consequences. In humans, one of the most social species, social connection is essential to nearly every aspect of health and well-being. Lack of connection, or loneliness, has been linked to inflammation, accelerated aging and cardiovascular health risk, suicide, and all-cause mortality.

Feeling socially connected depends on the quality and number of meaningful relationships one has with family, friends, and acquaintances. Going beyond the individual level, it also involves a feeling of connecting to a larger community. Connectedness on a community level has profound benefits for both individuals and society.

Related Terms

Social support is the help, advice, and comfort that we receive from those with whom we have stable, positive relationships. Importantly, it appears to be the perception, or feeling, of being supported, rather than objective number of connections, that appears to buffer stress and affect our health and psychology most strongly.

Close relationships refer to those relationships between friends or romantic partners that are characterised by love, caring, commitment, and intimacy.

Attachment is a deep, emotional bond between two or more people, a “lasting psychological connectedness between human beings.” Attachment theory, developed by John Bowlby during the 1950s, is a theory that remains influential in psychology today.

Conviviality has many different interpretations and understandings, one of which denotes the idea of living together and enjoying each other’s company. This understanding of the term is derived from the French convivialité, which can be traced back to Jean Anthelme Brillat-Savarin in the 19th Century. Other interpretations of conviviality include the art of living in the company of others; everyday experiences of community cohesion and togetherness in diverse settings; and the capacity of individuals to interact creatively and autonomously with one another and their environment for the satisfaction of their needs. This third interpretation is rooted in the work of Ivan Illich from the 1970s onwards. Social connection is fundamental to all of these interpretations of conviviality.

A Basic Need

In his influential theory on the hierarchy of needs, Abraham Maslow proposed that our physiological needs are the most basic and necessary to our survival, and must be satisfied before we can move on to satisfying more complex social needs like love and belonging. However, research over the past few decades has begun to shift our understanding of this hierarchy. Social connection and belonging may in fact be a basic need, as powerful as our need for food or water. Mammals are born relatively helpless, and rely on their caregivers not only for affection, but for survival. This may be evolutionarily why mammals need and seek connection, and also for why they suffer prolonged distress and health consequences when that need is not met.

In 1965, Harry Harlow conducted his landmark monkey studies. He separated baby monkeys from their mothers, and observed which surrogate mothers the baby monkeys bonded with: a wire “mother” that provided food, or a cloth “mother” that was soft and warm. Overwhelmingly, the baby monkeys preferred to spend time clinging to the cloth mother, only reaching over to the wire mother when they became too hungry to continue without food. This study questioned the idea that food is the most powerful primary reinforcement for learning. Instead, Harlow’s studies suggested that warmth, comfort, and affection (as perceived from the soft embrace of the cloth mother) are crucial to the mother-child bond, and may be a powerful reward that mammals may seek in and of itself. Although historically significant, it is important to acknowledge that this study does not meet current research standards for the ethical treatment of animals.

In 1995, Roy Baumeister proposed his influential belongingness hypothesis: that human beings have a fundamental drive to form lasting relationships, to belong. He provided substantial evidence that indeed, the need to belong and form close bonds with others is itself a motivating force in human behaviour. This theory is supported by evidence that people form social bonds relatively easily, are reluctant to break social bonds, and keep the effect on their relationships in mind when they interpret situations. He also contends that our emotions are so deeply linked to our relationships that one of the primary functions of emotion may be to form and maintain social bonds, and that both partial and complete deprivation of relationships leads to not only painful but pathological consequences. Satisfying or disrupting our need to belong, our need for connection, has been found to influence cognition, emotion, and behaviour.

In 2011, Roy Baumeister furthered this notion of belongingness by proposing the Need to Belong Theory, which asserts that humans have an inherent drive to maintain a minimum number of social relationships to foster a sense of belonging. Baumeister highlights the importance of satiation and substitution in driving human behaviour and social connection. Motivational satiation is a phenomenon in which an individual may desire something, but at a certain point, they may reach a point where they have had enough and no longer want or need any more of it. This concept can be applied to the formation of friendships, where an individual may desire social connections, but they may reach a point where they have enough friends and do not seek any more. However, Baumeister suggests that people still require a certain minimum amount of social connection, and to some extent, these bonds can substitute for each other. The Need to Belong Theory is a primary motivator of human behaviour, providing a framework for understanding social relationships as a basic, fundamental need for psychological health and well-being.

Neurobiology

Brain Areas

While it appears that social isolation triggers a “neural alarm system” of threat-related regions of the brain (including the amygdala, dorsal anterior cingulate cortex (dACC), anterior insula, and periaqueductal gray (PAG)), separate regions may process social connection. Two brain areas that are part of the brain’s reward system are also involved in processing social connection and attention to loved ones: the ventromedial prefrontal cortex (VMPFC), a region that also responds to safety and inhibits threat responding, and the ventral striatum (VS) and septal area (SA), part of a neural system that is activated by taking care of one’s own young.

Key Neurochemicals

Opioids

In 1978, neuroscientist Jaak Panksepp observed that small doses of opiates reduced the distressed cries of puppies that were separated from their mothers. As a result, he developed the brain opioid theory of attachment, which posits that endogenous (internally produced) opioids underlie the pleasure that social animals derive from social connection, especially within close relationships. Extensive animal research supports this theory. Mice who have been genetically modified to not have mu-opioid receptors (mu-opioid receptor knockout mice), as well as sheep with their mu-receptors blocked temporarily following birth, do not recognise or bond with their mother. When separated from their mother and conspecifics, rats, chicks, puppies, guinea pigs, sheep, dogs, and primates emit distress vocalisations, however giving them morphine (i.e. activating their opioid receptors), quiets this distress. Endogenous opioids appear to be produced when animals engage in bonding behaviour, while inhibiting the release of these opioids results in signs of social disconnection. In humans, blocking mu-opioid receptors with the opioid antagonist naltrexone has been found to reduce feelings of warmth and affection in response to a film clip about a moment of bonding, and to increase feelings of social disconnection towards loved ones in daily life as well as in the lab in response to a task designed to elicit feelings of connection. Although the human research on opioids and bonding behaviour is mixed and ongoing, this suggests that opioids may underlie feelings of social connection and bonding in humans as well.

Oxytocin

In mammals, oxytocin has been found to be released during childbirth, breastfeeding, sexual stimulation, bonding, and in some cases stress. In 1992, Sue Carter discovered that administering oxytocin to prairie voles would accelerate their monogamous pair-bonding behaviour. Oxytocin has also been found to play many roles in the bonding between mother and child. In addition to pair-bonding and motherhood, oxytocin has been found to play a role in prosocial behaviour and bonding in humans. Nicknamed the “love drug” or “cuddle chemical,” plasma levels of oxytocin increase following physical affection, and are linked to more trusting and generous social behaviour, positively biased social memory, attraction, and anxiety and hormonal responses. Further supporting a nuanced role in adult human bonding, greater circulating oxytocin over a 24-hour period was associated with greater love and perceptions of partner responsiveness and gratitude, however was also linked to perceptions of a relationship being vulnerable and in danger. Thus oxytocin may play a flexible role in relationship maintenance, supporting both the feelings that bring us closer and the distress and instinct to fight for an intimate bond in peril.

Health

Consequences of Disconnection

A wide range of mammals, including rats, prairie voles, guinea pigs, cattle, sheep, primates, and humans, experience distress and long-term deficits when separated from their parent. In humans, long-lasting health consequences result from early experiences of disconnection. In 1958, John Bowlby observed profound distress and developmental consequences when orphans lacked warmth and love of our first and most important attachments: our parents. Loss of a parent during childhood was found to lead to altered cortisol and sympathetic nervous system reactivity even a decade later, and affect stress response and vulnerability to conflict as a young adult.

In addition to the health consequences of lacking connection in childhood, chronic loneliness at any age has been linked to a host of negative health outcomes. In a meta-analytic review conducted in 2010, results from 308,849 participants across 148 studies found that people with strong social relationships had a 50% greater chance of survival. This effect on mortality is not only on par with one of the greatest risks, smoking, but exceeds many other risk factors such as obesity and physical inactivity. Loneliness has been found to negatively affect the healthy function of nearly every system in the body: the brain, immune system, circulatory and cardiovascular systems, endocrine system, and genetic expression.

Not only is social isolation harmful to health, but it is more and more common. As many as 80% of young people under 18 years old, and 40% of adults over the age of 65 report being lonely sometimes, and 15-30% of the general population feel chronic loneliness. These numbers appear to be on the rise, and researchers have called for social connection to be public health priority.

Social Immune System

One of the main ways social connection may affect our health is through the immune system. The immune system’s primary activity, inflammation, is the body’s first line of defence against injury and infection. However, chronic inflammation has been tied to atherosclerosis, Type II diabetes, neurodegeneration, and cancer, as well as compromised regulation of inflammatory gene expression by the brain. Research over the past few decades has revealed that the immune system not only responds to physical threats, but social ones as well. It has become clear that there is a bidirectional relationship between circulating biomarkers of inflammation (e.g. the cytokine IL-6) and feelings of social connection and disconnection; not only are feelings of social isolation linked to increased inflammation, but experimentally induced inflammation alters social behaviour and induces feelings of social isolation. This has important health implications. Feelings of chronic loneliness appear to trigger chronic inflammation. However, social connection appears to inhibit inflammatory gene expression and increase antiviral responses. Performing acts of kindness for others were also found to have this effect, suggesting that helping others provides similar health benefits.

Why might our immune system respond to our perceptions of our social world? One theory is that it may have been evolutionarily adaptive for our immune system to “listen” in to our social world to anticipate the kinds of bacterial or microbial threats we face. In our evolutionary past, feeling socially isolated may have meant we were separated from our tribe, and therefore more likely to experience physical injury or wounds, requiring an inflammatory response to heal. On the other hand, feeling connected may have meant we were in relative physical safety of community, but at greater risk of socially transmitted viruses. To meet these threats with greater efficiency, the immune system responds with anticipatory changes. A genetic profile was discovered to initiate this pattern of immune response to social adversity and stress – up-regulation of inflammation, down-regulation of antiviral activity – known as Conserved Transcriptional Response to Adversity. The inverse of this pattern, associated with social connection, has been linked to positive health outcomes as well as eudaemonic well-being.

Positive Pathways

Social connection and support have been found to reduce the physiological burden of stress and contribute to health and well-being through several other pathways as well, although there remains a subject of ongoing research. One way social connection reduces our stress response is by inhibiting activity in our pain and alarm neural systems. Brain areas that respond to social warmth and connection (notably, the septal area) have inhibitory connections to the amygdala, which have the structural capacity to reduce threat responding.

Another pathway by which social connection positively affects health is through the parasympathetic nervous system (PNS), the “rest and digest” system which parallels and offsets the “flight or fight” sympathetic nervous system (SNS). Flexible PNS activity, indexed by vagal tone, helps regulate the heart rate and has been linked to a healthy stress response as well as numerous positive health outcomes. Vagal tone has been found to predict both positive emotions and social connectedness, which in turn result in increased vagal tone, in an “upward spiral” of well-being. Social connection often occurs along with and causes positive emotions, which themselves benefit our health.

Measures

Social Connectedness Scale

This scale was designed to measure general feelings of social connectedness as an essential component of belongingness. Items on the Social Connectedness Scale reflect feelings of emotional distance between the self and others, and higher scores reflect more social connectedness.

UCLA Loneliness Scale

Measuring feelings of social isolation or disconnection can be helpful as an indirect measure of feelings of connectedness. This scale is designed to measure loneliness, defined as the distress that results when one feels disconnected from others.

Relationship Closeness Inventory (RCI)

This measure conceptualises closeness in a relationship as a high level of interdependence in two people’s activities, or how much influence they have over one another. It correlates moderately with self-reports of closeness, measured using the Subjective Closeness Index (SCI).

Liking and Loving Scales

These scales were developed to measure the difference between liking and loving another person – critical aspects of closeness and connection. Good friends were found to score highly on the liking scale, and only romantic partners scored highly on the loving scale. They support Zick Rubin’s conceptualisation of love as containing three main components: attachment, caring, and intimacy.

Personal Acquaintance Measure (PAM)

This measure identifies six components that can help determine the quality of a person’s interactions and feelings of social connectedness with others:

  • Duration of relationship
  • Frequency of interaction with the other person
  • Knowledge of the other person’s goals
  • Physical intimacy or closeness with the other person
  • Self-disclosure to the other person
  • Social network familiarity – how familiar is the other person with the rest of your social circle

Experimental Manipulations

Social connection is a unique, elusive, person-specific quality of our social world. Yet, can it be manipulated? This is a crucial question for how it can be studied, and whether it can be intervened on in a public health context. There are at least two approaches that researchers have taken to manipulate social connection in the lab:

Social Connection Task

This task was developed at UCLA by Tristen Inagaki and Naomi Eisenberger to elicit feelings of social connection in the laboratory. It consists of collecting positive and neutral messages from 6 loved ones of a participant, and presenting them to the participant in the laboratory. Feelings of connection and neural activity in response to this task have been found to rely on endogenous opioid activity.

Closeness-Generating Procedure

Arthur Aron at the State University of New York at Stony Brook and collaborators designed a series of questions designed to generate interpersonal closeness between two individuals who have never met. It consists of 36 questions that subject pairs ask each other over a 45-minute period. It was found to generate a degree of closeness in the lab, and can be more carefully controlled than connection within existing relationships.

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What is Alexithymia?

Published on by Andrew Marshall6 Comments

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.