Short-Term Psychotherapy and Emotional Crisis
Peter E. Sifneos
This book is about a condensed program of "anxiety-provoking" psychotherapy. In the second part of the book, dealing with "technical aspects" of short-term psychotherapy, Sifneos stresses that—for this program to work—the patient must be in tune with his or her own emotions. To emphasize the point, in Chapter 6: Selection of Patients, he introduces the term alexithymic to name those patients who are unsuitable for this therapy due to their lack of emotional insight.
The ability, then, not only to recognize and express emotions but also to verbalize them is significant. Some patients experience a difficulty in this area. When they are asked to talk about how they feel they mention repetitively and endlessly only somatic sensations, without being able to relate them to any accompanying thoughts, fantasies, or conflicts. Others seem to be unable to specify what it feels like to be angry or sad, and a few individuals fail to differentiate between pleasant and unpleasant emotions. They usually respond to such questioning by describing the actions they take under those circumstances and, when pressed for further details, show irritability and annoyance. Such patients seem to have limited vocabularies. They seem to have marked difficulty in finding appropriate words to describe their emotions. They usually look puzzled and give the impression they do not understand the meaning of the word "feeling". Because of these limitations, such patients tend to have difficulty in communicating with other people and appear uninteresting and dull. The interviewer, in turn, experienced in dealing with elaborate verbal communications of ordinary neurotic people, finds it difficult to evaluate such boring patients. Furthermore, because he is unable to make a psychodynamic formulation or to it the patient into a familiar diagnostic category, he tries to explain away the patient's difficulties by statements such as, "He seems to be denying his emotion."
I would like to introduce the word alexithymic (Greek a, lack, lexis, word, thymos, mood) to describe patients who present these difficulties. What is of interest is that during the evaluation interviews with them, a compromise is usually reached when finally the psychiatrist is forced to talk about the emotions of the patient by providing his own appropriate words to describe them. The patient, in turn, borrows these words gratefully, and by imitating, he parrots them back to his doctor without understanding their real meaning. Usually an impasse is reached. Some patients with psychosomatic illness fall into this category. They are not good candidates for short-term anxiety-provoking psychotherapy, and the question must be raised as to the contraindication of psychotherapy in general, which relies so much on verbal and emotional interactions, for such patients. What is the alternative? I have none, but I also feel strongly that psychotherapy should not be used for lack of something better. Research in this area may provide us with better treatment.
He goes on to quote some dialogue from a therapy session with an alexithymic patient:
The patient's voice was monotonous. She talked about her aunt, who had repeatedly borrowed large sums of money from her and reused to pay her back. The interviewer asked how she felt about this situation. The patient looked puzzled and said that she did not like it.
Doctor: How do you feel?
Patient: I . . . you know, I wanted to hit her over the head.
Doctor: I did not mean what you wanted to do. I wondered how you felt.
Patient: (silent for a while) I don't know what you mean.
Doctor: Did you feel angry?
Patient: I guess so.
Doctor: What is it like to feel angry?
Patient: You know, don't you?
Doctor: What does it feel like to you?
Patient: I don't know. There are no words to describe it.
And that is pretty much all that Sifneos says about alexithymics in this book. He only mentions alexithymia as a contra-indication for short-term psychotherapy. The rest of the book is concerned with a class of patients who are adept at recognizing their emotions and thus contrast markedly with alexithymics.