Challenges for Alexithymia Research: A Commentary on
‘‘The Construct of Alexithymia: Associations With Defense
Mechanisms’’
m
Stijn Vanheule
Ghent University
The author comments on an article by Helmes and colleagues
(this issue, pp. 318–331) that studied defense mechanisms related to
alexithymia. What these authors observed is theoretically meaningful,
and a distinct strength of this study is that the results are replicated in
three independent samples. The study is also exemplary for two
typical drawbacks— only student samples and self-report measures
are used. The author suggests that when studying alexithymia,
researchers use samples that contain a substantial number of
alexithymic subjects. Furthermore, variables such as emotional
processing and regulation should not be measured with self-report
questionnaires alone. Emotional processing and regulation are, in part,
implicit and researchers should consider this. The author argues that
the standard of alexithymia research could be raised by including
interdisciplinary perspectives and experimental methods, and by
embedding research more explicitly in theories. & 2008 Wiley Periodicals, Inc. J Clin Psychol 64: 332--337, 2008.
Keywords: alexithymia; defense mechanisms; assessment; sampling;
metacognition; psychoanalysis
Introduction
Four decades of clinical reﬂection and systematized research on alexithymia has
shown the relevance of this construct for clinical psychology. Alexithymia, which can
be deﬁned as a difﬁculty in processing and regulating affective arousal by means of
mental representations, proves to be prominent in a number of clinical disorders
(e.g., somatoform disorders, panic disorders, depression with dominance of vital and
somatic symptoms, posttraumatic stress disorder [PTSD], and eating disorders).
Correspondence concerning this article should be addressed to: Stijn Vanheule, Ghent University, Faculty
of Psychology and Educational Sciences, Department of Psychoanalysis and Clinical Consulting,
H. Dunantlaan 2, B-9000 Ghent, Belgium; e-mail: [email protected]
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 64(3), 332–337 (2008)
& 2008 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20467
Challenges for Alexithymia Research
333
It has not only been demonstrated that a substantial number of these patients have
pronounced alexithymia, but that alexithymia is signiﬁcantly related to outcome
variables of these disorders (Frewen, Pain, Dozois, & Lanius, 2006; Hund
& Espelage, 2005; Mueller & Buehner, 2006; Speranza, Laos, Wallier, & Corcos,
2007; Taylor, Bagby, & Parker, 1997; Vanheule, Desmet, Verhaeghe, & Bogaerts,
2007; Verhaeghe, Vanheule, & De Rick, 2007). Diverse variables, such as style of
interpersonal relating, concomitant psychological processes (e.g., dissociation),
course of illness, and therapy outcome have been linked to alexithymia (Grabe et al.,
2000; Porcellia & Todarello, 2007; Speranza et al., 2007; Vanheule, Desmet, Rosseel,
Verhaeghe, & Meganck, 2007).
The article by Helmes and colleagues (this issue, pp. 318–331) on the defense
mechanisms related to alexithymia adds to this ﬁeld. The authors demonstrate that
alexithymia is systematically related to increased emotional inhibition, immature
defense styles, and a reduced self-deception. This ﬁnding is important as it indicates
that alexithymia is associated with broader subjective strategies of dealing with
personally sensitive and conﬂicting information. The mechanism of emotional
inhibition designates the tendency towards blocking off the possibility of being
affected and aroused by events; the immature defense styles point out annulling
tendencies that come to the fore upon dealing with sensitive and conﬂicting
information. In my interpretation, the correlation with reduced self-deception
indicates that the type of defense at work in alexithymia is different from neurotic
defense, whereby self-deception is an essential element. Very early in his work, Freud
(1894/1962) described neurotic defense as the consequence of experiencing ideas or
intentions that are at odds with one’s ego. Examples of such antithetical ideas can be
found in what people experience as taboos, like elements in the sexual or aggressive
sphere. According to Freud, defense against an antithetical idea consists ‘‘of ‘pushing
the thing away’, of not thinking of it, of suppressing it’’ (Freud, 1894/1962, p. 47).
A result of this defense is that the antithetical idea is marginalized in mental life and
fades into the background. The self-deceiving tendency at work here consists of the
ego’s acting as if the antithetical idea was not there. Immature defenses, on the other
hand, rather than marginalizing mental contents, are more rudimentary than neurotic
defenses in that they aim at altogether erasing or externalizing these contents from
mental life, e.g., by denying them or by projecting them to others (Freud, 1936).
The radical nature of this operation implies that the ego no longer needs to act in
a self-deceptive way because the effect of this type of defense is that the antithetical
idea is no longer experienced as part of oneself. To conclude, the pattern of
associations Helmes and colleagues found is theoretically sound and in my experience,
corresponds to what clinicians can observe in their work with alexithymic patients.
A distinct strength of the study by Helmes and colleagues is that their results are
replicated in three samples, from two different countries. The replications, of which
the value cannot be overestimated (Rosenthal, 1995), indicate that what they have
found is solid, and not attributable to coincidental factors. Findings of this type
illustrate how alexithymia is not an isolated trait in someone’s functioning, but
embedded in broader patterns of functioning. This is very important as it helps
researchers and clinicians gain empirically supported insight into the complexity of
patients’ problems, which advances the science of clinical psychology (Westen
& Bradley, 2005).
Nevertheless, the study of Helmes and colleagues has two drawbacks that
characterize many studies on alexithymia: the exclusive use of student samples and
the exclusive use of self-report measures.
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The Exclusive Use of Student Samples
There is a clear tendency among psychological researchers to recruit the subjects for
their studies in the group that is most easily accessible to them, i.e., psychology
students, who frequently get credits for participating in research. However, when
studying clinical psychological topics it is of utmost importance that the
characteristics one is studying are markedly present in a substantial percentage of
the sample. Studying alexithymia or immature defenses solely in a student
population is problematic: Occasionally alexithymic subjects will be in the sample
(in our experience hardly 5%), but the size of this group tends to be too small to
make conclusions that are valid to explain the problem of alexithymic subjects in
clinical settings. Helmes and colleagues do not report how many of their subjects
actually suffer from severe or moderate alexithymia, but the means and standard
deviations they present brings us to presume that few alexithymic subjects were
involved in this study. It is advisable that when using student samples to study
alexithymia, researchers should also use samples in which a substantial number of
participants do suffer from the problem.
Moreover, studying alexithymia in student samples with the aim of making
inferences that are relevant for clinical groups presupposes that the measurements
used are invariant across those groups. Such a presumption that different groups
make identical interpretations of questionnaire items is something that should be
tested. To our knowledge only one study examined measurement invariance between
a clinical and a nonclinical group for the TAS-20 items (Meganck, Vanheule,
& Desmet, in press). In this study (among Dutch-speaking subjects) partial
invariance between these groups was observed (different interpretation of item 19,
which refers to personal problems). The absence of further research on the TAS-20,
or other alexithymia questionnaires, urges us to be careful with making generalizations between clinical and nonclinical groups.
The Exclusive Use of Self-Report Measures
The other drawback in the study of Helmes and colleagues is their exclusive use of
self-report measures. There are at least two reasons to object to this practice. A ﬁrst
one is purely methodological: The sole use of self-report measures leaves us with the
question as to whether associations found between two variables have been
inﬂuenced by the use of a single measurement method. In other words, we cannot
examine or rule out whether results have been artiﬁcially inﬂated by this method.
Using multiple measures, on the contrary, enables us to control for this.
Consequently, for measuring alexithymia the TAS-20 self-report questionnaire can
best be combined with instruments like the Toronto Structured Interview for
Alexithymia (TSIA; Bagby, Taylor, Parker, & Dickens, 2006), the modiﬁed version
of the Beth Israel Hospital Psychosomatic Questionnaire (M-BIQ; Taylor, Bagby, &
Parker, 1997), or the Metagcognition Assessment Scale (MAS; Semerari et al., 2003).
These are instruments that researchers and clinicians score based on interview data.
A second reason for not exclusively using self-report measures in the study of
alexithymia or defense mechanisms is more fundamental. There is a growing
consensus that the way in which people represent and regulate emotions is, in part,
implicit and not accessible to self-knowledge (e.g., Westen & Blagov, 2007). In this
respect, self-report questionnaires, which make an exclusive appeal to explicit
self-knowledge, miss a crucial component of the way in which people actually
process and regulate affective states. Consequently, researchers that exclusively rely
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on self-report questionnaires for studying emotional representations and strategies
of affect regulation tend to distort the accuracy of our knowledge on those topics.
For studying defense mechanisms, self-report questionnaires, such as the Defence
Styles Questionnaire (Andrews, Singh, & Bond, 1993), could be combined with
instruments like the Q-sort Vaillant, developed for measuring defenses (Vaillant
& McCullough, 1998). The Q-sort and the clinician-scored questionnaire developed
by Westen and colleagues for studying affect regulation could also be used (Westen,
Muderrisoglu, Fowler, Shedler, & Koren, 1997; Zittel Conklin, Bradley, & Westen,
2006). Regretfully, however, the literature shows that these combinations are rarely
designed. For a problem like alexithymia, the absence of such research designs is all
the more surprising because a number of authors note the paradoxical issue of using
self-report instruments to measure alexithymia: These self-report instruments ask
people to report a capacity that they, in fact, are supposed to lack, i.e., the mental
processing of affective states (Lane, Ahern, Schwartz, & Kaszniak, 1997; Waller
& Scheidt, 2004). Without simultaneously using instruments like TSIA, M-BIQ, or
MAS, it is questionable as to whether a study can actually provide a valid
assessment. This remark was also made by Taylor and colleagues (1997), the authors
of the TAS-20. They emphasize that researchers should make use of different
methods to measure alexithymia. Nonetheless, doing so is not a common practice.
Conclusion
To raise the standard of alexithymia research and make this research more directly
relevant for clinical psychological practice, a number of changes are needed. In line
with the study of Helmes and colleagues, replication in independent samples is
recommended; researchers should also include clinical samples, or at least
a substantial number of subjects with elevated alexithymia scores in their studies;
and for the measurement of variables associated with emotional processing and
regulation, researchers should not rely on self-report measures alone.
I agree with Taylor and Bagby (2004) that the quality of research in the ﬁeld of
alexithymia could be raised by including more interdisciplinary perspectives and
experimental methods. In this context, a number of experimental psychological
studies have already shown that alexithymic subjects process emotional information
differently than nonalexithymic subjects (Luminet, Vermeulen, Demaret, Taylor,
& Bagby, 2006; Mueller, Alpers, & Reim, 2006; Vermeulen, Luminet, & Corneille,
2006); functional magnetic resonance imaging (fMRI) studies have detected patterns
of neural activation concomitant of alexithymia (Aleman, 2005; Frewen et al., 2006;
Moriguchi et al., 2007); and psychophysiological studies into the mental processing
of arousal and into correlates of alexithymia are gaining attention (Guilbaud,
Corcos, Hjalmarsson, Loas, & Jeammet, 2003).
Furthermore, alexithymia researchers should pay more attention to embedding
research within theoretical frameworks, and to the elaboration of theories that can
guide clinical psychological and psychotherapeutic practice with alexithymic
patients. Theory helps us to integrate empirical observations and to grasp the
complexity of disorders; it enables us to formulate clear hypotheses, and assists us in
making inferences from research to clinical practice. Metacognition theory
(Dimaggio, Carcionne, & Nicolo`, in press; Semerari, Carcione, Dimaggio, Nicolo`,
& Procacci, 2007) and psychoanalytic theory with respect to attachment and
actualpathology (Lemche, Klann-Delius, Koch, & Joranschky, 2004; Verhaeghe,
2004; Verhaeghe et al., 2007) are theories I ﬁnd very promising in this respect.
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