Alexithymia

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sunlioness

sunlioness

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Has anyone here had any experience treating patients with pretty severe alexithymia? I have one right now and it's really hard to treat her with any sort of medication regimen because she can't tell me what she's feeling or even how the meds are affecting her for better, worse, or nil. At all. She has some borderline traits as well and a h/o a rather non-nurturing and chaotic family of origin so I was thinking that DBT might be helpful and I was going to talk with her therapist about that (though of course then I run into the "everyone knows it's the indicated treatment, but no one is trained to actually do it" problem), but I thought I would check in here and see what others may have had some success with.

Thanks!
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I think a multi-prong approach is often helpful, and has been my strategy in these cases.

1. DBT if available is great. There are some workbooks floating around too if group or 1:1 isn't available.
2. My analytic supervisor (self not ego-psychology), often encourages me to try out language with the patient, reflecting words and asking "does that fit for you?" This becomes as much a process of teaching them language they can use as much as anything.
3. Neuropsych or just psychological testing is another tool, though I haven't found it to be especially helpful in getting breakthrough new information.
4. Pinning them down on specific symptoms-- insomnia - early/mid/late (trouble falling asleep, staying asleep, etc.), rested in the morning, etc.
5. Non-verbal indicators of mood, such as a mood/faces chart, like this:
http://www.childtherapytoys.com/store/media/largeimages/14651.jpg
 
sunlioness said:
Has anyone here had any experience treating patients with pretty severe alexithymia? I have one right now and it's really hard to treat her with any sort of medication regimen because she can't tell me what she's feeling or even how the meds are affecting her for better, worse, or nil. At all. She has some borderline traits as well and a h/o a rather non-nurturing and chaotic family of origin so I was thinking that DBT might be helpful and I was going to talk with her therapist about that (though of course then I run into the "everyone knows it's the indicated treatment, but no one is trained to actually do it" problem), but I thought I would check in here and see what others may have had some success with.

Thanks!
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How bad is it really? Lots of mental illnesses are associated with alexithymia but I usually associate it with autism not BPD.

Nitemagi's response: excellent!
 
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Does she have a history of abuse? Is the Alexithymia associated with dissociations?

Another thought would be to focus on mindfullness therapy or ToM (;)).
 
Thanks, guys. No real overt physical/sexual abuse history. Not that she's disclosed anyway. Emotional abuse, definitely. Long long history of being devalued by family. In a way it's no surprise that she can't recognize what she feels because she's been emotionally invalidated and told she has no right to her emotions her entire life. I don't doubt that some measure of dissociation is going on and her presentation can be quite childlike at times, but I don't have enough to diagnose her with a dissociative disorder.
 
DBT really is great for people who haven't learned to understand, accept, and appropriately express emotions. There seems to be a significant lack of providers who are trained in it, but that doesn't have to stop people from getting some benefit from it. If there isn't a therapist in the area who offers DBT, what's stopping you from learning about it? Maybe her therapist would be willing to learn, too. It might not be ideal, but would be better than nothing. You could check at behavioraltech.org and see if there are either DBT providers in your area or trainings that you would consider attending. Marsha Linehan's books and videos are good, and there are also some useful self-help books, such as "The Dialectical Behavior Therapy Skills Workbook" and basic summaries of the skills available online - see http://www.dbtselfhelp.com/

I am a master's level therapist, and have not yet been able to go to trainings and get the certification I would like to in DBT, but I run DBT groups (I read both of Marsha Linehan's books and learned along with my clients) for youth in residential treatment. These kids often deny that they even have emotions, let alone words to describe them. They go from under-expressive to acting out of control, with very little in between. Those that are willing to do the work find DBT skills useful.

I also relate to alexithymia myself. Several years back, when I started therapy, I had no idea what my emotions were. I wrote an autobiography and my therapist went through it and labled my emotions for me. That was a start, and might be helpful to your client. What are her primary complaints? Can you give her some of the words to describe emotions associated with her symptoms, and check it out with her to see if it feels like a fit?

If you or your client are interested in knowing more about the effects of emotional abuse and invalidating environments, here is a link to one of my blog entries summarizing Marsha Linehan on that topic. http://rapunzel.psychcentral.net/2008/04/14/lets-talk-about-invalidating-environments-shall-we/ Dr. Linehan knows what she's talking about.
 
sunlioness said:
Thanks, guys. No real overt physical/sexual abuse history. Not that she's disclosed anyway. Emotional abuse, definitely. Long long history of being devalued by family. In a way it's no surprise that she can't recognize what she feels because she's been emotionally invalidated and told she has no right to her emotions her entire life.
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The very foundation for BPD. "Rotten childhood" disease.
I don't doubt that some measure of dissociation is going on and her presentation can be quite childlike at times, but I don't have enough to diagnose her with a dissociative disorder.
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Note that in devaluing environments, reporting abuse often is not believed. It can set a pattern of dissociation as defense, but can also set up the possibility of abuse within the family, the "no one will believe me," esp. if she tried to report at one point and the abuser was more persuasive (or threatening to whomever she told).
 
sunlioness said:
In a way it's no surprise that she can't recognize what she feels because she's been emotionally invalidated and told she has no right to her emotions her entire life.
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Oh, okay, so this is not "trait alexithymia", but more of a defense mechanism against chronic emotional abuse, as evidenced by transference in therapy? A presentation complicated by periods of dissociation, resulting in lack of memory--both for thoughts AND feelings--of traumatic events in the past?
 
I shy away from positing unremembered traumatic events in my patients as a rule. It may or may not be going on here. I have no way of knowing that. But I don't think I necessarily need to know that to effectively treat this client or any other. If it comes up, it comes up. I'm not going to go around digging for it (not that you were suggesting this) because in my experience doing so is destabilizing, confusing, and just causes more problems. (Not that I have ever done so actually, but I have seen patients who have had prior therapists who have done this).

As for transference in therapy, the poor girl is terrified of me and very clingy/needy with her therapist. Though she has trouble engaging in therapy and often spends her time in sessions sitting on her therapist's couch unable to speak. The clingy/needy stuff I'm familiar with and have worked with frequently.

Thanks everyone! Re-reading Linehan is definitely on my list of things to do and I do have the DBT workbook, which I can definitely lend to her therapist (her therapist is a really good friend of mine).
 
sunlioness said:
As for transference in therapy, the poor girl is terrified of me and very clingy/needy with her therapist. Though she has trouble engaging in therapy and often spends her time in sessions sitting on her therapist's couch unable to speak. The clingy/needy stuff I'm familiar with and have worked with frequently.
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Sunlioness, I don't know how anyone could be terrified of you! You're one of the nicest people that frequents this forum. :)
 
Aw, thank you, Maranatha. I like to think I'm not very scary either. But the first 5 minutes of every appointment involves her staring at me in seeming terror and answering every question with shrugs and "I don't knows." I can usually get her to warm up a little bit just by being friendly and asking unrelated stuff about what she's been up to, small talk, etc. But she's still just as scared the next time. Her therapist says that she always begs her to come with her to appointments with me so she "doesn't have to talk."

Having said all that, even though I am so scary, she must still think I'm doing alright because she asked her therapist (not me, mind you) what insurances I take because she wanted to refer a friend to me. :)
 
sunlioness said:
But the first 5 minutes of every appointment involves her staring at me in seeming terror and answering every question with shrugs and "I don't knows." I can usually get her to warm up a little bit just by being friendly and asking unrelated stuff about what she's been up to, small talk, etc. But she's still just as scared the next time.
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That's so sad. For some strange reason reminds me of a time we found a cat in our garden at night. It was hurt and looked scared at first but warmed up to us eventually. It was doubly sad when we realized it did have an owner and we couldn't keep it.

p.s. I mean no disrespect by the comparison. It is my own rather undifferentiated emotional reaction to helpless and victimized living beings.
 
I think an important issue to remember though is that this kind of fear is generalized and has nothing to do with us, necessarily. Just an aspect of transference. I always fall into the trap of starting to feel it's something I'm doing wrong, when really it's something about us being authority figures, or something miniscule. We may never know. My hardest is patients who have done too much meth and they just seem cognitively burnt out, unable to communicate. Seems like it's an alexithymia, except it's a more global deficit. Tough to treat.
 
nitemagi said:
I think an important issue to remember though is that this kind of fear is generalized and has nothing to do with us, necessarily.
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:)

Transference and countertransference can be set off by the most (seemingly) trivial thing, so I usually assume it does have something to do with the both of us. Patients, specially those with BPD or a history of abuse/trauma can be exceptionally perceptive, detecting your emotional reactions, ones you are trying to mask/or are unaware of. I find mindfulness and genuine openness to experience to be particularly helpful to me. I don't really do therapy but upon some reflection on my clinical work, which typically consists of cognitive assessment, with some "difficult" patients, I decided to read up on transference/countertransference.
 
borderline traits.... with alexithymia? Interesting. I saw an interesting art therapy technique used for pts with alexithymia. They are asked to draw an animal that represents themself, with the appropriate environment. They are also asked to draw a picture of themselves. There are some other specific examples but I'm having a hard time remembering at this late hour. I think the idea was to a) be able to see if it is globalized to more abstract thinking/processing and b) have something physical to work with to show them, "you said the Koala is tired, but the koala doesn't *look* tired..." I think it can also be helpful for patients who are shy or have a hard time verbalizing anything let alone their emotions or perceptions of emotions. I realize you're not this girl's therapist and so you probably wouldn't do these sorts of activities, but it's food for thought.

clinpsycmasters- if you're interested in transference/countertransference you should read "power in the helping professions" by Guggenbuhl-Craig.
 
I don't know what I feel about alexithymia.
 
If this board has taught me anything, it's that psychiatrists just love to play with words.
 
Does anyone know of any doctors specializing in treatment of alexithymia?
 
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