Alexithymia and therapeutic alliance: a multiple case study comparing good and poor outcome cases

Abstract

Alexithymia has been associated with poor outcomes in psychotherapy. This association has been attributed to a difficulty in patients expressing emotions, engaging in emotional tasks and also poor therapeutic alliances. This study aims to better understand alexithymic patients in psychotherapy. A multiple case study design was used. Cases were selected from a larger research project considering their alexithymia level and outcome status, based on the reliable change index and the client perspective on change. Four cases are presented: with and without alexithymia with good and poor outcome. The therapeutic alliance was included as a process measure, evaluated from both client and therapist. At the end a semi structured interview was conducted with both participants, individually. The analysis concerned the integration and triangulation of the therapist and client experience for each case. Each patient was briefly presented and then a focus was made regarding the perception of both participants on the therapeutic alliance and the emotional processing and change process of the client. Both alexithymic cases and the non-alexithymic poor outcome case showed difficulties in the therapeutic alliance, especially from the perspective of the therapist. In these cases, emotional impairments may have contributed to a poor therapeutic alliance, impacting on the outcome. We suggest that a great focus on the therapeutic alliance with alexithymic patients may increase the quality of treatment and it may be more useful for case conceptualization to consider each feature of the alexithymia construct individual.

Developing Emotional Skills and the Therapeutic Alliance in Clients with Alexithymia: Intervention Guidelines

“…In general, psychotherapy seems effective for clients with alexithymia. Nevertheless, it is a predictor of residual symptoms after therapy (e.g., [33]), impacts on the therapeutic alliance (e.g., [34][35][36][37]), clients present more difficulties in describing what they are feeling, tend to focus on their physical symptoms (e.g., [38]), and difficulty in processing emotions and engaging in emotional tasks [12]. There has been some discussion regarding treatment engagement, considering that alexithymic clients would present more challenges (e.g., [39]).…”

“…For example, facial expressions serve as ongoing cues that influence social interactions, convey personal feelings to others, evoke subsequent emotional responses in others, and influence other people's behavior [74]. Da Silva et al [36] compared alexithymic and nonalexithymic cases with good and poor outcomes. Both alexithymic cases and the poor outcome nonalexithymic showed difficulties in the therapeutic alliance, especially from the therapist's perspective.…”

“…In a study guided by an integrative metamodel [13, 36, 37], a mixed-methods longitudinal design was conducted to understand how emotional processing and change process evolved in 12 clients in psychotherapy [13]. Generally, alexithymic clients showed a significant change in psychotherapy.…”

“…In therapeutic interactions, these patients tend to focus on external events rather than on their mental states. In general, communicating about affective experiences is complex [61] and may evoke a communication interaction that promotes questioning from the other person [36]. Most therapists working with alexithymic patients refer feelings of boredom and a sense of less openness of the client, usually interacting with concise sentences or with yes/no answers.…”

Alexithymia and change process: Contributions of a phase model

“…One should have in mind that, from the therapist's perspective, this client did not present a personality disorder. Cases with alexithymic characteristics and a personality disorder certainly may present further challenges (Silva, Vasco & Watson, ).…”