When you don’t have the words…

By Hilary Norman.

“We often tell people to “ask for help” to “reach out”, to “share,” but there is a paradox at play here.  It’s often when you’re struggling the most that you are least able to articulate what it is you are feeling and what you need.” @white_owly

It’s not always easy to put feelings into words.  As this tweet suggests, it can be particularly hard when you’re feeling at your lowest.  Sometimes people worry about the consequences of being honest about their feelings, fearing an unhelpful or invalidating response [1].  But what if the barrier is not an unwillingness to talk, but rather an inability to do so?  What if you don’t have the words?

I volunteered for several years on a telephone helpline for people in emotional distress.  Early in my time as a volunteer I noticed that some callers seemed to find it easier than others to talk about their feelings.  Sometimes they were unwilling to do so, but at other times it seemed as if they were not able to articulate their feelings, or even to understand the question.  Some callers responded with broad labels such as “I feel angry”, “lonely” or “bad” but were unable to elaborate further, preferring to detail what had happened to them, or perhaps the physical symptoms that were the apparent cause or consequence of their distress.  We encouraged people to talk, but it was not always easy for them to find the words.

Alexithymia is a personality trait which means, literally, “no words for emotion”.  As well as difficulties describing feelings, it’s commonly characterised by difficulties identifying what it is you feel, and a thinking style that’s focussed on external events, rather than internal introspection and imagination [2].

Alexithymia is not something you either have or you don’t have.  Instead, alexithymic characteristics are ones people may experience to a greater or lesser degree [3].  People with very high alexithymia scores can find it hard to interpret bodily sensations that are typically associated with emotional experience.  This is powerfully illustrated in one case study of a women who scored highly on alexithymia.

“To the external observer she appeared to be on the verge of crying. However, she said that she was not upset, and did not feel sad. She explained that her eyes simply “do this” sometimes.”  [4, p.37]

Alexithymia is not classified as a disorder in its own right.  Described as a trans-diagnostic trait, alexithymia has been associated with depression [5], anxiety [6], gambling [7], alcohol misuse [8] and eating disorders [9].  Recent meta-analyses have found significant associations between alexithymia and both suicide [10] and self-harm [11].

It seems likely that, in the context of alexithymia, self-harm is used to regulate an emotional experience that is poorly understood.  The ability to identify feelings and put them into words is an accepted part of emotion regulation.  Merely labelling feelings can help in regulating emotions [12] and writing about personal experiences, particularly about negative emotions, is associated with positive health benefits [13].  People who are less able to articulate their feelings in this way may use other behaviours to help them cope.

There is encouraging evidence to suggest that alexithymia can be reduced using interventions designed to increase awareness of emotions and their association with bodily sensations [14].  It may also be that people with high alexithymia scores are able to recognise their emotional experience when it is expressed by others.  In a recent (not yet published) qualitative study conducted as part of my PhD, some of my participants described how they used poetry or song lyrics to express their own feelings.  This corresponded with the results of an intervention study on alcohol use disorder, which identified an unexpected therapeutic benefit of completing daily measure of mood [15].  Participants showing alexithymic characteristics were asked to rate the degree to which they felt each of a given list of emotions.  Just completing this exercise led them to identify, and subsequently interpret, feelings of which they had previously been unaware.  As one participant said

“It opened my eyes to look at and think ‘Wow, okay. That is what’s going on.’ To do [the mood measure] on a daily basis … it revealed a lot.” [15, p.9]

Researching alexithymia has made me much more aware that understanding inner experience and describing it to others is less easy for some people than for others.  Of course, it is right to encourage people to reach out for help when they feel distressed, and to provide safe places where they can talk about their feelings.  But it is worth remembering that there are many reasons it might be hard for people to ‘open up’.  Sometimes they may lack the words.  Sometimes we might need to find different ways to help them identify and express what it is they’re feeling.  And perhaps even find different ways to listen.

References

[1]      R. Wadman et al., “An interpretative phenomenological analysis of young people’s self-harm in the context of interpersonal stressors and supports: Parents, peers, and clinical services.,” Soc. Sci. Med., vol. 212, pp. 120–128, Sep. 2018, doi: 10.1016/j.socscimed.2018.07.021.

[2]      G. J. Taylor, R. M. Bagby, and J. D. A. Parker, Disorders of affect regulation : alexithymia in medical and psychiatric illness. Cambridge University Press, 1997.

[3]      K. V Keefer, G. J. Taylor, J. D. A. Parker, and R. M. Bagby, “Taxometric Analysis of the Toronto Structured Interview for Alexithymia: Further Evidence That Alexithymia Is a Dimensional Construct.,” Assessment, vol. 26, no. 3, pp. 364–374, Apr. 2019, doi: 10.1177/1073191117698220.

[4]      R. Smith, A. W. Kaszniak, J. Katsanis, R. D. Lane, and L. Nielsen, “The importance of identifying underlying process abnormalities in alexithymia: Implications of the three-process model and a single case study illustration,” Conscious. Cogn., vol. 68, pp. 33–46, Feb. 2019, doi: 10.1016/j.concog.2018.12.004.

[5]      K. Honkalampi, J. Hintikka, A. Tanskanen, J. Lehtonen, and H. Viinamäki, “Depression is strongly associated with alexithymia in the general population,” J. Psychosom. Res., vol. 48, no. 1, pp. 99–104, 2000, doi: 10.1016/S0022-3999(99)00083-5.

[6]      M. F. Paniccia et al., “Alexithymia in parents and adolescents with generalised anxiety disorder,” Clin. Psychol., 2017, doi: 10.1111/cp.12134.

[7]      P. A. Bibby, “Loss-Chasing, Alexithymia, and Impulsivity in a Gambling Task: Alexithymia as a Precursor to Loss-Chasing Behavior When Gambling.,” Front. Psychol., vol. 7, no. JAN, p. 3, 2016, doi: 10.3389/fpsyg.2016.00003.

[8]      F. A. Thorberg et al., “A Longitudinal Mediational Study on the Stability of Alexithymia among Alcohol-Dependent Outpatients in Cognitive-Behavioral Therapy,” Psychol. Addict. Behav., vol. 30, no. 1, pp. 64–72, 2016, doi: 10.1037/adb0000135.

[9]      H. Westwood, J. Kerr-Gaffney, D. Stahl, and K. Tchanturia, “Alexithymia in eating disorders: Systematic review and meta-analyses of studies using the Toronto Alexithymia Scale,” J. Psychosom. Res., vol. 99, pp. 66–81, Aug. 2017, doi: 10.1016/j.jpsychores.2017.06.007.

[10]    L. Hemming, P. Taylor, G. Haddock, J. Shaw, and D. Pratt, “A systematic review and meta-analysis of the association between alexithymia and suicide ideation and behaviour,” 2019, doi: 10.1016/j.jad.2019.05.013.

[11]    H. Norman, A. Oskis, L. Marzano, and M. Coulson, “The relationship between self‐harm and alexithymia: A systematic review and meta‐analysis,” Scand. J. Psychol., p. sjop.12668, Jul. 2020, doi: 10.1111/sjop.12668.

[12]    J. B. Torre and M. D. Lieberman, “Putting Feelings Into Words: Affect Labeling as Implicit Emotion Regulation,” Emot. Rev., vol. 10, no. 2, pp. 116–124, Apr. 2018, doi: 10.1177/1754073917742706.

[13]    J. W. Pennebaker, “Putting stress into words: Health, linguistic, and therapeutic implications,” Behav. Res. Ther., vol. 31, no. 6, pp. 539–548, Jul. 1993, doi: 10.1016/0005-7967(93)90105-4.

[14]    K. Cameron, J. Ogrodniczuk, and G. Hadjipavlou, “Changes in alexithymia following psychological intervention: A review,” Harv. Rev. Psychiatry, vol. 22, no. 3, pp. 162–178, 2014, doi: 10.1097/HRP.0000000000000036.

[15]    A. R. Krentzman, M. M. Higgins, K. M. Staller, and E. S. Klatt, “Alexithymia, emotional dysregulation, and recovery from alcoholism: Therapeutic response to assessment of mood,” Qual. Health Res., vol. 25, no. 6, pp. 794–805, Jun. 2015, doi: 10.1177/1049732315577608.

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Hilary Norman (@hilary_norman) is a PhD student at Middlesex University, investigating the relationship between self-harm and alexithymia.

 

 

*Featuring Photo by Priscilla Du Preez on Unsplash.