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Partial Hospitalization Treatment of the Alexithymic Patient: A Case
Study
Anthony S. Joyce,1Annika Nordhagen,2John S. Ogrodniczuk,3Laura E. Stovel,1
and Anthony Bjorge2
1University of Alberta
2Alberta Health Services
3University of British Columbia
Patients with alexithymia are a challenge to engage in treatment and require a diverse range of inter-
ventions to realize benefit. A partial hospitalization treatment program, offering multiple forms of group
therapy in an integrated system, may be particularly helpful for patients with alexithymia. We examine
the course of treatment for one alexithymic patient who participated in an 18-week intensive group-
and dynamically oriented treatment program in Edmonton. Group support and feedback emerged as
important elements in the treatment approach. Other features of the approach overlap with treatment
guidelines for alexithymia found in the literature. C2015 Wiley Periodicals, Inc. J. Clin. Psychol.: In
Session 71:167–177, 2015.
Keywords: alexithymia; partial hospitalization; group therapy; confrontation; reflective function
Psychotherapists often encounter patients who seem to have tremendous difficulty identifying
and expressing feelings or addressing the emotional aspects of their lives. Such patients may suf-
fer from alexithymia. Alexithymia is generally understood as a deficit in the cognitive processing
of emotional experience, reflected by a limited capacity to symbolize emotions and elaborate
upon emotional experience (Taylor & Bagby, 2004). This inability to cognitively symbolize and
communicate with others about their emotional experience suggests that alexithymic patients
have a deficit in or rudimentary capacity for mental state understanding (variously referred to
as mentalizing, theory of mind, metacognition, and self-reflection), which involves a variety of
processes (e.g., emotional awareness) that influence a person’s capacity to think about aspects of
the self and how these interact with the world around them (Dimaggio et al., 2009). Psychother-
apy may be a particularly challenging enterprise for those patients who suffer from alexithymia,
for they struggle with the skills that make up the crux of the treatment: an ability to differentiate,
verbalize, and discuss subjective experiences and emotions.
In psychotherapy, patients with high levels of alexithymia seldom present material sponta-
neously and will often fixate on their physical symptoms and the minute details of external
events. They have been described as having “a preference for the external details of everyday
life rather than thought content related to feelings, fantasies, and other aspects of a person’s
inner experience” (Bagby, Parker, & Taylor, 1994, p. 31). Further complicating treatment, the
establishment and maintenance of a therapeutic alliance with alexithymic individuals may be
difficult, as they tend to keep people at a distance and avoid interpersonal closeness (Vanheule,
Inslegers, et al., 2010). Not surprisingly, several studies have found that alexithymic patients tend
to have less favorable responses to a variety of psychotherapeutic treatments (e.g., Leweke et al.,
2009; Tulipani et al., 2010).
Alexithymic individuals commonly have a complicated clinical presentation that includes the
use of primitive and immature defenses (Parker, Taylor, & Bagby, 1988), preoccupied and fearful
attachment, acting out, dissociation, and passive–aggressive behavior (Taylor, Bagby, & Parker,
1997). These patients frequently report a history of trauma in early childhood (Berenbaum,
Please address correspondence to: AnthonyS. Joyce, Clinical Professor, Department of Psychiatry, University
of Alberta, c/o 116, 10728 82 Avenue, Edmonton, Alberta, Canada T6E 6P5; e-mail: ajoyce@ualberta.ca
JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 71(2), 167–177 (2015) C2015 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22152
168 Journal of Clinical Psychology: In Session, February 2015
1996). The breadth and pervasiveness of psychopathology associated with alexithymia has raised
the question whether alexithymia is related to personality disorder, with numerous investigations
confirming this association (e.g., Nicol`
o et al., 2011).
Our group recently examined clinical correlates of alexithymia in a sample of personality dis-
order patients who were attending a group-oriented day treatment (i.e., partial hospitalization)
program (Joyce et al., 2013). Alexithymia was highly prevalent in this sample, with 80% of the
patients endorsing moderate or greater problems in this regard. Associations with attachment
avoidance, primitive object relations, suppression of emotional expression, use of immature de-
fenses, and severity of borderline personality disorder were identified. Interestingly, alexithymia
did not have a negative influence on treatment outcome, suggesting that the partial hospital
approach was effective for patients regardless of their degree of alexithymia.
Day treatment, characterized as an integrated group therapy program that offers patients a
variety of intensive and coordinated group activities, may be particularly useful for alexithymic
patients. That is, different group interventions that employ diverse, but complementary, strategies
for understanding emotional experiences can provide alexithymic patients with the behavioral,
cognitive, and affective skills necessary to effectively perceive, reflect on, and communicate
affectively laden mental states, thereby facilitating these patients’ benefit from participation in
the treatment program. As a way to further explore the potential benefit of treating alexithymic
patients in a day treatment setting, in this case report we examine the treatment course of a
patient who met criteria for “full alexithymia” at the outset of therapy and who was seen to
benefit from treatment.
Treatment Program
The Day Treatment Program (DTP) is one component of the outpatient Psychodynamic Psychi-
atry Service of the Department of Psychiatry at the University of Alberta Hospital in Edmonton.
The DTP is an 18-week, group- and dynamically oriented partial hospital program. Approxi-
mately 80–100 patients, commonly with Axis II (usually from Clusters B and C) and comorbid
Axis I mood and anxiety disorders, complete the program annually. The DTP has been the
subject of several studies (Joyce et al., 2013; Ogrodniczuk et al., 2008; Ogrodniczuk et al., 2011),
including a large-scale clinical trial (Piper, Rosie, Joyce, & Azim, 1996), which revealed substan-
tial benefits of treatment that were statistically and clinically significant and maintained over an
average follow-up period of 8 months posttreatment.
Roughly one third of referrals to the DTP are from the affiliated Psychiatric Treatment Clinic
and two thirds from community physicians and therapists. The DTP is known to community
referral sources as a service that treats patients with personality disorders (PDs) or maladaptive
PD traits. Other inclusion criteria consider whether the patient demonstrates poor interpersonal
functioning, is at least 18 years of age, and has a reasonable capacity for group participation.
Exclusion criteria include active psychosis; active substance dependence; active suicidal or violent
intent, requiring hospital admission; significant social or medical instability that would make it
impossible for the patient to attend regularly and for the duration of treatment; and impaired
cognitive function such that the patient would be unable to participate in psychodynamic group
therapy sessions. The DTP offers an ongoing, structured therapeutic milieu characterized by an
emphasis on psychodynamic group psychotherapy. Patients participate for a time-limited period
of 18 weeks; an open-ended follow-up group for “graduates” is available. One to two patients are
admitted and one to two discharged in any given week. The objective of the DTP is to increase
the individual’s personal, social, and emotional well-being, with a view toward more effective
functioning. There is no individual therapy component.
Case Selection
We selected the case for this current report by reviewing those in the sample from our 2013 study
(Joyce et al., 2013) that had provided complete pre- and posttreatment outcome data (N=32).
Of these, one half (n=16) had scored above 61 on the total score of the Toronto Alexithymia
Scale-20 at pretreatment, which is defined as the clinical cutoff reflecting “full alexithymia”
Partial Hospitalization Treatment of the Alexithymic Patient: A Case Study 169
(Bagby et al., 1994). Next, outcomes of the 16 patients were examined, with reference to pre–
post change on a composite based on the Outcome Questionnaire-45 (OQ-45; Lambert et al.,
1996), the Inventory of Interpersonal Problems-64 (IIP-64; Horowitz, Rosenberg, Baer, Ure˜
no,
& Villase˜
nor, 1988), and the Quality of Life Inventory (Lehman, 1996). The use of this composite
indicator identified 7 of the 16 cases (43.8%) as demonstrating a successful outcome. The clinical
record for each good outcome case was then reviewed. Our objective was to identify a case
that demonstrated a clear “shift” during the course of treatment, moving from a position of
entrenched maladaptiveness to one of progressive change, with the clinical notes highlighting
therapeutic events contributing to that shift. The current case met these subjective criteria for
success.
Case Presentation and History
Janet, aged 51 years, was referred by her family physician for a psychiatric consultation for
depression. At the time of referral, Janet was on disability leave from her job of 19 years as an
assistant manager at a financial services agency and was receiving disability payments. She had
left her job because of “emotional instability” beginning several months prior to her referral,
due to “many work stressors.” Janet reported two previous marriages, both of which were
characterized by physical abuse. She was currently living with a common-law husband of 22
years. An adult daughter, aged 33 years, was living on the east coast of Canada.
Janet complained to the consulting psychiatrist of symptoms of depression and anxiety,
social discomfort and problems communicating with people, and excessive sleep. She alluded to
significant difficulty with drug abuse in the past and admitted to ongoing problems with alcohol
abuse. She had recently experienced considerable weight gain, attributed to her compulsive intake
of “comfort” food, a behavior that unfortunately exacerbated a preexisting reflux condition.
Janet reported multiple previous trials of medication, and a 5-year contact with a psychologist,
all of which had been largely ineffective in ameliorating her chronic dysphoria. At the time of the
consultation, her family physician had Janet on a regimen of antidepressant medications (Effexor
[venlafaxine] and Desyrel [trazodone]) and an atypical antipsychotic [Seroquel (quetiapine)] for
some months before the referral, with little benefit. Interestingly, the consulting psychiatrist’s
report indicated that he “could not establish any significant depressive features” but concurred
that interpersonal strains in the workplace were a significant source of distress for the patient.
The consulting psychiatrist did not suggest any changes to Janet’s medication regimen and
recommended treatment in the DTP.
Janet presented for the intake interview with the DTP therapist (AN) 3 months after her
referral to the program. When asked directly, she was unable to name a precipitant for her
presentation to mental health services. She described a chaotic early family environment with
seven children in the home, four of whom were significantly older half-siblings from her father’s
first marriage. Janet was the second youngest of the siblings. Her father was inconsistently
available in the home due to alcoholism; when present, he was frequently volatile and abusive.
Her biological parents split up when Janet was 4. Mother’s new partner moved in one year
later. Janet considers this stepfather figure her proper father, but admits being “rebellious” in
response to his strict rules and absences during the work week. Janet described her relationship
with mother as “strained” during her childhood and adolescence; she did not feel she could
confide in mother because the latter “had enough problems.” Her relationship with mother
improved considerably after Janet gave birth at age 17 to her own daughter. Janet also reported
being raped by an older half-brother at age 12 (he was 23), and frequent sexual assaults by a
maternal uncle when she was 13 to 14 years of age. She did not tell anyone of these incidents
because she had been threatened with violence.
Janet dropped out of school at age 16 and entered into marriage with the father of her
daughter. He was physically and emotionally abusive and a womanizer; the marriage collapsed
after 2 years. She managed to complete high school at age 22, but her second marriage that year
continued the previous pattern—her husband became physically abusive once the ceremony
was behind them and the marriage again lasted only 2 years. Janet described her two-decade
relationship with her current common-law husband as “more like roommates.” She noted that
170 Journal of Clinical Psychology: In Session, February 2015
the relationship had “rocky” periods after instances when her husband engaged in relations
with women he met online; Janet alluded to “lots of anger” about these incidents. The patient
acknowledged relying on her mother and her partners to care for her daughter and described
being “overwhelmed” by the demands of parenting. At the time of her presentation, Janet
reported rarely talking with her daughter, who lived some 4,000 kilometers away.
Janet’s peer relationships during adolescence were problematic, stemming from teasing she
received because of her “precocious development” of secondary sexual characteristics. She
responded to this by becoming a bully and physically confronting anyone making fun of her. As
an adult, she described having few friends because of her difficulties with trust and anger, and
expressed fears that any relationship would result in her being rejected or abandoned. The DTP
therapist speculated whether the experience of “a healthy, nurturing attachment” in the program
might allow Janet to address her experiences of deprivation and emptiness in her earlier years.
Janet initiated treatment in the DTP 6 months from the time of her initial referral and had
an initial interview with the team psychiatrist (LS) upon commencement of the program. Janet
described the interpersonal difficulties at her place of work in some detail. Her supervisor had
made derogatory comments about her job performance and she had been passed over for a
desired promotion. Further, Janet felt she had no right to speak out about his treatment of her
or her failure to win the promotion. In taking a medical stress leave from work, Janet felt that
“something good had been taken away” from her. The strain at work stimulated nightmares
of her childhood sexual abuse and led to what Janet described as symptoms of depression.
She complained of “being angry all the time” and “bottling up” her feelings. Her “emotional
eating” led to a ballooning of her weight to over 100 kilograms (220 pounds). In the spring
before her referral for consultation, Janet described an “impulsive” overdose attempt with her
prescribed medications, necessitating a short-stay admission to hospital. This represented her
second attempt at suicide in the preceding year.
The therapist and psychiatrist discussed their interviews with the DTP staff and a consensus
was reached regarding Janet’s diagnostic formulation. On Axis I, she was assigned a primary
diagnosis of major depressive disorder, recurrent, and additional diagnoses of dysthymia and
posttraumatic stress disorder, chronic with delayed onset. On Axis II, Janet was assigned a diag-
nosis of personality disorder not otherwise specified, with traits of the borderline, narcissistic,
and dependent personality disorders.
Course of Treatment
The 18 weeks of the DTP are divided into three phases. The early phase (weeks 1–6) offers
opportunities to learn relational skills that become important in later stages of therapy. The
middle phase (weeks 7–12) is often a period of intense work in the groups of the program. This
phase also features two family interviews, one with current family and the second with family
of origin members. The closing phase (weeks 13–18) emphasizes the termination from the DTP
and preparation for life independent of the program.
Early strain. Janet entered the groups demonstrating considerable distrust and resistance
to therapeutic work. Her assumption of a blaming stance toward others in her life (e.g., friends
who had “betrayed” her) was antagonistic to the other group members, making for an uncom-
fortable start to Janet’s therapy. The consistent support of the DTP staff and the group allowed
Janet to eventually establish a functional therapeutic alliance, and she cautiously began to fo-
cus on the deprivations of her early family life, particularly the paucity of emotional caring in
the home. This effort at examination was nonetheless a tumultuous one; the patient invariably
responded very defensively to inquiries or associations by the other patients. Based on her pre-
sentation to her peers and the staff of the DTP during early group sessions, the group identified
an important relational pattern in Janet’s life. Her description of her disengaged relationship
with her common-law husband, and her withholding of emotional contact in that relationship,
was underscored as having essentially the same dynamics as the unengaged and withholding
relationships she had experienced with the two father figures of her early life. This identification
set the stage for Janet’s subsequent work in the group.
Partial Hospitalization Treatment of the Alexithymic Patient: A Case Study 171
Intensive reflection on her life experiences was apparently quite arousing for the patient. In a
week 2 physical activity group, late in the afternoon, Janet was observed to be “out of control”
on the volleyball court. More globally, Janet was aggressively defensive and hostile toward
the group around any concerted attention to her issues. She was described in clinical notes as
“demeaning” toward the other patients, and as failing to recognize how this stance had likely
contributed to her angry and abusive attachments at various points in her life. Janet struggled
with the idea of being angry without behaving in a blaming fashion, that is, of “owning” her
own rage.
In a Patient Evaluation group at week 5, featuring direct feedback by group members and DTP
therapists, Janet’s avoidance of her anger was underscored by observations that she had said little
about her sexual trauma, the death of her mother or “best friend,” her common-law husband’s
infidelities, or her multiple miscarriages. The group also challenged whether her tendency to be
indirect with her anger was implicated in her work difficulties. Noting her “unavailability” in
interactions, Janet was invited to engage more during group sessions. Though it was clearly a
struggle for her to deliberately approach others, Janet accepted this invitation and made efforts
to engage more with other patients during and between group sessions.
Throughout her tenure in the DTP, the therapists attempted to work with the full spectrum
of Janet’s feelings. She was, however, very resistant to appearing vulnerable in the groups. After
the extensive admission interview, her therapist was aware of Janet’s fears of feeling abandoned,
hurt, or violated again, experiences that had been commonplace during her childhood. The staff
hypothesized that the experience and expression of anger helped Janet feel more powerful and
full of life, and consequently she was more willing to work on this emotion. This avoidance
naturally left Janet with little awareness of her fears of abandonment, loneliness, or aggression,
and certainly contributed to her problems with alexithymia. On one occasion, Janet was asked
if she could imagine letting herself cry in the groups; her response was a definitive “No.” Over
the entire course of her therapy in the DTP, Janet slowly became more aware of these fears and
her sadness about her childhood, but for the most part remained inclined to keep these feelings
to herself.
Janet’s difficulties with direct emotional expression, and the many ways she sought to avoid
her own emotional experience, were frequently captured in the feedback of the other patients.
Janet’s face was not overly expressive, but there could be subtle changes depending on the subject
matter. She often appeared angry (even when she was ostensibly unaware of these feelings), but
more commonly she presented a more neutral expression. On rare occasions, she might appear
to be experiencing sadness, e.g., with a down-turned mouth. During her tenure in the DTP,
Janet did not demonstrate tearfulness during any group session, something outside the norm
for patients in this program.
Dimaggio et al. (2012) have commented on the importance of therapists using nonverbal
signals to gradually help patients understand their range of emotions. The therapists and group
members would often point out changes in Janet’s verbal tone, facial expression, or physical
presentation (e.g., a shaking leg), asking her what feeling she thought the change in voice, face,
or body language was reflecting. Initially, Janet struggled with this type of intervention due
to her profound disconnection from her own feelings; in the later stages of therapy, she was
better able to put words to her internal experience. Over time, Janet was definitely more aware
of physical sensations within her body and knew that they were reflective of an emotion; she
nonetheless continued to have problems differentiating which emotion was being elicited during
therapy sessions.
By the midpoint of this early phase of the program, Janet’s work was primarily focused on
her feelings of anger. As noted, this may have served both defensive and esteem-regulating
functions. Janet faced two related confrontations in the group during this period. First, other
group members challenged her preferences for indirect expression of feelings and avoidance of
personal responsibility. Second, Janet was encouraged to reflect on the meaning of her somewhat
paradoxical interpersonal presentation: her passive and indirect interpersonal behavior, coupled
with her entitled attitude regarding special treatment. The group invited Janet to be more “real”
and “present” in interpersonal exchanges, emphasizing that reciprocity was critical to gaining
respect from others in the program.
172 Journal of Clinical Psychology: In Session, February 2015
Janet’s therapeutic work was also facilitated by a change in her prescribed medications. The
patient had complained of being sluggish on her current regimen of medication and so the
venlafaxine was discontinued. This may have allowed the patient to be in greater touch with,
and able to acknowledge, her affects. Additionally, the program’s structure, and the social contact
and support of the group, were important factors in allowing Janet to continue a difficult process
of therapy.
Work in the middle phase. Janet began the middle phase of therapy emphasizing work
on her problems “being connected to others.” An emphasis in the program on eliciting specific
autobiographical episodes, rather than accepting generalized statements (see Dimaggio et al.,
2012), was helpful in clarifying Janet’s experience of interpersonal relationships in the group.
It was clear that Janet wished for greater closeness with others, but simultaneously addressing
this wish stimulated her fears of subsequently being harmed or abandoned. Her behavior was
observed to oscillate between inviting greater intimacy and withdrawing, frequently during the
same group session. These observable shifts in demeanor were addressed by the therapists as
reflective of Janet’s internal conflict around closeness, and the group began to regard Janet with
more empathy and understanding.
In one session, she assumed the role of “angry mother” with another patient, and when
this was confronted, the discussion moved to her own inability to feel connected with, or be a
mother to, her own daughter. Fortuitously, her first family interview occurred during this period,
and involved her common-law husband and her daughter, the latter after a long flight across
the country. The interview was very painful, characterized by the daughter’s harsh disclosures
about her abuse between the ages of 4 and 7 by the patient’s second husband and the patient’s
denial of these incidents. Janet’s daughter was put into foster care at age 8, and alleged that
mother “did not want to know how bad things were.” By implication, the daughter’s subsequent
years on the street were linked to Janet’s failure with parental responsibility. Janet attempted to
deflect the shame stimulated by these painful confrontations and was resistant to invitations to
be closer with both daughter and husband. She responded to these invitations by engaging in
a triangulation of the relationship, e.g., raising an issue with her common-law husband on the
heels of her daughter’s direct request for greater intimacy, or vice versa.
In the weeks that immediately followed this family interview, Janet continued to emphasize the
difficulty she had acknowledging her own feelings of anger. This was certainly a valid emotion
regarding her own experiences of unresponsive or abusive mothering, but it was also regarded as
an effort to defend against the emotional implications of her daughter’s disclosures, i.e., feelings
of guilt, shame, and self-loathing. The feedback of the other members and DTP therapists was
quite important to Janet at this time, suggesting that other perspectives on her experiences
were possible and may have stimulated the development of a nascent reflective function in the
patient. An important element of the work at this point was to increase Janet’s awareness of her
emotional presentation (i.e., aspects of her vocal tone, facial expression, and body language) to
others at times during group sessions.
Mother’s birthday arrived during this period, prompting Janet to confront her feelings about
her parents’ accountability in her own experiences of abuse. Janet found it difficult to understand
that her parents may have been neglectful without intending to be, or to deal with similar
hypotheses as to why her boss may have mistreated her. Even in the face of confrontation
by other group members, Janet insisted on protecting her mother emotionally. Her primary
therapist attempted to work with Janet to draw out the feelings she had about her early childhood
experiences of deprivation, particularly feelings of sadness, but Janet was resolutely unwilling
to consider these feelings in any depth. She responded to these inquiries with statements such
as“She(mother)didthebestwithwhatshehad...“ThiswasthecaseevenafterJanet
had described that mother had had numerous children removed from the home by the child
protection authorities. Janet was able to acknowledge her desire to protect mother. She could
also acknowledge that no one is always capable of doing his or her best and that she had needed
more protection, yet on an emotional level she proved unable to apply that reasoning to her
mother.
Partial Hospitalization Treatment of the Alexithymic Patient: A Case Study 173
Over the course of this work, Janet slowly demonstrated a willingness to consider and then
accept the hypothesis that part of the reason she herself had struggled so much as a mother
was because of the lack of an adequate role model in her own childhood. This appreciation
of the legacy of her early childhood reflected some hard-won intellectual insight, but lacked a
degree of emotional insight because of Janet’s continued efforts to protect against feelings of
vulnerability. Acknowledging her mother’s shortcomings as a parent might have brought Janet
into a profoundly painful confrontation with her own shortcomings in the role.
This process of addressing her relationship with her mother was clearly difficult and painful.
At one point during the work in this phase of the program, Janet expressed a wish to drop out
of therapy and open a homeless shelter. In this way, she might make up for her own failings as
a parent with others who struggled with similarly painful legacies. In a sense, Janet defended
against the pain she was experiencing during the therapeutic process of reflection by fleeing into
fantasies of nonreflective and possibly gratifying action.
Janet was consistently challenged by other group members for avoiding the implications
of her daughter’s disclosures regarding her past parenting decisions and her intentions for
the relationship with her daughter in the future. Deflecting this focus, Janet instead shifted
attention to her common-law relationship, and questioned why she “took him for granted.”
A Patient Evaluation group at week 11 was quite different in tone relative to the first phase,
with less confrontation and more focus on linkages and empathic support. This may have
reflected awareness on the part of other patients that Janet was grappling with significant issues
and seeking closer relations but was constrained by her difficulties identifying and articulating
the associated mental states. Janet was empathically described as “holding on” to her anger
from childhood experiences, and “taking it out” on people, perhaps as a test of whether she
could indeed continue to be accepted by and connected to others. A distorted and idealized
representation of her mother following the latter’s death was challenged, given Janet’s reported
history, and she was encouraged to more honestly examine the relationships with the men in her
life (biological father, stepfather, common-law husband).
Janet struggled to be more direct with her feelings of pain and with an awareness of how these
were linked to her anger in sessions during the latter part of the middle phase. She also began
for the first time to acknowledge the emergence of sad feelings. This suggested that a process
of grieving what she did not receive as a child had been initiated. She was encouraged by the
group to consider the future she wanted in the relationships with her common-law husband
and daughter as a way of achieving some “balance” against the early relational deficits she
had experienced. Her peers noted that she had used others in the past but had been capable of
giving to others in the program. Janet had a very difficult time addressing this “push” for greater
closeness in her relationships with her daughter and husband. In similar fashion, the therapist
was compelled to comment on her “withdrawal” when her approaching termination from the
program, and the relationships therein, was brought up in the group.
Late phase and termination. In the latter stages of treatment, Janet was assisted by the
group to focus on identifying her feelings of pain, sadness, shame, and anger as valid expressions
of emotion associated with her early experiences of deprivation and abuse. Many patients in
the group were able to identify with this process. As she worked her way through a sequence
of these issues, Janet was also being encouraged to attempt greater closeness in the here and
now of the group and in the outside world with the significant others in her life. These attempts
were acknowledged as risky given her fears of being hurt or abandoned, but by this stage in
her therapy, Janet was able to appreciate the value of greater intimacy. The tension around this
therapeutic achievement was mirrored in her stance vis-`
a-vis the group: Janet felt gratified by this
process of addressing relational needs but found that any allusion to her imminent termination
prompted a response of withdrawal and increased anxiety.
Janet’s second family interview involved her stepfather and focused on the effect of her older
half-brother’s sexual abuse in her early teen years. Janet struggled to be direct with her anger
at her stepfather for failing to intercede. Around the same time, she reported attempts to be
more direct with her common-law husband about their relationship, risking greater closeness.
Similar efforts at self-assertion had been practiced in the group prior to being attempted with
174 Journal of Clinical Psychology: In Session, February 2015
these significant others. The attempts to be direct and risk greater intimacy had positive effects
but were not entirely successful, and Janet responded by becoming despondent and suicidal for
a brief period. Importantly, she demonstrated a capacity to request help, and the crisis was dealt
with relatively quickly and effectively.
Janet worked hard to acknowledge ownership of a tendency to push others away. In the closing
weeks of her DTP tenure, Janet began assuming more of a leadership role and consistently
practiced being more direct regarding her feelings in the moment. She confronted herself about
her arrogance with and criticism of her common-law husband, and expressed the intent to
continue working on the relationship. In the penultimate week of her treatment, Janet asserted
she had learned better coping skills, howto manage her anger more constructively, and to be more
direct regarding the range of her feelings. Although she struggled to say meaningful goodbyes to
her fellow patients, she stayed with the process determinedly. She was therapeutically discharged
after completing the full 18 weeks of the program.
Clinical Practices and Summary
The initial interviews with Janet underscore the relative lack of awareness she possessed regarding
her emotional life. Her history was marked by maladaptive ways of coping with feelings when
they became overwhelming or impossible to ignore, e.g., drug and alcohol abuse, “emotional
eating,” physical acting out. In particular, her inability to articulate any linkage between her
presentation and possible precipitants during the initial contact with the DTP therapist reflected
a profound deficit in the fundamental ability to attach meaning to experience. Information
regarding her early family environment and experiences of coercive sexual trauma, however,
do suggest that the development of alexithymia may have served as a means of surviving these
situations—expression of the emergency feelings Janet experienced at the time would have been
likely to significantly worsen her circumstances. The recreation of the trauma situation in her
work context likely stirred up feelings and memories that had not been adequately processed and
put substantial pressure on Janet to reinstitute a splitting-off of her emotions from her subjective
awareness. On this occasion, however, her effort at affective suppression proved insufficient.
A striking aspect of the review of the clinical records of the seven alexithymic patients who
had demonstrated positive outcome in the DTP was the similarity of their early history and
the immediate precipitant to their presentation at the program. The deprivation of a chaotic
home life, often due to parental substance abuse or mental health issues, was prominent in each
case. The experience of traumatic abuse during childhood was also characteristic. Regarding a
precipitating event, all the patients reported having to go on medical leave from their employment
because of an intolerably stressful situation with their peers. These work situations invariably
closely paralleled the individual’s early experience in the home or with abuse perpetrators, and
the defensive stance that had kept these unresolved feelings dissociated from awareness began
to crumble. When the dissociation could not be reinstated, the individual sought psychiatric
treatment.
Apart from an etiological view of alexithymia that conceptualizes the condition as a form of
psychological defense, neurobiological studies have identified physiological parameters of the
condition, including interhemispheric transfer deficits and reduced connectivity between limbic
structures (e.g., Moriguchi et al., 2006). These deficits would be reflected in poorly integrated
(cognitive, emotional, imaginal) processing of experience, limited affect recognition, and reduced
empathy in interpersonal contexts (Taylor & Bagby, 2004). Janet had difficulties in each of these
areas—her self-awareness was impaired and she had trouble understanding the perspectives of
others. Her clinical diagnoses encompassed a number of the conditions demonstrating high rates
of comorbidity with alexithymia: PTSD, eating disorder, depression, substance abuse, chronic
“systemic” physical conditions, and personality disorder.
A critical element of Janet’s success in the treatment program was her development of
greater emotional self-awareness. The facilitation of emotional awareness, and normalization
of the feelings identified, are central to the therapeutic approach in the DTP. This is par-
ticularly true in the early phase of the program when psychoeducational and skills training
components are emphasized. The “matrix” of diverse but integrated group approaches in the
Partial Hospitalization Treatment of the Alexithymic Patient: A Case Study 175
program supported Janet’s efforts towards a more sophisticated and stronger processing and
integration of her experience. That is, different interventions in the program reflected var-
ied but complementary strategies for understanding emotional experiences, many skills that
Janet did not have in her coping repertoire. For Janet, use of these strategies represented a
radical shift from her experience of “feelings” as embedded in the sensations of her physical
body.
The reactions of Janet’s primary therapist provided an interesting counterpoint to the patient’s
therapeutic development in the program. The therapist indicated that she always liked and felt
connected to Janet in part because Janet demonstrated a motivation to work and make changes
and was fully accepting of the treatment structure and boundaries. On occasion, the therapist
experienced frustration with Janet, particularly when the patient insisted on protecting her
mother emotionally. At these times, the therapist was able to feel anger towards Janet’s mother
or sadness regarding the patient’s early experiences, even though the patient complained of being
disconnected from these very feelings.
Over the course of the program, it was evident that Janet realized new behavioral, cognitive,
and affective skills that allowed her to better perceive, reflect on, and communicate affectively
laden mental states. She also developed a greater awareness of the effect of her feelings on others.
Group feedback was an essential factor in this process. For example, feedback from her peers
in the group often addressed the discrepancy between the content of Janet’s verbal accounts
and her physical presentation. In the majority of these instances, Janet’s feelings of anger—
and her tendency to avoid these feelings—were the focus of the confrontation. Attention to the
nonverbal aspects of communication (e.g., facial or bodily expression) helped Janet to appreciate
more subtle elements of her experience. In the later stages of her therapy, these would include
experiences of pain, sadness, grief and loss, states reflective of the vulnerability that Janet was
insistent on avoiding at the outset of treatment.
At the same time as she was becoming more acquainted with her inner life, Janet was also
symmetrically involved in the exploration of the emotional states of other group members. This
shared group experience allowed Janet to better tolerate her emotional arousal and simultane-
ously facilitated the emergence of a reflective process. Through this process, Janet discovered
that her experiences of anger could be discussed and resolved through verbal interaction with
others who were receptive and respectful. A profound contrast with the perspective on emotions
in her early family home likely meant these group transactions represented powerful correc-
tive emotional experiences for Janet. These transactions also allowed Janet to begin developing
empathy for others.
Developing a capacity to mentalize, and applying these newfound skills to a lifetime of
experience, is difficult work. The group frame of the DTP offers opportunities to connect with
others and functions as a caring, responsive attachment relationship for patients, many of whom
might not have experienced anything similar before. Janet’s intake therapist had speculated
about the profound effect this group-level factor would have for the patient. In the absence of
any collective group disturbance, the therapeutic process in the program is balanced between the
provision of responsive support and a confrontational “push” to address personal problems. The
empathic responses of peers and therapists in the group are essential to the supportive mirroring
of emotional states that allow individual patients to develop better mentalizing capacity. The
family interviews that occur in the middle phase of the program often provide considerable
“leverage” in the therapy course of individual patients, and Janet’s experience was a powerful
example of this factor.
The DTP approach demonstrates many points of overlap with treatment guidelines for work-
ing with alexithymic patients found in the literature (Krystal, 1982–1983; Vanheule, Verhaeghe,
& Desmet, 2010). Krystal (1982–1983) emphasizes first assisting the patient to observe the nature
of her alexithymic disturbances, specifically the tendency to experience physiological sensations
in place of emotions. The patient is then helped to develop greater affect tolerance by helping her
observe how she experiences and reacts to her emotions; the focus is on acquainting the patient
with her emotions as useful signals as opposed to something dangerous. Finally, the patient is
helped to find words to name and verbalize her feelings. The group therapy process for Janet
involved each of these elements.
176 Journal of Clinical Psychology: In Session, February 2015
Vanheule and colleagues (2010) take a more molecular approach to current difficult situations
in the patient’s life. The patient is first encouraged to put into words the chain of events that
make up the problematic situation. Next, the patient’s appraisal of the situation is made explicit
to identify what may be painful about the circumstances. Finally, the patient’s affective responses
and planned way of dealing with the difficult situation are addressed. Janet’s experiences in her
family interviews led to intensive reviews of the interpersonal situations in her life, with a focus
on articulating her emotional experience in each of these situations. As a result, Janet felt more
grounded in her understanding of these situations and was able to contemplate attempts at
resolution and repair rather than ongoing avoidance of the interpersonal issues.
In the course of her tenure in the program, Janet experienced an empowering sense of personal
agency and demonstrated a shift from passivity and resentment to active assertion and leadership,
a profound change for this woman. If Janet’s alexithymia is conceptualized as a defense against
painful affects, coming to terms with her difficult experiences and their emotional consequences
through therapy was associated with a decline in her alexithymic features and a concomitant
increase in her ability to be direct and assertive. At the same time, it was clear that Janet achieved
meaningful improvement in her capacity to mentalize about her own experiences and those of
others. The practice of reflection and open disclosure during group sessions helps to establish
these important skills more strongly. Active and continued practice of these skills following the
termination of therapy may, however, be required to ensure that treatment gains are consolidated.
In terms of the outcome measures used in the study, Janet demonstrated clinically significant
change on the overall score of the Outcome Questionnaire-45, significant movement on the
OQ-45 subscales of symptom distress, interpersonal relations, and social role functioning, and
substantial improvement on the Quality of Life Inventory. These improvements may have been
directly associated with Janet’s growing capacity for emotion regulation and communication.
Interestingly, the subscale scores of the Inventory of Interpersonal Problems showed little change
except in one instance: Janet rated “problems with being Intrusive” as significantly higher at
posttreatment. In a sense, she equated her growing sense of agency and assertiveness with being
more intrusive with others, suggesting that a degree of positive self-regard had yet to be stably
established.
The picture at the conclusion of treatment, then, was not unequivocally positive. The progres-
sive change Janet demonstrated during her time in the DTP, and those indications of positive
outcome at termination, might indeed have been dependent on her immersion in the intensive
therapeutic experience offered in the program. At the time of writing, 5 years after Janet’s termi-
nation from the DTP, she has returned to treatment in the program. It might be argued that the
changes observed during her first engagement with the DTP were not sufficient or robust enough
to protect Janet from encountering declines in her mental health at times of stress. However,
echoing how she responded to her suicidal crisis during therapy, Janet was able to recognize
on her own that assistance to deal with her affects was again needed—she requested that her
physician arrange a referral to the DTP on this occasion.
In her current therapy engagement, Janet has demonstrated that she has maintained the
gains achieved in the course of treatment described here, with a clear capacity to identify and
express her feelings. The focus of her work during this second tenure in the DTP has been
more on the central issues of vulnerability, lack of protection, and grief that underlay the anger
she addressed during most of her first treatment experience. Given the profound and pervasive
nature of alexithymic deficits, and the fact that Janet had been functioning with these deficits
for five decades, a lengthy and incremental process of progressive change is to be expected. Her
motivation and courage to persist in this process cannot be overlooked as a critical factor in her
therapy.
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