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This is to certify that the

dissertation entitled

Theory and Treatment of Alexithymia:
An Affect Theory Perspective

presented by

David Rose

has been accepted towards fulfillment
of the requirements for

Ph . D - degree in M

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THEORY AND TREATMENT OF ALEXITHYMIA:
AN AFFECT THEORY PERSPECTIVE

By

David Rose

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

2002

ABSTRACT
THEORY AND TREATMENT OF ALEXITHYMIA:
AN AFFECT THEORY PERSPECTIVE
By

David Rose

Alexithymia is a personality construct that refers to the inability to identify or
describe feelings. Alexithymia is associated with a wide range of negative outcomes
regarding both psychological and physical well being. Current understanding of effective
treatments for alexithymia is limited. This study aims to remedy these deficits by
studying alexithymia treatment from the perspective of affect theory. Affect and Self-
Esteem is a psychoeducational curriculum taught to undergraduate students at Michigan
State University that is based on the principles of affect theory. The present study
investigated the influence of the ASE curriculum on two measures of alexithymia, the
TAS-ZO and the LEAS, and on a measure of psychopathology, the BSI.

Results indicated a significant increase in LEAS scores in the ASE curriculum
compared with a control group, but no significant change in TAS-ZO scores. Contrary to
prediction, Obsessive-Compulsive increased significantly in the experimental group, and
there were significant interactions for Global Psychopathology, Interpersonal Sensitivity,
Anxiety, Hostility, Paranoia, and Psychoticism indicating a trend toward increasing
scores in the experimental group and decreasing scores in the control group. Further,

change in TAS-ZO scores, but not in LEAS scores, was a significant predictor of changes

in BSI scores. Finally, it was found that as LEAS scores increased, the correlation

between the LEAS and the TAS-ZO became more strongly negatively correlated.

Dedicated to Lisa Martin for her constant, wacky, and everloving support. I doubt I

would have accomplished this without you. Thanks Red!

iv

ACKNOWLEDGMENTS

I would like to thank the members of my committee including Gershen Kaufman,
Alexander “BMW-Fl” von Eye, Bertram P. Karon, and the highly esteemed Andrew M.
Barclay for their help, time, and assistance. Thanks guys! I would also like to thank
Laura Symonds for her assistance both as research mentor and for helping out with the
committee. A personal thanks goes out to Mike “Smell Ya’ Later” Cutler, Tamineh
“Queen of the Eyeroll” Gueremy, Brett “God, I hate those yuppies” Johnson, Dan “I’m
Dan Martin” Martin, Marc “Evil Metalhead” Paschke, and all the other wackos in my life
who helped to keep me sane during graduate school. You people rock! Finally, a super
special heartfelt appreciation goes out to Greta McVay and Seka Remsing for their

excellent support and warm humor.

TABLE OF CONTENTS

LIST OF TABLES ................................................................................. viii

LIST OF FIGURES .................................................................................. ix
CHAPTER 1

STATEMENT OF THE PROBLEM AND LITERATURE REVIEW ........................ 1

Alexithymia Theory and Research ......................................................... 1

Definition and Description of Alexithymia ..................................... 1

Comorbidity and Consequences .................................................. 4

Etiology of Alexithymia ........................................................... 8

Primary Alexithymia: Neuropsychological Factors ................... 8

Secondary Alexithymia: Retrograde Trauma ......................... 10

Secondary Alexithymia: Anterograde Trauma ........................ 11

Secondary Alexithymia: Social and Family Factors ................. 11

Treatment of Alexithymia ................................................................. 13

Affect Theory ............................................................................... 18

Script Theory ...................................................................... 22

An Affect Theory Approach to the Treatment of Alexithymia ...................... 23

Learning the Language of Affect ................................................ 24

Dissolving Shame Binds ......................................................... 25

Overcoming Trauma .............................................................. 27

Coping with Chronic Powerlessness ............................................ 33

Learning to Use Imagery ......................................................... 35

Conclusion .......................................................................... 36

A Psychoeducational Curriculum Based on Affect Theory .......................... 36

Unit I: Powerlessness — Affect — Stress Cycles ............................... 37

Unit 11: Shame and Self-Esteem ................................................ 38

Unit 111. Identity: The Self’s Relationship With the Self ..................... 39

Unit IV: Affect Regulation and Release ....................................... 40

Unit V: Interpersonal Relationships ............................................. 41

Prior Research ..................................................................... 42
CHAPTER 2

DESIGN OF THE CURRENT STUDY .......................................................... 45

Hypotheses ................................................................................... 46
CHAPTER 3

METHOD ............................................................................................. 47

Subjects ...................................................................................... 47

Measures .................................................................................... 47

Toronto Alexithymia Scale — 20 ................................................ 47

Levels of Emotional Awareness Scale .......................................... 48

vi

Brief Symptom Inventory ........................................................ 49

Procedure .................................................................................... 50
Data Analysis ............................................................................... 51
CHAPTER 4
RESULTS ............................................................................................. 52
Data Preparation and Data Cleaning ..................................................... 52
Data Analyses .............................................................................. 52
Hypothesis 1 ....................................................................... 52
Hypothesis 2 ....................................................................... 53
Hypothesis 3 .......... - ............................................................. 53
CHAPTER 5
DISCUSSION ........................................................................................ 54
APPENDICES ....................................................................................... 60
Appendix A: Table l ....................................................................... 61
Appendix B: Table 2 ....................................................................... 63
Appendix C: Table 3 ....................................................................... 65
Appendix D: Figure l ..................................................................... 66
Appendix E: Figure 2 ...................................................................... 67
Appendix F: Informed Consent Form ................................................... 68
Appendix G: Demographic Questionnaire .............................................. 70
Appendix H: TAS-ZO ...................................................................... 71
Appendix I: LEAS .......................................................................... 73
Appendix J: BSI ............................................................................ 94
BIBLIOGRAPHY ................................................................................... 96

vii

Table

LIST OF TABLES

Means and Standard Deviations for Variables by Group across Time
Repeated Measures MANOVA of TAS-20, LEAS, and BSI Scores

Surmnary of Regression Analyses for Change in TAS-20 and LEAS
Scores Predicting Changes in BSI Scores

viii

ii?

63

65

LIST OF FIGURES

Pge

Scatterplot of TAS-20 and LEAS Scores Where LEAS Scores are Less 66
Than 65 (g = .134)

Scatterplot of TAS-20 and LEAS Scores Where LEAS Scores are Equal 67
To or Greater Than 65 (r = -.01 7)

Chapter 1

STATEMENT OF THE PROBLEM AND LITERATURE REVIEW

Alexithymia is a personality construct that refers to the inability to identify or
describe feelings. Alexithymia is associated with a wide range of negative outcomes
regarding both psychological and physical well being. Current understanding of effective
treatments for alexithymia is limited. The few empirical studies that have been
conducted have several limitations. First, existing studies have used alexithymia
measures with poor psychometric properties. Next, the majority of treatment studies
have only used self-report measures of alexithymia. Finally, none of the interventions for
the treatment of alexithymia have been grounded in a comprehensive theory of affect.
This study aims to remedy these deficits by studying alexithymia treatment from the
perspective of affect theogr. This will also shed new light on the understanding of
alexithymia itself.

ALEXITHYMIA THEORY AND RESEARCH
Definitionjlml Description of Alexithvmig

Alexithymia is a widespread, but little known condition that influences the way
people experience and express emotion. More specifically, alexithymia, which literally
means “no words for feelings” (Sifneos, 1972), is the inability to identify, describe, and
distinguish between subjective feelings. The prevalence of alexithymia is estimated to be
39.8% in psychiatric outpatients (Taylor, Parker, Bagby, & Acklin, 1992), and 8 to 17%
in student samples (Campos, Chiva, & Moreau, 2000). Currently, the 20-item Toronto

Alexithymia Scale (”PAS-20) is the most psychometrically solid and widely used measure

of alexithymia (Bagby, Parker, & Taylor, 1994). According to these researchers,
individuals with alexithymia have difficulty in the three following areas: 1) identifying
feelings; 2) describing and expressing feelings; and 3) an externally oriented cognitive
style which reflects the inability to think about or reflect upon their own internal affective
experiences (Bagby, Parker, et al., 1994). As a result, individuals with alexithymia often
cannot tell whether they feel sad, angry, or anxious, despite being aware of unpleasant
sensations of physiological arousal (Krystal, 1988).

The externally oriented thinking associated with alexithymia is believed to stem
from a cognitive condition known as we operatoire, which means “thought operating”
(Montreuil, Jouvent, Carton, Bungener, & Widlocher, 1991). Because alexithymics
cannot symbolically represent and understand their inner environment, their perception of
the external environment changes, consequently they tend to focus on concrete objects
and the surface dimensions of objects. As a result these individuals usually present as
dull, mundane, unimaginative, and utilitarian; their verbal descriptions resemble a
sequential recitation of concrete facts. Not surprisingly, individuals with high levels of
alexithymia demonstrate impaired creativity and fantasy (Clerici, Albonnetti, Pupa,
Penata, & Invenizzi, 1992) and a lack of visual imagery (Campos et al., 2000;
Friedlander, Lumley, Farchione, & Doyal, 1997).

Alexithyrnics also suffer from aprosody, or lack of affect in speech, and a deficit
in the generation of spontaneous facial expressions. In addition, alexithymics have a
pervasive deficit in their ability to recognize emotional stimuli: matching faces with
words, sentences with words, sentences with faces, and faces with photographs of scenes

(Lane, Sechrest, Riedel, Shapiro, & Kaszniak, 2000). According to Buck (1988),

emotion has the following three components: 1) subjective feelings, e. g., “I feel sad”; 2)
facial and bodily elements of expression, e. g., frown, smile, crying, laughter, and voice
tone; and 3) physiological arousal, e. g., increases in heart rate or skin conductance. Thus,
although alexithymia is defined as a deficit in the ability to identify and communicate the
first component of emotion, subjective feelings, it is also accompanied by deficits in the
expression and perception of both verbal and nonverbal forms of emotion.

In recent years, there has been a growing consensus as to what alexithymia
actually measures. Most theorists argue that the key characteristic of alexithymia is that
there is a deficit in the symbolic representation of emotion (Clerici et al., 1992; Taylor,
Bagby, & Parker, 1997). This implies that subjective physiological sensations are
“normal” in terms of intensity. However, the patterns of autonomic arousal underlying
affect are poorly differentiated because of a linguistic deficit in which subjective feelings
are not semantically and verbally encoded. Therefore, it is believed alexithymics have
the three basic components of emotion, but what is lacking are the connections or the
linkages between the components.

Consistent with this line of thought, Lane and Schwartz (1987) have created a
developmental theory for the cognitive differentiation of emotional states based on
Piaget’s theory of the stages of cognitive development. They argue that the cognitive
identification and differentiation of emotions becomes increasingly complex with healthy
development. Further, Lane and his colleagues (Lane, Quinlan, Schwartz, Walker, &
Zeitlin, 1990) have developed a psychological measure, the Levels of Emotional
Awareness Scale (LEAS), to assess the developmental level of cognitive complexity of

emotion. The LEAS is comprised of five levels of increasing complexity. Participants

are asked to read a short vignette and to describe how both they and the other person in
the vignette would feel. At the lowest level of scoring responses refer to thoughts and not
emotions, whereas at the highest level responses refer to blends of discrete affects, such
as I felt “glad” or “disappointed.”

More recently, Bucci (1997) combined principles of contemporary cognitive
science with psychoanalysis to form Multiple Code Theory. Essentially, Bucci argues
there are three primary modes of thought: subsymbolic nonverbal (patterns of autonomic
arousal and sensory information), symbolic nonverbal (images), and symbolic verbal
(words for affect). In the absence of symbolic processing of nonverbal nonlinguistic
information, physiological activation may go unregulated and “activation is likely to be
prolonged and repetitive (Bucci, 1997, p. 165).” Bucci argues that in alexithymia all
three modes of thought are disconnected, and that sub-symbolic nonverbal information
may first have to be connected with symbolic nonverbal images before it can be linked to
symbolic verbal words for feeling.

Comorbidity agl Con_sec_mences

In some instances, it appears that alexithymia develops as a response to intense
negative affect. Support for this comes from research literature on comorbid
psychopathologies associated with alexithymia (Krystal, 1988). Alexithymia tends to be
found in populations that are exposed to painful and distressing circumstances.
Alexithymia has been found at high levels in brutally traumatized populations with post-
traumatic stress disorder (PTSD) such as concentration camp survivors (Krystal, 1988),
military combat veterans (Hyer, Woods, Summers, Boudewyns, & Harrison, 1990), and

survivors of repeated sexual abuse (Zeitlin, McNally, & Cassiday, 1993).

Hyer et al. (1990) studied the relationship between PTSD and alexithymia in a
sample of Vietnam Veterans (N = 227). They found 85% of the PTSD patients to be
alexithymic, using the MMPI alexithymia scale. In addition, these researchers observed
clinically that PTSD patients and alexithymics share several similar characteristics.
PTSD patients cannot read their own emotions and they tend to have many physical
complaints, much like patients with alexithymia. Other research has shown that
alexithymia and PTSD patients have similar patterns of neurotransmitters (Henry,
Haviland, & Cummings, 1992). Both groups were found to have abnormally high
norepinephrine levels, suggesting greater activation and effort of the left hemisphere
compared to normals.

Alexithymia has also been found at high levels in populations that have been
exposed to less acute traumatic situations, for example, such as those that lead to
depression (Honkalampi, Hintikka, Tanskanen, Lehtonen, & Viinamaki, 2000; Taylor et
al., 1992) and panic disorders (Parker, Taylor, Bagby, & Acklin, 1993; Zeitlin &
McNally, 1993) as well as in dysfunctional families and abusive relationships
(Mallinckrodt, King, & Coble, 1996), and also in stages of racial identity believed to
involve poorer adjustment and greater distress (Dinsmore & Mallinckrodt, 1996).

Because individuals who have high alexithymia levels have difficulty identifying
and differentiating internal states, it is difficult for them to use feelings as cues for self-
regulation and the maintenance of homeostasis. Accordingly, alexithymics have
difficulty regulating glucose levels, and high levels of alexithymia correspond positively
with high rates of diabetes, bulimia nervosa, and anorexia nervosa (Abramson,

McClelland, Brown, & Kelner, 1991; Taylor et al., 1992). The difficulty that

alexithymics have in identifying their feelings also leads to poor functioning in
interpersonal relations, especially those that are intimate (Swiller, 1988).

As previously mentioned, because alexithymics cannot identify and symbolically
represent their feelings, they often experience undifferentiated and unpleasant sensations
of negative arousal. Research indicates that alexithymics have a delayed perception of
internal stress states (N aataven, Ryynanen, & Keltikangas-Jarvinen, 1999). Taylor et al.
(1997) suggest that individuals with alexithymia may attempt to modulate these negative
sensations through food, the use of psychoactive substances, and compulsive behaviors.
They argue that deficits in the ability to self-regulate affect may explain the high
comorbidity of alexithymia with eating disorders, substance abuse, psychopathic
deviance, impulsive and acting out behaviors, and pathological gambling. Further,
alexithymia is associated with a threefold increase in the risk for death due to external
causes such as accidents, injuries, and violence (Kauhanen, Kaplan, Cohen, Julkunen, &
Salonen, 1996). Greenberg, Rice, and Elliott (1993) argue that psychopathology
originates, in part, because of the inability to identify and express emotion. Thus,
alexithymia can be seen as detrimental to the ability to process information regarding
one’s immediate environment.

Alexithymia is also related to a wide number of important personality constructs.
Recently, there has been a growing interest in “emotional intelligence” mainly in
response to Goleman’s work (1995). According to Taylor (2000), “. .. emotional
intelligence includes the ability to identify and label one’s own and others’ emotional
states, the ability to express emotions accurately and make empathic responses to others,

and the ability to reflect on emotions and use them in adaptive ways (p. 136).” A strong

negative correlation (r = -.72) has been found between alexithymia and a recently
developed measure of emotional intelligence, the BarOn Emotional Quotient Inventory
(Taylor, 2000). Another interesting line of inquiry shows that while alexithymics and
non-alexithymics have equivalent dependency needs according to projective measures,
alexithymics fail to acknowledge they have dependency needs on self-report tests
(O’Neill & Bornstein, 1996). These findings are related to another recent study which
shows that high alexithymia levels are associated with primitive defense mechanisms
such as passive aggression, projection, splitting, somatization, devaluation, and acting out
(Kooirnan, Spinhoven, Trij sburg, & Rooijmans, 1998).

Rates of psychosomatic disorders are also high among patients with alexithymia
(Krystal, 1988). Headaches, numbness, constipation, pain in joints, dry mouth,
heartburn, somatoforrn disorder, hypertension (high blood pressure), and inflammatory
bowel disease (ulcerative colitis and Crohn’s disease), all correlate positively with
alexithymia (Cox, Kuch, Parker, Schulman, & Evans, 1994; Jula, Salminen, & Saarijarvi,
1999; Porcelli, Leoci, Guerra, Tayloy, & Bagby, 1996; Porcelli, Zaka, Leoci, Centonze,
& Taylor, 1995; Todarello, Taylor, Parker, & Fanelli, 1995). Alexithymia is also related
to lowered pain tolerance thresholds and is found in high frequency among chronic pain
patients (Lumley, Asselin, & Norman, 1997; Nyklicek & Vingerhoets, 2000).
Psychosomatic disorders are approximately twice as common among alexithymics as
compared to the general population (Kauhanen, Kaplan, Julkunen, Wilson, & Salonen,
1993; Taylor et al., 1992).

Finally, alexithymia is associated with impairment of the immune system and

carcinogenesis (Todarello et al., 1994; Todarello et al., 1997). Todarello et al. (1997)

suggest that the inability to symbolize and modulate emotions may lead to an increase in
sympathetic arousal accompanied by elevation of blood norepinephrine levels, which
leads to the physiological state we call “stress.” This physiological stress state then leads
to a malfunctioning of the immune system, and subsequently to an increase in the risk of
cancer. These findings emphasize the utility of the alexithymia construct in studying the
mind-body relationship between psychological and physiological processes, an area of
investigation that is increasingly prominent in the research literature.
Etiology of Alexithvmlg

Alexithymia has two primary sources. Primary alexithymia has a biological basis
which involves either or both of the following: 1) disconnection of interhemispheric areas
of the neocortex via the corpus callosum (Parker, Keightley, Smith, Taylor, 1999; Zeitlin,
Lane, and O’Leary, 1989), and 2) reduced activity in the anterior cingulate cortex (Lane,
Reirnan, et al., 1998). Secondary alexithymia is related to psychosocial factors, which
are believed to result in a psychogenic “functional disconnection” of these
neuroanatomical pathways (TenHouten, Hoppe, Bogen, & Walter, 1985). There are three
possible sources of secondary alexithymia noted in the literature. First is exposure to
traumatic situations in the past, or proactive trauma. Next is fear of psychological
distress in the future, or retroactive trauma. Finally, there are various social factors and
family environments the directly impact the incidence of alexithymia.

Primary AlexithymiELNeuropsychological Factors. Neuropsychological research
suggests that alexithyrrria is related to a deficit in communication between the two
cerebral hemispheres. Historically, alexithymia was noted to have occurred in the “split-

brain” patients of the 19608. These patients had their corpus callosums severed in an

attempt to lessen the severity of intense epileptic seizures. Since the corpus callosum
connects the right and left hemispheres of the brain at the level of the cortex, it was
hypothesized that alexithymia was caused by a lack of communication of information
between the two hemispheres (TenHouten, et al., 1985). Buck (1994) states that humans
lack connections between the two hemispheres at the subcortical level and thus, the
corpus callosum of the cortex is the primary route for interhemispheric communication.
Two studies have used the tactile finger location task to determine the level of callosal
transfer in non-neurologically impaired individuals (Parker, etal., 1999; Zeitlin, et al.,
1989). The studies used the TAS-20 and the TAS-26, respectively, to measure
alexithymia. Both studies found a positive correlation between high alexithymia scores
and deficits in interhemispheric transference. Dewaraja and Sasaki (1990) found that
alexithymics suffer from a deficit in transferring nonlinguistic information from the right
to the left hemisphere, but not from a deficit in the callosal transfer of linguistic
information.

Recently, the first study on alexithymia using contemporary brain imaging
techniques was conducted (Lane, Reiman, et al., 1998). Participants were 12 nonclinical
females who were shown emotion inducing pictures, and were also asked to recall
emotional memories from their lives, while undergoing Positron Emission Tomography
(PET) imaging. PET relies on the injection of radioactive oxygen into the bloodstream.
Thus, PET is believed to be an indicator of changes in blood flow. Participants also
completed the LEAS. Results show a positive relationship between LEAS scores and
activation of the right anterior cingulate cortex. This suggests that individuals who are

poor at cognitively processing and differentiating their emotional experiences may have

reduced activity in this region, especially in the presence of emotion inducing stimuli.
These findings are consistent with our current understanding of the role of the anterior
cingulate cortex in cognition and emotion. Lane, Ahern, Schwartz, & Kaszniak (1997)
hypothesize that one of the many functions of the anterior cingulate cortex is that it is
responsible for the conscious awareness of affect.

SecggLarv Alexithymflefigade Tram There is much evidence to suggest
that previously occurring psychological distress and trauma, or retrograde trauma, is a
factor in the etiology of alexithymia. The intensity of an emotion that can be tolerated by
anyone at anytime is finite. People who have experienced emotional distress beyond a
certain threshold often experience automatization, robotization, freezing and momentary
paralysis, or even psychogenic death in extreme cases (Krystal, 1988). This going
beyond the threshold i_s trim and it is associated with the degree to which one feels
completely helpless in a certain situation. Therefore, as one approaches this threshold,
one is motivated to initiate activity to block or evade conscious recognition of emotion.

The blocking of intense affect that is associated with alexithymia may actually
serve an adaptive function in some situations. In environments that are emotionally
painful or where emotional expression is potentially harmful, alexithymia may act as a
buffer between the individual and the environment, thereby enabling the individual to
cope with an environment which the individual is unable to change (Dinsmore &
Mallinckrodt, 1996). However, if the blocking of painful affect causes permanent and
long-lasting change in that individual’s own functioning, then a psychopathological state

will ensue (Krystal, 1988). Once the affect barrier is in place, it is extremely difficult to

10

remove because the individual is highly motivated to avoid re-experiencing the intense
and negative affect that was associated with the traumatic event.

Secondary Alexithymia: Anterogr_ade Trauma. Anterograde tramna is the fear of
overwhelming psychological distress in the future. The individual believes he or she is
completely helpless to avoid the anticipated negative affect. Alexithymia is found in
patients who are diagnosed with terminal illnesses and medical conditions, such as
cancer. Fukinishi, Saito, and Ozaki (1992) found that alexithymia increased in patients
after the initiation of hemodialysis therapy. The researchers speculate that the increase in
alexithymia may be due to the activation of denial-defense mechanisms against
psychological distress engendered by the hemodialysis treatment.

Secondary Alexithymia: Social andi amilv Factors. Research has also shown that
alexithymia is related to sociodemographic factors. In a study of middle-aged men in
Finland (N = 2,682), alexithyrrria correlated positively with lower levels of education,
less annual income, poor social support, and lower occupational status (Kauhanen et al.,
1993). A more recent study found positive associations between alexithymia and low
levels of education, low SES, old age, and male gender (Lane, Sechrest, & Riedel, 1998).
A possible explanation for these results is that all of these factors are associated with
greater levels of psychological distress, from which alexithymia develops as a self-
protective coping mechanism. Thus, alexithymia may develop as a way to fend off the
chronic negative affects associated with lack of status, lack of power, and social isolation
in one’s social environment. Differences between the genders in affect socialization may

also be a risk factor for higher alexithymia levels in men (Levant, 1998).

One variable which has not been found to be related to alexithymia is intelligence.
A review of three studies by Taylor et a1. (1997) found only a weak negative correlation
or no correlation between alexithymia and intelligence. Thus, alexithyrrria does not
appear to be related to a deficit in verbal intelligence.

A number of studies have examined the role of both parent-child relationships and
family environments among alexithymics. Alexithymia is associated with low maternal
care, low maternal-child bonding, and insecure attachment (Fukunishi, Sei, Morita, &
Rahe, 1999; Solano, Toriello, Bamaba, Ava, & Taylor, 2000). Berenbaum and James
(1994) found that certain childhood family environments correlated highly with
alexithymia. The best predictor of alexithymia was having grown up in a home where
little positive and supportive communication existed. Alexithymia rates were found to be
high in people that grew up in family environments where family members were not
permitted to express, or felt unsafe, expressing their feelings. Lumley, Mader, Gramzow,
& Papineau (1996) found that maternal alexithymia and child alexithymia were indeed
correlated. They also identified a number of family factors that were positively
correlated with alexithymia levels, including under- and over-emotional involvement,
lack of family values, and poor family problem solving abilities. These findings suggest
that children who are fit raised in a family environment where they can learn to regulate
their own affects are at an increased risk to develop elevated levels of alexithymia
(Taylor, et al., 1997; Taylor, 2000).

The last 15 years has seen a large acceleration in the rate of growth of the
alexithymia literature base (Taylor, 2000). When aggregated, these research findings

indicate the alexithymia construct is related to a variety of risk factors for deleterious

l2

outcomes regarding both psychological and physical health. In addition, a number of
etiological factors have been investigated, suggesting that there are likely multiple
pathways involved in the development of alexithymia. Unfortunately, research on the
treatment of alexithymia is lagging in both in terms of quantity and quality compared
with these areas.
TREATMENT OF ALEXITHYMIA

Alexithyrrria has received much attention in the psychotherapy literature because
it predicts poor treatment outcomes, especially when psychotherapeutic interventions
requiring insight and expression of emotions are used (Taylor et al., 1997). According to
Krystal (1982), alexithymia may be the single most important impediment in treatments
involving psychoanalysis and psychodynarnic psychotherapy. Other theorists have gone
even further and cautioned that the use of psychoanalytic psychotherapy with
alexithymic patients could be harmful to them because they create excessive arousal
which the individual is unable to regulate (Taylor, et al., 1997). Subsequently, the first
theoretical attempts in the treatment of alexithymia were made by psychoanalysts who
had to use treatment approaches that were not founded on traditional psychoanalytic
theory. What subsequently developed was a trial and error approach to treatment.

Apfel-Savitz, Silverrnan, and Bennett (1977) used intensive group therapy lasting
two years. The therapy focussed on guiding clients to talk about feelings regarding life
events, the use of videotape to give feedback of nonverbal forms of emotional
communication such as facial expressions, and the use of meditation to relax clients so
they can focus their attention inside themselves. More specific details are lacking in their

report.

13

Swiller (1988) also used group psychotherapy to treat alexithymia. The first stage
in treatment was to teach clients how to label their affects, and some of this was done
individually before the client was introduced to the group. The group therapy
environment had to be safe, supportive, and empathic in order as to protect clients’ self-
esteem and allow them to explore their difficulties labeling emotions. According to
Swiller (1988), group therapy for alexithymia offers four advantages over individual
therapy. First, emotional arousal is dampened by the presence of others in the group.
Second, the alexithymic patient can see that other alexithymic patients are having the
same problems and therefore do not feel as isolated or unusual. Third, the client is able
to get feedback from the group about how others perceive the expression of their
emotions. Finally, alexithymic patients can mimic others who are more advanced in their
emotional skills. For these reasons, Swiller (1988) recommends that the group consists
of no more than three alexithymic patients per group of seven, and that the alexithymic
patients in the group be at different stages of treatment.

Krystal’s (1988) theory of alexithymia is largely derived fiom his understanding
of trauma and defense mechanisms from a psychoanalytic perspective. Krystal (1988)
argues that alexithymia is the result of a self-protective, homeostatic mechanism against
excessive psychological distress and pain. According to this theory, if the level of
psychological pain that is consciously experienced becomes too great, death can occur, as
in cases of psychogenic death. Therefore, as the level of psychological pain reaches a
certain threshold, a mechanism is triggered that causes a freezing of experience, thereby
dampening the amount of pain. This mechanism may in fact become permanent because

the individual is motivated never again to experience those painful feelings. As a result

14

of this process, the individual feels less emotion. From Krystal’s (1988) perspective,
alexithymia is not caused by a deficit in the ability to liguistically encode feelings, but
rather it is caused by emotions that are weak in intensity or absent altogether and
therefore difficult to differentiate or even detect.

This leads Krystal (1988) to view alexithymia as resulting from a regression (in
adults) or a state of arrest (in children) due to psychic trauma. Psychic trauma arises
fi'om any situation where an individual becomes overwhelmed by intense affect. Krystal
(1982) argues that there are three primary lines of normal affective development. First,
the differentiation of specific affects from a more global affect system occurs. Second,
individuals learn how to recognize and verbalize their various affective states. Finally, as
individuals learn how to verbalize their affect, the expression of affect becomes
desomaticized in its expression. According to Krystal, alexithymia is the regression or
arrest of affective development in these areas, and thus alexithymia is a state
characterized by difficulty differentiating affect and verbalizing affect, which modulates
an increase in psychosomatic distress. Regarding treatment, Krystal notes that traditional
psychoanalytic methods, which rely on introspection of affective experiences, are rarely
helpful in cases of alexithymia. However, he gives little specific information about
interventions that do work well in the treatment of alexithymia (Krystal, 1988).

Levant (1998) understands alexithymia as primarily developing from the normal
male gender role socialization process. More specifically, Levant argues that alexithymia
develops in males primarily because of two reasons. First, emotions that make one feel
vulnerable such as fear, sadness, and rejection are prohibited in males. Second, emotions

related to interpersonal connection such as caring, warmth, affection, and neediness are

15

also prohibited in males. Levant’s treatment for alexithymia in males takes a
psychoeducational and cognitive-behavioral approach to help clients accurately identify
and label their emotions, especially those emotions related to vulnerability and
interpersonal connection.

There are very few empirical studies which have looked at treatments for
alexithymia. de Groot, Rodin, and Olmsted (1995) employed intensive group
psychotherapy for eating disorders with 50 bulemics. Psychotherapy focussed on
symptom management, nutrition, body image, relationships, improving the identification
of emotions, and validating the expression of these emotions. The treatment group had
significantly reduced alexithymia levels compared to controls, although the majority of
participants in the treatment group were still in the alexithymic range after treatment.
The study also found that as alexithymia scores were reduced, so were binge/purging
symptoms of bulimia. One major limitation of this study is that it used the 26-item
Toronto Alexithymia Scale (TAS-26), which has been shown to have questionable
psychometric properties (Taylor et al., 1997).

Beresnevaite (2000) recently conducted a study on post-myocardial infarction
patients in Lithuania. Participants were assessed for alexithymia before treatment, next at
the end of a 4-month treatment, and subsequently at follow-ups of 6 months, 1 year, and
2 years. The treatment consisted of 16 weekly 90-minute sessions of group therapy over
a period of 4 months. The treatment consisted of four main components. First, subjects
were taught progressive muscle relaxation. Second, verbal and nonverbal expressions of
emotion were promoted by various techniques including role playing and nonverbal

mimicry, describing the emotional states and fantasies of self and others, and writing

16

down thoughts and fantasies while listening to music. Third, subjects were encouraged to
talk about inner experiences instead of external events by replacing utilitarian statements
with statements that expressed wishes and desires. Fourth, every session concluded with
a hypnotic type of relaxation to reduce any heightened physiological activity.

The control group received two 90-minute educational sessions about coronary
heart disease, including risk factors and coping methods. Also, five of the control
subjects received four sessions of progressive muscle relaxation. Results indicate
alexithymia levels dropped in the treatment group but not in the control group, and that
these changes were maintained until 2 years later. 55% of the subjects in the treatment
group demonstrated a reduction in alexithymia levels. In addition, a reduction in
alexithymia was associated with a reduction in cardiac events over a 2-year period.
Within the treatment group, 67% of the subjects who @ not experience a change in
alexithymia levels had cardiac events over the 2-year period, whereas only 18% of the
subjects who @ experience a reduction in alexithymia levels had cardiac events over the
same time period. The number of cardiac events did not significantly differ between the
experimental group and the control group over the 2-year period. This study has
limitations because it also used the TAS-26 to measure alexithymia, and there was a
small sample size of 20 in the experimental group and 17 in the control group.

Thus, the majority of work regarding the treatment of alexithymia is theoretical in
nature. Very few empirical studies exist. The empirical studies that do exist have
significant limitations due to the use of outdated and psychometrically poor measures of
alexithymia, and because the measures of alexithymia that were used rely on self-report.

Self-report measures have come under question in general, because “defensive deniers”

l7

may underreport psychological difficulties and distress (Shedler, Maymarr, & Manis,
1993), and specifically in the case of alexithymia, because the very skill needed to
accurately self-report is the skill being measured. Therefore, individuals who have
difficulty identifying and labeling their feelings may have low interoceptive awareness
and may not be able to accurately self-report their inner experiences (Lane, Sechrest, et
al., 1998). Another major problem with currently existing treatments for alexithymia is
that they are not based on any central organizing theory. What is needed is an
intervention which is grounded in a comprehensive and well-supported theory of
emotion: affect theory.
AFFECT THEORY

Beginning in the late 19508 and early 1960s, Silvan Tomkins (1962, 1963, 1991,
1992) introduced a new theory for understanding human behavior, to which he gave the
name m th_eqr;v. Tomkins’s formulation was revolutionary because he argued that
affect is the primary innate biological motivating mechanism in human beings. Affect
takes precedence over both the drives and cognition. The human being comprises a
series of discrete yet interdependent motivating sub-systems including affective,
cognitive, sensory, motor, pain, and drive mechanisms. Tomkins hypothesized that the
nature of the relationship between affect and cognition is such that affect influences the
affect-laden quality of cognition. For example, positive affect predisposes one to
recalling pleasant memories, seeing oneself and others in a positive light, and providing
positive attributions, explanations, or “reasons” for why an event occurred, whereas
negative affect does just the opposite (Tomkins, 1962, 1963). A child who has

experienced fear and shame due to physical abuse may tend to ascribe angry and hostile

18

intent to others in subsequent ambiguous social situations. This is consistent with
research by Dodge (Crick & Dodge, 1996) which has found a “hostile attributional bias”
in children who have been physically abused.

The purpose of affect is to impart a sense of urgency to anything associated with
it. Affect works as an amplifier. When affect is combined or co-assembled with any of
the other sub-systems, “the affect amplifies by increasing the urgency of anything with
which it is co-assembled (Tomkins, 1981, p. 322).” In this way, affect is the primary
source of motivation in human beings. Further, the other sub-systems have to be
amplified by affect in order to function properly. For example, if the sex drive is fused
with shame, every time the sex drive is activated, shame also will be activated, including
feelings of inadequacy and wanting to hide, a facial display of blushing or looking down,
and associated physiological changes, resulting in sexual dysfunction. In order for the
sex drive to function optimally, it must be fused with and amplified by excitement and
enjoyment, the positive affects. The excitement experienced during sex is the same
excitement experienced when attending an automobile race, or travelling to a new and
exotic location.

Tomkins’s theory posits that affect is innate and not learned. Tomkins has
theorized the existence of nine innate affects which are universal in all cultures. The
innate affects are defined as “sets of muscle and glandular responses located in the face
and also widely distributed through the body, which generates sensory feedback which is
either inherently ‘acceptable’ or ‘unacceptable’” (Tomkins 1962, p. 243). Thus, features
of the affective response include facial muscle responses, vocalization, respiration, blood

flow, skin responses, and various muscle responses.

19

Tomkins posits the face to be the primary site of the affective response (Tomkins,
1981). Each innate affect has its own corresponding facial expression. The affect
programs that control these facial expressions are located in the subcortex (Tomkins &
McCarter, 1964) and are triggered by different patterns of neural stimulation, in a manner
similar to how the ear detects different tones (Tomkins, 1981).

The following is a list of the proposed nine innate affects, along with the
accompanying distinct facial display (Tomkins & McCarter, 1964; Kaufman, 1992,

1996).

1. Interest — Excitement: eyebrows down, eyes track, look, listen

2. Enjoyment — Joy: smile, lips widened up and out, smiling eyes (circular
wrinkles)

3. Surprise — Startle: eyebrows up, eyes blink

4. Distress — Anguish: cry, arched eyebrows, mouth down, tears, rhythmic
sobbing

5. Fear — Terror: eyes frozen open, pale, cold, sweaty, facial trembling, with hair
erect

6. Anger — Rage: frown, clenched jaw, eyes narrowed, red face

Auxilig

7. Shame -- Humiliation: eyes down, head down

8. Dissmell: upper lip raised

9. Disgust: lower lip lowered and protruded

20

The affects with a double - name indicate differences in intensity, ranging from
mild to intense. Only interest -- excitement and enjoyment -- joy are considered to be
positive affects because one is motivated to maximize or approach these affects. They
feel rewarding. All other affects with the exception of surprise -- startle are considered
negative affects because one is motivated to minimize or avoid these affects. They feel
punishing. Surprise -- startle is a resetting affect, which quickly resets consciousness in
order to attend to another stimulus. These affects are found to be innate among human
beings across all cultures. In many cases, these affects are only seen exhibited in infancy,
as the expression of affect is culturally patterned. In a given culture, certain affects are
discouraged from full expression, while the expression of other affects is encouraged.

The nine innate affects are similar to the three primary colors, red, blue, and
yellow, in that they serve as the foundation for all other affective experiences. Like the
primary colors, all other affects are derived from these primary affects. The innate
affects also can be blended together. For example, contempt is a learned affect blend of
dissmell and anger, and depression is a blend of shame and distress which are conjointly
brought to peak intensity and prolonged for an extended period of time. Tomkins also
introduces the concept of affect complexes (Tomkins, 1981), where the same underlying
affect may be activated in different circumstances and in different ways. For example,
the innate affect shame, when activated before an audience, is termed embarrassment,
while shame activated in the presence of strangers is labeled shyness. Nonetheless, the
underlying affect of shame remains identical in these two situations. However, because
the activator of shame is different, there is a different and unique experience and

phenomenology for each shame complex. By extension, the same holds for each of the

21

affects. Thus, we can see the operation of the various innate affects in explaining such
affective states as ecstasy and hatred.

Strong empirical evidence supports Tomkins’ theory of innate affects. Tomkins
and McCarter (1964) found a .86 correlation between pictures of faces posed to represent
the primary innate affects and the judgements of affect. Further research by Ekman
(1971) has extended these results cross-culturally.

Tomkins argues that much of the experience and expression of affect that we see
among adults is not innate affect but rather pieu_do_ or backed-up flee}. Because the
expression of affect is highly contagious and leads others to experience the identical
affect, all societies control the expression of affect. Thus, the expression of affect is
inhibited by constricting breathing and suppressing both the vocalization and facial
display of affect. Backed-up affect also leads to changes in the endocrine system, which
in turn leads to stress. Backed-up affect is thus a risk factor for psychosomatic diseases
such as high blood pressure and asthma (Tomkins, 1979). Understanding the concept of
backed-up affect provides important insights into the mind-body connection.

Script Theory

Script theory is Tomkins’s attempt to apply his understanding of affect toward a
comprehensive theory of human personality. Tomkins introduces three concepts in his
script theory: scene. scene magm'fication, and flip}. A scene is the basic element in life
as it is lived (Tomkins, 1979). Scenes are essentially emotional memories, except that
they are not static “photographs” stored in memory. Scenes have the additional quality of
being dynamic, in that scenes can interconnect and firse directly together, and thus grow

in magnification. Scene magnification occurs when scenes comprised of the same affect

22

fuse together, becoming interconnected, and the affect thereby grows or is magnified in
intensity. Scenes become magnified when scenes of the same affect are repeated with a
difference. When shame is activated in different circumstances, for example under
different conditions or with different persons, the shame scenes fuse together and
magnify each other, thereby resulting in shame becoming a more pervasive experience.
Scripts are the rules for interpreting, responding to, controlling, escaping,
avoiding, and celebrating scenes (Tomkins, 1979, 1987). According to Tomkins, scripts
develop from scenes when three things occur. First, discrete scenes are co—assembled
into a farme of scenes and thereby undergo psychological magnification. Second, the
magnified scene is thought about or cognitively processed. Third, the individual then
designs strategies and tactics, scripts, for responding to that family of scenes in the firture
(Tomkins, 1979, 1987). The function of scripts is to increase overall positive affect by
increasing the frequency of positive affect scenes and decreasing the frequency of
negative affect scenes. Scripts originally develop from a family of magnified scenes, but

they also increasingly come to determine future scenes.

AN AFFECT THEORY APPROACH TO THE TREATMENT OF ALEXITHYMIA
Unlike previous attempts to understand and treat alexithymia, affect theory
understands alexithymia as arising from any combination of five sources. Therefore
these etiological factors must be assessed, with different psychotherapeutic intervention
applying to each of the five factors. Thus, affect theory allows us to be more specific
than any previously proposed theories, and we would expect better treatment outcomes

because of this increased specificity. The five factors leading to the development of

23

alexithymia are: 1) a lack of language for one’s affects; 2) affect-shame binds; 3) trauma;
4) chronic exposure to situations of powerlessness; and 5) imagery.
Learning the Langu_age of Affect

Alexithymia is more likely to develop in individuals if they have not learned to
accurately identify and label their inner experiences. For example, the subjective
experience of feeling painfully diminished and revealed as the piercing eyes of others or
the self are able to see our innermost flaws is best labeled as a we experience. Affect
theory allows us to develop a “roadmap” of inner experience, which helps us to become
clear and precise in the identification and labeling of our affects. Thus, when working
with individuals whose alexithymia primarily develops because they never initially
formed the language of affect and how to symbolically represent their inner experience
through language, treatment should focus on teaching clients the vocabulary of the innate
affects.

After the individual has gained a thorough understanding of the innate affects, the
individual is then able to engage in the process of Differentiated Owning (Kaufman,

1991 ). Differentiated Owning consists of three primary actions or steps: 1) exmriencing
the affect; 2) wing and accurately labeling the affect; and 3) Mg the affect as an
inherent and valid part of the self.

In experiencing the affect, the individual focuses attention inward and allows for
the experiencing of ambiguous physiological sensations to their fullest intensity. The
individual becomes fully immersed in the experience of interoceptive information.
Individuals may vary widely in their ability to recognize and consciously experience

internal events, which in turn influences their ability to approach and experience negative

24

affect. In a therapeutic context, the therapist increases the likelihood of approaching
unpleasant internal events by providing a relationship that maximizes the positive affects
of excitement and enjoyment while also minimizing or neutralizing negative affects,
especially shame, and also by enabling the client to cope more effectively with the
sources of negative affect.

Second, clients are helped to accurately name and label their inner experiences.
Language is the primary mechanism that brings inner experience into full conscious
awareness. Tomkins’s model of the affect system can be used as a theoretical guide:
together, therapist and client examine the client’s inner experience as it is lived, trying to
match up internal experience with affect phenomenology as well as activators of specific
affects. In this way, the group of innate affects and their activators help to serve as a map
which clients can use to illuminate their own inner experience.

Finally, clients must fully connect with and integrate the affects into their concept
of self by owning all of their affects. They must be able to say, and believe: “These
feelings are an important and valuable part of me.” This very important step allows for
both the valuing of the affects, and an increased social intelligence because the client
learns the evolutionary adaptive value of each affect. This in turn enables clients to have
more information at their disposal with which to make salient social decisions.
Dissolving Shame Binds

A shame bind develops when the affect of shame follows the expression of any
affect. The outward expression of any affect may be discouraged or prohibited by others,
resulting in the activation of shame. Initially, shame inhibits the expression of the

prohibited affect. Repeated exposure to further events during which expression of the

25

affect is prohibited and is thus paired with shame eventuates in inhibition of the internal
experience of that affect. The experience of the affect may be partially or completely
wiped away from awareness.

For example, an anger-shame bind might develop in a child if she is reprimanded
for expressing anger, even when appropriate. The reprimand can be any combination of
verbal and other non-verbal forms of communication, such as facial expressions or voice
tones of anger, contempt, disgust, or mocking and derisive forms of humor. Shame is
also elicited in this situation when the anger is met with indifference or an absence of a
response. A single event of high shame affect intensity or several events of low shame
affect intensity, which fuse together and magnify in intensity, may solidify the linkage
between the original affect of anger and shame. Subsequently, when anger is triggered in
this individual, she will have difficulty expressing her anger because shame will
spontaneously inhibit it. In addition, she may not experience any anger, but only shame,
or she may experience a mixture of both shame and anger.

It is at this point that shame binds can give rise to alexithymia. In this case, the
shame bind may be so strong that it not only prohibits the expression of anger, but also
erases the conscious awareness of anger. When asked to describe how she feels, she may
not be able to identify that she feels angry, but may only be aware of the experience of
shame, which may manifest itself through feeling wrong, bad, or even guilty.

Shame binds are commonly patterned by gender in the culture: females are
differentially shamed for expressing the affects of excitement and anger, whereas males
are commonly shamed for expressing the affects of fear, distress, and shame (Kaufinan,

1996; Kaufman & Raphael, 1996). Thus, the development of shame binds first inhibit

26

and control the expression of affect, but then eventually lead to diminished awareness of
the internal experience of affect.

To dissolve shame binds, they must be brought back into full conscious
awareness. The person needs to be able to identify all of their affects and label them
accurately. At this point, there are two routes available. First, the person can look
inward and identify their shame binds. Then they can follow this back in history and
become aware of early scenes in which the shame bind is rooted. This will be sufficient
to dissolve shame binds in many individuals. However, in cases where the shame bind
persists, scene transformation will be necessary. In scene transformation, the person fully
visualizes and re-experiences the shame in the original shame-bound scene. Transforming
the original shame scene involves imagining what was needed to in order to feel validated
and affirmed in the expression of the original affect.

Scene transformation alters the way the original shame scene is stored in memory.
The process of repeatedly replaying the original shame scene immediately followed by
the transformed scene breaks the bind between the original affect and shame and replaces
it with the fusion of the original scene to the new affects of enjoyment and excitement.

As a result, the person gradually experiences a sense of confidence and well-being in
expressing the previously prohibited affect.
Overcoming Trauma

In order to understand trauma from the viewpoint of affect theory, an

understanding of its three primary components is necessary: af_fe_c_t, we, and m.

Affect is the set of innate affects which are the primary motivators of human behavior.

27

Affect imparts a sense of urgency on our world and makes us care about whatever it is
that triggers the affect.

According to Kaufman (1992, 1996), scenes are comprised of three primary
components: affect, imagery, and language. Imagery includes not only the visual
representation of the scene, but may include records from other sensory modalities as
well, such as auditory, kinesthetic, and tactile images or sensory imprints. The language
component of the scene may come from a variety of sources: it could be the vocalization
of the affect associated with the scene; it could be something said by the individual
experiencing the scene; it could be something said by another person who is in the scene;
or it could manifest as inner dialogue or self-talk. For example, it is not unusual for
someone to say or hear “You stupid idiot!” at a subvocal level of communication to
oneself following a shame scene like making a mistake or blunder. Finally, affect
combines with imagery and language to complete the processes that generate the scene.

Affect-laden scenes stored in memory will fuse with other scenes of the same
affect in a process Tomkins refers to as psychological magm'fication (Kaufman, 1996). If
sufficient magnification of scenes occurs, a family of scenes -- also referred to by
Kaufman (1992, 1996) as a governing scene -- emerges which then captures and
dominates the self. For example, in cases of trauma, the emotional memory of the
traumatic event lays the foundation for the governing scene. An important aspect of
scene dynamics is that scenes can be re-triggered in the present by any new situation
which is sufficiently similar to an old scene but also different. Old scenes can be re-
triggered by activators in the present, for example, the smell of urine or the voice tone of

a stranger.

28

There are three ways in which scene dynamics play out. First, scenes can be
reactivated: here the affect, imagery, and language components associated with the
original governing scene or family of scenes are reexperienced in the present. Scenes are
reactivated by stimuli and events in the present which are similar to stimuli and events
associated with the governing scene. The scene reactivated may involve any combination
of affect, imagery, and language. For example, an individual may experience affects in
the present which are seemingly unrelated to any causal event. In this case, it is likely
that only the affective component of a scene has been reactivated and consciously
experienced, while the language and imagery associated with the scene are not in
awareness.

Second, scenes can be directly reenacted. Scene reenactment occurs when a scene
is both reactivated and when a role from the original scene is played out in the reactivated
scene. For example, a boy who was physically abused by his father may have this scene
reactivated when he becomes a parent himself. In the case of scene reenactment, he
could find himself playing either the identical or else a different role from the abused
child which he played in the original scene. When that reenactment involves role
reversal, the scene has been regs}. Thus he may find himself playing the role of his
father as an adult, and actually physically abusing his own son. He, in effect, has recast
the scene.

A third aspect of scene dynamics is that of scene intrusion. This occurs in the
aftermath of trauma when scenes of enormous affect invade or intrude directly into
consciousness, seemingly spontaneously. It is common for traumatized populations, such

as war veterans, to have “flashbacks” of traumatic scenes in which the individual

29

suddenly feels as though he or she is reliving the traumatic event. Consciousness is
completely overtaken and invaded by the intruding scene. Individuals may report
experiencing a blackout of current conscious functioning while being swept away by the
intruding scene. When scene intrusion occurs during sleep, it is called night terrors. In
the case of trauma, governing scenes of intense negative affect are created and are subject
to all three forms of scene dynamics.

Scripts are the rules for predicting, interpreting, responding to, and controlling
scenes. For example, a person who has been traumatized may develop a phobic script
because these encounters reactivate the unpleasant affect associated with the original
scene. Scripts originally develop in response to scenes, but increasingly they come to
determine future scenes. Thus, a female who is raped while walking alone at night may
seek out scenes which involve daylight and companions.

Trauma leads to the development of alexithymia in two primary ways. First, the
affect embedded in the traumatic scene may not be in conscious awareness. Scene
dynamics are such that any combination of the three elements of the traumatic scene --
affect, imagery, and language -- may or may not be available to conscious awareness
(Kaufman, 1992, 1996). For example, an individual who only has access to the imagery
component of the traumatic scene will be able to recall traumatic events in great detail
without experiencing any of the affect associated with the traumatic event. In other
individuals, an inner voice associated with either words actually spoken during the
traumatic event or new words spoken silently to the self may be the only component of
the traumatic event which the individual is aware of. In both of these cases, the

individual has lost conscious awareness of the affect associated with the traumatic event.

30

This makes it difficult to accurately identify and label affects associated with trauma,
thereby contributing to the development of alexithymia.

The second way that trauma leads to the development of alexithymia is that the
intense negative affects associated with trauma, such as terror, humiliation, and anguish,
in turn activate the pain drive system. At this point, the pain system goes into an
emergency response which is activated by the perceived threat to the physical integrity
and existence of the organism and a massive analgesic response is elicited, which
dampens the subjective experience of the intensity of all nonsymbolic information.
Alexithymia results fi'om this reduction in the subjective experience of the signal
intensity of the affects. Thus, the ability to experience all of the affects is interfered with,
and is replaced by a state of emotional numbness and flatness, accounting for symptoms
such as “psychic numbness” and “anhedonia” which are associated with severe trauma.

In the treatment of trauma from an affect theory perspective, the original
governing scene must be transformed. Scene transformation is comprised of three
primary steps. First, the scene must be fully recovered in conscious awareness. This
means that the three components of the scene—affect, imagery, language——must be
recovered and integrated into one coherent reconstituted whole. Second, one must fully
re-experience the affect embedded in the traumatic governing scene. It is not enough to
simply label and describe the affect. There must be a direct experiencing of the affect in
combination with the imagery and language from the scene. Full vocalization of the
original affect coupled with more relaxed, full breathing may be important components in
reexperiencing traumatic affect. A stronger working alliance and interperson_a_l bridge

(Kaufman, 1992) between therapist and client will make it easier for the client to

31

approach the affect embedded in the governing scene as opposed to continuing to avoid
it. The key component of a strong working alliance is the interpersonal bridge between
therapist and client, where mutual enjoyment is the primary affect in the relationship.
Enjoyment allows the client to feel cared for and respected, which results in the
subjective experience of feeling safe and secure.

A third step in the transformation of scenes involves the creation of a new scene,
in which the action and affect associated with the original scene are changed.
Reparenting imaggy is a technique that is used to transform scenes; the adult, stronger
version of the self is re-introduced into the original scene involving the younger self
(Kaufman, 1996; Kaufman & Raphael, 1991). When asked, “What is it you needed most
at this time to feel safe and secure?” The client begins constructing a new scene with
new action that is combined with the affect of enjoyment, the source of warmth and
safety. In a traumatic scene of victimization, for example, the victimization is stopped
through the introduction of the adult self who acts to stop or prevent the victimization in
the original scene. If the client believes that the adult self would have been unable to
have met their emotional needs during the traumatic event, the image of a trusted older
adult may be recruited and inserted into the scene, even the therapist if the client so
desires.

When the traumatic scene has been transformed, it may still be unexpectedly
reactivated, but the intensity and duration of the affect embedded in the governing scene
will be greatly attenuated. This allows the individual to cope in a more effective way
with the traumatic event as the individual becomes better able to successfully manage

scene reactivation.

32

Transformation of the traumatic governing scene will also reduce levels of
alexithymia. As the affect in the governing scene is released and transformed, the
analgesic barrier that protects the individual from reexperiencing affect slowly begins to
lift because it is no longer needed. Also, the affects associated with the governing scene
are now brought fully and willfully into awareness, where they can be appropriately
modulated and regulated by the individual.

Coping with Chronic Powerlessness

Power is the felt sense of inner control over events in one’s environment.
Powerlessness, the experience of little or no control over events in one’s life, lies on a
continuum with power. Power and powerlessness are extremely potent activators of
affect in a fairly predictable manner: power elicits positive affect, while powerlessness
elicits negative affect. A powerful governing scene is created in infancy and childhood
when human beings experience the inevitable period of helplessness, which is longer than
for any other species. Current situations of experienced powerlessness will tend to
reactivate the affects associated with helplessness in infancy. The affects that are
triggered by powerlessness include all of the innate negative affects, the affect blend of
contempt, which is a combination of anger and dissmell, and depression, which is a blend
of shame and distress that are conjointly brought to peak intensity and prolonged over
time.

Chronic powerlessness leads to the development of alexithymia because the
negative affects that are triggered are rapidly magnified in their intensity and are
subsequently suppressed. The suppression of the rapidly magnified negative affects

makes them difficult to readily identify and label.

33

In order to treat alexithymia, which arises from chronic powerlessness, two basic
steps must be taken. First, the specific negative affects that are triggered during
powerlessness must be accurately identified, experienced, and released. If the negative
affects are not firlly experienced, this will lead to backed up affect, which has deleterious
psychological consequences. Backed up affect leads to an exaggerated and prolonged
emotional response when that affect is triggered. Also, backed up affect inpacts the
endocrine system, leading to hormonal changes, and also adversely affects the
functioning of the immune system.

After the negative affects that are triggered by chronic powerlessness are
identified and experienced, at least two choices for dealing with the situation of
powerlessness differently must be identified. Choice creates power, reduces
powerlessness and helplessness, and thus reduces the chronic activation of negative
affect.

Power differences between groups are a very real and important part of our world.
It is crucial that the therapist validate differences in power experienced by individuals so
that identifying the affects associated with scenes of powerlessness can be explored and
new choices for dealing with powerless situations created. Examples of groups that are
more powerful in contemporary American culture include: adults, men, wealthy, whites,
boss, heterosexual, able bodied, Christian, formally educated, and born in the United
States. Less powerful groups include: youths, women, poor, people of color, worker,
lesbian, gay, bisexual, transgender, people with disabilities, Jewish, Buddhist, Atheist,
other non-Christians, non-formally educated, and recent immigrants. The affect

dynamics of powerlessness speak directly to group membership.

34

Lgarmnfio Use Image_ry

Affect theory puts a significant emphasis on the use of imagery. Tomkins argued
that information or “messages” become conscious only when they first take the form of
an image: “What is consciously experienced is M which is created by the organism
itself” (Tomkins, 1962, p. 13). According to Kaufman (1996), imagery is the link
between inner and outer experience. Thus, imagery is required for the internalization of
affect and scenes, which come to form the identity of the self. As already noted, imagery
encompasses auditory, kinesthetic and visual components. In this regard, empirical
research has found that alexithymia is associated with poor visual imagery skills (Campos
et al., 2000; Friedlander, et al., 1997). Further, Bucci (1997) argues that it may be
necessary for alexithymics to first symbolize physiological and sensory information with
imagery before connecting it with language. Deficits in imaging ability may develop in
alexithymia for a number of reasons, including shaming for daydreaming, shaming for
discussing dreams, and trauma.

Imagery is used in almost all of the psychological interventions discussed above.
Imagery is employed in enabling individuals to remember early scenes of powerlessness,
shame, and shame binding. And, in the reparenting imagery process, individuals are
taught how to use active imagery to transform traumatic scenes. Imagery is used identify
unmet developmental needs, to identify how those needs are to be met, and to provide
directly for those unmet developmental needs. It is hypothesized that the frequent use of
imaging techniques in affect theory approaches will help the alexithymic to increase their

imaging ability, thereby increasing the ability of the alexithymic to make affects

35

conscious and also symbolize them. This, in turn, allows for affects to be identified and
described more readily.
Conclusion

Affect theory views alexithymia as a multidetermined construct: any combination
of the five following factors may lead to the development of alexithymia. First,
individuals may have difficulty labeling affect because they never learned the language of
affect. Second, shame binds not only inhibit the expression of affect, but they also erase
the conscious awareness of affect. Third, trauma promotes alexithymia through the
disconnection of affect from imagery and language in the traumatic scene, and also by an
analgesic response from a hyperactivated pain drive system. Fourth, chronic
powerlessness leads to alexithymia because negative affect is activated and subsequently
suppressed, making it difficult to identify affect. Fifth, imagery may be necessary in
order to promote the symbolic representation and, in turn, the conscious awareness of
affect. Because of the greater specificity and precision of affect theory in understanding
both the etiology and treatment of alexithymia, treatment outcomes for alexithymia ought
to be significantly improved.

A PSYCHOEDUCATIONAL CURRICULUM BASED ON AFFECT THEORY

Kaufman (1991, 1992, 1996) has taken Tomkins’s affect and script theories and
developed them into a psycho-educational curriculum designed to improve overall
psychological health while also teaching the principles of affect. This program is an
analog of psychotherapy. The program is offered as an undergraduate psychology course
at Michigan State University, titled “Affect and Self-Esteem.” The course meets twice a

week for 80 minutes per class meeting over a 15-week semester. The course consists of a

36

conceptual mode in which students are taught how to apply principles of affect theory
and an experiential mode in which students directly engage their own experience through
various “tools” or psychological self experiments. These affect tools are translations of
the theory into action strategies. The course consists of five units, each two to four weeks
in length.
Unit I: Powerlessness - Affect - Stress Cycles

Power and powerlessness lie at opposite ends of a spectnun. Power is the felt
sense of inner control, and powerlessness is the experience of little or no control. Power
and powerlessness are activators of affect: power activates positive affect, while
powerlessness activates negative affect. Because human beings experience a lengthy
period of helplessness, which is longer than that for any other species, a powerful
governing scene is created. Current situations of experienced powerlessness will tend to
reactivate the affects associated with helplessness in infancy. The affects triggered by
powerlessness include any or all of the six innate negative affects, plus the learned affect
blend of contempt, a combination of anger and dissmell, and depression, which is a blend
of shame and distress that together are brought to peak intensity and prolonged over time.
Whenever adults encounter powerlessness, this will activate any combination of negative
affects. It will also re-activate the governing scene of powerlessness from infancy and
childhood.

Two sets of tools are used in this unit. The first set of tools consists of collecting
and storing positive affect by keeping two lists: a Happiness List and a Pride List. In the
first, participants are asked to recall five events each day that leave a smile on their face;

in the second, they have to recall five events every day that leave them feeling proud.

37

The purpose of these tools is to promote the storage of positive affect scenes, and to
transform pride from always being performance-contingent to being generated from
within. The second set of tools directly addresses the problem of powerlessness.
Participants are asked to identify and describe a current situation in which they feel
powerless, the affects experienced, and also to identify two choices for dealing with the
powerlessness scene. Becoming aware of powerlessness and creating choices for dealing
with it directly enhance power.

Unit Hzihame and Self-Esteem

Kaufman conceptualizes low self-esteem as shame-based. Low self-esteem is
shame that has been internalized, a state in which shame is the primary affect of the inner
relationship of the self. On the other hand, positive self-esteem arises from the affects of
enjoyment and excitement. Participants are taught how to identify the phenomenology of
shame and its associated features such as activators, facial displays, shame complexes,
and defending scripts. The role shame plays in low self-esteem and in various forms of
psychopathology such as eating disorders, addictions, depression, and anxiety disorders is
elucidated.

In the first of the tools in the shame unit, participants have to identify an early
shame scene from childhood, its associated affects, and how that shame scene influences
them now. The second tool involves identifying shame binds and describing the
experience of having these shame binds activated. The tools are designed to increase the
awareness of the impact of shame on the self, and to understand the role shame plays in

one’s life.

38

Unit III. Identity: The Self’s Relationship With the Self

Identity is defined as the selfs relationship with the self. Within the self, there is
an inner relationship between an observer part of the self or subject, and the observed part
of the self or object. Just as interpersonal relationships with others have an affective
component, so does the intrapsychic relationship with oneself. The affective quality of
this inner relationship is based on internalized affect embedded in scenes that derived
from early interpersonal relationships. According to how the self was treated by others,
now the self in turn treats the self. Thus, identity develops through a combination of
magnified scenes and identity scripts, which develop in response to those scenes. These
scripts reproduce shame. Identity scripts take the form of inner voices and may be
activated in situations such as looking in the mirror, making a mistake or blunder, or
meeting strangers. A total of twelve situations likely to elicit identity scripts are
explored. Three self-shaming identity scripts which re-produce shame are highlighted:
comparison making, self-blame, and self-contempt.

Participants are also taught how to access earlier scenes through imagery.
Development is conceived of as a series of emotional phases, much as rings of a grth
form the trunk of a tree, which are each an important part of the self. Reparenting
imagery is used to identify and access these scenes from the past, so they can be brought
to full awareness.

The first set of identity tools aims to identify and change inner self-shaming
identity scripts. This involves attending to inner voices and becoming conscious of what
they are saying, and then identifying what type of self-shaming script is operating.

Participants are urged identify whose voice is speaking the words, and also identify the

39

scenes in which the voice originated. Inner self-shaming scripts are then re-scripted by
introducing a trusted older figure in the original scene to provide what was needed. Self-
sharning identity scripts are changed to reflect enjoyment and excitement of the self. The
second tool, reparenting imagery, is used to transform shame or other traumatic scenes
from the past. The imagery involves the adult self comforting the hurt inner child, and
doing whatever the child needs to feel warm, safe, and secure. By changing the scene is
this way, the scene is fused with new enjoyment affect and thereby transformed, and then
stored back in memory as a changed scene.
Unit IV: Affect RegalLfion and Relea__sg

Participants are first taught the processes of differentiated owning, which
involves a focusing of attention inwards in order to expand conscious awareness. Next
they are taught the process of detachment which involves learning how to let go of
negative affect. After participants experience, name, and own their affects, they must
also find ways to release or detach from their negative affect. It is generally more
beneficial to have several different methods for detaching fiom negative affect because
flexibility and adaptability are thereby increased. Detaching from negative affect
prevents negative affect from spiraling and backing up, leading to stress.

The consulting with self tool allows individuals to focus inward and to determine
what affects and other inner experiences (drives, interpersonal needs) are most prevalent
in their life and to distinguish among them. Participants are asked to do this for 10
minutes every day. The second set of tools are detachment tools, which are used to
release negative affect. These include writing, humor, meditation, refocusing attention,

imagery, and self-observation.

40

Unit V: Interpersrml Relationahipa

The final unit takes these concepts and applies them to developing interpersonal
skills. There are three major sections to this unit. First, participants apply the concepts
of affect and scene for the purpose of identifying what they need in relationships.
Kaufman’s theory of interpersonal needs (1992, 1996) forms the basis for these needs.
Second, participants are urged to adopt a detached stance or an objective point of view in
order to consciously observe the other person. Again, the focus is on the M
behaviors of the other, including facial expressions. Third, participants are asked to
match their expectations and needs to what the other person can actually provide. Special
focus is given to the interplay among power, shame, and intimacy.

There is one relationship tool for this unit which consists of three steps.
Participants are asked to apply these three concepts to one important relationship in their
life. The relationship can be with a family member, friend, or romantic partner. The first
step is to identify their own specific needs and expectations in the relationship selected.
Second, the other person must be objectively observed and the quality of the match
between expectations and reality determined. Third, the relationship is examined for
power, shame, and intimacy.

The common element running through all units of the program is a focus on
increasing conscious awareness of affects and related inner experiences so that the
participants will have more inner control, more choices, and more power in their

everyday lives. Conscious awareness of affect is the foundation for achieving this.

41

Prior Research

There have been four empirical studies conducted on Kaufman’s psycho-
educational curriculum, Affect and Self-Esteem (ASE). Readett (2001) evaluated the
ASE curriculum in terms of four constructs: polarity theory, depression, the ability to
differentiate shame, and openness to feelings. Results showed that subjects in the Affect
and Self Esteem curriculum scored significantly higher on the humanistic ideological
position of the Polarity Scale compared with a control group. Results also indicated there
were significant reductions in depression and internalized shame, and a significant
increase in openness to feelings.

Mayne (1992) investigated the influence of both the ASE curriculum and a
cognitive-behavioral intervention for parents on pathogenesis, compared with a control
group of undergraduate psychology students. Pathogenesis, defined as the degree to
which one uses others to satisfy one’s own needs was measured by scoring responses to
the TAT as either pathogenic, neutral, or benign. Participants in all conditions were
assessed pre and post for pathogenesis. Responses where a dominant person fails to take
into account the needs of a dependent person, or responses that deal with themes of
loneliness, dependency, and helplessness, all are scored as pathogenic. Stories with
themes of potency, helpfulness, and success are scored as benign. Stories that are neither
pathogenic nor benign are considered to be neutral. Results indicate that pathogenesis
decreased in both experimental groups, but for different reasons. Participants in the ASE
curriculum showed a decrease in pathogenic responses, while participants in the

cognitive-behavioral parenting intervention showed an increase in benign responses.

42

Mayne concluded that there was support for the ASE curriculum decreasing
pathogenesis.

Meola (1988) assessed the ASE curriculum both pre and post for changes in four
variables compared with a control group: self-esteem, depression, state anxiety, trait
anxiety, and identification of shame. Results indicated there was a significant reduction
in trait anxiety and a significant increase in the awareness of shame, while no changes
were found for self-esteem, depression, and trait anxiety. Meola concluded that no
effects for self-esteem and depression were found due to a lack of sensitivity of the
measures used. In addition a qualitative questionnaire was administered to determine the
frequency of the use of each of the tools and their perceived effectiveness. Results
indicated participants used the tools fairly regularly and had a solid perception that the
tools were effective.

Finally, Rosenberg (1984) conducted a study of the ASE curriculum to determine
if change occurred in both locus of control and the ability to differentiate internal
experience. Locus of control is an important variable related to beliefs about the source
of power and change in one’s environment. Individuals with an external locus of control
believe they are largely at the mercy of external events, whereas persons with an internal
locus of control tend to believe that their own actions are largely responsible for
controlling events. Rosenberg hypothesized that locus of control would become
significantly more internal in the experimental condition. This hypothesis was not
supported.

This study also tested whether individuals would be able to differentiate their

internal experience better as a result of participating in the ASE curriculum. Results

43

indicate that subjects were significantly better able to differentiate affect and there was a
significant increase in the frequency of positive inner dialogue patterns. However, no
effects were found regarding a predicted decrease in the frequency of negative dialogue
patterns nor with replacing negative inner dialogues with positive dialogues, and negative
effects were found for the ability to differentiate inner dialogue patterns. In addition, the
tools were again assessed for perceived effectiveness and frequency of use. Participants
rated overall effectiveness of the tools as very effective, with a moderate frequency of
their use.

On the basis of these studies, there is evidence to support the hypothesis that
participating in the ASE curricultun will lead to reduced levels of alexithymia. Previous
research on the program indicates support for an increase in the ability to differentiate
affect, which is an important component of alexithymia. In addition, previous research
regarding the impact of the curriculum on psychopathology is mixed, having
demonstrated a reduction in anxiety, but no change in depression. Thus, measuring
several dimensions of psychopathology is warranted in order to assess the impact of the

curriculum on a wide range of psychopathology.

Chapter 2

DESIGN OF THE CURRENT STUDY

This is a longitudinal study investigating whether a 15-week psycho-educational
program designed to improve self-esteem and overall psychological functioning will lead
to a reduction in alexithymia levels upon completion of the program. A course on
Humanistic Psychology was used as a control group. This study employed an
experimental design with a control group and pre- and post- measures. Two measures of
alexithymia were used, the 20—item Toronto Alexithymia Scale (TAS-20) and the Levels
of Emotional Awareness Scale (LEAS). Recently, the TAS-20 has been criticized
because it is a self-report measure that is used on a population which, by definition, has
difficulty identifying and labeling inner experiences (Lane, Sechrest, et al., 1998). The
skills that are necessary for accurate self-appraisal may be missing in individuals who do
indeed have high alexithymia levels. Lane, Sechrest, et al. (1998) have suggested that a
performance measure of alexithyrrria, which requires subjects to label their feelings, may
be preferable to a self-report measure. LEAS is not a self-report measure, but rather is a
performance-based measure of the cognitive complexity of the awareness of emotion.
Therefore, as LEAS scores increase, the strength of the negative correlation between the
LEAS and the TAS-20 should also increase. Perhaps this helps to explain why research
thus far indicates only a weak negative correlation (r = -.19) between the TAS-20 and the
LEAS (Lane, 2000).

The current study was the first to use both the TAS-20 or the LEAS to measure

alexithymia in a treatment context. In addition, global psychopathology was measured

45

using the Brief Symptom Inventory (BSI), and a comparison was made between the TAS-
20 and the LEAS to determine which predicts changes in global psychopathology more
accurately.

HYPOTHESES

This study had three main hypotheses.

First, it was predicted that students who participate in a psycho-educational
program designed to improve self-esteem will show decreases in alexithymia and
psychopathology at the end of the course as measured by the TAS-20, the LEAS, and the
BSI in comparison to a control group.

Second, it was predicted that the change in LEAS scores between the beginning
and the end of the course will be a better predictor of changes in BSI scores than changes
in the TAS-20.

Third, it was predicted that the TAS-20 and the LEAS will be more strongly

negatively correlated as LEAS scores increase.

46

Chapter 3

METHOD

Subjects

The subjects included 101 participants enrolled in two undergraduate psychology
courses at Michigan State University. The experimental group consisted of students
enrolled in PSY 325, Affect and Self-Esteem. There were 37 students in the
experimental group that were sampled in the first week of class, 27 of whom were also
tested at the end of the 15-week class. The control group consisted of students enrolled
in PSY 488: Humanistic Psychology. There were 64 students in the control group that
were sampled in the first week of class, 37 of whom were also tested at the end of the 15-
week class.

Measures

Toronto Alexithymia Scale (TAS-20). The TAS-20 is a 20-item self-report

 

questionnaire designed to assess alexithymia (Bagby, Parker, et al., 1994). The 20 items
are rated on a 5-point scale, where 1 = strongly disagree and 5 = strongly agree. The
TAS-20 consists of the following three subscales: l) difficulty identifying feelings, i.e., “I
am often confused about what emotion I am feeling”, 2) difficulty describing feelings,
i.e., “It is difficult for me to reveal my innermost feelings, even to close fiiends”, and 3)
externally oriented thinking, i.e., “I prefer talking to people about their daily activities
rather than their feelings.” The internal consistency reliability for the three factors were
found to be .78, .75, and .66 respectively in a large sample (_I\_I = 965) of Canadian

undergraduates. A test-retest reliability of .77 for the total scale score, with a 3-week

47

interval between testing, was found using a separate and smaller sample (N = 72) of
Canadian college undergraduates. The TAS-20 also demonstrates good convergent
validity. In a sample of (N = 85) Canadian undergraduates, the TAS-20, as predicted,
was negatively correlated with measures of psychological mindedness (r = -.68, p < .01 ),
need for cognition (r; = -.55, p < .01), openness for experience (r = -.49, p < .01), and
positive emotions (I; = -.36, p < .01) and positively correlated with a measure of
neuroticism (r = .27, p < .01) (Bagby, Taylor, & Parker, 1994). Using this same sample,
the TAS-20 was found to have adequate discriminant validity as it was not significantly
related to either measures of agreeableness (r = .09) or conscientiousness (r; = -.21)
(Bagby, Taylor, et al., 1994).

Levels of Emotional Awareness Scale (LEASL The LEAS is designed to
measure awareness and differentiation of emotional states in both self and other.
Participants are presented with 20 scenes of vignettes, which are described in 2 to 4
sentences, and are asked to describe the anticipated feelings of themselves and another
person depicted in the vignette. More specifically, participants are presented with one
vignette per page, which is followed by two questions: “How would you feel?” and “How
would the other person feel?” Participants are instructed to write their answers on the
remainder of the page, using as much or as little space on the page as needed. Responses
for each vignette are scored on a scale from 0 to 5, where 0 indicates the lowest level of
emotional awareness and 5 indicates the highest, resulting in a maximum total score of
100.

For each vignette, there is a separate score for self and other. The lowest level

(Level 0) is scored when the subject replies with a thought and not a feeling. Level 1

48

reflects an awareness of physiological sensations such as, “I feel tired.” Level 2 consists
of action tendencies, “I’d feel like punching the wall” or vague words typically used in
other contexts, “I’d feel bad.” Level 3 responses contain one specific word for affect,
“I’d feel happy.” Level 4 responses are comprised of two or more Level 3 responses. To
get the highest score of 5, there must be a Level 4 response for bib self and other. Thus,
for each of the 20 items, there is a gefi score, an ghgr score, and a 1% score. The total
score is calculated by taking the higher of either the self or other score. For example, if a
participant scored a 3 on the self score and a 1 on the other score, their total score would
be a 3. The only exception occurs in the case where both self and other scores are Level
4. In this case, a total score of 5 is given. A glossary of emotional words is provided to
guide scoring (Lane, et al., 1990).

The interrater reliability of the LEAS is .84. and the internal consistency
reliability of the LEAS is .81 (Lane, et al., 1990). The test-retest reliability of the LEAS
is not available (Lane, Reiman, et al., 1998). Convergent validity was demonstrated by
correlations with two measures of cognitive maturity, a measure of Openness to
experience, and to a full range of emotions. Discriminant validity was demonstrated by a
lack of correlation with any specific emotion and with a measure of repression. In
addition, the LEAS does not correlate with the number of words used in LEAS responses,
indicating that the LEAS is not merely a measure of verbal productivity (Lane, et al.,
1990)

Brief Symptom Inventory (BSI). The BSI is a self-report symptom inventory
with 53 items designed to assess psychopathology. Each item is rated on a five point

Likert scale from 0 to 4, where 0 indicates no distress and 4 suggests extreme distress.

49

The BSI is currently widely used for both research and clinical assessment with such
diverse topics as cancer patients, psychoneuroirnmunology, pain assessment and
management, therapeutic intervention, HIV research, hypertension, and student mental
health (Derogatis, 1993). The BSI has a total of nine symptom dimensions including:
Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety,
Phobic Anxiety, Hostility, Paranoid Ideation, and Psychoticism. The internal consistency
reliability for the nine factors were found to be very good, ranging from .71 on the
Psychoticism dimension to .85 on the Depression dimension in a sample (N = 719) of
psychiatric outpatients (Derogatis, 1993). The BSI also demonstrates excellent test-retest
reliability. The stability coefficient for the Global Severity Index was found to be .90,
and coefficients for the nine BSI dimensions ranged from .69 for the Somatization
dimension to .91 for the Phobia dimension, in a sample of nonpatients (N = 60) tested
across a two-week interval. The dimensions of the BSI also show impressive convergent
validity with major measures of psychopathology, including the MMPI and the SCL-90-
R (Derogatis, 1993). In a sample of symptomatic volunteers (E = 209), the Hostility
dimension of the BSI was positively correlated (r = .42) with the Depression scale of the
MMPI.
Procedure

Students were measured during the first week and last week of the semester for
both the experimental and the control conditions. Participants were given a packet
including: an informed consent form, a socio-demographic questionnaire, the TAS-ZO,
the LEAS, and the BSI. Sociodemographic information included age, gender, and SES

so as to rule out possible confounding variables between the groups. The order of

50

presentation of the TAS-20, LEAS, and BSI was counterbalanced so as to rule out any
response bias. Subjects wrote their name on the informed consent form where it was
matched with a subject ID number. Informed consent forms were separated from the
packet, and stored separately in a locked cabinet, so as to ensure participant
confidentiality. The subject ID number was be used to identify all other forms in the
packet. Administration time took approximately one hour. Participants were entered into
a raffle for $50 dollars for students who completed both packets of questionnaires pre and
post in each class, in order to maximize participation and increase subject retention rates.
Data Analysis

First, a repeated measures MAN OVA was used to determine if there was a
significant change in TAS-20, LEAS, and BSI scores in the experimental group
compared with the control group.

Second, regressions were conducted to determine if the two measures of
alexithymia, the TAS-20 and the LEAS, independently predicted significant changes in
BSI scores compared with one another.

Third, the hypothesis that the correlation between the TAS-20 and the LEAS will

become increasingly more strongly negative as LEAS scores increase was tested.

51

Chapter 4

RESULTS
DataPrgparation and Data Cleaning

The scales for the TAS-20 and the LEAS were calculated by summing the items

for each scale score. Missing values were hand scored and were prorated by multiplying
the summed score of items by the total number of items in each scale and then dividing
by number of items for each scale that were completed. The scales for the BSI were
calculated by summing the items for each scale score and then by dividing by the number
of items for each scale score that were completed. Missing values were hand scored and
were also calculated by summing the items for each scale score and then by dividing by
the ntunber of items for each scale score that were completed.
Data Analyses

Hypothesis 1. A repeated measures MANOVA was used to determine if there

 

were significant changes in TAS-20, LEAS, and BSI scores from pre to post testing in the
experimental group compared with the control group (see Table 1). As predicted, LEAS
scores increased significantly (p < .002) in the experimental group compared with the
control group, indicating that the subjects in the ASE curriculum increased in their
cognitive awareness and differentiation of their emotional states (see Table 2).

Significant changes were not found in either TAS-20 scores or global BSI scores.
However, contrary to what was predicted, there was a significant increase (2 < .001) in
the Obsessive-Compulsive dimension of the BSI in the experimental group compared

with the control group.

52

Also contrary to prediction, there was a significant effect for the global BSI scores
X group interaction (2 < .020). There were also significant interactions for a number of
dimensions of the BSI including: Interpersonal Sensitivity X group (p < .032), Anxiety X
group (p < .007), Hostility X group (p < .002), Paranoid X group (p < .033), and
Psychoticism X group (p < .015). In each of these interactions, the trend was toward
increasing scores in the experimental group and decreasing scores in the control group, as
indicated by differences in means (see Table l).

Hypothesis 2. Regressions were conducted to determine if the TAS-20 and the
LEAS independently predicted significant changes in the BSI (see Table 3). Results
indicated that the change in TAS-20 scores significantly predicted changes in global BSI
scores (p < .012), suggesting that changes in a self-report measure of alexithymia
predicted changes in psychopathology. Change in LEAS scores was not found be a
significant predictor of changes of global BSI scores.

Hypothesis 3. The hypothesis that the correlation between the LEAS and the
TAS-20 will become more strongly negative as LEAS scores increase was tested. This
hypothesis was supported. When LEAS scores were below 65, the correlation between
LEAS and TAS-20 scores was mildly positive (r = .134), indicating that when LEAS
scores are low, they are positively correlated with TAS-20 scores (see Figure 1). When
LEAS scores were equal to or above 65, the correlation between LEAS and TAS-20
scores was slightly negative (r = -. 017), indicating that when LEAS scores are high, they

are negatively correlated with TAS-20 scores (see Figure 2).

53

Chapter 5
DISCUSSION

The first hypothesis predicted that alexithymia and psychopathology levels would
significantly decrease in subjects who participated in the ASE curriculum compared with
a control group. Results for changes in alexithymia were mixed. LEAS scores increased
significantly in the experimental/ASE group, but the TAS-20 did not change
significantly. The LEAS is a performance-based measure of the cognitive complexity
and differentiation of emotions in self and other. The TAS-20 is a self-report measure of
alexithymia that presumably measures one’s self-perception of one’s ability to identify
and describe feelings. Results indicate that subjects’ self-perception of their ability to
identify and describe their feelings, as measured by the TAS-20, did not significantly
change. Thus, subjects’ actual ability to label and describe feelings as measured by the
LEAS improved, but their self-perception of their ability to label and describe their
feelings as measured by the TAS-20 did not improve.

It was also predicted that psychopathology would decrease in the
experimental/ASE group compared with the control group. This hypothesis was not
supported. Results for psychopathology did not show significant main effects for
changes in global psychopathology, indicating that overall psychopathology levels did
not significantly decrease in subjects who participated in the ASE curriculum. However,
significant main effects for changes in the Obsessive-Compulsive dimension of the BSI
were found, but in the opposite direction than predicted. Obsessive-Compulsive scores
increased significantly in the experimental group compared with the control group. The

BSI Obsessive-Compulsive dimension is comprised of six items which indicate

54

difficulties with cognitive functioning including: “trouble remembering things,” “feeling

9,

blocked in getting things done, “having to check and double-check what you do,”
“difficulty making decisions,” “your mind going blank,” and “trouble concentrating.”
The BSI also showed significant interactions for the Interpersonal Sensitivity, Anxiety,
Hostility, Paranoid Ideation, and Psychoticism dimensions, as well as for global
psychopathology. The direction of all significant interactions showed an increase in
group means for the experimental group and a decrease in group means for the control
group.

Contrary to hypothesis, these results demonstrate a significant trend in which
psychopathology decreased in the control group compared with the experimental group.
One explanation for these results is that the BSI is a measure of state psychopathology,
which may not detect changes in trait psychopathology. The BSI asks participants to
determine their symptomatology based on the past seven days, and thus is a state A
measure. When Meola (1988) used measures of state and trait anxiety in her research on
the ASE curriculum, she found a significant reduction in trait anxiety only. Another
possible explanation is that the control class may have had some influence on a reduction
of state psychopathology scores, owning to the fact that subjects in this class spent a
significant amount of time engaged in laughter and play. Perhaps play behavior and
laughter serves to reduce state measures of psychopathology such as the BSI.

The second hypothesis predicted that the changes in LEAS scores would be a
better predictor of changes in BSI scores than the TAS-20. This hypothesis was not
supported. Changes in TAS-20 scores did significantly predict changes in the BSI, but

there was no significant effect of changes in LEAS scores on the BSI. It was

55

hypothesized that the LEAS would be a better predictor of psychopathology than the
TAS-20 because the TAS-ZO is a self-report measure, and individuals who have difficulty
identifying and describing inner events may also have difficulty accurately self-reporting
their perception of their ability to identify and describe their feelings. Both the TAS-20
and the BSI are self-report measures. Perhaps these results can be accounted for by a
self-report bias, with individuals tending to self-report high on all self-report measures.

The third hypothesis predicted that the TAS-20 and the LEAS would be more
strongly negatively correlated as LEAS scores increased. There was support for this
hypothesis because the correlation between LEAS and TAS-20 scores was moderately
positive when LEAS scores were below 65 whereas the correlation was slightly negative
for LEAS scores above 65. Lane (2000) has argued that the TAS-20 may be problematic
because it is a self-report measure of alexithymia. According to Lane (2000), in order to
accurately self-report one’s awareness of one’s feelings on the TAS-20, one must possess
the same ability that is being tested. If one is lacking in this ability, one’s self-report is
likely to be inaccurate.

On the basis of Lane’s (2000) argument, it was predicted that as LEAS scores
increased, the correlation between the LEAS and TAS-20 would become more strongly
negatively correlated. Results indicated that subjects’ self-perception of their ability to
identify and describe their feelings does not remain constant. Instead subjects evaluate
their ability to identify and describe their feelings more positively than their actual ability
to cognitively describe their feelings indicates, as measured by the LEAS. Thus, as the
ability to cognitively label and differentiate emotion increases, the correlation between

the LEAS and the TAS-20 becomes more negative. This lends support to the hypothesis

56

that it may become more difficult for individuals who already have difficulty identifying
and describing their feelings to accurately self-report their feelings of alexithymia on the
TAS-20.

The results from this study must be interpreted with caution because of the
limitations of this study. First, the number of subjects who participated in the study was
low. Greater numbers of subjects would have increased the power to detect significant
differences, and may have shed more light on some of the trends found in the current
sample. Second, approximately one third of the subjects at pre-testing dropped out and
were not post-tested. Because there is no way to measure the characteristics of these
subjects, there is no way to determine if there was a systematic pattern related to drop
outs, nor what influence the drop outs had on the current sample. Third, the BSI is a
clinical measure used to assess clinical populations. In this study the BSI was used on a
university undergraduate population, where rates of psychopathology are relatively low
compared to clinical samples, and thus the BSI may not be sensitive enough to be able to
detect psychopathology in a normal sample. Fourth, both the TAS-20 and the BSI rely
on the self-report of participants. Research has shown that self-report measures fail to
distinguish between defensive deniers, who underreport their distress or difficulties, and
psychologically healthy individuals (Shedler, Mayman, & Manis, 1993). Finally, the
events of the terrorist attacks of Sept. 11, 2001 , while presumably affecting both groups
equally, may have differentially influenced one group in significant but unknowable
ways.

Future research should address these limitations. To increase sample size, pre-

testing should not occur until the second week of classes, when participant enrollment

57

stabilizes. In addition, the prize for winning the raffle should increase from $50 to $100
because many participants indicated they came from households with an income in
excess of $70,000, and 850 may not be sufficient to sustain interest in the study.

There are also major concerns about the nature of the alexithymia construct itself.
According to Bucci (1997), alexithymia occurs when there is disconnection between the
nonlinguistic nonsymbolic, nonlinguistic symbolic, and linguistic symbolic dimensions of
consciousness. Kaufman (1996) also argues that for maximal psychotherapeutic change
to occur, language, affect, and imagery must be reconnected to one another in conscious
awareness. This is also consistent with clinical work. Clients may be extremely facile in
their ability to cognitively label their feelings, but if this is not linked together with
actually experiencing feelings and also actively creating imagery to reflect internal states,
then usually there is little improvement in these clients. Neither the LEAS nor the TAS-
20 measures all three domains of consciousness. Therefore, from an affect theory
perspective, neither one of these instruments is likely to be a completely valid measure of
the alexithymia construct.

In order to more thoroughly understand and assess alexithymia, researchers will
need to first be able to assess each of the three domains of consciousness (affect,
imagery, language), and then will need to be able assess the degree to which those three
domains of consciousness are related to each other. The difficulty of this task becomes
apparent when we consider the current ability to assess affect in general, which is still
limited. Yet, until researchers are able to measure these dimensions of affect with

reliable precision, they will not be able to fully grasp its relationship to alexithymia.

58

In summary, subjects’ actual ability to cognitively label feelings as measured by
the LEAS significantly improved as predicted in the ASE curriculum compared with a
control group. However, subjects’ self-perception of their ability to identify and describe
their feelings as measured by the TAS-20 did not change significantly. In addition,
psychopathology scores did not decrease as predicted in the ASE group, but instead there
was a significant trend for a decrease in psychopathology in the control group compared
with the experimental group. Finally, as LEAS scores increased, the correlation between
the LEAS and the TAS-20 became increasingly negative as predicted. Thus, it seems
likely that the LEAS and the TAS-20 are not measuring the same construct, and this
study raises serious concerns about their validity as measures of the alexithymia
construct. Future research conducted on alexithymia should incorporate both the LEAS
and the TAS-20 in an effort to further elucidate the relationship between these two

measures.

59

APPENDICES

60

APPENDIX A
Table 1

Means and Standard Deviations for Variables by Group across Time

 

 

Variable Group Time 1 Time 2
M S_D M S_D
TAS-20 1 45.162 11.258 45.519 11.362
2 42.531 10.474 43.105 10.363
LEAS 1 65.297 7.652 71.963 9.757
2 63.016 7.915 61.631 7.947
BSI l .834 .664 .985 .713
2 .893 .609 .767 .615
Somatiz 1 .510 .786 .626 .694
2 .589 .627 .491 .597
Obsess l 1.1 17 .823 1.506 1.030
2 1.122 .787 1.282 .822
Sensitiv 1 1.155 1.180 1.269 1.102
2 1.348 1.042 .929 .987
Depress 1 1.014 1.031 1.090 .987
2 1.083 .926 .964 1.027
Anxiety 1 .865 .765 1.186 .933
2 .935 .744 .756 .613
Hostilit 1 .741 .671 .862 .787
2 .930 .821 .733 .830
Phobic l .432 .635 .427 .613
2 .391 .574 .303 .485
Paranoid 1 .930 .822 1.015 .898
2 .892 .779 .700 .867

61

Psychotic 1 .800 .739 .862 .889
2 .858 .728 .595 .710

 

Group 1 = Experimental Group (ASE Curriculum)

Group 2 = Control Group

62

Table 2

APPENDIX B

Repeated Measures MAN OVA of TAS-20, LEAS. afli BSI Scores

 

 

Variable SS df MS F P
TAS-20 9.263 1 9.263 .254 .616
TAS-20 X Group 8.001 1 8.001 .220 .641
LEAS 283.205 1 283.205 10.928 .002"
LEAS X Group 338.713 1 338.713 13.070 .001***
BSI .127 1 . 127 1.260 .266
BSI X Group .579 1 .579 5.736 .020*
Somatiz .1 14 1 .1 14 .575 .451
Somatiz X Group .212 1 .212 1.070 .305
Obsess 3.647 1 3.647 13.341 .001 ***
Obsess X Group .276 1 .276 1.009 .319
Sensitiv .148 1 .148 .502 .481
Sensitiv X Group 1.417 1 1.417 4.802 .032*
Depress .05585 1 .05585 .161 .689
Depress X Group .483 1 .483 1.394 .242
Anxiety .615 1 .615 2.457 .122
Anxiety X Group 1.960 1 1.960 7.831 .007”
Hostilit .02197 1 .02197 .156 .694
Hostilit X Group 1.505 1 1.505 10.669 .002"
Phobic .05417 1 .05417 .396 .531
Phobic X Group .03078 1 .0.078 .225 .637
Paranoid .02437 .02437 .112 .739
Paranoid X Group 1.031 1.031 4.747 .033*

63

Psychotic ' .105 l .105 .552 .460
Psychotic X Group 1.205 1 1.205 6.316 .015”

 

*p<.05 **p<.01 ***p<.001

APPENDIX C
Table 3

Summary of Regression Analfies for Chgge in TAS-20 and LEAS Scores Predicting

 

 

 

Changes in BSI Scores

Variable b se b, t p
ChangeLEAS .010 .007 .176 1 .42 .159
ChangeTAS .018 .007 .320 2.60 .012*

 

*p<.05 **p<.01 ***p<.001

65

APPENDIX D
Figure 1

Sgatterplot of TAS-20and LEAS Scores Where LEAS Scores are Less Than 65 ( r = .134)

 

 

70 l 1

40t-

'DASTTYDAL

 

 

 

10 l l
40 5O 60 70

LEASTOT

 

66

APPENDIX E
Figure 2
Scatterplot of TAS-20 and LEAS Scores Where LEAS Scores are Equal To or Greater

_T_llan 65 (r = -.017)

 

 

 

 

 

80 I I
70— o —
O o
i 60— OO 0 o o _‘
5 50_ o. o -
(Z) 38 o o
I— 40‘ OO 000 000 fl
0
O o
o o
30— O O —
o
20 1 l
60 7O 80 90

LEASTOT

67

APPENDIX F

Informed Con_sent Form

MICHIGAN STATE UNIVERITY

CONSENT TO ACT AS A RESEARCH SUBJECT

You are invited to participate in a research study investigating emotion and psychological functioning. The
study is comprised of three questionnaires that take approximately 1 hour to complete. The questionnaires
will be administered during the first week and the last week of class. Participants who complete both sets
of questionnaires will be eligible for $50 to be given away during a raffle during the final administration
sessron.

Your decision to participate in this study will have no effect on your grade for this class.

You may experience some minor discomfort as a result of examining your feelings and your psychological
functioning.

You have certain rights as a participant in this experiment:

1. Even if you agree to participate, you have the right to change your mind and to not participate
before the experiment begins, and to do so without penalty. Even if you agree to participate and
have begun the experiment, you have the right to discontinue your participation at any time and
for any reason, and to do so without explanation or penalty. If you decide to discontinue
participation, all questionnaires and other information about you will be destroyed, and your name
will be deleted fiom all records.

2. You have the right to confidentiality. Your privacy will be protected to the maximum extent
allowable by law. To ensure this, you will be assigned a subject number, which will be the only
way to identify you in any reports about the study. Only the experimenters will have access to
files and lists that can be used to link your name with a subject number. Any publication resulting
from this work will not identify you by name or circumstances that would allow your identity to
be discovered.

3. It is unlikely that your participation in the study will elicit significant emotional distress or
discomfort. However, if you do have any emotional concerns, you may contact Olin Health
Center at (517) 353-4660 or the Counseling Center at (517) 355-8270.

4. If you wish further information regarding your rights as a research subject, you may contact the
Office of the University Committee on Research Involving Human Subjects (UCRIHS), 246
Administration Building, Michigan State University, East Lansing, MI, 48824-1046, by
telephoning or emailing the chairperson, David E. Wright at (517) 355-2180, and at
UCRIHS@msu.edu.

5. After the entire study is completed, if you have any questions or if you want a written summary of
the general results, you may contact the primary investigator, David Rose, M. A., at the
Department of Psychology, 149 Snyder Hall, Michigan State University, East Lansing, MI, 48824,
by leaving a message at either (517) 355-4599, or rosedavi@msu.edu. or Gershen Kaufman,
Ph.D., at the MSU Counseling Center, 207 Student Services Building, Michigan State University,
48824, by leaving a message at either (517) 355-2310, or gershk@post.couns.msu.edu.

Please print and sign below to indicate that you have read and received a copy of the consent form and that
you voluntarily agree to participate in this study.

68

 

Print Name Clearly

 

 

Signature of Participant Date

 

 

Signature of Witness Date

69

APPENDIX G

Demogr_aphic Questionnaire
Subject # &

 

Subject Number
1. How many siblings do you have?
2) What are the last four digits of your MSU student ID?

(# siblings) & (last 4 digits ID) = Subject Number &
(Do not use addition with these numbers.)

Demographic Questionnaire

2. Age
2. Gender Male or Female (circle)
3. What is your estimated annual household income for family of origin? If you

come from 2 or more households, average the incomes. (please check one)
Under $19,999 per year

$20,000 to $34,999 per year

$35,000 to $49,999 per year

$50,000 to $69,999 per year

$70,000 to $100,000 per year

Above $100,000 per year

70

APPENDIX H

TAS-20

TAS-20

Instructions: We are studying emotions and are interested in your experiences. Please complete this
questionnaire by circling the number which indicates your level of agreement or disagreement with each
statement. Give only one answer for each statement.

Neither
Strongly Moderately Disagree Moderately Strongly
Disagree Disagree nor Agree Agree Agree
1 2 3 4 5

 

l. I am often confused about what emotion I am feeling.

1 2 3 4 5
2. It is difficult for me to find the right words for my feelings.

I 2 3 4 5
3. l have physical sensations that even doctors don’t understand.

1 2 3 4 5
4. 1 am able to describe my feelings easily.

1 2 3 4 5
5. I prefer to analyze problems rather than just describe them.

1 2 3 4 5
6. When lam upset, I don’t know if 1 am sad, frightened, or angry.

I 2 3 4 5
7. 1 am often puzzled by sensations in my body.

1 2 3 4 5
8. I prefer to just let things happen rather than to understand why they turned out that way.
I 2 3 4 5
9. l have feelings that 1 can’t quite identify.

1 2 3 4 5

71

10.

12.

13.

14.

15.

l6.

l7.

l8.

19.

20.

Being in touch with emotions is essential.

2 3 4 5

. I find it hard to describe how I feel about people.

2 3 4 5
People tell me to describe my feelings more.
2 3 4 5
I don’t know what’s going on inside me.
2 3 4 5
1 often don’t know why I am feeling angry.
2 3 4 5
I prefer talking to people about their daily activities rather than their feelings.
2 3 4 5
I prefer to watch “light” entertainment shows rather than psychological dramas.
2 3 4 5
It is difficult for me to reveal my innermost feelings, even to close fiiends.
2 3 4 5
1 can feel close to someone, even in moments of silence.
2 3 4 5
I find examinations of my feelings useful in solving personal problems.
2 3 4 5
Looking for hidden meanings in movies or plays distracts from their enjoyment.

2 3 4 5

72

APPENDIX I
QAS
INSTRUCTIONS
Please describe what you would feel in the following situations. The only requirement is
that you use the word “feel” in your answers. You may make your answers as brief or as

long as necessary to express how you would feel. In each situation there is another
person mentioned. Please indicate how you think that other person would feel as well.

73

A neighbor asks you to repair a piece of furniture. As the neighbor looks on, you
begin hammering the nail but then miss the nail and hit your finger. How would
you feel? How would the neighbor feel?

74

2.

You are walking through the desert with a guide. You ran out of water hours ago.
The nearest well is two miles away according to the guide’s map. How would
you feel? How would the guide feel?

75

3. A loved one gives you a back rub after you return from a hard day’s work. How
would you feel? How would your partner feel?

76

4.

You are running a race with a fiiend with whom you have trained for some time.
As you near the finish line, you twist your ankle, fall to the ground, and are
unable to continue. How would you feel? How would your friend feel?

77

5.

You are traveling in a foreign country. An acquaintance makes derogatory
remarks about your native country. How would you feel? How would your
acquaintance feel?

78

6.

As you drive over a suspension bridge you see a person standing on the other side
of the guardrail, looking down at the water. How would you feel? How would
the person feel?

79

Your sweetheart has been gone for several weeks but finally comes home. As
your sweetheart opens the door... how would you feel? How would your
sweetheart feel?

80

8. Your boss tells you that your work has been unacceptable and needs to be
improved. How would you feel? How would your boss feel?

81

9.

You are standing in line at the bank. The person in front of you steps up to the
window and begins a very complicated transaction. How would you feel? How
would the person in front of you feel?

82

10. You and your spouse are driving home fiom an evening out with friends. As you
turn into your block you see fire-trucks parked near your home. How would you
feel? How would your spouse feel?

83

11. You have been working hard on a project for several months. Several days after
submitting it, your boss stops by to tell you that your work was excellent. How
would you feel? How would your boss feel?

84

12. You receive an unexpected long-distance phone call from a doctor informing you
that your mother has died. How would you feel? How would the doctor feel?

85

13. You tell a friend who is feeling lonely that she/he can call you whenever she/he
needs to talk. One night she/he calls at 4:00 am. How would you feel? How
would your fiiend feel?

86

14. Your dentist has told you that you have several cavities and schedules you for a
return visit. How would you feel? How would the dentist feel?

87

15. Someone who has been critical of you in the past pays you a compliment. How
would you feel? How would the other person feel?

88

16. Your doctor told you to avoid fatty foods. A new colleague at work calls to say
that she/he is going out for pizza and invites you to go along. How would you
feel? How would your colleague feel?

89

17. You and a fiiend agree to invest money together to begin a new business venture.
Several days later you call the friend back only to learn that she/he changed
her/his mind. How would you feel? How would the friend feel?

90

18. You sell a favorite possession of your own in order to buy an expensive gift for
your spouse. When you gave him/her the gift, he/she asks whether you sold the
possession. How would you feel? How would the spouse feel?

91

19.

You fall in love with someone who is both attractive and intelligent. Although
this person is not well off financially, this doesn’t matter to you — your income is
adequate. When you begin to discuss marriage, you learn that she/Ire is actually
from an extremely wealthy family. She/he did not want that known for fear that
people would only be interested in her/him for her/his money. What would you
feel? How would she/he feel?

92

20.

You and your best friend are in the same line of work. There is a prize given
annually to the best performance of the year. The two of you work hard to win
the prize. One night the winner is announced: your fiiend. How would you feel?
How would your friend feel?

93

BS

APPENDIX J

BSI

Instructions: Here is a list of problems that people sometimes have. Please read each one carefully, and
circle the number that best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR
BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Circle only one number for
each problem and do not skip any items. If you change your mind, erase your first mark carefully.

0 = Not At All
1 = A Little Bit
2 = Moderately
3 = Quite A Bit
4 = Extremely

sewewwrPpwsewewwrppwsewewwrpP”99V99N?

OOOCOOOOOOOOOOOCOOOOCOOOCOOOOOOOOOOOC

—~—~—_—fl_—~_~———~_———-~—__———_———~——

NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN

wwwwwwwwwwwwwwwwwwuwwwwwwwwwwwwwwwwww

Ahhbhbhbbbbhhh-fiA-k$hA-h-b-hhh-hhhkhbhbhbhb

HOW MUCH WERE YOU DISTRESSED BY:

Nervousness or shakiness inside

Faintness or dizziness

The idea that someone else can control your droughts
Feeling other people are to blame for most of your troubles
Trouble remembering things

Feeling easily annoyed or irritated

Pains in heart or chest

Feeling afraid in open spaces or on the streets

Thoughts of ending your life

Feeling that most people cannot be trusted

Poor appetite

Suddenly fi'ightened for no reason

Temper outbursts that you could not control

Feeling lonely even when you are with people

Feeling blocked in getting things done

Feeling lonely

Feeling sad

Feeling no interest in things

Feeling fearful

Your feelings easily being hurt

Feeling that people are unftiendly or dislike you

Feeling inferior to other people

Nausea or upset stomach

Feeling that you are watched or talked about by others
Trouble falling asleep

Having to check and double-check what you do

Difficulty making decisions

Feeling afiaid to travel on buses or other public transportation
Trouble getting your breath

Hot or cold spells

Having to avoid certain things, places, or activities because they frighten you
Your mind going blank

Numbness or tingling (cramps) in parts of your body

The idea that you have committed sins you should be punished for
Feeling hopeless about the future

Trouble concentrating

Feeling weak in parts of your body

94

38.
39.
40.
41.
42.
43.

45.
46.
47.
48.
49.
50.
51.
52.
53.

OOOOOOOOOOOOOOOO

—~_-~_~_——_~_~_

NNNNNNNNNNNNNNNN

wwwwwwwwwwwwwwww

Abbbbbhbhbhbhh-fib

Feeling tense or keyed up

Thoughts of death or dying

Having urges to beat, injure, or harm someone

Having urges to break or smash things

Feeling very self—conscious with other people

Feeling uneasy in crowds, such as shopping or at a movie
Never feeling close to another person

Spells of terror or panic

Getting into fiequent arguments

Feeling nervous when you are left alone

Others not giving you proper credit for your work and achievements
Feeling so restless you couldn’t sit still

Feelings of worthlessness

Feeling that people will take advantage of you if you let them
Feelings of guilt

The idea that something is wrong with your mind

95

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