اثر منفی آلکسیتیمیا بر روی نتیجه گروه درمانی برای سوگ و داغداری پیچیده:درمانگر ممکن است چه نقشی بازی کند؟

Abstract Alexithymia is a patient characteristic that reflects deficits in the cognitive processing and regulation of emotions. It is generally considered to have an adverse effect on the outcome of psychotherapy. Little is known about the processes through which alexithymia exerts this effect. One proposed mechanism suggests that patients with alexithymia trigger negative therapist reactions that contribute to poor outcome for such patients. This study examined whether therapist reactions to a patient mediate the relationship between alexithymia and outcome in group psychotherapy for complicated grief. Alexithymia was assessed with the Toronto Alexithymia Scale-20. Therapist reactions to a patient, reflecting the therapist's perceptions of a patient's positive qualities, personal compatibility, and significance as a group member, were assessed with a cohesion questionnaire. Outcome in several areas of functioning was measured. We found that alexithymia (specifically, greater difficulty in communicating feelings and greater tendency to engage in externally oriented thinking) was associated with less favorable outcome and that this relationship was mediated by therapist reactions to a patient. The mediation provided by therapist reactions to a patient accounted for approximately one third to one half of the direct effect of alexithymia on psychotherapy outcome. This suggests that therapist reactions to a patient represent a major mechanism through which alexithymia exerts its effect.

Introduction Patient characteristics occupy a central place in the treatment formulations of clinicians who are invested in providing psychotherapy. Knowledge of various patient characteristics is useful for determining whether psychotherapy should be provided, which type would be most effective, how long therapy should be provided, and which techniques should be emphasized. In brief psychotherapies, where time is limited and work must begin rapidly, selecting appropriate patients is particularly important. One patient characteristic that has received much attention in the literature and has been found to influence a patient's response to psychotherapy is alexithymia [1] and [2]. In general, it refers to deficits in the cognitive processing and regulation of emotions. However, a number of different descriptions of alexithymia have been offered in the literature. For example, alexithymia has been characterized as both an impaired capacity to differentiate and communicate one's emotions and a propensity to engage in externally oriented thinking (ie, focus on concrete details of external events) [1]. Individuals with high levels of alexithymia have also been characterized as using a communication style in which symbolic thinking is reduced and inner feelings and wishes are not revealed [3]. In addition, individuals with high levels of alexithymia have been described as having an impoverished fantasy life [4] and an impaired capacity for empathy [5]. Individuals with high levels of alexithymia are often aware of their emotional arousal; however, they have difficulty in differentiating emotions and verbalizing them [6]. They also have difficulty in discriminating between emotions and physical sensations and often express their emotional distress somatically (eg, in the form of a headache) [1]. In an effort to reduce the number of conceptions of alexithymia suggested in the literature, Taylor and colleagues [7] performed a factor analysis of a large number of items that have been used to measure the construct. They found that 3 core features (factors) could be used to conceptualize alexithymia: (1) difficulty in identifying feelings, (2) difficulty in communicating feelings, and (3) externally oriented thinking. This 3-factor characterization of alexithymia has become the standard for describing the construct. It is important to keep in mind that alexithymia is not a psychiatric disorder but rather a characterization of thinking, feeling, and relating processes among patients with a wide range of psychiatric diagnoses. Furthermore, alexithymia is not a dichotomous construct (ie, you have it or you don't) but rather a dimensional one (ie, people exhibit different levels or degrees of alexithymia). There has been much speculation in the clinical literature regarding the mechanisms by which alexithymia negatively affects the outcome of psychotherapy. One potential mechanism that has been consistently implicated is a therapist's negative reaction to a patient with high levels of alexithymia. Taylor [8] has written that patients with high levels of alexithymia are frequently observed by their therapists as dull, boring, and frustrating. A patient's repetitive and monotonous communications about external events may generate boredom in a therapist. This could cause the therapist to become distracted, have difficulty in concentrating, or have difficulty with remaining empathically attuned to the patient. At other times, the therapist may become frustrated with the patient's inability to link physical symptoms to inner feelings and life events. This frustration can lead to aggressive feelings and fantasies toward the patient. Taylor [8] has noted that therapists often experience intense feelings of despair and hopelessness, which persist well beyond the therapy hour, about the chances of helping patients with alexithymia. Krystal [4] has remarked that patients with high levels of alexithymia show aloofness that borders on indifference toward their therapist. He clarifies that this is not based on contempt or angry rejection of the therapist but is a virtual failure to interact emotionally with the therapist. For the therapist, this generates difficult and painful reactions such as hurt, rejection, and anger. These feelings may motivate the therapist to behave in a manner that communicates dislike, contempt, or frustration with the patient. Ultimately, the therapist may attempt to exorcise the patient from therapy to rid himself or herself of such feelings. Swiller [9] contends that for the therapist whose own self-esteem is closely tied to his or her ability to communicate with other human beings, patients with alexithymia may prove to be threatening because of their inability to communicate their emotional experiences. In such circumstances, the therapist may do little to maintain the therapy in the hope that the patient ends treatment prematurely. Thus, there are reasonable arguments that implicate a therapist's negative reaction to patients with alexithymia as a mechanism through which alexithymia affects the outcome of psychotherapy. However, we are aware of no study that has examined the potential relationships between alexithymia, a therapist's reaction to a patient, and psychotherapy outcome. This study may be the first to address this issue. The present study used data from patients who participated in a recently completed randomized clinical trial that investigated the efficacy of interpretive and supportive forms of group psychotherapy for complicated grief [10]. Complicated grief is a syndrome that involves a disturbed bereavement process. Individuals with complicated grief experience a constellation of symptoms that often include preoccupation with the lost person, anger about the death, and avoidance of reminders of the loss. Although many people who have experienced a death loss are familiar with these symptoms, the grief reactions of those with complicated grief reach intensities and durations that are extreme. Such reactions are often associated with other clinical complications (eg, depression and anxiety) and interfere with daily functioning. The clinical trial included comprehensive assessments of therapy processes. Among these assessments was a measure of the therapist's reactions to each patient. In the clinical trial [10], therapists were asked to rate each patient in the group on 3 aspects: the patient's positive qualities, personal compatibility, and significance as a group member. The purpose of the present study was to test the hypothesis that therapist reactions to the patient mediate the relationship between alexithymia and psychotherapy outcome.

3. Results 3.1. Step 1 Alexithymia factor 1 (difficulty in identifying feelings) was not significantly associated with any of the outcome factors: general symptoms (F1,91 = 1.06; P > .30; R2 = 0.01), grief symptoms (F1,90 = 2.86; P > .09; R2 = 0.03), and target objectives/life satisfaction (F1,101 = 2.04; P > .15; R2 = 0.02). Thus, it was not retained for subsequent steps of the mediation analysis. Alexithymia factor 2 (difficulty in communicating feelings) was significantly associated with outcome on the general symptoms (F1,91 = 6.58; P = .012; R2 = 0.07) and target objectives/life satisfaction factors (F1,101 = 5.09; P = .026; R2 = 0.05). Alexithymia factor 3 (externally oriented thinking) was significantly associated with all 3 outcome factors: general symptoms (F1,91 = 9.23; P = .003; R2 = 0.09), grief symptoms (F1,90 = 5.30; P = .024; R2 = 0.06), and target objectives/life satisfaction (F1,101 = 6.86; P = .010; R2 = 0.06). The findings suggested that a higher level of alexithymia (specifically, greater difficulty in communicating feelings and greater tendency to engage in externally oriented thinking) was associated with less favorable outcome. 3.2. Step 2 We found that alexithymia factor 2 (difficulty in communicating feelings) was significantly associated with therapist reactions to a patient (F1,103 = 7.07; P = .009; R2 = 0.07). In addition, we found that alexithymia factor 3 (externally oriented thinking) was also significantly associated with therapist reactions to a patient (F1,103 = 10.12; P = .002; R2 = 0.09). The findings indicated that a higher level of alexithymia (specifically, greater difficulty in communicating feelings and greater tendency to engage in externally oriented thinking) was associated with less positive therapist reactions to a patient. These findings suggested that therapist reactions to a patient could be tested as a mediator of the effect of alexithymia on outcome. 3.3. Step 3 3.3.1. Alexithymia factor 2, therapist reactions, and outcome The first set of findings concerned the relationships between alexithymia factor 2 (difficulty in communicating feelings), therapist reactions, and general symptoms outcome. The findings indicated a significant, direct association between therapist reactions to a patient and favorable improvement in general symptoms (t91 = −2.30; P = .024). They also indicated that the β coefficient for alexithymia factor 2 decreased (from .034 to .026) and was no longer significantly associated with general symptoms outcome (t91 = 1.91; P = .06). The second set of findings concerned the relationships between alexithymia factor 2 (difficulty in communicating feelings), therapist reactions, and target objectives/life satisfaction outcome. The findings indicated a significant, direct association between therapist reactions to a patient and favorable improvement in target objectives/life satisfaction outcome (t101 = −2.82; P = .006). They also indicated that the β coefficient for alexithymia factor 2 decreased considerably (from .032 to .022) and was no longer significantly associated with target objectives/life satisfaction outcome (t101 = 1.59; P = .115). 3.3.2. Alexithymia factor 3, therapist reactions, and outcome The third set of findings concerned the relationships between alexithymia factor 3 (externally oriented thinking), therapist reactions to a patient, and general symptoms outcome. The findings indicated a significant, direct association between therapist reactions to a patient and favorable improvement in general symptoms outcome (t91 = −2.01; P = .048). They also indicated that the β coefficient for alexithymia factor 3 decreased (from .038 to .029), yet it remained significantly associated with general symptoms outcome (t91 = 2.22; P = .029). The fourth set of findings concerned the relationships between alexithymia factor 3 (externally oriented thinking), therapist reactions, and grief symptoms outcome. We found that therapist reactions to a patient were not significantly associated with grief symptoms outcome. Thus, it is not possible for therapist reactions to a patient to mediate the effect of alexithymia factor 3 on grief symptoms outcome. The fifth set of findings concerned the relationships between alexithymia factor 3 (externally oriented thinking), therapist reactions, and target objectives/life satisfaction outcome. The findings indicated a significant, direct association between therapist reactions to a patient and favorable improvement in target objectives/life satisfaction outcome (t101 = −2.61; P = .01). They also indicated that the β coefficient for alexithymia factor 3 decreased considerably (from .036 to .025) and was no longer significantly associated with target objectives/life satisfaction outcome (t101 = 1.78; P = .078). 3.4. Step 4 Regarding the relationships between alexithymia factor 2 (difficulty in communicating feelings), therapist reactions, and general symptoms outcome, we found that the β coefficient for alexithymia factor 2 decreased significantly (z = 2.0; P = .046) when therapist reactions were included in the prediction model, relative to when only alexithymia factor 2 was included in the prediction model. Similarly, for the relationships between alexithymia factor 2, therapist reactions, and target objectives/life satisfaction outcome, we found that the β coefficient decrease for alexithymia factor 2 was significant (z = 2.0; P = .046). These findings indicate that therapist reactions to a patient mediated the effect of alexithymia factor 2 on general symptoms and target objectives/life satisfaction outcomes. Regarding the relationships between alexithymia factor 3 (externally oriented thinking), therapist reactions, and general symptoms outcome, we found that the β coefficient decrease for alexithymia factor 3 was not significant (z = 1.8; P = .072) when therapist reactions were included in the prediction model, relative to when only alexithymia factor 3 was included in the prediction model. However, for the relationships between alexithymia factor 3, therapist reactions, and target objectives/life satisfaction outcome, we found that the β coefficient for alexithymia factor 3 decreased significantly (z = 2.2; P = .028). These findings indicate that therapist reactions to a patient also mediated the effect of alexithymia factor 3 on target objectives/life satisfaction outcome and, to a lesser extent, general symptoms outcome. Our final analysis involved calculating the percentage of the effect of alexithymia on outcome (alexithymia → outcome) that is accounted for by therapist reactions to a patient (alexithymia → therapist reactions to a patient → outcome) for each of the 4 mediation relationships identified in the present study. These percentages inform us of the degree to which the effect of alexithymia is mediated by therapist reactions to a patient. Therapist reactions to a patient accounted for 32% and 47% of alexithymia factor 2's effect on general symptoms outcome and target objectives/life satisfaction outcome, respectively. Therapist reactions to a patient accounted for 30% and 45% of alexithymia factor 3's effect on general symptoms outcome and target objectives/life satisfaction outcome, respectively. Thus, the mediation provided by therapist reactions to a patient accounted for approximately one third to one half of the direct effect of alexithymia on psychotherapy outcome. These findings demonstrate that therapist reactions to a patient provide for a substantial mediation of the effect of alexithymia on outcome. Despite this, the results also indicate that the mediation provided by therapist reactions to a patient was partial and not complete. Although complete mediation is theoretically possible, it is unlikely in research on psychosocial phenomena. 3.5. Summary of findings In summary, the present study found that higher levels of alexithymia (specifically, difficulty in communicating feelings and externally oriented thinking) were significantly associated with poorer treatment outcome. In addition, higher levels of alexithymia were related to more negative therapist reactions to a patient. These negative reactions were found to be significantly related to less favorable outcome. Finally, the study found that when the effect of therapist reaction to a patient on treatment outcome was accounted for, alexithymia no longer had a significant effect on outcome. Thus, the findings indicated that therapist reaction to a patient mediates the effect of alexithymia on treatment outcome.