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Alexithymia, Negative Feelings in the Patient and Pejorative Feelings in the Clinician

Participating patients returned the completed questionnaires at their second visit to the outpatient department. The clinicians completed their questionnaires after the first visit of the patient and returned these questionnaires in a closed envelope to a research assistant with whom they had no professional connections. The research assistant anonymized and coded the questionnaires. One-way ANOVAs were used for normally distributed interval variables and Kruskal-Wallis H tests for nonparametric interval variables. 2 tests were used for nominal variables. Bivariate correlations were calculated using (partial) Spearman’s rank order correlation as the results of the HADS and the DDPRQ-10 did not have normal distributions. Since countertransference feelings are partly therapist related, we also conducted analyses by calculating adjusted individual scores [12] in the 19 therapists with at least 5 patients. The scores given by each therapist were corrected by the difference between the therapist’s mean score of his or her patient pool and the mean of all therapists’ scores. The number at this ‘patients with average therapist’ level was 235 (71.4% of the total sample). Two hundred sixty-four (80.2%) of the 329 eligible patients agreed to participate. Main diagnoses: affective disorder (n = 51), anxiety disorder (n = 38), somatoform disorder (n = 35), adjustment disorder (n = 21), other mental disorders (n = 69) and no mental disorder (n = 40). The 65 patients who declined to participate did not differ statistically from the participants in any of the socio-demographic or clinical characteristics or with respect to the location of treatment. All 35 clinicians agreed to participate in the study. The number of patients per clinician varied considerably. Most clinicians treated 2–6 patients. The association of alexithymia, defense style, tolerance of negative emotions, anxiety and depression and pejorative feelings of the clinician is shown in table 1 . Alexithymia is clearly associated with the defense styles: strongest with primitive defense style mechanisms, negatively with adaptive defense style mechanisms and moderately with the use of neurotic mechanisms. Alexithymia is also strongly associated with negative feelings such as anxiety and depression as well as with a low tolerance for negative feelings, especially for feelings of vulnerability. Alexithymia did not, however, correlate with the induction of pejorative feelings in the clinician. Pejorative feelings in the clinician (both unadjusted scores and adjusted patient with average therapist scores) were not associated with any of the patient variables. As all trait measures were strongly associated with the state measures for anxiety and depression ( table 1 ), we re-analyzed the association between the trait measures while statistically controlling for mood state. Now alexithymia remained strongly associated with primitive defense style mechanisms (r = 0.43, p ! 0.01) and less with adaptive defense style mechanisms (r = –0.18, p ! 0.01). The association of alexithymia with a low tolerance for negative feelings also remained significant although to a far lesser degree (ETS total: r = –0.20, p ! 0.01; ETS vulnerability: r = –0.16, p ! 0.05; ETS viciousness: r = –0.19, p ! 0.01). Also the association In several studies alexithymia proved to be positively associated with the tendency to experience negative affects and negatively associated with positive affects [1 , 2] . It has been suggested that this supports the hypothesis of alexithymia as the expression of a deficit in affect regulation corresponding to a lower level of emotional functioning, which includes the relative failure to develop adaptive defense mechanisms [1 , 3] . In the few studies [4–6] on alexithymia and defense style, alexithymia proves indeed to be associated with a primitive defense style and negatively with an adaptive defense style. However, in two [5, 6] of the three studies the effect of anxiety and depression was not controlled for. According to the clinical literature alexithymia tends to evoke negative countertransference reactions in the therapist, such as boredom and dullness [1 ]. However, hardly any empirical study has been done on the association of alexithymia and pejorative feelings in the therapist. In a cross-sectional study at three psychiatric outpatient departments we explored the associations of alexithymia with defense style and difficulties in tolerating negative feelings, and with pejorative feelings in the therapist. All consecutive new patients aged between 18 and 65 years who gave their informed consent were included. The patients were not informed about the measurement of countertransference feelings of their clinician as part of the study. Exclusion criteria were neurological or organic mental disorders, mental retardation, psychotic disorder, sensory disabilities, or insufficient knowledge of the Dutch language. Participating clinicians were mainly psychiatric residents, some psychiatrists and a few psychologists. Patients completed the Toronto Alexithymia Scale (TAS-20) [7] , the Emotional Tolerance Scale (ETS) [8] that in our study proved to have two scales (difficulties with feelings of vulnerability and with vicious feelings), the Defense Style Questionnaire (DSQ-40) [9] and the Hospital Anxiety and Depression Scale (HADS) [10] . The clinicians completed the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10) [11] . All scales had acceptable Cronbach’s alphas (0.74–0.90), except for the adaptive ( = 0.61) and neurotic ( = 0.48) defense style scales.