‘Jane’ is a client familiar to every psychotherapist. She is suffering, perhaps intensely, but struggles to put into words the feelings and internal conflicts that drive her suffering, except in the most limited way. She might pin her angst on something specific: she’s terrified of gaining weight, or agonises over the shape of her nose, or says she can’t control her drinking. But when asked to say more about her inner life, she comes up blank, or returns to her already well-trodden initial complaint, or perhaps dismisses the question entirely. It’s not, the therapist soon discovers, that she’s holding back; on the contrary, she doesn’t have the capacity to give a fuller description of her internal life.
People like Jane are alexithymic, a term coined by the US psychoanalysts John Case Nemiah and Peter Sifneos in the 1970s, from the Greek a (‘without’), lexis (‘words’) and thymos (‘emotions’). It refers to a cluster of features including difficulty identifying and describing subjective feelings, a limited fantasy life, and a style of thinking that focuses on external stimuli as opposed to internal states.
Yet even before there was a name for it, psychoanalysts would often describe clients with apparent alexithymia, who reached an impasse in treatment because of their concrete thinking, limited emotional awareness and dismissive attitude toward their inner lives. These people were prone to developing so-called somatic symptoms (bodily complaints such as pain or fatigue) and they used compulsive behaviours to regulate their feelings, such as binge eating and alcohol abuse.
Clinicians have since observed alexithymia among people diagnosed with a wide range of mental health problems, including post-traumatic states, drug dependence, eating disorders and panic disorders. The broad spectrum of problems with which alexithymia is associated is consistent with the notion that when a person can’t express her emotional feelings in symbolic form, such as through words or images, this leads the emotions to have a harmful effect on her physiology, which then manifests as bodily symptoms.
What’s missing in alexithymia is a capacity that Nemiah in 1977 called the ‘psychic elaboration’ of emotion. Alexithymia is an extreme form of a deficit that is present in all of us to varying degrees. Whereas some of us struggle to put our feelings into words in nearly all domains, others can speak with sophistication and complexity about their emotional lives in relation to their artistic pursuits, for example, but not their personal relationships. Developing this capacity – the psychic elaboration of emotion – is a life-long task with which we must all engage. It is a cornerstone of psychological self-knowledge. Moreover, the failure to foster this capacity in psychotherapy is one of the most common factors that undermines its success.
To explain what is meant by the psychic elaboration of emotion, we must first clarify the terms affect, emotion and feeling. In 1917, Sigmund Freud, with his usual foresight, described affects as composite experiences that include ‘particular motor innervations or discharges’ and ‘certain feelings’. Since then, psychologists have defined emotion as the neurophysiological and motor-expressive component of affect (ie, what happens in the body) and feelings as the subjective, cognitive-experiential component (ie, ‘what it feels like to have that emotion’). Meanwhile, the term affect has come to encompass both the emotional and feeling components.
For our purposes, let’s think of affect as being expressed in four different ‘registers’: somatic, motoric, imaginal and verbal (following a model first proposed by the French-Canadian psychoanalysts Serge Lecours and Marc-André Bouchard in the 1990s). In the somatic register, affect is expressed through internal physiological sensations, bodily disturbances and injuries. This is how affect is first experienced in infancy, through sensations such as pain, tension, warmth or nausea, in the internal organs, head, musculature and skin. Throughout life, the body remains our ultimate emotional backdrop, the place in which any experience we cannot know with our minds continues to leave its mark.
The next step up in complexity, also available to infants, is the motoric register, which involves the behaviour and action of the muscular body, including positive and negative manifestations (eg, twitches and pacing, but also silences and stillness). The infant squirms, wiggles, cries and smiles – all are reflexive enactments of bodily affective sensations. Yet adults equally make use of bodily activity as a means of expressing affect: schoolyard fights, slammed doors and enthusiastic hugs are all, in part, expressions in this register.
The next step in the chain that bridges body and mind is the imaginal, which involves using mental pictures and scenes to represent underlying bodily states. Its content can take the form of images as expressed in dreams, fantasies and metaphors. It is a pivotal step, for it is the first register that utilises symbols to represent affect. Crucially, these can be combined to allow for the creation of more complex meaning structures. Note that not all imaginal expressions of affect have this representational quality to the same degree: consider persecutory hallucinations, which are often experienced as ‘things in themselves’ without symbolic qualities.
The psychotherapist helps the client put into words affects that have remained unrecognised
Finally, the verbal register entails the manifestation of affect in language, in words and stories, explanations and insights. It is the pinnacle of our emotional architecture, allowing us to link past and present, to hold up an experience and to examine it from different angles, to put our emotions ‘on pause’ and to bridge, even if only partially, the gaps that separate us as individuals.
As the British psychoanalyst Donald Winnicott argued in the previous century, affect is foremost a bodily experience for infants, and it is only with a ‘good enough’ intersubjective environment – the relationship between mother and infant – that the ‘psyche-soma’ begins to unfold through the psychic elaboration of affect as bodily experience. Psychotherapy is similar in some ways. The relationship between therapist and client creates a new intersubjective space intended to promote the psychic elaboration of emotion – that is, the elaboration of affect into images and words, and the linking together of these images and words with increasing complexity and sophistication. The psychotherapist, like the ‘good enough’ mother, helps the client to put into words affects that have in the past remained unrecognised and unelaborated.
Let’s imagine that ‘Jane’ struggles with binge eating, consuming enormous amounts of food, often to the point of feeling physically ill. In our work together, we discover, through tentative steps of enquiry spanning several weeks, that before many of her binges, there is a barely conscious feeling of anger toward her work colleagues, who take for granted her willingness to ‘pick up the slack’. In fact, I suggest this possibility after she makes an offhand remark about staying at work late – yet again – before stopping at a fast-food restaurant on the way home. We start to become more curious about her experience of anger more generally, and in a later session she describes a fantasy (ie, an image) of herself pouring her coffee onto her boss’s desk, ruining his carefully laid-out papers.
My interpretation of Jane’s binge eating is that, as with many clients, it is driven by her struggles to translate affects – many of which might be described as ‘angry feelings’ – into words and images so that they can be further elaborated and subjected to reflection. Without this capacity, she turns to binge eating as a last-ditch effort to regulate emotions that feel dangerous and out-of-control. The fervour involved in eating large amounts of food provides a ‘motoric pathway’ through which she can express her affects, which brings temporary relief before the cycle begins again. In our work, Jane and I strive to elaborate her affects, to link the resulting representations together in increasingly complex systems. We talk at length about Jane’s history with anger through her life, including how the feeling was handled in her family. Over time, this provides Jane with a ‘thicker’ mental buffer of symbolised material – ‘the “immune system” of the psyche’, as Lecours and Bouchard call it – that protects her from internal and external strife, promoting reflection instead of counterproductive action.
As I hope this abbreviated example has demonstrated, the problem that Jane struggles with – alexithymia – points to a task with which we must all engage: elaborating our affects into images and words, and subjecting them to ongoing reflection. Although most of us are not alexithymic in the clinical sense, we all have ‘pockets’, some larger and others smaller, of our inner lives that remain unelaborated. And in psychotherapy as in life, while a single, brilliant insight can be deeply important, that alone rarely leads to sustained personal development and relief from emotional suffering. It is, on the contrary, the development of this capacity – the psychic elaboration of emotion – that leads, quite literally, to continued mental growth.