Difficulties in communicating about feelings: Context and Literature Review
Clinicians have observed that patients often have difficulty articulating their feelings (Freud A., 1966; Freud S., 1936). We have similarly observed this common yet peculiar phenomenon in our own clinical practice. Indeed, we have come to expect that patients will struggle to articulate their feelings when they need help with them. Especially in the brief patient interviews that are characteristic of current clinical practice, patients’ most meaningful and profound emotional experiences are often undeclared or unspoken.
What makes it so difficult for mental health patients to communicate their feelings? Several theories have been put forward. The psychodynamic tradition has been particularly focused on this phenomenon. Freud’s eventual understanding of this phenomenon was expressed in his Second Theory of Anxiety. Freud asserted that anxiety is a signal that any thought, feeling, or fantasy that threatens bonds with caretakers becomes dangerous and is to be avoided. The avoidance manifests as defenses which distort and distance the patient from dangerous feelings and can adversely impact the ability of the patient to recall and directly communicate such feelings (Freud, 1936).
Later, Sifneos and colleagues (1977) developed the concept of alex- ithymia, which refers to patients’ difficulties with identifying and describing their feelings, as well as externally-oriented thinking and a limited imaginal capacity (Bagby, Parker, and Taylor, 1994). Alexithymia can be assessed using a 20-item self-report measure, the Toronto Alexithymia Scale-20 item (TAS-20) (Bagby et al., 1994). Higher levels of alexithymia, as assessed with the TAS-20, have been associated with several adverse health outcomes, especially post-traumatic stress disorder (Frewen et ah, 2008) and chronic pain (Lumley et ah, 2011). However, many studies do not show robust correlations between alexithymia and health outcomes (Kojima, 2012; Lane et ah, 2015). Some have asserted the lack of strong associations between alexithymia and health outcomes may also be a problem with patients’ self- report: Is someone who has difficulty identifying and describing their feelings aware of such difficulties and thus able to accurately report them on a questionnaire (Lane et ah, 2015)?
Other constructs have been developed to assess patients’ overall comfort with emotional experience and expression, deriving from different theoretical traditions outside of psychodynamic theory. For instance, the concept of experiential avoidance, which derives from learning theory (e.g., classical and operant conditioning) and acceptance and commitment therapy (Hayes, Strosahl, and Wilson, 1999), describes attempts to avoid thoughts, feelings, memories, physical sensations, and other experiences, even when this avoidance creates harm in the long-run (Hayes et ah, 1996). Even while positing no unconscious conflict that motivates avoidance of negative emotions, experiential avoidance also emphasizes that avoidance of negative emotions can be detrimental to health and functioning (Hayes et ah, 1996). A self-report measure has also been developed to assess experiential avoidance, and, similar to alexithymia, this measure demonstrates some associations to health outcomes (Fledderus, Bohlmeijer, and Pieterse, 2010).
Other similar constructs that refer to psychological difficulties with emotional experience or expression come from other theoretical and empirical work. These include ambivalence over emotional expression (King and Emmons, 1990), affect control (Williams, Chambless, and Ahrens, 1997), affect phobia (McCullough, 2003), and conflicted emotions (Bhatia et al., 2009). Each of these concepts implies some psychological discomfort with emotions or emotional expression (e.g., ambivalence, need to control, or fear of emotions).
Still others suggest that certain populations may have more difficulty with communicating their emotions than others due to dispositional or cultural differences, rather than psychological factors. For instance, some research suggests that men and women may communicate differently about their feelings, and that men may be less likely to discuss their feelings openly (Borowsky et al., 2000; DeSteno, Gross, and Kubzansky, 2013; Else-Quest et al., 2012). African Americans and Hispanics may also be less likely to openly discuss their feelings (Borowsky et al., 2000). Indeed, a large cross- cultural literature identifies significant variability in the experience and expression of low mood (DeSteno et al., 2013; Kirmayer 1989). Other researchers have posited that developmental experiences and processes of socialisation may alter individuals’ capacity to express emotion (Briggs, 1970; Capps and Ochs, 1995; Shapiro, 2011).
Mental health patients often come to treatment distressed, and patients who are in distress can have more difficulty clearly articulating their distress, particularly when it is characterized by a great deal of anxiety that can interrupt their ability to think clearly and communicate effectively. Short-term dynamic psychotherapy models, among others, point to a clinical need for regulation of excessive distress to promote clear communication from patients about their feelings (Davanloo, 1990; McCullough, 2003).
Whether due to psychological conflicts about emotional experience and expression, cultural or dispositional differences, or distress, the difficulties patients have in communicating their feelings in the clinical interview are well-documented in the literature. In the next section, we go on to report additional examples of this phenomenon from our research.