Najmeh Fath¹, Parviz Azadfallah¹*, SeyedkazemRasoolzadeh tabatabaee¹ and Changiz Rahimi²

¹Department of Psychological, TarbiatModares University, Tehran, Iran.

²Department of Psychological,Shiraz University, Shiraz, Iran.

DOI : https://dx.doi.org/10.13005/bpj/491

Abstract

Alexithymia refers to difficulties in experiencing, verbalizingand regulating emotions.The present study aims to apply interpersonal psychotherapy principles (IPT)in reduction of alexithymia symptoms.Implementing the TorontoAlexithymiaScale(TAS-20) on384female studentsof the Shiraz University (Iran)andevaluatingthe scores distribution of sample group base on the givenscale, 30 students who were at leastone standard deviationabovethemean ofthe distribution, were randomly selected and divided into control and experimental groups(n = 15in each group).The experimentalgroup experienced interpersonal psychotherapyprogram during 12 sessions and the control group received no intervention. The groups were compared to each other by means of TAS scale and during two stages (post-test and three month follow up).MANCOVA results indicated a significant difference between the experimental and control groups in the three alexithymia features: difficulty identifying feelings, difficulty describing feelings and externally oriented thinking. At the fallow up stage however, there was a significant difference between the groups only in difficulty identifying feelings and describing feelings components. Itseemslogicalthat addressing effective foundations in Alexithymia occurrence (attachment difficulties in early life influencing adulthood) throughemotion regulation and modification within an interpersonal space which is one of the interpersonal psychotherapy goals at the present time, can lead to the improvement of Alexithymia symptoms.

Keywords

Alexithymia; interpersonal psychotherapy; difficulty identifying feelings; Difficulty describing feelings; externally oriented thinking

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Introduction

People usually communicate with each other through language. Transferring one’s feelings to other people and understanding their feelings and emotions is one of the most important human’s abilities to communicate. So the more a person is capable of identifying, distinguishing and describing his feelings and understanding other people’s feelings, the more effectively he can communicate. According to “Affection Exchange” theory (Neo-Darwinian theory)(1, 2), affectionate communications are considered as adaptive behaviors. Some people havinglittle capacity toexperience andexpresstheir emotionsin form of words,suffer from Alexithymia(3), introducingbyNemiah and Sifneos in 1970s(4): difficulty identifying feelings and distinguishing between received bodily sensations associated with emotions arousal, difficulty describing feelings, limited imagery process and externally oriented cognitive style (5).Bagbyet al.(2006) revealed that Alexithymiain factconsisted of twogeneraldeficits: decreased affection awareness which is visible at thelevels ofdifficultyidentifying feelingsanddifficultydescribingfeelingsandoperationalthinking(acognitive style recognized byreduced objective thinking(6).

Relationship between Alexithymia and interpersonal problems has been verified by a large number of studies(4, 7-12). Various studies have also indicated insecure attachment styles in people with Alexithymia (13-15).

Childhood destructive relationships and learning the insecure attachment style lead to more negative affection experiences and less ability to understand the emotions (16). If parents are not able to evoke infants’ emotional cues and fail as an external regulator of infants’ emotions, they may distort their normal emotional development (14).Parents not expressing their emotions or not responding appropriately to infants’ emotions can have a huge impact on their emotion regulation later in their life. Children comprehend their internal states (through the feeling labeled by others) first through social interactions particularly with their parents and ultimately empowered. Using facial expression and context, self-understanding, internal states perception and expressing them by means of language (16).Children having difficulty in this era are called Alexithymic when grown up (17). Therefore, various factors such as strikes, the neuropsychological-biological deficits, cultural-social influences and quality of attachment (insecure attachment style) are involved in alexithymia etiology.

Most studies so far have been addressing etiology and pathology of alexithymia rather than therapy and interventions. According to controlled studies and clinical observations, alexithymia treatment is too difficult. Implementing a research to provide  a treatment framework for  such patients, Vanheule et al (2011) presented a conceptualization of this structure based on interpersonally imbedded affect regulation(7). It seems that structured Psychotherapy focused on trainingis more effective for these patients (18). A number of researchers recommend the affect regulation based intervention for these patients (19, 20).

In general Psychotherapy or intervention method that can concurrently consider the lack of emotional regulation, interpersonal problems and related conditions, can take an effective step toward improving the lives of these individuals. According to mentioned theoretical framework, this study seeks to examine if applying the principles of interpersonal psychotherapy (IPT) can be effective in reducing alexithymia features. Interpersonal Psychotherapy is in fact a type of short-term therapy(21) which was first invented with the purpose of intervention treatment for depressed patients. Interpersonal psychotherapy is a focused intervention on the internal correlations of interpersonal problems and psychological symptoms(22).

This type of therapy, concurrently examine life events, mood disorders self-esteem and interpersonal processes (22). Interpersonal psychotherapyis an approachtargeting interpersonal problems, in order to resolve psychological ones (22).Examining the usefulness of interpersonal psychotherapy is necessary, as the fundamental logic of this intervention method is compatible with alexithymia characteristics and it’s affecting factors. Although mood and emotional disorders and interpersonal problems do not necessarily overlap in all cases, there are complex relationships between them which can be resulted from childhood damages such as lack of parents, being abused or experiencing improper family structure.

Furthermore, althoughIPT based on its title is an intervention method addressing interpersonal relationships, it was first invented and developed as a short-term therapy to treat mood disorders specially depression (21), concentrating on mood and emotional structures which probably can be effective in moderating alexithymia symptoms.

Method

The present study consists of control and experimental groups where the experimental group receives the intervention program but the control group receives no particular experience.In addition, considering the random placement of people in different groups, this plan is graded as true experimental design.

Participants

A total of 384 students from approximately 1000 female students from the Shiraz University (Iran)during the academic year 2011-2012were selected based on the availability sampling method, considering the population size and referring to Krejcie – Morgan table (1970). 30 students with at least one standard deviation above the distribution mean were randomly selected and placed into two groups of experimental and control, based on the Toronto Alexithymia Scale (TAS-20) and the distribution of scores.Individuals with no history of mental disorders drug addiction and disability were accepted to the groups. Participants were undergraduate students, and ranged from 18 to 25 years old(23).

Assessment Tool

Toronto alexithymia scale (TAS-20)

This scale was created to measure Alexithymia features by Bagby et al. (1994)(24).This scale is a self-report scale including 20 materials. Each material is scored on a 4-point Likert scale. Higher scores indicate a greater presence of alexithymia features with three subscales including difficulty identifying feelings(DIF),difficulty describing feelings(DDF) andexternally oriented thinking(EOT)(4).Psychometric features of this scale have been completely confirmed and the validity and reliability is achieved in different populations (11).Internal consistency of this scale is reported in the Persian form 0.85 A (25).

The Toronto Structured Interview for Alexithymia

This interview designed by Bgbay et al. was including 24 questions related to alexithymiafour dimensions (difficulty identifying feelings, difficulty describing feelings, externally oriented thinking and limited imagery processes). Items are scored on a three degrees Likert scale by the interviewer (4). Higher scores indicate a greater presence of alexithymia characteristics. Factorial validity, internal consistency and agreement between the graders have been reported to be good (6).

Conducting interview along with the TAS-20has two advantages: first examining imagery processes in addition to three dimensions measured by the scale, second addressing affectionate awareness problems through exploring and searching during the interview in people probably unaware of their difficulty in identifying and describing feelings while answering the scale questions (on each item the person is asked to describe a stress-causing situation and explain their feelings regarding the situation) (6). Interview was used in order to complete and confirm the data obtained through the mentioned scale in this research.

Therapeutic Method

Interpersonal psychotherapy (IPT) is a short-term therapy focuses on interpersonal problems. IPT aims to change or modify interpersonal relationships and expectations associated with them. It also help patients and other people improve a social support network in order to more effectively manage their interpersonal problems (26). In this research, the therapy was performed once a week, during 12 one-hour sessions.A brief description on the content of the sessions is as follows:

First and Second Sessions

A general interview and creating a personal history, surveying  the range of emotional interactions attachment styles and the pattern of emotion expression, communicating and creating therapeutic alliance, using the therapist’s emotional capacity and empathy for creating a feeling of security in referee within the therapeutic framework. Third Session: Surveying the referee’s style and relationship Network, conflicts appraisal and    exploring the cognitive ranges in connection with interaction space.Fourth and Fifth Sessions: Surveying theemotional interactions with important people, focusing on referee’s conflicts with important people, investigating economic dynamics (emotional investments) and their consequences,preliminary interpretations based on diagnosis, examination of referee’s feedback and providing acceptance preconditions, creating operational  therapeutic plans with the help of the referee, Sixth Session: Addressing the main communication problems in details, examining the referee’s capacity to understand and solve problems, Seventh Session: reaching alternative solutions for main complaints, reviewing and selecting appropriate solutions during the consultation process.Eighth Session: Using imagery and role playing in order to implement the solutions in treatment session and planning for solutions performance in real communications spaces. Ninth Session: Discussing the how of implementing the solutions and reporting their consequences,reviewing the problems and guiding the person to illustrate an emotional and communication space. Tenth Session: Reviewing the exercises, generalizing successful solutions to other situations and so forth. Eleventh and TwelfthSessions: Surveying thereferences emotions and feelings and related expressions about the changes in her communication environment, evaluating the treatment success based on reviewing three emotional performances in emotional distinctions, emotional perception and emotional expression contexts, highlighting the benefits of the treatment.

Implementing process

As mentioned earlier, 30 people having at least one standard deviation above the mean of the distribution, on TAS were selected from a sample of 384 female students.TAS for Alexithymia was then conducted and completed by the therapist. Also these people were considered in terms of entry criteria. They were then divided randomly into two 15-person groups. Then the desired intervention was randomly given to one of the groups.

Experimental group in fact received the interpersonal psychotherapy and control group received no particular experience. The intervention was given to control group once a week, during 12 one-hour sessions. After the treatment at the follow-up (3 months after the treatment), testees were measured by the mentioned scale meaning that both experimental and control group were evaluated in pretest, post-test and follow-up phases.

Results

In this section, findings regarding alexithymia subscales (difficulty identifying feelings, difficulty describing feelings and externally oriented thinking), will be analyzed. First, the descriptive findings are reported and then the data statistical analysis will be discussed. Descriptive indexes associated with subscales of alexithymia in the experimental and control groups at pretest, post-test and follow-up are reported in Table 1.

Table 1: Descriptive indexes ofAlexithymia subscales in two sample groups in pretest, post-test and follow-up

Group	time	Dependent Variable	minimum	maximum	average	Standard deviation
		Difficulty identifying feelings	2	26	15.13	6.87
	pretest	Difficulty describing feelings	3	16	9.4	4.34
		Externally orientedthinking	6	18	12.2	3.7
		Difficulty identifying feelings	1	11	5.8	2.62
	Post- test	Difficulty describing feelings	1	10	6.33	2.64
Experimental Group		Externally mode of thinking	4	15	10.07	2.81
		Difficulty identifying feelings	2	10	7	2.33
	Follow-up	Difficulty describing feelings	2	11	6.4	2.44
		Externally mode of thinking	5	19	10.93	3.39
		Difficulty identifying feelings	11	22	16.13	3.25
	pretest	Difficulty describing feelings	4	17	11.2	3.45
		Externally mode of thinking	4	21	20.13	5.27
		Difficulty identifying feelings	3	24	15.93	5.47
	Post- test	Difficulty describing feelings	2	15	10	3.85
		Externally mode of thinking	8	19	14	3.68
Control Group		Difficulty identifying feelings	1	24	15.33	6.31
	Follow-up	Difficulty describing feelings	4	17	10.73	4.17
		Externally mode of thinking	9	19	13.27	3.33

 

The results in table 1 indicate that the averages of all Alexithymia subscales scores were significantly low in experimental group comparing with experimental group. This is visible regarding all the subscales.

In the following, the obtained data will be analyzed. Considering this research aims to examine the efficiency of interpersonal psychotherapy method on Linear combination of these two subscales’ dependent variables, multivariate analysis of covariance (Manocova) is used for measurement. Also Homogeneity of covariance assumption (box’s test) and homogeneity of variances assumption (Levine test) are required before the statistical test.Multivariate analysis of covariance test results on the linear combination of Alexithymia subscales in the post-test is presented in table 2. Results suggest box’s (Box’s M=12.78, F=1.88, p>0.05) and Levin (p>0.05) test are not significant and as a result the assumptions used in this statistical test applies.

Table 2: The results of analyzing one-way multivariate covariance test on Alexithymia subscales at the follow-up

impact	index		F	Degrees of freedom between groups	Freedom degrees of Error	Significance level	Test power
		Particular value
Difficulty identifying	Pillai’s trace	0.16	1.42	3	23	0.26	0.32
Feelings pretest	wilks lambda	0.84	1.42	3	23	0.26	0.32
	Hotelling’s trace	0.18	1.42	3	23	0.26	0.32
	Pov-Ray Square root	0.18	1.42	3	23	0.26	0.32
Difficulty describing	Pillai’s trace	0.12	1.01	3	23	0.41	0.24
feelings pretest	wilks lambda	0.88	1.01	3	23	0.41	0.24
	Hotelling’s trace	0.13	1.01	3	23	0.41	0.24
	Pov-Ray Square root	0.13	1.01	3	23	0.41	0.24
	Pillai’s trace	0.315	3.53	3	23	0.03	0.71
Externally mode of	wilks lambda	0.68	3.53	3	23	0.03	0.71
thinking pretest	Hotelling’s trace	0.46	3.53	3	23	0.03	0.71
	Pov-Ray Square root	0.46	3.53	3	23	0.03	0.71
	Pillai’s trace	0.62	12.31	3	23	0	0.99
group	wilks lambda	0.38	12.31	3	23	0	0.99
	Hotelling’s trace	1.61	12.31	3	23	0	0.99
	Pov-Ray Square root	1.61	12.31	3	23	0	0.99

 

Table 2 indicate a significant difference (P<0.01) between different levels of the two groups (experimental and control groups) in the post test, regarding Alexithymia combination dependent variable(difficulty identifying feelings, difficulty describing feelings and externally oriented thinking. In order to figure out the levels of Alexithymia components where the difference between the two groups is significant, table 3 should be reviewed.

Table 3: The results of analyzing one-way multivariate covariance test on Alexithymia subscales at the post test

		Sum of squares	Degree of freedom	squares Mean	F	Significance level	Test power
Resource	Dependent variable
Difficulty identifying	Difficulty identifying feelings in follow-up	25.96	1	25.96	1.44	2.24	0.21
Feelings pretest	Difficulty describing feelings in pretest	21.01	1	21.01	2.12	0.16	0.29
	Externally oriented thinking	2.79	1	2.79	0.31	0.58	0.09
Difficulty describing	Difficulty identifying feelings in follow-up	16.57	1	16.57	0.92	0.35	0.15
feelings pretest	Difficulty describing feelings in follow-up	25.28	1	25.28	2.55	0.12	0.34
	Externally mode of thinking in follow-up	1.06	1	1.06	0.12	0.73	0.06
Externally mode of	Difficulty identifying feelings in follow-up	14.79	1	14.79	0.82	0.37	0.14
thinking pretest	Difficulty describing feelings in pretest	2.33	1	2.33	0.23	0.63	0.07
	Externally mode of thinking in follow-up	59.22	1	59.22	6.7	0.02	0.7
Group	Difficulty identifying feelings in follow-up	669.15	1	669.15	37.03	0	1
	Difficulty describing feelings in pretest difficulty describing feelings follow-up	76.03	1	76.03	7.68	0.01	0.76
	Externally mode of thinking in follow-up	82.67	1	82.67	9.36	0.01	0.84
	Externally oriented thinking follow-up
error	Difficulty identifying feelings in follow-up Difficulty describing feelings follow-up	451.79	25	18.07
	Difficulty describing feelings in pretest Difficulty describing feeling follow-up	247.33	25	9.89
	Externally mode of thinking in follow-up	220.09	25	8.84
total	Difficulty identifying feelings in follow-up	4828	30
	Difficulty describing feelings in follow-up	2407	30
	Externally mode of thinking in follow-up	4761	30

 

Based on the table 3, there is a significant difference between experimental and control groups (P<0.01) in the post-test after moderating the pre-test effects in the three Alexithymiasubscales including difficulty identifying feeling difficulty describing feelings and externally oriented thinking.Referring  to table 1, it can be found that observed differences are in favor of the experimental group. Actually,interpersonal psychotherapy has been effective in reducing Alexithymia features.

In the next phase, the effect of interpersonal Psychotherapy was examined in comparison with control group on Alexithymia subscales in follow-up. The results of Box (Box’s M=12.78, F=1.88, p>0.05) and Levin (p>0.05) confirms the assumptions of variance and covariance homogeneity, therefore using multivariate analysis of the covariance is allowed.

Table 4: The results of analyzing one-way multivariate covariance test on Alexithymia subscales at the follow-up

		Sum of squares	Degree of freedom	squares Mean	F	Significance level	Test power
Resource	Dependent variable
Difficulty identifying	Pillai’s trace	0.22	2.22	3	23	0.11	0.49
Feelings pretest	wilks lambda	0.77	2.22	3	23	0.11	0.49
	Hotelling’s trace	0.29	2.22	3	23	0.11	0.49
	Pov-Ray Square root	0.29	2.22	3	23	0.11	0.49
Difficulty describing	Pillai’s trace	0.32	3.6	3	23	0.03	0.72
feelings pretest	wilks lambda	0.68	3.6	3	23	0.03	0.72
	Hotelling’s trace	0.47	3.6	3	233	0.03	0.72
	Pov-Ray Square root	0.47	3.6	3	23	0.03	0.72
	Pillai’s trace	0.35	4.2	3	23	0.02	0.79
Externally mode of	wilks lambda	0.65	4.2	3	23	0.02	0.79
thinking pretest	Hotelling’s trace	0.55	4.2	3	23	0.02	0.79
	Pov-Ray Square root	0.55	4.2	3	23	0.02	0.79
	Pillai’s trace	0.45	6.37	3	23	0.01	0.93
Group	wilks lambda	0.55	6.37	3	23	0.01	0.93
	Hotelling’s trace	0.83	6.37	3	23	0.01	0.93
	Pov-Ray Square root	0.83	6.37	3	23	0.01	0.93

 

Table 4 indicates a significant difference (P<0.01) between experimental and control groups in Linear combination of the dependent variable (Alexithymia subscales) at the follow-up. In fact, the results demonstrate the maintenance of Psychotherapy effects during three months after the intervention.Table 5 determines this effect is significant in which dependent variables.

Table 5: The results of analyzing one-way multivariate covariance test on Alexithymia subscales at the follow-up

		Sum of squares	Degree of freedom	squares Mean	F	Significance level	Test power
Resource	Dependent variable
Difficulty identifying	Difficulty identifying feelings in follow-up	33.06	1	33.06	0.23	1.48	0.22
Feelings pretest	Difficulty describing feelings in follow-up	13.17	1	13.17	0.26	1.3	0.19
	Externally mode of thinking in follow-up	0.45	1	0.45	0.83	0.05	0.05
Difficulty describing	Difficulty identifying feelings in follow-up	25.01	1	25.01	0.3	1.12	0.17
feelings pretest	Difficulty describing feelings in follow-up	56.61	1	56.61	0.03	5.59	0.62
	Externally mode of thinking in follow-up	4.56	1	4.56	0.49	0.48	0.1
Externally mode of	Difficulty identifying feelings in follow-up	0.07	1	0.07	0.95	0.01	0.05
thinking pretest	Difficulty describing feelings in follow-up	0.02	1	0.02	0.96	0.01	0.05
	Externally mode of thinking in follow-up	72.33	1	72.33	0.01	7.65	0.75
Group	Difficulty identifying feelings in follow-up	411.48	1	411.48	0	18.42	0.98
	Difficulty describing feelings in follow-up	99.35	1	99.35	0.01	9.81	0.85
	Externally mode of thinking in follow-up	33.32	1	33.32	0.07	3.52	0.44
Error	Difficulty identifying feelings in follow-up	558.31	25	22.333
	Difficulty describing feelings in follow-up	253.16	25	10.13
	Externally mode of thinking in follow-up	236.44	25	9.46
Sum	Difficulty identifying feelings in follow-up	4895	30
	Difficulty describing feelings in follow-up	2669	30
	Externally mode of thinking in follow-up	4749	30

 

As seen in table 5, there is a significant difference (p<0.01) between the two groups regarding difficulty identifying feelings and difficulty describing feelings after moderating the pre-test scores at the follow-up With respect to table 1, average score of these factors in experimental group is lower at a significant level comparing with control group. The significant results indicate the maintenance of Psychotherapy effects during three months after treatment regarding mentioned factors while there is no significant difference in terms of externally oriented thinking.

Conclusion

As mentioned before, this study aimed to assess the efficacy of interpersonal psychotherapy in reducing Alexithymia features. The results revealed a significant difference between the experimental group (the group received the intervention) and the control group (the group received no intervention) after the psychotherapy (in the post- phase), in regard with the three characteristics of Alexithymia including difficulty identifying feelings, difficulty describing feelings and externally oriented thinking.

This means that interpersonal psychotherapy is effective in reducing Alexithymia features. There was a significant difference between the control and the experimental groups only in difficulty identifying feelings and difficulty describing feelings at the follow-up (three months after the end of intervention). According to surveys, no study has been conducted on examining the efficiency of interpersonal psychotherapy for improving Alexithymia features, also according to controlled studies and clinical observations, curing Alexithymia people is too difficult.

Higher levels of Alexithymia, predict more serious therapeutic consequences (5, 27), however a number of researches have mentioned the efficacy of psychotherapy on Alexithymia, according to a number of researches, if psychotherapy methods are performed focusing on the prominent characteristics of these people, it is likely to achieve a successful outcome.According to Vanheule at al. (2007),since Alexithymia people, clinically and practically tend to withdraw from others and refrain from sharing their experiences, one of the key activities of the therapist in order to identify provoking, describing related feelings and developing explanations associated with them is to reflect the patient’s feelings without imposing his own explanations(28).Considering this,Vanheule et al. (2011) offered a conceptualization of this structure in a research based on interpersonally imbedded affectregulationin order to provide an appropriate treatment for these people(7). A number of researches recommend interventions based on emotional regulation for treatment of these people (19, 20).

Due to the low ability of imagery in Alexithymia people, visual techniques are frequently used in treatment of Alexithymia (29). A number of researchers have examined the efficiency of other therapeutic methods on this personality variable.

Framarzi et al.(2013)Research aimed to investigate the efficacy of short-term Dynamic therapy emphasizing on Core Conflictual Relationship Theme in patients with functional dyspepsia, indicated indigestion symptoms improvement as well as  reducing Alexithymia features(30).Stingl et al. (2008) research found short-term Dynamic therapy effective in reducing Alexithymia symptoms(31). The findings of Simson et al.(2006) also confirms the effectiveness of psychotherapy on Alexithymia scores(32).

Reducing Alexithymia symptoms with interpersonal psychotherapy andconsidering theoretical basis of this therapeutic model and Alexithymia which both emphasize on attachment concept, seems to be debatable. The most important theory IPT is based on attachment theory. According to this theory humans have an inner drive to interpersonal relationships (33). Attachment establishment is an important element to form sustainable patterns of interpersonal behavior which leads to seek care and reassurance in a specified way by the person. According to this theory disruption in attachment process leads to distress in people.

Insecure attached people are more susceptible to distresswhile involved in interpersonal conflicts, after the loss of a relationship or looking to change the role; they have experienced less security in early life attachments as well as weaker social support networks (33). IPT most focuses on the ways patients exchange their attachment needs and create a social support network rather than trying to change the patient’s attachment style. IPT works on the patients’ current relationships considering their attachment style and help them exchange needs more effectively.On the other hand, there are various theories in terms of Alexithymia and problems relating that. One of the theories addressing these problems, inspired by psychodynamic concepts, seeks for the root of these problems in childhood and within Object Relations.Bowlby’s attachment theory (1988), is one the most important theories which consider the basis of such problems in the concepts of undeveloped emotional capacities and difficulty in emotional investment during childhood (5).

Theorists like Bowlby (1988) and other theorists of psychoanalysis refer to early attachment experiences on internal representations of oneself and others. In fact they try to examine the impact of Internal working model of attachment on future relationships and emotional regulation strategies in adolescence and adulthood.Attachment theory assumes that people use internal working models in order to regulate emotions. These models aremotivational-affective-cognitiveschemas which are made based on interpersonal experiences and later attachment events strengthen and moderate these primary schemas (5).

Attachment experiences in early life can be internalized to provide a prototype for later relationships as the primary attachment relationships do.These primary internalized attachment patterns remain stable throughout life and affect child’s future life (5). Primary caregiver sensitivity and responsiveness to the child’s emotional states, is a mainly determinant in learning distressing affect and communicating with others people (5, 11).

Children with secure attachment received coordinated and optimum responds from tenders and learned that expressing regulated emotions leads to positive outcomes. These children are more capable of performing symbolic games and expressing positive affections and indicated more adaptability and competency in later relationships than children with insecure attachment(5).

On the other side, deficient care may lead to insecure attachment pattern and prevent development of effective regulating skills of emotion (5). Therefore it seems logical that addressing features effective in Alexithymia (problems experienced in terms of attachment during childhood and lasting impact to adulthood) can lead to its improvement through regulating and modifying emotions in an interpersonal space which is one of the interpersonal Psychotherapy goals.

In fact, interpersonal psychotherapy has been able to suggest an effective method to reduce these people’s problems by using interpersonal principles, addressing individual feelings and particularly offering appropriate solutions for identifying feelings, expressing and applying them in interpersonal situations.In this method of therapy, awareness of feelings, confronting them, and the courage to express them are conducted in a communicative space which is an effective element in treatment efficiency. As mentioned above, providing required conditions for treatment are in consistent with known problems of Alexithymia people.

Differences between control and experimental groups in difficulty identifying feelings and difficulty describing feelings have remained significant after three months of therapy. In other words, changes occurred due to the therapy have been remained even after three months of therapy.But this difference is not significant in terms of externally mode of thinking.

As noted earlier, the study conducted by Faramarzi and colleagues (2013) short-term dynamic psychotherapy emphasizing the core conflict relationship was not able to modify the style of externally mode of thinking(30). Bgbay and colleagues (2006) showed that alexithymia  generally include two deficits: Reduced affective awareness which is visible in the levels of difficulty identifying feelings and difficulty describing feelings and operative thinking (a cognitive style is determined by objective thinking and visual processes)(6).

The deficiency is determined through affections symbolization and intellectualization, (reducing symbolic thinking) (34) or processing and regulation of emotions (5). A number of researchers consider Alexithymia on two components: emotional (difficulty identifying and describing feelings) and cognitive (externally mode of thinking) (5, 35-37).

Melin et al. (2010) consider externally mode of thinking as a hereditary trait (while considering the other features as state-dependent phenomena).Therefore, changes in the two Alexithymia emotional components are more likely to remain stable over time. Considering the fact that externally mode of thinking is a cognitive component, it is more unlikely to achieve sustainable results through therapeutic methods that focus on emotions regulation and variation (comparing with therapies focusing on individual cognitions and their variation).

Limitations ofthis researchincludedimplementation of the plan only in female groups, student population and a non-clinicalpopulation. Hence it is recommended to conduct the research on other groups such as non-student population, male population and groups with psychological diagnosis as well. Other limitation was implementing in a non-clinical population.

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