“Identifying and Describing Emotions”

Abstract

Certain individuals who sexually offend may have difficulty differentiating, identifying, and articulating emotions. These clients may prove challenging for therapists when engaging with them in treatment. Such clients may suffer from alexithymia. There has been a dearth of research regarding specific psychotherapeutic interventions for alexithymia in both the clinical and forensic fields. The present study provides results from a pilot study on the efficacy of a brief, four-session, alexithymia-specific intervention with adults who have sexually offended. The intervention also aimed to increase emotional awareness and psychological mindedness. The intervention was comprised of both mindfulness and mentalization treatment components. Thirty-two men (M_age = 41.8 years, SD = 11.9) convicted of sexual offences completed the intervention group. When compared with a matched control condition (n = 27; M_age = 39, SD = 10.8), the intervention was effective in decreasing alexithymia characteristics and increasing psychological mindedness. Results suggest that the intervention was an effective means of increasing emotional awareness in this population. These provisional results must be tempered by the limitations of the study. However, the positive findings warrant future investigation. Clinical implications and ideas for future work are also discussed.

Keywords

treatment effectiveness sexual interests sexual deviance

Alexithymia is a multifaceted construct that broadly refers to emotional awareness defects and regulatory problems (Taylor & Bagby, 2004; Taylor, Bagby, & Parker, 1997). It is a psychological phenomenon characterized by difficulty identifying feelings, difficulty describing feelings, an externally oriented thinking pattern, and a diminution of fantasy (Taylor et al., 1997). The differentiation of the alexithymia construct as having both a cognitive and affective dimension has been validated by a number of studies (Bermond et al., 2007; Larsen, Brand, Bermond, & Hijman, 2003). Early traumatic experiences are viewed as one of the primary etiological factors in the development of alexithymia (Krystal & Krystal, 1988). As alexithymia theory has advanced, the construct has been incorporated into the bourgeoning field of affect pathology and emotional dysregulation (Taylor & Bagby, 2013). It is for this reason that alexithymia may be a useful construct within the forensic field. A proportion of forensic patients have difficulties understanding what is occurring physically and emotionally for them. Intense but vague sensations of discomfort and unease may give rise to dysfunctional and destructive behavior (Vanheule, Verhaeghe, & Desmet, 2011). Such difficulties may be better understood under the rubric of alexithymia (Keltikangas-Jarvinen, 1982).

Most sexual offender therapeutic programs place an emphasis on the premise that teaching individuals who sexually offend adaptive ways to cope with high-risk emotional situations reduces the risk of reoffending (Marshall, Marshall, Serran, & Fernandez, 2006). Day (2009) argued that such a population is often characterized by multiple and chronic emotional difficulties. A related difficulty concerns appropriate strategies that can help individuals who offend engage in an emotionally meaningful manner when partaking in psychological interventions. The relationship between affect and treatment engagement is thought to be dependent on a number of related factors. These include both the client’s ability to access emotional states and the expression of emotions (Howells & Day, 2006). Difficulties in accessing emotions may impede treatment and may need to be systematically attended to.

Alexithymia and Individuals Who Sexually Offend

Researchers have revealed a role for alexithymia in different kinds of sexual dysfunctions (Madioni & Mammana, 2001; Scimeca et al., 2013). To date, there have been few studies that have focused on alexithymia in individuals who sexually offend. Alexithymia is often associated with a failure to use adaptive affective regulation strategies, difficulties appropriately expressing and suppressing emotions, and cognitive assimilation (Lumley, Lynn, & Burger, 2007). These are all deficits that have been reported as important in the treatment of individuals with sexual offending behaviors (Gillespie, Mitchell, Fisher, & Beech, 2012; Marshall, Cripps, Anderson, & Cortoni, 1999).

Zimmermann (2006) reported that alexithymia is one of the strongest discriminatory factors for juvenile delinquency. Manninen et al. (2011) reported that alexithymia characteristics correlated with a number of psychiatric problems, including internalizing difficulties and self-reported aggression. Moriarty, Stough, Tidmarsh, Eger, and Dennsion (2001) found that adolescents who had sexually offended had deficits in emotional understanding, experienced more interpersonal problems, and had higher aggression than an age-matched sample of adolescent who did not sexually offend. No differences were found in alexithymia scores between the adolescents who exhibited sexual offending behavior and a control sample of nonoffending adolescents. The authors highlighted the relevance of these deficits for any future intervention. However, the small sample size and use of adolescents who sexually offended limits the generalizability of these results to an adult population.

Enhancing empathy in forensic populations has also been linked to other general affect increases, specifically offenders’ own recognition of distress (Marshall, O’Sullivan, & Fernandez, 1996). Hudson et al. (1993) reported general difficulties in the emotion recognition skills of individuals who sexually offend when compared with control groups. Thus, emotional awareness and, specifically, alexithymia may be clinically relevant factors that are not adequately addressed with individuals who have sexually offended.

Treatment of Alexithymia

A crucial tenet of all psychotherapies is the assumption that individuals have some awareness of and access to emotions (Ogrodniczuk, Piper, & Joyce, 2011). Individuals with alexithymia present significant challenges to therapists with respect to therapeutic engagement (Ogrodniczuk, Piper, & Joyce, 2005; Taylor, 1995). Alexithymia is a factor that inhibits or compromises the formation and maintenance of the therapeutic relationship (Tacon, 2001). Notwithstanding the fact that the treatment of alexithymia is highly problematic in isolation, it is apparent that alexithymia also has the capacity to affect adversely on other treatment outcomes. All of the above factors have serious implications for rehabilitative efforts in effectively engaging individuals who sexually offend.

A few studies have provided preliminary evidence of alexithymia’s amenability to therapy within clinical populations (Beresnevaite, 2000; Grabe et al., 2008; Ogrodniczuk, Joyce, & Piper, 2013; Rufer et al., 2010). It has been surmised that supportive rather than interpretive treatment approaches that include psychoeducational components are the most effective treatment types and that alexithymia is partly amenable to psychological treatments (Kristjana, Ogrodniczuk, & Hadjipavlou, 2014; Taylor & Bagby, 2013). Despite these recent advancements, alexithymia intervention studies are still rare. To the authors’ knowledge, no alexithymia intervention studies have featured adults who have sexually offended.

Mentalization

Mentalization is one theoretical construct that may aid in the treatment of alexithymia. Mentalization is a term used to describe how an individual makes sense of their own thoughts and behavior (Allen, Fonagy, & Bateman, 2008). The concept has proved useful in providing a trans-diagnostic perspective on a range of psychological disorders, such as alexithymia (Lemche, Klann-Delius, Koch, & Joraschky, 2004; Moriguchi et al., 2006; Vanheule et al., 2011).

Fonagy, Bateman, and Luyten (2012) have recently described mentalization as a multifaceted component and acknowledged its close relationship to a number of its conceptual cousins, including alexithymia. Indeed, given the ubiquitous and multicomponent nature of mentalization, some authors have posited that alexithymia measures should be included in mentalization assessments, as they can tap into the deficits of affective processing (Luyten, Fonagy, Lowyck, & Vermote, 2012). This suggests that mentalization processes encompass a broad gamut and that alexithymia may be one specific deficit that falls within a larger mentalization rubric. Alexithymia corresponds most closely with a specific component of mentalization named mentalized affectivity, which concerns the identifying and processing of emotions (Taylor & Bagby, 2013). However, some authors suggest that alexithymia does not encompass the cognitive components of mentalization, namely, thinking about thinking or adopting a mentalizing stance (Taylor & Bagby, 2013). Despite this overlap between the two constructs, there has been a lack of research regarding individuals with alexithymia having specific mentalizing deficits. Subic-Wrana, Beutel, Knebel, and Lane (2010) found that patients with somatoform disorders showed deficits in both emotional awareness and other mentalization functioning. The authors suggested that such deficits may underlie the phenomenon of somatization and alexithymia. Moriguchi et al. (2006) showed that alexithymia was associated with impairments in mentalizing and perspective taking. This suggests that individuals with alexithymia characteristics may have specific mentalization deficits.

Mindfulness

The broad nature of mentalization is one of the factors that has aided in its increased appeal. However, the conceptual formation of mentalization spans a number of territories (see Choi-Kain & Gunderson, 2008, for a review of mentalization and its relationship with other constructs). Mindfulness has been cited as related to mentalization. Mindfulness has been defined as bringing awareness to the present moment (Hahn, 1976).

Attention is pivotal to mindfulness, much in the same way as it is in effective mentalization. Indeed, mentalizing has been labeled as mindfulness of mind (Allen, 2006). A receptive attention to psychological states has been cited as key to both processes (Brown & Ryan, 2003). Both also emphasize the integration of cognitive and affective aspects of mental states in encouraging simultaneous recognition and participation in internal experiences (Choi-Kain & Gunderson, 2008). Little work has been completed reconciling the two concepts despite the broad overlap between the two and the growing awareness of the possibility of some sort of theoretical integration (Allen, 2009). The ability of mindfulness to aptly capture the attentive nature of mentalizing suggests that it may be a useful mechanism in increasing the proficiency in the first step of mentalization, namely, awareness of emotional and mental states. Difficulty attuning awareness to emotional states and understanding are defining characteristics of alexithymia. Mindfulness techniques are not prominent in the forensic domain as yet, but preliminary research suggests that mindfulness interventions can reduce aggressive outbursts (Fix & Fix, 2013) and can aid in controlling deviant sexual arousal (Singh et al., 2011).

Psychological Mindedness (PM)

PM has been defined as one’s interest in the relationship among thoughts, feelings, and actions, with the goal of learning the meanings and cause of behavior (Appelbaum, 1973). There is significant overlap between mentalization and PM. Allen et al. (2008) suggested that the original conception of PM could be construed as an explicit mentalizing capacity that is needed to engage effectively in psychotherapy, as it requires a focus on one’s own mental and emotional states. This expanded operational definition means that the experiential-affective mode could include the ability to infer the mental states of others. Although interest in other’s mental states is a factor within PM, the actual ability to plausibly discern those mental states in not unlike that in mentalization (Choi-Kain & Gunderson, 2008).

Theory of Mind (ToM) Deficits in Individuals Who Sexually Offend

It should be noted that, within the forensic arena, ToM is the more prominent term used to describe what is essentially a similar process to mentalization. A number of authors (Keenan & Ward, 2000; Ward, Keenan, & Hudson, 2000) have hypothesized that ToM deficits may be an important factor in the genesis of sexual offending. This has been highlighted as a potential framework in which certain interpersonal, affective, and cognitive problems underlying sexual offending can be explained. For example, it has been argued that empathy deficits, cognitive distortions, and difficulty initiating and maintaining peer relationships may arise from ToM deficits (Ward et al., 2000). Keenan and Ward (2000) suggest that deviation can occur in the normal acquisition of ToM resulting in an inability to accurately and flexibly discern the motivations, beliefs, and behaviors of others.

Researchers have focused on the specific features of sexual offending and have found deficits in areas encompassed under the ToM definition. Difficulties in the areas of emotional awareness and empathy, (Covell & Scalora, 2002), perspective taking (Hanson & Scott, 1995; Kirsch & Becker, 2007), and the inference of the mental states of adults have been reported in the literature (Castellino, Bosco, Marshall, Marshall, & Veglia, 2011; Elsegood & Duff, 2010). These studies support findings that individuals who sexually offend suffer from deficits in their ability to infer mental states in themselves and others (Ward et al., 2000). The results also indicate possible difficulties concerning the awareness of one’s own mental states, ability to correlate mental states to external situations, and their ability to link actions and behaviors according to mental states.

To the best of the authors’ knowledge, no empirical studies have so far been focused on the prevalence of alexithymia in those who have sexually offended. The amenability of alexithymia to psychological treatment in those who have sexually offended is another area in need of research.

The Current Study

The aim of the present study was to investigate the prevalence of alexithymia in individuals who sexually offend and to determine whether significant difference existed between an intervention and a matched control group on measures of alexithymia following a brief intervention. Another purpose of the study was to determine whether there was a significant difference between intervention and control groups on measures of psychological mindedness following completion of the group. Finally, we explored the extent to which the intervention affected the emotional regulation strategies of adults who have sexually offended, especially in terms of emotional reappraisal and emotional suppression.

Method

Participants

Participants were recruited from two separate adult prisons in the Republic of Ireland. Adult males convicted of either a contact or noncontact sexual offence were eligible for inclusion in the study. A total of 121 men were called to meet the primary researcher. Twenty-two individuals declined to participate in the study. A total of 99 men consented to be screened to assess their suitability for the present study by the first author or a master’s-level assistant. A combined total of 37 individuals from both prisons scored below the alexithymia cut-off range of ≤ 51 on the Toronto Alexithymia Scale–20 (TAS-20; Bagby, Parker, & Taylor, 1994, see instruments subsection for full description of the measure). A total of 32 individuals (M_age = 41.8 years, SD = 11.9, age range = 24-71, median = 39) completed the intervention, with 10 men convicted of a sexual offence against an adult, 19 against a child, and 3 convicted for murder with a sexual element. The control sample was comprised of 30 men. Three individuals in the control group did not return to complete post measures. Thus, the control sample was comprised of 27 individuals (M_age = 39, SD = 10.8, age range = 20-69, median = 35), with 12 men convicted for an adult sexual offence, 12 convicted for a sexual offence against a child, and 3 convicted of murder with a sexual element involved. There were no significant differences in demographics between the two groups (see Table 1).

Table 1.

Participant Demographic Characteristics.

	Percent total N	N	Percent total N	N
	Intervention group		Control group		t
Age
≤30	18.7	6	18.5	5
31-40	40.6	13	37	10
41-50	25	8	37	10
51-60	3.1	1	3.1	1
61-70	9.4	3	3.1	1
70+	3.1	1	0	0
Conviction					.51
Adult offence	31.2	10	44.4	12
Child offence	59.3	19	44.4	12
Murder	11.1	3	11.1	3
Index sentence length					.58
≤5	15.6	5	29.6	8
6-10	46.8	15	33.3	9
11-15	15.6	5	22.2	6
16-20	3.1	1	0	0
Life	18.7	6	14.8	4
Time spent in prison					.59
≤3	50	16	59.2	16
4-8	37.5	12	29.6	8
9-12	12.5	3	7.4	2
13-18	0	0	3.7	1
Highest education level
Primary	18.7	6	18.5	5
Secondary	68.7	22	55.5	15
Post-leaving cert	9.3	3	11.1	3
College degree	3.1	1	14.8	4

Note. All ps > .05.

Informed Consent

The recruitment protocol received ethical approval from the first author’s university and the Irish Prison Service ethics committee. All participants provided written informed consent to engage in and participate in the groups before the assessment was completed. Informed consent was obtained with the first author present. A broad overview of what the research involved and what it would entail if the individual agreed to participate was outlined. Participants were informed of the rationale behind the group, the general benefits associated with increased emotional awareness, and what participation would entail if the individual agreed to participate. To reduce perceived coercion, it was stressed to participants that in no way were they obligated to participate and that declining to participate would not affect future contact or further engagement with the psychology service. Potential participants were also given names of other psychologists in the service if they wished to discuss concerns.

Treatment

The alexithymia intervention assessed in this study was a four-session, psychoeducational group that was derived and influenced from work by McMurran and Jinks (2012). Each session lasted 90 min. Two sessions were scheduled weekly, with each group completed over a 2-week period. Four separate groups were scheduled over a 5-month duration, with 6 to 10 participants in each group. No offence-focused work was carried out in the group. Individuals did not explicitly disclose details about their own offending but were encouraged to reflect on the possible emotional antecedents that occurred before difficult times in their lives.

The intervention was comprised of a number of components: Psychoeducational, a component that taught individuals how to identify emotions; Recognizing Emotions, an experiential component that aids individuals to identify another person’s emotions; and Self-awareness, which aimed to use mindfulness techniques in aiding individuals to attend to bodily sensations and emotions. Unlike the McMurran and Jinks group, the present study featured substantial psychoeducational components of Mentalization-Based Treatments (Allen et al., 2008; Haslam-Hopwood, Allen, Stein, & Bleiberg, 2006). In addition, the mindfulness component of this group was more comprehensive than the one described in the McMurran and Jinks group. Specifically, increased awareness is seen as a pivotal first step in increased mentalized affectivity (Allen et al., 2008). Thus, mindfulness was used as a mechanism to increase emotional awareness.

The first author designed the treatment manual. The intervention drew heavily from mentalization and mindfulness theories as well as psychoeducational input around emotions and emotional awareness. Due to the lack of a coherent mentalization treatment guide regarding alexithymia, psychoeducational and skills components were adapted from Haslam-Hopwood et al. (2006). One of the aims of the treatment was to develop the patient’s ability to mentalize by increasing their ability to mentalize affect. The group modules were primarily didactic in nature, combining psychoeducation and in-group exercises. Mentalization exercises such as “Just the Facts” and “Welcome to my Mind” were used in Sessions 1 and 4 to explore emotional awareness and mentalized affectivity (Haslam-Hopwood et al., 2006). The use of these nondisorder-specific interventions has been cited as important in the development of emotional awareness and regulation skills (Berking et al., 2008). An emphasis was placed on the importance of skill generalization and daily mindfulness practice. Overall, the group emphasized the importance of recognizing and experiencing feelings, as well as making connections between situations, interpretations, and emotions. All participants in the intervention category completed the group.

Session 1 provided a broad overview of emotions, individuals’ experiences of emotions, and thoughts around the use of emotions. A list of emotions was presented to the group, and discussion focused on the similarities and differences between the various emotions and how they are perceived and what cognitive and physiological response each have. This session also focused on the importance of thinking about thinking, the importance of self-awareness, and the benefits of this in relationships. A common theme discussed in the group was the need to not only think clearly but also feel clearly (Allen et al., 2008). As mentalization is an inherent capacity of mind, it was not taught, per se, to the group. Instead, an awareness of mentalizing, the benefits associated with it, and how to bring awareness to the process were the key learning outcomes of the session. Mentalization exercises such as “Just the Facts” and “Finding the Metaphor” were used during these sessions. “Finding the Metaphor” aimed to help clients convey mental states through metaphors and engage group members in speculating about peers’ feelings (see Haslam-Hopwood et al., 2006, for a description of the mentalizing tasks used in the psychoeducational intervention).

Session 2 focused on increasing emotional awareness and clarity. During the session, participants were assisted in improving their ability to identify, label, and differentiate emotional states. An emphasis was placed on the functionality of primary emotional responses. Participants were encouraged to identify both the information being provided by their primary emotions, as well as adaptive ways of acting on this information. Mindfulness techniques adapted from the Mindfulness Based Stress Reduction course (Kabat-Zinn, 1990), such as mindful sitting and mindful breathing, were also introduced at this stage and continued throughout the remainder of the intervention sessions. Participants were encouraged to practice mindfulness outside of sessions. Commercial mindfulness CDs were provided to participants.

Session 3 incorporated the previously learned mindfulness practices. The session also emphasized the ability of all individuals to mentalize as well as the need to attend to mental and emotional states. In addition to receiving psychoeducation on the long-term consequences of these approaches, participants were encouraged to actively monitor and assess the different experiential consequences of emotional awareness and willingness (i.e., an active process of being open to emotional experiences as they arise).

Session 4 contained an emphasis on grounded mentalization and the difference between mentalization and rumination. Participants were also made aware of the two fundamental mentalizing failures: not engaging in mentalization and distorted mentalization. The importance of using these skills in day-to-day life to become more emotionally aware was emphasized. The need for increased verbal communication skills and the importance of accurately communicating emotional states within the self and to other trusted persons was also explored. A brief synopsis of the group was completed. An overview of the topics covered over the four sessions and participants’ feelings about the group ending was also discussed. Worksheets, handouts, and slides for each session were developed.

Instruments

Participants were required to complete a battery of questionnaires containing a number of outcome measures and a demographic questionnaire. The measures were selected for their psychometric properties, and their brevity.

Toronto Alexithymia Scale–20 (TAS-20)

The TAS-20 (Bagby et al., 1994) was the primary measure of alexithymia. The TAS-20 is the most widely researched self-report measure of the alexithymia construct. The TAS-20 provides scores for three empirically derived factors: (a) Difficulty in Identifying Feelings, (b) Difficulty in Describing Feelings, and (c) Externally Oriented Thinking. Items are rated on a 5-point Likert-type scale. The TAS-20 yields a total alexithymia score and 3 subscales scores. Higher scores indicate higher levels of alexithymia. Individuals scoring ≥61 are considered high in alexithymia. Those with scores falling between 60 and 52 are considered moderate in alexithymia, and those scoring ≤51 are considered not alexithymic. Research confirms the original three-factor structure (Bagby et al., 1994; Parker, Taylor, & Bagby, 2003; Swift, Stephenson, & Royce, 2006), with satisfactory internal consistency reported for Factors 1 and 2 (Mattila et al., 2010). Cronbach’s alpha for the Difficulty Identifying Feelings subscale, Difficulty Describing Feelings subscale, and Externally Oriented Thinking subscale was adequate in the present study at .75, .81, and .68, respectively.

Twelve-Item Modified Version of the Beth Israel Hospital Psychosomatic Questionnaire (M-BIQ)

The Modified Beth Israel Hospital Psychosomatic Questionnaire (M-BIQ; Taylor et al., 1997) is an observer-rated questionnaire of alexithymia and is comprised of 12 items rated on a 7-point Likert-type scale. The observer questionnaire consists of six items pertaining to the ability to identify and verbally communicate feelings (Affect Awareness subscale), and six items pertaining to imaginal activity and externally oriented thinking (Operatory Thinking subscale). Evidence suggests adequate internal consistency and test–retest reliability (Arimura et al., 2002; Fukunishi, Nakagawa, Nakamura, Kikuchi, & Takubo, 1997). Inter-rater reliability (Kappa) was .73 for Affect Awareness and .77 for Operatory Thinking.

Balanced Index of Psychological Mindedness (BIPM)

Psychological mindedness was assessed using the Balanced Index of Psychological Mindedness (BIPM; Nyklicek & Denollet, 2009). The BIPM is a self-report measure consisting of 14 items scored on a 5-point Likert-type scale. The scale is comprised of two subscales: the Interest subscale that taps into one’s internal psychological phenomena and the Insight subscale. Internal consistency of the subscales has been reported as adequate (Cronbach’s α = .85 for the Interest scale and .76 for the Insight scale). Adequate reliability was found for the Interest and Insight subscales in the present study (α = .71 and .70, respectively). Convergent and discriminant validity has been reported with substantial correlations with related constructs such as emotional intelligence and negative correlations with alexithymia (Nyklicek & Denollet, 2009).

Emotion Regulation Questionnaire (ERQ)

The Emotion Regulation Questionnaire (ERQ; Gross & John, 2003) is a 10-item scale designed to measure the tendency of individuals to regulate emotions by using either (a) Cognitive Reappraisal or (b) Expressive Suppression strategies. The 4-item Suppression scale was designed to be brief but has shown good reliability, consistent evidence of a unifactorial structure, and convergent and discriminant validity (John & Gross, 2004; Srivastava, Tamir, McGonigal, John, & Gross, 2009). Cronbach’s alpha for the Suppression scale was found to be adequate at .72, but reliability was low for the Reappraisal subscale at .59.

Sample Recruitment

Potential participants for the study were identified by the first author from a prison database. The first author worked in the Irish Prison Service as a trainee clinical psychologist. Participants who consented completed the assessment battery. For 11 individuals, two raters were present for the observer-rated measure of alexithymia (M-BIQ) to ascertain inter-rater reliability (the first author and a master’s-level psychology student). These observations occurred twice, both before and after the intervention. Allocation to the groups was not randomized. The first 10 individuals who were suitable were placed in the first group, and this allocation continued for each successive intervention group. Exclusion criteria were as follows: inadequate language skills, presenting as acutely suicidal, achieving a score of ≤ 51 points on the Toronto Alexithymia Scale, and concurrent participation in the intensive treatment phase of a sexual offender program in the Irish Prison Service. This ensured that observed treatment effects were not attributable to the effects of one of the established treatment programs within the Irish Prison Service. The National Adult Learning Association guidelines for individuals with literacy difficulties were referred to, and researchers were present with all individuals when the questionnaires were being completed.

Thirty-two individuals were recruited into the intervention group. After the interventions were completed, 27 from the other prison site, who sexually offended, were placed in the control condition. Control groups were identified after the four intervention groups were completed.

Statistical Analysis

A MANOVA was first performed with the dependent variables to help protect against inflating Type 1 error. For between-group comparisons, the authors used χ² for categorical variables and t tests for continuous variables. The scores for the TAS-20 were submitted to analysis of variance (ANOVAs) with repeated measures (pre and post). Total M-BIQ, BIPM, and Emotional Regulation Questionnaire (ERQ) scores were also submitted to ANOVAs. When the sphericity assumption was violated, p values were Greenhouse–Geisser corrected. Effect sizes were estimated using partial effect sizes η². According to Cohen (1988), η² values of 0.0009, 0.058, and 0.1379 correspond to small, medium, and large effect sizes, respectively.

Results

At pretreatment, participants in the intervention group had a TAS-20 score of 65.9 (±8.9), and the control group had a score of 63.3 (±7.7), with both groups meeting TAS-20 criteria for alexithymia characteristics. Table 2 provides the means and standard deviations for both groups at baseline for each of the TAS-20 subscale scores. No significant baseline differences were found between the intervention group and control group on any of the three TAS-20 subscales. No significant baseline differences were found between the two groups on the total scores of the M-BIQ, BIPM, and ERQ scales.

Table 2.

Mean Scores for the Intervention (n = 32) and Control Group (n = 27) Participants at Baseline on Subscales of Psychological Measures.

Measure	Intervention (SD)	Control (SD)	t
TAS-20 total	65.9 (8.7)	63.3 (7.5)	.218
TAS-20: Difficulty describing feelings	18.6 (3)	17.8 (3.1)	.324
TAS-20: Difficulty identifying feelings	23.9 (5.3)	22.6 (5.5)	.351
TAS-20: Externally orientated thinking	23.3 (3)	22.8 (4.1)	.577
M-BIQ total	56 (7.4)	53.7 (9.2)	.295
BIPM total	29 (8.7)	26.4 (9.5)	.280
ERQ total	32 (10.1)	27 (8.8)	.820

Note. TAS = Toronto Alexithymia Scale; M-BIQ = Modified-Beth Israel Questionnaire; BIPM = Balanced Index of Psychological Mindedness; ERQ = Emotional Regulation Questionnaire.

All ps > .5.

Baseline Associations Between Outcome Measures

Alexithymia (overall TAS-20 total score) was not correlated with any demographic characteristics. The TAS-20 and the M-BIQ total scores were significantly correlated (r = .45, p = .001). Significant negative associations were also found between alexithymia (as measured by TAS-20 total score) and psychological mindedness, as measured by the BIPM (r = −.52, p = .001). A significant negative association was also found between the observer-rated measure of alexithymia (M-BIQ) and psychological mindedness (r = −.37, p = .004). No significant association was found between the ERQ and either of the alexithymia measures, or with the BIPM.

A meaningful pattern of correlations was observed among most of the dependent variables, suggesting the appropriateness of a MANOVA. Dependent variables were checked for normality, linearity, univariate and multivariate outliers, homogeneity of variance–covariance matrices, and multicollinearity. Psychological Mindedness violated the assumption of equality of variance, and therefore, a more conservative alpha level of .02 was used to determine significance for this variable. The MANOVA revealed statistically significant difference between the groups on the combined dependent variables: F(4, 53) = 6.01, p = .001; Wilks’s Lambda = .68; partial η² = .314.

When dependent variables were considered separately, the alexithymia self-report measure, F(1, 56) = 21.4, p = .001, partial η² = .27; alexithymia observer measure, F(1, 56) = 15.8, p = .000, partial η² = .22; and psychological mindedness, F(1, 56) = 12.8, p = .002, partial η² = .19, reached statistical significance using a Bonferroni adjusted alpha level of .02.

A series of one-way ANOVA’s was conducted on each of the dependent variables as follow-up tests to the MANOVA (see Table 3). ANOVA’s were also conducted on the subscales of the TAS-20. Bar the ERQ total score, all of the ANOVA’s were statistically significant, with large effect sizes (partial η²) noted. Mean scores on all the TAS-20 subscales significantly decreased for individuals in the intervention group when compared with those in the control condition. Significant decreases were also noted in the intervention group on the observer-rated M-BIQ total score. The BIPM intervention group total increased significantly compared with those in the comparison group. Analyses revealed that the ERQ total score did not differ statistically between individuals in the intervention and those in the control.

Table 3.

Means, Standard Deviations and Mixed Between Within Measures Analyses of Variance Assessing Group × Time Pre and Post Scores of the Two Groups.

	Intervention		Control		ANOVA F(1, 57)
	M (SD)		M (SD)		ANOVA F(1, 57)
	Pre	Post	Pre	Post	Group × Time	p	Effect sizes η²
TAS-Total	65.9 (8.7)	54.8 (10.4)	63.7 (7.5)	66.6 (9.6)	61.5	.0005	.242
TAS-DIF	23.9 (5.3)	18.6 (5.7)	22.6 (5)	22.8 (6.9)	17.6	.001	.231
TAS-DDF	18.6 (3)	15.9 (3.7)	17.8 (3.1)	20.1 (3.2)	36.4	.000	.390
TAS-EOT	23.3 (3)	20.2 (3.9)	22.8 (4)	23.7 (4)	17.8	.001	.238
M-BIQ-Total	56 (7.4)	46 (10)	53.7 (9.2)	54.8 (5.6)	32.2	.0005	.37
BIPM-Total	29 (8.7)	35.5 (8)	26.4 (9.5)	26.7 (9.9)	10.3	.002	.15
ERQ-Total	45.7 (9.4)	45.5 (9.5)	49 (9.5)	51 (8.4)	.917	.343	.00003

Note. TAS = Toronto Alexithymia Scale; TAS-DIF = Difficulty Identifying Feelings; TAS-DDF = Difficulty Describing Feelings; TAS-EOT = Externally Oriented Thinking; M-BIQ = Modified Beth Israel Questionnaire; BIPM = Balanced Index of Psychological Mindedness; ERQ = Emotional Regulation Questionnaire. F values are from 2 × 2 Group × Time ANOVAs.

Discussion

The aim of the study was to determine the effectiveness of an alexithymia-specific intervention with individuals convicted of a sexual offence. The intervention was comprised of both mindfulness and mentalization-based treatment components. Participants experienced positive effects as a result of the intervention and decreased alexithymia characteristics. Specifically, it was found that the alexithymia subscale scores decreased significantly in the intervention group when compared with the control group, with large effect sizes found for all of the three subscales of the TAS-20.

Decreases in alexithymia were evident across Factor 1: Difficulty Identifying Feelings, Factor 2: Difficulty Describing Feelings, and Factor 3: Externally Oriented Thinking scales of the TAS-20. Researchers have found that most of the reductions in alexithymia intervention studies are primarily due to decreases in either Factor 1 or Factor 2 of the TAS-20 (Ogrodniczuk et al., 2011; Rufer et al., 2010). The reduction in the present study of the Externally Oriented Thinking subscale may be due to the treatment group adopting a mentalizing stance (Allen et al., 2008). A mentalizing stance involves the group advocating an open, inquisitive, and curious stance regarding what is going on in the individual’s own mind and the mind of others. It is noteworthy that this explicit mentalizing stance, which places an emphasis on internal and external mental states, is not a primary treatment component of other alexithymia interventions (Grabe et al., 2008; McMurran & Jinks, 2012). It is possible that mentalization skills increase the individual’s ability to think about the varieties of thinking processes at play in interpersonal interactions. In addition, these skills may also promote a clear demarcation between inner and external reality (Target & Fonagy, 1996). It is also possible that the mindfulness approach of an open and inquisitive stance may have further helped in reducing Factor 3 (Bishop et al., 2004). Further research is needed to more precisely delineate which treatment component had the greater impact on decreasing the Externally Oriented Thinking subscale of the TAS-20 and the Operatory Thinking subscale of the M-BIQ. It is hoped that the current findings support the use of mentalization techniques with clients who present with alexithymia. However, it must be noted that mentalization is not synonymous with alexithymia, and differing mentalization deficits may be seen in individuals with alexithymia characteristics (Inslegers, 2011). Future work is needed to adequately adapt and implement mentalization as a possible treatment option for alexithymia.

Individuals in the intervention group showed an increase in psychological mindedness when compared with the control group. This change can tentatively be attributed to the intervention and suggests that psychological mindedness is not a fixed personality characteristic and is amenable to change through psychotherapy. However, a possible confounding factor is the possibility that those in the intervention group were interested in increasing their psychological knowledge by agreeing to attend the group, thus implying a readiness for introspection (Nyklicek, Majoor, & Schalken, 2010). Psychologically minded thinking about oneself involves awareness of one’s own thoughts and feelings. It is possible that the mindfulness exercises increased individual’s psychological awareness to internal states. Horowitz (2002) and Beitel, Ferrer, and Cecero (2005) found that mindfulness may be a necessary precondition for psychologically minded thinking. In addition, Beitel et al. reported that psychological awareness is a crucial factor in the development of psychological mindedness. Findings from the present study appear to support these interpretations.

There was no significant change in the ERQ total score within the study. This suggests that changes in alexithymia and PM were not associated with any change in emotional regulation strategies. On first inspection, this seems counterintuitive. It has been shown that more adaptive emotional regulation strategies are dependent on the degree of emotional awareness, with lower awareness leading to less adaptive strategies, such as suppression (Izard et al., 2011). Findings from the present study suggest that increased emotional awareness does not necessarily lead to more adaptive emotional regulation strategies.

The results of this pilot study are promising. However, they are also preliminary and need to be evaluated in light of the study’s limitations. One of the primary limitations is that each intervention group was led by the principal investigator. Treatment fidelity measures would be a useful addition in any further replication studies. Other limitations include the low Kappas of some of the subscales of the instruments used and the small sample size. Due to the relatively small number of men currently incarcerated for a sexual offence in the Republic of Ireland, small sample sizes are an unfortunate reality when working with such a specialized sample in the forensic field. The lack of a randomized control design can also be seen as a limitation in the present study.

The lack of mindfulness and mentalization assessment measures is another limitation in the present study. The inclusion of such measures in future work would help inform the exact mechanisms of change and what specific role each of these treatment components has on increasing emotional awareness. Objective behavioral measures may be a useful addition in further studies. This would help further elucidate whether alexithymia characteristics really did decrease or whether the intervention had simply given the participants a vocabulary for talking about their emotions. Although this group is based on the theory that changes in alexithymic characteristics are the result of increased mentalization and mindfulness skills, it is possible that the variability of mentalization skills can affect differing subfactors of alexithymia (Inslegers, 2011).

Clinical Implications

Findings from this study have a number of potentially relevant clinical implications. First, the findings suggest that alexithymia and emotional awareness difficulties are prevalent within this population. Out of the 99 individuals screened, 62 (62.6%) individuals met the criteria for at least moderate alexithymic characteristics. Considering that there are just over 300 individuals imprisoned for convictions of a sexual nature in the Irish Republic at any one time, it can be argued that this sample is broadly representative of this small, specific population. The prevalence of emotional awareness difficulties in this population is a factor that may have to be considered when working therapeutically with individuals who have sexually offended. Second, these findings suggest specific implications for intensive offender interventions. A prerequisite for such interventions is the ability of individuals to experience and accurately identify affect states among other factors that may lead to sexual offending (Day, 2009). Individuals who are emotionally inhibited may be limited in their ability to emotionally engage in therapeutic activities (Day, Gerace, Wilson, & Howells, 2008). Moreover, such an intervention, if integrated into a broader comprehensive treatment package that adheres to Risk Need Responsivity principles (Andrews & Bonta, 1998), may be a useful means of acclimatizing clients to psychological interventions, increasing responsivity, and providing interventions that help aid emotional awareness and labeling. This research also provides tentative evidence regarding widening the scope of mentalization and mindfulness-based interventions within forensic populations (Adshead, Moore, Humphrey, Wilson, & Tapp, 2013; Fonagy, Bateman, & Bateman, 2011; Singh et al., 2011).

Conclusion

In conclusion, this article offers encouraging findings for clinicians working with individuals who sexually offend and who present with emotional awareness difficulties. Improving our understanding of the affective dimensions of sexual offending is a prime area for further exploration. Research is needed to develop appropriate therapeutic interventions with individuals who sexually offend who present with alexithymia. This research highlights the benefit in assessing alexithymia in this population and presents a short, feasible intervention for treating alexithymia and emotional awareness difficulties. The research findings warrant further replication in both the forensic and general populations.

Footnotes

Acknowledgements

The authors thank Professor Mary McMurran and Mary Jinks for their assistance. Thanks are also due to Ruth Groarke and Muireann O’Donnell.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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