Written by Eric Rangel Oliveira, AMHSW
Estimated Reading Time: 15 minutes
Introduction
Have you ever been told you’re hard to read or felt that you couldn’t read yourself? For many people, emotions feel like a foreign language: hard to name, explain, and manage. In my work as a mental health clinician, I have come across many clients who are not lacking empathy or care, but instead struggle with a condition known as alexithymia. This term means “no words for emotions.” Bob’s everyday life mirrors the challenges faced by individuals with alexithymia. Through Bob’s story, we will explore the science behind emotional unawareness, its impact on mental and physical health, and how therapy can help turn confusion into clarity. If you have ever felt emotionally disconnected, misunderstood, or stuck without being able to express exactly what you feel, Bob’s journey may offer insight, validation, and hope.
What if the emotions we feel aren’t fixed reactions but something our brain creates based on past experiences, body sensations, and cultural learning? In this Emotional Regulation Blog Series, we will follow Bob (He/Him), a fictional yet deeply relatable character, on his journey from emotional numbness, withdrawal and anger outbursts to deeper connection and emotional mastery. Bob’s story was inspired by fragments of my own story and the stories of many friends, acquaintances and fictional characters I heard throughout my lifetime. His story may also resonate with the personal stories of so many readers of this blog post.
Bob, a gay man now in his late 40s, grew up in regional Australia in the 1980s and 90s under values of silence, stigma, and stoicism. Bullying at school, emotional neglect at home, and high parental expectations and complex developmental trauma set the stage for a lifetime of emotional difficulties for him. Bob’s life story is not unusual, but it reveals profound lessons about how emotions are shaped, how they shape us and how they can be transformed.
Why do I like telling fictional stories?
I believe that the most powerful learning happens when ideas not only make sense in our heads but also resonate in our hearts. That is why, instead of writing about theories, dry definitions or statistics, I have chosen to illustrate theories and concepts through the story of a fictional character. Stories help us connect, remember, and reflect, and they often capture the real-world complexity of mental health in ways that theories and concepts alone cannot.
Through this story you will:
- Understand how alexithymia is defined.
- Highlight where some researchers agree or disagree about Alexithymia.
- Attempt to clarify how therapy can help individuals who present with Alexithymia
Why You Should Read This Story and What You Will Gain
Ever felt a knot in your stomach but had no words for what it meant, or watched a friend shut down when the talk turned emotional and wondered why? Can you relate to these examples?
Why am I writing about this? Because, as a mental health clinician, I often found myself puzzled by clients who struggled to express their emotions. This led me to seek further training in the hope of better understanding and supporting clients with a condition known as alexithymia.
Through this blog post, I hope to introduce what, in clinical terms, is referred to as alexithymia. You will learn how researchers define this elusive trait, key symptoms, and their impact on well-being, as well as how we can use therapeutic tools to help clients when feelings go missing.
In summary, I hope this article clarifies the Concept of Alexithymia and helps readers navigate life with greater confidence and compassion for themselves and others.
Reader Disclaimer
This story explores themes that may be distressing or upsetting to certain individuals. While it is fictional and educational, it may still evoke strong or unexpected emotions in some readers. If you find yourself feeling overwhelmed, distressed, or triggered at any point, please prioritise your wellbeing. You may want to pause reading, speak with a trusted support person, or reach out to a qualified mental health professional for additional support.
If you are in Australia, you can contact:
- Emergency: 000
- Lifeline Australia: 131114 https://www.lifeline.org.au
- 1800RESPECT: 1800 737 732, https://www.1800respect.org.au
- Beyond Blue: 1300 224 636, https://www.beyondblue.org.au
- Kids Helpline: 1800-551-800, https://kidshelpline.com.au
- LGBTQ+ Crisis Hotline: 1800-184-527, https://qlife.org.au
- MensLine Australia: 1300-789-978, https://mensline.org.au
- National Alcohol & Other Drugs Hotline: 1800-250-015, https://www.health.gov.au/our-work/drug-help
- Suicide Call Back Service: 1300-659-467, https://www.suicidecallbackservice.org.au
Your emotional safety matters. This blog is here to educate, empower, and support, not replace professional care.
When Feelings Get Lost in Translation
Bob (he/him) is a 40-year-old gay male who works as an award-winning Chef in a restaurant. Ask him how business is, and he comes up with numbers, schedules, and his most recent menu plans. Ask how he feels, and the sparkle fades!
During his day, Bob interacts daily with colleagues, but his conversations are typically transactional and devoid of emotional depth. During morning tea, while others share stories about their weekend, Bob says:
“Yeah, I went to the shops. Bought food. Nothing much happened.”
Even when prompted with follow-up questions, “Did you go with anyone?” or “Did you have a good time?”, he simply responds:
“Just went. It was okay, I guess.”
He mentions people in passing (“My cousin came over”), but provides no elaboration about what they did together, how he felt about the visit, or whether he enjoyed the time. When a co-worker confides about feeling overwhelmed, Bob replies:
“That is unfortunate. Hope you manage.”
He does not ask questions or offer comfort, and his language lacks emotional markers. Over time, others describe him as “distant” or “hard to connect with,” though he is not hostile—just emotionally unavailable.
Bob is standing in the kitchen at work when a colleague, Sam, accidentally slices his hand with a utility knife. Blood starts to drip, and Sam grimaces in pain. Several co-workers rush over. Some gasp or wince but stay composed, offering support and calmly helping him get first aid.
Bob, however, freezes. His body tenses, his heart pounds, and he feels a dizzy sensation. He mutters, “Oh god, I cannot deal with this,” and rushes to the bathroom, overwhelmed. In the mirror, He looks pale and clammy. Bob avoids returning to the scene until he is sure it is over.
Later, a colleague says, “That was intense, but luckily, no one panicked.” Bob replies:
“I did not even know what I was feeling. It just hit me like a wave. I felt sick. I cannot handle stuff like that.”
When he meets up with her friend (Leo), who is visibly upset after a recent breakup with his partner, Leo starts crying and says, “I just don’t understand how he could leave after everything we went through.”
Bob pauses and responds flatly:
“Well, maybe he just wasn’t into it anymore. These things happen.”
Leo looks shocked by the response and replies, “I’m really hurting… I feel like I lost part of myself.”
Bob shifts in his seat, growing visibly uncomfortable. He replies:
“I don’t know what to say. You will get over it. Everyone does.”
Later, Bob tells another friend, “I felt so weird while Leo was crying… I just wanted him to stop. I didn’t know what he wanted from me.”
The other day, a group of Bob’s friends organised a surprise party for Leo in a restaurant.
The group smiles, claps, and cheers when Leo enters the restaurant. Most guests are animated, laughing, leaning in, and reflecting Leo’s joyful energy with warm facial expressions.
Bob, however, stays relatively still. His face remains neutral. He offers a small smile, but it is brief and doesn’t quite match the group’s energy. He says “Happy birthday,” but with a flat tone.
As the night continues, Leo starts to share an emotional toast, recalling a tough time in his life when friends helped him. Many guests tear up or nod empathetically. Bob, meanwhile, looks vaguely confused. Bob doesn’t mirror the sadness or emotional weight in the room. Later, Bob says to another guest:
“I could tell something meaningful was going on, but I didn’t really feel anything. I couldn’t tell if people were crying from happiness or sadness.”
The other day, Bob had to accompany his partner (Marcus) to the emergency department after Marcus injured his leg in a bike accident. When Marcus starts moaning in pain, Bob begins to feel tense and panicked. His heart races, and he begins to sweat. Instead of comforting Marcus, Bob steps back, crosses his arms, and mutters:
“I can’t watch this. I don’t know what to do.”
He quickly sits down across the room, visibly distressed and avoiding eye contact.
When James asks for help adjusting his leg, Bob responds, flustered:
“I think you should wait for the nurse, I don’t want to make it worse!”
Marcus then looks at Bob in shock and says, ” How can you be so selfish and uncaring? You just don’t care about me?”
Afterwards, Bob tells another friend:
“I felt so uncomfortable… I hated seeing him like that. It made me feel sick. I just wanted to leave.”
Bob was diagnosed with ADHD at 31, and as a Chef in a busy, award-winning restaurant, he powers through 14-hour work days on adrenaline, stimulant medication and then blows off steam by drinking large amounts of alcohol at the end of a busy shift at work.
Every now and then, Bob gets into arguments with Marcus. Bob frequently misreads people’s cues and feels secretly ashamed for “getting it wrong.”
Bob and Marcus frequently argue when Bob alternates between explosive outbursts of anger and withdrawing, isolating himself from James. One day, Marcus threatens to break up with Bob, saying, “I just do not feel you love me”. “You feel so distant” “It is like you do not even care”.
After starting to experience persistent chest tightness and fatigue, in the context of work stress and relationship problems with his partner, Marcus, Bob decided to consult with a GP. Bob also had a history of lingering migraines, acid reflux and stomach aches.
During the GP consultation, when the GP asks Bob how he is doing, Bob replies:
“I don’t know… Fine, I guess. Maybe tired?”
The GP requested some physical health exams, which indicated that Bob had very high blood pressure and cholesterol, a red flag for cardiovascular disease (CVD).
When asked by his GP how his routine looks, Bob describes a hectic routine (involving long days at work and social gatherings on weekends).
When asked by the GP how his mood is, Bob stated, “Meh, Fine, I guess.”
Bob could recite some of his supplier’s phone numbers, yet he couldn’t decide whether the tightness in his chest was due to worry, anger, or indigestion. That disconnect left him relying on medication and spreadsheets, rarely seeking comfort through a conversation.
The GP provides Bob with a few medication scripts for his acid reflux and also for his blood pressure, but also gives him a referral to therapy to address potential issues related to stress and anxiety.
“So my migraines, tightness in the chest and stomach aches might also be a result of bottled-up feelings?”
“Possibly. When emotion can’t find words, it often borrows the body” (de la Serna, 2018).
Bob Goes to Therapy
Bob starts attending Therapy with Mike (An Accredited Mental Health Social Worker)
Throughout his work with Bob, Mike (his therapist) assesses him for alexithymia, concluding that he rates high for Alexithymia symptoms.
So, what is alexithymia? What are some of the core deficits and symptoms of Alexithymia?
- Alexithymia is a personality trait marked by trouble identifying, describing, and expressing emotions; confusing feelings with body states; limited imagination; and an outward-only thinking style (Timoney & Holder, 2013).
- Alexithymia is characterised by weak emotional insight, poor empathy, and thin fantasy life (de la Serna, 2018).
- Among the main signs of Alexithymia are deficits in the ability to name feelings, mixing them with bodily signals, thinking concretely about life, and seeming emotionally flat (Nemiah et al., 1976).
Mike uses the Lane & Schwartz’s (1987) theory of emotional awareness to help Bob understand the five hierarchical levels (1- Awareness of bodily sensations; 2 -Action Tendencies; 3- Single Emotions; 4-Blends of Emotions; 5- Blends of Blends of Emotions) each representing a more complex understanding of emotions.
Over time, with repetition and consistency, Bob began to recognise patterns (like noticing that his body felt tense and his jaw clenched when he was angry, not just “bothered” ).
Gradually, Bob starts becoming more aware of the emotional ladder: raw body flashes → simple feelings (“angry”) → mixed feelings (“hurt and angry”) → nuanced insight (“I am ashamed because I valued that relationship”).
Video-game metaphors are used during the session: “Think of emotions as your HUD (ignore it and you get ambushed”).
Through the therapy process, using CBT and DBT techniques, Mike focuses on supporting Bob to increase his ability to perceive, understand, and manage feelings, aiming to expand his emotional vocabulary, link feelings to his body and context, build emotional regulation strategies, and work on interpersonal effectiveness skills.
Gradually, Bob was introduced to basic emotion differentiation strategies: learning the difference between agitation and anxiety, guilt and sadness, or shame and embarrassment.
Bob learned mindfulness techniques and practised naming feelings in therapy, e.g., “I feel… tight, maybe like I’m about to explode,” slowly becoming, “I think I’m angry because I felt dismissed.”
As Bob became more emotionally literate, he began connecting his drinking to emotional avoidance; he had used alcohol to “shut things down” when feelings became too intense. With the support of Mike, Bob also began reducing his drinking and experimenting with healthier emotional outlets.
Why Does Talking About Alexithymia Matter So Much?
Timoney & Holder (2013) explained that subjective well-being involves both how people think about their lives (life satisfaction) and how they feel emotionally (experiences of positive and negative emotions). Life satisfaction reflects a person’s overall assessment of various aspects of life, including relationships, work, and health. In contrast, happiness is more closely tied to regularly experiencing positive emotions and having fewer negative ones. In addition, Timoney & Holder (2013) stated that research shows that alexithymia is strongly linked to lower life satisfaction and reduced subjective well-being, primarily due to difficulties in identifying and processing emotions, even when accounting for factors like depression and physical health.
Timoney & Holder (2013) also explained that Alexithymia is closely linked to lower subjective well-being due to its wide-ranging impact on emotional regulation, mental health, personality traits, relationships, and physical health. Individuals with alexithymia often experience higher rates of depression, anhedonia, and social withdrawal, which diminish their life satisfaction and happiness. They also tend to come from lower socioeconomic backgrounds, possess personality traits such as high neuroticism and low extraversion, and frequently present with personality disorders, all of which are associated with reduced well-being.
Timoney & Holder (2013) also explained that difficulties in building and maintaining meaningful relationships further contribute to their emotional isolation and increased vulnerability to stress and psychological distress. In addition, alexithymia is associated with numerous health issues and maladaptive coping mechanisms, including avoidance and a diminished sense of control over life events. These factors impair physical and mental health outcomes and reduce opportunities for positive psychological experiences. Overall, the cumulative effects of alexithymia significantly undermine happiness and life satisfaction, highlighting the need for interventions that foster emotional awareness, resilience, and healthier interpersonal and lifestyle habits.
How Can Psychotherapy Help?
As a mental health clinician, I have encountered many clients who display high levels of alexithymia and whose lives illustrate some of the traits, symptoms, and impacts on their well-being and life satisfaction discussed by Timoney & Holder (2013). Alexithymia has been studied for over fifty years, with well-established conceptual and standardised assessment tools. I believe that research has done a good job of attempting to map its prevalence, personality traits, neurological basis, and links to various mental health conditions. However, where the evidence thins out is in treatment.
De la Serna (2018) explains that treating alexithymia is a complex process, primarily because individuals with high levels of alexithymia often do not perceive themselves as having a problem and are typically brought to therapy by concerned partners or family members. Their lack of emotional insight and motivation for change can at times pose a major barrier, as they tend to live in emotionally minimalistic “micro-worlds” where routine protects them from emotional unpredictability. Once diagnosed, therapy can help individuals learn new emotional skills. While they may never develop a rich emotional life, they can learn to recognise and respond to emotional cues more adaptively, improving their relationships and quality of life. Successful treatment requires gradually helping them exit this comfort zone, developing their emotional vocabulary, and training them to identify, understand, and regulate emotions through cognitive-behavioural strategies, role-play, and psychoeducation. Techniques such as mirror work, modelling, and audiovisual tools are used to enhance emotional recognition and expression, both internally and in relation to others. Therapy must also address how these individuals misinterpret or suppress emotional cues, often appearing cold or indifferent when, in fact, they are emotionally overwhelmed or confused. Group therapy may complement individual sessions by offering exposure to manageable emotional interactions, while family involvement is essential to support emotional learning outside of sessions. Ultimately, the treatment resembles learning a new emotional language, requiring patience, repetition, and gradually rebuilding social-emotional skills to improve interpersonal relationships and self-awareness.
While many treatments promise to reduce alexithymia, the evidence base remains limited and inconsistent. Most past studies were small or secondary analyses, making it hard to draw firm conclusions. A 2024 review by Tsubaki and Shimizu (2024) found that 17 different interventions lowered alexithymia scores; however, no single method stands out as a clear gold standard due to variability in study quality. They suggested, however, that cognitive-behavioural therapies (CBTs), including variants like acceptance and commitment therapy (ACT) and schema therapy, were the most commonly studied, comprising 67% of the interventions. These CBT-based approaches generally demonstrated significant reductions in alexithymia symptoms, as measured by the Toronto Alexithymia Scale (TAS-20).
Furthermore, Salles, Maturana de Souza, dos Santos, and Mograbi (2023) found that while DBT-based interventions may be associated with self-reported reductions in alexithymia and improvements in emotional identification, the evidence remains inconclusive due to methodological limitations, concluding that more rigorous research, including randomised controlled trials with standardised DBT protocols, is necessary to determine the efficacy of DBT in treating alexithymia.
In a 2023 study, Petzold and colleagues examined the impact of two different daily app-based practices—mindfulness meditation and a partner-based exercise called the “Affect Dyad”—on people’s emotions and thought patterns. Over the course of 10 weeks, participants practised for just 12 minutes a day, and the researchers monitored their feelings and thoughts before and after each session. The mindfulness group showed a clear calming effect: their minds were less busy with negative, future-focused, or other-related thoughts, and they felt a bit more peaceful and energised afterwards. These findings are important because people with alexithymia often struggle with racing thoughts and emotional numbness, so this type of calming, mindful practice may help them feel more grounded and emotionally aware. However, it’s worth noting that the study didn’t focus specifically on people with alexithymia, so we can’t say for sure how much it helps that group just yet. Still, the results suggest that mindfulness apps may offer quick emotional relief and improved self-awareness, even if the effects do not last over the long term. Compared to mindfulness, the Affect Dyad was more effective in fostering warm, positive thoughts about others, demonstrating how partner-based exercises can help build emotional connection. Overall, the study highlights promising, user-friendly tools that can support emotional growth and well-being in everyday life.
References
- de la Serna, J. M. (2018). Alexithymia, A World Without Emotions. Babelcube Inc.
- Lane, R. D., & Schwartz, G. E. (1987). Levels of emotional awareness: a cognitive-developmental theory and its application to psychopathology. The American journal of psychiatry, 144(2), 133-143.
- Petzold, P., Silveira, S., Godara, M., Matthaeus, H., & Singer, T. (2023). A randomised trial on differential changes in thought and affect after mindfulness versus dyadic practice indicates phenomenological fingerprints of app-based interventions. Scientific Reports, 13(1), 13843.
- Salles, B. M., Maturana de Souza, W., Dos Santos, V. A., & Mograbi, D. C. (2023). Effects of DBT-based interventions on alexithymia: a systematic review. Cognitive behaviour therapy, 52(2), 110-131.
- Timoney, L. R., & Holder, M. D. (2013). Emotional processing deficits and happiness: The mediating roles of meaning and social support. The Journal of Positive Psychology, 8(4), 276–285. https://doi.org/10.1080/17439760.2013.800904
- Tsubaki, K., & Shimizu, E. (2024). Psychological Treatments for Alexithymia: A Systematic Review. Behavioral Sciences, 14(12), 1173. https://doi.org/10.3390/bs14121173
Published by:
Eric Rangel Oliveira
Accredited Mental Health Social Worker
Founder of ERTC – Eric Rangel Therapy & Consulting
