Alexithymia
Alexithymia is a personality trait that refers to the inability to express emotions in words. The term was coined by psychotherapist Peter Sifneos in 1973, who used it to imply “no words for mood.”1 Over the past half-century or so, the alexithymia construct has developed and evolved into a refined paradigm, which helps us to understand the influence of emotions and personality on illness and health. The core characteristics of alexithymia are marked dysfunction in emotional awareness, social attachment, and interpersonal relating.2 Alexithymic individuals have difficulty in distinguishing and appreciating the emotions of others. This, in turn, leads to unempathic and ineffective emotional responding.
Alexithymia as an adjective for the diabetes care professional
Medical professionals have been criticized for being “alexithymic” by many observers. From a clinician’s perspective, an alexithymic diabetes care professional is one who is unable to empathize with the patient, or to understand the patient’s emotional status and needs. More accurately, the term describes a diabetes care professional who is not responsive to the psychosocial reality of diabetes. The psychosocial aspects of diabetes care have gained due recognition in recent years. The publication of comprehensive guidelines on this topic has improved awareness of the importance of psychosocial care as a part of diabetology praxis.3,4 Simultaneously, enhanced appreciation of the patient-centered model of care has created an environment where psychosocial aspects are given due consideration.5,6
The ideal diabetes care professional—preventing alexithymia
In overzealous attempts at being “patient-centric,” one often tends to undermine the importance of the fact that diabetes care is a two-way process. The diabetes care professional is as important a component of diabetology as the person with diabetes. It is this realization that lies at the heart of discourse on the professional hazards of diabetes care professionals.7
Comprehensive guidelines describe the characteristics of a good diabetes care professional in great detail. The mnemonic “CARES” is used to describe these properties: Confident Competence, Authentic Accessibility, Reciprocal Respect, Expressive Empathy, and Straightforward Simplicity.8 Another useful mnemonic, “WATER,” lists the steps that effective communication or conversation should include. WATER stands for a Warm welcome, followed by Asking and Assessing and then Telling the Truth. The information should be accompanied by an Explanation, delivered with Empathy, and followed up with Reassurance and a Request to Return.9 Recently, a three “I”s strategy has been highlighted as a means of reducing the distrust against the medical profession among the general public, and restoring its credibility. The three “I”s stand for Interaction, Information, and Involvement.10
In all these models, the emphasis is on responsiveness to patient needs and requirements. While this is in tune with patient-centered philosophy, its inaccuracte interpretation places undue burden on diabetes care professionals. A common, albeit erroneous, interpretation of patient-centered philosophy is that the professional is expected to deliver services “only” as per the “wishes” of the person with diabetes. The diabetes care professional is expected to be perfectly balance the biomedical needs of the medical condition and the psychosocial reality of the patient. Moreover, the diabetes care professional is tasked to shoulder this responsibility, irrespective of support from the healthcare system, or the patient’s family and community.
“Hyperlexithymia”—the other extreme
Focus on the patient, communication and empathy has led to the creation of “hyperlexithymic” diabetes care professionals. The “hyperlexithymic” diabetes care professional is one who has internalized (inaccurately and inappropriately) the philosophy of patient-centered care and of CARES, and who makes overzealous attempts to respond to patients’ emotions in an empathic manner. Such “hyperlexithymia,” however, comes at a cost.
The unrealistic expectation from health professionals, and their super-heroic efforts lead to what is termed “compassion fatigue” (CF). CF has been defined as a state of tension and preoccupation with traumatized patients by re-experiencing the traumatic events, avoidance/number of remainders persistent arousal (e.g., anxiety) associated with the patient.11 We paraphrase Figley’s definition, in simpler words, to make it relevant for the diabetes care professional. In this context, compassion fatigue is a state of emotional exhaustion, which occurs as a result of the inability to cope with the demands of providing care to persons living with diabetes.
“Eulexithymia”—the optimal path
The preceding discussion highlights the paradox being faced by diabetes care professionals in clinical care delivery. Should one promote hyperlexithymia, with its inherent potential for professional hazards, or should one encourage alexithymic medical practice, and tolerate the poor satisfaction levels it leads to?
As in most cases, the answer lies in the balanced approach. Balanced models and constructs are available which highlight the equal importance of the physician and other stakeholders of the healthcare system as well. These include the ancient Quadruple of Atreya, and the modern 3×3 P rubric.12
The term we propose is “eulexithymia,” which we define as a balanced ability to express one’s emotions and understand others’ feelings. When used to describe a diabetes care professional, a eulexithymic person is one who understands and responds to a patient’s feelings in a balanced manner, without letting oneself be unduly and inappropriately affected by them.
Achieving “eulexithymia”
“Eulexithymia” is not an easy state to achieve. Emotional equipoise is a desirable characteristic of diabetes care professionals. Eulexithymia is a state of mind that helps one gain this characteristic through continuous training and experience.
The process of training should begin during medical college, with communication and other soft skills being taught to undergraduate students. Postgraduates dealing with chronic disease must be taught motivational interviewing, stress management, and coping skills. Practicing diabetes care professionals may benefit from sharing best practice on how to reduce compassion fatigue and maximize compassion satisfaction. Such knowledge can be honed by experience, and improved by efforts.
Conclusion
The “eulexithymic” diabetes care professional should be able to provide a perfect blend of individualized biomedical and psychosocial care. This respects the tenets of patient-centered care and CARES. The diabetes care professional should also be able to avoid compassion fatigue, maintain his or her own health, and achieve compassion satisfaction as well.
We remind our readers that these theoretical constructs need to be subjected to the scientific method. We hope that this discussion will stimulate researchers to explore the concepts described here from an evidence-based perspective. Scientists from multiple specialties, including endocrinology, diabetology, psychiatry, psychology, and medical sociology, need to work together to understand the connection between eulexithymia and compassion satisfaction, and hyperlexithymia and compassion fatigue.
