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Alexithymic Traits as Predictors of Difficulties with Adjustment in an Outpatient Cohort of Expatriates in Tokyo

DOUGLAS BERGER, M.D. 2,3), ISAO FUKUNISHI, M.D.1), , JAMES WOGAN, M.A. 2), TOMIFUSA KUBOKI, M.D. 3)

Psychological Reports, 85:67-77;1999.

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1) Albert Einstein University School of Medicine, NewYork, USA 2) Tokyo Institute of Psychiatry, Tokyo, Japan 3) Tokyo University School of Medicine, Tokyo

Summary

The purpose of this study was to examine whether alexithymic characteristics, which are thought to be related to poor coping with stress, would be associated with variables thought to reflect adjustment to life abroad. Methods: The subjects were 56 expatriates living in Tokyo, Japan. The Expatriate Adaptation Inventory, the Toronto Alexithymia Scale, and the Social Support Questionnaire of the Stress and Coping Inventory were given to the subjects. Results: Stepwise hierarchical multiple regression analyses found that degree of alexithymia was significantly correlated with higher levels of dissatisfaction with life abroad and higher ratings on the perception of poor social support; and significantly correlated with scores reflecting increased satisfaction with life in one's home country prior to departure. Two alexithymia variables, difficulty identifying feelings, and externally oriented thinking, were found to be significant predictors of satisfaction with life in home country. Conclusion: The results suggest that because alexithymia was found to be associated with lower satisfaction with life abroad and higher satisfaction in the home country prior to departure, it may be a predictor of adjustment difficulties when individuals live abroad.

INTRODUCTION

Globalization of the world economy has led to an increasing number of employees of large corporations relocating overseas. International companies typically post expatriates overseas for periods that average three years in order to expand into foreign markets (17). Currently, approximately 500,000 foreigners live in Tokyo. The English-speaking foreign community in Tokyo is comprised mostly of employees of international corporations, along with language teachers, local-hire expatriates, diplomats, missionaries, and others. The cultural barriers between the Japanese and the foreign community in Japan have been well described (3, 4), and would be expected to pose a psychosocial stress on the coping of an expatriate.

Previous studies have described personality characteristics and behaviors which affect adjustment to living overseas. The importance of language and communication ability (18, 22), interpersonal skills (13), and cultural empathy (17) have been found to be significant contributors to one's adjustment to life abroad. In addition, cross-cultural adaptation has been shown to significantly affect job performance (5).

Adjustment to life abroad is a multifaceted process. Cui and Awa (1992) adopted a cognitive-affective-behavioral framework that included five major predictors of intercultural effectiveness: language and interpersonal skills, social interaction, cultural empathy, personality traits, and managerial ability (5). Of these factors, at least the former four appear related to the ability to identify and express emotions.

The concept of alexithymia was initially derived from clinical observations of patients with classic psychosomatic illness. Sifneos (23) proposed the term alexithymia to describe a cognitive-affective condition characterized by difficulty in identifying and describing feelings and in elaborating fantasies. Recent studies have now shown relatively high rates of alexithymia among psychiatric patients with substance use disorder, eating disorder, post-traumatic stress disorder, and panic disorder (14-16,19). Moreover, several studies have demonstrated that alexithymic characteristics are closely related to poor coping with stress, e.g., negative reactions to stress, poor social support, etc. (12). Because of this, we hypothesized that alexithymic traits would be correlated with variables that reflect adaptation to one's host country, and in particular perceived social supports. To our knowledge, a psychiatric study on the relationship between alexithymia and life abroad has not previously been conducted.

Methods

Subjects included 56 expatriates living in Tokyo, Japan who voluntarily sought psychotherapy with a psychiatrist at an outpatient clinic (private practice of author D.B.) over an approximately 2-year period from 1995 to 1997. Approximately two-thirds of the patients at this clinic are foreign, the remainder Japanese with a small percent mixed Japanese/foreign. Subjects heard of the clinic thru notices in news media or through referrals from other medical practitioners. None of the subjects were aware of the study prior to their first clinic visit. All provided informed consent for their participation in the study. Every patient who presented to the clinic over the study period and who did not have any cultural connection to Japan in their family of origin (ie. mixedcultural families with one Japanese parent were excluded) were asked to fill-out the data base. Approximately 70% of foreign clinic patients agreed to fill-out the data base. Data on the characteristics of those who did not agree to complete the data base or their reasons for such decision were not collected.

The subjects included 34 men and 22 women with an age range of 22 to 51 years, mean age of 32.7 years (SD=7.2). The mean length-of-stay in Japan was 56.1 months (SD=55.0; range 2 to 240). Home countries were North America (United States or Canada) (n=36), Europe (n=9), Australia or New Zealand (n=4), and Asia (n=5), and others (n=2).

Procedure

After obtaining informed consent, the Expatriate Adaptation Inventory (EAI) a self-report questionnaire consisting of three psychological variables thought to reflect adaptation to life abroad: a) satisfaction with life abroad (29 items), b) feelings towards host country (19 items), and c) satisfaction with life in home country (10 items) (Appendix1), was given to the subject to bring home to fill out on their own. The items in the EAI were developed after lengthy discussion by three of the authors based on extensive psychotherapeutic clinical experience with the expatriate community in Japan and other countires. Positive and negative reactions to both one's host and home countries thought to most likely to reflect the type of adaption to expatriate life make up the bulk of the items. The questions were answered using a 3-point scale (0=not true,1=somewhat or sometimes true, and 2=very true or often true). A full score for each factor was 58, 38, and 20 points, respectively. The EAI also collects demographic data.

The 20-item Toronto Alexithymia Scale (TAS-20) (1, 2) and Social Support Questionnaire (SSQ) of the Stress and Coping Inventory (SCI) (20, 21), were also administered.

The TAS-20 (15, 16) is a self-report questionnaire which assesses alexithymia and has three subscales: difficulty identifying feelings (factor1), difficulty describing feelings (factor 2), and externally oriented thinking (factor 3). The items are rated on a five-point Likert scale. The reliability and validity of the of the TAS-20 has been supported by various analyses (15, 16). Internal consistency of the TAS-20 was supported by adequate α-coefficients.

According to Zeitlin and McNally (24), scores on the TAS are treated as continuous variables, consistent with the view that alexithymia is a graded rather than an "all-or-none" phenomenon. In secondary analysis, the cut-off score was used to examine the prevalence of alexithymia. A score of 61/62 has been regarded as an acceptable cut-off score on the TAS-20 (ie. alexithymic when the score is over 62). A score of 51/52 has been regarded as an acceptable cut-off score of the TAS-20 (non-alexithymic when the score is under 51). Persons with a score between 52 and 61 are judged as borderline. Thus, the subjects were divided into three groups; alexithymic, borderline, and non-alexithymic.

The Stress and Coping Inventory is a self-report questionnaire battery compiled and edited by Rahe (20) and Rahe and Veach (21). The SCI represents a collection of newly developed and previously standardized scales that provide four stress indicators and four measures of coping with stress: health habits, social support, response to stress (negative responses to stress and positive responses), and life satisfaction. The total score for each coping subscale was reduced to a Likert scale format ranging from 0 to 3 points. The higher the score, the stronger the degree of measured coping.

Previous studies have indicated a significant relationship between alexithymic traits and variables reflecting social supports. Of the four coping subscales on the SCI, we examined the social support subscale. The social support questions measure the existence of an individual's social network, the utilization of this network, and a person's perception of the readiness of their network to come to their aid. The social have three subscales with 6 questions each: 1.) existence, 2.)utilization, and 3.) perception of helpfulness.

Partial correlation analysis, multiple regression analysis, and stepwise hierarchical multiple regression analysis were used. All differences were considered (Japanese version) for the Macintosh was used for statistical analysis.

Results

The prevalence rate of alexithymia was 7.1% (4 of 56). The mean scores and standard deviation on the total and factors 1, 2, and 3 of the TAS were 44.8+11.8 (range 21 to 66), 16.4+6.8 (range 7 to 29), 12.6+4.3 (range 5 to 21), and 15.7+4.4 (range 8 to 24). We examined the relationship of total scores as well as the three factors on the TAS-20 to three sections of the EAI that evaluate life abroad: a) satisfaction with life abroad, b)feelings towards host country, and c) satisfaction with life in home country.

Partial correlational analyses found that total scores on the TAS were significantly and negatively correlated with scores on satisfaction with life abroad (r54=-.342, p<.05), and significantly and positively correlated with scores on satisfaction with life in home country prior to departure (r54=.359, p<.01).

Multiple regression analyses were conducted in order to examine whether the alexithymia group factors on the TAS (alexithymic, borderline, non-alexithymic) were related to the EAI variables reflecting adaptation to life abroad. These group variables significantly predicted scores onsatisfaction with life in home country (R=.431, p<.01), but notscores on satisfaction with life abroad (R=.352, p=.08, non-significant), or with scores on feelings towards host country (R=.158, p=.73, non-significant). The standardized beta weight, which indicates which alexithymia variables were the best predictors of the life abroad variables, are presentedin Table 1 (Tables are not available on line). Two alexithymia variables, difficulty identifying feelings, and externally oriented thinking, were found to be significant predictors of satisfaction with life in home country.

Previous studies have shown that the degree of alexithymia may be influenced by age, but not by gender (20). Additionally, we considered the possibility of a state-reaction (secondary alexithymia), due to effects of length-of-stay in Japan on the expression of alexithymic characteristics. Hierarchical multiple regression analyses were conducted in order to examine whether or not the significant associations found betweenthealexithymia variables and the EAI variables were related to both sets ofvariables being associated with age or length-of-stay. For the analyses, we entered scores of these two sociodemographic variables in the first step, and all of the alexithymia variables in the second step. Results of this examination found that the alexithymia variables were still significantly related to improved prediction of satisfaction with life in home country (R=.576, p<.05), but not with scores on satisfaction with life abroad. This suggested that neither age nor length-of-stay alone could account for the significant associations found between the alexithymia variables and satisfaction with life in home country on the EAI.

Partial correlational analyses revealed that factors 1 and 2 of the TAS 20 were significantly and negatively correlated with scores on the perception of social support (PSS) subscale of the social supportscale of the SCI (factor1, r54=-.430, p<.01; factor 2, r54=-.325, p<.05), however, no significant corrrelations were found with wither the existence or utilization of SS subscales. In hierarchical multiple regression analyses, we entered scores of the PSS variables in the first step, and then the PSS and the alexithymia variables in the second step. Results of this examination found that the alexithymia variables were still significantly related to improved prediction of satisfaction with life in home country (R=.433, p<.05), but not with scores on satisfaction with life abroad. This indicated that PSS alone could not account for the significant associations found between the alexithymia variables and satisfaction with life in home country on the EAI.

Discussion

The purpose of this study was to examine whether alexithymic traits can predict difficulties with adjustment when individuals live abroad. We used the Expatriate Adaptation Inventory and Social Support of the Stress Coping Inventory. In addition, we used age and length of stay as sociodemographic variables associated with alexithymia. Because previous studies have shown that the degree of alexithymia may be influenced by age, but not by sex (9).

Partial correlational analyses indicated that degree of alexithymia was significantly and negatively correlated with higher levels of dissatisfaction with life abroad and higher ratings on the perception of poor social support; and significantly and positively correlated with scores on satisfaction with life in home country prior to departure. These findings indicate that alexythymia may predispose one to have difficulty adjusting to a stressful environment. Faced with the necessity to deal with novel social and interpersonal scnerios, as well as novel expected emotional and verbal reactions, inability to guage one's own emotionalreaction as well as difficulty in reading the emotional state of the society around oneself could be seen as a predisposition for uncertainty as well as conflict (or perceived conflict) and thus increased stress. In one's home country, where the expected social and interpersonal cues are already intellectually practiced, fewer instances of conflict or frustration would be expected to develop.

Some of the commmon social stresses reported by the foreign community in Japan includes that the Japanese do not express their feelings clearly, that the Japanese communication style is vague and superficial, that the Japanese sometimes appear to go back on what they seemed to previoulsy agree on, and that there is considerable exclusion of foreigners from many aspects of Japanese life. This particular constellation of social stresses has been discussed widely in the literature (3,4) and has seemed to us to cause varying degrees of adjustment difficulties in the foreign comunity in Japan.

Alternatively, alexithymia could conceivably result secondary to the stress. Recent studies have proposed that alexithymic characteristics are divided into two types: primary alexithymia as a personality trait and secondary alexithymia as a state reaction (6, 10). Generally, secondary alexithymia occurs when individuals are placed in severely stressful circumstances (10). We attempted to examine for the possibility of secondary alexithymia by looking at whether or not the significant associations found between the alexithymia variables and the EAI variables were related to both sets of variables being associated with age or length-of-stay and found that the alexithymia variables were still significantly related to improved prediction of satisfaction with life in home country, although not with scores on satisfaction with life abroad.

In previous prevalence studies in healthy controls, the rates of alexithymia were 8.3% (2 of 24 persons) (7), 4.7% (2 of 43) (8), and 8.9% (16 of 179) (11), respectively. Thus, previous studies have reported that the prevalence rate of alexithymia assessed by the Toronto Alexithymia Scale is less than 10% in healthy controls (7, 8, 11). In this study, the prevalence rate of alexithymia was approximately 7% (4 of 56).

These results partially suggest that the alexithymia was an independent predictor of poor adjustment rather than a result of it. Some of the problems in studying this issue include that this study was cross-sectional in design, and that we assumed that increased length-of-stay is positively correlated with increased stress when one's stress level might actually decrease with longer length-of-stays due to acclimation to the host country. Further study to clarify this issue will be required.

Most studies, however, report that the prevalence rate of alexithymia assessed by the TAS-20 is less than 10% in healthy controls (15,16). In this study, the prevalence rate of alexithymia was approximately 7% (4 of 56). Although the sample size of this study was not large, the prevalence rate was consistent with that of several prior studies. Alexithymia did not seem to occur more frequently than the typical (trait) prevalence rate. It was therefore suspected that the alexithymic characteristics assessed by the TAS 20 in this study reflected personality traits.

Multiple regression analyses indicated that satisfaction with life in home country in particular was significantly and positively related to two alexithymic characteristics, difficulty identifying feelings and externally oriented thinking. These characteristics were also significantly related to the perception of poor social support. These results supports the notion that alexithymic expatriates tended to perceive little social support from their foreign environment. Alexithymic characteristics appeared related to individuals' expectations the accessibility and responsiveness of available social support. Expatriates with alexithymic traits (in particular difficulty describing emotions) who perceive low levels of social support, tended to feel less satisfaction with life abroad and to rate higher levels of satisfaction with life in home country prior to departure. Stepwise hierarchical multiple regression analysis found that perception of poor social supports alone could not account for the significant associations between the alexithymia variables and satisfaction with life in home country.

Regardless of the level of perception of social support and sociodemographic data (i.e., age and length of stay), two alexithymic traits, difficulty describing emotions and externally oriented thinking, appear to be psychological predictors of adjustment levels when individuals live abroad. These alexithymic variables may be related to other predictors of cross-cultural adjustment (e.g. communication ability, interpersonal skills etc.), however this was not specifically examined in this study. Additionally, the subjects in this study may not have been representative, exactly how was not studied.

These results may aid mental health workers in their approach to expatriates and help to stimulate further research in this area. Focusing on the meaning of social cues and cultural differences in the expression of emotional states might be helpful in the psychotherapy of expatriates who are having difficulty with the host society. Social supports and adjustment variables as measured by the EAI might be the focus of corporate and embassarial personnel departments and/or employee assistance programes.

Further study is necessary in order to further evaluate the usefulness of data bases such as the EAI in the assessment of expatriate adjustment, as well as elucidate the intriguing questions posed by this study,especially the relationship of alexythymia and its relationship to social adaptability.

Acknowledgement

The authors would like to thank Ms. Yoshie Saito for her insights into the original concept for this study.