of Contents Page Statement of Originality 2 Overview of Portfolio 3 Acknowledgements 4 Part 1: Literature Review – The relationship between alexithymia and experiential avoidance: A systematic quantitative literature review 7 Abstract 8 Introduction 9 Method 13 Results 18 Discussion 43 References 49 Part 2: Research Project Empirical Paper - Can’t talk about it, won’t talk about it: How do alexithymia and experiential avoidance relate to men’s experience of psychological distress? 55 Abstract 56 Introduction 57 Method 67 Results 75 Discussion 81 References 96 List of Appendices - Appendix 1: Guidelines for Authors 108 - Appendix 2: Ethics Documentation 2.1: Participant Information Sheet 2.2: Participant Consent Questions 2.3: Poster Advertisement 2.4: Email Advertisement 2.5: Permission Request for use of the TAS-20 2.6: Permission to Use TAS-20 2.7: Letter of Favourable Ethical Approval 109 - Appendix 3: Toronto Alexithymia Scale (TAS-20) 120 - Appendix 4: Acceptance and Action Questionnaire-II (AAQ-II) 121
Table 2: Reported participant demongraphics across all included studies. Gender – male/female % Age Ethnicity Eduation Employment Relationship status (1) Beroccal et al, 2009 28.8% / 71.2 m = 34.5, SD 16.1 All caucasian 89.3% high school or above Not reported Not reported (2) Bilotta et al, 2015 61% / 39% m = 33.42, SD 11.89 Not reported Not reported 64% ‘blue collar’, 16% 8% undergrads, 12% employed Not reported (3) Landstra et al, 2013 100% / 0% m = 51, SD = 9 Not reported Tertiary education or above = 64% 51% full-time employment 49% in a relationship, 75% long term (> 5 years) (4) Losada et al, 2014 21.7% / 78.3% m = 61.73, SD 14.89 Not reported Not reported Not reported Not reported (5) Mennin et al, 2005 27% / 73% m = 19.52, SD 3.32 40% caucasian, 33% African American, 13% American, 4% Latino, 10% mixed heritage N/A – undergrad student sample N/A – undergrad student sample 97% single and never married.
Table 3: Correlations between measures of alexithymia and experiential avoidance reported in included studies. Study Measure of Alexithymia Measure of Experiential Avoidance Statistical test used Reported effect sizes Standardised effect sizes (r) p values (1) Beroccal et al, 2009 TAS-20 AAQ Pearson’s r .47 .47 < .01 (2) Bilotta et al, 2015 TAS-20 AAQ-II Pearson’s r .63 .63 < .001 (3) Landstra et al, 2013 DI, DD subscales of TAS-20 AAQ-II Pearson’s r .69 .69 < .001 (4) Losada et al, 2014 DI, DD subscales of TAS-20 AAQ-II Pearson’s r .19 .19 < .01 (5) Mennin et al, 2005 DI subscale of TAS-20 DD subscale of TAS-20 TMMS Attention TMMS Mood Repair TMMS Attention TMMS Mood Repair d .23 .47 .28 .34 .11 .22 .14 .17 < .01 (6) Orcutt et al, 2005 TAS-20 AAQ Pearson’s r .61 .61 < .05 (7) Paez et al, 2013 TAS-20 (Spanish Version) ERQ Pearson’s r .39 .39 < .01 (8) Panayiotou et al, 2015 (a) TAS-20 AAQ-II Pearson’s r .558 .558 < .01 (9) Panayiotou et al, 2015 (b) TAS-20 AAQ-II Pearson’s r .438 .438 < .01 (10) Stewart et al, 2002 TAS-20 EAS Pearson’s r .59 .59 < .001 (11) Venta et al, 2012 TAS-20 AFQ-Y Pearson’s r .42 .42 < .01
Table 4: Summary of mediation analyses from included studies. Study Population Sample Size Study Variables (measure, Cronbach's α)* Analysis Outcome Comments Beroccal et al, 2009 University students and general population - Italy 177 IV DV Mediator Alexithymia (TAS-20, α = .82) Emotional distress (Depression/anxiety subscale of the α = .69) Experiential avoidance (AAQ, α = .53) Hierarchical regression and Sobel test – Baron & Kenny method (1986). Experiential avoidance did not significantly mediate the relationship between alexithymia and emotional distress. Effect of alexithymia on emotional distress only 7% when experiential avoidance in the AAQ has been found to have low internal consistency. Also found within this study. BASIS-32 designed and normed for use during psychiatric hospital admission to measure change during treatment. Not designed as a general measure of psychological distress within the general population. Bilotta et al, 2015 General population – enrolled through Mechanical 315 IV Negative Emotionality X Avoidant Coping (Negative affect of the PANAS, α =.90; Avoidant coping items Moderated multiple regression The avoidance coping/negative emotionality interaction predicted levels of alexithymia, and this was Alexithymic participants = 27.3%
Turk, an online recruitment site – US. DV Moderator from the COPE, α = .90). Alexithymia (TAS-20, α =.90). Experiential avoidance (AAQ-II, α =.85). moderated by experiential avoidance. Avoidant coping and negative emotionality also independently predicted higher levels of alexithymia. Landstra et al, 2013 HIV+ men who have sex with men currently part of an anal cancer screening programme – UK. 187 IV DV Mediator Difficulties identifying and describing feelings (Subscales from α =.88). Note: also tested as the mediator Psychological distress (DASS-21, α =.94, α =.88, and α =.92 for depression, anxiety and stress respectively). Health-related quality of life (The Medical Study Short Form Health Survey) Psychological flexibility (AAQ-II, α =.91) Note: also tested as the IV. Mediation analyses using bias-corrected bootstrapping. DIDF mediated the relationship between psychological flexibility and mental health (depression, anxiety, stress and health-related quality of life). Psychological flexibility did not mediate the relationship between DIDF and mental health. Data collected at two time points, so longitudinal effects considered. ‘Completers’ had higher scores on the AAQ-II. 31% of participants did not complete time 2 data – expected likelihood imputation used to replace missing data. Older sample – average age 51 years. Correlation between anxiety and experiential avoidance significantly reduced between time one and time two, perhaps suggesting changes in coping as the screening programme progressed/they learn the outcome of screening. Post-hoc analysis revealed only 0.3 or less power to detect a small difference in model controlling for screening outcome. 20,
Confidence intervals in the model where experiential avoidance is the mediator are narrow, and all cross 0 by > .01, some crossing by as little as .005. Panayiotou et al, 2015(a) Students - Cyprus 205 IV DV Mediator Alexithymia (TAS-20, α =.83, α =.66, and α =.73 for DIF, DDF and EOT respectively) Psychosomatic symptoms (modified PHQ-15, α =.90). Experiential avoidance (AAQ-II, α =.87). Mediation analyses using bias-corrected bootstrapping. Experiential avoidance mediates the relationship between alexithymia and somatic symptoms. EOT was not related to somatic symptoms, and shared the smallest relationship with experiential avoidance out of the three TAS-20 factors (.17, vs .48 and .77). EA also did not mediate relationship between EOT and somatic symptoms Un-validated measure of somatic symptoms. However factor analysis carried out showing loading onto one factor. Panayiotou et al, 2016(b) Patients being treated for OCD - USA 163 IV DV Mediator Alexithymia (TAS-20, α =.58, α =.81, and α =.40 for DIF, DDF and EOT respectively). Depression (BDI-II, α = .95). Experiential avoidance (α = .83). Mediation analyses using bias-corrected bootstrapping. Experiential avoidance mediated the relationship between alexithymia and depression at both time points. EOT did not share a significant relationship with depression. Clinical population (71% OCD, 49% depression, anxiety disorders). Data collected at two time points, so longitudinal effects considered. High levels of depression in the sample.
EA also did not mediate relationship between EOT and depression at either time points. Reductions in experiential avoidance also mediated the relationship between reductions in alexithymia and improvement in depression scores following treatment. However only DIF was significant in this model. Venta et al, 2012 Inpatient adolescents 64 IV DV Mediator Alexithymia (TAS-20, α = .89) Difficulties with emotion regulation (DERS, α = .96) Experiential avoidance (AFQ-Y, α = .87) Hierarchical regression and Sobel test – Baron & Kenny method (1986). Experiential avoidance mediated the relationship between alexithymia and emotion regulation difficulties. Sample range young (12-17 years), but mean age comparable to young adults (m = 16.24 years). Very high levels of alexithymia, particularly amongst males (68.4% males, 31.8% females). TAS-20 not validated for use with children. AFQ-Y adapted from the AAQ – appears to be slightly broader in scope, as includes measures of cognitive fusion and general psychological flexibility. High levels of clinically diagnosed mental health problems (39.1% mood disorders, 23.4% anxiety disorders).
Men’s mental health research study Men’s mental health research study Ct Men’s mental health research study Men’s mental health research study Men’s mental health research https://surreyfahs.eu.qualtrics.com/SE/?SID=SV_cInQWCqzrwoOVCt Men’s mental health research study https://surreyfahs.eu.qualtrics.com/SE/?SID=SV_cInQWCqzrwoOVCt Men’s mental health research study https://surreyfahs.eu.qualtrics.com/SE/?SID=SV_cInQWCqzrwoOVCt Men’s mental health research study https://surreyfahs.eu.qualtrics.com/SE/?SID=SV_cInQWCqzrwoOVCt Men’s mental health research study https://surreyfahs.eu.qualtrics.com/SE/?SID=SV_cInQWCqzrwoOVCt Men’s mental health research study https://surreyfahs.eu.qualtrics.com/SE/?SID=SV_cInQWCqzrwoOVCt Appendix 2.4: Email Advertisement Are you an male? Could you spare 15 minutes of your time to help support men’s wellbeing? You are invited to take part in a brief online questionnaire that looks at factors impacting on the psychological wellbeing of men. Please click the link below to find out more: * LINK HERE * I would be extremely grateful for your participation, Thank you, Bryony Trainee Clinical Psychologist University of Surrey The study has been reviewed and received favourable ethical opinion from The Faculty of Health and Medical Sciences
Appendix 8: Direct and indirect effects of alexithymia on depression, anxiety and stress, through experiential avoidance Regression Coefficients Bootstrap results for Indirect Effects (95% confidence interval) DV Effect of IV on M (a) Effect of M on DV (b) Total effect (c) Direct effect (c’) Point Estimate Lower Upper Depression B SE t p .46 .05 9.69 <.0001 .51 .07 7.81 <.0001 .28 .45 5.82 <.0001 .05 .05 .88 .38 .23 .16 .33 Anxiety B SE t p - - - - .24 .05 5.44 <.0001 .15 .04 5.06 <.0001 .04 .04 1.24 .22 .11 .06 .17 Stress B SE t p - - - - .49 .06 8.12 <.0001 .28 .04 6.27 <.0001 .06 .47 1.18 .24 .22 .15 .31 Note: IV = Alexithymia (TAS-20); M = Experiential Avoidance (AAQ-II). Part 3: Summary of Clinical Experience
Part 4: Table of Assessments Completed During Training PsychD Clinical Programme Year 1 Assessments ASSESSMENT TITLE WAIS WAIS Interpretation (online assessment) Practice Report of Clinical Activity Cognitive behavioural assessment and formulation for a man in his thirties with Aspergers Syndrome experiencing distressing thoughts and beliefs. Audio Recording of Clinical Activity with Critical Appraisal A critical appraisal of a cognitive-behavioural intervention session with a man in his forties experiencing paranoid persecutory beliefs and derogatory voice hearing. Report of Clinical Activity N=1 A cognitive-behavioural assessment, formulation and intervention for a man in his forties, experiencing persecutory paranoid beliefs and derogatory voice-hearing. Major Research Project Literature Survey A literature survey documenting coping strategies used by men in response to anger. Major Research Project Proposal Does cognitive flexibility mediate the relationship between alexithymia and the experience of anxiety in men? Service-Related Project An evaluation of a pilot mindfulness group run for clients under the care of an adult Community Mental Health and Early Intervention service within a South-West London trust. Year 2 Assessments ASSESSMENT TITLE Report of Clinical Activity – Formal Assessment A neuropsychological assessment and formulation for a man in his 70’s experiencing cognitive and physical symptoms possibly indicative of possible dementia. PPLD Process Account A reflective account of the process issues within our Personal and Professional Development Group. Presentation of Clinical Activity Sex and Relationship Education with a 21 year old girl who has intellectual disabilities. Year 3 Assessments ASSESSMENT TITLE Major Research Project Literature Review The relationship between alexithymia and experiential avoidance: A systematic quantitative literature review Major Research Project Empirical Paper Can’t talk about it, won’t talk about it: How do alexithymia and experiential avoidance relate to men’s experience of psychological distress?