published in: Kiegelmann, Mechthild; & Gürtler, Leo (2003). Research Questions and Matching Methods of Analysis (pp. 109–124). Tübingen (Germany). Ingeborg Huber Verlag
A Qualitative-Heuristic Study of Feeling
Thomas Burkart
The qualitative-heuristic study on the experience of feeling I report on here represents the departure from the quantitative-deductive (hypthesis-testing) approaches which are currently dominant in emotion psychology (see Otto, Euler & Mandl, 2000; Scherer, Schorr & Johnstone, 2001). Emotion-associated body processes like electrodermal or cardiovascular activity are frequvently recorded by physiological measures, or researchers attempt to influence aspects of emotion experimentally using psychological induction techniques, or pharmacological methods. The emotional expression is described by standardised observation schemes. Even data on the subjective feeling component of emotion are usually collected quantitatively using standardised questionnaires. In appraisal approaches, however, an abstract (reductionistic) "minimalistic questioning strategy" is preferred, "characterized by one-item measurements of appraisal dimensions" (Schorr, 2001, p. 332, 337). Open qualitative studies are quite unusual (see Schmitt & Mayring, 2000), although, some quantitatively oriented researchers acknowledge their heuristic potential (Schorr, 2001, p. 335).
In contrast to these approaches this study approaches its subject openly using different qualitative methods, without limiting the subjects as they describe their emotional experience for example with the multiple-choice alternatives in a standardised questionnaire.The research question is quite open and broad: What are the characteristics and structures of emotional experience?
Research Method and Data Collection
The subject of this study is feeling, i.e. subjective and conscious emotional processes. Its focus is not emotion, a term which normally denotes, beside the subjective feeling, other unconscious related phenomena such as physiological processes (Otto, Euler & Mandl, 2000, pp. 13-17). The term emotional experience is used as a synonym for feeling.
The methodological basis of the survey is the heuristic methodology of Gerhard Kleining (Kleining, 1982/2001; Kleining & Witt, 2001). Four characteristics of the heuristic methodology are key:
1. The researcher, must be open and prepared to change his or her preconceptions about the topic if necessary.
2. The research topic is also open and may change during the exploratory research.
3. The perspectives must vary structurally as much as possible during the phase of data collection, so the researcher can view the topic from many directions.
4. The data are analyzed for common patterns.
The maximal structural variation of perspectives, which prevents a one-sided view of the topic, allows the researcher to gather information that is as varied as possible about the research object. This is achieved by a variation of factors probably influencing the topic of research considerably. Beside factors specific to the topic this are the method of research and characteristics of the subjects (such as gender, age, social state) and sometimes the researcher himself (Kleining, 1995, pp. 236-242).
The starting point of the research was a study of emotional experience using the method of group-based dialogic introspection (Burkart, 2002; Kleining, 2002; Kleining & Burkart, 2001; Kleining & Witt, 2000). This method has recently been developed at the University of Hamburg in a workshop, in which the participants themselves research their introspection. (For more information onthe research approach of the Hamburg group, see our homepages: www.introspektion-hamburg.net and www.heuristik-hamburg.net.)
The research procedure in this study–referred to below as the "introspection study"–was as follows: The participants, all members of the research group, agreed to observe a current feeling of anger and another actual feeling of choice by introspection during their everyday lives, i.e. attentively recording their experiences while the feelings occured. Shortly afterwards they made detailed notes on what they had experienced.
Some days later in a participants' meeting, each participant–one after the other–gave an oral report to the group on his or her self-observation.The other group members simply listened: they did not ask any questions, did not make any evaluations, or start any discussions.There was no group leader because all participants, as members of the research workshop on introspection, were familiar with the rules of group-based dialogic introspection.
Then a second round followed, providing the opportunity to supplement reports. As each participant reported, everyone in the group was stimulated to reflect on their own experience and to recheck their own report.
The oral introspective reports in the group were tape-recorded, and transcribed, as a pre-requisite for the analysis, which was done by one person individually.
Five male subjects participated in the introspection study. The topics of their introspection covered a considerable range:
1. Feelings of confusion and anger triggered by the actual task of introspection.
2. Sense of well-being sitting by the fireside.
3. Vehement reaction of anger after accidentally kicking a cat's bowl of food.
4. Reaction of rage after a provocation in a professional field (private nursing).
5. Complex process of feeling after completing an application for a scientific project.
6. Emotional processing resolving an assumed defect in a refrigerator.
7. Process of feeling during a one-hour jaw surgery.
Moreover, an additional note about the same introspective task was included by another male member of the introspection workshop who was not able to participate in the group meeting..
Using the method of group-based dialogic introspection it is possible to record rich data about the emotional experience with complex feeling processes as is shown in the following passage from the introspection reports, describing the participant's feelings after he finished the application:
The burden falls from my shoulders and then again and again joy flames up, for me a kind of a frisky joy. Well, the friskiness came. This arose anyhow from the stomach, then rises, starting in the stomach with a light prickling, rising in the chest with bigger bubbles. Then there is an all-pervading heartbeat, which sets my teeth on edge and an impulse to express the joy, jumping and saying: it's done and I did it.
Although group-based dialogic introspection allows researchers to collect differentiated data on emotional experience, like other scientific methods the method has some limitations and should be varied. In particular, the report in the group meeting of very private introspections about feelings may cause some participants to repress their self-observations. One participant mentioned reflecting on weather it would be better to keep certain impulses secret in order not to be seen unfavorably within the group (see section "the communicative effect of feeling"). The introspection study also has the disadvantage that its subjects are all middle-class males, with a university education, factors which may influence their emotional experience.
To vary the method and other aspects (such as gender, social status, emotional quality, mental health, intensity of feeling,duration of feeling, and recency of feeling) two additional studies were started and personal introspection data were also used.
In a study about feeling descriptions by psychotherapeutic patients, who probably have less difficulty being open than did the participants from the introspection study, feeling descriptions are gathered which vary the above-mentioned aspects (gender, social status, emotional quality, etc.) or contain a new characteristic of emotional experience.
So far these descriptions of feelings have been taken predominantly from psychotherapy session protocols from my own psychotherapeutic practice. The patients were asked afterwards, if they would agree to my using their description of feeling in this study. These descriptions of feelings were predominantly spontaneous descriptions of feelings, which were partially supported by therapeutic interviewing. I have also gathered some descriptions using a simple therapeutic technique of introspection: observing one's feelings with closed eyes and reporting them immediately or afterwards.
In all of this data-gathering it is likely that the psychotherapist has had no impact on the emergence of the feelings, but certainly has influenced how differentiated the discriptions were.
Because a selection effect may relate to a certain psychotherapist (such as one-sidedness of the clientele, singularities of the therapeutic interaction, a certain therapeutic method) and may influence the collected phenomena of feeling, I have begun to vary the therapists and the therapeutic method. Therefore I have begun to use published psychotherapeutic data; in addition to using descriptions of feeling from cognitive therapy, I have included seven descriptions of feeling from client-centered therapies.
Altogether this study includes 45 feeling descriptions of 20 persons (14 female, 6 male, ages ranging between 18 and 57, M =37,25 years).
In a further study, I am gathering feeling terms and descriptions generally common in our culture or in certain subcultures. I believe that terms like to burst from curiosity (in German: vor Neugier zu platzen) or see everything through rose-coloured glasses (in German: alles durch die rosarote Brille sehen) also mirror characteristics of the emotional experience, as well as cultural influences. These terms are collected in everyday life and in dictionaries, meanwhile over 400 feeling terms and descriptions.
I also include in the analysis personal introspection data not gathered using group-based dialogic introspection but important for recognizing certain characteristics of feeling (presently four feeling descriptions). The methodological procedure was to take detailed notes shortly after the self-observation of a process of feeling.
Data Analysis
The data analysis, which is directed at discovering common patterns or similarities, started with the open question about the characteristics of emotional experience. The process of analysis is a complex question-answer-sequence, with questions on the data (introspection reports, description of feeling protocols, feeling terms, personal introspection data) leading to answers, which were explored for similarities, resulting in new questions. For example the question about the common patterns of the above-mentioned introspection report, describing the participant's feeling after finishing the application, leads to the answer that joy is combined with certain sensations, body processes, and impulses to act. This analysis provoked a further question: Which sensations, bodyprocesses and impulses to act are found in other feelings. As data were analysed for similarities, this question led to the characteristic of feeling as a body-based experience (see section "characteristics of feeling"). As we recognize "local" patterns, which refer to aspects of the research topic, we can gradually approach common "global" patterns by discovering similarities in the local patterns (see also Kleining, 2003, pp. 9-23 in this volume for detailled description of qualitative-heuristic analysis). The goal of the analysis is to discover the structure that fits and then integrates all the data.
Results of Analysis
In the following overview I first present characteristics of feeling. I then move to the functions of feeling, which unlike the characteristics integrates large "areas" of the data structurally, although I have not yet found the structure which integrates all the data.
Characteristics of Feeling
Emotional experience has at least nine aspects:
Inevitability. It is impossible not to feel. Feelings always exist to some extent in experience, although not always in the focus of attention but as background feelings, like feeling good, droopy, tired, or peppy (see also Damasio, 2002, pp. 343-344). Indeed feelings can be impaired as in certain forms of severe depression experienced as painful emotional impoverishment.
Reactivity. Feelings are reactively experienced. Persons can experience themselves as falling in and out of love and being overcome by fear, sadness, or joy. Feelings can be influenced only to a limited degree. Thus people with emotional problems often suffer like the following patient: "I get angry about myself, because I am thinking again and again about this [anxiety that something may happen to his daughter; the author]. I have no switch to turn it off."
Body-based experience. Feelings are experienced as body-based. This is mirrored by typical feeling terms like shaking with anger, gutfeeling, ear-piercing, sick with fear, blushing with shame, butterflies in one's stomach. They are combined with processes like constriction, expansion, tension, swelling, ascent, and descent of sensations, which mobilise or demobilise the person (see also Rahm, Otte, Bosse & Ruhe-Hollenbach, 1999; Schulze, 1999). An example from the introspection study:
And [when] the cat food is scattered across the whole kitchen floor, I have a strong reaction of anger, almost rage. I notice that it is wavelike, that there is something rising from the stomach. I record an impulse to kick at the cat bowl, which I don't act out.
Varying intensity and quality. Feelings have a varying intensity and quality of body-based experience. Different qualities are combined with different body processes. An example from the introspection study:
If anger turns to aggression, the tonicity is heightened in a flash. The body "tenses." The "ego" feels constricted, looking for possibilites of relief, verbally by cursing, and/or bodily by jumping, waving about, discharging excessive energy in high doses. Sadness ... Characteristic in contrary to aggression, a rather low tonicity. The sensation of heaviness and constriction in the whole body. One feels squeezed, downhearted, and numb. Happiness: ... The body is moving out of love of motion. One hovers slightly over the ground.
Personal involvement. Emotional experience affects the person. It can shock, hit, move, churn, overwhelm, set ones teeth on edge, sweep along, importune, or make bashful. Feelings captivate the person to varying extents by involving the person, linking him or her to the process of feeling and the object of feeling, as in the following description of feeling from a female patient:
"If I am afraid [of X], I am trapped in myself. I am not able to relax. I can't think of anything else and feel totally unconfident."
Expression of pressure. Feelings are experienced inwardly and press to be expressed. The expression of feeling can discharge pressure (to burst with curiosity, to explode, to jump out of one's skin, emotional release). If expression is impossible, severe inner stress may arise, as described by the colleague who discovered mistakes in the project application he had already submitted:
Self-reproach and anger about myself. Why did you just do this, how could you just do this. And this anger couldn't get out. Thus I always had the feeling, it's eating me up inside ... Anger spreading as a wave, hot, can't get out. I am guilty.
Intentionality. Feelings are intentional. They have a reference, an object varying in extent (e.g. sympathy for a certain person or the whole world) and clearness (e.g. a spider phobia vs. diffuse anxiety or unpleasant feelings). The topic of feeling may be something external or internal, a situation, an incident, a person, or an object, perceived, remembered, or imagined. The feeling reference can cause an association of bodily experience between the person and the object of feeling, varying between fusion (e.g. to feel at one with) and delimited reference (e.g. I feel aloof, I feel alien).
Integral effect. Feelings colour all psychic functions integrally. Perception may be restricted to the feeling contents, for example in an anxiety attack. In a moment of fright or surprise one can distrust one's perception momentarily (not to believe one's eyes). Thinking may be experienced in a state of elation as a light task, with easy changes of contents, whereas in depression it is agonisingly slow, circling the feeling contents, for example the loss suffered. Feelings release wishes and impulses, like the impulse mentioned above to kick at the cat bowl. Feelings can block impulses, as in depression or in moments of fright (thunderstruck, dumbfounded). Feelings facilitate action or complicate it provoking an action change, like the participant from the introspection study, who's boredom initially hampers his reading a book on emotion and finally leads him to interrupt his reading:
The situation was as follows. I was sitting on a train, travelling from Munich to Hamburg, reading a book. This was the book Psychology of Emotions by X [he laughs, laughter in the group] ... And I realize that I am bored, I have a resistance to reading. On the one hand the demand to read to the end, to get to know it. But I realize that it turns me off, that I am slightly annoyed, bored. Okay, and then I stopped reading.
Feelings may facilitate or complicate memory retrieval; for example examination nerves lead to forgetting even well-learned topics. Actual emotions may cause one to retrieve forgotten experience with similar emotions.
Process character and Gestalt character. Feelings are processes that vary in duration (from cursory to enduring) and in complexity: one feeling vs. processes with several feelings, e.g. jealousy; the feeling process of a single person vs. feeling processes with several participants, e.g. escalating arguments. Feeling processes have a gestalt character that affects the structuring of experience. Two gestalt features are:
Figure-ground relationship. Feelings are in the foreground or the background of experience. When in the foreground, feelings are organized in figures experienced as entities, despite manifold elements (sensations, cognitions, impluses) and complex dynamics (e.g. jealousy with an interchange of suspicious spying, heavy reproaches, and fear of loss). When in the background, feelings may include moods, or ambiguous, or cursory feelings.
Reversable emotional figures with rapidly changing conflictive feelings, like love and hate, up to the clouds, down in the dumps. They are associated with crisis situations and facilitate processes of psychic reorganization (see also Rahm et al., 1999, pp. 67-68).
Feeling processes develop in a dialog with the persons inward and outward situation (needs, goals, state of mind and body; see also Ulich, 1992a, p. 51). They may have an internal or external eliciting condition, which the person perceives. Eliciting conditions are schematic, for example a threat or danger releases fear, while the loss of a beloved person causes sadness. They depend on interpretation. For example, not everyone interprets an event as menacing. They may depend on the emotional or physical state of the person, for example like the patient who, in a depressive state, is saddened by her music, whereas she can enjoy her music while in another mood. Eliciting conditions mirror the person's experience or history. An example is a lawyer's letter releasing fear in a patient because of a bad experience he had with the courts more than 20 years earlier. Feeling processes are also determined culturally; for example Christmas provokes emotion, and ownership of status symbols can cause pride or envy in our culture.
The Functions of Feelings
Feelings have three basic functions: the body-related evaluation or appraisal, the motivation to act, and a communicative effect.
Feelings as body-related evaluation or appraisal.
Feelings evaluate their reference–the object of feeling–integrally and body-based.This evaluation is related to current expectations, goals and needs. Some examples from the introspective data:
Frustration of the wish to learn something interesting about emotions by reading the book on emotions led to boredom and slight anger.
The successful termination of the project application led to euphoric elation.
Mistakes detected in the submitted project application caused feelings of shame, guilt, and depression.
The appraisal is schema-based with criteria like novelty evaluation, conduciveness to goals/needs, coping potential, and goal approach (e.g. Scherer, 2001). The appraisal process is frequently not conscious and therefore not accessible through introspection. The criteria, objects of appraisal theories (Scherer, Schorr & Johnstone, 2001), can normally only be concluded. The result of that appraisal, the particular quality of feeling, is not only cognitive but also an integrally psychic and body-based, moving experience, with a variably strong link to the process of feeling and the object of feeling.
The particular quality of feeling comprises a more or less intense transformation of experience of self and world in relation to the following 13 dimensions, detected in the currently available data on emotional experience:
Focus and extent of attention. How clear are the objects of perception perceived? How wide is the span of attention? For example anxiety narrows attention. In euphoric elation perception is less accurate.
Clarity of consciousness. One participant in the introspection study feels numbed by sadness; depressive patients can feel confused. When one is frightened or anxious it may be impossible to keep a level head.
Filtration. During a depressive mood positive feelings do not penetrate: "Everything is subdued and doesn't reach me." In euphoric elation one takes a rosy view of everything.
Readiness for action. Rage can lead to urgent impulses to take action. Fear can petrify us. In depression one feels paralysed. One patient experienced this as "a loss of spontaneity and immediateness." All his actions require "willpower."
Cognitive functions eased versus blocked. During joy and happiness one can think easily, in depression or panic one blocks it (e.g."I couldn't form a straight thought"), or circle around the feeling contents. Speech comprehension, speech production, and memory retrival can be complicated.
Varying bodily processes include tension (strained vs. relaxed), heaviness versus effortlessness, pressure, constriction, and an impression of heat versus one of cold. In rage or in anxiety one may feel strained, in joy relaxed. Depression may be combined with feelings of heaviness, with pressure on the chest. Joy may be combined with effortlessness, anxiety with constriction, shame with heat.
Comfort versus discomfort. During joy and happiness one may feel comfort, and discomfort during anger, depression, or disgust.
Attraction versus rejection. During revulsion one is disgusted, during infatuation attracted by the object of feeling.
Open versus uncommunicative. In joy one may be open, extroverted; in depression one may be introverted.
Familiarity, proximity versus strangeness, distance to other persons, objects, situations, to oneself.
Intensity, brilliance of colours and acoustic apperception. In euphoria colours are experienced as more intense, than in normal conditions; in depression colours appear more flat, wan. During a depressive mood sounds may be experienced as changed, louder.
Assurance versus insecurity. When afraid, one can feel instable; when proud, one may confident.
Experience of time. During boredom and depression the time experience may change, for example one can perceive it as agonisingly slow.
Different feelings are combined with different changes in these dimensions of experience, whereas each of the modalities of experience is not always addressed. This can be demonstrated by the feeling description already mentioned: "If I am afraid [of X], I am trapped in myself. I am not able to relax. I can't think of anything else and feel totally unconfident." Here the following combination of dimensions of experience is in the forground of her experience:
Attention: She cannot think of anything else.
Tension: She is not relaxed.
Openness: She is not open, but trapped in herself.
Assurance: She feels completely unconfident.
The transformation, which is dynamic, is related to one's experience of self, as well as to one's experience of the world. The transformation may be more or less intense and may occur more or less abruptly. Often it is so slight that the individual hardly perceives it. If it is strong and rapid, the person may experience herself or himself or her or his situation as completely changed, "as if a switch is thrown ." The following two descriptions by patients illustrate this phenomenon:
"If I feel good, I feel bewitched, as if I am a different person."
"When I left him [after breaking up the relationship], I felt like I was in a different reality. That is indescribable, that feeling. I have such a feeling, well like the first time alone, like really alone. I can hardly describe it in words, what that feeling is. Like in a different reality .... Numb. It doesn't reach me, what is going on here. I am absorbed by the experience I have just lived through." (Tausch & Tausch, 1979, p. 170).
Feelings as motivational processes.
Feelings motivate certain actions or action probing (mental simulation) by changing the person's body and psychic state, preparing action (or non-action), or by eliciting impulses to act. This change of state may include focusing attention on important information, changing one's readiness to act (up to the impulse to act), and changes in cognitive functions (e.g. ease of thinking vs. blocked thinking).
For example anxiety can lead to attention being narrowed on the situation eliciting anxiety and an activation of flight impulses. Rage leads to an activation with attention being narrowed on the rage-eliciting contents and attack impulses. Joy may lead, through an opening and ease of thinking, to a need for affiliation. Sadness can lead to introversion, to a narrowing of thinking about the loss.
Favoured are actions which produce a change to or a coping with, the feeling-eliciting situation or event in the desired direction. The boredom and anger of the participant from the introspection study who was reading the book on emotion led first to an interruption and then to a breakup of the reading.
On the other hand, feelings like joy or pride, particularly if they are experienced intensely, also lead to communication of the feeling eliciting event, like the participant from the introspection study who wanted to share his feelings with his colleagues after finishing the application.
If direct action is impossible for the person, feelings can cause action in fantasy (action probing). For example, the patient Mr. S. was angry at someone who gave him orders about his daughter. He occupied himself for several days fantasizing about how he could have acted differently in the situation, and simulating different alternatives with different reactions by his opponent.
The communicative effect of feeling.
Feelings have, in their expression, a communicative function. Emotional expression communicates the emotional state of the person to others rapidly and without verbal communication. It then evolves to an interactive effect. A baby's crying may elicit worried caring. Sadness can lead to sympathy and attempts to comfort. Joy can be contagious. Rage may be frightening, or daunting, or may enrage others.
Emotional expression, which presumably has a genetic basis, is culturally determined (see also Ulich, 1992b, pp. 121-126). In different cultures, different feelings are appreciated as valuable, important, and problematic.
Expressing feelings in public affects one's social estimation and can therefore cause anxiety, particularly if the expressed feeling contradicts social standards or one's own self-ideal. One participant in the introspection study exemplified this case:
OK, and then I am occupied with the question, should I tell it here [in the meeting of the introspection group], should I tell it completely? I toyed with the idea of not telling about this impulse of kicking at that cat bowl, because this would characterize me as an impulsive person. I was occupied with the question: Would I take the risk of such an appraisal or not? OK, and then I realized that to tell about that impulse to kick, that this is embarrassing for me, that this is something like shame.
Children learn which emotional expressions are acceptable and how to control their feelings. The outcome of emotional learning is self-control with a certain amount of control over the expression of feelings. Although our culture values controlling one's feelings and not expressing certain feeling aspects (e.g. not crying in public), false expressions of feeling can cause denial. Whereas we see authentic feelings as actually experienced, with a correspondence between inward experience and outward expression, we see false feelings as not really experienced, as "simulated," "played," or "feigned." Self-control, which should not be confused with a lack of authenticity, may be lost or succeed incompletely, as in the following examples of feelings described by patients:
"There I lost my temper and exploded."
"I can't cry. But I notice that it's here". [points to throat]
"My husband keeps it all inside. I see in his eyes, his face that he feels under par."
The last two examples show two aspects of incomplete selfcontrol. On the one hand the repression of feelings is only incompletely possible, on the other hand the control of expression of feeling may be lost whereas the latter may result from the former. If a person represses a feeling for long time, it may become impossible to express it (e.g. a person who cannot cry anymore).
Despite these limitations the emotional communication is formable with the restricted influenceable expression of feeling. For this reason emotional communication has a "dual nature," as involuntary communication of one's emotional state and restricted shapeable emotional communication by forming the expression of feelings with an amplification, attenuation, neutralisation, or masking of the felt emotion; these are rules of display that Ekman (1972) sets on in his neuro-cultural theory of facial expression.
Discussion
In contrast to the quantitative-deductive orientation of emotion psychology, in which qualitative approaches have only a shadowy existence, in this contribution open qualitative methods were used.
The results show that it is possible to gather rich data about the process of emotional experience using qualitative methods, in particular introspection; unlike many quantitative studies, qualitative methods does not narrow experience to some few variables, defined in advance and often abstract.
In the qualitative-heuristic approach that underlies this study, open research questions are of great importance in both data collection and analysis. In data collection they determine how multifaceted and broad the topic of research appears in data. The analysis is governed by open questions, which guide the search for common patterns or similarities and enable the gradual approach to the structure of the topic, connecting all data.
Although this global structure of feeling has not yet been found, the results do demonstrate some essential characteristics and functions of feeling. Thus some of these results confirm the findings of other researchers. The feeling characteristics reactivity, body-based experience, intentionality, and personal involvement are also mentioned by Ulich (1992a, pp. 49-57) as important topics of an "experience-phenomenalistic analysis." Other characteristics have already been described by other researchers, like the topic of inevitablity from Damasio (2002, pp. 343-344), although not in that term.
Also well known are the abstract functions of feeling: feelings evaluate the person's situation in relation to his needs and goals, serve as a motivator of action and for communication purposes (see e.g. Scherer, 1989). New indeed is the recognition that feelings are a more or less intense transformation of the experience of self and world in relation to certain dimensions of experience. In other words, emotional evaluation is formed with that transformation of experience. This recognition has some similarities to Sartre's (1939/1997) theory of emotion, which describes emotion as a magical transformation of the world.
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i I thank Gerhard Kleining for discussion and Rita Byrne for proof-reading.
ii Some members of the workshop on introspection are Thomas Burkart, Otmar Hagemann, Gerhard Kleining, Peter M. Mayer, Hartmut Schulze.
iii Heinz Schramm.
vi I thank my patients for allowing me to use session protocols.
v For example in the so-called alienation depression with a strong feeling of inner emptiness and of being dead. The patients are not able to be happy, or sad, to laugh, or cry. Everything seems to them to be strange and unfamiliar (Peters, 1990, p. 154).