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Clinical observations and controlled studies indicate that the treatment of alexithymic patients is most difficult. Moreover, stronger degrees of alexithymia predict worse therapy outcome. We argue that in order to make therapy for alexithymia-related disorders fruitful, a conceptualization of alexithymia in terms of interpersonally imbedded affect regulation is needed.Based on a re-interpretation of Freud's actual neurosis via Lacan's theory and contemporary attachment theory, we present a theoretical framework that incorporates these points. This framework helps us to explain why classic psychotherapeutic approaches fail, and to formulate principles for an alternative psychoanalytic therapeutic approach that addresses the theoretically discerned difficulties. A clinical vignette is used to examine how these principles can be implemented in clinical practice.Therapy with actual-neurotic alexithymic patients should focus on distressing situations, starting from which a three-step logic can be deployed. During therapy, mental representations on difficult situations in patients' lives need to be constructed by (1) putting into words the chain of events that makes up the distressing situation; (2) making the patient's appraisal of the difficult situation explicit; and (3) addressing affective responses and discussing the patient's way of dealing with the difficult situation.