Reflection, Validation, and The Power of the Blog

It may often be said that psychology is soft science at best, and maybe not science at all.  I beg to differ.  Through empirical tests (the same kind of tests that brought you dynamite and banana-flavor that doesn’t come from bananas) psychologists happened upon two of the most important discoveries ever.  We call them ‘reflection’ and ‘validation’.

If you do not know what these things are, let me tell you, because they will change your life forever.  Reflection is a person-centered therapy technique (Ackerman & Hilsenroth, 2003).  It refers to how to respond to a statement made by a client in therapy (or by anybody else trying to tell you about themselves and their life).  Let’s start by what reflection is not.  If my statement is “My boyfriend isn’t returning my calls and it’s making me go crazy” and my therapist responds with “It’ll be alright, he’s a douchebag (sic, technical term) and you’re awsome” that is NOT reflection.  Sounds nice, but note how it doesn’t mirror what I said.  If my therapist says “So you feel bad because you feel like he let you down”, that is reflection.  It is a nice repackaging of what I said that makes me feel like I was listened to and heard.  So I walk away happier. 

Validation is a similarly mind-blowing technique (Internet Encyclopedia of Personal Construct Psychology).  Again, let’s start with what validation is not.  If my statement is the same “My boyfriend isn’t returning my calls and it’s making me go crazy” and my therapist says that part about him being a douche and me being awesome and follows it up with “This is probably a blessing in disguise! You should be happy” that is not very validating.  It may be true, but it is totally not meeting me where I am emotionally at that moment.  And I walk away feeling like I’m stupid for being upset.  Not helpful.  A more validating comment is something along the lines of “I see why you would feel that way, it feels awful to be left hanging like that.”  Validation makes me feel like I’m not crazy for feeling the way I do. (To be fair, therapists have to be careful not to overdo this one.  Some people are crazy.)

You might say that these are not scientific discoveries because they occur naturally in good human relationships.  But then explosions and banana-flavor also occur naturally (just not in human relationships), and nobody’s saying they are not scientific. 

These are techniques that can be developed and applied to produce results in the world.  And the results are startling.  With reflection we feel seen, our existence matters (there are other words to describe this as we will discuss below). With validation we feel understood, we are not alone in the way we see the world.  These techniques are part of the way we are made to feel human.  

Though not always framed in the language of psychodynamic therapy, reflection and validation have been used in research.  I was at conference this week where one of the speakers was discussing work on emotionally expressive writing and how it helps patients diagnosed with cancer reduce physical symptoms and cancer-related doctor visits (Low et al., 2006).  When she discussed the mechanisms that might be underlying this association, she talked about ‘self-affirmation’ (Creswell et al., 2007) but what is self-affirmation if not reflection - the ability to feel more human by seeing yourself reflected on a page? Furthermore, they are now doing this by having cancer patients blog about their feelings and experiences related to their diagnosis and get feedback from their friends and family – which amounts to a sort of validation, doesn’t it? (I think blogging is validating :D).

I would like to end there, because I have presented only arguments in favor of my thesis.  But I won’t.  Because emotionally expressive writing doesn’t work for everybody all the time.  This form of coping has been shown to be beneficial in women first diagnosed with breast cancer, but not women in the later metastatic stages (Low et al., 2010).  Could it be that the experience was no longer providing the reflection and validation necessary?  Or is reflection and validation not what people want at that point?

Reflection and validation are not always the best option, even in a psychotherapy context.  For example, if a client says ‘I failed a class, I’m never going to amount to anything’ it’s probably unwise of the therapist to spend too much time reflecting and validating – it’s going to sound like agreeing!  At some point in the emotional process, you need to argue with that statement and instill hope (the technical term is ‘Confrontation’. Seriously, this time.)  

Maybe with patients in the later stages of serious disease, there is an analogous situation in that too much reflection of how bad things are is the last thing someone would want.    

I remember talking to a family-doctor friend at one point and trying to teach him the concepts of reflection and validation.  I was surprised that these concepts weren't taught in medicine.  But he said something interesting, that those of us at the intersection of medicine and psychology should know.  Doctors are taught to ‘support’ and ‘normalize’, not 'validate' and 'relflect'.  I was surprised at the time, because those are just two completely different things! And my bias was that reflection and validation are better. 

But being around very ill people changes the game.  If a person is in a lot of pain and feeling hopeless, maybe you want to be careful about reflecting.  Maybe you want to instill hope – not validate hopelessness. Supporting and normalizing might be much more helpful in those cases.

That being said, reflection and validation are often used by medical doctors as well (just maybe not formally taught as in clinical psychology).  For example, I was very sick with a respiratory infection for 3 or 4 weeks in January.  (It sucked.)  And one thing I noticed was how not only the doctor I consulted, but also many of my doctor friends made sure to say to me ‘I’m sorry that you feel so bad’ – which is a very reflecting AND validating comment!  Of course, a flu is not such a big deal you'd need to be careful about reflecting or validating my hopelessness, it's just nice.  They knew what to say. 

Schizophrenia in Developing Countries, or How the Self-Esteem Researchers Screwed Us All.

Fun facts:  Prognosis for schizophrenia is better in the developing world than it is in the West. (We will come back to this).

First, I want to make a point.  We in psychology are idealists.  When we get an idea, and it seems semi-supported by research, we like to tell people we have found the cure to life’s struggles and implement broad social changes to improve things.  A few decades ago, somebody noted that people with higher self-esteem seemed happier and more successful.  So they decided that if EVERYBODY had high self-esteem, they would be happier and more successful.  Note the mistaken assumption of causality here.  (And we wonder why the physicists won’t look at us!)

Here’s the reality, in case the self-esteem researchers got to you too: we are not all awesome at doing everything all the time.  And having people lie to us and tell us we are, though it might make us feel better on the spot, interferes with our reality testing in the long run. 

Here’s why.  In order to make sense of the ambiguous realities of everyday life, we need some kind of social consensus (Asch, 1951; Sherif, 1931).  Some researchers go so far as to argue that we have a need to compare ourselves to others (Festinger, 1954) because we are looking to make sense of reality (Sherif, 1931). 

The world is complicated.  People’s behaviour doesn’t always make sense.  If someone is brusque to you, you have to make a decision.  Are they being rude, are they in a bad mood, did you do something wrong, or is it a culture or personality disconnect?  On a day to day basis, these are the kinds of questions that we need answered.  And sometimes we just don’t know so we ask other people.  We use social consensus to decide whether someone was rude, whether an outfit is fashionable, whether we are rich or poor, and for just about any other question, big or small, that does not have an observable physical reality - and even then (see Asch, 1951, where 30% of people said an obviously longer line was shorter because everybody else in the room said it was. If you don't believe me, here's a link). 

That’s how important it is to know that the people around you - who you depend on for these answers - are being honest.

A child who wants to know if he is good at baseball or a teenager who wants to know if she is a good driver are looking primarily for the right answer.  The truthful answer.  Not the nicest answer.  We need to know that we perceive as right or wrong, everybody else perceives as right or wrong.  There’s something calming about that - and that's very nice.

Here’s the problem with telling a kid who doesn’t have an athletic bone in his body that he’s good at baseball:

HE’S GOING TO BELIEVE YOU!!!

Now back to the schizophrenics.

Schizophrenia is one of those scary mental disorders that baffles the medical community.  Oh we have a few ideas, but really, prognosis is pretty bad.  But somehow, in less developed parts of the world, it’s better (Isaac, Chand, & Murthy, 2007)

This should blow everybody’s mind. Quality of life is higher here. Medical care is better. People are nicer. There’s less war, disease, death. There doesn’t seem to be any reason diseased individuals should do better elsewhere. (To be fair, some have argued schizophrenics do not always do better in the developing world. Cohen et al 2008).

Unless the problem is that these people are hypersensitive to things that we do not do well here.  Like maintaining relationships with our families and reality testing.  We North Americans are good at many things, but we are not good at telling people when they are making us angry, when they are being rude, or when they suck at baseball.  We are also a highly individualistic culture that allows people to live most of their adult lives separated from their families (maybe not always a bad thing, but very isolating). 

Developing countries don’t have time for that nonsense.  Half of my family is of Algerian heritage (so I feel like I have the right to generalize my experience to the entire developing world).  And my experience is this: people are not concerned with your self-esteem, and families stick together just because.  (I actually think families stick together there because there is very little other form of social infrastructure - but that’s beside the point.) Families are more direct and, though not necessarily less dysfunctional, less afraid of their dysfunctionality.  And I think there is enormous therapeutic value there.

I think that in daily life we underestimate the therapeutic value of looking life’s ugly in the face and knowing we are not alone.  I think that a lack of acknowledgment of certain undesirable realities, even if it’s because we want to make people we love feel better, ultimately leads to problems in our basic understanding of the world and of our place in it.  And I think these problems can have graver consequences than just producing the occasional obnoxious individual with an inflated sense of self.