Psychology, Language, Science and Nomenclature

I have spent the past few weeks in the (infinitely long) process of making edits to my thesis.  And I have come to the following conclusion:

Research is annoying.

And, might I add, research in psychology is especially annoying.  Don’t get me wrong.  I love what I do, and don’t think I would find another field more fascinating.  But research in psychology has one big (very very big) shortcoming: our nomenclature stinks.

The types of models we work with in medical psychology are complicated.  They demand a combination of psychological and physiological constructs, the validity of which is often fuzzy.

Take depression, for example.  Depression is a construct that we spend a lot of time on in medical psychology, because, well 1) it is widespread, and 2) it happens a lot when people get sick.  In studies, it is typically assessed using self-reported symptom checklists that essentially ask people if they are feeling sad and hopeless, and if they have a variety of other symptoms of depression.

But are these symptom checklists really reflective of what we are looking for?  Or maybe that’s the wrong question.  Maybe the question should be, what do we mean by “depression”? 

To get a clinical diagnosis of major depression you can be either 1) sad, and 2) have no appetite, not be able to sleep, be restless, and cry all the time OR 1) have lost interest in things, and 2) have excessive appetite, sleep all the time, be lethargic, and never cry. (Or at least this was the case in DSM-IV...)  But that raises a question: are those two depressions the same issue?

Even worse, you can have depressive symptoms secondary to a negative event in your life (e.g., loss of job) or secondary to unresolved childhood abuse and PTSD.  Now those two things are definitely NOT the same thing.  The first is generally self-resolving as long as the individual has the personal and social resources necessary, and may or may not have startling health consequences.  The second implies changes in the CNS from a young age (Shea et al., 2005), as well as a different constellation of personal and social resources throughout the lifecourse, and is almost certain to have long-term mental and physical health consequences (Dong et al., 2004; Dube et al., 2009; Ramiro et al., 2010).

To make matters worse, we know that there are neural correlates to constructs such as depression.  There is no clean split between the physiological and the psychological constructs in medical psychological research.  Human psychology may be an epiphenomenon of biochemistry (but that gets us into a whole ‘nother philosophical debate).

So depression is complicated and comes in many forms.  But we often don’t make these distinctions in research.

The problem is that they all look like what you and I, and everybody and their brother calls “depression”.  Psychology does not have a periodic table of the elements to organise itself.  We rely on human languages.  And the problem with language is that it means whatever the people using it decide it means at any given point in time.

(Fun fact: Many languages do not have a word for “depression”.  What implications does this have for the study of such constructs cross-culturally?  Or again, maybe the better question is: Do these constructs exist cross-culturally? For an interesting discussion see Urban Semiotic.)

To be clear, I am not advocating reducing psychology to its neurological bases.  I am not a person who believes that you cannot scientifically examine subjective phenomenon.  After all, I am studying pain – it’s hard to get more subjective than that. (Although I expect there is a word for pain in most languages, which might make it slightly superior a construct to depression… Must look into that.)  But I think the question of how we in the human sciences create our constructs deserves more attention than it receives. 

If we are not going to invent new words to describe our constructs, then we need to know their limitations.  Perhaps depression as we know it in the West does not exist in all cultures.  Perhaps depression is a social construct that exists here that does not exist everywhere.  Alternatively, maybe depression as we understand it in the medical sense exists everywhere in different forms, and we have just decided to label it this way and need to be creative when studying it cross-culturally.  (Kind of like carbon atoms exist everywhere regardless of whether or not there is a term for them.)

We need to be less reliant on our languages.  Those types of depression described above may be qualitatively different as regards their physiological correlates, and if so, they may be responsive to different types of treatments.  Just because they all look like what the English language calls “depression” does not mean they are clinically identical or on the same continuum.

These are challenges in our field that many in the “hard” sciences hold against us.  And for good reason.  Until we can be quite clear about what we mean by a given construct and what we intend to pick up on when we measure it, we cannot pretend to understand its health implications either on the level of the individual, the group, or society.

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.  

Grief, Pain, Freud, and Melzack (Don't worry... this post is way more fun than it sounds)

I’m currently doing a masters thesis on the topic of pain. It’s interesting (to me). I’m examining the multiple determinants of pain in a sample of cardiac patients. So I’m studying the relationships among psychological and biological factors in predicting angina, a particular type of pain brought on by CAD. The reason I got interested in this area is that the heart has for so long been considered an organ tightly related to emotions (see this awesome website http://www.heartsymbol.com/) and because I have had chest pain since I was a child (Research is Me-search…)

The most interesting thing I have found about the topic of pain (read: emotional distress) is the combination of 2 theories: 1) the Neuromatrix Theory of pain (Melzack, 1993, 1999), and 2) Freud’s psychosexual theory of development.

Yes.

Here’s how.

Freud, as we know, was a neurologist (Galbis-Reig, 2004).  His theory, which many these days shorten to “aggression and sex”, was actually intended to indicate that the neural loops (he didn't use those words) laid down as children would dramatically influence personality later in life. He took his theory further in the discussion of “trauma”: the traumas of childhood were repeated in experiences in adulthood. (He was not the first to have this thought: http://en.wikipedia.org/wiki/Eternal_return#Friedrich_Nietzsche.)

But let's translate this into psychological distress speak: The emotional distress established in childhood would be repeated in adulthood.

Crazy talk? Maybe. (Of course not.) But then let’s fast-forward 100 years (give or take.) and get to Melzack’s new and improved theory of pain.  This theory is designed to explain physical pain, and grew out of observations of phantom limb pain, where in fact a limb that has been amputated seems to cause intense physical pain.

Melzack’s theory is a complicated piece of psychological thought, but boils down to this: 1) we have the capacity to feel pain, 2) this capacity is both innate (i.e., we are genetically predisposed to knowing what ‘burn’, ‘itch’, ‘peirce’ feels like) and learned (i.e., if we have been burned before, now we REALLY know what that feels like). According to this theory, there is no need for the peripheral body’s existence in order for humans to feel pain because the experience of pain only becomes translated in neural loops that ‘code for’ certain types of pain. That is to say that if you didn’t have a body, and were nothing but your brain, I could make you feel any type of bodily pain just by activating the right neurons. (I wouldn’t though.)

Doesn’t this sound to you a lot like the physiological version of Freud’s trauma theory? Especially when you think of chronic pains like back pain, joint pain, and oh recurrent chest pain. Some pattern for these pains gets laid down early on in life, and 20 years later, people are still complaining about it because it got worse. (And just in case you were wondering, there is a terribly poor relationship between how bad it hurts and how bad it's broken. That means, it doesn't always hurt more because it's more broken. Sometimes it is, sometimes it isn't.)

So what about a psychological neuromatrix? Old pains, laid down in childhood (rejection, abandonment, grief), would have formed their own neural loops, and the more those pains were felt, experienced, reminded, … the more practiced the neural loops became. The more practiced those loops become, the easier it is to activate them, until they would come to dominate. Until you couldn’t feel anything else. That's why childhood trauma is so bad. The neural loops for happy would be rusty, the neural loop for love may have atrophied…You need to practice those too, you know.

As an aside. Have you ever noticed how some people refuse to feel bad? (Those people annoy me.) You have a bad day and they say something along the lines of 'it'll be better tomorrow', as if anybody cares. But maybe those people are on to something. Maybe it's related to this fear of losing the ability to feel good if you spend too much time feeling bad that prompts some people to say “don’t be sad” when you’re sad. (Or just be sad for three days. THREE DAYS? See Paulo Coelho’s blog http://paulocoelhoblog.com/2011/02/18/past-and-present/ Some religions suggest to keep mourning down to a minimum too… I’m thinking Islam and Hinduism and I think there are others too http://en.wikipedia.org/wiki/Mourning). And maybe there's sound scientific logic behind this. Maybe we want to make sure we keep the neural loops for pain unpracticed. I think there’s something to that. You always need to remember that it is possible to feel good, and you should practice feeling good so that your mind (and brain) gets used to it.  

BUT – here’s the twist. Ignoring negative emotions doesn’t work. Psychology is all about not allowing people to repress negative emotion. Therapy is all about feeling those emotions, and realizing that that’s the only way through them. That was Freud's big discovery. (And yes I know that therapy has a bad track record when it comes to oh working and all... But more on that later. I'm still on this whole feeling-the-burn kick.)

As long as I'm bringing religion into this, “turn the other cheek” is a Biblical quote often used to encourage forgiveness over revenge. But I think it makes more sense to think of “turning the other cheek” as a response to something or someone causing you pain. For example, if someone hurts you, let’s say through rejection, and you get mad. Then the whole concept of an eye for an eye kind of breaks down doesn’t it? What are you going to take revenge on? And I think this happens a lot in romantic relationships: someone screws you over, and you go screw somebody else over to feel better about things (because often it’s impossible to take revenge off the original person). Does it work? Uhh. Don’t think so. (An other interesting site : http://www.healmybrokenheart.com/)

 

But turn the other cheek? That makes sense. It says “fine, go ahead and hurt me, hurt me again because I am going to deal with these emotions”. You know what that sounds like? Systematic desensitization (Wolpe, 1961)! The process of exposure through which people are taught to get over all sorts of things from snake phobias to motor vehicle accidents. Exposure seems to be the best form of therapy for dealing with trauma or post-traumatic stress disorder. In my opinion (and I’m sure I could find some references to back me up), the main ingredient operating in ANY form of therapy is exposure: therapists encourage patients to try new things, to form new relationships, to expose themselves to their fears – and then offer them the support they need to talk about those experiences, to experience them, to see how they are similar and different from the previous experiences that left a hurtful and sensitive neural trace.

The process of therapy is probably related to the process of creating new neural loops that are not painful, but that contain some elements from the painful neural loops. Some ingredients that seem to make therapy particularly useful (and likely to work...) are reflection and validation. These are fun ways that let the person know you connect with them, and your best friend is probably pretty good at this (though your parents may not have been...) 

But yes, reflection and validation... Possibly the way around the whole painful neural loops thing. how? I don't know, I'm just speculating here and this post is getting way too long. But it wouldn't surprise me if this activated mirror neurons that were instrumental in the process of building new neural loops... Hmmm. More to come.

Aggression, Social Psychology, Threat, and Communication

A couple of weeks ago, I was TAing a Social Psychology lecture on the topic of "Aggression".  A big topic, a great topic... Something you can really sink your teeth into... Metaphor that works on many levels.

At some point in the class, an interesting question came up (posed by me! yey TA!): "Why do people aggress towards others?"

Two answers really grabbed my attention: Threat (survival) and communication.

Threat, I had expected (it was in the readings). Communication, I had not.

But I loved these answers. Both answers really got me thinking (this is the point in the class where I lost everybody though.) Here's the thing about the "communication" answer though. I, too, have often found that there's nothing like a good fight to really connect with somebody. You bond on a deep level when you're willing to just go to the depths of your soul and pull out all that is most intense (ugly? maybe beautiful?) and show it to somebody else. That's really something. (Granted not all aggression gets this epic, but I think we can all agree that it can. "300" anybody?)

Here's the thing though. I wanted to get the students thinking about how these two motivations to aggress could come together and could grow apart.  Here's the reading in a nutshell: "People aggress towards others if they are under threat, because looking down on others makes us feel better about ourselves" (not verbatim, Wills, 1981). But, there's more: "Unless EVERYBODY is under threat. In that case, we just make friends." (also not verbatim, called "shared-fate" in Wills, 1981).

What does that tell you? (Well, who knows what it tells you, this is psychology, ok?) But I think you could make the argument that aggression is communication.  Does it stem from the need to communicate or does it EQUAL communication, that is another question. But I think you could pose the same one with threat, couldn't you? Is aggression a response to threat, or is it an expression of threat?

Hm. I don't know that that's known. Would probably depend on how we define aggression and threat and everything else. We could draw lines in the sand to make them distinct but they probably overlap.

I'm getting bogged down in the weeds. The point is, threat can lead to aggression, but it can also lead to affiliation (read: communication). That would put the two on par (aggression = communication).

But you could go deeper. You could say, we have a need to connect with other human beings. And you could say that aggression is one of the ways to do this. There are other ways: conversation, sex, writing, ... But how often have you gotten angry at somebody and lashed out because they just didn't get what you were saying or how you were feeling and you didn't know how else to tell them - but you really needed them to know you?