“Sight Sound and Sense” in “Sight, Sound, and Sense”
Verbal Patterns and Medical Disease: Prophylactic Implications of Learning
Physiological explanation has long been unsatisfactory in relation to two well-known groups of disorders: (1) the disability without demonstrable organic involvement that sometimes complicates the problem of compensation for industrial accidents, and (2) the so-called psychosomatic diseases (the group includes rheumatoid arthritis, hypertension, asthma, and ulcerative colitis most prominently). Both groups are often assigned to or claimed by psychiatrists, but in most instances those suffering from these disorders disclaim any neurotic symptoms.
For many years we (Shands and Meltzer, 1973) have been primarily interested in the applications of semiotic understanding to psychiatric and psychological problems. It has gradually become possible to find correlations in these two groups of suffering persons between the disease state and easily demonstrable deficiencies in higher semiotic functions. In the term used by Pavlov, these disorders are at the level of the "second signal system" instead of at that of the primary signal system of the reflex arc and physiological communication. The demonstrations presented below and elsewhere point up the close interrelation— for personal-social integration—of the two signal systems.
Since semiotic and cognitive functions in man are only developed slowly over many years in the process of intensive schooling, the inference from the hypothesis developed below is that education in a com plex society has the implication not only of self-improvement but also of prophylaxis in relation to diseases that seriously impair and disable large groups of human beings.
An initial problem of interest is that of “emotion,” since psychiatric “diseases” are alternatively classified as “emotional disorders.” As Skinner (1963) has emphasized, the principal question in the scientific investigation of "emotion" is that of accessibility, in other words, how are emotions known? Ordinarily there are three routes : First, we infer emotional states from the facial expressions and postures of others; we say, “Does your scowl mean that you are angry?” or “You look depressed today.” Second, there has developed, following the work of Cannon, a research tradition in which correlations between experimental states assumed to be “rage” or “fear” (“fight” or “flight”) and instrumental readings (e.g., amount of adrenalin, level of blood pressure, gastric secretion, and the like) can be demonstrated “objectively”.
Third, however, and somehow unexpectedly, many—but by no means all—human beings have access to their own inner states of emotion through the verbal description of inner physiological experience. To such self-observers the process seems “natural.” In the obviously “neurotic,” phobic patients are characterized by an exquisite sensitivity to their own inner states. Such a person may say, “My heart was pounding, my knees got all rubbery, my vision blurred, and my mouth was very dry,” in describing an anxiety attack. This ability, in our experience, is remarkably different in different persons, and in the disabled and the psychosomatic it is characteristically absent. In the reports quoted below, it is apparent that when asked, “What does that expression on your face mean? Are you angry?” the psychosomatic patient may not know what the questioner is referring to. The inability to describe feeling has been given a Greek name by Sifneos (1967), alexithymia, from “no” “word” (for) “feeling.”
This incapacity for self-description is specifically related to a lack of education, in two different degrees. In the disabled workman, we have routinely found not only the inability to describe feelings but also a severe cognitive lack. In Piaget's (1950) terminology, such a person when tested shows himself to be functioning at the preoperational level of cognitive sophistication, corresponding to the 7-year-old level in the normal, well-schooled child. Specifically, the disabled person characteristically cannot find simple similarities (apple and banana, dog and lion) and often cannot do simple serial subtraction: he is thus impaired in the logic of both classes and series (Shands and Meitzer, 1977).
The psychosomatic patient, on the other hand, may be highly intelligent and cognitively well trained, but show a major defect in affective function. He seems literally to know nothing about his own feelings and so little “consciously” about his relations to even his closest relatives. In Shands (1954) I suggested that losses of close relatives were often significant in the precipitation of psychosomatic disorders; now it is possible to add the suggestion that these losses are important because their affective implications cannot be taken into account. Patients of this sort are “unconscious” of their emotional situation, even when it is possible to infer a feeling state by examining their expressions. The situation has some resemblance to the neurological state of anosognosia, in which the patient does not know that he does not know. An internist specializing in the treatment of rheumatoid arthritis expressed this observation in saying that such patients were uniformly “inarticulate,” even when they were highly sophisticated in the social sense.
What seems to emerge as the most interesting hypothetical explanation is that we see here a general lack of education in the disabled, so that while the person is obviously of good “native” intelligence, he is still totally unequipped to deal with complex changes in his own condition and social context. In the psychosomatic patient, there seems to be a marked deficiency in education to intimacy and to the description to others of his or her own feelings, positive or negative. Some patients, especially Case 4, below, clearly show an awareness of their own inability. But this man says specifically in relation to an overt հօstile act, “I must have been angry“ and ”I don't think there was anything ‘physical’ about it.”
The heuristic suggestion emerges that in a complex civilization there is an actual prophylactic effect of education to knowing one's own feelings and their implications of relatedness to others. These two groups of persons seem specifically handicapped; the problem can be described as another kind of “retardation.” A further fascinating demonstrable aspect is that these people exhibit a completely unexceptional life pattern; they are not in the least “neurotic.” However, when they suffer a severe loss in some essential part of the context of their lives, they may suddenly collapse in a disintegrative state. In the disabled we have been able to describe a somatization reaction. In psychosomatic patients the collapse appears as the precipitation of an actual or ganic disease, or, later in the course, the recrudescence of a quiescent disease.
In our experience, the lack of formal education in the disabled is associated with a specific deficit in creative thinking. The claimant has difficulty in adapting to changed conditions by creating a new selfconcept that fits the new situation. In an often pathetic way, such a claimant says, “All I want is to be like I was before the accident and to go back to work.” In Piaget's language, such an attitude shows a major lack of the ability to accommodate to changed circumstances. Because he cannot accommodate, he cannot develop new assimilative schémas. The lack of adaptation means that the disabled person seems to himself discontinuous with his former self: he says, plaintively but indirectly, that he has lost his self, that he is not the same person any more. This inability falls into both the contexts noted above. The pre-accident and post-accident selves are not similar, so they do not fall into the same class; while the series “me1, me2, me3” experienced by most human beings seems to these claimants to have been interrupted. This observable is less prominent in the psychosomatic group, although Case 2 (see below) said, “I went into a kind of tailspin because, you know, with no athletics there was no me type of feeling.“ He said, “I no longer trust my body.” But he also said, “I didn't think it was an emotional type thing.” Persons demonstrating this “fracture” in the continuity of a life can be described in Piaget's language as unable to conserve the self.
In a complex civilization the self has to be learned in ways quite unknown in primitive societies. But more significantly for our purposes, in a complex society the self that is learned is very different in relation to the linguistic context in which the person lives. Those living in the context of a restricted code (Bernstein, 1964) learn a restricted self— that is, primarily a self that is context-dependent. In more highly educated persons, the context of an elaborated code allows the development of a far more context-independent self. I have elsewhere referred to the latter as a "generalized self" in noting how much an executive position in a multinational corporation requires that the person tolerate frequent moves and a generally "expatriate" status.
The most fascinating observable generally true of the psychosomatic group is a lack of development of the affective foundation of a selfdefinition in this generalized mode. This inability is shared with the disabled—but in the psychosomatic group it is possible to find many intellectually sophisticated persons who still report in very clear terms the inability to "know themselves" by feeling. In another way of putting this, the sophisticated psychosomatic patient may be an acute self-describer when the self is considered as an object. But such persons in our experience do not understand what it is to describe the self as a subject; they do not "know" subjective experience. Paradoxically, this observation can be phrased to say that this sort of person cannot "objectify his subjective feelings." He appears to have a specific problem in "intersubjectivity."
In terms used by Head, Bartlett, and Piaget, the utility of being able to describe affective schemas is closely related to the problem of conservation of the self. It is only possible to know oneself in totally different external contexts by knowing how one feels. If it is not possible to know "myself" from the inside out, but only from the outside in, then when the outside changes, "I" change. The problem is that of contextdependence, precisely the same as that of the child who, even while watching a liquid being poured from a vessel of one shape into a vessel of another shape, insists that the quantity must have changed: "There is more because it is taller."
This cognitive limitation is most interesting in its affective implication. The claimant says, in various ways, "I am not myself any longer; it's just not me," carrying out unavailing self-examination, as did the woman who looked closely at her injured ankle every morning for years to see whether it had gotten all right overnight. Most astonishing, however, is the consistent finding that the disabled claimant has lost his ability to enjoy all his previous activities. He shows what can be called anhedonia, a loss of the capacity to feel pleasure; as a dramatic example, there is a marked deficiency in or actual loss of the ability to have sexual intercourse.
In approaching these claimants with assumptions gained from working with psychotherapy patients, one is repeatedly impressed with the comprehensive lack of introspective skill or interest. The inability to conserve the self appears to be the reciprocal of the lack of a developed self-concept. The significant connection is that a limitation in a cognitive function appears to play an important part in producing a chronic disability. We believe that it is probable that this disability state is similar to that of wartime disabilities in service personnel. The inability to develop a definition to fit altered circumstances seems to lead to a loss of identity and specifically to the loss of the capacity for "enjoying oneself," with the continuation of a state of confusion. We understand the bodily complaints in such persons as a misinterpretation of input that convinces the claimant that he must have some "organic" illness. We call this condition a somatization reaction, one variant included in the "conversion reaction" diagnostic category.
PSYCHOSOMATIC DISORDERS
We have returned recently to review the psychosomatic problem in the light of our experience with disability. Interviews with a group of randomly referred patients are strikingly similar to others done more than twenty years ago. In reviewing material collected by other observers over a period of almost thirty years, the uniformity of report is astonishing. In 1948, Ruesch reported that in psychosomatic patients, "verbal, gestural, or other symbols are not connected with affects and feelings." In 1949, MacLean (p. 350) noted an "apparent . . . inability to verbalize . . . feelings." In the 1960s two French workers, Marty and de M'Uzan (1963) commented that psychosomatic patients do not "produce fantasies." In several papers Nemiah and Sifneos (e.g., 1970), together and singly, have pursued the same observation. They emphasize in one of their papers the frequency with which patients have more than one of these disorders, an observation suggesting that the "diathesis," or "predisposition," is more generic than specific (in sharp opposition to the once popular idea that a particular conflict had to do with a specific disease).
In a paper on "suitability for psychotherapy" published in 1958 but written several years earlier, I summarized the characteristic verbal patterns in the following categories: unsuitable patients (1) cannot describe feelings, (2) exhibit relations in which the human other is implicitly regarded as essential but is not "overvalued" in a romantic sense, (3) tend to use nonspecific pronouns (especially "you" for "I"), (4) make bizarre interpretations of sensations, and (5) display circumstantiality in accounting their experiences. Shortly thereafter, I wrote a paper (only now in press: Shands, 1975) in which a comparison was made between anxious college students and rheumatoid arthritic patients. In this paper it was reported that all of the characteristics of "unsuitability" were typical of the arthritic patients. What was perhaps more interesting was the "selection" test done (with serendipity) by urging psychiatric residents to work psychotherapeutically with arthritic patients. Without exception, it was impossible to persuade any resident to undertake psychotherapy with any arthritic patient, while at the same time the anxious college student was enthusiastically accepted even when the resident had to work overtime to find a place in his schedule.
Some of the experiences we had with such patients on a psychiatric ward in the fifties were interesting in relation to context-dependence. A patient who was given cortisone for rheumatoid arthritis developed a psychiatric complication and was admitted to a ward functioning as a therapeutic community. In this ward both nurses and patients wore street clothes in a major attempt to eliminate some of the traditional professional separations. The arthritic patient absolutely refused to go along with these ideas. Instead, he insisted on wearing pajamas and a bathrobe and spending most of his time in bed. He insisted that being in a hospital prescribed this kind of behavior, and nothing could persuade him to try any other.
Reverting for a moment to the disability problem (in this case related to an open heart operation), we followed and reported the case of a man who complained of severe chronic disability (Shands et al., 1973). He was offered admission to the psychiatric ward, but he drá־ matically refused to be admitted. In the case report the patient is quoted as saying, after being handed a form entitled "The Rights of Mental Patients," "There's nothing the matter with me. I'm not like these people here, I'll stay here only if I can be in a bed where they'll take care of me, in a real hospital." In addition, he said, "What, am I going to stay here and get like these people?" This question indicates his fear of being assimilated into the group of "crazies"; it is recurrently interesting that the person who cannot find similarities has the reciprocal difficulty, namely that he also cannot differentiate accurately. With reference to the specific problem of recovery from cardiac surgery, Willner has shown that his test of the ability to find analogies (= similarities) predicts the post-operative course: the better the analogies score, the better the prognosis.
With uneducated persons in the disability context, the lack of sophisticated ways of describing human relations and the closely connected feelings was not unexpected. In taking our understanding of the disability problem to the psychosomatic context, however, it was again —as it had been previously—astonishing to find how precise the above descriptions of the psychosomatic way of talking are. Several excerpts from the transcribed records of a series of interviews follow.
Case 1
A middle-aged black woman who had been a maid in a hotel reported that she had developed rheumatoid arthritis about ten years before. In the course of the interview she also reported that she had had hypertension for a long time. Asked specifically about important changes in her life at the time of onset, she said that her husband had died a few months before her arthritis began. Then she said that they had been separated, as though his death were of no account to her— but then she added that she had had to "bury him."
In the transcript, a "matter-of-fact" way of presenting herself comes through immediately. She reports the course of her illness joint by joint with no indication of personal (as differentiated from somatic) suffering at all. In answer to a request, "Tell me a little bit about what kind of problem you have . . ." she said, "Well, uh, this whole problem that I have, it swells, aches, and this is a traveling situation. It first started in my hands and went to my shoulders, then both of my knees. Now what's bothering me is my hand swells sometimes, fingers, the wrist, left knee, pressure, got so bad I couldn't stand at all, I couldn't hold my weight. Knee swoll up, had fever in it, ah, swelling. Then the right hip has been bothering me for years and ah, so now I went to therapy, they had gave me heat treatment on my left knee, which seemed to help, but still very weak and sore in it." The patient interpreted the nonspecific request as a concrete indication for a "travelogue" in which she reported the movement of the disorder from joint to joint over many years.
In an attempt to explore the emotional connotations of the disease, the examiner asked, "Does it bother you? How much does it. . . ?" The patient's answer runs, "Well, ah, it's about, it about, I have stiffness, too, you know, any position that I'm in too long there, it bothers me. If I'm sitting, then, you know, it bothers me to get up and move around."
Still pursuing the emotional connotations, the examiner asked, "Are there lots of things that you used to be able to do that you can't do any more?" The patient replied, "Well, of, see, as I get . . . it seems to me as I get older (laughs) this arthritis, ah, it bothers me more, and, ah, I say it travels, you know, and ah, ah, being in certain joints for about eight years, you see, it seemed better in that way, that before, I could walk. Before then I, December I came in here for about two weeks, before then I did my own shopping. I could walk 5 or 6 blocks, back and forth, push my cart, very active you know."
The examiner attempted to explore what it is easy to assume must be distressing feelings associated with the marked loss of mobility, asking, "And how do you feel about that, how does that make you feel?" Again the answer is quite remote from the point of view implied in the question; she said, "Well, for one thing that helped me a lot, ah, to understand my condition, understand my illness, what's happening with me, I wrote away to the Arthritis Foundation, and got a pamphlet on this thing, and I read about it, and I found that you've got to have a state of mind with it, because, ah, at first it bothered me cause I didn't understand it. I'd think I was getting better and I'd encourage myself, and I'd feel great and I'd build a big, you know, like I'm going to get well, and then the next thing you know I'm down again, and just, I have depression, I feel depressed, I got nervous, I'm upset, I cry, you know, but now that I know. . . ."
The examiner asked, looking for "inner" feelings, "When you get depressed, how does that feel inside?" The patient answers, quite characteristically, in terms of the "outside" rather than the inside, "Well, for one thing, when I get depressed is when I get, see, what depress me is to be helpless, and I've been like that, ah, I've been in the hospital with this arthritis twice, the first time was a month. But then I still didn't fully understand until lately, really, you know. . ."
The examiner begins a question, but the patient continues, "What depress you, what depress you, is that when it flares up you aching, you in pain, you can't sleep, you can't move in any position. With me, I couldn't walk I couldn't, I couldn't take the covers off me, I couldn't do anything, I couldn't move, I just lay there and ache, so I depressed, feel sick and tired, can't sleep, and, ah, you feel awful [laughs] you feel bad, that's all."
What is characteristic in this sequence is what we have called the "pronoun shift." Predictably, as soon as the psychosomatic patient begins to talk about a "sensitive" area in which one would expect a comment about "my feeling" what comes out is a comment about how "you" feel. What is most fascinating is that the shift is quite systematic: when describing action, e.g., "I couldn't move," the "I" is appropriately placed, but when it is a matter of feeling, "I" disappears and "you" appears, "You're in pain, you aching." This repetitive and predictable technique appears to have the effect of distancing the unbearable situation, of "disclaiming" its connection with "me."
Still persistent in seeking "inner" feeling, the examiner asked, "Do you have any feelings inside when you're depressed or when you feel bad and depressed like that?" The patient completely and concretely misunderstands, hearing the "inside" question as an inquiry about her digestive-excretory function, with reference to medication. "Well, ah, no, because, ah, I was aware of taking my medication, the pills I have, with milk. Right now, I'm taking Maalox so I, ah, never had no trouble, you know, with my stomach, because I always tried to—and then it's important to take your medication after eating, you know, to sort of save the stomach, like, and I take prune juice every night to keep myself open, you know, stuff like that, very important, and lately I try to cut down on my weight."
Case 2
The cultural requirement in a highly complex civilization for the internalization of the social environment is a curious circular process involving first an "externalization" of one's own behavior followed by an "internalization" of the description of that behavior associated with the perception of the internal components. A second, highly intelligent, arthritic patient described his own distaste for this process in clear fashion in the words, "On occasion people have said 'Why do you look so angry?' or 'Why do you look so glum?', and I don't feel this on my face. It's kind of unconscious. When people will say that, it's disturbing to me because I don't, I'm not that type of person who likes to be read that easily."
Further, he said, "At the moment I'm isolating myself too much, I don't know why . . . I think it's something I've always done. I mean I've always felt alone. I don't know if that's something you would understand, but I've always felt personally pretty much alone, from as far back as I can remember . . . When I was growing up I think I was very unhappy, I think I was unhappy a lot of the time. I couldn't really figure out why I was alone, it made no sense at the time. . . . I always felt different in that sense." Asked about girl friends, he said that he had a steady girl "from time to time," but when asked if that made him feel less lonesome, he answered that it made him feel "more vulnerable." In discussing what he describes as a fanatical interest in athletics prior to the onset of arthritis in adolescence, he said, "My athletics was everything to me, to me it was a tangible accomplishment and for someone who didn't know how to make friends very well, it was a very good way of, a lot of camaraderie, a sense of belonging. After that I guess I felt I didn't belong anywhere."
The importance of the externalization of himself is attested in his description of the disastrous appearance of arthritic pain: "One day I noticed that it felt like my right toe was broken . . . I felt like my whole body was falling to pieces." When asked, "How was that disturbing?" he answered, "Well, because I took a lot of pride in my body. I was lifting weights . . . As I said, athletics was my whole life . . . it was probably too much of my life . . . it got to be kind of like a fix, . . . I couldn't do without it, and I felt kind of trapped in it . . . I really was kind of going at it like a maniac . . . When I found I couldn't do it at all, I went into a kind of tailspin because, you know, with no athletics, there was no me type of feeling. I felt like my body was betraying me somehow, it didn't want to go along with . . . and football was what I was primarily interested in . . ." A moment later, he elaborated, "At first I didn't think it was an emotional type thing . . . I guess the feeling that sticks out in my mind primarily was 'where is it going to end?'— because I no longer trust my body . . . Along with the depression there was a kind of fear of 'Where—am I going to end up in a wheelchair?' kind of feeling."
In relation to the feeling he calls depression, the interviewer suggested the presence of "inner" feelings, saying "Did you notice anything inside when you felt depressed? in your chest? or your stomach? or . . . ?" The patient said, "I didn't have anything that I . . . you know, physically, like you just mentioned, that I associate with . . . because at first I didn't think it was an emotional type thing, I didn't think there could be any possible connection."
What is most striking from one point of view is the way in which this arthritic patient objectifies an alien body that "betrays me." He is unable to identify with his own body. In the athletic frenzy of his adolescence, he was lifting enormously heavy weights, in isolation, with no comment positive or negative from a family that apparently left him alone and expressed no interest of either an approving or a disapproving sort.
He described himself as intensely, "viciously" competitive on the football field to the extent that other players were afraid of him— but he felt no anger. His "body" comes through as a mechanical object, perhaps like the racing car of the dedicated driver—but an "object" to him with a "mind of its own." In the most peculiar fashion, when observed from the point of view of those sensitively aware of many nuances in bodily function, it is inconceivable that "the body" could be so alien an object.
In a sophisticated social system, it is necessary to develop a high level of skill in constructing a self that takes into consideration both the physiological and the social contexts, the first representing a "lower" level of integration, the other a "higher" one. The self emerges as a mediator, an "interlocutor" that "interprets" from the lower to the higher level and from the higher to the lower. To do this one has to integrate data derived from social process (primarily in linguistic terms) with data derived from "physical" or "organic" change.
Case 3
Another patient interviewed in relation to her rheumatoid arthritis, an elderly woman who had been a successful singer before her marriage, reported that she also had had hypertension for many years, with a surgical intervention in the form of a sympathectomy. This woman was pleasant, gracious, and cooperative. Her comments in relation to her human relations showed a considerable distance and a preoccupation with not getting close to others. She reported an idealized relation with her much older husband, but she could not describe any feeling of grief or sadness when he died, although in speaking of it many years later she shed a few tears in a transient episode of weeping.
She responded to a question-suggestion, "It still upsets you [to think about your husband's last illness]?" with a simple "Yes"; then, to the further probe, "Could you tell me about that? You haven't gotten over it?" she replied, "No, not quite. He was a marvellous man, and he was in a nursing home for [sighing] three years." Still pursuing the problem, the interviewer asked about her feelings at his death, and she replied, "Well, doctor, I felt I should have been strong enough physically to keep him with me, to keep him at home, but I wasn't." Here she suddenly wept, but she could not relate the weeping to any "inner" feeling.
In response to a question as to concern about being alone most of the time, the patient answered in the affirmative; then, asked "Does that bother you?" she replied, "Yes it does. I would like to do volunteer work if I were able, but with this arthritis, I can't accept something . . ." Further pursued, the patient answered in the affirmative again when asked if her limitations "got her down," but when asked, "What's that like? What does it feel like?" she replied, "Well, I'm not really a gloomy person. I do a great deal of reading. I don't know that I'd be happier if I had a lot of people around me . . . I've been a loner, I guess." She reported going out to dinner with an old friend, but "She was so gloomy, she's getting old, too, and she told me all her problems, and I wanted to get away from there."
In this excerpt, what is perhaps most noteworthy to a psychiatrist is the patient's reluctance even to hear about the feelings of other persons. The threat of "contamination" or "contagion" is apparent: if the friend talks gloomily about aging, she might make the patient feel gloomy, and it is thus easier to abandon a human relationship of long standing than it is to tolerate the possibility of being threatened with "feeling bad" in whatever way.
Case 4
A very interesting patient was seen on referral from the internist because of a previous history of psychosomatic disease. Although he has no current psychosomatic disorder, his character is consistent with the syndrome we have seen, and his method of talking about his problems is typical. This man was in "analysis" with two well-known analysts but without much benefit—and obviously without the kind of "material" usually considered essential for the analytic process. A highly intelligent and well-educated man, this patient commented that, "I was always good about keeping my appointments," but he recognized his own problem: "I would go in and just talk, constantly and unstoppably, but very superficially. It wasn't that I was holding anything back, it was just that nothing was coming out but trivia . . . and I really just couldn't even stop talking. I was sort of out of control. I talked the way a deaf person does when he doesn't want you to say anything because he'll be reminded of his deafness."
This man noted that there had been a mixup in appointments for one of these analyses, and he was perplexed for a long time about what happened. His major complaint about the analyst was that he could get no information from him about whether he had been at fault or whether the secretary had made a mistake; he thought the latter because his appointment was made by a woman he never saw again. He explained that it was vitally important to him because he thought he was going crazy; he remembered the second analyst as much more helpful because he was "giving guidance." In the contemporary relation with an internist, he complained of chest pain he feared might be cardiac in origin. The internist told him it was due to muscular tension. In explaining why he had continued to see this physician, he said, "I evidently looked very depressed."
This peculiar statement indicates that the patient "looked depressed" but did not "feel depressed." Asked about a feeling of depression, he answered, "Just very lonely and, well, sort of, I sort of say over and over to myself I'm really depressed, you know, that I wish I were dead. And it's true really I don't get much fun out of life, but I'm not really suicidal, it has nothing to do with that. In fact it's sort of an escape valve, it makes me feel much better and relaxes me." As he said this, he smiled broadly, and when the smile was brought to his attention, he said, "I smile too much . . . It's probably a way of dealing with people. I think I was told that if you smile other people will like you, you know, when I was a child."
Because of his chest pain he feared heart trouble, but at the same time he described himself objectively as "healthy." Sounding somewhat like a familiar TV commercial, he said, "I'm really in pretty good health, I'm not overweight, I don't smoke, I don't take drugs, drink too much, or anything like that. I get a reasonable amount of exercise."
About the mistake in the appointment that occurred many years before, the patient commented that he "talked elaborately about how he felt," but he showed complete incomprehension when asked about how that was in his body. He said, "I don't think it upset me physically . . . I just feel upset." Pressed, he said, "I must have felt hurt and angry . . . I really wanted to know what had happened because I couldn't evaluate my own behavior." He later described himself as "anxious and compulsive," pointing out that these traits were useful in his work— which he found "boring."
He described his relation to his five-year-old son as the one human relation of importance to him; he is "on good terms" with his divorced wife. He has (in his late 30s) no female or male sexual partner and has not had sexual relations with anyone for over three years, since his marriage broke up. He thinks he is "just too frightened to get involved at all."
Returning to the problem of feeling, the interviewer explained to the patient that many people can localize sensory experiences of bodily change in "emotional" states. This seemed a novel idea to the patient, and he went on to explain that he had had severe asthma as a child, but that it disappeared at puberty. Then he said that in his analysis he once threw a pillow at the analyst upon leaving the office. Shortly thereafter he developed a severe asthmatic attack, which lasted several hours; otherwise he had had none except during the time his marriage was breaking up and he was making some renovations around the house. He could describe significant events only from the point of view of an outside observer: to him feelings are not felt, they are inferred as a necessary extrapolation from his overt behavior.
In relation to his almost complete lack of friends or female companions, his comment on a long trip he took with his parents and brother when he was sixteen is notable: "I guess being thrown in at close quarters with them on an extended trip like that made me very nervous." He cannot, however, describe a nervous feeling: "very nervous" is an inference. He developed diarrhea and was later shown to have two small ulcers—thus a mild ulcerative colitis. He consulted a psychiatrist and saw him for several years—but "it really didn't get anywhere."
In this patient the combination of excellent appearance and intelligence, good economic situation, and good education with almost total isolation and absence of intensely pleasurable experiences was most striking. It is apparent that he avoided "entangling alliances" of any sort. His reports are full of "I must have been angry" or "I appeared depressed" or other external statements. In the situation in which he was rejected in favor of the other patient, he was not angry—his reaction was an intense need to know what had happened, because otherwise he "didn't know whether I was wrong."
The most extraordinary implication of this interview is the fluency and accuracy with which the patient presented an objective view of himself—without any trace of a subjective experiencing.
WHAT DOES IT MEAN?
This material demonstrates again a remarkable consistency in observation over almost thirty years in many different places by different observers. The consistency of observation, however, is associated with a considerable lack of consistency in interpretation. What I want to discuss is the degree to which interpretative efforts using psychological and semiotic systems of thought, for the most part previously ignored in clinical psychiatry, add to possible understanding. The interpretation to be presented is quite different from the usual psychiatric instance, since it ranges into the clinical implication of Piaget's work for adults.
I have not been able to find any detailed epidemiological studies of diseases of the sort in which we are particularly interested. There are, however, bits of "circumstantial" evidence that suggest a significant correlation. In a review of the problem of allergy by Holt (1967), there is a suggestion that this general disorder is a "disease of civilization." Holt cites as a specific example that infants born to Chinese parents in the United States and those born to West Indian parents living in London have a much higher incidence of infantile eczema than do those born in their parents' respective homelands.
Bohrer, an American-trained radiologist, responded to Holt's article by reporting that he had found a remarkably low incidence of allergic reactions to materials used in pyelography and angiography in Nigeria as compared with his expectations from working in the United States (1967). In Nigeria he had found a low incidence of disorders in the auto-immune class, such as thyroiditis and hemolytic anemia, as well as of ulcerative colitis, rheumatoid arthritis, and pernicious anemia. It was recently reported by Short (1975), a rheumatologist, that the "modern" disease rheumatoid arthritis appeared only three hundred years ago—although archaeological evidence shows ankylosing spondylitis to be much older.
A news report quoted the director of Lincoln Hospital in New York as saying that in the South Bronx, by general agreement the most disadvantaged section of the metropolis, there is an inordinately high incidence of hypertension, asthma, diabetes, and obesity. Since the population in this area is mostly black and Hispanic, the contrast to the low incidence of a similar list of diseases in Nigeria is striking.
The suggestion emerges that diseases in this general category may have some significant relation to progress and advances in civilization and its complexity. Inkeles and Smith (Becoming Modern, 1974) report on the extensive examination of about a thousand workers in each of six developing nations. A checklist of psychosomatic symptoms filled out in the course of a long and complicated interview procedure showed no increased incidence of medical complications that might be thought related to "modernization"—but then the authors take note of the fact that all their subjects were in the process of making a successful adaption to modernity.
In our experience, the disease states of interest tend to occur differentially in the unsuccessful members of this society. Secondly, these disorders occur only when there is some kind of crisis in personal or occupational status or in both. We have found very convincing indications that the problem is first one of predisposition then of precipitation —and as in any epidemiological context, it is obvious that many are confronted with the "stress" or the pathogen while relatively few are significantly affected. Perhaps the clearest example of this kind of sequence is that blacks living in the ghetto have an enormously higher incidence of hypertension when compared with middle-class whites, which is often attributed to the greater amount of "stress" undergone. When the control group of whites is compared with middle-class blacks in similar adaptive context, however, the supposed ethnic difference disappears. This finding suggests that it is not the simplistic notion of "stress" that is significant as much as the matter of relativity of "stress" and "resistance to stress." A strong differential susceptibility appears to be concentrated in those who are poorly prepared to cope with the complexity of our society.
A most important feature of Durkheim's (1897) classic work on suicide is his description of the anomic state of those who had lost (or never adequately developed) a sense of their own identity so that they felt themselves to be "unnamed"—itself an interesting indication of the importance of the word-labels attached to all of us. We have found a great deal of evidence in our disabled subjects that the crucial loss for many appears to be that of the occupational context and the fellowship of co-workers. In a technological society, it appears that there is so great an erosion of the traditional modes of self-identification in context (especially in the extended family and in the pursuit of religion as a central theme in life) that the context of work takes a larger and larger place. Inkeles and Smith (1974) state that the process of modernization is most accelerated through two artificial institutional contexts, the school and the factory; they estimate that three years in a factory is the rough equivalent of a single year in school.
From a slightly different standpoint, it is clear that what is the same in both, and different in both from the background of the preliterate person, is that these are artificial institutional contexts of a highly formal type. Both the school and the factory require a rapid, intensive process of socialization to a completely different set of norms and forms. The not uncommon occurrence of school phobias in children and the notorious "resistance" of ghetto children to the socialization involved in school work in modern urban centers speak to the same point. The first consideration in the school and in the factory is the development of what can be called in psychoanalytic terms a "transference to the institution," along with the development of a preference for the society of those already acculturated. There is thus required both an institutional and a new form of group transference in this somewhat extended use of the term. The school and the factory become "homes away from home," in a movement often fostered and intensified by the provision of recreational activities as a function of both school and factory—for the greater development of "school spirit."
SOME CONTRASTS
Carothers (1959) has given a description of preliterate Africans with reference to social context and to some of the implications of that context. He points to the "embedded" status of the human being in a preliterate culture.
A man comes to regard himself as a rather insignificant part of a much larger organism—the family and clan—and not as an independent, selfreliant unit; personal initiative and ambition are permitted little outlet; and a meaningful integration of a man's experience on individual, personal lines is not achieved. By contrast to the constriction at the intellectual level, great freedom is allowed for at the temperamental level, and a man is expected to live very much in the "here and now," to be highly extroverted, and to give very free expression to his feelings.
Here I would stop for a moment to take issue with the term "expression of feelings." What the author is talking about is significant action—but I know of no evidence that freedom of action is correlated with the inner perception we call "feeling" or "affect"; instead, there is a great deal of evidence that strongly suggests that only when action is internalized is it possible to speak of "feelings." This is implied every time a psychoanalyst talks about either "acting-out" or about "delay of gratification": it is the internalization of significant action that appears as feeling—and it appears as feeling only when it cannot he exhibited as action. Anger is internalized attack, appetite is internalized eating, passion is internalized sex—all predictive of possible outcomes of some current situation in which direct action is impossible, inhibited, or blocked. Sexual intercourse is very different from romantic love—although it is not infrequently the outcome of a period of romantic love, just as eating is often subsequent to the experience of appetite. But the act of intercourse involves "feeling" in quite a different sense from that in which one can (if he knows how) describe feeling in a psychiatric interview.
The problem of the highly civilized person in a developed social system is the reverse of those items cited by Carothers. He has to learn to think of himself as an independent, self-reliant unit; he has to learn how to differentiate, and tolerate differentiation, in the self-family context; he has to abandon primary identification in terms of his clan; he has to learn to live in the future (and the past), not in the here and now; and he has to learn to inhibit "free" action and to show highly structured and secondary skilled action.
Carothers describes the context of control in the preliterate:
Behavior is minutely governed from childhood on in a host of particular, concrete situations by meticulous rules and taboos, and not on the basis of a few broad principles which require personal decisions for their application. These rules acquire much of their force from the fact that they are sanctified by tradition and reinforced by supernatural "powers," and so may not be questioned. Explanations of events are given to children on magical and animistic lines, which are far too facile and too final, and effectively suppress childish curiosity and suppress the urge to speculate. . . . The African child receives ... an education which depends much more on the spoken word and which is relatively highly charged with drama and emotion.
Here again it is necessary to introduce a caveat. In the above sentence, drama and emotion refer to the situation "in the real," not in the formal, sense. In the formal sense drama connotes an elaborate illusional system like that of grand opera, and the eliciting of an emotion requires great ability to sit still, look first, and listen second, and experience emotion not in dancing, yelling, fighting, sex, and the like, but as a purely "inner" experience that can only be "externalized" by retrospective appraisal of "how moved I felt when. . . ."
In the preliterate society, every individual plant has a name and a use, and there are hundreds of them. On the other hand, the preliterate person is "embedded" in the clan or family and so is not "a particular" to himself. In the complex society in which "a few broad principles" govern social conduct, Einstein characterized the ideal of scientific problem solving as the pursuit of just those few broad principies. Einstein (1949:17) writes (in an "autobiographical note"), "I soon learned to scent out that which was able to lead to fundamentals and to turn aside from everything else, from the multitude of things which clutter up the mind and divert it from the essential."
The contrast is one between particularity of "objects" associated with "embeddedness" of persons in a preliterate society vs. departicularization of objects into categories and classes that constitute scientific "fundamentals" in a complex society. Generalization according to "simple principles" is carried out by an "individual" person; in Einsteins case, there is much to suggest that he could tolerate, to a remarkable degree, being alone—"an individual." The mutually inverse relation is similar to that of the private who lives in general quarters and the general who lives in private quarters.
CONCRETE–ABSTRACT
What is embedded in this discussion is the precise distinction between "concrete" and "abstract" in terms of thinking. Lévi-Strauss (1966) emphasizes that the savage who knows particular plants is a "scientist of the concrete"—a term that contradicts Einstein's assertion that the scientist learns to avoid "the multitude of things that clutter the mind." The "concrete savage" is characterized by a cluttered mind: Bartlett (1932) points out that the Swazi have an extraordinary memory for each cow, calf, or bull that was bought or sold and remember details of coloring, price, and the like from unimportant auctions years ago. On the other hand, the principle of special relativity is (in something of an oversimplification) an exploration of the implications of the fact that the speed of light is finite, one overwhelmingly important "fundamental."
When we see the contrast between two such polar extremes, it becomes more reasonable that the "savage" should react or act in the immediate, concrete, particular present, exhibiting his behavioral responses here and now under the control of particular rules his associates take as absolute and which they are highly interested in enforcing at every moment. He is "embedded" in his group, and he does not need internalized thoughts or feelings. Malinowski (1923) notes that the savage never considers language in terms of reflection, only in terms of action: speaking words is like paddling a boat. Only when it becomes possible to use a written symbolism is it possible to begin to imagine that the universe is "reflected in" verbal sequences, to use the metaphor of a mirroring technology, and thus to approach "reflective thinking."
At the opposite pole from the preliterate savage, we find "modern man," in Inkeles and Smith (1974), quoting Moore: "The traditional kinship structure provides a barrier to industrial development, since it encourages reliance of the individual upon its security rather than upon his own devices"—the implication is clearly that of "his [individual] devices" (p.74). They point to the emergence of women's rights (defining women as individuals, that is) as characteristic of modern societies, and to the use of birth control as a function of the same kind of "motivation." They go on to say, "Religion ranks with the extended family as the institution most often identified both as an obstacle to economic development and as a victim of the same process." Parrinder is quoted, "African society has traditionally been permeated with religion. But the ancient religious beliefs cannot stand the strain of modern urban and industrial life." Still further, "It is widely believed that . . . an almost inevitable tendency of modernization is to erode respect for the aged, and to foster a youth culture in which old age is viewed . . . as a dreadful condition to be approached with reluctance, even horror."
In summarizing these contrasts, it becomes apparent that "modern man" is abstracted man, disembedded man, who lives not in a world of immediate meaningful sensory experiences but in a world of remote indirect conceptual structures. Much of the history of contemporary rebellion against what is now the dominant theme of science and technology in the United States has to do with a disenchantment with the general and a reappraisal of the particular; with the task of the artisan rather than with that of the intellectual, especially the intellectual specialist; with feeling instead of with thinking; with "consciousness expansion" rather than with the development of analytic precision.
With this background, if we look again at the self-description given by the relatively young man in Case 4, we find a departicularized person. He insists that there is "nothing physical" about his actions, even when he seems to have been intensely "moved." He cannot stand the long continued presence of even his immediate family on a pleasure trip and develops ulcerative colitis in that context. His job is one of editing and preparing manuscripts, at which he is very good—but which he finds boring. He stays by himself except for seeing his small son. He thinks of himself as "healthy" because he does not smoke, is not overweight, and takes exercise—but at the same time he develops hypochondriacal fears. When the physician tells him that he looks "extremely depressed," he takes the physician's word for it—even though he can find no "depressed feelings" in himself. Instead, he says to himself, "I wish I were dead," without suicidal affect—and even with "relief." This man has a graduate degree from a first-class American university, he is solvent, obviously highly intelligent—and almost totally isolated and without feeling. A tragic "accident" of modernization.
To cope with life in a developed society one must develop "inner resources," significant personal relations based on personal preference, which in turn means selection based on feeling. "I" do not automatically associate primarily with an extended family, "I" select those I find "in harmony," those with similar "attitudes" and "interests." Instead of inheriting an extended family, "I" select a corporation, a psychoanalytic institute, a university department. In all of these "I" have to deal with the fact that membership is purely contingent and continuously dependent upon the acceptance of "me" by the other members of that group, whatever it may be.
The problem of "finding my way about" in so ambiguous a context is one of "consulting entrails," but in a somewhat different sense than does the haruspex. "I" have to know primarily from the inside out, what "turns me on" if "I" am to be turned on. It is not routine to live in a complex society, it is a constant struggle not only to survive economically but to continue to live in supporting social context. At the same time, in a big city, almost every trend works toward separating, isolating, differentiating citizens from each other.
The educational problem confronted by a member of a complex civilization is dual. In the first place, he has to learn intellectual schemas in the context of formal education, which for the most part are based upon and presuppose intensive training in the technology of literacy. On the other hand, and almost "covertly," he has to learn affective schemas that can serve as programmatic elements in his human relations. Scheflen (pers. comm.) has emphasized how large a part courtship patterns play in these affective schemas; in the cases cited above, each one shows a significant lack of success in making and maintaining satisfactory sexual relations. Where divorce is instantly and easily available, the maintenance of a marriage is a constant struggle rather than a matter "taken for granted."
What we have been working with in the above inquiry is the range within the human condition, in relation to the problem of relative describability. The disabled person who cannot "see" what may appear to be obvious categorical similarities (apple and banana, table and chair) may nevertheless have been a satisfactory member of his group and a satisfactory industrial worker until he became "other than himself" or "not me" through the complex processes of accident and bureaucratic processing of the implications of that accident. The disabled claimant appears to be in Humpty Dumpty's condition : he "had a great fall" and nobody (not the compensation board, the psychiatrist, the rehabilitation worker, etc.) was able to "put him together again' The situation demonstrates the britthness of personality integration in a cognitively unsophisticated member of a complex industrial society.
In terms used by Bernstein (1964) in referring to the implications of a restricted code, we find again the basic problem of "consciousness" : "Where meanings are context-independent and so universalistic, then principles may be made verbally explicit and elaborated, whereas where meanings are context-dependent and so particularistic, principles will be relatively implicit, or, as in regulative context, simply announced." The process of becoming "context-independent" is closely related to the process of abstraction as implied in the notion of "taking away from" a particular situation into a general context. In our observations, this problem is demonstrated again and again in the assumption that "my feelings" are the same as those of "everyone" and therefore need not be described or abstracted; in answer to the question "How did you feel?" the claimant says, "How would anybody feel if . . .". With this undeveloped describability, the person cannot know that his inner feeling may join two contexts in both of which he feels angry or anxious; instead, the two situations are unintegrated, and he cannot "separate himself" from the context to understand that both context A and context В induce "the same" inner feeling.
CONCLUSION
I have attempted to summarize some new ways of looking at old problems inherent in a semiotic point of view. When we speak of a basic science, we usually ignore the fact that the most basic study of all is the study of the way sciences are formulated. That is, before we can "know" a thing, we have to have a description of it and its name, with the definition forming the reciprocal of the name. Then when we begin to study studying, we find that the preliterate "savage," a scientist of the concrete in Lévi-Strauss's paradoxical term, knows an enormous variety of useful plants and animals as separate items. A true abstract science appears at the moment when, by keeping records of the various items, significant similarities to distant and past forms can be established. Then and only then does it become possible to construct categories and families of relata, and from this construction to set up hierarchies in various methods of comparing developments.
We can conclude that mentational progress depends not only upon man's inherent neural data-processing apparatus but also upon the technological adjuvants that appear in their own line of evolution. Until and unless human beings find a written technology, it is impossible to perform certain intellectual operations—although, on the other hand, once the implications of the written technology are developed and internalized, it becomes possible to carry out many intellectual operations "in the head" (i.e., in the "imagination" through projecting internal images). A truly transactional process appears, in which "projection" and "introjection" necessarily participate. What we first formulate "out there" is later discoverable "in here." Very interesting examples of this reciprocal "innering" and "outering" are to be found in the many analogues between the brain and electronic data processing.
At the abstract level, it is continuously fascinating, as the various components appear, to see the basic similarity between cybernetic and linguistic technologies and those discovered in neural methods. When Boole invented the binary code, he did not know that in its long-distance operations the nervous system uses the "all or none" principle represented by the 0,1 that is the core of binary codes. Influenced by "standing waves" in the electrical context and by the humoral "field" in the hormonal context, the nervous system shows many of the characteristics of the "more-or-less" pattern of the analogue computer. The leitmotif of all knowing is the similar in the apparently different and the different in the apparently similar—the construction of categories and the discovery of anomalies, a term used by Kuhn, meaning "un-named."
The process by which a human being learns how to split himself so as to become his own primary respondent is best described as one of inner speech, in which "I" talk (as it were) to "me"; then, suddenly shifting places, often quite without realizing that the "subject" is now different (both the subject matter and the subject-speaker), a different "I" hears a different message. It is only when such a system has been developed that it becomes possible to speak of a "self-concept," that is, of a definition of "me" by "myself." With a well-developed self-concept, a long step toward becoming an "independent individual" has taken place.
The peculiar operations included under "psychoanalysis" and "insight psychotherapy" using some variant of "free association" are all based upon the possibility of the externalization of inner speech in the presence of another who is thereby made privy to what most of us keep secret (often keep secret from ourselves!). The implication of this exposure of privacy is that the other who may do little or nothing except be there with an occasional explanatory comment becomes a highly significant other. Because this other knows "all my secrets" he becomes powerful enough to alter the internal conversation. Through projection, the other is identified with all those who in previous contexts "knew what I am thinking"—but as the therapist becomes powerful by projection, he also comes to have access to the program by introjective identification—so that in principle it is possible to change the program of control and thus change the "patient's" behavioral patterning. Obviously the process is only occasionally and partially effective—but in principle, it is overwhelmingly fascinating.
We have come to realize with an increasing sense of wonder and excitement that we have another comprehensive example of the same basic pattern noted above. The human being's program in a static description is the reciprocal of a complex set of programmings throughout his whole life history. What we know as a "personality" is the reciprocal of the "history" of his experience, a history more unconscious and indescribable than it is conscious and describable. The "elements" of the "program" are the assimilative schemata controlling behavior that have been learned through accommodation in "outer-oriented" behaviors.
In the latest development in this series it is possible for the human being, in Bartlett's (1932:206) imaginative phrase, to "turn round upon his schemata" and to learn how to describe his own behavior and, more important, his own implicit or inhibited behavior. These appear as significant "feelings." Human beings know how to describe actions in others by observing the others from the outside. Ultimately the human being, by "othering" himself in association with a preceptor (cf. Mead, 1934) comes to be able to describe himself from inside. We call this process by the everyday expression "knowing one's feelings," in a context in which feeling is primarily a descriptive term applied to affective schemata that include muscular, visceral, and glandular potentialities.
We have spoken of the goal of this development as the human being's arrival at the conservation of the self. As far as we can tell only the very highly educated person is able to know his own patterns and potentialities in terms of his feelings—so that he is able to be social or solitary depending upon the context in which he finds or places himself. In our experience, one gets to this point by paradoxically accepting the impossibility of freedom as the basic condition of relative freedom within some system in the construction of which one has at best only a very minor and unimportant part to play.
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