Lately, I’ve been directed to an article on analysing what patients with psychosis say in clinical interactions (link here). I think it’s a very good article, based on real-world data (clinical encounters), with a clear analytic framework. That said, I would like to comment one of the aspects of the paper.
I don’t want to summarise the paper. Let me just say that the authors, Alessia Zangrilli, Maev Conneely, Rosemarie McCabe, Federica Catalfio and Stefan Priebe, offer an 8-category catalogue for categorising what patients say. As I said, I think the article is very good, but one of the categories worries me and I would like to offer a critique (hopefully somewhat stinging) thereof. There we go then. Much of what I say I wrote about in my book Men’s Language of Emotions which is devoted to how people, and in particular men, speak of their emotions.
The first category is this:
- The patient describes how he/she feels and/or his/her present emotions and feelings, naming them explicitly.
It had predecessors, though, and they were
- The patient describes his emotions
- The patient describes his emotions, naming them properly
It is unclear why the authors shifted the category from describing emotions to describing them explicitly. The question I would immediately ask is why non-explicit descriptions of one’s emotions are somehow uninteresting. Is it because such descriptions don’t refer to ‘true’ emotions, or is it because it’s harder to spot non-explicit references? Both reasons (I can’t think of another one) are unsatisfactory. The form of the story hardly has a bearing on the nature of the thing it describes; difficulty in spotting the description is a serious concern, but simply circumventing it is hardly a solution.
Unfortunately, avoiding the issue seems to be the direction of travel. The initial intuition was to take on describing emotions, then the authors seem to have realised that that’s too hard, so they went through ‘properly’, a non-starter, moving to ‘explicitly’, which does seem to offer a way out. But does it? Is explicit emotion talk easy to spot? Let me offer two examples (taken from the book I referred to):
(1) [speaking of taking his daughter to university] I mean the night we left her at university she didn’t go in halls, she went into a students’ house. and that night was pretty traumatic, the drive back down the M6 was pretty dramatic. so, we’ve been used to her not being here.
(2) [speaking of his mortality] I suppose at the death of my father. That’s the first time I began to think of it. Curiously it has worried me less than I suspect it worries most people. Because I’m an atheist so I don’t fear anything is going to happen to me after death. Just afraid of the dying.
Are these explicit references to emotions? The reference to the trauma and the drama is quite in your face in the first extract, except it is predicated on the drive. Men do a lot of linguistic distancing when they talk about their emotions, but is it explicit? Note, incidentally, that there are no emotion labels in the extract. In the second extract, the fear of dying is again talked about explicitly, but never really linguistically claimed by the speaker. Is it explicit then? Is mentioning of a particular word enough?
The instructions for coding are as follows:
- The ability required by this item is to recognize and to pinpoint an emotion or feeling. Descriptions of physical/somatic sensations (i.e. I have a headache/pain) do not count. Therefore, we will code this item only when the patient uses the words of basic emotions, like fear, joy, anger, anxiety, sadness, shame, disgust or guilt, or when he/she describes how he/she feels referring to emotional states. This item also codes the description of feelings for someone else (i.e. “I am in love with her”) and for himself/herself (i.e. “I hate myself”).
To which my reaction is: wow! That’s a really surprising cop-out. The first problem is that the authors do not stop to think about people’s vocabulary ranges and the dominant speaking practices. Are we, for example, really mostly talking about anger by using the word ‘anger’? Judging by my own experience, I don’t think so.
Now, the authors do deal with extract (1) above. References to trauma and drama are out and that’s it. I find it deeply unsatisfactory, but I accept that the references are ambiguous, hard to decide. Extract (2) would be in, the speaker explicitly uses words from the list. All good? No, because I continue to have a problem with the authors’ insistence that a person must use certain words in order to say that they speak about emotions. Why? Well, because this is untenable. For example, let’s imagine someone says (my invented example):
- And when I saw here leave, Oh, gee, fuck me, bloody hell.
Is this describing one’s emotions? Bloody hell, of course, it is. Moreover, I think that it’s as explicit as it gets! When I use the example when teaching, I often ask what kind of emotions were described (or expressed). Students and clinicians immediately jump with the kind of words that you find in the coding instructions above, but my response is much simpler. They are the emotions which are explicitly expressed/constructed by: “Oh, gee, fuck me….”. This is because I reject the idea that emotions exist only if there are words which describe them. I also reject the idea that we need a label to understand what the person is saying to us and how they’re feeling.
There is an interesting aside here. Should patients be allowed to swear in front of their clinician? Whenever I ask such a question, most clinicians say that it’s inappropriate to swear in their surgery. It’s disrespectful, they say. I can’t disagree more. If you command respect by insisting that your patients can’t speak the way they speak, you really should take a break and think again.
But let me up the ante. Here is a fragment of an extract from the book on men and emotions. One of the informants said (it’s my translation from Polish):
- I would do something. I pace to and fro in the flat. No idea which way to turn. Where to go? Where will I go?!
The snippet is part of a longer narrative of an unemployed man trying to find a job after being made redundant, except he is unsuccessful, so he stays at home not knowing what to do. I think (and argued in the book) that his narrative is full of emotionality. I think it brings the imagery of a caged animal not being able to leave the cage/flat. The problem with it is that there are no ‘anger’ words, even better, there are no words which are stereotypically associated with emotionality. We may well argue that the narrative doesn’t describe emotions explicitly, though, I don’t think it’s a slam-dunk argument.
Here is another extract (translation from Polish):
- RC: I mean how I imagine the future. well, I can see two scenarios. First is that I shall eventually take up employment which will simply enable me, not only me, but also, say, my family, some kind of functioning. Moderately normal. And the other, well I am still on benefit right now and, I qualify. after a time, well, what’s left is black despair after losing the right to the benefit. Well, it’s difficult to live on, say, [my] pensioner mother, isn’t it? So the other is rather I don’t know (a little) macabre.
Is this, again, not a story about emotions? It seems not to qualify under the authors’ instructions, although I am really not clear. On the one hand, he does use the word ‘despair’, on the other, he doesn’t use it about himself, it’s externalised, something awaiting him. So, is he describing his emotions? Of course, he bloody is! The ‘black despair’ positions the speaker at the extreme end of the emotional spectrum, even if it is only to come. But is it?
A similar fragment (again in translation):
- When you are unemployed, you dream of blackness. Not a coffee, a woman, just blackness. You wake up at 5 in the morning in blackness. I have work now and I still wake up in blackness, because I know this fucking state. I know how it hurts
Is he talking about his emotions? Of course, he is. But the ‘emotion words’ nowhere to be found.
And we come to one of the most frequent problems with the psychological/medical approach to emotions and emotionality. It keeps focusing on lexis. And the problem is because language does not consist of words only. Not only are words parts of larger structures, but they are also used in contexts. And contexts can just about invalidate what you say on the surface, for example, because you have a grin on you face. Moreover, whatever can be said, it can be said differently, and there is never one way of saying it. Why, following the article authors, should only one way of talking be favoured?
Incidentally, it is worth noting that the authors do note context-dependency as a limitation of the study. However, in contrast to the authors, I tend to think this is a limitation too far.
To conclude, I keep liking the article, its foundation and methodological clarity are very good. I wish more could be like this. However, the category of speaking about emotions is lacking by some margin. The reductions imposed by it mean that too much is missed, in my view. The category becomes not one for describing emotions, but a category of ‘the patient is using certain words’ and that is not helpful at all.