The Zeigarnik effect: Uncompleted Tasks and Passover Memory

"There is a story of a certain pious man who forgot a sheaf of grain in his field [thereby allowing him to fulfill the commandment of leaving the forgotten sheaf in the field for the poor Deuteronomy 24:19]. He said to his son, 'Go and make an offering...'  His son said, 'Father, what makes you so happy about doing this commandment more than any other commandment?'  The pious man answered, 'The All Present One gave us all the other commandments in the Law to do on purpose, but this one [which involves forgetting] cannot be done on purpose.'"  Tosefta Peah 3:8

I was re-reading John Gottman's The Science of Trust today in between various tasks of preparation for Passover, the holiday of interrupted memory. 

In 1922, a petite 21 year-old newlywed Jewish woman named Bluma Zeigarnik sat in a cafe in Vienna and watched as professional waiters listened carefully to huge orders from large gatherings without writing anything down. Then she watched as the waiters flawlessly filled their orders. Always the astute observer, Zeigarnik later interviewed these waiters. As they moved rapidly from table to kitchen to table, she found they remembered everything the customers asked for. However, when she interviewed the waiters after they had filled the orders, they had forgotten everything... This later was coined the ‘Ziegarnik effect’. It is defined as follows. We have better recall for events that we have not completely processed. Zeigarnik found that on average, there is 90% better recall for ‘unfinished events’ than for events we have somehow completed.
Paul Klee's  Angelus Novus .  Walter Benjamin said of this painting "His eyes are staring, his mouth is open, his wings are spread. This is how one pictures the angel of history. His face is turned toward the past. Where we perceive a chain of events, he sees one single catastrophe which keeps piling wreckage upon wreckage and hurls it in front of his feet. The angel would like to stay, awaken the dead, and make whole what has been smashed. But a storm is blowing from Paradise; it has got caught in his wings with such violence that the angel can no longer close them. The storm irresistibly propels him into the future to which his back is turned, while the pile of debris before him grows skyward. This storm is what we call progress."

Paul Klee's Angelus Novus.  Walter Benjamin said of this painting "His eyes are staring, his mouth is open, his wings are spread. This is how one pictures the angel of history. His face is turned toward the past. Where we perceive a chain of events, he sees one single catastrophe which keeps piling wreckage upon wreckage and hurls it in front of his feet. The angel would like to stay, awaken the dead, and make whole what has been smashed. But a storm is blowing from Paradise; it has got caught in his wings with such violence that the angel can no longer close them. The storm irresistibly propels him into the future to which his back is turned, while the pile of debris before him grows skyward. This storm is what we call progress."

Zheyna Bluma Gerstein was born in 1901 in Lithuania, in the town of Prenai.  In one sense, that sentence tells you everything need to know of Bluma Zeigarnik nee Gerstein.  To be born in that place, at that time, with the name Gerstein, was to be on a collision course with one of humankind's most ambitious projects in the obliteration of memory.  Her work's title "Remembering Completed and Uncompleted Tasks" could be an understated, Proustian premonitory description of Europe and its Jews over the next 50 years.  Bluma Zeigarnik was writing a fortune cookie oracle to herself.

She marred Albert Zeigarnik when she was eighteen.  They moved to Berlin and she studied psychology with Kurt Lewin.  "Remembering Completed and Uncompleted Tasks" was published in 1927 and she received a doctorate from the University of Berlin.  Albert became a communist in the face of mounting Fascism.  In 1931, the couple moved to Soviet Moscow.  No more Viennese waiters with flawless memories.  There she could not claim the title of Doctor since a PhD was considered bourgeois and ideologically suspect.  She studied post-traumatic dementia and published little.  She worked with two greats of Russian psychology, Lev Vygotsky and Aleksander Luria, both of whom eventually ran afoul of Soviet repression of unorthodox scholarship, Lysenkoism and anti-Semitism.  Luria is famous among non-specialists for his case study, "the Mind of a Mnemonist," the story of S., also a Jew, a synesthete with a very nearly boundless memory who performed great feats of memorization in public, quickly looking at huge tables of numbers which he reproduced flawlessly.  S. eventually encountered the difficulty of being unable to forget the tables of numbers.  He was afraid that he would confuse the tables because he could see them all before his eyes long after they had been erased.  He resorted to various devices, technologies for forgetting.

[H]e began to throw away and then to burn the papers on which was written the material he needed to forget...
However the “magic of burning” did not help and one time, throwing the paper with the written numbers into a burning oven, he saw that on the remaining burned paper the traces still remained and he was in despair: it means that even fire cannot erase the traces of that which was supposed to be destroyed!
The problem of forgetting, which did not allow any naïve methods of burning papers, became one of the most tormenting problems with S.
— Ivan Samokish's translation

In 1940, Albert Zeigarnik was arrested and sent to a prison camp for ten years.  Bluma's time in Berlin and cafes in Vienna, her important work on memory which was now being celebrated and elaborated outside of Soviet Europe, all this was a liability.  Central European psychology of the 20's with its bourgeois (not to mention, Jewish) flavour could not have been more at odds with Stalinist-Marxist materialism.  She did not speak of it.  She had two small children.  To recall her past was to risk making her children orphans.  When Albert was arrested, family papers were seized, the relics of her past disappeared. 

She was sent away from Moscow to the Urals.   Her grandson, A.V Zeigarnik, wrote a long and loving biographical sketch of his grandmother.  In his telling, her life story in the post-war period becomes a series of ellipses and repressions of memory. 

"After World War II, Bluma began to prepare a dissertation based on the medical studies she had begun in that period. But just as the dissertation was nearing completion, it disappeared. To put it bluntly, while visiting Bluma at her home, one of her coworkers at the psychiatric institute had stolen it. Bluma then promptly destroyed all the drafts. She was afraid that it might be published, and she would then be accused of plagiarism. Today, such a turn of events may seem implausible, even absurd, but fear is sometimes more compelling than clear thinking.

Other aspects of her research were simply not publishable. For example, among the experimental methods used in attempts at restoring a patient’s motor activity, the following was actually tested: A stand-in, dressed in a military uniform, announces to the sick person that he is a commissar. The commissar gives orders to the patient, the fulfillment of which could lead to the restoration (possibly partial) of lost motor functions. Today, no documentary evidence about such experiments has been preserved; nor is there any data about their reproducibility. But one thing is completely clear: In those years, one could find oneself in prison for conducting such experiments, whereas now it is no longer possible to repeat them, at least not in Russia, since there are no longer patients with such a reverent attitude toward commissars or other political figures.

In 1943, when Bluma returned to Moscow with her sons, she found her apartment had been robbed. While they had been living in Kisegach, the authorities had housed in their Moscow apartment an unknown and unpleasant person. For some reason, this person considered everything his own property, with the result that he had used the home library and much of the furniture as firewood for the stove. It is possible that part of the family archive vanished during this time. During this resident’s struggle for warmth, he tossed into the fire, in addition to the writings of scholars who were unfamiliar to him, all the publications of Marx and Engels to be found in the home. (Does there not seem to be something mystical in this unabashed materialism?) The writings by Lenin, however, remained. Bluma had to endure numerous humiliations, but, after the intervention of a military prosecutor, the apartment was returned, and she was then finally able to resume her normal daily life."

In a final triumph of materialist erasure, Bluma's one reflection that has been translated into English about the Berlin period is hidden behind Wiley's paywall.  In 1984 she wrote a memorial for her old teacher Kurt Lewin on the occasion of his death.  For 32$ you can read and print the reminiscences of a pioneer of the study of the human mind, fugitive from fascism and prisoner of Stalin about her old beloved teacher and mentor on the occasion of his death.  She died four years later, to all appearances a loyal daughter of Soviet communism. 

I imagine a ghost, the memory of an unfinished task persisting even after the body that contained it has gone;  a waiter at a Viennese cafe, unable to forget, because she left before he could deliver her order, her odd meal, which he seeks to deliver year after year and which she can never receive; four cups of wine, three pieces of flat bread, like the poor people eat, a roasted egg, some bitter herbs, a shank bone, a bowl of salty water. 



Cheese factor five; the therapist's secret fear of being Elle magazine.

"How about a nice Wensleydale?"

"How about a nice Wensleydale?"

I broke down and did it.  Between appointments, I wrote index cards that said, "Your partner's favourite band," "What your partner was wearing when you first met," and "Your partner's secret ambition."  These come from a series of exercises developed by John Gottman called "Love Maps".  You hand the cards to the client and s/he says what s/he thinks is the right answer or asks his/her partner.  Gottman is one of the most prominent and serious researchers of couples ever.  There's a whole lot of theory and research behind "Love Maps" but the first time I handed these cards to my clients, I cringed a little (I hope I did a reasonable job of hiding it). 

My cringe went a little like this: "I went to graduate school for three years and then did post-graduate training for years afterwards.  Now I am doing an exercise that feels like it has been clipped from Elle magazine."

Love Maps has a high 'cheese factor.'  That kept me from using it for a long time even though it is an evidence-based practice for helping couples do better. 

What is it about cheese?  I rely on being able to offer people something they can't get from a popular magazine or an online quiz for my living and my sense of professional attainment.  Not only that, coming to someone who they believe knows a thing or two, helps people feel safe, which is a prerequisite of a lot of the work of therapy.  I worry that the pungent odor of cheese can destroy that confidence that my clients and I rely on. 

Its not just me.  My training has been aimed at instilling a sense that therapists have complex, scientific knowledge that allows us to serve as serious professionals with something to offer that goes beyond the self-help section of a book store.  I think that is true.  But I also remember what Sylvain and Elise told me (names are made up).  They came every week to therapy and used it really well.  But at one point they said to me, "You're nice and all and you're probably good at what you do but for us the metro ride over is the most therapeutic part of the whole thing. We never have a half an hour where we are just sitting and talking about what's going on with us." 

Family doctors are highly trained professionals who spend a big portion of their time telling people stuff that their moms could have told them; "Have some soup and rest."  "Stop picking at it."  Sometimes you need a professional to tell you (because you won't listen to your mom).  In plenty of cases the mechanics of having a loving relationship aren't rocket-science; be kinder to one another, develop affection, show caring, stop bad habits that drive one another away, pay attention to your own and your partner's feelings etc.  What is hard is making the commitment to do it; taking the weekly metro ride over to my office may be some or even most of the therapy. 

So now I don't cringe (much) when I take out the Love Map cards.  Some couples roll their eyes and laugh at how cheesy it is and I laugh with them, but usually they smile at each other they laugh at one another's foibles or shared memories.  When they do the Love Maps exercise, couples understand one another a little more.  They have a little more feeling of affection after they do it.  And despite doing something they could have done online or from a magazine, many of them find it worthwhile to come back. 

Not doing things because they feel cheesy is actually a pretty big issue for some clients as well as for their therapist.  Some people hate the idea that doing basic, pedestrian things is going to help them.  (I wrote little about this here).  As the therapist, I sometimes have to model that we can push past our impulse to eye-roll just like we can push past other things that keep us from doing what helps. 

I would love to know your experiences of cheese in therapy.  The person who sends in the best example will get ... hmmm. a lovely stilton? or perhaps a nice wensleydale? whaddya say Gromit?

Review: Saving Normal by Allen Frances

I recently heard the wonderful Ginger Campbell interview Allen Frances on the Brain Science podcast.  Almost before my headphones were off I had run out to buy Frances' book "Saving Normal, an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life."  Frances clearly and humanely outlines his case that "The cruelest paradox of psychiatric treatment is that those who need it often don't get it, while those who do get it often don't need it." 

I had some concern, even after the very thoughtful interview on BSP, that this would be a soft-headed screed against psychiatry.  I know a lot of people who have benefited from mental health treatment including psychiatric medication, and I think it is very wrong to frighten people away from psychiatry who really can use it.  I needn't have worried. Frances is a psychiatrist with a great love for the profession and confidence in the good it can do.  He is absolutely committed to the idea that psychiatry can be beneficial to seriously mentally ill people and at pains to illustrate that.

But he is also clear-sighted about the failings of psychiatry and medicine generally (he is very much talking about the US situation.  I will reflect a little on the Quebec context below).  The big failing Frances takes on is 'diagnostic inflation.'  He means the tendency to expand the criteria that are used to diagnose mental illness, either by loosening criteria for exiting illnesses or by 'discovering' new illnesses.  What prompted this call was the American Psychiatric Association's process to issue a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM.  Frances thinks the authors are too quick to expand definitions which will inevitably lead drug companies to step in and push for meds for people who could do without them.  Frances is in a good position to comment because he was in charge of the DSM-4.  He is very up front about his own failings in having lead that installment and apologizes for his mistakes.  It is extraordinarily refreshing to hear someone with such a level of authority offer a public apology. 

One of the diagnostic overreaches that he addresses is 'psychosis risk syndrome'.  We are close to being able to identify people who are at high risk of developing psychotic disorders like schizophrenia.  We know many of the risk factors including certain genetic markers, we think that delaying onset of schizophrenia means being less sick and we know that being very sick with schizophrenia is very hard.  Why not target teens who are at elevated risk and are exhibiting "prodrome" symptoms; self-isolation, quirky or aggressive behaviour in the hopes of forestalling or even preventing the onset?  Frances gives a very good answer to that.  First of all, target them with what?  The answer will probably be anti-psychotic medication.  We have no indication that taking anti-psychotics before developing psychosis will help stave off or mitigate the effects of schizophrenia and the side effects can be very serious, including obesity and diabetes and everything that comes with that.  And, he points out, we can identify teens who are at risk, but that would probably involve identifying a lot of kids who will never develop the disease and potentially subjecting them to this very serious intervention.  It begins to look a lot like the aggressive screening and treatment of prostate cancer, too many people, too invasive for limited benefit.  Frances doesn't mention the possibility that teens who are identified might benefit from interventions that have less potential downside like counseling about delaying use of street drugs including marijuana and psycho-education about reality testing.  Given the way Quebec is headed, it seems unlikely that we will see a targeted public health campaign that relies on disease prevention using labour-intensive methods like psychoeducation.  

Frances also alludes to something I have mentioned elsewhere in this blog; namely that not all conditions of the human soul are diseases in any recognizable sense and yet increasingly the DSM includes them.  The idea that mild to moderate depression, or attention deficit disorder, or anxiety is a neurochemical imbalance fits very nicely with a drug company's bottom line.  The emphasis of the last twenty years on neuroscience has tilted us towards a chemical fix for ailments of the mind.  Yet not one significant advance in diagnosis or treatment of mental illness has come out of all the important research on neuroscience so far.  Diagnosis remains entirely symptom-based.  The mechanisms for the function of treatments is poorly understood, if at all. 

All of this may seem very much like “inside baseball” for people who don’t spend their days thinking about mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don’t need...

All of this may seem very much like "inside baseball" for people who don't spend their days thinking about  mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don't need, medicines with serious side-effects that may not have been adequately tested on the populations for whom they are being prescribed.  He reports that the sale of anti-psychotic drugs at $18 billion (US) now delivers more cash to the pharmaceutical industry than anti-depressants.  Anyone who has any experience with them knows anti-psychotics are powerful medications with very serious potential side-effects.  They are helpful to people with psychosis.  But now they are being marketed for use with children and the elderly.  20% of people treated by primary care physicians for anxiety now receive an anti-psychotic as well, according to Frances.  The trend towards GPs prescribing psycho-active medication is troubling for Frances as well.  That GPs give out anti-depressants and anti-anxiety medications routinely should surprise no one, but I was amazed to learn that 50% of anti-psychotics are prescribed by GPs.  (I am not sure if that accounts for GPs taking over the prescription of anti-psychotics after an initial prescription by a psychiatrist.)  Frances goes through the familiar litany of the dangers and over-promises regarding SSRIs for treating the 'worried-well' market.  These are problems we see here in Quebec, though certainly not to the degree they are experienced in the US. 

Whose fault is all of this?  For Frances the answer is pretty clear.  Big Pharma and the big money it is willing to throw around to advertise direct to consumers (only in the US and -- apparently -- New Zealand as well), to co-opt the better judgement of doctors and researchers as well as to fight legal battles and pay fines when they get caught behaving badly (as with the off-label marketing of anti-psychotics for kids).  He gives policy recommendations for taming the excesses of big pharma.  Naturally, dear to my heart are all the plugs that he makes for psychotherapy as an alternative or adjunct to pharmacology. 

There is no organized psychotherapy industry to mount a concerted competitive push-back against the excessive use of drugs.
— Saving Normal

Here in Quebec, we are retrenching from any kind of public outpatient psychotherapy, at great cost to our well-being, I believe.  It is nearly impossible in Montreal to get psychotherapy at a CLSC (public health and social service clinic).  This despite the fact that we know that psychotherapy can sometimes head off   episodes of serious mental illness later for certain people and keep them from needing much more expensive hospital care.  Follow-up care after a psychiatric hospitalization is spotty and seems unlikely to get better with more cuts coming. 

The lack of a credible alternative is part of what is fueling the appetite for drugs. If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help.

While I am a believer in psychotherapy, if I have a quibble with Frances, it is over this.  My experience is that many psychiatrists and other psychotherapists have been and continue to be high-handed, overly jargonistic, faddish, opaque and sometimes deeply anti-scientific.  Frances himself mentions the terribly misguided satanic ritual abuse accusations of the 1990s and the role played by therapists who "developed and instant expertise on day care sex."  Many people mistrust us because they view psychotherapy as elitist mumbo-jumbo that changes tack every ten years.  All those primary care doctors who are prescribing medications rather than sending their patients to therapists don't trust talk therapy.  Why should patients?  Hell, I have met quite a few psychiatrists who don't have faith in psychotherapy.  The lack of a credible alternative is part of what is fueling the appetite for drugs.  If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help. 

Scientists discover 'cool' particle, teens yawn.

Scientists have measured 'cool' and determined who has it so teens don't have to worry anymore; they can just ask the adult with the pocket-protector and clip-board.  In a neat piece of social science researchers looked at how kids made themselves popular at age 13 and followed them through to age 23.  Kids who did things to look older at age 13 in order to be more popular, such as engaging in delinquency, hanging out with good-looking peers and engaging in romantic relationships were less socially successful at 23.   (It seems to me there may be a tad of wish-fulfillment of grown-ups who were unpopular 13 year olds).  This is moderately interesting for people who work with kids and for parents of teens. 

Castiglione looking cool

Castiglione looking cool

The researchers conflated popularity and 'cool'.  Scientists like things that can be measured; popularity among thirteen year-olds is relatively easily measured while cool isn't.  The kids I thought were cool when I was thirteen weren't necessarily engaged in 'pseudo-mature' behaviour and weren't necessarily popular.  James Dean's character in Rebel Without a Cause which the authors adduce is a loner not a collector of pretty people.  Rather the kids who seemed cool to me did whatever they with seeming ease.  The Italian's call this sprezzatura.  Castiglinone in the Book of the Courtier has one of his characters say:

What eye so blind as not to see in this the ungracefulness of affectation, — and in many men and women who are here present, the grace of that nonchalant ease (sprezzatura, for in the case of bodily movements many call it thus), showing by word or laugh or gesture that they have no care and are thinking more of everything else than of that, to make the onlooker think they can hardly go amiss?

Pseudo-maturity doesn't play into this definition of cool.  Of course it can be exhausting to be attuned to how one appears to others at all times and probably detrimental to one's cool, as well, but that is a feature not a bug of adolescence I suppose.  Now that we have adopted pseudo-youth for adults as an unquestioned value it is probably a feature of middle age as well.   One of the features of Castiglione's work is the way in which people of different ages reflect on the blindness of others and in turn betray their own prejudices. 

Thus it seems to me that old people are in like case with those who keep their eyes fixed upon the land as they leave port, and think their ship is standing still and the shore recedes, although it is the other way. For both the port and also time and its pleasures remain the same, and one after another we take flight in the ship of mortality upon that boisterous sea which absorbs and devours everything...

The Illusion of Explanatory Depth. Can you explain how your plumbing works?

My supervisor and mentor Sylvia always says that "clients come in with an idea about what the story is and our job is to confuse them."  I have seen this borne out.  Clients have a very firm idea about what the problem is and how they got there but no idea how they can solve it.  The therapist drills down and down and down, "slicing it thin" as Sue Johnson says.  "I don't think I understood that.  How does your mom being too lenient keep you from getting a job?"  "Sorry.  You said that when she gets angry, you shut down.  What does 'shut down' mean?"  "I missed that.  You were talking about how in 1985 you had a miscarriage and that was connected with not wanting to eat.  How does that work?" 

How does that work? 

I recently read about "The illusion of explanatory depth."  The illusion of explanatory depth is what research psychologists Frank Keil and Leon Rosenblitt call the human tendency to be confident that we understand something -- usually how a familiar but complicated piece of machinery works -- until we are asked to explain it.  Suddenly we recognize that a toilet or a sewing machine is way less familiar than we thought. The illusion falls apart and we become more humble.  We start to know that we do not know.  

I was amazed that nobody seems to have written about this in the context of psychotherapy.  It used to feel to me like this kind of questioning that psychotherapists were doing about a person's experience was disrespectful.  Aren't we supposed to see the client as the expert in his/her/their own story?  But there is a difference between being intimately familiar with something and being an expert in it.  Asking people to tell a coherent story about themselves and their difficulties can be painful but that doesn't make it disrespectful. 

One of the things that can happen in a family in difficulty -- particularly where there is a lot of secret-keeping -- is that the explanatory depth is very thin.  These families often have very limited, incoherent stories of themselves yet they are often very convinced that there narrative makes sense.  If a therapist asks clarifying questions it can feel very scary because the family may intuit that the illusion of explanatory depth is about to fall away.  Like all illusions, the IOED serves a very important function, it gives us a sense of coherence and comprehensibility in the face of things that feel chaotic and scary.  But more coherent narratives are therapeutic. 

John Byng-Hall citing the work of Mary Main among others wrote about attachment and coherent narratives in families.

This would suggest that making sense of the events that traumatized the attachments is important. But the most effective way of creating a coherent story line is to help the family to manage their current attachments in a way that takes into account all its members’ attachment needs. This will require them to tune into each other’s pain. The children might then also be able to tell a coherent story to their children.

One of the interesting elements of the IOED is that if we know that someone knows how something works, we take on that knowledge as if we knew it, too.  "Well somebody understands how a toilet works," our brains say, "So I must, too."  In a psycho-therapeutic context this can manifest as jargon not connected to real feeling or much detail; "I'm codependent."  "He's got a borderline personality disorder."  "It's because of early trauma."  "He's from Mars and I'm from Venus."   This is why a not-knowing approach by the therapist can be so important, even when it is frustrating for the client.  Families need to go from being familiar with their own family functioning and stories to being experts in them.  That doesn't mean they need to replace one prepackaged expert story with another, as easy as it is for our human brains to do that. 

When all goes well, the client or clients are able to construct a more coherent and flexible understanding of themselves, understandings that can better tolerate challenge and reorganization. 

Friendship, kids and mental health.

A researcher from Ste. Justine here in Montreal, Mara Brendgen did a really interesting piece of research about friendship as correlated with depression in children.  You can read the article (if you have academic access) or a nice summary of it at BPS Research Digest by Christian Jarrett.   By studying kids who have an identical twin with depression and kids with a fraternal twin with depression Brengdan and her colleagues were able to identify kids who were genetically pre-disposed to depression but not depressed themselves.  Then she looked at those kids and looked at the quality and quantity of their friendships.

Genetic vulnerability to depression in girls was less likely to manifest if they had at least one close friend. Stated differently, the apparent protective effect of having at least one close friend was magnified in girls who were genetically vulnerable to the condition. This means that for girls there was an interplay between genetic risk and the protective effect of friendship.

There was a beautiful piece on This American Life last week about a girl who had something like Asperger's.  Her stereotypical conversation and poor social reciprocity get in the way of friendships.  But she still wants friendships.  Eventually she becomes angry and aggressive because she is so lonely.  Her moms take her to all sorts of specialists (a humbling note for those who work with kids with learning and/or developmental disorders) and none of it really helps until... she makes a friend, a friend who is interested in the same things as her.   (It starts at about 41:00 minutes)

A question I have about Brengden's research (or Jarrett's summary, not sure which) is cause and effect.  While kids who are genetically pre-disposed towards depression may have fewer friends or friendships they value less, is that a cause or an effect or are they related through some other factor such as personality type or attachment style? 

There is a correlation between people with schizophrenia and social isolation which has lead to the recommendation (here, for example) that people at high risk of schizophrenia make a conscious effort not to self-isolate.  But we all know that correlation doesn't mean causation or else we would all demand more importation of Mexican lemons until highway deaths were eliminated (link to this and other bizarre correlations). 

Nurturing a kid's positive friendships and encouraging him/her to view friendships as worthy of investing some time and energy in seems to me like a good idea whether or not they are at elevated risk of mental illness.  Of course, for a kid who is less good at friendship or less interested in it placing a lot of emphasis on making friends can backfire by making him/her feel more incapable.  Socially awkward kids often view friendship as an ability akin to drawing or music that relies on a high degree of innate talent (it is interesting that many kids who feel bad about their ability to make friends do so around the age of nine or ten when they also start to notice that other kids are way better than them at some things without having to try hard).  It may be true that some combination of genes and very early wiring can make a person better at social situations than others, but I tell kids that friendship is more like riding a bike than playing music; it is something you can learn at just about any age, something you can always get better at by persevering and something you will never be able to learn do by watching others.  You need to try it, fall down and try again. 

When knowing isn't enough

I have been reading John Gottman's latest book "The Science of Trust."  It is an interesting read on the subject with some great little tangents into history of science which I really appreciate.  Gottman became famous after he was featured in "Blink" by Malcolm Gladwell because Gottman is able to predict with great accuracy if a couple will divorce based on very short interactions. 

I love Gottman's approach to relationship questions.  He is a social scientist perhaps first and foremost.  He has spent years having couples come into his lab and seeing what they do that works and what doesn't.  He has discovered that much of what therapists thought was true about relationships wasn't.  In some ways, thanks to Gottman, now is the best time in recent history to seek help for your relationship.  Gottman has identified what he calls "the four horseman of the apocalypse" for relationships; contempt, criticism, stonewalling and defensiveness.  Couples where these are regular features of conflict are likely to set off a cascade of negative feelings that can be very hard to recuperate from.

My biggest dissatisfaction with the book -- and with other things that he has written -- is that it seems to say that people should "Just stop it."

Sometimes I feel like Gottman's prescription is; Read the book, understand the pain you are causing yourself and your partner and don't do it anymore.  (John Gottman is a couple and family therapist as well as a researcher and I would love to know what his therapy is like and in what ways, if any, he goes beyond a psycho-educational model).

This approach is useful for couples who are feeling some rockiness and want some tips to help them address it.  But I find it limited for the couples who go into a therapist's office or the therapist who treats them.  These couples usually say something like 'I know I probably shouldn't ____________ (fill in the blank: criticize, stonewall, put my partner down, insult my partner) but when s/he does ______________ (fill in the blank) I can't help it.'

There is a limit to the power of our intellects to think our way out of emotional entanglements.  There are a few times in my career where I have instructed people to stop some really destructive behaviour and they have listened to what I said and then complied.  I can count those moments on one hand.  Usually, by the time I see people, they know that what they are doing is hurting them and/or the people around them and they continue to do it.   So far as I have gotten in the book, Gottman describes these "absorbing" states in which the interactions are "nasty-nasty" very well and documents the destructive consequences of them for a relationship.  He says that they are not subject to the same game-theory model he proposes for the other elements of relationships in which people in a couple act rationally by maximizing their payoffs.  He determined 'payoff' by having people rate the payoff for the interaction after the fact while watching video of themselves interacting.  They rate these very miserable moments as very low on payoff.  Why then do they get into these states?  Why not "Just stop it?"  Gottman's answer, as far as I understand it, seems to be a sort of black box; it is an absorbing state, not subject to rationality.  Deal with other states, foster more neutral or positive states when couples are in them and try to keep the couple away from the powerful gravitational pull of these interactions. 

Assessing payoff for these highly negative states in the way Gottman describes might be subject to an important methodological flaw that has implications for therapy; the payoff is clear at the time but hard to access afterwards.  My experience both personally and professionally is that when someone is very angry and in conflict with another person, especially a loved one, the assessment of 'payoff' changes dramatically.  After people really stop being angry, they will often say that they don't understand what happened when they were angry, why they acted the way they did.  They may even have trouble recalling the details of what happened.  There is a sense of dissonance or discontinuity with the angry state.  While a person who is very angry may make decisions that are incomprehensible to him/her later, those decisions make good sense to the angry person who is feeling extremely negatively stimulated; s/he wants to eliminate the negative stimulation.  This poses a problem for a person who is angry about the relationship because his or her partner is both the cause and the cure for the negative stimulation.  That's why we do things that both hurt our partners and simultaneously try to keep them under our control by either keeping them near or at a safe distance. 

Sue Johnson, the founder of Emotionally Focused Therapy, has a different take on this from Gottman that I think makes a good counter-point here.  She sees couples in therapy as needing to work on what I think of as the operating system level rather than the software level.  Those absorbing negative states need to be addressed precisely because they are not subject to intellectual scrutiny in the cold, hard light of day.  When I am calm and able to reflect, I do not have access to my operating system, to all the things that are going on in a primal emotional state.  I have to go to that state.  My partner comes along with me and if I experience my partner as a supportive figure (a positive attachment figure; Johnson's EFT is very attachment-based), then when I re-enter that state I will turn towards my partner rather than seeking to hurt and control.  

What trauma leaves behind

Trauma impacts mental health especially trauma in childhood.  In a previous blog post I wrote about how kids who are poor are more likely to be exposed to trauma than wealthy kids.  Now there is research that indicates that the effects of trauma can be biologically transmitted across generations.  The researchers subjected mice to trauma in the laboratory in the form of electrical shocks.  When baby mice were conceived using the sperm of the traumatized mice, the babies had a stress reaction to stimuli that were associated with their parents trauma, in this case a particular smell, and the effects seem to stretch over several generations.  The theory put forth by the scientists to explain this is epigenetics, that certain genes are 'turned on' or 'off' by experiences creating heritable traits as a result of what happens in the environment. 

If this carries over to humans, it could mean that a kid whose grandmother or grandfather experienced trauma could still carry the impact of that trauma in his or her body.  My clinical experience is that trauma does seem to pile up in families.  Sometimes the people who come into my office will describe three generations of abuse.  It can be hard to get out from under that.  Now we have another indicator of why that might be the case.  Not only can there be a cultural inheritance of trauma in a family, the genetics of one's descendents can be marked by traumatic experiences. 

On a more hopeful note, epigenetics may work to undo some the hurt of previous generations.  Researchers here in Montreal, at the Douglas Hospital, have looked at the effect on an epigenetic level of nurturing by a parent on mediating stress (more traumatized rodents).

Baby rats that are licked often by their mothers—with licking in rats fulfilling the same function as cuddling in humans—are calmer than rats that are not licked enough. Michael Meaney and his team delved further into this idea by tracking the imprint left by maternal care in the brain of young rats. They were able to do this because the action of licking influences the activity of a gene (called NRC31) that protects rats against stress; when activated, this gene produces a protein that helps decrease the concentration of stress hormones in the body. A specific part of this gene must also be activated via an epigenetic switch.

According to this theory loving cuddling can help kids deal better with stress than they might even if they have an epigenetic inheritance of trauma.  So why are you still reading?  Go hug your kids.