At first it doesn't make sense, but thorough investigation
of a person's problems is often a bad idea, and therapy is even worse.
A medical example. Most national guidelines for the management of low
back pain (including New Zealand's, which are among the best) recognise
that even one X-ray starts some people down the path to disability. The
same thing happens with chest pain [i].
A psychologist's example [ii]. I was called in as one of three
psychologists at a factory fatality, to try to prevent "post
traumatic stress disorder". Each of us took a group of about 15
people for about two hours, then we reported to senior management.
The first psychologist said "My group was very angry at management
for allowing this to happen." The second said "My group was a
bit angry". But my group wasn't angry at all, so I asked the other
two what they had said.
The first psychologist had asked her group "Are you feeling
angry?" The second had said "People feel all sorts of things
like …., but these are all normal reactions". Whereas I had said
"What are the best memories you have of this man?"
It's the old "scientific observer" fallacy. Social scientists
like to believe that they are observing, measuring, collecting data. But
asking questions changes the way the "observed" person thinks
and feels! We ask different questions, we create different realities.
Perhaps it works like this. Immediately after a traumatic experience,
many people have not yet labelled what they feel, there is no clear
emotion, just a "lot of stuff going on". The classic 1962
experiment of Schacter and Singer suggests that if you ask such people
"are you feeling angry", some will answer "Yes, I am!"
Of course, for most people that reaction doesn't last, but if one
person from every major incident doesn't recover, the community has a
major health problem.
Nevertheless, there is one good reason to intervene immediately after a
trauma - to prevent fear. If a person is emotionally agitated and leaves
the scene, they will probably feel better. But the psychologist doesn't
see this as a good result, as running away has just been reinforced. If
this is not dealt with, some of these people will find themselves avoiding
the place where the event occurred. They plan to drive past the place, but
suddenly find themselves on a different road, perhaps without even knowing
how they got there. They might develop all sorts of fears related to the
The way to prevent this (in fact the one significant action you can
take after a trauma) is to keep people safely in contact with the place
that it happened for about 90 minutes, until they feel that they are ready
Unresolved anger and fear are entry points onto the road to disability.
Our task is to guard the entrance to that road, and try to stop people
entering. Of course we won't always succeed, so some of us need to stand
at intervals down the road to let people off. The person who continues
down that road kills off their own future, because they become so angry
and hard to deal with that nobody can stand them anymore. Or they reduce
their own functioning to near helplessness because of fear (in the case of
back injury, often it's fear of pain).
It's as if disability has become its own disease.
So we don't want the test (meaning, our effort at diagnosis) to damage the person, but there is also the
question - what are we really measuring?
Take the "Effort-reward imbalance" questionnaire of Siegrist,
for instance [iii], a hot favourite test in stress research at present.
Some research is showing correlations between the "imbalance"
score and poor health, which appears to suggest that people who work hard
but are not rewarded get stressed. You might think it reasonable to
conclude that you are measuring objective facts about the job, but take a
look at some of the test items which are meant to be measuring
- I can get furious if someone doesn't understand me the first time.
- I do everything possible to be in control.
- I get furious when anybody questions my competence.
I agree that a person who scores high on these items is unreasonable
and bad tempered, but it misses the point to call this an
"effort-reward imbalance", as there is no reason to think that
this person will feel any better (other than momentarily) if they are
"rewarded" more. They sound to me like a bottomless pit!
The "Effort-Reward Imbalance" title of the test suggests a
see-saw, that all we need to do is to add more rewards to one side and the
balance tips in the positive direction. This "hidden image" draws us in without our realising.
We forget to ask, are people really like see-saws? Even if they are, should
we be asking,
is there only one see-saw inside each person? Could the one on which we're stacking more rewards
have already hit the ground?
So things are more subjective than we might like to think. We seek
certainty where there is none!
Even our apparently fundamental schemes for classifying psychological
problems seem less sound if you think about them. The American psychiatric
diagnostic scheme DSM-IV (1994) lists three symptoms that are required for
a diagnosis of "Post Traumatic Stress Disorder" or PTSD, which I
translate roughly like this:
- Avoidance - we don't want to go back to the place where the
- Intrusion - thoughts and feelings come unbidden into our
- Vigilance - we're always on the lookout for the same thing to
The scheme is elegant, and people with problems can recognise
themselves in it. But it's not very useful as a starting point for
treatment, so I rolled my own [iv]. It has two parts:
Fear and avoidance - learned in the body, this consists of an
emotion (fear) usually linked to an action (avoiding or running away).
Fear is conditioned and unthinking, its entire purpose is to keep me safe
by running me away from the thing that hurt me. If my fear has
"generalised", I might also be hypervigilant, because the next
threat could come from anywhere. I might also have nightmares. When I am
at the place where the accident happened I might "see" it as if
it is still present. For any of these reactions, treatment is by exposure
to the thing or place or event that I fear - and by staying there for an
hour or more. Repeat once or twice if necessary. But if the therapist
doesn't expose me to that which I fear, if they simply talk to me about
it, I am not very likely to get better. You see, I can talk about my
Bruised status and lost values. These are related but not
identical, so I'll discuss them one at a time.
Bruised status means that I feel that my control over my life has
slipped, that I am no longer safe in my personal world (perhaps including
my home). Perhaps I feel humiliated, perhaps I feel angry, but at heart
it's a status thing. I might constantly relive the event, for one and only
one reason - I am trying to make it come out better, trying to make myself
win! This reliving could be described as "intrusive memories" or
"flashbacks" but that description doesn't add to our
understanding, in fact it takes away. Or I might take legal action simply
in order to prove that I am a worthwhile person.
For most people, bruised status eventually heals. But for some, the
wound is deeper, and becomes what I call "lost values". The
world no longer makes sense, no longer seems "right" or
"fair" or "safe". "They shouldn't have done that,
it was wrong, nobody should treat anyone else like that". In its
strongest form, "why did God allow this to happen?" Again, what
is called an "intrusive memory" or "flashback" could
be an attempt to rewrite the past, to make it turn out the way it
"should" have been. "If only I had put security bars on the
windows, then I wouldn't have been robbed…"
So my scheme splits some things that the other joins, and joins some
things that the other splits.
Who's right? Or is it simply a pragmatic issue - which one works better
If you found my revision of PTSD to be just as convincing as the DSM-IV
version, then we have a fundamental problem. How much of psychology only
appears valid because it's appealingly written?
This problem has reached new heights as a result of factor analysis and
other sophisticated statistical tests, which unashamedly look at
"data" from angles that are impossible for humans. Yet it is a
human who, on reviewing the factor loadings of each questionnaire item,
must invent a term that seems best to describe that combination of
questions. You create the results as much as you discover them.
So measurement is the problem as much as it is the solution. Or to turn
that on its head, as measuring is going to change what we measure, why not
make our measurement tools therapeutic?
The opposite of saying "Let's see if you're disabled" is to
say "Let's see how you can take charge!" With that in mind, in
1984 I wrote the first "Pocket Ergonomist" with Dr Robin
Mitchell. It is a leaflet-size textbook on ergonomics which lets anyone
work out why they feel stiff and sore; it is available under licence in
New Zealand from OSH offices and from the OSH website.It has two aspects -
content, and method.
Content is the information needed to fix the specific problem.
The method is, naturally, empowerment, and this method is used
in everything that I write.
For instance, if you are working with a stressed person, give them a
Pocket Stress Reliever and pen, and suggest "Let's read this
together. If a paragraph doesn't apply to you, cross it out. If it does,
tick it or underline it." Make sure they use the pen, because most
people will read but not feel able to mark the page. Whereas once they
begin to cross things out and underline them, they start to
"own" what's written there.
Every problem identified in the Pocket Stress Reliever has an
associated, immediate solution, for instance:
"Too many unfinished tasks: Unfinished tasks are always on your
mind, just like a juggler's balls are always in the air. Too many balls
and they all fall down. Put them all down… now pick up just the most
important task… Give it your undivided attention, doing just the right
amount of work on it - not too little, not too much. When it is
finished, turn to the next task and make it your only task."
Of course, there are personal causes as well:
"… Because status struggles are innate, it is normal and
natural to feel depressed or angry when someone puts you down and you
cannot find a way to overcome them. Normal and natural does not mean
good for you! It is unhealthy to let these feelings hang around. To
avoid harming yourself with your own bad feelings, try to stop them
within one hour."
I find that, even though I wrote the Pocket Stress Reliever I get a
better result when I use it, rather than just talking to the person
without it. I think, but have no proof, that the benefit comes from
removing "David as the authority" from the equation. We can
simply talk as equals about information on a page, rather than me telling
them what to do, think or feel.
So the psychologist is co-creator of the future, not measurer of the
past. Even apparently objective tests are more like myths and legends than
they are like rulers. Like the American Indian shaman who heals through
drama, we create atmosphere and expectation through the tests we give, the
things we say.
It's time to stop pretending that we stand outside of life just
watching. We're in it up to our necks!
[i] Christopher Bass, Richard Mayou (2002). ABC of psychological
medicine: Chest pain. British Medical Journal 2002;325:588-591.
[ii] Brown D (2000). Time could be the active ingredient in post-trauma
debriefing. British Medical Journal 2000;320:943.
[iii] Siegrist J. (1996). Adverse health effects of
high-effort/low-reward conditions. Journal of Occupational Health
[iv] Brown D (2000). If DSM-IV doesn't work, let's try something
different British Medical Journal (e-letters) 9 July 2001.