Approaches to semiotics. [0002 2. printing. Re. ed.] 9783111349022, 3111349020

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JANUA LINGUARUM

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STUDIA MEMORIAE NICOLAI VAN WIJK DEDICATA

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CORNELIS H. VAN SCHOONEVELD

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STANFORD UNIVERSITY

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SERIES MAIOR

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1964

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MOUTON & CO. London . THE HAGUE • Paris

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APPROACHES TO SEMIOTICS CULTURAL ANTHROPOLOGY - EDUCATION LINGUISTICS • PSYCHIATRY PSYCHOLOGY

Transactions of the Indiana University Conference on Paralinguistics and Kinesics Edited

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THOMAS A. SEBEOK ALFRED S. HAYES • MARY CATHERINE BATESON

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1964 MOUTON & CO. London • THE HAGUE • Paris

© Copyright 1964 Mouton & Co., Publishers, The Hague, The Netherlands. No part of this book may be translated or reproduced in any form, by print, photoprint, microfilm, or any other means, without written permission from the publishers.

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This text was developed pursuant to a contract between the United States Office of Education and Indiana University, and is published with the permission of the United States Office of Education.

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Printed in The Netherlands by Mouton & Co., Printers, The Hague.

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PREFACE

The term semiotic, confined in earlier usage to the medical theory of symptoms, seems to have been introduced into philosophical discourse at the end of the 17th century by John Locke to cover one of the three branches of science, namely, the doctrine of signs, “the business whereof is to consider the nature of signs, the mind makes use of for the understanding of things, or conveying its knowledge to others”. The real founder and first systematic investigator of the field, however, was the subtle and profound American philosopher, Charles Sanders Pierce; as he himself observed: “...I am, as far as I know, a pioneer, or rather a backwoodsman, in the work of clearing and opening up what I call semiotic, that is, the doctrine of the essential nature and fundamental varieties of possible semiosis; and I find the field too vast, the labour too great, for a first-comer.” The unique place of semiotic among the sciences - not merely one among the others, “but an organon or instrument of all the sciences” - was stressed by Charles Morris who, in 1938, proposed to absorb logic, mathematics, as well as linguistics entirely within semiotic. “The whole science of language”, Rudolf Carnap then reaffirmed in 1942, “is called semiotic”, and, in 1946, Morris introduced further refinements when he distinguished among pure semiotic, which elaborates a language to talk about signs; descriptive semiotic, which studies actual signs; and applied semiotic, which utilizes knowledge about signs for the accomplishment of various purposes. In the final moments of the conference the transactions of which are set forth in the following pages, the well-known linguistic process Hanns Oertel called “analogic creation” was perhaps at work when Margaret Mead proposed semiotics - a plural noun possibly in pseudo-proportional analogy with “semantics” - as a term which might aptly cover “patterned communications in all modalities”. Implying the iden­ tification of a single body of subject matter, this summative word was incorporated, overburdened as it is, and not without remonstrations from several quarters, into the main title of our work. By choosing it for the title, we intend to stress the interactional and communicational context of the human use of signs and the way in which these are organized in transactional systems involving sight, hearing, touch, smell, taste. The selection of some single term seemed a persuasive device to advance unified research. On the one hand, by reckoning linguistics as a branch of semiotics, we meant to imply that coding in all modalities takes place within a cultural context as

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PREFACE

learned behavior at various levels of consciousness, and to underscore the relevance of the linguist’s model to the study of other semiotic codes. On the other hand, the methodological integrity of linguistics is preserved, for we also recognized that not all semiotic coded are indentical and that, in most cases, they have been and will remain most amenable to study by non-linguists. Sponsored by the Indiana University Research Center in Anthropology, Folklore, x and Linguistics, the conference, the immediate results of which are embodied in this book, was held in Bloomington, on May 17-19, 1962, with the generous support of the United States Office of Education (contract #SAE 9490). The meeting was attended by some sixty scholars (see pp. 289-294),who gathered for a discussion designed to focus primarily on paralinguistics and kinesics. While inquiry and debate not infrequently widened to comprehend other areas of nonverbal communication, there was also a tendency to view these problems with constant reference to language which is, as Edward Stankiewicz reminded us, “the most pervasive, versatile and organizing instrument of communication”, and a growing awareness that there must be similari­ ties of structure in communication in all modalities. Five “state of the art” papers were prepared and distributed in advance to all the participants in the original conference.1 Each paper, written by a specialist in one of the five principal disciplines represented (cultural anthropology, education, linguistics, psychiatry, and psychology), was the center of debate during a four-hour session, where it was reviewed and examined in an interdisciplinary context. This book fol­ lows the same pattern: each paper is reproduced with a minimum of after-thoughts and is then succeeded by an edited version of the actual transcript of the ensuing discussion. Slightly less than one half of the transcript was retained and is rendered here after considerable reorganization and stylistic revision, in the first instance by each individual to whom a remark was attributed and, in final form, by the editors. Pure, descriptive, and applied approaches to semiotics are all displayed by the contributors of papers and comments,* the variations in emphasis reflecting differences in specialty, professional interest, and personal preferences. Margaret Mead, instead of being asked to prepare a working paper, was invited to 1 The following seven papers, most of which have been published elsewhere, were also circulated, as background material, to all participants: Kramer, E., “Personality stereotypes in voice: a reconsideration of the data”, J. Soc. Psychol, (in press). -----, “The judgment of personal characteristics and emotions from nonverbal properties of speech”, Psychol. Bull., 60 (1963), pp. 408-420. Kroeber, A. L., “Sign language inquiry”, Int. J. Amer. Ling. 24 (1958), pp. 1-19. Moses, P. J., “Modern trends in singing”, Paper presented at the 1st Int. Congress of Audiology and Phoniatrics (Mexico City, August, 1961). Sebeok, T. A., “Coding in the evolution of signalling behavior”, Behavioral Science, 7 (1962), pp. 430-442. Trager, G. L., “Paralanguage: a first approximation”, Studies in Ling., 13 (1958), pp. 1-12. Voegelin, C. F., “Sign language analysis, on one level or two?”, Int. J. Amer. Ling. 24 (1958), pp. 71-77.

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PREFACE

present a lecture on the second night of the conference which would relate to its pur­ poses but would also be intelligible to a larger audience, as part of the Indiana Univer­ sity Horizons of Knowledge Lecture Series. Her lecture drew on materials which are being published elsewhere,2 and also on unpublished materials on which she and Rhoda Metraux, with Ray L. Birdwhistell as an active consultant, are working in a project, Studies in Allopsychic Orientation. Her paper which concludes this book was written subsequent to the reorganization of the conference proceedings and thus takes into account the continuity provided for by that rearrangement and by the dis­ cussions of future plans at the close of the conference. The continuing work of Thomas A. Sebeok in the “Linguistic evaluation of non­ verbal communication” is supported by the United States Public Health Service (MH 07488-01). The paper of Alfred S. Hayes was completed pursuant to a separate contract with the Office of Education, under which he is preparing a manuscript dealing with research relevant to foreign language teaching. Each of the five “state of the art” papers has a separate bibliography at the end save that of Weston La Barre who chose to integrate his extensive references with the body of his text. While insuring that all references were consistent with the require­ ments of the author’s particular scholarly tradition, the editors strove to make them fully accessible to readers from each of the other disciplines involved. Beyond that, however, we avoided interfering with any bibliographic apparatus. The editors particularly regret their inability to convey in this book not only an accurate multimodal representation of the formal proceedings of the conference, such as by sound recording or motion pictures, but also the rich informal verbal interaction among the participants which punctuates all events of this nature. Although specific guide lines for future programs of research and more exact theo­ retical formulations in semiotics have not been included here, the conferees concluded their deliberations with concrete plans for a symposium in which representatives of different sciences might bring their tools to bear cooperatively on a unified corpus of tape and film. The assistance of Alexandra Ramsay in preparing the manuscript for press and reading proofs is gratefully recorded. January, 1964

Thomas A. Sebeok Alfred S. Hayes Mary Catherine Bateson

* Mead, M., Continuities in cultural evolution, The Terry Lectures (New Haven, in preparation).

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TABLE OF CONTENTS

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Preface . Peter F. Ostwald How the Patient Communicates about Disease with the Doctor Discussion Session on Psychiatry.................................................. Chairman: John I. Nurnberger

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George F. Mahl and Gene Schulze Psychological Research in the Extralinguistic Area Discussion Session on Psychology........................... Chairman: Roger W. Russell

51 125

Alfred S. Hayes Paralinguistics and Kinesics: Pedagogical Perspectives Discussion Session on Language Teaching.................... Chairman: William R. Parker

145 173

Weston La Barre Paralinguistics, Kinesics, and Cultural Anthropology . Discussion Session on Cultural Anthropology................ Chairman: C. F. Voegelin

191 221

Edward Stankiewicz Problems of Emotive Language Discussion Session on Linguistics Chairman: Thomas A. Sebeok

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239 265

Margaret Mead Vicissitudes of the Study of the Total Communication Process

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List of Participants

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HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR by PETER F. OSTWALD

A medical doctor is concerned with total human functioning - the way the body works, how patients think, what they feel, and their activities in family and social situations. He must always emphasize the detection and correction of malfunction, and part of this primary task is to interpret a patient’s sign-making behavior correctly, be it linguistic, paralinguistic, or kinesic. The doctor listens to the patient’s words in terms of symptoms that point to disease; he looks for physical signs in order to re­ cognize underlying bodily malfunction; he postulates diagnoses as a guide for sub­ sequent management of the problem presented by the patient; and he administers the appropriate treatment to reverse tangible pathology and prevent further disability. Medical history-taking, examination, diagnosis, and treatment all involve com­ munication between two persons whose individual roles are usually quite clear and whose tasks are also well-defined. This is why clinical problems offer such interesting possibilities for investigation in terms of current theories about processes of in­ formation exchange. The purpose of this paper is to highlight but one aspect of the sign-making behavior of sick persons as perceived by physicians: communication without words.

THE PATIENT-DOCTOR RELATIONSHIP

An old physician has said: For him who has eyes to see and ears to hear no mortal can hide his secret; he whose lips are silent chatters with his fingertips and betrays himself through all his pores.(45) Physicians traditionally function in two-person relationships with their patients, and the assumptions of this clinical dyad must be understood if one uses it as a model for research in communication (27). From the beginning of his interaction with a patient, the physician alerts himself to visible, audible, palpable, and smellable signs that nonsymbolically transmit information about pathology. He is allowed to behave in such a way as to facilitate direct body contact with the patient, touching naked skin, listening to inner noises, and inspecting private openings so as to learn things which may be unknown to the sender. During the course of their interaction the patient

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PETER F. OSTWALD

(sender) also speaks to the doctor (receiver), using conventional verbal symbols for communication, yet neither sender nor receiver knows in advance what code is going to carry the significant information about disease. In one instance an immobile lump of the breast discloses cancer; another time this information cannot be obtained without surgical exploration and microscopic analysis of suspicious tissue. A highly charged emotional relationship may arise within this ambiguous communicational setting: the patient tends to relate anaclitically; he bares himself, trusts, and confides. The doctor on the other hand is expected to understand, to heal, and to protect the patient. Outsiders looking through a screen at what goes on, or listening to tape-recordings of what has happened, are likely to miss the very basic ingredient of clinical communication - the sense of intimacy, fear, hope, and other strong emotions shared by the two participants (75). Nor can this essential element in patient-doctor communication be artificially produced for experimental investigation (20). Hence post hoc description and anecdotal case presentation are generally used for teaching and research in this field. Lately linguistic transcription of verbal material (71), acoustic measurement of sounds (64), analysis of gestures and postures (16), and physiologic studies (44), have been applied in order to make more rigorously scientific investigation possible.

THE LANGUAGE OF THE BODY

The autopsy table was medicine’s greatest lesson to Man, a lesson in honesty and humility. It is medicine’s great spiritual contribution to human culture.(Lawrence Kubie, 42) The term “language” is used very loosely in medicine, and not within the specialized framework familiar to linguists. It can refer to any informative, expressive, or communicative activity of the patient - conscious or unconscious - and may even apply to something happening within part of the patient’s body, such as his skin, heart, or gastro-intestinal tract. Much of this has been documented, and for any student of body language there are three invaluable dictionaries: French’s Index of differential diagnosis (18), Dunbar’s Emotions and bodily changes (19), and Grinstein’s Index of psychoanalytic writings (34). From this vast material I shall review only what seems directly pertinent to the work of investigators outside the field of clinical medicine. The body as a whole Sizing-up a person is done in a split-second, but often these first impressions out­ last later ones. Of particular interest to physicians are striking abnormalities of body size or shape. These usually have physical causes: dwarfism, for example, results from lack of pituitary or thyroid hormone, achondroplasia, vitamin deficiencies, and other metabolic diseases (38). Gigantism is usually due to a tumor of the pituitary gland.

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But total appearance is also influenced by the patient’s feeding-behavior and exercise patterns, both of which can be upset through emotional conflicts. For example, obesity is often a sign that oral demands for love and attention are unfulfilled or unfulfillable; and cachexia can result from self-imposed starvation routines designed to achieve delusional goals (13). Relationships between physique and personality have been described in the work by Kretschmer (40) and Sheldon (84). Less well-known to the nonmedical world are studies of internalized concepts of the body and the effects of these “body images” on appearance and behavior (25, 79). Reactions to another person depend in important ways upon how one perceives, evaluates, and uses his own body and its component parts (17). The surface of the body The enveloping skin is a kind of advertising bill-board that broadcasts to the world what goes on under its surface. Fevers, infections, neoplasms, allergies, ageing, and circulatory defects are some of the organic processes which become manifest through dermal change (4). By means of pilo-erection, vasomotor change, pigmentation, exudation, and other signs, the skin also transmits information about the bearer’s emotions (60). Fear gives him goosepimples and pallor, anger produces flushing and mottling, itching annoys the victim and also the onlooker. Scanning the skin, a trained eye picks up significant pimples, scratches, scars, moles, tattoos, birthmarks, and self-induced lesions which stand out from the smooth homogeneous surface. The primary emotional appeal of that surface is probably related to the infant’s instinctive search for its mother; in dreams her breast is not infrequently symbolized as a “blank” screen (47). Various skin shades and colors also are associated with highly individualized ideas that stem from preverbal thoughts (39). For example, a Negro patient who had a dark-skinned father and a light-skinned mother alternately denigrated and whitewashed her own brown-ness. Depending on which phase of her ambivalence predominated, she would tan herself - to feel sweatier, warm, and more attractive - or despise the darker shades as dirty, masculine, and dangerous. The hair of the head is an especially important preoccupation for the dermatologist, who finds that it turns white or falls out under stress. Psychopathology includes hairfetishism, tearing-out-of-hair, and bizarre dyeing and dressing. Emotional reactions to baldness, haircuts, and visits to the beauty parlor tend to be surprisingly profound. For example, a college-graduate mother-of-three spent 24 hours in near panic after she sent her 9-year-old daughter out for her first permanent wave. This event apparently symbolized many of her own struggles over sexual identity and maturity. Paucity of body hair has forced the human animal to cover himself with feathers, furs,

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cloth, plastic, and other clothing. Fliigel has discussed this in psychological terms, pointing out that the body surface is covered not only for protection but also as a sign of modesty and for decorative purposes (26). The face Hippocrates described the “sharp nose, sunken temples, cold ears, hollow, vacant eyes, open mouth, loose, blanched lips, and livid, muddy color” of imminent death (92). For the living also, the expression of the face is of primary importance in communi­ cating what is wrong. Acromegaly, myxedema, hemiplegia, 7th nerve paralysis, psychoses, wasting, alcoholism, and many other diseases produce characteristic “facies”. Thorek has collected these in a book worth perusing, if for no other reason than to see how unsettling it is to view familiar forms in unfamiliar guises (92). According to Rangell, facial communication of emotion takes place primarily via the snout, a peri-oral “porthole [which is] the focus of greatest concentration of effector Within these response to emotions, at least in relation to the external world, relatively few inches of body surface, the tone, position in space, and direction of the skin and facial musculature denote how a person is at the moment” (72). Eyes declare the presence of jaundice (yellow sclerae), hyperthyroidism (bilateral exophthalmos), and neurological disorders (pupillary and oculomotor imbalances). Psychiatrists also gauge the sense of interpersonal relatedness by means of eye expression; schizophrenics tend to stare in an immobile, vacant fashion; hysterics may use their eyes to meltingly caress the surface of the doctor’s body; suspicious paranoid persons try to focus their eyes inside your head, as though this might enable them to read thoughts directly; the psychopath may shift his gaze watchfully, try to seduce, or give you the “evil eye” (22). Various forms of pathologic weeping have been described (32). Expressive automatisms called tics or spasm disorders may affect the facial muscles as well as other parts of the body. Included here are blinks, squints, sudden scanning movements with the eyes, and contortions of one or another part of the face. Their etiology ranges from epileptic foci of brain irritation (90) to psychoneurotic conflicts (/). Unless of organic origin, abrupt facial contortions usually indicate frightreactions ; they are signs of overwhelming fear produced by an external shock or by the undigested memory of a traumatic event in the past. Occasionally it is possible to pinpoint specific maladaptive processes which have produced and perpetuated a spasm disorder (23). For example, a young man entered the hospital for treatment of paroxysmal jerking move­ ments of his head, neck, shoulders, and pelvis which were accompanied by sudden harsh snorting noises. Psychotherapy disclosed that in early childhood he became convinced another person had “entered” his body, and the paroxysms now occur whenever he becomes uncomfortably aware of this inside outsider and tries to shake him out. Spastic torticollis is an expressive automatism characterized by stereotyped turning

HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR

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of the head to one side. Not infrequently precipitated while being shaved or during military inspections, this disorder may be a symbolic expression of the patient’s need to look away from threatening hostile-aggressive impulses which have been unduly stimulated or which cannot be controlled in socially-acceptable ways (57). Posture, gait, and movement of the body Posture, gait, and body movements are controlled by the integrated activity of at least three nervous systems: the pyramidal system (for volitional control of move­ ment), the extrapyramidal and cerebellar system (for involuntary aspects of muscle tone, balance, and motility), and the reticular-activating system (for attentiveness, alertness, and overall coordination) (33). Inputs from the external environment directly influence at least two of these - the pyramidal and the reticular-activating systems. Thus social stimuli play a major role in the initiation, reinforcement, and prohibition of various body movements. Furthermore, the patterns of posture, gait, and movement are altered by diseases of muscles, bones, and joints. Since body movement has such a large number of determinants, no one particular pattern can have much semantic specificity (73). The patient’s postures and movements communicate at best something generally about tension and tension-release. Without additional information, one could make no clear distinction therefore between, say, stiffness due to brain tumor, military training, rheumatism, hostility, meningitis, etc. The neurologist deals specifically with such diagnostic tasks. Reflex tests, motorstrength studies, electroencephalograms, and other techniques for getting at under­ lying neuro-muscular relationships must be used (53). It is important for the non­ medical reader to keep this in mind while studying texts about the symbolic (22) and the semiotic (77) significance of the various posture, gait, and motility abnormalities. The hands Free to move in space and richly represented in the cerebral cortex, the human hand can attain extraordinary importance in communication. Some rudimentary gestures may already be seen in infancy: for example, the newborn presents the palm for grasping, clenches the hands together for balance, and protrudes the thumb in touching the mouth. More elaborate analogues of this infantile hand behavior are later found in saluting, prayer, and the hitch-hiking sign. But only under acoustically unfavorable conditions, such as deafness or continuously intense noise, are hand languages ever systematically developed (58). Hand and fingers are terminal peninsulas of the human body and as such particularly susceptible to ageing, arthritis, arterio­ sclerosis, and other organic disease processes. Thus it seems extremely doubtful that diagnostic procedures based solely on the hand, for example in terms of its morpho­ logy (96), would be accurate beyond the point of the manual stereotypes taught by drama teachers (87). Sometimes in psychotherapeutic work it is possible to obtain insight into the

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personal meaningfulness of tremors, fidgets, thrusts, and other noticeable hand behavior (24). For example, an obsessive-compulsive writer, blocked in his efforts to produce a novel, folded his hands and propped them against his mouth during long intervals of silence in the therapy hour. Later he explained this as an expression of deep humiliation and suffering. Another patient stroked the carpet in the office at times when she felt an intense need to be affectionately fondled. Of further diagnostic importance are the products of manual activity. Sounds produced by hand range from simple mechanical noises to complex musical patterns (68): finger-snaps may be used to indicate the “a-hah!” feeling of sudden understanding. Scratching, finger-tapping, and knuckle-cracking also are used to express emotional states. Among visible products of the hand, writing has been most extensively studied from a psychopathologic point of view. Repetitiousness, clumsiness, fragmentation, ornamentation, and other handwriting characteristics tend to match the expression disturbances of speech and gesture (74). Sketching and tracing (7), smearing and modelling (54), and painting (55) are also used for psychodiagnosis and therapy. Contrary to the artist whose ego integrates a variety of elements into new symbolic forms, a mentally ill person tends to elaborate raw id material through crude, stereo­ typed visual symbols (41). The feet In ordinary social affairs one keeps his feet on the ground, encased, out of sight, and refrains from kicking. Not so in medicine where the patient’s horizontal posture elevates his feet to a position of equality with the head and the heart. The Babinsky reflex (elevation of the big toe and spreading of the little toes) is one of neurology’s most important signs. Part of a mass withdrawal response, this primitive reflex suggests the treeclimbing behavior of monkeys (94). Newborns have it: they engage in rough, pseudo-climbing thrusts and pedalling movements of the lower extremities. Once cortical control has taken over, primitive lower-limb reflexes tend to occur only under conditions of strong emotion or when the pyramidal tract is damaged. During arguments, for instance, the feet tense up; rage produces kicking and stomping; inhibition of aggression may result in hysterical paralysis of the legs. The lowly foot is also subject to circulatory drought and stasis. Arteriosclerosis, varicose veins, elephantiasis, diabetes, and other conditions affecting its nutrient supply tend to create most unpleasant pedal symptoms. Smell Doctors must be able to differentiate the stink of uremia, diabetes, alcoholism, lung abscess, and other serious illnesses. Even psychiatric diagnosis may be aided by a good nose, since the sweat of chronically schizophrenic patients carries a peculiar odor that rats and perfume experts are able to detect (86).

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The human smell brain lies buried beneath structures subserving “higher” intellec­ tual processes, yet is closely connected to both the cortex and the hypothalamic emotion centers (50). Its exact function in human communication is not known. Some psychosomatic facts about the nose have been presented by Holmes (37), and a delightful naturalistic book about the sense of smell is available (5). That social inhibition may be a factor in reducing nasal sensitivity is suggested by the fact that close to one billion dollars is spent in the United States each year on perfumes, cosmetics, deodorizers, and other toiletries (93). Olfactory sensitivity increases during pregnancy, in certain epileptic auras, and with some brain lesions. But cultural interests in synesthetic phenomena can account for heightened olfactory sensibility; take for example Des Esseintes in Huysmans’ “A Rebours” who doused himself with various perfumes. Pathologic oral fixations can also lead to nasal hypersensitivity. An obese, childish, postpartum depressive patient preoccupied herself with the smell of flowers in my office; a lonely young man dreamt that his mother forbade him to eat canapes with a delicious, pungent smell.

HUMAN SOUNDS

Language is a poor thing. You fill your lungs with wind and shake a little slit in your throat, and make mouths, and that shakes the air; and the air shakes a pair of little drums in my head - a very complicated arrangement, with lots of bones behind - and my brain seizes your meaning in the rough. What a roundabout way, and what a waste of time. (Du Maurier, “Peter Ibbetson”, 95) From the welter of primarily nonacoustic signs described in the preceding section, no physician could get more than a fragmented and self-contradictory impression of what is wrong with his patient. To learn more he has to listen closely to the sounds the patient makes, and this involves attention on both verbal and nonverbal levels (63). First the doctor “takes a history”, hoping thus to illuminate the sequential pattern of pathologic developments. He asks questions, receives answers, and - if he is a psychiatrist - encourages the active verbalization of fantasies and wishes. During all of this, the doctor attends closely to paralinguistic acoustic cues, for example variously intoned forms of “oh” and the nuances which support or belie overt meanings of words. A few noises and musical patterns have already been mentioned in connection with the language of hands and feet; I have discussed these in greater detail elsewhere (62). Other body sounds are systematically elicited from the patient during the physical examination. These range all the way from byproducts of the examination, for instance “aah” uttered during visualization of the posterior pharynx, to characteristic diagnostic sounds like the systolic murmur of aortic stenosis. While primarily

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informative about bodily events per se, many of these acoustic cues also have some­ thing to say about a patient’s mental condition, particularly when these sounds are used in place of words (81). A short vocabulary of body sounds Acoustic study of human sounds began only recently (69), and the following remarks should be taken as tentative hypotheses rather than as definitive or conclusive statements about the nonverbal soundmaking of patients. Rhythmic beats. - To come to another person’s awareness, the rhythmic beating sounds of the heart need amplification; this is done in the clinic by means of the stethoscope. Only in rare cases of syphilitic aortitis may cardiac pulsations become sufficiently visible for communication, through the patient’s rhythmic head-nodding (De Musset’s sign). Under conditions of physical contiguity - between mother and child, lover and beloved - the pulse can also be directly transmitted. This fosters a feeling of intimacy and is said to be a factor in the organization of rhythmicity during intra uterine and early nursery development (55). Breath sounds. - Acoustic signals transmitted by air generally play a more important role in communication than do those transmitted by contact. It is possible of course to breathe softly, in which case respiratory sounds are barely audible and have, at most, a mildly hypnotic effect. But due to the larynx, the practice one gets in childhood of stirring others to action with cries, and the amplification afforded by numerous resonating chambers, the respiratory tract is probably man’s best instrument for acoustic communication. Vocalization for speech comes off well in the expiratory phase of respiration. So do sighs, whispers, moans, hums (66), whistles (61), screams, and exclamations. Inspira­ tory sounds, in particular wheezing and snoring, tend to produce annoyance and alarm. Rasping noises. - While any sound can be noise in the sense of being unwanted (10), some sounds more than others are especially annoying. These include tooth-gnashing, fingernail-scratching, grinding friction between solid objects, and other noises with a nonharmonic pattern. So far as medical diagnosis is concerned, sounds of this type almost invariably indicate pathology. Rough heart sounds, peritoneal friction rubs, and crepitation in the joints generally point to inflammation, decay, breakage, or new growth which impedes the smooth frictionless gliding of one surface over another. Due to defective phonation or articulation, grating and rasping sounds may also get into the voice and communicate varying degrees of annoyance and un­ pleasantness. To a certain extent the reactions of listeners to nonharmonic acoustic patterns are further conditioned by the acoustic preference of their community (21). Spasms. - Spasmodic contractions in the gastrointestinal, respiratory, and urogenital tracts at times produce characteristic brief sounds: coughs, gasps, sneezes, retching, cramping, gurgling, and flatulence. These are basically sounds of reflex origin and indicate the body’s efforts to eject painful or useless irritants. Under certain

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circumstances spasm sounds come to be used in communication, however. How this may happen can best be seen through the analysis of a single sound, for example, the cough. The biography of a cough The cough is part of an unlearned, reflex ejection-spasm triggered when there is irritation in the patient’s respiratory passageway (3). Acoustically it is an intense, sudden, explosive, noise that can be heard at some distance. Should this noise fall on trained ears - any listener is at least partly trained since he too has coughed at some time in his life - it is then intuitively perceived in terms of something irritating. The listener may himself feel some irritation in the throat. More often however, he finds himself merely sympathetically in tune with the cougher, in the sense that a tacit agreement, “cough means irritation and riddance spasm”, leads to some mutuality. Now the listener may respond to his own reflex impulses to clear the throat, to reduce irritation, even to silence the cougher or escape from the unpleasant situation. Or he may inhibit these impulses and turn to the cougher in helpful ways. If he is a physician, then the listener uses his own sense of irritation to gauge that of the coughing patient. He may further search for the etiology of the cough, treat the patient, and try to prevent recurrence. These responses may all have the desired effects upon the patient and his cough. But something else can happen too: the patient may recognize that his coughing manages to arouse interest and help from the environment. Should he have difficulty in obtaining these reactions in other ways, he may then be tempted to put more and more vigor into his coughing, which thereby loses its instinctive spontaneity and becomes a pathologic symptom, like a tic. He may even learn to imitate a cough at times when it is not actually the respiratory tract but some other body part that feels irritated. If these counterfeit coughs succeed in eliciting the desired help and attention, then the patient obtains more than the usual amount of control over his environment through coughing. One could call such a non-reflex cough a sort of “verbal” operant (55). However, it seems more correct to think of this kind of sound-making as contrary if not inimical to communication with words. Like other pathologic forms of acoustic behavior used to gratify dependent, passive, infantile strivings, provocative coughing often tends to shut off the possibility of more complex linguistic communication (56). Laughter and crying Repetitive, uncontrolled, spasmodic chains of sound that accompany the release of accumulated tensions are man’s purest sounds for emotional expression. Laughter tends to be composed of shorter, more staccato, more high-pitched and more rapidlyrepeated tonal elements than crying. For example, the tinkly giggle contrasts easily with the mournful moan as extreme examples of laughing vs. crying. But towards the center of the laugh-cry continuum, it is difficult to make the distinction acoustic­ ally; at this point visual cues, such as the square mouth of sadness described by Darwin (14), become helpful.

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PETER F. OSTWALD

Psychiatrists pay a good deal of attention to the conditions that precede emotional sound-making, for instance the tension build-ups before laughter and the feelings of loss which precipitate crying. Laughter can also be produced by a sudden sense of incongruity (35). For example, in the joke-telling situation, the joker subdues the laugher by coaxing him into having evermore discrete fantasies. As soon as the laugher reaches a certain pitch of tense expectation, the joker “punch-lines” him with information that either is entirely unexpected or might only have been tangentially inferred from ambiguous hints contained in the build-up. Of interest here is the necessary inequality between joketeller and listener: to get a joke to work, the joker must emit verbal symbols continuously (words, puns, metaphors, etc.) while the laugher can emit only non-verbal signs (silent attentiveness, eyes lighting-up with anti­ cipation, outburst of noise after the punch-line). Variations on this theme are found in actedout jokes and comedy. Crying is usually a symptom of depression resulting from real or fantasied experiences of loss (29). As in the evaluation of laughter, the psychiatrist must consider not only a patient’s background and physical condition, but also social rules to the extent that these selectively prohibit or encourage certain forms of emotional expression. Also, as with other sounds, crying can be used to arouse sympathy, declare one’s helpless­ ness, or express anger. Often the best way to distinguish genuine from counterfeit emotional behavior is for the clinican to allow himself to respond instinctively to his patient and then to introspectively evaluate the depth of these intuitive reactions (78). Acoustic signalling and the origins of communication The science of bioacoustics is barely 5 years old (91). Yet with an eye towards the next section of this paper which deals with stunted and abnormal speech, one must venture a formulation about the ontogeny of normal human acoustic-communication: Meaningful sound-making originates in the nuclear child-mother relationship. It is here that reflexly produced acoustic patterns first jell into a repertory of signs and then symbols for information exchange. First there is the cry, which is life-saving in any culture that allows a mother to leave her child alone. This sound enables the other­ wise completely helpless baby simultaneously to summon assistance and to indicate how uncomfortable it is. At first no mother can tell with certainty precisely what physiologic tensions are rising and which of the baby’s vital needs demand satisfaction. Only gradually does the acoustic behavior of the infant become morphologically distinctive enough to enable the mother to discern cries of hunger from shrieks of pain, whines of soiled diapers from plaints for attention, delighted yelps from overexcited yells (49). To learn this “language” of her newborn, the mother proceeds much like any person who tries to communicate in a strange tongue: she touches, inspects, smells, and lives with the foreign visitor to acquaint herself with his behavior and to decipher the relationships between this behavior and the sounds he makes. At the same time she expects the stranger to do likewise. Babies make numerous sounds beside cries: smacking, cooing, hiccupping, humm-

HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR

21

ing, gurgling, whining, burping, coughing, sneezing, flatus, shrieking, spitting, and more (43). How mothers seize upon these behavioral cues for information about infants depends in large measure upon their native interest in sounds and their enthusiasm for playing the acoustic detective game. This in turn is probably a function of a mother’s personal experience as a child with her own parents and may also reflect the acoustic habits of her particular culture. For example, a mother may decide that there is no hunger-cry simply by listening for and acting upon the infantile lip-smacking noises which precede crying. This actually occurs, and more general inverse relationships between mothering and crying have also been do­ cumented (11). One occasionally sees this going too far: I recently learned of a mother who so rarely let her baby out of eye-range that the latter reduced its acoustic output to an occa­ sional mewling whimper. Clearly then, acoustic communication is historically associated in every person with the helplessness, immaturity, and absolute dependency of his own infancy. The transition from this life period into childhood is characterized by the use of “familylanguages” that contain acoustic elements derived from both infantile sound-making and parental speech (52). The final step into adulthood requires that the growing person wean himself from the pidgin-languages of his family circle and communicate with symbols useful to the community-at-large. Failure to accomplish this leads to all kinds of disturbances in communication (76), some of which will now be discussed.

SPEECH AND ITS ABERRATIONS1 ... Does not the eternal sorrow of life consist in the fact that human beings cannot understand one another, that one person cannot enter into the internal state of another? (I. P. Pavlov [70] p. 50). Verbal communication is a relatively late accomplishment, both in the history of the individual and the history of living things (36). It is not surprising therefore that aberrations of the speech functions are so frequently encountered in medical practice. Those due to developmental anomalies, for instance cleft-palate, or organic disease processes like laryngitis will not concern us here (48). Neither will I be able to cover the field of neurologic disturbance and its effects on[memory, language, and speech (31). Rather the focus is on relationships between personality disorders and those aspects of behavior which lead to meaningful verbalization. Nonhuman languages There are patients who “speak” like dogs, cats, chickens, billy-goats, monkeys, and other animals. Sometimes this is due to a degree of mental deficiency plus social 1 Investigations reported in this section were financed, in part, by grant T-59-144 from the Foun­ dations’ Fund for Research in Psychiatry.

.?.X

v. v?*r - •: K

\ v.

*■;

22

PETER F. OSTWALD

TABLE 1 The “ Vocabulary” of a Mentally Defective Patient

g=Ggn rm rm r P g k

A

a.

ju

a o

i jgg 3 5

a 3

i &

3

&

m g

hh

1

S-

Ka

n

&

mu

p—

ae

E a—a

ft O

O--------

isolation which in effect keeps the sick person from learning any human language. Cases have been reported of children reared by animals (72); also in the hospitals for chronic mental disease one finds patients who have no trace of recognizable speech.2 Table I displays this kind of acoustic behavior; it shows the output of a woman who has been in a State Hospital for 40 of her 45 years. She uses bleats and grunts — accompanied by several stereotyped gestures - to communicate with the staff in a rudimentary way about her feelings and needs. Another patient in the same hospital communicates only by humming; she emits simple song-like tunes as well as repetitious monotonal hums (see Table II). * Leonti Thompson, M. D., recorded the two patients demonstrated here.

►

HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR

23

TABLE II

A Mentally Defective Patient who Hums Song-like tunes:

-£

tyfJJj.rt J I J ^ 5 * -S'

Simple hums:

t

p

k p

Other mentally ill patients know how to speak, but produce the -sounds of animals at times when they feel themselves to be nonhuman. These are usually schizophrenics who, apparently due to deprivation of security and love early in childhood, turned to nonhuman objects for basic affection and contact (82). Omissions, repetitions, and errors Even patients who use a human tongue without difficulty are likely to make slips. Their omissions, repetitions, and errors tend to occur during moments of anxiety (51) and often stem from the inability to resolve some intrapsychic conflict under the stress of having to speak (28). For example:

24

PETER F. OSTWALD

A patient spoke of seeing the movie “To Have and Have Not’’ on TV. She had previously seen this film during her adolescence, and on the basis of a common appellation (Slim) had closely identified with the female lead, Lauren Bacall. In discussing the movie the patient for a while said nothing about the male lead. This was the first symptom of her speech disturbance: omission of an essential part of the topic. The second symptom, a syllablerepetition, soon followed; when she finally ventured to name the male lead, it came out “Hum-Humphrey Bogart”. The patient denied any awareness of the stutter until I mentioned it to her; and then she reconstructed her thinking in such a way that her speech symptoms became plausible: “Hum” called to her mind “humping”, a slang expression for sexual intercourse which she had guiltily and mischievously used as a teenager. Two other determinants for the develop­ ment of some hesitancy in pronouncing Humphrey Bogart emerged through our discussion: 1) For the past few days she periodically had the fantasy that her husband, a swarthy man who resembles Bogart, might be killed in an auto-accident. This fantasy led to an obsessional idea: “You’re not supposed to think about having intercourse with a dead man.” 2) The preceding day she had told me about certain of her ideas regarding pregnancy, but only now remembered how proud of her abdomen she was while pregnant. “It resembled the hump of an oriental male god.”

TABLE III

Some Examples of Speech Errors Type of Error

The Intended Sound

The Actual Sound

Single Sounds:

omission addition substitution transposition

front remnant affect Yale Journal

-► font remenant -*■ afTuct Jail Yournal

Syllables:

omission addition substitution transposition condensation

salivary Marietta taken Beruf suchen apprenticeship

-> -► -► -► ->

salary Marionetta taking Besuch rufen apprentiship

Words:

omission addition substitution transposition condensation fragmentation

you bastard stop working feet of film bowel movement reminder

-► -> -»■ -► -► -+

you please stop mother film of feet boom rema...

Level of Disturbance

HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR

25

Table III offers further examples of speech errors collected from a number of different patients and speakers. It is likely that linguistic rules for the formation and decay of language symbols are involved in the production of these disturbances (97). Therefore a combined approach by linguistics and psychiatry to these interesting symptoms seems called for. Stress, intonation, and pause anomalies In clinical work one usually studies clusters of symptoms called “syndromes”, not single isolated symptoms. Also in the analysis of verbal behavior, disturbance of a single phonetic variable may have little relevance, since several symptomatic disturbances usually occur within the same speech fragment (46). The unbalanced stress pattern demonstrated by the following patient, for example, occurred in the context of sloppy articulation, repetitiousness, and verbosity. A middle-aged lawyer, whose fortune and professional reputation had crumbled as the result of personal and economic failures, overstressed certain words and word groupings. Most notable were exaggerated or even incorrect stresses in word couples like “party pdlitics, police protection, possible partnerships”. From other information obtained about this man, it became apparent that he had failed to develop emotionally much further than the sexually ambivalent orientation of early childhood. For instance, in the face of extremely vengeful feelings towards women he quite generally directed his dependency strivings towards men. An analysis of the stress anomaly in his speech showed that the explosive overemphasis was a veiled calling out for his father, whose early death had robbed him of the emotional support needed to cope with a crippled mother and two elderly psychotic sisters. The patient had never given up the infantile babbled form of paternal address, pa-pa, in favor of more adult versions: p&pa, papd, father, etc. Now in his unhappy depressed state, energetic mouthing of the aforementioned word couples gave him an illusory way to magically call out for a father. His associations to the overstressed words (e.g. police, partnership) also revealed fantasies in which an omnipotent agent, usually masculine, was to rescue him from distress. A number of pathognomonic intonation patterns have been noted in the speech of psychiatric patients. Excitable and histrionic persons often exaggerate the normal pitch pattern of the language. When matched by an equally theatrical use of gesture, clothing, makeup, and perfume, these hyperinflections usually indicate a hysterical process (2). The patient seems to use dramatization as a kind of noise to impede the verbal communication of troublesome personal matters. Depressed patients often restrict the range of pitch variation in the voice. This symptom usually parallels a reduction of vocal intensity and speed. Words are uttered in a lusterless, monotonous way that communicates apathy and resignation. Anomalous use of pitch cues is noted among patients with schizophrenic illnesses, particularly children and adolescents whose autism also manifests itself through grammar confusion, neologisms, and disconnected word fragments (9). Verbal interaction with these patients is extremely difficult since one often cannot extract meaning from what the patient says.

26

PETER F. OSTWALD

TABLE IV Samples of Schizophrenic “Speech”

Sample 1:

\_J—L_n_^ patient:

t=51=6 th

patient:

oh§ nor

ei swa

Anoz

Sample 2:

X

th§ts.

doctor:

ho n d i ten.

patient:

5h5? 5

Arth5".

doctor:

on dir

ten.

?ow.

Sample 1 shows a verbal utterance that lends itself to 72 ambiguous interpretations. Sample 2 shows a fragment of confused conversation in response to the doctor’s question “Do you have any little brothers or sisters?” Take for example the 14-year old boy, samples of whose speech are shown in Table IV.3 during an acute excitement he produced what psychiatrists call a “word salad” - he was incoherent, babbling, constantly switching between a high and squeaky voice and a low droning one. Sample 1 is a characteristic spontaneous production which, if one tries to impose meaning upon it, can be interpreted in 72 different ways as follows: (Don’t) don’t tell

’what why by

you yours her

knows nose

* This and subsequent linguistic transcriptions were done by William Shipley, Ph. D., Associate Professor of Linguistics, University of California (Berkeley).

HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR

27

Sample 2 of Table IV shows what happened when one tried to converse with this confused patient. The doctor asks, “Do you have any little brothers or sisters?” Instead of a “yes” or “no” reply, the patient produces an ambiguous sound (line 1) which the doctor tries to translate into “hundred ten?” (line 2). The patient then makes some more of the same ambiguous sound (line 3) upon which the doctor now imposes the less absurd meaning “under ten” (line 4). Pause anomalies are best observed among stutterers. Fixated at pre-genital levels of psychosexual development, these patients get into a jam when they can neither express their anger through shouts nor inhibit it by keeping still (30). Unlike the overt psychotic who may lose control at this point, the stutterer immobilizes himself and frustrates the listener by emitting a sequence of repetitions, embolophrasias, cliches, or say-nothings.

TABLE V 48 Abnormal Pause Forms from 5 Minutes of Speech by a Stutterer ay o a ttt... 66 ?3 ?3 (sigh) 5s ?3 kkk... 6x... ?3... pppiyiy 3 kkk... send 3... 5s ?3... hwen || 3 sst... Ser 3 Ser 3 ppp... send 3 3 3 §iy... 6xt 3 3p... kffinat 3 Seynj... aydinow ?3 || &y... (long pause) dySlks meybiy... Sly 3 0ii)z... in 3 || 5isiz... aeksiliy 3 get 6p... £nd 3 11 sey aym... sey aym 3 ttt... tuwey ?3 gruwp... kin 3 || sst ssttiwdint 3 gsvsmint... wel ?3... bst 3 Sey...

wsz 3 aek&liy... tftw ?3 sey... Sey jist 3 luk... dlsow 3 tuw 3 ?3 ?3... OySfk 3 Saet 3... nat 3 nat 3 evriy... sekSliy 3 ?3... lukirj rayt 3 3 3 seksliy 3... w^y^y 3 10k 3 elshwer... a?nd 3 Sey left... mikst 3 gruwp... luk 3 lukSwvir... hawevir ?3 ow ?3... h&dey 3... giv 3 ttt... £ksliy 3 ?3 ksvird... downt 3 downt 3... Girjkay 3 || wel... aekgliy 3 ppp... Siyapmt 3 seks... in 3 || lOyk in sspSwrts... eniy 3 trsbil. wiS 3 wsrdz ^k§liy... aek§liy 3 3 haevnt...

■

' -

I 28

PETER F. OSTWALD

For example, a 21-year old college student complained of difficulty “tttttalking”. He tried to “chchchchchchchchchange” his “pppprogram” for school. He also complained of trouble “pppeeing” and found it “tttttough” going with girls. Table V shows consecutive pause anomalies in 5 minutes of a tape-recorded interview with this stutterer. Abnormalities in vocal intensity, register, and utterance rate Illness also takes its toll on the paralinguistic system (8). Like pianists who press different pedals to emphazise important themes, patients selectively vary their vocal intensity, switch register, and change speed while talking. Voice intensity can be measured by means of acoustic devices (89).

TABLE VI

Loudness Levels of a Blind Patient's Voice during Two Interviews He says:

energetically convey compliance

“Yes, o yes, oh, yes, eh yes sir!”

86 phons

indignantly deny responsibility

“He didn’t say who he was.”

84 phons

tensely explain

“It’s a little bit different; I don’t know just how to explain it, but...”

82 phons

.. an overstaffed office”

80 phons

humbly convey embarrassment

“I guess maybe I don’t use it enough, huh, huh”

78 phons

sadly contemplate his condition

“these treatments have done me quite a lot of good because...”

72 phons

painfully discuss his symptoms

“next to a woman I have the strong urge...”

68 phons

sadly acknowledge defeat

“I don’t think she cares anymore.”

60 phons

criticise : :

Vocal Loudness4

Patient tries to:

4 Converted from decibels re 0.0002 microbar to phons using the method of S. S. Stevens (/. Acoust. Soc. Am., 28, 1956, 807-832).

HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR

29

For example, Table VI shows acoustic measurements of the voice of a blind patient. Like many persons without vision, this man compensated for his communication defect by re­ sourceful use of acoustic cues (80). He selected vocal loudnesses over a range of 26 phons in order to convey shades of emotion and to over- or under-score the verbal content of his utterances. Register shifts have been described clinically (59) and can be demonstrated by means of acoustic filters that cut out part of the speech signal (88) or selectively measure the individual components of an intact signal (55). During experimental stress or acute emotional illness, acoustic energy fluctuates particularly in bands centered at 500 cycles per second (67). Table VII shows half-octave band analyses carried out during the opening (A) and the closing (Z) phases of 11 interviews with a 26-year old salesman who applied for psychiatric treatment following the breakup of his marriage. At that time, he was in a state of acute restlessness, trying to keep a more chronic sense of sadness and unworthiness from under­ mining his social adjustment. He was the younger of two sons and had usually gotten along pretty well by being a charming, boyish, friendly person and keeping away from intellectual or occupational competition. When on the spot, for example during “dressing downs” from superiors, he tended to become anxious and behave in an arrogant, provocative manner. This would get him into trouble, which he then tried to escape through passive resignation and submissiveness. The rapid alternation between provocativeness and submissiveness evident in this patient’s social behavior also appeared in his paralinguistic behavior (Table VII). Strident, querulous, effeminate soprano voices (upper curves) would alternate with flabby, resigned baritones (lower curves). These register shifts often took place within sentences, as for example in interview 1 (3-2-60), segment A: His high voice says “putting conversations and things into a negative”; this is cut short by an embolophrasia “b...uh”; the low voice then continues with “course of viewpoint”. The end (Z) of the first interview shows this same intra-sentence instability, but now each voice carries more energy than before. Compare Interview 1 just described with Interview 2 (3-7-60), which shows more acoustic stability both within sentences and within the hour. Now look at Interview 4 (3-9-60), which shows a little fluctuation at the beginning (segment A) but none at the end of the interview which has the voice fixed in a persistent high register (segment Z). A persistently high voice was generally associated in this patient with defensive negative attitudes; for example, after Interview 4 the patient broke two consecutive appointments with his doctor. Later phases of the therapy showed more intrasentence stability than did earlier interviews. Some most bizarre register shifts can be heard during schizophrenic excitements. For instance, the patient whose productions are given in Table IV dramatized his preferential use of certain vocal registers by emitting the high squeaky voice from the left side of his mouth and the low one from the right side. Disturbance in the rate of speech provides another criterion for the analysis of behavior; utterance rates can be objectively measured and are found to be influenced by personal and social variables (89). Particularly gross disturbances of speech rate accompany the cyclic mental disease called manic-depressive psychosis (6). During the manic phase the patient is under tremendous pressure and his speech speed-up is

; 30

PETER F. OSTWALD TABLE VII

Intrasentence Variations in the Acoustic Behavior of a Patient during Psychotherapy 70

TO

•0

*0

so

50

40

40

50 10

50 too

MOO

toooo

too

1000

SO

.000

too

IOOO

3-7-60

10,000

3

* O

*

o

j

vj

*

U

5

N

N Q

©

3-30-60

ts

O

* «

V3-3

to >4 Hi C

0,000

FREQUENCY IN CYCLES PER SECOND

Half-octave band analyses of 11 interviews are shown here. Solid graphs denote the voice at the beginning of sentences, and broken graphs at the end of sentences.

part of the general psycho-motor excitement. In the depression, speech is remarkably retarded, approaches inaudibility, and may cease altogether. Defensiveness during psychotherapy is another frequent cause of utterance-rate

J

HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR

31

change. Transient speed-ups or slow-downs may betray the emergence into con­ sciousness of unacceptable ideas and unpleasant feelings. For example: a self-supporting spinster in her early thirties spoke with extreme rapidity whenever she experienced erotic desires. A rigidly hypermoralistic attitude towards sex made the open recognition of such feelings absolutely unacceptable. Her feverish verbaliza­ tions also had the effect of minimizing any questions and explanations the therapist might offer in challenging her repressive attitudes. To be interrupted and talked to was a threat to her fantasy of being an independent asexual person. She recalled that rapid speech used to annoy her mother who complained of inability to understand what was being said. Over the years the patient had thus learned to use loquacity also as a way to keep other people at a distance. SUMMARY AND CONCLUSION This paper deals with the perceivable manifestations of disease processes which doctors are trained to recognize as symptoms and use as diagnostic cues. Some physical signs point directly to specific bodily malfunctions; others communicate in more general ways about emotional disturbance. Acoustic signals may do this also; but in addition, patients deliberately emit sounds for the purpose of verbal communi­ cation. Insofar as illness affects the voice and speech, specific abnormalities of communication with words are discussed, and detailed clinical examples are given. Both the normal and the aberrant usage of spoken language seem related to man’s peculiar cerebral organization, his orality, and the problems posed by his social living. The rift between sound and sense which heralds many human illnesses is a practical consideration for the clinician. But within a wider context one may ask whether these vexing disruptions between acoustic and semantic behavior do not betray a basic flaw in the way man applies soundmaking to the problems he must solve. How can communication about basic human needs and urgent human dilemmas be improved? An optimistic guess might be that we are on the verge of casting off outmoded ways of discourse in an effort to evolve more universal forms of communi­ cation. Perhaps the scientific study of paralinguistic and kinesic phenomena can here make its greatest contribution to the general weal. BIBLIOGRAPHY 1. Abse, D. W., “Hysteria”, in S. Arieti (ed.), American handbook ofpsychiatry, Vol. 1 (New York, 1959), pp. 272-292. 2. Allen, D. W., and M. Houston, “The management of hysteroid acting-out patients in a training clinic”, Psychiatry, 22 (1959), 41-49. 3. American Medical Association, “Dramatized cough”, JAMA, 177 (1961), 445-446. (Editorial.) 4. Andrews, G. C., Diseases of the skin (Philadelphia, 1947). 5. Bedichek, R., The sense of smell (New York, 1960). 6. Beliak, L., Manic-depressive psychosis and allied conditions (New York, 1952).

32

PETER F. OSTWALD

7. Bender, L., A visual motor gestalt test and its clinical use (New York, 1938). 8. Birdwhistell, R. L., “Paralanguage - 25 years after Sapir”, in H. Brosin (ed.), Lectures on experimental psychiatry (Pittsburgh, 1961). 9. Boatman, M. J., and S. A. Szurek, “A clinical study of childhood schizophrenia”, in D. Jackson (ed.), The etiology of schizophrenia (New York, 1960), pp. 389-440. 10. Broadbent, D. E., “Effects of noise on behavior”, in C. M. Harris (ed.), Handbook of noise control (New York, 1957). 11. Brody, S., Patterns of mothering (New York, 1956). 12. Brown, R., Words and things (Glencoe, 111., 1958). 13. Bruch, H., “Conceptual confusion in eating disorders”, J. Nerv. and Ment. Dis., 133 (1961), 46-54. 14. Darwin, C., The expression of the emotions in man and animals (New York, 1955). 15. Davis, H., and S. R. Silverman (eds.), Hearing and deafness (New York, 1960). 16. Deutsch, F., “Analytic posturology”, Psychoan. Quart., 21 (1952), 196-214. 17. Diethelm, O., Treatment in psychiatry, third edition (Springfield, 111., 1955). 18. Douthwaite, A. H. (ed.), French's index ofdifferential diagnosis, seventh edition (Baltimore, 1954). 19. Dunbar, F., Emotions and bodily changes, fourth edition (New York, 1954). 20. Erikson, E. H., “The nature of clinical evidence”, in D. Levner (ed.), Evidence and inference (Glencoe, 111., 1959), pp. 73-95. 21. Farnsworth, P. R., The social psychology of music (New York, 1958). 22. Feldman, S. S., Mannerisms of speech and gestures in everyday life (New York, 1959). 23. Fenichel, O., The psychoanalytic theory of neurosis (New York, 1945). 24. Ferenczi, S., “Embarrassed hands”, in Further contributions to the theory and practice of psychoanalysis (London, 1950), pp. 315-316. 25. Fisher, S., and S. E. Cleveland, Body image and personality (Princeton, 1958). 26. Fliigel, J., The psychology of clothes (London, 1950). 27. Frank, J. D., Persuasion and healing (Baltimore, 1961). 28. Freud, S., The psychopathology of everyday life, Vol. 6 of The complete psychological works of Sigmund Freud (London, 1960). 29. ------, “Mourning and melancholia”, in Collected papers of Sigmund Freud, Vol. 4 (1925), pp. 152170. 30. Glauber, I. P., “The psychoanalysis of stuttering”, in J. Eisenson (ed.), Stuttering - a symposium (New York, 1958), pp. 71-119. 31. Goldstein, K., Language and language disturbance (New York, 1948). 32. Greenacre, P., “Pathological weeping”, in Trauma, growth, and personality (New York, 1952), pp. 120-131. 33. Grinker, R. R., P. C. Bucy, and A. L. Sahs, Neurology (Springfield, 111., 1960). 34. Grinstein, A., The index of psychoanalytic writings, 5 vols. (New York, 1956). 35. Grotjahn, M., Beyond laughter (New York, 1957). 36. Hockett, C. F., “The origin of speech”, Sci. Amer., 203 (1960), pp. 89-96. 37. Holmes, T. H., The nose (Springfield, 111., 1950). 38. Hurxthal, L. M., and N. Musulin, Clinical endocrinology, 2 vols. (Philadelphia, 1953). 39. Knapp, P. H., “Sensory impressions in dreams”, Psychoan. Quart., 25 (1956), pp. 325-347. 40. Kretschmer, E., Physique and character (New York, 1925). 41. Kris, E., Psychoanalytic explorations in art (New York, 1952). 42. Kubie, L. S., “The eagle and the ostrich”, Arch. Gen. Psychiatry, 5 (1961), 109-119. 43. Kurtz, J. H., Tape-recording of the sounds of an infant during the first 24 hours of life. Langley Porter Neuropsychiatric Institute, (Aug. 1961). 44. Lacey, J. I., “Psychophysiological approaches to the evaluation of psychotherapeutic progress and outcome”, in E. A. Rubinstein and M. B. Parloff (eds.), Research in psychotherapy (Washing­ ton, D.C., 1959), pp. 160-208. 45. Lasswell, H., Psychopathology and politics (Chicago, 1930). Quotation from Preface. 46. Lehiste, I., R. S. Tikofsky, and R. P. Tikofsky, “An acoustic description of dysarthric speech”, J. Acoust. Soc. Am., 33 (1961), 1677. 47. Lewin, B. D., “Sleep, the mouth, and the dream screen”, Psychoan. Quart., 15 (1946), 419-435. 48. Luchsinger, R., and G. E. Arnold, Lehrbuch der Stimm- und Sprachheilkunde, second edition (Wien, 1959).

ft

HOW THE PATIENT COMMUNICATES ABOUT DISEASE WITH THE DOCTOR

33

49. Lynip, A. W., “The use of magnetic devices in the collection and analysis of the preverbal utterances of an infant”, Genet. Psychol. Monogr., 44 (1951), 221-262. 50. MacLean, P. D., “Psychosomatic disease and the visceral brain”, Psychosom. Med., 11 (1949), 338-353. 51. Mahl,[G., “Disturbances and silences in the patient’s speech during psychotherapy”, J. Abn. and Soc. Psychol., 53 (1956), 1-15. 52. McCarthy, D., “Language development in children”, in L. Carmichael (ed.), Manual of child psychology (New York, 1954), pp. 492-630. 53.i (McDowell, F. (ed.), Handbook of neurologic diagnostic methods (Baltimore, 1960). 54. Meares, A., Shapes of sanity (Springfield, 111., 1960). 55. Meerloo, J., “Rhythm in babies and adults”, Arch. Gen. Psychiatry, 5 (1961), 169-175. 56. ------, “Psychoanalysis as an experiment in communication”, Psychoan. and Psychoan. Rev., 46 (1959), 2-16. 57. Mitscherlich, M., “Psychologie und Therapie des Torticollis Spasticus”, in Proceedings of the 3rd World Congress of Psychiatry (Montreal, 1961). 58. Moser, H. M., et. al., Hand signals: finger-spelling (= Technical Note No. 49, Contract No. AF 19 (604)-1577) (Air Force Cambridge Research Center, 1958). 59. Moses, P., The voice of neurosis (New York, 1954). 60. Obcrmayer, M. E., Psychocutaneous medicine (Springfield, III., 1955). 61. Ostwald, P. F., “When people whistle”, Lang, and Speech, 2 (1959), 137-145. 62. ------, “Human Sounds”, in D. Barbara (ed.), Psychological and psychiatric aspects of speech and hearing (Springfield, 111., 1960), pp. 110-137. 63. ------, “The sounds of human behavior - a survey of the literature”, Logos, 3 (1960), 13-24. 64. ------, “A method for the objective denotation of the sound of the human voice”, J. Psychosom. Res., 4 (1960), 301-305. 65. ------, “Visual denotation of human sounds - a preliminary report of an acoustic method”, Arch. Gen. Psychiatry, 3 (1960), 117-121. 66. ------, “Humming: sound and symbol”, J. Aud. Res., 3 (1961), 224-232. 67. ------, “The sounds of emotional disturbance”, Arch. Gen. Psychiatry, 5 (1961), 587-592. 68. ------, “Sound, music, and human behavior”, in E. Schneider (ed.), Music therapy 1960 (Kansas, 1960), pp. 107-125. 69. ------, Soundmaking - the acoustic communication of emotion (Springfield, 111., 1963). 70. Pavlov, I. P., Lectures on conditioned reflexes, Vol. I (New York, 1928). 71. Pittenger, R. E., C. F. Hockett, and J. J. Danehy, The first five minutes (Ithaca, 1960). 72. Rangell, L., “The psychology of poise - with a special elaboration on the psychic significance of the snout or peri-oral region”, Int. J. Psychoan., 35 (1954), 313-332. 73. Rioch, D. McK., “Dimensions of human behavior”, in H. Brosin (ed.), Lectures on experimental psychiatry (1961), pp. 341-361. 74. Roman, K. G., “Handwriting and speech”, Logos, 2 (1959), 29-39. 75. Roose, L. J., “The influence of psychosomatic research on the psychoanalytic process”, J. Am. Psychoan. Assn., 8 (1960), 317-334. 76. Ruesch, J., Disturbed communication (New York, 1957). 77. ------ , and W. Kees, Nonverbal communication (Berkeley, 1956). 78. Riimke, H. C., “Problems of nosology and nomenclature in the mental disorders”, in J. Zubin (ed.), Field studies in the mental disorders (New York, 1961), pp. 73-84. 79. Schilder, P., The image and appearance of the human body (New York, 1950). 80. Schumann, H. J., Trdume der Blinden (Basel, 1959). 81. Scott, W. C. M., “Noise, speech, and technique”, Int. J. Psychoan., 39 (1958), 1-4. 82. Searles, H. F., The nonhuman environment (New York, 1960). 83. Shaw, R. F., Finger painting (Boston, 1938). 84. Sheldon, W. H., The varieties of human physique (New York, 1940). 85. Skinner, B. F., Verbal behavior (New York, 1957). 86. Smith, K., and J. O. Sines, “Demonstration of a peculiar odor in the sweat of schizophrenic patients”, Arch. Gen. Psychiatry, 2 (1960), 184-188. 87. Stanislavski, C., Building a character (New York, 1949).

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88. Starkweather, J. A., “Vocal communication of personality and human feelings”, J. of Communica­ tion, 11 (1961), 63-72. 89. Steer, M. D., and T. D. Hanley, “Instruments of diagnosis, therapy, and research”, in L. Travis (ed.), Handbook of speech pathology (New York, 1957). 90. Strauss, H., “Epileptic disorders”, in S. Arieti (ed.), American handbook of psychiatry (New York, 1959), pp. 1109-1143. 91. Tembrock, G., Tierstimmen - Eine Enfiihrimg in die Bioakustik (Wittenberg Lutherstadt, 1959). 92. Thorek, M., The face in health and disease (Philadelphia, 1946). 93. U.S. Bureau of the Census, Statistical abstract of the United States: 1959 (Washington D.C., 1959). 94. Wartenberg, R., “The Babinsky reflex after fifty years”, J. Am. Med. Assoc., 135 (1947), 763-767. 95. West, R., The pathology of speech and the rationale of its rehabilitation, quotation from G. DuMaurier, “Peter Ibbetson”, (New York, 1957). 96. Wolff, C., The hand in psychological diagnosis (New York, 1952). 97. Zipf, G. K., Human behavior and the principle of least effort (Cambridge, Mass., 1959).

DISCUSSION SESSION ON PSYCHIATRY

Chairman: Dr. Nurnberger Rapporteur: Dr. Ostwald

Ostwald: In the recording which demonstrates loudness levels in a blind patient’s voice, shown in Table VI, I am introducing the matter of acoustical measurements applied to the soundmaking of a psychiatric patient. This is a subject on which I would very much appreciate some discussion. My own attitude is that acoustical instruments are extremely helpful in disclosing very small differences in such factors as loudness or, objectively speaking, intensity levels of sound, and we are beginning now to use acoustical measurements also to determine pitch levels or frequency characteristics of the soundmaking of psychiatric patients. In this example (Table VI) the degree of loudness ranges from sixty to eighty-six phons,1 an unusually large range. This seems to be related to the fact that this patient is blind, and uses soundmaking as a very active instrument for manipulating the environment and also for orienting himself. Also, he is constantly responding to the effects of his sounds in lieu of vision. Discussant: Will you tell us what is a “normal” range of phons? Ostwald: Well, in the studies that we have, we normally get a range between about sixty-five and seventy-five. Let me tell you how I recorded and measured these sounds and that will perhaps clarify the situation. The patient is in an anechoic corner of the office and the microphone is ten inches from his or her mouth. The sounds are directly recorded on tape and measured by means of a half-octave band analyzer. The reason I chose this method is that it eliminates the extraneous noises around the clinic and also permits one to pick up more detail of the articulation pattern. Acoustical studies of conversational speech of persons who are not psychiatric patients generally show intensity levels of around sixty-five decibels; such measurements have usually been taken in anechoic chambers or other acoustically-controlled situations roughly similar to the setup I have just described. Mead : Have these been two-person situations? Ostwald: Not all the time. Some of these studies in the acoustical literature are done from reading or reciting prepared material, and I think that would be considered a one-person situation. 1 The phon is a unit of loudness level, equivalent to decibels at 1,000 cps.

*

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SESSION ON PSYCHIATRY

Freedman: Most psychiatric interviews take place in rooms which are sound­ proofed to maintain privacy but into which street and other extraneous noises may intrude. This may mean that the sound level in which a “typical” patient-psychiatrist interview takes place is higher than the measured decibel level of a patient-doctor interaction in an acoustically-controlled environment designed for research. When I have recorded therapeutic interviews and have listened to the tapes about six months later, I have often been astounded at the amount of extraneous noise that I had not “heard” at the time of the treatment session - ambulance sirens, automobile horns, and so on. This is quite aside from the specific patient communications to which I did not respond. Without realizing it, I blocked out, as I suspect the patient did, outside noises of very high intensity. I assume that we both must have raised the level of our own verbal communications to compensate for them. Birdwhistell : They are discovering at Columbia that when you cut the noise level below a given point you observe distorted behavior in your subjects. Several “quiet” laboratories that were built at great expense are now being torn out and being turned “live” again. You get systematically different behavior in too quiet a room. With psychiatrists and patients, one of the things we must do, if we want to do decent comparative work, is to make sure that surrounding sound is not reduced too low. Mead: We have been neglecting Dr. Ostwald’s actual suggestion that precise acoustical measurements can give us valuable data. His actual illustration of the blind patient was exceedingly interesting. We didn’t get very clear from him initially-which is one reason we weren’t sufficiently appreciative - that he was comparing the blind person with other patients in a controlled environment, where the doctor’s behavior and the shape of the room were constant, and the blind patient showed a different range of variation from the others. Now if recording at this level can be significant without being raised to other levels of analysis, this is very important for us to know. Every time we can use the simplest measure, we are lucky not to have to raise it to a more complex measure. The possibility of using acoustical data diagnostically should go on record. Birdwhistell: The context and recording technique must be defined so that you know where your data come from, and can measure and evaluate your results. That is, “kinesic” or “paralinguistic” data are subject to a given kind of methodology, subject to a given kind of discipline. In a sense, Dr. Ostwald has offered us a hillside full of data, full of gold and silver and coal, but the fact that we can find minerals there does not make our efforts minerology. Minerology comes when you use certain techniques of a very specific nature to identify, to check, to test, and to allow other people to run similar tests and checks. The fact that we have a vast array of material does not make it kinesics or paralinguistics. The real question is: How do we know? What is the situation, the context from which the data are derived? We must measure significance in terms of the situation of the patient. Otherwise, how can we provide a profile which makes it possible to separate abnormal, pathological, inappropriate

1

DISCUSSION

37

behavior from behavior which is totally expectable in a normal human being within a given context? Now, if we may turn to the figures in Table VII, we must ask you, Dr. Ostwald, what you think, from your studies, the variation in these lines, the systematic ir­ regularity of pattern that you see there, is about? From your theoretical position, why do these lines tend to take this particular shape? What is the nature of such shapes? Do you think that the fact that these are similar has a reference to illness, a reference to humanness or is this a patternment of communication? Is this the way in which human beings interact with each other by the pattern method? Ostwald: I think the question of meaningfulness and of the relationship between verbal measures and other statements about patients should be deferred until we have had a chance to hear Dr. Mahl’s paper, which focuses on some of these very questions. Kramer: The underlying similarity that is measured by a good many of these figures in Table VII is the voice of one person. The differences, I think, are significant. The similarities you could pretty much expect, since you have the person’s character­ istic tone of voice recorded. The strength of each frequency, the relative intensity of certain parts of the sound spectrum is an important constituent of the tone of voice. You simply have somebody whose voice you would recognize if you met again at a later interview. Mead: Dr. Kramer, the real issue here is: Would you recognize him in this context? Are we dealing here with the distinctive idiosyncratic characteristics of this individual or are these characteristics of the communications situation he is in? Nurnberger: I would like to ask how much of the type of pattern which is demonstrated in Table VII is culturally determined, rather than individually deter­ mined. If, for example, you were plotting the intensity and frequency of communica­ tion, the beginning and end of sentences or of interviews, with an Indian in Calcutta or Bombay, would you be able to isolate anything idiosyncratic, or would the contrast with this man who derives from a different culture be in terms of the particular type of communications situation? It seems to me you would be highly suspicious that variations in the beginning and ending of sentences, for example, which I think the curve in Table VII demonstrates, would include a strong cultural factor. Goffman: The problem is that we can’t fall back on saying: “I’m just dealing with what I’ve got here.” It’s our job to try to make explicit what it is we might be having here: American vs. Indian; ill person vs. well; a patient, medical or psychiatric, vs. a healthy person; a two-person interaction vs. a multi-person interaction; sub­ ordinate-superordinate vs. equalitarian interaction. There is a whole nest of rolesin-context to which we might impute any difference we find. Stankiewicz: I would like to reconsider what we call here, rather vaguely, “communication”. On the one hand, we have phenomena which are fairly constant under various circumstances, and which are not easily controlled by the patient. These are the olfactory or tactile phenomena, which are of a physical nature, as well

38

SESSION ON PSYCHOLOGY

as the various types of sounds you describe, not all of them produced by the oral orifice. These phenomena may be regarded as symptoms. If they communicate, it is by virtue of the fact that they can be given a diagnosis or tell us something about a physical state or disease. In the same sense, every physical phenomenon conveys information, so long as there are interpreters intent on explaining it. St. Augustine stated the problem clearly when he said that the flight of birds communicates, but it communicates differently to the seer, hunter, or birdwatcher. In other words, every­ thing can be interpreted with reference to a given context or in terms of some private code. This type of communication has to be separated from that conveyed by signs which are part of a communal code. I think that if we draw this distinction at the very beginning, we may be able to discuss the various modes of communication in terms of signs which have a fixed, coded value, as opposed to physical phenomena which allow for variable, socially or contextually determined interpretations. Birdwhistell: I wonder whether it might be profitable to divide our discussion between those things which are descriptions of expression within one body as con­ trasted to these things which are communicational, interpersonal. Ostwald: I don’t think that we tend to make much formal distinction between expression and communication in clinical medicine. This is a question that 1 think the other physicians on the panel will have something to say about. Kanfer: At the beginning of the paper my reaction was, as expressed before, that we are shifting from a description of pathology, which is in the structure of the organism, one which we observe and which gives us some diagnosis, to a description of functional relationships to someone else. At first, these two seemed to me to be differentiable but, on second thought, I would like to raise the question of underlying assumption here. Would you think, for example, of a skin disorder as being a communication in the sense that it is functional also, or would you differentiate it at some point as being only a structural property? Ostwald : I certainly am impressed by the literature in psychosomatic medicine2 which attempts to define the multiple relationships between different emotional states — for example intractable tension associated with anger - and physical structural changes in the body - for instance renal pathology associated with hypertension. This is a very important area for medical research and I think no one has the final answer to it.3 Two different approaches seem to be called for: 1) we must know on the one hand what processes are involved when an individual translates the symbolic messages that he perceives coming from the external environment into neurophysiological signals and patterns of reaction; 2) we must also consider what the internal makeup of a person may be which controls how he translates his internal neurophysiological patterns into the kind of expressive behavior which can be communicated to outside observers. To begin with, it will be important to differen* Grinker, R. R., and F. P. Robbins, Psychosomatic case book (New York, 1954). 3 Reiser, M. F., 4 Reflections on interpretation of psychophysiologic experiments”, Psychosomatic Medicine, 23 (1961), 430-439.

DISCUSSION

39

tiate transient physiological changes, such as blushing of the skin or labile hypertension, from more permanent or semi-permanent bodily changes, such as chronic scarring of the skin or fixed hypertension. We know that psychotherapy, which is an attempt to influence the body’s internal state through external symbolic forces, can make psychosomatic patients feel subjectively better and even at times reduce the degree of abnormal bodily responsiveness. But once an intractable state of bodily dysfunc­ tion has been attained, psychotherapy seldom if ever can do more than help the patient accept his disability and reduce the secondary turmoil associated with being ill. Birdwhistell: Would you say that blushing and blanching, for instance, to go back to this transitory response, are merely physiological conditions, capillary conditions, or do you feel that blushing and blanching are cultural and learned phenomena? Ostwald: I don’t see why they can’t be both. Markel: If we accept the fact that all these things are cultural and leave it to anthropology to describe them in an extrasomatic sense, then there is no problem. Mead: I do not speak of culture as extrasomatic; if you stated it like that, of course you would have a lovely time. But our general conception of culture is of a system of learned behavior embodied by the people who live in it, and their bodies grow in it all through their lives. Markel: The term doesn’t make any difference. Certainly the culture is always expressed by individuals, but there are cultural systems which exist over and above any individual. I think the question you are raising is answered if we assume that all behavior is culturally determined; the psychologists and psychiatrists study how the individual uses the system. Mead: If you go back to Darwin’s The expression of the emotions in man and animals,4 the one thing that Darwin was not dealing with that we deal with now is communication. He was discussing what makes the dog bare his teeth when he is angry: the dog perceives something and bares his teeth because of what he perceives, not to tell the other dog what he is going to do. I think this is the sort of dilemma that was presented by Dr. Ostwald’s paper, because it ran the full gamut. It started with things which are physiological, and may be identified in any culture, for instance worms that are picked up by eating certain foods and invade the liver and may produce jaundice. This is a geographic and not a cultural trait, so that any time that you pick up this worm you’ll get a state in the liver which could be identified by a physician whether or not the patient knew, whether or not the patient wanted to tell the doctor. If the doctor knew the phenomenon, he could read this sign from the patient. Ostwald: The doctor has to have the patient in a situation where the patient will allow himself to be examined in certain ways. Mead: Then the paper went on to complex relationships such as the individual 4 Darwin, Ch., The expression of the emotions in man and animals (New York, 1955).

40

SESSION ON PSYCHIATRY

learning to use regressive, infantile behavior as communication, which may interfere with higher communicative behavior. I think the reason we are arguing is because Dr. Ostwald has covered the whole range within the clinical picture. Birdwhistell : Dr. Ostwald, would you be prepared to say, as a clinical physician, that a symptom arises from a particular trauma or that a symptom is learned? That is, do you learn how to express where you hurt in a given culture and does the organism have to develop a method of sending a message to the external world in order to be taken care of? Or is the symptom located as an intrinsic element within the illness? If you can tell me that, I will know where you stand in your paper. I also have another question: Is the symptomatology we have been talking about a device to get special attention? This would include what are called successful symptoms. Generally speaking, we have only studied successful symptoms. That is, we have only recorded those which have gotten through to us. It takes a brilliant young internist to catch the patients who send the wrong signals! It may be only the man who is successful that we see. Nurnberger: Would you discriminate between a symptom and a sign? A sign is something that the physician uses, such as a heart murmur. A symptom would be something that a patient would complain about one way or the other. He might not complain about a murmur, but a physician would hear it. Birdwhistell: I can see the distinction, so I’ll back up and re-ask the question, with specific reference to such things as coughing, limping, gasping, differentiation in breath rate or heart rate - not murmurs, which we can isolate -, and such things as, for example, the drying up of mucus or an increase in the amount of mucus. Are these things essentially within and immanent in the trauma or are they learned organization? Or would you say this was a matter of degree? Pittenger: There is one other comment that seems to me important in terms of the paper. You speak of a cough as being, in a sense, unlearned. Very quickly or almost immediately one hears a cough, he hears it in context and he hears a particular kind of cough. It is one of my beliefs that there is almost no such thing as a spon­ taneous unlearned act within an event because we have learned the action in a context and we elaborate and extend it, or we contract it, or inhibit it, because of cultural learning about the context and about the meaning of this act in the place where we learned it. The child is dependent and helpless, but he is very quickly learning and being taught and trained for a whole set of contexts and reactions. I think that we underestimate the intensity and the volume of learning, and the im­ mediacy of the learning that is taking place in these events. Ostwald: Well, I will give you an example which I learned recently from dis­ cussion of this subject.5 These are observations taken on the battlefield where a person may suffer a very considerable bodily trauma, loss of a limb or something equally serious, and not develop a symptom, a complaint, until he reaches a certain 5 David McK. Rioch, M. D., in a lecture at Langley Porter Neuropsychiatric Institute, 1962.

DISCUSSION

41

level of the structure of the army organization, say the battalion aid station where there are people available who are either trained to respond to what has happened or able to respond in some intuitively helpful way. So I think both factors are involved: the physical trauma and the learning experience, the knowledge that the sufferer has of the appropriate place and time and person for complaining about the symptom. Pittenger : What a person does with what has happened to him is determined by his audience. Ostwald: Yes, I think that is important. However, a person can also be his own audience. Scott: We should be specific about a person being his own audience, because discussing the result of the habit formed when people become their own audience would lead to something which hasn’t been mentioned here yet. On the one hand, we must ask whether the person is conscious of what he himself is doing which may be seen or heard. Is the actor auditing or monitoring, or, on the other hand, is it the person watching or listening who is auditing, or are both? We should talk about the size of the field of consciousness in those in the world around about (the audience) and the size of the field of consciousness in what we call the person, the self, being observed. Both are continually varying. We must find ways of measuring the varia­ tion. The degree of self auditing, as well as the reaction to audience auditing, seems to have much to do with learning to change. Stankiewicz: I would like to address myself to the same question. Could we speak, perhaps, of some kind of a grading scale? If a person is lame, he might em­ phasize or attenuate his lameness for the sake of an audience, but if he is lame because a part of his leg is cut off, he could hardly conceal this defect. If somebody coughs, he may have a case of TB, for TB patients are known to cough. Do they do this for an audience or is coughing a symptom of the disease? Can coughs and lameness be imitated? And if so, do they serve a communicative function? Culture may control and modify the appearance of symptoms, but these are basically physical phenomena. Freedman: A scaled gradient between audience-determined or culture-con­ ditioned symptom communications and the purely physical signs would probably, paradoxically, have to vary idiosyncratically with individual patients or subjects, and with special sub-cultures or environments. For example, flatus or farting is considered many things but rarely a means of voluntary communication in our culture. Yet, on one of the wards of tuberculosis patients with which I was acquainted, farting contests were a principal means of prestige attainment, competition, and communication. The fellow whose volume and frequency were the highest had a considerable gain in status over the others! None of them considered this at all extraordinary - but they were aware of sub-cultural differences. When I commented on this, they acknowl­ edged that “a gentleman” wouldn’t understand; a gentleman, they said, “sneaksthem out”. Moses: In Bavaria, where everyone uses caraway seeds in bread, people love flatus. The way they dance the Schuhplattler shows that this part of the body [il-

§ i

42

SESSION ON PSYCHIATRY

lustrating by slapping the buttocks] plays a tremendous part. Is this satisfaction for them, or is it in any way communication? Certainly they start the day with flatus and they end with it because they have caraway seed in their bread four or five times a day. I wouldn’t know what this is. To me, it does not go under the term communication. Freedman : We do find a difference in somatization of psychiatric symptomatology as a form of communication in different socio-economic levels. For example, in one of our studies6 we were able to differentiate people who were in some diagnostic or treatment relationship with psychiatrists on the basis of increasing somatization and involvement of the total body as we went down the class-level scale. Now please don’t misunderstand me. I am not saying that we now know that this distinction necessarily holds for the differing social classes in all contexts; my observation concerns individuals who come in contact with psychiatrists. If you define your socio-economic levels by education, occupation, and residence, so that Class I is the highest and Class V the lowest, you discover significant differences in how the body is used as a psychiatric communicating system. When you come to Class IV, you have a high percentage of people who have bodily symptoms; when you get to Class V, again you have a much higher incidence of people who have serious behavioral difficulties with society. So you find increasing paralinguistic and kinesic symptomatology of psychiatric patients as you go down the scale. Birdwhistell: With regard to lameness, I think that even random observation around a rehabilitation center will show that there is a great difference between those individuals who are sending the signal, “I’m lame”, and those individuals who are working to cover their lameness. The way in which lameness is used at various times will vary. Now certainly if you don’t give the patient a prosthetic limb and he falls over every time he tries to walk, of course it is true that the cause is physical. But if you put on a prosthetic limb, it is perfectly clear from studying “rehab” situations that there are those who relatively easily learn not to send the signal, “I am lame”, and there are people who constantly send the signal, “I am lame”. This is probably not just an idiosyncratic matter; there is a pattern to it. Take the cough, for instance. The Kutenai Indian could tell the difference between a Kutenai cough and a Shuswap cough. It was a different type of cough and they coughed in a certain way. The Kutenai Indians coughed up their nose. This is part of being a decent Kutenai and not to have done so would mean being taken for a damned Shuswap! Stankiewicz: Sneezing is probably a physical phenomenon. Birdwhistell: Breathing is a physical phenomenon. Mead: I think it is very important that we don’t talk about cultural influences only on the level of whether you speak to the captain or the private about a wound, or cover your nose with a handkerchief, but that we should realize from the very *i^^ee

PSYCHOLOGICAL RESEARCH IN THE EXTRALINGUISTIC AREA by

GEORGE F. MAHL AND GENE SCHULZE INTRODUCTION Definition of the area Before describing and discussing “the state of the art” it is necessary to present a working definition of the “art” we are considering in this paper. When an individual speaks he engages in a special class of behavior — linguistic behavior. The essence of it is the production, via the speech apparatus, of institu­ tionalized sounds organized into institutionalized patterns. The immediate purpose of this behavior is to communicate with another individual, to interact by means of messages. From the strictly linguistic standpoint, speaking behavior is determined by two things: (1) the code itself and (2) the intention to communicate a particular message in that code. These linguistic factors, however, do not fully determine the behavior of the speaker. One important qualification is that the code does not completely mold or restrict the content of the behavior. There may be variations both within the linguistic behavior itself and in accompanying non-institutionalized behavior. Linguistic variations in­ clude the choice of the language (French or English, for example, in cases of polyglot participants), variation in dialect, the use of simple or complex sentences, active or passive voice, present or past tense, extensive or restricted vocabulary, etc. From the linguistic standpoint we may say, loosely, that the same message can be communi­ cated regardless of the alternatives used. Permissible, non-linguistic variations are greater. They include such things, in English at least, as variations in rate of speech, general loudness, general pitch level, throat clearing, belching, a wide variety of body movements, etc. Another important qualification to the strictly linguistic determination of speaking behavior is that, beyond the immediate communicative intention, other psychological states or processes are simultaneously operative. Of necessity, or adventitiously, or both, they enter into the determination of both linguistic and non-linguistic behavior. For example, a self-confident person may speak in relatively simple sentences with well controlled pitch and volume, and with few sighs or nervous coughs. An insecure person, on the other hand, may speak in complex, involved or even unfinished sentences, with poor pitch and volume control, and with frequent nervous mannerisms.

i

52

GEORGE F. MAHL AND GENE SCHULZE

The case for the listener is similar to that of the speaker. He hears and reacts to the institutionalized sounds, but his behavior is not fully determined by strictly linguistic factors. The permissible variations in the linguistics of the message and the non-linguistic behavior of the speaker are stimuli for the listener, arousing in him psychological states and processes beyond the strictly linguistic ones of receiving and decoding the message. Sentence length may vary considerably, for example, within the limits of acceptable English and convey the same explicit message to a listener. Yet increasing sentence length may cause a variety of listener reactions to the content or to the speaker: interest, boredom, annoyance, etc. Similar statements could be made about such things as the general rate of uttering the message, as well as the over­ all pitch and volume level used by the speaker. The preceding remarks, which deal very briefly with highly complex matters, point to the behavioral phenomena this paper considers. We will call the area “extralinguistic”.1 It encompasses extralinguistic phenomena in the speaker’s overt behavior. These Include both the permissible variations in the strictly linguistic (institutional­ ized) behavior and the non-linguistic (non-institutionalized) behavioral phenomena. Thus, extralinguistic phenomena subsume Trager’s paralinguistic phenomena. The extralinguistic area also includes, however, the functional relationships between the extralinguistic phenomena and the non-linguistic states and processes in the speaker and listener interacting in the communication situation. Speaker's covert states and processes include: a. immediate intention to communicate, allied linguistic factors.

Speaker's overt behavior includes: -> a. linguistic

Listener's covert states and processes include: -*■ a. linguistic

J