Peter Hagoort is director of the Max Planck Institute for Psycholinguistics (since November 2006), and the founding director of the Donders Institute, Centre for Cognitive Neuroimaging (DCCN, 1999), a cognitive neuroscience research centre at the Radboud University Nijmegen. In addition, he is professor in cognitive neuroscience at the Radboud University Nijmegen. His own research interests relate to the domain of the human language faculty and how it is instantiated in the brain. In his research he applies neuroimaging techniques such as ERP, MEG, PET and fMRI to investigate the language system and its impairments as in aphasia, dyslexia and autism.
Narrative medicine is a science, an art, a discipline that deals with the narratives of patients or carers. What we seek is whether there is some sort of concordance, of alignment among the words used by these people. Narrative medicine has also something to do with communication skills, even though it digs deeper. What do you think of that?
Something that is very important is the way the information is packaged. For example, if you say that with a treatment you have the 90% probability of surviving, that’s the same information of when you say you have the 10% probability of dying. The first one its very helpful in making people feel like they will improve, while the other makes them less hopeful. That shows that how the information is packaged in linguistics may have a helpful or hurtful contribution to the healing process.
Take the placebo effect for instance: the placebo is its narrative context. With a placebo medicine we can see in the brain that the area of activity is the same as the one affected by the opiate pain medicine. Language has an actual effect on the brain. Even in the symbolic landscape in which it operates, language affects neuronal mechanisms to a very similar degree to chemical or electro stimulation. That is remarkable. We, as humankind, in contrast to other species, are what the philosopher Daniel Dennot called the center of narrative gravity. It means that all the signals that go on all the time in our brain are integrated in a kind of coherent story that tries to make sense of what happens in the brain. That also is very much dependent on the characteristic of our language system: in contrast to other species, we have a very rich sense of center of narrative gravity because we have the symbolic system machinery to create stories and interpretations.
So, how important are language and narratives for the brain?
Very much. We are studying what is called enlanguagement of the brain. Our language system and linguistic capacity also influence our system of perceptions. For instance, it had been done this study in the 90s: participants were asked to react to some facial expression conveying either fake or true emotions. Fake and real emotions are performed by different muscles systems in our face, so there are subtle differences. Humans are generally very bad a distinguish these, at least humans with intact language system…
If you take away the language system, like with people with aphasia, it’s easier to distinguish the real from the fake emotions. The reason is that with language we impose our internal narration onto the world. If you take out the possibility, then, suddenly, you are more dependent on the signals themselves and less stuck with your narrative system. Now the signals have a stronger and therefore you get better rather than worse at reading them.
Does it happen also in case of people with autism?
Autistic people do not have a problem with recognizing words, they have problem with what we call derived speaker meaning. What I mean is, for example, if I come at your place and say, “it’s cold here”, you will easily interpret that a request and do something about it, so you answer will sound something like “shall I turn up the heat?”. However, I didn’t do an explicit request, I just made a statement. To make the inference from the statement to the right interpretation is called derived speaker meaning. That is what people with autism have problems with: they are unable to make inferential steps from the letteral meaning of the statement to what actually the speaker wants to convey with it. Likewise with conversation implicatures. If I ask my audience “did you like my talk?”, it’s very rare to have a very direct answer such as “no, we didn’t”; they might answer something like “its very hard to give a good talk”. The essence is the same, but you need to make inferences to understand the meaning behind the second statement. And that’s the ground on with people with autism have trouble
Let’s go back to placebo effect and to words that heals. Are these spoken words or nonverbal communications? Could you give us example of these words?
First, it’s not about individual words, but it’s about propositions. Language is a multimodal phenomenon comprehending words, hand gestures, facial expressions, etc. Those are all part of our language system, and they are all integrated. That of course means that we do need to include the non-verbal aspect in our study of a communication system.
Secondly, there is common ground which is the shared knowledge that the two parts involved in a conversation should have and it is what allow to play on the implicit and not explain every think. Common ground is often assumed event though it is not always there. The assumption of a common ground that is not actually there is often cause of miscommunication. And it is in relation to that common ground that some linguistics utterances have meaning and make sense. That is also called audience design: you have to take the stands of the person you are talking to, rather than your own in order to be able to operate effective communication. In the doctor-patient relationship the uncertainties – which often are originate by the miscalculation of the common ground – are detrimental for the healing process.
And lastly, there is the packaging of information, which can insert information in a positive or negative narrative. This is valid for words, expression, and multimodal expression – all the components need to fit together into a coherent narrative.
So what kind of language would you suggest to use to a doctor?
The patients are always different, so there is no general recipe. You have to know the patients and estimate at what level this person can understand the information in the way you are telling it. The patients usually are not interested in the label of the condition itself, but in how they can live with it or what can be done. It’s important that the physician communicate the possible solution for either coping or treatment, rather than using medical jargon that needs to be then explained.
What about using metaphors?
An acquaintance of mine, who is an expert in high blood pressure, told me that often the therapy doesn’t work because patients don’t stick to it as they were never properly told how it works. Something that in these cases usually works is giving them a narrative of a game: you are landing a plane and you need to lose height and the medication is what allow you “to lower your plan”. This kind of narrative is not related to the disease itself, but it helps to visualize the problem, to acquire some sense of responsibilities towards the treatment, to understand the active role they have (it’s not the drug doing all the work!). You give agency to the patient. The game framing replaces the medical framing in which a therapy is usually explained. This helps to overcome a certain sense of threat that one may have regarding the medical fraiming. This kind of metaphor are helpful to explain medicine.
We often hear battle/war/conflict metaphors in medicine, but those have a negative connotation since in those you can lose and its very tiring. I would rather make more positive things, framed in something enjoyable and with the agency included. Take the campaigns against smoking for instance. Showing people lungs blacked out by smoking is way less effective than making people you look up to say that smoking is not cool. Again, showing the negative consequences is less effective than showing a positive model.
Looking back or looking forward: when we are ill, we tend to look more at the pass and to feel stuck there; when we are healing, we start to look at the future. Nowadays there is a boom of autobiography, which is a good exercise, but they are deeply related to the past, so there is no use of the future. Even terminal patients are perfectly able to speak of the future: they speak of the next generation, of they children – they were thinking about the future in terms of posterity which is a very healing process. What do you think of that?
One of the things that language has is a tense system. In contrast to other species, we are not bound to the here and now, but we can think about the future and the past. The tense system in language indicates whether it’s about the past or the past. In a way, but this is completely speculative, one can induce forward looking things by using expression where the future tense is used more frequently than the past tense. And of course this has to go with some sort of content. A good exercise is to make terminal patients imagine that they have 15 years ahead and make them write what they would like to do in those 15 years. With this creative writing exercise, the patients become more future oriented and acquires a positive mind set. It’s even a way to make the patient experience things in his imaginary world.
So, are you a believer in the creative language power?
Yes. What is often not considered enough is that language is a central component of our mental life and that we not often use it to the full extent for wellbeing and treatment. A drug does not solve the problem alone. Doctors often do not understand the power of the right context in which the narrative itself is a placebo, but again placebo effect are real effects. What is still missing is systematic thinking of how we can exploit language in other to be useful to wellbeing and treatment.
What about the vaccination campaign? With the EUNAMES group we reflected about how poor was the audience design in the campaign and how normative and blaming was the narrative it was packaged in. Any comments?
This whole pandemic come all of a sudden, so no one was really prepared, and this implies that narratives were shifting all the time. On social media there are different subdivision of the narratives that amplifying themselves so that there are competing narrative that are hard to refrain in a joint narrative. And now is very difficult to get out. I believe that the kind of narrative that was need was an inclusive, positive, and gratifying one. We know from children a reinforcement works better than a punishment, and it works the same for adults. I think the vaccination narrative has been to much about punishment ant too little about reinforcement.