A medical example. Most national guidelines for the management of low back pain (including New Zealand's, which are among the best) recognise that even one X-ray starts some people down the path to disability. The same thing happens with chest pain [i].

A psychologist's example [ii]. I was called in as one of three psychologists at a factory fatality, to try to prevent "post traumatic stress disorder". Each of us took a group of about 15 people for about two hours, then we reported to senior management.

The first psychologist said "My group was very angry at management for allowing this to happen." The second said "My group was a bit angry". But my group wasn't angry at all, so I asked the other two what they had said.

The first psychologist had asked her group "Are you feeling angry?" The second had said "People feel all sorts of things like …., but these are all normal reactions". Whereas I had said "What are the best memories you have of this man?"

It's the old "scientific observer" fallacy. Social scientists like to believe that they are observing, measuring, collecting data. But asking questions changes the way the "observed" person thinks and feels! We ask different questions, we create different realities.

Perhaps it works like this. Immediately after a traumatic experience, many people have not yet labelled what they feel, there is no clear emotion, just a "lot of stuff going on". The classic 1962 experiment of Schacter and Singer suggests that if you ask such people "are you feeling angry", some will answer "Yes, I am!"

Of course, for most people that reaction doesn't last, but if one person from every major incident doesn't recover, the community has a major health problem.

Nevertheless, there is one good reason to intervene immediately after a trauma - to prevent fear. If a person is emotionally agitated and leaves the scene, they will probably feel better. But the psychologist doesn't see this as a good result, as running away has just been reinforced. If this is not dealt with, some of these people will find themselves avoiding the place where the event occurred. They plan to drive past the place, but suddenly find themselves on a different road, perhaps without even knowing how they got there. They might develop all sorts of fears related to the event.

The way to prevent this (in fact the one significant action you can take after a trauma) is to keep people safely in contact with the place that it happened for about 90 minutes, until they feel that they are ready to leave.

Unresolved anger and fear are entry points onto the road to disability. Our task is to guard the entrance to that road, and try to stop people entering. Of course we won't always succeed, so some of us need to stand at intervals down the road to let people off. The person who continues down that road kills off their own future, because they become so angry and hard to deal with that nobody can stand them anymore. Or they reduce their own functioning to near helplessness because of fear (in the case of back injury, often it's fear of pain).

It's as if disability has become its own disease.

So we don't want the test (meaning, our effort at diagnosis) to damage the person, but there is also the question - what are we really measuring?

Take the "Effort-reward imbalance" questionnaire of Siegrist, for instance [iii], a hot favourite test in stress research at present.

Some research is showing correlations between the "imbalance" score and poor health, which appears to suggest that people who work hard but are not rewarded get stressed. You might think it reasonable to conclude that you are measuring objective facts about the job, but take a look at some of the test items which are meant to be measuring "intrinsic effort":

• I can get furious if someone doesn't understand me the first time.
• I do everything possible to be in control.
• I get furious when anybody questions my competence.
  

I agree that a person who scores high on these items is unreasonable and bad tempered, but it misses the point to call this an "effort-reward imbalance", as there is no reason to think that this person will feel any better (other than momentarily) if they are "rewarded" more. They sound to me like a bottomless pit!

The "Effort-Reward Imbalance" title of the test suggests a see-saw, that all we need to do is to add more rewards to one side and the balance tips in the positive direction. This "hidden image" draws us in without our realising. We forget to ask, are people really like see-saws? Even if they are, should we be asking, is there only one see-saw inside each person? Could the one on which we're stacking more rewards have already hit the ground? 

So things are more subjective than we might like to think. We seek certainty where there is none!

Even our apparently fundamental schemes for classifying psychological problems seem less sound if you think about them. The American psychiatric diagnostic scheme DSM-IV (1994) lists three symptoms that are required for a diagnosis of "Post Traumatic Stress Disorder" or PTSD, which I translate roughly like this:

• Avoidance - we don't want to go back to the place where the event happened.
• Intrusion - thoughts and feelings come unbidden into our minds.
• Vigilance - we're always on the lookout for the same thing to happen again.

The scheme is elegant, and people with problems can recognise themselves in it. But it's not very useful as a starting point for treatment, so I rolled my own [iv]. It has two parts:

Fear and avoidance - learned in the body, this consists of an emotion (fear) usually linked to an action (avoiding or running away). Fear is conditioned and unthinking, its entire purpose is to keep me safe by running me away from the thing that hurt me. If my fear has "generalised", I might also be hypervigilant, because the next threat could come from anywhere. I might also have nightmares. When I am at the place where the accident happened I might "see" it as if it is still present. For any of these reactions, treatment is by exposure to the thing or place or event that I fear - and by staying there for an hour or more. Repeat once or twice if necessary. But if the therapist doesn't expose me to that which I fear, if they simply talk to me about it, I am not very likely to get better. You see, I can talk about my problems forever!

Bruised status and lost values. These are related but not identical, so I'll discuss them one at a time.

Bruised status means that I feel that my control over my life has slipped, that I am no longer safe in my personal world (perhaps including my home). Perhaps I feel humiliated, perhaps I feel angry, but at heart it's a status thing. I might constantly relive the event, for one and only one reason - I am trying to make it come out better, trying to make myself win! This reliving could be described as "intrusive memories" or "flashbacks" but that description doesn't add to our understanding, in fact it takes away. Or I might take legal action simply in order to prove that I am a worthwhile person.

For most people, bruised status eventually heals. But for some, the wound is deeper, and becomes what I call "lost values". The world no longer makes sense, no longer seems "right" or "fair" or "safe". "They shouldn't have done that, it was wrong, nobody should treat anyone else like that". In its strongest form, "why did God allow this to happen?" Again, what is called an "intrusive memory" or "flashback" could be an attempt to rewrite the past, to make it turn out the way it "should" have been. "If only I had put security bars on the windows, then I wouldn't have been robbed…"

So my scheme splits some things that the other joins, and joins some things that the other splits.

Who's right? Or is it simply a pragmatic issue - which one works better for treatment?

If you found my revision of PTSD to be just as convincing as the DSM-IV version, then we have a fundamental problem. How much of psychology only appears valid because it's appealingly written? 

This problem has reached new heights as a result of factor analysis and other sophisticated statistical tests, which unashamedly look at "data" from angles that are impossible for humans. Yet it is a human who, on reviewing the factor loadings of each questionnaire item, must invent a term that seems best to describe that combination of questions. You create the results as much as you discover them.
So measurement is the problem as much as it is the solution. Or to turn that on its head, as measuring is going to change what we measure, why not make our measurement tools therapeutic?

The opposite of saying "Let's see if you're disabled" is to say "Let's see how you can take charge!" With that in mind, in 1984 I wrote the first "Pocket Ergonomist" with Dr Robin Mitchell. It is a leaflet-size textbook on ergonomics which lets anyone work out why they feel stiff and sore; it is available under licence in New Zealand from OSH offices and from the OSH website.It has two aspects - content, and method.

Content is the information needed to fix the specific problem.

The method is, naturally, empowerment, and this method is used in everything that I write.

For instance, if you are working with a stressed person, give them a Pocket Stress Reliever and pen, and suggest "Let's read this together. If a paragraph doesn't apply to you, cross it out. If it does, tick it or underline it." Make sure they use the pen, because most people will read but not feel able to mark the page. Whereas once they begin to cross things out and underline them, they start to "own" what's written there. 

Every problem identified in the Pocket Stress Reliever has an associated, immediate solution, for instance:

"Too many unfinished tasks: Unfinished tasks are always on your mind, just like a juggler's balls are always in the air. Too many balls and they all fall down. Put them all down… now pick up just the most important task… Give it your undivided attention, doing just the right amount of work on it - not too little, not too much. When it is finished, turn to the next task and make it your only task."

Of course, there are personal causes as well: 

"… Because status struggles are innate, it is normal and natural to feel depressed or angry when someone puts you down and you cannot find a way to overcome them. Normal and natural does not mean good for you! It is unhealthy to let these feelings hang around. To avoid harming yourself with your own bad feelings, try to stop them within one hour."

I find that, even though I wrote the Pocket Stress Reliever I get a better result when I use it, rather than just talking to the person without it. I think, but have no proof, that the benefit comes from removing "David as the authority" from the equation. We can simply talk as equals about information on a page, rather than me telling them what to do, think or feel. 

So the psychologist is co-creator of the future, not measurer of the past. Even apparently objective tests are more like myths and legends than they are like rulers. Like the American Indian shaman who heals through drama, we create atmosphere and expectation through the tests we give, the things we say.

It's time to stop pretending that we stand outside of life just watching. We're in it up to our necks!

References

[i] Christopher Bass, Richard Mayou (2002). ABC of psychological medicine: Chest pain. British Medical Journal 2002;325:588-591.

[ii] Brown D (2000). Time could be the active ingredient in post-trauma debriefing. British Medical Journal 2000;320:943.

[iii] Siegrist J. (1996). Adverse health effects of high-effort/low-reward conditions. Journal of Occupational Health Psychology 1996;1:27-41.

[iv] Brown D (2000). If DSM-IV doesn't work, let's try something different British Medical Journal (e-letters) 9 July 2001.

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