Among the most powerful relationships in health is the relationship between smoking and lung cancer. The studies vary, but there is about a .40 magnitude correlation between smoking and lung cancer. If that number were 1.0, every smoker would get lung cancer. If that number were 0, someone who smoked would be no more likely to get lung cancer than someone who did not. A correlation of .40 is a huge number. It is big enough to win gigantic lawsuits and to require warnings to be put on every pack of cigarettes. It is big enough to scare an entire society to change its ways, so that we no longer smoke in restaurants and in college classrooms – indeed most buildings that we enter are smoke free and the number of smokers has plummeted.
What does a number of that magnitude really mean,
though? Well, there is a trick that
statisticians use to interpret correlations.
They square them. That’s right,
they multiply them by themselves in order to determine the “percentage of variance
accounted for in the second variable by the first variable." So, if we square .40, (4 X 4 = sixteen and
move the decimal to the right place) we get the number .16. So, 16 per cent of the variance in lung
cancer is accounted for by smoking. That
means that eighty four percent of the
variance in lung cancer is accounted for by something else. What else?
No single factor. Smoking is the
best predictor of lung cancer – so many, many factors – hundreds or even
thousands of factors are related to lung cancer in addition to smoking.
On some level this makes sense. We’ve all heard stories of someone who has
lived to 100 years of age and, when asked the secret of their longevity, they’ve
said that they smoke a pack of Lucky Strikes every day. And we’ve heard stories of people who have
never smoked in their lives and yet they have contracted lung cancer. The first person likely had many, many of the
environmental or constitutional factors that prevent cancer on their side, and
the second person apparently had other factors, none of them as strong as
smoking, working in concert to bring about their unfortunate situation.
What does this have to do with psychoanalysis? Well, Freud introduced the concept of
multiple determinism over a hundred years ago.
This is a fancy way of saying what the cigarette smoking example
illustrates – our thoughts, feelings, dreams, and actions do not result from a
single cause, but from multiple sources acting in concert and as a result of
weird compromises that emerge between conflicting sources. So the cigarette smoking example should be
something that psychoanalysts understand and live by, right?
Well, it’s not as easy as that, whether you are a
psychoanalyst or the woman or man on the street. We get overwhelmed when things get too
complicated. We want things to be
simple. When I hit the billiard ball, it
rolls in the direction that I hit it every time. That is a correlation of 1.0 and we want
correlations of 1.0 – or very close to 1.0 – all the time. And remember, in health, .40 (which we have
discovered – despite its power – is actually a very small number) is about as
big as numbers get in the world of predicting some distant outcome from some set
of behaviors. But this means that we are
only able to predict what will happen some of the time for some of the people
when a lot of other things line up in important but hard to infer ways. It’s pretty remarkable that we have any kind
of behavioral science at all, actually.
So Freud, who was a keen observer and a brilliant
theoretician, was able to see through this maze and recognize those big
predictors – the smoking cigarettes, if you will – and bring them to our
attention. That said, he was frequently
wrong, or saw the wrong aspect, but even when he was wrong, he was often able to provide an explanation that made narrative sense – meaning that it held
together the way that a good story does – so we gave him the benefit of the
doubt. So, for instance, as part of a
grand theory related to sexual development, Freud proposed that the way we are
toilet trained will predict aspects of our later personality – specifically that
if we are toilet trained in a lackadaisical way, we will be messy in our
approach to the world, but if we are given rigid direction, we will be neat,
orderly, even obsessive – and thus the term anal has come to describe, in
common parlance, those traits.
If toilet training actually is related to obsessional
symptoms, which it probably is, it is way down the list of things that predict
how obsessional an adult will be – so it has a really low number – and the
things at the head of the list – the ones that have the most power to predict -
don’t have a very big number. We don’t
have a great handle on what causes obsessive functioning – genetics is part of
it, and certainly the ways in which people interact with caregivers during their childhood are part of it – but Freud’s explanation was one that
was so clear and had such a compelling narrative arc that we were willing to
take it as a valid explanation.
We were also willing to do that because we want to reduce
complicated situations to more simple ones.
Freud was actually pretty humble about the reach of many of his
theories. He would say – look, this is
based on a small sample and I don’t know that it is relevant to other
populations or in other situations. He
did this at the beginning of Mourning and Melancholia, where he noted that he
was basing his formulation on very few cases, but the distilled idea – which does
violence to the very complex and subtle description that Freud offered – that depression
is caused by anger turned towards the self – became first a platitude that was
used to describe all depression and then a symbol of how psychoanalysis over
reaches – because it simply isn’t the case that all depression is related to
either the boiled down version or the more extended version. Some
aspects of some depressive
experiences are very well explained by the principles set forth in Mourning
and Melancholia. It is a very useful way
to understand some situations (just as cigarette smoking is the critical causal
agent in many cases of lung cancer), but it is not always the determining
factor – and many times is not even one of them.
But we are drawn by elegant descriptions and prefer simple explanations,
and so we boil down complex situations and people into very simple equations
and apply them beyond their useful limits.
But that doesn’t mean that narratives don’t serve very useful functions. We use narrative descriptions to capture some
important aspect or element of the lived life of the people that we interact
with. Psychoanalysts do this when they
offer an interpretation to a client.
Novelists and poets and screenwriters do this when they construct a
story in a particular way. I do it when
I interpret a book, play, or movie in a certain way – I reduce it to a
particular dimension.
I am almost always dissatisfied when I re-read a post about
just about anything. Despite being
generally satisfied - I usually feel like I have portrayed some important
element or story line of the piece I am describing, I also feel that I have not
gotten all of it. So, I have come to
accept that I can’t do that within the length parameters that I give myself,
but frankly I need to come to grips with the idea that a complete explanation
can’t be offered. Art – whether in the
form of a good book, play, movie, or lived experience (a dream or an
interaction with another person) – hints at the complex universe that we live in,
but it is not a complete representation of it.
The author uses his or her conscious and unconscious mind to construct a
narrative that reflects what could have led to a series of events that could
have occurred. We, as the audience, use
our conscious and unconscious minds to fill in the gaps in the narrative – to make
it into a plausible story that is both reducible to something understandable
and part of something more complex than we can hope to grasp. And this process, which I try to engage in
with these posts, captures (hopefully) some small but powerfully useful per cent of the
variance of something that is very complex – something that goes beyond the
story and merges into the vast murkiness of the millions of lives that people
actually live – lives that are never fully understood by anyone. The story doesn’t – and can’t - get anywhere
near all of that complexity, but having a handle on even a corner of it gives
us some power to appreciate it, to know it, and to be able to communicate about
it.
The number .40 can be both a very large and a very small
number – and our ability to make sense of the world necessarily falls short of
accounting for all of the variance in it, but it can provide a useful handle
that can help us account for more than we otherwise might. A good
friend of mine is one of the statistical gurus in our department. It is his position that a good research paper
tells a good story. The statistics need
to be used to create a narrative arc. The statistics, just like a good analysis of
a story, and just like a story that is about some event – real or imagined – is
a reduction. And a psychoanalytic
interpretation is a reduction – one that draws us back, away from what we are
engaged with, but also equips us to re-engage with it, to wrestle with it, but
to do that with a new tool in our hands, one that gives us a little more
leverage to move a little closer to flipping the thing we are wrestling with on
its back so that we can, at least for a moment, pin it down. That is just fine as long as we realize, whether we are statistician, psychoanalyst, or artist, that we have only pinned down a small corner of a vast network.
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