DOI: 10.31038/PSYJ.2023523

Summary

In Cameroon, the number of people with disabilities is estimated at nearly two million nine hundred and ten thousand (2,910,000). Thus, a little over 5% of the population of Cameroon suffers from at least one disability [1]. These alarming figures lead us to consider the issue of children’s disability and its impact on the health of their parent(s). Certain types of disability cause more suffering to caregivers and relatives than to the disabled person. Within the framework of our activities in clinical psychology with associations of parents of children living with disabilities, through clinical interviews with parents of children with Down syndrome and autism, we have observed that many of these parents present various forms of psychopathology related to the disability of their children: affective disorders, depressive anxiety disorders, acute stress, behavioral disorders, PTSD, etc. We wondered how to deal with these suffering parents. To answer this question, we administered the SPRINT (a recent traumatic event assessment scale) to parents of children with disabilities whose discourse highlighted their experience with their different child as traumatic. This evaluation allowed us to set up therapeutic projects with EMDR (Eye Movement Desensitization Reprocessing). Through a reading of seven clinical cases followed in Yaoundé, Cameroon, we were able to verify that EMDR psychotherapy is a useful care tool for the management of parents of different children in pain. For most of the cases, the first EMDR session was very satisfactory. The results obtained were astonishing: 04 parents saw their VOC (truth scale) rise to 7 and their SUD (suffering scale) drop to 2 at the end of the first EMDR session. For the 03 other parents, the VOC rose progressively over the course of the sessions to reach 7 at the sixth session with an economic SUD at 1, due to their sometimes traumatic childhood experiences.

Keywords

Disability, Child with a disability, Psychopathology, EMDR, PTSD, SUD, VOC

Disability and Society

Society is a group of men and women who are united by nature or by laws. These laws differ from one sphere to another. Thus, what is seen as taboo in one society may be normal in another. However, there are common features between societies with regard to the concept of norm. This norm is applied to each individual who, for the most part, is subjected to it without any choice. Those who deviate from this pre-established norm are considered a problem, a social case. It is in this logic that the person living with a disability fits in. “Disability” is used here as an umbrella term for impairments, activity limitations and participation restrictions that represent the negative aspects of the interaction between a person (with a condition) and contextual factors (personal and environmental). Disability is neither a purely biological nor a purely social phenomenon” [2]. A person with a disability is therefore a person with physical, mental, or sensory incompetencies that affect their activities of daily living and limit their actions in society. The concept of disability can be defined in several ways depending on the culture and society. In so-called Western societies, disability is seen as incapacity, a lack. However, it should be noted that the concept of disability has evolved in these societies with the scientific progress of the 19th century because it was not always so. In African society, disability is still considered by most people as a curse to be got rid of. In most regions of Cameroon, disability is seen and understood as something mystical, supernatural. With the mixing of populations, a slight evolution of mentalities, the advent of ICTs, and access to education, this conception is changing. 5.4% of the population in Cameroon suffer from at least one type of disability. Sensory impairments (3.6%) are the most frequent, due to (2.2%) for visual impairments and (1.6%) for hearing impairments, followed by motor impairments (1.2%) which are mainly deformities of the lower or upper limbs [3]. According to the same survey, “the proportion of people with disabilities is higher in rural areas (6%) than in urban areas (4%) and “this proportion increases steadily with age, from just over 1% among children aged 0-4 years to 6% among people aged 25-49 years and reaches 19% among those aged 50 years or more.”

Disability and Its Manifestations

Disability is an impairment that limits the subject in the efficient performance of his or her actions. According to the WHO, “disability is universal”. According to the INS and ICF International survey, it is defined as “a disadvantage resulting from an impairment or disability, which limits or prevents the individual concerned from performing a role that is normal for him or her, taking into account age, gender, and social and cultural factors”. The number of people with disabilities is estimated to be over one billion people, including about 15% of the world’s population in general, and in turn, one in seven people [4].

Disability generates clinical manifestations that are often poorly understood. Whether sensory, motor, mental or social, disability always poses a societal problem. The lack of expression of positive emotions by parents towards their children with disabilities is a striking modality of the functioning of families with a child with a disability in Cameroon. Today, many families or parents want to give the maximum to their disabled child. Unfortunately, they face several difficulties or sufferings that can put them at a disadvantage; among others; the gaze of the other, the mourning of the idealized child, the fear of reliving the same experience and the inadequacy of our environment in terms of infrastructure. Whether it is sensory, motor, mental or social, disability almost always poses a problem of social integration. The emotional suffering of families with regard to their children with disabilities is a striking feature of the functioning of families with a child with a disability in Cameroon. In our different actions carried out with the parents of disabled people, we noticed that several parents had psychological illnesses linked to their child’s disability. We wondered if the non-acceptance of a child’s disability could lead to a psychological illness? What can be done to help them? What types of psychotherapies would best respond to their suffering? From these questions arise a series of hypotheses among which the following one. Following a high SPRINT score in these parents, we can use EMDR therapy to treat them and especially to control the impact of the suffering during therapy.

The term disability has several definitions depending on the model (medical and social). Medically, it is defined as an incapacity, a deficiency, a lack, whereas socially, it is defined as an inadequacy. It is for this reason that the WHO, taking into account these two models, defines a disabled person as “any person whose physical or mental integrity is temporarily or permanently impaired, either congenitally or as a result of age or accident, so that his or her autonomy, ability to attend school or to hold a job are compromised. The French law of February 11, 2005 [5] on equal rights and opportunities, participation and citizenship of people with disabilities provides a simpler definition of disability. According to this law, disability is “any limitation of activity or restriction of participation in society suffered in his or her environment by a person due to a substantial, lasting or permanent impairment of one or more physical, sensory, mental, cognitive or psychic functions, a multiple disability or a disabling health disorder. Disability is a social notion rather than a medical one because the person living with a disability needs to move in a society to consider himself as an important being. In short, the term disability refers to the difficulty that an individual encounters in interacting with his or her environment and that is caused by an impairment that results in a permanent or non-permanent inability to access, express, understand or apprehend.

In Cameroon, the population of people living with a disability is estimated at nearly 10% of the 18 million inhabitants [6], a percentage that has doubled in four years since the INS and ICF International survey. To understand the psychological situation of this part of the population, we must invoke the psychology of disability, which condenses the entirety of the psychological needs and experiences of the person with a disability as well as those around them, without ignoring the characteristics related to their life phases. It allows for a better understanding of the needs, adaptation problems and significant interference according to the types of disability situations (motor, sensory, psychological or mental). To make this field of investigation more concrete, let’s look at the role of a psychologist.

The Psychologist in Question

The psychologist is a health professional whose role is to offer the individual a place to listen, to speak, and to maintain confidentiality in order to identify conflicts. He is trained in the psychological analysis of the individual, but also in the analysis of factors internal or external to the individual that influence this psychological functioning. He is an expert in conscious and unconscious psychological functioning. His analysis allows him to understand what is going on in the individual at the cognitive, affective and behavioral levels, contextual and social. To perfect this, he has the appropriate methods, tools and techniques. His essential skills are: psychological evaluation (audits, diagnoses, counseling, training, orientation), clinical interviewing, psychological support, therapeutic management. In this panoply of skills, there is one that allows the specialist to work directly with the patient or individual with a mental health problem.

The clinical psychologist is the one who works at the bedside of the individual. He promotes mental health through prevention, care and reintegration or professional orientation. He/she assesses the people who make a request in order to determine the nature, causes and potential effects of the distress (emotional, physical, social) felt by the person or group. He intervenes in order to prevent, treat and address psychopathologies, emotional conflicts, and skill deficits at the root of the dysfunction. He therefore intervenes for the promotion of health. It is in this movement that the clinician is training in psychotherapy. One of these revolutionary therapies is called EMDR

What is EMDR?

EMDR psychotherapy is a fairly new therapeutic intervention that aims to provide relief to patients with post-traumatic stress disorder by helping them to let go of traumatic memories. EMDR (Eye Movement Desensitization and Reprocessing) is a therapy developed in the late 1980s by Francine Shapiro [7]. With the aim of reducing the emotional charge linked to traumatic events, EMDR thus becomes a powerful tool for “cognitive restructuring”. It is a therapy that is currently used to effectively treat a wide variety of psychological disorders resulting from traumatic memories, including anxiety disorders, depression, stress and trauma [8]. But especially in Post-Traumatic Stress Disorder (PTSD). Shapiro’s theory stipulates that the information linked to the trauma is stored in a fragmented manner (images, sounds, smells, places, events, etc.) in the brain and that these different fragments are not linked together, which prevents the integration of the trauma into the memory. It presents a specific information processing system, which deals with traumatic memories, called Adaptive Information Processing (AIT), so that during the course of our existence, certain information is not processed, and therefore not memorized, which means that it is constantly present in our memory. This dysfunctional information remains unresolved and constitutes dysfunctional memory networks; their voluntary or involuntary recall is unpleasant and painful, and the emotion can arise unexpectedly as soon as the environment recalls the circumstances of the traumatic event. They are the source of various disorders such as intrusive thoughts and images, nightmares, fears, untimely startles, phobias… The objective of the therapy is to promote the transfer of information between the emotional and cognitive brains in order to stop the disorders.

The EMDR Procedure

EMDR combines several methods already used by other approaches. In particular: CBT (cognitive and behavioral therapies), psychodynamic therapies and Ericksonian hypnosis. It consists of eight essential phases: the patient’s life history and treatment planning (collection of anamnestic data, the most distant or most recent memories), the preparation of the patient (targeting plan in agreement with the patient), the evaluation (preparation phase for cognitive associations for the TAI), thedesensitization (bilateral stimulation), settling (positive cognition reinforcement), body scanning, closing and re-evaluation.

When life episodes generate too much emotional disturbance, whether they are small traumas (being humiliated as a child, witnessing violent arguments from one’s parents, etc.), or large traumas (rape, accident, attack, earthquake…), the information processing system is blocked. This leads to the following consequences: post-traumatic stress disorder, depressive, anxiety or eating disorders, drug addiction, various physical disorders… EMDR is based on a neurological model in which the alternating stimulation of the cerebral hemispheres re-establishes a process of re-connecting the elements of information processing (emotional, cognitive, physical) disconnected by the traumatic event. In other words, the adaptive process of information processing could be reactivated by the bilateral stimulations. Once reactivated, this system would process the traumatic material in an accelerated manner. Thanks to this system, negative emotions are neutralized and adaptive information arises spontaneously. EMDR makes it possible to establish a connection between the memory network that contains the traumatic memory and the memory networks that carry the adaptive, incorporated experiences that have meaning for the individual and constitute psychological resources.

The Principle of EMDR Therapy

After having had an initial clinical interview with the patient, the therapist verifies the patient’s problematic using a scale of his or her choice, after which he or she must respect the above-mentioned steps. The patient identifies a representative image of the most disturbing dysfunctional target memory, gives the negative cognition of himself, finds a positive cognition of the same register with a verification scale, identifies the emotions linked to the target, the related body sensations, and above all situates the suffering, the disturbance linked to the event on a scale. The cognitive evaluation of the target dysfunctional memory is done on a subjective scale and the degree of distress in relation to the target memory is evaluated throughout the desensitization phase. During this desensitization phase, the patient returns to the image from the beginning by making a kind of cognitive association, while simultaneously making eye movements from left to right in order to follow the therapist’s hand movements, which act as a dual-action stimulus (either in front of the eyes, on the knees, on the shoulders or beside the ears). After each series of SBA (bilateral stimulation) the patient is asked to report the associative information that was elicited during the EMDR session, the instruction given to the patient is either to move the eyes from left to right, to listen to the sounds produced by the hand, to listen to the vibrations produced by the tapping… at a regular rhythm, while thinking of elements of a traumatic memory.

The EMDR Session

Each classic EMDR session lasts between 45 and 90 minutes. The EMDR treatment begins with a preparation. It is important for the therapist to diagnose the type of trauma (simple, psychic poisoning or complex). The therapist also helps the patient to develop resources, not only to improve his or her relationship with himself or herself and others, but also to facilitate the treatment of the trauma. EMDR allows the brain to reprocess the emotional information in order to remove the trauma from the nervous system. Before beginning the EMDR treatment, the therapist follows the above-mentioned steps. In this way, he/she offers the patient a safe therapeutic space that will allow him/her toto confront the origin of his suffering and especially to take refuge in a comfort zone in case of abreaction.

As Martine Gercault [9] puts it so well Once the foundations of the work have been established, the practitioner will help the patient to locate and represent as accurately as possible the origin of the target event, to feel in his or her body the perceptions, emotions and sensations that are linked to it. While the thoughts and affects surface, the psychotherapist sweeps his or her hand in front of the patient’s face and the patient follows rhythmically with his or her eyes”. The reprocessing of a trauma can take from one to several sessions. To reprocess a traumatic episode, the psychotherapist invites the patient to focus on his or her memory, by being in contact with its sensory elements (visual, auditory, olfactory, kinesthetic, gustatory…), with the beliefs and negative emotions generated. The therapist then initiates a series of alternating bilateral left and right stimulations (30 seconds to a few minutes) of eye movements, sounds or tactile stimulations. As free associations of ideas emerge, the patients reprocess the different information linked to the memory, integrating them into their memory network in a functional, adapted manner. Between each series, the therapist asks the patient to take a deep breath and to share what came to mind during the stimuli. These successive and quite brief series of bilateral movements continue until the emotions are neutralized and the emotional scars of the past are emptied of their traumatic charge. When the traumatic memory is thought of again without emotional discomfort and associated with positive thoughts, the therapist moves on to the next phase. The traumatic memories lose their negative emotional charge, thus ending the suffering and negative reactions. It may happen that during a session, the patient experiences strong emotions; it may also happen that between sessions such emotions resurface, as well as other memories, as in any form of psychotherapy. In the end, the patient experiences an improvement in the emotional disturbance related to the memory being treated, and a calming. Through this process, images, perceptions and memories that were negatively encoded in the emotional brain are reprocessed and lose their dramatic intensity. The past adversity is replaced by the uniqueness of the event.

Procedure for the Parent Survey

The first step taken was to contact the heads of the associations we had identified for our investigation (WellbeingAfrica, an association of parents of children with disabilities that works for the rights of vulnerable people), the Little Prince and the Moabi [P²M], an association of parents of children living with disabilities whose main mission is the empowerment of people with Down’s syndrome and other disabilities). Having obtained the various appointments, we organized ourselves for the meeting with the targeted parents. Once on site, after a detailed explanation of the object of our research, we were allowed to “arrange” an appointment with the parents concerned. On the day of the meeting, we first proceeded with a sort of interactive discussion with all the parents present. The purpose was to give them all the explanations related to the research and to the importance of their participation, especially for their well-being.

After this collective meeting phase, which lasted about 20 minutes, each parent was taken individually in a more private setting of the institution (consultation room or office set up on site). There, we would conduct a clinical interview with the parent to ensure that he or she met the inclusion criteria for our sample. As a reminder, these criteria were: being a parent (father or mother) since birth, having denial of their child’s disability, having a psychological disorder related to their child’s disability, and especially having a high SPRINT score, willingly agreeing to take an active part in therapy… Once these conditions were met, we asked the parent to ask any questions he or she might have about our study. After these preliminary steps we would then make a well-framed appointment for the preparation of the actual therapy.

Post-Traumatic Stress Disorder (PTSD) Clinic

Post-traumatic stress disorder (PTSD) affects people who have experienced trauma caused by violence, disability, accident, natural disaster or war, or degrading treatment. How society views the trauma. Lack of support or negative behaviours of those around them (criticism, blame, lack of understanding and empathy, or hostile, controlling, intrusive or stressful behaviours) aggravate the symptoms. Victims feel painfully judged by others. Support from others is very important. Trauma-related thoughts made by the victim herself.

A set of symptoms can develop in a person following a confrontation with an intense stressful event (loss of an object) that would involve serious injuries or a feeling of helplessness. Such situations sometimes trigger strong anxieties, chills, sweating, trembling; and psychic sides such as dreams, flashbacks and sometimes avoidance of similar situations. The positive symptoms are: reliving, avoidance, negative alterations, neurovegetative disorders. These symptoms cause significant suffering in the person, leading to an alteration in their social and professional functioning, and many other important areas. Thus, the patient’s entire functioning may be turned towards the trauma and its memory. Victims will tend to avoid thoughts and conversations that remind them of the traumatic event, as well as places, situations and people that may remind them of the original situation. Their interests and relationships gradually diminish.

Presentation of the Cases

Case PS

PS is a young married woman of 35 years old, of Catholic religion, of Bamileke ethnicity. Her schooling level is that of the 4th grade. She carries out an informal activity that is very common among women in Cameroon, known as “bayamselam,” which consists of buying food products in bulk at the end of the fields to transport them to the city markets and sell them in retail. She is the third of five siblings and her 15-year-old disabled child is schizophrenic. During the interview, she appeared very distressed. She was born in 2003 in Yaoundé, the first of five children of PS, including one girl and four boys.

Case M

M is a young Cameroonian woman, 42 years old, of Bulu ethnicity, with a BTS level of education and unemployed. She is the first of two girls. She is the mother of J who was born on May 31, 1997. He is the only child of M and suffers from an autistic spectrum disorder.

Case E

E was born 55 years ago to a Christian protestant family in the Sanaga Maritime. She has a CEPE. She is a housewife, married and mother of five children, herself the fifth of seven children. She is the mother of Y, born in 2007 in Yaoundé, the fourth of her five children. 02 girls and 03 boys, she attends a local special school, she has a mental retardation.

Case T

T is a 48 year old housewife. Of the Foulbé ethnic group, she is Muslim, without school education, she is married and mother of seven children. She is the sixth of nine children. She is the mother of J, born in 2007, who is the first of these 07 children, of which 03 are girls and 04 are boys. He has been in the special SIL for three consecutive years.

Case X

X was born 45 years ago and is of Douala ethnicity. Catholic, with a literary baccalaureate, he is a service provider. He is the first of three siblings, including two boys and a girl. X is the father of K who was born in 1998. He would suffer from an autism spectrum disorder.

Case P

P is a 30 year old Gabonese, of Fang ethnicity, catholic, he holds a BEPC, he is a military man by profession and single with two children, he is the second of three siblings. He is the father of B who was born in 2002 in Yaoundé, the first of 02 boys and he is being trained in a specialized school in the area. He has been suffering from schizophrenia for two years.

Case Z

Z is a 38 year old housewife, of Bulu ethnicity, from the evangelical church, with no school education. An only child, she is married and has three children. The disabled child is the third of 8 years old, autistic, and attends an inclusive school in the area.

Analysis of the Data Collected during EMDR Therapy

Seven parents were recruited on the basis of individualized clinical interviews among the parents of children with disabilities, including five (05) mothers and two (02) fathers from associations of parents of children with disabilities in Yaounde. Before starting the therapy, we made sure of the type of trauma that each parent might have, because the arrival of the disabled child could be just the trigger for the suffering. After each session, we administered a Stressful Event Rating Scale (SPRINT) to the parent to assess the effectiveness of EMDR therapy. By doing this, we were able to treat all seven parents according to their individual schedules, over a period of 2 months, with an average of 5 sessions of 60-90 minutes each (Table 1).

Table 1: Analysis of the data collected during EMDR therapy

An insecure family context, a feeling of guilt related to a probable negligence during the pregnancy and the development of the disabled child, stereotypes, accusations and stigmatizations coming from the entourage, lack of projection in the future, feeling of devaluation, the look of others, the physical manifestations are the elements that emerge from the discourse of the different parents.

Clinical Case PS

For EMDR therapy, we need 08 phases: the life history of the subject, the assessment, the desensitization, the reinforcement of positive cognition, the body scan, the future scenario, the closure and the reassessment.

Clinical Aspects of the Test

The relationship with the clinician being well established, PS presents her apprehensions, suspects at the beginning of the manipulation as she declares “I trust you docta, even as I don’t know what I’m getting into, this doesn’t seem catholic to me, looking from left to right there scares me”. In spite of this, she lends herself to the game and respects all the instructions given for the good progress of the EMDR therapy.

The encounter with the therapy device immediately provokes a movement of surprise in PS. She smiles when I explain the course of the session. Regarding the eye movements, she said to me: “Docta, excuse me, but I am going to laugh”. This observation is recurrent with EMDR patients, because it is different from what they expect, not only do we not only do active listening or give them advice, but we also ask them to make eye movements, and to verbalize what comes to their mind during desensitization.

The Subject’s Life Story

PS is a young woman of 35 years old, of Catholic religion, of Bamiléké ethnicity. Her school level is that of the 4th grade. She is the third of five siblings and her 15-year-old disabled child has schizophrenia. Her score on the SPRINT test by Connor & Davidson 1997, translated by F. Mousnier – Lompré 2014 is 18. We made a targeting plan and listed 02 targets: The first is a conflict with her father because she never felt loved by him. The second is her child’s disability. With her permission, we started the therapy with the current situation, which is her child’s disabling illness.

Assessment of the Situation

The elements of the therapy are: the image which is the haunting voice of her daughter in crisis, the negative cognition “I am a bad mother”, the positive cognition “I am a good mother”, the VOC equals 2, the emotions are crying and sadness, the SUD equals 9 and as body sensation the pain in the throat and the heart palpitations.

Desensitization

This phase is marked by bilateral stimulations, breathing movements and especially by adaptive information processing (AIT). PS’s speech reveals an increased suffering following her daughter’s diagnosis. She revisits her childhood, her friends, her family, her marriage, in short, all the important elements of her life and notes a major fact that justifies her discomfort. Her behavior when she was young, she says in these terms: “I see myself with my brother making fun of people with a physical handicap, especially the neighbor’s son who had a limp”, “I can’t live with a handicap or put up with a person with a handicap”. As the therapy progressed, she understood that she did not have the right to decide for anyone, that life had its elements that she had to accept and deal with, that she had regained her values and, above all, that she had found meaning in all the efforts she had made since her daughter’s diagnosis, in all the appeals she had had to make for the child’s well-being, and, above all, that she had been a good mother because she had not abandoned her child in her situation of psychological illness. When the SUD drops to 1 economic, we move on to phase 5.

Reinforcement of Positive Cognition

We just check the positive cognition that she gave at the beginning namely “I am a good mother”, when the VOC goes up to 7, we go to phase 6.

The Body Scan

In a relaxing atmosphere, we go over all the parts of her body, always coming back to the disturbing image that we no longer name in this phase. We just say to him, thinking back to the starting image, and especially to the negative cognition that you stated at the beginning, we are going to do an examination of your whole body starting from the head, the neck… to the toes. The instruction is simple: every time she recently feels a knot, a pinch, a pain, an affect in any part of her body, she reports it to us and we desensitize. She has reported pain in her throat and neck and each time we ask her after the desensitization: “what came to mind”, until we get zero pain or manifestations in the body. Once the VOC is verified, we change phase.

The Closing

After having informed Mrs. PS that we will soon stop the session, we say to her: “you have worked well today, I encourage you to note down everything that appears in the meantime, you can report them to me at our next session”.

Reassessment

This session allows us to make a small evaluation of the previous one in order to desensitize the new elements if there are any. After six sessions, we have allowed Mrs. PS to have another look (admiring) on her child.

Results

The action of EMDR is based on the association of psychological and neurological processes. This technique allows the patient to revisit a traumatic event. This therapeutic action is understood as an information processing therapy during which the patient recounts the traumatic event by means of its cognitive, affective and physiological characteristics while concentrating visually, audibly on bilateral movements of an external stimulus until the psychological distress evoked by the traumatic memories diminishes or disappears (Shapiro, 2001).

We have experienced this in the seven parents who, after just two months of care, regained the smile they thought was lost forever. For most of the cases, the first EMDR session was very satisfactory for the parents because 4 of them saw their VOC rise to 7 and their SUD drop to 2. For the other 03 parents, the VOC rose progressively during the sessions to reach 7 at the sixth session with an economic SUD because of the sometimes traumatic experience of these parents.

Discussion

Contrary to other types of therapy which are all equally effective, EMDR has the particularity of not expecting patients to verbalize and perform precise tasks which will constitute the action of the treatment received. The effects of EMDR are less prolonged than cognitive and behavioral therapies, which facilitates the rapid recovery of parents who cannot feel good just by verbalizing their suffering. The main advantage of EMDR lies in the brevity of the application of this technique. Indeed, when properly indicated, it acts directly and shows positive effects in the first session. EMDR has been used in randomized controlled studies with a waiting list where placebo control groups show a definite therapeutic effect [10].

Conclusion

Our work highlights the action of EMDR therapy on the psychological problems of parents of disabled children. For these parents at the end of the therapies, each parent, who at the beginning felt a fair amount of suffering at the sight of his or her disabled child, found himself or herself satisfied with his or her life and, above all, found qualities to be amplified in order to consolidate each of his or her different child’s achievements. The results are very satisfactory.

The treatment is essentially psychosomatic and global. It would be interesting to verify the stability of the results in a few years by observing the parents concerned over the years. In the field of brief and effective therapies, EMDR is one more tool that seems promising.

We did this study in 2019, to check the sustainability of the therapy, we did an evaluation three months for each one after stopping the therapy and one year after. The advantage was that we stayed in contact with the parents in question.

References

1. BUCREP (2010, April 22) Results presentation report.
2. World Health Organization (2012) World report on disability. WHO. Disabilities and rehabilitation.
3. Institut National de la Statistique & ICF International (2012) Cameroon Demographic and Health Survey and Multiple Indicators (EDS-MICS) 2011. INS and ICF International.
4. World Health Organization (2016) WHO draft global disability action plan 2014-2021: better health for all people with disabilities. WHO.
5. Vernet O (2006) Law for equal rights and opportunities, participation and citizenship of people with disabilities. La lettre de l’enfance et de l’adolescence 64(2): 105-110.
6. Von Bernuth E, Gelfert L (2014) The social situation of the disabled person in Cameroon.https://vhandicap.net/La-situation-sociale-de-la.html
7. Shapiro F (2001) Eye movement desensitization and reprocessing basics principlex, protocols and procedures. US Guilford press. [crossref]
8. Lohr JM, Lilienfeld SO, Tolin DF, Herbert JD (1999) Eye movement desensitization and reprocessing: An analysis of specific versus nonspecific treatment factors. Journal of AnxietyDisorders 13(1-2): 185-207. [crossref]
9. Gercault M (2014) My father away, Amazon.
10. Bradley R, Greene J, Russ, E, Dutra L, Westen D (2005) A multidimensional meta-analysis of psychotherapy for PTSD. American journal of Psychiatry 162(2): 214-227. [crossref]

DOI: 10.31038/PSYJ.2023522

Abstract

The study reported here investigates the response to ideas about bullying, these ideas emerging from the interaction of a young, eight-year old researcher with an artificial intelligence system (Idea Coach). The program permits the researcher to suggest the topic (bullying), uses the AI Idea Coach to create sets of 30 questions about bullying, requires to the research to select four questions, lets the AI suggest 15 answers to each question, requiring the researcher to select four of the answers for each question. The program then combined the answers (elements) into small combinations, comprising 2-4 elements, each respondent of the group (110 individuals, ages 15-26) evaluating a totally unique set of 24 combinations (vignettes). Deconstruction of the vignettes based upon the response ‘makes sense’ reveal three different mind-sets, focusing on WHO is a likely bully, How to STOP a likely bully and less clearly but still emerging, the reason WHY person is a bully, respectively. The approach shows the feasibility of AI as an enhancer of critical and creative thinking, empowering students as young as eight years able to begin doing high-level, original scientific research, in a systematized, programmed fashion.

Introduction

This paper is part of a series of research studies conducted by young students, enrolled in elementary and in middle school, with the dual goal of teaching students how to think critically while at the same time working with them as researchers to explore issues of social relevance. A glance at the literature reveals that virtually all research is executed by professionals, occasionally junior professionals such as graduate students, but far more often by young and middle-aged professionals, following the structure of academic research. Even when the topic involves the experience of young people, such experience is analyzed through the ‘trained’, perhaps biased eye of the professional, who brings along a career of studies. The study of the experience follows the time-hallowed practices of the scientific method, although the ‘immediacy’ of the experience cannot be tapped because the researcher is not a young person.

Almost 80 years ago, the radio and television personality Art Linkletter starred in a show called House Party, starting in 1945 and ending in 1969. As described by Wikipedia. The host would begin a conversation by posing a question about life topics to a child, who usually responds with their own innocent, often comedic perspectives on the various topics…. In the show’s first inception, it would sometimes flash back to the 1950s and 1960s show Art Linkletter’s House Party, with Cosby joined onstage by Art Linkletter, that show’s host, to introduce the vintage clips. It would show kids (of the time), their same comedic reactions to whatever Linkletter would ask or say to them…

The foregoing quote suggests that we may learn a great deal about the way children think about the world, although it is clear that a great deal of this learning is second-hand, with the researcher observing the behavior, and commenting on it. In recent years authors Deitel, Moskowitz and Rappaport have collaborated to create a system whereby anyone can be a researcher, at least for the type of research known as Mind Genomics. The idea behind Mind Genomics is that by showing people combinations of ideas and measuring their response, one can learn what specific aspects of these ideas drive the behavior, viz., the aspects to which people pay attention. Rather than asking people to say what is important to them about a topic (viz., open ended question), or ask people to rate importance of different ideas, one idea at a time, Mind Genomics assumes that people will find it more ‘natural’ to respond to combinations of ideas. The rationale for this assumption is that in the world of everyday experience people evaluate combinations of features, rather than one single feature at a time.

Bullying

The topic of bullying is becoming increasingly important [1-3]. It may be that the availability of video technology on smartphones to record one’s bullying efforts has become a stimuli to become a hero. Bullying on the internet has been shown to be responsible for teen and child suicides [4,5]. Those are just the most serious cases.

The emerging science of Mind Genomics may help us understand what young people think is important. The study reported here is unique because it was set up by young researchers, in elementary schools (3^rd grade; Ciara) and in middle school (8^th grade; Cledwin). The study objective was to explore aspects of bullying from the point of view of the younger researcher, using Mind Genomics augmented with AI, in the form of Idea Coach. Idea Coach helped the researcher both learn about the issues involved in bullying, and to take an active role providing new-to-the-world knowledge about these issues.

The Mind Genomics approach has been previously discussed in a variety of papers [6,7]. Three previous studies have appeared featuring the efforts of these young researchers [8,9]. The objective of the studies is to deal with a serious topic, framed not so much by an experienced adult researcher as is usually the case but rather a research effort framed by a young mind. Often the types of questions intriguing the young researcher may well differ from the questions intriguing an older researcher. We almost never heard from the young researcher, and from young respondents. The study reported here and its companion studies allow us a peek into the mind of the younger researcher, and the response to test stimuli by respondents of the appropriate age.

Method

Mind Genomics studies follow a now-standard approach, using templated inputs and automated, rapid analyses. The almost automated approach exemplifies the vision of author Moskowitz to create a system which allows anyone to become a researcher (democratization), coupled with the goal of accelerated knowledge development (efficiency), and with the vision of creating large-scale databases of aspects of ordinary life, doing so in a simple, inexpensive, iterative, and world-wide manner (industrial-scale knowledge development). The Mind Genomics program itself is called BimiLeap, short for Big Mind Learning App. The program can be accessed by anyone with access to the Internet, at www.BimiLeap.com.

Step 1 – Identify the Specific Topic

This sounds simple, and eventually is simple. The novice researcher often thinks in generalities, not in specifics.

Step 2 – Create Four Questions Regarding the Topic of the Study

The respondent is allowed to choose any questions, as long s the questions tell a story about the topic. It is at this point that Mind Genomics proceeds to structure the way the researcher approaches the problem. The first encounter with requiring the researcher to ask a question can be frightening, and certainly off-putting. Most novice researchers freeze up at this point, perhaps shocked by the directness of the question. The most common initial reaction at this point is a sense of discomfort, and in some cases that discomfort simply ends the effort, with the researcher.

For the researchers who cannot think of questions, there is the associated AI feature, Idea Coach. The researcher simply writes a short paragraph, really 1-3 sentences, and Idea Coach returns with 10-30 questions. Idea Coach can be invoked several times, either with the same paragraph or with different paragraphs. Each time Idea Coach will return with a set of somewhat different questions. Table 1 shows a run of Idea Coach, prompted by the researcher request ‘Help me create questions about bullying.’

Table 1: Thirty questions emerging from Idea Coach, based upon the request to ‘tell me some questions to ask about bullying in school’.

Once the researcher selects the four questions, the next step requires the research to provide four answers to each question, specifically phrases which paint word pictures. Once again the researcher can either come up with answers, and/or work with the Idea Coach. For each ‘run’ of Idea Coach, comprising answers to a question, Idea Coach emerges with approximately 15 phrases which answer the question. This step in the process is much easier, simply because many people find it easier to answer questions than to pose questions. Answering questions relies on memory and experience. Posing questions relies more on critical thought because the researcher is going into a void, rather than filling the void under the direction of a question.

The process in Mind Genomics has been simplified, allowing the researcher to write the question to describe the topic, use Idea Coach to present 30 questions (and repeat as desired), select four questions, edit those questions when desired, and finally put in answers and have Idea Coach fill in the missing answers. In all cases the researcher is free to override the Idea Coach effort, whether overriding consists of editing the question/answer or even providing a new question/element based upon one’s insight.

Once the researcher has used Idea Coach to create questions, such as those shown in Table 1, the researcher select questions and/or adds in questions of one’s own. These questions are automatically inserted into the template. The researcher is then prompted to provide four answers to each question. The Idea Coach can provide answers to each question, providing 15 answers for each question for each ‘run’ of the Idea Coach. The researcher need only select four answers, or fewer answers, providing other answers as desired. The answers can be edited, as they were in this study, generally edited for simplicity, and recognizing the nature of the project. In this study the answers were edited by introducing the sub-topic, followed by a colon, and then followed by the text. In this way the element would end up ‘making sense’ in the format of Mind Genomics, wherein one element was presented atop another, not connected with each other, but part of the vignette.

Table 2 presents the four questions selected from the 30 questions at the start of the study. These questions may or may not have appeared in Table 1 for the simple reason that each iteration of Idea Coach produces different sets of questions. Table 2 also presents the four answers to each question.
 

Table 2: The four questions and the four answers to each question

Once the questions and answers are selected, the Mind Genomics program creates combinations of elements. These combinations are called vignettes. A vignette comprises a minimum of two elements, and a maximum of four elements. The structure of the vignette is specified by a layout called an experimental design. The experimental design for Mind Genomics was created to ensure the following properties:

1. Every respondent evaluates exactly 24 vignettes
2. The 24 vignettes are set up so that each of the 16 elements appears exactly five times and is absent 19 times.
3. A vignette has either two, or three or four elements.
4. A vignette can have at most one element from a question, often has no elements from a question, and never has more than one element from a question. This property is important. It is a bookkeeping feature which ensures that a single vignette can never have two different pieces of information of the ‘same type’. The problem becomes obvious when instead of the elements selected here, the elements are prices and brands. In the latter case we want to ensure that a single vignette can have at most one price, not two prices, which would be self-contradictory.
5. The underlying experimental design ensures that the 16 elements are statistically independent of each other. This statistical independence and the specific nature of the design allow the researcher to use statistical modeling (OLS, ordinary least-squares regression) to relate the presence/absence of the 16 elements to the dependent variable. Usually the dependent variable is the rating assigned, a simple transform of the assigned rating, or response time (the time elapsed between the presentation of the vignette to the respondent and the respondent’s rating, captured by the program).
6. A special feature of the experimental design is that it is permuted [10,11]. The permutation means that the underlying mathematical structure is maintained, but each respondent evaluates different combinations. From the practical point of view, the permutation means that the research ends up covering a lot more of the underlying ‘design space’. Rather than having to have a good idea of the ‘right test stimuli’, viz., the right test combinations, and then test those ‘right combinations’, the permuted design tests many more combinations. The patterns in the data emerge more powerfully when the large design space is explored, rather than when one focuses on what ‘thinks’ to be a promising area.

Study Execution on the Internet

The actual study is run in a straightforward fashion, using the Mind Genomics program, www.BimiLeap.com. The program both guides the set-up of the study, as well as executes the study. Once the researcher has set up the study, the next step is to ‘order’ respondents. Traditionally, this process has been arduous, typically because over the past decades respondent participation has dropped. The simple reasons are that people are busy, but also one can scarcely do anything in the commercial world without a sweetly phrased request inquires whether the person would be willing to complete a short survey about the experience. One or two such requests are acceptable, but one can expect resistance, despite the motto of the Marketing Research Association that ‘Your Opinion Counts.’

To remedy the issue of difficulty in recruiting respondents, the BimiLeap program contains a built-in facility to both issue invitations (links to the study), or to pay for respondents, specifying these respondents by a set of screens showing qualifications. The paid request is immediately sent to the associated ‘on-line panel provider’, Luc.id, which aggregates respondents, and provides the necessary respondents in a short period of time, perhaps an hour or so for 100 qualified respondents. This speed means that the entire study can be set up in 30 minutes or less, and executed in 90 minutes or less for 100 easy-to-find respondents. The result is a study executed form start to finish within the space of two or two and a half hours.

The actual study begins with a short introduction about the project, a set of classificaiton questions (age and gender fixed, and then a no/yes question of having been bullied in school). The respondent then proceeds to the actual evaluation of the 24 vignettes. The orientation is short, providing almost no substantive information. The objective is for the orientation to simply introduce the topic. The actual information is presented in the vignettes, the combinations of the elements. Table 3 below presents the orientation sentence, the rating question, and the five answers comprising a Likert scale.

Table 3: The orientation sentence, the rating question and the five point rating scale

Initial Analyses – Frequency of Selected Ratings by Groups of Respondents

Mind Genomics studies generate a great deal of data. We can approach the analyses in at least two different ways. The first way is to look for different patterns of responses, recognizing that we are dealing with different vignettes across all 110 respondents or 2680 vignettes, without the test stimuli having any cognitive meaning at all, other than being test stimuli, the responses to which are being measured.

Following the foregoing analysis, we can examine the frequency of ratings by groups. The first set of groups include the Total Panel, the genders, the ages, the groups who say they were bullied before versus not bullied before. The second set of groups is the mind-sets, individuals who think similarly to each other. We look at the 110 respondents divided into two mutually exclusive mind-sets and then three mutually exclusive mind-sets. Finally we look at the position of the vignette during the sequence of 24 vignettes (first to fourth quarter), and at the vignettes rated quickly (< 3 seconds) versus at the vignettes rated slowly (>= 3 seconds).

Table 4 shows the frequencies. There are occasional differences of 8% or more, especially for the ratings of ‘makes sense’ (5 and 4). There are a few differences for ‘makes no sense’ (1 and 2), and very few for ‘don’t know’. We conclude from Table 4 that there are differences in the measure ‘makes sense’, but beyond that deliberate overlooking of the cognitive meaning hampers our knowledge. It will be with the knowledge of what the elements ‘mean’ that we will make progress.

Table 4: Frequency of ratings assigned by the different, identifiable groups of respondents or vignettes. The numbers in the first three columns of each row should add to 100%.

How Elements Drive Ratings of ‘Makes Sense’ and ‘Doesn’t Make Sense’

The previous section considering the frequency of ratings showed that simply measuring responses to test stimuli suggests some differences among groups, although one would be hard pressed to learn more about the process of decision making. Fortunately, the cognitive richness of the test stimuli, viz., the simple statement, can be used by the researcher to reveal what the respondent may ‘think’ about a topic, even when the respondent herself or himself cannot articulate the rules by which the respondent makes a simple decision. Indeed, quite often exit ‘comments’ by respondents participating in a Mind Genomics study end up with the respondent insisting that it was impossible to ‘find the right answer that was deemed appropriate’ and that much of the answering felt like ‘guessing’ rather than like a reasoned rating.

A deeper analysis of the ratings shows, time after time, that there is a clear set of rules that can be inferred by the pattern of ratings, but only when the ratings themselves can be related to the presence/absence of the specific messages in the vignettes. That is, the pattern of ratings themselves fail to provide information as Table 4 above suggests. Yet, as the remaining tables in this paper will reveal, there are clear, consistent, and interpretable patterns, especially when we bring to bear the combination of OLS (ordinary least squares) regression, coupled with cluster analysis to identify similar behaving groups in the population.

OLS regression, colloquially known as ‘curve fitting’, relates a dependent variable to one or more independent variables. For our study, the regression equation is written as:

Dependent variable = k₀ +k₁(A1) + k₂(A2) … k₁₆(D4)

In words, the expected value of the dependent variable (e.g., Makes Sense, Top2, Rating 54) is the sum of 17 numbers. The first number, k0, is the additive constant. It is the expected the top of the dependent variable (e.g., Top2, Makes Sense) in the absence of elements. Of course, all 24 vignettes evaluated by each respondent comprised a minimum of two elements and a maximum of four elements, so the case of a vignette without elements is hypothetical. Yet, the additive constant (also called the intercept by statisticians) is estimated, and is considered to be a correction factor. We can use it as a baseline, from which all elements either add or subtract. The additive constant is usually high when the dependent variable is ‘Top2, Makes Sense’, and usually low when the dependent variable is ‘Bot2, Does not make sense’.

The regression analysis returns with positive coefficients and with negative coefficients. For our analysis we will present only the positive coefficients of magnitude +2 or higher. The blank spaces in the tables of coefficients actually have numbers, negative or zero coefficients, but in the interest of discerning the pattern we are primarily interested in the positive coefficients. In actuality, presenting the positive and negative coefficients clouds the results.

The top portion of Table 5 presents the positive coefficients for the Top2, viz., for the Total panel, two genders, three ages, and the first six versus the last six vignettes in the set of 24 vignettes. The additive constants are all high, but the highest for the younger respondents, ages 15-18 (additive constant 83) and ages 19-21 (additive constant 78). This is noteworthy. It says something about the proclivity of younger respondents to agree with the statements about bullying, especially since respondents ages 22-26 show a much lower value (additive constant 61). It is important to recognize that this type of granular information could not have emerged from conventional research, and may not have been recognized without the use of OLS regression.

Table 5: Parameters of the models for ‘Make Sense’ (Top 2), and for ‘Does Not Make Sense’ for self-defined groups, and for first and last test orders.

Moving now to the granular level of elements, we see many empty cells. These cells belong to elements which failed to drive a perception of agreement beyond the general proclivity to agree evidenced by the additive constant. What strikes us as noteworthy is that the majority of strong performing elements occur in the columns devoted to order of testing. There seem to be two types of elements, those which desensitize with exposure, and those which sensitize with exposure. The magnitude of the effect can be dramatic, especially when we see that the additive constants are virtually equal (63 for vignettes 1-6; 61 for vignettes 19-24).

Sensitizing elements (stronger tor vignettes 19-24, weaker for vignettes 1-6)

To stop bullying: Encourage students to speak up if they witness bullying.

To stop bullying: Bullying should be discussed openly and regularly, both in class and in assemblies.

Desensitizing elements (stronger for vignettes 1-6, weaker for vignettes 19-24)

Likely bully: People who are unhappy with themselves

Likely bully: People who are insecure

Likely bully: People who have mental health issues

When the analysis is reversed, focusing now on what does not make sense (BOT2), Table 5 suggests a different picture. As expected, the additive constants are quite low, hovering around 20. In turn, a low additive constant ends up allowing a variety of elements to emerge. Table 5 shows the greater number of low coefficients. Worthy of note are the three element responded to strongly by the youngest group of respondents, ages 15-18. Here are the elements which do not make sense to them:

Reason others bully: They want to make someone else feel bad

Reason others bully: They’re mean

Victims feel: Powerless

Table 5 gives us somewhat of a sense of the mind of the respondent. We find some messages to be strong, most messages to be weak. One hypothesis which emerges is that people may differ from each other in part of their life histories. For our study of bullying, a question which comes to mind is whether having been bullied (or at least answering YES on the up-front classification questionnaire) reveals itself in the pattern of responses to the elements.

Table 6 shows the parameters of the equations developed from the 38 respondents who said that they were bullied versus the parameters of the equation developed from the 72 respondents who said they were not bullied.

Table 6: Parameters of the models for ‘Make Sense’ (Top 2), and for ‘Does Not Make Sense’ for those who reported that were bullied versus not bullied.

There are some differences, not in the additive constant (baseline), but in the elements. Those who said that they were bullied find more elements to ‘make sense’ than those who said that they were not bullied. In terms of not making sense, those who were not bullied find more elements not to make sense.

Mind-Sets

A foundational principle of Mind Genomics is that for the world of the everyday there are differences in the way that people make decisions. These differences emerge in the granular level of the everyday, not necessarily in a way which sets one person apart from others. Researchers might call these individual differences, often recognizing that they could end up being a vexatious source of variability, hindering the signal, but signifying nothing. In contrast, Mind Genomics processes this variability through clustering respondents on the patterns of their coefficients for their models. The clustering uses all 16 coefficients for the respondent, viz, positive coefficient, 0’s, and negative coefficients, the latter two coefficients not shown in the tables. The method k-means clustering, uses as a distance measure the value (1-Pearson correlation between the corresponding sets of 16 coefficients for two people [12]).

The k-means program extracted two mind-set and three mind-sets, using the coefficients relating the presence absence of the elements to the ratings of ‘make sense’ (viz., Top3) The 110 sets of coefficients were used for in the k-means, with the additive constant not included Table 6 presents the non-zero coefficients, first for TOP2 (Makes sense), and for BOT2 (makes no sense).

The two-mind set solution suggest one group one group focusing on WHO is a likely bully, and a second group focusing on HOW TO STOP a bully. The three mind-set solution distinguishes among WHO is a likely bully from How to STOP a likely bully, and less clearly but still emerging from the reason WHY person is a bully.

It is remarkable that in the face of such a complex task, respondents are able to focus on what is important to them. It is even more remarkable when we see that only with clustering the responses do these groups emerge clearly, in a way that could not possibly be biased (Table 7) [13].

Table 7: Parameters of the models for ‘Make Sense’ (Top 2), and for ‘Does Not Make Sense’ for two and three mind-sets extracted from the coefficients using k-means clustering.

Discussion and Conclusions

The extensive literature on the topic of bullying has been created by adults, for adults, using the behavior of children towards each other. The inevitable effect of the research effort and the published result is to describe and explain the behavior of children as a combination of anthropology, sociology, and psychology. The researcher sits on the outside, observing the behavior, or talking to those involved in the behavior. Afterwards, the researcher translate the personal experience of the children into ‘adult, science-speak’, replete with statistics when relevant. Of course research ethics do not permit the researcher to induce bullying as part of an experiment, requiring observation and storytelling, rather than experimentation.

It is obvious that young researchers can construct simple questionnaires, and by administering these questions to the correct people the young researcher can learn a lot about the world from the point of view of other people. One need only look at the exercise of interviewing someone older about one or another life experience, the type of research that schools use to introduce students to the research process. Within that framework, the Mind Genomics study reported here presents the way people think about bullying. The data could be reported in that fashion.

The important activities of the Mind Genomics efforts occur at the start, when the study is designed and the questions/answer are developed, and at the end, when the results are analyzed. The Mind Genomics approach, modified by adding a coaching feature, enables the younger researcher to investigate topics in great depth, doing work which by virtue of the coaching and templating becomes valuable. When looking at the execution of the study, and the results, it would be hard to believe that the author of the study is a grade school student. That is precisely the point. The student has now done professional level research. The topics might be thought about initially by the mind of a grade school student, but quickly the execution and the results bring the student to a higher degree of understanding of the topic. It is the mind of the grade school student which frames the topic and selects the question. It is the research approach, the AI coaching, and finally the easy to read results emerging from powerful but ‘hidden’ analyses, which end up helping the student to get excited at the prospect of discovery, and accelerate the process of self-education.

References

1. Bradshaw CP (2015) Translating research to practice in bullying prevention. American Psychologist 70: 322-332. [crossref]
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4. Craig W, Boniel-Nissim M, King N, Walsh SD, Boer, M, et al. (2020) Social media use and cyber-bullying: A cross-national analysis of young people in 42 countries. Journal of Adolescent Health 66: S100-S108. [crossref]
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8. Mendoza, CL, Mendoza CI, Rappaport S, Deitel J, Moskowitz HR (2023) Empowering Young Researchers: Understanding the mind of prospective aides regarding elderly clients.
9. Mendoza CI, Mendoza CL, Rappaport S, Deitel J, Moskowitz HR (2023) Empowering Young Researchers: Exploring and understanding responses to the jobs of home aide for a young child.
10. Mendoza CL, Mendoza CI, Rappaport S, Deitel J, Moskowitz HR (2023) Empowering young researchers to think critically: Exploring reactions to the ‘inspirational charge to the newly-minted physician.
11. Gofman A, Moskowitz H (2010) Isomorphic permuted experimental designs and their application in conjoint analysis. Journal of Sensory Studies 25: 127-145.
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13. Hardy MA (1993) Regression with Dummy Variables. Sage.

DOI: 10.31038/PSYJ.2023521

Abstract

The study is part of a program set up to encourage young researchers (age < 18) to learn to think critically. The process shows the young researcher how to systematize aspects of daily life, create a database of specifics, and then explore the perception of these aspects by real people, using templated experimental designs and real ‘experiments’ on the web through a purpose-built application (www.BimiLeap.com). In this study respondents evaluated unique sets of 24 combinations (vignettes), each vignette presenting 2-4 statements which might have come from a ‘charge’ given to medical students and new doctors. Deconstruction of the response to these combinations at the level of individual respondents using regression analysis revealed which statements were perceived to be ‘important,’ which were perceived to be ‘memorable, which were both, etc. Cluster analysis of the individual coefficients from respondents revealed three mind-sets emerging, based upon the pattern of messages perceived to be important: MS1 – Dealing with the stress of the practice of medicine, MS2 – Dealing with difficult patients, MS3 – Aware of what is important to the patient.

Introduction

Empowering through Templated Experimental Design

This paper deals with the way a young researcher (Cledwin Mendoza) conceives of the way a medical school might inspire its students or give a ‘charge’ to a new doctor [1-4]. The topic of inspirational addresses given by senior professionals to newly-minted-professionals is of interest to middle school and high school students. It is their introduction to the world, a world about which they are curious, and excited to enter. The literature has publications on exhortations to the doctor, but virtually nothing from the vantage point of young people to whom the world of professionalism is both experienced but at the same time shrouded in mystery, the world of adulthood.

In this series of papers entitled ‘Empowering young researchers,’ we aim to look at the world of the everyday through the lens of the young researcher, in this case a junior high school student who is aware of the world, interested in the world, but whose sole experience is personal interactions with doctors, what he reads, and what he might see in the media. The research in this paper was designed and carried out using a new science, Mind Genomics. The objective of the research was to explore how ordinary people think medical students would react to inspirational and descriptive phrases regarding their teachings and ethical issues. The study is reported in the spirit of Mind Genomics, specifically a study of an everyday experience (the lecture or charge to a medical student), with the objective of learning what might be the inspiring messages and what might be the messages heard but soon forgotten.

Today’s computer technology allows people to do complex clerical tasks, often quite simply, by following a template. The template ensures that the person does the correct actions for each task, checks that the material is ready, and moves forward. As a consequence, the template ensures that the process will not run into a problem, at least in terms of the structure of the activity. Furthermore, what could be a complex, involved task might well become easy as the person filling out the template becomes conversant with the different steps. What could have been a boring, repetitive task may remain boring, but can be executed flawlessly over time. And, most of all, the learning to complete the template in general is fairly quick, although the material fitting into the template may itself be difficult.

Imagination about the Everyday

The history of science will show the increasing sophistication of the questions asked. From Aristotle who could only observe the world around and make conjectures, we move along to the world of experiments, where the notion was to understand how one variable ‘covaried’ with another variable, but more important, how one variable drove the other variable, viz., causation. As one readily recognizes today, the best experiments occur when the researcher is trying to understand how ‘nature’ works, searching doggedly in many cases for the rules of nature. At the same time there is the world of social science, the study of people, their social structures, motives, behaviors and so forth. Philosophers since Plato and Aristotle, and presumably many before them, were interested in why people behave the way they do. One never, however, feels that one can create a massive database about the many different aspects of people, at least in the social sciences.

Test Stimuli: Collaboration between the Researcher and AI (Idea Coach)

Mind Genomics works by creating a ‘bank’ of ideas (elements), presenting combinations of these elements to a respondent, having the respondent read and rate each combination on a fixed Likert scale, and then deconstructing the ratings to discover the contribution of each element. The process is mechanical once the elements are created. It is the creation of the elements which often stymies the researcher, leading to the abandonment of the project, or leading to an untenable delay in the project until ‘everything is just right’, everyone agrees with the choice of elements, etc. In the end, the task of creating the elements simply frightens many researchers, regardless of their experience or seniority.

The Mind Genomics template requires that the researcher select four questions which ‘tell a story’. For each question, the researcher is required to provide four answers. In the end, the raw material comprises the underlying story, knitting tighter the four specific questions, and the sixteen answers. Experience over three decades, since the early 1990’s, suggests that it is at this point in the process when many promising projects are simply abandoned by hopeful but frustrated researchers. The reasons for abandoning the project are not relevant, other than to say that there seems be a lowered tolerance for frustration in today’s researcher, and a belief that one should ‘know’ the answer, and select the ‘correct’ elements. Not being sure of ‘correct elements’ suffices to stop forward progress. Many researchers apparently suffer from “open-ended question anxiety.”

To remedy the problem, the Mind Genomics templated recently has been upgraded to incorporate Idea Coach, a user-friend tool based in OpenAI [5]. In the templated process, the researcher begins by providing the four questions. The researcher who would like ‘guidance’ chooses the Idea Coach button on the template form. The researcher then writes in a few sentences about the topic. Using that information, Idea Coach returns with up to 30 questions, from which the researcher can choose up to four. In the case where the questions do not all meet the researcher’s expectation, the researcher choose some, and repeats the Idea Coach effort, either with the same input (leading to a set of 30 questions, many of which are new), or with different input. The researcher ends up selecting four questions, some from AI, perhaps some from oneself, and can edit/polish before proceeding.

Table 1 shows the four questions. The Idea Coach was given the following background to the project:

Table 1: The four questions and the four answers (elements) for each question

We created this study to see what important precautions young doctors need to face in the medical world. Also to help young doctors so they don’t make a serious mistake.

It is important to keep in mind that the formulation of the question comes from the mind of a young person, a middle-school student. The question is simple, direct, and not formulated in the typical manner that has become the pattern of today’s science. The question is one ‘about the world,’ in the naïve yet profound way that could only be asked by a young person. As the data will show, this type of questioning can lead to profound, powerful, and actionable results, as well as be a part of an easy-to-construct corpus of knowledge about the mind of people facing everyday life.

The quality of the questions shown in Table 1 come from the nature of the Open AI. The researcher’s task is made much easier. The task now morphs from trying to think about good questions to reading questions and selecting those which make sense for one’s project.

After the AI and researcher have collaborated to create/select the four questions, the BimiLeap templated system moves to acquiring four answers to each question. Once again the Idea Coach helps in this task, but requires the deeper involvement of the researcher. For the case of questions, Idea Coach required questions needing very little editing. Not so with the answers. Idea Coach returns with statements. These statements comprise the answers but the statements must be edited. For example, consider element A1. Idea Coach returned with the second part of the element, specifically ‘They need to have a passion for helping people and a strong interest in science and medicine.’ The BimiLeap program for Mind Genomics would be better when the sentence is given an ‘orientation’, such as the word ‘Required’. The authors changed the elements, inserting the orientation word(s), so that the elements were more meaningful. A good analogy to this is the placement of items in a menu under the proper headings (appetizer, main course, etc.,) rather than just having the food on the menu.

The second thing to note about the elements is that they are long, and well-crafted. Virtually all users of the BimiLeap program have commented on the fact that the questions, but more importantly the answers, move beyond what they might have generated had they been instructed to think about the elements, and do research to find elements. This up-front work, possibly taking hours and days, and often leading to frustration in the wake of progress seemingly out of one’s grasp, now takes approximately 20 to 30 minutes, with potentially far better results.

The final thing to note is that hitherto a long, arduous, and often frustrating effort to create questions literally from one’s mind is now replaced by a far more pleasant, intriguing learning experience. The researcher no longer has to feel alone in the effort to come up with questions and answers, but rather now engages in a focused experience of discovering and choosing. In some respects the creation of the elements evolves into its own learning experience, enjoyed by the researcher, with a motivating power to drive exploration of just-learned ideas. What was a difficult moment in the design of a Mind Genomics experiment now becomes perhaps the first learning experience. The Idea Coach, and AI, moves away from a simple aide to become a teacher who reveals new dimensions of a topic to a researcher deeply focused on the topic. Ideas that were not even in the ken of the researcher can now be explored in moments, as part of the research effort.

The History of Mind Genomics

Mind Genomics traces its history to three disciplines, psychophysics, statistics, and consumer research, respectively. Psychophysics is the oldest branch of experimental psychology, seeking to understand how to measure the internal perception of physical stimuli, such as the sweetness of sugar in a beverage. The origination of Mind Genomics can be traced to author Moskowitz’s studies as a graduate student in the Laboratory of Psychophysics in William James Hall, Harvard University, directed by the late Harvard professor, S.S. Stevens. During the latter part of Moskowitz’s tenure at Harvard, with a Ph.D. awarded for studies of taste mixture, it became obvious that the approach could be used to mix ideas, and obtain a measure of the mind in terms of responses to these ideas. The effort would have to wait until Moskowitz was safely ensconced as a scientist at the US Army Natick Laboratories, in Natick MA, where he could begin small scale studies of mixtures of ideas. The taste work would lead to the appreciation of human response mixtures as the relevant topic to explore, whether mixtures of ingredients, or mixtures of ideas [6,7].

Statistics, the second discipline, provides Mind Genomics with analytic tools. The history of science is often presented in terms of the researcher isolating all forms of extraneous noise, viz. unwanted variability, in order to study a phenomenon. We need only visit laboratories to see the apparatus used for these studies to get a sense of how proud the researcher is of the ability to study a phenomenon in ‘splendid isolation;, without the interfering noise. On the other hand, there are many effects where many variables interact with each other, and in the end produce a response. The traditional methods of isolating the variable and then studying the behavior of that variable simply cannot work. Rather, it is a matter of creating specific combinations, allowing the variables to interact, but at the same time allowing the researcher to measure the behavior of each variable, even though the variables are in a mixture. It is this discipline, statistics, specifically the area of experimental design, which constitutes the second foundation of Mind Genomics [8].

The third foundation of Mind Genomics is the world of consumer research, where the focus in on the complex, real-world stimulus, rather than on the artificially created world of the experimental psychologist. The consumer researcher focuses on what consumers are exposed to, how they react to situations which occur in everyday life. Consumer researchers are not attempting to understand the deep fundamentals of thinking and behaving, but rather interested in behavior in natural settings, dealing with responses to real test stimuli, or at least test stimuli which could be real.

The Test Stimuli

The foregoing history of Mind Genomics serves as an introduction to the nature of the test stimuli. The stimuli comprise combinations of elements, rather than single elements. The rationale is that only with combinations of elements can the test stimuli make sense, have ‘ecological validity.’ When we isolate the test elements, the 16 phrases shown in Table 1, instructing the respondent to rate each element, one at a time, we end up presenting the respondent with stimuli that are almost meaningless. Of course we are interested in the performance of each element, but it is very hard for the respondent to rate each element. It may be that the respondent and rate each element with the same mental rules, but more likely the respondent will end up shifting the mental criterion for the rating. That shift may be hard to imagine for these data, but easy to understand when we turn to elements which comprise brand name, price, nature of the product features, and location where the product is bought. When the rating sale is ‘interest in buying’, the respondent has a hard time using the same criterion. The data may look correct, but the reality is that during the course of evaluating the different types of elements the respondent may have shifted the criterion many time to be appropriate for the element.

To solve the foregoing problem, viz., of presenting ideas as simulating something real, Mind Genomics uses the power of experimental design to create combinations of elements. The experimental design for the 4×4 structure (four questions, four answers for each) comes up with 24 combinations. Within those 24 combinations, each of the 16 elements appears exactly five times, and is absent 19 times. A single vignette can have two, three, or four elements, but no more than one element from any question. The structure is set up so that the data from a single respondent can be analyzed by OLS (ordinary least squares regression), which as shown below, will reveal the individual level combination of every element to the response. Finally, the Mind Genomics design is set up so that each respondent sees different combinations. No respondents see the same combinations until the number of respondents exceeds 250. This property of different sets of 24 combinations created by the same mathematical scheme is called a permuted design structure.

The Orientation and Rating Scale

Mind Genomics studies are typically conducted with populations of respondents who are unfamiliar with the topic. They know that they will be reading and evaluating different combinations of messages, but have no idea that the combinations, also known as vignettes, will be created by experimental design. The respondent generally follows the instructions, doing what they are told. Thus, the simplest way to do the Mind Genomics experiment is to tell the respondent a little about the topic, viz., a sparse background, and then instruct the respondent to read the vignette and assign a rating using a defined rating scale.

Table 2 shows the instructions and the rating scale. The instructions are very simple. A principle of Mind Genomics is that it is more productive to provide a sparse orientation and let the individual elements in the vignette provide the necessary information about the topic. We follow this practice in our studies. Simplicity makes the task easy for a younger researcher because there needs to be very little deep knowledge behind the question.

Table 2: The orientation paragraph and the associated rating scale

The rating scale in Table 2 merits more discussion. The rating scale actually encompasses two scales, one for important, and the other for remembering. Each point on the five point scale corresponds to one possible combination of thinking something is important and remembering the speech. Another thing to observe is that ‘remembering’ is first, and ‘important’ is second. In this way the scale is ‘broken up’ forcing the respondent to read the scale, rather than just remember a place on the scale, or at least that is the intention.

In order to prepare the data for analysis, it was first necessary to transform the scale. Users of data find it very hard to look at either the mean on the scale (which is meaningless for our broken up scale), or the distribution of ratings on the five-point scale. A simpler way to do things is to transform the scale values to binary (0 or 100). For simplicity, we abbreviate the word “Rating,” with “R” and the rating number. For example, “Rating 1” is abbreviated “R1,” etc. This study features two sets of transformations, one dealing with importance, and the other dealing with memorability.

1a. Important and Remembered (R5 only transformed to 100, rest of ratings transformed to 0)

1b. Not Important (viz., Not Necessary) and Not Remembered (R1 only transformed to 100, rest of ratings transformed to 0)

2a. Important (R5, R4 only transformed to 100, rest of ratings transformed to 0)

2b. Remembered (R5, R2 only transformed to 100, rest of ratings transformed to 0)

2c. Not Important (viz., Not Necessary) (R1, R2 only transformed to 100, rest of ratings transformed to 0)

2d. Not Remembered (R1, R4 only transformed to 100, rest of ratings transformed to 0)

With this transformation it becomes easier to discover patterns. The combination of rating scale points into those denoting ‘important’ vs. ‘not important’ allow us to isolate specific elements driving the perception of importance. Similarly, the combination of rating scale points into those denoting ‘remembered’ vs. ‘not remembered’ allow us the same power to isolate specific elements that the respondents feel will be ‘remembered’ by the medical students or young doctors. Keep in mind, however, that this experiment is done among the population of young people, ages 19-40. The same experiment could be done easily among medical students to discover whether they feel the same way.

Analysis 1

Do Different, Identifiable Groups of Respondent Score the Vignettes the Same Way?

In the foregoing introduction to Mind Genomics we made the point that each respondent in the study evaluated a unique set of 24 vignettes. This means that when we look at the distribution of ratings, we must keep in mind that we are not looking at the different groups of people evaluating the same stimuli, but rather evaluating different stimuli of the same type.

At this point it is worth pointing out that stopping here, just looking at the pattern of responses without any deeper analysis, would not be wrong. Indeed, the researcher who stops here, and supports her or his conclusions of similar patterns with conventional statistics, e.g., tests of statistical difference, would be lauded for defending the conclusion of ‘similar patterns’ using well-accepted statistics. Yet, as we will see below, when we move to the development of ‘mind-sets’, the researcher will be afforded the far deeper opportunity to understand the topic, one provided by the up-front efforts to create the test vignettes using experimental design.

Table 3 shows the average ratings for the six newly created dependent variables, for the key subgroups. Table 3 suggests similar patterns of response. Were we to stop here, we would not know anything beyond the observation that the patterns of transformed ratings seems to be similar across the different groups. As the subsequent analyses will reveal, our observation might seem correct on the surface, but is wrong. We would not, however, realize that there are deeper patterns, some of which are radically different from each other.

The groups shown in Table 3 are:

1. Total
2. Gender (male, female)
3. Age (18-29 years old, 30-40 years old)
4. Vignettes rated rapidly (response time < = 3 seconds) vs. rated slowly (response time > 3 seconds)
5. Mind-Set emerging from clustering (Mind Set 1 of 3 Dealing with the stress of the practice of medicine; M2 of 3 Dealing with difficult patients; MS 3 of 3 Aware of what is important to the patient).

Table 3: Averages of six newly created transformed variables, by total panel and by key subgroups. The averages are computed based upon the original rating assigned to each of the vignettes seen by a member of the subgroup. The numbers can be treated like percentages.

Building Models (Equations) Relating the Elements to the Newly Created Transformed Variables

We now move to the heart of Mind Genomics, creating equations which show how each of the 16 elements contributes to the newly created variables. Our analysis will focus on five of the six variables, as we see at the top of Table 4. We will look at the transformed variables corresponding to the highest level of performance (important and remembered), the transformed variables corresponding to ‘important’, the transformed variable corresponding to ‘remembered’, and then the complementary transformed variables of ‘not important’ and ‘not remembered’. The next set of tables will present the parameters of these five transformed variable for each identifiable subgroup previously presented in Table 3. The results will reveal a deeper, far more organized world, one emerging clearly due to the underlying experimental design.

Table 4: Values of the additive constant for five dependent variables (columns) and different groupings of respondents and vignettes, respectively

The first step to build the equation is to create the database. The database can be thought of as a rectangular file, one row for each vignette. Recall that each respondent evaluated 24 vignettes, so this database comprises 24 rows for each respondent.

The columns of this database contain the relevant information:

Column 1 – The unique identification number for the respondent. It is sufficient to label the respondents with a sequential set of numbers, starting with 1, and continuing. The study comprises the data from 102 respondents.

Column 2 – Gender

Column 3 – Age

Up to now the data for a specific respondent has been repeated 24 times. We now turn to the data for a specific vignette.

Columns 4-19 correspond to the 16 elements, with each element having its own column. For example, column 4 is reserved for element A1, column 5 or element A2, and so forth. For a single row, each cell (4-19) will be given the value ‘0’ when the element is absent from that particular vignette, or given the value ‘1’ when the element is present in that particular vignette. Since the experimental design prescribe that each vignette will have 2-4 elements, and not more than one element from a question, the database will reflect the design by having the number ‘1’ in two, three, or four columns, and the number ‘0’ in the remaining columns. The rationale for this specific coding, so-called ‘dummy variable coding’ [9], is that the coding enables the regression program to estimate the contribution of each element when the element goes from ‘state =0’ to ‘state = 1’, viz., present.

Column 20 shows the order of presentation of the vignette for a respondent, with the value going from 1 (first vignette) to 24 (last vignette).

Column 21 shows the response time, defined as the number of seconds elapsing between the presentation of the vignette to the respondent and the response. The response time is measured to the nearest tenth of a second. The response time is an important measure in the world of consumer researcher, insofar as it may indicate the presence of different cognitive processes [10,11].

Column 22 shows the rating assigned to the specific vignette by the specific respondent.

Up to now, columns 1-22 were generated by the BimiLeap program, along with data acquired during the course of the experiment. The data can be used for analysis ‘as is’, but consumer researchers prefer to transform the data so that they can investigate different types of answers. There are five specific transformations of interest, focusing on five different aspects of the decision. Each one creates a new dependent variable that will be analyzed in depth.

1. R5: ‘important’ and ‘memorable’. Ratings of ‘5’ are converted to 100. Ratings 1-4 are converted to 0.
2. R54: ‘important’. Ratings ‘5’ and ‘4’ are converted to 100. Ratings 1-3 are converted to 0.
3. R52: ‘memorable’. Ratings ‘5’ and ‘2’ are converted to 100. Ratings 1,3, and 4 are converted to 0.
4. R12: ‘not important’. Ratings ‘1’ and ‘2’ are converted to 100. Ratings 3,4 and 5 are converted to 0.
5. R14: ‘not memorable.’ Ratings ‘1’ and ‘4’ are converted to 100. Ratings 2,3 and 5 are converted to 0
6. To prepare for the analysis by OLS (ordinary least-squares) regression the BimiLeap program adds a vanishingly small random number (<10^-5) to each transformed value. The random number does not affect the coefficients of the regression equation, but ensures that the dependent variable will possess some minimal variation across the vignettes for each individual respondent. This variability is necessary for the statistical calculations.
7. The equation or model is expressed by the simple formula: DV (dependent variable) = k₀ + k₁(A1) + k₂(A2) … k₁₆₍D4)
8. After the parameters of the OLS model for importance (R54) are calculated for each respondent and stored in a second database, that second database to be subsequently used by a clustering program. The clustering program [12], uses the 16 coefficients (k₁-k₁₆) as inputs to identify groups of respondents showing similar patterns of 16 coefficients The clustering program assigns each respondent to one of two clusters, based upon similar patterns, and then assigns each respondent to one of three clusters, again based upon similar patterns. The output is the assignment of each respondent to one of two ‘mind-sets’ or one of ‘three mind-sets.’ The assignment is done using strict mathematical criteria. However, the names assigned to the mind-sets or clusters are based upon the elements which are the strongest performers. This criterion is known as ‘interpretability.’

Clustering generates groups of two and three mind-sets, with the name of each mind-set chosen based on the strongest performing elements in the mind-set, viz., the elements with the highest positive coefficients. Taking the three mind-set-solution as an example, Mind Set 1 of 3 is Dealing with the stress of the practice of medicine, Mind Set 2 of 3 is Dealing with difficult patients, and Mind Set 3 of 3 is Aware of what is important to the patient.

9. Each respondent belongs to several different groups. The first group is Total Panel, viz., everyone. The second grouping divides into the respondent being a male or a female. The third grouping divides into the respondent into younger (ages 19-29) or older (ages 30-40). The fourth grouping divides the respondents by the mind-set to which they belong.
10. Up to now, the vignettes were assigned to groups based upon the characteristic of the respondent, viz., a gender. We can also look at the vignettes, rather than at respondents to create groups. The fifth groups divides the vignettes by those that were evaluated quickly (operationally defined as response time, <= 3 seconds) versus those that were evaluated slowly (operationally defined as response time > 3 seconds). We can also look at the data focusing our attention on the speed of the response to the particular vignette.

Steps 1-7 above create a database that is readily analyzed by standard regression methods. The approach here is OLS (ordinary least squares) regression. We begin with the additive constant, k₀, shown above as part of Step 6. To review, the equation in Step 6 has 16 coefficients (k₁-k₁₆) and the additive constant. The additive constant is a ‘baseline’, defined as the expected transformed value were the vignettes to comprise no elements at all. The underlying experimental design ensures that all vignettes will comprise at lest two elements and at most four elements. The additive constant has no physical meaning other than as an adjustment factors. We can use the additive constant as a ‘baseline’, giving us a sense of the likely percent of responses to be obtained for a given dependent variable (e.g., R54), in the absence of elements.

6. Table 4 shows the additive constant for each of the groups (rows), and for each of the five dependent variables (columns). For each group and for each dependent variable the additive constants have been shaded for those groups showing an 11 point or higher magnitude of difference between any two members of the group. The large magnitudes of differences in a group are most striking for the three mind-sets, viz., those groups create on the basis of different patterns of coefficients.

We now turn to the important elements for the five transformed dependent variables, showing only those elements which generate a coefficient of +5 or higher. The standard error for Mind Genomics coefficients varies from 4-6 for most studies with a base size of 100. Furthermore, when elements with coefficients of 4-5 or higher are separately investigated, they often turn out to be relevant to the topic. Consequently, and in the interest of Mind Genomics studies as being early-stage explorations, the cut-off level is set to about 4-5. In this project the cut-off level was set at 5, to follow the conventional practice. In addition, the very strong performing elements are shown in shaded cells, specifically those elements with coefficients of +10 or higher. Finally, each table presents three sets of elements, each set sorted in descending order of coefficient value. The first portion of the table presents the results for relevant elements (coefficient = 5+) for the total panel, gender and age. The second portion of the table presents the results for relevant elements for the three mind-sets. Finally, the third portion of the table presents the results for relevant elements for vignette-based groups (response time, order of testing).

Mind Genomics generates a great deal of data, much of which can be analyzed in depth for the simple reason that the elements themselves are ‘cognitively meaningful.’ That meaningfulness leads to the ability to discern general patterns, but then to evaluate the nuances of each element.

7. If we were to summarize the results from the data in Tables 5-9 we would emerge with the conclusion that the strong results emerge from the mind-set, rather than from the self-profiled demographics of the respondents (viz., age and gender), and rather than from the non-cognitive nature of the stimulus (viz., speed of responses, order of testing (first half vs. second half)).

Table 5: Strong performing elements (high coefficients) for ‘important and memorable, R5’



Table 6: Strong performing elements (high coefficients) for ‘important (R54)



Table 7: Strong performing elements (high coefficients) for ‘memorable’ (R52)



Table 8: Strong performing elements (high coefficients) for ‘not important’ (R12)



Table 9: Strong performing elements (high coefficients) for ‘not memorable’ (R14)



Discussion and Conclusions

Traditionally, the combination of young students and ‘science’ has been to repeat experiments that have been previously performed, experiments whose answers are known. The student’s task is to replicate the experiment in the proper manner, obtain the results, and present the process to the teacher. Success in such a case emerges from the combination of executing the study properly and getting the ‘right answer’. The approach has worked for decades, as generations of students went through the process, some emerging with the feeling that ‘science’ is for them, whereas others emerging with the feeling that this process is not at all for them. A century and more of scientific progress, and the emergence of the modern world with all its technology and ‘know-how’ testifies to the success of the traditional process to learn science.

The world has changed. One can scarcely spend a day reading newspapers or now more frequently looking at the material flooding forth from the web, to get a sense that the traditional methods of teaching and exciting students no longer work very well. Perhaps it is the ‘tyranny of the small screen’, a phrase author Moskowitz coined to describe the everyday scene of people, young and old, glued to their smartphones. Perhaps the phones are smart, but the people seem to be less smart, or less educated, if one is to believe the ongoing reports in both the academic press and in the popular press, respectively.

In this emerging world, how then can students be excited? The approach presented in this paper constitutes one way of exciting students through becoming researchers. Happily, there is very systematized thinking about the problems of the everyday, the world where ordinary people live, the world in which they experience the aspects of the quotidian, the daily, the routine. What then could happen if this daily world, so accessible to people, so very ordinary, could be magically transformed into a topic for true scientific investigation, research which not only teaches the student how to think, but actually creates a unique, valuable, indeed absolutely vital corpus of knowledge about the world. After all, the study just reported here, done in just a few hours, from beginning to end, produces unique to the world, valuable information. Most of all, this valuable information comes from the minds of young students, the senior researcher aged 13 (Cledwin), and the junior researcher aged 8 (Ciara), respectively. Their efforts, their curiosity, exploring the topic, produces unique to the world information, the beginning of a large corpus of knowledge on communications to students in the world of medicine.

There is much to do, more than a billion students around the world, many of them that could be considered the ‘raw material’ of our civilization. Right now the issue continues to be concern about their learning, that they are not learning properly, that their motivation is lagging, that their attention is increasingly on the small screen. Perhaps it is because they are not involved in learning, that learning has become the ceaseless repetition of facts to be ingested, converted to bits of memory, and regurgitated at the proper time, somewhat like the cow chewing its cud. Expressed that way, learning is for the very motivated, and perhaps those who cannot escape this onerous task. But, and this is the important point, what would happen if the students could participate in world-wide projects which create separate topic-specific databases about the everyday, using templated experimental design, and using artificial intelligence. The escape would be into education, not away from education into mindless gaming. One could only imagine a world where thousands of students could collaborate and even compete as they jointly build large scale databases about the minds of people in society regarding the different aspects of daily living. An example might be a large scale database about different aspects of teaching and learning mathematics, across 192 countries, across the entire range from say 3^rd grade to end of college, focusing on the many dozens different aspects of teaching and learning mathematics. This effort alone, with 192 countries x 10 aspects of learning mathematics creates a unique, valuable database. One could only imagine the pride of participation and learning for students world-wide who volunteer to participate in this effort. And, to finish, the opportunities are unlimited. Truly in this case ‘the appetite comes with the eating.’

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DOI: 10.31038/PSYJ.2023514

Abstract

The presence of a study poses the problem of the subjectivation of body image disorders in adolescents addicted to psychoactive substances. We start from a clinical observation of schooled Cameroonian adolescents who develop a symptomatology of body image disorders in a sense that is strongly colored by mystical-cultural elements. However, until now, the analysis of the subjectivation of these phenomena has not really been taken into account in the psychoanalytical or phenomenological literature. Based on the theory of cultural relativism of Sow, in particular the theory of conflict relations, we sought to understand the role of cultural signifiers in the process of subjectivation of these disorders when we are under the influence of these substances. To this end, data were collected from three participants or cases, through semi-structured interviews and the DAST-20 test. The results were interpreted in the light of the conflict relationship theory of Sow [1]. It shows that body image disorders are dependent on the breakdown of relational networks, in particular the conflict between the adolescent and the Enemy (witch doctor, sorcerer); the disintegration of his relation to the Ancestor; of the relational rupture between his bio-lineage Family and the Ancestor. The clinical indications of these disorders testify to the impairment of the body, the vital and spiritual principles of the adolescent addict. This implies the objectification of ethno-clinical approaches in the process of detoxification and support for the weaning of addicts, especially school-going adolescents [2].

Keywords

Body image disorders, Teenager, Cultural signifiers, Subjectification, Psychoactive substances

Introduction

The contribution of cultural signifiers in the subjectivation of body image disorders is not taken into account in the scientific literature, in particular the psychoanalytical and phenomenological approaches with regard to their subjectivation of phenomena. Indeed, the image of the body has been theorized by several authors who decline it in several dimensions. Slade defines it as a multidimensional construct that includes two major dimensions, namely: a perceptual dimension and an attitudinal dimension. Price declines it in real body, in appearance body and in ideal body. Dolto speaks of the unconscious image of the body, which he subdivides into basic image, functional image and erogenous image. According to the literature, each of these components is likely to undergo distortions which inevitably modify the perception of the individual vis-à-vis his body, leading to bodily dissatisfaction that the DSM-5 retains in its definition of mental disorders. body image. They are also called body dysmorphia and classified in the nosographic category “obsessive-compulsive and related disorders” and is called “obsession with body dysmorphia” [3-6].

This bodily dissatisfaction is much more noticeable in anorexics, drug addicts and people with a disability or a significant physical condition. In anorexics, from an attitudinal point of view, in general, it is the thighs, hips and stomach that are perceived as having larger proportions than reality. From a perceptual point of view, body image disorder in anorexics is linked to negative judgments made about their own body. From this point of view, anorexics see themselves realistically but are extremely dissatisfied with their body image. The injection leads to a break in the skin for them while those who “sniff” it have perforated nasal septums. Drug addiction or intoxication can also lead to organic damage that alters the physical body with consequences for the subject’s body image and body self-image [7-11].

However, Dolto and Pireyre, starting from the psychoanalytical approach, underline the possibility for an individual who does not suffer from any physical ailment, to develop body image disorders. From the psychoanalytical point of view, the symptomatic elements of body image disorders such as feelings of omnipotence, invisibility, control or fragmentation, etc., refer to archaic bodily anxieties resulting from an absence of symbolization. In infants due to the fragility of the narcissistic foundations. These anxieties reappear in adolescence, which turns out to be an important triggering factor for previous frailties due to the profound changes in the real body of the adolescent resulting in significant psychological repercussions at the level of concrete, imaginary and symbolic reality [12].

At this delicate period of life, the recognition of bodily limits allows a stabilizing image and a protective envelope. Failing this, the adolescent starts looking for strong sensations which give him the impression of rediscovering this physical and psychic envelope, which is why he can feel beautiful, tall, strong, without an objective link with reality. Thus, among drug users, the fragility of the bodily envelope leads to a feeling of emptiness, the absence of bodily feelings, depersonalization, a feeling of fragmentation or of omnipotence [13,14].

These elements, which feed the clinical picture of body image disorders in drug addicts, were listed in the accounts of the three adolescents addicted to psychoactive substances who participated in this study. Their subjectivation of body image disorders that appear in their stories through the clinical indications mentioned above, departs from the psychoanalytical approach as far as the subjectivation of phenomena is concerned. These adolescents, in the sense that they themselves give from their own point of view, to the symptomatic elements of body image disorders that emerge from their discourse, evoke mystical-religious elements such as witchcraft, ancestors, the curse. These imaginary psychic productions highlight the three antithetical doublets of Ego (ancestors, sorcerers, witch doctors) that Sow sets up as interpretative registers in his theory of cultural relativism in general and particularly in his conflict relation theory, to account for the subjectivation of a situation by taking into account the cultural context in which it is inserted.

Thus, these elements of speech of adolescents translate their experience of consciousness in a strongly structured traditional universe which grants an important status to the imagination where hallucinatory images and mediumistic visions orchestrated by the absorption of psychoactive substances, are not only “thoughts more consistent than ordinary thoughts”, but also even more powerful means to access what is hidden but of high meaningful content. This articulation between individual imaginary productions and socio-cultural reality poses the psychism/culture relationship already mentioned by Freud, Roheim, Devereux and others. It is in this ethno-psychopathological perspective that the cultural relativism of Sow fits which, from the anthropological point of view, inscribes, like Hebga, the shadow which is one of the components of the person-personality, as a reliable anthropological foundation to account for the subjective experiences of subjects in relation to spiritual or psychic phenomena which are highlighted in this study, by the mediumistic and psychoanaleptic properties of drugs. In this perspective, the drug ceases to be considered as a simple object or a “fetish” object in the sense of Winnicott, to take on a mystical-religious connotation, since it is part of a pan-structured universe where everything is symbolic [15-18].

Thus, through its psychoanaleptic effects, the drug would act on the shadow to force a disembodiment or stimulate an apparent duplication in which emerge hallucinatory visions allowing the addicted subject to come into contact with cosmic entities, with the only difference that this contact is not facilitated by the state of sleep during which the shadow naturally leaves the body of the sleeper to temporarily join the World of the spirits, or that of the Ancestors, but is provoked by the uncontrolled and unsupervised taking psychoactive substances. It is then that the cultural signifiers inscribe the drug as the determinism of body image disorders, with regard to the syndromy that emerges from the discourse in a culturally symbolic way. Thus, the drug becoming an object of “bewitchment” or a “mediator” of sorcery acted by the deniers of Ego (witch doctors, sorcerers, ancestors), appears as disruptive of the social organization and inducing of psychopathological decompensation.

It is to articulate this link between the psychic productions of adolescents addicted to psychoactive substances and the realities of their socio-cultures that we pose the problem of this study from the cultural relativism of Sow, which is that of the role of signifiers in the process of subjectivation of body image disorders in Cameroonian teenagers addicted to SPAs. The objective of this study is to understand the role of cultural signifiers in the subjectivation of body image disorders in adolescents addicted to psychoactive substances. In order to better understand the psychic dynamics of adolescents, three sub-objectives have been formulated: (1) to understand the intentional action of witch doctors on the biophysiological vital principle leading to body image disorders in Cameroonian adolescents educated addict to psychoactive substances; (2) to understand the intentional action of sorcerers on the principle of life of the existing, leading to body image disorders in Cameroonian adolescents in school addicted to psychoactive substances; (3) understand the intentional action of the ancestors on the spiritual principle leading to body image disorders in Cameroonian teenagers addicted to psychoactive substances.

Method

This qualitative study is exploratory and is based on an ethno-psychopathological perspective. This approach was chosen given that the subjectivation of body image disorders in relation to socio-cultural organizers is an area of research that has not yet been explored. In this context, it is relevant to adopt an exploratory research approach in order to understand the phenomenon by collecting in-depth information on a limited number of participants. Furthermore, this study is one of the first qualitative studies to explore the subjective perspective of body image disorders in adolescents by calling on cultural signifiers. It aims to offer an initial description of these phenomena from the perspective of adolescents in conjunction with the socio-cultural context in which the phenomenon is inserted and gives it meaning. This study is part of an ethno-psychopathological perspective in the natural environment with three Cameroonian schoolchildren addicted to psychoactive substances. Its objective is to understand the role of cultural signifiers in the meaning that adolescents themselves give to the clinical indications of body image disorders that emerge from their discourse.

Participants

The participants of this research are made up of three Cameroonian schoolchildren addicted to psychoactive substances. To be selected, the participants of the study were subjected to the inclusion criteria and the non-inclusion criteria. As inclusion criteria, you had to be a teenager regularly enrolled in a school whose age varies between 11 and 25 years. By considering this age group, we subscribe to the definitional approach of Giedd [19], which extends the age of adolescence to 25 years following the results of research based on the analysis data obtained by magnetic resonance imaging (MRI) of many adolescent brains which show that it is at this age that the brain becomes mature; having been diagnosed as addicted to psychoactive substances or presenting an obvious problem according to the DAST-20 (Drug Abuse Screening Test) with a score ≥ 5. As criteria for non-inclusion, you had to have refused to sign the informed consent; interrupting interviews; being unable to continue the search; have scored ≤ 0 on the Problematic Teen Alcohol and Drug Use Screening Scale (DAST-20) of the body that emerges from their speech.

Material and Procedure

Participants were selected during psychiatric consultations. After a clinical interview and a syndromic record (based on the DSM-V), a diagnosis of addiction was made with the DAST-20 scale which evaluates the degree of severity of drug use ranging from 1 to 20. The score 1 to 5 indicates a low level of problems; a score of 6 to 10 indicates a possibly moderate level of problems; the score of 11 to 15 indicates a substantial level of problems; the score of 16 to 20 indicates the level of possibly severe problems. Adolescents with a score ≥ 5 were offered to take part in the study. Three were selected and agreed to participate in the study after reading the information leaflet and signing the informed consent. The selection procedure that we followed is the non-probability sampling method, which is an empirical method based on a well-considered choice of the selection of individuals by the researcher for the constitution of his sample. The interviews were guided by a grid including themes related to the research questions: 1) motivational factors related to the consumption of psychoactive substances; 2) body image disorders; 3) the psychic dynamics of cultural signifiers; 3) the cultural significance of body image disorders. This research project has been approved by the Ethics Committee for Research on Human Subjects of the Western Region (CERSH-OU) and the authorization to investigate issued by the healthcare firm Angel Gabriel of Bafoussam.

Analyses

We proceeded to a total transcription of the verbatim to not neglect any aspect mentioned by the participant. Afterwards, we proceeded to the coding of the interviews which will make it possible to deconstruct the texts by classifying the quotations by category and illustrating them with the descriptive elements of each person interviewed. Finally, we proceeded to the categorization which consisted in bringing together elements sharing common characteristics according to previously established criteria. The pre-existing categories are linked to the specific themes which relate to the main themes which are: the motivational factors linked to the consumption of psychoactive substances; body image disorders; the psychic dynamics of cultural signifiers; the cultural significance of body image disorders.

Results

The interview with case no. 1, whom we nicknamed “Gildas”, who is 22 years old, a student, single, lasted 27 minutes. He started using drugs when he was 17. Its polyconsumption includes drugs such as tramol, cannabis, alcohol, cigarettes and cocaine. The DAST-20 scale at Gildas showed a score of 16 points, which places him within a positivity threshold of 16 to 20 which reveals a possibly severe level of problems. The interview with case no. 2, whom we nicknamed “Stève”, who is 17 years old, a student, single, lasted 19 minutes. He started using drugs when he was 12 years old and in 6th grade. Its polyconsumption includes drugs such as cigarettes, taï, cannabis, tramol and “pebble”. Passing the DAST-20 scale gave Stève a score of 16 points, which places him within a positivity threshold of 16 to 20, which reveals a possibly severe level of problems. The interview with case no. 3, whom we nicknamed “Jonas”, who is 23 years old, a student, single, lasted 23 minutes. He started using drugs when he was 18. Its polyconsumption includes drugs such as cannabis, alcohol and cigarettes. His DAST-20 test score resulted in a DAST-20 test score of 11 points, which puts him within an 11 to 15 positivity threshold that reveals a possibly substantial level of problems. The analysis of the various speeches collected from each of the three participants confirms the presence of body image disorders which are expressed, among other things, in feelings of invisibility, invincibility, transparency, psycho-corporal emptiness, depersonalization, derealization., fragmentation, right of way or possession.

Depersonalization

Depersonalization is explained by the fact that the subject does not have the impression of being inside his body, nor of the world. The interface between the inside and the outside of the body is not delimited. She expresses herself in Gildas with words like: “It’s like an oppression (…) Once it’s the chest which seemed as if something moved inside… Afterwards you act as if you’re in the machine, as if you were in pieces. For Stève: “You feel as if someone is living in your body. For Jonas: “It makes us do things we didn’t expect, as if you were another person. “I thought I was above, so above that I turned into a glider”.

The Morsels

The morsels refer to the impression that his body is not unified. It is the effect of depersonalization that modifies the bodily experience leading to the subject, anxieties of fragmentation, bodily transformation, annihilation or division. Fragmentation becomes a disturbance of the image of the body insofar as the anxiety of fragmentation is a threat to the cohesion and continuity of the subject by breaking into pieces or bursting. Because of fragmentation, the individual cannot experience a stable identity. The subject is little differentiated from the object. It is translated by Stève in these terms: “I have the feeling that my body is divided into pieces. Bion (n.d.) quoted by Goyty [20] describes fragmentation anxiety as “emptying anxiety”. This feeling of emptying or psychocorporal emptiness is translated by Jonas when he says: “You no longer feel your body”.

The Derealization

Derealization is a state of consciousness or an altered perception or experience of reality that appears dissociated or external to oneself. Derealized people sometimes say that they feel unreal or like an automaton, with no control over what they do or say. This sense of derealization is evidenced in Gildas by lyrics like:

It’s as if I saw far from me. I also saw the little ones there, the guys were scaring me on the way. I even wanted to slap them… It’s as if you have to deal with the same person everywhere. When you talk to this one, he just laughs. Afterwards, you feel that it is not this one that speaks to me. You want to change, you feel it’s weird. Can you see a little?… Afterwards, you see, you have money easily (…) The eyes were turning as if it were going behind your head to get you to see things (…) Someone is telling you now, you mustn’t cheat on your wife, when you have a wife like that, like that. We finish talking to you, you leave. A woman comes out of nowhere and tells you she loves you. You are overwhelmed, you say shit to yourself. What is that.

For Jonas: “You do things without understanding…You have the impression of flying away, of speaking with spirits. For Stève: “It’s as if I was flying away. It feels like my feet weren’t touching the ground anymore.”

The Feeling of Being Under Control

Control or possession refers to the state of a person who is in the power of a demonic power. It can be done by bewitchment by means of objects or mediators such as food, animal vectors, instruments-amulets. This feeling of being under control is manifested in the subject by the impression that his body no longer belongs to him, that someone else is carrying his body or remotely guiding him. This feeling of being under control is translated in Stève by: “I tell myself that there is a spirit behind which controls me…I sometimes felt as if someone possessed my body. I do things without knowing and when I do, I find that what I did was not right. Right now, it’s not me who’s doing it.” For Gildas: “I have the impression that my body no longer belongs to me, that I do things as if someone was controlling me. Sometimes, in class, I heard a voice telling me “go out and have a smoke”. It was then that I left school to find myself in the neighborhood with friends. For Jonas: “Some say it’s bewitchment… As if a spirit was inhabiting you and pushing you to do things”

The Invincibility

Invincibility is expressed by the feeling of narcissistic omnipotence which gives the subject the impression of divinity. This feeling of omnipotence is expressed in Gildas by words like: “I could say that I cross the portal without the supervisor seeing me and I cross he does not see me…Even if there is a wizard in the neighborhood, I know that he cannot do anything to me because I am powerful”. For Jonas:

I felt invisible, super powerful. We believe we are capable of anything. When you take this, you change dimension. You think you are powerful. It puts you in a mind where you believe that you are capable of anything, that nothing can stop you. In my hallucinations, I saw life in a different way. I thought I was above, so above that I turned into a glider. I even had to forget who I personally was. I was like a god since I minimized or marginalized those around me.

Steve is of the same opinion when he says: “You are strong. You speak, everyone listens. You become like god”. The subjectivation of the participants in the study in relation to these different elements calls up the cultural signifiers available in the sociocultural field. This meaning given to the elements of body image disorders by adolescents addicted to psychoactive substances, will be apprehended from Sow’s theory of cultural relativism and in particular, his theory of relationship conflict.. Indeed, Sow postulates that all phenomena can only be understood in the socio-cultural context in which they emerge and which gives them meaning. It is in this perspective that he inscribes the mental disorder as the expression of a conflict between the individual and his relational poles, because in Africa, the sick subject is always the victim of an aggression external to him whose aggressor or denier of self or identity, can be the sorcerer, the witch doctor and the ancestor. In the context of this study, all these negative doublets of Ego use the culturally inscribed drug as a determinant of body image disorders because of its psychoanaleptic effects on the shadow or the ego of the subject who immerses his functionality in a hallucinatory dimension that is similar to psychic or paranormal phenomena that emerge from the discourse of study participants in a culturally symbolic way.

The Conflicting Relationship between the Ego and Sorcerers/witch Doctors

Sow thinks that mental disorder is “Ego ‘violated’ by the rupture, caused by an aggressive otherness, of one or other of its links, stemming from the fundamental constituent poles” (p.30). In this study, the first constituent pole is that of Ego and the sorcerer. All the participants in the study mention witchcraft as a possible explanation for the clinical indications of body image disorders that emerge from their speeches due to the mediumistic and psychoanaleptic properties of psychoactive substances. We can underline it in the student Jonas who says: “We say to ourselves that there is something behind. People of bad hearts, one mind. In the same perspective, Gildas affirms: “Sometimes they are said to have been sold into witchcraft or that they are driven by a spirit or by bad people. “For Stève:” But I think that this thing is not clear. There is something behind. Maybe witchcraft, spirits or an invisible hand”.

These different subjectifications of the elements of body image disorders given by the participants in the study, which underline the action of the horizontal antithetical doublet on Ego, highlight the importance of the etiology of the phenomena still considered in Africa as an indicator of disruption of social relations [21]. In the context of the study, the drug is not just a simple herb or profane object, but is considered a magic herb possessing powers which, however, are not innate to it, but are dependent on the antithetical doublets of ‘Ego who use it to reach their victims. This is noticeable in the account of study participants who speak of being “driven by a spirit or bad people.” As for Jonas, he is convinced of this mystical-religious character of psychoactive substances when he says: “In fact there is always a spirit in the matter there because as soon as you touch that, everything changes. Gildas continues along the same lines when he says:

Some will perhaps talk about the action of wizards, or will say that it was out of jealousy that someone would have done this. But I think there is a force behind drugs. It’s not simple. Because in the sect, we consumed it to get in touch with the grandmaster. I even distributed it to some young people to introduce them to our sect and when I met them later, something in me told me that they were already part of our number.

This account by Gildas accounts for the correlation existing between psycho6active substances and magico-religious practices or even between psycho6active substances and consumers who become people apart, sometimes endowed with supernatural and premonitory powers. This is noticeable in Steve as in most of the participants in the study, when he says: “You become invisible. It’s like you think something and that’s the only thing that comes. You become like a prophet. Anything you want, you get. You have the money without knowing how you do it. You don’t have the money but when you want the money, the money comes. So Jonas thinks it’s “real witchcraft.” The conflict that is expressed in this case is not psychic or internalized like a breach of the psyche, since it is located outside of the drug addict. It is a dynamic conflict which is situated, analyzed and actualized in the relations of the subject with one of its constituent poles which is an antithetical doublet in the rank of which the sorcerer or the witch doctor. It is therefore by design that the notion of conflict is inscribed in African psychopathology as the interpretative base of psychic phenomena whose aggressor agent is a negative doublet of Ego in the sense that it deconstructs Ego in its constitutive structure that is the person-personality. It is in this sense that Stève recounts his first experiment:

The first time, it is as if the plane had hit me. Everything vibrated in me. Because there are people who do like that there it takes them they die once. His pressure is raw, very raw even. Me when it took me hmmm. I was already screaming that I’m already finished. I was saying in my head that I’m already dead. The day there I said that I can no longer take. It is as if my soul came out of my body. But then I always took. There is witchcraft behind.

Along the same lines, Gildas describing his experience, says:

I feel like my body doesn’t belong to me anymore, that I do things as if someone is guiding me. Sometimes, in class, I heard a voice telling me: “Go out and have a smoke.” It was then that I left school to find myself in the neighborhood with friends… I not only heard voices, but I also saw the leader of the sect who often appeared to me to warn me or give me instructions..

As noted by Gildas, the persecuting violence that his shadow-soul undergoes is exogenous. For Sow it is this persecutory violence suffered by Ego and conceived as external to him, which allows Ego’s psyche to maintain and reinforce its internal coherence. Thus the notion of conflict relationship is an important psychological modality in Black Africa on the triple plane of the imaginary, the real and the symbolic. For Sow, the interpretation of the mental disorder requires that the persecuting external agent be identified, which also amounts to identifying the problematic dimensional axis of the attacked subject who, in the context of the study, is the adolescent addict to psychoactive substances. It is this approach that the parents of Silas opted for by consulting Nkamsi or witch doctors: “They went. The seers said it’s the drug. But that there is a spirit behind that people use to harm me. Thus, the psychocorporal disorder in relation to the psychoanaleptic effects of the SPAs which the student Silas faces, has as its conflicting pole, a spiritual entity.

We note here the importance of the imagination or the symbolic representations that furnish the psychic functioning of the addict subject. These representations concern the conflicting dimensional axis which is characterized by an enemy (spirit) who uses the drug as a fetish or a “mediator” because of its psychoanaleptic properties, to attack Ego in its shadow. The similarity of the content of the participants’ speeches makes it possible to realize the constituent background of the individual imagination in highly structured traditional African societies. These constituent resources of the individual imagination, although they vary from one pupil to another, do not present significant differences, despite the fact that the conflicting pole can vary from one pupil to another according to the frailties individual and socio-cultural determinants.

The Conflicting Relationship between the Ego and the Ancestor

In the African cultural imagination, the Ancestor or the ancestral signified is the founder and guarantor of the law, rules, principles or prohibitions. The respect of these laws and prohibitions, guarantees the development of the individual within the cultural community in which he derives his existence, because, outside this community governed by the law of the Ancestor, he is considered as a non-be. Thus, the entire existence of the individual is governed by these laws, the violation of which has consequences on all the existing relational poles. It should be emphasized that in Sow, the horizontal and ontogenetic dimensions are maintained and consolidated by the links from the major Pole of ancestral verticality. The set of all these relations constitutes an ordered totality, founded on and guaranteed by the Being of the Ancestor located at the top of the African cosmogonic pyramid.

However, the parents of Steve, Jonas and Gildas seem not to subscribe to this system of beliefs because of their Christian faith. Steve says: “They went. The seers said it’s the drug. But that there is a spirit behind that people use to harm me. That there are sacrifices that must be made because the ancestors are angry. Things like that. But my mother didn’t believe that. She is a believer. In the same perspective, Gildas, whose parents are Christians, says: “I have already learned that some seers say that it is the ancestors who are angry, perhaps because the parents of the victim did not perform certain rites.. For Jonas: “Some say it is bewitchment, a curse (ndô) and that the spirits of the ancestors are angry. “The curse called “ndô” in Bamileke country, is always the expression of the anger of the ancestors because of the transgression of a prohibition or the neglect of an important rite. The victim may not be directly affected by the transgression or neglect in question, but suffer from the faults of the parents. In this case, we speak of a “designated patient”. This shows that in the African cultural imagination, all acts and omissions have consequences.

Indeed, the transgression of the Word, of the Law of the Ancestor generates the rupture at the deep level of the cultural link. This transgression leads to a state of disorder, heartbreak and insecurity at the individual and collective level. Because, from the cultural point of view, the founding Ancestor of the clan or lineage is the only one who can totally and fully guarantee the physical and mental well-being of the subject. As much as respect for its law guarantees cohesion between the constituent dimensions of Ego, their transgression disrupts the harmonious relationship through its direct action on each of the constituent dimensions of Ego. Also, in traditional African thought, the vertical antithetical doublets of the self, such as wandering spirits and geniuses who had privileged relations with the Ancestor, are likely to influence the deep being of the subject and disorganize as much as the Ancestor, his relational networks. They can only be calmed by skillfully performed rites [22]. This is apparent from Silas’ account when he says, “The seers said it’s the drug.” But that there is a spirit behind that people use to harm me. That there are sacrifices that must be made…”.

Thus, given that in the collectivist culture, the individual has no life of his own apart from that of the community which defines his existence and his identity, any member of the collegiality who transgresses the taboos or refuses to submit to the law of the Ancestor, which ensures the cohesion and harmony of the group in the cosmic order, incurs the most severe sanction of the Ancestor, the Genii or the spirits who are attached to it [23]. In this study, the said sanction comes in the form of a mental disorder caused by the consumption of SPAs. This is the case of Jonas received in psychiatric consultation for acute delusional puffs with hallucinations. Apart from the transgression of an ancestral prohibition that the therapist must identify, or the refusal to perform a rite by the parents which would explain the mental health of the addict subject, the drug in itself constitutes an existential threat, since its use is part of the antithesis of ancestral principles and whose sanction can be collective because of the collective solidarity which fundamentally characterizes traditional societies. Thus, we realize to what extent the violation of a prohibition by an individual not only affects his relationship with the Ancestor, but also generates disorder in the relationship between the bio-lineage family and the Ancestor.

The Relational Disorder between the Bio-lineage Pole and the Ancestral Pole

The cosmogonic triangle of Sow, places the Being of the Ancestor at the top of the pyramid with at the other ends the bio-lineage family and the cultural community. The set of all triangular relationships constitutes an ordered whole, founded on and guaranteed by the Being of the Ancestor. Thus, apart from Ego, the vertical axis also articulates the Ancestor with the unity of all: individuals, family, lineage, clan between them on the one hand and, on the other hand, of all with the whole of the culture. This axis confers on all the “Existing” the fundamental dimension and consolidates their phylogenetic continuity on the triple level of Being, Existence and Culture. The vertical axis can be disrupted due to “outside the contract” [24] behavior of one or more family members. In this perspective, when the seer consulted by Silas’ parents says “that there are sacrifices that must be made because the ancestors are angry”, this implies that Silas is only a victim or a “designated patient”, the ancestors having just used it to express their anger vis-à-vis the family or the cultural community. In this perspective, the fault committed by an individual becomes systemic or collective. In this case, reconciliation with verticality requires an “oblative gesture of a sacrificial victim” which re-establishes the cohesion between the different constituent poles of the person-personality. This is what Silas’ story refers to when he says that “there are sacrifices that must be made”.

The disorganization of the ancestral relationship with the bio-lineage family can manifest itself directly or spread over time. This is what Stève points out when he says that: “Sometimes it is faults that were committed by ancestors that my parents themselves did not know. This story, which results from the diagnosis made by the seer on the etiology of Steve’s addictive behavior, reflects the resentment of the ancestral meaning that requires reparation so that misfortune moves away from the family, at least for the moment. Because the relationship with verticality remains fragile with the tellurian posterity because of their problematic behavior. Thus, the ancestor, because he is the reference, the ultimate recourse of the person-personality because he is the founder of the community and of the current cultural order, remains the veiled meaning of the mental disorder. of an individual who is in the context of this study, body image disorder in school-going Cameroonian adolescents, due to the psychoanaleptic properties of drugs.

In this context, the psychocorporal modification of the body due to the magico-cultural properties of drugs, is a warning and at the same time, a call to a prompt repair of a fault committed. It is a violence exerted on Ego which indicates a threatening symptom of the cosmic order and the communal balance. The disorder is always expressive of an exogenous violence that fundamentally calls into question the cultural relational structures, created by the Ancestor, which guarantee the place and security of all in the cosmic order. This challenges the members of the bio-lineage family of Silas, Jonas and Gildas to reconsolidate their disturbed relationship with the Ancestor. Thus, according to Sow, the traditional interpretation of phenomena foresees or classifies the different causes of conflicting disjunction of individuality, according to its constituent dimensions or constituent axes, as so many substantiated antithetical “doublets” of the constituents of the self. These constituent dimensions which are external to the individual, can only function in close articulation with the constituent elements (body, vital principles, Spirit) of the intimate structure of the person-personality of the individuality whose aggression is manifested by specific clinical signs, makes it possible to identify the latent signified which is more important than the objective clinical elements. This is how Devereux and Sow think that reflection on the psychological meaning of individual and culturalized psychic productions which are lived experiences of the subject’s consciousness, as manifest symptomatic material, must be articulated with the socio-cultural reality that sheds light on its significance and gives it meaning.

In this ethno-psychopathological study, the adolescent addict to psychoactive substances is culturally and theoretically considered as a person-personality. So, the symptomatology of the disorders of the image of the body which emerges from his speech as well as the meaning that he gives to it, must be grasped from the ethno-psychopathological point of view, as an attack on the constituent elements of the person-personality., namely: the biophysiological principle, the vital principle and the spiritual principle.

The Biophysiological Vital Principle or the Life-Soul

According to Sow, the aggression undergone by Ego on its biophysiological principle by the horizontal antithetical doublets of the self that are the marabouts/fetishers, causes psychosomatic affections among which: the state of social inhibition, fatigue physical, mental fatigue, sexual disorders, dreams of persecution, etc. These clinical indications of psychosomatic disorders were found in the participants in this study. Student Gilda expresses the achievement of her biophysiological principle in these terms: “You get up in the morning, you take. You don’t have the strength. You don’t want to do anything. You just want to sleep… You have a stomach ache, appetite disorder. Sometimes there are noises. You can’t sleep. If I go to bed at 8 p.m., even at two o’clock I will still be awake. My head would only be, it’s just spinning. Even the woman doesn’t say anything to you anymore. You have sexual weaknesses. In Stève, his syndromic summary retains insomnia and migraines. He himself recounts his first experience in these terms: “My neck hurt. It hit, it hit, it hit. Then you act like you’re in the machine. Like you’re in pieces. Once it was the chest that seemed as if something was moving inside. In Jonas, we note asthenia, insomnia, amnesia, tremor, dizziness, headaches, tachycardia, anorexia, etc. These syndromic summaries testify to a dysfunction of the biophysiological principle which results from the violence of the Enemy on Ego. This suffered violence, persecuting Ego, is orchestrated by a persecuting agent or an aggressive otherness which is outside of it and which allows the psyche of Ego to maintain and reinforce its internal coherence. Thus, for Sow, the persecutory object relationship is a banal psychological and psychosocial modality in Black Africa, on the triple level of the imaginary, the daily reality and the symbolic universe. Because, in the culture and the effective social praxis in Africa, these different objects of the activity of the psyche are not distinguished from each other, but maintain between them, a relation of continuity.

For Sow, this object relationship is expressed at the level of experience, essentially through themes such as possession, influence, devouring, etc. The story of the student Stève translates this experience well when he says that “there are times when I am smoking, I tell myself that there is a spirit behind that controls me… I sometimes felt like if someone owns my body. I do things without knowing and when I do, I find that what I did was not right. Right now, it’s not me who’s doing it.” For Jonas, “in fact there is always a spirit in the matter because as soon as you touch that, everything changes and it then awakens certain spirits in you which are not convenient, that’s a bit like that. Some say it’s bewitchment.” These different accounts of the experience of consciousness of students addicted to SPAs not only testify to the existence of a “structured imaginary cultural collective”, but also provide evidence of an attack on the biophysiological principle by an aggressive otherness. whose acts of destructive aggression do not spare the vital principle of the existing.

The Vital Principle or the Soul-Shadow

The vital principle or the soul-shadow is the internal principle which caps the biophysiological principle. It presides over the existence of individuality. Its role is to enliven the existing. Thus, life, strength and fertility are under his control. For Sow, the impairment of the principle of life of the existing is expressed through the following clinical signs: the feeling of being literally emptied, pumped of its substance; the symptomatic procession accompanied by a feeling of imminent death, with physical signs such as: palpitations, dry mouth, agitation, etc. We find these symptoms in Gildas whose syndromic summary retains palpitations and agitation. The student Stève is part of the same logic when he says: “I had the impression that my body at some point no longer belonged to me. It is the same for Jonas who says: “You no longer feel your body. “All of these lived experiences of consciousness reveal the disintegration of the life principle of the participants in the study. For Sow, this disintegration induces paroxysmal, acute anxiety without temporo-spatial destructuring, but with the feeling of imminent death, as can be noted in the student Stève: “I was already screaming that I am already finished. I was saying in my head that I’m already dead. For Jonas, “you no longer feel your body. Real witchcraft what… Some say it is bewitchment”. In fact, bewitchment is an operation by which one strikes a substitute for the targeted person (effigy, nails, hair, linen, etc.) with blows that are supposed to reach him.

In the absence of appendages (nails, hair, etc.), the sorcerer uses mediators which come in the form of food, animal vector, instrument-amulet to bewitch his victim or to gradually destroy his vital potential. He conveys the soul of sorcery in his acts of destructive aggression. The mediators through which the sorcerer conveys the soul of witchcraft include all the elements of nature in an environment where the sacred is omnipresent, a pan-structured universe. Sow calls these elements of the cosmos “revealing clues to the divine”. For Zahan [25], the environment here includes all the elements of nature that are in direct contact with man, from his body linen to the cosmos in all its complexity, including the soil with all its content (plants, minerals, living beings, all patrimonial assets). Drugs are part of this “patrimonial asset” or of these “indicators revealing the divine”. In traditional societies, it is used in mediumistic practices or for magico-cultural reasons because of its psychoanaleptic properties, as is the case with initiation into bwete among the Mitsogho of south-central Gabon. As a result, it can, beyond mediumistic visions and provoked and controlled hallucinatory images, serve as an “instrument-amulet” in which the sorcerer conveys the soul of witchcraft to harm his victim. This instrumentalization of drugs is reflected in the words of Gildas when he says: “But I think there is a force behind drugs. It’s not simple. Since in the sect, we consumed it to get in touch with the grandmaster ».

Always to translate this magico-cultural or mediumistic character of drugs, Stève says that “there are times when I am smoking, I tell myself that there is a spirit behind that controls me…It is true that people are going to say that I have been sold into witchcraft or that it is the spirits who want to destroy me”. As for Jonas: “You suddenly become powerful, as if a spirit were inhabiting you and pushing you to do things. You no longer feel your body. Real witchcraft what… in fact there is always a spirit in the matter because as soon as you touch that, everything changes. The experience of bewitchment by the drug revealed by the psychic productions of the participants in the study, accounts for the investment of the vital principle by the doublet of the self or the negator of existence which penetrates to the depths of the Being and Existence of the person-personality.

The Spiritual Principle or Soul-Spirit

The spiritual principle is the quintessence of the psychic life of Man. It is a spiritual substance made of intelligence and will which is indestructible and imperishable. It is in close relationship with the ancestral pole or the ancestral signified which is the only one to access the spiritual principle of the Ego. This principle is affected when the relationship of the Ego to the Being of the Ancestor becomes problematic. It is reached when there is a conflict with the most fundamental Tradition, that is to say the Being, the Word and the Law of the Ancestor. For Sow [2], the achievement of this fundamental component of the individual leads to the following clinical indications: a state of agitation with experience of confuso-oneiric consciousness, incoherent remarks, denudation, as well as a strong feeling of to be influenced, to be possessed. These symptoms evoke first of all problems with the vertical dimension which includes: the Ancestor, the genius, the Wandering Spirit. The inferred point of impact is the “ontological” dimension of the subject. This is the typical case of the acute psychotic outburst, which was noted in Jonas whose syndromic summary indicated acute delirious outbursts with hallucinations. It will emerge from his speech that his parents are Christians. Their religious affiliation is at odds with traditional beliefs, which creates relational difficulties between the Ancestor and the family or between the Ancestor and the Ego used as a victim. This is what emerges from the words of Gildas when he says: “I have already learned that some seers say that it is the ancestors who are angry perhaps because the parents of the victim did not perform certain rites… I had a friend, the kamsi had said with regard to his case, that the ancestors were angry because he had refused to subscribe to the ritual required to be Nkamsi”.

The symptomatology which reveals the attack of the spiritual principle includes not only the syndromes of the biophysiological principle and those of the vital principle, but also psychotic decompensations such as depersonalization, derealization, the feeling of being under control. The depersonalization is noticeable in the student Jonas when he says: “It makes us do things that we did not expect, as if you were another person. For Stève: “I have the feeling that my body is divided into pieces. As for Gildas, he translates this feeling with words like: “It’s as if I was flying away. Looks like my feet weren’t touching the ground anymore. Possession is evidenced in Gildas through the following account: “I feel like my body no longer belongs to me, that I do things as if someone is guiding me. Sometimes, in class, I heard a voice telling me “go out and have a smoke”. It was then that I left school to find myself in the neighborhood with friends. As for Jonas, he puts it this way: “It’s as if a spirit was living in you and pushing you to do things. Also, the hallucinations caused by intoxication with psychoactive substances in Jonas, which are unusual experiences of consciousness, far from being pure “regressive” and narcissistic chimeras, correspond, rather, to what Sow calls, a surreality. For him:

If Psychoanalysis as well as traditional culture make the content of the imaginary a manifest symptomatic material, referring to a latent structure which founds it, then clarifies its meaning and gives it meaning, the articulation of the contents of the “imaginary “traditional with the elements of socio-cultural reality seems to us better established and more coherent insofar as, not only does traditional society give a valued and privileged status to the imaginary (access to something else: the community signified articulating the verb of the ancestor who goes beyond and founds the singular subject) but, moreover, because the traditional values, as coherent with respect to the cultural link, make it possible to link, in a more satisfactory way, the links of meaning with a structuring principle for the set of subjects: the Ancestor. (p.63).

According to Sow, the hallucinatory vision which is an experience of lived consciousness, must be considered as a manifest clinical or symptomatic material which reveals the deep layers of the human psyche thus giving access to the fundamental signified which is the Ancestor. Thus, the hallucinatory vision or the state of trance-possession cannot have the same status as in Western psychiatry, quite simply because their structure, their meaning are absolutely different, proceeding from different anthropological Totalities. It is on purpose that intoxication with psychoactive substances, which resembles a “spontaneous” or “wild” psychotic experience, because it is not controlled by the usual rules, leads to psychotic decompensations (schizophrenia, melancholic, psychosis obsessive, etc.) which are serious mental illnesses because they proceed from the most intimate disorder in the Being of the Existing. It is essentially interpreted as resulting from a conflict with the dimension of verticality. This explanation is confirmed by the friend of Gildas considered “crazy” for having refused to subscribe to the rituals to become Nkamsi. All the “imaginary” productions of the participants in the study in relation to their subjectivation of phenomena are “uncovering” the deep layers of their human psyche which are part of the systems of thought and the real social practices of their cultural group. These are personal experiences of consciousness in traditional Africa that highlight the existence of a “structured imaginary cultural collective”. We can therefore say that the individual imagination literally draws from community praxis and ideology the essential intellectual elements of its mental elaborations. Because, all the stories of the participants as lived experiences, are made according to the cultural signifiers available in the social field in which they are inserted.

Discussion

The analysis and interpretation of the speeches of the participants in the study show that they give an important place to cultural signifiers through mystical-cultural elements. We note the occurrence of the words “witchcraft”, “spirit”, “ancestors”, etc., as an attempt to explain the paranormal phenomena that appear in their speeches and that they seem to have experienced under the effect of psychoactive substances. This meaning that the study participants give to the clinical indications of body image disorders that emerge from their accounts, is culturally embedded in Sow’s cultural relativism, in particular his relationship conflict theory which defines illness as a violation that disarticulates the Ego as a constituent reality (body, vital principles, Spirit) with its different constituent dimensions (ancestral meaning, biolineage family, socio-cultural community). The aggressor agents who are the deniers of Ego, are culturally signified as witch doctors, sorcerers and ancestors. The various pathologies which result from the aggression of Ego on its various components, are culturally indexed and are declined in psychosomatic affections due to the intentional action of the fetishers and the marabouts who disorganize the biophysiological principle or the soul-life; the morbid disorders which are due to the intentional action of sorcerers who disorganize the vital principle; the most serious morbid disorders which are due to the intentional action of the ancestors which disorganizes the spiritual principle.

In this study, the elements of culture evoked by adolescents in their discourse, include drugs as the determinism of body image disorders, with regard to the syndromy that emerges in a culturally symbolic way. Thus, drugs, which are part of the sacred in a pan-structured universe, appear to disrupt cultural organization and induce psychopathological decompensation. In his relationship conflict theory, Sow inscribes in the register of morbidity, fragmentation, depersonalization, the feeling of emptiness, etc., orchestrated by self-deniers on the vital principles of Ego (soul-shadow, soul-spirit). These clinical indications emerge from the discourse of adolescents as characteristic signs of body image disorders resulting in the feeling of having a split, transparent or bewitched body, etc.

For Hebga, these clinical indications, which translate the culturalized experiences of consciousness of adolescents as well as the meaning that they themselves give to them according to their own points of view, account for the paranormal phenomena that he explains from of his triadic theory which structures the human being into three components namely: the body, the breath and the shadow. He thinks that it is through the shadows that bewitchment, bewitchment, apparitions, visions, action at a distance, etc., in short, so-called paranormal phenomena are made possible. The shadow in Hebga is the parallel of what Sow calls “vital principle” or “soul-shadow”. It is the seat of individual psychic life and therefore the basis of paranormal phenomena. In the logic of Sow [2], it can suffer the effect of any immaterial intrusion that can immerse its functionality in a hallucinatory dimension that is similar to what Hebga calls paranormal phenomena.

In this anthropological, vitalist and dynamic perspective of phenomena, the drug through its psychoanaleptic effects would act on the shadow to facilitate the emergence of hallucinatory visions, thus allowing the addict subject to come into contact with spirits, with the only difference that this contact is not facilitated by the state of sleep during which the shadow naturally leaves the body of the sleeper to temporarily join the World of the spirits, or that of the Ancestors, but is provoked by the uncontrolled taking and unframed psychoactive substances that act on the shadow to force a discorporation or stimulate an apparent duplication. This apparent duplication is due to the power of the plant which, by its magico-religious and/or mediumistic property, highlighted by shamans in their traditional therapy, not only allows “access to the sacred world, but participates in the sacred especially when one is in a cultural context where the sacred is omnipresent through natural elements. Thus, the power of the drug is transferred to the subject’s body, investing his vital principles (soul-life, soul-shadow) as well as his body image to give him the impression of “flying away”, of ” to split” or “to be under the influence”.

For Hebga, on the psychopathological level, addictive consumers of psychoactive substances manifest the same clinical signs as those found in patients who are under the influence of bewitchment and who go through paroxysmal crises in which the fear of dying and where many somatic manifestations appear: respiratory and cardiac problems, gastric spasms, feeling of imminent death. The person convinced of having been sold, lives in the obsession of this diabolical market. He has the feeling of being split or of being emptied of his vital substance. His invisible self works away from his visible self. One could suspect here the feelings of depersonalization and derealization which are present in schizophrenia or melancholia and which are also found in people addicted to psychoactive substances.

According to Hebga like Sow, we can say that when teenagers addicted to SPA talk about witchcraft, ancestors or spirits to explain these clinical signs of body image disorders that emerge of their stories such as the feeling of depersonalization, of fragmentation, of psychocorporal emptiness, etc., they do not tell chimeras, but describe a phenomenon which basically corresponds to a traditional milieu, to something transcribable, decipherable. It is in this perspective that Nguimfack insists on taking into account the cultural material brought to the clinic as being first and foremost, psychic material. For him, the patient lives with this material on a daily basis and it guides his behavior, his thoughts and his vision of the world. While giving a special status to the cultural material brought to the clinic by the patient, he says that “if someone evokes witchcraft, beliefs or the curse to explain his miseries or even his postures in the face of them, it is, for him, of an element that culturally structures his psychic functioning at that time” (p.117).

This taking into account of culture in the understanding of disease developed from the work of Devereux, the originality of which lies in the understanding of people’s suffering in relation to their beliefs, their customs, their traditions, their history, in short their cultural meanings. By adopting such an approach, Devereux draws inspiration from these predecessors like Freud and Roheim to extend the discussion on the influence of culture in psychic construction. Beyond the universality of the unconscious that Devereux admits, he demonstrates that every human being is imbued with his culture.

Conclusion

The absence of a non-containing environment brings back the archaic problems in adolescence by modifying the experience of the subject’s bodily limits causing feelings of loss of body containment, loss of body content, which alters the function of the Ego-skin, thus pushing the individual in search of strong sensations which give him the impression of finding this physical and psychic envelope. He feels beautiful, tall, invincible, invisible, under the influence or even under the impression of freeing himself from existential constraints and finally mastering his destiny. However, these psychoanalytical and phenomenological explanations of the clinical indications of body image disorders, which constitute significant addictive problems, are not to the taste of the adolescents addicted to psychoactive substances who participated in this study. Their subjectivation of body image disorders based on clinical indications noted in their speeches, highlighted the cultural signifiers specific to their socio-culture. Their evocation of witchcraft, ancestors, curses or spirits to account for the disorders of the image of their bodies, testifies to their lived experience of consciousness or their imaginary production which, despite their individuality, is imbued with collective imagination in a panstructured universe where the persecutory object relationship is a psychological and psychosocial modality on the triple level of the real, the imaginary and the symbolic world which manifests itself at the level of experience essentially through themes such as possession, influence, devouring, depersonalization, derealization, etc.

This content of consciousness or culturalized material which explains the disorders of the image of the body by the achievement of the constitutive principles of the person-personality which disarticulates Ego with its constituent poles (vertical, horizontal, ontogenetic), must be articulated with reality. socio-cultural. Thus, the questioning of deep anthropological structures is likely to generate a state of ill-being in an individual, in his family and in the entire cultural community, since there is interweaving of links at the functional level between the structure of the person-personality of the adolescent addicted to SPAs and those of socio-cultural relations. It is in this sense that Nguimfack makes cultural material, clinically significant psychic material, since not only does it influence the vision of the world of the SPA-addicted adolescent, but also accounts for his psychic functioning in this moment.

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