Deepening Case Formulation with Tinbergen's Four Questions
"Nothing in biology makes sense except in the light of evolution" - Theodosius Dobzhansky (1973)
A good theory not only explains observations, but also enriches the narrative surrounding them. Modern evolutionary theory certainly transformed the field of biology, and although psychology is much more than just an extension of biology, I believe some of the core tenets have much to contribute to our field as well. Today, I would like to introduce four questions posed by pioneering ethologist and nobel prize winner, Nikolaas Tinbergen (1963), and demonstrate how these questions can be used to deepen and enrich case formulation for the practicing psychotherapist.
What Are Tinbergen's Four Questions?
Tinbergen sought to explain animal instinct, innate behavioral reactions to the physical and social environment, from a perspective that focused on adaptation and fitness. Through his life-long study, he came up with the following four questions that can be asked about nearly any behavior in nearly any species:
Mechanism: What elicits and maintains the performance of the behavior?
Development: How has the behavior developed during the lifetime of the individual?
Evolution: What need or challenge to the species did natural selection shape this behavior?
Function: What is the adaptive function for the individual performing the behavior in the current context?
These questions directly apply to psychological distress in humans as well! Although a comprehensive case formulation is outside the scope of this article, showing examples of these questions in action may help us better understand their significance. Let's expand these questions and apply them to a simple example case of panic disorder.
Case Details: Introducing Mr. K
Mr. K is a 38-year-old male married with two adolescent children. He is a manager at a local hardware store, and reports having close relationships with his family as well as several close friends with whom he spends time playing hockey at a local sports center. Six months ago, Mr. K was in an automobile accident, and although he emerged unharmed, he was shaken by the event. Since that time, Mr. K began to experience panic symptoms nearly every day. These symptoms have led to missed days at work, less time spent with friends, strained relationships with family, and most recently, refusal to leave his home.
The Question of Mechanism:
This question is all about the interaction between the individual's behavior and the antecedent environment. It is import to create a list of environmental stimuli that elicit panic attacks as well as those that do not. With these questions, we would also want to find examples of "failed panic attacks," panic attacks that "should have" happened, but didn't. From examining the common and disparate features of each of these situations (Funder & Covin, 1991), the mechanism may be better understood. For instance, what if Mr. K's panic attacks only took place when he was alone? Furthermore, once when he was having a panic attack, his wife entered the room and he calmed down. We would be able to conclude that solitude is an essential component of his panic symptom's mechanism. A deeper understanding of a symptom's mechanism is helpful because it identifies potential targets for a psychotherapeutic intervention--in this case, Mr. K's psychological experience of aloneness.
The Question of Development:
According to Mr. K's case history, he had never experienced a panic attack prior to the car accident. That said, he has certainly experienced the specific symptoms of rapid heart rate, rushing thoughts, profuse sweating, nausea, trembling hands, etc. at some point in his life previously. In childhood the physiological roots of this emotional experience existed, even if they were not fully understood or existed in the form of a more immature emotional experience (see Freud's "Rat man"; Lear, 2015). In order to retroactively assess the developmental trajectory of these experiences, we can ask questions about experiences related to panic like symptoms in early and middle childhood, adolescence, and early adulthood. Relevant inquiries can be made about how Mr. K explained these experiences to himself at each developmental stage as well as how other people in his life reacted to his psychological distress and/or his explanations of his experience. For instance, what if Mr. K's caregivers were dismissive of his anxiety symptoms as a child? He may have learned to internalize and mask anxiety symptoms, explaining to himself that these experiences are private and not to be shared with others. Understanding the development of panic-related experiences elucidates the trajectory (i.e., more and more internalization over the years) and also inform us of potential expectations and transference reactions Mr. K may have towards the treating psychotherapist.
The Question of Evolution:
Why does anyone panic? Although it is not particularly fruitful to attempt to understand psychopathology as an adaptive response in and of itself, it is important to understand that the underlying mechanism was shaped by natural selection (Nesse, 2019). Fear, anxiety, and panic are all likely byproducts of mechanisms evolved to assist in escaping predation. Summoning a sufficient amount of energy and diffuse focus to quickly detect and escape threats in precariously ambiguous situations is generally considered to be the primary function of fear and panic (Le Doux, 1998). Simply put, it is associated with self-preservation. This corresponds with the event that precipitated the first panic attack (car accident), and a productive line of questioning in this area will likely uncover partial awareness of other existential threats that Mr. K can no longer effectively repress. As this example shows, the question of evolution may provide a clue as to what fundamental human need is associated with the psychopathological symptoms.
The Question of Function:
Psychopathology is not only related to our species phylogenic development, but also has functional implications for the individual's current context (Sturmey et al., 2007). It is important to investigate the impact of Mr. K's psychopathological symptoms on his physical and social environment. Who does this hurt? Who does this help? What behavioral reactions does this elicit in other people? What actions are easier for him? Which ones are harder? From whom or what does his symptoms take 'space'? To whom or what do his symptoms give 'space'? From both a Jungian archetypal and internal family systems perspective, we could also ask to what part of the self do the panic symptoms give voice? In Mr. K's case, what if his wife showed sensitivity to his distress in a way that he hadn't experienced as a child? One possible function (among many others) for his panic symptoms would be to facilitate a corrective emotional experience. As all bodily systems seek to maintain homeostasis, some believe is likely that our minds pursue social and emotional healing as well (Martínez & De Francisco Vela, 2019). Sometimes the impact of symptoms of psychopathology point toward the direction of adaptivity and growth.
Tinbergen's four questions have transformed the field of evolutionary biology, and have much to offer the practicing psychotherapist. These questions provide a structured approach to guide our investigation and direct our clinical interventions. Questions of mechanism often illuminate potential treatment targets. Questions of development often inform symptom trajectory and transference reactions. Questions of evolution often ground psychopathology in natural human needs, reducing stigma through contextualizing suffering. Finally, questions of function reveal the adaptive importance of experiencing these symptoms right here and right now. These questions may serve to deepen our clinical formulation, enrich the narrative surrounding psychological distress, and bring more meaningful content into a dialogue that facilitates healing.
About the Author
Dr. Alexander Krieg is a professor, psychotherapist, and story-teller living in Kobe, Japan. His approach to treatment joins an evolutionary science-informed contextual behavioral approach with psychodynamic concepts and techniques. If you are a patient in Michigan or Japan and are interested in finding more about psychotherapy with Dr. Xander, please contact him via his website: www.kobeinternationalcounseling.com
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Martínez, A. H. & De Francisco Vela, S. (2019) Homeostasis sanatoris. A meaningfulness-driven product that stimulates physiological healing processes, The Design Journal, 22:sup1, 615-626
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