"Doctor, will I live longer if I give up alcohol and sex?"
"No, but it will seem like it."
The paradigm of the self as it is conceptualised in Western society includes an implicit assumption that one of the primary activities of the self is to engage in protective behaviours. This is a basic assumption in mass media promotion of healthy behaviours: 'Quit smoking' to protect yourself from lung cancer; 'Work safe' to protect yourself from injury, etc. Mass media social marketing campaigns inform the general population of the dangers to the self's existence of smoking, drink-driving, unsafe sex, over-eating, under-exercising and so on. These campaigns are based on models such as the Health Belief Model (Janz and Becker), the Fear Drive paradigm (Janis; McGuire), the Parallel Response Model (Leventhal), Thayer's Arousal Model, Roger's Protection Motivation Theory (Rogers & Mewborn; Maddux & Rogers), Ordered Protection Motivation Theory (Tanner, Hunt and Eppright) and the Extended Parallel Process Model (Witte). Fundamental to all these models is the assumption that people are motivated to protect themselves from harm. Information is provided that warns of the severity and likelihood of consequences of unhealthy behaviours. In some cases this information does motivate people to give up harmful behaviours and adopt safer options.
However, worldwide, we see an increasing prevalence of diseases such as heart disease, diabetes and cancer that are related to preventable causes such as obesity, smoking and a sedentary lifestyle. To meet this challenge, the media strategy has generally focused on how to get health information across more effectively, that is, by making it more persuasive, more vivid, more salient, more imminent, more probable, and so on. Media exhortations to: 'say no to drugs', 'Quit because you can!', 'Respect yourself' etc. do not always achieve the desired change and may increase frustration, hopelessness and even depression (Henley & Donovan).
It may be helpful to consider that this protection motivation paradigm does not take into account the prevalence of paradoxical behaviours, that is, behaviours that are harmful to the self (Apter). When talking about health, I think it is useful to divide paradoxical behaviours into two categories:
thrill-seeking behaviours such as sky-diving and bungie-jumping where the individual enjoys the experience of being at risk without (usually) craving it;
craved or 'addictive' behaviours (using the term loosely), such as smoking, binge-drinking, over-eating, drug-taking, where the individual craves a certain sensation and the gratification of the craving supersedes protective impulses.
In both cases, the individual knows the behaviour is potentially harmful but chooses to engage in it. In the first case, there is a conscious choice that the enjoyment of the thrill experience outweighs the risk. The person feels in control of the decision (even if the decision is to abandon oneself to the feeling of being temporarily out of control). In the second case, there is a need to gratify the craving, regardless of the risk. The person is fully aware that it is not in their long term self-interest but feels out of control of the decision (Lowenstein). This second category of paradoxical behaviours consists of many unhealthy behaviours targeted by health practitioners.
This paper discusses 1) the concept of the self in Western society; 2) the concept of paradoxical behaviour, distinguishing it from deviant behaviour; and 3) the suggestion that people may engage in addictive paradoxical behaviours to satisfy the 'empty self' (Cushman). Finally, the paper suggests that this attention to the empty self may be in a perverse way protective (though not healthy), and calls for a health promotion approach that directly addresses the needs of the 'empty self'.
Concept of Self
The concept of the self varies across cultures and time. Cushman (599) defined the concept of the self as 'the concept of the individual as articulated by the indigenous psychology of a particular cultural group.... the self embodies what the culture believes is humankind's place in the cosmos: its limits, talents, expectations, and prohibitions'. The Eastern concept of self extends 'beyond one's physical and psychosocial identity to include all other people in the world' (Westman & Canter 419) while the concept of self as it has developed in Western society 'has specific psychological boundaries, an internal locus of control, and a wish to manipulate the external world for its own personal ends' (Cushman 600). This Western concept of the self has been traced to Augustine's Confessions, identified by Weintraub (cited in Freeman 26) as the first reflective, autobiographical review of a life history in which selfhood is examined and understood.
The concept of self encapsulates the most profound sense of cosmic place, worth and meaning. One of the aspects of the Western concept of self is a sense of mastery, of being able to act upon the world.
Paradoxical vs Deviant Behaviour
Apter makes a distinction between deviant behaviour, which is defined by social norms, and paradoxical behaviour, which is defined as any behaviour potentially harmful either to the individual or to society. Parachuting would be an example of behaviour potentially harmful to the individual, while celibacy, by threatening the survival of the social group, would be behaviour potentially harmful to society. Neither of these behaviours would be regarded as 'deviant'. Apter (10) calls this sort of behaviour paradoxical 'because it has the opposite effect to that which, from a biological and evolutionary point of view, one would expect behaviour to have'.
While there will be considerable overlap in practice between deviant and paradoxical behaviour - child abuse, vandalism, drug and alcohol abuse, suicide, etc. would all be both deviant and paradoxical - there is a distinction in perspective between these two terms. Deviant behaviour, by definition, is always regarded by a society as anti-social (and therefore is often harmful); paradoxical behaviour is, by definition, always regarded by the individual's self-concept as harmful or potentially harmful (and therefore is also often anti-social).
As our self-concept is socially learned, it is difficult to arrive at a true separation of these definitions but the following example may clarify the distinction: smoking was a widespread, socially acceptable activity in the 1950s, even glamorised by Hollywood. When the scientific evidence showed that it was harmful to the individual's health, that is, paradoxical behaviour, many people were sufficiently motivated to quit. Since the dangers of passive smoking have been highlighted and smoking is becoming regarded as socially unacceptable, that is, deviant behaviour, many more people are trying to stop, and succeeding. For many people, motivation for change is successful when an activity is recognised as both deviant and paradoxical.
Social marketing campaigns have targeted these two areas for years, informing of health risks and dispelling the glamorous image. Yet, people still smoke, even when they know the health dangers and daily experience the open disapproval of others. At the extreme is the person who lies in a hospital bed with both legs amputated, being told and believing that continued smoking will result in the loss of remaining limbs, but who is still not motivated sufficiently to quit; this person is clearly exhibiting extreme paradoxical behaviour. It is useful to call this behaviour paradoxical rather than deviant because it is defined primarily by the extreme injury to the individual rather than the degree to which it departs from social norms.
Why an individual would persist in such irrational behaviour is a seemingly unanswerable question. As Menninger has said, 'the extraordinary propensity of the human being to join hands with external forces in an attack upon his own existence is one of the most remarkable of biological phenomena' (cited in Apter 10). In trying to understand it, we look at three alternatives: 1) what people say their reasons may be; 2) how people defend against knowledge of risk; and 3) the role of visceral influences.
Van Deurzen-Smith (165-6), an existential counsellor, gives some insight into the complexity of one of her patient's reasons for smoking:
The dangers of heart disease or lung cancer had, far from making her want to give up smoking, been a real secret attraction which had been hard to give up. She had experienced smoking as playing with fire and that was highly enjoyable.... smoking in this sense had represented her experience of her body as concretely her own. Inhaling smoke was like breathing fire and feeling extra-alive; exhaling smoke was like seeing her own body's power being projected out of her mouth. Carrying cigarettes and fire on her every minute of the day used to give her a sense of oneness with the substances of the natural world; it was like possessing the secret power of some magical ritual. When smoking she was in command of the physical world, she was master of her own destiny.
In other words, smoking had become an integral part of this person's self-concept.
An alternative viewpoint is that smokers simply defend against knowledge of the health risks. In an examination of 'psychic defences against high fear appeals', Stuteville identified three techniques which people use to reduce fear-arousal: a) they deny the validity of the information; b) they unconsciously assert 'I am the exception to the rule - it won't happen to me'; and c) they defuse the danger by making it laughable or ridiculous. He suggested that campaigns can be more effective if they involve a threat to significant others, especially children, or are made to seem 'offensive to small group norms' (45), that is, seen as deviant rather than paradoxical.
Lowenstein attempted to understand the discrepancies between what people do and what it is in their self-interest to do by postulating the operation of 'visceral factors', drive states relating to hunger, fear, pain, sex and emotions. He suggested that the need to satisfy these drives can supersede virtually all other needs, and that people consistently fail to recognise the strength of the influence of visceral factors in themselves and in others, despite all previous experience and evidence to the contrary. One of the characteristics of visceral factors is the effect of time-shortening so that immediate gratification outweighs long-term goals. Attempts to exercise self-control are made when thinking long-term and usually at the expense of short-term gratification (Lowenstein 288). Although this concept of visceral influences explains some irrational behaviour, Lowenstein made little attempt to explain why some people seem to be more at the mercy of visceral factors than others. For this, it may be helpful to explore Cushman's concept of the 'empty self'.
The Hungry 'Empty Self'
Cushman (600) identified the configuration of the concept of self in the United States as having developed into an 'empty self ... a self that experiences a significant absence of community, tradition, and shared meaning. It experiences these social absences and their consequences 'interiorly' as a lack of personal conviction and worth, and it embodies the absences as a chronic, undifferentiated emotional hunger'. It is this notion of emotional hunger that may have particular relevance to a discussion of paradoxical behaviours generated by cravings. Cushman referred to a strong desire for consumer products to assuage this hunger, but it may be useful when thinking of health to consider the hunger more literally, as a need to ingest substances (drugs, alcohol, food etc) and experiences (shopping, sex, speed, etc) to fill up the emptiness. Emotional hunger may lead to a number of self-destructive but self-nourishing and addictive habits, identified by Firestone as psychological defences against anxiety.
Cushman identified advertising as one of the two professions responsible for healing the empty self (the other was psychotherapy), while recognising that it is also one of the professions that perpetuates and profits from the psychopathology. Perhaps the responsibility falls to social marketing which is concerned with the marketing of ideas, attitudes and beliefs, including health and safety lifestyle issues. At present, it could be said that health promotion tends to make people feel bad (Henley & Donovan), with an emphasis on the dire consequences of unhealthy behaviours. Is it reasonable to suggest that social marketing could be used to try to heal the empty self?
Interestingly, this is already happening to some extent. Mental health is a priority issue and a recent mental health campaign in Victoria, Australia, 'Together We Do Better', stresses the need for community and social connection. Western Australia is exploring whether to undertake a similar campaign. The campaign includes messages relating to friendship, parenting, talking about problems, bullying, sledging, and inter-generational communication (Campaign materials). The overall aim is to work towards a more inclusive, caring, connected and tolerant society.
This paper has discussed the apparent limitation of the current paradigm in health promotion that people are primarily motivated to protect themselves by considering the prevalence of paradoxical behaviours, that is behaviours that are harmful to the self, especially those that are generated by a need to satisfy cravings. One explanation for such paradoxical behaviours is that they are motivated by visceral factors relating to physical and emotional drives. However, this does not explain why some people are more susceptible than others. Cushman's concept of the hungry, empty self, alienated from community and disconnected from social traditions and meaning, may go further to explain why some people are more susceptible to cravings than others. Social marketing could play a helpful role in healing people's sense of isolation in mental health campaigns such as VicHealth's 'Together We Do Better'.
Finally, it may be more intuitive to understand apparently paradoxical behaviour as an urgent attempt to heal the empty self. This would make it in a perverse way protective, though not healthy. This way, people are seen as doing the best they can to protect themselves against the most immediate threat to the self, a sense of hollowness and isolation. If so, the fact that this need is able to supersede other major health needs suggests that it is one of the most urgent imperatives of the self.