Alzheimer’s Syndrome and “Conversationalism”
In this paper, the author presents Conversationalism as a formal, quantitative, grammatical theory of conversation. Through many examples of recorded conversations, the author shows that the semantic-pragmatic theories of conversation are unsuitable for explaining conversations with Alzheimer’s patients. These particular conversations are typically characterized by the fact that the patient can answer politely, without knowing what he is saying, to words the meaning of which he has not grasped. The formal quantitative grammatical theory of conversation, instead, which puts itself outside the horizon of meaning and focuses on the text’s indicators, explains perfectly well not only the actual formal profile of a single conversation, but also the differences between successive conversations of the same patient. These formal, quantitative, grammatical differences allow us to calculate the types of changes (linked, for instance, to the evolution of the disease or to the therapeutic interventions) in the conversations over time.
The most simple way of presenting conversationalism is to demonstrate it in a field in which it has recently been applied: that of conversations with patients suffering from Alzheimer’s disease. It will however be necessary to give two brief practical definitions of both conversationalism and of Alzheimer’s disease.
The definition of conversationalism
Conversationalism is a conceptual and practical method, for clinical and research purposes, of conducting and then analyzing professional conversations with the particular category of interlocutors summarily referred to as patients.
The individuation and restitution of the narrative motif
The technical and clinical procedures of conversationalism are the individuation and then the restitution of the narrative motif discernible in the words of the patient, which is carried out by the professional towards the same patient. The narrative motif, which is always a paraphrase summing up the patient’s discourse, or at least a keyword in his lexicon, corresponds to some degree to the “script” in Transactional Analysis, to the “complex” in psychoanalysis, or to the “conflictual nucleus” in interpersonal analysis. The difference is that while complexes and conflictual nuclei are unconscious constellations which are part of the patient’s history and the script is a psycho-sociological structure of the person, narrative motifs are fragments of stories available in an encyclopedic repertoire: pure text forms without the need for reference to any extra-textual world.
The repertoire and distribution of grammatical forms
As regards the formal analysis of the text, conversationalism proceeds by simply counting certain grammatical forms, of which the percentage of incidence is then calculated. We will later examine this procedure, with examples of text fragments, but it should already be clear that conversationalism is a technique based on the text; the text of a professional conversation, recorded and then written down, which goes back to the text, dealing with the text as listened to or fragments of the text as transcribed.
The definition of Alzheimer’s disease
Alzheimer’s disease consists of disorders of the memory and orientation; mood changes which vary from apathy to attacks of rage; language alterations at first affecting the pragmatic-semantic functions, then affecting syntactical functions and leading only at the end to grammatical disorganization. There is a steady loss of the relational functions (at work as well as regarding daily tasks and the preparation or planning of meals) and those of personal management, which lead to the necessity for increasingly complete assistance from relatives or professional helpers who supply the patient’s needs by feeding him, washing him and supporting him in the few steps he is able to make in a room. The beginning of the disease takes place at about 60 years of age. The definition of “retrogenesis” (2) has been applied to the process of steady worsening of the disease with reference to the progressive return to the maturational period as far as early infancy and the first months following birth. The pharmacological treatments at present available are not able to stop the development of the disease, which is estimated as having an average duration of five years. Most studies of the disease deal with questions of the help to be given to the families and assistance workers who have to carry out tasks for which the resources available are often insufficient (3). When speaking of Alzheimer’s disease, it is important to bear in mind which phase of the disease one is referring to, whether it is the initial phase with mild symptoms, the second, central phase with serious symptoms, or the third phase with very serious symptoms (4).
Conversations with Alzheimer’s patients
The conversations with Alzheimer’s patients we have dealt with up to now regard the first or second phase, with slight to serious symptoms, during which phase language is affected particularly in its reference functions, with difficulty in finding words or in recognizing the meaning of the words themselves, while the grammatical structure of the sentences seems to be relatively well conserved. It is evident that in order to study conversations with Alzheimer’s patients adequately, we need a general theory of conversation which takes account of the particular characteristics of each separate conversation.
The presuppositions of the traditional theories of conversation
I will refer to these as: “the principle of communication” and “the principle that the speaker knows what he is saying”.
The principle of communication
In the usual theories of communication there are two strong presuppositions: 1- that the speaker knows what s/he is saying, in particular that s/he knows the meaning of the words s/he utters; and 2- that with his/her utterances the speaker communicates, meaning that s/he transmits information to a listener who can decode it. In the 1960s this presupposition was represented by the fitting slogan “it is impossible not to communicate”(5) Thirty years later (6), the principle of communication says more or less that each speaker, through the words s/he says, transmits information to his/her interlocutor, with the intention of saying what s/he says and of obtaining, with what s/he says, more or less what s/he intends to obtain; and, in turn, that each listener understands what the speaker says to him/her, both in the sense that s/he is able to understand the words of the speaker literally, and in the sense that from the speaker’s words s/he is able to decipher what the speaker wishes to say and what the speaker wants his/her listener to reply.
The principle that the speaker knows what he says
Let us now put these two presuppositions to the test of conversations with Alzheimer’s patients, while analytically following the theories of conversation.
The traditional theories of conversation
The most widespread theory of conversation to which, either explicitly or implicitly, a large proportion of clinicians make reference belongs to the field of pragmatic and behavioral philosophy, which is defined in linguistics as the pragmatics of communication, communicative interaction and linguistic acts, and is associated with the names of Austin, Grice, Wunderlich, Watzlawick, Beavin, Jackson, Palazzoli Selvini, Cecchin, Boscolo (7). The above-mentioned clinicians include those of systemic family therapy (8) of cognitivism (9) and of psychoanalysis (10) who deal with the recording and transcription of the texts of special conversations between a therapist and one or more patients.
It is useful to sum up the principal features of this theory. According to Grice, a conversation is a rational verbal transaction, between two or more participants who alternate in the roles of speaker and listener. It is governed by precise conditions, the principal one of which is the co-operative principle, which is specified in at least four corollaries called conversational maxims.
The co-operative principle
Grice formulates the co-operative principle as follows: “your contribution to the conversation should be that which is requested, at the stage at which it happens, by the aim or orientation accepted by the linguistic exchange in which it is employed.”
The principle of co-operation, as one can immediately discern, is based on various presuppositions of great linguistic complexity and these are at least the following: that the speaker has an aim, that the speaker has a series of intentions, that at any moment he is able to evaluate what is requested of him, that he has the capacity of choosing the right words to offer in order to satisfy the request, that he remembers what his aim was at the moment when he started the conversation, that he possesses an adequate faculty of monitoring the course of the conversation, and various others. The same principle of co-operation, or of the sharing of presuppositions can be found in the theory of conversation of the cognitive schools at present (11). But let us examine a fragment of a conversation recorded and transcribed by Gandolfo (12), between the psychologist and Mrs. M, from the 35th to the 39th verbal exchange.
- 35a. PSYCHOLOGIST: But do you keep looking for it even when you see it?
- 35b.MRS. M: Yes! Yes! If I need it I’m ready. If they put that piece of wood there now I’ll wait for the man, the other one, that one there of the wood, who works. Then he has put the car and everything I have and I don’t have anything else.
- 36a. PSYCHOLOGIST: What is the wood for?
- 36b.MRS. M: The wood is for stopping.
- 37a. PSYCHOLOGIST: For stopping what?
- 37b.MRS. M: Something that is put down from outside. Like the car for example, they put some wood no! Now they start it up and this goes. And that’s what the house is. That house is there and the wood. Just for feeling it, I don’t know how I would say that I feel like that, like an old lady of a hundred years, ugly. It will arrive, it should arrive, yes, it will arrive, maybe I’m getting old.
- 38a. PSYCHOLOGIST: How many years old do you feel?
- 38b.MRS. M: I’m very old. Nine? Can it be, or am I wrong?
- 39a. PSYCHOLOGIST: One can make mistakes.
The four conversational maxims
The principle of conversational co-operation, according to Grice’s theory, is specified in four maxims, which refer to the four Kantian categories of Quantity, Quality, Relation and Mode.
The maxim of quantity concerns the quantity of information to be supplied in a conversation and it can be formulated in one of the two following norms: “Give a contribution which is as informative as is required (for the accepted aims of the linguistic exchange under way)”; “do not give a contribution which is more informative than is required”. At this point let us examine the transcription of a conversation (13) between the psychologist and Mrs. E, from the 1st to the 3rd verbal exchange.
- 1b. MRS. E: It seems impossible to see, all the memory seems impossible to see, damn and blast, come off it, get away. Going to a rest-home, to see, to tidy up, to see, different to see. Damn and blast, but how come that it may have happened to see, damn and blast, come off it! What may have happened all the memory, but how may it have happened to see, and all the memory seems normal to see, damn and blast, that it may have happened to see. Holy Madonna. Is it different to see? It seems normal to see that it may have happened to see, it is different to see that it may have happened all the memory, all the memory normal to see, different to see, but God, it seems normal, for the simple fact that my husband is normal to tidy up, that it may be normal different to see, damn and blast, that all the memory that may have happened, to see, to tidy up, to see. But how come? That it may be normal to see, different to see, damn and blast. But how come?
- 2a. PSYCHOLOGIST: How come, in your opinion?
- 2b. MRS. E: It was normal to see, different to see. Damn and blast!!! But how come that it may have happened, to see, different to see, damn and blast.
- 3a. PSYCHOLOGIST: Something has happened!!!
- 3b. MRS. E: Come off it!!!? All the memory, it seems normal to see, all the memory, it seems normal, all the memory.
The maxim of quality can be summed up in the harder formula: “Try to give a contribution which is true”, or in the two softer formulas: “Don’t say what you think is false” and: “Don’t say that for which you don’t have sufficient proof”. But let us consider the verbal exchanges the position of which I will not specify here (in the original text they have a numeration) taken from a conversation recorded by Ennio Cocco and Silvia Bolis between Mr. E, his wife and the psychiatrist.
MR. E: For me Italian is the beautiful language.
PSYCHIATRIST: It’s your language.
MR. E: Eh, it’s your language and instead there, there there I’ve been, I’ve been like, 15 years, without even saying a word in Italian, eh?
PSYCHIATRIST: 15 years.
MR. E: Ohh!
WIFE (shakes her head)
MR. E: No?
WIFE: No, 8 years, 8 years.
MR. E: 8 years?
WIFE: Oh, yes.
MR. E: You’re sure?
WIFE: Oh, yes, 8 or 9 years, basically.
The 2nd and 3rd verbal exchanges of the conversation recorded by Emanuela Lo Re between the Psychologist and Mrs. B is also worth quoting:
2. MRS. B: And now I live at X, at my brother’s house, because we’ve got a house in the brothers, it isn’t a great house, but we’ve got our house.
3. PSYCHOLOGIST: And so you live with your brothers.
3. MRS. B: No, I live alone, we are there all together, we’re all brothers and sisters but everyone has his place, we’re all together, it’s like that.
The maxim of relation states as follows: “Be relevant”, which is to say “be appropriate in what you say” or: “make sure that there is, in what you say, an immediate relation of reciprocity on the level of logical attributions”. But let us consider the verbal exchanges between the psychologist and Mrs. B in the conversation recorded by Emanuela Lo Re:
PSYCHOLOGIST: You are still a mother, I imagine a grandmother too.
MRS. B: Oh, of course, of course, things I see them first to my children I see them then after all we are all Christians.
And also the conversation recorded by Silvia Bolis with Mrs. C:
MRS. C: Oh lord! Life is too bad.
PSYCHOLOGIST: Why do you say that?
MRS. C: I got married and, and to be alright, it has to is born and away!
PSYCHOLOGIST: You said you got married.
MRS. C: Married, when I got married I was, the others were too.
The fourth maxim is the maxim of mode which includes various injunctions: “avoid obscurity”, “avoid ambiguity”, “be brief (avoid unnecessary prolixity)”, “be ordered in your exposition”. Let us try to observe the injunctions of this maxim, as it were against the light, in the context of each of the conversations quoted so far and also within the conversation recorded by Attilio Giuliani with Dario, for whom a diagnosis of dissociative psychosis has been proposed.
DARIO: Then I understood something backwards of a person for my brain, but I was taken by someone, I was taken by someone.
ATTILIO: By a person, you thought of a person.
ATTILIO: You thought of a person.
DARIO: I thought of a person, but it’s not my fault, because years ago I connected something connectedaccio (14).
ATTILIO: You connected something and it had something to do with this person.
The inadequacy of the referential and communicative, or semantic-pragmatic, theories of conversation.
The traditional theories of conversation could be called semantic-pragmatic or referential-communicative, since they are based on the principles of intentional transmission of linguistic information, and on the referential competence of the speakers, which is their knowledge of the meaning of the words and phrases they use. From the previous paragraphs it should have become clear that these theories are incompatible with the conversations of Alzheimer’s patients. From this incompatibility we can come to two conclusions: we either decide that the verbal transactions of Alzheimer’s patients do not satisfy the conditions of the theory of Grice, and so we omit them from the category of conversation altogether and treat them as non-conversations, or we decide that the theory of Grice is not sufficient to account for conversations with Alzheimer’s patients, and so we search for a broader-based theory which will help us to account for the conversations with these patients.
A new theory of conversation
The theory we are looking for, which could account for the conversations of Alzheimer’s patients, will have to be a place in which the communicative function (in the sense of intentionally conveying linguistic information) and the referential function (in the sense of a competency in codifying and de-codifying the meaning of the words) are not continuous principles but occasional inhabitants. So, it is possible to have a conversation without communication, in which the speaker can provide verbal exchanges consisting of phrases which may even be well formed, the words of which he perhaps does not know, and in which the responder can reply with words whose meaning he does not know, to words whose meaning he has not understood. Within this new theory, as in traditional theories, there should still exist the rule of conversational courtesy, which makes it possible to give and take one’s turn in verbal exchanges at the appropriate time. In fact even if one can still consider as a conversation a verbal exchange in which communication and referential competence are absent, a conversation without a succession of verbal exchanges is unmaginable.
A formal, grammatical theory of conversation
A theory that could satisfy all the criteria listed above is a grammatical, formal theory of conversation which takes account of the pure, grammatical forms of a text. Here the word “text” indicates both single and sequential verbal exchanges, and “grammatical forms” indicates not only nouns and verbs, but also the propositional connectives, which are the elements whose syntactical function is to connect the words of a single proposition, of a single sentence, both within a verbal exchange and from a verbal exchange of the speaker to a verbal exchange of the responder, in particular in the figure of the anaphora, of the reprise (cf. above, the past participle married with an anaphoric function in three successive verbal exchanges: from Mrs. C to the psychologist and again to Mrs. C).
The conversational theory of conversation
The theory we have hypothesized just now is the conversational theory of conversation (which is that supplied by conversationalism (15) The conversational theory of conversation in fact deals with the production of words whose abstract grammatical forms can be the object of an inventory, of category distributions (the percentage of grammatical subjects, of nouns, of verbs in the infinitive) in single verbal exchanges, and possibly also of the counting of the differences from one verbal exchange to the next (with the result considered as consisting of this difference, as we will soon see). Let us now put the conversational theory of conversation to the test of a fragment of a conversation between Mrs. D and Mrs. F, recorded by Giancarlo Tamanza.
1. MRS. D: There is, there is, there is, there is, there, to be seen, now that one there is here, if to to, big, it’s Peter big, it’s too big, you is bigger he, of this one here, to ca ca ca. Now it goes away to, to, to, see, th that one which which which is there there, we should go there to see, y’let’s go to there, yes, yes, yes, it’s him which which yes, which here here which is bu now, that thing there, if sh, you leaning of no, you really can’t, you really can’t, of those things there, that that it fi finds too, finds big, if come on we joke.
1. MRS. F: Was there, is there something?
2. MRS. D: To to do without, do without, do without, do without yes, if you go there, go there, where it is to see, everything alright for me.
2. MRS. F: But the thing is escaped you? I say it now.
3. MRS. D: I don’t know. Try that if if if I know it, I tell you, if yes, if if, me, I don’t know, about it if I know, I don’t know anything.
3. MRS. F: Cat.
4. MRS. D: It’s tr.
4. MRS. F: There is, now there is something, we see it.
5. MRS. D: Is?
5. MRS. F: So it doesn’t light anymore?
6. MRS. D: For me.
6. MRS. F: Go and see no, go and see let me it, you go and see it, and it see it go, let me see, I’m dying.
7. MRS. D: Who are you dying for?
In its present activity regarding the texts of conversations with patients diagnosed as probably suffering from Alzheimer’s disease, conversationalism proceeds by individuating various textual indicators, which are lexical, grammatical and syntactical elements of the text of a person involved in a conversation with another person, which can be compared to the textual indicators of other inventoried texts of the conversations of other people or of the same people in later conversations. As regards the technical details of this procedure, one begins by counting all the words in a single verbal exchange. Then the percentage of the nouns and the verbs of the exchange is calculated, followed by the calculation of the reference index, which is the ratio between nouns and verbs. The frequency of the grammatical subject is calculated, which is the percentage of “I”s in the sentences compared to the number of verbs in the verbal exchange. The persistence, or loss, of the rules of conversational courtesy is noted, in particular as regards the taking and giving of turns in the verbal exchange at the right time. Finally the connection of the narrative motifs in adjacent turns in the verbal exchange is considered. The basic idea which lies behind this part of the research is that there may be, in the texts recorded, some specific textual indicators in the linguistic universe of Alzheimer’s patients, which become modified, developing in a precise way as the disease progresses.
The structure of textual indicators of Alzheimer’s patients
While bearing in mind that Alzheimer’s disease progresses with rapid and dramatic transformations, we can nevertheless try to determine the structure of five textual indicators which are more likely to be found in its initial or mild phases: a) a low frequency of nouns, at around 10-12% of all words; b) a low frequency of the grammatical subject, of the “I” in the sentences, at around 15% of all verbs; c) a poor negotiation of the narrative motifs, in the sense of the evidence of communicative exchanges of information, that can in fact appear to be absent; d) the balanced use of the rules of conversational courtesy, in the form of giving and taking turns in the verbal exchanges.
The formal grammatical theory tested with the texts of conversations with Alzheimer’s patients
Let us now try to filter, through our conversational sieve, the text of the conversation between Mrs. D and Mrs. F, quoted earlier. In the first verbal exchange of Mrs. D we can find 4 nouns out of a total 114 words, amounting to 3%. There are 24 verbs, amounting to 21%. From this we can then calculate the reference index, given by the ratio between nouns and verbs, which gives a result of 0.16. The concept and the calculation of the reference index are based on the hypothesis that since nouns are the first, and in some sense specific elements of the words by which the speaker refers to the world, a reduction of the nouns in a text would indicate a separation/distancing from the world or, to be more precise, a reduction of reference. We consider a reference index as low when it is under 0.50. In the first verbal exchange of Mrs. D there is no “I”, as if to indicate that the grammatical subject has been eclipsed. Let us sum up in a table the nature of the textual indicators in the conversation between D and F.
Let us now consider the other two textual indicators: the rules of conversational courtesy and the negotiation of the narrative motifs. In their conversation, Mrs. D and Mrs. F seem to make a balanced use of the rules of conversational courtesy, each of them taking and leaving to the other their turns in the conversation at the appropriate times.
Conversation without communication
It would seem to be a more complex task to evaluate the negotiation of narrative motifs. The negotiation of narrative motifs, in the forms of the individuation, by an interlocutor, of the narrative motif of the speaker, and of the restitution to the speaker of the narrative motif individuated, is taken, in the pragmatic-referential theories of conversation, as an index of the competence of verbal interaction, in particular of the de-codification and communication of information. But perhaps the situation is not simply, or always, like this. Let us consider the adjacent verbal exchanges 2F and 3D. Mrs F asks the question: But the thing is escaped you? I say it now.
and Mrs. D replies: I don’t know.
In this succession of verbal exchanges Mrs. D shows that she has adequately understood the interrogative form, or the form of the narrative motif, to which she replies in one of the conventional ways with which one replies to a question: I don’t know, repeated as an echo in the cataphora: me, I don’t know, and then in the hyperbole: I don’t know anything. But let us ask ourselves if Mrs. D has also understood the informational content of the interrogative of which she has understood the formal narrative motif. It would seem to be doubtful. In fact, without questioning Mrs. D’s de-codifying capacity, if we do not adhere to the prejudice that every sentence has an informational content which has necessarily to be sought out, Mrs. F’s interrogative phrase can reasonably be considered as without any informational content: it does not seem to communicate information; it does not possess the content of a narrative motif even though it has the form of a narrative motif. We are here presented with an extraordinary and complex situation in two adjacent verbal exchanges: a speaker F transmits a form of narrative motif to the interlocutor D, but not the content of a narrative motif, and the interlocutor D understands the formal aspect of the narrative motif but not its content, or its informational or communicational aspect (both because it does not exist, and because she does not have the competence to discern it). The sequence 2F/3D is a perfect example of conversation without communication.
The phenomenon of conversation without communication characterizes the conversations with Alzheimer’s patients that we have recorded and gathered (16). To account for these conversations the conversational theory of conversation proves to be appropriate, being a grammatical, formal, quantitative theory which goes beyond the limits of meaning. The calculations and numerical inventories of the textual indicators, which are inherent in the grammatical theory of conversation, make it possible to point out and verify the differences (which in conversational practice are considered as results) from one conversation to a following conversation or from one conversation of a patient to conversations with other patients, so as to make the inferences pertinent to the field of research established by the researcher.
The formal grammatical theory of conversation according to conversationalism
We can now try to formulate a definition of conversation, from the perspective of the formal grammatical theory of conversationalism, which would seem to be more liberal than the semantic-pragmatic or communicational-referential theory of conversation. Conversation is a succession (not an interaction) of verbal exchanges in which the rule of conversational courtesy has a constitutive position, which allows the interlocutors to give and take turns in their verbal exchanges at appropriate times, and in which the referential and informational communicative functions have an occasional place. According to this definition, one can therefore have conversations, such as, paradigmatically, those with Alzheimer’s patients, in which the speaker formulates words and phrases of which he possibly does not know the meaning, and to which the interlocutor replies without knowing what he says, to words whose meaning he has not understood.
Translated from the Italian by Tristram Bruce