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Action Research: The Psychology of Institutionalisation

This is the next installment of my action research project which is a documentation and analysis of the use of bureaucracies in delivering support services, the public, private and third sector…

 

institutionalisation

You can read the previous section of this project ‘Action Research: Disjuncture and Institutionalisation’ by clicking HERE.

 

This part of the research project discuss the realities of what get referred to as institutionalisation and how part of this is related to the early research of Martin Seligman and colleagues trying to account for apparent damage to the cognitive adaptations which normally happen in healthy responses to environment.  The preamble explores tangled issues about institutionalising factors.

 

Preamble:

Our focus on people encountering services tends to be drawn to the individual rather than the institution.  Our society embodies a failure to analyse and critique its own institutions and as a result individuals can become fuel for institutionalising perspectives; they can become a product, an output, a cost, a time expense, a complication, a workload, or worse painted as malfeasant (yes – it does happen).

 

Institutions have a natural depersonalising effect where both those staffing it and those who are the focus of the institutions fixed gaze become generic within it.  Staff suffer from compassion fatigue over time becoming exhausted from seeing so many instances of the given situation they have to work with; the creation of normative social bonds is commonly prescribed against to shore up power differentials and limit sympathies which can lead the professional to go ‘off rubric’.

 

Ladders of inference are created where the individual who encounters the institutionalised responses to their personal circumstances can start to understand the professionals as robots; as line managed parts of a machine which acts unsentiently as it moves through its program.

 

ladder of inference

 

When professionals work with broken tools it can often appear that the professional is incompetent, unwilling or uncaring; and institutional bureaucracies often have the effect of mitigating the efforts of the professional to extend humane support.  It may be that despite the efforts of a given professional to care and act in a caring way, the modes in which they are being governed transforms their efforts into inhumane outcomes.

 

Institutions offer people generic identities and as a result people get treated in stereotypical ways and start to behave in stereotyped ways.  This is exemplified in the manifestation of uniforms where people who become clothed in ‘uniform’ ways are representatives of the institution.  This can lead to dangerous consequences as so much power is invested in these abstractions.

 

The function of the institution (i.e. promotion of good health) which garners such reverence becomes a charter for action which incorporates unqualified deference; people confuse themselves or others for the authority of the contextualised function – the police misidentifies themselves for the law; the support worker misidentifies themselves for autonomy of the individual; the educator misidentifies themselves as the source of understanding; the parent misidentifies their presence as nurture.

 

It is in these abstractions that I believe injustices come about.  In these vacuums various consequences manifest from the spectres of wicked systems effects to the tragedy of bad actors.  People don outfits and become what the dominant narrative suggests them as; people have a tendency to be influenced by the clothes people wear.  Uniformity can be a strong trigger to dehumanizing behaviours.

 

Hetey and Eberhardt examine this psychology in their chapter ‘Cops and criminals: The interplay of mechanistic and animalistic dehumanization in the criminal justice system‘ arguing that “other styles of clothing, uniforms in particular, may become the person.  A uniform signals that what is important is the role, and not the person wearing it…Individuality falls away, the wearer is dehumanized, and the role takes precedence”.

 

[Hetey, R. C., & Eberhardt, J. L. (2014). Cops and criminals: The interplay of mechanistic and animalistic dehumanization in the criminal justice system. In P. G. Bain, J. Vaes, & J.-P. Leyens (Eds.), Humanness and dehumanization (p. 147–166). Psychology Press]

 

They draw on the work of Haney, Banks, and Zimbardo pointing out that uniforms can promote anonymity and deindividuation: “…subjects were given uniforms to promote feelings of anonymity. The guards’ uniform (plain khaki shirt and trousers, whistle, baton, and reflecting sun glasses) was intended to convey a military attitude and to give symbols of power. The prisoners’ uniform (loose fitting smock, number on front and back, no underwear, light chain and lock around ankle, rubber sandals and a cap made from nylon stocking) was intended to be uncomfortable, humiliating and to create symbols of subservience and dependence”.

 

[Haney C., Banks W.C., Zimbardo P.G. (1996) The Prison Simulation. In: Introducing Psychological Research. Palgrave, London. https://doi.org/10.1007/978-1-349-24483-6_7]

 

Such symbols of power, subservience and dependence are common to institutional settings where elements such as lanyards, coats, clipboards and other paraphernalia become imbued with the deep semiotics of institution.  These meanings are coded – intentionally and unintentionally – into the theatre of roles which people act out and in consequence set the scene for implicit bias to become fertile for dehumanizing behaviours.

 

The power of symbolic accoutrement is a part of the expressive matrix of the individual who adopts the garb of identity and these off-the-shelf identities shape behaviour.  In their paper ‘Deindividuation and Valence of Cues: Effects on Prosocial and Antisocial Behavior‘ by Johnson and Downing (1979), they report on how ‘costume cues’ shape the actions of individuals wearing them.

 

Various studies showed how “using lab coats and hoods to obscure the identifiability of individuals, have shown that such a manipulation increases disinhibition of socially undesirable behaviors (i.e., speaking obscene words and administering electrical shock to another person)…In the presence of Ku Klux Klan costume cues, subjects were likely to increase [electric] shock levels [to test subjects], whereas in the presence of prosocial cues, subjects were likely to decrease shock levels”.

 

[Johnson, R. D., & Downing, L. L. (1979). Deindividuation and valence of cues: Effects on prosocial and antisocial behavior. Journal of Personality and Social Psychology, 37(9), 1532–1538. doi:10.1037/0022-3514.37.9.1532]

 

Adam and Galinsky (2012) introduced the term “enclothed cognition” to describe the systematic influence which clothes have on the wearer’s psychological processes.  They found, for example, that wearing a white lab coat made participants perform better on a task that required an ability to pay attention to relevant stimuli and ignore irrelevant stimuli; the effect was dependent on the symbolic meaning of the clothing as they discovered there was an increase in attention when participants wore a white lab coat that was described as a doctor’s coat but not when they wore an identical coat which was described as a painter’s coat.

 

[Adam, H., & Galinsky, A.D., Enclothed cognition, Journal of Experimental Social Psychology (2012), doi:10.1016/ j.jesp.2012.02.008]

 

Hetey and Eberhardt discuss how when police officers get dressed for work perhaps their individuality falls away and examine how, just as women can become instruments for the use of others, so too can police officers on duty – they become reduced to acting as agents of the state, to instruments.  These kinds of psychological manifestations I consider to be a part of the ‘gravity fields’ which institutions produce and whilst doctors may pre-emptively be viewing patients as the cause of their own ills, patients may be responding by seeing the doctor as making a living from their suffering.

 

Here, for the purposes of this study, I am interested more in the psychological phenomena which are manifesting at the top of the power differentials as privilege dominantly shapes outcomes in the world.  People living out institutional roles become absorbed by them and act out the policies and stereotypes which are bound up with their meaning and function.  As a result individuals and communities can become gatekept and curated, endentured to the agendas of those at the tops of the power junctures – this too can be a case where an individual has become swollen with their identity as a parent.

 

When someone cannot escape their identity at the top of a power differential, I would argue that it tends to be that those at the bottom of the power differential equally struggle to escape the identity; this contributes to institutionalisation.  The stress reactions and social trauma of not having meaningful control over one’s own actions can impact in lasting and disastrous ways.

 

Many people self medicate for the psychological damages which come from such junctures particularly when it is an unacknowledged, disenfranchised grief – that is, grief which is not recognised or responded to.  There is some interesting work on the rise of ‘deaths of despair’ by Anne Case and Angus Deaton:

 

 

Over time, adrenal and cortisol levels wreck both the body and mind causing mental and physical illness.  The natural capacity for people to function is eroded as stress reactions impede cognitive function.  When individuals are rendered powerless by unaccountable systems and mediators of such systems, the marrow of existence is sucked out leaving a pain where something important to them once resided.

 

That pain can then be mistaken as the illness – as the cause of the problems which prompt an individual to seek support, guidance or nurture.  This is a misidentification which not-uncommonly goes on in institutionalised settings.  The pain of being crushed by a bureaucratic system is little expressed or documented as it sounds so mundane – how can pieces of paper or assemblages of words possibly be so damaging when we have become so familiar with ideas like ‘sticks and stones may break my bones but names will never hurt me’.

 

As situations get worse, many more rubric determined ‘interventions’ get heaped on and put into people’s lives in societies which increasingly alienate the individual from their rights and capabilities.  The unthinkable happens to many people as casualities of the road paved with good intentions; the very problem with the unthinkable is that it is not thought about; nearly everyone likes to think of themselves as acting in the right way.

 

 

People working in a bank surely think about all the good they are doing – right ?  People who administer social security surely think about the lives they are saving – right ?  Psychiatrist’s who are looking after psychological welfare surely think about the psyche’s they are healing – right ?  There are storms on the horizon that have been caused by human hands.

 

Never have I seen an institutional instrument which assesses the iatrogenicity of an institution; this I think primarily is because the institutions are protected at all costs. We dont see Prime Ministers or Presidents going to jail for the crimes they commit because of this.

 

Various forms of immunity from prosecution are widely seen in institutions such as education, government, healthcare, policing, companies and families – mistakes and malfeasance are kept from public view and a failure to hold people and organisations to account often equates to a failure to ensure that mistakes and malfeasance do not happen again.

 

Large companies often are given free passes from their obligation to pay taxes which pay for the upkeep of the infrastructure (i.e. roads, healthcare, policing, water and sewage etc) they use to deliver their goods and services often justified by the fact that they are ‘creating jobs’.

 

This type of injustice paradox has been discussed for centuries.  It is a part of the discussion in natural law that there are more important obligations, higher ideals, than obedience to the positive laws of the state.

 

Thomas Aquinas wrote about how “the force of a law depends on the extent of its justice…according to the rule of reason.  But the first rule of reason is the law of nature…Consequently, every human law has just so much of the nature of law as it is derived from the law of nature.  But if in any point it departs from the law of nature, it is no longer a law but a perversion of law”.

 

[Lloyd’s introduction to jurisprudence. (1994). Sweet and Maxwell. Page 89]

 

Aquinas was in no doubt that such perversions of law did not bind the moral conscience of people and could be ignored but this was subject to one  significant caveat.  The ‘law’ should be obeyed when to break it would lead to scandal or civic disturbance.  Aquinas weighed up the consequences of disobedience to unjust laws against the possibly deleterious consequences of permitting it, including the example that disobedience sets to others who may, as a result, choose to flout other laws which may not be morally defective.

 

This ‘domino effect’ argument is sometimes used today to counter advocates of civil disobedience.  But the evidence does not suggest that law breaking is particularly rife at times when civil disobedience is commonly practised. Finnis’s conclusion on this is close to Aquinas’s:

 

“…if an unjust stipulation is, in fact, homogeneous with other laws in its formal source, in its reception by courts and officials, and in its common acceptance, the good citizen may (not always) be morally required to conform to that stipulation to the extent necessary to avoid weakening ‘the law’, the legal system (of rules, institutions, and dispositions) as a whole. The rulers still have the responsibility of repealing rather than enforcing their unjust law, and in this sense have no right that it should be conformed to. But the citizen, or official, may meanwhile have the diminished, collateral, and in an important sense extra-legal obligation to obey it”

 

[Finnis, J., & ebrary, Inc. (2011). Natural law and natural rights. Page 361]

 

The point I am getting at here is that to the person suffering at the bottom of the power juncture it appears that injustice and unreason is passed by and over by those who work within institutions where they are protected by the sacred nature of its function.

 

Those in a privileged position absorb the privilege of the institution and do not get questioned; even more so, the conflicted policy cascades and organisational entropy which land on the person-in-need never get questioned as negative externalities and at worst, they become associated with the individual framed as the ‘entrepreneur of the self‘.

 

The more splintered and mercenary the organisations in charge of administrating public goods become (i.e. G4S, Capita, A4E) the more the injustice paradox looms over civil society and the more social and psychological harms are inflicted on the general population.

 

The tangled hierarchy (strange loop) is completed when pension funds become heavily invested in such organisations drawing an iron dome around the morally indefensible.

 

Living the reality of the Tuttle/Buttle phenomenon (beautifully articulated in the film Brazil), is not uncommon in the most deprived 20% of the population.  Life is great when you are pulling down stockmarket dividends which allow you to buy yourself out of situations and speculate on whether Sainsbury’s or Waitrose does the better Beaujolais when the race is on.

 

Life is a disaster when you are at the bottom of a capital race to the top which prices you out of even healthy staple foods – which encourages me to self medicate for the despair which comes from a no-win culture of Malthusian justifications for deliberate impoverishment of stretches of the population.

 

 

So what words can we use to name the structural issues which converge in institutions ?  Maladministration ? Incompetence ? Accident ? Corruption ? Complicity ? Exhaustion ? Pathobureaucracy ? If we look at the recent publication of the Daniel Morgan Independent Panel report in Parliament, we find the use of the term institutional corruption which they unpack in explicit terms.

 

www.danielmorganpanel.independent.gov.uk

 

 

Let’s take a moment to examine the way they deal with the term ‘institutional corruption’ as this is helpful across institutional contexts, from medicine to businesses, from social work to the third sector, from education to politics, and even within the institution of ‘the family’.  For these purposes I am drawing verbatim from the report linked to above.  Here is their breakdown of how they are using ‘institutional corruption’:

 

The improper behaviour by action or omission:

i. by a person or persons in a position of power or exercising powers, such as police officers;

ii. acting individually or collectively;

iii. with or without the involvement of other actors who are not in a position of power or exercising powers;

 

For direct or indirect beneft:

iv. of the individual(s) involved; or

v. for a cause or organisation valued by them; or

vi. for the benefit or detriment of others;

 

Such that a reasonable person would not expect the powers to be exercised for the purpose of achieving that beneft or detriment.

 

The Panel has used this defnition to consider the conduct of the police offcers involved in the investigations of the murder of Daniel Morgan. The Panel includes in its wider definition of corruption some instances of failures on the part of senior officers/managers, acting as representatives of their organisations. The documentation reveals the following wide range of actions and omissions by senior postholders on behalf of their organisations; many of these actions and omissions have been identified in the reports of other independent panels and inquiries:

 

i. failing to identify corruption;

ii. failing to confront corruption;

iii. failing to manage investigations and ensure proper oversight;

iv. failing to take a fresh look at past mistakes and failures;

v. failing to learn from past mistakes and failures;

vi. failing to admit past mistakes and failures promptly and specifically;

vii. giving unjustified assurances;

viii. failing to make a voluntarily commitment to candour; and

ix. failing to be open and transparent.

 

I argue that these things cause measurable and immeasurable harms and for those who are at the mercy of a given institution result in stress reactions that damage people’s capacity to think via the creation of double binds (i.e. no win situations).  Failure to see structural problems, failure to confront structural problems, failure to investigate structural problems, failure to oversee processes which cast light on structural problems, failure to change behaviours, failure to acknowledge the past, failure to take ownership of the bad along with the good, reliance on lipservice, lack of honesty, and an avoidance of openness and transparency are features of our sociological landscape we need to find ways of dealing constructively with.

 

Putting intention(s) and all the noble sucesses of institutions aside, the encounter which many people have is defacto corruption.  The function at the heart of the institution is undermined and by extension, the lack of this function in an individual’s life amounts to harms; this can be apprehended as deliberate.  Like a harddrive becomes corrupt and unusable, so can an institution and institutionalisation sets in through a complex of harms.  The distress and anxiety the individual experiences impacts on people through stress related illness (which I offer an account of in the work ‘Education as Human Development’).

 

A horrible truth about deindividuated, depersonalised, ‘scientifically line managed’, vertically abstracted hierarchical institutions and structures is that the pot plants and pets of those people working in the structures sometimes recieve higher prioritisation in actuality than the individual being funneled through a chained system.  A part of what happens is the anthropomorphisation of institutions as caring, intelligent and willful through the mechanism of aspirational projection; institutions are spoken of and treated as being human and I suspect that this contributes to a range of problems we see.

 

To illustrate this I am going to magpie from philosophy and adapt some thinking associated with Baruch Spinoza which speaks to what I am trying to communicate.  This is helpful to me in thinking about institutions, organisations, systems and their nature – as well as my relationship with them.  It is an experiment in borrowing syntactic reasoning from another context to lend new perspective on different problems.  In his book, ‘A History of Philosophy‘, Frank Thilly writes:

 

“Spinoza expressly denies personality and consciousness to God: he has neither intelligence, feeling, nor will; he does not act according to purpose, but everything follows necessarily from his nature, according to law; his action is causal, not purposive. God’s thinking is constituted by the sum-total of the ideas in the world. He has the power or attribute of thought which expresses itself in the absolutely infinite intellect or in the eternal and necessary modes of thinking, and these, in turn, express themselves in passing human minds. Spinoza sometimes, however, speaks of God having a knowledge of his own essence and of all that follows from it.”

 

By changing the use of the word ‘God’ to ‘institution’ it becomes:

 

“[Alex Dunedin]…expressly denies personality and consciousness to institutions: they have neither intelligence, feeling nor will; they do not act according to purpose, but everything follows necessarily from their nature, according to law; their action is causal, not purposive.  Institutional thinking is constituted by the sum total of the ideas in the system.  Institutions have the power or attribute of thought which expresses itself in the infinite intellect or in the eternal and necessary modes of thinking, and these, in turn, express themselves in passing human minds.  We can speak of institutions as having a knowledge of their own essence and all that follows from it”

 

Now whilst the organisation and policy matrix may lack intelligence, feeling and will, the humans who operate within its structure do not.  The issue is whether they are allowed to and willing to behave with intelligence, feeling and willfulness appropriate for when the situation does not fit the rubric.  What happens in the real world when the computer says no ?

 

 

People become institutionalised to their lack of understanding that there might be something which they can do, that there is an alternative course of action which can resolve an issue they face.  Imagination and adaptation eventually atrophy when they are not exercised and risk encouraging a ‘more-than-my-jobs-worth‘ response to anything which differs from the way things are done.

 

What is the P45 question for someone who is in a position of authority over another person ? At what point does it matter enough to challenge the way things are being done as not the correct, appropriate or functional way of doing things ?

 


 

Gregory Bateson
Gregory Bateson

The Psychology of Institutionalisation

Our learning accords to our environment and experiences. When it is a constrained environment, and thus one of limited experience, we learn those constraints and limits, adjusting our behaviour to what we can reasonably achieve. When we cognicize that we cannot help ourselves achieve a goal or aim in an environment, we learn that we are helpless.

 

Martin Seligman wrote about the psychology of ‘Learned Helplessness’. This feeds into the embodiment of institutionalisation in an individual’s life, particularly as situations of ‘Learned Helplessness’ damage the individual’s capacity to learn new behaviour. Amongst other things, I still have to relearn each day to eat when I am hungry, or sleep when I am tired, a legacy from being on the streets.

 

Seligman: “We have seen that a major consequence of experience with uncontrollable events is motivatonal: uncontrollable events undermine the motivaton to initate voluntary responses that control other events. A second major consequence is cognitive: once a man or an animal has had experience with uncontrollability, he has difficulty learning that his response has succeeded, even when it is actually successful.

 

Uncontrollability distorts the perception of control….They had difficulty perceiving that responses could affect success or failure….Learned helplessness produces a cognitive set in which people believe that success and failure is independent of their own skilled actions, and they therefore have difficulty learning that responses work” [102].

 

In this line of inquiry Martin Seligman’s work set out to explore how the cognitive reflex can be damaged when an animal is put into a lose-lose situaton. Seligman called what he articulated ‘Learned Helplessness’ from the observations of a psychology where individuals have difficulty developing new behaviour appropriate for given situations.  In this scenario ‘appropriate’ equates to meeting with success carrying with it the qualities which are understood as the capacity for adaptiveness which is associated with survival.

 

In 2016 Martin Seligman revisited this provokative work in a paper called ‘Learned Helplessness at Fifty: Insights From Neuroscience‘ written with the original co-author Steven F. Maier. Their original theorization that animals (human beings included) learned that outcomes were independent of their responses internalizing and operationalising that nothing they did mattered – and that this learning undermined trying to escape a negative stimulus.

 

Fifty years later these psychologists published on how they had formulated the observations incorrectly: “The mechanism of learned helplessness is now very well-charted biologically, and the original theory got it backward. Passivity in response to shock is not learned. It is the default, unlearned response to prolonged aversive events…which in turn inhibits escape. This passivity can be overcome by learning control…animals learn that they can control aversive events…the passive failure to learn to escape is an unlearned reaction to prolonged aversive stimulation. In addition the…pathway can come to subserve the expectation of control.” [102.1]

 

Seligman and Maier offer a physiological account of the underlying structures and biochemical involvements that operate in this psycho-behavioural phenomenon of apparent helplessness.  The default unlearned response to prolonged aversive events is mediated by the serotonergic activity of the dorsal raphe nucleus which inhibits escape. The activity of the medial prefrontal cortex inhibits the dorsal raphe nucleus. Alterations of the ventromedial prefrontal cortex-dorsal raphe pathway can come to subserve the expectation of control.

 

This opens up an interesting avenue of exploration as there have accrued several decades of research examining the relationship of serotonin with stress and trauma [102.2]. The brainstem structure of the dorsal raphe nucleus has particular characteristics which have been well documented.  There is evidence to show the coexistence of serotonin and substance P in raphe cells [102.3].

 

As well as this, there is evidence which suggests that Substance P acts as an opioid [102.4] (a substance with opiate activity).  Substance P has been implicated as this peptide also causes a naloxone-reversible analgesia [102.5].  Enkephalin neurons are closely associated with substance P fibers in the dorsal horn of the spinal cord. It has been suggested that the analgesic effect is probably due to activation of enkephalin fibers [102.6]. Enkephalins are endogenously produced opiates which are well documented for impacting on learning and memory [102.7].

 

This physiology is not only suggestive that prolonged aversive stimulae can impact cognition and memory but it also proposes a possible account for why trauma and stress might predispose populations to using drugs which act through the opioidal pathways.  Helplessness could reasonably be investigated as a physiological phenomena of endogenous release of opiates in response to trauma resulting in blunting of specific learning behaviours and memory as well as conditioning the individual for drug use.

 

Setting an outgroup-individual into cultural settings in which they are confronted with a multitude of scenarios where they cannot succeed sets the conditions for learned helplessness through prolonged aversive stimulation.  Gregory Bateson, the famous anthropologist and cyberneticist, and his research team at Palo Alto articulated the double bind theory of schizophrenia [102.8].

 

 

The double bind theory was developed by anthropologist Gregory Bateson and his research team in Palo Alto, California (1956). It’s framed through a systemic perspective and it talks about all the situations where you communicate with someone and receive conflicting messages.  They came up with this theory to try to explain the psychological distresses which have become associated with the term ‘schizophrenia’, moving beyond simplistic and purely material theories of mental ailment.

 

According to Bateson, a double bind is a communication dilemma that comes from a conflict between two or more messages. So it doesn’t matter what you do, because any choice you make will be wrong. This is a situation in which sociological causes bring about suffering and can lead to psychological disorders.

 

An example of this is: “A child tries to interact with their mother, who has trouble being affectionate. She shows how much she loves her child, but only with her body language. The child only sees signs of rejection. The verbal message the mother sends to her child doesn’t line up with the message her body sends. In the end, the child finds themselves trapped in a conflict between affection and rejection”.

 

The necessary ingredients for a double bind situation, as they detail it, are:

  1. Two or more persons
  2. Repeated experience
  3. A primary negative injunction
  4. A secondary injunction conflicting with the first at a more abstract level
  5. A tertiary negative injunction prohibiting the victim from escaping from the field
  6. Finally, the complete set of ingredients is no longer necessary when the victim has learned to perceive his universe in double bind patterns

 

The discursive nature of administrative systems I put forward as lending heavily to the institutionalisation of those who are tied to these systems for their week to week existence – they are dependent on a system which removes the means of autonomy, have inherent in them negative injunctions, and often have conflicting internal logic.

 

The lack of autonomy, the negative injunctions and conflicting internal logic can often cause anxiety, despair and anguish in the people working as professionals let alone the people who have to negotiate a system which is hostile to them.  People are at the mercy of the arbitrariness of various bureaucratic systems which has a maddening effect – it is ‘crazy making’ but the ‘crazyness’ is attributed to the individual not the unquestioned system.

 

People eventually break

 

deaths of despair cohort deaths 1 800x566 1

(See Deaths of Despair)


 

Bibliography

[102] Martin E. P. Seligman, ‘Helplessness; On Depression, Development, and Death’, ISBN 0-7167-0751-9, Page 37

[102.1] Maier SF, Seligman ME. Learned helplessness at fifty: Insights from neuroscience. Psychol Rev. 2016 Jul;123(4):349-67. doi: 10.1037/rev0000033. PMID: 27337390; PMCID: PMC4920136. https://pubmed.ncbi.nlm.nih.gov/27337390/

[102.2] Chaouloff F, Berton O, Mormède P. Serotonin and stress. Neuropsychopharmacology. 1999 Aug;21(2 Suppl):28S-32S. doi: 10.1016/S0893-133X(99)00008-1. PMID: 10432486. https://pubmed.ncbi.nlm.nih.gov/10432486/

[102.3] Baker, K.G. Halliday, G.M. Hornung, J.-P., Geffen, L.B., Cotton, R.G.H., (1991), ‘Distribution, morphology and number of monoamine-synthesizing and substance P-containing neurons in the human dorsal raphe nucleus’, Neuroscience, volume 42, Issue 3, Pages 757-775, https://www.sciencedirect.com/science/article/abs/pii/030645229190043N?via%3Dihub

[102.4] Stewart, J., Getto, C., Neldner, K. et al. Substance P and analgesia. Nature 262, 784–785 (1976). https://doi.org/10.1038/262784a0

[102.5] Frederickson, R. C. A., Burgis, V., Harrell, C. E., and Edwards, J. D., 1978, Dual actions of substance P on nociception: Possible role of endogenous opioids, Science 199:1359, https://pubmed.ncbi.nlm.nih.gov/204012/

[102.6] Hokfelt, T., Ljungdahl, A., Terenius, L., Elde, R., and Nilsson, G., 1977, Immunohistochemical analysis of peptide pathways possible related to pain and analgesia: Enkephalin and substance P, Poc. Natl. Acad. Sci. USA 74:3081, https://www.pnas.org/content/74/7/3081

[102.7] Martinez Jr. J. L., Weinberger, S. B., Schulteis, G, (1988), Enkephalins and learning and memory: a review of evidence for a site of action outside the blood—brain barrier, Behavioral and Neural Biology Volume 49, Issue 2, March 1988, Pages 192-221, https://www.sciencedirect.com/science/article/abs/pii/S0163104788905171

[102.8] Bateson, G., Jackson, D.D., Haley, J. and Weakland, J. (1956), Toward a theory of schizophrenia. Syst. Res., 1: 251-264https://doi.org/10.1002/bs.3830010402

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