Ep. 118: Dr. Lyn S. Turkstra - Renewing the License to Get Along

Sucheta Kamath: Welcome to the podcast, Full PreFrontal, exposing the mysteries of executive function. I’m here with Todd. How are you?

Producer: I am doing great. Boy, if the interview is as fun as our preshow banter with our next guest, this promises to be a really, really fun conversation.

Sucheta: You know, it’s always an exceptional joy for me to have a fellow speech and language pathologist, and I don’t know if I can call myself a fellow because she’s a different tier but before I introduce you to her, let me quickly tell you a story of a client of mine. So, my client who had a traumatic brain injury, and his brother lives in China and he came to visit, and so he landed the night before and the next morning, he said, “Let me take you for breakfast,” so I’m talking about adults. My client was 19 and his brother was 25, and so they go to, of course, a local diner and they are sitting down and they order breakfast, and he’s about to take a bite of his pancake and there’s something he sees outside and he gets up and starts running. So, my client’s brother is a little bit confused, he’s like, “What’s going on?” so my client is running and soon, he discovers that he’s running after a girl, and so now, this girl – this is, of course, by the way, like 8 o’clock in the morning, the parking lot is semi-full and this girl who was just walking away starts running seeing this mad looking guy running after her, so they’re both running in the parking lot and so finally, she shouts at her, “Can you stop? I want to take a picture,” and she’s like, “What?” so apparently, she had blue hair, she had dyed her hair blue and he wanted to take a picture of her to show to another friend of his how to dye blue. The reason I’m telling you this story is that we spent a significant amount of time discussing the situation with the client of how inappropriate it was to chase somebody in the parking lot to take a picture, particularly when you don’t even know them, and that, in the light that your brother has just arrived from China that you haven’t seen for a year.

So, this is why we need this expert today. It is a great delight and pleasure, and joy to introduce my guest today. Her name is Dr. Lyn S. Turkstra. She is a professor of Rehabilitation Science and Assistant Dean for Speech and Language Pathology at McMaster University, and she’s a perfect Canadian, so you’ll see when she speaks, and a faculty member in the McMaster neuroscience graduate program. Dr. Turkstra has published extensively on cognitive and communication functions after traumatic brain injury and she is a co-author of a 2011 textbook, Optimizing Cognitive Rehabilitation with another favorite of mine, Doctor McKay Solberg. She is a member of INCOG Practice Guidelines Committee for Traumatic Brain Injury Rehabilitation. It’s a big deal, founded by the Ontario Neurotrauma Foundation and Monash University, and is a consultant to the Veterans Health System and Department of Defense for Clinical Practice. She is highly accomplished. She was very hesitant to send her entire bio to me but I will brag on her. She is an ASHA fellow which is an incredible honor and she recently won a very precious award, maybe she will tell us about it, but welcome, Lyn, to the podcast. 

Dr. Lyn Turkstra: Thank you very much. I am honored to be here.

Sucheta: You know, this podcast is about executive function and I have been asking, and as a speech and language pathologist, I bet your answer will be extremely insightful, but I’ve been asking experts, when did you as a young person, as a young learner and thinker become aware of your own strengths and weaknesses, your own style of learning how to learn, and when did you develop full access to strategic thinking to manage your own life’s goals? 

Dr. Turkstra: I was listening to your podcast with Adele Diamond, one of my heroes in science and she was saying that she felt she developed executive function at a fairly young age, and I feel comfortable saying I did not, so I would say that it’s a journey and still saying and doing things that later, I wish I had not said or done as perhaps many of us do. Dr. Diamond also made a comment that I say often about executive functions being last in, first out, so I think I had a honeymoon between about age 25 and 40 when it was all working and now, I’m on the downside of that. So, one of my clearest memories actually related to our topic today of social communication is in high school feeling like I wanted to change my own behavior socially: be braver or not say something, or say something, and I feel that that was really a struggle for – as it is for a lot of adolescents, a struggle for a lot of years. At the same time, I think I had the school aspect of executive function down pretty early, so the academic side – strategies – probably at a younger age than that, maybe seventh or eighth grade, yup. 

Sucheta: You know, it's so interesting you say that, you're probably the first guest to have distinguished the EF maturation in two different tracks, one is the socioemotional development part of the self-regulation, and then the academic learning which is managing content-based learning, process-based learning, whatever. By the way, Adele is an exemption because most of my guests have said, and particularly Daniel Willingham who is a neuroscientist who studies how children learn to learn has said that, I have not thought about this or I don't think it was until college. I think you are in the advanced lane. But what's so interesting about what you said is the distinction again strikes to me and it's so related to the topic we are going to talk about, is the mastering or being able to do well in school is not the only thing which many, many, many people including parents think that that's the most valuable skill, but to me, I think we underestimate the value and importance of developing relationships, navigating how to read minds, and understand the needs of others.

So, that brings me to this first question that I have for you. Let's talk about the concept of social cognition. What is social cognition and how does the science inform us about understanding how to influence the world that we live in?

Dr. Turkstra: So, social cognition most broadly defined is the cognitive functions we use to accomplish social behaviors. That's such a broad definition, it's not very helpful because you pretty much need all of your brain to accomplish social behaviors, so I think most people think of it as a set of cognitive processes that primarily includes the processes you use to think about others and to think about the thoughts of others, which is Theory of Mind, and also the cognitive process you used to read social cues, especially reading emotions and that would be emotions from other people's voices or their body language, or their facial expressions.

Sucheta: I always thought, shouldn't thinking about your thinking be included in this as well, which is metacognition? Because how can we only pay attention to what others are thinking or what others thoughts are about their own thinking or their intentions are because it really is a dance between two individuals in our lives. So, what do you see is the relationship between cognition, the awareness of awareness and its relationship to understanding minds of others?

Dr. Turkstra: I'm glad you mentioned that because I should have included the awareness of your own feelings in the definition of social cognition, so that has not always been included because the research in social cognition has focused mostly on how you read other people but certainly, being as we say 'in touch' with your feelings and being able to think about your feelings in relation to those of others are part of the functions of social cognition.

Sucheta: This is another thing that I feel in my profession was missing, unlike psychologists who go through training to become maybe a counselor or a therapist, that they have to do their own therapy and kind of get to the bottom of some of the inner drama, so to speak, but when we had training, we never had a speech and communication drama, apparently, to address but I feel like dealing with traumatic brain injury, ADHD, or just difficult children and adults who are trying to find a way to help themselves, they have a little bit of a pushing attitude: they push you away or push the help away and that's why when I have discovered my own angst about being unsuccessful, so this knowledge of social cognition has helped a lot.

So, what I want to kind of get us into is if you can break us down, are the major components to social cognition that we should be thinking about, the three you mentioned, do they further inform us how to construct an understanding of the world? How should we proceed from here? 

Dr. Turkstra: Let me first respond to your comment about what we learn in our training because I do think that there are major things that anyone who works with other people should know, and so I think knowing something about, say health psychology, so what kinds of things change motivation, that's really important. Knowing something about how people learn which we don't learn very much about at school and also learning how to, basically our learning, to be metacognitive about our own executive functions that you described, I think, is not really an overt part of a typical graduate school curriculum. We have a problem-based curriculum in McMasters, so I always call it an executive function training program or a metacognitive training program, so I think students do learn tools to think about thinking and that they can apply to their clients, but I agree. I joked with my colleague Mary Kennedy. She has done research in metacognition for a long time and it's very difficult to explain that you study thinking about thinking about thinking. So, I think sometimes, people just don't want to think about it.

Sucheta: Yes. 

Dr. Turkstra: So, I think sometimes, people just don't want to think about it.

Sucheta: And it can be exhausting, actually, and another thing that came through my journey of working on executive function for the last 20 years, self-educated in terms of the social psychological processes, and that Thinking Fast and Thinking Slow book where he talks about 150 underlying psychological processes that we have no access to, like including our prejudices, stereotypes, or self-concept, or things like cognitive dissonance, and that has helped me tremendously to have better success with my clients' understanding because another thing, I think – and we are going ahead of ourselves a little bit – but I was thinking as a speech and language pathologist, working with clients, there's so much motivation for me to want to see them succeed that any difficulty they encounter or fail to succeed, I was personalizing it, and I also was getting a little angry or irritated, to be honest with you. I didn't like that they were failing, and so that third person perspective on this dynamic between clinician and the student or client, and witnessing it, and then facilitating as if I am the advisor of me, help me, but that came with maturity. It didn't come as part of any sort of training. So, I guess what I'm hearing you say, that's why social cognition is so important, that we can take better decisions.

So, tell us now the relationship between social cognition, thinking about one's own thinking, thinking about others' thinking, maybe you can talk a little bit more about Theory of Mind and where does this fit in helping people develop the knowledge that they need to have better relationship with themselves in the world? 

Dr. Turkstra: I think that's an excellent question, and in fact has been a fundamental question in research, certainly, in my area in brain injury but also in autism, and that is, what is the relationship between social cognition and executive function? So, for example, if I say to you, what do you think about what Todd thought about that broadcast? That's a grammatically complex sentence, and so some people might not perform well on that task just because the syntax is too complicated and they don't have the language skills. Also, for me to say, what do you think about what Todd thought? You have to unstick yourself from your own perspective and then shift your perspective to someone else's, and then ultimately, Todd's. That's an executive function, right? So, that's a switching aspect of executive function, so I think it's difficult when you think about something like Theory of Mind, it's difficult to think about how that could not require some basic cognitive functions and that when people seem like they don't have Theory of Mind.

Sucheta: So, recently, there is a fantastic movie that just came out. It's called Bad Education. If you get a chance, please watch it. It's a movie based on real life and it's a superintendent in New York, Long Island, and the embezzlement story, and Hugh Jackman is playing the superintendent and Allison, she's the assistant superintendent, and people discover that there is fraud going on and they come to arrest her. Well, she knows it's him who has actually done the fraudulent – under his advisement, the fraud has taken place, but he is reprimanding her in front of them that, "You should be ashamed of yourself for stealing from some institution like our school," and she's just looking at him, he's looking at her and you know he's telling her without words, "Go along with this so we'll come to the other side safe," and this happened and my children who are grown up children now, we all pause and one person in the family did not get it, and the three of us got it. It was so subtle, like why she agreed to take the blame when she was not responsible. I'm sorry, I'm going to the weeds of the story too much but what was so fascinating to me, that required that Theory of Mind switching perspective but watching two people's interaction and assuming the inner story that they were thinking and validation that they received from the look that one person gave to another, and in order to be even witnessing as a watcher of the story, you need so much knowledge. 

Dr. Turkstra: You do.

Sucheta: And that's why it's so boring for a lot of my clients if they have had a concussion or brain injury, they don't get it and they get disengaged; they don't enjoy the inner drama, and that's why I feel it's so important to teach these skills because it's one of the ways to enjoy, like the popsicle, I guess, of human interaction. 

Dr. Turkstra: That's true. But let me ask you though, can you teach it?

Sucheta: I'm a firm believer that yes, you can.

Dr. Turkstra: I'm a firm skeptic. 

Sucheta: Of course, I'm probably wrong. 

Dr. Turkstra: No, I would be happy if you were correct. So, I'm a researcher, so I'm always looking for evidence. I have not seen evidence that people derive generalizable benefits from that kind of skills-based training, so in other words, if someone looks at a lot of faces with a lot of emotions, do they actually just get better at brute force emotion recognition versus are people, say developing an internal strategy to verbalize, oh, if I see this configuration of facial expression, that means someone's angry? And it's the same with Theory of Mind, there are many, many training programs but above the age of about four or five, I have not seen evidence that those training programs fundamentally change the way a child with autism views the world as opposed to it being metacognitive, so as supposed to someone realizing, this is something I'm not very good at, so I need to either explain myself or use some kind of strategy, and I would even posit that some of that training makes people odd because they are very didactic about their social behavior which is not typical, and so sometimes, it can make them odder if they have learned something in their social cognition training. But however, I would be very happy to be proven wrong.

Sucheta: Okay, so very, very good point and I stand corrected – I'm sorry, I spoke too soon without understanding what you meant by "can it be trained?" I didn't pay attention to that 'it' part of it. I do agree. I don't even think in my work that I have tried to show people faces and emotions, and labels that have no merit and value. I will tell you what part of social cognition I was referring to that that can be coached, is to understand you are missing something.

Dr. Turkstra: Right.

Sucheta: Which is that metacognitive awareness, the banter people have and that banter bringing joy is something people do as an effort to connect and if you don't get joy or don't connect, you need to have some social appropriate behaviors that say, haha, oh, I'm sorry, I missed that, or something that bridges the gap which shows your interest but lack of skills, and I have found that to be helpful because then these oddballs or people who appear odd are always neglected because they don't participate in the casual conversation that forms relationships, so that's the part I meant, like metacognitive approach, not teaching pure skill for the sake of it. 

Dr. Turkstra: But there's a lot of that going on, and I do totally agree with you to the extent that it's important to the person. That's another funny thing about social skills, people seem to feel like we all need to, and –

Sucheta: Yes! So, we don't mean need them, you mean?

Dr. Turkstra: Well, no, I mean, I think, clearly, we've all abandoned some of them in the COVID-19 era but I think that it's in the eye of the beholder, so one of the reasons I got interested in sex – since we're talking a little bit about sex later on today – is that I think that we have, I want to almost say that it's like we are prejudiced to believe that everyone needs to view the social world the same way we do and I think you'll share this from a lot of family members of people with autism, you know, they will say that it's the sort of paternalistic view that because the social world is really important to me, it should be important to you as well – I mean, everyone should be able to do these things and be included but I also think it's good to respect the view of the individual person, and I think people vary wildly in how much pleasure they get out of certain kinds of social interactions and that we can't necessarily impose our view of what's an appropriate or meaningful social interaction onto a client, and I think we do that with other aspects of people's performance, like if someone has a stroke and they have aphasia or language problems, we would respect the amount of words they feel they need in their life but somehow, when it comes to social things, it's just like, oh, everyone has to have that. So, everybody needs to be able to take turns appropriately and everybody needs to be able to maintain a topic in a conversation. Well, maybe, you know, you're in a group of people who mostly just drink and grunt, and that's fine, that's what works in your social circle, and so that's what made me very mindful of are we a bunch of female clinicians imposing our idea of the gold standard of social behavior on a mostly male patient population and is that okay?

Sucheta: Wow, I think that's a profound observation, Lynn! And so meaningful for us to just hang back a little bit more. It's interesting, you remind me of Tony, the autism specialist from Australia. I once attended his presentation and he very fondly calls people on the mild part of the spectrum 'aspies,' and he says women have this feeling that they need to come in and rescue these poor lost men because it's more prevalent in men.

Dr. Turkstra: Mostly men, yeah. 

Sucheta: Mostly men, and then they are frustrated and you know, remember the play that says, "I love you, you're perfect. Now, change"? 

Dr. Turkstra: Yes.

Sucheta: So, I think we have, the majority of us in our field are women and we are so happy to take on this role of helping, and then sometimes, we may be imposing. That's a very, very important point that you make. So, what I'm hearing you say, that because of our personal prejudices regarding what kind of most competent social skills need to look like, we are imposing this framework or markers that you need to meet these skills or develop the skills to be considered proficient, and so you are asking us to think a little bit differently and ask the client, what is it that you want and assess the context, maybe. Is that the correct way to think about it?

Dr. Turkstra: That's exactly what I'm saying and it may be that there is a set of skills that we all need. I just haven't seen any data on that, and I think that a lot of the research on this area has been very reductionist, so you think people in the world, they are in a dynamic environment with lots of people and now, all these different mediums in which to communicate and it's fast and it changes over time; there are new words, there's new slang every month. I mean, how can you reduce that down to something? I mean, maybe you can reduce it conceptually down to you need to be able to control yourself, whatever that looks like in your setting but I think beyond that though, it's really up to that person in their environment and what works. One of the challenges I feel in brain injury is if you appreciate that someone has some social challenges, how do you help them identify an environment in which those challenges are not going to get them fired or evicted, or arrested? So, rather than saying, "Look, everybody needs to do this," saying, "Can you learn some strategies and then can we also find an environment that fits you?" 

Sucheta: What do you think about this phenomenon, I call this social skills journey from Mork and Mindy to Third Rock from the Sun, to The Big Bang Theory. I don't know if you remember and of course, I'm not from this country so I didn't grow up with this but coming from another country, I found this very fascinating that in the 70s, Robin Williams' show Mork and Mindy showed inappropriate behaviors in people who were not from this planet. Remember that he was from Mars, and the only way to justify this incredible inappropriateness or oddity was that, then came the era of Third Rock from the Sun that they are actually assimilated humans – still aliens, but they are living in different roles and within their roles, they are inappropriate, so their appropriateness is not wide. It's more channeled, and then came this socially affected inappropriateness which is The Big Bang Theory where they are collectively inappropriate and socially incompetent but highly successful, so now what has changed, I guess, is the world. Nobody has changed their social acceptability and I find that that has happened in the therapeutic context that the social acceptability index has gone down, so soft skills, if you don't have it, I guess, is just arrogant. He just spits or coughs, or burps and farts at the same time when he's going for a business dinner. I guess that's just Mork, you know? 

Dr. Turkstra: That is such an amazing because observation, Sucheta. I had not thought about that progression of television shows and I am old enough to have seen them all, so I do appreciate it. That's a culture change, but at the same time, we are in a social economy, right? So everyone's talking about these things and calling them soft skills which as you know, I've talked about before, offends me because there's nothing soft about them. They are actually very difficult to pull off that people are emphasizing that more and more, so what do we do in this culture that's getting a little more informal at the same time, social skills are becoming critical for employment in many, many workplaces? So, how do we resolve that?

Sucheta: So, what is the technical official definition of soft skills? And I really detest it honestly, Lyn, because soft skill, one implies they are not important. Second, as you mentioned, easy to master, and third is, preferred but not mandatory. Like suggested, recommend have soft skills but if you don't, you suck but we'll never tell you. 

Dr. Turkstra: And can I add a fourth to that?

Sucheta: Please!

Dr. Turkstra: I think it's pretty sexist.

Sucheta: Tell me, what do you mean by that? 

Dr. Turkstra: Well, because historically, women are better at these things, so I think to say that they are soft skills is dismissive for the reasons you were saying, your reasons one to three, but why would you choose to dismiss a set of skills that women are better at? And I honestly did not think of that until this moment when you listed those three things. 

Sucheta: Oh, my God, I never thought about that. 

Dr. Turkstra: But I do wonder if part of it is just kind of oh, that's sort of a girl thing, like it's not that important. Newsflash, it's really important. 

Sucheta: So, help us, help us understand the concept or the framework of soft skills and what is the role of soft skills in communication experts' lives when we help people develop them and also just maybe sidebar, do you find it cringe-worthy when you see people not having soft skills? What do you do? A little Lyn dies inside? 

Dr. Turkstra: Well, because I've spent so much of my life studying and working with teenagers, yes, there's a lot of those moments for sure, but I'm always extremely impressed by teenagers and adolescents because to be able to do anything when you are undergoing such massive hormonal fluctuations, I think, is really impressive, so all credit to them for being able to navigate that difficult stage of life. I have no idea what soft skills are. I mean, I know how they're defined in business: they are interpersonal skills. It's what we would call pragmatics, I think, in speech pathology for sure but I think it's actually a little bit like something else that Adele Diamond was mentioning, that you have one group of people who developed research related to self-regulation and another group who developed research related to executive function and they have similar concepts but don't talk to each other, so I feel like you have this business community that has developed this idea of soft skills and then there's a whole bunch of scientists who have dedicated their lives to trying to operationalize what it takes to have a successful social interaction, so I think that's what they are talking about. I mean, they are talking about pragmatics in our view, so the way you use communication to achieve goals. 

Sucheta: Building relationship, also progressing personal agenda without being selfish. 

Dr. Turkstra: Or being self-centered.

Sucheta: Self-centered. 

Dr. Turkstra: Yeah, I was going to say or being selfish and self-centered but disguising it in such a way that other people don't realize that you are pursuing your own agenda. 

Sucheta: By the way, this reminds me of my favorite, favorite, favorite article that I ever read on this topic, was Steven Pinker's article called Veiled Communication. What's so fascinating about that is the importance to veil it in order to show sophistication of your abilities. Instead of saying to somebody, "No, I hate it," you just say, "It's delicious. I'm just not hungry," like when you say that to somebody, why take such a circumvented approach to conveying intent? So, what do we accomplish by resorting to soft skills? 

Dr. Turkstra: So, I think people who study evolutionary biology would say that being direct when you disagree with someone or you want them to do something different is not the most effective approach, so you are not the most likely to achieve your goals by being direct, so somehow, we have evolved to be indirect but not in all cultures for sure. So, Sky McDonald, a neuropsychologist in Australia developed a hints test for people with brain injury to see if they could give an indirect request or a hint and we definitely – I translated it for teenagers and we definitely had teams from some cultures who said that the indirect is not valued in their culture, that being direct is valued. So, I wouldn't say it's universal that we are indirect or that we have veiled utterances but certainly, a lot of us seem to. It's really complicated for someone to navigate who does – I'm using the word navigate again – I think it's very complicated for someone who does not have good abstract thinking to figure out what's going on in the world because so much of what we mean is implied.

Sucheta: So, let's say I have an intent and I have a plan to communicate that with certain ways of constructing my sentence. Now, I realize if I say that, it's going to be perceived rude, so now I have to alter that presentation, veil it, that requires working memory and requires mental flexibility, and it does require hanging back to get all this sorted out and not blurt out what you think, what you feel, what you mean, and that's what I think a lot of people with brain injuries struggle so much because first, that filter is gone that allows you to hang back a little bit but second, I feel they struggle to come up with alternative things to do as an effort to veil things.

Dr. Turkstra: Right, but it's also – this is where I feel like I've been really – my knowledge about this has been really informed by the research on self-regulation because I feel that the process you described is mentally fatiguing and that for someone that already has executive function impairments, to manage all of that thinking is really resource-demanding and that some people run out of their mental resources to do that. The examples I always give when in my lab and when I give talks are first of all, happy hour, so I think that happy hour was developed because people were doing this veiling, being on their best behavior all day at work and then they just run out of it, and so it's like 5 o'clock, I am on the table drinking beer out of [inaudible] because I just can't do it anymore, and the other example is I feel almost every clinician I know says they are better at work than with their family in terms of their patience and their communication skills, and I think for us, our entire job is projecting ourselves differently than we would want to, so you're not going to say to your client, "Wow, you just regurgitated that out of your stoma in your neck." You are just going to say, "Okay, let's try that again," so people in general, but I think especially people who work in communication, we are all focusing our entire day on how to communicate in a way that is acceptable to the other person, meets their needs, and it's some manipulation of what we really want to say, and by the end of the day, you just can't do it anymore, and so my husband has a binaural hearing loss. I often talk to him from another room because I should get up and go and walk into the other room and talk to him face-to-face with good lighting but I'm tired and I don't want to do it anymore. So, I think the social world needs "soft skills." It's layers. As you say, Sucheta, it's layers of what I want, what I mean, how can I say it, I'm looking at their face, I'm reading their expression, it's not going well, I have to reshape, say it a different way, and so now, I have to backtrack, I have to keep in mind, as you say, I need the working memory to hold all this in my mind. I'm pretty impressed that any of us ever got that right. 

Sucheta: The point about self-regulation that stood out for me is that even – Roy Baumeister talks about these four ingredients of – actually, he used to describe three ingredients of self-regulation and then he added the fourth one but the first ingredient is standards, like what is the golden standard, so to speak, that effective regulation requires you to have that defined standard? And one of the things I feel that after brain injury, people sometimes lose that context of what that standard is, code switching. Second is monitoring, and by doing it right or appropriate, or like I am now on happy hour so I can spaz, but no, I'm still at work, it's not happy hour, and the third thing is the self-regulatory strength which is that willpower to do as you said and you're describing that lack of willpower, and as his discovery shows, willpower is literally gas in the car, so the more and more you exert, the less and less it becomes, and that's why we are worse at certain times, particularly when you return to work. I don't even know parents who are raising little kids at the end of the day, and the last is motivation. So, it's so interesting from the social skills point of view. So, how do you conceptualize building the soft skills? Or maybe you should talk about the myth that you just briefly addressed, that girls have better social skills than boys do and is there gender-related differences? And secondly, is there inherent advantage to them showing up better prepared to tackle socioemotional relationships?

Dr. Turkstra: So, before I answer that, let me just say that my first introduction to self-regulation was from Roy Baumeister and Kathleen Boss. 

Sucheta: I love him.

Dr. Turkstra: Because we were all at Case Western Reserve University at the same time. 

Sucheta: Reallt? I'm a huge fan and he's been my guest and I just have read every single book he has written, yes.

Dr. Turkstra: I saw, he was your guest! 

Sucheta: Very [inaudible].

Dr. Turkstra: I thought it was really funny when I saw he had been your guest because I was thinking, oh, my gosh, that's kind of how I started in this journey, was Kathleen Boss coming over to my lab.

Sucheta: Oh, I love it.

Dr. Turkstra: And it was a great thought to think about self-regulation fatigue for people with brain injury.

Sucheta: All the time?

Dr. Turkstra: Yes, and as I say, Mary Kennedy had been doing this work but yes, it was strongly influenced by Roy. So, way back to sex. Let's talk about sex.

Sucheta: Let's do it!

Dr. Turkstra: So, let's talk about sex but I want to make a distinction between sex and gender. So, sex is the biological construct. It has to do with your reproductive organs, and gender is the social construct which has to do with the extent to which you personally affiliate with the stereotype notions of femininity or masculinity in your culture. There's a very helpful graphic called the Genderbread Person and students and undergraduate studenta – Emily Hosokawa introduced it to me in our lab a few years ago. She was taking gender studies and the Genderbread Person separates out your different aspects of gender, so there's a gender that has to do with your appearance and how you choose to come across as more masculine or feminine. There is also your internal identity as male or female, there is also your sexual orientation toward male or female partners, so these are all slightly different aspects of gender and one of the most frustrating things for me as a researcher and clinician is that people use sex and gender interchangeably, so it's almost impossible to figure out when people have studied gender because they keep using gender to mean sex, and even the way people study sex as the way that we do it in my lab is we either ask someone to indicate whether they are male or female – that's rare. Mostly, we eyeball them when they come into the lab and we look at what their name is and we say, oh, that person was male and that person was female, and until fairly recently, right? I mean, this is all happening fairly recently. It wouldn't have occurred to us, to be honest, to ask how someone self-identified. Now, of course, we wouldn't even think to not ask that question and even to ask people what their pronouns are, but that's still only in the last couple of years, so we had been looking at both sex and gender for about the last, I want to say eight years or so. In research, we have biological sex which we did the old-fashioned way of just looking at someone's name, and then we have people complete something called the Ben Sex-Role Inventory which is a terrible tool from the 1970s and there unfortunately is nothing better. It has a bunch of adjectives and you say the extent to which they apply to you, and some of them are stereotypically feminine words like 'cooperative' and some are stereotypically masculine like 'leader' or 'leadership,' so we have both of those variables and we have found times when one correlates with something and not others. So, for example, the self-ratings of gender correlate with self-ratings on the behavior rating inventory of executive function.

Sucheta: Really? 

Dr. Turkstra: Yes, but biological sex did not correlate with self-ratings in adults. 

Sucheta: So, help me understand how to interpret that. Why? 

Dr. Turkstra: It's really interesting. It's like – I mean, I don't even know what that means. All I know is that there are things going on here that we don't understand yet, but is it possible that executive function ability is influenced by sex hormone levels?

Sucheta: I won't be surprised.

Dr. Turkstra: But we don't know that though.

Sucheta: We don't know but because it's influenced by the regulatory system in the brain and accessibility to certain neurotransmitters allowing you to inhibit it, what if that access is interrupted or disrupted? 

Dr. Turkstra: But your brain is bathed in testosterone, right? And so of course, you have androgen-sensitive receptors. Otherwise, there would be no PMS [inaudible] so I mean, maybe that's possible and I mean, from working on brain injury, of course, this has so many repercussions but I don't think it's just brain injury. I think just in general in science, I just pulled up an article from 2019 by Grissom and Reyes that's called Let's Call the Whole Thing off: Evaluating Gender and Sex Differences in Executive Function and their conclusion was there's no evidence that there are any and I'm curious to know if that's because we are looking at biological sex.

Sucheta: Wow. 

Dr. Turkstra: And we don't know! 

Sucheta: My goodness. Well, sounds like this is a very cutting-edge approach or perspective. I don't think people were even thinking about these differences mattering or as you said, the case histories or the way the candidates are recruited for a research project, that is never asked. It's interesting, I think I briefly mentioned, but one of the things that I became aware of – not even aware of the way you are talking about gender and sex, and the interplay between the two. For the last 20 years in my practice, I have a very small practice of working with a transgender population and particularly, those who come to a speech language pathologist for voice change are M to F, males transitioning to a female role because they identify with a gender of a female even though their body [inaudible] markers or not, and having worked for the last 20 years, one of the things feminizing your voice to me has less to do with the pitch but it's the affect you are as a woman, and it's been so interesting because when I started practice, most of the people, men who were coming out were in their 60s or then, it became 50s, then in their 40s, and only in the last five to 10 years in my practice, I have seen people who are coming out in their tweens, like teens and 20s, but what's so interesting about that process, they were describing the process that they were expected to be less assertive in their presentation, they were supposed to be more thoughtful looking, they've got the feedback that they were to domineering and their hesitation in their decision-making needed to be visible. So, for example, it's like, "So, I'm not really sure if I know how best to solve it but if I give it a little thought –" so they had a lot more verbiage and believe me, I was getting a little caught up about how to appear less threatening in women. So, a lot of these men that I saw who are undergoing transition, they were in a very high position in their professional careers and they had the means to go through the transition as well, and they found it very difficult to take almost like a gender-assigned role, a subservient role. Anyway, I'm just curious about what even triggered all these thoughts about studying of this, and what bearing do you see us having in the way we support the needs of these clients that we have?

Dr. Turkstra: I think one of the things for me that triggered it was many years ago, an adolescent with brain injury came to talk to my class. I was at the University of Arizona, so it was really a long time ago and he was talking about his speech language pathologist then he said, "She kept saying to me, 'Well, that's inappropriate, that's inappropriate, that's inappropriate,' " and he said, "I think saying that, that's inappropriate," and so I was thinking, what are we doing? You know, I just [inaudible] what are we doing? And I don't know, I just started to wonder because as I mentioned before, we have so many female therapists and a lot of communication disorders have a higher prevalence in males, so we do often have a lot of male clients and when you hit the adolescent years, whatever your diagnosis was as a young child, executive function impairments and social challenges are sort of what's happening, so kids with ADHD, kids with language development or language disorder, kids obviously are not just in the spectrum but it doesn't really matter what you had when you were young because adolescence is the time for executive function big developments. A lot of kids with communication disorders are struggling at that time and a big part of their goals are social, so if you think here, we have all these female clinicians working with mostly male clients who want to get dates or whatever or just interact socially, I just started to be concerned that maybe we were imposing our views and by our, perhaps I mean views of women and even potentially some male speech language pathologists might have more stereotypical feminine qualities, not that they're not quite masculine but they may have more of the things that people think as stereotypically female – helping, collaborating, being empathetic – whatever, and so I just wondered if that was not a good thing. And so, we did this, we have a paper that's in review right now, a student who is doing her masters with me, her name is Emily [inaudible] now. He was Emily [inaudible] at the time, we took a questionnaire that's used in brain injury asking about a bunch of negative social behaviors, so the social behaviors came from the literature in pragmatics and we were meant to endorse on this questionnaire, do you do these things? Never, sometimes, or often. So, for example, interrupt or say things that are vague or make inappropriate comments. So, there's a whole bunch of items like that, so we were interested to know if males and females without any kind of an injury would rate themselves the same on those items, and we were also interested in people's standards about those behaviors. So, Emily gave the questionnaire to undergrad male and female students and she asked each participant to rate how bad would this be if a woman did it and how bad would this be if a man did it, so what I thought was that female and male participants would all say that the standards were higher for women and that on the list of bad behaviors, most of them, you just write them up if a guy does it, so like, you know, saying something appropriate, people say, "Well, that's not a problem if a male does it because males do that kind of thing," and that was not the case at all. What happened was, the female respondents overall were harder on everybody. 

Sucheta: Really?

Dr. Turkstra: So, they had higher standards for women and higher standards for men.

Sucheta: Wow!

Dr. Turkstra: Yup, and it was a fair amount higher, I have to say, so if you're the clinician and you have more exacting standards for social behavior, is what you're doing rehab or 'hab'? Are you trying – and that's what prompted me to go back to the literature and look to see, is there any biological basis for differences in reading social cues? That was the other thing I thought, if women are better at reading social cues than males, then it's even worse that we are trying to get males to do things women do if they can't even read the cues. 

Sucheta: So, what does your research so far say? Are there biological differences?

Dr. Turkstra: So, from what we were able to find in the typical literature, there is a small but significant female advantage kn just recognizing emotions in other people's faces. We have not seen any advantage in Theory of Mind, and I haven't looked at the literature on [inaudible] or feeling in touch with your own feelings so I don't know about that, so women seem to be a little bit better at reading emotions. However, the emotions, the stimuli people have been using to test it are so basic and if you look in the literature, the places where women seem to do better is what it's subtle, when it's like a complex or subtle situation. There's a fantastic comic – there's a comic strip called Zits – 

Sucheta: I love Zits! 

Dr. Turkstra: Right? Teenage humor. 

Sucheta: I have all of them, yes. 

Dr. Turkstra: Oh, great, then you probably have seen the one, there's a girl facing a boy and they have thought bubbles and the boy is thinking, "Hi,"  and the girl is thinking head to toe, every single thing about the boy, like oh, look at that hair, you know what I mean? His posture is really bad, and acne – there's all these thoughts, and many years ago, on a focus group of teenagers, a teenage boy said to me, "Ma'am, we are just happy when anyone talks to us." So, I have to think that when things are more complex, women may have an advantage. I think to me, a thing to keep in mind is first of all, what are your own expectations and can you separate your standards from what's appropriate for your client and your client's environment? And also, I'm not saying women should excuse behaviors by men – I'm not saying that all – all I'm saying is just to be mindful that what you're thinking of as your treatment target may be influenced by your own perspective as a female and your own beliefs about what's socially appropriate behavior and that those may not be the same for everyone.

Sucheta: I think this is a profound nudge. It's a nudge because it's a very subtle thing, many people may not even have thought about gender-related expectations having any particular influence on the way you treat others or the way you set the expectations for others. There are so many thoughts that come to my mind. I'll start one thing. So, the first thing that occurs to me is that when you think about women's role in society, and if you read Stephen Pinker's book on Angels of Our Better Nature and Evolution of Cultured Human Behavior, a culturation process, I guess, I was fascinated about how women who are less violent would nudge a man to maybe take a plate when you eat instead of eating the meat straight from your hand, that that slight nudge kind of corrected these behaviors and assimilated them into society to formulate a family unit. I feel, I don't know if we have taken on this role to fix things or make things better as a cultural role before we even become therapists. I feel that maybe playing an incredible influential way is that we believe that it is somehow our role and responsibility to tweak people all the time – forget in therapy or not. 

Dr. Turkstra: Well, we are a biased sample, right? Because clearly, we got into this profession because we wanted to – to use your terms, tweak people, which I'm pretty sure refers to metamphetamine at this point, so I want to choose a different term but I think that we may have gotten into this to try and modify people.

Sucheta: Modify, and second thing is, I think what occurred to me as you were speaking is that this idea of room for improvement versus tolerating inappropriateness, I'm experimenting with this, and this is again my growth in my clinical practice versus my client's growth in presenting brain injury in a better way, okay? I used to get very annoyed with inappropriate patients which were all of them, and I used to insist on how to fix it, how to participate, what engagement looks like, primarily because they were not paying attention. They couldn't engage in the protocol or etiquette and that became a bigger obstacle for me, not them, then I encountered a friend of mine who would let kids do whatever they wanted, like she was doing therapy, one time we were talking and she said, "The kid was on the floor," and she was in her chair so she couldn't even see the kid directly well but she allowed that, and to me, I was so appalled by that. I would never allow it, let alone continue therapy, you know? But that kind of made me a different window into allowing therapy and meeting them where they are is not such a bad thing, you know? And so, that is something that I'm thinking about that as we are helping people, can we meet them where they are and not try to fix every part of everything. And lastly, my question to you is then, the pain you feel for not being effective in casting the change the way you want it, what do you suggest we do because there are so many ways to get better and if you are dealing with men, for example, as a group, their standard is different and they are never going to be that standard that you envision. Is that a failure on our part to show them a different way?

Dr. Turkstra: I'm not sure I would make any generalizations about men and women.

Sucheta: Okay, great, sure, [inaudible].

Dr. Turkstra: I think I would say – I mean, it's person first, right? I mean, we are doing patient and client-centered care, and so I think clinicians, we have a little bit of a different agenda, so I think in science, it's important to really understand where there are differences and the implications of what those differences are. I think in life, it's important to understand what really matters, to think about what really matters, like choose your battles, you know what I mean? So, yes, that behavior is not exactly to my standards but if I have Theory of Mind, I can imagine that from the other person's standards, perhaps my behavior is not meeting their standards either, so I could think about that in my everyday life, and then in clinic, I think the same, we could just think carefully about what aspects of behavior are going to be the most important for life participation for this person. We can't tackle everything. I went through a phase when I was mostly working with teens thinking that if teens are so focused on their appearance, that maybe if they had like their hair was blue and they had closed the gap, they would fit in more if they had 40 hours of speech therapy. And so, the thing that has really struck me even in a school system for kids is that the expectations for social behavior at each grade level are not based on any data. They seem kind of arbitrary to me and I guess your comment maybe shed some light on that for me which is maybe it's what the teacher needs the kids to be doing in class at that time, but I couldn't – I mean, I look to see, when you say you're supposed to be able to formulate an argument in grade 2, like why grade 2? I know some three-year-olds that are pretty effective in arguing and I know some 30-year-olds that are not particularly good at arguing. It's like, where did that come from? So, what I am hoping will change things is just if we ask ourselves, when you're setting some kind of goal for yourself for your interactions or for your clients, to put a little thought into is this something that really is going to make a difference for that person? And of all the things we could change, what's the one that's going to get them what they want? They want that date, they want that one best friend, they want something to do on a Friday night as do we all, so that's what I would say to me is to just think about that.

Sucheta: And I'll end with this quick story that a few weeks ago, you and many of your colleagues did a TBI workshop which I attended which was so helpful to me even though I was, of course, came away by saying, how did I not know that? So, shame on me.

Dr. Turkstra: You did it, you did probably know everything that was in that conference, I'm sure. 

Sucheta: No, but I implemented this technique immediately called the GAS, the acronym stands for goal attainment – too logistical about it but what was so interesting is I was working with a very difficult client who is very resistant, and so I took – memory is my problem, and so I kind of started where he wants to be which is in order to improve memory, if he got organized, his memory will improve, but he doesn't want to get organized, he just wants to improve memory, and he wanted to do Jimmy Kwik. He's a guy who had a TBI, traumatic brain injury, and then he turned his life around and now he speaks about it, and so he wanted to take the course by this guy and I said, you can have a therapist or Jimmy Kwik, you decide, you know? So, I watched a video of him and took the suggestions – he had 10 suggestions, so I took three suggestions from this Jim Kwik, so I combined what he wanted. He wanted this, so I said I was unwilling to give it to him. I wanted to give him what is right for him and he did not want it, so I literally changed, I started giving him what he wanted and we completed a one-month assessment and I said, are we working on the goals that are important to you? And guess what, I got 100% on that test. I have never gotten 100% from this dude ever, and I was so happy. It's not making progress the way I think but the way I think was not making progress to begin with. But now, I'm literally doing everything he wants, what's important to him. I'm listening to him, I'm letting go of his abrasiveness, I'm fixing comments like 'that's too rude, that's too obnoxious,' and that just has helped our relationship. So, thank you.

Dr. Turkstra: I love that, I think that's fantastic! And the best part about that which you kind of believed there was, was that he was evaluating you on some scale that gave you 100% and I think that's fantastic. We should all do that. 

Sucheta: Yes, I do have an exit interview for every session, so I send that to my clients and they tell me what I did well, tell me what I did poorly, and tell me what you would like to see me tomorrow, and so I do that exit interview with clients which is a very helpful way of dealing with people and their agency. But be prepared to get a dagger in your heart though. 

Dr. Turkstra: Right.

Sucheta: People are very, very clear telling you what didn't help. 

Well, Lyn, I cannot thank you, I have indulged utterly for my personal greed and benefit, and I'm sorry, listeners, we went too long, and Todd, thank you for your patience. You now see why I adore this wonderful woman, and thank you, Lyn, for being magnificent in all you do and really taking us on this journey to think differently about our own prejudices and viewpoints that may be interfering rather than helping us succeed, but the very issue that we want to accomplish is to help people. Thank you.

Dr. Turkstra: Thank you very much to you both. 

Producer: Well, as a man, I'm just so glad that you guys both talk to me, so thank you for that. Sadly, what a fun conversation, that's all the time we have for today. If you know of someone who might benefit from listening to today's show, a teacher, principal, coach, a parent or a student, we would be most grateful if you would kindly forward it to them. So, on behalf of our host, Sucheta Kamath, today's guest, Dr. Lyn Turkstra, and all of us at ExQ, thank you for listening and we look forward to seeing you again right here next week on Full PreFrontal.