Sunday, July 1, 2012

The Truth About Stress

Author: Angela Patmore
Publisher: Atlantic Books, London, 2006

About the Author:

Former University of East Anglia research fellow and International Fulbright Scholar. Her book, Sportsmen Under Pressure(1986) was a Times sports book of the year. The Truth About Stress was shortlisted for the MIND Book of the Year Award 2007.

General Thesis

  1. Stress is a bad concept. Not defined.
  2. The stress response has been pathologised but is vital to our survival.
  3. We are medicalising a response to contingencies when we should be managing those responses to contingencies.
  4. That most drugs to treat anxiety and stress are next to useless if not dangerous.
  5. That the stress industry is largely un-regulated and is costing governments, business, and individuals too much money.
  6. That the best approach to managing stress is to introduce people to stress. Inurement. Basically, train people to cope with stressful events.

page 81
"This [steady state hypothesis of physiology -Cannon's] has led to the fight-or-flight mechanism being viewed as a hard-wired, primitive, malfunctioning sort of bodily self-destruct system, that is even referred to in some of the literature as 'the fight-or-flight syndrome', as though the survival mechanism were an illness."
I despise the steady state idea, the concept does seem to have had a a pernicious influence on peoples' thinking about biological processes. I prefer a concept from aeronautical engineering: dynamic instability. Modern fighter aircraft are inherently aerodynamically unstable but this has the great advantage of making them inherently much more maneuverable. Physiology is typically about responding to contingencies. Our metabolism is not striving towards some homeostasis but constantly shifting through various phases. It is dynamic. Over recent years there has been a substantial re-evaluation of brain function, with a distinct shift towards a more dynamic view of how brain structure changes at both the macro and micro levels to various contingencies; sometimes in surprisingly large measure. I am fascinated by the responsiveness and lack of stillness in biological processes. It seems that being constantly moving is a more manageable state rather than trying to maintain a homeostatic state. Dynamic instability in modern aircraft only became possible with computer controlled flight, leaving me to wonder what computational gems are waiting to be discovered in bio-molecular processes. 

I suspect the author is under estimating the acumen of the relevant researchers and may even be mis-understanding the literature. The fight-or-flight response can become pathological when it is being constantly activated at high levels. It's primary evolutionary function appears to have been to avoid immediate life threatening situations. But maintained over extended hours it can create problems. So the fight-or-flight response has great value but only within certain bounds of function. The same is true of inflammation. Whilst in these days inflammation is akin to the devil, limiting inflammation can have serious implications for pathogen defence and wound healing. Inflammation, like the fight-or-flight response, has great utility within a given time frame but if sustained can cause considerable damage. The two are closely inter-related(see below). So as I like to think: a little stress goes a long way. Avoiding challenge, avoiding risk, reminds me of this wonderful line from Miller
The man who looks for security, even in the mind, is like the man who would chop off his limbs in order to have artificial ones which will give him no pain or trouble.
Sexus, page 339.
Page 82
"Mason felt that emotional subtleties had been overlooked by Selye. He argued that stress was really a behavioral concept rather than a physiological one."
That touches on a very important point that relates to a principle theme of the author. Just what do we mean by "stress"? Mention the word "stress" to most people and they will in the very least have some inkling of how you are feeling. As a means of expressing a state of mind the word "stress" has linguistic value, it provides a starting point for further exploration. So when a patient says to a doctor "I am feeling stressed" the doctor may well know it is a vague term but will quickly have some idea of how to investigate the patient's condition.

"Stress" as a concept is analytically useless. We can only refer to specific stressors within various contexts, not some generalised convenient catch all word. If we are to understand what we mean by stress we must abandon the concept of stress.

The same conundrum exists with respect to "depression", "schizophrenia", and I imagine a number of other conditions. For example, an autism expert once quipped that when you've met one autistic you have met one autistic, the implication being that all individuals labelled as autistic represent a spectrum of behaviors. So we can hail some success in that they now talk about Autistic Spectrum Disorder, but even that implies a linear progression towards some full blown condition and does not do justice to the high variability that exists within that spectrum. The current concepts are the best available, there is a general recognition that we need to do better and a general admission that we don't know how.

In my world "stress" is only a word, not a concept. It points to a commonality of human experience that we identify with the word "stress". Physiological studies show high variability to various stressors which can change markedly across different strains of laboratory animals. I recall one observation that the smell of rat urine left in the lab can change the stress response of mice. So extrapolating from animal studies to humans is a nogo logical step. Even extrapolating from human studies across various cultures and differing life experience is fraught with peril because different cultures can play vital roles in shaping our responses. This comes back again to remarkable plasticity inherent in physiology and behavior. We are not machines, we are highly responsive organisms that are in constant communication with the environment. One important qualification though: there is considerable evidence that our physiology is "tuned" during our developmental years and this tuning sets the parameters of adaptation. Whether or not this tuning is reversible I do not know, but I am confident that that in some instances it is reversible. I just don't know of any evidence.

Chapter 5, "Psychoneuroimmunology" is essentially an assault on the whole concept.

The author is unfair in some respects. She again stresses that the whole discipline suffers from using stress as a concept. It is a big problem. How do you analyse a fuzzy concept? (I trust you now understand why politics is a horror of obfuscation.) Too much has been made of the findings in this field but at times I get the impression the author is trying too hard to dismiss it. In PNI the research may use the word "stress" but many experiments are about identifying the impact of specific stressors.

This is somewhat of a paradoxical situation because the author is right to challenge the use of stress as a concept but then presumes that the researchers themselves are unaware of the ambiguity of the concept. The authors are often using the word stress in the same way I referred to above: it is linguistically convenient. We know the ambiguity and if I bother to read the study I will often find they are referring to results of a very specific context. Where things can go astray is in the "discussion" part of the paper, wherein the authors might lose their way and begin extrapolating the research results in unwarranted ways. Where it becomes ridiculous is when these findings are extrapolated to human beings, with learned helplessness(see below) being a prime example.
page 84
"Above all, questions must be asked about the relevance of PNI stress research to our society. Even on its own terms, how does this new research actually help people?"
PNI stress research is extremely useful to three groups: PNI researchers, stress management purveyors, and those trying to invent a 'magic bullet' ....
I recount the famous story of when Faraday first demonstrated the electric motor and some smart alec quipped, "What use is it?" to wit Faraday replied what use is a newborn baby? Most disciplines when they begin are littered with nonsense. Many scientists realise in their latter years that an embarrassing number of their earlier experiments were wrong. If you stop because it is a mess you are not going to solve anything, you are just letting the problem fester. The author seems to be suggesting that because stress is not defined we can forget about it. The text has some excellent observations but fails to address the principle challenge: find a a new way to think about "stress". The problem is not ontological, it is nosological.
"To be fair, even stress scientists themselves do not generally believe that 'stress', is an immediate cause of disease. ... 'Short term stress' is not usually seen as the culprit."
Yes, but if the author was truly fair this should have been emphasised at the very beginning. Even in the year 2000 the work of Sapolksy et al, a synthesis of the then current research makes it clear that immediate stress, that where the fight-or-flight response has optimal value, does provoke a "permissive phase" which the whole physiology is not only prepared to maximal energy expenditure but also there is a distinct mobilisation of cerebral, endocrinological, and immunological resources to counter the potential threat. However, it is important to note that the enhanced immunological inflammatory response is then typically dampened by slowly rising cortisol levels. Whereas inflammatory mediators can be stored and released in large quantities(think of allergic reactions), cortisol must be produced and this can take several hours. It's all very complicated. The work cited above is comprehensive but perhaps a little dated now. I don't know, I haven't kept up with that literature.
The picture seems to get more complicated but I believe that review provides a very useful broad conceptual framework for thinking about these issues.

p. 110-112 - Learned Helplessness

On these pages the authors address the famous concept of learned helplessness, first developed by Martin Seligman and Steven Maier in the 1960's. The experiments are unpleasant, exposing dogs to painful electric shocks but allowing them no escape. Eventually they stop trying to escape, even when it can be possible to escape. I have seen this concept used in some very strange ways, with some arguing that welfare induces learned helplessness. I have never understood such an interpretation. What I do know is that concept has not been particularly successful in explaining human behavior. We are not dogs.

The author makes this observation:
In my work as a trainer rehabilitating the long-term unemployed, I come across this tragic syndrome on almost every course. I call it dole sleeping sickness. ... They stop trying and failing because these rejections hurt, and they simply wait for Godot, or a lottery win, or a miracle. .... Ironically, a lot of them claim to be suffering from stress, or think that arousal is the cause of their problems. If only that were the case."
Most of us have probably seen people in similiar states with respect to certain problems in their life. I think the author is mistaking the cause of the reports of their stress. Long term unemployment invariably means poverty and the slow loss of resources until you live like that Zen Master holding onto the branch as he hangs off a cliff. One bad storm can cause your doom. It is that constant living at the edge so much so you are bundled off to some last hope intervention to help you find work, that is the stressor. Creatures need comfort zones. When I first heard about evolutionary perspectives on Life suggesting it was all some great struggle with all this competition going on, I looked outside and the animals seemed relaxed and in no need of Prozac. There are some category issues here, perhaps concepts like "competition" and "co-operation" are poor concepts for explaining evolutionary dynamics. I wish I hadn't thought of that. Latter.

The fight-or-flight response is about an immediate quick threat. Most organisms do not have to be constantly on guard, they have sensory cues that are like passive electronic warfare, picking up cues to potential threats and only then does the fight-or-flight response come into play. Death threats come but most of the time the organism is more concerned with the other 2 Fs. Long term unemployed are stressed but not aroused. Arousal has been extinguished, perhaps, just that, the emergence of glucocorticoid resistance, which can takes weeks or months and results primarily from sustained high output of cortisol, can induce an systemic pro-inflammatory state that in turn induces cortical atrophy in the temporal lobes(documented in sustained major depression but hey it can grow back, sometimes) and a series of other changes that basically make it harder for neurons to function at an optimal level. For example, a major pro-inflammatory cytokine, tumour necrosis factor, can impact of RGS 7 which in turns impacts on NMDA receptor function, the major excitatory neurotransmitter class because it, much moreso than AMPA receptor activation or even solely, establishes the vital second messenger dynamics that enable memory consolidation over the long term. So by inhibiting NMDA this pro-inflammatory cytokine, now elevated because glucocorticoid resistance is preventing the feedback that controls inflammation, is actually making the task of finding a solution more difficult. This is a dangerous state, as the author notes a state of learned helplessness also appears to impair the immune response, this is also a hallmark of glucocorticoid resistance.

The redeeming value of this state is that having given up hope one can be reasonably happy, the challenge being to weather the occasional storm. So whereas the author suggests that in this state the person is much more predisposed to illness and that learned helplessness is actually the real reason why chronic arousal can cause bad health outcomes, I am suggesting she is failing to realise that 1.) what they are saying about their causes of the behavior may be completely irrelevant, and, 2) they know the game, they will provide the necessary persona for the bleedin' course but have in their own peculiar and somewhat parasitic way adapted to become sufficiently content with their situation in life. Humans are like that. Thus these people in a state of learned helplessness are no longer experiencing sustained cortisol and other adrenal hormone secretions, thereby slowly reducing glucocorticoid resistance and improving their overall health. They have adapted.

I suggest the author is falling into something of a naturalistic fallacy here, presuming that because the fight-or-flight response has adaptive value it must always have adaptive value. In fact in many modern contexts for humans the last thing you want is the induction of the fight-or-flight response. I have been in crisis situations and had virtually no visceral response I can recall, either during or after the event. I was, however, extremely analytical and clear headed. I was very quick to anger with anyone around me who was responding with emotionality. It was as if they were the bigger danger! They were, they were distracting the rest of us from doing what needed to be done. So I had every right to be angry with them! Yet everyone was probably experiencing some activation of the fight-or-flight response, each of us responding in our individual way. And guess what, even that so-called primitive hard wired response set can be highly modified by one's life experience, genetic constitution, and prevailing contingencies. So we may think of the fight-or-flight response as some instinctual response, but it sure is a malleable one. Instinct! Analyze that!

With regard to the long term unemployed the author is overlooking the obvious. At least they are not insane, for to keep doing the same thing and expect something different ... . Some people escape long term unemployment by finding other ways to make money, whether it be online or starting a business or on the black market or becoming a criminal. But to suggest that people must keep doing something that they know is pointless reminds me of that wonderful scene in the movie Cool Hand Luke where the character played by Paul Newman is instructed to dig a hole and fill it up, dig a hole and fill it up ... . Ironically what is demanded of these people is that they are essentially gambling on a win, in the hope that sheer numbers of applications and bleedin' courses will bring reward. But of course we should never encourage the downtrodden to gamble ... .

Denmark has a better idea: the long term unemployed aren't sent to some bleedin' course, they are slotted into a job. It works, for if a person is in a state of learned helplessness and even depression the mere opportunity to escape the stressors of constantly being on the edge of doom will lift the gloom and strongly motivate them towards escaping yet another bleedin' course. I touch on this form of "coercion" further below.

This is where the problem of stress in modern cultures becomes interesting because it has become something of an issue in recent years, thereby proving yet again that anything ambiguous is more likely to become a big issue than anything clearly defined. Something is going on, I'll grant that, but the explosion in stress related claims for compensation and illness has boomed in recent years. With rose coloured glasses I suggest that once again it will take about a generation for the general population to develop appropriate responses to this modern malady. As the author argues the research will be to little avail in these matters, at least the research based on animal studies and physiological analyses. That may change into the future but it is important to remember that psychopathologies in general have very poor biomarkers; if any. This may be more of a philosophical\analytic problem than empirical one. I suspect it is. Guess. My bad. Difficult.

This is odd and funny:
p. 125
Professor Lehrl subjected German holiday-makers to a battery of IQ tests. After a week their average IQ dropped by 5 per cent, and after three weeks, worse. .... A three week trip to the seaside lowers of the IQ of the average holidaymaker by about 20 points. Lehrl thinks we have to fight every day to keep our intelligence, suggesting the brain needs a workout as much as the body."
Yeah, like I'm really motivated to do IQ tests while on holidays. Really ... .

The text does a great job at revealing some of the absurdities of the current stress management craze. The stress management industry is now huge, amorphous, populated with services ranging from reiki therapy to drugs, and does appear to develop a very worrying pro-active stance that reminds me of "ambulance chasers". I am delighted the author notes that trauma counseling has no empirical support and may even do more harm than good. Thus ...
p. 247
Indeed, the NHS Centre for Reviews and Dissemination report concluded that: 'counselling, by itself, has not been shown to produce sustained benefit in a variety of groups at risk.' 

 I have been told accounts by people who were being "strongly encouraged" to undergo stress counseling after a traumatic event. Oh please let it happen to me, I would relish the opportunity to have the counselor reduced to ashen faced horror and unpleasant excretions as I recount in minute temporal and physical quanta the horrors of whatever mandated counseling.

However, let us not throw the baby out with the bath water.
p. 234
Some 'stress counsellors' are surely above reproach. ... who base their advice on common sense rather than theories, so do not prolong treatment for economic reasons .... 
Some people will benefit from stress counselling, just as many people appear to benefit from various forms of "therapy" which have no empirical or conceptual support. I don't know, the placebo effect is up to 30% in controlled studies and many psychopathologies are self-limiting. So I suggest that we may have evidence here for untapped adaptive potential that represents a current shortfall in our broad analytic approach to these issues. Perhaps I'm over reaching here but this again points to the deeper problem that being because we do not have a valid model of behavior, and in principle that may not even be possible, we can never be certain as to the limits of adaptation inherent in organisms and especially us. In anthropology humans beings are sometimes referred to as specialist generalists. We  are remarkably flexible organisms, perhaps even moreso than our known history indicates. That is cause for optimism.

I'll admit it, despite the studies that suggest no benefit, I do think that some people do benefit and that one cannot simply assume that benefit was a result of the placebo effect or the self-limiting nature of the pathology.
p 238
"For many practising within the therapeutic professions, the great genius among them was the late lamented psychiatrist R. D. (Ronnie) Laing, who did so much to humanize and normalize serious mental illness. ... Such intimacy with his patients is widely recognized to have cost the psychiatrist dear, for Laing himself was institutionalized."
It must be over 20 years ago now, I was standing on a balcony approximately 2.5 kms as the crow flies from where I am now sitting. A psychiatrist said to me that some of his colleagues had met R. D. Laing and thought he had a a few kangaroos loose in the top paddock. The author here is asserting that because of his empathy towards his patients Laing needed institutionalisation and previously downplays the stress experienced by various other individuals as being more a product of their imaginations than any real pathology.

Additionally, it is not true that R. D. Laing is held in some great esteem by the therapeutic professions. I know the Scientologists love him and undoubtedly many more do but the author is adopting a strangely contradictory stance here from which I infer she has more than some sympathy with the notion that "mental illness", because it cannot be clearly defined, therefore does not exist; just as she appears to argue with respect to "stress". Before Newton Gravity Existed.

What a strange concept: to "normalise mental illness". Hmmm, shall I squeeze that Bell Curve into an Overwhelming Ball?(Sorry Gauss and Eliot)

Where she deals with the concepts of Post Traumatic Stress Disorder I am largely disappointed. Again I receive the impression that she is attempting to eliminate the condition. She does cite the excellent work of Ben Shepherd, War of Nerves, which is a brilliant examination of how war induces psychopathologies. Recommended reading. So I find it odd for this text to dismiss PTSD when even in War of Nerves the author states that for every physical injury there will be two psychiatric injuries. Additionally, as recent conflicts have so amply demonstrated, this is not some simple psychological\physiological dichotomy, the evidence clearly points to not just psycho-pathology but neuropathology and the clear possibility that the two are inter-related.
... Cochrane Collaboration, which provides worldwide guidance for doctors, reviewed the evidence for trauma stress counselling as a means of preventing PTSD ion1999, looking at no less than eight randomized trials. It concluded that such counselling was a best useless and at wo94rst made peop0le more likely to suffer PTSD."
But that is not denying PTSD, just that we still don't know to treat it.

Chapter 17, "Nation Sedation" is about the use of drugs to treat stress. This is a minefield. There is something odd, strange, untoward, in this ever spiralling use of drugs to treat various behavioral disorders, especially in relation to children. In my country, Australia, the problem does not seem so pronounced, but in the Britain and the USA it is bizarre. For example, I stumbled upon an abstract with the opening sentence .... One in four children in the USA have a behavioral disorder that impacts on their academic performance [meaning unchanged, I can't recall the exact words]. I was amazed by that. If that is true, something is seriously wrong. If that isn't true, something is seriously wrong.

It gets even funnier

The author does a good job bringing together some examples of how absurd our responses to the "stress epidemic" have become. Here's a gem:
"After an episode of Coronation Street in which Toyah Battersby(played by Georgia Taylor) was raped, the Independent Television Commission(ITC) upheld complaints from members of the public that ITV had failed to offer a viewer support helpline."
That's a good example of where it has become ridiculous. People have necks, turn your head away from the TV. Now that's learned helplessness, they couldn't even get out of the lounge chair to turn the TV off. They probably even had remotes. I am completely mystified by this, why would anyone want a helpline for TV? What a puzzling behavior. That flexibility of human behavior is not necessarily that teleological, with the possible distribution of responses giving rise to behavioral displays that make comedy possible.

The Author's Proposed Solution.

Chapter 19 Inurement

What strikes me as odd about the author's approach to the problem is that it is not an approach that addresses the central theme of her text: how to treat stressed out individuals. Rather, and I have considerable sympathy with what she is proposing, she argues for inurement, or as I now find psychologists are more frequently talking about, "resilience". Oh gosh aint that grand we're gonna adopt another folk psychology concept to try and cover the holes left by using the last folk psychology concept.

The text makes reference to the glories of the Roman armies and how people back then were trained to be tough and resilient. That is all well and good, it is sort of obvious that exposing human beings to a series of challenges and potential threats, especially in their developmental years, will facilitate the development of behaviors that will enable the individual to address similiar challenges latter in life. Last time I looked though I didn't see armed barbarians walking down the street. The types of stresses confronting modern individuals are not necessarily best adapted too by adopting strategies to repel invading Goths.

Her perspective may reflect her experience in sports psychology. She has worked at elite levels, where one is dealing with a very select sample of human beings. These are people who are excellent at repeatedly performing non-productive tasks. Athlete say, I can run fast. I say, I have a phone(Here I come Constantinople!). Athlete say, I can swim fast. I say, we are land based mammals. It is amazing what human beings will do. We worship people who engage in behaviors that by the demands of our own society are utterly unproductive, anachronistic, and weird. Fortunately it is only a small percentage of the population engage in these odd behaviors, leaving the rest of us to watch and enjoy the display.

We do need to think about the stresses of modern life but with emphasis on "modern". These problems are not intractable, it is obvious that despite the increases in stress related costs and illnesses over the last two decades the greater proportion of the population has adapted to the new contingencies. It is clear that the stress industry has excessively promoted stress as a health issue when it is fundamentally an adaptive challenge. It may even be true that modern life, technology, and governance has reached a point where it is protecting us from too many potential dangers. As two leading intellectuals astutely observed while watching a pop music video:

"This is music for white people who have never had anything bad happen to them."

Bevis and Butthead.

Suffering can be good. Even St. Paul writes somewhere in Romans ... suffering produces perseverance, perserverance, character, character, hope, and hope does not disappointed us because we have faith in God. .. So tough luck atheists, you're on your own. Modern incarnations of christianity, insisting that your holiness should be reflected in the financial success of this life, the self-esteem jazz, positive psychology, New Ageism and that Buddhist mis-interpretation that one should always be in a state of peace, as if being angry, sad, or any other "negative emotion" is a bad thing. A huge swath of modern psychology has adopted the mantra happiness and nothing but happiness, we have happiness in order not to die from an honest thought. (Originally Nietzsche, Art and nothing but Art, we have... ) The tragedy is that Buddhist and New Age ideas do have considerable merit, we could potentially learn a great deal from the themes and perspectives promoted by these activities but once again these have been co-opted for the benefit of maintaining the status quo, when it is precisely the status quo that needs to be challenged. We need more rebels, not people who are using these disciplines as means of better managing the way through this world. As the French writer Camus observed: a culture needs its metaphysical rebels. Always. The truth does not set you free, that was a huge lie. The truth is coercive. You want the truth, go find someone in a bad mood.

While the author demonstrates considerable rigour in examing the literature relating to stress she then seems to abandon this rigour when proposing solutions to stress and critiquing some other issues. So while I agree with her that there is a problem with the current treatments of mood and stress related disorders, it is somewhat more complex than just about vested interests and shoddy studies. To put the matter simply: the idea that the emergence of mal-adaptive behaviors, which may have been present for years but upon encountering particular contingencies actually constitute a behavioral disorder, can be quickly modified by a drug or a good talk denies the obvious fact that behavioral modification is generally painful.


So to conclude, and this is somewhat in line with the author's general ideas about stress management, I'll mention this little story I read. Unfortunately I can't reference it but the details are sound.
A psychiatrist was treating one of his acrophobia patients(fear of heights) and decided to call in a behavioral therapist for desensitization therapy. On one occasion the therapist was standing behind the patient who was supposed to walk into an elevator but was hesitating. So the therapist pushed the patient into the elevator. The psychiatrist was surprised by this, but it appeared to work.
We can be scared of being scared, which is being scared of our responses, ourselves, which is funny. Clinical mental health generally abhores the idea of coercing patients into doing something. The goal is to cajole, encourage, smooch the person towards adopting new behaviors. Strange thing, in life in general we behave, as Saint de Simon noted long ago, in a civilised fashion because it is in our best interests to do so. I will not speed, at least not on this road, because I might get a speeding fine. I will not be an asshole because people will not like me. I change because if I don't I am faced with unpleasant contingencies. In therapy though, "unpleasant contingencies" are not allowed. I am not talking about punishment, but rather pain. The pain required to change.

What seems to have been forgotten is that even adopting behaviors irrespective of how ready we feel or how competently we execute those behaviors can be far more beneficial in creating the desired behavioral changes than waiting for some epiphany or "moment that just won't come"(Springsteen) or "more than a feeling"(the band Boston). I did not become a good squash player by thinking how to be a good player I spent many hours per week by myself on the court practicing the fundamentals of the game. We generally recognise that if we wish to improve responses in many contexts then we must practice those responses but the therapeutic context seems to under value this strategy. This is not just about theories of behavior, there are ethical issues lurking here.

This blows the problem wide open. It isn't just about what happens in therapy, it opens up a pandora box of moral dilemmas that is frightening to address. It goes beyond ideas like freedom and dignity so I suggest Mr. Skinner's famous work as a starting point that may help you develop other ways of thinking about these issues. When I first read it I was clearly too stupid to understand it, it is only now a long time latter that I have come to appreciate that Skinner, even if he failed in his goal, was attempting to point us towards something very important not only for psychology but our culture, our laws, and our understanding of ourselves. The same call has again gone out. Nancy Andreasen, former Prof of Psychiatry at Harvard, in the closing paragraph of her book Brave New Brain(2001), calls for exactly the same re-evaluation of all we thought we have been. Of these two it can be said: a prophet is not recognised in their own community.
"We simply lack the knowledge to cure society as well as individuals.
Confronting this fact seems especially imperative at this time. Psychiatrists are frequently called on to prescribe quick treatments for a variety of social ills, such as the rising rates of crime and violence. Instead of appealing to the specialty of psychiatry to "fix" violence or reduce general unhappiness, all of us, as members of the human community, need to recognize that the sense of "self" in our post-turn-of-the-century worlds may be in need of repair. There has been a widespread move toward materialism, quick fixes, instant gratification, and a superficial sense of success, which is reinforced by the fast-paced cyberworld that we live in. The answer to our many current social problems must come from individual people, who must reappraise their sense of "self" and reach an appropriate perspective on what constitutes a sound moral compass and meaning in life. The need to search for a personal moral compass to guide our individual lives in the twenty-first century is a need that transcends medical intervention, but which has a very real impact on how we choose to employ medical science and what we expect from it. In the era of the genome, fraught as it is with a variety of crucial moral questions, we must all make an agonizing reappraisal of who we are, what life is, what life means, what we must do to help the other human beings who share our world with us, and what we can do to make it a brave new world."

Brave New Brain, Andreasen, 2001.

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