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The Neuroscience of True Grit

When tragedy strikes, most of us ultimately rebound surprisingly well.
Where does such resilience come from?

Toning Down the Brain's Alarm System
When faced with danger, the brain initiates a chemical cascade that primes you to put 'em up or run away. In turn, a series of chemicals in the brain can dampen this response, thereby pro­moting resilience to stress. One key chemical cycle begins when the hypothalamus releases corticotropin-releasing hormone (CRH), causing the pituitary gland to secrete adrenocorticotro­pin hormone (ACTH) into the bloodstream, which triggers the adrenal glands (near the kidneys) to release the hormone corti­sol. Cortisol heightens the body's ability to respond to challeng­ing situations, but too much can over time cause lasting dam­age. To help keep things in check, a series of chemicals (two shown below) dampens the stress response. Drugs or psycho­therapy might stimulate production of these stress busters.

In fall 2009 Jeannine Brown Miller was driving home with her husband after a visit with her mother in Niagara Falls, N.Y. She came upon a police roadblock near the entrance to the Niagara University campus. Ambulance lights flashed up ahead. Miller knew her 17-year-old son, Jonathan, had been out in his car. Even though she couldn't make out what was happening clearly, something told her she should stop. She asked one of the emergency workers on the scene to check whether the car had the license plate "J Mill." A few minutes later a policeman and a chaplain approached, and she knew, even before they reached her, what they would say.

The loss of her son—the result of an undiagnosed medical problem that caused his sudden death even before his car rammed a tree—proved devastating. Time slowed to a crawl in the days immediately after Jonathan's death. "The first week was like an eternity," she says. "I lived minute by minute, not even hour by hour. I would just wake up and not think beyond what was in front of me."

Support came from multiple places, including her own person­al decisions. Five hundred of Jonathan's classmates from Lewiston-Porter High School attended the wake and funeral, a demon­stration of sentiment that helped to assuage the pain. She also found solace in her devout Catholic faith. After two weeks she re­turned to work as a human resources consultant. A couple of months after the accident she could visit the restaurant where she and her son had breakfasted the day he died. Support from the community never wavered. A ceremony honored Jonathan at the high school graduation, a Jonathan "J Mill" Miller Facebook page receives regular updates, and a local coffee shop serves "76" coffee in memory of his now retired football number. A year on she still cries every day, but she has found many ways to cope.

When the worst happens—a death in the family, a terrorist at­tack, an epidemic of virulent disease, paralyzing fear in the midst of battle—we experience a sense of profound shock and disorien­tation. Yet neuroscientists and psychologists who look back at the consequences of these horrific events have learned something surprising: most victims of tragedy soon begin to recover and ulti­mately emerge largely emotionally intact. Most of us demonstrate astonishing natural resilience to the worst that life throws our way. 

The Mechanisms of Resilience

Sigmund Freud had written in 1917 of the necessity of "grief work" in which we take back the emotional energy, or libido, as he called it, that had been invested in the now "non-existent object"—in other words, the deceased. This century-old view of the psyche as a plumbing system for channeling subliminal life forces pre­vailed, in the absence of evidence to the contrary, until recent de­cades. That is when psychologists and neurobiologists began to probe for alternative explanations.

One of the things they began to look at is the nature of resil­ience. The term "resilience" (from the Latin re for "back" and sali­re for "to leap") joined the psychological lexicon from the physical sciences. . .

Resilience begins at a primal level. If someone takes a swing at you, the hypothalamus—a relay station in the brain that links the nervous and endocrine systems—churns out a stress signal in the form of corticotropin-releasing hormone, which begins a chemi­cal deluge telling you to put up your dukes or head for the hills. Your brain pulsates like a flashing light: fight or flight, fight or flight. Afterward, the biological typhoon subsides. If you are con­stantly called on to defend your turf, a set of stress hormones gush constantly. One of them, cortisol, produced by the adrenal glands near the kidneys, can actually damage brain cells in the hip­pocampus and amygdala, regions involved with memory and emotion. So you end up an emotional and physical wreck. Luckily, the vast majority of us have resilience on our side . . .

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Can we lower medical costs by giving the neediest patients better care?

The New Yorker | January 24, 2011 | Medical Report | The Hot Spotters

by Atul Gawande MD

If Camden, New Jersey, becomes the first American community to lower its medical costs, it will have a murder to thank. At nine-fifty on a February night in 2001, a twenty-two-year-old black man was shot while driving his Ford Taurus station wagon through a neighborhood on the edge of the Rutgers University campus. The victim lay motionless in the street beside the open door on the driver's side, as if the car had ejected him. A neighborhood couple, a physical therapist and a volunteer firefighter, approached to see if they could help, but police waved them back.

"He's not going to make it," an officer reportedly told the physical therapist. "He's pretty much dead." She called a physician, Jeffrey Brenner, who lived a few doors up the street, and he ran to the scene with a stethoscope and a pocket ventilation mask. After some discussion, the police let him enter the crime scene and attend to the victim. Witnesses told the local newspaper that he was the first person to lay hands on the man.

"He was slightly overweight, turned on his side," Brenner recalls. There was glass everywhere. Although the victim had been shot several times and many minutes had passed, his body felt warm. Brenner checked his neck for a carotid pulse. The man was alive. Brenner began the chest compressions and rescue breathing that should have been started long before. But the young man, who turned out to be a Rutgers student, died soon afterward.

The incident became a local scandal. The student's injuries may not have been survivable, but the police couldn't have known that. After the ambulance came, Brenner confronted one of the officers to ask why they hadn't tried to rescue him.

"We didn't want to dislodge the bullet," he recalls the policeman saying. It was a ridiculous answer, a brushoff, and Brenner couldn't let it go.

He was thirty-one years old at the time, a skinny, thick-bearded, soft-spoken family physician who had grown up in a bedroom suburb of Philadelphia. As a medical student at Robert Wood Johnson Medical School, in Piscataway, he had planned to become a neuroscientist. But he volunteered once a week in a free primary-care clinic for poor immigrants, and he found the work there more challenging than anything he was doing in the laboratory. The guy studying neuronal stem cells soon became the guy studying Spanish and training to become one of the few family physicians in his class. Once he completed his residency, in 1998, he joined the staff of a family-medicine practice in Camden. It was in a cheaply constructed, boxlike, one-story building on a desolate street of bars, car-repair shops, and empty lots. But he was young and eager to recapture the sense of purpose he'd felt volunteering at the clinic during medical school.

Few people shared his sense of possibility. Camden was in civic free fall, on its way to becoming one of the poorest, most crime-ridden cities in the nation. The local school system had gone into receivership. Corruption and mismanagement soon prompted a state takeover of the entire city. Just getting the sewage system to work could be a problem. The neglect of this anonymous shooting victim on Brenner's street was another instance of a city that had given up, and Brenner was tired of wondering why it had to be that way.

Around that time, a police reform commission was created, and Brenner was asked to serve as one of its two citizen members. He agreed and, to his surprise, became completely absorbed. The experts they called in explained the basic principles of effective community policing. He learned about George Kelling and James Q. Wilson's "broken-windows" theory, which argued that minor, visible neighborhood disorder breeds major crime. He learned about the former New York City police commissioner William Bratton and the Compstat approach to policing that he had championed in the nineties, which centered on mapping crime and focussing resources on the hot spots. The reform panel pushed the Camden Police Department to create computerized crime maps, and to change police beats and shifts to focus on the worst areas and times.

When the police wouldn't make the crime maps, Brenner made his own. He persuaded Camden's three main hospitals to let him have access to their medical billing records. He transferred the reams of data files onto a desktop computer, spent weeks figuring out how to pull the chaos of information into a searchable database, and then started tabulating the emergency-room visits of victims of serious assault. He created maps showing where the crime victims lived. He pushed for policies that would let the Camden police chief assign shifts based on the crime statistics—only to find himself in a showdown with the police unions.

"He has no clue," the president of the city police superiors' union said to the Philadelphia Inquirer. "I just think that his comments about what kind of schedule we should be on, how we should be deployed, are laughable."

The unions kept the provisions out of the contract. The reform commission disbanded; Brenner withdrew from the cause, beaten. But he continued to dig into the database on his computer, now mostly out of idle interest.

Besides looking at assault patterns, he began studying patterns in the way patients flowed into and out of Camden's hospitals. "I'd just sit there and play with the data for hours," he says, and the more he played the more he found. For instance, he ran the data on the locations where ambulances picked up patients with fall injuries, and discovered that a single building in central Camden sent more people to the hospital with serious falls—fifty-seven elderly in two years—than any other in the city, resulting in almost three million dollars in health-care bills. "It was just this amazing window into the health-care delivery system," he says.

So he took what he learned from police reform and tried a Compstat approach to the city's health-care performance—a Healthstat, so to speak. He made block-by-block maps of the city, color-coded by the hospital costs of its residents, and looked for the hot spots. The two most expensive city blocks were in north Camden, one that had a large nursing home called Abigail House and one that had a low-income housing tower called Northgate II. He found that between January of 2002 and June of 2008 some nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million.

Brenner wasn't all that interested in costs; he was more interested in helping people who received bad health care. But in his experience the people with the highest medical costs—the people cycling in and out of the hospital—were usually the people receiving the worst care. "Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise," he told me—failures of prevention and of timely, effective care.

If he could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs. And, if the stats approach to crime was right, targeting those with the highest health-care costs would help lower the entire city's health-care costs. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden's medical facilities accounted for thirty per cent of its costs. That's only a thousand people—about half the size of a typical family physician's panel of patients.

Things, of course, got complicated. It would have taken months to get the approvals needed to pull names out of the data and approach people, and he was impatient to get started. So, in the spring of 2007, he held a meeting with a few social workers and emergency-room doctors from hospitals around the city. He showed them the cost statistics and use patterns of the most expensive one per cent. "These are the people I want to help you with," he said. He asked for assistance reaching them. "Introduce me to your worst-of-the-worst patients," he said.

They did. Then he got permission to look up the patients' data to confirm where they were on his cost map. "For all the stupid, expensive, predictive-modelling software that the big venders sell," he says, "you just ask the doctors, ‘Who are your most difficult patients?,' and they can identify them."

The first person they found for him was a man in his mid-forties whom I'll call Frank Hendricks. Hendricks had severe congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of smoking and alcohol abuse. He weighed five hundred and sixty pounds. In the previous three years, he had spent as much time in hospitals as out. When Brenner met him, he was in intensive care with a tracheotomy and a feeding tube, having developed septic shock from a gallbladder infection.

Brenner visited him daily. "I just basically sat in his room like I was a third-year med student, hanging out with him for an hour, hour and a half every day, trying to figure out what makes the guy tick," he recalled. He learned that Hendricks used to be an auto detailer and a cook. He had a longtime girlfriend and two children, now grown. A toxic combination of poor health, Johnnie Walker Red, and, it emerged, cocaine addiction had left him unreliably employed, uninsured, and living in a welfare motel. He had no consistent set of doctors, and almost no prospects for turning his situation around.

After several months, he had recovered enough to be discharged. But, out in the world, his life was simply another hospitalization waiting to happen. By then, however, Brenner had figured out a few things he could do to help. Some of it was simple doctor stuff. He made sure he followed Hendricks closely enough to recognize when serious problems were emerging. He double-checked that the plans and prescriptions the specialists had made for Hendricks's many problems actually fit together—and, when they didn't, he got on the phone to sort things out. He teamed up with a nurse practitioner who could make home visits to check blood-sugar levels and blood pressure, teach Hendricks about what he could do to stay healthy, and make sure he was getting his medications.

A lot of what Brenner had to do, though, went beyond the usual doctor stuff. Brenner got a social worker to help Hendricks apply for disability insurance, so that he could leave the chaos of welfare motels, and have access to a consistent set of physicians. The team also pushed him to find sources of stability and value in his life. They got him to return to Alcoholics Anonymous, and, when Brenner found out that he was a devout Christian, he urged him to return to church. He told Hendricks that he needed to cook his own food once in a while, so he could get back in the habit of doing it. The main thing he was up against was Hendricks's hopelessness. He'd given up. "Can you imagine being in the hospital that long, what that does to you?" Brenner asked.

I spoke to Hendricks recently. He has gone without alcohol for a year, cocaine for two years, and smoking for three years. He lives with his girlfriend in a safer neighborhood, goes to church, and weathers family crises. He cooks his own meals now. His diabetes and congestive heart failure are under much better control. He's lost two hundred and twenty pounds, which means, among other things, that if he falls he can pick himself up, rather than having to call for an ambulance. . .

Read the entire report in the New Yorker, January 24, 2011, Issue . . .
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How the new sciences of human nature can help make sense of a life.
  

The New Yorker | Annals of Psychology | Social Animal
by David Brooks

Researchers have made strides in understanding the human mind, filling the hole left by the atrophy of theology and philosophy.

. . . Occasionally, you meet a young, rising member of this [Composure Class] at the gelato store, as he hovers indecisively over the cloudberry and ginger-pomegranate selections, and you notice that his superhuman equilibrium is marred by an anxiety. Many members of this class, like many Americans generally, have a vague sense that their lives have been distorted by a giant cultural bias. They live in a society that prizes the development of career skills but is inarticulate when it comes to the things that matter most. The young achievers are tutored in every soccer technique and calculus problem, but when it comes to their most important decisions—whom to marry and whom to befriend, what to love and what to despise—they are on their own. Nor, for all their striving, do they understand the qualities that lead to the highest achievement. Intelligence, academic performance, and prestigious schools don't correlate well with fulfillment, or even with outstanding accomplishment. The traits that do make a difference are poorly understood, and can't be taught in a classroom, no matter what the tuition: the ability to understand and inspire people; to read situations and discern the underlying patterns; to build trusting relationships; to recognize and correct one's shortcomings; to imagine alternate futures. In short, these achievers have a sense that they are shallower than they need to be. 

Help comes from the strangest places. We are living in the middle of a revolution in consciousness. Over the past few decades, geneticists, neuroscientists, psychologists, sociologists, economists, and others have made great strides in understanding the inner working of the human mind. Far from being dryly materialistic, their work illuminates the rich underwater world where character is formed and wisdom grows. They are giving us a better grasp of emotions, intuitions, biases, longings, predispositions, character traits, and social bonding, precisely those things about which our culture has least to say. Brain science helps fill the hole left by the atrophy of theology and philosophy.

A core finding of this work is that we are not primarily the products of our conscious thinking. The conscious mind gives us one way of making sense of our environment. But the unconscious mind gives us other, more supple ways. The cognitive revolution of the past thirty years provides a different perspective on our lives, one that emphasizes the relative importance of emotion over pure reason, social connections over individual choice, moral intuition over abstract logic, perceptiveness over I.Q. It allows us to tell a different sort of success story, an inner story to go along with the conventional surface one.

To give a sense of how this inner story goes, let's consider a young member of the Composure Class, though of course the lessons apply to members of all classes. I'll call him Harold. His inner-mind training began before birth. Even when he was in the womb, Harold was listening for his mother's voice, and being molded by it. French babies cry differently from babies who've heard German in the womb, because they've absorbed French intonations before birth. Fetuses who have been read "The Cat in the Hat" while in the womb suck rhythmically when they hear it again after birth, because they recognize the rhythm of the poetry.

As a newborn, Harold, like all babies, was connecting with his mother. He gazed at her. He mimicked. His brain was wired by her love (the more a rat pup is licked and groomed by its mother, the more synaptic connections it has). Harold's mother, in return, read his moods. A conversation developed between them, based on touch, gaze, smell, rhythm, and imitation. When Harold was about eleven months old, his mother realized that she knew him better than she'd ever known anybody, even though they'd never exchanged a word. . .

Read the entire article from the New Yorker, January 17, 2011, issue . . .
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