How to stay calm when you know you'll be stressed by Daniel Levitin
Introduction
A few years ago, on a cold winter’s night in Montreal, I made the unfortunate mistake of leaving my keys inside the house. As I stood on that porch after getting back from my friends place at around midnight, shivering under the wrath of 0 degrees Celsius, I realised this could be a long night if I didn’t figure out something quick. As if teasing me in my moment of vulnerability through the window, I could see my keys on the kitchen table inside, warm and cosy, sitting exactly where I left them. Frustrated, I decided to go and frantically attempt to open all of the windows around my home, but much to my disappointment they were all locked. Knowing a locksmith at this time of night would cost a small fortune and may take a couple of hours to arrive, I weighed up my options. I couldn’t stay at my friend Jeff’s place that night because I needed to get my passport in my suitcase inside to get on an early flight to Europe the following morning.
So I decided to pick up a large rock and throw it through my basement window. After clearing up the shattered glass on the floor, I put up a piece of cardboard over the window, aiming to get my contractor to fix that in the morning. A costly decision yes, but cheaper and quicker than a locksmith, so I justified it.
I’m a neuroscientist by training, so I know exactly what was happening in my body during the stressful event on that night. I had copious amounts of cortisol being secreted, raising my heart rate, modulating my adrenaline levels and kicking off sympathetic activation which ultimately works to cloud my thinking. While I can talk all about what was happening in my body in retrospect, it's impossible to identify that your judgement is clouded when you're experiencing it. So when I woke up on only a few hours of sleep that morning and was bombarded with anxiety about the damages I was going to have to pay, whether I was going to catch my flight in time, my meetings I was going to have later that night and so on, I didn’t have time to think logically about the real reason I actually broke into my own house in the first place. What I mean by this is I ended up driving all the way to the airport and it wasn’t until I got to the flight desk that I realised I had left my passport at home! So I ended up racing back on the icy roads back to my home which took 40 minutes each way desperately hoping to get back to the airport in time to catch my flight. As I got there, I managed to make it just in time but they had given my seat away, so I ended up with a seat right at the back of the plane that would not recline. Perfect to give me plenty of time to reflect on my objectively erratic thinking and disordered choices over the last day.
The Premortem:
So I guess it begs the question; are there things that I could do, systems that I could put into place to prevent bad things happening? Or at least mitigate the likelihood of bad things snowballing into a catastrophe. I didn’t really get to answer to this until a month later, when my thoughts began to crystallise on this very issue. I was having dinner with Daniel Kayneman, the Nobel prize winner and as I somewhat embarrassingly retold him the events of that forsaken night, he told me that he had been practicing prospective hindsight (also known as the premortem), as he had learnt from the psychologist Gary Klein. In contrast to the calamity of a postmortem which aims to mop up a mess after-the-fact, the premortem is all about how one can look ahead and map out all the things that could go wrong in a situation to brainstorm ways to prevent them from happening or at least minimise the damage.
Spatial Memory
So what kind of things are involved in the premortem? Well let’s start with the easy ones. First of all around the home, designate a place for things that are easily lost. There’s a lot science to back this up based on the way our spatial memory works. Our hippocampus in the brain has evolved to keep track of the locations of important things; including where the well is, where the friendly and enemy tribes live, how squirrels find their nuts, etc. In fact, a study was done whereby a squirrels olfactory nerve was cut off, but despite this, it was still able to find its nuts, due to its hippocampus and its spatial memory. Our hippocampus is however not so good for things that move around. So, designate a spot in the home for putting stuff you assess as easily lost; perhaps dust off that old bookshelf in the loungeroom you haven’t used for years, and turn it into a storage centre for your car keys and other valuables. Maybe use one set of desk drawers in the study to specifically put your passport and other essential travel items. When going on an overseas holiday, take a photo and mail a copy of it to yourself of your flight booking confirmation and other essential documentation. Remember that when you’re under stress, you release cortisol, which is toxic to the brain. Part of the premortem is accepting that your judgement is clouded when you’re under stress.
The NNT
What about other real world applications, you ask? Well, there’s arguably no more stressful situation than when there’s a life changing medical decision about to take place. And at some point, all of us are going to be in that position to make these momentous decisions about the trajectory of one’s medical care, so it’s important to look at applying the premortem in these contexts too.
Let’s take this example
Let me cut off the case study right there. At this point, I would ask David if he would consider asking the doctor a question which will likely make him feel uncomfortable answering, and pharmaceutical companies even more so. David should ask the doctor about the “Number Needed to Treat” (NNT). It’s the number of people that need to take a certain drug before one person is helped. I hear your silent protest, don’t worry – I can see you sitting there exclaiming “but that’s stupid – the number should be 1. My doctor wouldn’t give me something that doesn’t work”. But unfortunately that’s not how science works, and it’s not the doctor’s fault or anyone’s fault really – it’s just because research is ongoing in most medical fields. GlaxoSmithKline (GSK) estimates that 90% of the drugs work in only 30-50% of people. So the NNT for the most widely prescribed statin is actually 300, according to research practitioners Jerome Groopman and Pamela Hartzband and independently confirmed by Bloomberg.com. I even ran the numbers myself.
David may still be sitting there, and while knowing that 300 people will need to take this drug in order for you to reap the benefits of it, he’s still willing to try this drug. At this point, I would ask David to ask about the side effects of the drug. In this case, the doctor has a duty to disclose that in about 5% of patients, there are some serious side effects of using statins including gastrointestinal issues, debilitating muscle and joint pain. David may still in this moment want to take the risk, and is getting increasingly agitated. Here’s where cortisol starts to kick in and cloud David’s judgement, and the catalyst for poor decision making.
This case shows the importance of thinking ahead in time, and do the critical thinking beforehand. If 300 people take the drug, 1 person is helped and 5% of those 300 people have side effects meaning 15 people. You are 15x more likely to be harmed by the drug than helped. Now I’m not advocating for refusing to take medications from your doctor at all – or to refuse to take drugs. I’m just stressing the importance of thinking about big decisions when your brain is free of the stresses situations can pose, with the key example here being a clinical environment. In fact, you have a moral and legal right to this information as part of informed consent.
For the most widely performed surgery on men over the age of 50, the removal of the prostate for cancer, the NNT is 49. That’s right – 49 surgeries are done for 1 person to benefit. The side effects in this case occur in 50% of patients; impotence, erectile dysfunction, faecal incontinence and so on. If your lucky, these will only last a year or two.
Summary
Think ahead in life, and prepare for the worst. You need to make decisions about your life all the time, including whether to choose a shorter life that is pain free or a longer life that may have to deal with more suffering later on. It’s important to practice this kind of thinking when you're in a sound mind, rather than when in stressful settings. Remember that in times of stress, cortisol is released which shuts down essential organs which primes our body for fight or flight responses, and while giving us a boost of energy it unfortunately impairs our rational thinking.
Accepting that we are flawed is the first step, but the next step is to think about all the possible things that could go wrong, and prepare so you can provide a safety net of rational contingencies in these cases. I make no claim that I’m the most organised person, but since my incident in Montreal I’ve installed a combination lock with an easy to remember passcode and backup key, and while I may still have hundreds of unread emails, at least I have not been locked out of my house again.
