I I, pp.
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AND HEALTH PSYCHOLOGY
Abstract-Despite long-established roots in experimental psychophysiology and psychosomatic medicine, behavioral medicine and health psychology have only recently emerged as recognized, highly visible disciplines within medicine and the behavioral sciences. The rapid development of these fields has resulted partly from important scientific advances in the biomedical and behavioral sciences and partly from changing societal concerns and values. The latter include a greater preoccupation with individual self-expression and self-fulfillment, a decline in respect for authority per se, and an increased skepticism about social institutions. Coupled with these changes has been an increasing desire to take responsibility for one’s own life and, in matters of health, of one’s own body. The ways in which scientific advances and social changes have influenced the shape of contemporary behavioral medicine and health psychology are explored with the aid of two illustrations: the growth of a developmental perspective in behavioral medicine and health psychology; and work and health, including the effects of job stress and unemployment. Finally, the author stresses the need for a greater sense of community and concern for others, if we are to succeed in creating a growth-enhancing, health-producing climate for society as a whole and for each of us as individuals. Resume-Bien qu’enracinee depuis longtemps en psycho-physiologie experimentale et en medecine psychosomatique, la medecine du comportement et la psychologie de la Sante ont emerge relativement recemment seulement, en tant que disciplines reconnues par la medecine et les sciences du comportement. Le developpement rapide de ces disciplines s’est produit en partie grace a des progrts scientifiques importants dans les sciences biomedicales et du comportement et en partie parce que la societe a tvolue quant a ses finalites et ses valeurs. II existe en effet une preoccupation grandissante pour I’auto-expression et I’epanouissement individuel et un declin du respect pour I’autorite per se avec un scepticisme grandissant quant a la valeur des institutions sociales. Avec ces changements, s’est revele un desir toujours plus grand de I’individu de prendre en charge sa propre vie aussi bien en ce qui concerne sa Sante et son propre corps que le reste. Dans cette revue, I’auteur explore les influences que les progres scientifiques et les changements sociaux ont cues sur la medecine du comportement et la psychologie de la Sante: il se sert pour cela de deux exemples: la croissance dune perspective developpementale dans la medecine du comportement et dans la psychologie de la Sante et egalement I’influence du travail ou du manque de travail sur la Sante. Entin, l’auteur souligne qu’il faut developper au sein du public un sens plus grand de la communaute et une plus grande preoccupation pour autrui: c’est la la cle du succes si I’on veut creer un climat favorable a la croissance et a une meilleure Sante individuelle et collective.
ROOTS in experimental psychophysiology and psychosomatic medicine [I], behavioral medicine and health psychology emerged as recognized, highly visible disciplines within medicine and the behavioral sciences less than two decades ago [2, 31. Until recently the dominant focus within medicine, including psychiatry and the burgeoning field of clinical psychology, remained on the etiology and treatment of disease, rather than on prevention and the active promotion of health. Furthermore, within medicine generally there was, for the most part, relatively little recognition of the complex roles played by psychological and social factors in the development of illness or the improvement of health [4,51. Based in part on an invited address to the 92nd Annual Toronto, Canada, August 24-28, 1984. Reprint requests to John Janeway Conger, School of Medicine, Denver, CO 80262.
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It would have been difficult indeed in the early 1950s to conceive that the Institute of Medicine of the National Academy of Sciences, under the leadership of David A. Hamburg (with the strong support of Julius B. Richmond, then Surgeon General and Assistant Secretary for Health) would select health and behavior as a preeminent focus of the Institute in the late 1970s and early 1980s a self-assigned mission carried out with signal success [51. Nor could one have easily predicted the concommitant flourishing of an active, productive Division of Health Psychology of the American Psychological Association or the formation of an Academy of Behavioral Medicine Research [2, 6, 71. How did all of this happen? Behavioral medicine and health psychology are concerned with the role of behavioral factors, not only in the etiology and treatment of disease and illness, but also in the active promotion of health, both physical and mental [3, S-IO]. Furthermore, they are at least as concerned with prevention as with treatment. If one accepts these basic tenets, one understands how the strong emergence of these disciplines has been a function both of important scientific advances in substantive knowledge and new methodologies and also of important social, psychological, economic and demographic changes in the world in which we live.
AND THE GROWTH OF HEALTH
Rapid scientific advances in biology and medicine have contributed to the growing importance of biobehavioral approaches in several ways. For one thing, as noted in the Institute of Medicine’s study on Heulth and Behavior , “the burden of illness in this country has shifted from acute infectious diseases to chronic diseases with multiple interacting risk factors, which predominately include such behavioral elements as smoking, alcohol, exercise, diet, and response to stress [5:21]. Indeed, as much as 50% of current mortality from the 10 leading causes of death in the United States can be traced to “lifestyle.” These include deaths from heart disease and stroke, cancer, accidents, poisoning, and violence-including family violence. Continued progress in reducing mortality and, equally importantly, in reducing health-related restrictions on activity from hypertension, heart conditions, eating disorders, and the like, will depend in large measure on our ability to prevent or modify such behavioral risks to health as cigarette smoking, excessive consumption of alcohol and a variety of other drugs, unhealthful dietary habits (including excessive consumption of calories, cholesterol, fats, and salt), lack of appropriate physical exercise, and problems in coping with stress [2, 5, 8, 111. While scientific progress in the physical prevention, diagnosis, and treatment of disease has dramatically increased the relevance of biobehavioral approaches and their potential importance, recent substantive and methodological advances within behavioral medicine and health psychology have created many exciting new avenues of research and practice. Recent advances in knowledge of the mechanisms involved in stress-related immunosuppression and new or improved methods of measurement of a variety of indices of immune function have facilitated a wide range of animal and human studies of the role of behavioral factors in the functioning of the immune system, and in the onset of immunologically influenced illnesses [12-141. Better psychological measures are improving our ability to assess risk for coronary heart disease, as in the case of “potential for hostility” and inability to express anger, as apparently the critical components of what has come to be known as Type A behavior [ 15, 161. Recent developments in the ability to measure hormones and brain control of hormones, that were previously unmeasurable, may help us to better understand a number of health-related behavioral issues, such as the effects of stress and exercise . We are gaining a much more sophisticated and dynamic un-
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derstanding of the metabolic processes involved in smoking and in eating behaviors, including the effects of repeated cycles of weight loss and subsequent gain [18, 191. Research in attribution theory, coping behavior, social learning theory, behavior modification, mass communication, social cognition, cognitive styles, stage theories of development, self-management theories, and locus of control, each of these approaches and others, though often far removed initially from research on health and illness or prevention and treatment, has proved useful in furthering research and practice in behavioral medicine and health psychology.
OF SOCIAL CHANGE
While the increasing emphasis on health, prevention, and the importance of behavioral factors is partly a logical consequence of scientific advances, it is also the result, as is so often the case for new directions in the scientific enterprise, of changing societal concerns and values. Furthermore, the motivation for this greater attention to prevention and the active promotion of health has come at least as much from public pressures and concerns as from changes within the health professions themselves. The so-called “me” decade of the 197Os, or what Christopher Lasch has called “the new narcissism,” had its roots in the greater “freedom to be me,” to do “one’s own thing,” that emerged from the 1960s [20, 211. Initially, for many at least, the insistence on one’s own individual rights and the need for self-expression was linked to-indeed, in large measure stemmed from-a concern for the rights of others. Although this concern had its roots primarily in the civil rights movement in the early 1960s. it rapidly expanded to include other victims of discrimination and stereotyping-native Americans, the poor, gays, children, women, and the elderly. As awareness of the difficulty of achieving meaningful social change set in, as well as a growing recognition that the social revolution of the sixties, like all revolutions, had produced not only its triumphs but also its share of casualties and walking wounded, the picture shifted. What emerged was a greater preoccupation with oneself and a diminished concern with the needs of others, particularly strangers, in the confusing world in which we live today. As noted elsewhere, this preoccupation manifested itself in many ways as we entered the 198Os, some positive, some negative . On the positive side, many Americans, particularly but by no means exclusively the young, showed a renewed interest in their own physical and psychological well-being. Exercise, conditioning programs, concern for nutrition and environmental pollution, stress management, meditation, relaxation techniques, and the like became the order of the day. In many of their concerns with fitness, members of a new generation of consumers were considerably ahead of many scientists. physicians, and other presumed sources of expert knowledge. In nutrition, for example, physician education, or even serious interest, was astonishingly inadequate and even now generally needs considerable improvement. One of the important social changes of the 1960s and 1970s that helped to establish a new kind of health consumer was the decline in respect for authority simply as authority, the loss of an unquestioning faith in social institutions that was one of the legacies of the civil rights movement, the Vietnam war, Watergate, corruption at the highest levels of government, and destruction of the environment [20, 22-241. Skepticism increased toward all social institutions-government at all levels, big business, big labor, the schools, the press, the military, even the churches and the courts. Consequently, it would have been rather surprising if skepticism about the infallibility of scientists and health professionals,
John Janeway Conger
and especially their institutional embodiments, had not also increased, not only among lay people but among professionals themselves. Coupled with this shift has been an increasing desire to take responsibility for one’s own life and, in matters of health, of one’s own body. For many, simply carrying out Olympian medical or other health-related dictates is no longer enough. They want explanations about mechanisms, about risks, about alternatives, in what they view as a partnership of interest. With rather irrefutable logic, they assert that proprietary bodily rights, if any, belong to them, not to practitioners or the professions or even the laws of the land. This relatively new shift in role relationships, which an increasing number of the new generation professionals (particularly the more personally secure and less defensive) are encouraging, owes much to the efforts of the women’s movement as the phenomenal success of books like Our Bodies, Ourselves, (“a book by and for women”) provide eloquent testimony [251. It probably should not be surprising that in a number of ways women appear to have taken a somewhat more active role in this effort than men. After all, an important aspect of the women’s movement involved a conscious, determined effort to reexamine stereotyped, previously unquestioned role relationships, particularly those in which dependency, compliance, and accepting another’s definition of oneself, played a prominent part. All of these characteristics frequently have characterized the role of patient, as most of us have been acutely aware at one time or another, particularly during the temporary regressions of serious illness.
OF SOCIAL CHANGE
Current social, psychological, economic, and demographic changes in today’s world have not only helped to influence the shape of contemporary behavioral medicine and health psychology, and the values they reflect, they have also played an important role in determining the dimensions of many of the kinds of problems that confront these disciplines today. In one way or another, these continuing changes are having a significant impact on almost all areas of concern within health psychology and behavioral medicine -from stress and coping, psychoneuroimmunology, and disease prevention to health promotion, treatment of eating disorders, cardiovascular disease, and compliance with health care regimes. Two topics of current interest may serve to illustrate this point: developmental perspectives in behavioral medicine and health psychology, and work and health.
PERSPECTIVES IN BEHAVIORAL HEALTH PSYCHOLOGY
As a developmental psychologist, I naturally welcome the increasing focus of these disciplines on a developmental perspective [26, 271. Clearly, patterns of health or illness in later life frequently have their biological and behavioral roots early in life and are affected by intercurrent events throughout the course of development. This is particularly likely to be the case for patterns of positive health and of disorders associated with aging, including cardiovascular disease, cancer, and depression [2, 51. Consequently, for example, investigations like those of Karen Matthews and others of genetic and experiential origins of Type A behavior in children and adolescents (particularly such apparently critical components as “potential for hostility” and inability to express anger) are
Behavioral medicine in a changing world
most encouraging [28-301, as are studies of the effects of acute and chronic stress early in life and of the development (or lack of development) of coping skills [3 1, 321. There are, of course, other important reasons for adopting a developmental perspective. Risk factors, as well as the nature and extent of opportunities for prevention or intervention, vary with age. In infancy, for example, low birthweight, inadequate nutrition. accidents, and parental neglect or abuse, are among the leading contributors to mortality and morbidity early in life; among the elderly, social isolation and loss, inadequate diet and health care, and decline in the effectiveness of the immune system rank high. Each life stage has its unique challenges, opportunities, and vulnerabilities, many of which have important implications for subsequent patterns of health and behavior. In terms of risk and of opportunities for effective intervention, preadolescence and early adolescence emerge as particularly important stages of development. The onset of adolescence is likely to be a more challenging and difficult developmental period, both for young people and their parents, than either the middle childhood years which precede it or the years of emerging adulthood that follow it. It is typically a time when the individual begins to struggle in earnest with the search for his or her own unique identity, for a sense of who one is and is going to become as a person. This requires a perception of the self as separate from others (despite similarities to them), and a feeling of whoieness, of selfconsistency, not only in the sense of internal consistency at a particular moment but also over time [33, 341. The adolescent, particularly the younger adolescent, is faced with rapid increases in height, changing bodily dimensions, newfound cognitive capabilities, and the objective and subjective changes related to sexual maturation. In addition to these internal changes, he or she is also faced with rapid changes in societal demands and expectations during this period, including the development of a greater independence from parents, choice of educational and vocational goals, and new kinds of relationships with same and opposite sex peers and adults. Obviously, all of these developments challenge the young person”s feeling of self-consistency, and he or she needs time to integrate them into a slowly emerging, positive, self-confident sense of identity. Because the young person is in a state of flux during this transitional period, it is likely to be a time of both heightened opportunity and increased vulnerability. Under favorable conditions, adolescence may provide an opportunity to rework and resolve long-standing, but inappropriate and maladaptive, ways of responding that may be impeding the young person’s continued development [35, 361. Adolescence is also a time when many of the values, interests, patterns of behavior, and ways of coping that will characterize one’s adult life style are formed, for good or ill. As an increasing amount of research indicates, if a young person can develop during these critically important years adaptive ways of responding to the challenges and stresses of life and can avoid health-damaging behaviors, he or she is likely to continue to do so in the adult years. For example, if a young person can avoid smoking, excessive alcohol or drug use, sexual acting out, or disturbed eating patterns during this transitional period, he or she is markedly less likely to engage subsequently in these behaviors 127, 33,37, 38]. This, of course, is one of the principal reasons for targeting smoking and other prevention programs at preadolescent and early adolescent levels [5, 271. Similarly, establishment of positive patterns of exercise and nutrition, of a health ethos, and of adaptive mechanisms for coping with stress is also likely to yield continued future benefits 117, 31, 39, 401. At the same time, however, adolescents are likely to be more vulnerable than adults to the adoption of health-damaging behaviors. In part, this reflects the openness to change, the still uncertain sense of self, the need to define oneself as separate from parents, the greater dependence on and conformity to peers, the heightened risk taking, and the still
John Janeway Conger
relatively limited future time perspective that have traditionally characterized early adolescence. But it also reflects the effects of social changes in today’s world that increase adolescent vulnerability to maladaptive behaviors. For one thing, opportunities for becoming involved in drug use, unplanned pregnancy and other forms of problem behavior abound. Secondly, adult society generally in today’s world, lacking any strong, coherent, reasonably unified set of moral and social values of its own, provides at best a fragmented, inadequate model for young people . Under such circumstances we are not too surprised that use of drugs-though generally leveling off and in some cases (such as marijuana use) declining-still remains near historic highs, that adolescent suicide rates have tripled since 1940, that 11% of all adolescent girls between the ages of IS and I9 in metropolitan areas in this country become pregnant each year, or that eating disorders such as anorexia and bulimia, which are related to identity problems, appear to be increasing [33, 41, 421. The involvement of caring, but authoritative parents provides the best assurance that a young person will get through the adolescent period without excessive turmoil and with a reasonable degree of immunity to internal psychological difficulties and to destructive external pressure, including deviant peer group influences [43,44]. But being an effective parent can be a difficult task in a world characterized by geographic mobility and urbanization, isolation of the nuclear family, a lack of community support systems, age segregation, a decline in adult authority and faith in social institutions, and a rise in youth culture. These societal trends, combined with increases in two-job families, single parenthood, separation, divorce, and remarriage, and, for the poor and many formerly middle-class industrial workers in the rust belt and elsewhere, unemployment and social dislocation continue to make the task of effective parenthood a difficult one for many.
WORK AND HEALTH
Another area of behavioral medicine and health psychology in which social change is having a significant impact is that of work and health. As Robert Kahn and others have noted, work can affect health in a variety of ways. Most obvious, of course, are the direct effects of a polluted or dangerous environment, or one which makes physical demands which do not take into account normal physiological and physical functioning (4.5, 461. In terms of the pervasiveness of their effects, however, social-psychological and behavioral aspects of work deserve at least as much attention. Impersonal working conditions, work that is repetitive and monotonous but still requires close attention, work that has no observable relationship to an ultimate outcome, work in which little or no responsibility or control is delegated to the worker, and work that receives little social recognition, all may produce both subjective and psychophysiological responses to stress, including in some instances chronic disease [ 17, 45-481. Conversely, however, occupations with high degree of direct responsibility, combined with heavy time pressures, can also produce negative health effects. When air traffic controllers were compared with second-class airmen, hypertension was four times as frequent, and diabetes and peptic ulcer twice as frequent in the former group 1491. Even within occupations, significant differences related to these job characteristics can be found. Thus the incidence of hypertension and coronary heart disease is greater for general practitioners than for pathologists and for trial lawyers than patent lawyers f45, SO]. The social climate of work organizations and relations with coworkers can also affect employee health, as indicated by physical symptoms, absenteeism. and sick call rates [45, 48, 51, 521.
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Clearly, recent and continuing social changes have important and still largely unexplored implications for health psychology and behavioral medicine. What will be the effects of increased automation on worker health and well-being? What are the health consequences, positive and negative, of two-career, or more commonly, two-job families? How important for the health of women attempting to combine career, marriage and childrearing are a husband’s psychological support and sharing of homemaking activities, or the availability of adequate day care, support services during illness, and the like? The nature of a job can have important consequences for health, both psychological and physical. What will be the health consequences for women, as more and more move into what traditionally have been primarily male occupations? Will they show the same or differing consequences from men as more women become the trial lawyers, family physicians, or advertising executives, or upper-level corporate managers ? What are, or will be, the implications for health of the marked changes in vocational values that have taken place among young people since the latter 196Os? And finally what steps can realistically be taken to promote the workplace as a healthenhancing, rather than health-damaging environment? For example, Levi and his colleagues  suggest a number of potentially encouraging interventions requiring more research, including: l l l l
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increasing the workers’ control over the work arrangements; providing chances for worker participation in decision making; avoiding monotonous, machine-paced, or short but frequent work tasks; maintaining attentional processes and reaction requirements within the range of human effectiveness and capability; helping workers to see the relevance of their work; avoiding over- and under-work load; avoiding social isolation and facilitating support systems and social contacts among workers; and allowing greater freedom of movement in work tasks.
How feasible are such steps? To what extent is it possible to achieve an appropriate balance between organizational needs for productivity and individual needs for physical and mental health? An increasing number of U.S. companies, particularly in newer brain-intensive areas such as high technology, are supporting health, nutrition, and exercise programs, preventive and counseling services, and day care or other support services [46, 54-561. Such programs have had a prominent place in Japanese corporations for some time. What kinds of health promotion programs are most effective, and how can they be more widely instituted?
AND JOB CHANGES
All of these, and many other aspects of the relationship of social changes to work and health need additional exploration. In many ways, however, these consequences are dwarfed by what Robert Kahn  has called the “the growth of unemployment stress.” Earlier studies of plant closings have documented the effects of job loss: distrust and pessimism, clinical depression, reduced living standards, bitterness, anxiety, irritability, anomie, loss of self-esteem, sharp increases in child and spouse abuse, even suicide [45, 571. The longer the unemployment, the more pronounced were the symptoms. In one plant closing study [57, 581, unemployed workers were found at one stage or another to have increased levels of norepinephrine (noradrenaline), protein bound iodine, serum glu-
John Janeway Conger
case, pepsinogen, and serum uric acid. Hypertension appeared early, but tended to decline if subsequent employment was found; peptic ulcer and arthritic symptoms also increased. The implications of such findings for current social employment trends should be a matter of urgent concern with respect both to older, structurally displaced workers such as former workers in the “smoke-stack” industries of mid-west U.S., and the young, particularly minority youth, in larger cities. Since the recession of the early 198Os, mental health clinics in states like Michigan and parts of Ohio and Indiana have reported being overwhelmed by service needs. Rates of depression, suicide, divorce, spouse and child abuse, and alcoholism have risen significantly. Family physicians and clinics report marked increases in psychophysiological problems and a mixture of anger, distrust, depression, and loss of self-esteem. In a work-oriented society, in which the prevailing folk ethic is that competence, hard work, and doing what society expects will lead to fulfillment of the American dream, there is likely to be a sense of betrayal when a sudden plant closing over which one has no control leads to unemployment and, all too often, a loss of one’s life savings. There are also likely to be adverse consequences for psychological and physical health. But what of young people who are denied admission to the world of work in the first place? Despite the current economic recovery, nearly four out of every ten black teenagers seeking work are still unemployed, and in some inner-city areas the teenage unemployment rate has run as high as 70% or more . We know that such social conditions may produce feelings of alienation, discouragement, loss of self-esteem, increased alcohol and drug use and delinquency, and among adolescent girls increased pregnancy rates, infant morbidity and mortality, and, in some cases, child abuse and neglect . There is still much we do not know about the consequences of lack of meaningful employment opportunities on physical and psychological health and illness. But one thing seems certain: In a work-oriented society nothing is more negative than for an adolescent on the threshold of adulthood to be told by society, in effect, that he or she is simply not needed. Finally, we are seeing clear indications of the adverse consequences for health of the recent economic recession and the Administration’s policy of redistribution of income from the poor to the well-to-do through tax reductions at upper levels, and cuts in food stamps, aid to dependent children, school lunch programs, infant health and nutrition programs and the like [601. A well-controlled study in Massachusetts of the effectiveness of one such program (the WIC program), which provides coordinated health and nutritional services to poor mothers and their infants, found that participation by pregnant women for at least four months resulted in significantly higher birth weight, less prematurity, and decreased neonatal mortality . Furthermore, the longer the participation in the program, the more impressive were the results. Even from a purely financial perspective, the relatively small cost of these nutritional programs is a good investment; it saves later medical and educational costs that are required for children who may have birth defects, mental retardation, or other problems as a result of poor prenatal health care and nutrition. There are indications nationally that rates of infant mortality and morbidity which had been falling steadily in recent decades have now plateaued and may even be rising slightly.
A SENSE OF COMMUNITY
Such findings as these raise an important, even urgent, question: Can the members of a society collectively hope to achieve optimal physical and mental health unless the social
Behavioral medicine in a changing world
structure of the society is itself functionally sound and healthy? And what, in fact, do we mean by a healthy society? In our view the health of a society, like that of an individual, depends on the health of each of its parts for the simple reason that none of the parts can function adequately in isolation-from each other or from the whole. This is true at every level of organization: molecular, biochemical, physiological, psychological, and social in the case of individual health; individuals, family and friends, neighborhoods, communities, the nation, and the community of nations in the case of society and social organization. In particular, research in health psychology, social psychology, and behavioral medicine has made it clear that social support networks can play an important, sometimes essential, role in mediating the effects of stress and stimulating the development of effective coping strategies. For example, adequate and available social support systems can reduce the number of complications of pregnancy for women under high life stress, aid recovery from myocardial infarctions, reduce child and spouse abuse, reduce psychological distress and psychophysiologic~ disorders following job loss, and provide a buffer against emotional and cognitive problems associated with aging [20, 62-641. Yet we are faced with a paradox. Many of the same social changes that have led to a greater concern with prevention and the active promotion of individual health have also tended to work against the maintenance and development of social support systems and a sense of community. For one thing, urbanization, geographic mobility, age segregation, and the generally mistaken notion that “bigger is better,” have all tended to increase the relative isolation of individuals and families from effective communication with other individuals and social institutions. Direct, personal, and continuing interactions in an atmosphere of shared responsibility have become rarer and more difficult, whether with school officials, local government, law enforcement officials, employers, or even health care agencies and hospitals. All too often what should be cooperative, mutually supportive efforts to solve problems become instead adversarial confrontations, especially for the poor and powerless in the current political and economic climate. At the same time, at a more personal level, many of the same social forces that have led Americans to a renewed interest in their own physical and psychological well-being have led to a diminished concern with the needs of others, particularly strangers: on the one hand, the greater preoccupation with self-realization and self-expression (the “freedom to be me”) that was the legacy of the 196Os, and on the other hand, a feeling of diminished ability to influence events in the surrounding world and to establish intimate and lasting relationships with others that was a legacy of the so-called “me decade” of the 1970s. Overcoming the cumulative effects of the various forces that have mitigated against the development of individual and social support systems and a strong sense of community will not be easy. In the final analysis, however, success in creating a growth-enhancing, health-promoting climate, both for society as a whole and for each of us in our individual lives, will depend on our ability to temper our pursuit of freedom with a sense of commitment, a willingness when necessary to subordinate our own immediate desires to the welfare of other human beings. In what have been, and can continue to be, productive efforts to reexamine old stereotypes about social, sexual, and family roles “to realize oneself,” one must be aware that self-realization is not synonymous with self-indulgence, that concern for others is a necessary ingredient of a healthy concern for self, that intimacy is not one-way, and that there can be no true freedom without responsibility and commitment 1201. In our adolescent fantasies we may at times wish it were otherwise, but the fact remains that in the life of a society, as in the lives of its members, there is simply no such thing as something for nothing.
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