by John Crocker
Notebook in hand, I arrived at a beautiful house in Marin County. Japanese gardens surrounded the house with bamboo trees and a trickling stream. When I knocked on the stately door, my study participant, Kumi, graciously welcomed me. After removing my shoes and entering the immaculate living room, I noticed the serenity of the home. Kumi lived with her Japanese-American husband, who was away working at the time of my visit. The couple had no children. Kumi was in her midthirties and dressed in a casual but elegant style.
Kumi was an issei, an immigrant who was born in Japan. I never ended up asking the questions I had intended to ask during our interview. Instead, I listened as Kumi spoke candidly about her feelings of isolation over the previous ten years, living away from family in Japan and having limited social connections in California.
“My situation is not the best here because I am too far away from my family,” she confided.
Even though Kumi was a member of the local Buddhist temple, she felt she would be frowned upon if she complained about her situation and lack of friends, since she lived in a beautiful home and had no financial worries. Her main focus was taking care of her home and being a good companion to her mate. “My husband is very involved with his work, and my main purpose is to maintain the home, cook for the two of us, and provide for him emotionally.”
Kumi poured out her feelings about her life. Growing up in Japan, she had been an excellent student and had considered becoming a doctor. She was also closely connected to her family. “I was fond of my mother and full of happiness when my cousins came to our house for celebrations. When I needed someone to talk with, I had two good friends from school I could turn to.”
Kumi’s self-discipline did not prevent her from having lots of fun with friends and relatives back home. Now, her support system, other than her husband, was thousands of miles away, and she could not see how it would ever be replaced in a California suburb.
As a medical student, I was probably not as intimidating as an experienced professional, which I believe made it easier for Kumi to reveal her feelings. I didn’t have the training to know how to respond in a clinical manner, but I realized that Kumi wasn’t really seeking medical advice, just reaching out and needing to talk.
Having so recently returned from Africa, I felt sad for Kumi as I recalled the comfort and support I received from the Gombe community. I too had been far away from family, but I had a purpose and a community of friends to provide emotional support. I thought also about the close-knit members of the various villages and how those villages functioned. It would be unlikely that people would feel isolated in such communities.
I never asked Kumi why she didn’t have children, for fear that this might bring up another issue I wasn’t qualified to address. I felt uneasy about inadvertently stirring up her emotions, and suggested she contact the Buddhist priest, who could provide spiritual support and perhaps find a role for her in the temple and a counselor to talk with. I hoped I’d been an empathetic listener, providing at least a small opening for Kumi to express some of her feelings. I realized more than ever the importance of viewing a person’s health from many angles and how crucial it is for a strong extended family or community to provide emotional support in one’s life. In Dan Buettner’s book Blue Zones, five communities of people living in areas such as a coastal Italian island, Japan, and Loma Linda, California, were found to live to ripe old ages in part due to strong social bonds with family or community.
I wonder even today how Kumi dealt with the few choices she appeared to have. I wonder if, over the years, she found her way into social activities and groups that shared her interests and culture. I saw that for Kumi, feelings of loneliness were defining her day-to-day life. In recent years, there has been a lot of research on happiness and its effect on health. This research has found that the one factor that seems to assure well-being is not wealth, status, or marriage—but strong social bonds.
Carl and ADHD
Understanding the survival strategies of the chimps enabled me to be more engaged—and less intimidated—by certain conditions I encountered later in my practice. This was certainly true when I worked with an eight-year-old named Carl, who had ADHD, or attention deficit hyperactivity disorder, which manifests itself in focus problems and in being restless. During an appointment with Carl and his mother, I viewed his condition from an evolutionary perspective.
Even when I spoke directly to Carl, his eyes searched the exam room and his body was in constant motion. As he tapped his hand on the exam table and kept crossing and uncrossing his legs, he resembled, in a way, a caged, restless chimp.
Many youngsters with ADD or ADHD excel in sports; many have superb endurance and high intelligence. They often have a powerful focus in certain areas, such as computer work and activities requiring concentration, such as engineering. Often, however, they have profound difficulties in school because of the need to sit still in the classroom and listen quietly. Their performance drops and so does their self-esteem. With lower self-esteem comes a steady loss of confidence in all areas of their lives—even activities they once felt secure doing become fraught with anxiety and fear of failure.
Both Carl and his mother lit up instantly when I asked his mother, “Can Carl stay focused when he’s left alone to build with Legos?”
Carl nodded with interest, and his mother said, “Oh my gosh, you wouldn’t believe what Carl can do with Legos!” She described his ability to focus and follow directions to build large and complex structures while Carl looked proud.
Working with Legos requires concentration, motor skills, and willingness to persevere. There are other examples of “play” activities that reveal a child’s talents, despite seeming like they’re just recreational outlets. Playing with Legos illustrated some of Carl’s strengths, and as we discussed what Lego play required of Carl, his mother saw his engineering talents and creativity validated. These traits were in full swing during this activity.
His mother said, smiling broadly, “I thought working with Legos was just playtime!” This activity hadn’t communicated anything significant to her about her son, but now both Carl and his mother saw its importance.
I asked Carl, “How’s school going?” and he just shrugged. He wanted to talk about his Power Rangers and his new Star Wars laser sword. He took a startling leap off the table to demonstrate a powerful action-figure pose, holding his light saber.
As he did this, I told Carl, “I would definitely choose you to be my guide if I were traveling in an African forest and facing a threatening leopard,” and he perked up even more, holding his chest a little prouder. I could see that he would be physically and emotionally driven to defend against an enemy, his searching eyes and quick reflexes crucial to spotting and responding to danger. Carl was not overly aggressive; he just needed to move. His brain didn’t have the pathways activated to allow him to be sedentary and calm—it was not in his genetic wiring. The usual confines of modern living were challenging to him.
I couldn’t help but think that Frodo would have scored high on the ADHD scale. He exhibited many ADHD traits, such as restlessness, high activity level, searching eyes, and an inability to patiently attend to subtle social cues from others, yet he successfully served in his community. He was an excellent hunter and attained alpha male status, channeling his innate aggressive and athletic tendencies to the benefit of the group as a whole. Though most male chimpanzees show aggressive behavior during dramatic displays or when they perceive a threat, Frodo wore those attributes on his chest most of his waking hours. With his large, muscular body, he demonstrated a genetic predisposition to a high level of aggression when he hunted with superb success, nearly broke Jane’s neck, and stole an infant from a Tanzanian mother.
Carl’s genes evolved for a reason, even though the standard school setting was not the ideal place for him to exhibit his talents. The evolutionary perspective seemed to shed some needed light on Carl’s clinical condition. My reinforcement of his personal strengths and ta
lents helped him to feel better about himself and attain feelings of confidence. With that came trust—from both Carl and his mother.
In Carl’s case, the medication Ritalin was needed to help him focus in a school setting. It helped him manage surroundings that didn’t always play to his strengths. He was able to function and succeed in a school environment without undue struggle and frustration. While such medications must be managed carefully, they can activate a pathway in the brain for the type of focus required in the classroom. When a child does indeed need such medications, and the medications work the way they’re supposed to, the child is able to adapt to the demands of school and of peer relationships. Being able to adapt and feel successful leads to a much more positive view of one’s self and being an overall happier person.
My heart would always hold a special spot for kids who were struggling with ADHD. My professional understanding of how talented these patients can be has grown steadily over the course of my career. Hardwiring of the brain resulting in attention disorders also likely bundles with it wiring for many positive characteristics. These traits often go unnoticed because of our focus on the less desirable ones. An impulsive child is often creative, but only the impulsiveness catches the adult eye. In reviewing the literature about common positive traits in people with ADHD, I have seen consistent statements about heightened creativity, spontaneity, intuitiveness, and thinking outside of the box. In my practice, I coach parents to be mindful about focusing on their children’s strengths, likely improving the children’s self-esteem and even their social interactions with peers and teachers.
In the chimp community, both alpha male aggression and ADHD characteristics such as those exhibited by Frodo are necessary to the species’ survival. Though the survival of our own species may now depend on collaboration and intelligence more than on powerful aggression, we can still be hardwired to be more like Frodo than is useful. But when we understand that Frodo-like hardwiring, we’re able to view and use those traits in more productive ways. By recognizing these primitive, instinctive behaviors and reactions within ourselves, we can channel them appropriately. Sports, wilderness adventures, and scientific and technological exploration may continue to provide adaptive outlets for our innate aggressive or restless tendencies.
Sandra and a Sense of Purpose in Chimps and Humans
My observations of chimpanzees convinced me that they are programmed to have a strong purpose—whether it’s caring for an infant, patrolling the border of the community, or simply searching for food. In humans, this might correlate with a deep inner need or drive to be useful, feel appreciated, or feel a sense of accomplishment.
When I encounter patients with depression or anxiety, there are usually complex reasons for the condition. This often includes a family history of depression or difficult early-childhood experiences, but I also take into account the role of purpose in people’s lives. I recognize how evolutionary genetics may program us to feel rewarded for accomplishing tasks we set for ourselves. If a person loses that sense of purpose, depression or anxiety can follow. Sometimes, patients may not even be aware that their sense of purpose has been altered for some reason. They may not make a connection between their feelings of depression and their loss of purpose.
Some of the happiest retirees in my practice talk about the activities that fill their lives now that they no longer work at traditional jobs. They may care for their grandkids, volunteer at senior centers, or work part-time to supplement a fixed income. These activities increase retirees’ feelings of self-worth, giving their lives enhanced meaning as they adapt to aging and the changes it brings. Active and involved retirees tend to be more at peace with the passage of time and their changing place in the world. They don’t feel isolated or shunted aside.
In contrast, I also see male and female patients who fall into depression after they’ve retired from their careers. Their strong sense of identity from their careers has been suddenly lost. Even though a retiree may have time to relax and have fun, there is still a major adjustment to losing this strong life purpose. As one sixty-eight-year-old man told me, “I never thought I would miss work so much.”
In a chimp community in the wild, purpose is ever present. There is no “retirement” for chimpanzees. Foraging for food, fending off baboons or other groups of chimps, building elaborate nests each night, and caring for infants—mother chimps give birth into their forties—are required duties that might also make any primate feel fulfilled.
As a doctor, I see firsthand the key role a sense of purpose can play in a patient’s feeling of well-being. I entered the examination room one morning to find my patient Sandra there, looking miserable. She had two young children, and a husband who traveled a lot.
Sandra admitted, “I guess I’ve been struggling with depression off and on for a while. I don’t know why—nothing’s really wrong. You’d think it would be better when Mark was home, but I almost feel like it’s worse then.”
She went on to explain that when her husband was away on business, she put on her running shoes, literally, and managed to keep it all together. Her husband’s absences put added pressure on her but also provided her a kind of outlet. Running the household and immersing herself in added responsibilities seemed to either distract her from her depression or alleviate it temporarily. With her husband away, Sandra felt a greater sense of purpose, which filled up the time and prevented her from engaging in introspection. Nonetheless, her depression would always come back. Being endlessly busy can provide a kind of solace, but it won’t solve the underlying problem if there is more than just purpose involved.
I suggested that Sandra talk to a counselor to help her understand more about the roots of her depression. “You need to make sure your own needs are being met so you can manage the daily challenges of your busy life.” I thought that with a counselor’s help she might also consider the possibility that her husband’s absences freed her of certain conflicts related to him and that she needed to work on those issues.
When I next saw Sandra, she said, “Thanks for sending me to that counselor. We talked and I realized that I had a conflict between wanting a career in teaching, like my mother had, and wanting to be available for my kids.” She looked much more animated than she had on her last visit as she filled me in. The counselor had said Sandra needed to find her clarity of purpose and identify what she really wanted. Also, she needed to take into consideration the effects meeting her needs would have on her children and husband.
By identifying what she wanted to do with her life, Sandra was able to find ways to follow that path without sacrificing other purposeful demands. She began taking night classes so she could teach a few years down the line, once her children entered school. She found a way to balance their needs with her own. Her face shone with enthusiasm as she shared her vision for the next phase of her life as a working mom. She had set a goal and found new purpose.
With such a seemingly high rate of depression in my medical practice, I decided to ask Jane about the incidence of depression in wild chimpanzees. I hadn’t recognized it in the chimps I had studied during my student days at Gombe. After pondering the question for a few seconds, she said, “Genetically inherited depression would be selected out of any given chimp population’s gene pool in the wild.” Typical symptoms of depression, including lack of interest, social isolation, low energy or fatigue, and lack of appetite would interfere with the chimp’s ability to survive in the wild. Situational depression however, did occur in the Gombe chimps, especially when a young chimp lost his or her mother.
Flint was deeply depressed when his mother died, but lasting cases of depression other than those related to a death were not seen in the Gombe chimps. In the wild, they generally thrive emotionally in an environment they’re wired for, fulfilling what we think of as purpose.
For some humans, a lack of fulfillment can be insurmountable and lead to anxiety and depression, drug abuse, or all three. Additionally, feeling conflicted about one’s ow
n desires can produce anxiety and depression. Modern human life can be filled with foggy uncertainties. We are faced with more choices than chimps and therefore have a stronger need to define our roles and desires in life. The chimps seem to live a life of clarity and drive, as survival behaviors consume most of their waking hours, at least in adults.
Frances and Eddie: Life’s Changing Seasons
There were certainly spiritual moments during my time as a student at Gombe, and I experienced several epiphanies while living in the wild with our primate cousins. One day, four months after arriving as a student, I found myself next to screaming chimps soon after a colobus kill—but I recognized that my heart-pounding response to danger was offset by having an experienced field assistant next to me as well as by my growing understanding of chimp aggression. The forest was my classroom, and the caring attitude of my fellow researchers helped me realize the importance of bonding with those around me. This would be a lifelong influence, and it inspired me as a physician. It sparked an enduring drive to connect with my patients on a very deep and long-term level.
I formed an exceptionally strong bond with Frances, a seventy-five-year-old who had been a patient of mine for twenty-five years. I had enormous admiration for this down-to-earth, wiry, and gracious environmental activist who had given much of her time and money to help preserve the beautiful lands of Washington State.
One day when I walked into the exam room to see Frances, she burst into tears. This unshakable, physically strong, emotionally poised hero of mine was more vulnerable than I’d ever seen her before. “I’m sorry,” she said, taking a tissue.
I shook my head. “Don’t be sorry. What’s going on, Frances?”
“I’m terrified Eddie’s Alzheimer’s disease is advancing rapidly.” She managed to choke out her story. Frances was miserable, feeling she was losing her relationship with her husband after fifty years. Once she had managed to share that, she sobbed for several minutes, then looked up at me with a tentative smile and said, “Damn, life can be tough.”