by John Crocker
I knew at that moment that despite her pain, Frances did not want to give up hope. The hardy soul who was spending her retirement years repairing trails and fund-raising to preserve Mother Earth was determined to help keep her relationship with her husband alive. She still had the fiery will that had seen her through the many environmental fights she waged. I found her indomitable spirit remarkable.
Because I’d known Frances for so long and we shared a common bond with our love of nature, I didn’t immediately start talking about the specifics of Alzheimer’s, or talk about the effectiveness of medication that can be mildly helpful in some patients with dementia. Instead, we sat together and talked about life. In the small exam room decorated with photos of my own past adventures, I sat close to Frances while she took me back to her earlier days with Eddie. As we talked, it felt as if we were both reliving some of her past experiences with him and also mourning together. We talked about when she first met her husband.
“I boarded a city bus in the pouring rain wearing the most ridiculous old hat to keep my head dry,” Frances told me, her eyes bright with the memory. “Eddie was twenty-seven years old and very handsome. He looked over at me and asked, ‘Where did you ever find a classy hat like that?’ When I took it off, the pooled rain on the top poured onto his lap. We both laughed so hard that I’m sure people on the bus assumed we were the best of friends, which we soon became. We had forty-five more years of friendship during our marriage, and I hope we have a few more.”
This was not a medical encounter, and neither was it a diagnostic exchange. This was a shared emotional and spiritual experience similar to ones I’d had in the forest. In Gombe, more than anywhere else, I had witnessed the coming and going of life, the changing seasons, and the rising and setting sun. My long history with Frances certainly made this intimate sharing possible, but I think it could have happened even between strangers if both were tuned in to their feelings and the spirit of the natural world.
Counselors point out that when most people hear a person express emotional pain and distress over a particular situation, they respond by trying to fix it. Many times, however, the person experiencing the pain needs someone to just listen and be with them. An attempt to “fix” things may not provide comfort. There are experiences in life that aren’t “fixable.” Loss remains loss; sorrow remains sorrow. These are human experiences that we all face at one time or another. When we extend comfort and understanding, the challenge we face is often to simply “be” with the sufferer. As soon as we try to “make it better,” we’re no longer present with him or her in the journey—we’ve removed ourselves. In this situation with Frances, I knew we could discuss treatment options for Eddie later, and we did. For the moment, all she needed was to talk and be heard. Since so much of my time studying the chimps involved merely observing them, this may have engrained in me the habit of quietly observing and listening to my patients before jumping in and trying to fix their problems.
As Eddie’s condition worsened over time, Frances adapted surprisingly well. She discovered other outlets for her emotional well-being in an Alzheimer’s support group and enjoyed the support of others in her community. She has accepted that her love for Eddie endures but that his disease has forever changed her communication with him. Now when I see her, we talk more about her than about Eddie, as Frances enters a new season in her life’s journey.
Robert: Nature Eases Anxiety
During thirty years practicing medicine, I’ve seen patients with anxiety of some form nearly every day. At Gombe, I saw how anxiety could be adaptive but also detrimental if sustained for long periods. For a chimp to patrol the border of his community in a relaxed state might not produce the desired outcome, but to remain in a constantly vigilant and tense state of fight-or-flight is also not sustainable. The high-ranking chimps with pent-up energy and anxiety would let it all out when needed, in displays or just quick drumbeats on a hollow tree buttress. Here, again, my jungle experiences illuminated my practice.
Robert was a patient in his thirties. Single, he worked full-time in the maritime business and enjoyed his work and social life, but his usual level of anxiety had increased. We explored several possibilities and could find no clear answer as to why he felt more anxious than usual.
Soon his increased anxiety was affecting even the most mundane aspects of his life. Robert spoke nervously during one of our appointments and then got a bit choked up as he told me, “I don’t even like to drive the car anymore because I’m afraid something will happen to me.”
I pictured the male chimps Satan, Figan, and Evered pacing along the border that separates their community from the southern community. Always in motion, they seemed tense, but they appeared to be directing the adrenaline that naturally built up in their systems into powerful swaggers and movements. The chimps released their pent-up hormones in aggressive displays and charging behavior.
Then I pictured Robert sitting in traffic with his anxiety and tense muscles, worried and seemingly paralyzed. No movement or release of tension was possible, except for perhaps groaning or shifting in his seat. The adrenaline would likely be passively circulating through his blood as the byproducts and cortisol built up, making Robert feel uneasy and eventually tired. If only he could charge down a hillside, climb high into a tree, or let out a loud vocalization that people could hear hundreds of yards away, he might well feel better.
There are drugs that work well in relieving chronic anxiety and are usually safe and non-habit-forming, including some that are also used to treat depression by elevating the level of the neurotransmitter serotonin. Robert wasn’t interested in taking medication, so we designed a rigorous exercise program that involved jogging every day. It could be as little as fifteen minutes, but twenty to thirty were even better. I did not bring up tree climbing or hurling kerosene cans.
For anxious patients, I sometimes demonstrate relaxation techniques that they can do on their own. One that I shared with Robert involves slow breathing and picturing oneself on a warm, sandy beach or in another favorite sanctuary. These visualization techniques have been used in meditation and prayer for centuries and can also be used to self-calm. Patients find that they can create a sense of tranquility during this exercise and are then able to transfer it to other parts of their lives. Eventually, they can get to the relaxed state with just a quick visualization or a few deep breaths.
During the guided breathing exercise, Robert seemed to enter a relaxed state right away. He closed his eyes and sank deeper into the chair; his arms and legs didn’t move. He looked so restful that I stopped talking and just let him be. Occasionally patients fall sound asleep in a few minutes. When I asked Robert to slowly open his eyes, he smiled and didn’t say anything. I asked, “Do you want to describe your peaceful place?”
He looked at me with raised eyebrows and said, “It’s not a warm, sandy beach. It’s the apple orchard at my grandparents’ farm in Eastern Washington. My grandparents always took time for me, and whenever I visited them, they would walk with me through the orchard. They loved telling me stories and hearing about my life. I knew I could tell them anything. I always felt secure when I was around them. At times, I sense the same comfort even when I’m alone among the apple trees.”
“Wow!” I said. “That sounds like a wonderful place.”
I thought of my own daydreams of the African forest, and I could relate to the security Robert’s grandparents had provided him amid the trees. His apple orchard was like my Gombe. We all carry some special place inside us that we can retreat to during times of stress. To find that place, and hang on to it, can give us refuge when life’s stress becomes too much. And it’s so often outdoors, and it’s so often a place in which we’ve experienced loving support.
Robert had received the training to do his professional work well but not the tools he needed to accommodate his specific wiring of being a highly vigilant and cautious person. In the chimp community, touching while grooming and embracing after excitement c
an create calmness in seconds. Vigorous travel through the forest also likely helps expend energy and release the tension built up during everyday chimp life. In our modern and fast-moving human society, however, long periods of time can pass before we touch another person, breathe fresh air, or move our bodies, other than our hands to manipulate our electronics. Interpersonal conflicts with friends and coworkers can cause stress and anxiety that remain bottled up for long stretches of time. I wonder sometimes if our complex brains that enabled us to build a computer and fly to the moon have also pushed us into undesirable emotional states.
Perhaps as humans, our next mission should be to better understand how to create that feeling of calm and those joyful interpersonal connections that nurture us throughout our lifetimes. I suppose this was one of the reasons I became so excited to study early primate development, searching for clues as to what we need early on in our lives to support long-lasting inner peace and self-confidence. With each passing year in my practice of medicine, I have learned more about how an individual’s unique genetic makeup will influence this formula. For instance, a more extroverted and less sensitive person might have thrived in Robert’s job and social situation without the accompanying paralyzing anxiety and without needing to learn the coping skills Robert had to learn to be more happy and well-adjusted.
Ruth, Margie, Scott, Faben, and Madame Bee: Creative Adaptations in Humans and Chimps
Having studied human biology in college and then observing chimps as they adapted to tough conditions, I often think about how people and other primates learn to face environments for which they might not be genetically or emotionally suited. Sometimes I even picture certain friends or patients in an entirely different place and time, such as a mountain village in Nepal, a town in northern Italy in the 1800s, or an ancient African forest, thinking that their traits might be more appropriate there. Carl, for instance, might have been a shining star in a past century helping out on the farm using his mechanical skills or caring for animals, maintaining a strong sense of purpose. He might have been greatly appreciated instead of criticized. Robert, with his anxiety, might have been a good castle guard in medieval times as he paced the perimeter watching for invaders. In addition to some of my patients and the Gombe chimps, my grandmother inspired me with her creative adaptation skills.
My grandmother Ruth, who lived to 106, surrounded herself with beautiful trinkets and sparkling jewelry and always wore elaborately designed scarves to complement her attire. She dreamed of having a stately Tudor home like the ones her husband designed and built overlooking their city, but my grandparents’ house in Portland was small and on a busy street, with Grandfather’s business office attached to the front on the lower level, and the upper level rented out as an apartment. Nonetheless, Grandma Ruth made the living room and dining room on the main floor her sanctuary. Ceramic Chinese lanterns above the fireplace, oriental carpets, and fancy satin curtains made you feel like you were in a grand palace. She adapted to her modest circumstances by creating a vibrant, luxurious space that expressed her artistic nature.
Grandma Ruth had also purchased an ornate, gold-colored, tinseled staff. Somehow this decorative item made its way from her house to mine when I was growing up. At times, my siblings and I would flash it around in play. It became a reminder to me of Grandma Ruth’s sumptuous living room—emblematic of her personal fantasy—but more important, it became part of my own escapes into fantasy and daydreams, as I imagined the staff belonging to a prince or a queen. Imagining these different scenarios served as an escape from conflicts at home or boring lessons in the classroom. Even today, I can picture the staff and immediately feel transported into creative times in my life, whether daydreams about flying carpets or dressing in wild costumes for Halloween.
In my practice, a teenage patient, Margie, also used fantasy to adapt to daily life. When I met Margie, she initially appeared to be a nonconversant, disinterested, and unanimated teenager. She wore mostly black.
Then I asked about the book she was reading, which had winged dragons, towering castles, and swirling capes on its cover. With a smile that could light up a dark room, Margie said, “This is what keeps me sane.” It was post–Harry Potter reading that consumed much of her time.
Fantasy-adventure books may have been just a straightforward interest, but Margie was both very smart and quite sensitive to her surroundings. She admitted being overwhelmed by a fast-paced family life with both parents in business and keeping tight schedules at home. Margie couldn’t see the point of this pace, and wanted more free time just to relax and be herself. She was expected to get top grades and do well in swimming, and was encouraged to run for student body vice president for the leadership experience. Instead, Margie found her creative niche by writing for the school paper and cultivating a few close, mildly eccentric friends who made her social life interesting. She had identified a safe and stimulating environment suited to her personality and talents. Reading fantasy novels had helped her balance the demands that her world placed on her by propelling her into creative outlets that were meaningful to her. It was intriguing to hear how her individualistic behavior helped her adapt to her stressful surroundings.
It has also been my privilege as a doctor to learn how individuals adapt and succeed while facing extreme physical challenges. Scott was a patient who had become quadriplegic in his twenties when riding in the back of a pickup truck that struck another car. Today, forty-two years after his accident, Scott is still thriving with his wife and grown stepchildren. Though dependent on help from others and struggling with his health, he maintains an amazing attitude. His deep-rooted optimism and humor about life serve him well. He always communicates with me from a positive perspective, even when shaking from a fever or acknowledging the need for a leg amputation. “It won’t affect how I dance in my wheelchair, which I’ve done for the past twenty years,” he told me before his leg surgery. I’m in awe at how Scott and other patients forge ahead with their lives despite the obstacles, dispelling preconceived assumptions about how their lives will evolve.
I remember observing two chimps at Gombe who survived and adapted to physical challenges. Madame Bee and Faben contracted polio, and each lost the use of an arm, which would seem insurmountable in the wild. Nevertheless, Faben adapted to his handicap by learning to walk upright, and with one very strong, functional arm, Madame Bee raised all her offspring. Since survival in the chimp community requires that each individual care for himself or herself after childhood, watching these chimps adapt and live without help was very impressive.
We parents all try hard to engender adaptability in our children. Still, a child’s temperament or innate traits, which we can’t control, can deeply affect the equation. The shy, sensitive child or adult will certainly learn to adapt differently than the outspoken extrovert. In the case of the chimps, it’s clear that their need to survive in the wild tests their temperament to a high degree, as in the case of losing a mother. Flint, at age eight, was the only Gombe infant over the age of six to die as a result of his mother’s death. Perhaps his emotional dependence on Flo was partly due to his dependent and submissive nature—in contrast to the more independent chimps, who could adapt to surrogate mothers as they survived the loss of their own.
I believe that one’s ability to bond well and be adaptive in close relationships with other people may be a result of forming a trusting bond early in life with one or both parents, but I realize that some of my patients learned to adapt well to life’s challenges despite a harsh early environment. Perhaps genetic traits are at play in these cases, once again underscoring the importance of both nature and nurture in our development.
Whenever I ponder the remarkable adaptive behaviors of humans and chimps, my thoughts return to Grandma Ruth. Though her gold-tinseled staff is long gone, I keep it in my memory, conjuring images of designing floats for the Portland Rose Festival Junior Parade and of Grandma creating an exotic wardrobe and adorning her modest home with treasures she’d
found at thrift shops or yard sales.
But most important, I’m reminded of Grandma Ruth’s mantra: “I am very grateful for having had such a wonderful and long life.” I try to remember the word “grateful” when life is challenging. I hope my sons can use their creativity to adapt to life’s trials and that Fifi’s great-great-grand-offspring can do the same. And I hope that being raised by loving parents helps them too.
Personal Stories Keep Me Going
Many other patient relationships have kept my interest in and appreciation for my profession going strong over the years. This compensates for the necessary but more tedious time I spend on the computer viewing lab results and nursing-home requests and refilling prescriptions for medications. In some ways, my months of observing chimpanzees without ever getting bored remind me of the thousands of patient encounters that still bring enthusiasm and joy to my work.
My eldest son, Tommy, with his interest in Eastern religion and meditation, pointed out to me that being totally “present” during these patient interactions might also explain why I feel so content when I’m in the exam room with them. I can’t think ahead to the next consultation or commitment or look back, regretting not having completed some task or another. When I’m with a patient there is no opportunity for my mind to wander. I take in a variety of information that requires uninterrupted focus. I must listen carefully to the patient’s history and symptoms as I formulate a diagnosis, contemplate a possible treatment plan and consider psycho-social issues that might be contributing. It is rather like being a detective vigilantly sifting through information for clues. Some refer to this state of intense focus as being “in the zone.” I am there, fully absorbed, mindfully attentive with the patient just as I was while observing the chimpanzees at Gombe.