an outlier


A statue of Buddha in Phnom Penh with a rare expression of intense concentration, unlike the serene expression one usually sees on his face

I have no idea whether most people in the world are happy with the work they do, or what drives them to do what they do.

About fifteen years ago a doctor working in the same hospital as I requested me to see her son because she was worried about his career plan. The boy was a 23-year-old graduate from one of the best engineering colleges in India. He had rejected a paying job that he got through campus placement and chosen to join an organisation that worked for the upliftment of slum dwellers, for a small monthly stipend.

He was self-assured and calm during the conversation. There were no psychiatric symptoms at all and nothing to suggest a personality disorder. He believed that what he was setting out to do was right for him. He was also clear that he wasn’t going to be a financial burden on his parents.

Subsequently I met many youngsters like him and began to realise that it wasn’t uncommon for people of this generation to do something like that.

Most people get degrees that lead to jobs. They look for jobs that pay well and give them a few perks as well. They enjoy the office atmosphere, the company of co-workers, the work itself and the pleasure of an independent income. They look forward to the future. As I said, that’s what most people do.

So who are these outliers? When someone tells me about one of them this is how it often sounds:

  • There’s no rush for him to get a job as he doesn’t have student loans, because his parents are affluent;
  • He doesn’t have to earn and save up to buy stuff because his parents gave him everything even before he thought of asking – spoilt kid, born with silver spoon, doesn’t know the value of money;
  • He knows his parents have enough assets that he will eventually inherit, so he never has to work in his life;
  • He will eventually marry a rich girl and get money from the bride’s parents as well!

When I actually get to know the youngster I discover a wholly different inner world, where none of these are on his radar. They are the minutiae of his life that he barely notices. If he is charming and relaxed I might take a little time to make sure he’s not a clever manipulator skilfully pulling wool over my eyes. Instead, he is intense and rarely cracks a smile, and never attempts to please. There’s an air of urgency and earnestness about him.

I wrote about the brain’s reward centre in my last post. It is apparent that this boy’s brain doesn’t recognise a good job and its perks as a reward. His reward centre seems to urge him to do something that makes a difference to people in need: helping the poor seems more fulfilling to him than writing code.

Did the ‘mature’ defence mechanism of altruism develop naturally in him through childhood because he was raised in a peaceful home, without much conflict with his natural empathic disposition? That is, protoaltruism of parents giving rise to generative altruism in the child. Or is this pseudo-altruism covering up his issues? Altruism is a mature defence mechanism, but a defence mechanism nevertheless.

The concept of altruism has always seemed fraught to me. Sometimes I think it’s better not to look too close when some good comes out of someone’s altruism, though I wonder if it will ultimately harm the doer, but the doer will not recognise it as harm because – wait, is he a masochist! Okay, okay, that’s enough. I simply don’t go there.

Why did Prince Gauthama leave his kingdom, palace, wife and infant son and ultimately become the much-revered Buddha? His background and the sequence of events that led to his renunciation have never been a cogent enough argument to convince me that it was a sudden decision. Maybe it was brewing in his head for years before he took the step.

Perhaps something similar happens to youngsters like the boy whose story I began this post with. A kid gets into a professional college at eighteen in India. That’s too young. In the four years at university he might discover that he isn’t cut out for it. By the time he works out what else he would rather do, four years pass and he’s in the final semester. He decides he might as well complete the course and get the degree and figure his life out later.

How people’s brains are wired is a combination of genes and environment, the way you can create many shades of green by mixing different shades of blue and yellow, adding black or white – or even orange – to get any number of shades. The phenotype doesn’t automatically tell you the genotype. How did you get this particular shade of green in this painting? No idea!

The daily newspaper has been featuring one or two ‘Lockdown heroes’ everyday. If I were to ask these generous people why they did it they might say: “I like doing this, I like helping people.” I wouldn’t want to ask, “Why do you like doing this?”

Everybody’s insides look the same on the operating table – unless there is a diseased organ – and the depths of everybody’s mind might too. So anyone’s answer to “Why do you like doing this?” is bound to disclose self-interest and take away from the warm, fuzzy, happy altruistic feeling. So, “I like doing this” should be morally good enough to qualify as untainted altruism.

To come back to the altruistic kid in question, every engineering grad doesn’t aspire to be a Nadella or a Pichai. Sure, the idea takes a little getting used to for parents, because everything you read and hear says the opposite. Parents need to believe in their youngsters and support them in finding their niche. Usually nobody has the clinching argument in these heated family discussions, neither parents nor kid, because the moot question is what will happen to the kid’s career in the – unknowable – future.


because the human brain is plastic

This is a heuristic take on therapy.

Listening to a patient is not very different from listening to a friend in trouble. As the patient tells her story, you feel her emotions and note her expressions, choice of words and factual consistency, apart from watching for telltale signs of physical illness. You empathise.

Meanwhile, the patient gauges whether you are able to understand her situation and emotions. It’s a two-way process, a lot of it non-verbal, during which mutual trust is established.

Psychotherapy sounds like something the patient passively receives. It isn’t. It’s a dialogue. The patient is a therapist’s ally because she knows herself much better than anyone else does. As professors often reminded us in college, “the patient tells you much more than she thinks she’s telling you, so listen.”

People see a therapist regularly for years for certain conditions, but I’ll leave that aside for the moment. I think therapy, by and large, ought to be brief and goal-directed. The idea is to help a patient learn to catch fish, not sell her some every week. For that I need to do some data mining within her history, personality and current situation and find her raison d’etre.

What keeps her going in life, what motivates her?

Does her motivation come from outside or from within? The type of motivation – external or internal – that drives people depends on their genes. I know that sounds discouragingly immutable, and that bothers me too. But if you look at families you know, or even at your own parents, siblings, aunts, uncles and cousins, you can see how that might work.

To give a simple example, you work either for a reward, or solely because you enjoy it. If your motivation is only internal and you love your work but are underpaid because you didn’t think of negotiating your salary when you accepted the job, you might feel shortchanged and get depressed and anxious. Therapy might help you discover that you need to develop external motivation as well.

But here’s the thing. By nature, you believe a job well done is its own reward. Asking for a raise is something you force yourself to do, something you’re not entirely comfortable doing. You might wish you weren’t wired that way.

Many of the sad stories of people who messed up their lives, and the happy ones of people who fought incredible odds to get somewhere in life, are algorithms that gave them a choice at every point. What motivated them to choose as they did?

A father tells me that he controlled certain personality traits with much effort long before his son was born, but the teenager now exhibits the same distressing traits and risky behaviour. What does it mean, considering only nature is in play here, not nurture, at least to the extent that the father consciously controls his behaviour? Traits – good and bad – are inherited and make you to do things? If this boy should grow up to be a ‘psychopath’, a court won’t let him off because genetic traits motivated him to steal, mug or kill. So therapy might prevent the predictable outcome.

Does learning ‘better coping skills’ and ‘developing mature defence mechanisms’ through therapy merely mean that you learn to exercise self-control and behave more appropriately, tucking away your maladaptive tendencies somewhere in a dark recess of your mind? Or does it change you at a deeper level? Or do people just grow up and grow out of certain attitudes regardless of therapy?

Then, there are people who are satisfied with who they are and what they have. Aren’t they motivated to be famous or acquire more stuff? Perhaps they have simpler ambitions and are easily satisfied. Maybe they are naturally risk-averse. Or wise. Maybe they don’t care about being judged. Or they may be detached souls who consider life a brief stop on a much longer journey of the soul. Either way, that’s how they are wired.

So, is it all down to the genes that control motivation? Where does volition come in then?

There is a tiny structure called the nucleus accumbens in the base of the forebrain. It’s called the ‘reward centre’. The nucleus accumbens is part of a loop that aggregates a lot of information that the brain receives. It is concerned with processing motivation, reward, choice, aversion, fear, impulse and pleasure ­–­ pretty much everything that makes you do, or want to do, anything at all. Your genes might decide what your brain considers a ‘reward’.

Does this mean that therapy changes something in this loop? As the brain is plastic, new neural connections occur every time you learn something. And these new connections possibly change the way you think . . .

Perhaps the new connections re-wire parts of the prefrontal cortex – the part of the brain that thinks and makes decisions – to respond in a more measured way to signals from the reward centre clamouring for gratification. So there is a biological basis for therapy as a treatment modality in Psychiatry.

As the nucleus accumbens also plays a role in reinforcement learning, the new way of thinking possibly becomes second nature. If this is so, the boy in the case mentioned earlier might be able to stop himself from mugging the man walking alone on a dark street if he has received the right type of therapy! Rehabilitation of juvenile offenders is a huge issue for which therapy focusing on each child’s unique reward system might be useful.

There’s so much published about how therapy works and how each part of the brain works. But I don’t think we know how they come together.

In my first year at medical college, I found Embryology fascinating. While it was easy to see how each organ and system was developing, I never understood how they started working. I still don’t.

A page from my Anatomy record – FY MBBS (eons ago!)

For example, the sino-atrial node, the self-sustaining pacemaker in the wall of the right atrium of the heart, starts beating when the embryo is less than a month old. It starts producing action potentials (electrical activity) that start the heart beating, and this continues till the end of life! I can’t imagine how it does that, though I understand how voltage-gated ion channels in the cell membrane generate action potentials using energy from adenosine triphosphate.

And this is a single structure with a single function. Maybe the answers lie neither in biology nor in psychology, and we ought to look for them elsewhere. What I found regarding the sino-atrial node was completely beyond my comprehension. This is a study by mathematicians!

So I won’t pretend that I can completely figure out something as complex as what happens in your brain when you talk things over with another person! The point is that the human brain is plastic, and that gives us scope to change ourselves. We can free ourselves from the constraints of negative emotions like anxiety and depression – all of which are controlled by the brain – and let our spirits soar.