Delayed Gratification And Life

It happened several years ago, when one of the immigrants of Mexican origin I frequently saw as a patient in the poorer counties of California came to see me and pulled a pen and a steno pad out of her purse.  My Spanish was a bit more rudimentary than it is now. She was matronly, with mostly grayed hair in the classic bun.  She asked me if I could spend a few extra minutes with her.  I told her I would take all the time I could, and try to serve her needs. It wasn’t her, she said.  It was her youngest daughter, aged 13. 

I told her I regretted that I did not see children. No, she could talk to me about this.  I started to protest that such discussions were usually not very helpful. She smiled, but was insistent. Her daughter was far and away the smartest of her children and got the best grades in school. She wanted her daughter to grow up to be a doctor lady.  A really nice one like me, who didn’t yell or anything. She wanted to know as much detail as possible about how I was raised, so that she could raise her daughter the same way and have her become a nice doctor-lady like me. I told her that rather than try to replicate my upbringing, she should concentrate  on talking about values and goals with her daughter, who would have to feel a great love for the profession and a great need to help sick folks in order to go through the long years of study required. Even if I had known then what I know now, I could maybe have explained it in Spanish, but she would have struggled with the concept. She herself had been pulled  out of primary school to work in the fields by her parents.  It was marvelous that she could write — let alone wanted to take notes on what I said. I find it takes time and effort to keep up with the “literature” — the published research of my own subspecialty of psychiatry — which is psychopharmacology. But those lovable psychologists! With questionnaires and observations of behavior, while I tended to end up doing research that generally ended up with samples of bodily fluids. I can look up and read things; with the internet, I can do it more efficiently than I ever could before.  Of course, I cannot dream of reading it all. My advantage here is — well, age.  I can tell some things simply because I have been reading published “things;” kicking around, reading medical research, for many years, about (oh my God) 50 years. Still, I read reviews and analyses written by others, so I can be “reminded.” Just last night, I got reminded by a video of Michio Kaku, a distinguished (and generally fun) popularizer of theoretical physics. In his video speech to an assembly “The Future of the Mind” of Microsoft folks, he asks if any of them knew what single human characteristic was more likely than any other to predict human success, and could be measured quite early in childhood. (Thank goodness for YOUTUBE!) I thought I might know, and I did.  (Of course, I was surprised that he did….) The characteristic is the ability to delay gratification. My eighth grade geography teacher knew about it, too. I don’t remember exactly what we were discussing when she asked if any of us liked Hershey bars. Every hand in the room went up. She asked if, should she offer us each a Hershey bar right there, would we accept it and eat it right away. Again, all of the hands went up.  No mysteries here.  I will admit, however, that I already suspected some of my “dieting” (anorectic) classmates were lying to appear to be normal. The next question was, if we wanted, we could turn down the Hershey bar today.  If we did, she would give each person who turned down the Hershey bar today, two Hershey  bars tomorrow.  Who among us would prefer to wait for two Hershey bars tomorrow? My hand went up, along with about five other girls. I already had visions of keeping one Hershey bar for myself and giving one to my baby brother, who always helped me carry my books home from school. Teacher smiled and said “Congratulations.  You are probably going to stay in school longer, get a better job if you choose to work, and make more money than the girls who choose to get a Hershey bar today.” The closest we had to a class clown was sitting in the back and asked if we could have our Hershey bars now. She got some giggles.  None of us got Hershey bars. The psychologist who is generally credited with having been the first to measure the ability to delay gratification is Walter Mischel and his team at Stanford University, working in the late sixties and early 70’s. He did not use Hershey bars, but they are not all that far off.  Sugary treats reign. He used marshmallows.  In his video, Prof. Kaku refers to the crucial test as “the marshmallow test.” A child, say between the ages of 4 and seven, has a marshmallow on the table in front of them.  The child is told simply that if they leave the marshmallow on the table for 15 minutes.  If the child does not touch the marshmallow, the child is rewarded with two marshmallows in 15 minutes. Heaven forbid I should imply that I was a smart-alecky kid, but I would probably have raised my hand and asked how long I had to sit there and stare at marshmallows until I could get the whole damned bag. I may have had some talent at patience but I was far more talented at overeating. The amount of investigators who have replicated this test — not to mention followed the test subjects for decades — is staggering.  I have been convinced with surprising efficacy that this single characteristic or trait is the best predictor now available for conventional measures of “success.” Intelligence surely is not.  I have seen plenty of high-IQ types in jail, with substance abuse problems, or even wallowing in quasi-complete obscurity. Next logical question that I wanted an answer to: can delaying gratification be taught? The answer seems to be a rather resounding “yes.”  There does seem to be a bit of a problem with actually teaching this to folks, though.  It is a problem which, in academic medicine, we used to call the “town and gown” problem A piece of scientific finding may be easily hailed as “truth,” but may not be integrated into daily practice.  It may not be accepted or even known by the folks on the front lines who are doing the day-to-day taking care of people. This is where the internet can help us pick up the slack. The only hitch is that most of the practical ways to teach the delay of gratification are in the realm of proprietary knowledge, sometimes even “knowledge for sale.” The knowledge of, for example, how to teach toddlers how to delay gratification, is embedded in courses on how to be a better parent on multiple websites.  Some are free, and will be emailed to you if you give your email.  Me, even trying to plow through the literature, I can’t discern much about what works and what does not, as I don’t work with children, anyway. Ask a child psychologist about this one. Among the life difficulties for which inability to defer gratification seems to predispose someone for we find addiction. I see addicted adults for underlying psychiatric difficulties. This website gives some very concrete insights on how adults can learn to delay gratification. I am heartened to see that many of the suggestions here for specific ways to teach people to delay gratification are thing I have used with patients in other ways. Meditation in its many incarnations has helped many. Making future goals and focusing on future visualizations are both very useful methods that help people recover from a variety of ills. This idea of delaying gratification may be approached on levels ranging from concrete goal-setting to the dreamiest and most philosophical, abstract methods. Tremendous amounts of human philosophy intersect at this concept. “Short term” vs. “long term” planning is part of this.  “Living each day as if it is your last;” is somehow part of this. So for me, at least, the next obvious question is if we can establish any structural or functional correlates to this delay of gratification. As they often do, those folks at Scientific American (here, writer Melanie Bauer).  The famous “marshmallow test” is mentioned, as well as more ailments. Components of illnesses such as obesity and type II diabetes can be (to some extent) redefined as difficulties of immediate vs. long term gratification in terms of food choices. I always hope, as soon as I learn about specific brain localizations of pathways and functions, that it will be possible to progress to applying this knowledge to therapeutics. It definitely is, but rarely as quickly or as efficiently as I would wish. My brain has definitely progressed from when I was a neurosurgeon, for I certainly don’t believe the (neuro) surgical paradigm of “cut it out” will be exquisitely helpful, except for some neoplasms or focalized vascular pathology or such. Skills training may be supplemented or (someday,even) replaced by electrical or electromagnetic focal (transcranial) stimulation. The core question is one of the precision of cerebral localization. A whole lot has happened since the German anatomist Brodmann mapped the functions of the areas of the brain in 1909. This article, referred to in the Scientific American review above, actually provide direct observation of the function of human neural pathways in financial reward. These pathways — this “reward” system — is deep but real.  I have been there in cadaver dissection.  The structures named are like old friends: amygdala, striatum, dopaminergic midbrain. But I know full well now how things progress.  First comes the research, usually on a rodent brain, to get the maximum detail of the anatomophysiology, of the pathways and the chemicals. Here is the (summary) description of a pathway between the hippocampus and the nucleus accumbens that has been directly associated with immediate vs. delayed food choices by a rat. The knowledge increases.  I can’t begin to describe how this applies to maybe lightening the burden of my patients with addictions, but I am very excited, and trying to hover the forefront as best I can navigate.