Baby steps towards a bigger cause.

I still remember the day when my Professor of Psychiatry  told me, that it took him quite a while to find a bride who was willing to accept a “mental” doctor for a husband!

It has been almost thirty years since, but despite enormous strides taken by science and society alike, the ground reality for patients suffering from mental illnesses, especially in India, is still one shrouded by secrecy or shame.

On a day to day basis, we encounter a wide range of patients who need help, but deny themselves, for fear of being branded as mental patients. On the other extreme, we see relatives or well wishers of patients who try their own form of counseling not realizing that they are doing more harm than good! Every patient in the inpatient department of our hospital, coming from various socio- economic- cultural- religious backgrounds, is bound by the common factor of the presence of a talisman of some kind,either round their wrist or their neck, waiting to cure the illness if the doctor cannot!

In a population which fast succumbing to the high levels of stress in today’s world, the statistics regarding mental ill health are truly scary. Every one in four individuals anywhere in the world would have suffered from  mental ill health at some point in their lives. Depression ranks third among illnesses which kills the patient. And India, estimates say, has about  50 million people who need mental health care. Unfortunately, the supply of mental health professionals to handle such a huge load of patients is dismally low! We have currently in India,  about 3800 psychiatrists,398 clinical psychologists and 850   psychiatric social workers. There are no registries for counselors at all!

Even with the intent of helping the patients as best as we can, we, as mental health professionals face the problem of having too little time and too many who need it.

Hence, I feel it is the duty of every human being to finally start recognising that we need to chip in our little bit in order to elevate the status of mental health. Government agencies, NGO’s and media can only do so much if the public at large behaves like an ostrich with its head buried in the sand.

A few things which I believe we can inculcate are:

  1. Start by regarding the mind as a tangible organ of our body. One of the reasons that we refuse to consider a diseased mind is because, we cannot accurately locate the whereabouts of it. It is vague, complex and therefore out of bounds to any physical testing, apart from analysing our behavior. But this does not make it non existent. We need to start teaching the habit of recognizing emotions and their healthy expression in children, so that they learn to understand their minds early. Then on, recognizing the stress and negative emotional states may become easy and non stigmatic.
  2. Do not regard mental health professional as enemies in disguise. It is frustrating to see well educated, intelligent people take their kith and kin to quacks or magico religious healers and subject them to different kinds of torture. Eg. Thrashing, burning, keeping them hungry for days, making them eat leftovers etc. The common excuse given is that they were worried that the doctor would addict them to medicines!!! As if the torture meted to them was better than suffering from an addiction! We are commonly asked whether medication can ruin kidneys or whether we can cure a disease without medicating(when they have no qualms about swallowing diclofenac indiscriminately for their arthritis!). The need of the hour is to learn to trust that the doctor knows his job as he has been trained for a minimum of two to three years in psychiatry. At least, he is better than the neighbor who makes tall claims about the state of the patient’s kidneys(which we apparently spoil by medicating) without having studied biology for the past so many years of his life. We would love to help if you would just let us.
  3. Realize that, just as there are different treatment procedures for the body, the same follows for the mind. Discuss treatment options clearly, and realize, please, that we will not be standing with an electrical prong waiting to give an ECT to anyone who happens to walk inside the door!ECT is a valid, useful form of therapy and not used as punishment as depicted in many movies.
  4. Many mental health professionals are reaching out to the general public by way of television, media, articles and public programs to raise awareness about mental ill health. Listen, read and believe only what is coming from a genuine source, and not what gathers most trp’s, as in the case of television channels airing programs of regression therapy and past life therapy. They are false. Period.
  5. When you meet a person who confesses to feeling depressed or upset or has some trouble with his emotions, kindly refrain from offering suggestions like”You need to use your will power to come out of this” or “Look at someone worse than you, you will feel better”. Mental illnesses have nothing to do with will power. The strongest, most wealthy and physically healthy among us can succumb to mental illness. It would be better to find the best counselor in town and gently direct the person to speak with them. The counselor in turn can gauge the problem and decide whether he/she needs a psychiatrist.
  6. Do not judge the patient, after treatment, based on his illness. Mental illness makes us behave uncharacteristically. Do not hold grudges against the patient for their bad behavior during the illness nor judge him/her for the rest of their lives based on this. It is harmful for their self confidence. Eg. If a person tried to attempt suicide, do not reject his application in a job place or his proposal for marriage. Instead, ask whether the person has taken his full course of treatment. Discuss with the doctor in detail, how well the person is and how much responsibility he can handle. This solves much of the problem rather than enhancing it.
  7. Do not hide the fact that someone has suffered from mental illness, especially when the person is getting married. We see marriages breaking down in our consultation rooms, for this very reason, that the spouse discovered the illness after the wedding. Every person has a right to decide on the kind of spouse that they want. Deceit wont help. Give your child the confidence of owning up to facing a difficult illness and still believe in their self worth.Then look for a spouse. In an arranged marriage scenario, there may be a lot who shy away from proposals, but believe me, your daughter or son would be happier with a person who genuinely accepts them and respects them rather than live in shame and neglect.
  8. Practice acceptance. We never shy away from accepting any of our physical ailments. In fact, sometimes, we exaggerate them. But mental stress and strain are denied consistently. Unless we ourselves are unaccepting of our problems, there is no way the society will accept it. It was an exhilarating moment for us when a postgraduate student of surgery came up on stage at a public function to own up that she had suffered from schizophrenia and achieved what she wanted despite of it. We need more celebrities, survivors of traumatic stress disorders and people around us to start accepting their problems without shame. Only then, can the dignity step in.

Most of what I have written about is something that we all can practice at an individual level. If we can inculcate it and spread the word, we can probably inch closer to the WHO theme of this year’s mental health day”Dignity in mental health”.

Can we get some respect, please?

Philippe Pinel removing physical restraints from a mentally ill woman in La Salpêtrière,France
Philippe Pinel removing physical restraints from a mentally ill woman in La Salpêtrière,France

There are a few illnesses in the world which resemble Voldemort! They exist but cannot be named or accepted. And mental illnesses top this list.Both the patient, as well as relatives, seem to be in a state of denial. In my practice,I have seen a range of behaviors which constitute this stigma. People sitting in front of me, suddenly getting a call on their cell phones, hurriedly pick it up and coolly proceed to tell the caller that they are in a cinema hall or market while making pleading faces at me; patients requesting to be seen urgently because they spotted a fellow villager entering the neurology section of the hospital (which makes him a patient with a respectable illness); or a mother who gets the child to the clinic without informing the father or grandparents!

The word  stigma, apparently originated in Greece. In Greek society, stizein was a mark placed on slaves to identify their position in the social structure and to indicate that they were of less value. The modern derivative, stigma, is therefore a distinguishing mark of social disgrace attached to patients in order to  identify and to devalue them. Stigma occurs in two different ways. One, wherein the general public, family and friends of the particular patient happen to discriminate the patient, and two, where due to this discrimination the patient himself begins to demotivate and hate himself.

There are box full of myths all over the place about the cause, nature as well as cure of mental illnesses. Hence, patients are feared for their potential violent nature, lack of will power and apparent genetic heritability of the illness. Stigma in any form is obviously painful and causes a lot of stress and loss of confidence in the person, but the amount of stigma faced by women having mental illnesses is really demoralizing.

I had a 25 year old girl, recently married who had had a relapse of psychotic illness(in which she behaved abnormally, got angry, aggressive and tried to assault the mother in law). This girl was our patient for the past two years and was completely stable with medication. Some time ago,the mother cautiously broached the topic of whether they could get her married. As is the custom, I took time to explain to her that it would be better that the prospective groom come for a counseling session; that he be in the knowhow of her illness and how it was quite harmless; that I would try and dispel myths which he may be having. If he did not agree, then it would ok.  She could get married to someone understands her illness and still accepts her!

When this was discussed within the family, it was met with strong opposition. The family felt that telling anyone would spell doom, not only for the girl, but for her younger sisters who were also of marriageable age. Hence, the mother carefully un wrapped the medicines from the wrapper, made different boxes and hid it in the girl’s clothing so that she could consume it as stealthily as possible. Unfortunately, post marriage, the girl discovered that the wardrobe given to her was in a landing where anyone could walk in any time, and hence started missing doses to avoid being discovered. This led to a relapse, the groom’s side discovering the tablets and blaming the girls’s side for cheating them.

Now they were sitting in front of me, the sulky husband, the fire brand mother in law to one side, the teary girl in the middle and the defensive mother of the bride to the other! And to take the matter to its logical conclusion, there were about 10 panchayat members who had tagged along!

The boy was unwilling to take her back, the Mom in law said, “If they lied about this, there may be other things too”. The mother who had spent heavily on the wedding, alongside a fat dowry, was livid.“Well, she was fine in our house. It is your fault she is this way. And if you want us to take the girl back, you may as well pay us back all the dowry and expenses of the marriage”. The panchayat members were cajoling, “Think about the girl. Who else will marry her? You have to give her a life. Take her back. She will listen to whatever you say and live like your servant!”(Well, this was supposed to be in support of the girl!)

In between all this, the girl was sitting eyes downcast and teary. It made me feel so low and depressed to imagine how she was facing this. She was unwanted by her own family, a burden which was now someone else’s responsibility. Otherwise, she would have to be kept at home and taken care of unto death. The husband, understandably felt cheated, but looked willing, if not for the mother in law who was already making plans for his second marriage and a second dowry! The panchayat felt that the deed had been done and it was now the girl’s fate to suffer at the hands of a spineless husband, and a tyrant mom in law!

This does not happen to be an individual instance. Whenever men develop a mental illness, we find the parents almost magically find brides for them who are willing to “adjust” to being with a husband suffering from an illness or disability. We have seen instances of husbands convincing wives (who are mentally ill) to agree to their second marriages, wives taking domestic abuse of aggressive, alcoholic  husbands with resignation and accept their husband’s infidelity with a pinch of salt. All the while feeling that either their children, or parents or the husband may feel bad if they desert them!

Parents of young girls are devasted when they hear of their child or relative having a mental illness. They take great pains to hide it from near and dear with the fear that they may spread word and spoil her future marriage prospects. All thoughts of education, job etc etc just fly out the window, and the only question that looms large is whether their daughter will get a good husband. Immediately, she becomes a second class citizen.

But reverse the picture, men seem to think that it is impossible to adjust with anything other than perfect. The minute their wives are diagnosed with a mental illness, there are barbed comments, outright disgust and a permission to insult their spouses any which way they please. Everything becomes their fault.I may be over generalizing here, but the ratio of men and families being nice and supportive to women suffering from mental illness is impossibly skewed in the wrong direction.

And the women themselves, in between suffering from an illness that shakes their very core, have to deal with a hostile world. No wonder, many of them relapse repeatedly.

Spreading awareness about mental illnesses, bringing up our girls to develop a sense of self worth, teaching them to fight back and not take crap( I mean, if the husband does accept the girl back, how could she live with him knowing that he did not even stand up to her??) may be over simplified solutions to a very complex problem. We have a long way to go. And a lot of awareness to spread. And a lot of confidence to build. Till then, there are thousands of those who suffer indignity in silence.

Indian woman mourns death of her relative killed in tsunami in Cuddalore