Shrink's Views

ramblings of an unknown psychiatrist

Archive for the ‘challenge’ Category

My Art in BITS

Posted by Dheeraj Kattula on April 27, 2013

“The Path” [ June 2008] was appreciated by my family and friends in a social network. My interest in art resurfaced, but I did not paint for the next 7 months as I got busy. I was in BITS, Pilani in the month of January 2009 attending a contact program. The students of Andhra Samithi were holding art competitions. I had a BITS ID number, so I participated. I had about 90 minutes to complete both entries.

I got 1st place for painting “Stop Terror” and 2nd place for sketching “Towards 100 % literacy”. I was thrilled. BITSians are very talented bunch of students. They have a very strong Arts club. Winning in BITS meant, I too was part of – a league.

I decided to start painting again when I got back to Baripada, the place where I was working.Is there anything I learnt during this competition? Yes!!! Not to feel ashamed of asking for joining ‘others’ !

1. I was an outsider, who was visiting BITS for a contact program.

2. I was around 10 years older than the youngest participant and 5 years older than the oldest.

It was embarrassing to go and ask ‘kids’ if I could compete with them, but I did it. What gave me greater joy than winning a prize was participating with young people who were pursuing art even after getting into professional courses. I am glad that I was with them.

The following are the prize winning entries in the competition.

 Image

Title: Towards 100% Literacy [ 100 % Aksharasyatha Disavaipu ]

29.1.2009

Pencil on Paper

Image

Title : Stop Terror

29.1.2009

Watercolor

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The Spy Who Knew Himself : a story

Posted by Dheeraj Kattula on May 18, 2012

They were those times when terror occupied the consciousness of common men. Even though the fringe elements were successful in creating mayhem, fear psychosis lasted only a short while. Life just goes on for a common man, till death comes knocking at his door. It is a privileged few who fight for causes higher than themselves. I believed that I was one such person. So I sharpened my awareness of what was going on around me. I was still a student of Electronic Engineering.

I received a message, if I would like to cooperate with the CIA as an agent. I took time and then agreed. I had to leave my home without informing my parents or my brothers. It was a secret assignment. I went to Mumbai and kept track of the movement of Taxi’s in Mumbai Central station. I learnt to communicate in a specific code. I dropped the messages in the waste paper bin near the railway reservation counter. Other agents would pick them up from there. I did my job well. They could verify the information that I was sending was true. However they can never know what is in my heart. I was serving my own national interest.

I never got paid for my services from the CIA. Occasionally they sent agents to give me messages through food packet covers. They would give me these as leftover food. The food was a bonus in those cases. I was pretty busy with my tasks at hand. I sometimes didn’t shave for weeks and understandably many mistook me for a beggar. The cops never asked me for a platform ticket. They probably knew I was a double agent. They just let me do my job. I occasionally napped in the platform itself.

Few years into the job, I realized Indian scientists perfected the BINTAAR technology, a wireless technology with which they could read my thoughts. They could know the messages I was sending the other agency. It was then that I started feeding misinformation to my primary recruiters. After all they were not doing the job they were to. There was enough knowledge in open space to know the origin of terror in the region, but they were not acting. I thought it is better to let the company waste resources by chasing some of my misinformation. I had to do this in right mix. Everyone knows that a complete liar is easily found.

I realized that even the Indian intelligence agency was not right in its intent. Some of the agents who were supposed to pass me cigarette butts would grimace looking at me. I noticed them chat about me and even make fun of me. There wasn’t a need for that. I was doing field work and was not under cover like them. They ought to have treated me with respect. I know I should not personalize issues and jeopardize national interest. I informed my handlers through BINTAAR that I was not interested in Mumbai anymore and would rather work somewhere where stress would be lighter. I wanted a break from work. I was working 24 x 7 x 12 for 10 long years. I did not want to be disturbed by any agents.

I took a train to southern part of India. I just hopped and changed trains so as to not leave a track. I posed as a beggar in town in Tamil Nadu. I lived on a street and people helped me with food. I was at times irritated with few agents moving around. I sometimes lost my cool and shouted at them. I was once approached by a nice looking guy. He offered me food. He called me to his office which he said was nearby. He walked with me at my pace. He had a genuine smile. I wondered if Intelligence agencies were recruiting psychology majors for their debriefing work. If they were doing so, it was a good thing. I was quite stressed. He made a ‘free chart’ and offered me to stay in a home in a nearby town. I agreed. Few men came in an hour’s time and took me to a home for homeless people. I qualified for it as I did not have a proper home. In a larger sense India is my home and I was free to be anywhere. They gave me medicines to help me. They also did some blood tests and found them to be normal. The detailed procedures they went through, I thought they were trying to size up a double agent. You could never trust a betrayer, no matter if he has betrayed others for you. I was in no mood to protest or even think deeply for my conscience was clear.

In a couple of days the guy who saw me came along with his seniors to our home. They were all very excited to see me. It was after a long time that I saw someone happy seeing me. They asked me about a variety of things and then finally asked me about if I had a family. I always knew about my family but it was sort of in the background. This break from work, living with a community of homeless people reminded me of the joy of family. There is nothing like the own family.

I had made our telephone number into a musical mnemonic. I rattled the number out. They made a phone call. Apparently my family left the village, but had given their new contact details. In couple of phone calls my family was traced. They came in a week’s time to the homeless home. My mother was bent with age but she mustered enough energy to come all the way. I was surprised to see how much my brothers had grown up. They told me that my father had died two years ago. It was his last wish that my brothers never give up looking for me. I bid good bye to my new friends. Before we left for our home, I visited the office of guy who debriefed me. He was in fact a psychiatrist. He wrote a letter to a local psychiatrist to follow up my care.

I have been following up locally in my town for five years now. I take an injection once in two weeks and a couple of pills. I have no interference from any intelligence agents these days. They have disconnected me from BINTAAR. I live with my brothers. I help my eldest brother in his mobile shop. I have done a course to deal with mobile repairs. I am now in mid thirties. My family wants me to get married. I feel shy but I too long to have a family of my own. I would reveal the fact that I need to take these medications for a long time before I marry anyone. One who would accept me as I am, deserves my love and commitment for life. Now I too live the life of a common man, enjoying life till death comes knocking at the door.

———————————————————————————————————————————

This is a fictitious story of a homeless mentally ill person. References to people and agencies were coincidental.However the story is inspired by the work of CMC Vellore’s Department of Psychiatry Unit III ‘s work along with an NGO Uthavum Ullangal in caring for the homeless mentally ill.

This patient is a case of Paranoid Schizophrenia. He was a homeless mentally ill person living around the Mumbai Central Railway station. He had no links with any spy agency. It was a grandiose belief that he held. He later developed persecutory and referential delusions. He had ‘thought broadcasting’ phenomena. He also used neologism called BINTAAR meaning ‘without wire’ to explain his experience. He developed partial insight especially regarding the need for treatment. He recovered well with medical management and family support.

Mental illness is treatable. Homeless people can be reunited with their families with some effort.

Posted in challenge, fiction, love, psychiatry, schizophrenia, stigma | Tagged: , , , , , , | 6 Comments »

Missed Adoption: a poem

Posted by Dheeraj Kattula on February 17, 2012

I did a seminar on Adoption in the Department of Psychiatry today. It was focused on mental health issues regarding adoption. I ended the seminar with a note that adoption is an alternative to abortion. The final power point slide had the following poem. I wrote it from the perspective of Tiny, who was aborted at 19 weeks of gestational  age by her teenage mother.

 

I am now in heaven,

with God on my side.

I wish I had lived,

to grow as a child.

To feel gentle streams,

and play in the rain,

to see sweet dreams,

and feel what is pain.

You snuffed me out

before I could cry.

Wasn’t I as vulnerable

Mom, answer me why?

You could have given me

to others who needed a kid.

There are so many childless,

you could have found a bid.

If you’d given me away,

in my early days,

I ‘d have been quite normal,

in all possible ways.

Had you given me up,

a  few years later,

I’d still have survived,

problems could’nt matter

There are psychiatrists around

to treat possible problems.

I request those living around,

to consider old solutions.

Reject Abortion

It cant correct an error

Consider Adoption

Its so much better.

– Tiny

Posted in challenge, poetry | 2 Comments »

Marital Dyads: Likes Vs Opposites

Posted by Dheeraj Kattula on June 14, 2011

Statistically the ones at extremes are at the risk of being abnormal. At least they are worth studying, as they are definitely a different group compared to the rest. Marital dyads are as innumerable as the number of couples that exist. Let us take personalities of each individual in a dyad. In a random world there would be all sorts of combinations. Most people would share some aspects of personality with their spouse but would also differ equally in other aspects. A very few dyads would be absolutely identical or polar opposites. These special groups are worth looking at.

We could call the dyads in which the personalities of the couple are identical as mirrors. The partner in the mirror knows exactly what the other person likes because he likes it too. He does it and there is joy everywhere. What is disliked is disliked by both, so it would not figure in their lives. Mirror would be very happy.

The dyads in which the personalities are totally opposite, would understandably have friction. What is liked by someone for reasons arising from his/her personality could be disliked by the other person for very valid reasons. Even if the individuals alternate in decision making, one of them would be giving up every time. To avoid this giving up, they could choose to do their own thing independently. This would mean doing less stuff together. This could indicate a lesser quality in relationship. A level of unhappiness or decreased marital quality would be part and parcel of the marriage of opposites.

Is this the end of the story? Likes make happy couples and opposites only manage to pull on. In a hedonistic world, where pursuit of happiness is the ultimate thing, this could be true. One need not only be happy when his/her choice was THE choice. One could choose to be happy letting the other choose. Not that the choice induces happiness in him, but understanding that one is letting the spouse be happy with this, could induce happiness.

Sometimes choices are not simple. They could indicate different priorities, values and judgements. Here when one gives up, he/she gives up something more than a choice. It could be painful. Such adjustments have to be made for a marriage to remain healthy. That kind of giving up leads to maturity. This opportunity to grow in maturity does not occur in the mirrors. It is a consolation and positive externality in the marriage of the opposites.

A home with opposites covers  every perspective under the sun. As they relate to friends and society they can connect with a wide range of people because of their shared understanding. They can help people much more because of this. They would enjoy a much richer social life in this world. The mirrors on the other and would connect with their own kind. Their circle would reinforce their original behaviors. They may not change much in life. They can only enjoy life of a club.

An epicurean may feel that happiness is all that is needed. What is the benefit with maturity? Growing in maturity can be a reason for someone’s happiness. The idea that happiness is the measure of a person’s life is immature.

Whatever type your spouse is you have reasons to be happy. Don’t you?

Posted in challenge, love, marriage, social | Tagged: , | 6 Comments »

Love – Feeling, Reason and Choice: a story

Posted by Dheeraj Kattula on September 19, 2010

Background:

This is continuation of the story “Rights and Love”. If you have not read it, you could find it by clicking this. It was a story about a lawyer called James. His wife Agnes suffered with Schizophrenia. Under the influence of some delusions she attempted to murder him. He recovered and then took care of her. Despite all care she had not improved much. He continued to care for her despite the risk of harm that he could suffer. He surprised everyone with his love.

Love: feeling, reason and choice

It was nearly six months since Tab Clozapine was started. James reported that Agnes was doing well. She was not suspicious as before. She had started working again two weeks ago. She had put on some weight, but she got back the smile that she always had. As Agnes waited in the queue to get her medicines from the Pharmacy, James was called back by Dr Manas to the consultation room.

Dr Manas said “Mr James, I was glad to hear that Agnes is doing well. I wanted to tell you something. Do you have few minutes?” James was so happy that Agnes has improved so much. His eyes filled with tears as he said, “Of course doctor, you are always there for us. Please go ahead.”

“I have resigned my job here and I am moving to Kolkata. So I have transferred the care of Mrs Agnes to Dr Gurupreet Kaur. You have seen her during the in-patient stay. She is a fine doctor”, Dr Manas said as he looked away from James and stared into the empty sky through the window. He did not notice the crushed look on James’s face, as he nodded his head. James liked Dr Manas. He was a good doctor.

Suffering is not new to Dr Manas. He saw it every day. He was used to it. Despite his heroic efforts, his patients continue to succeed in suicidal attempts; they go off medications and relapse into full blown illness episodes. This was part of his life, but there was some suffering different about the case of Agnes and James that touched him.

“Mr James, I have seen many families with mental illness. They all care. If they did not care, the patients would not have been brought here or the family member would not have come here. I have seen people get beaten in episodes of rage. I have seen domestic violence exist in chronic form, but I have never seen one who had a brush with death because of an attempted homicide by a wife, care for his assaulter with so much of dedication and persistence. I admire you, Mr James. How do you do it? Is your marriage a love marriage?” Dr Manas inquired.

James smiled and replied, “I do not know if you could call it a love marriage. I guess you could. Agnes and I went to the same Church in Bangalore. Her parents had passed away in a road accident in her childhood. Her grandfather brought her up. He was a retired railway employee. They lived on his pension. He had multiple strokes and developed dementia. Agnes took good care of him. She used to bring him for the mass regularly. She was also active in the Sunday school.

I liked the way she behaved with children and elderly people. She was simple and had a simple lifestyle. I was interested in providing legal aid to poor people in Mumbai. I wanted to marry a girl who could fit in. I reasoned Agnes could be the right girl. I discussed this with the Church father. He was very happy. Agnes agreed to marry me. We got married after she finished her graduation. In the meantime her grandfather passed away. Then we moved to Mumbai.”

“Oh I see. Looks like you took a logical decision. Isn’t it?” Dr Manas asked.

James replied, “Yes sir. It was a 100% rational decision. I never had any flutter in my heart seeing Agnes nor did I miss sleep. In fact I have not had the feelings for Agnes that I once had for a girl…(smiles)

I had this feeling of being in love when I was in my 3rd year in the Law College. Permit me to leave her unnamed. She was the only daughter of a top criminal lawyer in Bangalore. She was obviously going to take over her father’s practice. Her father defends crimes done by politicians and their goons. She would have to do the same.

I desired a just society. If I married her, I would be aligning myself with enemies of truth and justice. I knew she was not the right girl for me.

Trust me; this knowledge did not help me lose feelings for her. I would get energized as if I had two cups of chai, if she were to just say a hello. I just cannot explain it. This ‘love’ seemed real, as I could feel it strongly. It lasted a year till she started going around with a minister’s son.” He smiled and added, “Thank God for that match! My emotions left. ”

“You said that you never had strong feelings for Agnes, but you seem to demonstrate love that I have not seen before. How is that?” Dr Manas asked inquisitively.

“Dr Manas, I have decided to love my wife Agnes. However she is, whatever she does, I will love her. I mean I would act in her interest. I might not have feelings like I had in college. I might not be as rational as when I had decided to marry Agnes. Love here is a choice I make.

In College years my feelings of love were not even in line with reason. They felt most real, but they were most deceptive. These feelings just evaporated. Imagine trusting those feelings and taking life decisions. My reason was stronger than my feeling when I decided to marry Agnes. If the situations did not change, reason would have been sufficient cause for a lasting marriage.

But things changed. You know it. I could have started a new life without her. Getting her out of prison and living with her in the same house with no one else, when she was still suspicious of me goes against sound reason. It was a choice I made to love Agnes that mattered. I thought in her interest. I had risk. I had fear. I faced it. It was ultimately a choice I made.”

“Mr James, I like the choice you made. I respect it. I appreciate it. In fact, you have inspired me to make such a choice. I normally don’t discuss my personal life with patients or their families, but I think you are different and I thought I could share this with you.

Let me first tell you that I hate Kolkata. I am a Bengali .I believe anyone who wants to work hard and grow cannot do so in Bengal. So, I always wanted to move out of Bengal.

I was involved in research which was being done in collaboration with the Indian Statistical Institute in Kolkata. I fell in love with a mathematician there. She was beautiful, brilliant and a Bengali. I had all reasons and all the feelings to get married. We married and were happy for few months. I then noticed that she was drawing closer and closer to her equations and was distancing herself from me. I do not suspect her for having an affair or any thing, but I felt she was not contributing to our relationship. I felt she was not valuing our relationship. Her equation was not an equality.

I got an opening here in Mumbai. I came here thinking that the distance would make her realize my absence and seek me. It did not work out. A couple of months ago I sent a divorce notice to her. Then I saw you. I saw what you were giving after having tasted what you had received. I knew this transcended reason and feelings. I thought I too should choose to love my wife.

Last month I called her and asked her forgiveness. I told her that though I hate Kolkata, I am willing to join her in Kolkata because I choose to love her. To my surprise, she wept. She felt sorry. She felt ashamed to call me and was desperately waiting for me to call. She too asked for my forgiveness as she had not been concerned for me.

She has requested a transfer to Indian Statistical Institute in Bangalore, with the idea that I can join NIMHANS. It is a matter of time that this would come through. I am glad I made the right choice. If I chose freedom as a right, we both would have lost. As I chose love, we both have gained.”

“I am so glad for you, sir. May God bless your marriage.” James blessed as a matter of fact.

Dr Manas held the hands of James and thanked him. Agnes came to the door after buying her medicines. They bid good bye to the doctor. Wiping his tears, the psychiatrist wondered when love as a choice is so beautiful and worthy, why we humans are so reluctant to choose it.

Posted in challenge, distress, drug therapy, emotion, ethics, fiction, love, marriage, psychiatry, schizophrenia, social, statistics | Tagged: , , , , , , , , | 11 Comments »

“Can you please give me some poison?” – Part III

Posted by Dheeraj Kattula on July 10, 2010

It was usual Wednesday morning. Patients on Clozapine lined up to get the investigation request signed. It is a quick process for the doctors to sign a small bunch of slips. The OPD assistant filled in those slips and gets the job done. I looked up for a moment to see the patients. I saw Murugan’s aunt. I had come to know her well by then. You can read the posts “Can you please give me some poison?” and “Can you please give me some poison?- Part II” to get the context.

The first post was about this lady who was the sole care giver for her nephew who had Schizophrenia. She was struggling for long to get him well. It required an admission into hospital to make him better. She had no supports to facilitate that. In that post I promised that old lady that I would visit her village to help her bring her nephew to the hospital.

The second post was about my visit to their village and my encounter with the patient. Though I could not bring the patient that day, the patient came to the hospital for an admission as a voluntary patient. He was started on Tab Clozapine, the most efficacious anti-psychotic drug in the world after a fully informed consent. He improved much and got discharged. The senior psychiatrist of the hospital made a rare exception to Murugan by making hospital purchase Clozapine from an outside pharmacy to be given to Murugan for free. Murugan was lucky.

He was supposed to come every week for a routine blood test. This is because the drug Clozapine is associated with a rare but dangerous side effect in which the blood cells required for fighting the germs decrease badly. In rare instances, it can cause death too. Therefore we are very careful in monitoring the counts of those blood cells every week.

Murugan’s aunt asked me how she could get his test done as he has not turned up. What?!!! A Clozapine patient has not come for the routine blood test. He could die of agranulocytsis, where his blood cells which fight infections get reduced in the blood. The fact of this risk had been explained to both of them many times. They consented to come regularly for blood tests with their thumb impressions. Our explanation should be quite fresh in his memory. How can he not come? How dare this dear lady come and ask for ‘repeat medicines’ like it had been the practice before? I had every reason to be irritated.

I asked her, “OK. Why has he not come? Did we not tell that he MUST come for blood tests? What is he doing at home?” She said softly, “He has gone to the mill.”

“Mill? Did he go for work?” I asked with surprise.

“Yes. He started working last Friday. He gets Rs 120/- per day.”

Oh my God! This guy had not worked productively in any place for the past 20 years. He never earned a rupee. From my experience in their village, I knew that he had potential to work. When I was waiting at the bus stop, I heard a man call him out. Murugan had come with me to send me off. This man told Murugan to be ready by 6.00 am the next day. Apparently, that man wanted help in keeping an eye on a four wheeler for an hour the next day in a nearby village. All that Murugan would have received for that job is a bunch of beedis (rolled tobacco leaves about ¼ the size of a cigar).

I was amazed. Murugan has got a job in a spinning mill. I remembered my co-passenger had asked me if I was looking for such a job in a mill. Murugan has successfully found such a job. I credit Clozapine for such magic. If Clozapine was to continue, then it is mandatory that he came for the test.

I pulled a small sheet of paper and wrote a note to him. “Dear Murugan, I am very happy that you have found a job. Congratulations. Your blood test is very important. Do come and get it done.” I expected them to come the next day, but Murugan came back to get the test done before we closed work that evening. I also had an opportunity to write a letter to the manager of spinning mill to kindly give him leave on Wednesdays, so that he can come for certain blood tests which are necessary for his problems.

Next week I found Murugan had not gone back for work. His aunt prevented him from delivering the letter. She thought I had probably written to the manager mentioning details of his mental illness. She reasoned that such a letter could go against him because of the stigma attached to mental illness. She felt I was uninformed about the status of the real world as I was limited to ‘high society’!

I reassured her and explained to her what I had written. Murugan then informed me that it was not only this fear but the prophet-parrot had predicted that Murugan was in a ‘bad time period’. In India soothsayers/ fortune tellers use parrots to pick cards which are supposed to bear the secrets of the future of the client. His aunt had wanted to shield him away from authorities, just in case they stopped him from work. He was as irritated about her behaviour as me. I gave her a strong dose of scolding. Poor people take even a scolding in good sense, when they think that you are a concerned person. You cannot assume this for the rich patients. The rich though can be deceived by sweet talk even if you are not really concerned.

Next week Murugan was back. He had delivered the letter to his manager. His manager was okay with a weekly ‘off’ on Wednesdays. Murugan would regularly come from now on. His aunt wanted a letter to get a weekly ‘off’ from her company too. We gave one for her too. She too would get a weekly ‘off’ on Wednesdays. From now on she can happily accompany him. I am amazed at how much difference a typed letter sent to an employer by the doctor could make to the patient. I would use this method more and check if this makes any more difference than just encouraging patients to go for work.

Murugan’s story is a miracle. It is a miracle because of Clozapine, health care workers, hospital and the spinning mill which employs him. It is thrilling not only to see a homicide and suicide prevented, but also see lives transformed when modern medicine works along with social services and occupational rehabilitation.

Does this old lady want poison, now? May be…to kill rats and cockroaches! 🙂

Posted in challenge, drug therapy, emotion, indian society, love, psychiatry, schizophrenia, stigma | Tagged: , , , , , , , , , | 4 Comments »

“He will get bed sores and die in about three months. Take care of him. Feed him with what he likes.”: Medical Model VS Family Practice Model

Posted by Dheeraj Kattula on June 29, 2010

He was discussing about his experiences after he came down from the mountains. He was doctor doing medical work in the communities based in nearby hills. He was posted there by our hospital for a couple of months. Of the many things he told that day, I remember this story clearly.

He had seen a 74 year old man with a fracture in his femur in a hilly village. He asked me what he would have done. It was a simple answer for me. I said, “You would have told them to bring him down to the hospital. We could give some charity, even if they cannot pay fully. The bones can be fixed.” There were five competent orthopaedic surgeons in our hospital at that time. He smiled sarcastically. He wanted to make a point, but what he said shocked me.

He had said, “I told them, that he might not live very long. He cannot move here and there because of his broken hip. He will get bed sores and die in about three months. Take care of him. Feed him with what he likes. Let him enjoy the time he has.”

I was filled with malaise. What?!!! How can a doctor say this kind of stuff? I couldn’t control myself. I asked him, “Wasn’t it inhuman? Fractures are treatable. Isn’t it? Then why not offer it. How can we give a death sentence for a treatable condition?”

He laughed at me as if I was talking rubbish. I heard his argument keenly. Probably, it was to rubbish his argument to boost my egoistic ethical pride. He said, “Listen, this old man has a son who is the only bread winner. His daughter-in-law is a house wife. His grandson is now in standard 10. His grand-daughter is in standard 8. It costs about Rs 5000/- to bring him down from the hills in a vehicle. The cost of treatment in the hospital would at least be Rs 30,000/-. They do not have that much of money. If I do send them down, they will have to bring him back after a discussion with a orthopaedic surgeon. In the bargain they would have spent off large amount of money. Just in case they go ahead and treat him, they will have to sell off their house. If they sell it off, then they will have to live in the street.”

I was listening. He went on, “If they spend all that they have, the grandson may not pursue education beyond high school. The grand-daughter would have to discontinue school to add to family income. All this might add one or two more years to a 74 year old man. Is adding a couple of years to such a man worth losing the future of a whole generation?”

It was a tough call. I was a new graduate then. I was trained in the medical model. I was supposed to tell the best medical treatment available to the patients and let them decide what they wanted. I realized this model absolves me of any feeling of guilt. The truth is I do have in my mind what is better, but still I would have done what is ‘right’. My friend’s argument did not convince me.

After about 6 years of that incident I am wondering if that ‘right’ that I would have done is really right?  What would I do if I were in that old man’s position? I am absolutely sure I would rather wish a better future for my grandchild than live a few extra years. I have heard grandparents in India bless their grand children, “Let my years be added to you.” Of course that does not mean that one can assume this sentiment in every case?

The point is that my friend is a family physician. His expertise is not only in managing health problems at a primary level but also in understanding clinical problems and treatment options in the light of socio-economic conditions and the values of the family. His model makes people happier and fulfilled more than the medical model which has the appearance of being more scientific. May be it is time the specialists learn to use the broader model. This can be done when; in addition to eliciting clinical histories clinicians spend some more time with patients in understanding their and their family context and expectations.

PS: This event happened about 6 years ago. Today, thanks to Chief Minister’s insurance scheme and 108 ambulance services, patients like the one described can get free treatment in our hospital.

Posted in challenge, children, Diagnosis, distress, economics, education, ethics, indian society, medicine, philosophy, social | Tagged: , , , , , , , , | 3 Comments »

“Can you please give me some poison?” – Part II

Posted by Dheeraj Kattula on June 20, 2010

This is the continuation of the life story “Can you please give me some poison?” Please read it if you can, to get the background. It was about a lady who was the sole care giver for a nephew who had Schizophrenia. She was struggling for long to get him well. It required an admission into hospital to make him better. She had no supports to facilitate that. In that post I promised that old lady that I would visit her village to help her bring her nephew to the hospital.

I did not keep the promise. Life is quite busy in Oddanchatram. Four weeks passed and the lady came back as proxy for review. I can never forget the look on her face. It showed how much of expectation she had of me and how I had let her down. I had missed four weekends to do a job I promised. If I had a conscience, I had to do something that week.

On the third day, I wound up my work by 5.00 pm and rushed to the Oddanchatram bus-stand. I bought a large coconut bun as a gift. The bun is usually cut into eight pieces before being sold. It was not very costly. In fact it was the item with maximum volume for a given price in that bakery. I believe volume matters to the poor and price matters to the rich in judging the quality of the gifts. I had filled my mp3 player with psychology lectures, to listen during the travel. I never switched the player on, as I was sooooo excited.

I would fulfil my promise. My challenge was to bring an unwilling disturbed patient, who had never seen me before, to the hospital for an admission. I didn’t have a team to assist me. I couldn’t apply restraints. I was not carrying rapidly acting injectable antipsychotics. I heard from a Public Health practitioner that practicing psychiatry in community is like trying to control a lion in the jungle. Controlling a violent patient in hospital is more like controlling the lion in a circus, he said. I was prepared for the worst. I kept my ID card, so that I can get help from people and police…Just in case…However my plan was to talk the person into a voluntary admission.

 I reached the nearest town in an hour. I had to wait to catch a bus to her village. It was getting dark and cloudy. It could rain at any time. I had second thoughts. Is it possible for me to bring an involuntary patient through this complicated travel back to Oddanchatram in a rainy dark night? Though I could abort my mission at that time, I did not. Could I face that lady again, without keeping my promise? Only God knows if one gets another chance. In about 20 minutes, I got the right bus. I asked the co-passengers, to tell me when the right village came. A teenager told me to follow him as he was to alight in the same village. He enquired if I too was going there to find job of a daily wage labourer in the spinning mills located in that area! This is when I was wearing formal clothes and leather shoes. I consoled myself, thinking I was able to relate with him so much that he identified me as a co-worker. 🙂

Once I got down from the bus, I found a street running perpendicular to the main road. I enquired from people if it was the right place. I asked for Murugan’s *house. “Which Murugan?, they asked. Reluctantly, I said,“Mentally deranged Murugan.” I was not comfortable using such a label to identify him. His aunt had wanted me to enquire like that. She had said, “If you ask for the ‘Mentally deranged Murugan’, even the village dogs will show you the way to our house.” I was told to go near the temple, located deeper the village. It started to drizzle. I walked faster. I found a group of people in a circle, chit chatting and having fun in verandah of the village school. When I asked, they pointed to a man who was engaged in a chat with another group nearby.

 He looked like an average poor man. Thinly built and unshaven, he wore a shirt and a lungi. His lungi was pulled up so much so that it exposed his thighs. As I looked at him and his mannerisms, I understood, he could easily be an object of mockery. It was difficult for me to imagine that he could be stoned to death in the village as his aunt portrayed. He smiled innocently as I introduced myself as a doctor from the hospital where he gets his medicines from.

He was happy to receive a guest. He left his group, as he understood that he had to take me to his house. On the way he said that his aunt had brought the Injection but he could not yet get the shot, as the village nurse was not coming regularly. By then it began to pour. We ran to his house, which was not very far from that school. He was surely not as bad as I thought.

 His house had tiled roof and brick walls. It had three compartments. One was the corridor, right in front of the door. On the left was an elevated area, which was used as a kitchen on distal end and store area on the proximal end. On the right side there was another wall which had a door in the middle. The door led to a bedroom. That room had a cupboard, a chair and a trunk. Few clothes were scattered on the floor. His aunt was cooking rice at that time. She was excited when she saw me. She hurriedly cleared the scattered clothes and ordered Murugan to get me a ‘colour’. I figured out that she meant a cool drink. I told her not to bother as it was cold and raining. I had the magical thinking that rain would stop soon. Aren’t some of us are extreme optimists, especially if we take some action?

They spoke in a language called Kannada. I asked about their roots and how they came to Tamil Nadu etc. I then moved to the business of getting Murugan back to the Hospital. I knew the journey was long and difficult. I did not mind the cost of throwing the half cooked rice away to get back to Oddanchatram as fast as possible. I gave the coconut bun. Murugan was happy to take it. He asked me if it was cake!

I gave Murugan the Flufenazine shot that was due to be given. I explained the reason for my visit to Murugan. I asked his aunt about what she wanted to do. Murugan listened to everything. At last he asked me if I would be there in the hospital, if he came. It was as if he said, “If you are there, then I will come.” I got excited. At least some rapport has got established.

In my heart I was keen on taking him personally. I cannot believe judgement of a psychotic person. It could change anytime. His aunt told me if Murugan said something, he would do it. She said, “Now that Murugan knows you and likes you, I will not have any difficulty in bringing him to the Hospital.” I thought I would leave the issue at that point. This was more so because of logistic problems.

The rain showed no inclination to stop. It was already dark and getting late. If I delayed any further, could miss the last bus passing through the village. I packed and secured my mobile and mp3 player in a plastic cover. I walked to the bus stop in the heavy rain after bidding good bye. Murugan also walked right beside me. He wanted to give me a ‘send off’! I enjoyed getting drenched. The tiredness of the day got washed away, as I walked with the hope that Murugan would come to the Hospital after many years.

Three weeks later, Lo behold! Murugan and his aunt came to the hospital for an admission. We had already decided that Murugan’s aunt need not pay any money to the hospital for the in-patient care. There was an arrangement made to procure free food for him too. We explained the possible side effects of Clozapine and the need to come to Hospital weekly for a blood test, before we started him on Clozapine. He and his aunt agreed to the contract. On Clozapine, his behaviour started improving. Before we reached the full dose, I had to go to another part of the country for some work. So I did not see him at discharge. I heard that he improved much by the time of discharge.

What a joy it is to be involved in people’s lives to change it for the better. In the trip to his village I learnt much. The label of being ‘mentally deranged’ transcended even love. Even his dear aunt used it. It was not as bad as I thought. The stigma of mental illness is less palpable in villages, as people did relate with the patient. They chatted, played and smoked with him. After all, he was their friend who got ‘mentally deranged’. The picture was different from what his aunt described. Anyway, what I saw was a snap shot. I might understand these issues more in the future. Murugan comes regularly for follow up, now.

What happened after Murugan got discharged? That would be covered in a future post.

———————————————-

* Name changed

 ‘Murugan’ is a very common name in Tamil Nadu

Posted in challenge, distress, drug therapy, indian society, psychiatry, schizophrenia, stigma | Tagged: , , , , , , , , , , , , | 15 Comments »

“There is a limit to suffering one can take. I have to poison her before she brings disgrace.”

Posted by Dheeraj Kattula on April 5, 2010

She had an innocent smile of a child on her face. It was the first time I was seeing her. She was of dusky complexion, cute looks and shy behaviour. She had been on low dose anti-psychotics for few weeks. Her mother complained of her missed periods. Every day, we reassure a lot of people regarding menstrual abnormalities secondary to anti-psychotic use. As I reassured them, I could see that her mother was not satisfied. She complained of swelling in her lower abdomen. I smiled sarcastically at her ignorance. I felt she was worried thinking of menstrual blood getting accumulated down there.

Ignorance is fought with education. A couple of minutes of psycho-education could let them cool down, I thought. As I reassured them again, I noticed a smile of the patient. It was not the usual smile. It had a touch of mental retardation. I became serious. I knew she is a likely victim of sexual abuse. She was single, female, poor, beautiful and mentally disabled. I looked at her parents again. They obviously knew better than me of the possibilities. That was why they looked so distressed. They were afraid of the worst possibility- PREGNANCY.

The elderly couple also have a son. He has chronic Schizophrenia. He is dependent on them. The patient in front of me was dependent too. The grown up children cannot do any meaningful labour in the marketplace. Their mother is the bread winner. Their father is unable to work anymore because of old age. He minds the kids at home. The old lady was already in tears. I told her that she was not alone and such suffering is not uncommon. I realize these words are empty. Suffering hurts most when it hurts you.

She wiped her tears with the free end of her saree. She said “There is a limit to suffering one can take”, as she blew her nose she added, “I will have to poison her sometime, before she brings any disgrace to us.” I could understand her pain. I was shocked to see her daughter smile innocently as she heard this. I knew why this ghastly filicide had not happened till now. It is not tough to kill someone who would submit to you with a smile. It is impossible. Her mother loved her much. She just did not know how to handle her situation,  if at all there is a right way to handle it.

I wanted to send the patient for a pregnancy test. I also wanted to treat her with dignity as an individual with some ‘capacity’. So I asked her if ‘any man had come close’ to her. She agreed with a shy smile. My heart sank. Her mother nearly fainted. She reached out to the nearest bench that was available. I told them not to worry. We could find out if she is truly pregnant in the first place. Her missed periods could be due to medicine itself.

 Her parents did not want the test!!! Why?? I was shocked. They should be asking for it not me! They told me that a test would take time and if they do not go back in time, their schizophrenic son might wander away. Our OP assistant gave them an idea. Her father could return home and mother could take the patient back after the tests are over.

After a couple of hours, I saw them again. The pregnancy test was NEGATIVE. I sighed with relief. I am pro-life. I cannot think of recommending an abortion. We don’t do it in our hospital either. In fact if she was positive, I really do not know what I would/ should have done. Thank God! The old couple would not get another dependent into their family. They also did not have to kill a weak and helpless unborn child.

I told the mother to teach her to keep a distance from unknown men. Of course I know the ones who abuse are usually the known men. But here it was the case of an unknown man. Her mother told me that she had beaten her number of times to teach her that lesson. I wondered why she had to beat her daughter before an act was done! She knows her daughter and their situations better. I better not theorize how to handle these at this stage.  Anyway, now that the patient has experienced a ‘reward’ for the act, I predict she would continue to seek it. This is not my guess .It is the law of effect in maintaining behaviours called ‘operant conditioning’. I suspect that the mother understands this risk. She can never be in peace.

They left, temporarily relieved. I know God does not test us beyond what we can stand. I hope and pray they do not fail the test. We can imagine but we would never know tough it is. How could one help the patient live in safety? What should this mother do now, to prevent such happenings? What are her options given that are such daughters have right to liberty granted to them by International law like Convention on Rights of People with Disability? Where do local laws/ policies stand in situations like this?

Do comment and help me write the responses to the questions stated above in my future posts.

Posted in behavioral therapy, challenge, children, distress, ethics, law, love, mental retardation, schizophrenia, stigma, women's issues | Tagged: , , , , , , , , | 11 Comments »

“Can you please give me some poison?”

Posted by Dheeraj Kattula on March 7, 2010

She came closer and asked in a soft voice, “Can you please give me some poison?”

I tried masking my shocked spirit with a layer of professionalism. I enquired “Why?”. I avoided her eyes, so as to not threaten her with my piercing look. I conviniently flipped through the medical records. The records belonged to a man who was in his late thirties. She had come proxy for the patient. She was in her late sixties.

She had been coming like this for the past 6 years. She took medicines and gave them to her ‘son’, whenever it was possible. She reported that he liked injections! Thank God for it. Every two weeks, he got a shot of Injection Fluphenazine Decanoate, a long acting drug which controls mental illness. I heard her sob. She was in tears. Why on earth would she need poison?

She was a widow. Her husband had passed away when she was relatively young. She has a son. He is married and settled. He lived less than a kilometer away from her, but did not care for her. She lives with her ‘son’, who was in fact a nephew, son of her sister. She too was a widow. When she was on her dealth-bed, she took a promise from this lady.The promise was that as long as she was alive she had to take care of her son. Truly, she kept her word. Every time the clinical notes were written, it said “Proxy- Mother”.

The old lady was bent with age and was getting weak. She is afraid that she might die at any time. She felt that if she were not alive, her ‘son’ get stoned to death in the community because of his behaviors. His behaviors were abnormal as his disease was not controlled.  His disease was not well controlled because of non-compliance. He was non-compliant, because he was severely psychotic. He was still severely psychotic, because his treatment was not complete. To break this cycle, he required a hospital admission. That could make him slightly better. If he became slightly better, his compliance could improve furthur and then his outcome could improve even more.

Why is he not admitted then? He hated to come to the hospital. This old lady cannot force him to come by herself. Her own son is not bothered about her or her ‘son’. How could she bring the patient? She therefore reasoned that it was better to poison him painlessly rather than leave him alive to the fate of a difficult life.

I did not know what to say. I held her trembling hand. She sobbed harder. I asked her if could visit her village and help her bring her ‘son’ for an admission. She agreed. I took her address. I feel the pressure now. It is uncomfortable to be the only earthly hope for someone. It is that discomfort that leads us to put in extra effort. It is that extra effort that makes the world a better place.

Posted in challenge, distress, love, psychiatry, schizophrenia, social | Tagged: , , , , , , | 12 Comments »