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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.

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

Rights and Love: a story

Posted by Dheeraj Kattula on September 7, 2010

He was a tall man. Dark and young, his name was James. He came for a full cup Chai* five years ago. He never stopped coming. To him, Chai was like petrol. It kept his engine running. He made friends easily. He became friends with Rafique on the very first day. Rafique was here to buy his bundle of beedis. The minute James realized that Rafique has just discontinued studies; he spent an hour with him to get him back to school. He failed. Of course! Who can convince a thug in the making. I have been hearing Rafique’s mother Salma begging him to study properly for the past 10 years now. It was of no avail. Rafique played the fool throughout his school life. He was no different from most of the guys in Dharavi. Honestly, at his age I was like that too. I left my home in Allepy when I was younger than Rafique. My original name is Abdullah. People now call me Nair. When I came to Mumbai, I wanted to be a hero, a star.  Fate had its way. I became a chaiwala*. I work hard and earn my roti*. That is a decent life. Isn’t it? At least I did not do crime.

Even though Rafique did not take advice, he realized that James was his well wisher. He became his friend and partner in his work. James was like a student who was interested in finding out our problems. He wanted to know about our lives. He wanted to find how we decided what was right and what was wrong. He wanted to know what we did when we perceived injustice. Rafique helped him meet up people in the slum. James came twice a week and did his job. He never missed his full cup special chai in my shop.

In about a year, James started educating us about our rights. He told us about how the real system ought to work. We knew how it worked. The constable on beat was the symbol of all authority to us. Give him a free cup of chai, he would not bother you for the day. The other symbol of power we know is the neta*. His ilk come here before the elections and would never show up again. The bigger guys here keep in touch with the netas. James taught us that these fellows are there to serve us and not get served by us. He also told us about the court system. In fact, that year Police picked Zuber and locked him up. They had suspected him in some bomb-blast case. We knew Zuber as a hard working tailor. He was cool and liberal. He could have no such links. James came to our rescue. It was then that we came to know that he was a lawyer. It seems he had studied in one of the best law colleges in India. I heard it is in Banglore. To us he was like God. Zuber was back. We learnt we could fight.

He fought few other court cases for our slum people. One was a divorce of Janaki and Kadam. Kadam’s drinking was routine. He beat his Janaki black and blue. One night she fell on a doorpost and bled from her scalp. It required 4 stitches to control that bleeding. Next weekday was the day James usually came to our slum. He spoke to Janaki and other neighbors and reported to the police. Police laughed at the issue. They said domestic fights between husband and wife are normal and they should be sorted at home and not police station. With James around they anyway had to register the case. James tried counseling Kadam. I would not have even tried. Some people won’t change. Atrocities on Janaki increased. Janaki decided to leave Kadam. Where would she go in Mumbai? How would she feed herself and her little five year old son Babul? She was concerned as Babul too was getting beaten regularly. She was also afraid that he could become like his father.

James fought for her and got her a divorce and also the custody of the child. Guys like Rafique too were not very happy with the divorce thing happening. Why? Aren’t other women adjusting with alcoholic men? Aren’t other women tolerating few beatings received from their husbands? James reasoned that we all have basic rights common to all mankind. One such thing is a right to life, liberty and security. He said our liberty should end one foot away from his neighbor. Here we had Kadam always violating his wife’s right to security and exercising his pseudo-liberty. He also felt Janaki could leave her husband exercising her right to liberty. I can very well understand that. Marriage should be based on mutual continual nurturing relationship. I was sort of convinced that she had a right to break the marriage. James also found Janaki a house maid’s job in Rajiv Gandhi Nagar, which is not too far from Dharavi. Kadam has died two years ago in a train traffic accident. Obviously, he should. He was totally drunk and was crossing the railway tracks. I wonder how he had survived 40 years on those tracks.

During last year’s elections most of our area’s people had gone to election campaign programs for money. There was very little business. I could have some personal time with James. I asked him about how he spent rest of the time. He said that he visited slums in Thane and Pune on a regular basis. He was doing the same thing that he has been doing to us, providing legal aid. I asked him how he managed to live. He smiled and said that few friends support him. Many of them were from a  network of Lawyers. There were others who also contributed. A dozen of them gave about Rs 1000/- each per month. That probably washed their conscience of the guilt of not doing anything for the poor. Many of those lawyers had monthly income running into Lakhs*. His wife Agnes was a teacher in a school and she earned another Rs 5000/-. They managed their livelihood in Mumbai with that money. It was difficult to imagine the kind of place that he was staying. He probably was not too better off than us.

Last year, he started coming less frequently. I was busy with pregnancy of my wife. I did not notice that I did not see him for six months. He came two weeks ago. He looked tired and worn out. His head was low as he walked past my shop.  I shouted for him, “ Saab. Chai?”  He pulled himself to the bench in my shop and sat down. I gave him his usual -special full cup Chai. He looked at me as he sipped and smiled. He looked older and mature. His dynamic force was gone. He was sober but looked to be in control. He finished his cup and went to meet others in the slum. I got busy with my work.

That evening I met Rafique. I told him that James had come that morning. I also shared my observations and expressed my wonder at the change. Rafique smiled and said, “You will never believe what he has gone through. He appears different, but this is what he really was- all the time that we saw him.” “Why? What happened? Tell me what you know”, I asked knowing very well that Rafique being close to James would know more.

Rafique narrated this story, “ Agnes, the wife of  James Sir had been suspecting him of having an affair with someone. She put strictures on where he could go, when he would be back, whom he would talk to and so on. She also felt that he was trying to kill her. Six months ago she stabbed James in his stomach with a knife. James was lucky; the knife pierced his bowels but spared his blood vessels. His neighbors heard the shriek and rescued him. They took him to Lokmanya Tilak Municipal General, Hopital in Sion. They did an operation and saved him. In the meantime his wife Agnes was arrested for attempted murder.”

“Oh! My God. It should be tough on James to go through all this”, I asked “What happened next?” Rafique said, “I am still shocked at what James has done. After his discharge, he fought for release of Agnes and won the case. He then got her treated in a psychiatric facility. They gave her shock treatment and medicines.” Rafique added, “She had not responded well to treatment. She is now on the best medicine in the world for her problem. James Sir takes her for blood tests every week. She still has not improved. She is suspicious of him even now. James Sir still lives with her, though he had to change the locality. The locals requested him to vacate. Our great lawyer chose not to fight.” I felt numbed. I could not say anything. Rafique had his cup of chai and left.

I could not sleep well that night. How can James live with his wife after what she did to him? How can he continue to be with her when she still poses a threat on his life? How can he share home with such a dangerous woman? Why can’t he divorce her and start a new life? He has helped so many people start afresh.

When he came today, I asked him, “Saab, Can I ask you something personal?” He agreed with his usual smile. “Saab, I heard what has been happening in your life from Rafique. I feel very bad about it. I want to know why you want to continue living with a person who is suspicious of you and has tried to even murder you? Can’t you choose a life of liberty that you want us to have? Why…?”

James then said, “Nair, we all have rights. Don’t you realize, if we all had our rights then nothing will be left. We all give up our rights for those we love. Don’t we? You have every right to eat from what you earn. Would you spend it eating Chicken Biryani alone or would you spend money to eat normal food with others in family? I have a right to liberty. I can divorce her as she would not allow me to be close with her, but I also have a duty to care for her. I have made a promise to be together in health and in disease, in happiness and in suffering. I will keep my promise even if it means to give up some of my freedom.

“But…You fight for our freedom”, I asked. He said, “Yes, I do fight for freedom and so many other rights. Many of our friends are unaware of their rights. If they are aware they would like to claim them. I help in raising awareness and helping fight to claim it. If someone does not want to claim a right for a different purpose, it is absolutely acceptable. It would be nice if that purpose is rational. Do you remember, last year Shinde joined BSc in Maths though he got a quota seat in Engineering. It is rare for someone to get to college level from Dharavi. Everyone scolded him. I knew he had a higher agenda. He wants to prove himself. A person who can run does not need crutches. Shinde will come up in life. He will live with self respect. Watch him. Anyway coming back to the point, rights give people a chance to make their life beautiful. Giving up your rights too can make life beautiful. In the case of me and Agnes, it is not yet beautiful. I agree I do not know what can happen to me, but that is alright. In a grand plan of people caring for their family, it is already beautiful.”

As I saw him walk away, I wondered James did give up much to be with us and has made life more beautiful for us. I found a new definition of love: That which makes the subject give up his/her rights to make life more beautiful for the object of his love.

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*Chaiwala- One who deals with Tea.

*Roti- Pancake made from wheat. Contextual translation- bread.

*Neta– Leader, usually political.

*Lakh- 100,000.

*Saab– Sir

PS:( added on 25th September 2010) A sequel to this story “Love: Feeling, Reason and Choice” can be found here.

Posted in distress, drug therapy, education, emotion, ethics, fiction, gender, indian society, law, love, marriage, psychiatry, schizophrenia, stigma, women's issues | Tagged: , , , , , , , , , , , , , , , | 18 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 »

“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 »

” I could not tell him that he is HIV positive for two weeks ! “

Posted by Dheeraj Kattula on May 3, 2009

He was young and suave.  Like many educated metro-Indians, he spoke English more fluently than his mother tongue. I could see bandages around his wrists, which he tried to cover with a full sleeves shirt. His grandpa arranged his appointment a day before. He wanted to share things regarding the grandson in private. He did not want to reveal ‘personal’ things in front of the grandson to avoid embarrassment for everyone.redribbon

Basically his grandson had become a ‘drug addict’ and was using intravenous drugs. He was not seen in his college or the neighbourhood for a couple of days, when someone intimated the grandpa. His grandpa rushed to his college immediately on a taxi. The patient was found lying unconscious in his room. He was ALIVE! He was taken to a nearby hospital and was treated for sepsis with intravenous antibiotics. He had developed a major infection. All the points from which he had shot drugs were swollen and were oozing pus.

The patient’s only concern was to find out if he had to continue antibiotics or not. We could connect well. He was young , English speaking gentleman, who felt no one is interested in him and I was a person interested in all aspects of his life if not personally at least professionally :-).  I asked him to do a couple of blood tests. He readily agreed. I asked the lab technician to also do the HIV test. I had reasons to suspect a immuno-compromised state in him and also had the responsibility to protect our staff involved in his care.

I did not do the pre-test counseling or tell him about which tests were done. Reason- I did not want to rake up a emotionally disturbing issue in the beginning of a therapeutic relationship. I thought once I develop rapport and stabilized him, I would bring the topic, re-do the test and then declare the result to him.

Following this, I had a couple of sessions with him. His childhood experiences, his brought up under his mother after a painful divorce from the father, his troubled school life, his grief when his mother was diagnosed of cancer, bereavement  when she died, his lost love during college years, his one night stands and his encounters with the ‘drugs’. He was a talented man. He had a scrap-book full of songs he had written during intoxicated states. They resembled the songs written by rock stars. They lyrics were full of emotion, even if devoid of rhyme and reason 🙂

I had few sessions with his grand father too. He was an old man of about 75 years. His wife had died when he was relatively young. He brought up three children. The eldest was a nurse, mother of the patient. She had a troubled marriage with an alcoholic man. She found peace in divorce. She brought up her son all alone and sent him to a metro city for his graduate level education. She was diagnosed of cancer and subsequently died.  The old man had a paraplegic son who was dependent on him. The third child was a responsible one, who was single and worked in another part of the country. Grandpa had a comfortable pension, which was in addition to the pension the patient received. Their family income exceeded the salary of a consultant doctor of the hospital!

He came on a regular basis for two weeks. In the third week, I mustered courage to tell what had to be inevitably told.

I asked him,” What do you know about HIV?”

‘A bad disease.’

“How do you think it spreads?”

‘When a person is not careful during…’

“Ok” ,I added “also a child can get it from a HIV +ve mother during birth and people who share needles when they take drugs”. I could see anxiety in his eyes.

“Is there a possibility that you could get HIV?”

‘No, I cant get it.’

“I am saying if there is a slight possibility, as you have said already that…”

‘Yes, possible.’

“Would you like us to test you for it? The result would be between you and us. That is all”

‘Ok. Where can I do it?’

” Here itself. You can give a blood sample  now. We will tell you the result tomorrow. That should be Ok. Can you tell me what would you do, if you were positive?”

with a smile,  he said”Just live till I die.”

“I have some good news for you. Nowadays with newer medicines life expectancy in nearly equal to not having the disease if the person who is HIV +ve takes regular medicines. If you are +ve would you take these medicines?”

‘Sure, sir. Where will I get them?’

“Let us first do the test.Ok?”

Test was done. I already knew the report.

“What do you think is the result?”

long pause.

I nodded my head slowly. He understood. He did not mind me sharing this with grandpa.

” What should we do now?” they asked.

I told them all the details I had gathered from CMC, Vellore’s Department of Medicine ( and Infectious Disease ). They planned to go to the nearest centre for T4 cell counts within a week. I never saw them since then. Our staff told me that they had come, when I was on vacation. It seems he was looking much better nourished. Thank God, he is still alive…

I still wonder, why is it that I did not ‘break bad news’ for two weeks!!! It looks so simple now 🙂 Was it my own anxiety that he being unstable, might do something drastic like commit suicide or less lethal step of relapsing into drug use? Was it my psychological voyeurism to understand a ‘case’ with multiple problems from many dimensions?  Was it my fear to loose a psychotherapy client due to distress caused by a medical diagnosis? Was it me buying time to get the best information possible for his further management?

I do not know and might never know my own fears and motivations… I went by ‘gut’ and probably, was right. I feel timing was right in breaking bad news in this case. The reason is that the manner in which it happened and it’s outcome was smooth, predictable and under control.

Why did they then stop following up??? !!! I do not know, and I have no guesses. I hope that he is following up in the center which gives them Anti- Retro-viral Drugs and that they a managing his psychological and substance abuse related problems.

What do you think?

Posted in challenge, distress, drug therapy, emotion, ethics, psychotherapy, substance abuse, suicide | 2 Comments »

“I will pay in full for I promised to sell my land”

Posted by Dheeraj Kattula on April 29, 2009

He was sick from Makara Sankranthi season. He muttered to himself and beat his wife black and blue. He shouted obscenites and village people avoided him. He was suspicious of people harming him, so he kept aloof. He suspected hisown  father to have a realtion with his wife. That was the reason that he was so irritated with his father and aggressive over his wife.

His beliefs overwhelmed him and he wanted to die. His father brought him one evening and he had to be given chemical restraints (pychiatric medicines in form of injections )before he could be admited. Injections are not painless. His backside was aching continuously after he recieved few shots. He understood that the hospital staffs are supportive. They give injections but also him give ice packs and comforting words. He started taking oral medicines.

He responded within a week. His hallucinations came down and his delusions were loosing their grip on him. He beacme very loving towards his wife and father too. He wanted to live, have children, educate them and do well. Nearly two weeks from admission, it was time to get discharged. His father wanted to pay ‘full’. We offer people to pay prospectively too. A poor family becomes much poorer following a hospital admission. When we asked again he said he now had cash, so it was no problem. I asked him, how he got that cash. I could then smell the handia, the local rice beer from his breath. He said he promised off to sell 6 ghunt land for Rs 6000/- . This was to pay a bill of Rs 1800/- !!! When we did not mind it being paid in installments without interest !!! One could suspect the balance amount would run down his throat within a couple of weeks as alcohol. I told him to cancel off the deal and pay whatever he could from his own reserved. He had about Rs 1000/-. Rest was to be paid over 8 months as Rs 100/- per month.

What is the possibility that this family with a schizophrenia patient would default? Minute. The whole purpose of admission was to remit the symptoms AND educate the family on drug compliance issues. Basically driving home the fact that He will do well as long as he takes medicines. Can’t you see how medicines have helped within the last few days? If he stops medicines, he will be back to the way he was. At that time these medicines may not work. We will have to then go for costlier medicines.If you want to stop medicines for financial resons and you do it, you would end up spending more!’

There is less chance for a patient to leave psychiatric services here and go anywhere else as the over all costs are cheaper and quality of services provided are better. Quality measured in the ‘time spent with patient’ and ‘time spent with family’.So there is less chance of losing to the competition.

Occupational rehabilitation is encouraged so patient becomes economically productive in ways such that in the long run cost of treatment is seen as an investment in generating income to the family.

I hope to see this patient back after 20 days from now. I do not want to see him as a psychotic in patient again i.e. I wish treat him in the OP for rest of his life. I know I can only wish…

Posted in challenge, distress, drug therapy, economics, schizophrenia | Leave a Comment »

psychotherapy beyond boundaries

Posted by Dheeraj Kattula on April 28, 2009

He was allotted to me as I could speak Bengali. He was slow in his movements and in speech. He used words which I did not understand and spoke with a accent difficult for me to comprehend. I had many cases to see that day and I had reasons to feel irritated. I listened to him. He was depressed. He had seen psychiatrists in Europe, Bangladesh and in India. He had received many drugs from many people. He had lost hope in everything.

He should be admitted as an in-patient with the level of hopelessness and suicidal ideation. One cannot be admitted into the Mental Health Center, Vellore without a accompanying relative. So, If I wanted to help him I would have to treat him on an OP basis. I had many OP psychotherapy appointments and I had my hands full with full quota of IP patients too. I gave him a time slot for an afternoon session with him. That day I saw him sitting in front of my room right in the morning. He greeted me humbly, understanding my busyness, not expecting to be seen immediately.

I liked this guy’s commitment to therapy. I decided to give my my best. His visa was for 30 days and few days are already gone. I had to hurry. I squeezed in some time even during my duty days to see him on a regular basis. I remember I had a session with him between 9.00 and 10.00 pm! I struggled to communicate with him. He understood that I was struggling. He tried to be helpful ! I started him on a rapid modified Cognitive Behavioral Therapy (CBT). I failed miserably to even communicate what an automatic negative thought was. So I focused on behavioral issues.

His diagnosis was Dysthymia with Depression. We had also started him on an antidepressant called Imipramine. As he and I struggled together, I remember on one occasion I shouted so much at him that it was audible outside my consultation room. This was because he was nodding in that session as if he was understanding so as to not displease me! But to me the time was FULLY wasted, a reason to feel displeasure.

My therapy was primarily supportive, as my glorious plan of CBT failed. There were many issues he discussed with me. His anger over his brother, who had cheated him of all his savings for 5 years, his sexual problem after being married thinking marriage would lift him out of depression, his poor supports in Europe, treatment failures everywhere and many other things.

I was listening patiently. In a sense, buying time for the time tested Imipramine to work. He was on a pretty good dose of 175 mg.The time for his going was nearing. I took an opportunity to ask if it was possible for him to forgive his brother unilaterally. He said it was impossible. I prayed with him once. I gave him a exercise for my last session. He had to make a ‘mixture’ using puffed rice, onions, tomatoes, some sweets and boondi.

I will never forget the last meeting. He came in unexpected on a day I had to leave to another campus to see patients. Every minute with him would crunch my lunch time. The expression on his face made me skip lunch. I ate the ‘mixture’ he had bought. Told him that it was very good. I took him to my supervisor and told of his improvements. I wrote letters to the psychiatrists, who might have to follow him up. I gave my personal email ID and mobile number. This is usually not done in our set up. I did it as I felt he might not be able to send a email himself but if he ever required help I could offer it over telephone.

A year later I received a phone call from him. I was having my final PG exams. I could not give him much time. I told him ‘DO NOT STOP medicines. Show my letters to psychiatrists there and follow their advice.’ I had written long term treatment plans in the letter.

I received another call 6 months later. I was in Baripada. My Tamilnadu mobile is roaming. I use it for sms only. I picked it as it was an international call thinking it was my aunt calling. He told me that 6 months ago when he had cal led had  I told  him to follow up locally. They had changed the   medicine. The changed Imipramine to a newer drug. He slowly slipped into depression again. He had stopped work. He wanted to come, wherever I was for getting treated! I gave him my address.

Lo Behold ! In a month’s time he was in Baripada. He shocked our staff and our town people, who heard this. He got admitted. I restarted him on Imipramine. He improved in 2 weeks and went back. Last month he called from Europe. He told me that he is doing well and has also got a promotion. I congratulated him. I was happy for him and for myself too !

I was wondering what is it that has brought him from thousands of miles to get treated from a young psychiatrist like me? It would have lessons for me to learn and be consistent about. It was :-

1. Willingness to take up extra work despite a lot of busyness, if that is the only way another person can be helped.

2.Willingness to invest time and energy, without looking for rewards.

3.Looking at a person as a whole not as a label.

4.Being really committed to well being of a person, even if minor departure from protocol.

5.Using time tested medicines.

6.Being available.

It was not that the doctors, who saw him were incompetent. They could not give him hope at a personal level. To them he was a case, who was treatment resistant. To me he was MY patient who has problems. I do not deny that failures on his part would not have affected me, with this sort of an attachment, but at times it is that attachment only that holds a person who is sinking.

There was two things that he told me in this Baripada admission that I would never forget.

‘Sir, I have forgiven my brother fully. I hugged him and cried. My relationship with him has been restored, but this depression has not left me.’ He need not tell this as I had never pushed him to it. I had just suggested it. Traditionally psychiatry is neutral regarding forgiveness etc, but I sense some of those things matter a lot to people.

‘Sir, If you had not given me an appointment soon after you saw me to explain me the treatment plan and the time required to improve, I would have gone and slept  on a railway track in Vellore itself.’

I realize there are many opportunities which come our way to make a difference in people’s lives, if we are patient enough to respond.

May God give us such patience at all times.

Posted in depression, drug therapy, psychotherapy, suicide | 3 Comments »

lesser the better

Posted by Dheeraj Kattula on April 26, 2009

She was 26 years old. A mother of a three year old child. She was well dressed and well kempt. An old patient of ours brought her to our OPD ( out patient department ) for vague somatic complaints that she had been having for the past 2 years. She was not keen expressing her problems as well. I usually enquire regarding stressors even in a general OPD. To me young hesitant woman ususally means- domestic problems with husband or mother-in-law.

She lived in a nuclear family and her husband was very loving. As I probed into her more deeply, I realized that the patient was quite severly depressed and was also having suicidal ideation. I encouraged her attender to admit as soon as possible indicating high suicidal risk. She wanted to come the next day. A hospital admission is not that simple.

Patient’s families have to hand over their cows and hens to others to care for. They should arrange for someone to take care of their feilds. They also need to arrange for cash. Most payments are out of pocket in rural India. They need time to go and bring utensils, rice, dal and oil to cook nearby. Most importantly they should arrange for someone to stay as an attender.

She came the very next day for admission with her husband. I could see her in detail. She revealed that she had been hearing voices that others could not for the past two and a half years. She had also been suspecting few relatives of doing witchcraft against her. She was barely able to do her household work. She was managing well, due to her extremely suportive husband. Clearly her diagnosis was Paranoid Schizophrenia- continuous course.

I started her on antipsychotic Risperidone 2 mg. In the evening hours I spent time with her husband regarding her illness, its nature, course, treatment strategies, prognosis and outcomes. The voices in her ears came down within 3 days. I had planned to go up on the dose to 4 mg before discharge. I decided against it. Many a time we go up on the dose rapidly expecting results quickly. Thoogh many patients might respond at lower doses.

She bacame aware of her problem as an illness. She feels there is no reason to die if her voices go away. She has hope that treatment is helping her. Why go up on the dose? The patient is not going to run away anywhere. If she does not respond with 2 mg over 2 weeks then I would go up.

By increasing her dose to 4 mg would I not double her treatment cost? It she develops extra pyramidal side effects (tightness and rigidity), she would require medicines to control that. This would triple her cost. By being conservative in a relatively safe situation benefits are fewer medications, better compliance, lesser cost, lesser side effects and probably better effectiveness.

Posted in drug therapy, economics, schizophrenia, suicide | 1 Comment »