Shrink's Views

ramblings of an unknown psychiatrist

Archive for the ‘psychotherapy’ Category

Marital Conflict: an abstract painting

Posted by Dheeraj Kattula on December 2, 2011

Marital Conflict

Title: Marital conflict

Watercolor on handmade paper

24 x 32 cm

2.12.2011

Realistic art is technically challenging and abstract art is ‘technically challenged’, so I thought and refrained from abstract art till now. Art need not be technically complex and simplicity may not be meaningless.This painting has taken a lot of thought and very less time.I call it ‘Marital Conflict’.

Any marriage is attacked by strong emotions and deep passions as represented by the red. It can be shielded by patience, serenity and wisdom as represented by the cool blue. In that love lives on, represented by the form of heart. There is peace, represented by white.In that context partners experience growth, as represented by green. Due to stressors, personality factors and rarely mental disorder this buffer is lost. Peace is found in separation as seen in the inverted funnel.Partners may grow but not to the level they together could as shown by the sizes of green blots.The blue drops above offer hope that outside forces can increase the buffer to protect love, peace and growth through social support,therapy and God’s enabling.

 

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Posted in art, love, marriage, personality, psychiatry, psychotherapy | 2 Comments »

Bollywood, Brothel and Being Born Again: a story

Posted by Dheeraj Kattula on September 25, 2010

This is a sequel to the story ‘A Dirty Job’ that I had written a couple of weeks ago. You can read it by clicking this.

It was the story of a girl who had very traumatic childhood. She landed in a brothel at an early age. She was rescued from there. She was given therapy to overcome her problems. She was also trained to live a decent life. She chased a dream to dance on film sets after she gained majority. She ended up having an affair and mothered a girl child. Hunger and desperation pushed her to the streets to solicit men.

The story was harshly realistic, reflecting lives of scores of women who land in brothels having chased a Bollywood dream. Is life over for them or is there any other way? Please read on…This story reflects a hope that I believe in.

Bollywood, Brothel and Being Born Again

Bollywood dream is over. I was not getting chances as expected. I made a new choice- to do the dirty job. I had detested it. I always had maintained that I would never do it. I was warned of this by few people. I wonder how they saw this possibility. I do not even want to think about where I went wrong. I always had prided in living in the present. No one knows what the future holds and no one can change the past. So why bother about these things which are not in one’s control. This is how I always thought. The doctor I had met used to advise me of being mindful, but my mind was full of ‘never mind’ philosophy. I think when one crosses boundaries and chooses to go far away from the previously set boundaries; it becomes easier as one moves along.

Having slept with a man once again to satisfy my hunger pangs, I was willing to continue this to sustain myself and my child decently. I went to Kamathipura and joined a brothel. I was given a small room. There were four others with me sharing the room. There were times when two of us were servicing our clients with only a cloth separating us. In the beginning I was a bit disturbed when I used to hear my daughter cry when I was engaged at work. I could see her through the diaphanous cloth which was to shield my shame. I have since gotten used to it. It is all right for a child to cry once in a while, especially if the tummy is getting filled thrice in a day.

I do not know why, but many of my clients come back to me for more. I had a record for this in our brothel. Mohammad Altaf was a local goonda who used to come for me frequently. He looked terrifying. He always carried his revolver with him. Another such regular client was Inspector Chogle. Chogle used to even bring biscuits and milk for my kid. Chogle had apparently recommended one of his bosses an IPS officer Mr Tripathi. He too came regularly. My status in brothel increased. I was given some freedom of movement. Moreover, I was voluntary here. Other girls who were trafficked from Nepal and Andhra had no contact with outside world except the clients.

One day Chogle came and told me to dress well for an outside engagement. He took me in a taxi to Bombay Orchid Hotel. He told me that it was one of the best hotels in India. The hotel looked astounding. He took me to a room more luxurious than the hotel. It did not require me to be an intelligence officer to know that I might have to service a big-shot.

I was shocked to see him. He was a minister. Everyone in the country knew him. Xavier Francis was his name. I had seen him debate on TV on issues of women like rights, dignity and self- reliance. He always wears Khadhi and speaks desi stuff. This is his real face- sleeping with young women in star hotels. After the job was done, he threw two bundles of Rs 100/- notes. I had earned Rs 20,000/- in one hour! I was thrilled. Suddenly he asked me to return the money. As I was giving him back, he tore few pages from a book that was placed near the table lamp. He wrapped the money in those papers. He then secured them with my rubber hair bands that I had left on the table and gave back the money to me with a smile. I liked his gesture.

When I went back to my brothel, I unwrapped the covers to take the money out. I was about to throw the papers, I thought I could as well read them. It was long since I read something in English. I might forget it fully if I did not read on and off. One sheet was the first page of a book. It had a seal stating ‘placed by Gideons International’. The other sheet had a story.

It went like this,

“But Jesus went to the Mount of Olives. At dawn he appeared again in the temple courts, where all the people gathered around him, and he sat down to teach them. The teachers of the law and the Pharisees brought in a woman caught in adultery. They made her stand before the group and said to Jesus, “Teacher, this woman was caught in the act of adultery. In the Law Moses commanded us to stone such women. Now what do you say?” They were using this question as a trap, in order to have a basis for accusing him.

But Jesus bent down and started to write on the ground with his finger. When they kept on questioning him, he straightened up and said to them, “If any one of you is without sin, let him be the first to throw a stone at her.” Again he stooped down and wrote on the ground.

At this, those who heard began to go away one at a time, the older ones first, until only Jesus was left, with the woman still standing there. Jesus straightened up and asked her, “Woman, where are they? Has no one condemned you?”

“No one, sir,” she said. “Then neither do I condemn you,” Jesus declared. “Go now and leave your life of sin.””

I got shocked. There were many things that I did not understand in the story like what are olives, who was Moses, what is this trap thing for this man Jesus etc but I did understand one thing. I am like that woman. I could be caught by police and tried according to the law. This would not happen as people like Chogle sleep with me. This man Jesus was different. He could have condemned that woman but he did not do that. He did not use this position in any other way too. He just told her to go and leave the life of sin. “Go now and leave your life of sin”- that statement rang in my ears for few minutes. I was so lost in these thoughts that I did not even notice that brothel keeper and my co-workers came and took away my money.

When I came to senses, I did not even feel the loss of money. I was awakened. Something was new in me. May be like a sapling. It was alive and growing. I was beginning to see things a bit differently. I do not know how to explain this. I could no longer enjoy the services I rendered. I was lost in some other world. My regulars also noticed a difference. Many of them asked me if I was not well. In fact I was feeling more than well. I realized that there is a thirst in me that needed to be quenched.

A few days later I was on my way to a beauty parlour. I was on an over-bridge near railway tracks. A drunkard walking with a cup of tea on the bridge spilt some tea on my shoe. I looked around for some waste paper. I saw an old man stand in a corner of the over-bridge giving away some booklets. I took one and tore a sheet from it to wipe my shoes and threw the rest of the booklet away.  Just as I was about to throw the sheet off, I realized I could read some English like I did on and off.

The passage went like this:

“Now he had to go through Samaria. So he came to a town in Samaria called Sychar, near the plot of ground Jacob had given to his son Joseph. Jacob’s well was there, and Jesus, tired as he was from the journey, sat down by the well. It was about the sixth hour.

When a Samaritan woman came to draw water, Jesus said to her, “Will you give me a drink?” (His disciples had gone into the town to buy food.)

The Samaritan woman said to him, “You are a Jew and I am a Samaritan woman. How can you ask me for a drink?” (For Jews do not associate with Samaritans.)

Jesus answered her, “If you knew the gift of God and who it is that asks you for a drink, you would have asked him and he would have given you living water.”

“Sir,” the woman said, “you have nothing to draw with and the well is deep. Where can you get this living water? Are you greater than our father Jacob, who gave us the well and drank from it himself, as did also his sons and his flocks and herds?”

Jesus answered, “Everyone who drinks this water will be thirsty again, but whoever drinks the water I give him will never thirst. Indeed, the water I give him will become in him a spring of water welling up to eternal life.”

The woman said to him, “Sir, give me this water so that I won’t get thirsty and have to keep coming here to draw water.”

He told her, “Go, call your husband and come back.”

“I have no husband,” she replied.

Jesus said to her, “You are right when you say you have no husband. The fact is, you have had five husbands, and the man you now have is not your husband. What you have just said is quite true.”

“Sir,” the woman said, “I can see that you are a prophet. Our fathers worshiped on this mountain, but you Jews claim that the place where we must worship is in Jerusalem.”

Jesus declared, “Believe me, woman, a time is coming when you will worship the Father neither on this mountain nor in Jerusalem. You Samaritans worship what you do not know; we worship what we do know, for salvation is from the Jews. Yet a time is coming and has now come when the true worshipers will worship the Father in spirit and truth, for they are the kind of worshipers the Father seeks. God is spirit, and his worshipers must worship in spirit and in truth.”

The woman said, “I know that Messiah” (called Christ) “is coming. When he comes, he will explain everything to us.”

Then Jesus declared, “I who speak to you am he.”

I got excited as I read this. This is the same man Jesus. I had difficulties in understanding everything. Of course I was reading a passage out of a story book and I cannot get an understanding reading a small portion. I asked the man distributing for another copy. He gave piercing looks and looked at the booklet I had thrown away. It had landed open and face down on the railway tracks. I knew what I had to do. I ran as fast as I could and got there before a train came and destroyed it. I sat in the platform and read through this booklet. It was called ‘Gospel of John’. It was about Jesus. It says a lot of things about love.

It said that “God so loved the world that he gave his one and only Son, that whoever believes in him shall not perish but have eternal life. For God did not send his Son into the world to condemn the world, but to save the world through him.”  It also said, “Light has come into the world, but men loved darkness instead of light because their deeds were evil. Everyone who does evil hates the light, and will not come into the light for fear that his deeds will be exposed. But whoever lives by the truth comes into the light, so that it may be seen plainly that what he has done has been done through God.”

What I had read earlier was also in this booklet. I realized that I was living in dark. In reality brothels are dark places. Many of our clients want their visits to Kamathipura to be kept in dark. I was living in dark and I was doing evil. Do I have a choice? Can I make a living for my child and me in a way that is not evil? Even if it were to be possible, was I willing to come into the light?

I realized that if I could do it, it would mean plainly that I have done this through God. I prayed to God to help me know the right thing and do the right thing. I went back to my brothel. Life was never the same. I could not enjoy my work at all. It was seen by my clients and soon my brothel keeper would know it. I could fake being happy, but I could not bring myself to do it. There was a discomfort welling within me about being untruthful. I could not even fake it for my survival. I was happy acting in line with my feelings.

I decided I must leave this brothel and this life style. I can work as a maid servant and life a truthful life. I should not let my daughter enter this dirty world if I really love her. Usually the brothel keeper never lets me out with my daughter alone. I had to find the right reason to take her out. That very week Chogle gave two passes for an amusement park nearby. One was for an adult and one was for a child. I had the right reason to go with my daughter and no one else would be with us.

Where would I go with my kid in Mumbai? Whom could I trust? I just wondered. I remembered that things are possible with God. I phoned Mohammad Altaf from a phone booth. I knew Altaf was a goonda and was a ‘bad guy’. Anyway, I decided to trust him, as he was on the wrong side of the law and was faithful to people on the wrong side. Chogle, Tripathi, Xavier etc appear to be on the right side of the law and are unfaithful to the ones on their own side.

Altaf came in about 15 minutes. I told him, “Altaf, I want to leave this trade. I need money to leave this place. I know that you are a tough guy, but I also know you are a good guy. So I have trusted you. Please help me. I want to do the right thing.”

“Laila. Come let us go to ATM…How much do you want?” he asked. “How much ever you can offer”, I answered. He gave me Rs 10,000/- and said, “Leave Mumbai. It is not safe here. They will be able to get to you. Wait for a minute… I will buy you a burqa from the shop near the mosque. You can cover your face.”

He came within five minutes and gave me a burqua. He told me to go behind the pan shop to wear it. In the meantime he took my daughter behind a barber’s shop and cut off the hair of my daughter and dressed her up like a boy. I was so happy for his resourcefulness. We had a chance to escape in nice disguise. As we were about to leave, he got emotional, “Laila, I wish I was a good guy. I would have given you a new life. My life has no future and so I can never commit. I would always love you.”

I always had this intuition that Altaf was a good guy at core but had life had built this tough shell around him. What else can you expect? His mother was also a worker like me, who died of HIV few years ago. He never knew who his father was. I was glad at least he realized there is something called love. I prayed that he too understands God’s love and power to change our lives.

I took a train to the place where I was treated as a teen-ager. I still remember the doctor who cared so much for me and gave me so much of advice. I hoped that he was still there. The hospital had not changed much. Extensions had been made in existing buildings. I went to the room where he used to meet me. I peeped in. He was there. His hairs have greyed a bit and he has put in few kilos of weight. His assistant wanted me to show the appointment card, which I did not have. All of a sudden the doctor came out, probably to grab a cup of tea in between few sessions. I called out for him. He took a couple of seconds, but he recognized me by my name. I was so happy. I was Laila, Lovely or Darling to many men according to their choice, but to the doctor I was, who I really was. He told me to wait till he finished his appointments. He asked me if I had eaten before he went in and resumed his work. I knew I reached a place which had some concern for me.

The wait felt very short. I told my whole story to him. He was not amused. He took it in as if he knew it all. He made some phone calls and then told his assistant to take me to the destitute home. He told me this was a short term arrangement till we could work out a long term plan. The home had 20 destitute women who were old and infirm. They had been deserted by their families. I enjoyed work in the home. Those ladies took good care of my daughter as well. I began to learn their language. There was a nurse who visited us twice in a week. She used to sing songs of Jesus at the beginning and at the end of her work. I shared with her my story. She got excited. She started praying with me for future of me and my child. I began to realize that this place was not my long term home. I wanted to move back to the brothels and help rescue many little girls and young women who are forced in to this trade.

I discussed this with the doctor. He bore the same expression he had when I had shared about wanting to be a dancer in Bollywood. He was true in believing that sparks should be kept far away from fuels. He thought it was intrinsically risky with the promise of earning powerful enemies. There was also the risk of me falling back into the trade. He encouraged me to stay at destitute home to help in the daily chores. He also encouraged me to complete my schooling.

I found a new love for books. They told me about how the world operated, a world created by God. This love made me learn with enthusiasm unlike the way I studied earlier. In a couple of years, I finished my XII standard. I even appeared for the Nursing School Admission test in the hospital where I had got treated. I got selected. My doctor and his friends supported me by paying my fees. They were also supporting my daughter’s school education.

In five years I completed my Nursing course and accumulated two years of experience. My daughter finished her VIII standard. It was an easy choice for me to wait for four more years till my daughter finished her XII standard and secured a seat in Nursing School. I continued to feel the pull to go and rescue girls who were caught in the dirt of flesh trade. I discussed with my doctor. He felt I was a mature woman now. He had developed links with NGOs who are trying to rescue girls and women who were trafficked. He said he would put me in touch with one of those NGOs. I put my daughter in hostel attached to our destitute home. My daughter knew the importance of my work. She was glad to release me. There was a mobile in the home. I could contact her anytime in the evenings.

In the first one month of my job, we were off on a raid. My job was to provide support to the rescued girls. We had social workers, volunteers and police in the raid team. The vehicle’s windows were covered. When the door opened and we alighted, it was like a déjà vu for me. The scent was familiar, the landscape, the building…everything. In fact it was not a déjà vu-It was all real. We had come to the place where it whole thing had begun for me about 20 years ago.

We rescued 15 girls that day. On our way back, I had tears in my eyes. I too had been rescued once, but I had fallen back. I needed a saviour. I knew these girls need a lot of love and a lot of grace to make this rescue meaningful. In our journey back, I prayed for each of these girls as they slept around me in the van. Maybe I lacked someone’s prayers and therefore I got back into the mess. I would not let that happen to these children. I have received love and it is time I share it.

Epilogue:

I became 50 years old few weeks ago. My daughter has become a nurse. She is a nursing tutor in the hospital that took care of us. Her husband is a Physiotherapist. They have a beautiful daughter Raksha.

I chose not to marry again though I had few proposals. I dedicated my life to a mission to rescue girls and I did not want any other engagement in my mind.

I have had my own share of problems too. I have been assaulted numerous times during the raids. I have had fractures a couple of times. Once I had a gunshot wound in my thigh and I lost a lot of blood. I was reminded of my saviours shed blood for me. Without sacrifice of some body, no good would come to this world.

I have been part of numerous rescue operations. Hundreds of girls have got rescued under my eyes. I do not know what has happened to each. I am sure there may be quite a few who have gotten back to the trade. I also know of numerous examples of those who get a new life after a rescue. I have seen them marry and establish homes and families. It is such stories which keep me moving forward. God has been faithful. He always gave me the needed strength. I would carry this on till my death. That is what I am called for.

******

Goonda- Ruffian/ Hooligan

Khadi- Indian fabric usually made employing rural populace

Desi-Refers to people, cultures and products of Indian subcontinent

Burqa- is an enveloping outer garment worn by women in some Islamic traditions to cover their bodies in public places which includes woman’s loose body-covering, head-covering and the face-veil.

Posted in children, christian, distress, education, emotion, fiction, gender, indian society, love, marriage, parenting, personality, prayer, psychiatry, psychotherapy, religion, social, spiritual, stigma, women's issues | Tagged: , , , , , , , , , , | 11 Comments »

The Dirty Job: a story

Posted by Dheeraj Kattula on August 27, 2010

My mother was admitted in the hospital. She had burnt herself. We went to see her every day. Our grand mother took us there. The doctors in the Government Hospital were not friendly. They would not let us stay in the burns ward for long. My mother suffered from burn injuries, which I still think were not very serious. I have seen many with worse burns make it to life. She died within a week of her admission. It was the doctors who killed her with their treatments.

Ramesh took Choti and left the village just after my mother’s admission into the hospital. Choti was born to my mother and Ramesh last year after they started living together. I think my mother knew she was going to die, even though she was conscious in the hospital. She wanted her family to take custody me and my other siblings Babloo and Moti. Her family is big. My grandma and her other children promised to take my brother. They did not want me or my sister. After all we were girls and they were afraid that we would grow up to be like our mother. I was seven years old and my sister Moti was four. An old lady in our village took sympathy on us and took us in. We addressed her respectfully as an aunt.

I missed my father and mother. My father was an alcoholic, but he loved us. He visited us every alternate day and gave us stuff to eat. My mother had wanted to keep him away from us. She used to shout at him, when she saw him meet us. I realize she too loved us. She was beautiful. We all look like our dad. Choti looked like our mom. I missed Choti too. My father never took another woman. He loved our family. A few months after mother’s death, I heard his body was found in a gutter in the neighbouring village.

This aunt who took us into her home was old. She found it difficult to control me. I was indeed naughty when I was small. I was always in the street playing with other girls. I did not help her as much as I troubled her. She put me into a hostel. I like school. I studied for five years.

In the summer holidays, I came back from hostel to be with my aunt. She was taking us to her native village. I refused. It was a dirty little village. We would have to share our room with two buffalos that they have. The smell was horrible. Instead of going I could stay alone in our village. She told her friend who lived few streets away to take care of me.

Her friend whom I called as Padma mausi took me to her house for a couple of days. She fed me well. I liked her. She took me to her aunt’s place which was few more streets away. The house had many young girls. They were all involved in dirty work. I knew that. My aunt too was involved in it, when she was young and able. There are no dirty little secrets in our village. Everything was open. Even primary school children knew what happened behind closed doors.

Our village had night school. It was where all children slept, when their mothers were busy with dirty work in the night. I knew it all, so I could tolerate it. I could accept the girls in the brothel. We played in the free time. I got good food there. It was better than what my aunt gave.

After a month, the care taker of the house called me into her room. A young man was there. She showed me to him and left the room. I was afraid. I screamed. He was strong. I could not fight. It was painful. I wept. He abused the care taker for giving him such a lousy girl like me. The care taker smiled and said, she is fresh to the trade. I was beaten that night for having shouted. Padma mausi never came again. Neither did my aunt. I was stuck there. I am now a 14 year old prostitute.

I could not leave the brothel. I was confined to the indoors. I had freedom inside. I could wear anything. I could eat as much as I pleased. I had the company of many girls, though many were older than me. Once you get used to everything you begin to enjoy what you once detested. I enjoyed the company of men. I liked the sensations of my body. When I lived in hostel, I liked Abdul. I dreamt of marrying him. His memories have got erased now. I lost the fear of men. I have seen them all. The rowdies who come and demand us for free, the police who are supposed to protect us, young men contemplating marriage, middle aged men who lost fancy for their wives and old men whose wives have died.

I was kept hidden for the fear of a police raid. I was moved from one brothel to another for protection. Indeed there was a raid and I was rescued. I was kept in a home run by the Government. Apparently my brother Babloo contacted a NGO and they had organized the rescue operation. I hate Babloo for having done this. I had adjusted to a new life. I was even enjoying it. I did not have to go to school. This rescue screwed my life up.

I was kept in this Government run home. I was not yet 18 years old, so I did not have right to be involved in this business. There were many girls like me in that home. Many of them were forced into it, just like me. They too began to enjoy their new life, just like me. They too were not getting any money, just like me. The men who came to us gave us money. We were to hand it over to the caretaker. She would give back a small amount to the older girls. The younger ones would only get food, clothing and accommodation.

After I joined the new home, they did some blood tests on us to check if I had contracted any disease namely HIV. I did not get it. The new home had a teacher who came to teach us some basic stuff. I was best in my class, as I had completed my primary school. Most other girls were dumb. I was getting irritated with their fixed schedule. I used to shout back to the teacher and the warden. They would beat me at times. They also taught us moral ways to live. I could see from the lives of our teacher and other staff that there are better ways to live.

I get confused at times about what is happening? The past and future flood me with irritation. I get tensed and do things that I later regret. I just cannot control it, when I get into that rage. Last year I broke the TV, Computer and telephone in a fit of rage. They thought I became mad.

They took me to a doctor. He admitted me in their hospital. He was a young man. He looked respectable. I saw him joking a lot with his friends in the hospital canteen, but he was serious with me. He looked straight into my eyes. He probably was mystified with my story. He had sessions with me regularly.  I avoided his eyes in the beginning. I became more comfortable with him and shared more freely. Of course I avoided many areas which were uncomfortable for me to discuss with. In fact I do not remember much of those either. He was interested in those things, as if they had a key to a treasure.

He asked me one afternoon, “You did not go to your aunt’s village because you would have been uncomfortable. Am I right?” I thought it was obvious. He then asked me, “If you had gone off to your aunt’s village, would you have gotten into this mess?” I was shocked. It is true; I would not have gotten into this puddle of shit if my aunt was around. She was old. She was in the dirty trade herself, but she was strong enough to protect us. He then said,” There are many things in life, which are uncomfortable. If we run away from them, then we would get into situations which are even more uncomfortable. Isn’t it?” I agreed.  He then added, “Can you see a difference between what feels good and what is good?” I did not understand that, but I nodded. He smiled and said “Good!”

He taught me how to relax my mind and how to ventilate my anger in acceptable ways. The day of my discharge grew nearer. He asked me of my dream. Of, what I wanted to be. I told him what I always desired, “A dancer, in the movies.” I could see his eyes sink. He was not happy. He tried to tell me that it felt good to be a dancer in the movies but it might not really be good. He said that the movie industry had risks for girls like me. He said it is likely that vulnerable people may get into wrong things.

I am sure I am not getting into bad things. I detest the dirty work myself. I would never do it to get a chance to be on silver screen. There is something called talent in this world and people would recognize and reward it. The doctor is educated. He can know what is in books. He cannot pick dancing talent. He has stereotypical beliefs on movie industry. Other girls in our hostel have danced on movie sets. They have told me that they did not have to do dirty work to get dancing chance. They told me the heroines do it not dancers.

When I got discharged, I could see that the doctor smiling. His smile was empty. It looked as if he knew something dangerous was lurking around. More knowledge spoils the mood for everyone.

Next year, they will release me from the home. I still am unable to love my brother Babloo, though he had done everything in my interest. It is probably because I fomented hatred over him just because he caused me the discomfort of moving me to the Government home from the brothel. I don’t care about Choti and Moti too. It has been many years, since I saw them. I have lost feelings for those whom I can call as a family. I can be a free bird with no restraints. I can chase my dreams. I can go to Mumbai and try my shot in movies.

Epilogue:

"The dirty job is always available."

After discharge from home she went to Mumbai to become a dancer. She fell in love with a light-boy. He left her after a year, leaving behind a two month old daughter in her hands. She was hungry and her baby had no milk to feed. She came to know why her mother sought Ramesh despite having a husband and three kids. The main roads are busy and side lanes are dark. The dirty job is always available.

PS: (added on September 25th, 2010) There is a sequel to this story ‘ Bollywood, Brothel and Being Born Again’.You can find it here.

Posted in behavioral therapy, bussiness, distress, economics, emotion, fiction, gender, indian society, personality, psychotherapy, social, stigma, women's issues | Tagged: , , , , , , , , , , , , , | 5 Comments »

A Game of Marbles: a story

Posted by Dheeraj Kattula on July 26, 2010

“Trrrrrrrrrring…Trrrrrrrrrrrrrrrrrrrrrrrrrrrring”.

Yeaaaaaah! It was a long bell. It meant we were free to go home 40 minutes before the usual time. The Sanskrit period got cut. Wow! That was good. I had an extra 40 minutes to play marbles with my buddies, till my dad came to pick me up from school. We rushed out of the classes shouting with joy, as if released from a prison. In few moments we were in the playground.

Sundar dug up small hole in the ground. That was the ‘home’ for the game of marbles. I drew a line 10 feet away. We threw our marbles towards the home and landed at different points. We all knew each other’s marbles. The marbles had a lot of similarities but had many differences as well. They were all of different colours and there were different designs inside the marbles, giving each one a distinctive appearance. The marbles had minor differences in size and mass, making them functionally different from each other too. Few marbles suffered scratches and cracks from long term use, but had sentimental values attached to them as being lucky etc.

Sundar had a beautiful blue marble. It was a delight to see the brilliantly transparent sphere which was perfect in every way. It was heavier and therefore difficult for other marbles to knock it off. We all knew it had a magical touch of luck because of which Sundar was always at command in the game.

My marble on the other hand was a simple light green marble which had bubbles of various sizes in it. It had a twisted yellowish leaf embedded in glass. It was not a heavy marble, not very attractive one because of its dull colours and scratches; it was prone to be knocked off to far distances from the home by other marbles, but it was mine for the previous one year. I liked it and endured it, though I knew that all other marbles were better than mine.

Sangram had a marble as brilliant as Sundar’s but of a different colour. Sangram’s marble was dark green, as green as a thick forest. He too did well at the game but he never liked to lose to anyone. He hated Sundar for his lucky marble. He always complained that Sundar’s victories were because of his marble and not his skill.

Darshan loved the game of marbles but never bought a marble. He watched us everyday as we played. He wished that he played. He went to the shopkeeper everyday and asked for a blue marble that was like that of Sundar. He prayed to God for the blue marble daily. He desperately wanted to play. He wanted to be in command if he played. He felt there was no point in being on losing side, even if the game were to be enjoyable. So, he waited for the blue marble.

Tejas was our class topper. He was our friend too. He was never interested in the game of marbles. He said, “What is the point in a game of marbles? You guys play trying to get to home and also keep knocking each other off from the home once you get there. The cycle goes on and on. So, playing marbles is just a waste of time. I can as well have a short nap till my mom comes to pick me up.”

I was usually a loser, as I always was trying to get back to home to get normal status rather than being in a commanding situation by knocking someone away. I never gave up, though. I always tried to get back to the home. It was difficult for me to say that I have lost or that I quit. May be that is the reason my daddy says that I would make a good scientist. It seems scientists fail many, many times before they succeed.

My friends teased me for I was a loser every day. As far as the game goes, it is true as most of the time I am in a sub-normal status. But, I am still a happy boy. Winning is fun. It is great, but playing is fun too. Trying to win is fun too. Status of being in command feels good for some time, but that status is lost as soon as someone knocks you far from home. So, it is a threatening situation. By being in losing side, I had nothing to lose. I defined success as ‘trying to get to home’ and not ‘getting to home’. In that way I was always succeeding. My friends defined success as ‘being in command’ near the home. On and off they were bound to fail, so felt irritated. To me the game was either fun or more fun, it could not be otherwise.

I was about to get to the ‘home’, I heard the horn of my daddy’s bike. One cannot miss that sound. It was time for me to say bye to my friends. I offered my marble to Darshan, if he wanted to play. He refused. On my way back, daddy asked me about what was going on. I told him everything I have told you.

He listened intently and paused for a few moments. Then he said, “Son, the game of marbles that you were playing is like living a life on this earth. We are all like marbles, different from each other in quite a number of ways, endowed with different innate abilities. When you threw the marbles, you all fell at different places from the ‘home’. The home in this world signifies – success. You were born to me and mummy. We are both educated. We can afford your English medium education in this Convent. The abilities that you were born with and the environment that you landed up in, puts you in an advantageous position to get higher education and ensure success. There are many who did not get this privilege. At the same time, we do not have resources to send you to an international school for education, which could have given you even greater exposure.”

I asked, “Isn’t that inequality in opportunities and abilities injustice?”

He replied, “We are not here to find why that difference exists. What we do with the privilege that is given to us is more important. You did the right thing, by not complaining about having a great marble like that of Sundar. You played with what you had. Though it looked as if you were losing, you did wonderful by enjoying every moment that you were playing. That is the point.”

“They were better in a way. Isn’t it, daddy?” I asked.

“Sure! Many were better. But were they enjoying it. I guess Sundar is feeling a false guilt because of attributing his successes to his marble rather than his skills. Many people want to do something great by themselves without the support of what the world has already offered to them. Noble as it may seem, it is an unending road in quest to prove oneself. It leads only to frustration. Enjoy what you have. Share it. Why bother about ‘why’ you have it?”

“Hmmm. I see it. What about Sangram?” I asked.

“Sangram was jealous and so he spoilt his own peace. Even if he won, he did not have Sundar’s marble. So, he would not be happy even on winning! On the other hand Darshan waited for the right marble, as if there is a ‘right’ marble that exists. Marbles are what you appropriate as yours and that is all. There is no ‘appropriate’ match or a ‘perfect’ marble. He should have taken a good marble from the shop and been content with it. Isn’t he missing all the fun, in anticipation of a ‘great fun’ in future?”

I enquired, “What about the brilliant boy Tejas, daddy?

“Tejas did not realize that when we played marbles, it is not to prove a point but to enjoy the game. That is it. We are out here in this world. We are free. We can as well live happily. Why worry over unanswerable questions?”

“I get you, daddy. I get you.” I said.

“Son, remember that the game can go on forever, but we might not be there till the very end. When daddy called you, you had to leave your game and come over. Isn’t it?”

“Yes, I did, Daddy.”

“Just like that we do not know when our Heavenly Daddy will call us home. We must be ready to leave our game of life at any time. We can enjoy our life. But we should play the game according to the rules. Do not forget that you should not let fellow players define the success in the game of life. Son, define it yourself, in a way you will be happy playing. Remember that after the game there is a banquet. Today mummy has made Payasam* for you. You deserve it after your success at the game of marbles. Don’t you?”

“Thank you, Daddy. I love you.”

Soon they reached home and enjoyed the Payasam. Payasam had a little less sugar than required. But they were all happy, for it was not the taste which made the dish successful, it was attitude of love with which it was made and served.

*Payasam- a south India sweet dish made with milk

Posted in education, emotion, fiction, psychotherapy, spiritual | Tagged: , , , , , | 4 Comments »

Lost everything & gained a new life: Turnaround in three days of Hospital Admission

Posted by Dheeraj Kattula on November 28, 2009

She was an 18 year old young lady. Orphaned at an early age, she was brought up by her maternal grandparents and uncles. Her dad deserted her to remarry a woman of his choice. A couple of years ago, she dropped out from school and joined a cotton factory. She was hard working. She had savings of about Rs 35,000/- within about 3 years of work. She was attracted to a nice co-worker of hers and desired to marry him. He too reciprocated her love.

All her maternal uncles were alcoholics. They wanted to dispose her off cheaply. They arranged her marriage with a man who was already divorced and was twice her age. She was not interested in this proposal at all. The groom asked her in private if she was interested. She agreed. She knew that her uncles were listening. One of her uncles had threatened to poison himself if she did not consent for the marriage.

The marriage was over within hours. It was time for the ‘first night’. She told her husband that she would not allow him to touch her. Both of them had arguments throughout the night. Of course she managed to protect herself.  By the way even if he had raped her, it would have been legal in India. Here marriage indicates permanent consent for sex. She created a scene the next morning telling everyone that she cannot live with him. The groom’s family was aghast. They had spent Rs 1,50,000/- on the marriage. They had borne all the expenses as it was not easy for him to get proposals because of divorcee status.

They took her to a Police Station. The relatives of the girl were there too. They gave in writing that she had given a consent. They also wrote that they will have nothing to do with her, if she walks out of the marriage. They did not want  any voice in her favor to surface. One of her uncles beat up his own father with a thick stick and bruised him in areas that cannot be seen easily. He kept the old man away from the Police station. Few other uncles thought it was good to take her to a psychiatrist, so that he can change her mind. That is how she landed in my office.

I admitted her to separate her from stressful zone. She was under pressure from all sides. Her grandfather stayed in the hospital as a caretaker. She came to know that all the money she had saved during her 3 years of work was used up by one uncle. When he took the money, he had told her that he would buy her golden jewelry. She had lost almost everything now.

Her newly married husband pursued her in the hospital. He paid her grandfather money to foot the bills. She was angry with her grandpa for accepting help from that guy. She knew that it could become a liability and restrict her freedom. Poverty and want pushed her grandpa to receive the money. He began to counsel her to change her mind. After all the groom was a benevolent man! They shared their room with a patient with Schizophrenia. The mother of the patient was a 70 year old lady who had faced much difficulties in life. She too started counseling her to reconsider her decision. She was of opinion that it is better to get married to a rich man who did not have vices (whatever be his age) than remain unmarried.

The girl was fed up with all these inputs. In the hospital she had respite from torture of her uncles. She began to think more clearly. I listened to her and gave her support. I gave her little advice to remain calm and not lose her temper when her husband came. We knew he would come. We knew if he walked away from marriage then all problems would be over. Next time when her husband visited her, she remained calm and chatted with him. She explained to him that he would not be happy with her, as she liked someone else. She told him that she respected him and felt bad about what he has gone through. He tried to convince her that they could start afresh. With time he realized that it was futile to try it if she has absolutely no feelings for him. He agreed for a divorce. I do not know if it can be called a divorce. What had happened was hardly a marriage. What ever be the semantics, she would have a new life.

She was afraid of her uncles. She could no longer live in the same village. She told her grandpa that she was willing to take care of him, if he followed her. She was a skilled worker and she could easily find a job in cotton industry. He agreed. He wanted to bid good bye to few people in his village. If he were to do it, he could inadvertently give away the plans to his sons. He decided to move to a new location soon after discharge from the hospital. He would begin a new life. His grand daughter would be his care giver.

I had enormous joy in dealing with her and her grand father. They had real life problems. They had no money. They were surrounded by crooked relatives, who could not be trusted. They were on the verge of giving up. The girl had suicidal ideation and man had no idea of what was going on. A timely admission and supportive therapy filled them with hope and helped them decide what was good for them. I learnt that at times, apart from allowing ventilation of distress, all we need to do is to offer a platform for mindful thought on choices and their consequences.

Posted in adjustment disorder, alcohol, distress, indian society, marriage, psychotherapy, suicide, women's issues | Tagged: , , , , , , | Leave a Comment »

The Cultures of Depression

Posted by Dheeraj Kattula on October 21, 2009

Here is an article written by my teacher Prof KS Jacob. It is a well articulated argument for need for a wider perspective on depressive illness.This article appeared in newspaper “The Hindu” on the 18th of October 2009.Here is the link and the article follows:-

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Diverse models of depression have been proposed and debated. Much of the confusion that exists in this area is because of disputes about the nature of mental illness. The confusion is compounded by the fact that core depressive symptoms, such as sadness and feelings of hopelessness and helplessness, are also found in medical diseases, as reactions to stress and as part of normal mood.

Medical model: The medical model considers psychiatric disorders as diseases, supposes brain pathology, documents signs and symptoms and recommends treatments. The disease halo reserved for the more severe forms of depression is also conferred on people with depressive symptoms secondary to stress and poor coping skills. The focus for diagnosis of depression centres on symptom counts without assessment of context, stress and coping skills. The provision of support by health professionals mandates the need for medical models, labels and treatments to justify their input. Insurance reimbursement also necessitates the use of disease labels. Consequently, psychiatric culture now tends to view all depression and distress through the disease/medical lens.

Perceptions in primary care: Patients visit general practitioners (GPs) when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms. Bereavement, marital discord, inability to cope at work and financial problems also lead people to seek help from their doctors. In this context, the major challenge is to distinguish between distress and depression. Depression in patients encountered by GPs is often viewed as a result of personal and social stress, lifestyle choices or a product of habitual maladaptive patterns of behaviour. Consequently, GPs often subscribe to psychological and social models of depression.

Population perspectives: Social adversity is often seen as a cause of depression by the general population. Under such circumstances, people are reluctant to consult their GPs, counseling is the preferred treatment and antidepressants are viewed with suspicion by patients as they are considered addictive. Religious models are also popular. The general population seems to simultaneously hold multiple (and often contradictory) models of illness. They seek diverse treatments from assorted centres offering healing. The protracted course of depression secondary to chronic stress, lifestyle and poor coping results in people shopping for varied solutions.

Pharmaceutical approach: The pharmaceutical industry has espoused the cause of the medical model for depression. It has aided and abetted the medicalisation of personal and social distress to its advantage. Sponsoring educational activities and professional psychiatric and user meetings and conferences have helped shape medical and patient opinions. While pharmaceutical companies play a major role in the development and testing of new treatments firmly rooted in the medical model, in actual practice theirs is a culture driven by profit rather than by science.

Competing cultures: The medical model is defended by the powerful biological psychiatry movement within the specialty of psychiatry and by the pharmaceutical industry. But the other models and cultures of depression emphasising psychological and social issues are equally valid in the contexts of primary care and the community, but lack the academic clout and financial resources to present their points of view. The different ‘cultures of depression’ and the pressures from these divergent perspectives need to be acknowledged.

The issues which need to be re-examined include: (i) the heterogeneity of the concept of depression, (ii) the (in)adequacy of a single label of depression, relying solely on symptoms counts, to describe the diverse human context of distress, (iii) the need for clinical formulations which clearly state the context, personality factors, presence or absence of acute and chronic stress and extent of coping, (iv) the fact that antidepressant medication is not the solution to mild and moderate depression and should be reserved for severe forms of the condition, (v) re-emphasising the need to manage stress and alter coping strategies, using psychological treatment for people with such presentations, (vi) de-emphasising medicalisation of personal and social distress and, (vii) focusing on other underlying causes of human misery including poverty, unmet needs and lack of rights.

Clinical presentations: The syndrome of depression includes depressed mood, loss of pleasure in almost all activities, poor concentration, fatigue, medically unexplained symptoms, insomnia, guilt and suicidal ideation. Three categories of depression can be identified from a clinical and treatment point of view. The first, called adjustment disorder, is a normal reaction to acute and severe stress in people with a past record of good coping. The magnitude of the stress would temporarily destabilise many people with good coping strategies. By definition, the condition is time-limited and people usually settle back to normal lives within a few weeks or months. There is an absence of a family history of depression or suicide. The self-limiting nature of the condition means that support is all that is usually required and results in good outcome.

The second type of depression is characterised by its chronic nature (called dysthymia). Stressors, usually mild and multiple, precipitate, exacerbate and maintain the symptoms. The onset of such depression is usually in early adult life and such people usually have a long history of depressive symptoms. Their moods fluctuate and are usually responsive to changes in the environment. They also have a history of maladjustment and poor coping in response to past stress. The mainstay of treatment is psychological interventions which focus on improved coping, changes in personality, attitude, philosophy and life style.

The third category is called melancholia. In addition to the basic syndrome of depression, symptoms of melancholia include a pervasive depressed mood with minimal response to environmental change, global insomnia, early morning awakening with low mood worse in the mornings, significant loss of weight and restlessness, agitation or slowed movements. Melancholia usually occurs later in life and there may be a family history of similar depression or suicide. Such presentations may be also part of a bipolar disorder (manic depression), which has extreme mood swings, or may be due to medical, neurological and endocrine disease. The treatment of choice is antidepressant medication, management of the underlying medical causes and hospitalisation.

Management: Clinicians and psychiatrists managing patients with depression should be able to hold multiple models of depression. They should be able to appreciate the diverse cultures of depression and choose appropriate treatment strategies. Clinically, there is a need to look beyond symptoms and explore personality, situational difficulties and coping strategies in order to comprehensively evaluate biological vulnerability, personality factors and stress. The treatment package for such presentations should include psychological support, general stress reduction strategies (for example, yoga, meditation, physical exercise, leisure, hobbies) and problem-solving techniques (for example, cognitive therapy) for subjects presenting with ‘depression’. Antidepressant medication should be reserved for the severe forms of depression with hospitalisation and electroconvulsive therapy for those with high risk of harm to themselves and to others. People can present with a mixture of clinical presentations requiring a combination of approaches. A psychosocial formulation of the clinical presentation, background and context will put issues in perspective.

The progressive medicalisation of distress has lowered thresholds for the tolerance of mild symptoms and for seeking medical attention for such complaints. Patients visit physicians when they are disturbed or distressed. Grief at loss, frustration at failure, the apathy of disillusionment, the demoralisation of long suffering and the cynical outlook of pessimism usually resolve spontaneously without specific psychiatric intervention. Distress and emotions should not be mistaken for pathology; fear and apprehension should not be labeled as anxiety, or sadness as depression.

The failure of individual models and cultures to explain all aspects of depression seen in diverse settings has led to the development and use of multiple models, which argue for the need to accept the many perceptions as partial truths. These models should be viewed as complementary rather than competitive, with some being more valid in a specific context than others. Patients present to physicians with their illnesses while doctors diagnose and manage disease concepts. The failure to bridge the gap between disease and illness and healing and cure is a major cause for the contemporary confusion in the diagnosis and management of depression. There is a need for more pragmatic approaches which move beyond the specific models of depression and narrow ‘cultural’ perspectives.

( K.S. Jacob is Professor of Psychiatry at the Christian Medical College, Vellore.)

Posted in adjustment disorder, depression, Diagnosis, mood disorders, psychiatry, psychotherapy, religion, social, suicide | Tagged: , , , , , , , | 2 Comments »

Loss and Meaning

Posted by Dheeraj Kattula on May 31, 2009

Background:

A friend of mine chided me for my previous post saying that it comforts people wrongly in finding refuge in chance. She also felt that though the post assumed the existence of God and our human response of thankfulness was well placed, the post had hinted that God created ‘chance’ and sat distantly as world operated according to His laws of probability. This post argues from a ‘more spiritual’ vantage point.

Let us first see the following two cases:-

Case 1

A senior advised me to spend more time with one of my patients who was a brilliant engineering student from one of the IITs. My friend said “His intelligence is a risk factor for him committing suicide. Support him well and instill hope or …”

I followed this advice. The last I knew of this boy, he was doing well.

Case 2

Another therapist started his patient on Cognitive Behavioral Therapy on an out-patient basis. This patient got admitted in a general hospital the very next day following a high- intention and high- lethality suicide attempt.

Observation

Loss in life is real. We might deny it, rationalize it or laugh at it, using the innumerable defenses that we have. There is another chance for some things but there are none for few. What happens, if a person fails his IAS exam in his final attempt? His years of hard work in preparing for such an exam do not find too many alternative uses. Rationally speaking those years of preparation are ‘wasted years’.

My senior friend’s point is that an IITian appraises major mental illness in himself and its repercussions on his future life more catastrophically. The difference between having an illness and not having one is huge for him. This difference might not be much for a line worker in a factory. A line worker might not have aspirations which get shattered so badly, as he might not really know what he has lost or might lose because of his illness.

A purely rational appraisal of loss might be very painful in reality. So what is the option? Do we encourage by being/keeping in dark? Do we down-play the loss? Do we offer empty hope?

Note

Coming to terms with loss involves cognitive and emotional aspects. Coming to terms cognitively might worsen ‘pain’ as discussed above. Coming to terms emotionally by definition eases that pain. Victor Frankl said “Suffering ceases to be suffering as soon as it finds meaning”. Such a concept is not of the realm of cognition or emotion but is of a deeper level.

victor frankl

Victor Frankl

He says further “For the meaning of life differs from man to man, from day to day and from hour to hour. What matters, therefore, is not the meaning of life in general but rather the specific meaning of a person’s life at a given moment”.  He suggests between stimulus of life event and the human response to it there is a space. In that space is our power to choose our response. In that response lies our growth and our freedom.

We all have our own specific vocation or mission in life; we must carry out a concrete assignment that demands fulfillment. We cannot be replaced, nor can our life be repeated, thus, our task is unique as our specific opportunity to implement it. I might call it God’s will for my life. But whatever, such view which is sometimes beyond reason, buffers us from major losses and helps us live better.

Posted in challenge, distress, emotion, psychotherapy, spiritual | 1 Comment »

” 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 »

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 »