The Spy Who Knew Himself : a story

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

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

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

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

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

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

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

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

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

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

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

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

Rights and Love: a story

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.

Hell’s View on Mind, Mentally Ill and Mental Illness: Satan writes to Screwtape

Prologue:

The Screwtape Letters is a Christian apologetics novel written in epistolary style by C. S. Lewis, first published in book form in February 1942. The story takes the form of a series of letters from a senior demon, Screwtape, to his nephew, a junior tempter named Wormwood, so as to advise him on methods of securing the damnation of a British man, known only as “the Patient”.

One must know this background to understand the following post. The following is a letter written to Screwtape by the father below Satan himself. It addresses issues of the mental illness and mind.

Letter:

Depths of Hell

21st Century. Year of the Enemy

Dear Screwtape,

I bring greetings from the depths of our eternal home. I have heard of your progress from your junior aid Wormwood. He gave me the news that you have been active in trying to understand and use the interface of spiritual and mental realms for our purpose.

I must warn you of the dire consequences of making yourself too obvious. Our success lies in our subtlety. You know it clearly that the ones who are obsessed with us and the ones who do not even believe in our existence are not our threat. In fact they are safe in our hands. I use the word safe only for sarcasm. You know the truth that they are actually unsafe in our hands 🙂

Many of our Enemy’s children are slowly coming into our camp. They are quite obsessed with us. Many of them do not even realize it. They know us. They can drive us out of our subjects with the authority of the Enemy. What is good for us is that they see us in everything. What our Enemy intended for them is to know Him more deeply. We can keep them preoccupied with us and distract them from Him. We can make them hate us more, thus filling their heart with more hatred. This distracts them from showing love for their brothers through their actions.

I see you have done a good job in the area of mental ill-health. Of course, I cannot credit you with making people mentally ill. I know some of this is beyond our capacity. We can only hurt those subjects as much as we are allowed by the enemy. You have quite nicely convinced many that mental illness is caused by us. It is a great lie. I love it. It is useful in quite a number of ways.

One, it keeps people in search of a magical-spiritual cure, which we can use for drawing them closer to us by involving them in rituals that are not pleasing to Him. Secondly, this preoccupation helps them keep away from medical attention. This makes the subject live in a psychotic state, away from reality. This makes him lose contact with the world that the enemy has created and makes them live in a world of lies. Remember our job is to steal, kill and destroy. We steal, kill and destroy the time of our subjects through this.

When we encounter any illness, we can use it for our purpose. We can use mental illness, even more. Our weapon of lies is very powerful. You are using it well. People fear mentally ill. They think that mentally ill subjects are violent and dangerous. Those of them who fear us also think we are causing these patients to do their behaviors. What a joke! We can laugh at this even in hell! The subjects who seem to be walking around normally and living their life successfully could probably be much more in our control. In fact they could be much more dangerous than subjects with mental illness.

We must realize that every bad thing that happens to His children is a good thing-gone wrong. For example when a man works hard in his business, he is doing what our enemy intended him to do i.e. to provide for his family and share with others. This good can be made to be bad when he works hard to make more and more money to the point of neglecting his family. It can be made to be bad in another way, when he earns for his family only and does not give out to anybody else. I am sure you have been using these distraction tactics to deviate our Enemy’s children.

Basically evil is qualitatively only slightly different from what is good. It is at times quantitatively only a changed proportion. Now why do I say this, we cannot take credit for the evil in the world too. We have not created it from anything. Evil is only the deviation from what our enemy meant in this world. We love it though.

If a person takes cocaine, he will get a high. Cocaine works in his brain and alters the chemicals in different areas. If a person takes Diazepam, he will get sleep, as Diazepam acts on certain areas in the brain which induce sleep. Did you or I create these substances? No! Can you or I control that effect? No! It is bound to happen in a world created by our enemy. In fact all of the day to day functions are regulated by chemicals in the body.

Our enemy has created certain chemicals, when present in right quantities make subjects happy. If these are not present in right quantities or if their proportions deviate then the subject loses his happiness and become depressed. If this is severe he may become suicidal and may even end his life. We love imbalance. We want his subjects to die if they are depressed. We can rejoice in death of a human subject, but we do not earn points. What extra have we done? It may be more like a person with cardiac failure dying with a cardiac arrest. Would I give you any points for it? Absolutely not!

These guys with mental illness lose capacity. Even the earthly Courts of Law give them some immunity by considering them not criminally responsible if they were to do a murder under specific circumstances. Our Enemy loves them much more. How much more he would be gracious towards these mentally ill on the day of judgment!  These people might get away with much of what they do due to their illness. Remember to not take credit for what bad happens to them and do not feel happy when they do something bad.

Mind is a good playground for us to demonstrate our skills. You and I cannot know exactly what our subjects are thinking in their mind, but we can input thoughts in their mind. I am not speaking of the thought insertion seen in what the humans call Schizophrenia or the intrusive thoughts seen in what they call Obsessive Compulsive Disorder. These phenomena as I said earlier are not out doing. If I hear of you take any credit for this kind of phenomena seen in your assigned subjects, you would be demoted in the hierarchy of Hell.

What you would be given credit for is, when you can instill a normal human with automatic negative thoughts. By this you trigger a volley of negative thoughts. These affect the subject’s mood making him anxious, angry, bitter or depressed. I agree that this is more pronounced when he is mentally ill. You would get no points for that. You would score if you use this on normal people, happy people, loving people, and obedient people and successfully make them lose contact with what our enemy intended them to keep in touch with, by painting a darker picture of reality even if it lasts for a short while. I would be happy if you could do this long enough to make thought patterns freeze. They should ultimately submit and react to thoughts that arise in the minds without questioning it rationally. This would ensure the subject’s drift away from the Enemy.

By the way I liked your letters to Wormwood. I have asked new recruits and slow learners to read the letters to improve their performance. Wishing you all the very best in accomplishing our task.

Hail Me!

Your Father below,

Satan

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

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! 🙂

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

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.

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* Name changed

 ‘Murugan’ is a very common name in Tamil Nadu

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

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

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

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

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

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

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

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

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

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

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

“Can you please give me some poison?”

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

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

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

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

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

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

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

The Cultures of Depression

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.)