Shrink's Views

ramblings of an unknown psychiatrist

Posts Tagged ‘psychiary’

The Spy Who Knew Himself : a story

Posted by Dheeraj Kattula on May 18, 2012

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

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

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

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

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

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

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

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

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

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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.

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

Love – Feeling, Reason and Choice: a story

Posted by Dheeraj Kattula on September 19, 2010

Background:

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

Love: feeling, reason and choice

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted by Dheeraj Kattula on August 31, 2010

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

Posted in christian, depression, fiction, humour, OCD, philosophy, psychiatry, religion, schizophrenia, science, spiritual, stigma | Tagged: , , , , , , , , | 15 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 »

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

Posted by Dheeraj Kattula on July 10, 2010

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted by Dheeraj Kattula on June 20, 2010

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

———————————————-

* Name changed

 ‘Murugan’ is a very common name in Tamil Nadu

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

“Can you please give me some poison?”

Posted by Dheeraj Kattula on March 7, 2010

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

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

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

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

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

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

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

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

‘Agreement’ among Psychiatrists and Legal proffessionals:Towards better Mental Healthcare and Justice

Posted by Dheeraj Kattula on October 12, 2009

Consider a psychiatrist who diagnoses ‘severe depressive disorder with psychotic features’ in a patient. He makes diagnoses like this everyday. How can we be sure that he is making a right diagnosis? How do we judge? Usually this would be based on his qualifications and training. Isn’t it? What is training? How does training help?

A psychiatrist learns a set of criteria based on which he makes the diagnosis. He learns this process by observing senior psychiatrists till he begins to identify signs and symptoms just like them. This happens to every student of psychiatry. So at the end of a long period of training every student would probably make same diagnosis on seeing the same patient. Practically this does not happen in all cases. It would be in ‘typical’ cases but not all cases. When two doctors see a patient separately and diagnose a patient to have an illness or clear him as not having an illness, we can say they are in ‘agreement’. When one diagnoses a illness and another clears the same patient as not having an illness, we can say they are in ‘disagreement’.

The criteria for diagnosis are formulated in such a way that agreement of responses is made possible to the maximum extent. For example, we can study two psychiatrists by making them assess 100 patients among whom there are few patients with depressed mood. Each psychiatrist is asked to evaluate for depressive symptoms. At the end of the study usually psychiatrist A and psychiatrist B would have agreed on certain people to have depressive symptoms and certain to not have depressive symptoms. There would be certain people whom A would have said to have depressive symptoms which B would have cleared them off as not having depressive symptoms. There would be another set of people whom B would have said to have depressive symptoms which A would have cleared them off as not having depressive symptoms.

If B was a 10 year old boy who would toss a coin and call all ‘heads’ as ‘depressive symptoms’ and all ‘tails’ as ‘no depressive symptoms’, there would still be some agreement between A and B. This is because of chance. Isn’t it? We can adjust for chance ‘agreement’ and find ‘true agreement’ by calculating a statistic called Kappa. If Kappa is high, it means that level of agreement is high.

Lately, I have found many lawyer friends. I discuss legal issues with them. I have been learning much from them. I also bore them with theoretical questions like this one- what is the level of agreement among judges while sentencing convicts?

For example there are 100 convicts. How would Judges A and B sentence them? There would be few to who both might give strict punishment. There would be few for who both would give liberal punishment (not so strict). There would be few, for whom one would give a strict punishment and another would give a liberal one.

Judge A

Punishment strict

Punishment liberal

Judge B

Punishment strict

🙂

😦

Punishment liberal

😦

🙂

Intuitively the level of agreement ought to be high, if one were to have faith in the legal system. The smiley in the table indicates that there is no problem when there is agreement.The sad face reflects feelings when a person could possibly be getting the wrong sentence.

To my surprise, many of my lawyer friends felt that agreement would probably be less. I was also shocked to see that they were comfortable with this lack of ‘clarity’. I sensed how other doctors perceived the low agreement levels in few of the psychiatric diagnosis. But ‘psychiatric diagnosis’ is of less significance than a ‘sentence’ in court. A disagreement in psychiatry might mean a patient might take a medicine for few extra months. Whereas a disagreement in a court of law might mean a death sentence for someone!!! How can lawyers be comfortable with this sort of system?

There is another principle which operates in the legal system. That principle allows a party to ‘appeal’ to a higher court. Just in case a party feels justice was not delivered in a court of law, then the party could appeal to a higher court. The higher court would look at evidence again and pass a fresh judgement. Courts are organized in such a way that there are 3-4 levels till which a case can be taken up. How on earth does this help? Let us see it- statistically!

Let us assume an average Judge has 90% accuracy in making his judgements. If he were to sentence 1000 people, he would have 900 correct decisions and 100 errors. If these 100 go to a higher court, 90 sentences would be corrected and only 10 errors would remain. If these 10 go to an even higher court 9 would be corrected and only 1 would end up getting a wrong sentence. This model assumes that every judge has 10 % error in judgements. The truth is that as we move to the higher courts there would be judges with less error rates. This is because higher courts have judges with more experience and better track records. This ensures that justice does get served.

Hmmm… Now I know realize why they were comfortable. It reminds me of what I do when I have a diagnostic dilemma in an atypical case. I would ask my peers to see the patient. If we ‘agree’ I assume that we are right. Something like this happens when courts use a ‘jury’. What do I do when my peer and I ‘disagree’? We ask a senior’s opinion. It would be usually someone with more experience and knowledge. Hey…That is like an ‘appeal’ to a higher court in the legal system. What can be done if the agreement among judges at higher courts is low? Make the law more comprehensive and clear! This is similar to what psychiatric researchers do, while revising the diagnostic criteria.

Wow! Is it not amazing to see commonalities in approach of lawyers and psychiatrists? We also share a common desire for our clients. That is the client’s well being. But, it is funny that we don’t seem to understand each other in our arguements. We would…soon 🙂

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