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A case of mental shrine of a dead husband

by Himanshu, posted in psychiatry, Psychotherapy, Uncategorized

                              A case of mental shrine of a dead husband

I was referred an Indian girl, aged 18. She had come to visit her maternal uncle. She was suffering from an obsessive-compulsive neurosis. She had seen several psychiatrists in her region, in southern India. She was in UK for holidays and break. Her maternal uncle was a general practitioner and friend of mine. He asked me to see her.

She was suffering from an obsessive-compulsive neurosis for about a year. She had a number rituals regarding washing and cleanliness. She was on appropriate medication prescribed by her Indian psychiatrist. There was not much improvement in her clinical condition.

I started my enquiry into her life. She was a daughter of a famous general practitioner. When she was just 16 years old, she met a young man of 19. He immediately fell in love with her. About six months after an initial meeting he started asking for marriage. She had no feelings for him. She rejected his proposal. He continues to pursue her. After seven negative responses from my patient Anita, he started threatening her. He attempted several wrist cuttings. He also took an overdose. Anita harassed by his behaviour, out of pity, agreed to marry him. Her family tried to change her mind, but she remained adamant. Her marriage was disaster. A month after their wedding, her husband committed suicide. After this grief, some stage she developed her symptoms. Few months after this incident, her father started talking about her remarriage. Anita refused to enter in any discussions and declared that she was never going to get married again.

It seemed to methat she was holding considerable guilt and saw herself responsible for his death. Next several sessions I explored Her guilt. I explored why she felt responsible for his death. I was able to show her, inadequate aspect of her husband’s personality. After several discussions she was able to see did she had agreed to marry him under pressure and out of guilt, as she was unable to walk away from him. These discussions, lead to a reduction of her guilt and symptoms. In a professional meeting I met her maternal uncle, who told me that whatever I was doing was working and I should continue.

In the next phase I started exploring about difference between pity and love. Confusion between the two needed to be sorted out, pity is not love and it is an inadequate reason to start relationship. End of all this discussion I asked her, if in reality she loved her Dead husband very much so that she has cleared its shine in her mind and wanting to live that rather than start a new life. I asked to think about it in her own space. 

The next time I saw life she was symptom-free. I saw her again a couple of times and help her stop medication. About a year later I had an invitation from Anita’s maternal uncle to India to her wedding. 

In Psychiatry, we too much concentrate on symptoms and not fully recognise the person behind the symptoms. It seems to me that a person’s life, incidents in a person life generates negative emotions like anxiety, depression, guilt, shame, anger etc. These negative emotions express themselves in the different psychiatric conditions. Hence, I think it is important to explore a person’s life and traumatic incidents. It took fourteen hours of my time but changed her life.

My Blogs on Facebook on Mental Health

by Himanshu, posted in Deep Psychology, Mental Health, Uncategorized

Blogs will be added here as it appear3d in Facebook


Himanshu Ghadiali

20 June at 22:08 · 

Psy1 

MADNESS -1

Ego is a Center of Consciousness. Ego growth is necessary in understanding and dealing with the world. Ego growth is dependent on genetic factors like memory, intelligence etc. and external factors like nurturing environment. 

When our difficulties, conflicts appears greater than our Ego’s capacity to deal with it, we experience ANXIETY. When our difficulties, conflicts produces loss and our Ego cannot immediately digest it, we experience SADNESS and DEPRESSION. When our difficulties, conflicts creates situation when our Ego is overwhelmed of unconscious, we experience MADNESS. This could be simple situation or Very complex situation.


Himanshu Ghadiali

21 June at 13:42 · 

Ps\ay-2

ANXIETY 

Anxiety is a response to threat. Function of anxiety is to prepare us to deal with it. Physiological response of fight or flight.

UNKNOWN is always greater and infinite than KNOWN, as it is limited. UNKNOWN is potentially threatening as we do not know what it would produce. It may confront us with friends or foes or both. Hence unknown situations are always threatening and produce anxiety. Normally we deal with anxiety with two responses. Firstly trusting ourselves, that while ago I had met with similar situation successfully and recognising I have capacity to meet such situation. Sometime getting encouragement from our elders and friend. Seconding meeting or confronting unknown situation. When we recognise that we have met unknown situations successfully, we grow in confidence, means that our trust in our ability- our Ego capacity grows.

With some people, they are so hooked into negative experiences of past, some are so self-critical, some are so guilt laden or some are so convince of their inferiority that they cannot appraise their situation realistically. They cannot grow in confidence, even they have dealt with unknown situations successfully. These are the people who suffer chronic anxiety.

For me, going to new town or places were always source of excitement and I never hesitated. But since mobility difficulties and my restrictions, brings me anxiety when I am required to go to new place. In order to reduced anxiety, I have to do homework, to find out where can I find suitable parking. Sometime I have to make arrangements of parking beforehand.

Fear enhances fear – a man in blue

by Himanshu, posted in psychiatry, Uncategorized
Fear enhances fear – a man in blue

 

Fear is a response to a physical threat. While Anxiety is a response to a mental threat. Acute anxiety and fear has similar bodily and physiological responses. The body is ready for either fight or flight.
As a psychiatrist, I have dealt with anxiety all the times, but rarely you get opportunity to deal with fear, unless it is hidden under phobia.
When I was working in east London, at St. Clements hospital, one morning, as I arrived at 9am. A senior house officer stopped me and said he needed my help. Apparently, a man became aggressive and was out of control at his work place. Police were called to tackle him. While resisting arrest he fell in a blue dye drum. He was completely covered in a blue dye. It took eight policemen to arrest him and bring him to St. Clements as he was aggressively fighting with them. S. H. O. told me that he could not take any history and his attempt to give him tranquiliser met aggressive response. He only knew that he was agitated in workplace and every attempt to pacify him met with more agitation. Workplace had to called police. While trying to run away from police he fell in a tub of dye.
I went to see the patient. He was on floor. He was held by seven police officers. Two officers were holding right leg, one right arm. One was holding his head. Another officer was holding left arm and remaining two left leg. Eighth officer was ready for any assistance. I tried to make contact with patient. I said “Hello”.
He responded “You pakki go home” he continued “you pakki chapati.” I was unperturbed from his racial attack. I responded, “Have you ever tasted chapati?” He seemed unsure of my response to him. He replied “No.” I further responded, “then you do not know what you are missing in your life.” Without being threatened by him symbolically I communicated that I have something to offer him. He had no further response. Few seconds passed in silence. He further asked, “Doc do you have a cigarette?”
“I don’t.” but I turned to police officers if anyone has a cigarette which can be spared. One officer gave me a cigarette. I was about to give him, but his both hands were held by the officers. I asked a police officer who was holding his right hand to let it go. He was hesitated, but I encouraged him with my eyes. I gave the patient a cigarette in his released right hand. Another officer helped to light up his cigarette He started taking puffs. He was no longer agitated. I said “look at yourself. What is your condition. I like to admit you in the ward, where you can clean up yourself. We will give you some tranquiliser so sleep for a while. Later we will talk about your situation”. He agreed. We got a couple of nurses from the ward to accompany him. All police officers released him. His agitation had disappeared. I did not have to section him under mental health act or arrange a compulsory admission or had to give him medication against his wish.
I was able to move situation with minimal intervention. Both patient and police officers were tired of their situation. Patient needed grace exit, without losing his face from situation. If I would have reacted to his aggressive and racist behaviour, or I would have responded with institutionalised aggressive behaviour like “I am a doctor, you do what I say or threaten him with compulsory admission under mental health act, would have been locking into his aggression. By taking about chapati and granting him a cigarette, I was offering him an unthreatened human response. He was able to give in gracefully.
Fear breads fear, aggression breads aggression. Lots of time fear is expressed as aggression. Hence it is very important that health care staffs, police officers, prison officers etc should have good training so they learn to cope with aggression from their clients without reacting.
15-06-2018

Depression as a self-punishment

by Himanshu, posted in psychiatry, Psychotherapy
Depression as a self-punishment
In psychiatry, you look at the constellations of symptoms in patient and compare them to symptom patterns of various psychiatric illnesses. In that way patient’s symptoms fit into a classification and get a diagnosis and treatment follows. As a psychotherapist, I know each patient are unique with their own life experiences. In common symptoms, each patient is expressing their unique life conflict in a special way. There needs an investigation and an exploration.
I was trained into these two disparate disciplines, which is not easy to reconcile. As I had to reconcile and integrate two culture in myself, namely Indian and English. That experiences help me to integrate psychiatry and psychotherapy in myself. Consequences of integration of two cultures, in myself gave me ability to become objective to both Indian and English culture. I belonged to both and none. I remained marginalised. With reconciliation of both disciplines, I had greater range of treatment options in my armamentarium. I could offer psychiatric diagnosis as well psychological formulations. I could offer psychiatric treatment in terms of medication or psychotherapy or combination of both. Patients had their choices. Psychiatric treatments are passive treatment. Drugs and ECTs (electro Convulsive treatment, passing electric current and inducing convulsions in patients), their courses produce positive results in patients.    While psychotherapy is an active treatment. Patient must explore life conflict and traumatic events. Actively think about it, relive it and correct it. No psychotherapy is possible without patients’ motivation and active participation.
When I took over a new job in Staffordshire, I inherited a lady patient. She was in her early forties. She had thick file. She was being admitted twice or thrice a year for last ten years with diagnosis of unipolar recurrent Depression. She would be admitted for three to four weeks. She would respond to course of ECTs very well. She will get better and go home. When she was admitted under my care, I felt the need to reassess her and understand her patterns. Lead nurse told me she is a good patient, she responds to ECTs, I must start immediately. I said I like to observe her, reassess her, so for the time being I will refrain from giving her ECTs. He told me that three psychiatrists have seen her before and diagnosed her unipolar Depression. What new thing I was going to find? I was depriving her valuable treatment. He started stirring up. He persuaded patients husband to demand ECTs for his wife. I persuaded him to have a patience, and give me sometime if I could find a way to treat her without ECTs. Lead nurses demand continued. I told him that in the last ten years she had spent more than two years in the hospital in total.
I should have a grace and let me have half the time, if I could find the way to change the course of her illness. I was fighting on two fronts. The lady patient, who was submissive good wife had very little to say about herself or about her marriage. Three weeks passed, I did not make any progress. I started seeing her husband with her. On exploration, I found that before this breakdown, she suddenly demanded to go on shopping by herself. In order to protect her, husband said no. but she defied him and went shopping. Next day she became depressed. I tried to explore any pattern with previous depressive episodes. Her husband could not remember all episodes but what he remembers that there were some similar patterns. She wanted to do things, which was not usual for her. Subsequently she would become ill. I tried to explore with her what made her want to go shopping? She had no answer for it. She told me that she heard some women talking about it on the bus station and she also wanted to go shopping. She told me that she enjoyed shopping but felt bad as well. She could not really described me her internal mental process.
Attribution is helpful as well a problem in psychology. Correct attribution will lead to unfolding of psychological process but incorrect attribution leads to closed, fixed psychological state. I did not have clear proof to internal psychological process in her, but I was going to make hypothesis and test out with them. If I was correct in my hypothesis, we will see some resolution. If my hypothesis was wrong, there will be no change.
I made hypothesis that this submissive lady, from time to time she makes an assertion, keeps her own identity and her ego going. Despite her submission, she does make assertions from time to time and keep her ego separate. This assertion causes to be guilty and makes her Depress.
I saw the lady and her husband together. Discuss her behaviour of assertions. I encouraged it and told them it is good for her. Her husband should support her. I dealt with his anxiety to protect her. He was encouraged to listen to her. I encouraged them to engage more activities together which can be fun. She had been in hospital for six weeks. I gave her leave to go home for three days. Three days later when she returned, both she and her husband reported that she was normal. I could be discharged her six weeks after admission I was able to discharge her without giving her any ECTs. I was in that job for three years. I followed them in outpatients. She had no relapse of Depression. She did not need to be admitted into hospital. Over the period of years, she looked more animated. In some outpatient clinic I had to advice, some aspects of marital relationship.
It would have been easy to prescribe her ECTs. Lead nurse would not be stirring up problems for me. I had to cope with six weeks of pressure from Lead nurse. He was reading my notes all the time, as there was no substance four to five weeks, he had more weapons against me. I was source of gossip. Some of junior nurse and social worker started understanding what I was doing. But lead nurse was so institutionalised that he remained skeptic even after discharge of the patient.
I was taught that practicing medicine is an art. You gather your information from so many different places and you apply them in treatment. In current NHS, which is management top heavy, practice of medicine is a tick boxes and follow the institutional advice given by NICE. Last year BBC had series “doctor in the house” where Dr Chatterjee showed that visiting family and the house, how he dealt with chronic condition by holistic approach. In current NHS, which runs with false economy, has no scope of true medicine. Worse thing is that new generation of doctors only learning part object approach than holistic approach.
24-05-2018

Search for Salvation Part 1

by Himanshu, posted in Uncategorized

Search of Salvation (part 1)

As a child, I was acutely aware of pain. I was a troubled child. Around age of four or five I was deeply fearful of death. I used to have nightmares where death was theme. I had spent lots of nights being awake and frightened in bed. I cannot remember all the insecurities, but I wanted to stop all the sufferings caused by emotional pain, I did not know way out. I came across concept of ‘Moksha’ which made sense as an answer to my problem. If I can achieve Moksha, I will stop suffering.

A couple years later, Jain temple and Upashray (where Jain Monks reside and give their sermons). We had monk staying in our colony during Parushan (eight days of Jain religious festival giving Jains to meet their religious obligation) During those eight days Monk reads Kalpsutra, twice a day. Kalpasutra is a Jain text which consist of biography of several Tirthankara. In Jainism Tirthankara are the guide for the Jain community. On practical purpose Tirthankara are treated as the God. I was also studying in a Jain school, so we were off school for eight days during Parushan. So, I used to hang around temple/upashray. Listening to various sermons. Having contact with different monks, understanding their life style. One of the Monk, Subodhsagarji gave me the Manta to worship the goddess of knowledge and gave me whole structure of Upasana(Worship). I felt special. I felt relationship with the goddess. Increased activities around temple/Upashray gave me recognition and special responsibilities. These increased in rituals and recognition amongst Jain community reduced my anxiety.

When I was sixteen, I started attending my Guru’s sermon every Monday evening. He had started helping to understand Jain Text ‘Tatvarth sutra.  He took two tears to explain first Shlock(stanza). He initiated my internal journey.

When I was sixteen/seventeen, I was troubled with other people. In one of my private discussion with my Guru Kiranbhai, I expressed my desire to learn other people’s motivation. At one stage in our discussion, he told me “Know yourself and you will understand the universe.” Although I did not fully understand meaning and importance of it but it was printed firmly on my mind.

 

Know yourself and you will understand the Universe

 

We tend to evaluate other people’s thinking, feelings, behaviour and attitude from our own perception, thinking, feeling and attitudes which may be subjective. As a result, our evaluation may be prejudicial, A far from the truth, contains our projections.

Unless we become objective about our internal mental process, our thinking, feelings, attitude etc. we will not be able to see the truth about others. To become objective about oneself is get to know oneself. A very arduous process.

 

When I finished my undergraduate medical studies, my family wanted me to take up cardiology or orthopaedics. My own inclination was towards psychiatry. Pressure on me was great to avoid psychiatry. My Guru Kiranbhai came to rescue. He explained to my family that the Mind is the King of the body. Anything I can do to learn about Mind, that will be best use of my time. He actively encouraged me to my post-graduation in psychiatry.

As a postgraduate I realised that you hardly learn about the Mind in Psychiatry. Psychiatry concerns itself with illnesses of the Mind or behaviour. Psychotic illness is thought to be caused by biochemical changes in the brain. Main reliance is on medication to find any improvement in the condition. Neurotic illnesses or personality disorders are mainly treated with pragmatic behavioural modification. There are some psychological theories about development of mind, by various psychologist like Freud, Jung, Adler, Horney, Sullivan etc. They do not carry much credence in main body of Psychiatry but used by small group of therapists.

Some of my experiences in India, made me interested in Freudian theories and I decided to train in psychoanalysis. For that purpose, I decided to come to UK. Once I came to UK, I got my first job in Bexley Hospital as a resident houseman, junior doctor. I also started working under Dr Ted Hurst, a Jungian analyst. I also started exploring how can I get into training of analyst. I had a reference a consultant in Tavistock clinic. This consultant was retired to Scotland. So, I saw another consultant. He was not very encouraging. He asked me why did I want to go through masochistic exercise. I felt he could not understand my passion and enthusiasm. I had travelled thousands of miles to unknown country. He suggested I start with trainee analyst. I became depressed after that meeting. A few weeks later I went to analysts meeting, they were receiving a talk from an eminent family therapist. I found talk very interesting and informative. But the discussion followed was disappointing and disheartening. The way some of the members of audience attacked speaker aggressively, was unbelievable. I wondered if you do not change after analysis, what is the point? I wondered my journey to UK was fruitless? Should I go back to India? I needed to work for in UK for year and half to pay off my father for aeroplane ticket he paid. Prospectus looked very bleak.

In desperation, I wrote a letter to my Guru Kiranbhai explaining my mental struggle and disappointment.  I received an answered in fortnight.  He sent me recorded massage on a cassette tape. One side of tape he explains, in Jain text starts with first sentence Namo Arihantanam. Namo means I bow down to, Arihantanam means one who has killed all his enemies. Enemies means all internal enemies anger, hatred, envy, grid etc. etc…  He further explained in ardhmagadhi (language used in Jain text, that was the local language at that time), Namo Arihantanam, Arihantanam Namo or Ari Namo Hantanam are all grammatically correct. Why Jain sutra starts with Namo? I bow down to is the humility we need as our first attitude. He said if I want to learn about Freud or Jung, I should take their books, I should bow to them and pray what is in you come in me.

I found this was very useful advice. When we read something, or listen to someone, we tend to interpret what they are saying. This interpretation could be miles away from what they are saying. To understand book or a person, what they are really saying, we need to enter them. For that humility is most important attitude. For me patients were never patients, but they were Guru, who were helping me to understand consequences of their life experiences.

Second side of tape talked about Patrata. Patra means vessel or pot. Deeper the pot more it contains. Types of pot may have different capacity. Patrata means yours containing ability and your deservedness. In Guajarati, there is a saying that you cannot carry lioness’s milk in ordinary pot. He was saying that you will only receive, depends on your Patrata. I became preoccupied in improving and extending my Patrata.

I had learn two important concepts. 1. Humility towards teacher and subject. 2. Yours Patrata. Yours deservedness.

Democracy needs Wisdom

by Himanshu, posted in Uncategorized

2500 years ago, when Buddha walked in India, there was a city called Vaishali, was a direct democracy. The men of the city directly elected their council, who manage the government of city. Because of this democracy, the city was able to protect itself against bigger and powerful kingdoms. It had remained unbeatable over fifty years.

 

Amrapali a most beautiful woman was born in Vaishali, She was a desire of most of men of city. Men desired her to become a city-prostitute, so she belongs to all the men of the city. The matter was taken in the council. She was offered a privilege position of the city prostitute, a respectful position with lots of benefit. Amrapali did not want to take this position. She wanted to marry and become housewife. The council decided to vote. The head of council, urge not go on that path, against desire of Amrapali, but the men of city voted as they desire. Amrapali was forced to become the city –protitute against her wish by democratic vote. The council head’s wisdom was not heard.

 

Several years’ later, Amrapali was visited by neighbouring king. Because Amrapali’s palace was protected area, he could stay there easily, without being recognise. He learnt about all the weakness of Vaishali and several months later he attacked Vaishali and destroyed it. Democracy is powerful, but also needs wisdom to succeed. All democratic decision cannot be right.