Category: 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