Thursday, 30 October 2014

Book Review of "Cafe Latte" by Amit Shankar

It was at the book launch of "Cafe Latte" by the Ahmedabad Book Club that I first had the pleasure of meeting "writer" (no "author", pls!) Amit Shankar. His modesty (he forbade us from using the "a" word!!) and down-to-earth attitude were quite refreshing. Over casual chit-chat, I discovered that we had a lot in common. We had both attended prestigious colleges at Delhi University. We both had MBA degrees from some of the top B-schools of India. We both had begun our careers in advertising and marketing........and of course, we both had a love of the written word.

During the book launch, I volunteered to read the first story. The title "Cafe Latte" was enticing enough to want to start the book as soon as I had a copy in hand. The reading of the "The Black Widow", which I did, was quite an experience for me. Reading a thriller, trying to use my brains and figure out the end, while reading aloud the story to an unfamiliar audience, and feeling the goose bumps.....unforgettable! I finished reading the entire book in one night, which is quite a paradox, a paradox which the book itself is. It is interesting to the point of being un-put-down-able, while at the same time, the web, which each story spins around the reader, takes a while to come out of before one can move on to the next story. 

"Cafe Latte" is a collection of 18 short stories. The language used by the writer is simple to read, but quite deep when it comes to understanding the context and concept being described by him. Some stories are as short as 4 pages like "A Rose for Her" while some others, like "Code of Honor" and "The Lion, The Leopard and The Hyena" are around 12-15 pages each. Each story has what is called a "twist in the tale" (like Jeffery Archer's book of the same name). In most of the stories, the writer has left the climax a bit open-ended......something for the reader to understand, imagine or simply spin-a-yarn for himself/herself. Some stories are sweet, like a drop of hazelnut in the latte. "The Guardian Angel"  is one such story. Some sad, some scary, some inspiring, some psychological thrillers and some "points-to-ponder".

While reading "Cafe Latte", I could clearly pick out two aspects that I found most appealing. One is that Amit Shankar is also a passionate musician and that passion comes out in stories like "Temple of The King", "The Jazz Player" and "The Guardian Angel".  The other is his respect for all human emotions, and his acceptance of them, without any moral lessons, as reflected in the stories. What at first read is a simple story, on a deeper level, is a solid tapestry woven from the threads of human psychology and philosophy. Like the "Slice of Life" ads, which apparently just want you to buy a soap or cream, but are actually hitting at some aspirational target deep within your psyche. Questions are thrown up, answers to which require a very profound understanding of the human mind and the ways in which it works,.......or doesn't. Of course when the writer is an ad man, that's no surprise!

As for me, my favourite stories from the collection are "The Black Widow" and "Every Mouse Ain't A Mickey Mouse". Why? Well, if I start taking a class of literature on "Cafe Latte", whose going to enjoy the caffeine kick? 

So, go get your own copy and enjoy a nice Sunday afternoon with cafe latte and ........"Cafe Latte" !!

Friday, 10 October 2014

Unchain The Maladies

October 10, 2014. Today is WHO Mental Health Awareness Day.

Mental illnesses, for whatever reasons have received very little attention, from the population in general, and the medical profession in particular. Law makers haven't had much time to look at the issues related to mental health either. As a result, we have an acute shortage of trained medical personnel, paramedics, counselors, treatment options and facilities, laws to deal with complexities arising out of mental illnesses, support for the mentally disabled, and the biggest lacuna of all - a proper understanding of mental health by the society at large and even the patients themselves.

It would be easy to rattle off statistics stating which organisation says how many doctors per 1000 population or how many hospital beds per 1000 population, but such an insertion here is not the idea behind writing this post. Those statistics are available on any number of websites of any number of organisations. The purpose behind writing this post is to discuss briefly and touch upon the various issues related to mental health which need to be addressed urgently. This assumes special significance as the statistical websites also dish out rates at which mental illness is growing. Almost exponentially with time. As if India's population and mentally ill population were fighting a race as to which outgrows the other.

Mental illnesses or disorders are a broad range of disorders. There are disorders like Major Depressive Disorder, Bipolar Disorder, Borderline Personality Disorder, Schizophrenia, and various varieties of neuroses and psychoses, forming a part of these affect disorders. Then there are developmental disorders like Down's Syndrome. There are also many learning disorders like Autism, ADHD, Dyslexia etc., some of which also qualify as developmental disorders. These disorders affect people from newly born babies to nonagenarians, or a rare centenarian. So one notion that needs to be dispelled is that all people with a mental disorder are MAD. Or Mental. Well mental means having to do with the mind, and if a person is not mental, I'm sorry, it means that that person does not have brains up there. So, all human beings are mental in that sense. And as we can see clearly, there is a method (of classification) even in madness.

The only physical illness that comes even close to the affect disorders is cancer. Just like cancer, these disorders are easier to treat and remission is more achievable if the disorder receives attention and treatment early on. The more one drags one's feet about seeing a professional and taking the prescribed treatment, the longer the treatment takes, and the lesser chances of the disorder going into remission. Then there is always a chance of relapse, like metastasis. Treatment involves chemotherapy, psychotherapy and talk therapy plus lifestyle changes. Changes in diet, exercise schedule and meditation. One very strange thing with mental illnesses is that patients, and society in general, are very resistant to the idea of medication. I haven't seen anyone dissuading a cancer patient from taking chemotherapy, despite the havoc it wrecks on the healthy cells as well. Yet when it comes to mental illness people react to chemotherapy as if a healthy person were being poisoned. Or worse still, that a mentally ill person is so weak that he or she is not able to fight the disease on his/her own and has to depend on medicines. Why this segregation? Why the discrimination with the mentally ill? Nobody insinuates that a diabetic is not able to fight insulin impairment on their own because they are weak. Neither are insulin shots or metformin tablets frowned upon. Why the double standards?

The basic premise behind this discrimination is again the presumption "It's All in the Head", addressed in my last post. This is the result of total ignorance and callousness of society towards mental health issues and mentally ill patients. It's a case of us and them. And people are so proud of and blissful in their ignorance!!

Most mentally ill people are not dangerous. A very small percentage of them become violent and pose a threat to society. But mostly, if they are violent, the biggest risk they pose is to themselves. Suicide is the ultimate form of danger to the person. But other self inflicted injuries are not very uncommon, and some of these injuries may be suicide attempts. Well, what prompts a person to take his or her own life? Pain. The pain of living a life without any joy, any hope, any motivation, any meaning. Just breathing, eating and eliminating are not enough for a human being. Everyone is born with a brain. And when that brain goes out of control, and despite desperate efforts if the brain refuses to yield back its control to its owner, or refuses to work as efficiently as it once used to, the human being sans that brain feels so helpless that living day to day and trying to appear normal becomes worse than hell. The pain is so much that if is not constantly addressed by medication, family support and psychiatric help, freedom from pain is enough to motivate a person to take their own lives and move beyond the pain. The pain is as bad as the pain of cancer. Alas it is invisible! And the world thinks it is all in the "Head".

Another fact that needs reiteration is the disproportionately small number of mental health care professionals available, when compared to the population size. Doctors do not prefer to specialize in Psychiatry. It is not as glamorous or lucrative as surgery or cardiac intervention or some such other uber ultra super specialization. The medical community itself shows little respect towards their psychiatrist colleagues. A neuro person is a neuro but a psychiatrist is a shrink. Psychiatric inpatients are difficult to handle and hence, even nursing staff prefer to keep away. The ultimate exhibition of callousness on the part of nursing staff is the ill-treatment they mete out to the psychiatry ward patients. Laughing at their crying or other eccentric behaviour, using physical violence against even non-violent patients, and in some extreme despicable cases, sexual abuse of  and /or sexual assault on patients, specially female patients. There is an even greater shortage of trained counselors and psychotherapists. Even the available personnel are first lured away by corporate setups and schools, where working conditions are more convivial, salaries are attractive and there is less morbidity to deal with. Hence the pool of trained professionals to actual work clinics and hospitals is minuscule. So who deputizes or temps? Of course untrained casuals, who end up doing more harm than good.

The mentally ill also need a lot of care at home. They need acceptance and compassion from family. They need their family members to become caregivers. But due to different circumstances in different households, often that does not happen. The biggest obstacle in care-giving at home is acceptance. Family members are reluctant to accept the diagnosis, and the implied prognosis. They may see the signs and symptoms, but may defer seeking professional help. It is a matter of great "shame" that they have a mentally ill family member. And then comes the ubiquitous theory of  "It's All in the Head"! The patient is not mentally ill. He or she is just mentally "weak" and if the mentally "stronger" family members scold, threaten or cajole the person into becoming "bolder and stronger", that's all. That's all that's required. No medical or professional help. One of the worst forms of this non-acceptance on the part of family members is the beating or use of physical violence against the patient. The father, mother, brother, uncle or whoever, believes that a good beating or locking up of a patient will cure them pronto of any affectations. Such incidents make one wonder who is actually the mentally sick person here? Another really cruel practice is discussing the patient with others in derogatory terms in front of the patient, as if the patient were just a piece of furniture or prop kept there. And in India, every one is an expert on anything and everything. So what different is psychology or psychiatry? Everyone becomes a pop psychologist and starts counselling the patient. This further pushes back the patient from whatever gains he or she may have made from treatment. Mentally ill family members are often seen only as a burden to be cursed day in and day out. They are hindrances in the enjoyment of life by other family members. Parents, brothers sisters, friends, how can you do this? What if it was you?

Mentally illness takes a different turn altogether when society starts viewing a mental disorder as a supernatural phenomenon. Schizophrenia is often deemed to be possession by the demons. Exorcism and other equivalent rituals are performed on the mentally ill to drive away the evil spirits. The patient is thus deprived of the requisite medical help. The patient's condition often worsens. Sometimes such rituals are dangerous and may even claim lives of the mentally ill.

The socio-economic status of the patient’s family plays a big role in the fate of the patient. Families belonging to higher SECs (Socio Economic Class) can afford the treatment and care. They are also more aware of mental health issues and have the basic education to understand the complexities involved. However, the lower the SEC the patient’s family belongs to, the more difficult it is for the patient to get the treatment and care. Many families, unable to manage their daily living, cannot afford to take care of an economically unproductive member. The amount of effort, money and resources involved in caring for the mentally ill, makes it an impossible task. One member of the family keeping watch over the mentally ill one, translates into two economically unproductive members of a family, which needs each member to earn something daily, just to survive. So the mentally ill are turned on to the streets to fend for themselves. Some beg, some simply languish. Some also bear the brunt of brutality at the hands of a society which just needs an outlet for its frustrations. Or just an object for crude enjoyment - enjoyment that they feel the more affluent society denies them. So the poor, homeless, witless, and pathetic mentally ill are sometimes shooed away, laughed at, stoned, kicked and often beaten by passers-by. 

Treatment of mental disorders is expensive too as it is a long drawn out process. It may take years to cure or at least bring to remission any episode of Major Depressive Disorder. Bipolar, Personality and Schizophrenic disorders are even more expensive to treat. Care giving at home is also proportionately expensive. In most cases, patients are not able to care for themselves. It may extend to others in the family too. A depressed mother may neither be able to care for herself nor for her children. They all need to be taken care of. Consultation, chemotherapy, psychotherapy and followups are all expensive affairs. Plus, there is loss of productivity, especially economic productivity, on part of the mentally ill persons. Yet mental disorders are still not identified as disabilities under the Indian statute. There are some guidelines of the Ministry of Social Justice and Empowerment, dated 2002, which purport to bring certain kinds of mental illnesses as per IDEAS (Indian Disability Evaluation Assessment Scale) under the ambit of disability. However the last piece of legislation in context of mental illness is the Mental Health Act 1987. There are many individuals and bodies working even now to get the draft Mental Health Act, 2013 approved. Getting medical insurance for mental illness is another herculean, if not impossible, task.

And there was the Indian Lunacy Act, 1912, which though repealed and replaced by the 1987 Act, continues to exist in spirit, if not in letter. According to this Act, the mentally ill or "lunatics" were to be segregated and kept in confinement in order to protect society from their "dangerous" presence. There are many institutions for the mentally ill, still called Lunatic Asylums, where the mentally ill are kept in chains. The infamous incident at Erwadi (TN) where 28 inmates were burned to death as they could not escape the fire, due to being chained to their beds, is a very painful reminder of this practice. There have been fires at mental hospitals in Russia and New Zealand too, where mostly women and children perished in the fire. Due to lack of enough hospital personnel, the practices of chaining patients is adopted for violent patients. But being chained for being ill? As if being mentally ill was a grievous crime?

It is said that prevention is better than cure. One may see a number of health camps dealing with the heart, diabetes, cancer obesity, dentistry, wellness and what-not. I am yet to see a camp for promotion of mental health at any hospital in any metro, what to say of smaller cities. We are a society obsessed with academic achievement. Hence, everyone talks about IQ; no one about EQ (Emotional Quotient). Resources are scarce and the population is ever increasing. Hence, physical fitness, academic excellence, sporting and extra-curricular achievements, receive the attention of schools and parents. But no one prepares a child for dealing with LIFE. Mindfulness practices are never taught. Meditation, moderation, dealing with failure as well as success; these topics do not find space on any school curriculum. Parents are quick to enforce discipline and comb through every assignment, yet never spend time teaching life skills to the child. "It's OK. We love you, no matter what." That's all that is required to make a child blossom into a well-balanced and secure individual.

Even in offices, health camps never focus on mental health. At the most, there may be some discussion on stress busting or reducing work stress. That is not enough. It is like telling people to eat a well-balanced meal at any other health camp. Nothing specific; only general wisdom. No education is given whatsoever on what are the signs and symptoms of mental illness. A person maybe mentally ill but may not know it. He or she may simply not be aware of what his or her changed mental state - thoughts and beliefs - imply. So instead of shying away from mental illness, or only glancing at it obliquely in health camps, there need to be camps focused solely on mental health, if prevention is to be a serious alternative to treatment of mental illnesses.

In conclusion, it would be enough to say Unchain. Unchain society from the chains of rusted beliefs. Unchain the mentally ill from bearing the cross of the stigma they are chained to, and forced to carry with them. Unchain the mentally ill from the metal labels of "Weakness" welded on their foreheads. Unchain the collective family consciousness from the locks of "burden" in the form of mentally ill family members that they feel they are chained to. Unchain knotted beliefs and attitudes. Unchain minds. Unchain spirits. Unchain the mentally ill. Unchain the maladies from which our mental health system suffers.


Wednesday, 8 October 2014

It's ALL in the HEAD

Whenever confronted with a person with a mental disorder, the general reaction is : It's all in his/her head.

True. It is in the head because an organ vital for a human being's existence, The Brain, resides inside one's head. The more subtle and unseen Mind too resides in the head. Hence, "mental" disorder. Hence, it's in the head.

But is it All in the head? No, absolutely not. There are various factors contributing to a mental disorder. Broadly split, they can be bundled as Nature factors and Nurture factors. Nature factors are those which are inherent to the individual, and not dependent on the environment. Like genetics, heredity, severe trauma to the brain by means of injury. However, Nature factors, mostly, only predispose an individual to be a likely candidate for a mental disorder. They cannot cause or create a mental disorder, even a chemical imbalance induced one.

This brings us to the more important of the two factors: Nurture. Nurture is a very wide term used to club together factors dependent on the individual's environment. Upbringing, early childhood experiences, treatment by elders and peers, environmental stressors, traumatic experiences, sexual abuse, physical and/or mental abuse, frustration in reaching one's life goals; the list can go on interminably.

Whether a person will develop a mental disorder depends on the interplay of Nature factors and Nurture factors. Again, broadly speaking, if both Nature and Nurture factors are pathogenic, a person may develop a mental disorder. The changes in a person's mental outlook and behaviour are initially classified as a "Disorder" only. Even DSM (Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association) classification uses the term "Disorder". However, if the disorder does not correct itself soon enough, either by itself or after intervention by Psychiatric professionals, then long term treatment options make it an illness. Whatever the terminology, even a mental disorder is as serious an illness as any other physical illness. It is as debilitating, as disabling. The only difference is that there are no fevers, no rashes, no broken bones, no surgery. Hence, it is invisible for the most part to people, other than those whose mind and self-esteem the disorder erodes everyday.

We, as society, are all part of the environment (hence, Nurture factors) of each and every other human being on this planet. The physical and mental energies do interact on some level, which will most likely be unknown to us. Decisions taken in a corner of the world may have repercussions on a far removed spot on the earth. We all are individually and collectively responsible for the Nurture factors involved in mental illness, even though the persons suffering may be total strangers to us. For example, the prejudice that Indian society holds against the birth of a girl, may be a major contributing factor in the development of pathological symptoms in a girl child and her parents. So, those who smirk at persons with mental illnesses, please wipe that ugly smile off your face. You are as much of a contributor towards the genesis of the illness by creating an environment in which the illness grows. You also contribute to the severity of the illness by being the architect of an artificial "shame" around mental illness, which deters people from approaching health professionals for help at an early stage, when the disorder is more amenable to cure.

We are not all medical professionals. It may be difficult for us to understand a mental illness without suffering from one ourselves or by watching a dear one suffer. A person with mental illness may keep smiling through the tears. But that does not give you, me or anyone the right to say that it is ALL in the head. It is not. It is as real as cancer. It eats away the mind just as cancer eats away the body. Of course, there is no life without a body. But ask anyone suffering from a severe mental illness: what is life without a mind?

Tuesday, 7 October 2014

The Rubber Ball is not a Person

There is a very attractive turquoise blue swimming pool. It engulfs all ones' senses and brings about the most beautiful, the most serene feeling. People sit by its sides and relax. People dip in for a swim. Some for fun. Some for sport. Some for competing to win. Some just for learning a survival skill. They are people. They are lucky.

There is a rubber ball. That is my head. Inside it is my mind, occupying it like the life air of the ball. Life sits by the sides and tries to push the ball in. Again and again. I feel squeezed. I feel tremendous pressure. Pressure between the hand pushing my head deep down into the water and the water pushing it back up due to buoyant forces. The game between Life and Water goes on. Sometimes, the pressure is so much that I feel my head ball will burst and water will rush in, forcing the life air out. The rubber, deflated, will either sink to the bottom of the pool. Or will float lifelessly, uselessly on the turquoise blue surface.

Yet, till now, every time Life's hand has pushed my head down, I have fought to resurface. Bobbed back. Refused to cave in to the pressure between the opposing forces, Life and Water. I do not trust water to throw me back up always. For water is uncertain. It flows whichever way the it is made to. It occupies whatever space or shape it is made to. We drink it for life. Yet, it so often, takes away life. Floods. Viruses and bacteria nurtured by it. Its deadly friendship with electricity.

The people who sit around, they don't know that the ball contains a human mind. They either sit back and enjoy the bobbing game, or sometimes join in. They throw the ball around and laugh. It is a game. A sport. If they start drowning all hell breaks loose. They are people. They can be seen drowning. But not a ball. Not a ball's struggles to stay afloat. After all, a ball is a ball. It is made for sport. It should know how to float by itself. It is not person. A drowning person needs help. Not a rubber ball.

So, I depend on nobody. A ball cannot control water. And what you cannot master, you cannot trust. I know I have to fight back myself. For myself. I have to resurface. I have to bob up even though I know bobbing always involves up-and-down. Down, but then there is also an up.

This is how the world treats people with mental illnesses. They first want to know how can someone develop a mental illness. Like how can a ball drown?  Only people with physical illnesses are real sufferers. They are drowning and need to be saved. A rubber ball is a rubber ball is a rubber ball. It is just full of air and hence, needs no saving. It can save itself if it wants to by just floating back up.

Yes. With most mental health patients, this is what happens. They cannot depend on anyone to save them. They depend only on themselves for survival. They fight Life's crushing hand and the pressures of an uncertain watery environment. They fight back and forth. Sometimes the head really feels like it is going to burst. But then bursting is not an option. The only option is self-preservation. To fight back. Bob back up. Even though one knows that nature's forces will drag it down again. Make it bob down. But, then one also knows that one has to withstand the drag and bob back up. Right back up.