From Leadership in Indian Psychiatry: Converting Thoughts to Action

From

Leadership in Indian Psychiatry: Converting Thoughts to Action

(1947-2022)

EssaysinHonourof ProfessorB.S.Chavan(400pages)

Eds. R. Srinivasa Murthy and Nitin Gupta

Released on March 24,2022

Psycho-Oncology: Caring, sharing

and being connected-What matters

when Facing uncertainities of life-

Personal experiences

Rajeev Gupta in conversation with R.Srinivasa Murthy

Introduction

Illness is a great leveler in life. Major illnesses ‘changes life as one knows’. All illnesses disrupt the lives of individuals and families. There is need to understand the change(s), develop a new lifestyle, along with treatment and depending on the illness face uncertainities. This is mostly true for all of mental disorders and chronic conditions like cancer, chronic kidney disease, hypertension, diabetes etc.

The need in these situations is for ‘totality’ of care.

This need for total care and the special place of psychiatry was expressed by Prof.Wig, during the 2013, Golden Jubilee Celebrations of the Department of Psychiatry, Postgraduate Institute of Medical education and Research, Chandigarh on September 16, 2013 as follows:

“Ours is an unique specialty. We should be proud of it because this is a specialty that combines the best of science with the art of healing., much more than any other medical specialty. There are three things in my mind which our specialty does. First thing is that our specialty, looks at the problem in totality. We are not thinking only the problem in terms of symptoms, organ system but in totality. We consider what is this person, his/her background, the environment of the person and the totality. Second thing in psychiatry, we are thinking of the human suffering much more deeply than any other specialty does, we do not stop with the symptom but the inner anguish and suffering. Third thing is that the treatment consists not only of drugs but psychotherapy, counselling etc. This is what distinguishes psychiatrists from other specialties”(1)

Almost similar view was expressed by Lieberman(2) in his book tracing the history of psychiatry.

‘Psychiatry is like no other medical specialty; it transcends a mere medicine of the body to touch upon fundamental questions about our identity, purpose and potential. It is grounded upon a wholly unique doctor-patient relationship: The psychiatrist often becomes privy to patients’ private worlds and innermost thoughts-their most secret shames and most cherished dreams. The intimacy of this relationship places grave responsibility for the patients’ welfare on the psychiatrist, a responsibility that psychiatrists have often failed to live up to- but no longer. The modern psychiatrist now possesses the tools to lead any person out of a maze of mental chaos into a place of clarity, care and recovery. The world needs a compassionate and scientific psychiatry and I’m here to tell you, with little public fanfare, that such a psychiatry has arrived at last’

However, there is concern about the decline of the above approaches to be replaced by simpler medication approach or behavioral interventions as expressed by Straker and Winship (3)

‘Asaformoftherapy, adeepexplorationofthepsychicworldhasfallenoutoffavourin recent decades. Instead, there has been a movement towards quicker fixes, such as cognitive behavioural therapies. These approaches attempt to harness the rational mind to examine the distorted thoughts, them use self help strategies to effect behavioural changes. We are encouraged to challenge our internal irrational thoughts with evidence from the external world, to use positive affirmations to bolster our self esteem and to monitor our behavioural responses. These are all useful strategies particularly with less complex issues butadeeperexplorationofourinternalworldsremainsvaluable. Wearelivinginanage that prioritises the outward image over inner reflection’.

It is against this background, there is need for documentation of both the need and the approaches to provide ‘total’ care to persons/families facing complex medical challenges in general and end of life situations in particular. What better opportunity to demonstrate it than when qualifiedandexperiencedpsychiatristscomefacetofaceintheirlifewiththese challenges and record/share how they faced them, as well as demonstrate both the value and feasibility of the ‘total’ care. Major part of professional life of a psychiatrist is devoted to help people to recover and find new meaning of life. It is natural for people to want to know how psychiatrists,respondshimself/herselfinachallengingsituation.

Two of us (the authors) have lived with the diagnosis of cancer. Dr. Murthy has documented his life experience in detail (4)

My illness dates back to about two and a half years. Following the symptom of passing blood in the urine, I was investigated and diagnosed with cancer. I was operated to remove the tumour and it was followed by chemotherapy. I was assessed at that time to be cancer free. However, there were many challenges as major part of my bladder was removed and I needed to frequently visit the bathroom. In addition, for follow up cystoscopy was to be carried periodicallyand Iwasadvicedtogettheenlargedprostateremoved.

ThelifejourneyofDr.RajeevGupta,ofLudhiana, issharedasanillustrationofthis

understanding of changed life situation as well as how it can be addressed. It is the outcome

of a series of conversations in the last few months of living with a life threatening life

situation.

You have been unwell for few years, could you share the

experiences?

About 6 months back, during the follow up evaluations, fluid in the abdomen(ascites) was discovered. As the fluid increased I was investigated fully and found to have spread of the illness todifferentpartsoftheabdomen.Sincethediscoveryof‘relapse’Ihavehad chemotherapy, immunotherapy and symptomatic treatment. The worst aspect of the recent illness is the pain and the frequency of urination. Overall, the illness has progressed rapidly changing my life course. In a way I am facing an uncertain situation ahead of me. I am making plans to accept the inevitable.

What has been the experiences of various treatments?

I have had surgery, chemotherapy and radiotherapy at different stages of the treatment

programme. Of the triad of treatments, chemotherapy is the challenge. Following each chemotherapy session, there is severe effects on the body in the form of tiredness, loss of appetite, some intestinal symptoms and sleep disturbance. From an active life, in a matter one day of chemotherapy session, I was reduced to being in bed most of the day. In about 4-5

days, these get better and soon the turn for the next therapy session comes! During the weeks and months of chemotherapy, life as I knew came to a halt. In my case, because of surgery, my ability to hold large amounts of urine is limited which requires me to visit the bathroom frequently. In the relapse period the challenges were different. During this period there were

frequent hospitalisations for investigation and treatments. At a particular point I was moved from treatment to palliative care with the possibility of death a reality. The uncertainty of not knowing how long is the life was challenging. The severe pain, interruption of sleep was

challenging, in spite of the use of strong pain relievers. Being a doctor, I knew what was happening to me all the time, which was both an advantage and a disadvantage in that I could dent that I am slowly getting close to end of life. I am sharing one message I shred with my teacher and friend Dr. Murthy both by texting and talking over phone. Many times I texted:

‘Today was a bad night .Twice sleep was broken because of acute pain abdomen’. Though I am on regular buprenorphine patch (narcotic pain killer). Though effective

earlier losing its effects. I am advised to double its strength but not of much effect ) Advised morphine tabs or fentanyl lollipops . A doctor shared that his brother badly turned dependent on them . He developed severe depend ence/ craving and these narcotics made his life miserable and she advises me to be patient with these narcotics and not get

succumbed to the temptation of going to stronger ones.’ The choices are grim- to use medicines for relief and risk dependence or suffer. Another message was as follows: ‘I know the end is coming. May be a few months away. Now my mind is well prepared. No turmoil. No restlessness. My family has taken active control of everything’.

3. How do you accept your current uncertain life situation?

I had no other option. I have totally avoided seeking ‘magical solutions’. It is amazing how

often other people suggest to try one or other intervention that seems to cure the problem. For

me, this is not acceptable. None of us is immortal. My knowledge of medicine, both helps

me to realise the reality of the end of life situation, as well as work out a method of

addressing end of life.

I will focus on the current situation where my life is full of uncertainties and death is a

serious possibility. My approach to my life situation is as follows:

‘How much hard one may strive to live, death is a reality. Even Hiranykashyap and

Ravana, who were given blessings of immortality had to die. Death is a blessing. It creates

space for viable life’.

The source of support is the self and the family. In my life situation, I have to accept the uncertainty. Icountmyblessings,fullyutiliseallthe availablesupportandcare,getthebest possible health care, and not have unrealistic expectations.

My wife and family have been the major source of strength. My wife is a tower of emotional and physical support. She stays with me during all treatments and now makes me the centre of attention and makes my life comfortable.

Caring, sharing and being connected to people who matter was the strength to depend on.

In my situation, everyone can make a difference, friends, relatives etc. I think it is important to not ‘exclude the person’ or avoid keeping in touch with a person with life threatening situation.

There are three needs that can be filled by others, namely, CARING, SHARING and CONNECTING. Avoiding the person, disconnecting or making light of the situation or raising false hopes is the thing to avoid. Insincere advice giving is an another thing to avoid. I have been in regular contact with Dr. Murthy and we have discussed all matters. It has been of great help. The fact that he shares the world of living with cancer helped a lot. Support and understanding is what is needed by the patient and his family. Of course, there have been some small incidence of negative response on knowing that I have cancer diagnosis.

Unlimited emotional support from others is the vital elixir. Ill person wants to be looked after and have the satisfaction that everything is being done .

“Youwillbesurprised thatIhavenomemoryofsufferingsofthelastfewmonths.Iam full of deep gratitude to everyone. For example, the way my granddaughter shows concern and her love takes me to an another world of hope and peace. The visit and care by my supporting staff, for example they bring flowers when they visit me and ask about my welfare and comfort. These small gestures mean a lot. Everyone and every act can make a difference to the ill person. My sincere suggestion is that do not hold back to show your care to your patients, it means a lot to them.”

What has been the sources of support during the illness

journey?

Availability of CARING has been important to you, can you

share experiences that made a difference.

6. What are the concerns that you face at this stage of life? How

do you choose to live in this life situation?

As I have shared in the earlier section, I do not have the fear of death. However, it is

important that there is as much freedom from suffering as feasible, and my medical team has

addressed that fully. Pain takes you to a different world and pain relief should be a priority.

I worry about future of my family, though they are secure financially. There are other

concerns for the patients I have looked after for many years and their future.

I am given to understand by Prof. Murthy, who has been patient and a caregiver in pallia tive

care, that religion/ spirituality is a source of support. I come from a family where religion is

not a part of our daily life. As it happens I can not utilise this resource. Those who have

religious resources to use, should fully utilise to make sense of suffering and end of life.

7.What are the lessons that you would like to share with others?

From all of these experiences I can share the following points:

2. 3.

The illness has been a learning experience in many ways. In my life, cancer has entered on a

number of occasions. When I was in final year of MBBS, my mother was diagnosed with

breast cancer and she died withing a short period. I was very much part of her illness journey.

Recently, my brother in law passed away within a short time of diagnosis of cancer. He had a

lot of pain and suffered a lot.

I have professionally helped hundreds going through challenging life situations. I have seen

their suffering, the way they cope and their sources of facing adversities.

Life is always uncertain, and all of us mortal. It is important to recognise and

cognise this reality in planning life. It is not that effort in personal and

professional life should be restricted, but it is to acknowledge the uncertainities

oflife.Itisimportantto acceptthegoodfortunesthatcomestoeveryone.

Live for your values. Values are what determines the direction for life. I recall,

Prof.Wig repeatedly quoting, ‘Characher is the destiny of man’. By living by

ones’ values there is satisfaction and feeling of fulfilment.

Make plans depending on your specific life situation. I have seen patients

making all types of responses to adversities. On many of the occasions, when the

situation looked dark and hopeless, there were positive developments. There is

hope all long as there is life and it is always possible to make a new beginning.

Relationships and being connected to others is important. This is an important

point, especially at this time of the history of mankind, where individualism is

glorified. In the ultimate analysis, it is relationships that makes life worthwhile.

If you are well, reach out to someone who is suffering and if you are ill, do not

hide your suffering but reach out and utilise all the available supports. It is

amazing how the most insignificant person can make a difference to life.

Develop a method of recognising and coping with adversities. Without being

trite, it is important to recognise that adversities are part of life of all individuals.

Learn to see the brighter side or the alternate side so that hope does not

disappear from life. Count also on the blessings of your personal life situation.

Dr. Murthy has shared a lot about the value of spirituality. If you are a spiritual

person of whatever orientation, utilise the resource to make sense of the

adversity, to overcome suffering and find meaning of life. I know it is a powerful

source of support and I have seen it in my patients and their families.

I can summarise my whole experiences as the RECOGNITION OF CARING, SHARING

and CONNECTEDNESS.

8.How has your Psychiatry experience helped you in the illness

journey?

There are three aspects of being a psychiatrist that has helped me.

Firstly, I have a fuller understanding of the bio-psycho-social aspects of illness and health.

This understanding helps to think of holistic solutions.

Secondly, I have access to a wide range of coping mechanisms when faced with ‘distress’. I

recognise how important it is to focus on self -care, how to share feelings or get the feelings

out by journaling, to use distraction like music, art and to look at the life situations from

different viewpoints. I also did not hesitate to fully utilised the professional supports of all

types from Prof. Murthy, with whom I have been regular contact and shared all the

challenges to my excellent medical team.

Thirdly, the opportunity to have been of service to a large part of the community, from

different backgrounds, different life situations, has increased the range of options to utilise in

the current challenging life situation.

As a consequence, in the current situation I am at peace with life and myself.

Discussion:

Living with uncertainties of life is a great teacher. The recent pandemic has made everyone of to rethink about life. I will share two recent examples. You all would have read about Subroto Bagchi (of MINDTREE fame) and Sushmita Bagchi donating hundred of crores of rupees to build medical facilities. The expressed,

‘It made Susmita and me, and at the same time Partha and Radha, rethink timelines. It gave us a sense of urgency like never before. We had a shared belief that we must spend our money for the larger good in our own lifetime. The Covid-19 pandemic told us, don’t think a lifetime can be a long time. Engage now, tomorrow may be too late…..

Long back, Susmita and I chose to focus on

healthcare due to personal reasons. Her mother battled cancer and later

dementia. My mother was blind, and my father had mental health issues.

Through deeply personal experiences, deeply personal choices present

themselves. That is how we decided to work on mental health, vision, cancer and

ageing. We decided to set up a large cancer hospital and a palliative care centre

in Odisha. This will be one of the largest cancer cure and care facilities in the

country.’(5)

Ms. Anjana Menon has written about the seven months of living in Kerala under the lockdown situation and shares her insight of the period as follows

“Often, we are so caught up with what is broken that we forget to celebrate what is working…… that the lasting image of the quarantine would be the resilience of the human spirit despite the hardships. (6)

One request to fellow psychiatrists and other mental health professionals. We all must learn to share our live-in experiences both to demonstrate that it is possible to face the worst of life situations with hope as well as to show what are the different ways to face adversities. By this process, we will build a pool of culturally appropriate experiences for the general public.

The multiple and regular conversations with Rajeev has been a source of learning for me. I have shared with Rajeev, that I hope I will have the same wisdom in a similar situation in my life. I am thankful to Rajeev for making me part of his life journey as well as agree to share his life experiences. I see it as an important contribution and hope that many more of us will write our life journeys. Such narratives can humanise medicine and society.

REFERENCES:

1.Wig N N. Inaugural address on the occasion of Golden Jubilee Celebrations of

Department of Psychiatry, PGIMER, Chandigarh. September 16, 2013.

2. Lieberman J A . Shrinks: the untold story Psychiatry. Widenfield and Nicolson. Somerset.2015.

3. Straker G, Winship J. The talking cure. Macmillan. 2019.

4.Srinivasa Murthy R. Lessons of Being a Patient–Personal Thoughts about Psycho-oncology in India. Mens Sana Monogr 2016;14:171-86.

I see sharing of life journey as a way of fulfilling the concept of ‘total ‘care of the

person outlined by

Prof.Wig, our beloved and esteemed teacher.

5. Tejaswi M. This isn’t yet another fancy hospital, future of medical knowledge will unfold in IISc.- Bengaluru: Subroto Bagchi. The HINDU, FEBRUVARY 17, 2022.

6. Nagarajan S. We are so caught up with what’s broken that we forget to celebrate what’s working,” says author Anjana Menon. THE HINDU, FEBRUVARY 24, 2022.