When I was studying medicine, psychiatry wasn’t the most respected (or respectable) subject. It still isn’t. Something about the “psychiatry ward” made it different from the rest. It wasn’t so much that the infrastructure was different; after all, it was a government hospital. It was more in the way the name was uttered, it was in the way we (as medical students) felt about it- in the curious yet ambivalent glance thrown its way, to see if a patient would appear and if we would be able to figure whether there was something odd about them. A similiar interest was evoked by the psychiatry resident. “What does a psychiatrist look like, talk like?” “So, he chose psychiatry , eh?? Hmmm”. Fascinating, or just “psycho”, which translated to “plain weird”.
This breed of people: the mentally unwell and the ones who knew how to treat them, were curiosities.
This curiosity in some of us, including me, turned into a wish to know more. The discipline started out for me very much as discovering what mental illness looked like or could look like. Trying to identify the symptoms, to find the signs of abnormality, to define the atypical and find when it becomes abnormal and in which compartment one could fit in the abnormal.
The aspiration as a post-graduate was to diagnose correctly, quickly, and accurately, finding the right phenomenon that the books taught us could exist “…aah that’s a Capgras delusion”; “…ooh people do hallucinate and that’s what they look like and act like”. “That’s depressive disorder and this one is anxiety disorder”. It was implied - the good diagnostician was the better professional. So we all delved into phenomenology and classification and spotting these symptoms within the larger world of the human being in front of us. We learnt what to spot and how to elicit these signs. However, as I met more people and witnessed more stories, I experienced that it wasn’t just about spotting what was obvious, but about finding what they were sometimes hiding from themselves. It was also about knowing how to help them see, and show to me, what was happening inside their worlds. I understood that the key lay in being able to be witness and to bear witness to these experiences and stories.
When I had started off, it was about focusing on finding the phenomenon, but I learnt slowly to see the person behind and alongside the illness. I learnt to look for their often frightened, and sometimes wilting sense of healthy self, into which this thread of abnormality was actually woven. In trying to find that part of self, they had to see it too. Sometimes, it takes a witness to validate that it exists, even though it is theirs to own. I learnt the joy of being able to find it and relate to it, so that they could, too. How the authentic connection to the person, the ability to be really interested and respectful, brought the phenomenon out.
Meanwhile, I slowly became aware of another journey within. The one that the books don’t warn you about. The one that is about you.
I realized the constant need to be aware of what I was saying in the presence of a fragile mind, grappling with my own anxiety of saying the wrong thing to a patient, surviving the anxiety of knowing that I had talked to someone an hour before they attempted suicide, and had not detected anything amiss. The inadequacy and self-doubt evoked when I heard that the medication that I had prescribed was taken by the young lady a few days later as an overdose. The need to develop an ability to absorb being laughed at by someone you are trying to treat, just because they are bipolar; of being insulted, sometimes approached inappropriately, sometimes sought persistently in high distress situations that occur in their lives, while you may be having that well deserved once- in- a –really-long-while, holiday. The books didn’t tell you many things, especially the kind of stuff that prevented the patient, whom you had just seen in the ward, flinging a well timed kick at your behind while you proceeded on rounds.
Neither do the books say that watching and experiencing people who are unwell can unravel layers within you that you didn’t know existed. I don’t think most of us understood when we started off trying to be psychiatrists, that it was not so much about the subject, but what it evoked in each one of us. What confronting mental illness day in and day out could mean to the self within.
So there I was, on a new journey, which was the merging of the outside and the within. It made me realize that while “treatment” in psychiatry mostly aims at decreasing or managing the illness itself, there is silence about the experience of mental illness and the aftermath of this experience on a person and their identity, including their social image and inner expanse. And that there is an effect undefined on the “doctor” too. There is some work on how to grow the positive and healthy self, but it doesn’t often come from the field of psychiatry.
So I had to start searching beyond. It has brought me to look at that last paragraph in the Psychiatry textbook in a new way. Preventive health care. It dawns on me, I don’t need to work so hard to only find the mental illness, I need to work harder to look at mental health. At how one builds the self. Can we build it? Can it be taught? In schools and homes and on the media and everywhere. Can we make a science of it? Can we make it into music and poetry and art? Can we accept it as part of our fabric?
Several years into being a psychiatrist, I wonder not so much about mental illness but about how to nurture from birth the mental health of each and every child born, each family and each community. Can we have the right kind of mind diet for every child? Just like religion, and food, and language, is there a way to make it all-pervasive?
This awareness and presence of the reality of our internal worlds, and how it interacts with our truly shiny external world. Is there a way to make the efforts and value of it equal to, if not more than the external world?