Why care what I think about you?
What I like about you are qualities that I value in myself.
What I don’t like about you are qualities that I dislike in myself.
My liking or disliking of you is mostly about me, and very little about you.
I was driving through Bangalore, past a few men riding the kind of expensive bikes favored by the weekend cyclist, but instead of streamlined Lumen helmets, Gandhi topis on their heads.
A few kilometers away, nearer Freedom Park, I negotiated the car past a crowd of about 50 protestors on motorbikes, a few trailing behind in cars.
In the past the protests that I had witnessed usually involved the beleaguered poor shouting against the atrocities of a government that didn’t care about them until election time. But this time is different: as so many newspaper reports have noted, this time, it’s the urban middle class who are on the streets.
The protests of the past had always been on foot, but this one is on wheels.
Whether or not these protests will help change India for the better, one thing is for certain: these protests are not really about corruption.
These protests are not about any one issue at all. The protests are an emotional outburst, the cry of an aggrieved segment of society, pent up anger, and energy – there is a celebratory self-congratulatory quality to the protests, as if the purpose of the protests is achieved simply by the protest itself.
Down with Corruption! is a battle cry, a collective scream fuelled by the frustration of many injustices; the frustrations of living a capitalistic life in a world governed by relics of the Nehruvian state, but also frustrations that must come from elsewhere, the simmering discontent, anger, dissatisfaction and stress of an emerging middle class that feels its ambitions thwarted in one way or the other.
This is not a protest, as much as a collective catharsis, a group therapy session, the membership of which is marked by wearing Gandhi caps, shouting slogans, anger coursing through the veins.
There is nothing as exhilarating as the power of righteous anger. This is our Woodstock without the music. Our primal scream.
A recent WHO study stated that India has the highest number of depressed people in the World – about 9% of people in India had an extended period of depression within their lifetime and 36% suffered from what is called a major depressive episode, depression that lasts for a smaller period.
While there were certainly flaws in the way the study was presented - the data released was only for data collected near Puducherry, and cannot be extrapolated to the rest of India – I am surprised at the reaction of the country’s leading mental health institution – NIMHANS.
According to newspaper reports, psychiatrists from Nimhans said “most people who come to tertiary mental health care centres have moderate to mild forms of depression”; and echoed the health ministry’s position on the report, “We Indians are happy people.”
That reaction is even more depressing than the report of depression. In order to address a problem we have to first acknowledge that the problem exists.
And there’s no doubt that Indians are facing unprecedented emotional challenges. A study published in the medical journal, The Lancet, in 2004 concluded that “The rates of suicides are several fold higher than those reported anywhere in the world… 148 per 100 000 for young women, and for young men 58 per 100 000,” at least ten times as much as in the west.
But you don’t need a study to tell you that emotional distress in India has increased. Almost everyday, newspapers carry reports of suicide and violent crimes. Look around you, and you see beleaguered parents, stressed employees, turbulent marriages, divorces, and teenage angst. We are definitely a society in stress.
A society that has seen the dismantling of old values, the disppearence of previous norms and social mores, all in the space of ten years, and that too in a country where 75% of the population is under the age of 35.
We are changing like no society has ever changed before, and as any psychologist will tell you, change = stress.
So why this curious reaction from the Indian ministry and mental health establishment?
Sigmund Freud would probably term their reaction, “denial”, a “primitive psychological defence mechanism”. ( Defence mechanisms are a way in which our minds shield ourselves from anxiety. You can read more about this here, and I will discuss defence mechanisms in further detail in subsequent posts)
I am no alarmist. I am a realist. And there’s no sense in burying our heads in the sand. We have to see clearly the crisis, and the opportunity that exists in this crisis.
Let us not deny that the symptoms exist. But let us see and frame the symptoms based on what we know about our country and society, and not in purely western terms.
First, I have to remind you that depression is a construct, not an objective entity. We don’t have blood tests or MRIs for depression. Psychiatrists diagnose depression based on “diagnostic criteria” – if a person has certain symptoms, then, by consensus, psychiatrists would state that the person is suffering from “depression.”
So, for example if a person is sad, distressed and is not sleeping well and eating well and there are no other medical causes for these symptoms, psychiatrists would diagnose depression.
While this is useful in treatment and research, this sort of approach does not address the heart of the issue. The cause of a disease – “etiology” in medical parlance – is not part of the psychiatric diagnostic criteria. In other words, the diagnosis of depression is a construct, and an incomplete one at that.
It’s true that many Indians are feeling distress – anxiety, meaninglessness, worry, anger, self-analysis, doubt, uncertainty, emptiness - but to merely call it depression (as the WHO report did) does not help us find a solution; and to minimize the existence of this issue (as the mental health establishment did) is to ignore the problem altogether.
The Gap
The London underground system famously tells commuters to “mind the gap”, to watch the space between the platform and the train.
The advice is apt for any individual or society undergoing a transition. “The gap”, in terms of human potential development, is the space between your current state and your desired state. Picture a trapeze artist letting go of one bar, and reaching for the next. Imagine the exhilaration and the anxiety before you grasp the next bar and finally get to your desired destination.
I believe that India is currently in “the gap”. We are in a state where we have let go of old social structures, and we haven’t quite grasped the next ones yet. And because we haven’t found or firmed up a new way of doing things we are still at a loss.
The widespread emotional turmoil, the existential vacuum, the sense of confusion, is in fact a preparatory stage for transformation.
In this “gap”, we have the opportunity for positive growth and transformation, into a new way of being.
Conclusions
Here are my conclusions about the WHO report:
1. The WHO report is true in that it captures the state of a society in flux, change and confusion.
2. However, western notions of “depression” are not directly applicable to contemporary India.
3. We are going through significant change
4. We are in “the gap”.
5. We have an opportunity to transcend and transform ourselves from this gap into a whole new way of being where we can let go of the past and reinvent ourselves using all the positive attributes of the past and letting go of all the things that held us back.
6. These are challenging, exciting, and yes, interesting times.
7. In order to transform into positivity, we cannot blithely ignore the WHO report and the current state of our country.
We have to first acknowledge that something is going on.
36% of our country are not happy and unafraid to acknowledge it. But they are not depressed.
They are in the beginnings of change. The beginnings of positive transformation.
Look, I dislike glib new-ageisms, and touchy feely cliches as much as the next person.
But this I know: As a physician and psychiatrist, I help people rediscover their own inner source of healing. I facilitate a person’s journey to wellness. My treatment is to help the brave, the courageous people who come to my clinic, rediscover their source of strength, their resilience, their reservoir of healing. My job is to help them remove the obstacles that prevent them from connecting with this source.
And so, as I do this work that I feel so privileged to be doing, I am searching for a word to replace “patient”, a word that I dislike; from the Latin “patiens” literally “to suffer”, the word “patient” connotes a person who is passive, who lies in wait for the physician to heal him or her, a word that seems to me a relic of the paternalistic medical model that is the very antithesis of my practice philosophy.
But what is the alternative?
Therapists and counselors often use the world “client” and although I use the word too for want of a better alternative, I find it almost as distasteful as “patient”. From the Latin for “follower” (or so the internet tells me, I might be wrong), the word “client” is more suited to professions far older than medicine. Or worse, it is reminiscent of the legal system.
The words “consumer” and “customer” have been tried by some physicians, but these are more appropriate to the world of business and the marketplace; no matter how bad the current system of medicine, I like to think that the majority of physicians are not motivated by money; our work is a vocation, and the guiding principles are empathy, compassion, and above all, the well-being and best interests of the person who is seeking treatment.
“Health-seeker” is another possibility, and I rather like the phrase, although it’s a bit cumbersome. Also, to me at least, “health seeker” seems to suggest that the seeking has not yet come to an end, that the person is still laboring, still searching, with no indication whether this search has yet to bear fruit.
So what is the answer?
I am not sure yet. But the word that replaces “patient” or “client” has to encompass the following:
1. If you seek treatment, you are not “dysfunctional” or “sick” or “diseased”. You are facing challenges in your life, emotional or physical and are seeking a solution to these challenges.
2. Your desire is to lead a better life, to realize your potential, to transcend obstacles. Just because you seek help does not suddenly make you any “sicker” than someone who has not sought the help of a professional. It might mean that you are smarter, braver, more courageous.
3. In helping facilitate your journey to wellness, I learn about bravery, about the strength of a human being when life is hard, I learn about hope, resilience, and faith.
I value you, and I respect you. And therefore, I seek another word to describe you, and my role in your journey to wellness.