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Depending on your perspective,  Time is infinite and multidimensional. Or Time is linear (with a past, present, and future) and finite.

Our calendar, our clocks, hours minutes, days, years  – these are constructs, we made these to organize our world, so we can make appointments, and meet and do business and ensure an efficient usage of time. Of course, the notion of “efficiently” using time will not occur to someone who sees time as stretching outwards, possibly into infinity.

New Year parties are a celebration of linear time, a celebration of a social construct. And New Year’s resolutions are a manifestation of this perspective.

But the truth is that resolutions have to come from within. They cannot be forced.

You tell yourself that you want to lose weight, that you want to get some exercise, you want to achieve new sales targets, spend more time with family and so on.

If you are really diligent you might break this down into specific goals – lose 2 kilos a month by joining a gym and eating 10% less and so on.

But unless you have made a shift within you, these resolutions will soon be ignored, or worse still, the oppressive weight of  unattained goals will begin to sap you of the very energy you need to attain your goals.

So, instead of making resolutions, I suggest you take this time for renewal.  (If this sounds a bit New agey or flaky, let ,me remind you (as articles often do this time of year) that most new gym memberships in January are wasted.)

Today, instead of making a list of resolutions, set some time aside for reflection and meditation.

Consider the following:

The highs and lows in your life this past year: visualize significant events and allow the emotions to wash over you. Note down what action of yours you were the proudest of, and what action you were least proud of.

The first memory you have of yourself in 2011 – what were you feeling and what were you doing?

How does this contrast with your most recent day? What is different and what is the same?

Reflect on the fears that inhibit you.

Consider what you are passionate about.

Gratitude for what you have – your health, your family, your friends, life.

Reflect on any new people in your life, and those who are not so much a part of your life now.

Consider the billions of people on this planet, each having experienced a year of significant events.

Reflect on the infinity of time and the briefness of one year.

Consider your existence on this planet, the briefness of it relative to the eternity that surrounds you on either side of existence.

Accept all that has happened to you  Accept where you are at present. Accept that everything will happen as it should.

Have a Happy New Year!

When you find yourself, you will find a flowing river.

Almost every one of us makes plans that are never executed, resolutions that are dead on arrival – competing priorities and interests, the lack of time and energy, one day passes into the next and our plans stay unrealized.

With time, the weight of unrealized intentions becomes oppressive and many people finally give up trying because the tension between expectation and reality becomes unbearable.

At the heart of procrastination is a unrealistic desire for perfection. The perfect book, the perfect game, the perfect psychotherapeutic manuever – none of these are possible of course, because perfection is an aspiration, never a reality.

In order to stop procrastinating, we have to understand that there is no such thing as perfection. Or rather, no matter how good your work or craft, it can always be improved.

If you wait for perfection, you will never complete your task.

So for example, in order to update this blog regularly, I have to let go of my self-imposed impediments – if I am focused on the quality of the results, then paradoxically, I will not be able to immerse myself in my work.

Instead, it is far more effective, liberating and enjoyable to immerse oneself in the process.

Sachin Tendulkar plays the perfect cover drive when he is immersed in the shot itself, rather than thinking of hitting the ball for a six.

Life is in the process, in the work, in the action, not in the results of our actions. The desire for perfection is a manifestation of the remnants of an infantile ego. The true mature adult realizes that it is right to pursue perfection, but not to fear imperfection. Eventually, we learn that life itself is fully lived when we embrace the imperfection of it.

This insight is not fresh of course, it has long passed into cliche.  That is the nature of truth- wisdom and insight have to be dredged out of the quagmire of cliches and truisms.

At any rate, this is my way of saying that from now on, I will be updating the blog much more frequently. As always, these posts will explore issues of the mind and body, but they will be far more unedited, stream of consciousness, and personal. Imperfect, but hopefully of some value. Just like life.

In India, a person who attempts suicide is a criminal – according to section 309, “Whoever attempts to commit suicide and does any act towards the commission of such offense, shall be punished with simple imprisonment for a term which may extend to one year or with fine, or with both.”

It is ridiculous to prosecute a person who has just tried to kill himself or herself. This law points to a deeper problem – that people often think of suicide as rational and volitional, an act of a person who can reasonably appraise their current situation and the consequences of their actions.

Nothing could be further from the truth – suicide occurs when emotional problems or mental illness makes a person believe that death is the only way out of misery; the person is driven by emotional forces that are sabotaging the normal workings of the mind. Such a person needs our empathy, support and treatment, not prosecution and harassment.

Although the law might be revoked soon, unfortunately, the public’s perceptions of suicide will take a while longer to change.

Recently, an IIM student, Malini Murmu, a 22 year old girl committed suicide.
A day before her suicide, her boyfriend allegedly broke up with her and posted a self-congratulatory, insensitive and cruel message on Facebook.
He is alleged to have said, “’Feeling super cool today. Dumped my new ex-girlfriend. Happy Independence Day.”

Apparently, she hung herself shortly after reading the message.

My heart goes out to her family and friends. Her death is a tragic loss.

While I completely empathize with her family’s attempts at trying to make sense of her death by blaming the boyfriend, the sad truth is that nobody is to blame for her death, not even Malini herself. Suicide is an impulsive action, and often indicates a pre-existing emotional problem, perhaps depression in this case. Depression is a clinical illness, causing hypersensitivity to rejection, a loss of self-esteem, hopelessness and worthlessness; in this context, even the breakup of a relationship might seem like a good reason to kill oneself.

But it is incorrect and ultimately destructive to attribute Malini’s suicide to the boyfriend’s post on Facebook, however cruel and immature it was.

I have been really saddened and frustrated by the way that the media in India has been reporting on this story and suicide in general.

Even therapists seem to be either misquoted or misinformed. A “relationship expert” on NDTV was quoted as saying, “With relationships starting and ending on Facebook, youngsters do not realize that public embarrassment often may drive people to kill themselves.”

Utterly ridiculous.

If public embarrassment results in suicide, then Facebook is the most dangerous site in the world.

Our media often reports on suicide in a way that indicates widespread misconceptions about suicide and mental illness. Suicide is often seen as a mystery, a conundrum that has a singular answer; and reporters often try to answer the question, why did this person commit suicide? The reporter then goes on to explore and investigate external circumstances often resulting in the harassment of those left behind: Did the mother shout at the daughter on the day of the suicide? Did the girlfriend say something hurtful?

The incorrect assumption seems to be that there is always a direct, proximate, and reasonable external cause for the suicide.

Read any story about suicide in our newspapers and you will see sentences such as:

He committed suicide due to financial problems
Or
She killed herself due to chronic back pain.

(By the way, chronic pain is often a result of depression or other undiagnosed and untreated emotional problems)

Now the words “due to”, implies that there’s a direct cause and effect between the event and a subsequent suicide.

These statements ignore the fact that suicide occurs because of problems in the mind, not due to external circumstances – stress is often a matter of perception, and perception is altered by states of mind, and states of mind altered by mental illnesses.

In a sense, a misinformed media lays the groundwork for further suicide, or at the very least does not play the important role that it could in suicide prevention.

Let me be clear – there’s no doubt that Malini’s death and suicide is a tragedy, a devastation for her family, her friends and for society. But to attribute the cause of her death to the boyfriend’s words on a social networking site, indicates a tragic lack of understanding of the emotional forces that lead to suicide.

When relationships break up, people are often going to say hurtful things – Facebook just records these words for posterity.

But the act of suicide is almost always an irrational one and often a result of a mental illness.

While the boyfriend’s words would not have helped Malini’s state of mind, when we say that he is directly responsible for her actions, we are implying that killing oneself is an understandable and reasonable response to emotionally hurtful words. Surely, this cannot be true? If it were so, then we are all in danger of either committing suicide, or precipitating suicide – intemperate and hurtful speech is unfortunately a part of human experience.

Tragic as Malini’s death is, we would be doing her and her family a disservice by demonizing the boyfriend, by implying that she killed herself over this immature man.
By holding his words responsible for her death, we are sending out the message that young women are vulnerable and weak, and would understandably kill themselves if their relationships didn’t work out.

No relationship is worth killings oneself of course.
Instead we could prevent suicide if the media and society at large informs people of the truth – that emotional distress, when it crosses a certain threshold, indicates the need for professional intervention, that emotional problems and stress are treatable , and that events by themselves are almost never the direct cause of suicide.

Human beings desire explanations. We desire meaning, especially when confronted by tragedy. And so we often look for a direct and simple explanation.
But in trying to understand suicide, let us not compound the tragedy by reaching for simplistic explanations.

There are thousands of Malinis out there. Our task is to ensure that we prevent deaths, that her suicide was if nothing else a wake-up call.

Here’s what we need from the media:

1) More responsible and informed reporting on suicide. I would urge reporters to spend more time understanding the causes of suicide, and in their reporting, to explore the role of mental illness in the causation of suicide.

2) To avoid sensationalizing the issue, and seeking simplistic explanations.

Finally, if you have a friend or family member who seems chronically sad, negative, hopeless or feeling a low sense of self-esteem, or has a history of impulsive acts when emotionally distressed, then reach out to him or her, get them to see a mental health professional.

Many suicides can be prevented by intervention before it’s too late.

Only with the the participation of an enlightened public and media, can we reduce the frightening and tragic epidemic of suicide in our country.

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.

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.

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.

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.