Tag Archives: J. Clin. psychiatry


Dr Shyam K Bhat MD is a
Psychiatrist and Integrative
Medicine specialist.

He is board certified in
Psychiatry, Internal
Medicine, and
Psychosomatic Medicine,
with additional certification
in clinical hypnosis

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Simple Fools


Ten years ago, as an intern, I was sent to a small village about 60 miles from Mangalore for a mandatory “rural posting.” It was a foreign world and I, a young and relatively affluent city-dwelling fellow, thought that the month was a terrible imposition. One evening, I was walking around the village market and came across a small shack where tea was sold. A group of old men were gathered around a rickety table. They looked at me curiously as I ordered a cup of tea in broken Kannada, the vernacular language.

“You are from the city, eh?” one old man asked me.

I nodded.

“No one is happy in the city, no, thatha?” one of the other men said. It was more of a statement than a question.

The old man nodded and invited me to sit down with them. “Come on, young man,” he said. “Let me tell you a story.”

That evening, as I sipped a cup of incredibly sweet and strong tea under the light of a kerosene lantern, with the ubiquitous moths flitting around the lamp and the smell of jasmine from the nearby flower seller filling the cool air, the man told us this story. To me, 10 years later and thousands of miles from that village, it still seems relevant and meaningful, even profound.

Or maybe I am just being nostalgic. You decide.

T. G. Chellappa Rajagopal was his full name, but everyone called him Chella. He lived just down the road and owned 2 acres of land, where he grew cashew nuts and rice. His father had done the same, and his father’s father had also done the same, waking up at dawn to tend to the crops, shouting at the few laborers, watering the trees, and then, during the harvest season, hiring a truck to take dried nuts to the village market to sell for a pittance.

His neighbor, Ramaswamy, owned a similar farm and occasionally the two of them would meet and talk about such things as the weather and the latest gossip from the village.

“How is everything, Chella?” Ramaswamy said one day, “Rain might not come this time, I think.”

Chellappa nodded but looked out into the distance. Of late, he was wondering if this was all there was to life. He was 25, and, if his parents had been alive, they would’ve been looking for a girl from a decent family for him. As it was, his father’s younger brother, who lived in the city, had already sent word that it was time for Chella to settle down.

Ramu, a few years older, was already married and had one son. Ramu’s life, as far as Chella was concerned, seemed to be going the way of everyone else’s—marriage, children, grandchildren, occasionally nagging wife, worries about the weather, and then, ultimately, death.

What was the point? Chella wondered.

“I am thinking of getting a job in the city, Ramu,” Chella said suddenly. He wasn’t sure why he said this. He hadn’t really given it much thought, but now it seemed like a good idea, as if in saying it, he had opened up a world previously closed to him.

Ramu laughed loudly. “Very funny, very funny,” he said slapping his thigh, guffawing, and shaking his head.

Chella was irritated; he was not sure why. “You fool,” he said suddenly, standing up.

“If you want to live like this, go ahead. I am leaving. Enough of this nonsense.”

Ramu stopped laughing, and looked at Chella with a shocked expression. “You are serious, Chella? What will you do, man? We only have a BA degree, don’t forget, and that too from Kumbla college. Who will give you a job? What will you do in the city? No one will marry you, and you will be making at most a 1,000 rupees—”

Chella cut him off. Ramu was his friend. They had grown up together here in the village, had explored the woods as boys, eaten wild berries, learned how to cultivate the soil, but Ramu had always been contented with this life, unwilling to explore. When they joined the college at Kumbla, Chella had first realized that his life in the village was no more than a triviality.

When they would watch a movie at the village theater, Ramu would whistle and clap with innocent glee, but Chella would look at the images and wonder what it would be like to live in the city, with all the chaos and the glitter and promise.

So, while Chella would feel like he was being left out of something bigger, Ramu was quite happy to stare at the images on the screen, as an observer and not as a participant: to him, those images were a window into another universe, fascinating and enjoyable, but not really part of his world.

Ramu’s reaction to Chella’s desire to go out into the world then was not unexpected, but it was still irritating.

“You stay here, and do what you want,” Chella said. “I am going to live my life like a man, not a dumb animal.”

Chella sold his land, and a month later, he was gone.

Years passed. Life went on in the village. Ramu continued his farming, he had 2 more children, both girls, and he had to work hard to save money for their weddings.

Occasionally, when he sat out on his veranda with a beedi and coffee, he wondered what had happened to Chella. But most evenings, he would not think about too much other than his crops and the weather. Occasionally, Ramu would secretly watch scantily clad fashion models on his new television, marveling at their bodies, but also wondering how any father could let his daughter parade like this in front of strangers.

Chella, meanwhile, had worked hard in Mangalore. In his first job, as a clerk in a small finance company, he had impressed his superiors with his dedication and intelligence. He was promoted twice, then transferred to Bangalore, where he eventually started his own real estate company.

Within 10 years, Chella had become a rich man. He bought a palatial house in Indiranagar, became a member of the golf club, and married a convent-educated girl, who worked part time in an NGO. They threw lavish parties and often appeared on page 3 of the local newspaper, a sign of having arrived on the Bangalore social scene.

Along the way, Chella learned to speak English well. He polished his accent, purged every trace of the vernacular from his diction. To hear him talk to his Rotary club friends, a whiskey in hand and a cigar in another, wearing his Raymond suit, one would have never guessed that Chellappa Rajagopal was from a small village.

His children went to an international school, for which Chella paid more than he had ever earned in an entire year as a farmer.

But by the time he was 50, Chella began to wonder, Is this all there is to life? A colleague of his died of a heart attack, another left his wife for a younger woman. It seemed harder and harder for Chella now to remember not to lapse into his Kannada accent. When he ate dinner at home with his wife and children, he felt like a guest, like an actor playing a role, and not a real human being.

One evening, instead of his customary shirt and trousers, he decided to wear a lungi, just as he used to back in the village. His wife looked at him aghast. “What are you doing?” she said. “The Mehtas are coming home for dinner tonight. You look like such a villager. Please wear something nice.”

The next morning Chella took a flight to Mangalore and then hired a taxi to take him back to his village. Maybe, he thought, once he saw Ramu’s plight and the miserable way people lived there, he would be thankful for his achievements.

When he got there, it was like he’d never left. Ramu was sitting on the veranda, smoking a beedi. It was humid and hot, and as always, the loud noise of insects—crickets, dragonflies, mosquitoes—filled the air.

He could see Ramu squinting, wondering who was coming to visit at this time of the evening.

The house looked no different, with the green of the moss on the walls, the slightly dirty tiles of the roof. The only sign of progress was a large dish antenna on the roof.

“Who is that? Chella? Is that you?” Ramu exclaimed. He stared at Chella for a second and then said, “Yeno, Chella? What a surprise! Come in, come in. Savithri, see who’s come,” he shouted. Ramu and his wife welcomed Chella so heartily, that somehow, he felt guilty for ever having left.

After dinner that night, he and Ramu sat out on the veranda. Ramu seemed quieter than Chella remembered, and he struggled to make conversation, to try to find something to say. What did they ever talk about all those years ago? Chella could not remember how they’d ever been friends. He felt uncomfortable and nervously lit one of those beedis. Ramu, on the other hand, seemed at ease.

“So, how is the city, Chella?” he asked.

“Good, good. You should come and visit,” he replied, although he did not mean it.

They sat there in silence, with Ramu making the occasional comment about the weather and Chella telling him about his business.

It seemed so different from his conversation with his golf friends. There, it seemed, someone was always waiting for their turn to speak, and there were few gaps in conversation. People in his social circle laughed loudly, talked quickly, and had a lot to say.

But here, when Chella spoke, Ramu just listened. He didn’t comment, did not apparently feel the need to contribute to the conversation. He also seemed curiously unapologetic about asking the most basic questions. “They have tall buildings there now, no?” or “I have heard that there are bars in Bangalore, and women are going there alone and dancing. Is this true?”

Ramu also didn’t seem to feel the need to say anything remotely interesting or funny. Now he was boring Chella with more conversation about the weather. “Rains were good this year and so the market—”

“Are you happy?” Chella interrupted. “Happy?”

Ramu looked puzzled by the question. He smiled shyly, seemingly embarrassed by this turn in the conversation. “Oh, I don’t know, Chella. We don’t think about all that.”

The next morning, Chella said bye and walked to his taxi. Ramu and his wife stood at the door, waving a cheerful goodbye. Thank God I left, Chella thought. These people have no interest in the world beyond their little farm and their little lives.

And as for happiness, they don’t even think about it at all. Such fools they are, Chella thought.

Such simple fools.


American Idols


I enjoy watching “American Idol,” and I have not missed a single episode I this season. I suspect I watch the show for the same reasons that most people do—not for the singing, which frankly is a distraction, but for the human drama: the joy, the hopes, the dreams, and, in many cases, the pain of an almost delusional belief in one’s talents. “I can be anything I want to be” is a common refrain from participants.

In one typical audition, a woman, 21-years-old, blonde and attractive in a generic sort of way, informed the judges that she would sing a Céline Dion number. She smiled, cleared her throat, and began. It was obvious from the first second that she could not sing, although she had clearly spent a lot of time in front of the mirror. She looked the part of a diva, as she stared soul-fully at the camera, then closed her eyes and hit an excruciatingly high note, with vibrato thrown in for good measure. She was completely out of tune, but when she stopped, she looked as proud as an operatic soprano at the end of an aria.

“How do you think you did?” Simon, the acerbic British judge, asked with a barely disguised sneer.

“Great!” she said.

“Not a single note was in tune,” he said. “You cannot sing.”

Later, she wiped away her tears. “I don’t care what they think. I am a star.”

Her mother, with her carefully coiffed hair, glared indignantly at the camera. “My daughter sang for the Mayor; those judges don’t know what they’re talking about!” she said angrily.

No wonder her daughter thought she was destined for instant fame and success. “You are special. You can be who you want to be,” she has heard over and over again, in a well-intentioned, but misguided attempt to increase her self-esteem. Her teachers, glib talk show hosts, New Age gurus on television, self-help bestsellers, pop-psychologists—everyone has told her that success is simply a matter of believing that one is special, that nothing is beyond reach, if one truly believes in oneself.

Unfortunately, she has not been told the entire truth—that self-confidence can come only from a realistic appraisal of one’s unique strengths, talents, and weaknesses. She has not learned that a sense of achievement comes from attaining realistic goals, that success does not come merely from wishful thinking and faith. So, when she does not achieve her goals, the implication is

“I did not believe in myself enough.”

When she fails an audition, like she did today, she believes that, instead of reappraising her talents and goals, she should instead strengthen her resolve to become a celebrity. When I see her crying on TV, it seems to me that a part of her must know that society has lied to her. When she insists, “I am a star,”

her voice rises—she seems anxious, perhaps coming to the slow realization that she might never be rich or famous.

But she fights this knowledge and makes herself believe in her eventual stardom more and more, until the discordance between reality and her belief seems almost delusional. She is terrified of a life of relative obscurity. And who can blame her?

Her mother, and the media, and society have made her think of life as empty, unless lived under the glare of a camera. For her, and so many like her, public adulation has become the only worthwhile source of happiness and self-worth.

Our society has become a crucible of narcissism.

At the clinic, I see a new patient. Linda is a 22-year-old college student who has been referred to me by her school counselor for the evaluation of possible depression. “I’m fine when I’m out with my friends. You know, we’re all laughing and having a good time, but if someone says something negative, it really bums me out,” she says.

I’ve been seeing an increasing number of patients with a form of atypical depression, without the classic leaden paralysis: low mood that brightens after a positive social encounter and declines in the face of the slightest criticism. I think that the same social forces that create those overly confident contestants on “American Idol” are responsible for the growing number of patients like Linda.  They are both casualties of an increasingly insular society, where some people pursue glamour and celebrity to meet their growing need for social approval, while others, like Linda, became mildly depressed, vaguely dissatisfied with their lives, their happiness contingent on the fickle nature of social approval.

On another episode, a 23-year-old man from a small town in Texas said after an appalling audition, “My life is awesome; it’s like a reality TV show.” He said this honestly, openly, without any trace of irony. I wondered what he meant. Maybe he was trying to say that his life was dramatic enough to be of potential entertainment value to the general public, but I wondered: Did he live his life as if performing for some invisible camera, like an Orwellian nightmare? Either way, it was clear that he judged his life by the standards of movies and television. Happiness is when life is like a TV show.

It appears that celebrity worship is associated with poorer mental health.1 But is there a cause-effect correlation? Does celebrity worship lead to depression or does depression lead to celebrity worship? I found some interesting information online. A prominent ABC News columnist quotes a media observer as saying, “Gossip magazines are proliferating for the same reason that prescriptions of antidepressants and other psychotropic drugs are proliferating. They dull our emotional pain.”2

I resent this frivolous comparison of prescription medicines to gossip mags, but I remember at least one patient who reported that she was able to cope with depression because of an interest in celebrities. “They are like my friends,” she said.

She is chronically depressed, has a severe dependent personality disorder, and is acutely sensitive to perceived rejection. I think it’s no coincidence that she has an interest in celebrity life. Identifying with their lives gives her a sense of meaning, and even though this meaning is trivial and fragile, it’s better than the emptiness that she feels otherwise.

The gossip mags, the media, and society’s preoccupation with celebrity are both the cause and effect of depression. For the “American Idol” hopefuls and for some of my patients, life seems bland in comparison to the glitz they see on television, a life that is always out of reach, despite their fervent desire for stardom.

The media perpetuate depression by distorting fundamental values, by holding up the life of glamour as the only worthwhile life. Diabolically, the media first creates the need and then offers itself up as a solution. First, the barrage of images of a glamorous and ultimately unreal life worsens the depression, and then, when the person’s life seems meaningless and trivial, the media whisper cunningly, “Watch our shows, identify with the celebrity lifestyle, and you might forget your insignificance.”

That ABC report had it wrong. Gossip mags are not like prescription drugs, but like drugs of abuse—decreasing pain transiently, only to make it worse.

A few days later, I notice a headline in the papers. “Junk Food—The New Tobacco,” it reads, referring to recent attempts to treat the junk-food industry in the same light as the tobacco industry.

I am waiting for the day when the headline will read, “TV—The New Tobacco.”

But for now, I still watch TV. I am trying to quit.

REFERENCES

1. Maltby J, Day L, McCutcheon LE, et al. Personality and coping: a con-
text for examining celebrity worship and mental health. Br J Psychol

2004;95:411–428

2. Gray K. Celebrity worship syndrome abounds: is America’s obsession

with stardom becoming unhealthy? ABC News. September 23, 2006;

http://abcnews.go.com/Entertainment/story?id=101029&page=1

 


Sweat


Freud probably never participated in a sweat lodge ceremony, or he would have had quite a bit to say about it. There was something distinctly oedipal about the medicine woman’s description of the ceremony: “The sweat lodge,” she said, “is like the womb of Mother Earth.”

Unlike the more conventional conferences I’d attended in the past, this one—for integrative medicine—was open not just to physicians, but to practitioners of all persuasion, some more esoteric than others. From Ayurveda to QiGong, to Reiki to energy healing—nothing, it seemed, was off limits. As a diversion to the conference, the organizers had arranged for a sweat lodge ceremony to be conducted at the Indian Health Center of Albuquerque. My knowl-edge of Native American culture was minimal, and I’d never read a description of a sweat lodge ceremony. I naively envisioned a relaxed evening, kicking back with a cold beer, chit-chatting, talking with interesting people from all over the country, sharing ideas and thoughts about health and medicine. A perfect antidote, I imagined, to my otherwise mundane life back in the Midwest.

My colleague Amy told me she’d been to a “sweat” years ago. “A spiritual experience,” she said. I was intrigued and asked her to tell me more about the ceremony. “Well, the brochure is pretty accurate, except, I think, the actual experience is more intense.”

I looked at the brochure closely for the first time: Native Americans hold frequent ceremonies for purification, spiritual renewal, healing, and education. These ceremonies take place in structures called sweat lodges. Rocks are heated. The people who enter into the sweat lodge spend time praying together. . . . Steam from water poured on the hot rocks causes them to sweat. . . . The mind, emotions, and spirit of the participant are purified through this ancient ritual of prayer. Sessions for men and women are held separately.

Only 5 other men had signed up, which was surprising, given that this was a conference where the attendees were more likely to be open to such relatively arcane practices. We were greeted at the door by a lady who introduced herself as Martha.

“She’s the medicine woman,” Trevor, an internist from Arizona, who’d apparently been to a sweat lodge ceremony before, informed me. She was in her mid-50s and looked like a kindly aunt. I found myself momentarily surprised to hear her speak just like any other American.

Somehow, the words “medicine woman” had conjured up a stereotypical image in my mind, a result of watching too many old Westerns. I was almost as bad as anyone who had ever said to me in wonderment, “You are from India, but your English is so good, and you don’t wear a turban!”

She explained the protocol of the ceremony. “First you make an offering to the fire, say a small prayer, and then we go into the lodge. You enter clockwise, we pray clockwise, every-thing is done in a clockwise manner. After we go inside, the firekeepers will bring in the Grandfathers.”

“Grandfathers?”

“The hot rocks. They are called Grandfathers,” she explained.

We followed Martha outside, as she led us to the lodge located on the far side of the health center. I was expecting a log cabin, such is my ignorance, but the “lodge” turned out to be a tent of sorts fashioned out of tarpaulin and blankets and supported, I later learned, by a frame made of willow.

Two young men, silent and strong, greeted us with a nod.

“They are the firekeepers,” Martha informed us, as she gave us each a pinch of tobacco from a pouch. “You offer this to the sacred fire, and we usually say a prayer with the offering,”

she said.

I hadn’t prayed in a long time, and I waited for everyone else to go first. Finally, I said a silent “thank you” to an amorphous higher power and threw the tobacco into the fire. Red sparks arose from the flames, and the smell of tobacco filled the air. This was the first, and probably the only, time that I would associate the smell of cigarettes with a spiritual experience. Even this most noxious and reviled plant, I realized, has a cultural significance that is lost with its use outside a ceremonial context.

We were then instructed to say, “All my relations,” a loose translation of a Pueblo prayer, and then go into the lodge. Martha was the first to enter. I waited and watched as everyone went inside, forced by the construction of the lodge to almost crawl. I understood that this was meant to be a humbling experience. Stripped down to our boxers, and now compelled to crawl into the tent, it was as if we were forsaking our roles as physicians, or nurses, or therapists. Inside that tent, as Martha said, we were all the same. I took a deep breath, said the prayer, “To all my relations,” and crawled in, not knowing what to expect.

My eyes slowly adjusted to the dark. I could see the silhouettes of the others, seated in a semicircle. Martha sat on one side of the opening to the tent, and I sat down on the other. The earth felt cold in comparison to the stifling warmth. A small pit had been dug in the center of the tent, and I was aware, as we sat there, that there was no space to sit up or even move about very much. As a child, I had traveled in crowded buses in Bangalore, in packed trains in Bombay, and yet I was uncomfortable with this much physical proximity. I wondered how the other participants, unused as they probably were to such situations, felt.

“Bring the Grandfathers in,” Martha shouted out, through the flap.

“Careful. Watch out.” Through the small opening, the firekeeper maneuvered a pitchfork with 3 large smoldering rocks into the pit. Martha placed what looked like herbs onto the rocks, and a sweetish-acrid smell filled the air.

I had read vaguely about mind-altering substances used in such rituals, and I asked, somewhat nervously, “What’s that?”

“Cedar and sage,” she replied.

I was beginning to feel apprehensive and wished that I had read more about the ceremony before participating. This was a far cry from what I expected. Where was the relaxing evening, the well-lit sauna, the cold beverage, the casual conversation?

As if sensing my discomfort, Martha asked, “Before we begin, is anyone claustrophobic?”

I have never thought of myself as claustrophobic, but now I began to wonder. “No,” I replied. Apparently nobody else felt the need to answer.

“Bring the water in,” Martha said, and a pail of water was passed to her. In the shadows, her heavy lidded eyes looked at all of us in turn. “You are healers. I honor you and respect you,” she said. “Remember, inside this tent, we are all family.” And with that, she poured water onto the rocks. Steam rose up in a hot cloud. The smell of sage and cedar and the heat filled my lungs. I swallowed, tried not to panic. And then, Martha said to the firekeeper standing outside, “Close the flap.”

I have read descriptions of hell and of torture chambers, but this was far worse. I was inside a dark, hot, smoky, sealed container. The air was hot, hotter than any sauna that I had been in, and it was so black and dark that when I looked around me and didn’t see a thing—not even the absence of a thing—the space inside seemed to expand from a few feet to an infinite and unfathomable distance.

Martha picked up a drum and began to beat it loudly. Then, she began to sing in an ululating, haunting fashion.

I had heard my patients’ descriptions of panic attacks, of unbearable anxiety, and I understood what they were talking about in an academic fashion, but for the first time, I felt the beginnings of the all-encompassing terror that they must feel. Someone began to sing as well, and then, inexplicably, screamed unintelligibly, then fell silent. Thoughts raced through my head—What if I can’t take this? What if something happens? What if I lose my mind? What if I pass out? But you’re strong. This is only a tent. You can sit it out. Just close your eyes and surrender to the moment.

But the panic worsened. My thoughts and my senses were obliterated in the heat, the noise, the smoke, the darkness. My heart pounded. I tried to breathe evenly, but the heat made me gasp. I wanted to get out. But I didn’t want to appear weak. I was hoping someone else would bolt, that I would not be the first person to leave. I closed my eyes, struggling to stay calm. I do not know how long I sat in that manner, trying to keep a lid on my anxiety, but I finally told myself that I did not have to do this.

“This is not for me,” I said, when the drumming and the singing abated. “I would like to leave,” I said in what I hoped was a level voice.

Martha immediately responded. She opened the flap, I don’t remember how, and shouted to the firekeepers, “He is coming out.”

I crawled outside, feeling relief and shame and exhaustion and, strangely enough, a mild euphoria. Later, after I had recovered a bit, I waited by the fire, loathe to go back to the waiting room or to take a cab back to the hotel. I could hear drumming and chanting now and then, and I wondered how everyone else was faring inside the tent.

The entire process seemed to be designed to penetrate defense mechanisms, perhaps even to break ego boundaries within a culturally sanctioned, controlled environment. This was as brief, and as dynamic, as therapy could get.

I watched as the firekeepers, the 2 young Pueblo men—Alex and Steve—tended to the hot rocks in a large stone fireplacelike structure.

“It’s good to know your limits,” one of them told me, when I confessed to feeling a bit silly for leaving so early. For all his youth—he must have been in his late 20s—he had the manner of a wise therapist. “There is no right or wrong. You stay as long as you want; you come out when you are ready. Now was not the right time for you. On some other day, you might have stayed there for the entire ceremony. Sometimes, you are there for only a minute. Whatever works for you is fine.”

“Whatever works for you is fine.” A cliché, but in the cool night air, after the terror inside the tent, the platitude seemed like a profound realization, an insight into the conduct of my life.

I felt strangely cleansed and relaxed, as I watched the rich amber of the rocks glowing in the fire. The sky was clear. The air smelt faintly of sage and tobacco. In the distance, the Sandia Mountains looked like a sweat lodge for the Gods themselves. I could still hear the drum beats and the chanting and the singing.

Therapy, I realized, comes in all forms.


Contagion


What made you want to leave?” I asked.

“I just didn’t think the doctors cared,” he replied, referring to the orthopedic surgeons, although by all accounts they’d done an excel-lent job of fixing his hip.

The surgeons had frantically consulted us, ostensibly for depression, but probably because they thought he was a “difficult” patient: the evening before he’d threatened to leave the hospital against medical advice. Now, he seemed quite reasonable and willing to talk. His affect was depressed, as he slumped on the bed, talking with us in soft tones.

“I have been feeling sad for a while,” he admitted, when suddenly, the door burst open, and a young lady stuck her head in.

“Hi!” she exclaimed. “How are you?” If she was aware that her behavior was in stark contrast to the prevalent mood in the room, she didn’t show it. “I’m the speech pathologist,” she said, and then with a bright smile and a wave, she added, “You guys talk, I’ll come back later,” and breezed out of the room.

There was a pause, and then the patient shook his head, “I won’t be talking to her,” he said.

“How come?”

He thought about it. “She’s too—young,” he replied.

“Too young?”

“Yeah, I guess—Look, I just don’t want to talk with her, like I don’t want to talk with those surgeons. You guys are different.” We completed our assessment, and he thanked us for our time.

Later, I wondered why establishing a rapport with the patient had been relatively easy for us and so much more challenging for the surgeons and other staff. It occurred to me that “young” was the patient’s way of expressing the obvious dissonance between his low mood and the speech pathologist’s breezy attitude. He did not want to speak with her because her emotional state did not resonate with his own internal experience. Possibly, the surgeons had been similarly ebullient, as they usually are, and this grated on the patient.

It struck me that the resident and I had adopted the patient’s emotional tone: his low voice, the slightly drooped posture, the restrained affect.

And we had done this instinctively today, as we did all the time. Like most mental health professionals, indeed like most people who are so-cially attuned, we unconsciously calibrated our demeanor to achieve an emotional resonance with the person we were trying to connect with.

Empathy, I was reminded, is a complex process, a dance of intimacy in which physicians follow the patients’ lead, even step into their shoes, in an effort to understand them. But I was also reminded that empathy has a dark side. After all, empathy is from the Greek “to suffer with.”

And suffer, we certainly did. It is no coincidence that psychiatrists have the highest rate, among all physicians, for substance abuse, divorce, and suicide.

That evening I reviewed the literature on empathy and emotional resonance. I perused the vast body of literature on the phenomenon of “emotional contagion,” the tendency to display and experience other people’s emotions. I had, for many years, made it a conscious habit not to worry about my patients’ problems once I left the hospital. On a cognitive level, their problems were not my problems. Their pain was not my pain. But in trying to understand my patients, in trying to empathize with their situation, even if only for the sake of diagnosis and effective treatment, I was taking some of their pain home with me. The tiredness I sometimes felt, that no doubt all psychiatrists feel, was not so much from physical exhaustion, as it was a side effect of empathy.

I read with fascination about “mirror neurons” first discovered in primates and in humans hypothesized to be located in the inferior frontal cortex. We are, the literature suggested, hard wired to mirror someone’s emotions—to feel happiness when we are around happiness, to feel sad when we are around sadness.

The surgeon deals with patients’ physical pain with a mixture of bravado and action, with medications and the edge of a knife. But a psychiatrist primarily deals with emotional pain. For a psychiatrist, then, pain is something to be explored, to be delved into, and ultimately, to be understood, perhaps even mirrored, before effective intervention is possible. It seems perverse that the more empathetic one is, the greater the risk of “contracting” a negative emotion.

The next morning I met Sandra, the psychiatry resident, at the doctors’ lounge. We discussed the cases we had seen and the new consults that had come in overnight. I sipped a cup of coffee, now acutely aware that as we sat at this table discussing depression, delirium, and suicide, in an earnest and somber manner, a group of family practice physicians joked and laughed as they discussed their patients.

I discussed the issue of emotional contagion with Sandra and asked her if she ever felt fatigued.

“You know,” she replied, “now that you mention it, I have been feeling tired, and we’ve not been that busy.” She gestured in the direction of the family practice group. “When I was doing FP for 6 months, we were actually far busier. Even though I was physically tired then, psychiatry is much more draining.”

There it was. Empathy and emotional contagion taking their toll.

But then I was reminded of a patient I had seen some months before, at my outpatient clinic. His depression had responded to venlafaxine, and he was in remission. But, even though he denied symptoms of depression, on that day, he seemed subdued.

“You are not smiling as much as you usually do,” I said to him.

“Well, you know that nurse of yours isn’t here any more. She usually put me in a good mood,” he said. “She laughs and jokes with me, so I’m usually smiling by the time you come into the room.” At that time, I actually felt a pang of disappointment. All the while, I’d thought it was my treatment that had him smiling. Although, undoubtedly, the medicine had effected his remission, the smiles and the cheer that he displayed in my office were not because of a pill, but because of a nurse’s ability to transmit her emotional state to this patient.

Had Sandra and I, and perhaps other psychiatrists, forgotten that emotional contagion was a 2-way street? Why was it that we did not attempt to alleviate the patient’s mood by modeling a happier mood? Although, an overly lighthearted, carefree attitude like the speech pathologist’s would not be effective, surely there was a middle ground?

An effective leader judges the emotional temperature of a group, then first matches it himself, before attempting to change the collective mood. In much the same manner, maybe we should be emotional coaches, who first resonate with the patient’s mood and then gradually change that state by modeling happier behavior. Somehow, that seemed counter to all my notions of empathy—that it should be “natural,” that it should be genuine. Such a conscious calibration of empathy seemed disingenuous. But then, if it made the patient feel better, and kept us emotionally healthier, perhaps that indeed is the answer.

I thought of the psychiatry inpatient ward and the pervasive atmosphere of gloom that I’d always sensed there. As I thought of all the hospitals I had worked in over the years, I could not think of a single psychiatry ward in this country, or in England, or in India that was not similarly cheerless.

Every psychiatry ward runs the risk of becoming a self-perpetuating environment of despair. The ward in our hospital has no obvious imperfections. The wooden floors are burnished to a fine polish. The place is well lit. The nurses’ station, recently refurbished, is bright and has new furniture. But the place always has the unmistakable miasma of gloom, as if depression has seeped into its very walls.

A colleague of mine, during residency, had once told me that she handled the stresses of work by surrendering the problems to a higher power. The way she put it, “I wear a small cross, and then when I come home every night, I take the cross off and put it in a corner. It is a symbol of my problems, and every night, I put it away. It’s like a talisman that protects me.”

I used meditation, my colleague used prayer and a ritual, some used exercise, some used sublimation, and perhaps some of us resorted to repressing our feelings, or suppressing our empathy. But I wondered why we did not talk more about how we could prevent the transmission of negative emotions within our profession.

A few days later, as I left a patient’s room I saw a sign: “Wash your hands to prevent the spread of infection.”

I did as it said and went to see my next patient.