insurance exclusions

I was surprised when the Supreme Court recently questioned why insurance companies didn’t cover the cost of psychiatric treatment under medical insurance. Didn’t they? I didn’t know that. After the Mental Healthcare Act was enacted in 2017 the IRDAI (Insurance Regulatory and Development Authority of India) had issued a directive to all insurance companies to do so. But it obviously didn’t happen.

Okay. ‘Mental illness’ is a slippery slope for sure, like euthanasia, living will, Do Not Resuscitate orders, pro-life arguments and punishment of juveniles for heinous crimes. People have different notions of mental illness to begin with.

The Mental Healthcare Act, 2017 defines mental illness as follows:

A substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs.”

All of these are observations that a psychiatrist makes in the course of a patient’s Mental State Examination. His inferences can be construed as subjective and biased by anyone who chooses to do so. For example, if I think a patient is severely depressed and admit him because I think there is a risk of suicide, will the insurance company reimburse him if the suicide doesn’t happen? Will I be suspected of profiteering in some way from the patient’s hospital admission?

Insurance contracts are structured between providers and insurers both of whom benefit from a patient being hospitalised and sent through lab and radiological investigations, procedures or surgery. So ­– between doctors, hospital owners, insurance people and patients – does anyone trust anyone else anymore?

Regarding mental illness, insurance companies list exclusions in their brochures and policy documents, like depression, alcohol-related illnesses, ‘nervous breakdown’ and anxiety, all of which we recognize as symptoms of mental illness needing treatment.

Some are also smug about the fact that since most mental illnesses need only outpatient treatment very few patients can take advantage of the IRDAI directive to cover psychiatric treatment. True. Which means, any directive will look good on paper but won’t benefit patients.

There seems to be no consensus among concerned parties on what constitutes mental illness in spite of the legal definition. Our criteria are often unacceptable to non-psychiatrists, and the way insurance policy documents are worded suggests that insurance agencies think we are out to con them!

If we tell them that Panic Disorder is a mental illness and not a character flaw, that it is not something that afflicts a weak person who can’t face life, they are sure to think it’s a scam.

They are equally likely to think Major Depressive Disorder is sadness caused by ‘overthinking’ about things that don’t concern you, when your job is to work, eat, deal with your social media, watch something on your phone and go to sleep.

What about OCD? They most likely believe that a stubborn person who believes she knows best about cleanliness and perfection doesn’t deserve insurance if she ends up in hospital due to her cleaning mania. She’s clearly got her comeuppance.

People with AIDS, alcohol-induced health problems and reconstructive surgery are not covered by insurance. Looks like insurance people think these people brought it upon themselves and must be punished!

What about grief that eventually turns out to be a patient’s first Major Depressive Episode, precipitated by bereavement and needing hospitalisation?

And anorexia, bulimia and other eating disorders? I haven’t found any insurance company that covers Eating Disorders – they probably view rejecting food as entitled behaviour!

Autoimmune disorders are exclusions too! So are behavioural, neurodevelopmental and neurodegenerative disorders! How come? If anyone needs help, these people need it most because their illnesses are not curable and need lifelong treatment. The word insurance literally means assurance and comes from the French seur, meaning safe, which comes from the Latin securus meaning ‘free from care, secure’. The idea of insurance implies kindness and support – how ironic!

Don’t people who run insurance companies learn these things as part of their training? I’m sure they do, or else how would they be so good at finding loopholes!

There are only two conditions lay people seem to understand as mental illness: one, schizophrenia, only if the patient has florid hallucinations and delusions and is violent; two, the manic phase of Bipolar Disorder where even a casual observer can see that the patient’s behaviour is off-kilter.

No insurance agent seems to know that for every mental illness we see as strange behaviour, there’s something happening in the brain to cause it, just as the illnesses that his company does cover have an underlying malfunction in some organ. The disorder is not in the mind but in the brain, a large organ, just like the heart, liver, kidneys and lungs! As I’ve said before, Psychiatry is Neurology at a cellular/biochemical level.

I can’t imagine being a consultant to IRDAI and giving them advice on providing insurance cover for mental illness. It would be incredibly hard to convince people in the insurance business that a mental illness is as real as fractured bones or a ruptured appendix.

Half the world can’t imagine something they can’t see. They need something tangible like a BP reading or a blood test or a CT scan report, just as the other half of the world wouldn’t know how to hustle and make serious money instead of sticking with a safe job and a fixed salary. It’s just the way different people are wired.

No matter how much we try to increase awareness, the concept of mental illness is hard to convey because there are too many grey areas. For example, is someone with Antisocial Personality Disorder mentally ill? Or is he a morally bankrupt criminal who ought to be in jail? If admitted for surgery following an attack by a rival gang, and APD is diagnosed through his history, and psychiatric treatment is attempted, should the insurance company cover his psychiatric treatment as well? Who decides this?

The Indian Psychiatric Society has much to clarify about mental illness if we are to make things easier for our patients. To whom, I don’t know. The government? The IRDAI? Insurance companies? Why will the latter be interested when they don’t stand to gain?

I guess it’s down to lawyers, insurance people and the government – mainly the government – to come up with guidelines, preferably with input from the Indian Psychiatric Society. The sheer number of suicides in our country should make recognition and treatment of mental disorders a priority without creating so many stumbling blocks in the form of insurance exclusions.

hoping for miracles

Work has always been about food and safety since the beginning of human time. It still is for most people. But some of us have moved away from that basic premise and work to fulfill either our higher needs or unmet psychological needs. We tend to treat food and a safe home like collateral benefits.

At one extreme, Elon Musk says, “Why do you want to live? What is the point? What do you love about the future? If the future does not include being out there among the stars and being a multi-planet species, I find that incredibly depressing.”

I don’t deny that the launch of his manned rocket is a huge feat. It’s just unsettling to have news of his rockets and driverless cars juxtaposed with images of hunger and homelessness of millions caused by corona, then Amphan, Nisarga, Christobal and earthquakes and forest fires.

But then, everything else can’t stop just like that, right? So other things happening – like the launch of Falcon 9 with two brave people inside – alongside the march of the corona virus, worldwide protests against racial discrimination, and extreme weather events is just how life works.

Far removed from Elon Musk’s reality there is a lot of anxiety in the world of ordinary people right now. Anxiety, unfortunately, is not something that happens in a small corner of the mind. It involves the whole person. It can eventually cause high blood pressure, a heart attack or a stroke if it becomes chronic.

I think everybody knows most of this, but I’ll do a quick recap:

  • It starts with the eyes and ears observing and transmitting data to the back of the brain.
  • In a flash the information reaches the forebrain, which interprets it and sends it to the midbrain, the emotional part we have in common with lower animals, and we feel fear.
  • This sets off a cascade of stress-related hormones that course through the blood stream and whip the heart, lungs, guts and kidneys into action, preparing us for fight, flight or freeze.
  • So the heart beats furiously, blood pressure goes up, lungs pant out heaving breaths, sweat glands pour out sweat, the stomach churns, and there might be an urge to run to the bathroom, as all systems are in overdrive.
  • Within the brain itself, the hippocampus opens the folder of memories related to the current fear and reminds us how terrible it was the last time around.
  • And the amygdala computes the emotional value of the information and decides how awful we should feel.

Different neurotransmitters are released in the brain at each stage of information transfer. There are more brain chemicals swirling around in an anxious brain than the number of mind-altering ingredients in a glass of LIIT!

Anti-anxiety medicines stop this hectic activity and reduce restlessness, depression and confusion. I prescribe them if anxiety is severe, and only for a short time, because they cause dependence in the long term. So they are not a solution.

Patients pour out torrents of anxious thoughts. I have to separate factual fears from free floating anxiety and look for a silver lining in their reality. The mind of a super-anxious person is like a blast furnace. Somebody has to collect the slag, turn it into skid-resistant asphalt aggregate and use it to pave the rutted road of his life, and that’s what I do! I use the period of relative calm when a patient is on meds to sort out things through therapy – to some extent. So this is only a partial solution and that too, only for some patients.

I realize that one might learn all the mental gymnastics therapy can teach, but when there’s hunger and fear and creditors knocking on the door, autosuggestions to be positive might seem delusional. There is a limit to cognitive restructuring and trying to neutralize negative thoughts in the face of reality. And reality is so harsh for millions that therapy doesn’t even enter the picture; it would be like Marie Antoinette allegedly said, “let them eat cake”.

There isn’t always a simple solution, hence the number of corona-related suicides in the news. We need more than psychiatrists and mental health workers to reduce the suicide rate because people don’t kill themselves for the simple 2+2=4 reasons that relatives and friends usually give the police. Despair – a complete loss of hope of getting support – pushes people over the edge when a trigger like corona comes along and wrecks their fragile financial systems.

I hear from those who received regular rations from the Public Distribution System in the last four months that they were okay because they didn’t have to go hungry during the lockdown. That, and physical shelter, is what we didn’t give the migrant labourers who wound up walking across the country for thousands of miles to reach home.

As I said in my last post, we can’t control everything in life. The idea of God is a natural outcome of people having to deal with a difficult present and an unseen future, like now. Hoping for miracles is not that different from your therapist telling you to be positive in a hopeless situation.

I sometimes think that what people are going through is more like grief at the death of someone dearly loved than any other emotion. The new normal is an unalterable reality and we are never going to get back the life we knew and liked. There’s a profound sense of loss.

Those who depended on the gig economy in some way, including the migrant laborers who trekked across the country in thousands, are devastated. Even those who stayed afloat financially feel grief for the loss of a familiar way of life, mixed with relief and gratitude as in ‘there, but for the grace of God, go I.’

People who had slowly crawled out of poverty are mourning for the lives they had painstakingly constructed, rupee by rupee.

  • I talked with Kiran, a 23-year-old who works for a small event-management company putting up decorations at venues. No events, no gigs, no income.
  • Ashwini, a young assistant at a dentist’s office, has been on half-pay since her employer sees only occasional emergency cases due to corona risk.
  • Sunil, the barber near the market, shut shop just before lockdown and rushed back to his hometown. The owner of the general store next to the barbershop says he isn’t coming back now fearing institutional quarantine.

I don’t know how these people will rebuild their lives when this sad chapter is over. Maybe they are more resilient and stronger in spirit than I think. Mothers forget the intense labour pains of their first delivery and go on to have more children – my friend Mario’s mother had fourteen!

Viktor Frankl, the famous neurologist and psychiatrist, did a lot of meaningful work after surviving the Holocaust. He lived to be 92. Maybe the ability to forget pain – despite having every single memory stored somewhere in the brain – is a gift. It’s probably what keeps us going, because none of us go through life unscathed.

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For perspective, this is where I’m coming from. This is from a post I wrote a few months ago:

“I keep coming across this statistic in the media: India has only 0.75 psychiatrists per 100,000 people. This is apparently the reason for countrywide neglect of mental health.

How can that be? We are talking about mental health here, not mental illness. Psychiatrists are medical doctors who treat individual patients suffering from mental illness, while other agencies are responsible for the mental health of populations. Substandard education, nutrition, housing and healthcare systems, unemployment, corruption, inadequate infrastructure and safety, disillusionment due to chronic mismanagement by successive governments, coupled with unattainable aspirations ­­– these are responsible for compromised mental health.”

https://drshyamalavatsa.wordpress.com/2019/12/09/a-sisyphean-task/

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changing constructs

There’s much talk among psychiatrists about dealing with people affected by the corona pandemic. What can a psychiatrist say that people haven’t already got from the deluge of information and inspirational quotes that their friends have shared on social media? Be optimistic, don’t panic, eat a balanced diet, exercise, sleep well, maintain a routine, don’t give up hope, do yoga and meditate, learn something new – this will pass!

People say that we are all in this together. But we are not.

  • Those who can work from home and draw the same salaries as before are not affected much. Nothing has been taken away from them except the frills, the inessentials.
  • Those whose occupations need them to go out, like shopkeepers and domestic workers, who have dependent family members and survive on a steady income, find it hard to make ends meet.
  • Those whose business involves perishables are likely to feel doomed, like fruit and vegetable farmers
  • Those who have factories that can’t allow in workers because of social distancing norms can’t hope to recover soon.
  • Those who have been laid off as their employer is downsizing will find it hard to get another job. Maybe they could use the time to upskill?
  • Those who have lost jobs but have fairly substantial savings could husband their resources and wait out the pandemic.
  • Those whose work entails a lot of travel really don’t have a choice till travel safety details are worked out.

And so forth. There are so many realities needing different solutions.

I might understand and comfort patients, but can I offer them real help? Patients are fearful, anxious and vulnerable, especially now with all the uncertainty. As a medical professional I can’t even assure them that a vaccine will soon be available because that’s not certain at all. Sometimes a patient’s reality is so stark that my words sound like a bunch of hollow platitudes to my own ears. I can prescribe medicines but they’re only palliative and won’t solve the patients’ problems.

Right now, sitting safe at home, not much affected by the pandemic, I feel something akin to survivor guilt when I see images of the worldwide suffering this virus has caused. I have no solutions and it doesn’t look like anyone else in the world does either. If I had to counsel someone hit by this disaster my key word would be acceptancethat we don’t have as much control as we wish. This is something most disadvantaged people are aware of all the time. It’s us middle class Indians that are brought up to believe we can do anything and we should let nothing stand in our way. So we stubbornly try to slash through, rather than slowly make our way around, obstacles. Maybe we need to modify some of our personal constructs.

Our grandparents had a clear idea of their limitations and accepted that some things just befell them and they had to cope. They had to find strength within themselves and their community. They accepted that natural disasters and epidemics were not under their control. The idea that gods watched over them was also helpful in accepting the vagaries of life, including suffering, and I think this is a source of strength for a lot of people even today.

People used to save for a rainy day. There was always a nest egg to cushion the impact of a crisis. I think the current reliance on credit rather than savings has taken that away. Not only do people have no savings, they now have loans to repay as well, and no income. Should we re-think our approach to earning, spending and saving money when things settle down somewhat?

We seem to have lost direction as a species. We are living in the Anthropocene epoch that started in 1950, the epoch of human-induced global change. Imagine – an epoch named after the destruction we have caused! For delineating a new epoch, geological impact must be global, and has to be big enough to appear in the geological record of the earth. Like plastic pollution and nuclear testing are both part of our Anthropocene epoch. Maybe this applies to the global impact of the creation of the corona virus in a lab – if proven – as well.

born under an unlucky star

Parents feel immense grief and helplessness when too many things go wrong, one after another, in the life of their adult child. So they get him to come back home, to take care of him until things are better. They say he was born under an unlucky star.

What is Luck? This is what researchers who have been studying Luck have to say:

  • Luck is subjective, and a positive attitude can make you luckier.
  • Alert people who watch for opportunities can create good luck by grasping a chance quickly.
  • Lucky people tend to use serendipitous encounters cleverly, though they might say, “I got lucky”.
  • Lucky people vary their routines and thus increase the likelihood of serendipitous events.
  • Successful gamblers hone their betting patterns to get luck on their side. I don’t know how that might work, but that’s what they say.

Is there no such thing as pure luck that is controlled by Destiny alone? I do believe there is. Some people seem more prone to having things go dreadfully wrong with everything they try. I think the fear and negative attitude are a result, rather than the source, of bad luck.

I’ve heard people described as ‘someone whose touch can turn gold into mud’, the opposite of ‘someone with a Midas touch’. Some of them have gone from mistake to astonishing mistake, so you might wonder for a moment if they did create their own bad luck. But if you listen carefully to their story you can quite see that they couldn’t have done things differently in the circumstances of the time. Only in hindsight does it look like they could have.

As psychiatrists, we don’t usually make room for luck in interpreting patients’ problems, especially as people in India express it in astrological terms like, “Our astrologer told us he is going through saade-saatha shani”, and we know nothing about Astrology. We are trained to look at events in a patient’s life pro forma:

Problem

How did it start and progress

What was the immediate cause

Why does it persist

What has been done about it so far

Has such a thing happened before

Family history

Personal history

How is his current mental state

Though we empathise, our primary job is to objectively work out how best to alleviate his distress using solutions that Science offers.

Answering our questions can’t be easy for the patient. He can’t always justify the steps he took as he tried to scramble to his feet after each slide. He can’t explain why all his efforts have failed. He looks and sounds utterly defeated. That’s when the accompanying family member protectively steps in to say that he has had a lot of bad luck, and gives a number of instances.

His family is not going to abandon him when he is down and out. This impression could be something that inched into my mind subliminally over the years. Or, it is unconscious cherry picking I did out of a need to believe in human goodness, because I’m one of those people who read the newspaper every morning.

These cases give me hope that people still care, though things I read make me feel that we are done with all that, and now it is only about making the world high-tech, obviating the need for human beings and their troublesome emotions. Of course, I’m also aware that for every person who gets support from a loving family there are many who aren’t welcome back in the fold, but well . . .

With the corona virus unleashing a sort of guerilla war on us, a lot of young adults who are graduating from college this year are apprehensive. For many, confirmed job offers have been rescinded. Those who graduated last year and are in their first job are no longer certain what will happen to them. Young people who started new enterprises in recent years, and have not yet broken even, are worried. Those studying abroad are in limbo, online classes being a poor substitute for the vibrancy of real college life.

It’s bad luck that the corona pandemic intersected with their lives at this point in time. Many of them will suffer from anxiety and depression, and incipient psychotic illnesses will flare up in those at risk. It’s quite likely that many of these graduates will be jobless and need family support for an unpredictable length of time. This is pure bad luck and it’s not because of a negative attitude, a lack of alertness, or wasted chances.

They will eventually find a way around it. Some say “And this, too, shall pass away” was first carved by wise sages on a finger ring for an unknown Eastern monarch centuries ago. Some say the Eastern monarch was King Solomon. Some say Rumi originally wrote these words, and some say Rumi got them from Attar . . . Whatever their source, these wise words are our common inheritance, they belong to everyone, and are especially comforting for youngsters who might be feeling very unlucky in these locked down times.

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hikikomori

There are many lost kids out there. They are either dragging their feet in college for years after they are supposed to have finished, or have graduated but are disinclined to apply for jobs. Some of them take up jobs that are far below their ability and qualification. They use the paltry pay as pocket money and continue to stay in their parents’ home, neither asking for nor contributing anything.

What bothers parents most is the stonewalling, the refusal to engage in a conversation about it. The worst cases are where the kid stays holed up in his room with a laptop, does not come out even for meals, and raids the fridge at night.

There is no word in English – nor is there one in the DSM-5 ­– for this. However, the Japanese have a word for it: hikikomori, which roughly translates to acute social withdrawal. Hikikomori are adolescents or adults who have withdrawn totally from society, not leaving their room for weeks or months on end.

This phenomenon has been studied most in Japan because the country’s demography, culture and current job situation have apparently turned many youngsters ­– and adults – into hikikomori.

Who are these reclusive youngsters who quit mainstream life? This is a generalisation based on kids I have seen in clinical practice. A hikikomori in India is most likely to:

  • belong to a middle- or upper-middle-class family
  • be described as ‘sensitive’ and more inclined towards the arts, though he might hold a degree in science, business or law
  • have been sent to the ‘best’ educational institutions, hence expected to ‘succeed’ spectacularly by everyone, including extended family, a daunting situation that he is not up to facing
  • have done extremely well in school but poorly in college
  • have a recent history of failure, either academic or in a romantic relationship
  • not want to attend family events because he’ll have to explain why he is doing nothing
  • muse about whether all the slogging through school and college was worth it because life is pointless
  • tell you he’s reading philosophy and it makes more sense than the boring lectures in college
  • say that he sleeps during the day and sits up all night because it is peaceful

All these young people unhappily searching for meaning and direction, looking for peace, trying to hide from nosey relatives to protect their parents’ honour . . . It’s sad. Why is this happening to our kids?

One reason could be that they never got a chance to find out what they wanted from life because parents had set the course for them. To give parents their due, most see education as a means to a career and a steady income, not necessarily an exciting job. After all, they are funding it. The tussle over choice is now a common Hindi movie trope, and Indian parents are hopefully re-thinking Education.

Anyway, right now we have to do something about these apathetic kids. Without motivation there’s no impetus to go anywhere, get a job, do anything. So they stay in their rooms, numb, lost in their own world.

The apathy you see in hikikomori is not different from the apathy of a patient with a lesion in the prefrontal cortex, because that is the part of the brain that buzzes with ideas and energy to explore new possibilities.

One part of the prefrontal cortex gets you energised to make a plan; another sets the tasks for carrying out the plan; another executes it; another part monitors the execution; another part moderates your emotions. The foremost rounded part of the brain, the frontal pole, coordinates all of this, plus input from some other parts of the brain. So there can’t be any progress without energisation, the starting point for action. This is apathy, and it manifests as withdrawal. That is what neuroscience tells us.

Psychology says there is a deficit of Theory of Mind, i.e. difficulty understanding others’ intentions, and how their own behaviour impacts others. This is the same kind of deficit one sees in people with autism spectrum disorders and schizophrenia! So, the tendency to withdraw rather than confront might be a stable trait, that is, hardwired in the personality. Anyone trying to help a hikikomori re-integrate into the mainstream would have to consider this limitation.

There is no established way of dealing with hikikomori as yet. We probably have to connect with them, find out what energises them, light a spark and hope the other steps in the prefrontal cortex follow. We have to be supportive until they are ready to test the waters. This is not easy and it takes time. It might not even succeed. Meanwhile, we need to reset our priorities vis-à-vis raising children before we start giving these unhappy people labels or creating a new category in the DSM-6.

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an outlier

 

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A statue of Buddha in Phnom Penh with a rare expression of intense concentration, unlike the serene expression one usually sees on his face

I have no idea whether most people in the world are happy with the work they do, or what drives them to do what they do.

About fifteen years ago a doctor working in the same hospital as I requested me to see her son because she was worried about his career plan. The boy was a 23-year-old graduate from one of the best engineering colleges in India. He had rejected a paying job that he got through campus placement and chosen to join an organisation that worked for the upliftment of slum dwellers, for a small monthly stipend.

He was self-assured and calm during the conversation. There were no psychiatric symptoms at all and nothing to suggest a personality disorder. He believed that what he was setting out to do was right for him. He was also clear that he wasn’t going to be a financial burden on his parents.

Subsequently I met many youngsters like him and began to realise that it wasn’t uncommon for people of this generation to do something like that.

Most people get degrees that lead to jobs. They look for jobs that pay well and give them a few perks as well. They enjoy the office atmosphere, the company of co-workers, the work itself and the pleasure of an independent income. They look forward to the future. As I said, that’s what most people do.

So who are these outliers? When someone tells me about one of them this is how it often sounds:

  • There’s no rush for him to get a job as he doesn’t have student loans, because his parents are affluent;
  • He doesn’t have to earn and save up to buy stuff because his parents gave him everything even before he thought of asking – spoilt kid, born with silver spoon, doesn’t know the value of money;
  • He knows his parents have enough assets that he will eventually inherit, so he never has to work in his life;
  • He will eventually marry a rich girl and get money from the bride’s parents as well!

When I actually get to know the youngster I discover a wholly different inner world, where none of these are on his radar. They are the minutiae of his life that he barely notices. If he is charming and relaxed I might take a little time to make sure he’s not a clever manipulator skilfully pulling wool over my eyes. Instead, he is intense and rarely cracks a smile, and never attempts to please. There’s an air of urgency and earnestness about him.

I wrote about the brain’s reward centre in my last post. It is apparent that this boy’s brain doesn’t recognise a good job and its perks as a reward. His reward centre seems to urge him to do something that makes a difference to people in need: helping the poor seems more fulfilling to him than writing code.

Did the ‘mature’ defence mechanism of altruism develop naturally in him through childhood because he was raised in a peaceful home, without much conflict with his natural empathic disposition? That is, protoaltruism of parents giving rise to generative altruism in the child. Or is this pseudo-altruism covering up his issues? Altruism is a mature defence mechanism, but a defence mechanism nevertheless.

The concept of altruism has always seemed fraught to me. Sometimes I think it’s better not to look too close when some good comes out of someone’s altruism, though I wonder if it will ultimately harm the doer, but the doer will not recognise it as harm because – wait, is he a masochist! Okay, okay, that’s enough. I simply don’t go there.

Why did Prince Gauthama leave his kingdom, palace, wife and infant son and ultimately become the much-revered Buddha? His background and the sequence of events that led to his renunciation have never been a cogent enough argument to convince me that it was a sudden decision. Maybe it was brewing in his head for years before he took the step.

Perhaps something similar happens to youngsters like the boy whose story I began this post with. A kid gets into a professional college at eighteen in India. That’s too young. In the four years at university he might discover that he isn’t cut out for it. By the time he works out what else he would rather do, four years pass and he’s in the final semester. He decides he might as well complete the course and get the degree and figure his life out later.

How people’s brains are wired is a combination of genes and environment, the way you can create many shades of green by mixing different shades of blue and yellow, adding black or white – or even orange – to get any number of shades. The phenotype doesn’t automatically tell you the genotype. How did you get this particular shade of green in this painting? No idea!

The daily newspaper has been featuring one or two ‘Lockdown heroes’ everyday. If I were to ask these generous people why they did it they might say: “I like doing this, I like helping people.” I wouldn’t want to ask, “Why do you like doing this?”

Everybody’s insides look the same on the operating table – unless there is a diseased organ – and the depths of everybody’s mind might too. So anyone’s answer to “Why do you like doing this?” is bound to disclose self-interest and take away from the warm, fuzzy, happy altruistic feeling. So, “I like doing this” should be morally good enough to qualify as untainted altruism.

To come back to the altruistic kid in question, every engineering grad doesn’t aspire to be a Nadella or a Pichai. Sure, the idea takes a little getting used to for parents, because everything you read and hear says the opposite. Parents need to believe in their youngsters and support them in finding their niche. Usually nobody has the clinching argument in these heated family discussions, neither parents nor kid, because the moot question is what will happen to the kid’s career in the – unknowable – future.

 

because the human brain is plastic

This is a heuristic take on therapy.

Listening to a patient is not very different from listening to a friend in trouble. As the patient tells her story, you feel her emotions and note her expressions, choice of words and factual consistency, apart from watching for telltale signs of physical illness. You empathise.

Meanwhile, the patient gauges whether you are able to understand her situation and emotions. It’s a two-way process, a lot of it non-verbal, during which mutual trust is established.

Psychotherapy sounds like something the patient passively receives. It isn’t. It’s a dialogue. The patient is a therapist’s ally because she knows herself much better than anyone else does. As professors often reminded us in college, “the patient tells you much more than she thinks she’s telling you, so listen.”

People see a therapist regularly for years for certain conditions, but I’ll leave that aside for the moment. I think therapy, by and large, ought to be brief and goal-directed. The idea is to help a patient learn to catch fish, not sell her some every week. For that I need to do some data mining within her history, personality and current situation and find her raison d’etre.

What keeps her going in life, what motivates her?

Does her motivation come from outside or from within? The type of motivation – external or internal – that drives people depends on their genes. I know that sounds discouragingly immutable, and that bothers me too. But if you look at families you know, or even at your own parents, siblings, aunts, uncles and cousins, you can see how that might work.

To give a simple example, you work either for a reward, or solely because you enjoy it. If your motivation is only internal and you love your work but are underpaid because you didn’t think of negotiating your salary when you accepted the job, you might feel shortchanged and get depressed and anxious. Therapy might help you discover that you need to develop external motivation as well.

But here’s the thing. By nature, you believe a job well done is its own reward. Asking for a raise is something you force yourself to do, something you’re not entirely comfortable doing. You might wish you weren’t wired that way.

Many of the sad stories of people who messed up their lives, and the happy ones of people who fought incredible odds to get somewhere in life, are algorithms that gave them a choice at every point. What motivated them to choose as they did?

A father tells me that he controlled certain personality traits with much effort long before his son was born, but the teenager now exhibits the same distressing traits and risky behaviour. What does it mean, considering only nature is in play here, not nurture, at least to the extent that the father consciously controls his behaviour? Traits – good and bad – are inherited and make you to do things? If this boy should grow up to be a ‘psychopath’, a court won’t let him off because genetic traits motivated him to steal, mug or kill. So therapy might prevent the predictable outcome.

Does learning ‘better coping skills’ and ‘developing mature defence mechanisms’ through therapy merely mean that you learn to exercise self-control and behave more appropriately, tucking away your maladaptive tendencies somewhere in a dark recess of your mind? Or does it change you at a deeper level? Or do people just grow up and grow out of certain attitudes regardless of therapy?

Then, there are people who are satisfied with who they are and what they have. Aren’t they motivated to be famous or acquire more stuff? Perhaps they have simpler ambitions and are easily satisfied. Maybe they are naturally risk-averse. Or wise. Maybe they don’t care about being judged. Or they may be detached souls who consider life a brief stop on a much longer journey of the soul. Either way, that’s how they are wired.

So, is it all down to the genes that control motivation? Where does volition come in then?

There is a tiny structure called the nucleus accumbens in the base of the forebrain. It’s called the ‘reward centre’. The nucleus accumbens is part of a loop that aggregates a lot of information that the brain receives. It is concerned with processing motivation, reward, choice, aversion, fear, impulse and pleasure ­–­ pretty much everything that makes you do, or want to do, anything at all. Your genes might decide what your brain considers a ‘reward’.

Does this mean that therapy changes something in this loop? As the brain is plastic, new neural connections occur every time you learn something. And these new connections possibly change the way you think . . .

Perhaps the new connections re-wire parts of the prefrontal cortex – the part of the brain that thinks and makes decisions – to respond in a more measured way to signals from the reward centre clamouring for gratification. So there is a biological basis for therapy as a treatment modality in Psychiatry.

As the nucleus accumbens also plays a role in reinforcement learning, the new way of thinking possibly becomes second nature. If this is so, the boy in the case mentioned earlier might be able to stop himself from mugging the man walking alone on a dark street if he has received the right type of therapy! Rehabilitation of juvenile offenders is a huge issue for which therapy focusing on each child’s unique reward system might be useful.

There’s so much published about how therapy works and how each part of the brain works. But I don’t think we know how they come together.

In my first year at medical college, I found Embryology fascinating. While it was easy to see how each organ and system was developing, I never understood how they started working. I still don’t.

IMG_1976
A page from my Anatomy record – FY MBBS (eons ago!)

For example, the sino-atrial node, the self-sustaining pacemaker in the wall of the right atrium of the heart, starts beating when the embryo is less than a month old. It starts producing action potentials (electrical activity) that start the heart beating, and this continues till the end of life! I can’t imagine how it does that, though I understand how voltage-gated ion channels in the cell membrane generate action potentials using energy from adenosine triphosphate.

And this is a single structure with a single function. Maybe the answers lie neither in biology nor in psychology, and we ought to look for them elsewhere. What I found regarding the sino-atrial node was completely beyond my comprehension. This is a study by mathematicians!

https://www.frontiersin.org/articles/10.3389/fphy.2013.00020/full

So I won’t pretend that I can completely figure out something as complex as what happens in your brain when you talk things over with another person! The point is that the human brain is plastic, and that gives us scope to change ourselves. We can free ourselves from the constraints of negative emotions like anxiety and depression – all of which are controlled by the brain – and let our spirits soar.

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it is what it is

My friend has taken a fortnight’s leave from hospital work and might extend it if she needs to. She is a specialist in Internal Medicine. She is in her fifties and her mum is over eighty, hypertensive and diabetic. She says she can’t expose her mum to the corona virus.

She talked anxiously about this with me for nearly two weeks before taking the step. It’s an ethical dilemma that many doctors have faced since the onset of the pandemic. It’s an individual decision, but there isn’t always a choice because there are legal contracts, apart from your own pricking conscience.

Doctors and others in the medical field are now referred to in the media as soldiers. The analogy fits only up to a point. Soldiers and their families know from the outset that they may have to die for the country; doctors and nurses don’t. It’s not common or expected that we die in the line of duty.

So there is fear of being infected, of passing it on to family members and fear of dying from it. Added to that, there is anger about not having enough protective equipment, anger towards patients – some of whom are acting entitled out of their own fears, and anger against the world for not acting fast enough to control spread of the disease.

Doctors working with infected patients are now reaching out for help in dealing with all these emotions. Used to keeping emotions under control, doctors have no experience with an overload of anxiety, anger, sadness, and a sense of danger, though nobody minds the physical exhaustion much because that’s not unusual. But this time even that has been excessive.

Psychiatrists and psychologists are offering online CBT ­– Cognitive Behaviour Therap­y – or at least basic counselling ­– to these overwrought people.

What is CBT?

It’s a way of changing a person’s negative view of his problem and the way he consequently responds to it. The therapist focuses on the patient’s thoughts, beliefs, associated emotions and attitude towards the situation he is facing. The goal is to identify the problem, think of possible solutions and choose the best one. Something like this:

  • How do you know this thought is the truth?
  • Why do you think it can’t be wrong?
  • What is the worst-case scenario if your belief is correct?
  • What’s the best?
  • If someone else asked you for advice with the same worries what might you tell her to do?

All this takes time. Held to this line of reasoning, the patient starts seeing the situation a little more realistically. He gets that there are serious limitations to his power to effect all the changes he wants. He gradually reaches a level of acceptance: it is what it is. There might be an associated sense of loss, sadness or helplessness in this, but it’s better than a constant anxious muddle in his head I suppose. It’ll keep him going so he can do his job, nothing more, for that’s the need of the hour.

Many doctors have died from contracting the virus from patients. What could have been done differently? I don’t know what to think anymore. In any case, reviewing the past won’t change the present, though it might help in planning for the future.

We often don’t realise that the world is a decent place only because of all the little cogs in the wheel of this composite entity called People functioning as a whole. Every worker fills a need. There is a division of labour that exists in all societies – bees, ants or us – and we contribute our mite to the whole. Right now it’s the turn of doctors and nurses, and of people who supply food and other essentials, to do their bit.

If we think the corona pandemic is a wake-up call we ought to listen, learn and change. If we choose to treat it like the pandemics that have come before and say “this too shall pass” and go back to exactly what we were doing before the pandemic, well, I’ll have to find the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference. I hope we don’t go back to being our blasé selves.

For the time being it is what it is, and governments are trying their best to deal with its effects. Meanwhile, we have all been forced to live the epicurean way, and some of us may develop a liking for it and continue with lathe biōsas even after the pandemic is over!

 

yoga in alabama

Quoting from Newsweek:

The Alabama board of education in 1993 voted to prohibit yoga, hypnosis and meditation in public school classrooms. The ban was pushed by conservative groups, and some schools have reported complaints from parents who say the practice endorses a “non-Christian belief system”.

From The Guardian:

The ancient practice of yoga has its roots in Hinduism though it is now a common form of exercise practiced across the world, including in private gyms in Alabama. 

A bill brought by Representative Jeremy Gray, a Democratic legislator from Opelika, is on the proposed debate agenda Tuesday in the Alabama House of Representatives. If the bill passes with a two-thirds majority, it will then go to the Senate for further debate. 

Gray’s bill seeks to dissociate yoga from its religious roots, and says that local school systems can decide if they want to teach yoga poses and stretches. However, the moves and exercises taught to students must have exclusively English names, according to the legislation. It would also prohibit the use of chanting, mantras and teaching the greeting “namaste”.

From CNN:

“Critics of the bill often see yoga as a part of the Hindu religion that can’t be separated”, Gray said. “The exclusions are part of the political compromise”, he said, “and are better than not allowing students access to any of the emotional or physical benefits of the practice.” 

That sounds like cultural appropriation, but I’m not going to concern myself with deciding whether it is.

Yoga is very much a part of Hindu religion. It originated as part of Vedic religion thousands of years ago. In Sanskrit, yoga is derived from yuj meaning ‘union’ – union with the divine after quieting the five senses. It is not just an exercise routine but is used as one outside India.

Like haldi doodh, an Ayurvedic treatment for balancing the three doshas, is now called turmeric latte and sold at Starbucks!

Yoga is good. Haldi doodh is good. Ordinary people don’t have to acknowledge the origin of anything they use. That’s only for academics. So why these disclaimers, distortions and little deceptions?

In a hyper-connected world people from distant countries are exposed to other cultures. That’s unavoidable. Throughout history people have tried to alter or influence other cultures to be more like theirs, never realising the other culture is subtly rubbing off on them too! That’s how yoga has entered the lives of non-Indians.

Christian evangelism by Americans has been going on in India for many decades now. Here are a couple of excerpts reflecting dissatisfaction with it.

  • In India, evangelism has always been a cause for concern as it poses a severe threat to the demographic stability of the country. In this report, we elaborate on the zeal of the missionaries and the extent of their efforts to convert people to the worship of their ‘One True God’. The Joshua Project is a ‘research initiative’ that seeks to ‘highlight the ethnic people groups of the world with the fewest followers of Christ’.
  • Joshua Project focuses on catalyzing pioneer evangelism and church planting. 

If you haven’t heard of the project, this is from wikipedia:

  • The Joshua Project is a Christian organization based in Colorado Springs, United States, which seeks to coordinate the work of missionary organizations to highlight the ethnic groups of the world with the fewest followers of evangelical Christianity. To do so, it maintains ethnologic data to support Christian missions.
  • The goal of the project is to identify people who “do not have enough worshipers of Jesus Christ” and provide the needs and support to evangelize about Christianity and Jesus.

Not so strange, is it? Everybody has misgivings about ‘the other’ infringing on their territory and trying to alter their way of life.

All human beings want to keep their tribes safe and cohesive. They like who they are and don’t want to change. Not unlike the parents of school children in Alabama, Hindu Indians don’t like the propagation of American religion in India. They have the same worries about Christian missionaries as Mr. Gray and the parents of the kids in Alabama have about yoga being taught in American schools.

Are India and the US both religious democracies rather than secular democracies then? In which case, why are we pretending to be secular?

There is a small point I need to add. Even if American children are taught yoga using English translations they are still exposed to yoga per se. Won’t they explore it further if they benefit from it, as the school and Mr. Gray intend them to? Isn’t it pointless to shield kids from something they will question anyway, given the inbuilt BS meters that all kids are blessed with?

I would think it’s simpler to tell them that this is not a Christian thing but it’s good for them. Hindu children in Indian cities enjoy decorated Christmas trees and gifts and cake at home on X’mas Day, minus the religious underpinnings, knowing that Christmas honours the god of many of our friends.

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a pillar in an ancient temple at Hampi with carved figures in yoga asanas

https://www.newsweek.com/yoga-banned-schools-alabama-hindu-christian-gym-class-1491247

https://www.theguardian.com/us-news/2020/mar/08/alabama-yoga-ban-public-schools-prohibit-namaste

https://edition.cnn.com/2020/03/10/us/alabama-lift-yoga-ban-public-schools-trnd/index.html

https://www.opindia.com/2018/11/christian-evangelism-and-the-joshua-project-a-conspiracy-against-hinduism-india/

https://www.missionfrontiers.org/issue/article/joshua-project

https://en.wikipedia.org/wiki/Joshua_Project