Mind Over Meds

How I decided my psychiatry patients needed more from me than prescriptions.

One day several years ago, I was reaching the end of my first visit with a patient, J.J., who had come to see me for anxiety and insomnia. He was a salesman for a struggling telecommunications company, and he was having trouble managing the strain on his finances and his family. He was sleeping poorly, and as soon as he opened his eyes in the early morning, the worries began. “I wake up with a list of things to worry about,” he said. “I just go through the list, and it seems to get longer every day.”

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Aeschylus, Prometheus Bound

A recent essay in the press described a case of Obsessive Compulsive disorder encountered in Azad Kashmir. The writer expressed her distress at the entirely ‘biological’ i.e. medical treatment of the disorder by local practitioners leading to poor results and significant harm to the patient. The author, to her credit, attempts to broaden the understanding of the illness utilizing psychotherapeutic methods employed by leading lights in the field of Psychiatry and Psychology including Carl Gustav Jung, Frieda Fromm Reichman and others. However, her analysis lacked a consideration of what might be generically termed ‘environmental’ factors, more specifically the socio-economic and religious factors at work in the genesis of Obsessive Compulsive disorder and other mental illness. The title of this essay comes from an experiment conducted by American Psychologist David Rosenhan in 1972. The experiment tested the validity of psychiatric diagnosis by having a group of normal, non-mentally ill individuals pose as psychiatric patients to gain admission into a psychiatric hospital and also tested the ability of mental health professionals to detect the truly mentally ill from amongst a group of people of people who were not ill. The experiment concluded that it was difficult to distinguish the ‘sane’ from the ‘insane’ in that setting. It also concluded that the whole process of diagnosing patients lent itself to ‘massive errors’.
This experiment has a direct bearing on all patients treated anywhere with the treatments currently at our disposal. The method of Freud, Psychoanalysis, which formed the basis of the theories of Jung, Reichmann, Kernberg, Adler, Klein and a generation of psychotherapists, posits that psychopathology or mental illness results from unconscious conflicts and desires usually originating in a person’s childhood. This method focuses largely on ‘intra-psychic’ processes i.e. feelings, desires and impulses generated by a person’s own mind to the exclusion of the outside environment. The most trenchant critiques of this method have been made by other schools of thought that tend to focus more on outside influences. These include cognitive behavior therapy, gestalt therapy etc.

A Freudian approach neglects some crucial factors. Why is it that all over the world, not just in Pakistan but in the USA, UK and Western Europe the psychotherapeutic method is being abandoned in favor of biological interventions i.e. medications? The answer to this question requires some historical perspective. Psychoanalysis was born in the ferment of the last years of the 19th century. This was a time of great upheavals in Europe with wars, revolutions and counter revolutions. The first Russian revolution was to follow in 1905, followed a few years later by the First World War and then the October revolution in Russia which resulted in the formation of the first workers republic, the USSR. Freud’s theories, which counseled a ‘looking inward’ rather than towards the existing social and material conditions gained rapid popularity in the ruling circles of the day and in fact, his most loyal patients belonged to the upper classes of the time. After World War II, the governments of the USA and Western Europe provided generous benefits to their workers including mental health benefits for long term therapy including psychoanalysis. This was a way of weaning them away from ‘dangerous’ ideologies like Socialism, at that time the ruling philosophy of a large part of the world’s population, soon to be joined by China. The USA could afford to do this because it had emerged as one of the world’s two remaining superpowers after the war with an intact infrastructure, a huge balance of payments credit and a highly industrialized economy. In contrast, Europe was in ruins and the German, English and Japanese empires had been destroyed. The massive aid plan to rebuild Europe, known as the Marshall plan, was also an attempt to forestall a ‘revolution from below’ by workers fed up with wars and slaughter.
This was the background against which psychoanalysis received a major boost in popularity especially in America. Starting in the 1970s however, the economies of the Western countries including USA slowed and profits began dropping again. The reasons are beyond the scope of this article but it led to a series of efforts, continuing to this day, of taking back the gains made by the working class in most of the twentieth century. This is why all of the ‘welfare’ provisions of years past are under attack including higher pay, pensions, social security and healthcare. A consequence of this last is the shift from psychotherapy, which is labor intensive and less profitable, to medications which generate much higher profits for both the medical establishment as well as drug companies. This is not an isolated phenomenon, as mentioned. It goes hand in hand with efforts to roll back all social welfare provisions including spending on healthcare, infrastructure, education, mass transportation, clean water etc
In a country like Pakistan with a limited industrial base and a largely agrarian economy, a focus on biological interventions for mental illness serves the same purpose. It helps to mask the most significant causes of mental illness, poverty, lack of education and social and educational inequality. This is also a significant, and often neglected, reason for the rise of religious fundamentalism. Social injustice, poverty and lack of economic opportunities lead inevitably to frustration and anger which can breed anxiety, depression and other kinds of mental illness or, if directed ‘outwardly’, lead to anger and hatred. This can easily push a person towards religious fundamentalism as a perceived ‘solution’ to these problems. Economic ruin and the resultant social upheaval was exactly what made the rise of Hitler’s Nazi party possible after the First World War

There is no doubt that the mental health needs of large parts of the population in Pakistan are neglected and that this leads to untold suffering. However, the struggle to provide more efficient and meaningful care to those in need cannot be conducted in isolation. It must be part of a larger struggle to reform society as a whole in a just and humane manner. Only then can one see real, meaningful changes occurring in people’s mental health.

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The author is a Psychiatrist practicing in Arkansas, USA. He can be reached at ahashmi39@gmail.com

We shall go on after taking a breath.

-Meer Taqi Meer

In the medieval morality play of the same name, the title character Everyman is visited by Death who informs him that it is time. Everyman pleads for mercy, protests that he is not ready but to no avail, Death informs him that he must make the journey but tells him that he may take a companion with him.

In despair, he casts about for help. Fellowship, representing his friends initially agrees but when he hears of his destination, refuses to go with him. The same with Kindred and Cousin, representing family. He is forsaken in the same way by each of the allegorical characters; Worldly Goods, Knowledge, Beauty and Strength. Only one, Good Deeds agrees to accompany him to the end illustrating the Christian moral of the play: only good deeds accompany a person beyond death.

Terminal illness, death and grief have always been fertile ground for therapy but my recent brush with it was enlightening. Late in the evening as I was getting ready to leave my clinic I saw the blinking phone light indicating a new message. It was a woman who identified herself as a relative of Ms. M who I had treated in the past. Ms. M, an elderly woman in her seventies, was in a local hospital from complications of pneumonia, had developed respiratory failure and was on a ventilator (breathing machine). In her will, she had named me as her ‘health care proxy’, meaning if there were any further complications, her doctors were to contact me and accept my judgment as final including turning off the machine if her condition was felt to be terminal thus allowing her to die. Even though I had always been interested in end of life issues including death and grieving, this was a little unsettling. I called the family back and told them I would try to help in whatever way I could.

Much has been written about death over the centuries. While dealing with terminal illness and death is never easy, in a poor country like Pakistan, there is a more resigned attitude towards it. This is compounded by the lack of access to adequate health care for the majority of the population. During my medical training in Lahore helping people fight off serious or life threatening illnesses in the hospital was a herculean task often ending in frustration and failure due to lack of simple blood tests and medications,. By the same token though, nobody lingered on in a debilitated state for too long. Either they recovered and went home or they went on to their ‘heavenly abode’. Partly because of this all of us as young trainee doctors in Lahore developed a sense of medicine in a social context i.e. how social factors such as poverty and lack of education affect a person’s health. I still remember a young girl, perhaps in her twenties, mother to two or three young children who died while I was a trainee in our Tetanus ward. She had contracted Tetanus, an easily preventable disease from having used a dirty rag to clean a minor wound. By the time we saw her in the hospital, she was already in the advanced stages of the illness, paralyzed and having repeated seizures. She eventually died of respiratory failure since we had no working ventilators or breathing machines in our ward.

Ms. M, although she was a life long smoker and had severe respiratory problems from it, had no trouble accessing the best health care since she happened to be an American. Unlike tens of millions of Americans who lack adequate access to health care, she was also elderly and thus covered by the government healthcare program for the elderly and disabled called Medicare. It was spring, ‘flu season was in full swing and she had developed a cold, then pneumonia and now was on a ventilator and unconscious. Somewhere along the way, she had decided after having seen me for a few visits that she liked me so much (or perhaps disliked or distrusted her family enough) that she put me in charge of making life and death decisions for her. Until the phone call, I had no idea she had done this. I remember thinking rather ruefully that this was my reward for being so interested in the subject of death and dying.

Unlike most industrialized countries of the world including Europe, Canada or Japan, the US has never had any semblance of a ‘national health care’ system meaning the government has never assumed responsibility for providing a basic level of healthcare for all citizens. This has always been denounced as too ‘socialistic’ and since profit is the supreme goal of all capitalist enterprise, healthcare too has always been subject to the profit motive. Over time with the efforts of various social and political movements, more health care has been offered to segments of society that cannot purchase it in the open market. This has come to include the elderly, children, those disabled from physical and mental illness etc but there are still vast numbers of people who get by from day to day without basic health coverage, one major illness or accident away from financial ruin and poverty.

In such a system, dying is bad for business. The dead take no medicines, do not get admitted to hospitals and make no money for anyone. Therefore, if it can be helped, people are not allowed to die. This became painfully clear to me in my first year in the US when as a young intern in a large hospital for retired military personnel, I treated patient after patient admitted to the hospital from local nursing homes. Many were in their eighties or nineties, had advanced dementia, could no longer speak, walk, eat, dress themselves or perform any daily activity yet were kept alive by the application of the latest medical knowledge and technology. As trainees, we were expected to treat these elders when they developed an infection, a bed sore from lying on one side for too long or some other medical complication. I still remember trying to draw blood from an old, black man who must have been about ninety and, for all intents and purposes, could do nothing at all except lay in bed in a fetal position. It was 2 in the morning, I was exhausted and after trying to get his blood for the third time while he tried to punch me, the absurdity of what I was trying to do seemed comical. I became increasingly vocal about my views as I progressed in my training to the point that one of my teachers in my last years of training jokingly nicknamed me ‘the executioner’ for my opposition to keeping people alive in this state.

For the moment, though, this was the state Ms. M was in and fate, with her usual macabre sense of humor, had appointed me her guardian angel. The first thing I needed to do was find out what she herself would have wanted. I talked to several family members, all of whom had been estranged from her for years and many who were now consumed with guilt for having been out of touch. After some discussion, we decided that she would probably not want to linger in the state she was in for any longer than she had to. In the meantime we had to decide how aggressively we wanted to treat her as her chances of complete recovery were slim.

A person who is dying can arouse intense feelings in those around them. For the family, there can be regret, guilt, anger and shame for having ‘mistreated’ (in their minds or in reality) the dying person. ‘Survivor’s guilt’ is the self descriptive name given to the condition where the surviving family or close friends suffer for having lived while the loved one died. This can be particularly intense if the death is sudden, unexpected or traumatic such as in an accident or sometimes in wartime. It can be overwhelming if the dead person is a child or if, as happens in my profession, the death is by one’s own hand. A terminal illness in an elderly person usually allows for partial grieving to occur while a person is still alive and thus may mitigate the grief after.

According to some, even though death and its reminders are present all around us, most of us work hard at ignoring them until it forces itself into our awareness because of the death of a loved one or our own brush with it. This is one of the reasons that a parent’s death is so hard, particularly the last surviving one. We are now defenseless against the dark angel of death and must fight it alone.

Fortunately for me, Ms. M eventually recovered from her pneumonia and I was never called upon to ‘pull the plug’ and send her on her way. I have not seen her since she recovered but I hope she and her family found forgiveness and love in her illness and are closer as a result. A brush with death or serious illness can, in some cases, be liberating. Having faced the end, one can now see day to day life as transient and feel free to create our own meaning for it. It can allow for a calm equanimity that is possessed only by those who reflect deeply on life and accept its evanescence.

Some Buddhist teachers call this ‘embryonic compassion’, the seed of true compassion and love for all beings. It forces us to face life in all its beauty, pain and joy rather than forever looking away while we reach for the next item on our ‘to-do’ list. Socrates is reputed to have said ‘the unexamined life is not worth living’. Each and every one of us faces choices, fears, joys, sorrows, hopes and disappointments every moment. It is only when we slow down enough to savor them that we are truly living.

I think very few of us would be comfortable saying that letting the child die is an option they would take, and we are likely to be very uncomfortable being in the company of people who would say that. I know I would be. Most people would probably save the child, though with a lot of ache about losing their new car: their pride and joy. Letting the child die would be ‘morally reprehensible’, and possibly legally too (I am not a lawyer but for my example it does not matter whether it is so or not): you are letting great harm come to another human when you could have saved them with no bodily danger to yourself and with only financial cost to you, but a cost that you can easily bear (remember this is not my means of earning transport…but my ‘feel good’ car). Most of us, I hope, will agree, that the right action to do, is to save the child (if it helps, think that it is your child and someone else standing there by the track…what would you like him/her to do?).

But the strangest thing is that we are allowing exactly the situation described above to occur around us all the time. And all of us know of it, read about it and talk about it but most of us do not do anything about it. Only the other day we heard that a mother had killed two of her children and herself because she could not afford to pay for food and other necessities for the family in the meager salary that her husband was earning. Less than a week ago a working man had burnt himself to death because he could not service the loan he had taken from a bank and the bank’s collectors had been rude to the person’s sister and mother (the Finance Minister said, and on the floor of the Senate of the country, that this would be investigated fully).

We know thirty-five odd percent of Pakistanis are living below the poverty line: that is they are barely making enough to pay for their food. We know a significant number of the nation’s children suffer from malnutrition, a significant number do not have access to inoculations that they need to survive, a majority do not have access to basic health facilities that allow them to take care of even treatable conditions such as diarrhea, millions of them do not have access to safe drinking water, sewerage facilities and a safe environment, and tens of millions of our children do not have access to even basic education.

All of us know this. Are there many of us who are preferring to have our feel-good cars and other such non-essential expenditure when people are dying? Is this moral? Does this make a lot of us morally culpable and close to being murderers?

You will notice that the issue is not ‘essential expenditure’. What I need for my own essential expenditure, or for my family, probably has the same need-importance as anybody else. So that is not the issue here and we are not arguing that we should not be spending our money on our needs or saving some for the future. It is beyond the need that is the question. We thought most people would not have a problem ‘sacrificing’ the second car, however much they might mourn the demise of the car, when the choice was between human life and the car. The situation is exactly analogous: when the choice is between non-essential expenditure and human life, why do so many of us indulge in conspicuous consumption rather than in giving this money away to help others.

We should put in a few caveats. First, we are not talking of whether saving other people is the responsibility of the state or not. Even if you are paying all your taxes and have lived up to your legal obligation there, the issue is with what ‘you-as-an-individual’ spend on non-essentials. State’s failings are a separate topic for a separate article.

Second, we are not talking of money that people save for the future either. So the argument that I do not give away what is beyond my needs as I need to save that for the future does not apply here. We are not talking of what people save, though there is a moral question of what is appropriate level of savings for yourself or your family when others are dying, but let us leave that aside for another paper too. What is being talked about here is just the money spent on conspicuous consumption: the massive houses, the luxury cars, the airplanes, the lavish holidays, the extremely comfortable living, the excessive electronic gadgetry, the latest mobile phone sets, the overflowing wardrobes and the dozens of footwear that are almost never used.

There is no way of justifying that when you grant that allowing the child to die to save your car is wrong. If, of course, you say that you would have let that child die, then there is no quarrel with you…this article cannot help you.

Third, it is also clear that none of us can really hide behind the facetious argument that we cannot find deserving candidates to help. With a large number of NGOs (in nutrition, health, education, and so on) of good reputation working in the country, it is hard to argue that we cannot find one that would suit us. Furthermore, if one looked at one’s relatives, neighbourhood, and/or place of work, one is bound to find people who could use the extra rupee in a much more useful way than the rich could. With poverty levels at 35 percent odd, vulnerability levels at 70 percent odd, and with food inflation the way it has been for the last few years, it would be surprising if anyone in the country does not know a few people who could do better with some financial help.

There are millions of Pakistanis who are lucky enough, talented enough, or skilled enough to be in a bracket that allows them to earn more than what they need (including prudential level of savings) for themselves and their families. But a lot of us spend the ‘extra’ money on luxuries. When we know there are people who are dying of hunger and basic need deprivation out there, and in their millions, it is clearly immoral, whether it is illegal or not, to continue doing this.

Whether we call this an unrealistic picture or a utopian one or a strict one, it does not really matter, it is the truth. Most religious and secular moralities I know of would agree. Rather than change our notion of morality, should we not think of changing our behaviour?

E-mail: faisal@nation.com.pk

This article was originally published on the The Nation website.

There are few who argue that corruption can be good for growth outcomes. Some make the argument that corruption acts as the much-needed grease in very distorted and inefficiently regulated environments. But these arguments do not really internalize the distortion within the system when addressing the effect of corruption. Places where institutions are not properly designed or embedded, opportunities for corruption are created endogenously by people in power so that they can gain at the expense of the people at large. So corruption, in these situations, does grease the wheels, but it is not going to be much help for overall and long term development since the distortions in the larger structure would always be too big to allow rapid and broad-based developmental changes to occur.

Corruption is probably present in all societies, and possibly at all levels. It is the scale, the depth and the frequency of corruption that vary across societies. Some societies have been able to minimize the impact of corruption to a level where it does not impact the life of the citizen in most circumstances. She can be sure that the judicial system, the police system, and most administrative systems will deliver reasonably even without her offering any bribes. She can be sure that any formal contracts that she goes into, with any private citizen or a government agency, will most likely be honoured, or she will be able to exact compensation from the defaulting party, and at reasonable cost.

But for many other societies the expectations mentioned above are too difficult to fulfill. Pakistan is definitely such a society. Here the level and extent of corruption is very high. Corruption has in fact become so institutionalized and systemic that it has now become a part of our perceptual framework. We do not even realize some forms of corruption for what they are, and even if they are pointed out to us, they do not irk us enough.

Some years ago one of my close relations was posted in one of the key administrative positions in the district administration of Lahore. Around Eid ul Fitr his household received some 200 odd cakes from various people. Most of them were passed on to other people, whom he wanted to oblige, but a lot did end up in the various refrigerators and freezers that the household had and were enjoyed for quite sometime. The same thing happened at Eid ul Azha but with meat. And it is not the fact that this relative had a lot of friends. The very next year, when he was not in that key position anymore, the number of cakes went down to almost single digits.

Why do people send such ‘gifts’ to public officials? And why do we not recognize it for what it is: corruption. It must be the case that the people who send these cakes must think that their interaction with the official is likely to be affected positively if they send the cake or at least negatively if they do not. Why should the citizens care? It must be the case that some benefits, whether legitimate (the grease argument) or not, are tied to the goodwill of the official. But this is exactly what corruption is.

A lot of people will think that this is too trivial an example to base a case on. But it is not. It has been chosen specifically to show how endemic, embedded and systemic the issue of corruption has become. And you can take as many examples of it as you like. A lot of government officials, especially from departments like the police, income tax and so on, who have higher frequency of interaction with the public, enjoy a multitude of benefits at the expense of the citizens because they can confer favours on these citizen in return or at least not become an obstacle in the legitimate affairs of the citizens.

The executive gym of one of the most expensive health clubs of Lahore has quite a few government officials, from grade 18-21, who are members. Some have family memberships. The market value of the membership must be twice the total salary of these officials. So how are they able to afford this? It must be the case that the club, a private organization, is subsidizing the membership of these officials. But why? Again, it must be that either the club is getting some benefits from these people or is afraid of these people and what they can do. Whatever the reason, this is corruption, but a form that is just taken for granted by everyone, and in fact some officials just think that it is their right to have such benefits.

What is even more disturbing is that in some places forms of corruption have been institutionalized and legalized so that they cannot be called corruption any more. There are clubs in Pakistan that offer subsidized membership rates to government officials. There are government departments in Pakistan who offer ‘benefits’ to their employees that are really payoffs. Prime land is distributed amongst employees of certain departments. These lands are usually acquired from the private owners at a pittance and then given to employees for relatively low prices as well. The price difference with the market gives the employees opportunities for making large gains at no risk at all. Similarly there is a bank in Pakistan that offers credit cards with very high ceilings to army officers. The high ceilings set for these cards are not, in any way, justified by the salaries that these people get. But this is a good way of extending credit to these important people.

One can come up with as many examples as one likes of these legalized forms of channeling benefits to specific groups of employees within the government structure of Pakistan. And they span almost all departments and sectors. One can gauge the importance of these benefits from the fact that though government emoluments are lower than comparable market ones, the demand for government jobs continues to be very high, and the premiums that people are willing to pay to get to some of these jobs are also very high. This is due to the private and sometimes institutionalized stream of benefits that are attached to these jobs and careers. This explains why people choose customs, income tax or police department if they do well in the CSS examination.

By supporting appropriate initiatives the society has expressed its desire to root out corruption, and the various governments that have been in power have also worked on the issue, but we have not really taken an in-depth look at what corruption really consists of. Our anti-corruption agencies, including NAB, focus on trying to arrest the big culprits. That too is needed, but what is more important is that we have a better understanding of how corruption has become entrenched in our system, institutions and even in our perceptual framework so that its most debilitating forms are just taken for granted. The more vicious forms of corruption lie in the small instances and not in the large. This is where all governments have failed so far. We can reduce the instances of frauds against banks by improving prudential regulations, lending practices, and by torturing people as NAB does, but this will not eliminate corrupt practices from the society. It will just make people more careful. To root out corruption we have to look at the networks of power and privilege which we have designed, institutionalized and legitimized over the years and see how we can make them more open, democratic, transparent and most importantly fair.

This is a much more difficult task then setting up NABs and putting generals, who themselves are amongst the largest beneficiaries of corrupt networks of privilege, in charge of the recovery processes. It is a task that requires wider participation of the citizenry at large, and it is a task that can only be taken up by more democratic and open institutions like the parliament, the provincial legislatures, and the various levels of the elected local governments. It is a task that will require wider participation, and especially the participation of the civil society and the non-governmental organizations (NGOs). And it will not be possible to embark on this task without active support from and participation of the popular media. Newspapers and private television channels have to take the lead in pointing out some of these corrupt practices, ensuring that people involved in the institutional design process take due notice, and following up on the issues to ensure that requisite changes have been made. Unless this more open, democratic and participatory process takes place, corruption in its more endemic, systemic, and institutionalized forms cannot be tackled.

Corruption is a curse. It hinders development, slows down the potential fast trackers, reduces incentives for hard work, and creates niches of riches and privilege for people who do not deserve it. In other words it undermines the social contract of a society, and the basic tenants of justice and fair play, which form the cement that holds modern societies together. Most Pakistani institutions are very corrupt, and to the extent that we have even legalized and legitimized some of its more subtle forms. This needs to change if we are going to survive as a polity and a society. But the change requires very broad-based effort and participation of a very large percentage of the citizenry if we are going to challenge and remove some of the more entrenched forms of corruption and interest groups that are benefiting from the existing setup. This is the main challenge for the current democratic government.

“If all the drugs were thrown into the ocean, it would be all the worse for the fishes and all the better for mankind.”

What would you give for a pill that made you happy or thin or helped erase the pain of losing a loved one?

As anyone who reads a newspaper knows, some of these pills already exist, others are on the way. Is it wrong to take a pill to change the way you feel, any more than to change your blood pressure or treat an infection? Does it make us somehow less ourselves, less human?

There are legitimate concerns about our knowledge of psychotropic medications (i.e. medications that affect the brain). However, those who take the position that this is an either/or proposition fall into the same reductionistic trap that they are criticizing. The fact that medications are not as effective, or as benign, as advertised on TV or touted in popular journals and magazines is hardly news. It takes very little effort to find information that contradicts every claim of efficacy and safety. Dig a little deeper and one can enter the slightly paranoid world of ‘antipsychiatry’. In fact the debate about the efficacy or otherwise of psychotropic medications is as old as the field of psychopharmacology itself.

Some people, however, conclude that all medications cause serious problems and that their benefits are entirely a placebo effect (i.e. the medicine itself is causing no appreciable benefit; rather it is the patient’s perception that helps them).
Are these conclusions any more scientific than what they are criticizing?

It’s true that our knowledge of mental functions is, in fact, extremely rudimentary and the current tools at our disposal, crude. The basic building blocks of the central nervous comprising the brain and spinal cord system are cells called Neurons. The number of neuronal connections in the brain exceeds several billion and the possible combinations of each are several orders of magnitude greater than that.

Is it any wonder that we are mostly in the dark about how our brains function? On the other hand, compared to even 20 years ago, we have come a long way towards a basic understanding of neurochemistry and neurophysiology. We know more today about neurotransmitters, localization of brain functions, effects of trauma on the brain and the effect of degenerative changes on brain structures and function than we have ever known and our knowledge is accumulating at an accelerating pace.

I often describe medication for mental illness with an analogy of a broken TV. You can unscrew the back panel, get inside and fix what’s wrong or you can give it a swift kick on the side and hope for the best. Our current approach to psychotropic medications is, at the moment, more akin to the latter.

This does not mean that using medications for mental illness is a useless exercise. There are strong and ever growing research data on the effectiveness of these medications. Also, the placebo effect is not confined to medicines only for psychiatric or emotional illness, it occurs with drug trials for all kinds of medicines including those which are, at least to the lay person, beyond reproach, e.g. antibiotics and pain medications.

I have seen again and again in my practice that medications do help, albeit for a short time and sometimes with unpleasant side-effects. The ‘poop-out’ syndrome is a common occurrence in all patients taking psychiatric medications. It refers to the phenomenon that happens with a majority of antidepressant medication (particularly the SSRIs or Serotonin Specific Reuptake Inhibitors like Prozac, Zoloft etc. It is also being increasingly recognized in newer medications such as Effexor etc). Most people on these medications for more than a few months will, at some point, experience a diminishing effect on the same dose of medication, even though they may be taking it religiously.

The issue of non-compliance aside, there is a perfectly reasonable scientific explanation for this. The principle of homeostasis is a well known one. It refers to the tendency for the human body to attempt to move towards equilibrium in the face of an applied stress. This is the reason muscles grow bigger if exercised regularly. It stands to reason then, that if we alter brain chemistry by introducing foreign chemicals into the body, the brain will attempt to compensate by trying to move towards homeostasis. If the baseline (i.e. usual) state of brain functioning has been depression, anxiety or what have you, it will move back towards that state in spite of medications.

This is the reason that non-medication interventions such as psychotherapy, exercise, social skills training etc are crucial. Medication provides a ‘window of opportunity’ which can be anywhere from a few weeks to a few months during which the patient has to try and change the factors in their life that led them to the dysfunctional state in the first place. This may mean psychotherapy to deal with past abuse and trauma, marital or individual therapy to deal with relationship or occupational problems or group therapy to deal with socialization or substance abuse problems etc. The problem arises if people assume medication to be the end per se, rather than a means to an end. It is this group of people who will make endless rounds of doctors for more and different medications.

Regarding the research that claims that medications cause brain damage, irreversible and/or disabling side effects etc, once again, one needs to have some perspective. The commonly prescribed antidepressants are some of the most widely prescribed medicines in the world. In the US, of the ten most prescribed drugs across any specialty (not just Psychiatry), three are antidepressants. This translates into millions of people taking these medications at any given time. Prozac was first approved in the US in 1987. This means we are in year 20 of the SSRI era. If we add the older antidepressants (which came out in the late 50s) into the mix, the antidepressant era has now been around for close to a half century. Of course people have experienced side effects, some quite serious but the proportion of these is small compared to the number of people who have taken these medicines. One needs to be circumspect about drawing premature conclusions.

The same can be said about the other major classes of psychiatric medications, the so-called antipsychotics, used for more severe mental illnesses like Schizophrenia and Bipolar disorder, the benzodiazepine group or ‘nerve medicines’ like Valium, Xanax etc and the most recent group, the ‘mood stabilizers’ like Lithium, Depakote etc.

So, do medicines help people or not? The answer is a qualified yes. If a person is willing to work hard to change the factors that led to their illness in the first place medicines can provide the necessary initial impetus to get a person moving in the right direction. Subsequently with continued hard work in therapy, groups, vocational training, avoidance of drugs and alcohol etc, the illness can be kept at bay. However, mental illness, I often tell my patients, is more akin to other chronic illnesses like Diabetes and Hypertension rather than acute illness. It can be controlled but usually not eliminated.

Our goals with therapy and medications are the same. Remodeling and refining those neuronal connections in the brain that control certain emotional states, hopefully eliminating or greatly reducing the negative ones and allowing the positive ones to flourish. Both psychotherapy and medications accomplish the same goal albeit in a different way and with different time frames (one can also argue that meditation, prayer, yoga, exercise, talking to close friends and loved ones etc can have similar effects).

Psychiatric medications can be a useful means to an end. They can help people begin their path to recovery and, used judiciously, can be lifesavers. However, as with everything else in life, ‘Caveat Emptor’.

A perennial favorite in expatriates’ discussion is “the old country”. When it comes to the land that gave us birth, a gentle golden halo surrounds and colors our memories, making the present that much more painful and cruel. I have never been to an expatriate gathering that did not include a discussion of how things are in the old country. Usually this discussion follows the predictable pattern of either enumerating all the things wrong with the land of your birth, prefaced by a mention of the latest atrocity, bombing, sectarian violence or gang rape incident or a long list of things commendable back home and missing here in the Godless, secular West. The stated or unstated longing to be ‘back home’ is thus indulged or rejected or both, depending on the mood of the gathering.

Of course, the obvious fallacy of this approach is never questioned. What most of us long to return to is not the land of our birth, per se. It is instead, that mystical, magical place where our memories were formed, that time when we were blissfully unaware of adult responsibilities and burdens.

In his seminal essay, “A Free Man’s Worship”, Bertrand Russell put it thus:

“This is the reason why the Past has such magical power. The beauty of its motionless and silent pictures is like the enchanted purity of late autumn, when the leaves, though one breath would make them fall, still glow against the sky in golden glory. The Past does not change or strive; like Duncan, after life`s fitful fever it sleeps well; what was eager and grasping, what was petty and transitory, has faded away, the things that were beautiful and eternal shine out of it like stars in the night. Its beauty, to a soul not worthy of it, is unendurable”

This also is a core tenet of Freudian psychology (or more properly Psychoanalysis), which states that a person’s conscious thoughts, feelings and actions at any one time are but a thin layer of perception on the vast storehouse of emotions, impulses and desires that is the all-encompassing “unconscious”.
For Freud, the unconscious was a repository for socially unacceptable ideas, wishes or desires, traumatic memories, and painful emotions put out of mind by the mechanism of psychological repression. While past thoughts and memories may be deleted from immediate consciousness, they direct the thoughts and feelings of the individual from the realm of the unconscious. In classical psychoanalytic thought, the unconscious is the real ‘engine’ behind human thoughts, feelings and behavior and thus is the most fertile avenue of exploration during psychotherapy.

Another feature of the unconscious is that, like the past, it is evergreen, it is never really past. In other words, the shame, the guilt, the anger, or other feelings that one experienced as a child or an adolescent are never far away. Even if they happened decades ago, as far as the unconscious is concerned, they may have happened yesterday or even a few minutes ago. In that sense, the unconscious, like dreams, does not follow the rules of logic and rationality. In fact, dreams are often a reflection of the turmoil in the unconscious mind, something that led to Freud calling them ‘the royal road to the unconscious’. In Psychoanalytic psychotherapy, dreams are considered an integral part of unmasking the feelings residing in the unconscious mind.

This longing for the ideal, unblemished utopia is also the reason behind a common myth, that of the ‘good old days’. A gathering of senior citizens would be incomplete without a recounting of the how good things were, ‘back then’. It is usually accompanied by a litany of complaints against the youth of today; how they have become immoral and irreligious, how bad things are regarding everything: crime, inflation, pollution, political uncertainty, war etc. Some writers and intellectuals of our age, impressed with this myth, claim that human progress itself is a myth and that mankind is doomed, its future bleak. Popular cultures including movies, books and TV shows reinforce this mindset. The obvious conclusion is, of course, that progress is dangerous, that we should all look backward to a supposed ‘Golden Past’ for inspiration. This is the ruling philosophy of terrorist groups like Al-Qaida and various Christian, Jewish and Hindu apocalyptic sects.

Of course, like all myths, the myth of the “Golden Past” too, falls apart upon closer inspection. This desire to return to ‘never-never land’ is as futile as it is foolish.

First, to restate the obvious, the past was never golden. It only appears so because, as Russell put it so eloquently, what was ‘petty and grasping’ has faded away. In addition, looking back from the perspective of the present, one only sees the things one cannot find in the present, overlooking the fact that many of things one takes for granted today were unheard of in the distant or even the near past. Seniors may reminisce about bread that cost 2 paisas for a loaf or gasoline at 1 rupee a gallon overlooking the fact that not many people had a car to put gasoline in, or that nobody had air-conditioners or televisions or stereos or telephones or computers and so on.

In the words of the Greek philosopher Epicurus “Do not spoil what you have by desiring what you have not; but remember that what you now have was once among the things only hoped for.”

In contemporary Psychology, this would be referred to as a focus on the ‘here and now’. It is also a central feature of the Buddhist philosophy of ‘mindfulness’, the technique in which a person focuses on his or her present moment, intentionally excluding all thoughts of past regret and future fear.

In fact, one can argue that this is the only true path to happiness. It may sound like a cliché but being thankful for what you have right now is the only antidote to the longing for the good old days.

Only if one can cultivate that thankfulness, the quality that Allama Iqbal referred to as “Istighna”, can one stop saying:

Yaad-maazee azaab hai yaaRab
Cheen lay mujh say hafiza mera

(Remembrance of the past is agony, my Lord
Seize from me my memories)

Only about one percent of the people, it is believed self-actualise. This small minority, however, has the capacity, as a result of going through the experience, to radically change their own lives as well as leave a profound impact on the lives of others around them. The motive in self-actualisation, it appears, is the beginning of the human journey from mortality towards immortality.

Pick up any recently published book on the subject of industrial or organisational psychology and you are bound to find a major part of it devoted to human motivation and its impact on organisational productivity. Long aware of this linkage, psychologists have been experimenting with the variables that impact it. Based on these studies, many views and theories have been advanced. One of the most prominent theories of motivation is that of Maslow.

Abraham Maslow’s Jewish parents had migrated to the USA. He was born in 1908 in New York, and studied at the University of Wisconsin, completing his undergraduate and graduate studies eventually obtaining a PhD in psychology. After receiving his doctorate he started teaching psychology in New York; where he had the opportunity of meeting eminent psychologists like Alfred Adler, Karen Horney, Erich Fromm and Max Wertheimer. Later he served as president of the American Psychological Association, an indication of the respect his work commanded in the academic-scientific circles in the USA. He died in 1970. His theory of human motivation incited a lively debate and renewed interest in what propels human behaviour.

Based upon his observations and experimental results, Maslow talks about special kinds of experiences connected to human motives. One such is a “plateau experience” — something that radically and profoundly changes a person’s perceptions of the world. Once this happens one experiences one’s surroundings in an intense way, and comes to have a heightened appreciation for life. It is different from the mundane routine of life, which is usually a dull, drab repetition of chores.

A client revealed, a couple of months ago, that he had recently got a call from a childhood friend who complained of not feeling too well and asked him to drop by and take him to a physician. Arriving at his friend’s residence, he found him in some discomfort. As they sat down after the exchange of greetings for a friendly banter, the host complained of heaviness and pain in the chest. His breathing became shallow and laboured and before the physician could be called he lost his breath. His visitor tried unsuccessfully to revive him, then drove him to a nearby hospital, where upon arrival he was pronounced dead. The client revealed that for days afterwards he had trouble reconciling with the fact that an apparently hale and hearty man, whom he had known since his childhood, had departed so suddenly. Within a few days of the experience, he said, he decided to visit India and see the Taj Mahal. The sudden bereavement, he said, had brought home the fact of his own death and he realised that did not want to die without seeing the Taj! An example of how a plateau experience motivates one through a sudden and intense awareness of the world and heightened appreciation of life.

Then there is the “peak experiences” — a short-lived experience of intense joy and excitement, coming, it would appear, from the deep crevices of the soul, when one feels fully alive. However the feeling is transient. Such experiences come suddenly and are gone in a flash. Some Muslim sufis have described such soul-stirring experiences but here is a more recent description:

“A whole month and a half after entering his class, I finally told Lee that I was ready to do my first exercise. The following week he called on me. Sitting on a chair centre stage, I was as nervous as I’d ever been in my life. It seemed to me there were many more people than usual in the class that day, and I figured they were there to see me fail. But I launched in, placing my fingers around an imaginary glass of chilled orange juice. I closed my eyes and before long felt myself alone in a world of sensation; the nerves in my fingertips felt the cold. I opened my eyes and lifted the glass slowly, testing its weight until I could feel it in my hand, and as I brought the glass to my mouth, the taste buds on my tongue worked up in anticipation of the sweet, acidy wetness. For the first time I was experiencing something unique to actors: I knew I was on a stage before an audience, pretending — yet at the same time I was all alone and totally in the moment.

“What happened next was the most important moment in my life up until then.

“Lee was quiet, looking at me. Then in a low voice he said, ‘I see a lot of people go through here, Jane, but you have real talent.’

“The top of my head came off, birds flew out, and the room was bathed in light. Lee Strasburg told me I was talented. He isn’t my father or an employee of my father’s. He sees actors all day long every day. He didn’t have to say this. I know he’s not one to ‘make nice’.

“In that moment my life did a flip-flop, though I didn’t understand at the time why it had such a powerful effect on me. When I walked outside after the class, the city felt different, as If I now owned a piece of it. I went to bed that night with my heart racing, and when I woke up the next morning I knew why I was alive, what I wanted to do. There is nothing more exquisite in life than being able to earn your living doing what you love (that, and being capable of love). All I’d needed was for someone who was a professional and who didn’t have to — to tell me I was good”.

This is Jane Fonda, two-time Oscar-winner, in her book My life so far — an example of a peak experience motivating her to choose a life-long career in acting.

Then there is self-actualisation — a more complex process but unlike a plateau or a peak experience a rather permanent one. It does not happen in a flash. It is more like a drive, a propelling force within the personality. It is as if a part of the self seeks expression: not the ordinary, daily-life kind of expression, but a more solid, relatively-permanent expression. It is the urge to do that painting, the desire to finish that novel, the drive to complete that musical score: when a person is propelled by the need to express his creative urge, when all other needs are fulfilled or may be ignored. The person is possessed by “capacities that clamour for expression”.

The philosopher Wittgenstein, who left his teaching job at Cambridge, withdrew to a small village in Austria to teach at a school thus gaining valuable time for reflection and contemplation, is one example of a person propelled by this motive. Francoise Gilot describes in her My life with Picasso how involved he would in a painting. He would paint for long hours standing in his atelier, day in and day out, sometimes for weeks, never leaving the house, until he had finished that painting. Nothing would distract him form his work — not even the visit by a borderline-insane ex-wife who physically wrestled with Gilot in the same studio. And of course all of us know about Michelangelo’s involvement while painting the Sistine Chapel when he ignored the most trying physical circumstances for weeks and months on end. Of course we are talking about super humans; but then that is what self-actualisation is all about. Only about one percent of the people, it is believed self-actualise. This small minority, however, has the capacity, as a result of going through the experience, to radically change their own lives as well as leave a profound impact on the lives of others around them. The motive in self-actualisation, it appears, is the beginning of the human journey from mortality towards immortality. Mere mortals shy away from it.

It turns out that after almost thirteen years working at a large multinational engineering firm, he had attended a workshop conducted by a consulting firm. He was so impressed (and probably so tired of the corporate treadmill) that he immediately began learning more, eventually quitting his full time job to become a home based trainer. He admitted, again laughingly, that his sanity had been questioned by more than one person. The concepts he described were nothing new. There was a lot of emphasis on ‘people centered management’, ‘personal growth’, ‘valuing the person as an individual’ etc. Given Pakistan’s steady industrial growth, the demand for such services is unsurprising.

However, one theory, based on the work of American Psychologist Abraham Maslow (1908-1970), would posit that these interventions would likely fall a little higher on the spectrum of human needs than the average employee in Pakistan is able or willing to accept.

Maslow`s “hierarchy of needs” theory is often depicted as a pyramid consisting of five levels: the four lower levels are grouped together as “deficiency needs”, while the top level is termed “growth needs”. While deficiency needs must be met, growth needs continually shape behavior. The basic concept is that the higher needs in this hierarchy only come into focus once all the needs that are lower down in the pyramid are satisfied.

In general, the lowest hierarchy belongs to physiological needs such as breathing, food, water, sleep, etc. The next level can be termed ‘safety’ needs such as security of the body, of property, employment, resources, health etc. Only after these are fulfilled can one move on to the next level of ‘love/belonging’ (consisting of friendship, family, sexual intimacy etc), then to the ‘esteem’ level ( self esteem, achievement, respect for self and others) and finally the apex of the pyramid, ‘self actualization’, which may include things such as creativity, morality, spontaneity, lack of prejudice, problem solving etc. This last level can also be termed ‘growth needs’ or ‘spiritual needs’.

A cursory glance at society in Pakistan would suggest that most people are struggling to fulfill their safety needs and perhaps moving towards love/belonging. If anything, the last few years have seen a regression of most people’s needs towards safety, as anyone who has had a cell phone snatched at gun point or had their home invaded can confirm. To expect the average worker in Pakistan to appreciate the higher level needs may be a bit premature.

I was also interested, as a student of human behavior, in the individual motivations of my friend. What would drive a person to give up a secure, well paying job and strike out on an uncertain, though perhaps more exciting future?

To answer this question, one can look at the work of another pioneer in Psychology, Erik Erikson (1902 – 1994) a German developmental psychologist and psychoanalyst known for his theory on social development. Erikson’s best known work is his theory of the eight stages of development, spanning the entire lifespan.

A complete discussion of every stage is beyond the scope of this brief article. Suffice to say that Erikson theorizes that each stage of life, from infancy to old age is marked by specific conflicts, or challenges, that must be successfully resolved for the person to grow and mature psychologically. Failing this, a person is ‘arrested’ or ‘stuck’ at that particular stage and may grow frustrated and embittered.

As an example, the very first stage, labeled by Erickson as “Oral-Sensory”, lasts roughly through a person’s first year of life. The conflict at this stage is labeled “Trust vs. Mistrust”, referring to an infant’s struggle to reconcile its conflicting images and perceptions of its primary caregiver, usually the birth-mother. At this stage, the infant must learn that the mother who feeds her and nurtures her may not be able to fulfill all its needs immediately. Learning to handle the resulting feelings of anger and frustration towards the mother is the primary challenge.

These stages can be enumerated as follows:

1. Infancy to 12 months:
a. Psychosocial crisis: Trust vs. Mistrust
b. Main question asked: Is my environment trustworthy or not?

2. Younger Years (1-3 years)
a. Psychosocial crisis: Autonomy vs. Shame and doubt
b. Main question asked: Do I need help from others or not?

3. Early Childhood: (3-5 years)
a. Psychosocial crisis: Initiative vs. Guilt
b. Main question asked: How moral am I?

4. Middle Childhood (6-10 years)
a. Psychosocial crisis: Industry vs. Inferiority
b. Main question asked: Am I good at what I do?

5. Adolescence: (11- 18 years)
a. Psychosocial crisis: Identity vs. Role confusion
b. Main question asked: Who am I and what is my goal in life?

6. Early Adulthood: (18- 34 years)
a. Psychosocial crisis: Intimacy vs. Isolation
b. Main question asked: Can I give and receive love?

7. Middle Adulthood: (35-60 years)
a. Psychosocial crisis :Generativity vs. Stagnation
b. Main question asked: Will I ever accomplish anything useful?

8. Later Adulthood: (60 years to death)
a. Psychosocial crisis: Ego integrity vs. Despair
b. Main question asked: Has my life been worth it?

Erikson`s research reveals how each individual must learn to hold both extremes of each specific life-stage challenge in tension with one another, not rejecting one end of the tension or the other.

To return to my friend, using this framework as a reference, one can theorize that he would be at the cusp of stages 6/7. Since he is married, with a family, he has presumably met and resolved the challenge of intimacy and love relationships and is now grappling with the issue of “generativity vs. stagnation”.

Between the ages of 35 to 60, people will find themselves “responsible for maintaining the world.” Their world has settled into a permanent career, life partner, family etc. They are expected to give of themselves to maintain this and the larger world. This is a new and often times daunting task. Like all psycho-social crises, flexibility and adaptation are essential in successful resolution. This stage is also the preparation for the ‘final act’ as it were, the last stage of psychological maturity where a person takes stock of their life, feels content about what one has achieved and prepares for one’s exit from the world.

The term ‘mid-life crisis’ also denotes an attempt to resolve this stage successfully. After having worked hard to make a career, start a family etc, one may start asking oneself ‘Is this all there is?’ This can be healthy if it leads to introspection resulting in a person shaking off old, outmoded ways of thinking, embarking on new challenges and growing psychologically. It can also be a source of distress if one indulges in impulsive career changes, extra marital affairs or other self-destructive behaviors.

As far as I could see, my friend seemed happy and enthusiastic about his new career. Most people who find themselves in similar position would likely not take the major leap of faith he has. However, this does not, in and of itself, signify mental pathology or impaired judgment. On the contrary, such counterintuitive decisions can often lead to personal and professional growth and at the very least provide a person with a learning experience that can help them face subsequent challenges productively. If he has planned well, he may do just as well in his ‘second career’ and in fact, as a society, we can all benefit from challenging conventional ways of thinking and behaving to overcome some of the obstacles facing us as a nation.