My Patient, my guru

Fashionable half-nudes trailed across the television screen in the duty room. The tube light had blown the fuse nearly a week ago but no one had bothered to replace it. It was almost pitch dark and I was on a twenty-four hour duty in the one and only mental health centre in the township.

Did someone knock on the door? Maybe, it was just a hallucination. Whenever I sit alone, I imagine there is somebody outside, knocking at the door just to wake me up. So I always keep the door of the duty room open. That was so, until recently. But two weeks back, a patient came into my room and asked me to ring up the chief minister with whom he wanted to discuss some important administrative problems. Claiming to be a special nominee of the World Bank, he wanted to place a demand for a swimming pool, a cinema theatre and some luxury cottages for the hospital inmates. When I refused to comply with his request, he became excited, flung some bricks, took out a knife and threatened to use it against me if I did not work in the interests of the poor patients. Fortunately, the security guard reached the room in time and overpowered him.

The music from the chime clock announced that it was 11 p. m. There was another knock on the door. Again and again . . . . A torch light peeped into the room – it was Santhamma, the assistant. “There’s an emergency in Ward 7. Please come with me, doctor.” Suddenly, the phone rang. The duty sister Sudha spoke, “I wasn’t getting the line all this while. Please come to Ward 7, doctor. A patient is in a bad condition. Please . . . it’s urgent.”

Urgent. It takes about ten minutes to walk to that ward! Our hospital premises covers an area of 8-9 acres and has nearly fifty wards, housing more than 1,500 patients. Nearly 25 doctors work in this institution for the mentally disturbed. Most of the patients come from the backward class of the society. Usually they are dumped here by their relatives when all their resources have been exhausted in private treatments and magic or religious cures. Life and its values seem to lose their significance when a close relative – son, father, mother or sister – leaves the patient in the ward and absconds.

I put off the television and washed my face. After locking the door, I walked towards Ward 7. Santhamma was walking by my side. It was raining lightly. I’ve always loved rain because of its smell and colours. I like to believe that people enter life and go towards death through the rains.

Santhamma’s words roused me from my thoughts. We had reached Ward 7 by then. She said in a cool and calm voice, “Everything’s over. You just have to sign and certify. She was hanging from the roof of the sister’s room”. That calm, I knew, came from 25 years of experience at the mental health centre.

It was a case of suicide.

“What’s her name?”

Santhamma did not know. I walked towards the room. The duty sister and the head nurse had already arrived. In an attempt to resuscitate the patient, someone had cut the rope and brought the body down. It was Bhama, who had been admitted nearly a year back. She was wearing a yellow pajama and kurtha. Bhama detested the colour because she felt it symbolized death and degeneration. Her eyes were wide open and protuberant. A few scratches on the legs and thighs indicated the last moments of distress. The other end of the rope was still hanging from the ceiling that was nearly 10-15 feet high. I wondered how Bhama had managed to climb to that height. How could she achieve it? But most manic patients are capable of unbelievably athletic feats.

I could not register her pulse. Or her heart beat. There was no sound of air entering the lungs. The pupils were enlarged, fixed and unresponsive to light. She had passed away. Her death had to be certified. There were numerous other formalities to be completed. The RMO and the Superintendent of the hospital were informed of it. A phonogram was sent to Bhama’s brother. The sub-inspector of the local police station was alerted. And finally the body was shifted to the mortuary. The post-mortem would be done the next morning.

Those were my last tender moments with that girl. With a drop of saliva dripping from her mouth, a spurt of urine staining the pajama and a speck of faeces trying to find an outlet, Bhama had left us forever. My hand rested on her forehead. There was a numbness in my mind. A prayer came to my lips. But I didn’t believe in God. So who was I praying to? I came back to my room, carrying memories of Bhama with me.

Sudha, the duty sister who accompanied me, enquired, “Why are you so silent, doctor?”

I loved silence when I was tense. Perhaps it was the result of my early lessons in meditation.

“I know. It pains to face death, doesn’t it?” Sudha asked.

“Perhaps.” I did not want to admit to her that death, sex and God were my obsessions.

“This is nothing. I’ve faced more traumatic situations before. Once a woman handed three rupees to me and asked me to take care of her family. I thought she was merely joking. But within an hour, she jumped from the roof of a two-storied building.”

“Did you feel anything then?”

“Initially, yes. I couldn’t sleep for a whole week. Whenever I closed my eyes, I would see the dead woman in front of me, asking me why I was not taking care of her family. But as time passed, I got over it. Why should I feel unhappy? When a person decides to die, no one can save him. It is destined to happen. No one can change fate. That is the universal law, isn’t it?”

Will time heal my wound too? I wondered.

This is Bhama’s story. She was just one among the hundreds of patients I have seen in the hospital but I don’t know why I felt specially drawn towards her. To this day, she stands like a guru to me, a person who tried to remove some of the darkness from my world.

I don’t know when my interest, some would call it my obsession, in Psychiatry began. Initially, like any young student in the Medical College, I believed that only the ‘mentals’ would feel attracted to that branch. I even had an aversion for Psychiatry then. Or were we made to cultivate that aversion by people who knew very little about this field of medicine? Gradually, however, I began to get interested in the subtle difference between reason and madness. During my childhood, I had been told that the innocent suffer the least. But my experience with mentally ill patients taught me that they suffer because they find it difficult to tolerate the eccentricities of the world around them. I was convinced that madness was only a disease and I slowly began to study the disease – illness – disability continuum.

What intrigues me most is the society’s attitude towards mentally disturbed individuals. The world never knows how they live. During the initial days of a person’s illness, even his relatives are reluctant to accept it. Later when they understand it, most of them want to keep the patient in the mental health centre. What they never realize is that mental disorder, like heart disease or diabetes, is an illness and that there are effective ways of treating it. Most of the time, the patient too does not know how he lives. A psychotic has no insight into his condition. A neurotic is concerned about his suffering as well as his future but is not capable of understanding his situation. Sometimes a patient is aware of his symptoms and is eager to understand the cause but prefers to ignore it.

I had known Bhama since her college days. We were neighbours. I had observed her walking alone through the street, with bowed head and a bundle of books in her arms. It was in front of my house that she had taken her first lessons in bicycle riding. Through the window of my room, I would watch her fall from the bicycle, get up quickly and mount it again. I would watch her smile and play with little children living next door. Little did I know that I would be treating her one day.

One morning, Bhama came into my room and sat opposite to me. This was the first of our confrontations as a patient and a doctor. “I cannot sleep, I cannot eat. I don’t have interest in anything. Why do I get up in the morning? Can’t I go on sleeping forever?” Deep sighs. Prolonged silence. Drops of tears. Bhama was telling me about her depression. She had not brought any relative along with her and she did not want me to inform anyone either. However, she promised to bring her sister or brother on her next visit. She left, carrying my prescription for an antidepressant.

Within 30 minutes, she was back, in a furious mood. “Am I a mental patient? Is this a drug for mental illness? The medical shop man says so! I’ll not have these tablets.” She stormed out, leaving the prescription behind her. That was the end of our first session.

Days passed. One Sunday night, at around 11, the telephone bell woke me from my reverie.

“I’m Bhama. How are you? Can I have you?” Her voice was trembling.

“What do you want, Bhama?”

“Can we sleep together?”

“Why not? You sleep in your house and I will sleep in mine!”

“I’m not joking, you fool. Can we have sex?”

I realized that she was now entering the dangerous zone of manic depressive psychosis, a condition where the two extremes of madness met – one of severe depression and the other of boundless excitement. “Come and meet me tomorrow, with one of your relatives,” I said.

She yelled foul words and hung up angrily.

A few days later, she ran into my room. This time she was accompanied by a relative – her ten-year-old niece. Perfumed and looking pleasant, she greeted me. “May I speak to you alone?” she asked. The little girl went and sat outside.

“There’s nothing wrong with me now. I’m okay and doing well. I went to see a film yesterday. In it, both Mammooty and Mohanlal fall in love with Juhi Chawla. You know, Juhi is a good actress. And smart too, like me. What gorgeous costumes she wears! Most of the good dress designers are in Bombay. Bombay should have been the capital of India, not Delhi . . .” She went on to talk about A. B. Vajpayee, Monica Lewinsky and the latest Malayalam movies. “I only have severe chest pain now. Here . . .” She pointed to her left breast. I took my stethoscope but she grabbed my hand and started rubbing it against her breast. Immediately, I called her ‘relative’ inside, gave Bhama a prescription and asked her to come back with an older relative. A week later, I read in the newspapers that Bhama had been caught with a man in a hotel during a raid. The man was a local rogue. Her relatives came to see me the next day. They did not know what to do. No other member of the family behaved in such a manner. This was a very embarrassing situation for them.

Bhama hailed from an orthodox Brahmin family which had its roots in north Kerala. Her parents had married against the wishes of the family as it was a consanguineous relationship. Besides, there was another reason for the opposition. Bhama’s mother was not financially well off. Theirs was a reasonably good married life. Bhama was the youngest of the three children and much pampered. Then, for some inexplicable reason, her father committed suicide. Bhama was only three years old then.

She was very calm and resilient in her behaviour during childhood. Although she had very few friends, she was exceptionally brilliant in her studies, respectful towards elders and deeply religious. The first signs of madness began to surface when she was studying in high school. She became highly nervous and introverted. In college, she fell in love with a boy and started losing her grades. Once Bhama even tried to elope with her boyfriend but was caught by her brother before they could even reach the bus stand.

By now, her family started noticing mild changes in her behaviour. She would spend longer hours gazing at her image in the mirror, spend time and money on make-up and luxury items. She would tell her family that she should have been born in a rich family and curse her ill-luck. Bhama wanted others to treat her with respect, as if she were a princess. But this did not happen always. The tendency seemed to increase when she was angry or irritable. One day, when her brother could no longer tolerate her pretensions, he threw away her make-up articles. Bhama stopped talking to her family for a whole month. She would get up in the morning, take her breakfast, sleep all day and go to the kitchen only for dinner. During this interval, however, she would take good care of the pet dogs and keep them well fed. Bhama loved them deeply. They were her private property and she did not like anyone looking after them.

Worried at her behaviour, Bhama’s mother consulted an astrologer who was famous for suggesting effective rituals and talismans that would cure various ailments. The finding was that Bhama was going through ‘kandaka sani’, a very bad and protracted phase. There was even a possibility of her attempting to take her life, he said. He prescribed some rituals that the entire family would have to follow. Strangely enough, Bhama co-operated with them. The rituals had done the trick and the relief was palpable. Shortly afterwards, however, Bhama reverted to unpredictable ways. She caught hold of her pet dog, kissed it and threw it into the well, screaming that even dogs had started misbehaving with her. Bhama’s brother brought her to me and once again she was put on antidepressants and mood stabilizers.

A few days later, on returning after a busy day in the hospital, I saw a car parked in front of my house. Inside the boot of the car, lay a huddled figure. It was Bhama and she had been bundled tightly with a rope. On seeing me, she spat out, “You cheat! Why are you so late? How dare you look at me like that? Do you want to see my arse, you fool? Go and hang yourself. I want some food. Can you give me a good meal? Release me from these chains. O my God! Satan is coming . . . Do you know anything about the states of mind? God has given me the power to hypnotize you and all the other fools. Why don’t you understand that?”

Sadly, Bhama had gone beyond retrieval. I learnt that she had refused to take the medicines I had prescribed for her.

“Can you admit her to the hospital?” Her brother was eager to know.

“Who will stay with her?” I queried.

There was nobody. But she had to be admitted. I went through her case sheet, written over the past several weeks since she was first taken in. Bhama – 28 years. Studied upto B.Sc. Suffering from manic depressive psychosis. Prescribed haloperidol (to control her false beliefs and hallucinations), lithium, carbamazepine (both to prevent further relapses and to stabilize her mood state) and lorazepam (a sedative).

She had been interviewed by a senior medical officer and his initial assessment was: patient hesitant to come for interview. Has to be persuaded by staff on duty. Restrained with bandage clothes. Touch with reality absent. Inadequate personal care. Deficient interpersonal relationship. Poor rapport. Not very cooperative with the examiner. Talks a lot. Uses abusive and filthy language initially. More social talk when rapport finally established. Increased psychomotor activity. Not willing to sit on the stool for examination and expresses willingness to stand near the door and answer questions.

After a detailed interview, he had written down his impressions: she flies from one topic to another with only superficial connections. There is no disorder of the form and constructs of her thinking. There are delusions of persecution, reference and grandiosity. Auditory hallucinations are present. Her persistent and sustained emotional tone is that of elation. Moment to moment emotional response is appropriate to her mental state. Poor attention and concentration. She is well oriented in time and place. Able to identify relatives and other individuals. Has good memory and reasonable intelligence. Able to understand and formulate general ideas from specific situations. Ability to take decisions, considering the various aspects of the situation, is impaired. Does not have any insight into her illness. The overall picture is one of psychotic illness – most probably bipolar mood disorder – currently mania with psychotic features.

I used to visit Bhama once a week as she was under the care of another doctor and I wanted to avoid unnecessary interference in her treatment plans. Sometimes, she would raise her head and grin from the shadowy darkness of her cell. Once, she was tasting pieces of faeces from her plate. Seeing me, she asked with love, “Will you have it?”

The drug treatment seemed to have no effect on her. This was not surprising because most psychotic patients have no insight into their illness and so refuse medication. They may pretend to take a tablet, but will keep it under the tongue or deep inside the cheek only to spit it out as soon as the relative or duty sister leaves the room. So the advice given to each newly recruited nurse is “Stay with the patient for about 3-5 minutes after giving the tablets and leave him only after ensuring that the medicine has been swallowed”.

Bhama’s condition showed no sign of improvement. Besides, she was refusing food. Finally, the doctor had to decide on Electro convulsive therapy (ECT) commonly known as shock treatment. There was a positive change after that but Bhama objected to medicines. Treating her, especially without a relative in attendance, was becoming difficult. I went to Bhama’s house to meet her mother. But the poor lady was helpless. “What should we do? And what can we do? It’s her fate. We can only pray to God,” she said, tears rolling down her cheeks.

That evening Bhama’s brother and his wife came to see me. He spoke about his domestic responsibilities and inability to cope with the increasing problems. I had little patience with him and curtly asked him, “How would you feel if you were in the same position?” Stunned, he quickly got up and left the room, leaving an envelope on my table. Before closing the door behind him, he turned and shouted, “Don’t you try to teach me love and affection. If you can keep her in your institution, do it. If not, do what you like . . .”

I opened the envelope and found one thousand rupees in it. I bought a blue sari (I had read in some books that blue had the power to heal. Besides, Bhama liked the colour.), matching blouse, a hand mirror, a comb, a tin of talcum powder and a few other make-up items. The very next day, I went to Bhama and handed them over as her brother’s gifts. Bhama tore the sari and blouse piece to shreds and threw away the other things. “If my brother wants to give me these things, let him come here,” she yelled.

As I walked out, Bhama called from behind and asked, “Don’t you want to give me anything?”

“Will you accept it?””

“Try giving me.”

I always carry a Milky bar chocolate in my pocket and I handed it to her.

“You are nice and kind,” she said, sitting in a corner of her cell and chewing the bar. A deep sigh rose from the depths of her being. I could feel it rock the entire the building.

Another day she wanted to have a copy of the Bhagavat Gita. When I went to see her the following week, she wanted to teach me a couple of stanzas from the Gita. “You doctors have no awareness of the spiritual realms of the human psyche. You can learn about that from me. If you miss this opportunity, you may never get another one,” she said.

Some days later, I spoke about Bhama to my professor, Dr Venkitachalam and he accompanied me to her cell. A ghastly sight awaited us there. Bhama was applying faecal matter on her face and singing a romantic film song.

“Hello, did you take your bath today?” my professor asked her.

“How can I? There’s no water inside this cell. And they won’t take me out.”

That was true. There was neither power nor water supply in the cell. If she were taken outside, Bhama would make life hell for the hospital staff.

“Would you like to take a bath?”

“If you take me out . . .”

“Will you cooperate with the staff?”

“Mmm . . . yes.”

He asked a nurse and a couple of patients from another ward to bathe Bhama. And as I watched on, he went over to Bhama and with fatherly affection, cleaned her face with his hands. Later Bhama took her bath, cooperating with the staff as she had done never before, had tea and snacks with us at the hospital canteen and willingly returned to her cell. Before she left, she touched my professor’s feet and thanked him with a show of warmth I had never seen in her. I saluted my professor inwardly because I knew he was a true guru. Back in his car, he patted me lovingly and said, “We need knowledge only while examining the patient. But we should have compassion always because that is what the patient needs.” This was a lesson I had never learnt from any textbook before.

After some time, Bhama was discharged and sent home but no one would accept her. She had to be readmitted to the psychiatry ward. Two months later, she tried to commit suicide. I went to see her and talked to her for nearly two hours. That was to be my last meeting with her. What she told me then will remain deeply etched in my heart for ever.

“You know, Krishnan,” she said, “let me call you by your name only for today. I need to talk to a friend, if only it is for a single day. I’ve never had friends but that never bothered me. But I’ve always carried the wish of having a father figure in my life. Neither my mother nor my siblings could ever fill that gap, no matter how hard they tried. One day, when I was in the fifth standard, I overheard my mother say to my sister in a fit of anger, ‘I don’t know who among you two is going to get your father’s illness. Somebody has to have it!’ I had known that my father had hanged himself but I never knew the cause. The next day, I went to my neighbour who was a nurse and asked her why people committed suicide. She said it could be because of depression. Depression, I learnt from a dictionary, meant mental illness and I knew it was incurable. I loved my siblings so much that I didn’t want them to have it. So I started pretending to be mad. That way perhaps my family would be saved.

But by the time I reached the tenth standard, I began to hate my family for having accepted my illness and thus ruined 5-6 years of my life. Now I wanted to make up for all that I had lost. I indulged myself in everyway possible, even had physical relationship with a friend. One afternoon, when my grandmother was combing my hair, I asked her why people became mentally ill. She replied, ‘When people become unfaithful to God, God curses them and then they are possessed by evil spirits.’ ‘How do people become unfaithful to God?’ I asked her. ‘When people succumb to the pleasures of the flesh.’ ‘Is it so, grandma?’ ‘It’s written in the scriptures, my child. It cannot be wrong. But why should you worry? I know you are a good child – the pride of our family.’

I felt sad and started praying to all the gods. I meditated, I cried. It was on one of those days that I came to you. I realize now that I should have taken the medicines you had prescribed. I was not aware that I was going mad. I don’t have any complaints against God. But if I ever meet him, I’ll ask him why there is so much pain, sorrow and suffering in the world. I remember that one day you asked me whether I had seen God. I don’t remember what I said in reply. But today I can tell you sincerely that I’ve seen him. He was here when your professor cleaned my face that day. He was here when the duty sister gave me the injection to quell my violence. He is here with me now, when you are listening to me.

But it is also true, Krishnan, that we don’t want to come to your world. It is an alien world. What are we expected to do there? We face problems there. Or are we the problems ourselves? We may not be able to do anything productive in the future. We may never have anything to give the world. I like you and that professor of yours. But the ward sister tells me that he is no more. Good people never stay long on this earth. And why should they? Their role is to show you the way. It is your job to go forward. You’ve been kind to me all these days. Should I thank you for it? Why should I? Every doctor is expected to be nice.

You may be wondering why I’m telling you all this. I myself don’t know. I don’t know whether we may be able to talk to each other tomorrow. As your Zen says, let us forget the yesterdays and the tomorrows. Let us be here, now, in the present moment. I realize that you’d like to know how it feels to be mad. I’m sorry that I don’t have an answer. You know, it’s such a short distance from here to there. Yet, once you’re there, there’s no return to the previous state. Thank you, Krishnan, thanks a lot.”

She stood up and walked to her cell. As she reached the door, she paused, tilted her head, grinned and shouted, “You fool . . . you wretched dog . . . will you have me?”

Should I cry? Or laugh?

That was the last time I saw Bhama.