Some Professional Experiences

This narrative of some of my professional experiences attempts to present circumstances in which I arrived at certain conclusions like: (a) Subjective personal experiences can be valid contributors to integration of a professional's world-view. (b) Concepts and constructs relating to diagnosis and other systems of understanding and practice are useful only as reference-systems. Rigidity in their use can be counter-productive. (c) Mental health profession is not always indispensable to patient's well being. Professional pride is an obstacle to learning. (d) Psychotherapy is not consciously done, but is a natural consequence of therapist's efforts to understand the patient and his/her predicament. Therapist's qualities play a predominant role. (e) Usefulness of therapeutic methods and techniques is dependent entirely on how the therapist uses them. (f) Absolute therapeutic effectiveness is a myth. (g) Indian mythology can offer a system of “Psycho-pathology,” a system of explanation and management, parallel to existing systems.

pathology. un-manifest and manifest to be according to our scheme of things.

So, our diagrzostic constructs need not and do not trlr~~a\~.s corresporzcl to what is happening in the priticrlt.
As mentioned earliel; their best use is only r1.v wferrrlre-points and coriceptual templates for rlre corirlerlierlce of ~rt~derstandirlg and communiccrtion. Giving them any importance beyond these purposes will jeopardize the efficient management ol'patient, by distracting and diluting our conscious and un-conscious involvement with realproblerns that require attention and even masking the prob-le~ns. About a decade later. the concept of 'spectrum of disorders' began to appear in professional literature.
Such constructs and conceptual frameworks mentioned above are equally important, if not more, in the field 01' psychotherapy.
'Schools' of Psychotherapy, or Just Different Perspectives? While at Napsbury, I simultaneously worked for three consultants, looking after some of their patients. One was a senior Jungian Training Analyst, another was a disciple of Maxwell Jones and an expert in Therapeutic Community, and the like. The other was an Eclectic. We used to conduct therapeutic ward-group meetings twice a week in a 'sub-acute' ward, and once a week in an 'acute ward.' My psychotherapy supervisor was a Kleinian Analyst. In that hospital, a clinical psychologist colleague of mine was undergoing training in Freudian Analytical Group Psychotherapy. Upon my request, his supervisor permitted me to p;u-ticipate in the group-sessions as a silent participant. After over a year, this privilege was ter-minated, and I never came to know what complications if any in the group process or in the traineetherapist led to this decision.
Possibly, as a consequence of this exposure to many 'schools' and modalities, I lostabsolute faith in 'schools of psychotherapy. ' ' For example, suppose that two psychiatrists believe in two different sets of concepts. If they happen to read through a detaiied case history, each will 'see' evidences for one's concepts. Also, in my patients, I have been able to understand different parts of pathology by applying concepts from different schools. As mentioned above in respect of diagnosis, we can not expect the patient and hislher family system to develop psychopathology according to our concepts and constructs. This is the reason for emergence of so many schools of psychotherapy to make some workable sense of the extreme variability The point I am trying to make here is: while concepts and constructs are essential for any clinical or therapeutic work, rigid adherence to them can, or will be counter-productive. Once, I suffered from the concept of 'castrating patient.'

Face, or Loose Out
As mentioned earlier, I was an active participant in therapeutic ward group meetings on the lines of therapeutic milieu. The participants were patients, nurses, doctors, consultants, and at times, even patients' key-relatives. After a year, I started conducting weekly-once ward group meeting on my own in a 'sub-acu~c' ward, consisting of only patienls and myself'. I discussed the proceedings 01' each mecling with the consultant. Afier a few weeks, when a mecting was about to end, one patient said, "you are no good," and anotherjoined, "you are useless." I was stunned, and momentarily lost my bearings, but, some how managed lo say "we will discilss this issue in our next meeting." I continued to be preoccupied with this experience, and was sleepless for two days.
After 4 days, while discussing about this ses'sion with the consultant, I expressed my preference that either thc consultant attends the meeting with Ine to 'buffer the crisis' ('bail-me-out'), or gets another registrar to take-over the group. The consultant's advice was stern: "Go and face the group. Otherwise, you will never be able to face a group again in your life." He suggesled a few alternative stratcgics to adapt in the next meeting. I did attend it. invilcd disc~lssion about my conduct and role in the group. I was astonished to find the same two patients cxtremcly supportive and insightful in he discussions. When that meeting ended, 1 fell extremely confident of my self, that 'I can manage any group any where.' Then, I lost absolute faith in the 'castrating patient.' I do

not ll~earl that sucli a l,l?e~iornerza does not exist. It had hap/>ened to nle! I mearz that it should everrtirully he po~sihle to s~~~c e s s f i~l l y 'wade' through any the/-upeutic situatio~i, however unpleasant. The hlunt message is: therapist's despair is suicidal to ,fi~rther learning. Be h o p~f i~l and think positively.
There is alwnjs u cvuy out! Rigid adherence to iuiy concept or construct can be dangerous.

At a personu1 level, pcltients are not hostile to thera-pists; they dare riot be so to their benefcrctor!
Negative-feelings emerging in therapy are part of the therapeutic process. Therapist has to make positive use of them so that both patient and therapist learn from it. Believe in the ancient wisdom, "whatever happens is for the good." There may however be exceptions, as in the case of patients with active and violent paranoid delusions.
In this conlext, it is necessary to underscore a point: Do not be afraid of~nukirig rnistakes, while at the same time, being cautions no1 to commit known mistakes. Fear of making mistakes prevents uscful learning, and perpetuates wrong learning. There are too many variables operalive. most of them un-known. and it is impossible to negotiate an 'error-free thcrapeutic conduct.' The only insurance against consequences of 'mistakes' is the triad of sincerity (honesty), genuinity (absence of pretence), and empathic good-will.
During that period, I was fortunate to recognise another concept, the professional's self-concept (professional-ego) that could perhaps, 'castrate' further learning if given a free reign.

Patients Can Get Well Without Me!
A patient whom I followed-up regularly was an unmarried man in his thirties, living alone and working as a fitter in a factory. His diagnosis was 'paranoid depressive psychosis.' His delusions were centered arround a perambulator in his back yard. It was the perambulator in which his grand mother used to take him out daily after he was orphaned early in his childhood. Even under adequate maintenance treatment, he continued to have depressive and psycholic symptoms, with acute exacerbations now and then with suicidal intents and hostility requiring admission and ECTs. Over a period of time, I began to dread the prospect of seeing him. Every encounter with him was a reminder of my clinical impotence in bringing about any further improvement in his clinical state.
During one such follow-up review, I was very surprised to see him happy and smiling. I had never seen him smiling earlier, and for those readers who have read P.G.Wodehouse, 'my jaw fell with a thud!'. I greeted him, "I am glad to see you well and happy. I am interested to learn how this excellent change came about." He reported: (i) a few days ago he happened to cry in the factory. (ii) the personnel-officer took him to his office and enquired, (iii) he cried out hisTears and worries relating to the perambulator, (iv) the personnelofficer drove the patient home and took away the perambulator, and (v) his fears and worries ceased, and depression disappeared! This account was a terrible shock to me and an affront to my professional ego. Momentarily, I even felt angry, "how dare he get well with out my help?" Of course, a few months later, his symptoms recurred; but, were milder.

I lost absolute faith in the indispensability of mental health profession(a1). A patient can get well, and survive by rnearzs arid rnethods other than offered by rnental health professional! Also, the patient is capable of and responsible for doing
so. I f so, 'why has he come to consult?' 'Why the patient has chosen not to put these abilities to use?' Psychotherapeutic effort with any patient should attempt to answer this question. It is this attempt that contributes to favourable therapeutic outcome. Psychotherapy happens while the therapist is attempting to understand 'why this patient has not been able to manage his or her problems?' But, the outcome can be extrelnely variable.

Sincerely believe that putietit is capable of getting well and surviving by tnearis and rnrthod.~ other than offered by riierital health profession.
Actively and positively, give resl~onsibility to patient. Of course, this principle may not apply in its entirety in such cases as mental retardation. etc.

Professional or persorral pride (us different from 'self-respect 'and 'corrjidet~ce ') is a serious huntli-
cup to learn and prrtctice psychotherapy I believe that effective urid continued learnirlg requires a state analogous to humility, something like: 'I do not know, I want to know ...." In contrast, professional pride is a characteristic of one who knows!

Swami Vivekananda'a Cannons
In this context, it is interesting to consider what swami Vivekananda has said about teaching and learning. Here, we have to remind ourselves, tlinl in a therapeutic situalion bilateral 'teaching-learning' is taking place between the patient and the therapist. The cannons are: (a) "Real teaching is: teaching how to learn. The student will then do his own learning." In psychotherapeutic setting. best therapeutic benefit is when the patient learns how to cope. The next cannon gives clue to how this can best happen. (b) "Best teaching is when the teacher is not aware he is teaching, and best learning is when the student is not aware of being taught." While applying this cannon to psychotherapeutic situation, two questions pose themselves: (i) When is the therapist unaware of 'doing psycho-therapy (or teaching patient how to cope?)' ( i i ) When is the patient unaware of being 'taught (or, helped)?' The answers are: The therapist is unaware of doing psychotherapy when he or she is busy understanding the patient. Even interpretations are only meant to lessen resistances and/or 'loosen-up' further abreaction or inllow of information. The patient is unaware of 'learning (to cope)' when he or she is busy interacting with and responding to the therapist.

Consequent to the above points, a few corollaries emerge: (a) Psychorherclpy is riot done, but happens. It happel~s when art iruiividua[k distress is favourably ntodified hy irlteraction with another individuul.
It llappens when there is concern for another's distress, empathy, good-w~ll, intent to relieve distress, and hopeful and sincere effort. These are 'desirable therapist qualities' advocated by Rogerians.

(b) As said earlier, patient benefits not by therclpist 's objective of doirig psychotherapy and consequent behuviour; but by hidher objective of understanding: why, how, urzder what circumstances, and for what reasons is the patient bz distress?
Consciously, or un-consciously, in a parallel fashion, the patient too will be following this 'understanding' and learns coping strategies in the bargain. (c) Psychotherapeutic benefit is a consequence of desirable therapist qualities. Without these, Inere methods, techniques, and concepts are useless. Therefore, these qualities should ideally become focus of training in psychotherapy. Even if they belong to the phenomena of personality, I believe that they can be cultivated andlor strength-ened. Now, it is very easy to appreciate how thc pride of being a therapist (a product of professionalego), of being a 'guru,' or of 'doing psychotherapy' can be a serious obstacle to therapeutic benefit.

Therapist and His Tools
I now shift the time and place to eighties and nineties at NIMHANS. From 1983 to 1994. I was involved in the department's psychotherapy training programme for psychiatry residents. and in evaluating their therapeutic performance. During this period, about 250 residents were trained and assessed. The department's efl'ort was to ofl'er a uniform training with he help of: (i) a stri~cti~red format of training and supervision, both thcoretical and supervisory, (ii) weekly mecting of the supervisors to exchange experiences in thcir weekly-once supervision-sessions. and (iii) structured assessment of the residents' skills at the end of each course. There were three important vanables in the training programmc: the supervisor. the resident, and'the patient.  Sutru~II~zuri') is to a play. The therapist plays a major role in the therapeutic outcome.
Apart from the abovc cvents, there were also many, less dramatic evcnts and, pcrhaps many more events that did not registcr in my conscious awareness that con~ributcd to my learning.

Too Many Variables ("Too Many Cooks")
Therc are many variables operative in psychotherapy. Therapist's personality and choices of concepts and techniques contribute to a continuum ol.'theraPeutic methods at least in two dimensions, as figuratively rcprescntcd in appendix-1.
Then, there are variables that infucnce the psychotherapeutic outcome. The important ones are: (i) Patient. (ii) Diagnosis. (iii) Socio-environmental context. (iv) Therapist. Consequently, the outcome necessarily follows Guassian distribution on each of the four dimensions. Therefore, absolute therapcutic el'fectiveness is a myth. The logical consequences 01' this fact are shown in Appendix-2.
But. it is essential to remember our ancient tenet that no sincere effort ever gets wasted. Evcn if the patient and therapist are unaware of it, even if there is no manifest therapeutic benefit, the patient carries forward 'credits' from previous therapy (or therapies) to reap the benefit with some later thcrapist!

Effect of Inevitable Age, and Mythology
In my younger days, I had always wondered why more and more people take to religion and mythological stories as they agc. Even when I became interested in collecting concepts relating to mental health in Indian mythology and related literature, I did not find thc answcr. However. the exercise contributcd to certain changes in my therapeutic orientation, which may appear radical in some respects.
( I )A chapter (110.4) titled 'Psychotherapeutic Paradigms from Indian Mythology' in Thempelrtic Use of Stories (Ed. By Kcdar Nath Dwivedi. 1997. Routledge. London) describes thc first of thc cffects. I was convinced that components of ideal human behaviour are almost same as those ol'desirable therapist qualities. as well as those that corrclatc with state of well-being. Thal is, an individual who has components ol' ideal bchaviour as a part of personality will not only be inherently mentally hcalthy, but will also have a potential l o be a 'natural' psychotherapist.
(2) The second was a conviction that: as illnesses and difficultics (miseries) in human lil'e arc incvitable. a state of health is not defined by their absence, but by the individual's ability to effectively manage these inevitable challenges.
(3) Consequent to the second, the third was a conviction that mental health is not a passive state. but has to be actively earned by lhcing the challenges, bearing the difficultics, managing the adversities, gracel'ully accepting un-avoidable limitations and failures, and re-attempting as appropriate, etc.