New Delhi, India
|Setting the mind free|
The cacophony of the psychiatric ward paused for a moment as a young woman was ushered in by two hospital attendants and her frail, frightened mother. She laughed garishly and cussed in rural vernacular with wild abandon. She spoke in loud unapologetic spurts, like pennies falling out of pockets, and moved like a whirling dervish. Mala was fourteen years old and had bipolar disorder; I was the resident in charge of her admission.
Mala and her mother came from one of the poorest fringes of northern India, where life trudged along like an unwieldy bullock-cart trying to catch up with a gentrifying urban landscape. They lived in a time and space where mental affliction belonged to the realm of evil spirits and notorious djinns; seeing a doctor for mental illness was unheard of. Her father was a daily wage labourer and her mother, who stayed with her at the hospital, had never been to school. Delhi and its concrete labyrinths were as alien to her as her daughter’s condition; she had a hard time finding her way about and the elevator terrified her. A cousin, who worked as a plumber at the hospital, had convinced her to bring Mala to Delhi to treat a second episode of mania. The first manic episode had been attributed to the wrath of the village gods; the local hakim took two hundred rupees to calm the ruffled tempers of the deities and gave the parents an amulet to tie on their daughter’s wrist. Clearly it was not enough.
Mala in her manic episode was a complete antithesis to her social situation. Her mother recounted with horror how she would sing boisterously in front of her uncles and refuse to keep her voice down. Men in her village were not used to such insolence from their daughters and they thrashed the devil out of her. But the devil refused to be subdued, and Mala spent the next few days gallivanting through cornfields and interrupting conversations with jaunty words of greeting and inappropriate humor. While her mother spoke in a voice that wavered with the weight of lifelong subjugation, Mala’s voice rang through the ward loud in a sonorous demand for attention.
I was confident and clear-headed when describing her management plan on ward rounds: it was a classic case of bipolar disorder. But then I was asked a few more questions.
“Does her mother understand what she has?”
“How long do you think they will follow up with us?”
“Can they afford long term treatment?”
“Will they be able to get her married?”
A haze of smoke infused my clarity. I grappled for answers, but none of them sounded too convincing. I knew how to tame this thunderbird; the question was how to heal her life. To treat her in the midst of ignorance, poverty, and gender-based disparity was the conundrum. In certain parts of India, women cannot afford to have mental illness. It is hushed like a terrible family secret. Medicines, if taken at all, are stopped after marriage. If the woman relapses, she is often sent home in disgrace, as if mental illness was a character flaw. The real magnitude of her condition dawned on me and I staggered beneath its weight. Mala, the all-singing, all-dancing village lass had bigger problems than bipolar disorder.
I was conscious of the chasm that separated our disparate worlds. But over the next few weeks an unspoken bond formed between Mala’s mother and me. It permeated the social alienation that had gripped her since the day she left her village. She confessed that every time she went out of the hospital she was sure she would never find her way back again. In the ward day-care room, Mala was ecstatic to find crayons and busied herself by drawing people, houses, elephants, cows with humongous bells around their necks, sailing ships, and chains of mountains. She drew airplanes, which looked more like catfish, and proudly proclaimed that she would fly one someday.
As days passed her symptoms subsided and her expansive spirits began to ebb. It was only a matter of time until she would find her way back to being the submissive adolescent girl who did her chores without a complaint and accepted her fate without a murmur of protest. Although her clinical condition was improving, her path seemed strangely divergent from the road to recovery. I talked to her mother, who swallowed uncomfortably every time I mentioned long term medicines and follow ups. She blanched visibly when I told her about possible future episodes and gave me a stricken look when I insisted that Mala should go to school. With the help of social services we were able to take care of treatment expenses, but the real challenge was the parochial mindset rooted in centuries of cultural conditioning.
Mala’s father visited her only on the day she was discharged. Travelling to Delhi meant two days’ lost wages and spending another three days’ earnings on train tickets. He admitted ruefully that his daughter looked a lot better and agreed to bring her for follow- up visits. He even smiled when she showed him the row of catfish airplanes she had made.
I saw Mala four weeks later, her mania had resolved .
Mala in her manic episode was a reckless thunderbird who soared to dizzying heights without inhibition. Dealing with her illness involved great responsibility and treating her symptoms was only the first step. In the process of taming these thunderbirds, we are often in danger of clipping their wings. When I first met Mala, I was sure of myself because I understood her symptoms. I realized later that there were bigger questions to fathom; I had to address the realities of her life. The first step in encouraging change is to talk to people from a place where they can bond with you. When the cold intimidation of a clinical position gives way to warm friendliness, socially and culturally marginalized patients and their families are more likely to ask questions, allay their fears, and question age-old beliefs. Education without paternalism does bring change, even if in modest proportions, and change, no matter how gradual, brings hope. I hope for better things in Mala’s life, because thunderbirds need to be healed instead of tamed.
ANANYA MAHAPATRA, MBBS, MD, DNB, completed her post-graduation in psychiatry in 2014 and is currently working as senior resident in All India Institute of Medical Sciences, New Delhi. She is involved in clinical duties in out-patient, in-patient community setting and academic and research activities. Her post-graduate dissertation paper based on bipolar disorder was awarded the Samuel Gershon Junior Investigator Award 2016 by the International Society of Bipolar Disorders. She has published research articles in the field of psychology. This is her first article on medical humanities.