I was thinking of writing about the future of Psychiatry. Surprisingly, Ajeesh has raised this issue in his reply to the post on "Many face of love". (It should have been Many faces). He writes that Psyhcology and psychiatry may be taken over by neurology in future. I have heard the same arguments from many other doctors, mostly neurologists and internal medicine specialists. Theoretically it sounds natural as neurology is THE medical speciality dealing with brain. But there are a few issues in practice. The incidence of major psychiatric disorders are much higher compared to the pure 'neurological' disorders.The most common neurological condition is epilepsy. This is being treated by psychiatrists, internists, pediatricians and the GP without much problem. The skill sets needed to practice hard core neurology is different from those needed to practise psychiatry. In neurology things are more concrete and precise. In the field of mental health, most of the disorder are still vague and abstract. Enormous verbal skills are needed to listen to the patient, and offer psychological treatments. A neurologist may consider all this including the time spent for establishment of rapport as a waste. Of course, a neurologist or any other doctor with the right inclination can practice psychiatry well. Psychiatrists will outnumber neurologists in most countries. I view things in a different light. The psychotic disorders need mostly drugs, some education about how to handle the illness (for the patient) and education about how to handle the patient (for the relative). To some extent this can be done by any willing doctor with reasonable expertise in psycho pharmacology, if there is a good social worker to help him with the education part. Usually most doctors are uncomfortable with these patients as they are prone to violence and cause disruption in their respectable consultation rooms. This is why they avoid seeing such patients. The most common mental disorders belong to the category of neurotic disorders (anxiety, somatization and minor depressions). Here more intensive psychotherapy is needed. Hence a mental health professional is needed. My view is that these disorders are best handled by a good G P with adequate training. If psychiatry is going to be taken over by another speciality, I wish this will be by the speciality of General Practice. This is more beneficial for the persons with the most common forms of mental illnesses. They can approach the GP without fear of stigma. If the GP has some training and is willing to spend some time, he can manage such cases properly. Thus a G P who is willing, can be trained to manage most mental illnesses and reduce the stigma. Only the most difficult cases and those with multiple diagnoses, need to be send to Psychiatrists. In fact this is true of most specialities. A good G P with adequate training can at least rule out serious conditions and refer only those cases needing real specialist care. It is sad that the speciality of G P is not developed in our country. I do not know why this is so. But I am sure this is one important step towards reducing health care costs. The general practitioners should outnumber the total of all the specialists together in a country. I hope at least some of my friends and colleagues will respond to my arguments.
This is a news item reported in the press from Kochi 2 weeks ago. A boy and a girl who were in love got their marriage registered and proceeded to a jeweller to buy ornaments. They quarrelled over the request made by the girl to the salesperson (to give a good purse as compliment). The groom hit the bride on the cheek in public. She ran out lamenting "if you dare to beat me on the day of registration, you may kill me on the day of marriage". (The families had planned a wedding function after a month). The boy was furious and threw the bag containing jewels and cash to the nearby sewage canal. Later some of this were recovered with the help of police. Many who read this might have wondered 'Were they truly in love?'. I think love is very much misunderstood in our society. Several sex scandals in Kerala started with a boy (who acts as an agent of a sex racket) abducts a girl in the name of love. I think it is worthwhile to explore the psychological aspects of love. Earlier I had written about love. This time I shall attempt to go a bit deeper. What I write is based on the work of a psychologist called Robert Sternberg. He has divided companionate love into 2 - intimacy and commitment. So we get three dimensions including 'passionate love'(which was discussed in the earlier post).Sternberg speaks of nine types of love based on the permutations and combinations of these three dimensions. If passion (erotic or sexual attraction) alone is present it is only infatuation.If intimacy (warmth, closeness and sharing in a relationship) alone is present it is just called liking.If both passion and intimacy are present it can be called Romantic love.Combination of passion and commitment is called fatuous love.Combination of intimacy and commitment is called companionate love.If only commitment (intention to maintain a relationship in spite of difficulties and costs that may arise) is there it may be called empty love, devoid of any intimacy and passion.True or consummate love only occurs if all the three ingredients - passion, intimacy and commitment - are present. In the early phase of any relationship, it is passion or erotic attraction that dominates. Later on feelings of intimacy and need to be together arises. But it is only after some time the third factor emerges. This is very important for long term stability of the relationship. Of course some level of maturity and interpersonal familiarity is needed to take a decision to stay together forever. If people who fall in love are willing to take some time to understand these underlying dimensions that can influence their behaviors, many later disappointments can be avoided. Frequently young people equate erotic attraction with consummate love and commit themselves. This can lead to disappointment later. Before proceeding with any relationship some degree of intimacy is needed. This can later pave the way to development of commitment to maintain the relationship. True, satisfying relationships that last can only be built on such firm foundations.
Dear Dr Vijayan and others,Any establishment tries to hide some fundamental facts from people to attain their selfish gains or hidden agenda. This is true of religion, political parties and other social movements. That is how movements which started as genuine mass movements become another establishment later on. Rarely only one can see a mass movement without any hidden agenda. I do not share the view that doctors are the most greedy, wicked villains in our society. I repeat my earlier statement that there are good, fair and bad individual in any organization or community. There are few popular myths held by malayalis regarding doctors. One is that doctor is next to god. The other is that one should not lie to a doctor or lawyer. Many people repeat this parrot fashion. This could be one reason why doctors are manhandled when a patient dies. If we think we are next to Gods we have to be infallible. But we enjoy the first as it glorifies us and pampers our egos. But we do not want to be beaten up, so we resort to the defence "We are not Gods". I think both these are wrong. A doctor is like a glorified technician. Like the difference between an ordinary cab driver and an aircraft pilot. It is better to be realistic and popularize this view. Obviously humane approach is very important for a doctor. Regarding government's role: Landlords never willingly gave their excess land to farmers. It was the government who enacted laws and took over the land. Why our Governments are not regulating the drug industry is because the political parties also stand to gain from the mess. That is why whatever Dr Ekbal or others did has not changed anything in our country. Dr Vijayan sounds like a Christian missionary appealing to sinners to repent and return to God with his appeal to the conscience of doctors. What I say is that no such appeal is needed. If one is sure that offences will be booked, nobody (doctor or politician or God men) will dare to violate laws. This is what happened in UK, Australia, USA, New Zealand etc. Everywhere the Governments enacted rules to regulate the practice of medicine. This is their duty, just like the doctors duty to their patients. Why they do not do this is because of their hidden agenda. Dr Vijayan is silent on this and blames individuals for the evils due to failure of the system.
Let me put in another argument, just for arguing. Dr Ekbal and many others were dead enemies of computerization. All of them used to repeat that computerization is a hidden agenda of capitalism etc. But now none of them travel without their laptops. They cannot think of a day without access to Internet. Clearly they were wrong and had missed the bus. Are you sure that they won't swallow their words again ? Will they later realize that private firms are needed to pump in money for drug research ? History of drug research shows that it was a few original workers who contributed to humanity by developing the wonderful drugs we have now. The issue is not to drive away all private participation. The need is for regulatory authority. Only the government can do this. That too only at the national level, by seeking participation and support of the ethically minded minority in the profession. But only honest politicians will dare to do this. There is no point in speaking like religious preachers appealing to conscience. In conclusion, let me add that I have no intention of defending unethical practices of doctors. Those who are good will regulate themselves, those who are not good, hell is thy abode! I too have started to preach!
We are motivated to do things by our needs. But all needs do not have the same power to motivate us. The best theory to explain human motivation was put forward by a prominent humanistic theorist called Abraham Maslow. Maslow has conceptualized that human needs can be arranged into a hierarchy. The most basic needs (usually based on satisfaction of biological needs and drives) have to be satisfied to a reasonable extent for a person to become concerned about the needs at higher levels.
Tier 1 - Physiological needs like hunger, thirst etc.
Tier 2 – Safety and security needs.
Tier 3 – Belongingness, love and affiliation.
Tier 4 – Achievement, recognition and self esteem needs
Tier 5 – Cognitive needs, that is knowledge and understanding.
Tier 6 – Aesthetic needs, that is for order and beauty.
Tier 6 – Need for self actualization. A person can be fully happy if he is able to fulfill his real potential.
This theory has been highly influential in the fields of psychology, behavioral sciences and management studies. The strength is that it integrates the biological needs of a person with his social and emotional needs, thus achieving a synthetic or holistic perspective.
Maslow says “What a man can be, he must be” (or he should rather attempt to become).
