Thursday, December 29, 2016

MANAGEMENT OF AUDITORY HALLUCINATIONS

Ladies and gentlemen,


I am a field-worker in health. Once in awhile I come here, by your courtesy, to share with you a little of what I have seen, heard, felt and did in the jungle of life outside these fortresses of learning. In the battle against disease both are necessary and complementary - the fort and the foraying soldier.


This morning I shall tell you a little about how I met a person with auditory hallucinations and what transpired. What I speak of covers about an year, and what I describe to you will be an unavoidably poor substitute for what literally took place. However, here it is:


Mary, 22 years, is an Indian French citizen of Pondicherry. Came with her father, a Mr. Joseph, 60 years, a French pensioner. He heard of me through a common friend of ours, Dr. P, an ex-officer of the local medical service, who also came along. I have no signboard, no consulting hours, and no monetary transaction, explicit or implicit. They came one evening at about 5 p.m.


“Well, Sir, what is it about?” I asked.


“This is my daughter, sir,” said Mr. Joseph. She is hearing all sorts of voices, she is crying, not wanting to go out of the house - now more than three months. Maybe we are at fault. My good friend, Dr. P, suggested we see you. Such a good girl, we can’t understand what happened. Some doctors said schizophrenia.We have not given any medicines, and we did not want to go to the mental department. We would be grateful if you could take charge of the case. We, the parents, are getting old, and we have no sleep. We have come to you. Do you think she is suffering from schizophrenia, sir?

Mr. Joseph and Mary know Tamil and French and can speak halting, hesitant but reasonably clear English. But not much diction is required to convey suffering. There is a suggestion of tears in the gentleman’s eyes, and Mary sits with bowed head, and a faraway frightened look on her drawn features.

“Very sad,” I said, but let me be clear as to what my position is. You ask me if I will take charge of the case. Last night I slept some five or six hours. I do not know who took charge of me during that time, when I did not know where my head, foot or heart were. During those six hours the world apparently got on very well without my supervision. You, too, Mr. Joseph must have slept some hours, and during that time, you, your daughter and the world were certainly not in your care or charge. Just to say I am in charge of something, as a sort of polite or legal formality is alright, I suppose. However, seriously to believe in it, and for a fool who cannot look after himself eight hours a day to behave as if the world and life rest on his white coat and pills and make others believe this fable is a bit too much. I do not subscribe to this common, but dangerous fiction. Wiser persons than I have said this. For me this is not a platitude - so, I say, I cannot take charge.


“I have heard and I know all the questions and arguments. I only state my position as honestly as I can see it.


“The second point you raise - Do you think it is schizophrenia? I have not seen schizophrenia, sir. If Dr. P or you have seen it let me know, and I shall be most happy to meet it. All I see is your daughter sitting looking frightened. I see you there looking worried, and talking to me. I am aware of myself seeing, listening, talking, anxious to help you, wondering about the last move I made in the game of chess I broke off just now, wondering whether my opponent is juggling with the pieces, also if there is enough sugar for tea for four people, and back again as to how to interact with you and be of some help. All this I see, hear, feel and know. Schizophrenia, I have not met. Will your mind be at rest if I also said your daughter suffers from schizophrenia? I comment.


“No, sir,” said Mr. Joseph, “but they tell me that it is incurable and that worries me.”


“I know that very well,” I said. “I know that schizophrenia is a word that can cause havoc with your peace of mind. Shall we talk about your daughter or shall we talk about schizophrenia which I have not seen and do not hope to see.”


Here, Dr. P intervened. “But, doctor, you have to make a diagnosis. Schizophrenia is recorded in standard textbooks. How can that be if no one has seen or known schizophrenia, and how can they prescribe medicines?”


“Oh, well, you can write about God without ever having seen him, and prescribe holy water, sandalwood paste, prasadam, and verses on love and brotherhood. You see the beautiful brotherly world of murder and hate created by all these people who write about what they have not seen. Those few who have actually seen and felt do not preach or prescribe and do not hide behind saffron clothes or white coats. They having seen grant everyone the right to see or not to see, and see what they can; and they interact with others as one fully independent human being to another, becoming more and more harmonious in their interaction. Same is the case with health. The habit of talking and writing about things one has not seen is the most fashionable psychedelic drug addiction one can think of. On this dope one can go on a trip, describing, discussing, discoursing about things one has not seen, completely forgetting the habit of clear seeing and acting. The pushers of this habit abound, and the dopers multiply and all are happy in this symbiosis.”


“You see the vice of it. We have talked about everything except your daughter. I am making my position clear. I can only operate with what I can see, hear and feel and know. I may be wrong, but there are other doctors and persons and you are always welcome to see them. After all you are the concerned persons. Whatever you decide. I am available and you are welcome to see me.


“Now, suppose you let me hear a little more about your daughter. Maybe I better ask her myself. Listen, miss, we have been talking about you and not to you. Is it true that you hear voices, and that you are not happy?”


After a moment’s silence, she nodded, and said ‘Yes’ in a barely audible voice. Both Mr. Joseph and Dr. P began encouraging her. “Come on child, don’t be afraid, answer the doctor. Don’t keep him waiting. It is true you hear voices, is it not? Yes sir, she may not reply, but she hears voices and I think she is shy, sir…” and so on and so forth.

At this point let me say that it is most instructive to watch people exhorting, coaxing, pressing others to talk, and also interpreting their talks and silences. This is especially so with a child, or a patient who is automatically reduced to the state of an imbecile unable to answer for himself. Parents answer on behalf of their children, wives and husbands on each other’s behalf - all explaining and interpreting the concerned person’s gesture, speech, silence and intention. ‘Oh, doctor, she does not really mean it. She is shy. But at home she says differently, doctor. Come on don’t be afraid. Did you not say to me you had stomach pain on the left side. Now you sit mum. Don’t believe him or her, doctor - I know what he means… and so on.’ Meanwhile the helpless party referred to sits sulking, fuming and hopelessly outwitted and often feeling murderous. The number of people who claim to know exactly what the other person is meaning or thinking is really phenomenal. Of course, psychologists and psychiatrists do the same thing more artistically, more authoritatively and more profitably.

I allow the transaction to run its course. I said to the girl - “See how anxious they are. Would you like your father to tell me what he knows?”

She nodded. My intention is to restore to the personal autonomy, as quickly, as skilfully as I can. At least her token permission must be invited and obtained.

“You see, sir,” began Mr. Joseph, “this girl was in France with her younger brother - gone there for some study. She fell in love with a boy, a Muslim. Somehow, we parents did not like it very much. I must tell you, my daughter is a graduate in French and Mathematics and was teaching here in the local French Institute. She went to France to study some more. But this other thing happened and we called her back from France. She came back and the boy also lost interest. She has usually been very quiet, obedient, and has studied well, and her school where she teaches mathematics has a very good opinion of her. After her return, after some days, she thinks people are talking about her, and not only that, she says she hears them even though they are not in front of her and she thinks that all that is real. She thinks that the Muslim boy is in Pondicherry because she heard his voice speaking clearly to her. Meanwhile we got a good boy from a known family. The marriage has been arranged. She also agreed. The marriage date was fixed. But a few days before that the boy was diagnosed as suffering from TB and is in hospital. So we had to break this also.

“This is our sad plight. We are in your hands. We will do what you say.”

“What does your wife say,”  I asked.

“Oh, sir, she is fighting with me. Says it’s all my fault - and the disgrace of breaking a marriage agreement and add to all this, our daughter’s mental condition.”

“You are a Catholic, I believe. Have you gone to the Sunday Service? Has Mary accompanied you” I ask.

“No sir, we want, but Mary feels that people are talking to her and she is not willing to move out of the house.”

“Did she sleep well last night. Mary, did you sleep well, sleep at all.”
“A little,” she said.

  1. “These voices disturb you all the time. For instance, can you say whether they disturbed you last night?”
 M.    “Not much.”
  1. “Are the voices talking to you now in this room?”
 M.    “Yes.”
  1. “What a brave and healthy girl you are! The voices are talking to you and yet you are able to listen to me and answer my questions. Did you help your Mummy in the kitchen today?  What, you carried a vegetable basket into kitchen. Very good, and all the time the voices talking to you. By the way, do you ever ask them to shut up and go away.”
 M.    “But they don’t go away. They are real. My parents tell me they are                         imagination. The doctor also said, they are imagination - but they are real.”
  1. “Of course, they are real, they must be very real to you, just as your telling me you hear voices is very real to me. If anybody told me that I’m imagining hearing you, I shall be very annoyed. By the way, Mary, can you recognise the voices.”
M. “Some I can.”
  1. “Do they say pleasant or unpleasant things? Do you like to hear these voices?”
M.      “No. They make me cry.”
  1. “But some may be pleasant. Anyway good or bad you wait to hear more and more. You know, sometimes when we think people are talking about us, we go nearer and nearer and sometimes, even stop at a door to hear more clearly. It maybe. But listen - Can you listen to that dog barking in the backyard and that street quarrel going on outside this closed window.”
M.      “Yes. But these voices are real though I can’t see them.”
  1. You can’t see the fog and the men fighting in the street. See my point. Even though you and I are hearing the barking and shouting we are carrying on an important conversation, doing our work, just as you carried the vegetable basket for your mother. See my point. You are putting your stress on whether the voices are real. I am putting stress on your capacity to do things you want, whatever the voices are. I also want to say, all sorts of noises and voices are going on all the time in and out of our heads. Shall we all wonder and weep?

“Now, child, and you, sir, listen carefully to me. The human machine is the most complicated and gifted machine on earth. All the marvellous gadgets you see are mere child’s play. Hearing voices, seeing sights, feeling and thinking things and doing various things - Sometimes some parts over-act or act out of tune. If one part goes a bit odd we don’t label the whole machine as useless. Some of us can only think thoughts, others hear, others see. But the more purposefully the machine is put to work the more the parts adjust themselves.

“Each one of us here is having hundred irrelevant thoughts, and hearing all sorts of noises but we still carry on. Everyone in Pondicherry is usually engaged in talking unpleasant things about one another, especially about near and dear ones. At one time or another one has taped them and the cassette players in our brains sometimes run out of control. But Mary here is able to ignore them and put a little of her attention to other things.

“You are doing some important work. Somebody is shouting at the door. You can show interest, argue with them. If you don’t succeed you can shut the door. If not you can have your ears plugged. Since Mary is unable to get rid of them we can try to help her by one medicine or another to close the doors a bit. The main point is to see that hearing voices is only a possible normal property of one’s brain gone overactive. Just now if you go to JIPMER outpatient, or you survey the people of Pondicherry you will find a thousand men like Mary troubled with this intrusion. Instead of seeing one’s strength and capacity to deal with these noises, as they deal with other disturbing intrusions, people indulge in gossip, philosophically discuss whether the world is real or unreal, brand each other as mentally ill, and do anything but deal with the matter in hand. All this talk may not help Mary. But still we can now and then come back to talk about it.

“Mary, can you tell me if you tried any medicine and if any helped you. For instance when you were anxious or worried did you take any medicines in the past. Can you remember, Mr. Joseph?”

“She occasionally used to take Calmpose, sir, when at examinations or so, I think,” said Mr. Joseph.

  1. “Have you taken any for this trouble?”
 M.     “No.”
  1. “Supposing, you take Calmpose for a day or two - by the way you know what you used to take - half, one or two - what is it? Would you like to try today and tell me?
M.     “I take one at night. But I don’t know.”
Mr. Joseph. “You please prescribe with your own hand and blessings, sir, she does not know.”

  1. “Mr. Joseph. This is another point I must tell you. Please note this. The human body is not made by a medical committee. It is not a test tube. It can report to itself. The makers have put a monitoring unit inside to serve its movement and equilibrium. This monitor is stifled, suppressed and disturbed and miseducated. I would be an ass to think that I know all the dozen answers to Mary’s trouble, which has now become your trouble and my trouble. Only by patient interaction we can try to steer this collective vehicle. So let Mary tell me tomorrow or when she feels like it the effect of Calmpose. You can also tell me. Mary, do you believe in the Mother Mary and Lord Jesus.”

Mr. Joseph intervened, “Nowadays I don’t see her praying. I am telling my wife also to pray.”

  1. “Mr. Joseph, I am not a religious man. But what I want to say is that if you believe in the Lord, you must pray and the worst thing to do is to tell others to pray. If you yourself tell the Lord your troubles with trust that he knows the answers, there will be immediate results. First during those few minutes you will stop arguing with your wife, next for a few minutes at least the burden of your heart and lungs and mind becomes less, and the Lord himself will have some peace of mind to enable him to do His work better. I am not joking.”

Mr. Joseph. “Is this curable, sir. Can we think of her marriage? My wife keeps pestering me.”

  1. “There is nothing to cure. Only there are problems to solve. Now we seem to be in a traffic jam. Let us wriggle out of it. I have no advices to offer. I am only a sort of apprentice engineer, as all human beings must learn to be, to be able to steer this complex car.

“Let us see how things proceed. You may be seeing me in a day or two. She will be able to slowly guide me about the medicines by a little trial. You are always welcome.”

Now I rapidly take you over the next months.

In a few interactions, with ups and downs in the first month, a dose of 1 to 2 mg Eskazine and Pacitone during the day and 25 mg Largactil at night was approved by Mary as most nearly effective and very satisfactory to Mr. Joseph and his wife. Then she began taking tuitions. Once she complained of lack of concentration at tuition, and was in tears. I then gave her a pencil and notebook and made her concretely teach me Pythagoras’ theorem. She did it very well. I told her, concentration is a useless word. It is better to say exactly what one is exactly able or not able to do. Both she and Mr. Joseph were made to share with me the verifiable fact that there are things one can do, and one just cannot do at any given moment. Putting attention on the things one can do rather than wasting time harping over or resisting, trying to stop things one cannot stop causes a bit of wear and tear on the human body.

She has passed one French University examination and preparing for another. She was taking a single 5 mg Eskazine for some time and asks me if she can stop it. I reply that one has not come on earth to take medicines or not take them but to be useful to one another and put the body to use, and this aim takes care of the rest.

The body is tough and can take care of overdose or lower-dose as long as the aim is firm. She can try and tell me.

They see me once in a month or two. She is giving tuitions, helping her mother, studying for examinations. The other day Mr. Joseph brought me a small rug knitted by a 70 years old aunt of Mary. I thanked them and illustrated to Mary how the making of the intricate rug was of great help in organising the patterns in the brain and helped the lady to keep young.
The relation between accurate external activity and the total health of the brain was illustrated, and the need for Mary to participate in as much physical activity as she can stressed. These were not vague advices, but meticulously worked out to suit the actual conditions of her usual work. The parents are relaxed and Mr. Joseph has a more lively and less tragic approach to life.

This is a sample of total interaction with a family in which disease is seen as the precipitate of a chronic, mutually reverberating chaos of faulty perceptions and the need for an equally painstaking relearning of realistic attitudes by the participants.

A distinction should be made between respectability, acceptability and reality. Hearing your colleague talk to you and getting angry or disturbed is respectable and acceptable. But hearing his voice in his absence and getting disturbed is unacceptable, therefore unreal. The most real part is the disturbance itself, which is quietly shelved aside and little done to correct it. How on earth can you say that somebody is seeing things or hearing things he or she cannot see or hear. It is a divine providence that a majority (not so large) of persons including psychiatrists are not blessed with the faculty of hearing each others’ beautiful thoughts about themselves.  And what a blessing that many persons including doctors and politicians sleep 8 hours a day, condescending to let the world run, the stars rotate and the birds sing without their being specially in charge of the proceedings for personal supervision and correction.

I plead guilty of not having recorded her birthdate; if the parents are consanguineous; or if any of her aunts or uncles heard voices; or measure her rating on the Hamilton depression scale. I also forgot to allocate her and her father as 64% to the psychiatrist, 37% to the psychologist, 5.5 % to the psychiatric social worker and the rest to the local urban health centre. Also more than once I talked to them accidentally on the road rather than by proper appointment. The proceeds from this venture were a tasty homemade christmas cake and a handmade rug and a number of smiles.

As I said this is a field worker’s report.

Now, I am having auditory hallucinations, I hear someone saying - Empirical mush!

4 comments:

Tomichan Matheikal said...

It was interesting reading this narrative. But I'm left confused what the auditory hallucinations were actually.

Gita Madhu said...

I cannot, alas, enlighten you as these are the writings of my father, the late Prof Surya.
However, when I read his writings in the spirit of his instructions, I always find something I can put to use in the here and now.
This was probably a lecture he gave at NIMHANS long after he resigned and joined an ashram.
I've undertaken to type out all his writings that are with me but will not offer comment or interpretation.

Rajeev Moothedath said...

"Only by patient interaction we can try to steer this collective vehicle."- A true statement.Unfortunately, unlike the doctor in the report, today nobody has the time to interact with patient in detail, let alone the whole family...

Gita Madhu said...

All I can say is he did that kind of thing. As a doctor, as a human being, as a father, I have not met such a one ever besides him. Thank you for your words.