As kids, we denied visiting the doctor. Our parents and guardians used to just pick us up, put us on the shoulder and walk to the doctor. Our behavior was generally temper tantrums and anger outburst. The reason is, as kids, our experience with the doctor is having a pattern which built a belief.

Stimulus 1: Visiting the doctor.

Stimulus 2: Doctor injects vaccine.

Emotion 1: Before injection – uncertain.

Emotion 2: After injection – sad and angry, shame.

Cause (injection – unpleasant stimulus) leads to effect (negative impression on the doctor).

            This impression will be evidently proved by the doctors during the first 7 to 10 visits to the doctor – because vaccines. It is after this, when the kid is taken to the doctor, when the doctor doesn’t give injections and prescribes medications instead, the impression on the doctors according to the child changes. This shift in the impression proves to the child that previous belief what he/she believed was wrong. Thus, the child feels free to walk in to the clinic with minimum hesitation. 

            Similarly, our beliefs towards “talking to therapists” is unreal because of the first impression on the therapist or therapy as a process. This is because of the social media, movies and serials that show these mental health professionals to be behaving reserved with a loaded syringe in hand and staring the mind through the patient’s eyes, giving electro convulsive therapy, hypnotizing, etc. on the other hand, they show the people who approach the psychologist or a psychiatrist to be an antisocial element or into severe psychiatric conditions like schizophrenia or a criminal or a mentally retarded. 

            

Here is a fact. Nether of them are true. Media has wrongly educated the general population as a result of which there is a social stigma. Like how a kid understood with experience, we too should. Your experience is your best teacher. The only way to experience is either witnessing it directly or by listening to experiences from people who have witnessed it without preconceived notions.

Please feel free to meet a professional therapist because, your mental health matters.

Pavan M Srivatsa Counselling Psychologist and Consultant Psychotherapist Chakshu Counselling and Psychotherapy Centre, Rajajinagar Bangalore, Karnataka, Republic Of India. pavanmsrivatsa@gmail.com +919886622309

Dad, Mom, Cira Doe and Jane Doe.

                  Anashku, aged about 41 years had called Cullinan – the psychologist by 3:30 P.M on a Saturday seeking an appointment. They knew each other for 8 years and this was the first time, Anashku asked Cullinan for a help. It was later understood that it was for Anashku’s son Jane Doe.

                  Anashku was working as a waiter in one of the oldest hotels in Democratic Republic of Bingle while his wife was working in a garment’s factory as a tailor. They were earning a decent income by struggling hard day in and day out. This couple had a couple of children. Cira Doe, aged about 17 years, doing her under graduation in one of the recognized colleges in Democratic Republic of Bingle while Master Jane Doe was studying his 10^th grade.

                  Mr. and Ms. Anashku got Jane Doe to the hospital to talk to Cullinan. Cullinan investigated and assessed the patient and advised Anashku “Jane Doe needs intense, frequent and long-term therapy to be as functional.” The father was devastated to listen to the treatment plan and questioned Cullinan “What is the reason behind my son’s present condition? Can it be cured? Will my son be fine? I love Jane Doe. I want him to be normal – like other guys of his age.” 

Ms. Anashku asked if there are any medicines for Jane Doe instead of therapy. She added to it that she was ready to give him medicines secretly without the knowledge of the patient. They were educated about the pros and cons of drugs on the client’s body and mind.

Story of Jane Doe

Pre-Birth – the mother’s psychological health

During this phase, as the mother was fed with healthy and nutritious food but the environment was emotionally contaminated because of her father’s alcoholism and frequent fights between her parents. This had an impact on the emotional state of Mrs. Anashku. She had been in this environment during the 6^th, 7^th, 8^th and 9^th month of pregnancy.

“I was scared almost all day – every day and I have spent many sleepless nights because of my parents. It was almost every day, my parents used to fight.” Said the patient’s mother.

On the day of delivery

“My parents threatened me saying that they would kill the baby if the baby is a girl again. I was into labor pain and these people talked to me this way.”
She also reported that her mother was in the labor room during the procedure. 

“No woman would have faced this kind of situation in their life. I was so near to death.” She added.

Mrs. Anashku passed out because of excessive bleeding and intolerable pain. After she became conscious, she understood that she had given birth to a male child.

Jane Doe’s infancy and early childhood

Jane Doe had been with his mother in her parents’ house as Mr. Anashku had no parents to take care of infant Jane Doe. It was also understood that Mr. Anashku was working two shifts to make money. During this period, Cira Doe was put in a day care.

“Fights were still going on and things started worsening.” Reported Mrs. Anashku. She also added to it that Jane Doe had a delay in achieving developmental milestones. She specified that Jane Doe started speaking when he was 2 years and 6 months old.

On probing, it was understood that Jane Doe had limited linguistic abilities. Also, Jane Doe was finding it difficult to maintain eye to eye contact with others. “He never spent time with anybody except his grandfather.” Said the mother. Mother was going to work in the garments during this time.

She explained that she left her parents with Jane Doe when he was around 3 years old.

Jane Doe’s schooling

Jane Doe started his schooling and was observed to be comfortable staying in school from the very first day. Jane Doe was spending time with Cira Doe was, by this time, a passive aggressive child with issues with mother, father and younger brother. Sibling rivalry and bullying started at a very young age for Jane Doe. Cira Doe used to make Jane Doe starve till the late evening. As a result of which Jane Doe was underweight or into malnutrition. It was evident because, it was understood that his academic achievements were below average and was having frequent physiological illness during his 10 – 12 years of age. The patient’s mother also reported that he had been cared by his grandmother when he was hospitalized. Parents also reported that they have never spent quality time with the Jane Doe. Jane Doe started bullying others after he came to 7^th grade. It was understood that the teachers had been calling the parents with a list of complaints  about Jane Doe’s problematic behavior, attendance shortage, vulgarity and physical fights.

“We four are staying together since about 2 years now. I am shocked to see my son behaving this way. He doesn’t respect elders, he doesn’t listen to anything we say, he doesn’t talk to us. All he does is – hanging out with friends, smoke, drink, pick up fights with neighboring area people and play games on mobile phone till late night. No seriousness at all.”

When probed about the negative history of Jane Doe, his mother remembered an incident which she thought was not important to present in front of the therapist. “I don’t know if it is important for you to know about this or not, but, he had galloped from the house and was away from us for a week. We lodged a missing complaint. He came back after a week. He said that he was in his friend’s house during this period. We were so scared during this time. His behavior completely changed after this incident.”

Recent history – Even during lockdown, Jane Doe was not wearing masks while going out, was going out to buy and sell pigeons, dogs and cats, was not maintaining social distance. It was also understood that Jane Doe and his friends were into cannabis use every day during the lockdown period (60 days). Mr. Anashku reported that he had been finding it difficult to arrange money for essentials as Jane Doe was robbing money from home for his cigarettes and cannabis. This resulted in a fight between the father and son which ended after Jane Doe slapped Mr. Anashku for questioning him about money. This made Mr. Anashku call Cullinan for an appointment.

Problematic behavior of Jane Doe that leads to a classic diagnosis are as mentioned below:

·       Drug abuse (explained below).

·       Steeling money.

·       Physical and verbal aggression (initiating fights)

·       Serious violation of rules and getting into arguments with others.

·       Gambling.

·       Limited prosocial emotions (Callous).

·       Selective mutism associated with passive aggression.

·       Excessive lying for materialistic gain like cannabis, cigarettes and alcohol or money to buy these.

·       Truancy.

·       Lack of guilt for his behaviors, decisions and outcomes.

·       Attention and concentration distortion associated with partial impairment in immediate memory which is not explained by any other conditions.

A part of verbatim when Cullinan was with Jane Doe and his parents:

Father: I don’t know if I have been expressing love or not expressing love to my son. I love my son from the bottom of my heart.

Mother: Yes sir, I too love my son. I wish I spent time with him, sharing some stories and incidents. I never observed how my son grew up. I am feeling guilty now. I wish we could go back in time and make things right.

Jane Doe: Sir, I don’t want them (pointing at the parents). They don’t deserve to be parents. (walked out of the room).

Mr. and Mrs. Anashku were devastated after listening to Jane Doe’s words before he left the hospital. 

Jane Doe had his own vehicle in which he went to meet his friends while his parents were sobbing in front of Cullinan.

Diagnosis: Conduct Disorder with Childhood-Onset type Associated with Limited Pro-social Emotions.

Co-Existing - Substance Use Disorder because of Child Neglect and Upbringing Away from Parents.

Line of treatment:

1.          Lack of insight – with problematic external locus of control.

2.          Mutism during therapy with minimum/ no eye to eye contact and communication.

3.          Denial to take personal therapy.

4.          Apathic state of emotion and affect.

5.          Addiction to cannabis, alcohol and cigarettes.

·       Jane Doe is advised to be under surveillance of medical experts for further investigation.

·       Jane Doe’s father was also referred to a rehabilitation centre for his Substance Use Disorder.

·       Family therapy and Psychoeducation to family members to make them understand how to minimize Jane Doe’s problem behavior.

·       Individual therapy for both the parents as they were observed to be neurotic.

A gentle note to readers:

Dear all, the money you save and the property are your assets you own for your children’s secured future. Make sure that you are not too busy to ignore or neglect your children’s present. If they don’t have parents in their house, they find parents outside.

Jane Doe and the wrong therapist.

         Jane Doe, aged about 20 years was on his wheelchair when he was brought to the hospital. Unhygienic, long – untrimmed beard, flat affect – neck bent down and tapping his left foot to the peddle of the wheelchair. Maybe Jane Doe was irritated or angry for being in the hospital. He was admitted after the formalities. His father was a small-scale business owner and mother was having her own store where she sold antique jewels. Jane Doe had discontinued his engineering course from Bingle Institute of Engineering, Bingle. 

         Jane Doe’s father reported that Jane Doe had been in depression during his final year and so, he quit his studies. He took medications for 3 months and was fine after that. He had been working in our factory to learn about the business. “He was better before. Now, he has become worse. I guess it’s a relapse.” Said Jane Doe’s father. 

         Jane Doe’s mother cried while explaining about his behavior during childhood. Being inattentive, not following the instructions, going against the wish of their parents, verbal and physical aggression in the school, truancy and low academic performance. She added to it that Jane Doe was not interested in studying engineering. “He never wanted to study engineering. He wanted to do interior designing course or architecture. His father forced him to take up and so he agreed to it half minded.” She then broke the news about his relationship breakup that happened when Jane Doe was in his 7^thsemester/ 4^th year as a result of which he was depressed. “Jane Doe was taken to a psychiatrist. He completed the course of medication. He was better till 2 weeks after the psychiatrist asked us to stopped the medication. He started worrying more and more. His sleep reduced, he skipped his breakfasts almost every day. He was then taken to Nomads’ Counselling Centre in Bingle City. Google says that the therapists there are good. But after he went to take counselling there, his mental health became more worse. We are here now.” she completed in a breath. 

         Jane Doe was kept under observation for 2 days. He was then brought to talk to the counselling psychologist who gathered the information from his parents. Jane Doe was initially uncomfortable talking to Cullinan but, was gradually feeling comfortable sharing. Jane Doe initially talked about his sadness and his present situation which is making him feel depressed. He added to it saying – “what on this planet is permanent, sir? We all are temporary. What is the point in taking these medications? What is the point in talking about what happened in the past and what I am doing in the present when the future is so uncertain?”

Now, Jane Doe is working in his father’s office, has a good social relationship and has worked on his relationship with his parents. Jane Doe is expected to fly to Titanium City in a couple of weeks to receive an award for his achievements as a young entrepreneur. His parents are happy for his achievements too.

         But why was the relapse? What was the reason behind Jane Doe’s severe depression and racing negative thoughts? The answer to this is – meeting the wrong therapist.

         When Jane Doe’s sadness overtook him even after he completed the course of medication for the first time, he was taken to a counsellor. This counsellor though – was not a professional counsellor. She had no proper certificates nor the minimum eligibility criteria to call herself a counselling psychologist. All she had was a 3 months diploma course in basic counselling skills from Nomad Academy, Bingle. Also, she had another diploma in understanding children’s behavior. She had then started practicing counselling. When Jane Doe was into depression – 1^st phase, he met this counsellor who – at the right time put these words in the mind of Jane Doe which became his belief: “what on this planet is permanent, sir? We all are temporary. What is the point in taking these medications? What is the point in talking about what happened in the past and what I am doing in the present when the future is so uncertain?”

The way Jane Doe perceived it might be different from what the counsellor actually meant. A right therapist would understand or probe to understand what the client or patient has understood from each session. 

WHAT WE SAY, HOW WE SAY, WHEN WE SAY, WHAT WE MEANT, WHAT THEY UNDERSTOOD AND HOW IT CHANGES A PERSON’S LIFE MATTERS A LOT.

-            CULLINAN

Young Jane Doe Problems

 This story talks about Jane Doe, a 27 years old male – a C.A to understand if he actually has a solution to his problems. During the first session, Jane Doe’s thoughts were showing a red flag. He had been sliding towards depression and had developed alcohol as a coping mechanism. As the sessions continued, it was understood that the unresolved conflicts during childhood and pent up emotions are the reason behind why Jane Doe had to go through this phase of life.

 Every person has unresolved issues. But not every unresolved issue leads to pathology. When it is triggered by an external factor or stimulus, it becomes pathology. To conclude, every person is vulnerable. All you need to do is to take care of your mental health, physiological health and spiritual health.

Identifying Information:

 Jane Doe, Male, aged about 27 years, walks to the Counselling Centre with a list of complaints. On the outside, he had completed his CA and had his own firm with more than 15 people working in his organization.

Presenting complaints/ reasons for the visit:

1. Reduced sleep and appetite. (Since about a year)

2. Frequent nightmares. (3 to 4 scenarios repeated about 5 times in the past 6 months.)

3. Palpitation/ racing heartbeat, short breath, stiffness in facial muscles. (Since about a year)

4. Pain in forehead region and headache complaints were frequent. (Since about 6 months)

5. Scared about the future. (Since about 4 months)

6. Usually feeling sad or anxious all day every day. (Since about 2 months)

7. Increased alcohol use. (Since about 6 months)

Informant:

 Jane Doe comes up and talks about the issues all by himself. He explains that he has been in this state from the last 6 months. Jane Doe acknowledged that his friend forced him to take therapy instead of worrying about his issues over alcohol. Therapist thus directs Jane Doe to meet him weekly once for 7 sessions to which Jane Doe said “yes”.

Story of Jane Doe:

 Jane Doe is the last son to the parents who worked in their won farm. Jane Doe has a brother and a sister. Brother is staying abroad with his wife and a child whereas the sister is staying in her husband’s home with 2 children. Jane Doe shared and still shares a good relationship with his mother, sister and brother. When he was questioned about how his relationship with his father is, Jane Doe explained that he passed away 11 years ago due to excessive alcohol consumption which resulted in leaver scleroses. When probed, Jane Doe explains about his disturbed relationship with his father because of his habits of drinking, violence against mother, himself and the sister (brother had left to Bingle to study). Jane Doe explains that his father was doubting on his wife and always used to claim that she had affairs with other men and this was the reason why the fights began. “It used to end after my mom started bleeding.” Said Jane Doe. He adds to it saying “I was locked in the room and I could hear my mom crying and my dad hitting her with a block of wood or a plastic pipe or rubber tube. I could even see it through the window (Cries). I couldn’t save her. (cries).” Jane Doe’s then class teacher talks to his mother and takes care of him in her house when he was in his 8th grade. Jane Doe explains that he was always an academic achiever and had been in top 10 list.

After completing his 10th grade, Jane Doe shifts to Bingle City to Study 11th,12th and further, staying at his brother’s place. This is again Jane Doe – “I was happy on one side for staying away from my dad, so that I can study peacefully and achieve something great. But, at the same time, I was feeling worried and anxious thinking about the way my dad would be treating my mom. I even thought that my mother would be no more to see my achievements and would either be killed by my father or would commit suicide because of my father.”

Jane Doe continues explaining that it was difficult for him to concentrate on his studies and used to call his neighbor or teacher who cared him for 3 years, to understand about the present situation. He praises his neighbor saying that they were patient and was talking to him and explaining him about how things were. Jane Doe then explained that his father died in a minimum facility hospital after 3 days of hospitalization. He was pronounced dead 4 months prior to Jane Doe’s 12th grade exams. Jane Doe – “His death is something that made my mom’s life peaceful. I was liberated from my anxiety and worries. I was so revealed and so was my sister. My brother was not so much affected because he was in the hostel ever since his childhood and had been detached from the family.” He adds to it that he could concentrate on academics better after the death. He explained that the mother and sister were staying in the farm house. By this time, the farm had started minting money and had a great turnover. Jane Doe calls these “The Golden Days”. He then started studying in B.Com. during which his sister got married. Jane Doe proudly said that he was one among the university toppers.  He then continued with his masters (M.Com.) during which his brother got married. Few months after which the first nephew was born.

“I used to go to my village weekly once to see my mom, my sister, my brother in law and my nephew happy. I still do it. But, because of the present issues, I have not gone there since a couple of months.” Said Jane Doe. 

 Jane Doe, after completing his masters in commerce, had appeared for C.A examination and had cleared it in the 3rd attempt. He explains that he had the potential and caliber to do it. Jane Doe then worked under a CA for a couple of years after which he started his own firm and is a successful entrepreneur.

 He explains another incident which has an impact on his beliefs. This is the Verbatim.

Jane Doe – “There is another incident that makes me scared about the future.”

Cullinan – “What is that about?”

Jane Doe – “It was on my nephew’s second birthday, an incident happened which I can never forget. (Paused). We were celebrating his 2nd year birthday in our farmhouse. We had invited more than 200 people and almost all of them showed up. We had organized a cocktail party and dinner. Everything was going fine and smooth till late evening. Right before the bartender opened the bottles, my nephew fainted due to a THI (Traumatic Head Injury) after which we rushed her to the hospital and first aid was given. We reached home in an hour and saw only two people waiting for us to say Bye and everybody left without having food and drinks. It was all my sponsor for the party. We all felt so bad after this. We decided not to plan or organize any such parties in the future.”

 These were the exact words Jane Doe talked to me during the therapy. He further explained that he had started withdrawing from parties and meeting friends. He explains that he drinks with one of his close friends in his house. “My house has a small bar. I invite my friend. We drink, we eat and we talk about random things. When I talked about my issues to him, he instructed me to meet you in person and gave your phone number.”

 This was jane Doe prior to his visit to CCC. During the process of interrogation, Jane Doe opened up saying that he has been in physical relationship with 4 women who he met on Facebook, Tinder and Bumble. He also added to it that it was not a relationship and was a casual thing. He calls it “friends with benefits.”

Jane Doe claims that he has never been into any problems or conflicts because of these kinds of relationships.

“My mother is now forcing me to get married and she has already started searching for a girl. This makes me feel more anxious.” He said. He added to it that he is well settled financially, socially and is physically stable. He complained that he had been feeling emotionally unstable – which is making him reject every girl his mother suggests. Jane Doe acknowledged that this behavior made him feel guilty. To overcome this feeling, Jane Doe chose alcoholism as a coping mechanism. He acknowledged that he has never been to meet the girls he has been in a relationship with – in the past 4 months and claimed that it might be one among the reasons behind why he has been rejecting every girl his mother is suggesting him. He continued explaining about his friends who are married and are not happy – claiming that to be one of the reasons for his anxiety. While Jane Doe was thinking about the reasons for his problems, his anxiety increased as a result of which he had become verbally more expressive.

Cullinan then made him relax on the couch and let him free to speak after mild relaxation. Jane Doe, while talking to Cullinan, suddenly pauses while explaining about his brother’s marital relationship issues, he questioned Cullinan about the probable reasons behind why he is facing these issues. 

WE AS THERAPISTS USUALLY DON’T BE DIRECT IN OUR APPROACH – AT LEAST NOT DIRECTIVE WHEN IT COMES TO PROVIDING INSIGHT TO PATIENTS WITH TRAUMATIC AND UNPLEASENT PAST LIFE EXPERIENCE.

Jane Doe was probed. He then understood that he was scared because, he believed that celebration leads to tragic ending. He also became aware of his belief that he doesn’t believe in women that much.

It was clear that Jane Doe’s present situation was because of his childhood experience where his father was abusive towards his mother, where the father was alcoholic and was abusive towards Jane Doe himself. His parents’ marital relationship was the only example he has – either to follow or to reject (either as a positive role model or a negative role model). Jane Doe, as he was powerless as a child, had no freedom to express his experienced emotions. Adding to it, presently, it is clear from Jane Doe’s words that his conscious belief is that he might become like his father. To cope with this stressful situation, he is taking a flight from stimulus that makes him respond according to his beliefs. Adding to this, the nephew’s birthday incident that wasn’t successful because of a disaster has an impact on Jane Doe’s belief. 

“Celebrations will always have a tragic ending” – Jane Doe’s exact words. To overcome this, Jane Doe, as mentioned above, takes a flight from the stimulus that puts him in the celebration scenario. 

These beliefs were gradually resolved by imposing psychotherapy on Jane Doe for 4 sessions.

 It has been 8 months after termination, I read a message from Jane Doe which read – 

“Dear Cullinan,

I am Jane Doe. Hope you remember me. I am all well now. thank you for helping me out. I need a 10 minutes appointment to meet you and invite you to my marriage. Please inbox the time and date so that I can come with my fiancé. 

Yours truly,

Jane Doe”

Sketch by @Chiyaan Bala