Mental Health
Expert Interview: Retired Professor of National Institute of Mental Health and Neuro Sciences, an Institute of National Importance, Government of India.
Expert Interview: Retired Professor of National Institute of Mental Health and Neuro Sciences, an Institute of National Importance, Government of India.
Dr. R. Srinivas Murthy
Dr. R. Srinivas Murthy
1. On learning of your cancer diagnosis what was your 1st reaction?
1. On learning of your cancer diagnosis what was your 1st reaction?
At the current level of understanding of cancer as an illness and its care, which is limited in terms of the ‘çurability’, there are five thoughts that come to mind.
At the current level of understanding of cancer as an illness and its care, which is limited in terms of the ‘çurability’, there are five thoughts that come to mind.
Firstly, there was a sense of doom and possibility of suffering and end to life( I recall vividly, my first thought, when the doctor told me of the diagnosis: ‘My life will not be the same now onwards’.
Firstly, there was a sense of doom and possibility of suffering and end to life( I recall vividly, my first thought, when the doctor told me of the diagnosis: ‘My life will not be the same now onwards’.
Secondly, there are feelings related to pain/suffering associated with the treatments like surgery, chemotherapy and radiotherapy, the cost of treatment and the burden on my wife.
Secondly, there are feelings related to pain/suffering associated with the treatments like surgery, chemotherapy and radiotherapy, the cost of treatment and the burden on my wife.
Thirdly, there was s a sense of ‘loss of the life as it was before the diagnosis’. Life will never be the same after the diagnosis in a number of ways- restriction of activities, food intake, travel, taking responsibility and thoughts about the future etc.
Thirdly, there was s a sense of ‘loss of the life as it was before the diagnosis’. Life will never be the same after the diagnosis in a number of ways- restriction of activities, food intake, travel, taking responsibility and thoughts about the future etc.
Fourthly, there were the questions, why me? What did I do wrong to get this illness? ( I was not a smoker, I was a vegetarian all of my life, I was a teetotaller and led a good life in public service). Why has God given me this illness? Philosophical questions about the meaning of life, after life and the purpose of pain/suffering were also part of my reaction.
Fourthly, there were the questions, why me? What did I do wrong to get this illness? ( I was not a smoker, I was a vegetarian all of my life, I was a teetotaller and led a good life in public service). Why has God given me this illness? Philosophical questions about the meaning of life, after life and the purpose of pain/suffering were also part of my reaction.
Fifthly, the sense of uncertainty necessarily bring the concern for the loved one. How will they be without me? What can I do to secure their future?
Fifthly, the sense of uncertainty necessarily bring the concern for the loved one. How will they be without me? What can I do to secure their future?
The following quote from the book Emperor of maladies’summarises the feelings at the time of diagnosis:
The following quote from the book Emperor of maladies’summarises the feelings at the time of diagnosis:
“You have cancer.” These simple words come as a terrible shock. Life, as you know, changes in an instant and nothing is the same again. Panic and fear overwhelm you as you desperately pin your hopes on doctors and the medical treatment.
“You have cancer.” These simple words come as a terrible shock. Life, as you know, changes in an instant and nothing is the same again. Panic and fear overwhelm you as you desperately pin your hopes on doctors and the medical treatment.
However, since I was at the later stages of life, and had completed most of my professional goals and had a fairly secure financial situation, the predominant feelings were related to the treatment, change in my life activities and the spiritual questions.
However, since I was at the later stages of life, and had completed most of my professional goals and had a fairly secure financial situation, the predominant feelings were related to the treatment, change in my life activities and the spiritual questions.
2. Describe your sense of despair on learning of the diagnosis.
2. Describe your sense of despair on learning of the diagnosis.
Sense of despair is not one single emotion. It is a mixture of the five concerns that I have described above. In my situation, the despair was for the end of my professional and personal life as I knew for nearly 7 decades and the thought that I will live for the rest of my life with a permanent sense of ‘uncertainity’. I cried a little for what I thought I had lost, feared a lot for the future and worried for the safety and security of my wife in particular and nieces.
Sense of despair is not one single emotion. It is a mixture of the five concerns that I have described above. In my situation, the despair was for the end of my professional and personal life as I knew for nearly 7 decades and the thought that I will live for the rest of my life with a permanent sense of ‘uncertainity’. I cried a little for what I thought I had lost, feared a lot for the future and worried for the safety and security of my wife in particular and nieces.
The chemotherapy sessions were not as much a horror as I had heard about and read about. The angelic nursing team were efficient, courteous and the medical consultants were always with me and could be reached easily. As my body was battling the cancer, or the chemotherapy, at times it was not clear what was the battle about, who is the attacker and the attached, there were bigger challenges.
The chemotherapy sessions were not as much a horror as I had heard about and read about. The angelic nursing team were efficient, courteous and the medical consultants were always with me and could be reached easily. As my body was battling the cancer, or the chemotherapy, at times it was not clear what was the battle about, who is the attacker and the attached, there were bigger challenges.
My personal life came to a grinding halt. The year was important, being the Golden Jubilee of my completing schooling(July 2013), and Golden Jubilee of the postgraduate centre where I trained as a psychiatrist(September 2013), Golden Jubilee of joining the medical school(Aug 2014), all passed by my staying at home. I will never meet many of my colleagues, who had gathered on these occasions. There was no clinical work, no meetings, no travel. I had to stop travelling to Bhopal, which I was doing every month for a week of work with the disaster population. I would summarise it as ‘an year of losses’.
My personal life came to a grinding halt. The year was important, being the Golden Jubilee of my completing schooling(July 2013), and Golden Jubilee of the postgraduate centre where I trained as a psychiatrist(September 2013), Golden Jubilee of joining the medical school(Aug 2014), all passed by my staying at home. I will never meet many of my colleagues, who had gathered on these occasions. There was no clinical work, no meetings, no travel. I had to stop travelling to Bhopal, which I was doing every month for a week of work with the disaster population. I would summarise it as ‘an year of losses’.
The challenge that my wife and family faced was equally challenging. The extra efforts to prepare fresh food for each meal, drive me to hospital for blood tests, chemotherapy sessions, besides single handedly running the home was the burden of my wife. Besides worrying and coming to terms with her own fears, she had to handle my emotional lability, irritability and the ups and downs of medical condition like falling platelets and an intervening herpes infection, half-way into the chemotherapy!
The challenge that my wife and family faced was equally challenging. The extra efforts to prepare fresh food for each meal, drive me to hospital for blood tests, chemotherapy sessions, besides single handedly running the home was the burden of my wife. Besides worrying and coming to terms with her own fears, she had to handle my emotional lability, irritability and the ups and downs of medical condition like falling platelets and an intervening herpes infection, half-way into the chemotherapy!
There was no organised psychological help to me or my wife, as the medical team was battling the cancer and not our fears and problems. There was no social worker, counsellor or self-help group, in this top class tertiary cancer care centre!!
There was no organised psychological help to me or my wife, as the medical team was battling the cancer and not our fears and problems. There was no social worker, counsellor or self-help group, in this top class tertiary cancer care centre!!
My professional life took a nose dive, and it looks like I will have to rediscover my professional work which limits travel and lower levels of energy. Lucky that I am 67 and feel that I have given my best and have limited desires for professional achievements.
My professional life took a nose dive, and it looks like I will have to rediscover my professional work which limits travel and lower levels of energy. Lucky that I am 67 and feel that I have given my best and have limited desires for professional achievements.
The social life was equally challenging. My wife and I, contrary to the routine practice of keeping the illness secret, took the decision to share the information with all our family members, friends, colleagues and wellwishers. Part of it was the need to stopping clinical work,(transferring patients under my care to other colleagues) and stop my monthly travel to Bhopal. However, equally important was our desire to draw on the support of social network. Looking back, this was the best thing that we did. Nearly everyone ( yes, few friends broke their long standing friendships- probably they were phobic to cancer) supported us in a wide variety of ways. The phone calls, emails, personal visits, books sent were all very valuable to be continuing to be connected and find emotional energy to go on during periods of despair and distress. Thank you friends for this valuable and thoughtful support. Your support was valuable to both of us.
The social life was equally challenging. My wife and I, contrary to the routine practice of keeping the illness secret, took the decision to share the information with all our family members, friends, colleagues and wellwishers. Part of it was the need to stopping clinical work,(transferring patients under my care to other colleagues) and stop my monthly travel to Bhopal. However, equally important was our desire to draw on the support of social network. Looking back, this was the best thing that we did. Nearly everyone ( yes, few friends broke their long standing friendships- probably they were phobic to cancer) supported us in a wide variety of ways. The phone calls, emails, personal visits, books sent were all very valuable to be continuing to be connected and find emotional energy to go on during periods of despair and distress. Thank you friends for this valuable and thoughtful support. Your support was valuable to both of us.
Of all the challenges, the most difficult was to confront the new reality of ‘living with uncertainity’. There were so many issues relating to finding meaning in the suffering, thinking of the end of life and a bigger issue of the meaning of life. Necessarily, I entered an area that I had not given much importance all the 7 decades, namely the spiritual aspects of human existence. To be frank, this has been the most valuable benefit of the illness and I can say I am at greater peace with myself in this area, due to the illness.’
Of all the challenges, the most difficult was to confront the new reality of ‘living with uncertainity’. There were so many issues relating to finding meaning in the suffering, thinking of the end of life and a bigger issue of the meaning of life. Necessarily, I entered an area that I had not given much importance all the 7 decades, namely the spiritual aspects of human existence. To be frank, this has been the most valuable benefit of the illness and I can say I am at greater peace with myself in this area, due to the illness.’
3. How did you come to terms with it?
3. How did you come to terms with it?
Being a doctor, I knew that the essence of the response will have to be to do what is the best in the situation. My wife and I did not delay the needed treatment. The advised surgery and chemotherapy following the same was immediately initiated. The sequence of events are vivid in my memory. After a full day of work, ( as I did not think anything as serious as it turned out was waiting for me) I had the initial consultation on a Monday evening, The colonoscopy on Tuesday to confirm the diagnosis, and got admitted to hospital on Thursday and was operated on Friday. Time is the essence in initiating treatment. I know a number of people in a similar circumstance would think of a second opinion, delay the surgery and look for alternative therapies. From my professional experience, these delays are a way of expressing ‘denial’ and cause harm to the person. If I can summarise the way I came to terms with the diagnosis is by ‘acceptance’. I feel this is the starting point for finding a rational way of coming out of the situation. One other important strategy I used was to acquire correct information by asking the treating team, books ( technical and memoirs) and other patients in a similar situation.
Being a doctor, I knew that the essence of the response will have to be to do what is the best in the situation. My wife and I did not delay the needed treatment. The advised surgery and chemotherapy following the same was immediately initiated. The sequence of events are vivid in my memory. After a full day of work, ( as I did not think anything as serious as it turned out was waiting for me) I had the initial consultation on a Monday evening, The colonoscopy on Tuesday to confirm the diagnosis, and got admitted to hospital on Thursday and was operated on Friday. Time is the essence in initiating treatment. I know a number of people in a similar circumstance would think of a second opinion, delay the surgery and look for alternative therapies. From my professional experience, these delays are a way of expressing ‘denial’ and cause harm to the person. If I can summarise the way I came to terms with the diagnosis is by ‘acceptance’. I feel this is the starting point for finding a rational way of coming out of the situation. One other important strategy I used was to acquire correct information by asking the treating team, books ( technical and memoirs) and other patients in a similar situation.
4. Being a mental health professional was it was perhaps easier for you to grapple with it. Tell us about the social infrastructure available to you at that time .... that would have helped you cope with the situation.
4. Being a mental health professional was it was perhaps easier for you to grapple with it. Tell us about the social infrastructure available to you at that time .... that would have helped you cope with the situation.
My immediate family consists of my wife only. She is a professional and fiercely independent person and took full charge of the ‘uncertain’ situation with her sense of responsibility and love. This was really very very important. We do not have any biological children. We have brought up two of my nieces and my sister-in-law and my nieces form an essential family unit of mine. In addition two brothers and their families, and a large number of friends and colleagues formed the [peripheral support network. The availability of immediate family support is very vital. I still recall how important it was for me and my wife, to see my niece from London, take the first available flight and be with us for the surgery. I was also lucky to have the financial support of the NIMHANS medical insurance scheme. Regarding my own ‘tsunami’of emotions, I was aware of my past work with people in a similar circumstance, the measures I had offered to them to address the situation and the awareness of the uncontrolled flood of emotions. This helps but I experienced all of the emotions that I had seen in others in a similar situation.
My immediate family consists of my wife only. She is a professional and fiercely independent person and took full charge of the ‘uncertain’ situation with her sense of responsibility and love. This was really very very important. We do not have any biological children. We have brought up two of my nieces and my sister-in-law and my nieces form an essential family unit of mine. In addition two brothers and their families, and a large number of friends and colleagues formed the [peripheral support network. The availability of immediate family support is very vital. I still recall how important it was for me and my wife, to see my niece from London, take the first available flight and be with us for the surgery. I was also lucky to have the financial support of the NIMHANS medical insurance scheme. Regarding my own ‘tsunami’of emotions, I was aware of my past work with people in a similar circumstance, the measures I had offered to them to address the situation and the awareness of the uncontrolled flood of emotions. This helps but I experienced all of the emotions that I had seen in others in a similar situation.
5. If there was a deficit in mental health interventions for psycho oncology how do you see filling it up?
5. If there was a deficit in mental health interventions for psycho oncology how do you see filling it up?
It is correct to say that in India, at this point in time, in most of the care centres, the focus in on the physical aspect of cancer care. I experienced the same. So many times, I wished my doctor asked me the three simple questions relating to emotional life, similar to the way they look at the blood results etc.
It is correct to say that in India, at this point in time, in most of the care centres, the focus in on the physical aspect of cancer care. I experienced the same. So many times, I wished my doctor asked me the three simple questions relating to emotional life, similar to the way they look at the blood results etc.
How has this illness impacted your life?
How has this illness impacted your life?
What are the things you worry about yourself and the family?
What are the things you worry about yourself and the family?
What are the measures that give you strength in a difficult situation?
What are the measures that give you strength in a difficult situation?
I must share that though I was receiving treatment from a leading hospital and a very capable group of doctors, I got no emotional support. The only thing that was said, ‘do not worry, everything will be OK”. I must admit that this reassurance is facile to a cancer patient.
I must share that though I was receiving treatment from a leading hospital and a very capable group of doctors, I got no emotional support. The only thing that was said, ‘do not worry, everything will be OK”. I must admit that this reassurance is facile to a cancer patient.
The diagnosis of cancer is like a ‘tsunami’ which comes suddenly and wipes out everything in its way and leave behind ruins. There is need to address not only the physical needs but also the emotional and spiritual needs.
The diagnosis of cancer is like a ‘tsunami’ which comes suddenly and wipes out everything in its way and leave behind ruins. There is need to address not only the physical needs but also the emotional and spiritual needs.
6. What according to you is urgently needed in the world today to counsel cancer patients and their families?
6. What according to you is urgently needed in the world today to counsel cancer patients and their families?
There is an urgent to need to recognise the multidimensional impact of the diagnosis of cancer. Each person and their immediate caregivers need to address three important impacts of the diagnosis. Firstly, they have to understand the full dimension of the illness- the nature of cancer, the stage of cancer, the available interventions. Understanding and acceptance is the starting point for the next two stages of coping with cancer. Secondly, they have to ‘recreate’ a new future for themselves, based on the above knowledge - this could be in terms of possible shortened life, the economic impact, the life goals to choose etc. Thirdly, they need to develop a plan of action to fulfil the new life goals. I would call it as ACT. Accept, Create a new you, and Take action to reach the new goals.
There is an urgent to need to recognise the multidimensional impact of the diagnosis of cancer. Each person and their immediate caregivers need to address three important impacts of the diagnosis. Firstly, they have to understand the full dimension of the illness- the nature of cancer, the stage of cancer, the available interventions. Understanding and acceptance is the starting point for the next two stages of coping with cancer. Secondly, they have to ‘recreate’ a new future for themselves, based on the above knowledge - this could be in terms of possible shortened life, the economic impact, the life goals to choose etc. Thirdly, they need to develop a plan of action to fulfil the new life goals. I would call it as ACT. Accept, Create a new you, and Take action to reach the new goals.
It is unfortunate that majority do not achieve these. The predominant reason is the unwillingness of the doctors , families to share the diagnosis. Indian studies have reported more than half of the patients do not know that they have cancer. If you do not know what is facing you how can you address the same?
It is unfortunate that majority do not achieve these. The predominant reason is the unwillingness of the doctors , families to share the diagnosis. Indian studies have reported more than half of the patients do not know that they have cancer. If you do not know what is facing you how can you address the same?
There is need to understand the experiences of the living with cancer diagnosis, treatment and recovery from the Indian perspective. This is important as we have different views to life, our family functioning is different, there are limited availability of state social supports, the medical care is largely one of out of pocket payment and social attitudes to cancer vary in different communities.
There is need to understand the experiences of the living with cancer diagnosis, treatment and recovery from the Indian perspective. This is important as we have different views to life, our family functioning is different, there are limited availability of state social supports, the medical care is largely one of out of pocket payment and social attitudes to cancer vary in different communities.
Most importantly, all the persons diagnosed with cancer and their caregivers should be given the skills to address the physical, emotional and spiritual needs. In this there is greater need in India for self-care measures, as there are limited numbers of professionals and most people are reluctant to seek emotional health support.
Most importantly, all the persons diagnosed with cancer and their caregivers should be given the skills to address the physical, emotional and spiritual needs. In this there is greater need in India for self-care measures, as there are limited numbers of professionals and most people are reluctant to seek emotional health support.
There is sufficient evidence to demonstrate the value of psychosocial care in (i) decreasing distress; (ii) limiting the occurrence of anxiety, depression, sleep disorders; (iii) improving quality of life; (iv) enhancing the acceptance of treatments; (v) minimising the use of pain relievers;(vi) adherence of life style changes like giving up smoking and (vii) survival period.
There is sufficient evidence to demonstrate the value of psychosocial care in (i) decreasing distress; (ii) limiting the occurrence of anxiety, depression, sleep disorders; (iii) improving quality of life; (iv) enhancing the acceptance of treatments; (v) minimising the use of pain relievers;(vi) adherence of life style changes like giving up smoking and (vii) survival period.
Equally important, the following self-care measures can alleviate emotional suffering and give better quality of life, namely, physical exercise, reading of others experiences, writing down personal feeling and thoughts, yoga/meditation, listening to music, sharing of feelings, living for the present, making spiritual sense of the illness and full utilisation of social supports.
Equally important, the following self-care measures can alleviate emotional suffering and give better quality of life, namely, physical exercise, reading of others experiences, writing down personal feeling and thoughts, yoga/meditation, listening to music, sharing of feelings, living for the present, making spiritual sense of the illness and full utilisation of social supports.
7. Did being a mental health professional make it easier for you to come to terms with it and then to grapple with it?
7. Did being a mental health professional make it easier for you to come to terms with it and then to grapple with it?
Yes and no. Let me begin by sharing the areas, where my professional experience was of no use. The worst time of my illness was when I developed herpes infection affective my eyes area, which had the potential to make me blind.at that period I felt hopeless and saw no purpose in life. Similarly, as a consequence of chemotherapy, I was very tearful in emotional situations. This was not in my control.
Yes and no. Let me begin by sharing the areas, where my professional experience was of no use. The worst time of my illness was when I developed herpes infection affective my eyes area, which had the potential to make me blind.at that period I felt hopeless and saw no purpose in life. Similarly, as a consequence of chemotherapy, I was very tearful in emotional situations. This was not in my control.
Knowing what I was going through and what will help me, I used everything I knew to my recovery. I fully used the self-care measures I described above for my recovery. To be specific, my life now is different in the following ways:
Knowing what I was going through and what will help me, I used everything I knew to my recovery. I fully used the self-care measures I described above for my recovery. To be specific, my life now is different in the following ways:
1. I give a lot of attention to my physical health in terms daily walking, care with nutrition and adequate sleep and rest;
1. I give a lot of attention to my physical health in terms daily walking, care with nutrition and adequate sleep and rest;
2. Reading of both technical literature and personal experiences of other people in a similar situation is an important part of life;
2. Reading of both technical literature and personal experiences of other people in a similar situation is an important part of life;
3. I write down my feelings and experiences regularly;
3. I write down my feelings and experiences regularly;
4. I am working on developing emotional health materials for self care of persons diagnosed with cancer and their caregivers, as a way of addressing the needs of these groups;
4. I am working on developing emotional health materials for self care of persons diagnosed with cancer and their caregivers, as a way of addressing the needs of these groups;
5. I have changed my life goals to limited areas that are easy for me to cope and achieve - for example I limit travel and work more from home. I am less concerned with hurts, recognition by others and other worldly rewards;
5. I have changed my life goals to limited areas that are easy for me to cope and achieve - for example I limit travel and work more from home. I am less concerned with hurts, recognition by others and other worldly rewards;
6. I read and think about spiritual aspects of life;
6. I read and think about spiritual aspects of life;
7. I have a life approach of ‘living with hope and coping with uncertainity.
7. I have a life approach of ‘living with hope and coping with uncertainity.
8. What is the current status of Psycho-oncology in India?
8. What is the current status of Psycho-oncology in India?
The term ‘psycho-oncology’ is a recent development all over the world. It can be traced to the initiatives in Sloane Kettering Hospital by Dr. Jamie Holland in the 1970’s. In India, the initiatives have been since the 1990’s. The India initiatives can be grouped under the following areas:
The term ‘psycho-oncology’ is a recent development all over the world. It can be traced to the initiatives in Sloane Kettering Hospital by Dr. Jamie Holland in the 1970’s. In India, the initiatives have been since the 1990’s. The India initiatives can be grouped under the following areas:
Firstly, the initiatives of voluntary organisations to provide emotional support along with material supports to people with a diagnosis of cancer and their care givers at various stages of cancer journey. Notable organisations are: CanSupport in Delhi, VCare in Mumbai, Palliative care initiatives in Kerala state;
Firstly, the initiatives of voluntary organisations to provide emotional support along with material supports to people with a diagnosis of cancer and their care givers at various stages of cancer journey. Notable organisations are: CanSupport in Delhi, VCare in Mumbai, Palliative care initiatives in Kerala state;
Secondly, there are professionals addressing research to understand the needs of the persons diagnosed with cancer and their caregivers. Notable groups working in this area are from NIMHANS, Bangalore, Adyar Cancer Institute at Chennai, IIT Hyderabad, Tata Memorial institute in Mumbai.
Secondly, there are professionals addressing research to understand the needs of the persons diagnosed with cancer and their caregivers. Notable groups working in this area are from NIMHANS, Bangalore, Adyar Cancer Institute at Chennai, IIT Hyderabad, Tata Memorial institute in Mumbai.
Thirdly, we are seeing the initial efforts of writing memoirs by people diagnosed with cancer / caregivers- notable books in this category are by Vijay Bhat / Neelima Bhat, Uma Girish, Neelam Kumar, Krishna Vattam, Yuvaraj Singh, ...
Thirdly, we are seeing the initial efforts of writing memoirs by people diagnosed with cancer / caregivers- notable books in this category are by Vijay Bhat / Neelima Bhat, Uma Girish, Neelam Kumar, Krishna Vattam, Yuvaraj Singh, ...
Fourth group of initiatives that has come up are from informational technology professionals to provide support through the internet. CAREER PROGRAM a Bangalore based group is an example of this initiative.
Fourth group of initiatives that has come up are from informational technology professionals to provide support through the internet. CAREER PROGRAM a Bangalore based group is an example of this initiative.
All of these initiatives are important. There is greater need for enlarging both the scope and depth of these efforts.
All of these initiatives are important. There is greater need for enlarging both the scope and depth of these efforts.