Perspectives on Psychiatry: Chapter 1

I cannot fully understand all the forces that shaped who I am today: a psychiatrist, husband and father in his middle age. Personally, I don’t believe that we as human beings actually make any decisions, in the way one would normally understand what it means to make a decision. Rather, I believe that our minds direct us, relying upon past experiences, an assessment of current circumstances and also our minds’ own unique proclivities and priorities, leaving us with the illusion that we have made a choice. I cannot say that I made a decision to become a psychiatrist any more than you could say (I would argue) that you made a decision to become whoever you are. 

My life experiences and particular traits dictated the purported “decisions” I made that led me down this path. Looking retrospectively, we human beings seem to turn the historical details of our lives into a narrative played out upon significant, causal events. For instance, my mother (who, in many respects “wore the pants” in our home,) is a physician who worked as an anatomic pathologist for the Veterans Administration in Cleveland, Ohio for the majority of her career. My uncle and aunt were also physicians, he an ophthalmic surgeon, she a pediatrician. (Soon enough, you will learn about their significance in my life). Moreover, when I was just embarking on my college experience, my sister had already matriculated into medical school.

You could say that I come from a family of physicians. By various estimates, one in five physicians has a parent who is a physician. But the other four do not. There are of course many variables that influence how one ends up becoming who one is. My family tree alone is not a sufficient explanation. And, my parents never “pushed” me to study medicine. Rather, it was the case that doctoring held a certain, unspoken prestige in my family and in the cultures in which I was raised. 

Many of my parents’ immigrant friends in Northeastern Ohio were also physicians–perhaps even the majority of them. My parents’ social circle was composed almost entirely of Malayalees, immigrants from Kerala, the South Indian state from which they hailed. 

In those days, (the 1960s and 1970s,) the vast majority of immigrants from India were highly-educated professionals, such as physicians, engineers and scientists. 

Another factor that led me down this path in life is that I excelled in the sciences in my early schooling and found the subject matter compelling enough. Although I have a creative streak that has long been undernourished, I was too risk averse by nature to pursue a purely artistic path. Another unspoken tenet within my family: that the powers that be would never support a purely creative life path, deeming it impractical.

In the generation of my parents, being a physician afforded more than some modicum of financial security. In many ways, human beings are no different from all other animals on this planet–we are all fundamentally motivated by our own survival. In human societies, under our current economic and political systems, we ensure our own survival as adults by finding ways to achieve financial security through the means most accessible and tolerable to us. 

My late father attended the Indian Institute of Technology and did postdoctoral work in electrochemistry at the University of Pennsylvania. (Apparently he had an interest in and knack for hard sciences.) When it was time for him to embark on a career, he left the world of academia to pursue a career in industry, working as an engineer for a large defense-contract electrical and electronics company that produced, among other things, bearings for the automotive industry. But he did not earn as much money as my mother did. So from the vantage point of a child in my family, all other things being equal, it must have seemed like a better bet to pursue a career in medicine. Still, I know that I was never primarily motivated by money; for whatever reason, power and wealth had limited appeal for me. Besides, ambition in the realm of business seemed to have very little capital in my nuclear family. Both my parents were salaried employees for their entire careers. 

In my view, they lived their immigrant lives exemplifying practicality, comfort and community rather than unbridled ambition. They wanted their children to live up to their potential, certainly.  But, they didn’t care seem to care if we achieved any status or recognition by society at large–as long as we did as well as they did and our decisions made practical sense and allowed us to build lives in which we could live comfortably.

In paving the path to becoming a psychiatrist, certain traits also likely played a role: introversion, an interest in the inner experiences of people, basic observational skills, the ability to pattern recognize and make connections.  But why clinical psychiatry? Why not dermatology or radiology or oncology or urology–or some other subspecialty of medicine? Why not a career in psychiatric research? Or academia?

Here, the single most important factor, I believe, was the experience I had of enduring significant turmoil and emotional pain in my formative years. My childhood was marred by disruption and loss. At the age of six months, my mother and father sent me away to live with my mother’s parents and extended family in Kannur, a small town along the North Malabar coast of Kerala, the southernmost state in India on the West Coast. Over a period of seven years, I did not once see nor hear from my birth family in Ohio. During this period of time, I was raised by my maternal grandmother and grandfather, an aunt (my mother’s sister) and uncle (my aunt’s husband), several great aunts, a great grandmother and several paid servants who lived with us. 

Then, seemingly out of nowhere, when I was seven years old, my mother and sister (age 12 at the time) came to retrieve me from what felt like the only home I had ever known.  Leaving Kerala–my entire family there, the earth, the verdant groves of coconut palms, the culture, the monsoons–and coming to the United States–specifically to Northeastern Ohio, to people whose skin tones and mannerisms I had never seen in the flesh, to a family I didn’t know at all–comprised the most difficult loss I endured in my life. All subsequent losses would touch upon the infinite pain of this loss, for it was the loss of so many things at once: the loss of family I trusted, the loss of country and culture, the loss of identity and, most importantly, perhaps, the loss of emotional safety. 

My parents could not fully grasp my pain, unfortunately, nor could they be with it, for it would implicate them as adults capable of inflicting significant emotional pain onto a child.  For my part, I’m certain that I did not express my pain in a way that was understandable and acceptable to them.  I recall the experience of never being able to trust them fully and hiding my suffering from them as much as possible.

My parents did not have the emotional wherewithal to handle the guilt that would have welled up within them were they to join me in my pain. In a way, my relationship with them was doomed from the start; an origin story such as mine, in all likelihood, cannot give rise to a happy, fulfilling family experience. The bonds that form between a parent and child over many years in early childhood just were not there. Nor could they have been, for the story would not have written itself in the way that it did ultimately, had there been these emotional bonds. 

I have no doubt that the sum of that experience shaped my interest in the mental suffering of others, their inner experiences, that side of themselves that people tend to keep private or only share with their most trusted confidantes. Because there was not for many years an effective outlet for my emotional pain, I learned to deal with it by myself as best as I could. You could say that my mind determined, given who I was and who my parents were, that it was the modus operandi that was most likely to ensure my survival within my family system. 

Every sentient being on our planet, I believe, is ultimately a type of biomachine that is directed by a biological operating system, to borrow a term from the world of computer science. The subjective “I” that has any kind of agency is simply an illusion generated by the operating system itself, giving us the sense that we have free will.  Ultimately, as we gain more knowledge about the inner workings of these biological operating systems, all animal behavior, including human behavior, will be predictable, based upon mathematical modeling.  Then, we will be able to regard ourselves fully for who we are: biological robots with no control over our lives.  Every decision that is made by a sentient being, ultimately, is the only one that could have been made given the circumstances at the time of the “decision.”  In the same vein, the collective behavior of large groups of people can also be predicted, the more we understand how groups of sentient beings influence one another.  

I’ve always been struck by the observation that the lack of an individual’s free will begins with life itself.  No child makes a decision to be born. We are all summoned into this thing called Life by the actions of others who, of course, could not consult our future selves. Although I have no regrets about being born, I did not decide to be born. And, I did not decide who my parents would be, what type of family I would have, my genetics, my phenotype, my country, my culture and my time on this Earth along the grand continuum of Time. And, I did not decide, certainly, to endure the difficult circumstances I faced in my childhood on my own. Nor did I consciously decide, as an adult, to repurpose my suffering into a career in the healing arts.

As a practicing psychiatrist (or any type of mental health treatment provider, for that matter), it’s not difficult to see how shame and the fear of vulnerability or rejection motivate people to hide their suffering from others. One of the cruel ironies of mental illness is that it tends to push other people away. There is an energetic cost, in other words, to dealing with another person’s mental illness. The minds of others, when confronted with the mind of someone who is experiencing mental illness, not infrequently decide to turn away from that individual. If our mind determines that the return on investment for supporting another person’s mental distress is low, it will opt to disengage with that individual. I use the business term here purposefully–not nonchalantly–because the economic structure into which we are born also shapes how we deal with mental illness. The pressure to function optimally in a society such as ours does not help matters. It is another way in which natural selection operates in the world of sentient human biomachines.

In the United States, as in much of the western world, we are living in what is being referred to as “late stage capitalism,” an era in which extreme wealth discrepancy results in the increased energetic cost of survival for the masses. A relatively small group of the extremely wealthy have an outsized influence on our global environment, and the rest of the population is valued only for their ability to provide labor and make purchases. In this environment, people who suffer from mental illness are seen as a drain on resources, unable to fit within the expectations of a lifetime of participation in the capitalist hierarchy. Moreover, those who are able to participate more effectively within this capitalist system, are themselves individually taxed when they interface with someone with mental illness. The care-taking role, however limited, comes with an energetic cost, depleting the internal resources of the caretaker, rendering the individual less fit to participate in an increasingly unforgiving economic system with fewer and fewer safety nets. 

Throughout history and to this day, people experiencing more extreme forms of mental illness, such as schizophrenia and other psychotic disorders, have been forcibly removed from the view of society through various punitive methods, such as incarceration and long-term institutionalization. Even for noneconomic reasons, such as the discomfort–or horror, even–the fit majority experience when confronted with an unfit minority, societies as a whole could not tolerate the full expression of individuals in these extreme states. 

For someone suffering from mental distress who has the knowledge that they are an energetic cost to those closest to them and society at large, it is easy to feel profoundly alone in the world, sometimes painfully so. Every relationship, from friendships, to family relationships to love relationships to professional relationships and the relationship one has with one’s society, has a calculus that defines it. Simply put, when one party, on a chronic basis, takes more than they give back (as defined by the other party), the relationship becomes strained. It’s difficult to know whether people with forms of mental illnesses that rob them of this insight and awareness are cursed or blessed. 

For anyone interested in understanding the energetic cost of tolerating mental illness on society at large, Foucault’s Folie et déraison is a must read. It details Europe’s handling of “madness” over many centuries, analyzing works of art, texts and historical documents. For me, one of the most striking descriptions from the English-language translation of a more abridged version of his full treatise, relates to his description of the confinement of “mad” people beginning in the 1600s. Apparently, approximately one in one-hundred people in Paris were removed to these houses of confinement over a short period of time. Given that the global prevalence of schizophrenia is about 1% of the population, it is tempting to speculate whether the entire cohort of Parisians with schizophrenia was institutionalized during this Great Confinement.

When presented with such ample evidence that certain expressions of mental illness and certain forms of mental distress are intolerable to others and to society at large, it is not surprising why many people suffer alone, as I did certainly in the second half of my childhood.  The emotional cost to my parents of being with my pain was simply more than they could bear.

Not surprisingly, as human beings have gained more knowledge of our biological machinery and the environmental factors that shape it, explanatory models of mental illnesses have evolved.  These explanatory models have either contributed to or alleviated the suffering of individuals. Even in recent human history, not too many centuries ago, certain forms of mental illness were regarded in purely religious terms–such as demonic possession–in various parts of the world. Much more recently, homosexuality was pathologized and medicalized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1973.  Separate from this matter, the history of psychiatry itself in the Western world has quite a few dark chapters with which to contend.

If the trait of compassion is to have any role in the evolution and survival of our species, it is worth noting that the suffering of individuals with mental illness can be alleviated, in part, by a compassionate reaction by the environment–and, conversely, that the negative attitudes of society towards certain traits expressed in the human population can victimize individuals through labeling, pathologizing and discrimination, aggravating mental distress.

Those who embark on a journey in the healing arts presumably find something compelling in the suffering of others. Perhaps it’s a reflection of themselves from times past. Or the chance to do something that feels meaningful. Compassion and knowledge of mental suffering–its genesis, expression and treatment–are the cornerstones of the healing professions that interface with the mentally ill. 

For me, it wasn’t just my lineage, my parents’ expectations, my knack for science, or my introverted personality that led me to psychiatry over other fields of medicine or any other career. It was all of those things and none of those things. And it was the accumulated experience of suffering mentally and emotionally on my own in a way that was not soothed by my immediate environment, that led me to this field.