issue 209 - July 1990
The good doctor
Guruji heals madness in a village near Delhi. Sudhir Kakar, trained
as a psychoanalyst in the West, finds much to admire in his work.
JHARSETLI, a village 40 kilometres north-west of Delhi, lies in the heart of Haryana's farm belt. Similar to other villages in the area in most respects, a part of it has acquired a semi-industrial facade because of its proximity to the main highway. There are small repair shops with antique lathes and grinding machines. Worn-out truck tyres stacked in heaps announce the arrival in the village of the industrial era. There is an appealing air of grubby vitality in this part of the village, a seediness not of decay but of impending birth.
The dharmashala in which the doctor - Guruji, as he is commonly and respectfully known - works and lives was constructed many years ago by some pious rich people as an inn to provide poor travellers and pilgrims with shelter. Guruji took over the building in 1963 and hung out a simple sign with the inscription Manasik Chikitsa Kendra - 'Centre for the Treatment of Mental Illnesses'.
The inn-hospital is a decrepit, single-storied structure. Lying almost at the outer edge of the village, a couple of hundred yards off the highway, Guruji's domain is isolated from the rest of the village and has an aura of self-sufficiency. Despite the faint purr of traffic from the highway and the whiff of exhaust fumes, the inn has the quality of a stage village with its temple, its pond in which water buffalo wallow, its pair of pie dogs taking their ease under pipal trees, and the surrounding fields.
Guruji seems very much at home in these surroundings. He is a 60-year-old man with humorous eyes that belie the apparent strictness of his manner. Dressed in a freshly laundered dhoti, a clean white turban wrapped neatly around his head and a rough khadi coat buttoned up to the collar, he walks with the gait of a man accustomed to expect deference.
Resolving medical problems, admonishing the transgressors of rules, arbitrating disputes, cracking jokes with a deadpan expression on his face, Guruji is clearly the hub of this community and the force that holds it together.
The bulk of his clients comprise severely disturbed psychotic patients from nearby villages and towns. To watch him interview these patients is to watch a master at work.
Two men walk up with a patient between them. He is a middle-aged man who drags his feet as he walks. His hair is unkempt, his eyes bloodshot, his face haggard from exhaustion.
'Where do you come from?' Guruji asks them. They mumble the name of a nearby village. 'What is wrong?' he asks the patient gently.
The three men start to speak at the same time. The patient has great difficulty in being coherent. One of his companions interrupts.
'Don't believe a word he says, Guruji.'
'Why shouldn't I believe him? Because you think you are normal and he is mad? "Don't believe what he says, Guruji."' He mimics the man. He turns back to the patient, his expression gentle again - there is no trace of a professional 'caring' in his words or the jarring chord of insincere concern in his voice. 'What is wrong with you?'
'Don't fight with me. I...' The patient's speech is again jumbled.
'Brother, I haven't understood you. Is your throat dry?' The patient nods. Guruji asks one of the companions to fetch a glass of water. The man drinks the water but is still unable to speak. Guruji looks inquiringly at the companions. They explain that the patient is engaged in a legal battle with his brother over some land. Recently he has become uncontrollably excited in the court, shouting, screaming and ready to hit anyone who tries to restrain him.
'So you have come to me after fighting so much!' continues Guruji, smiling. Then un a feigned scolding voice: 'I won't keep you here. Tomorrow you'll also fight with me, will you?' The patient is visibly relaxed. He nods his assent and then realizing he's made a mistake, vigorously shakes his head in denial. Guruji speaks to all of them. 'Go and sleep inside. I will check his pulse tomorrow morning.'
Guruji clearly feels he has a mandate to id the patient's struggle, not only against his illness but also against those who by their conduct either 'cause' or perpetuate the illness.
Most therapists in the West, although they pay lip service to the patient's interest, find it economically and professionally imprudent not to act as the agent of the family and society. 'In your tradition', he once said to me, 'largactyl is given and the patient is made to sleep. As long as he is asleep he won't trouble anyone. The patient's family is satisfied and so too is the doctor. As far as the patient is concerned, he is too drugged to complain. How convenient for everyone!'
At any given time, there are generally eight to ten patients living in the dharmashala together with their family caretakers. They are severely disturbed, the most common presentation - from a Western psychiatric viewpoint - being catatonia, a schizophrenic disorder manifested in posturing, mutism, facial grimaces and mannerisms. In the acute excitement stages, when delusions of grandeur, loquacity and hyperactivity prevail, the patients require physical restraint.
The medical regimen is generally uniform. It starts in the morning with a purge to the head' - a 'nasal' treatment in which medicine is administered through the nose and eyes, which is extremely painful - and continues with regular herbal tranquillizers, digestive powders and a sleeping pill at night. All the medicines are prepared on the premises by the patients, participating quite literally in the process of their own cure.
I attribute Guruji's healing success to two main factors. The first is his personality. It is clear that he has a well-defined professional identity and authenticity which have their roots in his strict adherence to his own therapeutic tradition (ayurvedic medicine), in contrast to the 'flexibility' and eclecticism of many therapists in the West.
The second is that his treatment of psychotic patients fulfils most of the criteria for an ideal milieu therapy. His institution is small and near the population it serves. It is open and there is much movement between the inside and the outside. Patients have many of their personal belongings and their own clothing available to them. Small groups of patients and their family members come together with the staff members in meaningful work (preparation of medicine) and social interaction.
We know that such a humane, therapeutic community which provides predictability, certainty and continuity of experience can gradually replace the patient's pseudo-reality with a new reality, promoting a resolution of painful tensions and enhancing self-esteem.
Guruji himself, however, emphasizes the physiological rather than psychological explanation for his therapeutic successes. 'In Ayurveda,' he says, 'the cure of mental illness takes place primarily on the plane of the body. We try to determine the bodily functions that have become disjointed. the patient should have a good sleep, eat properly and the bowels must move more regularly. If these three functions are put back in order then the patient is already half cured.'
The world seen through the eyes of Indian healers seems, at first, very different from Western tradition. Human freedom, for example, in the traditional Indian context implies an increase in the potential to experience different inner states while limiting action in the outer world. In the West, the notion of freedom seeks to increase the potential for action in the outer world while keeping the inner state as constant, and rational, as possible.
Each culture has consistently underestimated the strength and attraction of the other. Having experienced both, I know that we would benefit from an awareness of the relativity of all healing approaches, and a recognition of the universality of their concerns. And I also know that the Western psychotherapeutic tradition could learn a great deal from the work of people like the Good Doctor of Jharsetli.
Sudhir Kakar works at the Centre for the Study of Developing Societies in Delhi. He is the author of Shamans, Mystics and Doctors (Mandala 1984).
When I first moved to Hackney in London's East End as a medical student in 1971 I saw the graffito: 'HACKNEY - AN ASYLUM WITHOUT WALLS'. Not surprisingly I have lived here ever since.
Hackney has always been a resort for madhouses and mad people. For nearly 300 years it achieved notoriety for its private madhouses. There were three major ones, standing within a few hundred yards of each other. One was founded by William Batty, who gave his name to one epithet for madness. Another, 'barmy', derives from a second of the Hackney madhouses, which was called 'Barms House'. So Hackney has left its mark on the history of madness. It's a reputation we've kept to the present day.
One of the most obvious reasons for this is what might be called 'social drift'. If you take 100 people with a very severe psychotic illness like schizophrenia and look at their parents, you find that they are absolutely typical of the country as a whole. But if you are schizophrenic, you cannot think straight, concentrate, hold down a job. You slide down the social classes and you move to areas like Hackney.
When you get here today you find that the madhouses have gone or are going. Instead there are psychiatrists like me. Many times I'm called up by a local doctor and asked to do what is called a DV - a domiciliary visit to assess the mental state of an individual.
It's always rather a thrilling event. Before I go on a DV I feel a bit like a private eye. I get out my cassette recorder, the key instrument for a DV. I unload it, check there's a fresh tape in the cartridge, load it, put the lock on, have a quick dummy run - for all the world as if it were a revolver.
Then off I go. In fact, I have to spend a lot of my time asking silly questions of people while standing in all sorts of silly places. 'Do you hear voices!?' I shout through letterboxes and up at open windows. I often feel very foolish.
I look for certain features, like the floor. The stickiness of the floor is significant. Early one Saturday morning, for example, we visit a woman whose behaviour has led to the evacuation of the other three people in her block of flats. We knock on the door. She lets me in. The passageway is dark. All over the wall there are little round holes, like the craters of the moon. They are caused by the end of a broomhandle being banged against the walls and ceiling. She says that one reason for her not going out is that upstairs there are about one thousand people assaulting children. She bangs against the wall to stop them. But they go on. And so does she.
The floor is very sticky. One of the reasons for this is that there are six cats living in this house. They're never allowed out. The floor is never cleaned.
There are other things I look out for. In most houses in Hackney, like anywhere else, the TV is never turned off. If I go into a house and it is turned off I get worried. This is because a very common thing among people with mental illness, which is not properly understood, is the way they feel that other people can read their mind. It's very frightening, this - the thought that people actually know what's going on in your mind. It's like being mentally naked in the street. The TV constantly inserts its images and thoughts into our minds and some people come to feel that the news reader is talking directly to them. So they keep it turned off.
For my part, I sometimes think of the film Psycho as I walk up the bleaker staircases to people's homes in Hackney. And there are other things about my job that remind me too much of Ghostbusters for comfort.
But then, we psychiatrists are a pretty strange bunch too. Herman Bosman, a friend of mine, has written about one of his regular clients, who has long resided in a mental hospital. 'They're barmy here,' this gentleman informed him. 'Male nurses, schizophrenics, psychiatrists, paranoiacs, pathologists, homicidal maniacs, keepers and attendants.' Nor were the psychiatrists much better. 'There was one fat mental specialist with a queer glint in his eyes who kept on asking me if I heard voices. He meant when you hear voices and there aren't any. Well, I never heard voices. And if I did, I wouldn't have been mad enough to tell him. And every time I told him I couldn't hear voices, you should have seen the look of disappointment that came into his face. I have the uneasy feeling he heard voices all day long, talking all kinds of blah to him. And he wanted me to say I heard voices so he wouldn't feel so alone.'
Trevor Turner is a consultant psychiatrist.