Yousuf Raza – MHA Caught between Destigmatization & Glamourization
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Yes, in the name of Allah, peace and
blessings be upon the Messenger of Allah.
Peace be upon you, everybody, and peace be
upon you, Dr. Muhammad Azam Khalid.
Peace be upon you, Dr. Yusuf, how are
you?
I am fine, Alhamdulillah.
How is everything going on your end?
Alhamdulillah, everything is fine.
Yes, Dr. Yusuf, so, why this topic?
Yes, that's a very good question.
This topic is important considering that we overdo
our job.
When we talk about mental health awareness, and
we've seen that as a trend, particularly in
the West, and we're seeing that more and
more in Pakistan as well, that so much
focus is put on mental health, so much
awareness is created, that those who don't have
problems, they start having problems there as well,
and the stigma is challenged so well, that
it almost becomes something of a thing to
have, something sought after, something to be proud
of, that we have a mental health illness,
and it should be there.
We have a natural self-victimizing tendency as
human beings.
So, in a way, they also get a
trigger, a justification, and, you know, it's glamorous
to be depressed, it's glamorous to have a
diagnosis, and so that is a problem in
and of itself, that if we only talk
about awareness, and don't address this trend of
glamorization, that's going to be unjust.
But, Yusuf, but this also has a role,
the research that psychiatrists like us have done
over the past few decades, that those who
are depressed are actually very intelligent, those who
look at society very carefully, that's why they
get depressed, those who are manic are very
creative, those who are schizophrenic are very philosophical.
So, we have spread all these myths.
True, true, that is true, that there is
a role of all of these aspects, that
when we talk about countering stigma, then the
people who have experienced or are experiencing mental
health challenges, we paint them in such a
positive light, as if to suggest that it
is the thing.
And those myths may not all be wrong
either, that their truth in its place, the
empirical evidence to support that in its place,
we have also seen in our clinical experience,
that there are people who are experiencing the
symptoms that they are experiencing, or the challenges
that they are experiencing, precisely because they think
about these things differently from the rest.
That their way of looking at things, their
way of looking at society, is very different.
And if we look at it in a
different way, then the issues that exist in
society, to be completely normal in that would
be a problematic thing.
So, I see what you are saying, I
think I am doing just that right now
as I am speaking.
Promoting or in a sense glamorizing, the entire
problem of mental health.
So, why is this problematic?
If a person considers himself to be depressed,
and he is going to a psychologist or
a psychiatrist, then why is this problematic?
Isn't it a good thing that it is
possible that he is really depressed and he
gets some help?
So, why is it problematic?
It is possible that he is really depressed
and he gets some help.
But on multiple accounts, at one level, the
people who are genuinely experiencing problems, it is
an insult to their suffering.
If we develop as a self-fulfilling prophecy,
and this is something that I like to
call the Google Syndrome as well, I don't
know if that's a term or not, but
I am thinking it should be.
We googled or we saw online, that mental
health illnesses are being talked about.
And the symptoms that are elaborated about mental
health illnesses, most of the symptoms we all
have experienced at some level.
So, imagine all this from that, that I
have this too, and then praise that thing
on yourself.
And then create a self-fulfilling prophecy, create
a belief that yes, I am depressed.
And when this belief is created that I
am depressed, then the belief is then going
to give rise to the symptoms themselves.
However, that process works, but that leads for
a person to develop those symptoms, which weren't
there to begin with.
And then it is giving us as individuals,
a justification for being irresponsible, a justification for
not taking care of whatever social responsibilities, personal
responsibilities we may have in victimizing ourselves.
And then that will give rise to genuine
problems, which will then give rise to actual
psychological challenges.
So, those diseases are not there, they have
been iatrogenically, i.e. as a result of
the efforts of doctors, those diseases will be
created.
And that's problematic.
That is something that we don't want to
promote.
Like I said earlier, those who are genuinely
going through those issues, it's an insult to
them that their suffering, or, you know, for
somebody who took it, who learned to have
this from reading so much about it, or
hearing so much about it, or, you know,
it's by seeing how glamorized it is, takes
that upon themselves, then they can start having
genuine problems, their functionality can be impaired, and
so on.
So, but the other extreme of this, that
is just as drastic, that is just as
dangerous, that they don't have to pay any
attention to it, and where the suffering is
legitimate, just to brush it, to do that
kind of work.
So, then there is a problem with both
extremes.
So, then how to judge whether a person,
and how to judge in that as well,
that he is sad, or he really needs
professional help for depression, let's say.
I think that's a very valid question, and
there is no straightforward answer to that.
As psychiatrists, as people who live in a
society where mental health problems are made worse
by stigmatization, that such problems that didn't exist
before, get worse due to stigma.
So, as mental health professionals, it's a responsibility
that we raise awareness, and take a stand
against stigma, that this should not be stigmatized.
But at the same time, it is also
our responsibility that we don't go into it
so much, that we take the matter towards
glamorization, and start exacerbating the problems from there.
So, the first step that I would suggest
as a balance, and I would like your
thoughts on this as well, is that first
of all, we need to identify the presence
of these two phenomena.
These two things are in the society, these
two are extremes, there is stigmatization, and there
is glamorization as well.
And both of these are the losses, and
they are exactly the losses, that have to
be taken into consideration.
Now, for a layperson, who is experiencing life,
and comes across these awareness campaigns, or what
mental illness looks like, on the internet, on
social media, for them to come to a
decision, or for them to come to a
conclusion, that do they have it or not?
Do they need professional help?
Are they just victimizing themselves?
Are they shying away from an actual problem?
It is always important to get another person's
opinion.
It is always important that in the family,
in the friends, it doesn't even have to
be professional help to start off.
Initially, trustworthy members within the community, within the
social circle, if in the conversation with them,
you get a feel of things, that there
is my opinion, which after reading all these
things, obviously, I don't become a professional by
reading stuff written by professionals.
But still, it is a concept.
So, bounce it off of other people that
you can trust.
Get their input.
Get their input.
And if your personal opinion, their response or
feedback, if that is taking you in that
direction, then getting a professional opinion, getting a
responsible professional opinion, may not be a bad
idea to begin with.
One thing that, one other thing that I
would suggest is that before you found out
about depression, anxiety and all of that, you
should look at your life before that.
What was the level of functionality in that?
What was the level of your relationships in
that?
What was the level of your personal sense
of distress in that?
So, get a good gauge of that.
And compare that, when you start to know
about all these things, when you start to
know about all these things, when you start
to see all these things on the internet,
when you start to see all these awareness
things, did that impact my functionality?
Have I started to mess up more now?
So, that comparison will also be a helpful
indicator.
What do you think?
I don't think I can say anything more
than that.
Because you have said enough for us.
But I would definitely say that, as a
psychiatrist or a psychologist, if a person comes
to you with an issue, it is okay
if you tell them that you don't have
an issue, and you don't need to do
anything.
It will take some time.
I have, in my experience, 2-3 people,
I can remember right now, that I don't
have an issue.
I am doing alright.
I am doing this, I am doing that.
But I just thought that I should get
a check-up, to see if I am
okay.
Just like, I have to go to the
northern areas, to get a check-up, to
see if everything is working properly.
So, this over-consciousness, that I don't have
an issue, this too, and in this over
-consciousness, the role of self-help books, that
there are so many self-help books in
the market, that if someone has read 7
-8 of them, and you don't have an
issue, then you can always find 5-7
issues in yourself, that I have this issue,
I have that issue, I have that issue.
It's like, you can make the whole world
a homogenous solution, where everyone is the same,
where everyone is the same.
So, this over-consciousness, this too, we get
to see this too, especially, in this over
-consciousness.
I remember, Azam, from what you said, I
remember, that we had a morning meeting, in
the Institute of Psychiatry, and a patient was
presented in an emergency, and I presented him
in the morning meeting, and after the presentation,
when it was time to give the diagnosis,
after giving the presentation case, we used to
give our assessment and diagnosis, so I said
in my diagnosis, that the patient has no
mental illness, or there is no diagnosis for
this patient, he does not have any, he
does not fulfill any criteria.
So, the appreciation I got from Mr. Fareed,
and the praise he gave, that we have
such a tendency, that if someone comes to
us, we have to leave them after diagnosing.
Not doing that, is such a big deal,
especially, and obviously, I was presenting somebody, who
had come to me in the ER, through
an emergency.
So, to get that, and now that we've
entered into practice ourselves, we come to this
recognition and realization, that those self-help books,
and they are going to sell, if they
make you believe, that you have problems, that
they can solve.
So, the first part of their job, is
to make you believe, that you have problems,
and because they are very effective, in communication
and in marketing, they can make you believe
that, even if it's not true.
But our DSM mentality, as mental health professionals,
in which we put all humanity, and all
people, in some or the other diagnostic box,
has developed a tendency, that even within psychiatrists,
and clinical psychologists, in our practice, we're waiting
for catchphrases.
If someone says, if a person is sad
in front of us, and says, there was
a time, I was very happy, oh, I
was very happy, mania.
What happened?
This is not mania.
That's not what it is.
I mean, in the limited interaction, that we're
going to have with people, we're going to
look for, just these catchphrases.
With some or the other diagnostic criteria, their
dots can be connected, and then put the
person into that box, and start them on,
whatever pharmacotherapy, that we have to do.
So, this diagnostic labeling, even therapeutically, we know,
it's not, until and unless, we're dealing with
very severe cases, until and unless, it's paranoid
schizophrenia, well established, bipolar affective disorder, you know,
severe depression, okay.
There, diagnostic labels make sense.
But short of that, most of the people,
that we work with, clinically and professionally, they
can just as easily, go without a diagnostic
label.
But, self-help books, phenomena, DSM mentality, or
pharmaceutical companies, that, you know, the way they
market themselves, to doctors and to patients, that
has, led to the glamorization, or, you know,
the, you know, making this undesirable.
Okay.
We all do that, in our daily lives.
Okay.
Just, two weeks back, I saw someone, came,
engaged, made an engagement, uh, to me, or,
maybe, we'll see that, session book, maybe, we'll
see that, session book, maybe, we'll
see that, session book, But,
he was anticipating, you know, that's, that's very
true.
See, um, there are certain normal reactions, to,
such experiences that we will have in our
life.
Again, But if we lose a loved one,
whether that's a breakup or an engagement breaks
off or divorce or separation or the death
of a loved one or a serious illness
that comes in the family or the person
is inflicted, there will be a normal reaction
of sadness and it should be there.
That's a sign of good health.
If we have experienced a loss in our
life and we are saddened by that loss,
then that's good.
Not being sad where there is sadness, that's
problematic, there's something wrong going on.
Right?
We don't have to put a number to
it, we know how long it takes people
to recover from this level of life change
or loss in life, depending on whatever it
is.
We all have an idea.
If it's happening more than that, that it's
been a long time since the loss, still
that sadness is not going away, still that
sadness is not going away and now that
our, and we've been saying this from the
very beginning, the line that you brought up
with reference to Freud, the loss of ability
to work and to love, right?
So when that starts happening, then we should
probably take it to a professional help to
get that addressed.
Otherwise, there is no need.
These are challenges that are a part of
life.
We are all sad, we all know how
to cry, we are all afraid, we all
sometimes don't feel hungry.
It's okay.
That's fine.
If the duration is too long and we
start getting impairment on the functionality, that's when
we should probably consider, you know, seeking out
professional help.
If we talk a little more about what
we talked about in the beginning, we see
that a lot of people, especially those who
are related to literature, poets, scientists, those who
are related to any creative field, it looks
like they have a higher frequency of mental
illness.
So do they have any connection to this?
I do feel that there is, and we've
seen evidence of this as well.
There are multiple researches, although there can be
contradictory results, but we do find evidence that
a lot of creative people will have a
greater vulnerability, a greater tendency towards mental illnesses
as well.
The other side of the story is true
as well.
In experience of mental illness or a mental
health challenge, it sets the stage for you
to look at the world in a different
way or look at that side of the
world that other people will not notice.
And that adds to the creativity and that
contributes to how creatively or how much novelty
you can bring into the world.
So I conform to that.
I do feel that that does happen.
So, Yusuf, does everyone who is depressed or
sad, should they also start writing poetry when
they are sad?
Creativity is not just poetry, but I will
say this much.
There is an expression that poetry allows, that
art allows, that music allows, that language in
prose does not allow.
And if the expression of our emotions can
engender a level of satisfaction or a level
of growth in our mental health, then it
is a very good idea to have that
aesthetic side of ourselves, which is our aesthetic
dimension as human beings.
To make some arrangement for that is a
very good idea.
Even in the routine, we don't have to
wait for us to have a neurotic break
or a breakdown for us to come to
that realization.
In a lot of people, a breakdown such
as that is a sign that you have
this ability and it is necessary to bring
it forward.
In a lot of people, it doesn't have
to be all cases of depression, but in
some people that is true.
So why not?
There is a link there.
But that's not all curative.
If you start writing poetry, depression will be
fine.
Okay.
So, Yusuf, the title you gave was glamorization
and stigmatization.
Isn't it that the
cause of both of these is a very
big self-awareness or
self-criticism?
That's a wonderful point.
Thank you.
We know for a fact that, for example,
Frankel gives this example that a patient came
to him who was a very wonderful violinist.
He used to play the violin very well.
And one day he thought, why don't I
take one step at a time while playing
the violin, what is the first step?
What is the second step?
How do I keep my hand first?
And he's like, he had decided not to
play the violin.
He became so hyper-focused.
One such thing that was on the periphery
of his focus, let's say, he came to
the center of that focus in such a
way that he couldn't work at all.
And those of us who have learned how
to drive or any of those motor skills
that we have adopted, if we start thinking
so much about them, that anxiety, that tension,
this is what happens in stage fright as
well.
This is what happens in public presentations.
This is in most public performances.
If we start doing this, then precisely what
we want to do will not be possible
due to this hyper-focus.
And that's one of the ways that emotions
work.
Especially if we keep this concept in mind,
the way happiness, how Frankl defines happiness, that
it is a by-product of genuine pursuit
of meaning.
That in your social life, in your personal
life, if there are any meaningful activities happening,
if there are any genuine achievements happening, then
as a by-product, happiness will come.
If we make that by-product a focal
goal, then it becomes more elusive and more
evasive.
And that is true not just for happiness,
that is true for depression.
If a person starts doing his self-diagnosis
daily, that I was sad today, I was
sad today.
Now that sadness, just putting yourself under the
microscope, has magnified it more than what the
experience actually was.
And we have to, in a lot of
ways, when we are addressing mental health challenges,
identify how mental health improvement comes from a
lot of indirect channels.
The more we catch depression directly, and start
fixing it with both our hands, that's precisely
what is going to increase the depression.
And we know that for obsessions as well.
Even in OCD, if we catch the obsessive
symptoms and start going into it, and start
making it more of a focus of attention,
the obsession needs this to get worsened, to
get exacerbated.
And the greater focus in a lot of
our therapeutic strategies as well, the people who
are coming to us with these emotional challenges
having become the center of attention, is to
try to bring the other dimensions of their
life into focus, bring the rest of their
family into focus, bring society into focus, bring
a higher purpose or cause into focus.
And we find that when those things do
become a focus, as a byproduct, as a
side effect, mental health challenges or mental health
problems or symptoms also start improving.
So, as campaigners for mental health, we need
to also know when not to focus on
mental health and when to focus on the
other dimensions of the human being, all of
whom, there's a confluence within our emotional experience
from all of these different dimensions.
So, Yusuf, a very obvious question that you're
seeing will arise, what should we do and
what not to do?
If you can, the many vague things you've
said, if you can put them into bullet
points, what to do and what not to
do, so that we can move towards the
questions.
Okay, before I go into this, before I
answer your question, I do feel that whenever
we talk about stigmatization, we need to balance
that out with identifying the phenomenon of glamorization
as well.
But when we talk about glamorization, we also
have to come back and refocus and identify
stigmatization as an issue as well.
I don't know if we've been able to
speak about this in the past or not,
but stigmatization, especially in our society, exaggerates and
exacerbates many psychological problems so much that for
an individual, manifesting with physical symptoms, that their
depression is manifesting as physical symptoms, is more
acceptable, is more acceptable as compared to coming
in the form of overt sadness or crying
or, you know, psychological symptoms.
So, to put it another way, that in
Pakistani society, psychological problems are more likely to
come in the form of physical symptoms.
More pains, more digestive problems, more loss of
functioning in a particular part of their body,
and what is its root?
What is its origin?
Psychological problems.
Why is this more in our society?
Because no one will lift psychological problems, no
one will appreciate them, no one will pay
attention to them, the solution to the problem
will not be that way.
It is more likely that physical symptoms will
be addressed.
Not that anyone does that deliberately.
This is a way of our psyche, that
I need help, and I need problems to
be solved.
So that's how much of a role stigmatization
plays in the worsening of psychological problems.
So, this I wanted to say before we
move on.
Now, to answer your question, see, first up,
we need to know that there is stigmatization
which leads to mental health challenges.
The second thing we need to know is
that there is glamorization as well, in identifying
how much attention is being given to this,
and that this may be a way out.
We have the tendency to victimize ourselves, and
we may resort to a diagnostic label.
And I have actually gotten this from one
of my collaborators.
He said that he had ADHD.
After a lot of back and forth, when
I convinced him that he didn't have ADHD,
he said, okay, then I'll have to work.
So that in itself is betraying a tendency
within us that how these diagnostic labels give
us a clean chit.
So awareness of both these phenomena is important.
Both these tendencies are present in our society,
in our individual selves.
In the third step, self-diagnosis, that's
how the process will start, understandably.
We start with ourselves about what we think
about it, what our opinion is, what our
conclusion is.
But it shouldn't end with that.
To corroborate it, to get feedback on it,
to acknowledge it, to confirm it, or to
reject it, we should be open to other
people's input.
And that input can come from reliable and
trustworthy sources within our families and friends.
If the level of distress or problem is
even higher, then we should look towards responsible
mental health professionals.
And responsible mental health professionals should recognize that
our job is not only to diagnose, but
where diagnosis is not possible, it is also
important to explicitly state that there is no
diagnosis.
Okay?
So now we're ready to move on to
questions, Azam?
Yes.
So I'm going to take the seat of
the journalist and now you can become the
one answering the questions.
Very funny.
So I was asking, what are some of
the traits, you tried doing that again, didn't
you?
What are some of the traits to identify
if someone has victimized themselves?
So, well, I think you've already given the
answer.
It's not going to be a straightforward answer,
but you would have to look at whether
the judgment you have on yourself is warranted
or not.
The second thing is, is the person evading
any responsibility?
And then, what are the effects of that
victimization on their life?
If you think he's gaining something, but not
losing anything, then you should be suspicious that
his victimization is not deliberate.
As far as the matter of victimization is
concerned, which is not deliberate and is unconscious,
then the question becomes more important as to
why this is happening.
Because there might be something that is really
his right and he's not getting it.
And here, what I mean by right is
what we call private gains.
They are mostly of those categories.
They have respect, affection, love, which they should
get from others.
They should get it from their relationships or
people around them, but they're not getting it.
So, there cannot be one straightforward answer that
this will happen, and that will happen.
You have to look at all these domains.
Most likely, I think it's important that if
we do this conversation with ourselves, that I'm
not victimizing myself, and for its corroboration, I
should talk to others.
But we should refrain from passing these judgments
about other people.
Look, he's victimizing himself.
I don't think that's appropriate.
Even if that victimization is coming from someone,
then as you said, a genuine need that
is being denied to them, that may be
the reason.
So, before passing this judgment on someone else,
you have to do FCPS psychiatry.
And for that too, they should give you
this right.
Even FCPS psychiatrists go to society randomly and
say, oh, look, victimizer, oh, look, borderline.
No, this is a right that you have
only if somebody gives it to you.
And for that, they have to pay you.
And they have to sign up for that.
Okay, now I'm opening myself up to your
clinical judgment.
Go ahead and make it.
Okay.
All right.
Anaya is asking, Azam, what is the difference
between grief and depression?
Is it just a level of functionality?
So, yes, functionality is very important.
But functionality, in itself, does not affect.
It affects the severity.
So, grief is a normal, expression of any
loss.
And it should be.
If it's not there, then it's abnormal.
And I said, any loss.
So, any loss.
It could be the phone call or grief.
It's very cheap, but still.
So, but, but, but, but, and still depression
at least in its initial
stages where it is at its peak can
mimic depression but grief subsides and the person
returns to his functionality but in depression it
will not be like that, it will be
persistent and severe but
in depression we may not be able to
make that connection but Yusuf, after the death
of a loved one, it can also be
depression even if that is visible, but we
cannot diagnose it as depression without giving it
2 weeks of normal grief
we
cannot diagnose it as depression but loss of
ability to express love and care is normal?
No, it is not normal because love and
care are human functions it is just like
if my car is running on 3 gears
and 4th is not, is it normal?
No, it is not normal because for any
human, he cannot fully express his potential until
all his gears are working properly and love
and care is one of the most important
gears of any human like Azam said, it
is a joke but it is an accurate
depiction of what goes on in our society
there are certain professions that are designed to
take that away from us but on a
serious note, it is necessary for their profession
if a surgeon starts caring in the sense
that if he doesn't hurt anyone, he can't
work a certain type of ruthlessness is
necessary for you what
are a few things a person having a
fearful avoidant attachment style should work on to
improve?
the relationship is maybe between a mother and
daughter or anyone in a social space Hussna
just read Mary Ainsworth and asked you a
question I would be very cautious there Hussna
in being so definitive in saying that I
have a fearful avoidant attachment style even as
a specialist, as a psychiatrist or a clinical
psychologist I would not make that judgement for
myself or about myself I would take it
to another professional I would take a session
from Azam and talk to him and then
I would ask him to tell me is
my suspicion correct or not correct I wouldn't
self-diagnose even as a mental health professional
I would always fall back to another professional
and then once they confirm or disconfirm or
if it's a manifestation of another problem then
I will proceed from there make sense?
I hope that helps answer your question Yusuf,
just one thing how safe is it to
do a diagnosis?
I think I will say it as many
times as you'd want me to say it
do not put labels to yourself do not
attach labels to yourself even I would implore
mental health professionals most of the people that
you're dealing with probably don't require a label
or a diagnostic category either a very small
percentage does when we put someone in a
diagnostic box then we ignore their personality, their
life, their multiple dimensions of what has not
come in front of us we don't take
care of that when that label is attached
to someone we know that patients of schizophrenia
don't get physical or medical help adequately simply
because of the label when they go to
a physician whether they are in Europe or
America this is empirical evidence from across the
board just because of that label all their
symptoms are explained in that label even their
genuine physical problems are not adequately expressed so
just to use that as an example I'm
not saying that who has schizophrenia shouldn't be
called or shouldn't be given the diagnosis of
schizophrenia I'm saying that we should avoid the
possibility that if I give a diagnosis to
a person that person is depressed or this
is a borderline personality disorder then all my
subsequent interactions with that person they won't be
able to see anything beyond that and until
I can't see them I'm not going to
be able to help them become more than
that diagnostic label rather I'm facilitating in reducing
their life to that and just that and
we've seen the devastating consequences of that in
our practice we don't want to do that
all right so I think we're done for
today Azam, we call it a wrap thank
you for all the wonderful questions people and
if you I think there's a couple that
we did leave out but feel free to
reach out to us in our inboxes and
we will see how best we can help
you out with those questions and with this
our campaign for Mental Health Awareness concludes finally
now what we are going with this campaign
was an initiative of Telepsychiatry Pakistan which despite
my minimal involvement and Azam's minimal involvement our
team, our mental health coaches my media team
worked very hard to share content with you
all we had talks in different places with
different audiences spoke about mental health raised awareness
as best as we could so full credit
to the team for doing a wonderful job
I wouldn't there's so much that would not
have been practically we didn't even know what
was going on to be honest so much
was going on Dr. Samia Iqbal Dr. Omar
they've been going around giving talks Afifa, Fatima
Dr. Maryam Javed despite a lot of personal
okay thank you all Allah Hafiz