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May 07th 2017 print

George Thomas

Encouraging the Unwell

Being smart doesn’t make psychiatrists, as a body at least, immune to irresponsibility and foolishness. One of author Tanveer Ahmed's pet peeves is the way every mental affliction, from sadness upwards, is being medicalised, labelled a condition and therefore in need of treatment

Fragile Nation
by Tanveer Ahmed
Connor Court, 2016, 212 pages, $24.95
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Tanveer Ahmed demonstrated his commonsense optimism in his memoir The Exotic Rissole (2011). That book ended with his success, on the third attempt, to convert his medical degree into qualifications to practise as a psychiatrist. Fragile Nation is his report on the mental state of the nation, based on his subsequent professional experience.

The first and most obvious thing about the book is that it is surprisingly cheerful and hopeful. Ahmed is fascinated by people and by the challenges his work presents. His predominant theme is that his patients are not helpless victims, no matter what the cause of their suffering, but people who have somehow lost the ability to live fully. He sees his task as guiding them to ways of rediscovering the ability to cope with life’s vicissitudes.

He finds that such guidance, offering a proper balance of sympathy and firmness, and reminding his patients of the rewards and penalties that are the consequences of their behaviour, leads in most cases to satisfactory improvement and allows his patients to get on top of their problems and resume normal life. He attributes their recovery to “their extraordinary courage and grace in the face of tremendous adversity” and their “wide variety of responses to crafting a meaningful life”.

He does not claim to cure his patients. He can only show them how to cure themselves; which is where the courage is required. This is one crucial way in which psychiatric medicine differs from medicine more generally. Physical ailments are cured largely by following medical advice and waiting. Recovering from psychiatric ailments takes courage.

The courage psychiatric patients need is not the passive courage they may have used to try to put up with their troubles, or the destructive courage they may have used to lash out wildly in desperation, but the positive courage that draws on their virtues and recovers their full humanity. It must be truly encouraging to people at the end of their tether to be shown how they can make their way forward again using their own inner resources.

Ahmed recounts a wide variety of his cases, across a range of social classes, ethnic groups and geographical areas. He approaches each patient as an individual with unique circumstances. He is not bound by theory. While he has studied and read widely and continues to do so—the fifty or so references in the book would supply a year or two of fascinating and instructive reading to most of us—he does not try to fit his patients to his theories, but rather uses his theories where they can help each patient.

He explains, for example, that while the usefulness of prescription drugs has its limits, drug therapy can work in many cases. Patients suffering from their own damaging behaviour brought on by anxiety can often be treated with anti-depressants. Where their anxiety has led to bad mental habits—severe neuroses, we might have said in the past, but Ahmed does not use that term—and the bad habits in turn have intensified the anxiety, a course of anti-depressants can take away the anxiety, and the bad habits, for a few months while Ahmed brings his patients to an understanding of where they have been going wrong and how they can avoid relapsing in future. A bad habit can be extremely difficult to break, but an encouraged person who has broken a bad habit and understands its dangers can avoid a relapse relatively easily.

Of course, I am simplifying, just as Ahmed has simplified in order to explain his work to people like me. Despite some idiosyncrasy of expression this is a very readable book, especially considering that psychiatrists are an elite among the elite who practise medicine.

Still, being smart doesn’t make psychiatrists, as a body at least, immune to irresponsibility and foolishness. One of Ahmed’s pet peeves is the way in which every mental affliction, from sadness upwards, is being medicalised, labelled as a condition which therefore is in need of psychiatric treatment. Happy people tend to function better at everything. Sad people can find all aspects of life difficult, especially if their sadness has persisted for a long time; but that doesn’t mean they have a mental illness.

Ahmed points out that PTSD diagnoses, which have been useful in treating those who suffer severely from war-front experiences, have widened in recent years to take in people who have experienced something from the normal range of upsets we all have to deal with: “a distressing image on television, a serious health diagnosis, to even normal experiences such as giving birth”. He is dubious about the mental health claims of asylum-seekers in detention. Why, he asks, would people who have survived war, persecution, displacement, hunger and fear, and made perilous journeys across the sea, suddenly “fall in a heap when a fence was placed around them” and they are secure, sheltered and fed? Are such places so intrinsically damaging for children, as we are constantly told? He quotes one former child inmate who doesn’t remember feeling traumatised: “We just played. We didn’t know it was bad.” Ahmed points out that the genuinely difficult part for asylum-seekers is coping with extended periods of uncertainty about their future, being unable to plan for themselves or their families, whether that time is spent in detention or in the community.

Sadly, there are many incentives for discontented people to claim mental affliction, and many people in the “caring” professions who think it is their duty to help them do so. Ahmed’s patient Angelo, for example, was “able to maintain a highly structured daily routine, planned meticulously” yet “was socially withdrawn, had strained family relationships, lacked motivation to work and often suffered disrupted sleep”. On the basis of those commonplace symptoms Angelo’s GP certified him as “depressed”, and so he was able to receive income protection. It could only happen “in wealthy countries like Australia”, says Ahmed, “where insurance was paying him to remain unemployed and conduct an alternative lifestyle”.

Another example is the supposedly abused wife in an arranged marriage. Arranged marriages are common among our migrants from the Middle East and South Asia. In many cases a great deal hangs on the success of the marriage: her (it’s usually a woman) family back home are relying on her to send money back to them, and perhaps hoping her success in obtaining Australian citizenship will help more of the family migrate in future. If the marriage fails, which is also common, she can retain her migration status if she claims to have been abused by her husband and has suffered as a consequence “a diagnosable medical condition”. “It’s quite an obscure loophole in our rules,” Ahmed observes, “but one that migration experts are all too aware of.”

Ahmed believes that drug addiction, like many other mental afflictions, is “more a bad habit than a disease”, and points out that most illegal drugs do not cause addiction in most people, and most of the people “who overcome addictions do so with no formal treatment”:

Like being overweight, addiction results from the incremental build-up of multiple decisions over a long period of time, usually in the form of reducing some kind of pain or distress in the short term as opposed to taking on the much harder process of confronting larger problems or inadequacies.

In treating addicts he finds it most effective to allow them to regard their addiction as a disease at first, in order to win their confidence and get them into treatment. Then he introduces firmness to balance the kindness, and sets them some clear goals. “Treating addicts like fragile victims of disease,” he says, “disempowers them and helps no one.”

The most worrying chapter in Fragile Nation is the one on teenagers. Most people, at some stage in their adolescence, when their bodies and minds are changing and they are trying to come to terms with the challenges and imperfections of the world, can be sensitive and fragile. Social media, which seems to offer them community, in fact tends to isolate them from the people and the world around them—their real community. At a time when they need to be gently buffeted by new ideas and experiences so they can develop powers of discrimination, tolerance and resilience, they are instead retreating into something resembling the protected world of childhood, where they encounter nothing to disturb their feelings or opinions.

Given the manifold pressures on today’s teenagers that Ahmed enumerates from his experience, the social media phenomenon tends, he says, to be an intensifier of problems rather than a cause. But as a former headmaster told him, teenagers are not the best people to handle smartphones: “They’re P-plate minds with full access to V8 technologies, sometimes a recipe for disaster.”

Tanveer Ahmed and his colleagues are certainly not going to be short of work in coming decades.

George Thomas is deputy editor of Quadrant.