​Not so ethical conversation…the unanswered questions
 
For any psychiatrist , a patient in complete remission and back to full range of functioning is a mark of work satisfaction.
 
Sunita ( name changed) is a 38 year old lady who gives me the reasons to qualify for above. She was married at the age of 28 yrs and the stress of marital duties unmasked her schizophrenia 2 years into her marriage. This resulted in her being scorned and abused. She did not get any support resulting in her illness becoming worse. There followed serious of hospitalizations culminating in her husband divorcing her.
 
Post returning to her parents, Sunita began to get proper, consistent treatment and support. She recovered rapidly; has been in full remission for past 4 years. She now is also employed.
 
About 6 months ago She expressed about her desire to remarry. She was forthcoming that she longs for companionship and was trying to convince her parents who were hesitant, for they remembered the wretched life she had to undergo in her previous marriage.  I, on my part was supportive of the decision if her would-be husband is made well aware of her illness and is willing to support her if she needs help. I emphasized to her parents that a loving and supportive partner can indeed help improve her quality of life further.  Thus satisfied they all began to look for a suitable groom for her
 
Recently, Sunita informs me that she has found a 42 year old gentleman Ramesh (name changed) whom she wishes to marry. Ramesh visited her house along with his family and they too have expressed their agreement for this match.

Midlife Crisis in Indian Women: notes from the private psychiatrist’s desk.
 
Recently I have taken to filing the slips of paper on which I write down my patients’ history, my impression and the treatment plan. Try as I might.. I could not really take down history in Maudsley format on the ever-present laptop in my clinic. This is largely so because over the years I have only gotten faster in surfing but the typing remains 2 finger, clumsy and slow. Coming back to the filed slips, which I periodically browse – it seems revealing that there is a pattern of presentation in a subset of my women clients.
 
These women mostly their 40s present with somatic symptoms and do better with lengthy appointments and detailed medical examination (I know you are thinking that medical examination should anyways be done for all patients – what I mean here is that there is deliberate slow and comprehensive medical examination). Another way of putting this across would be to state that the comprehensive medical examination by doctor appears to be endorsing and therapeutic.
 
We are all long aware of the fact that the women in India are more likely to present with somatic symptoms. But this awareness applies to all ages and of course with a slightly lower extent to men as well. The pattern I notice however, is that these women are actually well adjusted in their marital lives, have loving children and caring husbands. There is absence of any financial, interpersonal  (read as ‘in-laws’) or kindling mental illness which is responsible for their presentation. Often family presents the case as ‘There is everything (luxurious amenities) in the house, the husband is on a good position and the children are now in college – she has lack of nothing!’
 
Now, a lot has been written on midlife crisis in men since Elliott Jacques, the Canadian psychoanalyst coined this term in 1965. There have also been articles in media about midlife crisis in Indian men, but there is not much attention given to Indian women. Most of the articles talk about managers and IT professionals but not much about the Indian housewives.
 
In a typical scenario, the woman after marriage gives up her career to take on the duties of managing the house. Soon a child comes along and there is no time to rest – she works nonstop managing cooking, cleaning, laundry, school related chores for the next 10-15 years.
 
Then, comes a stage in the life of the family where children are into adolescence and it is no longer ‘cool’ to hang out with parents, whom they actively seek to shut out from their private world. College hours are longer and mummy is not needed to help with academic chores. Around the same time, her husband is in a senior position in his organisation or the business in busier. This requires him to stay away from house for long hours. In fact, if she does seek some intimacy from him, he finds it odd as he is used to his wife being ‘busy’ in the household chores. The woman finds herself in a situation where she feels ‘un-needed’ and deserted. She has no career to fall back on and the people whom she had kept in the ‘center-of-her-universe’ no longer do the same for her. This existential distress is very unnerving and it is possible that being in a ‘sick-role’, and its resultant resumption of attention towards her from the family helps validate her ‘importance’ and hence reassuring. Recovering now will her put her at loss! Additionally, an excess of free time available in this stage of life – provides opportunity for brooding and ruminating.
 
Recovery is in minor increments, yet missed appointments are fewer. A change needs to happen in their life circumstances for actual recovery to occur. I find that discussing the above referred dynamics helps in her getting acknowledgement and appreciation for her sacrifices. I have also found that encouraging her to indulge in small pleasures (which she may have denied herself for the sake of family) and learning new skills is redemptive. These Indian women who live in ‘sacrificing or deny-self-for-others’ mode receive very gleefully the opportunities to use Whatsapp, Facebook and other opportunities to socialize. Resultant, marked improvement in their symptoms contributes to our work-satisfaction.
 
If we as clinicians are aware of this phenomenon which plays out in Indian cultures, perhaps there will less psychopharmacology and its consequent harms, better rates of recovery and joy for all stakeholders. If other professional colleagues also can identify a similar sub-set of patients in their clinics - this calls for a formal scientific investigation.