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Trevor is joined by Dr. Vihang Vahia, a psychiatrist in Mumbai, India, and founder of the N.S Vahia Foundation. Vihang discusses mental health and psychiatry in India and the stigma that exists in the country.
Vihang also discusses the collaboration between McLean and the N.S Vahia Foundation, as well as his future hopes for the partnership.
Trevor: So what day is this for you here? Three? Four?
Vihang: No, I’ve been here now for eight days. More than eight days, nine days? Yes.
Trevor: Nine days? Yeah. Oh yeah, how are your dance moves coming along?
Vihang: Oh, you’ve got that, yes. My granddaughter has been teaching me how to dance, and she’s abandoned the whole notion. She’s given up on me. Now my grandsons are teaching me all the music of Lion King. So, I’m all into Lion King at this point in time.
Trevor: Right. Now, is it your dancing, or does your granddaughter just need to learn patience? Maybe you are a good dancer, and she just doesn’t have the capability to see it yet.
Vihang: I know. The elder one has abandoned my dancing skills completely. She’s seven, and the five-year-old says maybe the next time I come, she would have learned how to teach me.
Trevor: You might need the proper teacher?
Vihang: That’s right.
Trevor: Okay. So you’re having fun visiting your family?
Vihang: I think the grandchildren are the best anti-grief.
Trevor: Talk more about that.
Vihang: I lost my mother recently. And I was in the U.S. when my mother passed away. So my first reaction was to rush back, but I couldn’t have reached for the funeral. I mean, they would have had to preserve her for me to reach there and my brother and I thought that was not the best thing to do. So he went ahead with the funeral. We have cremation in my community, and I stayed back, and I was with my granddaughters, and they could see that I wasn’t quite myself, and they took it upon themselves to make sure that I’m cheerful. They’re just seven and five, so they got reaction, but it worked.
Trevor: What did they do to cheer you up?
Vihang: Oh, they would sing, and they would dance, and they’d make me dance and talk about food which I like and genuinely kind of be laughing and make me play with the dolls. And my grandson, for example, he left a toy car with me to play with when he goes to the school so that I don’t feel lonely. Yeah, he’s done it and is McQueen for me to play with, and that’s McQueen for him is like the Nobel prize, but he’s left it with me.
Trevor: Can you think of any better way to deal with grief than that for you?
Vihang: Well, at this point in time, I think work is the best anti-grief rather than sitting back and getting nostalgic. To be engaged in something to do ahead and the kind of feedback that we had and the kind of meetings that we have had, they’re immensely positive.
Trevor: You seem to be handling it well.
Vihang: Well I should like to think so. Yeah.
Trevor: Yeah. I’d be a mess.
Vihang: It’s my profession to control them.
Trevor: But you’re also human.
Vihang: Well I am human, but well, we have the satisfaction of having done all that we could from my mom for the last three years that she wasn’t quite well. I used to visit her twice thrice sometimes six times a week and sometimes twice a day when I had to and I think we managed to do pretty well. She went happy. She went smiling.
Trevor: That’s good.
Vihang: That’s good.
Trevor: Smiling’s good. Yeah. So, how many more days do you have, or are you going to stay around in the area for a while?
Vihang: I’m scheduled to leave on the 23rd of October.
Trevor: And where are you off to next?
Vihang: I’m going back to Mumbai.
Trevor: Do you travel a lot.
Vihang: Well, I do. I do travel a lot. Both my sons are in the U.S., and I travel a lot for work and talks.
Trevor: Yeah. Do you like that?
Vihang: I love it.
Trevor: Yeah. You like to be moving around?
Vihang: I like to be moving around. I like to be meeting people. I like to be interacting with people, like to learn new things, new food, new people, new knowledge, sharing knowledge it helps.
Trevor: I’m the opposite. I like to stay home. Same food. No new knowledge. I kind of like the same thing. I’m not much of a traveler. I’ve only been outside of the country a few times, and one of those times was Russia of all places. Yeah, I know. You gave me a look. But no, I’m sure I should probably heed some of your approach because that sounds like a way to have a more enlightening experience out of life.
Vihang: But you are an intense person the way you have designed this studio.
Trevor: I am intense, that’s true. How did you get that?
Vihang: That’s my job to assess people.
Trevor: Yeah. I am intense, and I think because of that, I tend to isolate.
Vihang: A lot of people who are cerebral more than physical are very intense, and they don’t travel as much as I, for example, do.
Trevor: Yeah. You couldn’t be more accurate.
Vihang: Yeah. Thank you.
Trevor: Yeah, that’s exactly it. I think probably because of my intensity, everything, not just myself, but everything feels so intense except home with my cat. Yeah. So it’s a little too much.
Vihang: Well, I understand. I mean, that’s the way people are.
Trevor: Not everybody, but a lot of people. Yeah.
Vihang: So there’re kinds and kinds of people. It also depends on your profession. And what you’re required to do in your line of work. Like my line of work is with people. I need to understand people. I need to understand how people think. I need to understand how people deal with stress in life. I belong to a profession where I need to repeatedly tell people that you can’t have life without problem. In fact, life without problems will be so boring. Absolute monotonous.
Trevor: It might be the worst problem.
Vihang: Yeah. So you’ve got to have new things happening to you that require you to adapt to the new situation. And I need to tell people that I learned over various experiences, including experiences when the flights are delayed, and the way people respond to delayed flights is never say, “Oh my God!” Say, “Okay, let’s deal with it.” And that’s probably a culmination of my exposure to yoga, Indian philosophy, my parent’s teaching, my own profession. My patients taught me this, patient’s relatives taught me this; is you can’t have life without problem, and life cannot always be predictable. And the way to be happy is not to get swayed when you are stuck with something that you didn’t expect, but to say,” Okay, let’s deal with it.” Not, “Oh God! Why did it happen to me?” Point is, it has happened. So let’s find ways of dealing with it without falling apart.
So how does one prepare to deal with problems and not fall apart? So one is what you learn with your own professional training, your own experiences on what patients have told you, what you’ve seen in your patients, what you’ve seen in yourself, what you’ve seen in your close family members, what you’ve seen in your own children growing up. In my case, even my grandchildren growing up. There are some people who are genetically predisposed to be not able to handle stress on uncertainties in life. And they are the ones who get into what psychiatrists so lovingly label as bipolar disorder or schizophrenia. But the point is we are dealing with an era of depression and you would find every single professional authority saying that, including the world health organization, depression is by far the most common morbidity of mankind and people said that 18th century was the century of inventions, 19th century was the century of progress, 20th century was the century of anxiety.
And the way things are moving, we’re probably heading for a century of chaos, and we’ve got to learn to deal with it. We can’t fall apart, or we can’t succumb to what the reality situation is, we’ve got to learn to live with it and come out stronger. Every time we deal with a problem, without falling apart, we come out stronger and deal with more intense problem the next time. And will there be a problem next time? You bet there will be. You can’t have life without problems. Life without problems will not be worth the next day of your life. You have to have problems. You got to able to find ways out of it, come out victorious and take on the next problem. That’s happiness.
Trevor: Is this a foundation of something that you communicate to your patients? Because you and I have extremely different points of view about how to handle a problem and I need to adopt your line of thinking because that’s far more effective and far more serviceable not just to myself but to society as a whole. It sounds like dealing with these problems, we’re all in this together, and it’s less about the individual.
Vihang: So everybody likes to be praised, and you said nice things about me, and I like it, but the point is there’s never a complete right or wrong in this world. None of us is 100% right or 100% wrong—
Trevor: Oh boy. I can’t handle that at all. I need the world binary.
Vihang: Life is not binary, and life is not a binocular region also. Life is not just what’s in front of you. Life is what’s besides you. And the common metaphor I cite to my patients is I ask them, “Do you drive a car?” And everyone says, “Of course we do.” So I say, “Okay, let’s see what are the steps that you follow when you start driving a car.” So it all begins with switching on the engine. And I would say, “Before that.” And before that is you get into the car. So I said, that’s like getting into the problem that you’re facing, and then you switch on the engine. And I would say that’s like setting your mind thinking in the direction of where you want to go. The third step is to take off the handbrakes, and that’s probably the most important lesson in life.
Is that whenever we face something that we are not happy to be faced with, the tendency is to go into fault finding. Who’s to blame for my problems today? And I tell them it doesn’t matter who’s to blame. You can’t go back in life, go back in time, and change things. Things have happened, and you’ve got to face it. So the next step after you have taken off your handbrakes or released the handbrakes is that you adjust your rearview mirror because you got to know what’s behind you. You got to learn from your past experiences. You got to have your side mirrors because you got to know what are the issues that you’re going to face alongside, but you got to be focused on what’s ahead of you. Whereas driving a car, if your attention is on the rearview mirror or on the side mirrors, you’re going to bang into a big obstacle. You can’t do that.
A wise person is focused on what’s ahead of him or her, whereas being completely and totally aware of what’s behind you and what’s by your side so that you negotiate your path and get the best out of your car. Life is exactly like that. You can’t lead your life looking at the past. Life is too short to dwell in the past, good or bad. But it’s important to learn lessons from the past, good or bad, and release the handbrake. Don’t get stuck in the past. Think of what’s ahead and no matter how bad the road ahead, if you’re cautious and careful and if you go at a proper speed, you can always negotiate your car to diverse out the bumpy roads without getting hurt, that’s life, and that’s the way you live life. That’s a part of the oriental philosophies of meditation and yoga. Yoga is more intense. Meditation is more contemporary, and the principles of meditation are at par with what we lovingly in the oriental culture call the Western medicine, which would essentially mean the British and the American kind of mental schools of thought.
And the philosophy is that whenever we are under stress, we get anxious, and we lose our sleep and we start thinking of a whole lot of things, which are sometimes over-inclusive or too tangential, but the wisdom is to be focused and learn what are the streams of thought or the kind of thoughts that are adaptive and distractive. And this discursion can be controlled by tangibly school of meditation. There are multiple schools of meditation. One of them says that, and a person is ... He does whatever the person does in life. The environment responds. So people around you either praise you for what you’ve done or find fault with what you’ve done. So when you do whatever that you do, you either fail or you succeed. Success is good; failure is better.
Trevor: Are these core values that are communicated are a part of the N.S. Vahia Foundation?
Vihang: We do. We do multiple things in N.S. Vahia Foundation. So, we have the—
Trevor: And if you can go into a little bit of the history of it too and how it started.
Vihang: The N.S. Vahia Foundation, it’s interesting. In the year 2007, my father was seriously sick. He was recovering from a subdural hemorrhage, a brain hemorrhage, and I had to go for a presentation in Chennai from Mumbai. So the physicians looking after my father said, “Go ahead and do your work and come back.” And I went to Chennai just for a day, and as I was at the conference, some of my father’s students came up to me, and they said that, “We can’t let the memory of Doctor N.S. Vahia go unrecognized.” The story is that Doctor N.S. Vahia was the son of a village postman, and he was hand to mouth all his early life. He came to Columbia to study psychiatry, which was not a very well-known branch, and then he came back, but even in that era, in 1947, he brought an EEG machine back to India with him. And then, he started the department of psychiatry at the KEM hospital, which is a general hospital in Mumbai, which happens to be the first general hospital department of psychiatry in the country.
Before him, psychiatry was in mental asylums, and his department had an EEG machine before the neurology department of the hospital had an EEG machine. So he was a man despite being trained in psychoanalytical psychiatry, was aware of the brain, and the role of brain in mental health and mental illness. He pioneered the concept of adopting some techniques of yoga and meditation in the treatment of anxiety disorders. The Indian population wouldn’t respond well to psychoanalysis, but there was this some kind of exposure to the concept of yoga and meditation in almost all Indian population. Yoga is more intense, and it has a bite of connotation of religion. Meditation is free of any religious connotation. So my father and his team adapted meditation in the management of anxiety disorders, this was around the time when chlorpromazine had just been invented, so psychosis was being treated with chlorpromazine and ECTs, but anxiety disorders and hysteria and dissociative disorders, which are pretty common, were treated with meditation and Indian version of psychotherapy as it were.
Trevor: To positive results?
Vihang: With markedly positive results. There were some who were more interested in the mindfulness theories of Buddhism, which is in some ways similar with minor differences, but in India it was meditation that helped or just schools of meditation, my father adapted pathologist, because it was close to the contemporary theories of mental illness and the concept of mental health. During his life in the year 2006 that was a year that I was alluding to I and a group of my colleagues, we had set up a kind of a journal club. We used to call it psychiatry CC, CC meaning current concepts. So we believed that unless we continuously brush up our knowledge, the level of knowledge freezes at the last qualifying exam, and we got to keep us as updated with the current concepts. So we call it this psychiatry CC. It was a group of 20 people who met once in a month, actually once in six months, and discussed the newer things that we had learned or read or heard.
Trevor: And let me clarify real quick, is mental health in India, is it growing exponentially or is it on a steady rise? Where is it at this point as the foundations had been established?
Vihang: Lots of things have happened. This foundation had a role to play in that we taught our colleagues to come out of the, what I call eminence-based psychiatry in that what the teacher says goes, to evidence-based psychiatry. So the whole team of N.S. Vahia Foundation has been evidence-based psychiatry. We get speakers from all over the world, we have had speakers over six countries and 20 of the most leading institutions of psychiatry, and we have had what we call the masterclass, and we discuss things, and then we carry the message further and we kind of read further from that. So even as this setup, I think as good luck would have it, psychiatry started growing. And the boost then came when public figures to name one Ms. Padukone, who was a very popular, very well-known Indian actor. She went on the TV—
Trevor: Wait, which one?
Vihang: Padukone. Ms. Padukone.
Vihang: So, she went on the TV sharing her experience of depression, and she said depression is nothing to be afraid of, nothing to be ashamed of. And she admitted that medicines helped. Then she founded a NGO called the Love Life and Laugh Foundation. And her organization has done lots of good. People have now started accepting that mental illness is not contagious. It is not the curse; it is not the planetary influences.
Trevor: These were the stigmas of mental illness in India?—
Vihang: The stigmas. The attitude of the population in general against mental illness has not been very healthy, and we are now into advocacy, and this foundation, the Love Life and Laugh foundation, has done a lot to help destigmatize the mental illness. The government of India has done its bit in the sense we have a network of primary healthcare centers into the most distant or the rural areas or the inaccessible areas of the country. India is a huge country with large population, and very few doctors and the government has now set up district-level mental health medical center, and almost every single district now has a psychiatrist at the district level. So there are pros and cons. The psychiatrists who work in the community remote areas do not have easy access to exchange their views or participate in learning experiences, exercises, and they’re so engrossed, are so caught up dealing with the patient care that they have more time to develop themselves.
The physician development isn’t at its best though there is huge exercise now on to make sure that the newer trends in mental health care percolate down to the most remote areas of the country, but as you would well understand, we are too many patients, the workload is immense, sometimes people have to see 100 patients in a day, saying 10 hours if you’re seeing 100 patients, it’s not more than three-four minutes per patient and—
Trevor: That doesn’t sound like enough time to establish a proper diagnosis?—
Vihang: Yeah. If we don’t do whatever that we can, nothing will happen to them. Then they’ll go to this faith healers and extortionists. So we’ve got to do the best that we can, but the point is somehow it seems to work. Even when my colleagues in the rural areas are seeing hundreds, sometimes I mean, 50 patients in a day, they’re delivering. If they were not to be able to deliver, the workload would not continue. The patients would stop coming to them. Why is it that in spite of the patients receiving hardly a minute or two per patient, why do they keep coming back? Because something good is happening there. Academic psychiatry is immensely ... That’s the core psychiatry, but the field psychiatry, which does not match the standards laid down in academic psychiatry, somehow seems to deliver because the patient population growth and the numbers are increasing even in the most remote areas, which by the Western standards are giving them not good care, but the patients are getting well.
Trevor: So correct me if I’m wrong, that the foundation is growing. It’s established, it’s growing, but it can’t meet the demand because people are seeing that the foundation and this therapy is yielding positive results; therefore, more people are coming?
Vihang: It’s not just the foundation.
Trevor: Yeah, it’s mental health in general.
Vihang: Foundation is less than a pebble in the pond at this point in time. It’s restricted to a small area in the country. It began at the city level, and it’s still very regional, but the Indian Psychiatric Society and the basic enterprise of the medical professionals in India, which is the driving force, my colleagues, my students, my junior colleagues all over the country, those who are not even my direct students, there is a hunger, there’s a desire to deliver. Foundation is a small part of the Indian scenario. It’s a very small part, but then it’s our observation for which we’ll never get credit or acknowledgment is that the model that we set in motion in Mumbai and Maharashtra in 2008, it’s being mimicked by various other people.
I see that some of the activities that we would have done being done a year later in some other parts of the country, sometimes it looks like they’ve mimicked our activities, they just pick the leaf out of our books, but you can’t even call it plagiarism. They pick up a notion, they pick up an idea and develop it to suit their needs, and that’s what knowledge is all about.
Trevor: So it’s fracturing but in a good way?
Vihang: In a very good way. And I feel my father would be proud that when he started his department of psychiatry at the KEM hospital as the only general hospital, department of psychiatry has now spread to 460 medical colleges. Every medical college has a department of psychiatry, a full-fledged tertiary care department of psychiatry. And then most teaching hospitals, they have what we call satellite hospitals or peripheral hospitals. Majority of them have a department of psychiatry. Maybe not very fanciful investigation techniques, but they have the diagnostics, and they’re the therapeutics, both drug therapies, and other therapies. We have a shortage of doctors. We have a shortage of psychologists, but something is happening. Patients are getting better, patients are responding, patients are getting aware. Even the internet has a role to play. The young boys and girls, virtually every high school student knows how to use the computer. And then we have the Google.
I often call them the internet medical graduates. They read the Google, and they acquire medical knowledge. These internet medical graduates also get into some confused states and sometimes create problems by somehow getting medicines that they shouldn’t be using. But overall it helps them to accept mental illness as a health issue, and some of the myths and misconcepts are—, and some myths and misconcepts get generated and they misinterpret the Google or sometimes on the Google you have opinions written by people who are opinionated and not knowledgeable and somehow their language at times seems to appeal to the vulnerable. So there are problems out of internet medical graduation.
Trevor: But it’s at least. Even in this process of them doing their research and kind of cobbling together a bunch of concepts or treatments that may not help, but even in that process, they’re normalizing mental illness. They’re accepting that it’s an issue. They’re seeing the treatments out there.
Vihang: They accept that they have a mental issue, they make a diagnosis that suits their ego, and then they want medicines to suit the diagnosis that they have acquired out of internet, and it takes quite a while to convince them that the internet diagnosis is little different from the clinical diagnosis. And then we need to spend time to tell them why it is what it is and not what they think it is. Some rebel, some quarrel, some confront, but they eventually come around. They eventually come around if you don’t impose your views, they come around when you suggest, explain, and tell them to think it over themselves. Then they come back.
But if you say, “Shut up and listened to me.” They don’t listen to you. So you’ve got to make them change their way of thinking, which is sometimes a challenge, but also fun in clinical practice because once they change their views, it might take a few weeks, might take few days, and sometimes it may not occur at all, but once they change their view and they start seeing logic in what the doctor’s saying, they adhere to the treatment, then they’ll follow every word you tell them. It takes time, but it works. So the N.S. Vahia Foundation focus is now getting more crystallized. The core group at the N.S. Vahia Foundation now feels that we need to have focused work or exercise for the next, maybe five years. We need to have a plan rather than doing something every year; we need to have kind of a schedule that we want to set up for ourselves. In India, the drug industry is very well developed. Sometimes, very jokingly, we say that the source of continuing medical education is what the field staff of the drug company tells us.
We want to go beyond that, and the only way to go beyond that is to set up a system. My colleagues and I have an ongoing exposure to the developing trends in psychiatry. We note with enlightenment, if I were to say so, is that the concepts and the lines of treatment keep changing. What was eternal truth five years ago is no more the favorite line of treatment today. So there’s a need for constant update and like I mentioned, the clinical workload is so much that we don’t necessarily actually get time to keep us as updated as much as we should. So, as we we’re looking for some kind of a long-term association with the best of the mental health care institute in the world, it happened, I think it’s the destiny that brought us in contact with the McLean. This is not to flatter you, but our association with the McLean has been the most satisfactory and an eye-opening experience for us.
Our association, which jelled late 2018 and that resulted in a huge activity in 2019, early February of 2019, has been kind of a landmark activity, a kind of a concept changing activity. What we did this time is that we did not focus on diagnostics. We did not focus on direct therapies. We focused on case management and technology. So we had speakers who narrated their experiences to young psychiatrists, 250 of them, on how DBT and CBT works in children, in adults, and in a particularly concerning anxiety disorder called the obsessive compulsive disorder. And we had hands-on experience being shared with long discussions when the speakers from the McLean answered every question; we had a 20-minute presentation and two-hour discussion on each presentation. And then, of course, the role of technology in mental health care and patient management.
So what McLean did for us is a translational research. We are so used to hearing of academic research. What we need is a translational research. We need someone who would, if I may sound so selfish, filter out the most important from relatively not as important as of today, knowledge. Maybe what is not as important today might become very important next year. But as of today, what is the translational aspect of the research that we have? We at the N.S. Vahia Foundation believe that the McLean has the core group that does very original research, which might be unique in the U.S. or if not the unique, one of the important centers of research on that topic in the U.S. So we at the N.S. Vahia Foundation look upon our association with McLean as a source for rejuvenating ourselves, and at this point in time, our association with McLean has been our dream come true. That we have no hidden agendas, and we all seem to be on the path of opening avenues for continual medical education filtered for us to know what’s important rather than trying to sort out what is applicable and not applicable.
So, one of the activities `I like what we’ve done so far, is in the view now want to have week-long training programs with continuous interaction between the selected mentees and the mentor for a while. So if it turns out right when a mentor comes to India, trains a small group of mentees, the mentees would have continuous or some channel of communication with the mentor over a period of time, but the mentees themselves would spread out. And the ripple effect is what we are looking at. Our theme today is to put those pebbles at a pace where it doesn’t become a tsunami, but put those pebbles when comfortable ripples spread to all my colleagues, no matter how distant part of the country. That’s what our current dream, which is about to be realized, seems to be at.
Trevor: Thank you for listening to Mindful Things. The official podcast of McLean hospital. Please subscribe to us and rate us on iTunes or wherever you listen to podcasts. If you have any suggestions for special topics or future guests, email us firstname.lastname@example.org and don’t forget mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673 again; that’s 877.870.4673.
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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.
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