When I first found out that there was an ACT OF TERRORISM being committed at two mosques in Christchurch New Zealand on Friday resulting in 49 Muslims killed and many others injured, I was devastated.
I had to stop my studying for awhile and just devoured the news that were spreading like bushfire in my Facebook newsfeed. I wanted to cry. But I couldn’t. My eyes just refused to cooperate to tear up. So, I was left with deep heaviness in my chest instead. I know that the heaviness will go away if I just cry. (This is my problem. It is always difficult for me to cry. I think if I could just cry, I can relieve this ache in my chest.)
I have been to Christchurch when I was a medical student. I went there with my housemates for a holiday during the first semester break of my 4th year of medical school. We enjoyed our New Zealand trip very much because New Zealand is just such a beautiful country. I never thought that this tragedy could happen in New Zealand because my impression was New Zealanders were much more tolerant towards ‘other’ people compared to their Australian counterparts. They are more progressive in terms of giving their indigenous people (the Maoris) their rights and privileges. The rights of the Maoris in New Zealand are better preserved and protected than the rights of the Aboriginals in Australia.
So when something heartbreaking like this happened in Christchurch, I just could not process it!
And then I found out that the evil perpetrator behind this massacre was an Australian who has a Neo-Nazi political leaning.
Well…. I love Australian people. Most of them are lovely and kind. But some of them can be such racist rednecks! Five years in Australia taught me all I need to know about white supremacy and racism. My experience in Australia shaped me into the kind of person I have become now. I am a person who is super-sensitive to any form of racism or supremacy or ‘budget bagus’ group. You can judge anyone as an individual if you are so inclined. But don’t overgeneralize the whole group because of any mistake done by some individuals in that group. I COULD NOT tolerate that EVER. Muslims living in the West post 9/11 would understand the kind of suffering we had to endure when we were all painted with the same brush. To them, either we were evil terrorists or oppressed Muslim women! Either way, we were treated with suspicions and being looked at as inferior just because we wore the hijab outside the house.
I remember how I felt like I had to prove myself as a Muslim medical student in Australia. I had to do MORE to get the same kind of respect or esteem that the Australians effortlessly enjoyed. As an introvert, it took some adjustment for me to push myself to be extra-friendly, to be outspoken in tutorials, to join group discussions, to mingle with people (now doing these things is much easier for me these days… especially the outspoken part. Haha) I had to do all these extra efforts in an attempt to contradict the degrading narrative of what being a Muslim woman was perceived to be (when actually, I really preferred to keep quiet and just went home and read my books). Whenever I couldn’t answer any question in the tutorial group, I felt so embarrassed (more embarrassed than I would have been if I were in Malaysia) because I felt like I was feeding the stereotype that Muslim women are stupid by my inability to come up with a sensible answer. I felt like I had to say something (anything!) in the tutorial even when I had nothing to say. I felt like I had to fill up my speech quota of the day in order to appear fully switched on and involved in the tutorial discussion. I felt that way after finding out that some tutors had complained to the admin that “the Malaysian students are too quiet and not participating in the tutorial discussion”. So during each tutorial session, I doubled my effort to appear extrovert because apparently, the more you talk, the more intelligent people think you are. *rolled eyes* (And yes, Australians are very extrovert! And so, people who are too quiet would be thought of as less intelligent or less capable) So, I strove harder in order to contradict the stereotyped image of what being a Muslim woman was. My sweetest moment was when my assignment on Health Equity Selective was being put up on my uni website (in our students blackboard page) as an example to the juniors in the batch below mine on how to write a Health Equity Selective project in the category of Psychiatry. Me, an International student whose English is only a second language, got the opportunity to display my assignment as a guidance for the juniors to emulate when doing their psychiatry Health Equity Selective… I was over the moon! (Yup, I had chosen Psychiatry for my Health Equity Selective project. I have been interested in Psychiatry since I was a medical student and had chosen that field for my elective.) I was over the moon because I felt like I had proven a point. It was like, I was saying “See… a Muslim student is not that stupid. If we don’t talk as much in our tutorial session, it is because some of the things are obvious already… that it is not even worth mentioning. And English is our second language… it takes more energy for us to come up with any sort of conversation compared to you guys. If we are a bit slow in articulating our thoughts, that is only to be expected, isn’t it? Besides, we just don’t feel the need to stand out all the time.”
My Malaysian juniors were like “Kami bangga sangat tengok Health Equity Selective Kak Afiza masuk dalam blackboard. Malaysia boleh gitu!”
I am proud of my juniors too. I was proud whenever I see my Malaysian juniors were more well-adjusted and had assimilated better with other Australian students compared to us, the seniors. The juniors learned from our own mistakes and put more effort in making Australian friends. They experienced less criticism that “the Malaysian students do not mingle with people. They like to keep to themselves and don’t put in any effort to assimilate with the whole batch”. As the years progressed and we started getting more Malaysian students among our junior batches, I thought, we were doing such a good job of portraying that Muslims were not as bad as what were shown in the media. Slowly but surely, I felt like the stereotype against Malaysian students were eroding. My heart burst out with pride when I saw how Malaysians were very heavily involved in our university Islamic Society (I myself was the treasurer of University of Newcastle Islamic Society at one time) and we were always the front-liners when it came to interacting with non-Muslims at the Islamic booth during Islamic Awareness Week. Compared to the Saudi or other Middle Eastern Muslims, Malaysian leadership shone bright in the Islamic Society. (Perhaps because our command in English was better than them). We could answer controversial questions about Islam quite well while guarding the booth. All in all, we were making pretty good progress.
But it could get pretty tiring. Always having to prove yourself over and over again is tiring. Whenever there were new incidents of terrorism and bombings in the Western world, I felt like all our hard work to prove that Muslims are good people were completely undone. And we had to do it all over again. Prove ourselves all over again. It was exhausting. Mentally and physically draining.
But I never regret any of it! Because the struggle that I had gone through made me who I am today. There is beauty in the struggle that we have to face in order to live up to our Muslim identity and Muslim ideals when we are living in a non-Muslim country. Looking back, I was my best self in spirituality when I was a medical student in Australia. Because of the struggle I had to face in Australia, I was more conscious of God and more connected to my religion than I ever was in Malaysia. I invested more time to learn about Islam properly (partly because I had to prepare answers for the questions that non-Muslims liked to ask). I was my most patient self when I was in Australia… because I was carrying the image of a Muslim and I did not want my bad behaviour to tarnish the name of my religion. In Australia, I had a purpose GREATER than my own self because I had to be a small ambassador to my religion! So despite all the struggles and the difficulties, I was very motivated. Our social support were the usrah-attending seniors who kept reminding us to be good, to do good, to strive for the hereafter and not just the dunya. (This is the part of myself that I miss the most, now that I am in Malaysia. I miss the Afiza who was nice. Because the current Afiza is not so nice! Hahah. Somehow, after coming back from Australia, I have retained my outspokenness but have not retained being nice. Perhaps because Malaysians are not always nice too….they are not always ethical…they don’t have values of respect or punctuality or cleanliness or efficiency…. they can be lazy… they can trample on your rights… and if I am too nice and not outspoken enough, I will be oppressed. And I don’t want that.)
Allah had planned my life so beautifully, Alhamdulillah.
At 18 years old, I was grieving the death of my friend. Looking back, maybe I had an existential crisis at that time because I was so shocked by the fragility of life. That my friend could die at such a young age! I wondered, what was this life all about? For two years, I was wondering to myself about existential stuff, but afraid to vocalize them out for fear that they would label me “tak kuat iman”. And then Allah sent me to Australia where I met religious people who could answer all my questions. Alhamdulillah, my existential crisis resolved then. I became a firm believer. I came across someone in Melbourne who answered my questions patiently, systematically… scientifically, even! Suddenly, I felt a sense of spiritual awakening that I had never experienced before that summer, which was my first summer in Australia. I knew then that Islam is logical; that it makes sense! If things do not make sense, you must double-check whether it is truly religious in the first place. I was ecstatic and grateful for all that I had learned that summer. It is nice to have real faith! (I was so relieved! Finally, the horror of the Israilyat stories I had to swallow in KMB can be vomited out once and for all without feeling any guilt. That’s why I will always love Australia, the place where I had experienced an exponential growth, mentally and spiritually! There would never be a time when I think of Australia without a sense of nostalgia. It’s just not possible. Some of the things I had learned in Australia STILL influence my behaviour until now!)
I believe, some Muslims would have an existential crisis after witnessing this current heartbreaking incident. Some of the family members of the deceased might experience what I had experienced during the period of grieving. They would start questioning… why are there so many dreadfulness in this world? Why do people do evil things? Why didn’t God do something about it? Why didn’t He intervene? Why is this world so unfair? Why was I even created? What am I supposed to do in this life? Is Islam really the right religion? How do I know that? What if I am in the wrong faith… what will happen to me when I die, then?
They might have all these questions as they deal with the death of their loved ones. And hopefully, they will go through the cognitive process of finding the answers… and finally be at peace in their faith. You cannot bury these questions and silence your conscience. Repressing your doubts will not help you find peace. You must actively engage with your intellect and answer the questions that you have about the religion, about faith, about life after death. Otherwise, you will always be in doubt. And it won’t be real iman. You will not experience true peace that comes with firm belief. You will not feel confident to take any action, to speak up, to do what you believe is right… because you are not even REALLY sure if God is real and that He will help you out of any trouble.
So, don’t bury your internal existential crisis or your philosophical conflict. Answer them! Seek and you shall find! And believe me, what you find will be beautiful and priceless!
I have been busy preparing for my CASC exam these days. As usual, I am at my most neurotic self while preparing for exams, LOL. I would start thinking about how much money will be lost if I fail my exam. I would start thinking about “ah, aku dah tak larat nak study! I just want to be a chronic MO.” Hahha.
Sometimes, I mourn my lack of time for fiction reading. It is ridiculous how much I sweat the small stuff.
I forgot that there are other more important things in life other than being a nerd and passing your exam. I forgot that my fiction-reading are trivial, picisan stuff! Stuff of amusements and ‘main-main’.
In other parts of the world, people are fighting for their lives!
On the same day that the mosques in Christchurch were attacked, Israel had also launched series of airstrikes across Gaza! We have thousands, if not millions, of our Muslim brothers and sisters in various parts of the world undergoing physical and mental suffering… all at the same time! And I am worried about exams? And about reading fiction? Gosh, Afiza… you are preposterous!
Sometimes, I have to admit, I can be really stupidly ridiculous. I am done worrying about trivial stuff! Because there’s more to life.
For as long as I can remember… everytime I was overwhelmed by my study, some sort of tragedy would be breaking news and made me realize that my struggle was not significant at all in the general scheme of things. For example, in 2010, while I was preparing for my final General Medicine exam, the Turkish ship Mavi Marmara, which was a civilian ship bringing aid to the Palestinians, was attacked by the Israel Navy in May 2010. The attack by the Israel Navy was bravely resisted by the civilians on the ship; nine activists died and many were wounded. I was worried sick about my exam at that time. But after reading about what had befallen the Mavi Marmara ship, I had felt similarly ridiculous as I am feeling now for being too worried over small stuff when people are fighting for something greater than even their own lives!
I composed a poem for Mavi Marmara at that time entitled FORGIVE MY SCOWL which I had uploaded into the poetry section in this blog. I composed that poem after taking a pause from studying my General Medicine notes in order to clear my muddled head and to lift up the overwhelming heaviness in my chest.
This is also why I am taking a pause from my CASC studying and writing this post today. To clear my head. To lift up the heaviness in my chest. Because I just couldn’t cry. Because to compose a poem, it would take a much greater mental strength than I possess. Because I am too mentally exhausted by all the bloodshed.
I pray, that all Muslims would unite together and peacefully respond to this sad calamity in a positive way. I hope, there will be no revenge bombing by Muslims because it would only make matters worse for our brothers and sisters in the West. Trust me, I had enough experience of how terrible it is to be in the West when so-called Muslims commit an act of terrorism somewhere. (Nak masuk lecture hall keesokan hari pun rasa nervous! Rasa malu! Belum lagi rasa takut kena attack bila terpaksa jalan berseorangan.) Please, no revenge bombing targeting innocent people, be it Muslims or non-Muslims. Please, no more bloodshed.
I leave all my readers with a reminder to live in this world like a traveler or a stranger. Because, really… isn’t that what we are? Until we reach our final destination, we are only a traveler along the path of life. Hopefully, we will find something precious and beautiful along the way.
When I was an IB student in KMB, part of the World Literature component that we had to study was the novel The Great Gastby, authored by an American novelist, F. Scott Fitzgerald.
Though at that time as a teenager I was not that enamoured with this magnum opus of F. Scott Fitzgerald, the FIRST TWO SENTENCES of this novel had stayed with me until now.
In my younger and more vulnerable years my father gave me some advice that I’ve been turning over in my mind ever since.
“Whenever you feel like criticizing any one,” he told me, “just remember that all the people in this world haven’t had the advantages that you’ve had.”
We had to analyze the novel as a student. And I just kind of wrote in my literature analysis that we shouldn’t be judgmental towards other people because we don’t know what other people have gone through in their lives to cause them to behave a certain way now. By the way, I got an A for my literature analysis of The Great Gatsby at that time. But all I wrote in my essay was some wishy-washy namby-pamby crap that I feel embarrassed to be recalling now.
Trust me, I have changed my mind. I think the longer I am in psychiatry, the more objective I become about things that I read and what I should tolerate and not tolerate. Or maybe it is just the effect of me being older and wiser.
I believe that what happened to you in your past DO affect your life now…. but only up to a point. Whether or not you let the past haunt you, it is ON YOU. It is YOUR DECISION.
If I could go back in time and do the literature analysis all over again, I would probably changethe tune of my essay and write something like this instead: “We all have different life story. OF COURSE none of us will have the same kind of advantages and disadvantages. That’s just life. It doesn’t mean you can excuse yourself when you do something bad or maladaptive. Instead of wallowing in your disadvantages in life and comparing how other people’s lives are much more advantageous than yours, you should move forward and think about how you could make your life better, isn’t it? Mr. Gatsby deserved what he got in the end! He should have moved on a long time ago and stop pining for a married woman.”
Trust me, I have no sympathy for the great Mr. Gatsby.
As a psychiatry MO, I am going to be honest and admit that I have favourite cases and favourite patients. I mean, that is only natural. That’s why we have subspecialty, right? Because we don’t always like all types of cases even though we DO see and manage them all to the best of our ability.
And, let’s face it. We do have favourite patients, don’t we? We don’t discriminate our patients in terms of treatment and resources but there are certain patients we like to see MORE than others. That’s just human.
So, what sort of patients do I like? Well, I like patients who help themselves because it makes it all worthwhile. Because without the patients helping themselves, there is nothing much I can do to help them that would work long term. We can psychoeducate till kingdom come, or do daily home visits, or call them every day to update on their progress, or we can repeatedly give them compliant therapy…. over and over again…. but nothing will stick long term until they accept their illness, and make THAT VITAL DECISION to take the meds and perform all the non-pharmacological measures we tell them to do. My whole investment in effort and time to maketheir mental health better depends LARGELY on the fact of whether or not they themselves will do what I have told them to do! I can do my best… but it won’t work if THEY don’t do their best. We are not going to be there for them 24/7. And we shouldn’t haveto. Part of the responsibility should be shouldered by the patients themselves and their family members.
So yup… I do have favourite patient’s family members too. The more cooperative the family members are, the bigger the smile that I bestow towards them as a form of greeting at the start of the conversation. LOL.
It is kind of disheartening sometimes. When the reward for our hard work (seeing the progress of our patients is a reward) depends on the patients themselves taking that leap of change…. it can be disheartening because some of them just refuse to take that leap.
So when patients (or their family members) ask me about their prognosis or if they will ever get better, I said truthfully “You will get better. Not all conditions can be cured… but they do get better. But how much better you get depends on YOU.”
And that’s the problem. And that’s also the solution.
YOU are the solution. Regardless of your background! Regardless of your advantages and disadvantages in your past! Regardless of what had happened to you in the past and the present, YOU are the solution to your own problems. Make that decision to take your medication. Make that decision to not let your past determine your future. Make that decision to put some effort in doing all those lifestyle changes! Make that decision to do your CBT homework! Make that decision to feed your thoughts with positive self-affirmations as you were taught to do in your CBT sessions. Make that decision to practice that deep breathing exercise and the relaxation techniques taught to you. Do it for you!
Because I cannot do it for you.
What are the values you must internalize in order to move forward DESPITE your past andyour disadvantages?
Because trust me, if everyone can behave badly by citing random disappointing things that had happened in their lives as the cause of their depression/borderline personality/ antisocial personality/addiction, then everyone can get away with crimes because “oh, it is not my fault. I had a deprived and disadvantageous childhood, you know”.
“Oh, I murdered that guy because he reminded me of an ustaz in a Maahad Tahfiz who had sexually abused and sodomized me when I was younger! It’s not my fault. Don’t judge me if you don’t know my past.”
But when you are arrested by the police and subsequently sent to be evaluated in Hospital Bahagia Ulu Kinta, we will only determine whether or not you were of sound mind when you had committed that murder and whether or not you are fit to plead! Regardless of whatever bad past experiences you had, we are only going to be interested in the soundness of your mind! We are only interested to know whether you knew what you did was wrong and contrary to the law! That’s it! We might be interested in your past… but only up to a point. The court may take note that you used to have a disadvantageous childhood… but you will STILL be punished. It is only right for you to be punished. Your bad past will not suffice in the court of law to justify your crime!
Regardless of whatever childhood adversities you have experienced, by the age of 18 you will be treated like an adult in the court of law! You would be assumed to have had the maturity of an adult and you are accountable for your own action. You cannot turn around and blame your parents when you are addicted to drugs… because your siblings who are NOT addicted to drugs ALSO have the same parents as you! The judge in court will not entertain wishy-washy, sappy sob story of an excuse like that! Even in Islam, we are accountable for our sins at the age of puberty! The reality should not be distorted to adjust to YOUR subjective experience! Instead, regardless of whatever bad experiences you have had, you must make the effort to adjust to the reality. If anyone can be excused based on ‘subjective’ experiences of childhood disadvantages, then that’s it! There should be no law and order. Everything must be grey and blurry, then!
Likewise, the reality is such that when you behave in a counter-productive manner or in a socially inappropriate manner, most people will reject you. Regardless of your past! People who are going to deal with you day in and day out are not going to care about how difficult your past was after a certain point! Their sympathy can only go so far. So the onus is on YOU to rise above your past and change your behaviour if you want to lead a fulfilling life. And we are here to help you do that. But you must be willing to put in some effort without always blaming others for every single thing that goes wrong in your life.
In Psychiatry, we also learn that there are certain risk factors that predispose someone to having depression or other mental illness. But some people do cope well with life despite having those risk factors! How come?
So my take home message isthis: Your past DO affect you… but ONLY up to a point! You are not totally helpless against your past! Because the rest of your life is determined by what you are going to do now in moving forward.
And you can turn over a new leaf by internalizing certain values in your life that I am going to enumerate below. Please take note that I am not disregarding or invalidating all your past experiences and all the injustices that had happened towards you. I am just giving you a way to move forward.
“Doktor, ingat senang ke nak usaha? Pesakit depressed memanglah tak larat nak exercise, nak buat behaviour activation semua. Bila doktor cakap kena usaha… macam stigmatizing. Ada doktor suruh pesakit kencing manis usaha supaya pancreas diorang keluarkan insulin? Tak kan…”
“No, I won’t tell type 1 diabetic patients to put in an effort to force their pancreas to produce insulin. However, I do tell them to put in an effort to take their insulin, to controltheir diet, to exercise and keep a healthy lifestyle. And this is what I am telling you to do too. It is not stigmatizing. It is factual.” This was my answer to the patient (who also had some component of personality on top of her depression). Very matter-of-fact, very reality-based.
To be honest, I NEVER like the ‘mental illness stigma’ poster that compared depression with diabetes. It is so inaccurate, and we should stop saying “Jangan stigmatize pesakit depression. They cannot help their behaviour. They lack serotonin. Just like pancreas orang yang ada diabetes tak boleh keluarkan insulin, orang depressed pun tak boleh keluarkan serotonin. When you tell depressed people to put an effort, it is a stigma! You don’t tell diabetic patients to produce insulin, do you?”
Ugh! Gosh! I cringe inwardly whenever I hear misleading things like that.
I agree that we should not stigmatize mental illness! But I disagree about depressed patients not having to put in any effort in dealing with their depression! Asking people to put in some effort should not be construed as stigmatizing! In ANYTHING we do in life, effort is vital! In ANYTHING!Stop trying to tie our hands from telling our patients to put in some effort! What do you want me to say then…. tak payah usaha langsung?
As a Muslim, Allah will not help us without us putting in our effort! To Muslims, that’s a fact! I am not going to distort reality just to align myself with the content of a bad poster. I am not going to distort facts just to appear FALSELY empathetic and sympathetic when the reality is different! If we cannot tell them to put in some effort, then how about asking them to go to occupational therapy? Doesn’t that require some effort? How about asking them to attend their CBT sessions or their psychotherapy? Doesn’t that require effort for them to do their homework?! How about asking them to practice deep breathing exercise and do some physical activities? Doesn’t that require effort?
The only condition that doesn’t require your effort is when you are in a state of coma! You don’t tell ICU patients to put in any effort, sure! But for the rest of us, the requirement for a good, healthy and balanced living is our effort. The faster you internalize this idea, the faster you will improve your life, Insya Allah.
So, please! Please stop promoting mental health awareness by comparing depression with diabetes! That’s like comparing apples and eggs. They are not even in the same category! (at least, comparing apples and oranges can fall under the category of fruits! But apples and eggs are two different categories altogether, get it?). For one thing, there is no component of the ‘mind’ in the Pancreas! There is no intertwining interpersonal conflicts and ongoing social stressors in the development of Type 1 Diabetes! So Type 1 Diabetes patients really cannot change anything much in the way they behave to help their condition. But this is not the case in depression! So, how is this a good and fair comparison? Neither the diabetic patients nor the depressed patients are treated fairly by this comparison.
And Wallahi, this comparison should cease to exist! (Adoi, penat! Too much emotion has been invested in writing about this alone, LOL. Pheww!)
To quote Kevin MD:
Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The (depression-diabetes) analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding “mind” that exists in the realm of feelings and relationships.
I prefer to compare depression with having a fractured lower limb in terms of how effort would improve your outcome. “Katakanlah awak mengalami kemalangan jalan raya dan kepatahan kaki lalu tidak boleh berjalan. Lalu, saya pun beri kepada awak tongkat untuk bantu awak jalan. Sudah tentu berjalan dengan tongkat dengan kaki yang patah lebih susah berbanding sebelum kaki awak patah. Tetapi tongkat itu serves its purpose untuk bantu awak bergerak walaupun memerlukan lebih banyak tenaga. Tapi jika awak masih duduk di kerusi dan tidak mahu berjalan walaupun sudah diberikan tongkat, maka tongkat itu langsung tak berguna! Bila awak duduk dan baring sahaja, ini akan membawa risiko mendapat bedsores dan secondary infection yang lebih teruk lagi. Apabila saya berikan awak tongkat dan suruh awak berusaha untuk berjalan, tak bermakna saya menidakkan kemalangan yang berlaku dan kesakitan yang awak alami kerana patah kaki. Tetapi saya bantu awak untuk move forward WALAUPUN ya, saya akui awak kemalangan dan ya, saya akui awak memang sakit dan patah kaki. But the tongkat is here, isn’t it? Are you gonna take it and walk or are you going to just sit down, not using the tongkat and instead repeatedly go back and forth questioning why the accident had happened to you? And why aku patah kaki dan orang lain tak patah kaki? Because think about it….How is that going to help you? Now… let’s get back to your depression. I am giving you your medication and I have scheduled CBT sessions for you with our clinical psychologist… will you take it? When I told you to put in some effort to do all these measures, to try to go to work… I am not denying your depression and I am not saying it is going to be easy! It is hard! Of course going to work while being depressed is ALWAYS going to be much harder than going to work without any depression… that goes without saying! However, now I have given you some medication, and you will be seeing our clinical psychologist for CBT sessions….these things are the tongkat! Yes, it is still harder to go to work compared to when you were not depressed… but now, going to work is becoming more achievable, isn’t it? Compared to when your depression was not treated at all, now even though it is STILL hard… it can be achieved right? Just like it is still painful for a man with a broken leg to walk with a crutch, but at least with the crutch, the man with a broken leg can now walk, isn’t it? Will you at least try first?”
Most patients who already have some spark of optimism inside them can relate with the ‘patah kaki’ analogy FAR BETTER than the diabetes analogy, in my experience.
Really… I am not a vague, wishy-washy person. I am always the ‘bottom line’ kind of person! I want to know the truth, the reality, the actions that I need to do and what is the possible outcome I can expect. And therefore, I don’t like to comfort people with half-truths. I do adjust my style of giving away the real truths to my patients depending on their personality and the appropriate context…. but I am not gonna give them empty words of comfort. I am not gonna tell them it is okay when it is NOT okay. I am gonna tell them, “What happened is not ideal but what are you gonna do about it? Let’s face it and deal with it! It will be hard but it can be done. I will help you… but again, it will only work if you help yourself because a lot of things require effort on your part!”
And most patients recognized the truth and they gravitate towards it! The sunnahtullah is such that deep inside, all of us want to know the truth. And when we give the truth to them, it builds trust because they know that this doctor is not lying and pretending to care about them! Sure, some of them don’t like to hear the truth and they might hate us for awhile. But the seed of doubts regarding their actions has been planted in their minds…. and eventually they will think and evaluate the matter again.
But patients who STILL persisted in playing the victim card (usually a personality component is involved here), will continue to deteriorate. And my heart sinks.
As a psychiatry doctor or a therapist, among the first thing we should do (after allowing them to ventilate and express their distress), is to get them to internalize the value of effort! We will not get anywhere if they still persist that they are victims of their past and therefore they will always be ill and flawed because their past can never be changed and therefore there is no use for them to put in any effort.
That is really such a tragic way to think about life. We must pull them out of that mindset before anything can ever change. But unfortunately, it is STILL their decision to change their mindset! At the end of the day, we can only do so much to help them. The ultimate outcome lies in their decision.
Having A Growth Mindset
The opposite of having a growth mindset is having a fixed mindset. The worst thing that can happen to anyone is to have a fixed mindset. Having a fixed mindset would wreak havoc in your life because you have basically internalized learned helplessness. Learned helplessness is bad, folks! With learned helplessness, people can be driven to suicide because they believe nothing they do will ever change the situation and there is just no hope left.
Biologically, we learned about brain plasticity which is the ability of our brain to change through life with our experiences and our training! It correlates perfectly with the value of having a growth mindset.
From the psychological point of view, Piaget’s theory of cognitive development talks about how our mind and our mental schemas are always adapting and accommodating…. for the rest of our lives. So we are not always stuck in our bad childhood memories. Provided you put in some effort, you can overcome your disadvantages!
While I do think that me hearing out your feelings and allowing you to ventilate your problems do help to de-stress you while you are facing your crisis, I am more interested to know what you are going to do about overcoming your limitations in life? That’s the BOTTOM LINE always.
With a growth mindset, you will have a positive and optimistic outlook in life because YOU JUST KNOW that whatever it is that is happening to you, you can master the steps that you need to take to overcome the challenges! You just need to grow your mind by expanding your horizon with new skills, new set of positive thoughts and new set of behaviours. When you have a growth mindset, you know you can learn and re-learn and un-learn your way into a better coping mechanism.
You won’t say things like “Dah aku memang macam ni. Family aku dulu ajar aku macam ni. Memang dah tabiat aku. Memang aku tak boleh nak ubah… nak buat macam mana?”
I am not saying that it is easy to change your habits! A person with a growth mindset ALSO might be resistant to change because they are already comfortable with their own habits and personality. But when it is important for them to change and adapt (perhaps, there is something at work that they have to be in-charge of that requires a new set of behaviours and habits), they will make themselves change their habits and behaviours because they know that the only constant in life is change! And if they have to do it, then they have to do it!
So, will you continue to practice? Will you continue to study and acquire knowledge and skills for the betterment of your future? Will you be willing to put in some time and effort (goes back to effort, doesn’t it?) to do what has been taught to you during your CBT sessions so that your new skills slowly become second nature and would be automatically activated in the future with much less effort than what you have to put in now?
You will do it, when you have a growth mindset.
If you have a fixed mindset… don’t worry. This is the beauty of the concept of having a growth mindset. You can unlearn that fixed mindset NOW, and start to learn to have a growth mindset.
Having An Internal Locus Of Control
In psychiatry/psychology, locus of control is defined as the degree to which people believe that they have control over the outcome of events in their lives, as opposed to external forces beyond their control.
If you have an internal locus of control, you believe that events that happen to you is the result of your own doing rather than the external forces outside your control. For example, when you have an internal locus of control, you would believe that you had passed your exam because you had studied hard and went to all the lectures and tutorials that were given at the uni and because you had prepared accordingly. You did not think it was the external factors beyond your control that had made you pass. You did not think that it was just luck or because other people were doing even worse than you or because the teachers like you better than your other classmates. You are less likely to conform to your surroundings when you have an internal locus of control.
If you have an external locus of control, you believe that you had no control over the events that had happened to you and there was nothing you could do to influence the turn of events. For example, you believe that you would never pass the exam because the subject was too hard and the lecturer did not like you. So there was nothing you could do to pass your exam. You believe that the result of your exam somehow depends on all other external factors except your own effort. Having an external locus of control makes you more likely to conform to expectations and environments because you want your life to progress smoothly.
In general, when it comes to motivation and drive, having an internal locus of control is much healthier than an external locus of control.
However, having too much of anything is never good. Having a much too internal locus of control can also cause you to blame yourself and will make you feel unnecessarily responsible for something that you could never help. And that can also predispose you to depression. See the diagram below to see what I mean regarding imbalanced locus of control and why it would be bad to have too much of either.
The key word here is balance and reality check! I have mentioned before that I like the truth! I like reality check! Those are the two words I use a lot with my patients. You are entitled to your feelings and you have a right to them because it is YOUR feelings…go ahead and have them. But at the end of the day, your feelings do not necessarily reflect the reality. And if adjustments need to be done, your feelings must be compromised to give way to the truth or the reality! You must start learning to feel the right thing! (yes it can be done!) Because your feelings, even though you have a right to them, are subjective. But the truth and the reality are the objective facts! It will make your life much easier and less turbulent if you can learn to feel the right thing.
As Muslims, we know that things that happen to us are decreed by Allah. But because we don’t know the decrees of Allah yet (I don’t know whether I will pass my exam or not, for example) we are ORDERED by God to put in some effort to attain what we desire. So the locus of control is balanced here. You are neither too sad nor too happy about things that happen to you in this life. Because you know that whatever bad or good things that happen to you have already been decreed by God and eventually anything bad and good will simply run its course! It will pass! There will be a next challenge to conquer and then the next, and the next…. until you breathe your last air! Bad events hurt… but give it time. Put in some effort, work at it again! Continue! Persevere! Feed that internal locus of control.
And when a disappointing outcome arrives… recognize that some things are out of your own control but it does not nullify your effort at all. It’s just life!
For example, someone passing their viva is a combination of effort, studying and doa (internal locus of control) and examiner factor, your health issues during the time of exam, and the type of caseyou get (external locus of control). That is the reality! Nothing in life is TOTALLY in your control. And nothing in life is TOTALLY under the control of the external forces. Perhaps, when you realize this fact, your feelings about anything will be in moderation.
I suggest that people take up reading as a hobby. Not because it is my hobby and I am very much in favour of that habit (haha… mungkin ada juga komponen biased sikit. Because I will always think that reading is superior to any other hobby hahah… so yup, ada biased sikit) but because it is the one good hobby that will benefit anyone regardless of gender, social status, and whatever past experiences you have had.
Even if you read commercial fiction like Harry Potter, you will feel like “Wow…. this kid could fight the evil Lord Voldemort by the virtue of his effort and perseverance. Setakat kena marah dengan consultant, that is nothing to be scared about. I will turn up to work and finish my housemanship regardless of how bad I kena marah. I can overcome this!” Hahha. Okay… that is an extreme example. After all, Harry Potter is a fictional character and most people don’t try to relate their lives with fictional characters to sooth their feelings. So, you might not think that reading Harry Potter can ever motivate a disillusioned houseman (though actually it works with a lot of ardent readers out there! It certainly works with me!)
But you can also read biography/autobiography of really inspiring people. Autobiography books are real-life events! In my last blog post, I talked about the biography of Muhammad Ali and how inspiring he was. If you are a Muslim, you can read the seerah of our Prophet and his companions (I have mentioned before that Umar Al-Khattab is my favourite superhero). Read about the history of Jerusalem and the oppression committed by Israel towards the Palestinian people who are still persevering and fighting for justice and freedom (Netanyahu is worse than Lord Voldemort, okay!). Read the biography of Mahatma Gandhi and Nelson Mandela and the sort of sacrifices they had to make for the sake of freedom and social justice.
I am not saying that reading protects you from depression or neuroticism. But it broadens your horizons, knowing that people are always struggling sometime, somewhere. You get to live the lives of many people through reading, and you get to find out how all these various people cope with their own mistakes andtheir own troubles (After all, the best way to learn is to learn from other people’s mistakes and troubles…. rather than making the mistakes and having the troubles yourself, right?).
If you just read (the right material), you will have a better coping mechanism. It improves your logical thinking and your abstract reasoning which will make it easier for your therapist to work with you. Some of your CBT homework require some reading too. You are more likely to do it if you already love reading.
If you don’t like reading, don’t worry. Focus on getting a growth mindset, first… and then you will know that you can adapt your brain into loving to read… and it WILL benefit you.
For Muslims, it is no coincidence that the first verse that is revealed by Allah to our beloved Prophet Muhammad (PBUH) is to read! Iqra’, remember? Get some knowledge! Internalize the values that you read and use it as your guidance in making any decision! Our parents can only teach us so much… because they have only their own experiences to tell you about. Their way of doing things and their experiences may not be applicable to you. And so, we read in order to experience the lives of many people so that we can have a big arsenal of weapons to choose from whenever life strikes us hard.
And as a therapist, sometimes we need to set up boundaries with our patients. We have to let them experience the consequences of their own behaviour. We should not be enabling and reenforcing their bad behaviour by always giving in to their demands for attention and validation when what they are doing are obviously wrong and maladaptive.
They have to stick to their appointments and learn to deal with the consequences of being late to theirCBT/Psychodynamic session. When they throw a tantrum, we should ignore them until they are willing to behave well and until they can state exactly what sort of problems they want to discuss with us in a rational and calm manner. Behave like an adult and we will treat you like an adult.
Some patients will manipulate their counsellors or their therapists or their doctors. It is important that we recognize that behaviour and not accidentally rewarding them.
A few years ago, I myself had terminated a therapeutic relationship with one patient when he had thrown a tantrum at the nursing counter in order to see me. My late HOD, Dato’ R, happened to be at the counter at that time and managed the situation by telling him that I was covering addiction clinic and he must see other doctors. The patient should have come during his allocated appointment time but he didn’t.He had come earlier than his scheduled appointments so many times in the past and I had told him not to do it. I told him that he had to learn to deal with his feelings by the techniques that had been taught to him. And I told him that he should go to the ED for any emergency that crops up in between appointments. I was hoping that by making myself less accessible, he would learn to deal with his distress by himself using the techniques that had been taught. But he still didn’t.A few days later, he came tothe clinic again (again, without an appointment) and I decided to see the patient one last time to terminate the therapeutic relationship. I told the patient that what he did at the nursing counter a few days ago was unacceptable and I think he should see other doctors. I was very firm. You must follow the rules, or bear the consequences. After I terminated the therapuetic relationship, he did not see any specific doctor since then and was placed in the general pool for any doctor to see. As far as I know, there is no issue since then.
One day, I happened to bump into him at the supermarket. He was polite and did not try to detain me when I said that I need to excuse myself to finish shopping. That was a huge improvement! A few weeks later he came to the clinic, and he had requested to see the doctors in room 2 (happened to be my consultation room on that day). The clerk at the counter was firm and said “But you didn’t follow appointment. Pergi bilik 5. Lepas ni kalau nak request doctor mana, datang ontime.” And he abided by that instruction without insisting to see me in Room 2. Very good behaviour that he had displayed there! So, I have made a decision that if he ever comes on time later on and requests to see me, I will grant him his wish as a reward for his much improved behaviour.
I am very particular about time and sticking to agreed rules and negotiated terms. That is one of the ways I know that the therapy is working. I have an aversion to being manipulated and controlled. I don’t like it and I won’t allow it in my therapeutic relationship with my patients. On this, I am very firm. I don’t think it is healthy to be there for your patient 24/7.
At what point is your patient going to be able to learn to think for themselves andsolve their own problems if you are always there to be depended on whenever they are in crisis? Once we have agreed on the negotiated rules and terms, we must stick to it. Early in the treatment, there might be some adjustments and hiccups along the way. But by the time the adjustment period is over and the patient is still crossing all sorts of boundaries… then a serious talk must be conducted to establish what is okay and what is not okay in this therapeutic relationship. Any more crossing of boundaries is no longer healthy for either party and perhaps we should pass the case over to our colleague.
And that’s what I did.
Maybe as I grow older and mature into the profession, I might learn differently about what to expect and what to tolerate with regards to therapeutic relationship with my patients, but being controlled and manipulated and being forced to give in to that kind of behaviour will not be something I will passively tolerate. I don’t think that will ever change about me.
On the other hand, another patient of mine who had successfully internalized the values of effort, and having a growth mindset and having an internal locus of control (unfortunately she STILL hasn’t internalized the values of reading, haha) had successfully managed all her crises in the 3 months when I was not around in the clinic (because I was doing my forensic attachment in HBUK at that time). When she saw me shortly after I returned from HBUK, she had said “Doktor tau tak dalam masa 3 bulan ni banyak sangat benda jadi kat saya. Tapi saya boleh handle sendiri, doktor. Doktor tau tak saya dah berhenti kerja yang dulu. Waktu tu saya sangat stressed dan nak sangat jumpa doktor… tapi nurse kata doktor pergi attachment. So saya pun pendam sajalah and handle sendiri. Alhamdulillah, sekarang saya dah dapat kerja baru. Dan gaji saya lagi bagus dari kerja saya yang dulu.”
I was overjoyed that she could handle things for herself. I said to her something along the lines of “Bagus! Memanglah semua masalah kena handle sendiri. Kalau saya ada pun, apa saya boleh buat? It’s your job, it’s your life… you have to make your decision and stick to it and then put in the hard work. And then, there will be another challenge… and you will handle it again just like you have handled it in the past. These things will continue for the rest of our lives. Memang awak boleh buat pun. Congratulations! Lepas ni bolehlah bagi appointment 3 bulan sekali pula.” I teased.
“Dua bulan dulu lah, doktor!”
I laughed. “Saya tak ada tiga bulan hari tu, awak okay jer! Pernah dengar tak, necessity is the mother of invention? Bila benda dah jadi dan kita terpaksa handle sendiri, waktu tu lah kita discover our real abilities. The situation NECESSITATES us to grow! We must start creating opportunities for you to handle crises yourself in between appointments. You can do it! In fact, you have done it when I wasn’t around!”
I cannot wait until I can give her a four monthly appointment. Hahah. Yes, she is one of my favourite patients. Because she internalized those values I had listed above, she is much better now. So, I like seeing her because I feel like all the time spent in my session with her was not in vain. Not wasted. But eventually, it is our responsibility to make sure our patients can be confident to let us go. One day, I might have to move elsewhere, work in another state. I am not going to be there for them 24/7. It is an unrealistic expectation to be placed on any doctor or any therapist! And I refuse to do it for any of my patients. It is kinder in the long run that we maintain boundaries and make them self-sufficient. It is the kindest thing you can do to anyone…. to provide them with a fishing rod instead of a limited supply of fish of uncertain duration. That kind of uncertainty will create unconscious distress in them because they will always be wondering “Can I survive without my therapist?”
So, I have told her that next time, we are going to try for a 3 monthly appointment regardless of whether or not she feels ready. She just smiled… because she knew I always do what I said I would. Or maybe it was a smile of someone who is confident enough not to worry too much any more.
Why worry when everything has been written and all you have to do is to go through it and do your best until you breathe your final breath.
I leave you guys with one of my favourite songs by Sami Yusuf. This song teaches us that when it comes to dependency, there is only ONE entity that we REALLY cannot live without… and that’s the way it should be in this life. That’s the reality. All the dramas in your life should take a pause to acknowledge this fact once and for all. And trust me, you will be happier for it.