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|Year : 2018
: 60 | Issue : 4 | Page
|Saving the sweet bird of youth
Ajit V Bhide
President, Indian Psychiatric Society Head, Department of Psychiatry, St Martha's Hospital, Bangalore, Karnataka, India
Click here for correspondence address and
|Date of Web Publication||28-Nov-2018|
|How to cite this article:|
Bhide AV. Saving the sweet bird of youth. Indian J Psychiatry 2018;60:377-83
Chairman Sir, and my dear fellows and members of the Indian Psychiatric Society: I stand before you in humility for the high office you have bestowed on me in unanimity. It would however not be honest on my part if I do not admit to a certain tinge of pride in holding this office wherein I promise to uphold the high traditions of our society.
On this occasion, I would like to pay my humble respects to my teachers who helped kindle in me a thirst for knowledge and helped me get a perspective and a hold on life and steered me in my chosen profession. Prof. Prakash Shetty, Prof. Om Prakash, and Prof. MV Warunny, I do remember in particular from my undergraduate days as having been the most important influences. Prof. Ravinder Lal Kapur, Prof. Ravishankar Pandey Prof. S Kalyanasundaram, and Prof. GG Prabhu were inspirations, not just teachers, in my postgraduate days.
High academicians have graced this post in the past. I come from a relatively humble background. I am, however, eternally grateful to the institutions that taught me and in each of which I had occasion to serve: St John's Medical College, the National Institute of Mental Health and Neurosciences and for over the past three decades, St Martha's Hospital, all at Bengaluru. My bio data opens with the lines that I completed all my education from school to postgraduation in a radius of about 2.5 km, and said only partly in jest, that this has greatly helped broaden my vision.
There is another group to whom owe a debt of immeasurable gratitude: this is a small group of professionals who have been a sheet anchor to me as dear friends, collectively a sounding board, a source of support, encouragement and solace, a second family to me, through almost three decades. I will not embarrass them by naming them; most of them are here today. We started as a group that met on a Friday every month and gave ourselves a dubious rubric: Thank you my dear Shukracharyas. There are a number of other friends to whom I am grateful, too numerous to name here. I owe a great deal to the Indian Psychiatric Society, Karnataka Chapter members, who were the principal motivators to bring me here.
And of course my own family: my wife Chanda, my children Harsh and Riddhi, my parents late Col Vasant Bhide and Indumati Bhide and my siblings Vijaya Damle and Jayant Bhide, each with me forever, in what they have given me.
There are important issues before us at the IPS. The decriminalization of same gender sex is a stance we need to take without delay. There is also the curious case of our profession suddenly not being recognized as the right one to certify what clearly is in our realm: specific learning disability. Then, there is the long battle over the impracticalities in the legislation concerning our profession. These along with some other issues will need urgent attention, which with your active support I shall work on.
You may wonder why you are not holding a copy of the address. I have never circulated any of my presentations, with a conscientious effort to go green. I crave your indulgence and promise that in a short while from the ANCIPS the address will be made available on our website and in due course in our journal.
| Saving the Sweet Bird of Youth|| |
I intend today to focus on the vulnerable years that need our attention: adolescence and early young adulthood, the years between the ages 15 and 25, give or take a few. The WHO astonishingly now defines adolescence as being between the ages of 10 and 24. This may or may not have taken into consideration the phenomenon of biological maturation in our species arising earlier and earlier; the age of puberty across the world is much earlier than 45 years ago.
The canvas of psychopathology in this period is too vast to cover you would agree, in the span of about half an hour.
The cliché goes that wealth of the nation is overwhelmingly in its youth. Weather-beaten though this statement be, with meaning it remains rich. The cherished years are also the vulnerable ones we have come to realize even as over a century ago we began to abandon the notion of our young ones as the noble savages.
India has over 310 million people in this age range at present. This has rightly been called an asset, a demographic dividend as we get used, unfortunately, to the language of the marketplace. But how fulfilling and psychologically healthy are these years to those in this bracket?
Of the many maladies of this phase, I will focus on a select few.
| Adolescent Crises|| |
This phase is marked by certain vulnerabilities: over 120 years ago, the fact that the serious illnesses we now call the schizophrenias, were more likely to be diagnosed, and even to begin in the years of adolescence, was recognized. It was followed by a somewhat romantic age when psychological vulnerabilities were psychologically rather than biologically explained.
The school of psychoanalysis from Freud through his followers encouraged this trend. In the West, an acknowledgment that adolescence was marked by a turbulence that came to be thought of as normative and was labeled a crisis became widely accepted.
Just beyond her youth herself, the American anthropologist Margaret Mead was already wary of this idea of a necessary adolescent crisis. She journeyed to Samoa to study the sociopsychic world of the youth there and found her hunch validated. No such crisis was encountered there. I wonder what she would have found had she journeyed to pre-independence India.
Her research, that told us that the adolescent crisis was far from universal, caused a stir, but the disbelief seemed to settle down in less than a decade. Many years later, her findings and indeed her honesty was called into question; but more recent investigation finds the naysayer not quite intellectually honest himself.
But closer home, what have we to say of adolescent turmoil in our own backyard?
Prof. TS Saraswathi of Vadodara made the sharp observation that in India, the very concept of adolescence seems an upper middle class and upper class one. As for the rest, a person was thrust into adult roles from childhood itself, quite possibly because primacy has been given to the eventual earning and reproductive tasks.
Late Prof. MAM Khan of Hyderabad observed that adolescence was marked by no crises in India circa the period of the country gaining independence but identity problems surfaced and grew in the following decades. He conjectured that the heady winds of success in India's freedom struggle in which many youths participated, could well account for the youth being free of the turmoil in the early years of Swatantra Bharat.
I remember listening to Prof. J S Neki over three decades ago, challenging many aspects of Erik Erikson's model of psychological development. He expounded then on how the concept of the ideal personality in India was going through a sea change. The traditional role model of the hero Ram of the Ramayana, an obedient duty-bound son, subservient to parental wishes and unquestioning of the authority of elders, very popular across India for centuries, was now transmuting to the Western ideal of the independent, ambition, and material success driven go-getter. That astute observation continues to be valid and I suspect has percolated swiftly though not completely to the rural sections of our populace.
The “adolescent crisis” was also considered in the period after Mead, and possibly influenced by her findings, as being an artifact of modernism and socioeconomic liberality. The ancient scripture of the Hitopadesa partly concurring with this conception states:
“When youth, wealth, authority, or an indiscreet nature,
Can each be the cause of one's undoing
What could be the greater disaster
Than the foursome in one person dwelling?"
The perception then that youth is a time of Strum und Drang (Stress and Strain) of unimpeachable and even arrogant individualism, rebellion does indeed in clinical practice seem more common among the privileged classes, but my no means does it spare other segments of society. The findings of research in the last half-century now tell us this could well be on account of the neurobiological changes that the maturing person is unbeknown to her or him, undergoing.
| Existential Neurosis|| |
Bombarded by forces overwhelmingly beyond their control, young persons are often caught in a vortex of existential neurosis often without even realizing it. Life seems purposeless, and this makes morality irrelevant. Frankl called it the existential vacuum.
The epidemic rise of the overprized value of material happiness drives young folk to rash decisions, adventurism at times but almost always, a certain emptiness, to gain that “happiness.” The famous abhorrence of nature for vacuum pulls in forces that can have quite deleterious and even devastating mental effects.
In the desperation of purpose searching, during the years that Erikson first identified as those of Identity Formation versus Identity Diffusion, some gravitate to the apparent security of various shades of ethnic identity. From here to ethnocentrism: the belief that only I and my tribe are right is a short and calamitous trajectory. The cult identification pathology does not figure in our diagnostic systems and never will; but the toll it takes on mental well-being of both, the individual and his/her society is beyond calculation.
A number of other pathologies are important, many of which ensue in the context of that existential void. These are the ones I intend to concentrate on.
Some young persons enter a phase of indolence and irresponsibility that burdens the parents. In many of them, this “cool” mien and lifestyle really is a manifestation of the existential vacuum that needs to be unmasked. For the clinician handling these individuals poses quite a challenge.
| Addictions|| |
Getting dependent on different mores or substances has many roots, and we know that the earlier a habit gets entrenched, the more difficult it becomes to eradicate. The last half century as I said, has seen exciting discoveries in the maturation of the brain, aided maximally by sophisticated radiology, which now posit the importance of biological alterations, pathologies that correlate or even might explain myriad disorders. For now, we will look at the two principal kinds of addiction: chemical and behavioral.
| Chemical Addiction|| |
The prevalence of substance abuse and addiction among the youth, while widely varying across the country, seems maximal in urban areas and certain geographic locations. Prof Pratima Murthy, Prof. Vivek Benegal and others of the NIMHANS group, on a survey of published data in our journal, the Indian Journal of Psychiatry, reported that alcohol use varied from 7% in Gujarat where prohibition is in imposed, to over 75% in the North Eastern state of Arunachal. It does seem that youth are particularly prone to be enticed to substances of abuse.
Quite recently, Dr Lucy Raphael and colleagues from Kerala, in a survey of college going youth find that about one-third of them are afflicted. They were in fact looking at what are generally considered less harmful forms of abuse: smoking tobacco, the use of alcohol, and chewing paan, though there were a few cases of cannabis and narcotic use too. A much greater prevalence was noted in males, and the place of residence also seemed to play a part, those residing at home being a little less vulnerable than hostelites and paying guest students. What is important to me in this survey is that over a quarter of the users had a history of substance use in elders in the family and over half had peers indulging in the substance use. We are thus guided to the multiple directions our preventive efforts need cover.
Punjab, where illicit chemical use has alarmingly risen in the past two decades, probably has the most tragic tale that has made an impact on the state's politics and even been the subject of cine Hind (my term for the so-called Bollywood). A recent survey showed that high school children had a prevalence of over 66%. In Punjab not only are urban youth affected, but also this menace has reached down to the villages.
This led the government to seek professional help from our colleagues, Prof. Basu and Prof. Awasthi at Chandigarh, who developed the pyramidal “Punjab model” incorporating the strategies of supply reduction, demand reduction and harm reduction. Of these, demand reduction through effective public education would obviously merit our main focus. Youth need to be made critically aware of the seductive temptations that lure them into the drug trap. Anecdotal evidence suggests that both youthful cynicism and hopelessness among those already caught in the snare, become not only impairments to intervention but these phenomena feed each other. This undermines the educator's efforts considerably.
Elegant animal experiments elucidate why the preadult brain is more vulnerable to becoming victims of addiction, not only of a chemical nature. Could these be extrapolated to humans? The evidence seems to suggest it can.
| Behavioral Addiction|| |
No behavioral addiction has been the cause of despair among parents of young persons, and occasionally, the young person herself or himself than the now rampant “screen addiction.” I am sure every clinician here has encountered this over the past two decades or so. The doleful, desperate parents who complain of their teenager being hooked to the mobile phone are totally commonplace now.
Screen addictions have been called electronic cocaine. Worse, they have been likened to the Trojan horse, deceptively decorative and presentable, but actually a subterfuge that undermines psychological health and even survival. Recent research clearly indicates that very early exposure to a portable screen can cause neurological damage and functional impairment through the addiction it can bring in. Dopaminergic mechanisms and malfunctioning circuits in the pleasure/reward pathways have been implicated.
In India, the malady tends to be maximal in the early part of the group we are looking at, 15–20 years of age. Many unwitting and unsuspecting parents have yielded to the young persons' requests or demands for a smartphone and not uncommonly this is the entry into a maze, escape from which is most trying. An excessive reliance on the seemingly innocuous gadget creeps up on the individual, not unlike the boa constrictors vile grasp on its unsuspecting victim, who gets crushed and consumed. Arguably the most vicious pathways this phenomenon then takes include addiction to screen games, chat lines, sexual titillations and social media.
Today I shall deal only with one aspect of the social media addiction: the selfie, a phenomenon of self-photographing that earned its name somewhat recently and became widely prevalent five years ago.
| Selfies and So-Called Selfitis|| |
As the technology for photography became less complicated, it became widely accessible in terms of cost and operation to almost everyone. This then took the form of people who had not many pictures taken of themselves, beginning to photograph themselves with great ease and at a swift pace. The advent of and rapid access to the smartphone caused it to become widespread. The selfie became as commonplace as the morning sun.
What seemed a cheery venture has become an obsession of pathological intensity for many. I used to believe that an unusual preoccupation with selfie-taking was necessarily just another variation on the theme of obsessive-compulsive syndromes, from the benign to the dangerously severe. There is much more to it, however.
Many in our profession have urged that the selfie-taking obsession/compulsion be recognized as a disorder by itself. There are good reasons to support this idea, There have been criteria about how frequent must selfie-taking should be, and in what circumstances, and so on, for the phenomenon be called pathological. However, the clumsy and even unfortunate title “selfitis,” I feel is not suitable for the condition; aggravating though it is, it is not an inflammation.
Researches into the phenomenon of selfie-taking clearly show that quite often there is an excessive preoccupation with body image among the takers. This is especially manifest in not merely taking many pictures of oneself, but also repeatedly viewing them on a social medium like Facebook or Instagram, and craving the approval of others.
Young people, needless to say, are far more likely to being caught up in this pursuit and given that this is the age when competitiveness is almost automatic for youth, many set out to outdo the frequency and variety of selfies, jousting with their peers. Intense rivalry and even pathological jealousy can ensue from this preoccupation.
It has become increasingly common to equate the selfie-taking obsession/compulsion as being reflective of narcissism, the excess self-love that figures in the extreme as a personality disorder. Quite often, this perception of narcissism among the youth gets scoffed at, disparagingly dealt with and in an often unwittingly manner a bad situation is made worse. How so? To understand this let us look at the phenomenon of narcissism of youth in some detail.
| Narcissisms in Young People|| |
The coming of age years can be marked by quite normal love for oneself, as physical gender attributes become better defined, prowess at different skills becomes prominent and the thrill of independence comes to assert itself.
Almost 25 years ago, Bleiberg gave a useful paradigm of normative and pathological narcissism in adolescence. Speaking from psychoanalytic leanings he stated that “normal adolescents achieve a partial disengagement from their internalized parents without finding themselves bereft of limit-setting and direction-giving capacities, (without being) unable to maintain basically good relationships with both their real and their intra-psychic parents. Normal adolescents can construct an ideal that guides their transition into adulthood."
Not all young persons go this healthy way: some get imprisoned in a fantasy of an omnipotent sense of self, with a refusal to see their shortcomings and vulnerabilities, projecting disowned self-experiences onto others, almost constantly demanding public affirmation of their illusory power.
Varied developmental factors go into the eventual emergence of a narcissistic personality, even developing at times into a personality disorder. Bleiberg has looked at certain patterns somewhat distinct from each other, though I believe they very occasionally might overlap:
- The histrionic-exhibitionistic type: the personality constellation is woven around the person's beauty or talents, with constant seeking of adulation and admiration, a sense of exhilaration when this need is met, and a tendency to feel crushed, to brood or even turn spiteful if it is not
- The vicious psychopathic type: characterized by ruthlessness and a tendency to dissociate and deny pain, helplessness and vulnerability, and resulting in a pattern of exploitation, intimidation and manipulation. They are hypervigilant, constantly scanning for threats or blame and are haunted by the expectation of some attack
- The masochistic self-victimizing type: the personality is organized around the experience of being victimized and their apparent sense of helplessness masks an inner feeling of superiority and sometimes an illusory conviction of power.
The narcissistic core constitution has possibly some genetic vulnerability, which is a new realm of research. The heritability index of narcissistic traits is about 53%. This does indicate that environmental factors do play a role in the eventual emergence of the disorder of personality. Most important in these is a hostile atmosphere in the developing years. Abuse of various kinds: physical, sexual, child neglect, and emotional all contribute. The last mentioned is probably the most common but also the most difficult to delineate and study.
To return to the issue of why labeling a young person on the selfie march as narcissistic to his/her face is unwittingly making a bad situation worse, suffice it to say that the labeling might be accurate but considerably undoes the possibility of correction and salvage. In dealing with this individual, there has to be an empathetic understanding of the fact that this condition emerges from emotional scarring, not the least at home, from elders including parents, the school and the peer group. Deprived of perceived affection, many seek that love and affirmation in oneself. Limited clinical experience suggests that this can best be handled in re-educative therapy.
In a world where loneliness has become epidemic, many of our selfie marchers are intensely lonely people who find solace in being with themselves; they are not mature enough to internalize that metaphor and genuinely find comfort in solitude. Not for them what Shankara called
(from the company of good people to a state of not needing company).
Rather, they find fulfillment or at least seek to do so by more and more physical ascertainments of their worthiness, even in their own images when no others are theirs.
This same loneliness I have referred to is the reason I assert why more young people today are more prone to giving up the ghost in a literal sense.
| Depression Desperation and Suicide|| |
Five years ago it was averred that at 35 per 100,000 population, India had the highest youth suicide rate in the world. The commonly stated reasons for suicides included family problems, failed romances, physical illness, depression, financial difficulties, and academic problems. In a significant minority, the cause was not known.
Overlapping reasons can be there and in my experience, they often are. Cumulative stresses obviously are more likely to lead to breakdown. But the reports take only a little cognizance of this.
Have we addressed the issue of how many of these departed had felt totally or almost totally isolated? Many of us have had the experience of learning that young people are highly lonely when the attempt is made to end one's life. Ironically among the city-dwelling young, many suicides have unbelievable numbers of Facebook friends but that is a register of hollow friendships. Increasingly we live in inner spaces and so-called friends are actually barely acquaintances.
Many inspiring articles and books have addressed these issues, not the least from our colleagues in the Indian Psychiatric Society from across the country. At times there has been, if I may say so a certain naivety on our part in understanding the angst of the affected. I think suicide prevention among the younger sections of our population has to be a thrust area for our work. The anomie, the lack of firm guideposts that is attendant on a continually transiting culture with marked social, educational, economic and social disparities is mind-boggling no doubt, but that is a poor excuse for not stemming this tide of desperation in our youth.
| Emotional Abuse and Issues of Discipline|| |
In the range of abuse of the young, emotional abuse is the one least discussed though it occurs, apart from being by itself, as an accompaniment of physical and sexual abuse. Inconsiderate remarks at one milder end of the spectrum, and extremely harsh rebukes laced with sarcastic and demeaning statements at the other characterize such abuse commonly. Prof Shekhar Seshadri drew my attention a few decades ago to how derogatory angry remarks from elders such as “Wish you'd never been born!” “What did I deserve to have a child like you?” “Why don't you just go die?” “Better would it have been for me to die than suffer your behavior,” can have a devastating imprint on the young mind and become the nidus for extreme rebellion, or suicidal preoccupation or both.
Depressed, psychotic and personality disordered parents, teachers or other care givers are most commonly the perpetrators. Sometimes the perpetrators not conscious of the deep scars they are inflicting; some of these wounds never heal, especially if the abuse has been chronic. Incipient anger, frustration, psychological defeat and a poorly formulated sense of guilt, shame or revenge then can blossom into ugly culmination.
Education in parenting and child-rearing practices, consistent disciplining and understanding of the young mind are necessary in such instances.
This is not to suggest that disciplining and punishment have no role in shaping the young. They are indeed essential but need to be humane and without causing the young person to feel humiliated. Tough love does indeed beget good results when practiced with wisdom, caution, and clarity of purpose.
| Pointers from Positive Health|| |
The first documented effort to study a healthy personality rather than get caught in the morass of psychopathology was probably the study of American First Lady, Eleanor Roosevelt by Abraham Maslow.
Today however, the credit for positive psychology is given to Martin Seligman, who as president of the American Psychological Association, certainly articulated its importance and gave it a much-needed new impetus.
In the area of youth development, American psychologist and Professor of Education, William Damon has dealt with the need to reemphasize moral development and cautioned against the culture of fostering indulgence. Howard Gardner, much remembered for awakening us to the possibilities of changing minds to healthier outlooks, recognizing seven factors and six arenas of change of mind. Extremely popular in the last two decades or so, has been the concept of “flow” by Mihaly Csikszentmihalyi. Flow is defined as being completely involved with the activity at hand, with the ego fading away, and one's skills being used to the utmost. It equates with what is called hyperfocus except that the latter tem tends to have negative connotations, flow quite the opposite. In the Indian terms it equates with or single mindedness. It has many commonalities with the current buzzword, “mindfulness."
American pediatrician Dr Mel Levine has drawn attention to the victimization of young people in different contexts and has been an inspirational voice on their behalf. His writings have also focused often on preparedness of young people to face the hazards of life. “Ready or Not: Here Life Comes” is the self-explanatory title of a book for late adolescents and young adults.
Miriam Akhtar in the UK, not as well known as any of the above, has simplified the positive psychology for youth, and devised what she calls the Happiness Zone: this comprises eight “Zones.” The Feel good zone deals with positive emotions, the future zone deals with optimism and gratitude and the “Me” Zone with recognizing one's strengths. Then there are the Chill Zone for meditation and healthful relaxation, the Change Zone for motivation and goal setting, the Me to You Zone for healthy relationships. Finally there are the Body Zone for Nutrition and physical activity and the Bounce Back zone for building and fostering resilience.
Using these modules which to me do seem to have an overlap, vulnerable young persons in the fifteen plus age group in an empirical study showed some remarkable changes such as discontinuing alcohol and substance use, greater confidence, personal happiness and other positive emotions, re-engaging with abandoned education or job pursuance, and much reduced negative emotions and pessimism.
In our own country there is stupendous work in positive mental health for youth. The work of Anand Nadkarni and the Institute of Psychological Health at Thane and that of Dr C Ramasubramanian at Madurai are just some shining examples.
Or to adapt from the prayer of St Francis of Assissi.
| Where There is Despair Let Us Bring Hope|| |
We have too often been enamored of the Western models of development. Prof. Malavika Kapur has made a careful study of indigenous models, many with a long past that are quite fascinating. Prof Saraswathi has also alluded to our need to absorb what is healthy in our traditions.
My humble submission as well as my earnest plea to all of you my professional brethren is to look at our young folk with greater understanding and fellow feeling. The age of anxiety is still upon us, with one country now having a Minister in its Government to address the epidemic of Loneliness! More than ever before between the middle of the second and the middle of the third decades of life are a generation much misunderstood and often needlessly maligned by the others, especially elders perceiving them as selfish, self-absorbed and engaged in a malevolent tyranny of other age groups.
Delving deeper into the psyche of such individuals and indeed collectively of the entire generation would be an education and a challenge to our capacity for patience, empathy, creativity, indeed to our entire range of therapeutic skills.
It is gratifying that the Indian Government has a scheme: the Rashtriya Kishor Swasthya Karyakram which covers mental health along with other health issues. Gratifying too, is that the programme operates now with apps, which would quite appeal to our youth. I am not at all sure, however, that our profession has been given adequate or even any representation there. That is another matter we need to take up.
I trust this address may be a clarion call for us to take up youth mental health with seriousness and devotion.
Chairman Sir, I thank you and my esteemed audience for your patient listening.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Dr. Ajit V Bhide
Vasant Vihar, 79, Amarjyothi Layout, Sanjay Nagar, Bengaluru, Karnataka - 560 094
Source of Support: None, Conflict of Interest: None