Episode 7 of En Ullae S2 is a harrowing tale of Ramesh’ descent into utter despair due to his alcohol addiction. After the lilting trill of a happy alcohol buzz wears off, people in the throes of addiction often experience a sense of bitterness and desolation. It’s an artificial stimulant that when consumed, releases endorphins, neurotransmitters that promote a feeling of euphoria and help reduce stress.
Some instances of alcoholism are undergirded by an anxiety disorder, according to Dr Rajesh Jacob. He posits that people attempt to “treat” symptoms of anxiety by self-medicating with alcohol, ameliorating the discomfort of social situations through chemically induced disinhibition and happiness. They become chattier, and won’t choke during conversations – an alluring prospect for chronically anxious people.
Ramesh, now advanced in age, wistfully recounts how he fell into alcoholism. At 15, he and his friends would entertain themselves with drinks and idle chatter at a ‘kopitiam’, a Singaporean colloquialism for ‘coffee-shop’. Dr Jacob reminds us that despite being a stimulant, long term alcohol abuse invariably leads to depression or anxiety. Alcohol addiction can stem from a variety of factors – from the ‘angry, drunk father’ to early over-exposure to alcohol, and everything in between. Hassan Mansoor, a recovering alcoholic, confesses that his first foray into Bacchanal pleasure was during his secondary school years(junior high) for you Americans). He doesn’t remember the time with rose-tinted glasses, though – his adolescent years were marked by incessant violence, physical altercations and poor academic performance. He’d thought it made him look “cool”. Beer, whiskey, “Boon Kee Low”, “Paddy”, its name derived from its roots as a rice wine, and “Deer”. All of them cheap highs.
We’re then treated to a vignette in which a listless Ramesh, rake thin, gets into an argument with his doe-eyed girlfriend over whether wine should be drunk at lunch. Both of them are adamant that they hold the moral high ground – Ramesh, with his insistence that wine is “not hard liquor”, and Reena, with the awareness that his alcoholism is ruining not only their relationship but himself. We learn that the long-suffering Reena has tolerated Ramesh’s equivocations and excuses for four years, and she’s at the end of her tether.
(Click on the link for a version with English subtitles. Remember to click on the ‘Settings’ button to reveal the English subtitle selection. https://www.mewatch.sg/en/series/en-ullae-s2/ep7/954631 ) Dr Jacob explains that genuine awareness of an alcohol problem can only legitimately come from within, and external criticism is met with a wall of anger and irritation. In the early stages of alcohol addiction, one usually does manage to induce some level of happiness. As the disease progresses, drinking no longer “feels good” and chemical dependence means that consumption is imperative to avoid withdrawals. Alcohol withdrawal symptoms include hand tremors, which can set in as quickly as 4 – 6 hours from the last drink, insomnia, anxiety, psychological cravings, palpitations and sweating. Alcohol addiction is a vicious cycle, according to Dr Jacob.
Most people suffering from alcohol addiction start off with social drinking, which isn’t a problem in itself. However, addiction is a chronic, progressive disease which Dr Jacob measures with three factors of varying severity: drink frequency, duration of drinking, and cravings. Ramesh admits that his family life and relationships suffered. Getting blackout drunk was a nightly affair, which left his wife paranoid of his infidelity, when in fact he was unconscious in a ditch somewhere. He wouldn’t remember the events leading up to the loss of consciousness, a form of anterograde amnesia. Eventually, his wife takes out a Personal Protection Order (PPO) against him, the Singaporean variant of a restraining order.
The spiral into full throttle addiction isn’t a pretty sight. Just being in the presence of his drinking buddies would catalyse a night of binge drinking, invariably followed by a hangover in the morning made all the more unbearable by guilt over the slow rot of his cherished relationships. Work performance suffered, many a medical certificate was sought, culminating in joblessness.
Dr Jacob explains that addiction leads to productivity impairments at work. A sure sign of dependence is the need for a drink in the morning to curb tremors and imbibe him with enough energy to perform as a barely functioning alcoholic. Day drinking and surreptitious alcohol breaks are common. When in active addiction, one’s happiness (in the form of craving relief) takes precedence over that of others, and empathy goes out the window. Ramesh is reduced to a pitiable state, cajoling once close friends to spot him the occasional tenner – in their eyes, he is reduced to a shadow of his former self. Now jobless and without an income, he burdens his children with the restitution of his loans – he is now too functionally impaired to perform any meaningful work. His wife is now the sole breadwinner, and the guilt in his voice is apparent, even today.
Ramesh only manages to stop drinking for some length of time at 48 due to chest pains. After a successful heart bypass, he turns to drink again. Then comes the second bypass, which he sullies with an infection brought on by his inveterate drinking. Alcohol and heart medication should not be taken together, but his addiction blinds him to a sanguine truth. It is only after last-ditch surgery is performed that he cultivates some restraint, managing to abstain from drink when he recuperates for a month in the hospital. He is 68 when he finally gets into recovery.
All manner of physical ailments accompanies alcohol addiction. “From the head to the feet”, Dr Jacob says. The brain is atrophied such that fits, falls, bleeding, subdural hematomas and dementia become common. Liver cirrhosis brings about jaundice and bloody stool. Peripheral neuropathy, a feeling of pins and needles in the hands and feet arises from damage to nerves outside the brain and spinal cord. Even sexual performance suffers. If diabetes is comorbid, the body becomes much poorer at sugar control.
Dr Jacob recommends a ‘biopsychosocial’ model for treating alcohol addiction. “Bio” refers to medical treatment in the form of total abstinence (detoxification) and medication. “Psychosocial” refers to psychological counselling to treat addiction, medication to reduce cravings, and therapy sessions with the family. In short, a treatment model that aims to target likely risk factors for relapse.
Nobody takes their first drink and thinks, “This’ll be the death of me”. Fortunately, if people suffering from alcohol addiction take a step back and consider their mind, their physical body, and their loved ones, and combined with proper support and therapy, recovery is possible.
If you’ve been pottering around the Promises Healthcare’s ‘Our Team’ page, and are new to the world of mental health in that you’re considering making the leap to seeking help from a mental health professional, it’s our hope that this casual guide to demystifying the titles, designations and dizzying abbreviations that adorn each profile will point you in the right direction.
For starters, there’s one thing that each of our mental health professionals have in common. They all possess at minimum a Master’s level certification in their discipline, so you can be assured of all their competencies.
As we’ve shared in a previous article, a psychiatrist is at their core a medical doctor, which certifies them to prescribe neuropharmacological support – i.e., medication.
But of course, psychiatrists more often than not do indeed possess relevant counselling and psychotherapy certifications, because being well-versed in the craft of patient care in the mental health sector does help them delve deeper into the minds and psyches of their clients, and assist them in skilfully and empathetically overcoming boundaries that some clients may consciously or unconsciously put up that stymie the therapeutic process.
Prescribing the most effective neuropharmacological support is buttressed by the psychiatrist’s skill in interpersonal communication, both verbal and non-verbal. Psychiatrists often describe themselves as observers, but it goes without saying that navigating these one-on-one interactions requires input from their side of the desk. While you might think that psychiatrists have reached the peak of the career trajectory of a mental health professional, keep in mind that by no means should you think of a psychiatrist as the fount of all mental health knowledge. Think of the ‘helping’ professions encompassed in the form of a large tree, rooted in a common desire to help people in need and supported by a trunk of science and evidence based knowledge , from which grows different branches representing the many ways in which mental health professionals can help someone in need – certain disciplines are applied more rigorously in helping certain conditions or situations. This is why Promises is described on our page as a multidisciplinary team of mental health professionals. Your treatment plan is provided by our team, and under the shade of our tree, you will be prompted to reach for certain branches – but at the end of the day, it is your choice to pick the leaves which seem most lush to you.
Psychologists differ from psychiatrists in one key authority. They are not medical doctors, and therefore cannot prescribe you medication. You’ll notice that our stable comprises a good number of clinical psychologists – so, what exactly are they, and how can they help you? Clinical psychologists possess doctorate degrees in psychology, and are imbued with the ability to cater to clients who suffer from any number of the discombobulating disarray of mental health conditions which sadly, are still negatively stigmatised in society. Think schizophrenia, bipolar disorder, depression, and their ilk. A clinical psychologist can make a diagnosis for you, if you think you are suffering from a mental health condition. Using the tools in their arsenals which they are trained in, such as psychometric testing, intelligence testing, personality testing, and much more, their diagnoses are firmly rooted in evidence based science. You could then make the logical conclusion that if they deem your condition treatable with medication, they would refer you to a psychiatrist. There’s a lot of symbiosis going on in our clinic!
The difference between Counsellors & Psychotherapists
We’ll deal with counsellors and psychotherapists next, because the two fields are very much intertwined, aligned in some facets, while possessing in granular detail key differences. Counselling and psychotherapy are both broadly concerned with betterment of clients in need, and there is significant overlap in the goals of either mode of therapy. Now, on to the differences, which will help you better distinguish which leaf you’d like to choose. First, there is a temporal difference between the two in both the length of treatment and how far back into your life each mode of therapy delves into in order to solve your current issue.
Counselling, on one hand, tends to favour clients who are more self aware and sensitive to their emotions and thought processes, and need a helping hand in unpacking a recent difficulty or life altering experience that they wish to resolve. This is rather unlike psychotherapy, rooted in a humanistic tradition – some may refer to it as height psychology, a term which gained currency during the time of Abraham Maslow and his espousement of self-actualisation. Psychotherapy, in this sense, takes a long, lingering look at a person’s past, life changing experiences, deep seated traumas and neuroses, or any relevant factors – all to help a client gain mastery of self (self awareness) and challenge them to enact the necessary life changes that lead to self improvement. You might well think of counsellors more as “advisors”, and psychotherapists as the “life guides”. Of course, detract nothing from both disciplines – their practitioners chose their specialities precisely because they fit into their world-views and probably, because they thought that they were good at it!
How do you choose?
Of course, given the array of therapeutic modalities and mental health professionals, we understand that choosing the right leaves can be a bewildering experience. That’s why we feel it’s best that you browse the profiles of our therapists, read their biographies and see which of them you feel most comfortable seeing. In the near future, Promises Healthcare intends to refine and streamline your selection process by having a list of issues or conditions that you are having problem(s) with – your input will then guide you to the mental health professional in our team that is best equipped to deal with your issues. For now, take a deep breath, sit back, read, absorb, think with clarity about what you want to deal with, and pick one to make an appointment with. Choosing the right therapist isn’t a one hit wonder – it takes time and patience, but rest assured that we’ll do our best to help you in that regard.
This episode of En Ullae touches on psychosis. This case study was about a man who had developed schizophrenia and became obsessed with the ‘spiritual safety’ of his partner. The building tension served to demonstrate the dangers of ignoring the symptoms of psychosis, which his partner was predisposed to do, in her untoward position as the long-suffering partner in a dangerously unstable relationship. Dr Jacob characterised psychosis as rooted in an unshakeable belief in false delusions – people who suffer from the condition are often willfully blind to reason, which he cautions against trying to impose on them when the time is inclement.
Prem, the unfortunate man with all the symptoms of hallucinatory schizophrenia, began to cast an evermore imposing spectre in the relationship, causing much distress to Rani. His delusions began to take such a toll on their relationship, with even the good tidings of a baby in the oven twisted into a string of abortion by Rani, afraid that he would bring harm to her and any prospective child she would bequeath upon them – he professed to see the child as a harbinger of doom, as the embodiment of the devil. Midway through the episode, the viewer is treated to the appearance of two ambiguous personalities – a man and a woman, whose blue lanyard faintly conveyed some sense of authority. We are left uncertain as to their actual responsibilities – they are at times quizzical, unwilling to manifest the “good cop, bad cop” trope. No matter, it is not the point of the episode to further entangle the convoluted plotlines – they serve as plot devices which encourage Prem’s own narrative to unfold – to the end, he remains stolidly convinced that his stabbing of Rani had taken her to a better place, the expression on his face almost beatific at times.
Dr Jacob, at this point, sees fit to caution the viewer against harshly attributing homicidal tendencies to persons with psychosis. He presents the statistic that even less than 15% of homicides are perpetrated by people mentally unsound. Noting the prevalence of drug use and antisocial tendencies that colour this 15%, he confidently steers the viewer away from making too quick a conclusion – it is in everyone’s best interest to step back and evaluate statistics grounded in good science, instead of leaping to the easy conclusion that Prem was beyond rehabilitation.
If you’re considering seeking help from a mental health professional / psychiatrist, there’s a pretty good chance that you’ve realised there’s help out there that can assist you with whatever concern you have on your mind. Your mind may be in disarray, but remind yourself that whatever stigma against seeking mental help may exist in your mind, it’s there because of your lived experiences – created by the culture you live within. There’s absolutely nothing wrong with wanting to get better, or better yourself, and to feel constrained by some vague idea of what it means to be “a man” or “a strong woman” is unwarranted.
If you’re fearful of revealing your innermost thoughts and feelings to a stranger (by virtue of it being your first visit), keep in mind that your psychiatrist is first and foremost a doctor, bound by the Hippocratic oath, and second, believes in the value of offering a non-judgmental listening ear through their training and moral code. If that doesn’t comfort you, you should be aware of legal constraints that exist in your favour to protect the information that you share with them. Notwithstanding of course, if there is reason to believe you intend to injuriously harm yourself or another.
Because of the anxiety that may roil your thoughts, it may do you well the night before to sit in silent contemplation and pen down the reasons or thoughts you intend to divulge. Having a concrete list to bring into your psychiatrist’s office will help you ground yourself and serve as a reminder that you’re there for good reason – to get help. Nothing to be ashamed of, nothing to hide, nothing to unconsciously lose behind a preponderance of mistrust or other self-serving attitudes. Your psychiatrist’s office is a safe space.
If you feel that all this is a hard ask, consider bringing along someone whom you trust and knows you well, with your best interests in mind. They can serve as a calming influence that soothes your inner turmoil. Furthermore, they might be able to helpfully point out if there are discrepancies between what you tell your psychiatrist and the truth of the matter.
When you step into your psychiatrist’s office for the first time, you will most likely be greeted with an open-ended question such as “How may I help you today?”, or “What’s been bothering you?”. It’s normal to feel overwhelmed by the variegated ways you can choose to answer their greeting, especially if you have issues with how you are perceived by others. But remember, this is their way of getting to know you, especially since they have nary a clue of why you may have decided to make good on your appointment.
Because of the time constraints on your visit (your psychiatrist’s office is a place of business after all), you can expect them to try their best to elicit responses through a line of inquiry that their best judgment will allow them to evaluate and cohere into an accurate as possible diagnosis of your mental condition, if you are indeed suffering from one. No psychiatrist is a soothsayer or mind-reader, and you should be aware that the help you receive will very much be preponderant both the truthfulness of your responses and the skill of your psychiatrist, who is also trained in reading cues and tells that they feel will help them make a diagnosis.
As your visit comes to a close, based on the personal proclivities of your psychiatrist, you can expect a number of permutations to happen. They may prescribe you medication, if they feel confident in their diagnosis. They may point you towards psychotherapy or counselling (the difference between the two we will delve into in another post), they may prescribe both the former and the latter, or they may hold off on either if they feel that they cannot in good conscience do so.
Of course, it is very much your right to evaluate for yourself if the synergy between your initial choice for a psychiatrist is optimal for you. If you feel comfortable with them, do feel encouraged to continue on course, or if not, seek out another psychiatrist per a trusted friend’s recommendation, or look online for one that seems more promising in terms of a potential therapeutic alliance.
Ultimately, don’t forget that your psychiatrist has your best interests in mind. They are committed to formulate a treatment plan for you that runs parallel to your values and is in line with your goals.
Promises Healthcare is committed to providing mental health services to those in need, and has realigned how we provide these services in light of the current COVID-19 pandemic. Not only do we practice strict social distancing in the clinic, we have a new teleconsultation service up and running. This may be a blessing for those who are not yet comfortable with in person visits. Simply visit our main website and visit our teleconsultations page.
Alternate services of help are also provided by the Ministry of Health & National Council of Social Services in the public health and non-profit sector respectively. The Minister for Health has also written in response to a question regarding the use of Medisave for mental health therapy and counselling treatment: “No Singaporean will be denied access to necessary and appropriate healthcare because of an inability to pay.”
In this episode En Ullae on Postnatal Depression, Dr Rajesh Jacob shed light on what some still view as a taboo reaction to what society views as a blessing – the birth of a child. Postnatal or Postpartum Depression is marked by a dip in mood, emotional turmoil, sleeplessness, and changes in eating habits. It can haunt a mother who has borne her flesh and blood for over a year, or the pall might lift after just two weeks.
This episode started out light and buoyant, with scenes of carefree courtship. But the fortuitous chemistry of an arranged marriage that might have heralded exemplaries of the nuclear family, under different circumstances, was to be tested by the wife’s struggle with Postnatal Depression. The coming child would serve as a lightning rod, bringing strife into the relationship. Even before the little baby girl’s conception, the couple disagreed on whether to have one – but cultural pressures enveloped the mother with a pained acquiescence with living up to the status of an “ideal mother” – at odds with her inner values, although she scarcely knew it. Dr Jacob noted that the immense pressure of a cultural belief in the Indian community that a child was “God’s gift” would serve only to create uncomfortable dissonance within a mother who is not ready to bear fruit.
At some point during one of their many arguments, the husband even goads his partner with the suggestion of abortion, despite the medical impossibility of aborting a 6-month old fetus in Singapore. The child, inevitably emerging from the womb, healthy, would only highlight the difficulties that the couple would face.
Dr Jacob was quick to point out the boorish behaviour of the husband, noting that in such situations, the support of family members, especially partners, is crucial in alleviating the symptoms of Postnatal Depression. Dr Jacob went on to warn potential mothers that past depressions were risk factors and that difficulties during the birthing process that might, for example, warrant emergency Caesarean sections, would prove additional risk factors.
The working mother and father were presented with additional difficulties simply by virtue of the husband and not being able to support the wife when needed. Her slow descent into Postnatal Depression began with the naggings of a vague sense of agitation, exacerbated by tiresome nights and a feeling of malaise. Eventually, she would begin comparing herself to an idealised version of what a Mother should represent, having taken care of relatives’ kids at the age of 13, she felt she had no excuse for her failures. Dr Jacob noted that the unfortunate situation should serve to highlight the dangers of an internal dissonance that would only elevate the crisis. At her nadir, she even contemplated the act of suicide, pulled back from the edge by her maternal instinct. Her child’s cry saved her.
In these situations, Dr Jacob made clear that she should ideally have been separated from her child, for the family’s sake and checked in to a mental health clinic for treatment. Luckily for them, her husband initiated contact with his own mother, seeking her assistance in caring for the baby. Taking pressure off the mother in situations such as these is of critical importance, who has to learn that she needs time and space to soothe her own mental health crisis. The health of the family unit is somewhat predicated on the stability of the maternal figure, so such a step makes a whole lot of sense. Much attention needs to be shone on the precariousness of these unfortunate situations, so that other prospective mothers are aware of the risks and the steps they can take to avert such crises.