Category Archives: Issues & Debates

Supports for family members in grief

Basic & General, Issues & Debates

Sometimes when we don’t hear from a patient for long, we’ll start worrying about them, especially if they are depressed, or worse, with suicidal caution. But too many patients come and go every day in the clinic, it could be difficult to remember everyone.

Sometimes I think we wouldn’t even know if and when a patient ends his or her life, unless we read it from the news or the family member contacts us.

Yes family member does contact us and tell us about the news when it happens, not all the time, but they do. And one main reason they usually call us and inform us regarding the patient’s suicide, is that they want to question us.

“He’s been taking the medicine prescribed by the doctor regularly, how did this still happen?”

“How come the medicine he was prescribed with wasn’t helping?”

“The last time when she went to your clinic, did doctor say anything? Did she say anything?”

Yes, I understand this and that (sometimes I think they just need someone or something to point their fingers at). But we’re only an outpatient clinic, all we can do is not much, though we do try our best including using phone calls or emails to reach and support them in their daily lives.

The sister was in tears when she called. The last time I heard from the sister was almost a year ago. She said he’s gone, their brother, the six sisters’ one and only brother. He jumped off from the balcony of an apartment.

They still couldn’t accept the truth.

And no, she didn’t call to question us, to blame it on us. She called to ask if she and the other sisters should come for an appointment as they are all feeling really low and depressed.

She was explained that they can certainly come for an appointment if they feel the need, but this is part of grieving, absolutely normal for people to feel depressed, guilty, lost, empty, angry … And the duration of this period could be few weeks, or even up to few years (some research suggested 4 years as an average of grieving period after losing a love one). Some people can function absolutely well during this period (though never take that these people are cold-blooded, they just deal with loss differently) while some need to take some time off or even go for professional counselling services or help.

Sometimes it’s the part that we often overlook – the needs of the immediate carers and family members of our patients – alive or dead.

How much courage does one need to jump off a building?

Clinical Case Studies, Issues & Debates, Schizophrenia & Psychotic Disorder

There are various ways people can use to end their lives, but when it comes to jumping from height, it always makes me wonder how much courage it requires to take that step, and do they regret as they are falling down before hitting the ground? Are they terrified? Do they think about going back?

This is the third patient in the past 3 weeks.

The first two both were longstanding depressed patients, both had attempted suicide in their history, so though it was heartbreaking, at least it didn’t shock us as much as the one who chose to jump off from an apartment far away from his house this week.

He had been diagnosed with paranoid schizophrenia for years. Never a negative person, he could function well in work and with family, maintaining with medicine.

Nobody would have anticipated that. Not even his caring sister. And with the method he chose to terminate his life, he does show how determined he was.

So never think that people with depression are the only ones who would attempt suicide.

So never think that those who think about suicide would always mention it before the attempts.

So never think that long-term mentally ill patient without previous suicide attempt are very unlikely to commit suicide.

Also, never think the reason everyone suffering from mental illness end their lives due to their mental illness, there are still various other possible explanations, and suffering from mental illness, is just one of them.

Please give yourself a second chance. Malaysia suicide hotlines:

The Befrienders
03-7956 8144/ 03-7956 8145
www.befrienders.org.my

Life Line Association Malaysia
03-4265 7995
http://lifeline.org.my/cn/

Agape Counselling Center Malaysia
03-7785 5955 / 03-7781 0800
http://www.agape.org.my

If you come across someone who’s suicidal: https://huibee.com/2020/05/somebody-you-know-is-suicidal/

Placebo effects in psychiatric drugs?

Anxiety Disorder, Clinical Case Studies, Issues & Debates

I understand a lot of anti-depressants, anti-anxiety and anti-psychotic drugs that we’re using today have had quite a long history, we’re talking about a few ten years. But is it possible, that what works in some of them, is not the active ingredients in it, but the fact that it’s prescribed and taken, and patient’s belief in the pill(s), so the patient feels better? (If this definition is not clear enough for what placebo effect is, please check google here.)

Recently we have this typical anti-psychotic drugs ran out in the whole of country (i.e. nowhere you can find this drug, unless some expired ones in an old patient’s drawer). So having no choice the psychiatrist has had to replace it with other drugs, drug A, a stimulant that works the same but will be more stimulating (so patients can’t take it at night to avoid sleep disturbances) or drug B, another anti-psychotic that’s more sedative (suitable for patients to take at night).

Most of the patients are fine after the replacement of this old anti-psychotic drug, whether it’s with drug A or B, some with other medicine more applicable and appropriate for their current situations. Except two patients.

They both claimed that after replacing the medicine, they find it difficult to fall asleep (a common symptoms of anxious people: difficulty getting into sleep). When we tried to explain that the old drug is non-sedative (not assisting you to sleep) but also non-stimulating (not making you more awake/alert), and that 95% other patients who’ve had the medicine replaced found no problems, these two patients insisted that they need this old anti-psychotic drug to sleep.

In fact for one of the patients, the psychiatrist has come to realize that she’s no longer present with agitation or any psychotic-related symptoms, and so has replaced it with a tranquiliser, which should in fact be sedative and make her sleep better, as compared to the old anti-psychotic drug. But still, she struggled.

As a psychologist, I’d always observed and noticed the psychological effects of psychiatric drugs. How’d you explain this? Can we start to prescribe some placebo to help patients to sleep better?

Can we allow a severely depressed patient to make the decision?

Clinical Case Studies, Depression, Issues & Debates

She’s gone, on Tuesday (more about this patient here: Depression & ECT).

As written on my previous post (link above), she underwent a course of six ECT and got much better. During the past year, she did voluntary work, travelled around (to South Africa, Japan etc). Every time she came back for follow up and saw me in the clinic, she had this big wide smile on her face, including the last time I saw her, last week.

Past few weeks she’d been calling me a lot, since her house renovation, which put her under some pressure. Then slowly all her negative thoughts came back. Lacking drives, lying down a lot, negative and suicidal thoughts, all returned, like how she was before the course of ECT last year, despite the increase of her anti-depressants.

She started to ask if she should come for another course of ECT. We kept helping and supporting her, and supporting her extended family to support her. Last week she asked again. And finally the consultant psychiatrist had also agreed that she should undergo ECT. When she was told that she could have it, she became hesitant and indecisive again. So she came for consultation and was told that she could take her time to think about it, and if she wanted it, she could call us and we’d arrange it (of course we also arranged what she should/could continue doing every day).

Few days later she rang me in the clinic, telling me she’s feeling much better, just did voluntary work in the temple. She was feeling quite positive and thought she’d make it. So much relief in me.

Few days passed and I was busy. This morning I heard from her cousin. She was gone, with medicine and half a bottle of herbal liquor. When they found her (the patient lived alone in KL, her family couldn’t reach her on phone all weekend long and came all the way from Malacca to see her), she was still conscious, but with white foam coming out from her mouth. They called the ambulance. But the patient refused to get into the ambulance. The medical staff said it’s against the law to force someone into the ambulance, so they left! The patient went back to sleep later and …”rests in peace”, as the way her cousin put it.

Is it right for us to leave the decision of whether to do ECT with her? Should we be the ones who make the decision for her? Could we be the ones?

Is it right for the ambulance staff to leave, just because the person refused to? Despite knowing that she most probably need a stomach washout, is it right that they let her make the decision herself?

Is she capable to make these decisions? She’s severely depressed, despite the medication, could she judge and reason then decide?

Practically I’ve always been told that we can’t really make any decision for patients, all we can do is to explain the options, treatments and procedures to the patients and family (if applicable). But how if they’re single and suicidal, with not much familial support? Are there exceptions? Can we push them to go for ECT?

Where to find Hypnosis or Hypnotherapy in Malaysia?

Basic & General, Hypnosis & Hypnotherapy, Issues & Debates, , , , , , , , ,

I’ve come across this question three days in a row, of people asking for hynotherapist in Klang Valley or Kuala Lumpur or Malaysia.

All the while I never really mentioned to people that I’ve a diploma in Cognitive Behavioural Hypnotherapy (accredited by the UK College of Hypnosis and Hypnotherapy), especially ever since I came back from the UK. I thought the Malaysians would hold so many misconceptions about hypnosis that if I were to tell people about this qualification of mine, people were going to be worried what I was going to do to them! (Make them give me all their savings?!)

But these people that I spoke to kind of change what I thought, although some of their beliefs of what hypnosis can do are still not quite true or slightly exaggerated (based on my training background of evidence-based cognitive behavioural hypnotherapy & clinical psychology).

Here I’d like to introduce a few basic introductory (text) books to self-hypnosis, mainly cognitive behavioural based and empirically supported, you can learn more about them and perhaps try to practise them at home, do let me know if you have come up with any problems or obstacles. Not that I’ll definitely be able to answer all your questions BUT I do know a number of therapists in the UK who use hypnosis to help people in their own private clinics.

Books: 

Alladin, A. (2008). Cognitive Hypnotherapy: An Integrated Approach to the Treatment of Emotional Disorders.

Heap, M. & Aravind, K. (2002). Hartland’s Medical & Dental Hypnosis (4th ed.)

Lynn, S. J. & Kirsch, I. (2005). Essentials of Clinical Hypnosis: An Evidence-based Approach (Dissociation, Trauma, Memory, and Hypnosis Book Series)

Robertson, D. (2012). The Practice of Cognitive Behavioural Hypnotherapy: A Manual of Evidence based Clinical Hypnosis. (my review here)

Straus, R. A. (1982). Strategic Self-Hypnosis.

(The Alladin’s and Lynn & Kirsch’s text books are easy to understand, especially when you have some backgrounds in psychology or practicing self-help; The Robertson’s book is the most extensive resources on CBH you can ever find!)

Websites:

A wide range of resources about what hypnotherapy can do, a private clinic in South Manchester: Manchester Hypnotherapy & Counselling

N.B. If you do come across any hypnotherapist in Malaysia please do share it here!

Thought Challenging or Thought Accepting?

Basic & General, Issues & Debates, , , , , ,

Which do you think is better or more workable? To challenge your thought or to accept it?

Traditionally, the psychologists of Cognitive Behavioural approaches emphasize that our thinking style is what causes us to respond emotionally to events, so it’s our thinking style that determines our feelings, our ability to overcome and steer through when adversity strikes (Reivich, Shatte, 2002).

However, the Mindfulness and Acceptance-based approaches suggest that it’s not so much of the content of our thoughts and attitudes that matters, it’s our relationship with them, i.e. how we respond to them.

So the former approach traditionally teaches people to gather evidence and dispute the logic of unhelpful thoughts, whereas the latter approach says we can simply acknowledge the thoughts and distance ourselves from them, without getting into an internal struggle.

Have you ever tried to control or avoid unpleasant experiences and later coming to realize that it’s affecting you even more and causing more discomfort? (e.g. some noise while you’re trying to sleep; your worries; some palpitation and fears)

Psychological suffering (feeling sad, anxious, guilty etc) is very common and so realistically cannot be avoided. Our attempts to avoid or control painful internal experiences can compound and prolong our emotional suffering, at the same time damaging the quality of our lives.

I’ll subsequently write more posts on how to practise and achieve that. But from now on, start to notice those unpleasant experience, acknowledge them and accept them, instead of trying to control or avoid them.

10/9/14: Check here for some tasks  to explore Mindfulness and Acceptance.