How important is self-esteem really?

10 06 2013

I chanced upon the following statement when reading a paper for my psychiatry research.

Empowerment, self-efficacy, hope, and self-responsibility
have become touchstones for the recovery movement
with the assumption that they will bring many
positive outcomes and benefits on their own. However,
many decades of psychological research have shown
that efforts directed at boosting self-esteem and its congeners
do not yield anticipated benefits to individuals;
rather, self-esteem, empowerment, and hope are consequences
of adaptive, productive behavior, and self improvement
which leads to social competence and its
associated rewards.

Which appears to say that self-esteem, on its own doesn’t seem to count for much, and it’s backed by evidence beyond anecdotes or personal experience.

Baumeister RF, Campbell JD, Krueger JI, Vohs KD. Does
high self-esteem cause better performance, interpersonal success,
happiness or healthier lifestyles? Psychol Sci Public
Interest. 2003;4:1–27.


Dangerous Psychos

28 08 2012

Image from the Straits Times Press


It’s my psychiatry posting and I happened to do a bit of pre-reading last week by pulling out this book. It had a cute title and the language seemed pretty reader friendly. I am generally not impressed by the content of medical or scientific books directed to the lay public, but this one had a lot of important information beyond just the medical. This paragraph really forced me to reconsider stereotypes.

The reality is that it is rare for mentally ill patients to ever be dangerous to others. Yet this group, insignificant as it inevitably is, receives a disproportionate amount of attention in the media, which, as a result of sensationalistic reporting, creates an aura of  ‘dangerousness’ around psychiatric patients, tarring all with the same brush.

The reality is that violence is so ubiquitous in society that the act of incarcerating a few individuals gives little (if any) extra safety or public protection. There are far more dangers in society than the potential risk posed by the mentally ill. Dangerous drivers, for instance, cause far more potential harm, as do industrial companies that flout safety regulations

There’s a lot more to that tiny book (106 pages) and I highly recommend you take a look. It’ll be available in the NUS Library once I return it, in a couple of days.

The other very real problem is that the mentally ill might be dangerous to themselves.  Sept 10th is World Suicide Prevention Day, and although I think it’s sadly ironic that it’s commemorated a day before some of the most horrendous suicide attacks in recent history, I think it’s an important message that a) it’s unfortunate that people should feel so crappy that they want to kill themselves and b) this might be largely preventable, if they get help early.  As I mentioned in a post on my old blog, there’s stigma associated with getting psychiatric help, which, in the 21st century, we shouldn’t be having. It’s ok to see a counselor if you think you can’t cope, there’s absolutely nothing wrong with that and it doesn’t make you a weak person.

If you ever contemplate suicide, drop the Samaritans Of Singapore (SOS) a call at 1800-221-4444 or an email at They’ll know how to help.

The Spectre of Death

4 02 2012

Death and The Maiden, c1908. I saw this painting on display when Musee D’Orsay brought selected pieces from its collection to SAM


One morning, I was walking past a cubicle in the wards. There was someone wailing inside. Usually there is a nameplate with the patient’s name on it, but it wasn’t there outside this door. I remembered her name though. I had seen her yesterday. I kept walking till I reached the nursing counter. There was a pad of forms, the first one was half filled. It was a Death Certificate. I wasn’t entirely shocked. The old lady had taken a turn for the worst, yet there was something … final and conclusive to the event. It was a mixture of sorrow and relief.

I used to imagine that there is this Spectre of Death walking, moving around the wards. Watching every move that happens and occasionally sniggering when doctors try too hard to save someone from the jaws of death. I sometimes imagine the spectre following me around the wards and sometimes having his eye on the patient I’m supposed to see. Theoretically, that image is very symbolic. Every time you go around meeting and examining patients, there is a very real risk that you will catch, and pass on some bug which might eventually kill someone. Which is why we disinfect our hands, twice for every patient.

I think I have an ironic imagination. A hospital, we imagine is almost a safe zone where we go to cheat death. Just the other day, while we were walking back home, I expressed concern that the traffic is unforgiving and we should be extra careful. My buddy quickly retorted, “Don’t worry, you’re just outside the emergency department” and smiled. The truth is that the hospital isn’t a safe zone, people die there all the time. Medicine cannot save everyone.

I also find that we pity terminally ill patients. I think concern and sensitivity and wanting to alleviate suffering is warranted, but not pity. Pity, at least the way I see it, carries this epistemic arrogance that the patient is going to die while I live, which though probable and likely, ignores the fact that you might be the one having an accident while crossing the road. The patient is fairly safe in the ward. In fact the next day, the patient might be the one in shock, “Oh! What a pity, that was a fabulous doctor. So sad to hear of his death”. Be careful.

The ECG strip of someone who’s heart beats then stops, never to start again. (From some website)

I recall another time when I was with my mentor in the ICU. ICU cubicles have these big windows so doctors and nurses can look inside and keep an eye on the monitors. This particular one had the curtains drawn up. On the desk just outside was a long strip of ECG paper. It looked blank, but on looking closely, you notice it’s a flat line. Missing the usual energetic spikes from a living heart. In the adjacent cubicle, was a newborn. In one cubicle, the end of life, in another, the beginning. You sit there and think. You fill up the gaps in between, how does a newborn turn into a deceased old lady? How was I born, how have I lived, how will I die? It is not something that I consciously thought about but my mind wandered in that direction.

Eventually, you cannot avoid the ultimate question, what happens after I die? Everyone seems to have an answer for that. You will go to heaven or you will get another body or  you will cease to exist. People also seem to offer ways of influencing the specific postmortem (as in after death, not the autopsy) outcomes. Do this and you will go to heaven, do that and you will be born in a great family. As much as I think it’s an important question to think about, I don’t think are are definitive answers. As scary as that is, we need to come to terms with that. Since we do not know what the future holds, the important question becomes, what do we do now? Yet that message is often lost in routines and stupid, boring jobs and pretentious responsibilities.

I spent the last week in Palliative Medicine, learning to look after patients with terminal illness. We had a segment on breaking bad news and helping patients plan for their last days. It’s a sensitive moment that needs compassion, clarity, time and a lot of emotional poise on your part. There is something about the painting at the top of the post that makes it so appropriate. It’s a sort of Angel placing a comforting wing around the girl. A hand sticking out, saying, “Wait, listen to me, clearly”. There’s a lamp there to provide clarity. Sure, death isn’t fantastic news, but it’s a natural essential process. You are born, you die. It’s simple. A character from Murakami’s Norwegian Wood remarks “Death exists, not as opposite, but as a part of life”. The important point they tried to hammer into us in school was that you can only help people come to terms with their death, when you come to terms with mortality, both in general, and specifically your mortality.  The way I see it, when the time comes, I am supposed to step up to the role as the harbringer of bad news, yet still be the comforter (not just chemically), the one who brings clarity and perhaps some hope. After doing palliative medicine, I have realised, I AM the Angel of Death.