Dr. Qaadri

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Psychotherapy as Illumination
PATIENT CASE HISTORY

By Dr. Shafiq Qaadri

"Tell me about your childhood," I said to Victoria, true to the psychotherapy cliché, at the beginning of our acquaintance years ago. I didn't realize that my easy empathy would be agitating memories long suppressed within the subterranean refuges of her mind.

Over the years, family physicians witness patients struggling through many challenges. The practice of medicine is like live theatre - drama, tragedy and farce unfold regularly. But physicians only rarely meet actors who are unique: people who have endured such concentrated misfortune, yet shown such resilience, that their doctors themselves are changed by the performance.

The Oxford English Dictionary, in its fashion, offers several meanings for the word Victoria: the embodiment of victory, supremacy in struggle and conspicuous bravery. In my mind, however, Victoria is the name of an extraordinary woman who personifies all these definitions.

Recalling her traumatic and horrifying life, Victoria smiles with a flourish of dismissive humour. That impossible smile is an illumination, a tribute to her spirit, that prompted me to play her biographer.
A convoluted path brought her to my office in search of personal peace for body, mind and soul. And she would be surprised to know how much she has enlarged my vision.

To introduce the unpolished, raw clinical observations: Victoria is in her mid-50s; she had her first child at the age of 13, the result of incest; she is 5-feet-3 inches tall but now has a serious weight problem due to a pituitary tumour; and she is on medications for hypertension, diabetes, arthritis, ulcers, emphysema, panic attacks and depression.

Despite all these difficulties, Victoria manages to be charming. Part of her grace is that she transcends such encapsulated summaries of the facts of her "case". The energy of her personality shines through it all. She has taught me that our medical notations do not approximate her as a person - I have learned from her that categorization is diminishment. She makes sure that I know her as a person with a past and a context, not as a medical curiosity, not merely as a diagnosis.

"My father was not a pleasant drunk," Victoria said. "He would scream and slap me around because he really wanted a son." I wondered in disbelief how any father could be so hurtful. "That's why I hate it when a man shouts, because to this day, I get this sick feeling like it's my dad coming for me."
The term "post traumatic stress disorder" was not current then - we had to have a few more well documented wars for that - so Victoria was unaware of why she winced before authority.

As I listened, I sensed that my board-certified, medically licensed compassion was turning into the real thing. A fellow human being was trusting me with painful details of her core self, her very soul.
"As I got older, and my mother got more frail, my dad began to pay too much attention to me. He got too touchy-feely. He would walk into the bathroom unannounced and try to help me change. He'd insist on shampooing me and showed too much interest in my puberty."

I sensed where her words were leading, feeling uneasy as she continued.

"Then one day," Victoria cringed to recall, "he put me through a hell I'll never forget. On the bathroom floor, he attacked me. He got on top of me and all I knew was he was putting something inside me and it hurt."

Victoria had been raped by her own father. She was 12 years old at the time.

Confronting this violent disgrace was difficult both for Victoria and for me. To respond, I could not use the suggested stock phrases from our training manuals. It was not the sort of thing that could be lip-serviced, deferred till the next appointment, or relieved with medication or a platitude.

A physician is supposed to remain immune - clinically aloof - to what he hears, but this was too poignant, and it demanded honest emotion from the both of us.

It is remarkable how this tragedy endures for her, how it can well up afresh. "It has helped me to talk about all this... I can finally cry," Victoria said at one point. I could feel the hurt resonating in her mind: A humiliation sustained 40 years ago could still make her tremble.

Victoria's delicately nurtured facade and painstakingly reconstructed self-esteem can easily collapse. Then the tormented child in her sobs desperately.

Curiously, little things provoke flashbacks, like the cold feel of linoleum tile on a bathroom floor. "I was just taking a bath at [my present] home, and I leaned up against the wall. Suddenly I got shaky, my heart started to pound, I couldn't breathe, I felt trapped and I just found myself screaming. I didn't know why."
Subconsciously, her mind had recreated the scene of her assault, triggered by the feeling of her wet back against the tile. She remembered being pinned down by an unwanted heaviness and relived the terror.

Occasionally, Victoria still has such panic attacks, and experiences tremors, palpitations, shortness of breath and a sense of doom. Her latest episode was provoked by the odour of stale whiskey.

Soon after the violation, Victoria began to get unaccountably ill. "I'd wake up in the morning vomiting like crazy, I lost my appetite and I started to miss time from school. They thought I was faking so I could cut class." A school counselor labeled her as an "attention seeking problem-child, suffering from a conduct disorder." Victoria herself accepted this verdict.

I believe she has still not outlived the insult sustained at the hands of those school authorities. "They told everyone I was just pretending," she remembered, "but I kept gaining weight, my ankles got swollen and I didn't have my period for two months. How could I fake that?"

Finally, a doctor announced the illusive diagnosis to a shocked school board: Victoria was pregnant. No one had considered the possibility - it was inconceivable that a teenager that young could be pregnant.
In the summer of 1961, abortion was not an option, so a baby girl was born of that unnatural union with her father. The child was immediately seized for adoption by the Children's Aid Society.

"I have this dream over and over," Victoria recalled wistfully, "that a young lady with auburn hair will surprise me at my door and tell me she's my lost daughter. But something always keeps me from meeting her." Victoria has had no contact with her child since the initial separation. She still carries a tattered wallet-sized baby photo, her only reminder, waiting for an unlikely reunion.

"My dad threatened to kill me if I ever told anyone the truth. He said mum would be so hurt she'd hate me and leave." In those days, there was no acknowledgement of the problem, and there were no incest-survivor groups.

Silently, this unreconciled trauma festered for years. The official story was that the baby was fathered by an irresponsible schoolmate.

"My dad tricked me into believing that it was my fault. I know that's crazy, but somewhere inside I still think that. If somebody tells you something long enough, you believe it."

Through therapy, together we have insulated her crushed self-esteem with many layers. But I sense underneath it all she still thinks of herself as unworthy. Her betrayal by authority figures, forced loss of innocence and superimposed code of silence - all these continue to distort her emotions.

"Doc," she asked me, "do you think I'll ever feel whole again? Maybe I might have finished school, not be so scared, not gotten married when I was just 18." I just nodded reassuringly, unable to offer glib answers. She is still confronting the hurt inside.

...

Victoria met her husband in unlikely circumstances, in a mental health centre when they were both psychiatric in-patients. She had been admitted for a worsening of her depression, and her husband had paranoid schizophrenia.

"The nurses would report on us if we talked to each other too long," she recalled. It is unwritten ward policy that resident patients must not fall in love with each other. "Sometimes he's a jerk, but he's still my jerk," she says.

They are still together after 36 years.

"When my husband hears voices, or thinks the KGB is after him, or the TV's giving him special messages, I just give him his pills and hold him. We get through it okay most times." I admire the contentment she is able to derive from a taxing companion.

"After we got out of the hospital, we moved in together. Four months later I was pregnant." The Children's Aid Society assessed Victoria at the time: "Too unstable, uneducated, socially imbalanced and unsuitable as a parental caregiver." Victoria recalled, "I was bitterly upset. They took my second child, my baby boy, out of my life."

She became obsessed about her son and craved knowing anything about him. "I always wondered where my baby was. I just wish I could have watched him grow up, been a part of his life."

This obsession reverberated in her mind to the extent that she had delusions. Seeing a young boy on the street, she recalled, "I thought that must be my son, I have to go and tell him he's mine. If it said on the radio that a child had died in an accident, I'd cry because I thought, 'That's my baby'."

Her displaced motherly affection was showered on random replacements as she longed to rekindle the maternal bond.

Twenty-five years later, there was a reunion. Victoria came to my office trembling and declared, "I got a letter saying my biological child wished to meet his natural parents. By the way, I didn't know I was a grandmother."

The disclosure rules of the adoption agency had been relaxed. There was now a registry through which, if both parties, parent and child, wished to see each other, the agency would broker a meeting. Victoria was so agitated, so afraid of being resented and shunned, that she and I decided to postpone the originally scheduled meeting for several weeks.

Finally, at a long overdue reunion, Victoria's elated son welcomed her into his life. The novice grandmother was delighted to meet his three children.

"That was one of my happier days," she remembered. "I could see that he accepted me as his mother. I got a chance to love my son." Victoria gained a sense of validation and renewal for an episode that had previously only shamed her. At that meeting, her son presented her with a poem, which she sentimentally framed.

...

In the mid-70s, nine years after the birth of her son, Victoria's next struggle began. "When I was 27, I started to get terrible headaches. I'd vomit, see spots, even get dizzy." She was tagged with many diagnoses, from youth-conduct disorder to migraine headaches.

Then something more ominous transpired: She started to lose her peripheral vision. An eye-specialist consultation revealed a swelling at the base of her eyes. Something was growing inside her brain pushing on her eyes, on the optic nerves.

"I thought they were kidding. I thought, great, what next? The surgeon showed me my brain scan. He said I had a lump the size of a golf ball. He said it had to come out."

The CT scan of the brain revealed that Victoria had a tumour of the pituitary gland known as a craniopharyngioma. Neurosurgery was prescribed. Not intervening would mean first blindness, then death.

"I started to think about suicide. How much more could I take? It's scary enough if they operate, say, on your stomach. But on my brain? I didn't want to lose my mind, to turn into a vegetable."
I was awestruck to learn all that she had endured.

Victoria knew that a brain operation was a higher order of surgery than other procedures, that it was an invasion of her inner sanctum, her private domain. "I was scared of the people who had just had brain surgery."

Typical of a neurosurgical ward, the postoperative patients were not inspiring models of health. Many were shells of their former selves.

"I begged them to let me go home and deal with my headaches alone. But then water started to seep out of my nose." The tumour had eaten away at the base of the skull. "They said they'd have to do emergency surgery, otherwise I'd get a brain infection."

Confident in her neurosurgeon, Victoria finally consented to the surgery that saved her life. She remembered gratefully, "I finally met someone whose will to save me was stronger than my will to die."
With the loss of the pituitary gland began her physical derangements. "I just kept on gaining and gaining weight. I went from a sexy 115 pounds to being a wrestler. I'm now 300 pounds." Her massive obesity has led to many physical and psychological complications.

"How can I have diabetes," she demanded, "when I don't eat sugar?" I patiently tried to explain the difficult concept of insulin resistance. Essentially, the insulin she does have will not cover her body size, so the blood sugar stays high.

"I don't eat too much damn salt, like you told me," she exclaimed. "So why should my blood pressure be up?" I took out ominous diagrams of arteries clogged by the effects of high cholesterol and heart strain.
"So you mean this cushion stuff in my knees," she asked, "is just being crushed under my own weight?" I showed her working models of an arthritic knee, and how degenerated cartilage allows bone to grind on bone.

"Doc," she bargained, "please don't take away my cigarettes. My whole life they've taken things away." This is a matter of an uneasy truce between us. I used to appeal to her to stop damaging her lungs and aggravating her other conditions. As a virtuoso smoker, however, Victoria wheezes happily through 30 cigarettes a day. Unrepentant, she annuls my reprimands with a smile.

"So being a ballerina," she inquired mischievously, "is definitely out of the question?" I just smiled. "You know, doc," she decided, "I hate the pituitary gland."

I thought to myself, "Yes, Victoria, me too."

Victoria's emotional baggage and physical ailments taint her capacity for happiness. "I used to feel sad all the time. I could never fall asleep properly, I'd cry for no reason and I thought I deserved to feel this way. For years, no one put a name on what I had." Her clinical depression continues to suppress her vitality.

"I tried so many pills over the years," Victoria recalled, "I used to feel like a pharmacy." I was startled to see how many mood altering drugs she had been prescribed, none of which seemed to help.

In truth, our earlier medicines often worked simply by sedating people. The joke used to be, "You can't be depressed if you're not awake for it." These medications had so many side effects that the reputed cure was often worse than the illness.

Finally, one medication made the difference. "Doc, those [antidepressant] pills you gave me," she said, "I think they're making me feel better." Such grateful comments are the sustaining rewards of family practice. I was proud to see the medication working. I thought, "I can change the way she feels; I can temper her moods and help to revitalize her life."

A paradigm shift in antidepressant therapy occurred years ago with the introduction of the SSRIs. Whatever the theories about how the medications work, I am gratified to see Victoria more settled - in a state of delicate, situational, but working tranquility.

...

Being Victoria's doctor has been humbling, frustrating, and yet fulfilling. Knowing her has enriched my perceptions. Together we have worked through her personal odyssey from her shattered childhood to the violent incest to her present functional peace.

She has provoked me to a new level of unanticipated empathy. She has dealt with her extreme adversities with painful honesty, ready tears, blossoming confidence and defusing humour.

Sharing this triumph, both doctor and patient, observer and the observed, have been moved, made more whole. I have been privileged to know her inspiring dignity and her genius for survival. Listening to her catharsis has made me more appreciative, more conscious, of the glory of each moment.

To have seen her repeatedly reclaim her sense of self through all her trials sensitizes me to the preciousness and fragility of life. Our mutual journey through psychotherapy has been an exercise in humanity and an illumination.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education (CME) lecturer. www.doctorQ.ca

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