Wednesday, January 16, 2008

Sarah: Already Dead

Sarah is a 45-year-old female brought to us by an angry sister and a concerned daughter. It seems that Sarah has been in a relationship for the last 20 years with an alcoholic husband. Although he’s been trained as an auto mechanic, he chooses to work at a part-time unskilled job where he’s paid $300 per week under the table. Sarah has been shouldering the responsibility of raising five children, at her husband’s request, rather than working.

During the years of being full-time mother and homemaker, much has changed for her. For one thing, Sarah has put on weight. A lot of it. So much so that her tiny 5’1" frame is suspending well over 450 pounds of flesh. It is the kind of morbid obesity that could make many morbidly depressed, which she was.
To make matters worse, Sarah developed a pulse-pounding, unable-to-breathe, paralyzing kind of panic disorder, to the point that she was no longer really able to leave the house. She couldn’t do too much of anything because every time she did, it seemed, along came the anxiety. And with her size and medical history, shortness of breath, dizziness and a feeling that you’re going to pass out, or die, right there on the spot.

Before I could actually meet with Sarah, I had to meet with her volatile sister, Mary, who was waiting very impatiently in the lobby. I was prepared for a fight as her sister had been calling a litany of hospital personnel to complain I wasn’t giving them the quick service they expected. They had been waiting over an hour (not outrageous for a busy ER in a large metropolitan area) and if I didn’t attend to them immediately, sister would be on the phone lodging a complaint with my superiors and their superiors, maybe even the Congressman.
What I found when I arrived in the lobby was a woman who looked well beyond her real age. Deeply wrinkled skin and her hair pulled up into a pile on her head.
"I tell you, I’m just so tired of this shit with her," Mary said. "She has been living with me and my husband for four months now. That husband of hers barely works and can’t hardly pay us rent."
"So why do you let her live with you?" I asked.
"I don’t know. I’ve been trying to be the good sister and not let her live in the streets. They’ve been living in a motel for the last two years until they finally got kicked out because of his drinking and putting holes in the wall. Plus, they couldn’t pay the bills any more."
"So her husband is violent?"
"Yeah, when he’s drinkin’."
"Does he ever hit her? The children?"
"Oh, yeah, but he never hits the kids. He wails on her ass, though. He’ll kick the crap out of her."
"Has she ever tried leaving him?" I pressed.
"No, no, no. She’s crazy. She just sits around all day, she won’t bathe most of the time, she won’t clip her nails, she throws trash all over the floor. She’s a pig. I need her to be admitted because she needs psychiatric help."
"Has she ever tried to hurt herself?"
"Uhm, no, She talked about it a few times, wanting to, but no, she’s never made an attempt that I know of."
"When did she last talk to you about wanting to kill herself?"
"About a month ago."
"Has she ever tried or threatened to hurt anyone else?"
"Oh, no she’s never done anything like that. But she is crazy, just look at how she keeps herself. I told her and that sonofabitch she’s married to they need to get their shit together or get out."
Further questioning revealed nothing especially "crazy" about Sarah. "If this is all there is," I explained, "the chances are slim that we’ll be hospitalizing your sister."
"You mean that’s normal behavior?" she snapped.
"No, I mean that’s not something that someone would get hospitalized for."
Mary sighed with resignation. "Well, I’ll just wait out here." I could almost see the dread-filled thoughts racing through her mind: No no no, I thought we were going to get rid of her, but now I have to take her back home. What will my husband say? What are we going to do?

My encounter with Sarah began when I found her lying in bed, breathing through a nasal cannula, with her daughter looking appropriately forlorn at her bedside. Sarah seemed to have been beaten down by life.
"I just can’t do anything I’m so sick. I would work, but I can’t. I thought I was going to die this morning. I can’t hold any kind of job like this."
"So tell me more about feeling like you were going to die this morning," I wondered.
"I just felt this tightness on my chest and I couldn’t breathe. It felt like someone was sitting on my chest. I feel this way every time I try to leave the house. My sister has to do the grocery shopping and stuff cause I can’t do this."

Sarah continued by recounting the many trials life has brought upon her. She told of an abusive, philandering husband with whom she stuck no matter what the sacrifice. There were bills piling up and no chance for housing in sight, save staying with her resentful sister, and her husband insisted on working a job that earned the family a marginal $200 a week in "under-the-table" income. She said it was because he was drinking buddies with the boss, so he had no interest in working anyplace else. So Sarah had seemingly accepted a fate of underclass existence for herself and her children, a life in which she had no choice but to be a victim, all to hold onto a man whom she "loved" and "just couldn’t leave."

As I write this, I am keenly aware of how I’ve summarized my encounter with Sarah, unlike my dialogue with her sister. Is it that I’m tired of this case? Or perhaps I’m just tired of writing at this point? No, no. I think my issue is boredom with Sarah, not with her case. Whereas her sister was lively, even irritating, Sarah felt more like a blob. Or maybe an emotional black hole, one which would suck the energy out of everyone and everything around her because she felt so dead already. This is the stuff of countertransference: Using the extraordinarily well-refined senses of intuition and feeling, rather than the highly fallible cognition and thinking, we therapists can feel our way to a diagnosis. When I can enter Sarah’s world and feel this sort of deadness, a numbing sensation of life collapsing back on itself, I know her unconscious is talking to mine. It’s telling me that Sarah is experiencing a personality disorder, a relatively chronic condition which won’t be amenable to acute inpatient treatment.

Disposition: I saw Sarah was not a danger to herself or others. There was no reason to hospitalize this lady; she needed ongoing psychotherapy and support. I supplied her with a handful of referrals and she was discharged back home.
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