The e-mail came totally unexpected. "Hi, I was surfing the net and read some articles you published. I enjoyed the ones about tai chi. Hope you are well, Sandy Wells [not her real name]." Those brief comments caused me to remember another time and place almost 30 years ago.
I had just finished my psychiatric residency at the University of British Columbia and moved to a small, isolated community on the Pacific coast. The town survived on logging, fishing, and newsprint production and could be reached only by traveling on two car ferries from Vancouver. It had a population of around 20,000, and I was for many years the only psychiatrist. Initially planning to work there for a couple years, I remained in practice for 20, retiring because of illness.
The very first week I opened my office, Sandy was referred to me by her family doctor. She was 18 years old, thin, blond, and potentially attractive. What impressed me during the initial consultation was the "vacant" look in her eyes. Over the years that she came to see me, that blank stare persisted. It seemed to prevent me or anyone else from reaching her. I learned that she had been born and raised near the town and that the members of her family were working class and uneducated. She was not close to her mother, and her father had committed suicide when she was younger. He had chosen a particularly gruesome method that guaranteed success. She was closest to her sister-in-law, her brother’s wife, and often resided with them. I came to depend on this sister-in-law whenever I needed family support and intervention.
I diagnosed Sandy as suffering from depression. There was ample evidence of genetic influence in her family. Back then, DSM-III was making an initial appearance and psychopharmacology depended on tricyclics, phenothiazines, and benzodiazepines. Since I had just finished my psychiatric training, I was eager to apply my counseling skills. Also, it was the 1970s, and R.D. Laing was my role model.
Sandy never initiated conversation. Her answers were brief and usually consisted of, "What’s the point in seeing you, Dr. Uhlmann? I just want to kill myself." I tried to find aspects of her life that were positive, that could ignite a spark of hope. I was unsuccessful. To Sandy, everything was black and negative. I saw her weekly in an attempt to establish rapport and create a meaningful connection for her to at least one person. She attended sessions but never really involved herself. I wondered if I was expecting the impossible. Today I would probably diagnose a depression with psychotic features and immediately treat with medications. "Hindsight is 20/20."
Living and working as a physician in a small community, I had the benefit of knowing patients in greater contexts than office visits. I saw my patients at work and play, knew their families and social networks, and was familiar with teachers, probation officers, employers, ministers, social workers, etc. This was extremely helpful in providing aspects of treatment that office or hospital visits alone can never achieve. In Sandy’s case I got to meet her family and other support systems, which were few indeed. She had an excellent family doctor, and we were able to provide each other with mutual support. We both understood that Sandy was extremely suicidal and that the only question was when, not if.
But Sandy continued to see me. Insight was not her strong point. In vain I would often bring up issues from her past, such as her father’s suicide, or current family issues. She seemed unable, rather than unwilling, to discuss emotionally laden topics. She resisted most psychotherapeutic attempts by restating how she lacked feelings and only looked forward to her death. Often there were long gaps between therapy sessions, after which she would leave saying our sessions were useless. She honestly could not understand my motivation in seeing her. She was hopeless, why did I persist in trying to introduce some happiness into her life? Every time she left my office after one of these conversations, I would worry about her killing herself and would prepare myself for the news.
Sometimes she was more suicidal and depressed than other times (although the qualitative difference was slight). Then I would call her family in and have her committed to the hospital for a brief stay. By this time she was also taking various doses of antidepressants and antipsychotics. Yes, ECT was administered as well, several times over the years. She also was transferred to tertiary centers in Vancouver for second opinions and treatment recommendations. She was the recipient of various individual, conjoint, family, and group psychotherapies as well.
Did I say "conjoint"? Yes, Sandy became pregnant in her late teens, and she later married and had a second child. Nevertheless, she experienced little or no joy in her life. She functioned as well as possible as a parent and partner, but her abilities were limited by her "illness." Her husband accompanied her to office visits, and I did my best to explain to him the rationale of current treatments. I also had to prepare him for the very real possibility of her suicide. He worked hard at the local mill and then came home to care for Sandy and the children.
The visits to my office became more infrequent over the years. We all seemed to finally accept that Sandy was who she was and would likely remain that way despite our interventions and expectations. I gave up trying to be Professor Higgins with Eliza Doolittle. At times she took medications provided by me or her family physician. Sometimes she stayed briefly in the local hospital, mainly to protect me from charges of malpractice. She never did "get better," and when I left my practice my only consolation was that she was still alive.
Then from cyberspace came the e-mail. I responded cheerfully, asking about her present life. The second e-mail was also brief. She is now a grandmother! One child is finishing a university education. She hopes all is well with me.
Is she happy? I didn’t ask, and she didn’t comment. Why is she still alive, when I was convinced suicide was inevitable? I don’t have an answer but would like to believe I played a small role in her survival.
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