The Sacred and the Profane

‘Nature, Time and Patience are the three great physicians’
H.G.Bohn


This time around, she seemed worse than ever. I was asked by one of our therapists to help with a Pakistani woman who was, according to her husband ‘going completely crazy’. Even before I heard her name, I suspected it was Ms. L.
She was sitting on the floor, barefoot, in a rumpled shalwaar kameez while her husband sat in the chair next to her looking worried. She had her dupatta wrapped completely around her head and was slowly rocking back and forth, mumbling something unintelligible. Our therapist, a young Vietnamese-American woman, looked in equal parts, mystified and apprehensive. Ms. L had been a challenge for me to treat for 3 years. She was from Lahore, my native city and the first time I had seen her, she had appeared extremely ill, fitting the layman description of ‘madness’.

Her husband had lived in the US for many years and along the way had married her, a cousin. She had remained in Lahore where he would visit for extended periods of time. Over the years they had four children the oldest of whom was around 16. Once their parents had passed on and with the children getting older, she had persuaded him to reunite the family and moved with the kids to Arkansas. That was when the trouble began.

It is a truism that all formerly colonized people have a tortured attitude towards their colonizers. Like so many countries in Asia and Africa, Pakistan, too, has never managed any semblance of autonomy. Our very existence as a state has always depended on precarious and harshly conditional ‘aid’ from the US and other Western ‘donors’. It is also a truism that states have no friends, only interests, thus ‘aid’ never comes without strings attached.

This leaves its particular psychological stamp on everyone living in such a society. One symptom of this is an ambivalent, alternating idealizing and demeaning of the colonizer country, in our case, the United States. Growing up in Lahore, I, too, consumed American culture and longed to see that promised land. In Medical school, it was the focus of most of the more ambitious students. Unlike the fantasies, the reality is a little different. Of course America is the land of opportunity but it is also the nation where capitalism has been practiced in its purest form for over 300 years. This automatically implies continuous and rigorous hard work, very little security in case of unemployment or illness and a pervasive social isolation that is unimaginable in a still largely feudal, collective society like Pakistan. This can unhinge the best balanced minds hence the term ‘culture shock’. I still recall with a shudder my first year in the US when I alternated between exhilaration and sheer, mindless panic. I was of course, much younger than Ms. L, single and from a westernized, English speaking, liberal family. In her case, she may as well have arrived on an alien planet where no one dressed or talked like her and no one understood how she felt. She rapidly descended into depression and then madness.

The first time I saw her, she had been hearing voices, she thought there were ghosts in her house and she felt the pictures on the walls talking to her. In addition, the Quranic wall hangings taunted her, some days she thought they were changing shape and moving, other days she felt as if they were cursing her. Her children seemed to adjust much better , a reflection of their youthful, more malleable personalities. Her husband was concerned but also exasperated and angry. Ms. L herself, in the throes of her misery and madness, couldn’t see that there was anything wrong with her. Like most people with severe mental illness, she had no insight i.e. she thought it was things ‘out there’ that were wrong.

Mental illness has always been, and remains, a controversial construct. Ancient accounts of mental illness can be found in the writing of sages like Hippocrates and Al-Farabi but there has always been a vigorous, and usually healthy, debate about the effect of societal factors on a person’s state of health, both mind and body. It is also true that mental illnesses have, at times, been convenient labels for people with inconvenient beliefs. Thus men in England in the sixteenth and seventeenth centuries would leave rebellious wives in insane asylums to be rid of them. The same would be done for relatives whose properties and fortunes were coveted. Finding someone to label them ‘mad’ would be a convenient way to expropriate their fortunes or ensure a favorable inheritance. In the former Soviet Union and Nazi Germany, political dissidents would be labeled mentally ill and confined to hospitals or labor camps or in the case of the Nazis, killed off. In present day America, the burden of mental illness falls disproportionately on the poor and prisons house the largest number of mental patients in the country.

In Ms. L’s case it seemed pretty obvious that her illness was due to her social isolation and the loss of her cultural and religious identity. Over time, the one friend she made was an elderly woman from her neighborhood who was, like most people in these parts, a devout Christian. She encouraged Ms. L to come to activities with her, usually organized by her Church. This was not necessarily to preach but because in the ‘deep South’, where we live, churches are as much part of the landscape as mosques in Lahore. Her company was some comfort to Ms. L but of course, in her fragile state, she was very impressionable and the next thing I knew, she was sporting a Christian cross around her neck. We even had a discussion one time with her asking me to help her choose between ‘Jesus and Mohammad’ and describing her pain being pulled between the two (i.e. Christianity and Islam). In addition, Ms.L, like a lot of people from Pakistan and other pre-industrial countries, rejected the idea of ‘mental illness’ as a weakness or punishment for her real or imagined ‘sins’. Her mind produced a variety of ‘physical’ symptoms; nausea, dizziness, stomach pain etc to disguise her mental agony.
Despite a strong family history of mental illness in one of her sisters who still lived in an institution in Lahore, she refused to take medications or participate in treatment. If she took medications for a while, she would get better, the voices and visions would stop and she would be happier but then the reality of her situation would set in and she would begin to descend back into her insanity. She would start beating her children for no apparent reason, would start throwing furniture or household groceries into the front yard saying they were contaminated or run out into the neighborhood and make a scene till the neighbors called the police.

At first, in my naiveté I blamed her husband for not being supportive enough. After several months I decided that perhaps she couldn’t manage here in Arkansas after all. She had said several times that she wanted to return to Lahore and take the children back instead of allowing them to grow up in Godless, secular America.

It is a delicious irony that first generation immigrant parents begin to pine for ‘the old country’ just as their children are coming into their own as strong, confident citizens of the new country. Having grown up in close knit families, we long to escape to far off fantasy lands we have seen on television or read about in books where people seem happier. Once in those lands and now parents ourselves, we tremble at the thought of raising our children without any guidance, helping them navigate the minefields of school and social lives without the slightest idea of what we are doing. In the worst cases, as Indian-American Psychiatrist Salman Akhtar has pointed out, this can lead to attempts by parents to impose a pre-conceived child rearing model in a social setting where it is entirely redundant. It can lead to significant family distress and in severe cases, mental illness in parents, children or both. When nothing else seemed to be helping, I convinced her husband to send her and the family back to Lahore. They wanted me to find her a doctor in Lahore so I gave them the contact of a friend and thought that was the end of it.

Now here she was again, back to remind me of the perils of trying to find a simple answer to life’s questions. Her illness seemed worse than ever. On a couple of occasions I had to put her into the hospital when she became unmanageable at home. In spite of her illness and the ensuing chaos at home, her children adjusted well. Her oldest daughter, who had actually been admitted to medical college in Lahore only to be uprooted again, got into a prestigious pre-medical program at an exclusive private college in Arkansas which happened to be located about 2 ½ hours from where Ms. L lived. This precipitated another round of hysteria, mid-night phone calls from her husband and another hospital stay in which she begged me to persuade her husband to bring her daughter to a college close to her. This alternated with her being convinced that she was pregnant, a physical impossibility since she had already gone through menopause. At the psychological level though, it made perfect sense. Unlike men who have maintained their millennia old social roles, the role of women has been in constant flux for several hundred years. In a feudal society like Pakistan, where a woman’s role is (was) primarily child rearing and managing the home, certain milestones in a child’s life bring challenge. The child who starts elementary school can bring intense feelings of emptiness and worry. I experienced this first hand when our oldest, now eight, started pre-school and his mom started falling to pieces with worry. The time when a child actually leaves home, usually for college or work is even more painful. In Ms.L’s case, with her pre-existing vulnerability for breaking down under stress, it brought on another episode. This time I was a little wiser and refused to give in to her emotions, much to her husband’s relief. She insisted that her daughter was unhappy and pining away for her (thus seeing in her daughter what she was feeling herself). I even arranged a family meeting where I met her oldest daughter, a charming and confident young teenager, cheerful, though slightly perplexed by her mother’s behavior and obviously doing well in college and away from home.

Eventually, things settled down and Ms.L is now well. At the last visit, she seemed happy and calm, a little overweight which can be common side effect of medications. Her husband described her as ‘100%’ better. Knowing the relapsing nature of mental illness, I advised them to enjoy her wellness but expect bumps along the road. I have no doubt that her illness will rear its frightening head again but I also have no doubt that in the end, if she truly wants to fight her inner demons and retain her sanity, she will, with or without my help.