Chapter 10: Families in conflict

Don and Mary, both aged 42, married late in life and were joyfully looking forward to their first child. They were very upset when the daughter was born with Down syndrome. We had long discussions in hospital and I persuaded the parents to keep the child and promised the necessary support.

At the six-week postnatal check Mary entered my rooms weeping bitterly and stating that she could not cope. She wished Claire had never been born and she wondered why I had not smothered the child at birth. She talked about adoption and even sterilisation, although these were against her Catholic religious beliefs. A long counselling session followed and she was prescribed antidepressants for her obvious postpartum depression.

Two weeks later she was coping better, but she stated that she was concerned about Don who was very irritable and rejecting her sexually.

On review four weeks later she seemed quite bright and said, ‘You grow very fond of these little people, Doctor—they have a very loving nature’.

Then five days later a distraught Mary rang to say that Don had run away with a 19-year-old girl and was living with her in a flat in Melbourne.

OUTCOME

After four weeks Don rang Mary, stating that he wanted to return home. Mary, following advice, agreed to this and eventually the family unit settled into a serene relationship. Nine months after Claire’s birth, Mary became pregnant. They considered an abortion but eventually decided to accept the risk.

Counselling proved very difficult but was supportive. The story ended happily with the arrival of John—a picture of vigorous health.

Wendy, aged 26, was the self-possessed, dynamic theatre sister of a nearby hospital who was married to a logging contractor. She was delighted with her first child delivered under our care. Over subsequent weeks she presented for help and advice at least weekly with her baby boy. There was some uncharacteristic irritation when we advised against circumcision. However, knowing her competence, I reassured her (and myself) that she would cope just fine.

Her husband rang me to say that he was concerned about Wendy because she had lost considerable interest in him, the house and many things, especially sex. She was also ‘bitchy and flying off the handle easily’. When I next saw Wendy I discussed many of her problems and said I thought she had postpartum depression and should take medication in addition to counselling and support from myself. She dismissed her problems as simple ‘postnatal blues’ and said that she did not need nor would she take any medication.

DIAGNOSIS AND OUTCOME

One week later Geoff rang to request a house call. When I arrived I found Wendy slumped on the kitchen table weeping while Geoff was holding the baby. ‘I came in to find her trying to drown the baby, and then she was going to slash her wrists’, he said.

‘I’m just a failure as a mother and a wife. Everyone thinks I’m hopeless. I am hopeless’, whimpered Wendy.

Wendy eventually responded to support amitriptyline and electroconvulsive therapy. It took about 12 months for her to return to her normal, effervescent, coping self.

A classic case of postnatal depression had emerged under our noses and we were fortunate not to be answerable to a case of infanticide and suicide.

All of Us In General Practice Become familiar with the situation that lends itself to the label ‘lame duck survival’. Typically, two people are involved; perhaps they are sisters who have not married and live together, or are a married couple without children. When one member becomes permanently ill or handicapped the balance of the partnership often alters: the healthy partner takes on the role of caretaker, manager and controller; the other becomes totally dependent. This is not the catastrophe one might imagine; the once dependent partner—the ‘lame duck’—survives, often coping remarkably well.

Mrs C’s LAME DUCKS

Mrs C’ s case illustrates an extreme example: she became responsible for a whole flock of ‘lame ducks’.

Married at an early age and against the wishes of her family, Mrs C strictly and carefully raised four healthy children (two boys and two girls). Gradually it became apparent to her that the attractive young man she married was becoming ineffectual and difficult, dependent yet aggressive; his behaviour was strange and incomprehensible. Eventually he became psychotic and was diagnosed as a chronic schizophrenic.

Mrs C’ s two daughters married (at a relatively early age, as their mother had done) and each had two children. For some reason these offspring (all male) became difficult and ‘hyperactive’; Mrs C agreed to take a large share of the burden of minding her grandsons. This she did in addition to taking on a job as a chef’s assistant (to prop up their ailing family finances) and looking after her psychologically disabled husband.

Mrs C had a strong personality indeed, but worse was to follow. Her older son, handsome and bright, refused tertiary education and chose apprenticeship to a bricklayer. Without warning he became severely depressed and suicidal and, despite hospitalisation, electroconvulsive therapy and antidepressant medication, took a rifle from his treasured gun collection and shot himself. As a suicide attempt it was unsuccessful but it destroyed his eyesight. Discharged from medical care, he went home to the care of his mother.

By now Mrs C’ s parents were old, infirm and becoming totally dependent. Being their only daughter, Mrs C was expected to look after them; this she did.

The catastrophe

Eventually the death of Mrs C’ s aged mother (from renal failure) alleviated her caretaker load a little. Then one morning, totally unexpectedly, the dominant and apparently indestructible Mrs C was found dead in bed. Her family was stunned; even as he administered the last rites, the parish priest expected her eyes to open at any moment.

The consequences

Mrs C’ s father was admitted quickly to a nursing home as a chronic invalid. Her two daughters and their difficult sons matured remarkably quickly. The indifferent Mr C sold the family home and, with his blind son, moved into a town house where he lived in a zombie-like state with tardive dyskinesia and monthly phenothiazine injections. Amazingly, Mrs C’ s son began to function relatively well: perhaps he assumed a type of caretaker role? (Mrs C’ s younger son, her fourth child, had managed to escape the family turmoil. Although dependent on his mother, he matured through a trade apprenticeship and marriage and is well.)

Caroline H, a 37-year-old mother of three boys (aged 16, 14 and 12), presented one day with a common condition—pregnancy. As I greeted her at the door and asked her how she was she said, ‘Good, thank you, Doctor’. When I closed the door and asked how I could help she started crying. ‘I feel terrible, upset, confused—I’m pregnant and Ronnie is furious. He says I have to get rid of it, otherwise he’ll leave me and the boys’. I knew them as a fine hard-working family who had recently started a now flourishing business.

The idea of terminating her pregnancy seemed so wrong and totally alien to one’s medical training in respect for life. I quietly explored the reasons for their not wanting the baby. It was apparent that Caroline was confused but Ronnie at 44 years old felt he was too old to be bothered, and he had heavy commitments. Furthermore, he was angry that the birth control, left to Caroline, had failed.

OUTCOME

I asked if the couple could come to talk it over the following evening. At this meeting I could sense that Caroline would like to have the baby but Ronnie was ambivalent. I asked them to list the pros and cons of having another child versus abortion. Down syndrome was high on their list of concerns. I then told them a personal story. I was one of three boys and my mother, at age 43, unexpectedly had a daughter. I was 17 at the time and I recalled the immense joy that normal beautiful child brought to our family of teenage boys. They went away to consider the problem and Ronnie rang a few days later to say that they had decided to keep the baby.

Seven months later we delivered a normal little girl. It was one of the real highs of my career, which was punctuated by many highs and lows, to see that girl grow into a beautiful woman. And this was not the only time—déjà vu!

In the euphoria just after the birth Ronnie passed an interesting comment, ‘You take an oath not to kill or do abortions, don’t you, Doc?’

‘No, we don’t take such an oath. Perhaps the ancient Greek physicians did but we just collect an official piece of paper to testify we are doctors. The only words of advice from my professor were “Always examine your patients and don’t have affairs with them”’.