Tales from the Valley of Death. Rachel E. Menzies
Ross G. Menzies
There are many schools of psychotherapy from short-term, solutions-focussed methods to long-term, insight-oriented approaches. The clinical work of both authors is heavily based on the cognitive-behavioural tradition which emerged from experimental psychology in the laboratory in the middle of the last century. Compared to most approaches, cognitive behavioral therapy (CBT) is generally a brief process since it directly targets the unhelpful thoughts, beliefs and behaviours that are interfering with the individual’s functioning. It is not uncommon for a complete course of CBT to involve less than 20 sessions and occur over less than 6 months. However, in intractable and complex cases treatment may be ongoing for many years. As the reader shall discover, the stories that follow generally involve such individuals.
Mary first came to see me in the spring of 2015 when she was 25 years of age. She was an imposing figure — broad framed and tall, striding into my rooms with apparent ease and confidence. Mary was not one to suffer fools gladly, if at all. She had experienced the worst of mental health services and had developed a healthy scepticism for psychologists and psychiatrists. But under this external strength and doubtful gaze, there was a palpable fragility. Mary was an odd mix of cutting wit and a soft interior — an iron fist with a marshmallow centre.
Within the opening minute of our first meeting she was talking about death or, more particularly, her death. It was clear that her life had been dominated by a genuine terror of her own passing. All she could think about were the many ways that she could die. ‘We’re so fragile, Ross’ she told me. ‘Haven’t you realised that it can happen at any time?’. She imagined death from panic attacks, collapsing in elevators or on public transport, allergic reactions, choking, poisoning, infection from germs and a variety of obscure illnesses. She had fears of cars, planes and other modes of transport. She was even terrified that she might inadvertently take her own life by suddenly driving into oncoming traffic. Mary told me that she couldn’t listen to certain songs and artists that she associated with death, and she had magical mantras and rituals that she had to perform to eliminate the chance of death when dark thoughts or images arose in her mind. She was particularly scared of being alone when death finally came to call on her. ‘I can’t face the possibility of fading into death’s arms with no one there — no one to offer me support, no one to comfort me’.
Diagnostically, Mary was a complex woman. She met the standard criteria for Obsessive-Compulsive Disorder (OCD), Panic Disorder, Agoraphobia, Illness Anxiety Disorder and, at various points, Major Depressive Disorder. She had extremely high scores on virtually all the psychological questionnaires and surveys that I administered. Her depression and anxiety scores placed her in the most severe one per cent of the community. When I tested her fear of death on commonly used questionnaires, her profile of scores was extraordinary. Some people fear oblivion — not being, not existing, missing out on events to come (that is, the death of self). Others dread the actual process of dying, whether it’s the slow decay of the human body from tumours or a more specific terror of the actual moment of death (the dying of self). Mary’s test scores showed that both issues were extremely prominent in her mind. She had the highest death of self and dying of self scores that I had ever seen. Surprisingly, despite all these difficulties, her self-esteem test scores were very positive. Again, strength and weakness in the one package.
Of all of Mary’s difficulties, her most disabling symptoms related to eating behaviours. She reported extreme terror around the possibility of dying by choking or through anaphylaxis. She worried that she might suddenly develop allergies to foods that she had previously no problems with. She had not eaten peanuts, or any legumes, for many years, and her diet was extremely restricted. She was essentially limited to bananas, watermelon, onions, tomato and bread. Moreover, if she found a ‘safe’ food or fluid, she would restrict her exposure to a single brand of the product. For example, when I met her, she could drink vodka, but only Absolut vodka. ‘How do I know what goes on in the other factories? How do I know it’s safe?’ she told me. This protective behaviour even extended to bottled water — Mount Franklin was not just preferred; it was the only brand of water she could drink. And she always drank with her jaws closed tight. She would suck fluid through her teeth to protect herself against foreign objects. ‘What if there is glass in the bottle? Even a tiny shard could kill me. Why would anyone take the risk?’.
Right from our first meeting I was struck by how limited and difficult her life had become. How can one comfortably eat anything with the constant threat of allergic reactions, choking, poisoning and consuming glass and plastics? ‘Well’, she told me in a whisper, ‘when I’m out, I eat most of my meals at the hospital’. I remember how stunned I was when Mary revealed this to me. Initially, I didn’t even understand what she meant — I was just deeply and profoundly shocked. She explained that she would buy food and drive to the nearest hospital emergency department and sit outside to eat. ‘Ross, you just never know when it’ll save you’ she declared. ‘I just want to know that doctors are there if something goes wrong’. In situations where this wasn’t possible, she would comfort herself by at least knowing how close the nearest medical aid was. She refused to visit any part of Sydney that was more than a few minutes from an accident and emergency department, even if she wasn’t eating.
In so many ways Mary was among the most disabled women that I had ever met. In addition to her fears, her mood could rapidly change. She went through regular periods when she was too sad to leave the house. During the early part of our work together we would often talk on Skype because of her immobility. At the best of times, given her agoraphobia, she could only attend my rooms in the company of her partner. However, when her mood deteriorated even this wasn’t possible.
I knew from our first session that Mary’s treatment was going to be slow and long. She’d been weakened by years of chronic disability, and I feared that her chequered history with mental health services would also hold her back. But as time went on, she grew stronger and stronger in therapy. Step by step she slowly advanced. I taught her that the treatment of anxiety was like trench warfare: ‘Just move the trench forward ten paces, bunker down, and don’t let the enemy break through your defences. Small gains are all we need between sessions, Mary — that’s the way we’ll win the war’.
As weeks turned into months, the gains grew larger. I could see Mary becoming empowered in her recovery. She became more positive, optimistic and animated in sessions. She was increasingly engaged and attentive — an ideal patient who was eager to learn and even more eager to recover.
At the time of this interview, Mary had seen me 54 times over three years and she had dramatically improved. Through daily exposure to feared foods and fluid she had slowly mastered meal times. Her first steps were small — merely changing the brand of her bottled water was a cause for significant celebration in the opening weeks of treatment. Slowly she added more foods, and gradually she eliminated all her safety behaviours and magical rituals. She stopped eating near hospitals and slowly reclaimed her life.
Mary is now eating freely, coming to sessions on her own, and travelling with much greater ease. Her mood has been stable for many months and she is completing a course in Fine Arts. She recently married and is enthusiastically building a life with her new husband. To say that she is free of anxiety would be an overstatement, but she is an entirely different person to the woman I first met.
Our interview with Mary
| Ross: |
Thank you so much for talking |