I first met Cecilia in a nursing home, the forth in her career. Her GP, one of many, was at the end of her tether, so were the staff of the home. The nurses could cope well with the dependency needs, such as having to feed them, attend to their hygiene, put them to bed etc., but not with the abuse. And abusive Cecilia certainly was. Since her arrival in the home two months previously she had pinched, kicked, bitten and spat at those who tried to care for her. Why? Was she mad or plain bad?
When Cecilia was brought into the consulting office, I was struck by a strange incongruity between the frailty of her figure and the sharpness of her look. She was in her early eighties, twice widowed, and her only daughter was in regular, if anxious contact with her and the staff. Her long psychiatric history with numerous and varied attempts at treatment (which had even included the prospect of brain surgery) was a sad witness to doctors' impotence in the face of the unfathomable. Cecilia’s memory was good, and I was not able to observe any signs of clinical depression. And yet there was obviously something wrong with her. I suggested an admission to a psychiatric unit, an offer that she greeted with sceptical indifference, and the nurses with an audible sigh of relief.
Cecilia was born into a working-class family, the second youngest of six children. By the time she was in her teens, most of her older brothers and sisters would have either left home or were on the verge of leaving. Her parents quarrelled frequently, and she remembered being regularly punished by her father for defending the mother. One thing Cecilia never lacked — courage. She was probably the most intelligent member of the family, a quality that proved to be a mixed blessing. She could see things that others could not; moreover, she also said things others would have been too frightened to even think. And yet nobody seemed to be able to help her to make much constructive use of her intelligence. When a sharp mind cannot be constructive, it almost has no choice but to be destructive.
There was a five-year gap between Cecilia and her older brother, but Vera, the last addition to the family, was only a year younger. She was also beautiful and the parents' favorite. Yet she never had the guts to stand up for herself, let alone anyone else. Perhaps that is why even the battered mother preferred this 'pretty mouse'. Cecilia remembered how on the way to school she often pinched Vera’s delicate white skin until her sister screamed with pain. And if her sister mentioned anything to the parents (which she never dared to), there would be a ‘double dose’ the next day. Longing for love, Cecilia felt unable to earn it, so that taking revenge on the one who could, became her set pattern of behavior. What she could not have she seemed bent to destroy. Thus, she came to know a bittersweet taste of envy, a taste that would accompany her for the rest of her life. To the point of distraction.
Meeting a young handsome accountant at the age of 26 was Cecilia’s chance for happiness. Particularly that Vera never managed to attract any man and had to reconcile herself to the life of a nurse for the aging parents. After marriage, Cecilia acquired a position as an office clerk and enjoyed her new role of a respectable wife. A few years later she conceived and was looking forward motherhood. ‘Perhaps the gods liked her after all? No, they did not!’ Before she delivered, her husband was struck by Tuberculous meningitis. His death shattered Cecilia’s hope for happy life. She was back in an all too familiar position of a loser.
Against all odds the baby girl was born well and healthy. Cecilia’s mother-in-law looked after Margaret until she was ten. Aunty Vera sometimes took her on holidays, but the youngster sometimes wondered why such a beautiful woman was unmarried and looked so sad. Meanwhile Cecilia worked hard to support herself and her daughter. A few years later a young, respectable lodger moved in, and this helped to pay the bills. John was training to become a vicar.
Margaret grew to become an attractive young woman and after turning away quite several suitors she decided to marry John. They fell in love when Margaret went away to study accountancy at the college. To aid preparations for their wedding she returned home to her mother. But something unspeakable must have happened between the two women and instead of arriving at the altar Margaret was admitted to a psychiatric hospital, with a nervous breakdown.Perhaps when Cecilia looked into the mirror, she kept seeing her daughter, much beautified by love? Mirror mirror on the wall…Yet, John turned out to be a real prince, and they married as soon as Margaret was released. Shortly afterwards Cecilia married the neighbor. Neck and neck!
Again, the happiness was not meant to last, and the new husband died from a stroke a year later. Meanwhile, Margaret became pregnant and delivered a healthy boy, and two years later a daughter. The couple seemed to live a content and harmonious life, at a ‘safe’ distance from Cecilia, and Margaret’s contact with her mother was limited by natural obstacles. Almost as a testimony to their marital relationship she became pregnant again. Virtually on the eve of her daughter's confinement Cecilia went mad. Virtually! She suddenly took to the streets at night, barely in her dressing gown, and ran amok. This resulted in her immediate admission to a psychiatric hospital, with a diagnosis of a depressive illness. Fortunately, John had enough sense to keep the news away from Margaret, so that a normal delivery took place. Strangely, however, the daughter born that night was to suffer from anorexia nervosa years later.
Cecilia had at least twelve further sojourns in various psychiatric hospitals and was treated with high doses of anti-depressants, electro-convulsive therapy, and even brain surgery was considered. My involvement was only one of many, a small loop in a long chain of doctors. Meanwhile, the nurses on the assessment ward were repeatedly telling me that Cecilia behaved in a nasty fashion and would often hit or pinch them when they were trying to help her with daily hygiene etc. She was invited to the ward-round and as I was helping her to the chair, she slapped me across the face. At first, I was speechless, then furious. Nobody has ever done this to me before. Obviously experiencing such behavior at close range fueled my motivation to do something about it.‘Why have you done it?’ - I shouted at her. Cecilia could not explain but apologized seductively. I insisted she left the room immediately, and she staggered to the door in dead silence. During a discussion that followed a decision was taken to keep a cool distance from Cecilia and to go ahead with ECT. Perhaps she is mad rather than bad, or so we hoped.
A few days later, I was passing through the ward, when another female patient stopped me and asked if she could skip her last ECT treatment due next week. She anxiously told me she was having a strange premonition and was feeling frightened.When I leaned forward and touched her hand, trying gently but firmly to reassure her, I could feel a piercing ‘Salieri look’ on my back. It was Cecilia's. She must have watched me talk to the fellow-patient, presumably with much more affection than she herself would have received. I tried to suppress this observation. Not for long.
Although normally I sleep well, that night I could not. I woke up quite early and for some strange reason I started to think about my elderly lady due for her last ECT, about Cecilia and what might happen. I suddenly realized that it was Monday, the day of the treatment, and also that these two would have been the only patients to be taken in an ambulance to the nearby general hospital for the treatment. It was quite likely that they would be just by themselves during at least part of the journey. Could Cecilia do something to the other patient? Could she…frighten her to …death?
Suddenly I felt electrified. I must speak to the nurse in charge. Now! Never mind that it is only 6 a.m. This I did. To my astonishment the nurse confirmed my worries. She told me that for some time Cecilia had been following the other patient, watched her wherever she went and was making her visibly frightened. That night she hardly slept and begged the nurse not to send her for ECT but would not say why. I made an instant decision - let’s cancel the treatment for both. I shall come earlier and have a talk with them.
I saw the ‘victim’ first. She looked as white as a sheet and mumbled somewhat incongruously when I asked her what exactly she was frightened of. Than I rephrased my question: ‘whom were you frightened of? You must tell me!’
‘Nobody! Nobody!’ - she cried, trying to leave the room. I stopped her:
‘It was Cecilia, wasn’t it?’
‘How do you know?’ she whispered and slid down to the chair. ‘I was so frightened of her. I am so silly. I…thought she was going to do me some …harm.’ What? - I asked. ‘I am so silly… I thought… she might…kill me.’ - she exclaimed amidst floods of tears. I called the nurse and asked her to stay with the patient for a while.
Cecilia came next, looking as innocent and frail as ever. Without further ado I went straight to the point, spelling out her destructive jealousy straight to her face. I swiftly moved on to her revengeful feelings for her sister and for her own daughter, for the nurses and how she was poisoned by envy and how she was poisoning others.
‘It is impossible to love you or be good to you! You also cannot stand when people are happy!’ -- I exclaimed.
Cecilia was silent for a while, and then whispered ‘…and…I…hate myself too.’ I was stunned. She did not try to defend herself. In fact, she looked relieved, as if some weight were lifted of her shoulders. For a moment I thought that perhaps we may have made some breakthrough… Perhaps?
I could not afford to take any chances for the sake of other vulnerable patients. The very same day Cecilia was transferred to an acute admission unit for younger patients. To offset what could be perceived as a rejection, I promised to visit her for an hour each week.
During our talks she fluctuated from open hostility, through armed neutrality, to something akin to intimacy. The nurses told me that she was certainly looking forward to our tête-à-tête. And so was I. Suddenly, when we appeared to have been making some progress in our relationship, Cecilia developed a fulminating pneumonia. For a week she seemed to be on her deathbed and needed to be given intravenous fluids and antibiotics. I still remember a scene at her bedside when I came in the afternoon to visit her as usual. She looked so vulnerable and forsaken. For a moment, I was tempted to hold her hand, but I looked into her eyes, and what they were saying shocked me: ‘Don’t touch me or else I die. Love can kill me.’ I hesitated …and I didn’t. As I walked away in silence, I could hear her sigh of relief. She recovered soon afterwards, but I never quite did, and I think that this was probably the saddest moment in my whole medical practice.
As Cecilia came back to life, so did her envy. She was soon discharged to a new nursing home, only to bounce back under my care two years later, with the usual history of kicking the nurses in the genitalia, pinching their breasts and spitting at them when they cared for her. Her daughter Margaret came to see me to ask whether she should take her mother home and look after her. I had met the daughter on several occasions previously, and she appeared to understand (intellectually) the problem. She said to me once: ‘My only hope about my mother is to give up hoping… that she can love me’. Her loving and insightful husband was often the chief voice of reason and he persuaded Margaret not to take her home. Margaret resigned herself to the fact that for the protection of the family her mother should stay in the hospital forever. But from time to time she would insist on talking to me again, and that seemed to help her to carry her burden of guilt. Cecilia, on the other hand, looked reasonably content, and I often saw her reading a book, or just watching the world go by, whenever I visited the ward she was on. Sometimes she faintly smiled to me. I think it was better that way.
COMMENT: Melanie Klein’s ‘Envy and Gratitude’ had helped me greatly to understand and endure this experience.