Categories
The Observant Immigrant

To be or Not to be…

 Candice Louisa Daquin takes a close look at death and suicide.

The Death of Socrates by Jacques-Louis David (1748-1825) Courtesy: Creative Commons

Recently I’ve been grappling with the imminent death of a very dear friend. She is very young. Maybe her youth or maybe my attachment to her, makes this particularly moving to me. I have dealt with death before and it is never something as simple as going softly into the night. Yet it is something we must all deal with, multiple times, often intimately and up-close-and-personal when it comes to our turn. This may be a macabre subject but, in a way, it shouldn’t be because it’s the one thing we will all are guaranteed to experience. Maybe it’s time to see death and dying differently?

In my friend’s case she wanted passionately to live. She didn’t want to get cancer in her thirties and have the rest of her days taken up with trying to survive. It’s unfair, it’s horrible, it’s what most of us fear. Despite this, her grace leading up to her death, including her time in the Hospice, had been startling for me. I saw a change in her, that I found unexpected and illuminating. One could have argued it was the hand of God touching her, those who do not believe might have mooted for inner peace. As much as I rail against her dying, and wish stupidly something could prevent it, what helps is knowing what I feel and think is nothing compared to what her family is experiencing, and it puts things in perspective and demands that I rein my feelings. By that, I don’t mean ignore the sadness, but put it in a context because everything is a context.

My context is: A few years back my beloved cat died, I was very upset. But I knew he was a cat who lived a long life, and he was ‘just a cat’ versus a human. For me, that context is different (despite ultimately believing us all equal). If my father passed on, it would devastate me more than say, a stranger, and that’s just being honest. When my grandparents died, I was very upset, but I put it in the context of expecting grandparents to die and whilst I still think of them and miss (some) of them, I’m able to cope. I think this is true with my clients, they rationalise by contextualising. It’s how we cope with grief and fear. When we cannot do this, we usually develop some type of imbalance and that can cause us to have unexpected responses like feeling as if it is the end of the world if your pet turtle has passed on. Everything is context-based. While it might seem insensitive to admit this, it’s what keeps us sane.

People can be dismissive of others pain. I have often heard people say things like: “Well her parents died more than a year ago, don’t you think she should be ‘over’ it by now?” Invariably when their time comes to lose their parents, they may finally understand why most people don’t get ‘over’ it when they lose parents, or siblings or their children. Others believe you are weak if you don’t ‘suck it up’ or that there is some time limit on grieving. In the faith I grew up in, we tend to give a year for grieving for parents (or close relatives) which allows the griever to not feel guilty (or guilted) for their emotions – it frees them. On the other hand, it could be negative if say, after a year they feel worse as many do because grief is not linear. Nothing is perfect. The important thing is to have empathy and realise we all process differently and there is nothing that is wrong or right, except for the individual.

If we all die, then we shouldn’t stigmatise illness or fear it but many people do. It is the great unknown. In modern times, a worse fear is suffering. We may not know what happens when we die, but we know suffering and nobody wants to suffer, but increasing numbers of people do. Why? We always suffered to some extent. In wars people would lie on battle fields for long periods of time dying of awful wounds. In modern times we harnessed the power of pain killers and believed ourselves free of pain and thus, suffering. Despite this quite the opposite phenomena has occurred. In some ways people suffer more.

Why? Because with the advent of ways to prolong life, came medication that extended life but it came with a price. When a person gets cancer say, it’s no longer a death sentence. Many recover fully and go on to live long healthy lives. For those who get a late diagnosis however, the cancer might have spread so much so that eventually it will take their life. This is where modern medicine seems to shine. There are a plethora of medications that prolong life. No, not cure but cause remission or sustain life for a period of time.

If you are someone with children or grandchildren, living an extra two years might be worth the astronomical sum it costs (if you can afford it) but at what cost? Many of these drugs cause horrible side-effects and do not reduce suffering, in fact it is the suffering (toward death) that becomes the experience. You could say, we have prolonged suffering in our attempts to give people ‘more time.’ The question then, is it worth more time and what do we mean by more time?

Whilst doctors want to offer hope, they do so more out of a stubborn desire to ‘try anything’ rather than because the six months they may give a dying person, is really beneficial when you consider the sheer backbreaking cost (bankruptcy from medical costs being the #1 reason) and very small gains (six months more of life and you have spent all your money on a treatment which only benefits Big Pharma, according to Dr. Azra Raza in her ground breaking book about death and dying, The First Cell). The unwillingness of doctors to give up, is admirable and very human (who wants to tell someone there is no hope?) but it brings with it, a false promise.

In the modern world, people have smaller families by and large, and as such, many of us when we get older and more likely to die, may have less obvious incentives to live if we get sick. It’s not so much a wish to die, but a pragmatism about death and dying. Easy in theory, perhaps less so in practice, we must all eventually deal with this issue. Better to consider it before the time comes, hence the increase of living wills, whereby we inform doctors and loved ones, what we want to happen should we get sick. Again, macabre maybe, but imminently sensible, and useful when doctors are not mind-readers and cannot predict what a patient coming into Emergency may wish by way of life sustaining treatment.

Speaking of life sustaining, one debate long held relates to dementia. Right now, if you were to write in a living will that should you get dementia you do not want any life sustaining treatment that would only include if something actually happened to you, such as a heart attack or your kidneys shutting down. For many with dementia though, it is the day-to-day living that is hard, both on the individual whom on some level knows they are not themselves, and on those who care for them. Whilst it seems inhumane to some, to consider letting people with dementia die, those lucid enough to know they have dementia will often wish to die rather than live, without any hope of recovery and the mental state of a child without any chance of growing up. Since dementia is so common place and we’re all living longer, this is a real issue and yet little is done to combat the increase in dementia patients who may often have nobody to look after them and no funds for full time care. What should be done?

Clients of mine with parents suffering from dementia will often describe the agonising decision to put them in care if they have the financial wherewithal or take care of them at home, often at great expense (loss of job, career). Some wish nothing more than the opportunity to care for their parents or loved ones, whilst others feel guilty for wishing it were anyone but them looking after their dementia patient. Both perspectives are understandable. For some there is a redemptive quality to caring, and it comes naturally. For others, financial or emotional reasons may make being a person who cares for others, incredibly hard. It is not surprising that older carers such as the husband of a woman with Alzheimer’s, often dies before the wife. The actual act of caring is exhausting as it may be redemptive, and nobody should be blamed for being unable to do it. Sometimes however, there is no choice, with rising costs for elder care, especially with dementia. It makes me wonder what will happen if the predicted number of elderly develop dementia. Will it be common place to see them walking the streets without anyone to look after them? Take me for example, should my father develop dementia and I live in a different continent, what would I do? This is something many of my client’s fear and yet little is done to resolve this issue by world Governments.

Some people believe dementia patients should be allowed to access euthanasia. As of now, all countries with some degree of access to euthanasia ask that the patient be ‘sound of mind’ – which would not apply to someone with dementia. But even if you write a living will stipulating that you wish to have euthanasia if you get dementia, this is a tricky situation because by the time that would apply, you would not be sound of mind, so it negates the ability to have euthanasia. Furthermore, what of unscrupulous relatives or friends, jockeying for inheritance or to financial gains? How can this be stopped from being misused? How can we gauge whether someone with full blown dementia really wants to die? The reason this matters, is by the time a woman is 80 she has a 1/3 chance of dementia of some kind and by the time she’s 90 that chance is 1/2. This is and is going to affect a huge swath of the population and as such, these conversations need to be had. The only way we do this is to consider what end of life means and how best to end life.

End of life conversations are common in therapy. Clients may be bereaved. They may have a partner dying of a terminal illness, they may have lost a child, parent, friend. Perhaps it is a relief to have counselors because many people don’t want to ‘go there’ and talk about death and dying as if it is contagious. It’s a hard subject, a sad subject, and difficult to put a positive spin on it. Life can be tough enough, without considering dying before it’s time, but that’s exactly what we should do to protect ourselves.

The other subject not discussed in depth is suicide. It’s one thing for us to die of disease, we know that’s a possibility but we’ve always struggled with the idea of suicide. For most of history, suicide has been variously unsanctioned by society-en-mass, but the question is why? Is it an ancient fear of the ‘unnatural’ impulse to die? That we work so hard to stay alive, it seems absolutely wrong to wish to die? Or something else? Whilst Emile Durkheim (1858-1917) wrote on suicide and many have questioned this, no one person that I’m aware of, has managed to figure out what our collective horror is in relation to suicide.

Let’s play devils advocate for a moment. What is it about the decision of another wishing to take their life that causes people to react so strongly? Is it the same as abortion? Pro-life over Pro-choice? Or the visceral horror we all have about dying? If the latter, why does it matter so much to us what others do? What right do we have to intervene? Yet we do, societally and individually. One might say we’re just trying to save lives, but do we put as much passion into feeding the starving or rescuing women from abusive relationships as we do banning abortion and making suicide illegal or socially frowned upon? When it’s not illegal, it’s considered ‘weak’ and a ‘cop out’ (to use an American term). The only society where suicide was really ‘embraced’ if such a thing can exist, is Japan, and nobody really knows why that singular country took the notion of suicide to such an artform.

Suicide bombers today may be Muslim fundamentalists protesting against the tyranny of an oppressive country. They are sold on the idea the after life will be a paradise, and much of what they are told is not from the Koran but from the machinations of those who impel them toward acts of terror. When a young person blows themselves up to destroy others, this is not the suicide we think we understand, but an act of anger, revenge, justice or ignorance. Suicide in its more common form is less about revenge or justice but can be about ignorance or anger. Ignorance in that many young people kill themselves almost upon an impulse, with little pre-thought or planning, just in a reactionary ‘of the moment’ way, that shocks loved ones who didn’t see it coming because it may not have been (coming). There is an element of ignorance to this act, they may be copying others, or reacting abruptly, and had they known more in that moment, they would possibly have looked back on the act and regretted it. As such the impulsive element of the act could be viewed as ignorance/nativity.

Anger is a very common reason for suicide, although probably the one everyone is most familiar with is despair (depression). Ironically anger is as much as incentive for suicide as despair, because of the heightened tendency to react with both those emotions. It is in that heightened state that many attempt or complete suicide and those who survive, often realize there were other options they wish they had taken. For the committed, then suicide is a personal decision, perhaps based on a terminal illness diagnosis or long-term suffering. Despite this people intervene and tell anyone who wishes to die rather than linger and suffer, that they are weak for taking this option. I have always found that fascinating and awful, because I see it exactly the way I would putting my cat to sleep. I did it out of mercy and love. I did not want my cat to suffer. A human being is not a cat but the same emotion applies. Where is the true difference?

The difference lies in religion. People who condemn people for taking their lives are not universally religious but many are. The tenants of a religion might dictate that someone should not take their life. I have always wondered why, because I believe most religions were written and created by humans and so it begs the question, why were they so intent on stopping people from taking their own lives? I can understand that if a God exists and says we should not take our lives, this would give pause to many. But it also creates a challenge, because what God would wish someone to suffer terribly?

This is a very personal decision and that’s my final word on whether someone should choose suicide if they are suffering. To some extent it should be the right of the individual and never anyone else, what they do with their life and death. I recall Brittany Maynard (1984-2014), a young woman with a terminal cancer in her 20’s talking of her right to end her life rather than brutally suffer and I felt then, even if I did believe in God, I would not strip her of that right, because I did not want her to suffer and I could not believe any God or human would. Again, if we have tools in place to deal with these issues, then people who are suffering terribly, do not have to battle through this, at their most vulnerable.

Many of us may not know this but suicide if we’re talking technically suicide, is incredibly common. Old people often stop eating and will themselves to die when they have had enough of life. Technically that’s suicide even if they do not see it that way. Maybe it’s more natural than we imagined? Likewise, hospices and long-term care facilities will medicate terminal patients at the end to hasten their death and relieve some of the suffering. Effectively causing a person to die before their ‘time’ if we think in God-given terms. I do not begrudge this because these carers are seeing people suffer in ways few of us can imagine, if there is not a mercy to ending a life of agony, then I don’t know what mercy really is.

The stigma of suicide is incredibly pervasive. Just like mental illness, suicide is seen as ‘not right in the head’ and a weakness. How sad that society believes judging those during their worst times is the right thing to do? How is that going to help someone choose anything else? And what of their right to end their suffering? This begs the question: Is it right to die before your time? And by right, what do we mean? Who is the judge of what is right and wrong? For some, it’s easy, it’s God and most Gods say suicide is ‘wrong’ but again, why? And at what cost? For those of us without God, then right and wrong become moral principles that we try to adhere to. Is there a downside to morality being the choice of humans rather than something more than us? Absolutely. We are flawed and liable to influence, but sometimes trying our best is all we can do. I would like to think I would be merciful before judging if someone I loved dearly wished to end their life. It would of course depend upon the circumstances, as it should.

Switzerland is the only country in the world where you can elect euthanasia for no specific reason. In America in the ten states that permit some degree of euthanasia, you need to be close to death and have a terminal illness.

Why is death sad?

Switzerland is testing a 3-D-printed pod that its creator says can painlessly end someone’s life in a matter of minutes. The device is called ‘Sarco’ and users can potentially end their lives at the push of a button. The advantage of this system is he pod becomes filled with nitrogen gas, which lowers oxygen in a person, until they fall unconscious and this occurs fast, within a minute. The idea of a truly painless death by euthanasia is why this was invented and users do not Sacro suffocate they die fast of oxygen deprivation after they’ve fallen asleep.

Some have argued a machine like this could glamorise suicide (although how, is not explained) and that it may be overly appealing to a mentally ill person seeking death. I don’t really agree. If there are checks and balances in place that work effectively, this won’t be an issue. The real issue is who wants to consider people taking their lives when death is sad? And how do we access without bias, who is ‘eligible’ for euthanasia and who can be helped another way, that doesn’t involve a premature death? After all, someone in the throes of depression, may wish legitimately to die, but what if a year later they are well enough to be glad they didn’t die? Those kinds of grey areas must be resolved before euthanasia could ever be expanded or wide-spread.

The Netherlands and Belgium permit assisted suicide for patients with unbearable physical or psychological suffering. Which differs from the USA where it can only be for terminal end stage physical illness. Switzerland has less qualms, making it a destination for ‘suicide tourism’ which again, is very sad, but perhaps what is sadder, is that they have to resort to this and what about those who don’t have the means? People assume those who are pro-euthanasia must be eugenicists or simply not care about others, but often the extreme opposite is true, just as it is with Pro-Choice advocates, who believe choice is freedom and the basic right of any woman.

Should we be able to die because we’re simply ‘tired of life’ or should we be expected to carry on to the ‘bitter’ end? This is such a cultural dilemma and maybe suicide became more acceptable in Japan because they reframed the concept of death, making it honourable to commit suicide (or as a means of regaining honor) just as suicide bombers find honour in the act. Should we need honour or some justification to believe suicide needs to be part of any argument about end of life? Maybe this is also connected to concepts of the death penalty. It is believed by many that America will not have the death penalty in years to come, that it’s a faded system that doesn’t work and scapegoats the most vulnerable. I see the death penalty as very different (a consequence for a bad act) than legally assisted suicide (to end suffering) and thus, when I consider arguments about end of life with clients, my considerations are about their quality of life and not, the myriad ways we can consider forms of dying.

In an ideal scenario nobody would wish to die, perhaps. Why? Because so much can be found in living and those who love us would not wish to lose us. Realistically however, people get sick, people get tired, people suffer. As long as we recognise this in ourselves and others, then debates about what end of life represents, will be part of a larger conversation and a necessary one. Perhaps if we cannot see anything positive in this, we can at least not shun it until it is too late. Likewise, we could consider that death is not the worst thing to happen to us, though suffering might be (or the suffering of those we love) and ways of alleviating suffering that are compassionate, should be part of the conversation.

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Candice Louisa Daquin is a Psychotherapist and Editor, having worked in Europe, Canada and the USA. Daquins own work is also published widely, she has written five books of poetry, the last published by Finishing Line Press called Pinch the Lock. Her website is www thefeatheredsleep.com

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The Observant Immigrant

When is a mental illness not a mental illness?

By Candice Louisa Daquin

Shakespeare’s King Lear: Was he mad or grief stricken? Courtesy: Creative commons

Depending upon the country you live in, you may have to think back a long time or not so long, to imagine a time when talking of mental illness wasn’t mainstream. For many countries mental illness is still a taboo, but the internet has made knowledge of mental illness more wide-spread. You could be forgiven for thinking most people suffer from some form of mental illness. In reality, statistically, the majority do not. Most of us however, go through hard times where we may exhibit behaviour shared with those suffering from mental illness.

Having just finished co editing a large book on mental illness, I began to think about how we swung from one extreme (never acknowledging mental illness) to another (talking about it all the time). As a psychotherapist this isn’t perhaps surprising but the extent to which we label and evoke mental illness as explanation, might be.

Sometimes atypical behavior isn’t mental illness.

Teens, the elderly, the dispossessed, so many groups may suffer what seems like a mental illness but it really a natural response to a challenging situation. The adjustment of growing up. The challenges of getting older. Losing partners. Losing parents. Hormone changes. Trauma. Treating these events, the same way you would someone with a long-term mental illness like schizophrenia is ignoring the difference between an illness and a causative episode. With health insurance companies demanding categorisation in order to approve insurance, there has been a gradual shift toward ever-increasing terminology and labels. The problem with this is someone going through depression because they lost a parent can be seen as mentally ill — just like someone suffering from severe schizophrenia. But the two are not the same. We must be careful not to confuse malaise and regular responses to trauma and challenges, with a deep-rooted illness that might not be as curable. Why? Because we’re no longer understanding crucial differences in what we deem mental illness.

Therapists and medical professionals can be far too quick to state unequivocally that someone is mentally ill. This matters because just as ignoring mental illness and not talking about it, is wrong, so is over diagnosing it. The reason being, when you label someone, you set into motion years sometimes of inaccurate diagnosis and treatment which can do more harm than good.

Before you dismiss this as a rare event, think again.

Here are some case studies (real names not used) I have come across in my work:

John was told he was bipolar and was sent to an outpatient ‘group’ in a local residential center for mentally ill people. This was on the basis of his arguing repeatedly at his place of work and finally being fired. He also had several car accidents that he put down to ‘feeling angry’ and he attacked his wife during an argument. He was prescribed high dose psychotropic medication and his insurance was charged for the expensive therapy he received daily.

His family were horrified to find out their father was ‘suddenly’ mentally ill with bipolar disorder ll in his late sixties. They didn’t question the authority of the doctors until it became obvious something else was going on. At that time, he had sunk into a deep depression and seemed to be losing his ability to drive. The family asked the psychiatrists whether he could have dementia, to which they were repeatedly told — no he’s mentally ill. Firstly, this is an erroneous way of describing a condition as blanket-diagnosing mental illness, and second, they were wrong. John had the beginning of Alzheimer’s and his delayed diagnosis caused great heartache for everyone involved.

The question of how any competent psychiatrist could have diagnosed John with Bipolar ll which rarely if ever ‘suddenly happens’ late in life, is but one example of how a system will fit a diagnosis to its dominant perspective, in this case an assumption that certain behaviours are always congruent with a mental illness. John like many with Alzheimer’s did share some symptomology but nobody bothered to consider an alternative diagnosis and thus, the incorrect medication, expense and uncertainty caused a sad diagnosis of Alzheimer’s to become even more protracted and painful. Equally it should be mentioned for the sake of fairness, that there is an over-abundance of dementia-related diagnosis of older people where other causes are not considered and this is the same shortsightedness.

Liza, was diagnosed with schizophrenia based on muted affect, spells of catatonia and trauma response as well as insomnia, severe anxiety and depression. She exhibited paranoia and fearfulness as well as despondency and out bursts of anger. Even if those symptoms could fit the diagnosis for schizophrenia, they are too generalized to be assumed as such. Nevertheless, Liza was given EST (Electric Shock Treatment) and institutionalised for years, without another diagnosis being considered. It turned out Liza had never had schizophrenia but after years of medication it was hard to tell what was causing her behaviour. It wasn’t until years later when she began to open up to a therapist who cared, that Liza found out her symptoms were the reactions of severe childhood abuse and sexual abuse. These had never been considered because she was not asked about sexual abuse, and did not volunteer about it (most sexual abuse survivors don’t). It was easier to medicate her and inflict EST on her, than really understand what was going on. Liza went on to live a full life, but with the scars of her experiences and a deep mistrust of the psychiatric field (rightfully!).

These are two of many, many stories I could share of clients with misdiagnosis histories that caused them and their families a great deal of suffering. Of course, there is the flipside of people not being diagnosed with a mental illness and equally suffering and I acknowledge that happens too. The purpose of this essay is to consider the epidemic of over-diagnosis and how, maybe with good intention, we’ve swung from one extreme (nobody is mentally ill) to another (if in doubt, it’s a mental illness).

Whilst I am the first person to say accurate diagnosis and treatment can save lives when it comes to the mental health field. I have seen how doctors and practitioners can be subject to the undue influence of social trends in diagnosis and medication and how this can influence the accuracy of their diagnosis. Psychotropic drugs can have life-long effects which if that’s your only choice compared to the misery of a mental illness, you will accept, but what of those who didn’t need them in the first place? My concern is the over-medication and over-diagnosis of certain kinds of mental illness set a cascading storm into motion.

A colleague of mine who works as a psychiatrist had her own experience of being on the ‘other side’ when she developed a sudden onset illness. The illness included heart palpitations. My colleague went to the ER with chest pains thinking she might be having a heart attack. The physicians on call determined she wasn’t and their next recourse was to suggest it was an anxiety related issue. They prescribed anxiety medication and recommended she saw a therapist. My colleague went another appointment only to find out she was sitting in front of a psychiatric nurse. Despite her own qualifications as a psychiatrist, she said at the time she felt vulnerable, unsure of what was happening and very afraid. She explained her feelings of fear to the nurse, alongside her concern that she had no definitive diagnosis. The nurse did not refer her to another medical doctor for further tests. She recommended heavy duty anti-anxiety medications.

Because my colleague is a psychiatrist, she had the presence of mind to decline but it got her wondering what would have happened had she not been clued into the failings of the system? She could easily have been taking strong medications for a ‘suspected’ case of anxiety, without really finding out what was wrong and caused her heart palpitations. It took my colleague a long time to finally get an answer. A rare disease. With treatment she recovered. The lesson she learned however, terrified her. She now understood how at the mercy of doctors most patients were and how often diagnosis wasn’t a precise science or even an educated guess, but more of a ‘by rote’ method that was deeply flawed.

She showed me the thirty something bottles of medications she was given with every appointment and explained that had she been truly suffering from a serious mental illness, she would have had more than enough to overdose with, even given the safety protocols of modern medicine. She also explained the ease with which she was given extremely powerful drugs, without a documented diagnosis and how many side-effects those medicines potentially had. She is now an advocate for change, hoping the medical industry and the pharmaceutical industries can be cautioned against rash diagnosis and over-medicating. It worries me that it takes an expert in the field to raise a red flag and I remain pessimistic about her success in changing a well-oiled system that earns billions in kick-backs and profit from the perpetuation of an illness rather than a cure.

Getting into hospital unless you have a heart attack or amputated limb isn’t easy any more. The model is more about treating patients and sending them home. This works for many, and expands on the ‘care in the community’ concept with mental health (which has floundered since inception, creating huge groups of homeless mentally ill) but does not work for everyone, especially those with harder diagnosis. Consequently, many of us have learned what it feels like to be a patient going through a broken system, what you had to do to get what you needed and how hard that would be if say, you were in the throes of a serious illness (be it mental or physical). Some doctors are responsive, caring and compassionate, whilst others merely check a box. The inadequacy of systems set up to help both the physically and mentally ill is underfunded and the level of treatment often fractured, in favour of cost-saving protocols that were often unapplicable to those they served. How challenging must it be for patients to seek good help during some of the hardest times of their lives?

I have sympathy for the over-worked/under-paid GP/family doctor who is restricted by insurance protocols and limited in what they’re able to offer their patients. I understand how it may seem easier to offer an anxiety medication or label someone bipolar, than spend weeks trying to get to the real cause. But you don’t heal anyone with a wrong diagnosis, and you mar the field of psychiatry by misdiagnosis. It’s no wonder I’m often mistrusted as a mental health worker, because so many of my patients have had negative experiences of being judged, marginalised and labeled, by previous psychotherapists and doctor. It only takes one person to assume you’re not coping and must be clinically depressed, to set into motion a whole chain of events. What if that practitioner had looked beyond the obvious and considered the evidence more closely? But sometimes it’s easier to reach for the prescription pad. You are doing someone a disservice if you medicate a vulnerable person on the basis of basic symptoms rather than looking at the whole picture. It’s a catch-22 situation with such short appointment times and a burgeoning patient load.

In prisons, where a high number of inmates have mental illness that are not treated through accessible programmes, drugs have become the surrogate for competent therapy. It is simply cheaper to drug a patient than offer 1-1 therapy. Whilst it may not be fiscally possible to offer low-cost or free therapy to everyone who needs it, we shouldn’t use drugs as a substitute if they’re not the answer. Most psychotropic drugs were designed to be used short-term but many people take them for years. If you imagine some of those people could be misdiagnosed or not really suffering from a mental illness so much as a hard time that will resolve, then you’re responsible for drugging people who shouldn’t have ever been drugged. How is this an answer to anything?

In nursing homes, patients with dementia and other diseases often take over ten medications that ultimately won’t cure anything but will make the pharmaceutical industries rich. The reason? To keep them compliant and calm. So they won’t bite, make a fuss or tax the underpaid staff. Again, I can sympathise with wanting to medicate a troublesome patient, but in shrugging everything off to mental illness we lose touch with the real cause and effect and shirk our responsibility to accurately treat people. Maybe with fewer doctors and ever-increasing medical costs this is no longer possible, in which case as more of us age and get dementia or alzheimer’s, expect to see a steady increase in the use of psychotropic medication as a means of management.

I have met many who have had similar sudden onset, long lasting catastrophic illnesses. Many of them were told by doctors that these illnesses were psychosomatic or psychiatric in origin when it turned out to be a hundred percent physical. Whilst I don’t deny that some illnesses can be psychiatric in origin, many are not and women are far more likely to be told their illness is ‘in their head’ or ‘an issue of nerves’ – and this not just from the medical industry, but their families and friends. Like anything, when you’re in a dark place it’s very easy to convince yourself, the doctor is right, which can further exacerbate misdiagnosis and unnecessary suffering and stigma.

For the seriously physically ill, this is as bad as having a heart attack and being told ‘you are anxious you need to calm down’. It is counterproductive and often causes people who need help not to seek it. The blurring between the physical and the mental is unacceptable. Whilst there is clearly a mind-body link, assuming everyone with anxiety must be mentally ill (rather than anxious for a good reason) is short-sighted and potentially damaging. Likewise, labeling every woman histrionic because she’s panicking about something, is using mental illness categories as a weapon.

The gender divide between how doctors treat female versus male patients is a long-standing inequality, based upon the old concepts of hysteria (a female term applied toward women only) and the link between mental instability and the female body. Whilst it is true that menstruation, hormones and menopause can definitely change a person’s mood, this is not the same as true mental illness and it is high time we understand the difference between feeling anxious or depressed and suffering from clinical depression or anxiety. The only way we achieve this is by quitting our tendency to label certain groups without further enquiry. This includes women, people of colour and lower-income persons — all of whom are more often assumed to be mentally ill than other groups.  

The harm of a misdiagnosis is, as I said earlier, as bad as no diagnosis. The rush to come to a conclusion is something that turns into a scarlet letter for the bearer. Despite our best attempts, mental illness is still stigmatised, and as such, once diagnosed, this can affect everything from future job prospects, marriage, friendships to even housing. In the information age, medical privacy is constantly under assault, and even future employers are able to find out about people’s private lives. Should they discover that person has a mental illness that they stereotype as being negative, this could reduce a person’s equal chances. The old adage, ‘crying wolf’ also applies because we over-diagnose and popularise in unhealthy ways. That causes people to shirk when someone really does need help.

Why do we stigmatize the mentally ill? I often hear from clients who are overmedicated and some who are undermedicated, both extremes existing because one provokes the other. A lot of psychotropic medication is not effective and placebo at best, leaving the medical industry with a big question mark as to how to help the mentally ill. Whilst I don’t have all the answers either, I would say, ensuring someone is really mentally ill before acting on it, is one positive step toward reforming a broken system. Currently so much money is spent on mental illness but people are not getting better, they are getting sicker. That means something really isn’t working. I’m not convinced the recent move to online psychiatry is the answer either, given the danger of powerful medications. I’m also not convinced strong medications like Ketamine and Ecstasy should be given without close monitoring. I’m all for creative thinking in medicine, but not without caution.

Finally … when is a mental illness not a mental illness? We should be open to alternative diagnosis rather than the category of mental illness as a catch all for when we’ve no better answer. Just because something isn’t apparent, doesn’t mean it’s a mental illness. There is so much the medical industry doesn’t know and often it takes patience and commitment to discover a rare disease. If we didn’t spit people out and try hard to see as many people as we could, we might have time to discover the real cause and not send people home with incorrect medication. It’s damaging and it further stigmatises those who really need mental health treatment. On the other hand, sometimes feeling anxious is just feeling anxious, and not something to pathologise. We will all feel depressed or anxious at times, it doesn’t mean we need a category and our current system doesn’t seem to have another option. How about we start with asking the patient – what do you think is going on? Often, we learn the most from our patients, and they will help us know whether they have a mental illness or are just going through a hard time. The difference between providing short-term supportive care and getting someone on a life-time of strong medication is huge and we need to have our eyes wide open.

Candice Louisa Daquin is a Psychotherapist and Editor, having worked in Europe, Canada and the USA. Daquins own work is also published widely, she has written five books of poetry, the last published by Finishing Line Press called Pinch the Lock. Her website is www thefeatheredsleep.com

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PLEASE NOTE: ARTICLES CAN ONLY BE REPRODUCED IN OTHER SITES WITH DUE ACKNOWLEDGEMENT TO BORDERLESS JOURNAL.

Categories
Stories

Do Not Go!

By Moazzam Sheikh

Pleased, beaming, yum yumming, she finished cooking pasta sauce the way he liked ‒ a bit more garlic and a dash of chilli powder ‒ and turned down the flame real low, the sauce simmering indolently. She was about to reach for a packet of flat spinach noodle to add to the boiling water when she fully realized that he wasn’t home yet. Mid-November and already dark beyond the windows, he could catch a cold, a flu, perhaps pneumonia. Touch wood, she whispered. One could trip, break wrist, hip, summoning visits to the hospital, restricted movement, crutches. A train of thought too frightening, she shook her head and cleared her throat. She set down the pasta on the countertop, unopened, reading the label mindlessly.

He went for his walk in the daylight though sometimes he did step out in the late afternoon. However, as far as she could remember he always returned before sundown. His routine she could depend on for the last two years. He must have misjudged, she shuddered, suddenly feeling hot in the kitchen. Although she breathed deep to calm her nerves, she couldn’t concentrate. The moment she tossed noodles into the water followed by a pinch of salt and half a spoon of olive oil, she regretted it. Pasta didn’t like to be left in water half-cooked. Agitation nudging her fear, she felt she’d have to turn off the stove and go out looking for him if he didn’t return in the next five minutes.

Five minutes passed and she frittered away a few more, paralyzed by indecision, when she cocked her ear to the noise of feet shuffling out in the corridor, nearing the apartment door. It turned out to be a sound conjured by hope. She snapped out, turned off the stove, and grabbing her keys and a light sweater, which Ronny had bought for her on her birthday, exited the building. Encountering the actual darkness which the onset of winter had ushered, despite the street pole lights, her heart sank further.

He could be anywhere, she inferred, and not knowing where that anywhere was, she could be walking in the opposite direction, away from him, lengthening his torment. She took a deep breath, again, and walked to the corner where her avenue intersected the busy street. From there she tried to scan the foot traffic in four directions. Her eyes traveling as deep as a block and beyond, and despite the thinness of the crowd due to the nippy winter air, she failed to spot a lost figure resembling him. She walked eastward unaware of the silent prayers her subconscious mind had been offering with little regard for her resolve throughout her adult life to not rely, as she put it many times, on the crutches of religion. She recognised it and let the prayers continue consoling her heart recalling the distinction she sometimes made between religion and spirituality. The fact that she also didn’t consider herself very spiritual, though nothing wrong with being one, amounted to very little right now. She was most concerned, at the moment, with his safety; her personal problems could wait.

A big sigh of relief! She spotted him outside Fresh Donuts, looking lost as she called out to him from across the street.

“I don’t know what happened. I just couldn’t figure out which way to go,” he explained, embarrassed.

She’d too felt like that many times, she came this close to voicing her thought, mesmerized by the doldrums, juggling personal life, work, moral obligations. As they walked home, she holding him by the arm lest he trip, he said he knew she’d be worried. The more he worried the more he lost his sense of reference. When he thought of asking a stranger for help, he shied away because he couldn’t remember the address or the cross street. He had enough sense to accept that he stood lost on Clement Street. That didn’t help much though, he laughed. She told him she was grateful and impressed he didn’t panic. Help would’ve come sooner or later. Nervous giggles escaped from their mouths as they neared the apartment. A combination of relief and premonition. At home, he went straight to the bathroom to relieve himself and heard her say that the pasta was going to be a little below his standard, not what counts for normal, a little soggy, fluffy perhaps, but the yummy sauce, she promised, would make up for it. She didn’t have to tell him about the tiny bit of rum she’d added to the sauce.

“Don’t worry, honey. Your father is hungry and will eat anything.”

She wanted to say thank god, you’re an easy eater. Not like Ammi, but she bit her tongue. When they sat down to eat, she hesitated but eventually wondered aloud if he remembered her phone number, which to her relief he rattled off without a hitch. Ah, the memory had returned. He said he’d eventually stop a passerby. She felt relieved and the food began to amble down to her stomach with more ease. The sips from her beer soothed her throat. She wished he’d share her beer, relax his strict adherence to the doctor’s advice. Perhaps another time. That night when she went to bed, her mind drifted to her brother struggling to survive in New York, in and out of rehab several times for the last couple of years. He’d already done his bit, taking care of their parents till mother died, mercifully quickly, without a whisper in her sleep. A silent heart attack, they said. Soon after her brother’s life unraveled. He couldn’t take care of father, who then faced a choice of moving back to Lahore or San Francisco.

She avoided sharing with Ronny the episode of father getting lost, but when she saw him a few days later she realized he had the right to know what’s been on her mind. Despite all the good qualities Ronny possessed as a human being, and lover, there was a cold side to him. A person is like a coin, Ronny relished using that metaphor, with two sides, at least. Where she saw his insensitivity, or impatience, towards certain things, he saw drawn boundaries, standing up for what was right, his rights, personal values, spaces, desires, likes and dislikes, cultural or personal baggage and so on. After having dated for more than a year, they were going through the process of exploring the possibility of getting hitched to each other. They both agreed they wouldn’t mind having a child or two. Her eggs were drying up. With a sense of urgency, one day Ronny did ask if she’d consider marrying him first in order to get pregnant. Though he was far from being Mr. Perfect, she’d already weighed the pros and cons of living with her boyfriend Ronald Ngyuen. Their plans got disrupted when Mr. Bhutta — that’s how Ronny preferred to address her father instead of by first name ‒ was brought by her to live in San Francisco. Despite old age, her father would’ve liked to live near his son. Even if that meant moving into a facility for elderly living. He also suggested moving back to Lahore. Neither choice was practical when emotional and economic reasons were taken into consideration.

Kausar initially cheered up to the idea of having father around. His liberal, open-minded side had pleasantly surprised her when he indicated that he considered his children adult now and the fact that they weren’t living in Pakistan anymore, his son and daughter had all the right to lead their lives without any pressure from the parents. Her mother turned out to be a bit more conservative than the children had realised, but she too sided with her husband’s wisdom. The couple tried their best to warm up to whoever their children were dating in college, and when a new partner showed up, they accepted him or her. There was a brief period, before the mother passed away, when the parents wondered if the mess their son had found himself in was, in fact, something do with their hands-off attitude once he went to college. But in their defense, they argued, Why, then, had Kausar turned out fine?

He went missing again. That time she couldn’t find him anywhere in the neighborhood. Blocking off a deep sense of foreboding, she called Ronny, busy assisting with the mounting of his photographs for an exhibition.

“I’d call police,” he suggested coldly. “They’ll spot him soon wandering around, lost.”

“I wondered if you were on your way, we could drive around in your car and look for him,” she said calmly, stifling her panic.

She knew he couldn’t come just like that. His suggestion made sense. Yet her fingers froze recalling the incident, was it somewhere in New Jersey? A cop seriously injured an elderly Indian man on a neighborhood stroll. He’d been visiting his son to help babysit his year-old grandson. A woman called the police about a suspicious looking man wandering around her neighborhood. The man from India, short and effeminate looking, in his mid-fifties, wearing glasses with thick lenses, did not speak English, only Hindi and Gujrati, was admiring neat looking cookie cutter suburban houses, their large fronts, mowed lawns, trimmed hedges. The already irritated cop lost his patience and slammed the visitor to the floor, paralyzing him forever. The jury, comprising of majority of white men, acquitted the cop because the man who’d come to help his son and daughter-in-law had ‒ the defense attorney pointed out ‒ committed a misdemeanor by leaving the house without identification papers. It made sense to people defending the cop. Don’t frustrate a cop; it doesn’t matter whether you pose a threat or not. The burden of failure to communicate is on you. She shook her head. She only hoped the San Francisco cops had more humanity and better training. Tonight!

In the end she dialed 911. Yes, an older man matching his name and description had been reported lost and an ambulance had taken him to General Hospital. Ronny had to stop everything and drive her to the hospital’s emergency ward. Thank god, he’s okay. He smiled sheepishly, his guilty smile although it wasn’t his fault. The old man had blanked out and made the mistake of approaching a passerby, who, unable to help and make father remember Kausar’s address, or phone number, had taken upon himself to call the ambulance. As per their procedure, by law, they had to run all kinds of tests now, check his vitals, to make sure he was fit to leave. It’s going to take a couple of hours. A senior nurse told her she’d have to be patient. Ronny had to return to help with the exhibition but would come back soon to take them home.

“What happened, Abba?” she asked, patting his hand, consoling a worried, defeated father.

She dreaded the moment she would have to contemplate the possibility of dementia snatching him from her. The fact that he actually stood right below her flat but couldn’t recognise it left Kauser stunned. What is he going to forget next? she wondered. As melancholy crept in, she tried to fight it off with positive thoughts. She was going to do everything in her power to make sure he didn’t succumb to the cruel malady without a fight. She admitted she could never have imagined it’d come knocking on her door so soon. She made up her mind to read up on the latest research, borrow or buy books on physical and mental exercises, and foods that help keep memory strong. She wouldn’t let him forget his wife and children’s names.

He didn’t forget their names or the names of his friends, past neighbors, even colleagues. As days went by, she felt relieved seeing him settle down a bit while accepting that he couldn’t venture out alone anymore. He’d never been the stubborn type. He could be feisty but not of late. She relied on Ron and one of her neighbors Doug to give company to her father when she had to go out. Thankfully, she could do most of her work from home. Both Ron and Doug enjoyed conversations with him on topics of mutual interest, especially foreign policy and history. Father’s humility impressed Doug, who besides having a crush on Kauser which he’d hinted at a few times, studied History with a minor in International Relations at Kent, Ohio State. On and off, he’d been reshaping the old man’s worldview crystalized by what he called Eurocentric education, although her father considered himself a political person, having taken part in ending General Ayub’s reign. Even when Bhutto was hanged, he openly criticized the military takeover under General Zia, right around when she left Pakistan. It’s a miracle that he didn’t lose his job at the Mayo Hospital.

“It’s the rigor, intensive studying at medical schools which kill critical analysis among most doctors. It decimates nuanced thinking. Otherwise, they’re very intelligent people,” Doug once said to her after he’d finished a long conversation with father on the topic of African countries and their independence from European powers. Ron and Doug, on the other hand, tolerated each other courteously. Doug saw Ron as a typical Vietnamese American unable to criticize America openly lest someone accused him of ungratefulness. Or worst still, telling him to go back to Vietnam! He found Ron’s critique of modern society, by which Ron meant modern western society, inadequate through his photography. Ron was content with what he’d been doing for the last several years, visiting Vietnamese seniors all over the country, photographing them in black and white, their faces, creased and ageless, eyes nostalgic and confused, capturing the front of their homes and apartments, the interior where east and west adjusted around each other. True, he avoided asking overt political questions, he still considered his work political. Kauser agreed with both.

Without appearing to be overt, Kauser played mind games with Father to see if he forgot important names. She asked him about their childhood, his childhood, when he first saw Ammi-jan, whether he remembered his grandparents, his neighborhood in Ludhiana before Partition. To her surprise his memory was crystal clear. She began to breathe a sigh of relief. What a scare he gave her! She’d hate to part with him, send him to a nursing home or back to live with one of her cousins. Better to be at the mercy of your own children, she insisted, however spoiled they might be, than the nurses or distant relatives.

“But what about your life, Kay?” asked Ronnie rhetorically one afternoon as they sat at a sidewalk table of a bar for happy hours near her apartment. She had set Mr. Bhutta up with munchies and a clean print of a classic of early Hindi cinema which she’d found on Youtube. One certain way to tie him down for two hours, she smiled sadly.

“What about it?” she asked, puzzled.

“I thought we were supposed to try living together . . .”

She picked up where he trailed off, “Get married,” she paused, sighed, “and make a go at having a child.”

Was she smirking or smiling? She couldn’t tell because her face had quickly reverted to appearing placid. Then as she took a sip of her drink, her forehead furrowed a bit.

“Kay, I know you have a lot on your mind and it’s affecting your work,” he waited for her to interrupt him, but she just looked away, far to the end of the block milling with neighbors out shopping. “But I am not sure what your plan is.”

“Plans about what, babe?” she asked without irritation.

“Oh, forget it!” he said, pretending to relax. “This is not the time.”

She fixed him with a stare. He dared her. Her face softened, a crease appearing around the side of her mouth. A beautiful woman, he thought. Still, he didn’t smile back.

“Are you quitting on me, sweetie?”

“No!” he replied. “I’m afraid I might lose you.”

She was tempted to ask how? Instead, she opted for silence. She knew the answer. Both Ronny and she had small apartments, and with rents the way they were, they couldn’t afford to quit their rent-control apartments and risk eviction. She hated to see her father as a burden or a barrier to her happiness. When he looked at her again, she nodded gently, conveying that she understood his apprehension. She placed her hand on his, then squeezed it.

“Me too. We have to trust,” she said.

As they walked back to Kausar’s apartment, they held each other close, her head nudging into his chest despite they almost tripped a few times when their legs bumped into each other. Yet they persisted, mimicking an image from a movie most likely, ignoring the awkwardness his short height had produced, bravely laughing it off. They kissed, outside the building, under the faint glow of streetlights, her ajar eyes catching an anti-Trump sign in a neighboring window.

“I’ll come over soon as he falls asleep,” she said. 

She heard him puttering around in the kitchen when she entered. Had the movie ended? She called out, asking if he needed help with something, as she took off her shoes. He emerged, smiling nervously, like a child caught rummaging through kitchen closets looking for cookies and candies.

“How was the film?” she asked.

“I’d seen it before but had forgotten it. One of Dilip’s best I think,” he said. “His acting so subtle, so controlled.”

“So you enjoyed it. That’s good.”

The screen had been turned off. The plates were still there which she collected now. Only when she went to the kitchen did she notice one of his shirts slung across his shoulders. Was he thinking of changing into a clean shirt? A dress shirt? She observed him quietly. He stood in the living room for a long moment, then turned to the wall and took a step. She couldn’t see him, so she left the kitchen and hid herself from him, beside the door. He was looking at the calendar. She’d forgotten to change the month. Did he know it was the wrong month?

“Why do you have that shirt on your shoulder?” she asked casually.

He noticed the shirt, surprised, held it, examined it, still puzzled, then looked at Kauser for an answer, smiling vulnerably. “Did you put it here?”

“Me? Abba, why would I? You must have done it.”

“Why would I do it? You’re crazy,” he mocked her and put the shirt down on a chair.

She called Ronny a little later and made up an excuse about feeling a little ill. Could be a cold, no, not a flu, she hoped, but rest was probably the best option. He said, okay, he too was feeling tired and ready to hit the sack.

A few days later when she returned from Ronny’s place a little after one in the morning, he was gently snoring away. Relieved, she decided to take a quick shower. His snores had stopped. She changed into her pajamas and crawled under her duvet covers. She’d hoped to fall asleep right away, after a nice time with Ronny, but found herself tossing and turning, questioning if it was the absence of his snores that disquieted her. She zoned out briefly before becoming fully awake. She got out and tiptoed to his room only to be shocked to notice the blanket pushed aside. Not in bed. When did he get up? Is he in the kitchen or living room? Both rooms were unlit, though her eyes by now had adjusted to the dark.

“Abba?” but no response came.

Did he collapse? She rushed through the apartment switching on the lights. He was nowhere. And then she noted the unlocked front door. She almost fainted. It was ten after three in the morning. Oh god! she cried. She chided herself instantly as she recognized her first impulse was to call Ronny.

Standing at the corner, she looked as far as her eyes could see, north, south, east, west, deserted streets with shuttered down shops, a sprinkle of cars parked on either side of the streets. She felt paralyzed. Too scared to cover the neighborhood territory on her own at this time of night. An uncanny fear, a sense of embarrassment, made her resist calling police. What if they arrest her for elderly negligence! What could she have done to stop him from sneaking out like this? Tears began to roll out of her eyes. Who could she wake for help? She dialed her brother’s number with unsteady fingers. It rang and rang with no possibility of leaving a message. Unawares, she shouted into the phone, “Come on, for god’s sake, pick up the phone! Abba’s missing! Again!” She cursed a few times before hanging up.

Taking a deep breath, she dialed 911. A professional, sympathetic voice came on. She was about to offer Father’s description after a standard drill of questions when she heard the front door in her building’s portico opening. She was startled to see Doug and her voice faltered.

“Kay, your father is with me,” he said.

“What? . . . Wait. Officer, I think my neighbor has found him . . . Thank you,” and as she hung up, she asked Doug, “How the hell did he . . .” and she burst out crying.

Doug walked up and held her, escorting her back into the building.

“I’m so afraid of him getting hurt,” she explained through sobs.

“He’s back at your place,” he said. “Lights were on in every room, and I knew you’d gone looking for him. You can always wake me up.”

She thanked him before finding her own balance with her feet searching for the stairs. He followed her down the corridor.

She stopped. “What did he say?”

“I heard the knock. Honestly, I was worried,” he giggled. “I opened the door and there he was, standing, looking confused. He almost didn’t recognise me when I said, ‘What’s wrong Anjum?’ Instead, he said he was hungry.”

“Just three doors down he lost his bearing?” she marveled aloud.

She knew from his expression that the fear in her eyes was clearly discernible. She tried to soften the tension on her face. They now stood outside her apartment, momentarily, lost for words.

“You should get some sleep, Doug,” she said.

“I won’t be able to. I’ll be up if you need me,” he replied before turning.

“I won’t be either,” she paused. “You’re welcome to come in if you like.”

“You sure?”

She nodded before pushing the door. She could hear his snores. Instead of calming her down, the sound made her furious.

Kauser didn’t bring up her father’s encroaching dementia, only found it ironic, when Ronny began talking about his exhibition of photographs of the Vietnamese American diaspora. He found the population of elders divided into half and half, those who had somehow managed to live with or nearby their children and those who either lived alone or in nursing homes.

“I plan on visiting Vietnam after the reception. You wanna come with me?”

Insensitive! was her first reaction, but she rebuked herself for focusing on the negative.

“Is it to see your father?” she asked. “I hope he’s not ill.”

“No, he’s very fit. I just want to visit, not particularly him, but he’ll be there of course. I want to surprise him.”

“You know I can’t. I have to sort out . . .”  she said.

Two weeks passed without an incident, except that once or twice he mixed up Kauser with his wife and his sister. It could be dementia, or it could be just old age. She, too, once called Ronny by her ex’s name John, the bread maker, always called him Johnny, never John.

Ronny flew to Vietnam for a month but left the idea of extending his stay open. Kauser understood now more than ever. He’d mentioned it before, though always wavering, afraid of encountering a father who, after defecting to the North, had abandoned him and his mother, who had no choice but to rely, as she put it, on the help provided by her brother employed by the Americans.

When Ronny, a year old, got sick, and was taken to the hospital, his mother and Ronny were eventually taken care of by an American soldier, a nurse until the Fall of Saigon. Thereafter, they continued with the American. The two younger sisters born in Cotati, California, lived together as a family. That was why it was always difficult to watch Vietnam War movies which portrayed all South Vietnamese women as whores for the pleasure of American soldiers, Ronny had explained it to Kauser and others. Dylan, Ronny’s stepdad died young from heart trouble, overweight, diabetes, and failed kidneys. It was more from grief that his mother, Ronny alleged, cursed Dylan for things which didn’t make sense to him or his sisters, having moved away to different colleges. One of the sisters, the elder, said that Dylan’s death was caused by his memories of American War in Vietnam. Kauser had met the mother and sisters several times and liked them very much, enjoyed getting together with them in Cotati, despite her dislike for similar places, over Thanksgiving and Christmas.

“Dylan was more a Buddhist, than Presbytarian,” intoned Ronny’s mother.

The sisters grew up more or less atheists, even before they moved to Cal, two years apart.

Kauser’s brother had promised to visit soon, said he’d been going clean and things were starting to work out on his end. There was something about the whole conversation which failed to convince her of a probable happy ending. After speaking with him she’d weep a bit. What is he thinking? she wondered. Is he going to take father off her hands? Abba was also becoming less and less conversant, even forgetting the fact that he’d just been fed, getting annoyed or angry that Kauser was depriving him of food.

“That’s elder abuse, Kauser!” he admonished her weakly.

She couldn’t stop laughing and hugged him tight, fearing she was losing her grip on him. She saw him one mid-morning sitting by the window, staring at the foot traffic, and heard a voice in her head whisper, “He’s gone!” She couldn’t help but shout, “Don’t leave me, father!”

He turned and, as if feeling caught, defended himself, “I am not going anywhere. What made you think so?” he pleaded rather than demanded.

Then she heard her own voice in the realm of silence, “No, you are. Abba, you’re already gone,” walking away.

Suddenly, her friend Miriam was back from traveling and offered to help out with being around her father when Kauser needed to step out for work. Doug was there too. Thanks to her supervisor, she could accomplish most of her work from home. Her brother had to postpone his visit for personal reasons, as he said with an added stress, not because of medical reasons.

“I understand. But I need you to sort this out before something happens,” she told him over the phone and regretted it.

In reply, she heard a sigh. She knew once off the phone, he’d weep too. Perhaps she could think about moving there, but the rent situation was untenable.

“I can’t find him, Kay,” he laughed a sarcastic laugh. “They say he just disappeared one day about six months ago.” She was speaking to Ronnie.

She failed to detect any pain in his voice.

“Oh my god!” she cried sympathetically. “What are you going to do? How are you feeling?”

“I don’t know. I have looked around at all the possible suspect places. I can’t do much.”

“Are you taking care of yourself?”

“Yes, I am. How about you?”
 “I’m okay. Are you coming back then?” she asked.

There was a silence that seemed to linger a tad too long.

“Hello?”

“I’m still here,” he paused again. “I think I’m going to stick around a little longer.”

“I see.”

“There’s this guy, a very good photographer; he wants to do a joint project. About the war,” he explained.

She felt terrible, deflated after hanging up. It turned out to be a wise decision to go out on a stroll with her father. They grabbed fresh spring rolls and sesame balls and ate them in the park watching kids run around the play structure, kicking sand, shrieking, tripping, crying.

“You were like him,” he pointed to a little boy who seemed to burst with energy. “Maqsood was the opposite.”

“You mean Qasim!” she corrected him.

“Yes, Qasim,” he seemed startled. “Who’s Maqsood?” he added before he broke down, weeping.

She didn’t comfort him, simply watched him; just let him be, she reasoned. Perhaps that’s all that was needed to cure his dementia! He stopped soon, raised his head ‒ a complete absence of tears. As if he forgot he’d just wept a minute ago. The food preoccupied him now. She struck up light conversation now and then, but she really wasn’t in the mood. Her thoughts wandered. She needed to be in control of her thoughts or else she wouldn’t survive. The way things were, she told herself, she wouldn’t. She saw herself succumbing to mild depression. Or it is anxiety? she asked. She must preoccupy herself with chores to stop bleak thoughts from entering her head. She saw herself walking out of the park to 19th Avenue which turns into a freeway to Golden Gate Bridge, her thumb sticking up offering herself to be hitchhiked to never come back. His, “Look at that brat,” chuckling, brought her back from her reverie.

Next time they spoke she couldn’t share Ronny’s excitement over his trips into the countryside collecting material for his project.

“There are so many stories here to be told,” he said excitedly.

He went on and on. A method of deflection.

“I am reaching a breaking point,” she said.

“Babe, tell Qasim to come and help out,” Ronny advised.

“He’s coming,” she lied. “I’m just tired.”

The real reason Ronny went to Vietnam was to distance himself from her personal problem, she was convinced. Her father’s health had started to affect her work now, not to mention her personal life. Abba’s doctor had brought up the subject of looking into the possibility of admitting him to a senior facility such as Laguna Honda. It sent shivers down her spine. There would be no way to know if the staff abused him. She imagined forgetting to visit, spacing out, forgetting him. Or worst, he not recognising her. Although she let it sink in, those hard choices had to be made, she wished she could just take him to Pakistan, where relatives and neighbours still stepped in. There was no one she could now rely on, she mourned. Abba had not stayed in touch with anyone because he got tired of helping out for his children worked in the US. He also encouraged the children to not stay in touch with their cousins. And now she was on her own. Just last week she overslept and missed an important meeting. Last night, she had to decline an invitation to Sheila’s baby shower, and she already knew, unless she could get Doug or Miriam to be with Abba, she wouldn’t be able to go to Ajit’s party. An old news item resurfaced in her mind, about a middle-aged Indian immigrant in Foster City hitting his eighty-year-old, wheel-chaired father on the head with a hammer, not with the intension of killing him but so, he mistakenly believed, he could be admitted to a nursing home; he couldn’t look after the old man alone. Sick! She shook off the thought. How people could stoop so low in difficult circumstances, she cried silently.

Qasim was back in rehab. His estranged wife, Laurie, called to tell Kauser that she and her kids have washed their hands off. Narcissism, she said, was at the root of all his problems and now no one could help him, let alone expecting help from him. When Laurie enquired about Anjum, Kauser told her how he’d tried to sneak out again. “Thank god, he couldn’t unlatch the door from inside, and the noise alerted me. I can’t even go to the bathroom!” Kauser pretended to laugh. Laurie understood as only another woman could, relating to her own situation while taking care of two very demanding children without her husband. Laurie said she wished she lived nearby. That sentiment touched Kauser deeply. She didn’t want to worry her sister-in-law too much by telling her that his appetite had also dipped. Should she end father’s misery by suffocating him with a pillow? She thought of shocking Laurie but ended up feeling awful.

That night Kauser snapped at her father for the first time in her recent memory when he began about his father serving in the Indian British army on the African front. She told him curtly to stop beating the dead horse. He was taken aback and gave her a look of deep hurt. She felt remorse but allowed that feeling to be overtaken by a surging wave of melancholy. It also didn’t help that Doug and Miriam had hit it off while having dinner at Kauser’s apartment with Miriam going gaga over a dish brought by Doug. Doug knew Ronny wasn’t coming back anytime soon, then, why, Kauser wondered, hadn’t he made a move? She believed she’d given enough hints. Unconsciously, she blamed her father for this snub. Doug, too, had quietly moved on.

She opened a bottle of wine, thinking, bizarrely, of previous lovers and sat down by the window after tuning the radio to a jazz station. A trumpet seemed to be searching, frantically, for the bluest note possible. But only succeeding in finding a red, blazing hot one. She was on her second glass. The music changed. Then on her third glass, she contemplated the sun lowering itself behind trees and rooftops and actually dropping dead, unleashing a snowstorm. She felt an obscure rage darting in and out of her body.

She wondered, worried, though absent-mindedly, if she was on her fifth or sixth glass when she saw the world around her beginning to spin. She knew better not to get up. Just sit there and follow the movements of the shadows she could vaguely discern, pale ghosts tiptoeing across the hardwood floor of the rooms, faces contorted while smiling and angry making a go at grabbing her attention to say something frivolous or important, cackling and some shouting, a few mocking her, one even sticking its tongue out at her. Sitting at the bottom of a sea of stupor a shadow emerged from one room and dissolved beyond the door frame. A click of the doorknob eventually beyond the water ripples pricked up her ears, only mildly, but her body sank back into the chair of its own volition, drained of the will to assert itself. She thought she heard, as she took another sip, her own voice utter the words Do not go . . . into the night! But the memory of her own sound dissolved slowly.

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Moazzam Sheikh is the author of The Idol Lover and Other Stories and Cafe Le Whore and Other Stories. He has translated across Urdu, Punjabi and English, notably the fiction of Naiyer Masud, Intizar Husain, Ikramullah and Nadir Ali. He is also noted for being the editor of A Letter From India: Contemporary Pakistani Short Stories (Penguin, India) and Chicago Quarterly Review’s special number on South Asian American Issue (2017). He is a librarian in San Francisco and lives with his wife and two sons.

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