Samuel’s mother had not been our patient. I listened carefully as he recounted the events of the preceding few months – how what initially appeared to be simple constipation turned out to be due to a bowel tumour. How at the age of 89, and with multiple other health problems, she had been too frail to withstand any treatment. She had succumbed rapidly, leaving Samuel bereft.
He was blaming himself: why hadn’t he pushed her GPs to investigate things more quickly? If he had, she would still be alive today. And he was blaming her doctors: surely they’d failed her, treating her with laxatives while the cancer steadily grew?
I expressed sympathy but was careful not to collude – there was nothing that could have been done; he was simply recounting the story of someone reaching the natural end of their life. But the process of grieving has several well-defined stages, and guilt and anger are two of them. That was where Samuel seemed to be just then.
He kept returning. No matter how I tried to vary the perspective – dwelling on the excellent care he had given her over many years, and how long and happy her life had been – he remained stuck on the idea that his mum would still be alive had he and her doctors acted differently. Once seated in my consulting room he showed no inclination to move, ruminating repetitively until I was forced to bring each consultation to a close. And it sounded like other people were feeling the strain, too: he was driving his sister to distraction, he told me; and his friends. He couldn’t help himself. He couldn’t talk about anything else. He was repelling everyone around him.
I referred him to a bereavement counsellor, hoping this might help him to process events. Within a few weeks she was on the phone to me, overwhelmed by his obsessive thoughts. She wondered whether anti-depressant medication would help. Depression is another stage of normal grieving and generally shouldn’t be “treated” – but it was becoming ever clearer that Samuel’s grief had become pathological.
I mentioned him at our practice’s informal coffee-time chat, where we bring cases for discussion. I was part-way through describing the situation when Emma, another GP, suddenly interrupted.
“Ah!” she said. “It’s Cat Man! I’m sure of it!”
She was right, too. Buried away in Samuel’s notes were entries from years before, when he’d been under Emma’s care following the death of his cat. The parallels were uncanny: he’d developed obsessional guilt and anger, blaming himself and the vets for failing to preserve the life of his moggy, who had – to any objective analysis – reached the inevitable end of the road. Emma had struggled with the same abnormal grief: Samuel had consulted repeatedly, impervious to any attempt to help him move on, entirely consumed by his cat’s demise. In the end, Emma had persuaded him to see a psychiatrist, and treatment with clomipramine – an old-fashioned anti-depressant with a particular efficacy in obsessional states – had brought recovery.
Armed with this insight, I suggested a similar approach when he next returned. He was resistant at first: no pill was going to bring him Mum back. That was unarguable, but at the end of a very long consultation I’d managed to persuade him that bereavement had tipped him once again into an episode of mental ill-health that we could treat. It wasn’t entirely plain sailing – he abandoned treatment a couple of times out of guilt for taking tablets to numb, as he saw it, the pain of his mother’s loss. But in the end he stayed on the clomipramine for long enough for it to take effect, and mental balance was restored.
It had been clear-cut for Emma all those years ago: much as we love our pets, Samuel’s reaction following his cat’s death was obviously off the scale. Naturally, grief at the loss of our kith and kin is often profound, making the line between the normal and the pathological that much more difficult to discern.