My patient came to me recently, with a tinge of happiness in her voice, as she said, “I did as you said, doctor. I am finally free. I am so happy now.”
I swallowed. “What did you do?” I waited with bated breath.
“I’ve left my husband. I gave him 3 years but he never changed. I am done with that useless man”
“Are you doing this for you? Are you doing this because this is really the right thing to do, FOR YOU? Or did you leave the man because you simply wanted to follow what I said when you asked me what I would do if I were you?”
“I have always known you were right. I just didn’t have the courage to do what I have to do. Your words gave me the right push to make that move.”
She is an educated lady of nearly 60 years of age and thus our whole conversation was in English. She is one of my favourite patients.
I do have favourite patients, you know. I can’t help it. I treat all my patients the same – that is, I give them what they need. But with some patients, consultations with them feel more stimulating than usual because they themselves are psychological minded and they ‘get’ what you are trying to say. These people usually have the capacity for self-reflection, self-examination, introspection and personal insight. When you ask them a question (which is meant to get them to think for the answers themselves, even though you already knew the answer) they give a delightfully honest answer that helps you to help them. I like these kind of patients.
This particular patient, let’s call her Mrs H, is a well-off lady. She has her own pension and has invested in a few lands as an asset. She has her own house in KL prior to coming to Alor Star. She plays the piano as a hobby, and she already has a grown-up son from her previous marriage. Unfortunately, when she first came to me in 2013, she had just recently remarried to a 70 year old Kedahan man, for whom she had left her KL hometown. She was stressed by that marriage. She felt cheated, used and taken advantage of by her new husband and his family. She was in the clinic crying her eyes out because she felt like she had made a huge mistake.
Even though at that time, I wanted to tell her that “yup, you probably did make a huge mistake” but I refrain myself (of course). You see, therapists in general TRY not to impose their own opinion on their patients. It is okay if you cannot help having judgmental thoughts, but you should not APPEAR to be judgmental. You MUST preserve the illusion that you are always on the side of the patient. The patient should always feel safe to confide in you about anything… and they would only feel that way if you give off the vibe of being understanding and non-judgmental. But human beings, as a species, are active thinking beings! Judgment and thinking are what make us so special. I would be LYING if I say I don’t judge what my patients do. Part of the evaluation process HAS to be judgmental. If you don’t judge, you can’t diagnose. If you can’t diagnose, you can’t treat.
If you go back to the psychoanalytic era when Freud and his followers reigned supreme… they could make snap judgment about others without any evidence whatsoever and they called it psychoanalysis. Hahha. Those were the DARK AGES of psychiatry, in my opinion.
So to be clear, I am a judging, thinking being. (Believe me, ALL OF US are. I am just more upfront and honest about it). But I just don’t have to tell my patients about what sort of judgment I come up with, that’s all. Instead, I store that judgment in my head and use it to treat the patient. I use my judgment to help them.
Some patients have zero insight about their marital problems.
“Saya tunggu dia nak berubah. Saya okay ja. At least, mak mertua saya baik. Suami saya pun kadang-kadang baik.”
“Apa contoh kebaikan yang puan dapat dengan dia? Tadi puan kata, dia tak cukup duit, kahwin sampai tiga. Siap perabih duit puan nak tanggung isteri ketiga. Kereta dia pun puan bayar. Kalau puan rasa dia baik, puan report kat saya benda-benda yang tak baik saja saya dengar selama ni. Apa kata puan habaq apa yang dia baik pula hari ni?” Nice, soft tone was used to mask the biting sarcasm. (So, dear readers, please reverse and read again my dialogue in a softer inquiring tone. Haha)
Some patients have good insight about their marital problems.
“Doktor, saya memang tak tahan dah dengan suami saya. Saya memang nak bercerai. Ni lawyer suruh mai psikiatri, sebagai bukti yang saya trauma dengan perangai suami saya. Senang ada surat doktor kalau pi mahkamah nanti. So saya mai lah.” This patient is direct, honest, and knows exactly what she wants. I like these sort of patients too. But…
“Baguslah puan dah ambil keputusan yang tegas dalam hal ni. Cuma saya tak bolehlah nak buat-buat puan ada kemurungan kalau puan tak murung.” I am also direct and honest. I like direct and honest patients because I reciprocate and mirror their own style, which is really my default style, anyway.
Some patients know what to do already, but they couldn’t commit to any action because they are afraid of the unknown.
“Saya tak mau orang mengata. Saya tak mau jadi janda kali kedua.”
Mrs. H belong in this category – fear of the unknown made her stay on until one day she couldn’t take it anymore. And neither could I.
So, it took her 4 years (2013-2016) to ask me “What would you do, if you were in my place?”
I was very upfront about it. “It is not my place to tell you what to do. After all, it is YOUR marriage and you are the one who have to live your life. Not me. But since you asked me about what I would do if I were you….well, I would leave him. But then, you have to understand that we make decisions based on specific context and our own natural inclination, and our own personality. My personality and my personal inclination is such that I can never love someone I cannot trust; and I can never trust someone I cannot respect; and I can never respect someone who cannot fulfil his responsibilities. I am very strict about these things. If I have a husband such as yours, I would have left him a long time ago. Of course, some women have such a huge capacity for love that she can continue to love just anyone regardless of whether or not she can trust and respect that person… so if she’s okay with that, who am I to insist otherwise?” I paused, allowing her to digest what I really meant. “At the end of the day, we live with the decisions we have made. I don’t mind to continue seeing you, because trust me, medication cannot cure you. Your husband is the perpetuating factor to your depression.”
She is an intelligent woman, dear readers. She knew that I also had had enough. She knew that my “some women have such a huge capacity for love” is an euphemism for “misplaced loyalty”.
I have mentioned before that it is not enough that we do what we like. We have to learn to like the right thing. For example, I have to learn to like literature. Haha. And I end up liking it.
Love and loyalty is also like that. Learn to love and be loyal to the right person. The person you can respect and trust.
So when one day she finally said, “I am finally free, doctor,” it truly made my day. It took her four years of suffering before she would commit to a decision. And that was only because she had asked me personally about what I would do, and I was impatient enough to actually give it to her. Who knows what would happen had she asked the question sooner.
Some psychiatrists would probably say that I am unduly influencing my patients.
Well, to be honest, we all influence patients in variable ways and extent.
I don’t like to stick to only one blanket way of dealing with patients. I would use different approaches for different kinds of patients.
As a doctor (and especially in psychiatry), we learn that there are a few models of doctor-patient interaction, namely:
The Paternalistic model: It is assumed that the doctor knows best and the patient is expected to follow the doctor’s decision. Usually this approach is desirable in emergency situations. However, this approach may result in clash of values.
The Informative model: The doctor is seen as a dispenser of information. The choice is left wholly up to the patient. May be useful in one-off consultations, but may not work well if strictly followed on long-term professional relationship.
The Interpretive Model: Here, the doctor will be treating the patient for a long time and might know his/her patient well and understand the circumstances of their micro- environment. Here, shared decision-making is established.
Deliberative Model: The doctor here may act as a friend or counselor to the patient, where information dispensing is coupled with advice on a course of action. This is commonly used to enable lifestyle modification and to address maladaptive coping.
Some doctors like to use only one approach regardless of what type of patients they are dealing with. Maybe they like that particular style and think it is the best interaction style with every patient. For example, some prefer the informative model because they think it is the most neutral and would suit most people. Maybe they don’t know the patient enough and therefore doesn’t want to feel responsible should something bad happens as a result of the patient following their advice.
I don’t know. To me, in each specific case, whatever model of doctor-patient interaction that we use, it actually reflects on our own conviction or our own insecurities about that particular case.
We learn from experience and we would know what approach to use for each of our own patient. Paternalistic style won’t work well with manic patients, for example. It would only make them more irritable towards you and you would then lose the patient.
I would use the informative model for someone who is educated, and like to make her own decision, especially if I don’t know this patient all that well (other than that she is educated and has good judgment skills). I would NEVER use this informative model for someone with low education level. I wouldn’t want to take a chance of her making the wrong choice as a result of her disadvantaged background. This model requires that the person on the receiving end can make sound judgment based on the information that doctors have given. This is not the case in patients with low education attainment.
With Mrs. H, I have known her for 4 years. She is educated, and yes, I could stick with the informative model if I chose. But I know her case inside and out. I know her micro-environment. So, I think I am still within my professional boundaries if I use the Interpretive Model and Deliberative Model with her, especially when she had specifically asked me about what I would do if I were in her place. (To be honest, interpretive model is my preference, most of the time. Followed very closely by deliberative model. If I just want to be informative, I could just ask the patient to read a lot and google, right? Pfft. A doctor is more than that.)
She asked me a question. I gave her the answer.
Whether or not she would follow my advice, was totally out of my hands.
When I was in my early 20s, my mother imparted to me a piece of her wisdom when she said, “Older women and older men are not the same. Older men benefit more when they remarry after having lost their wives. But older women would lose a great deal if they remarry after having lost a husband. If anything happens to your father, I will never remarry.” She declared, confidently.
She came up with that epiphany after listening to the woes of her friend who was in the situation of suffering after remarrying at a very mature age of 50. It was not unlike the situation that Mrs. H herself was in when she remarried at the age of 60 in 2013.
At that time, I thought my mother was being loyal when she said she would never remarry. But actually, she was just being smart. She was right. There is very little benefit in remarrying when you are already old.
All the benefits are on the elderly man’s side – they get a free maid and a free nurse, all combined in one person. In fact, sometimes they even get a free financial provider if the women they marry are richer than them.
Mrs H could have enjoyed her own money and her own freedom had she remained single at that age of 60. She has the company of her friends from surau and the care of her own son. She could have been far more well off than she currently is if she did not remarry a man who was older than she was (and therefore, couldn’t even work or provide for her financially because he was too elderly). Had she remained single, she wouldn’t be expected to do any housework or housechores if she didn’t want to. She didn’t have to cook or clean or look after another person when she herself was at the age of 60. Her son wouldn’t come to resent her because she had to obey her new husband and hurt the feelings of her only son. She wouldn’t have to play the role of a breadwinner to an elderly husband when she herself was not that young.
But…unfortunately… she had remarried.
Her pension, which should have been enough for herself, was no longer adequate. So she had to work, selling sandwiches, because her husband was no longer fit to work. Her husband’s children expected HER to care for THEIR father just because their father had married her.
This is the problem with our society!
The elderly man who had lost his wife wants to marry again. And their children also prefer their elderly father to marry again…so that they won’t have to be the ones who have to care for their own father and their father doesn’t have to live with them, disturbing the dynamic in their own household.
BUT, they don’t provide their father the money that is required for their father to be a husband again. So the new wife suffers! The household money would not be enough. In the case of Mrs H, the husband’s children often scolded her when she asked them for money. Such nerve! Such audacity!
Don’t get me wrong. I am not giving a blanket statement that elderly people shouldn’t get married. I am questioning the fact that some responsibilities might not be met with such marriage. (so, if you can fulfil your responsibilities, go ahead and marry even if you are already at 100 year old of age)
My own grandfather had remarried at the age of 72 to a 40 year old woman. That means, my new step-grandmother is younger than my own father! My grandfather remarried NOT because my father refused to care for him, but it was because my grandfather preferred to marry. I remembered feeling so perplexed that my grandfather at the age of 72 STILL wanted to marry another woman. It was all done within 6 months after my grandmother died. It just boggled my mind at that time. I didn’t say anything to my grandpa about what I felt. To be honest, I was really disappointed because I had expected that my grandfather would live with us.
I did NOT expect that he would remarry! My grandpa should have looked forward to playing with his great-grandchildren instead of playing house with another woman. I felt quite personal about the whole thing.(well, but to be fair, my sister was not yet pregnant at that time and there was no great grandchildren around to play with, yet.)
But since my grandfather just wanted to marry no matter what, my father had asked around for anyone who wanted to marry his 72 year old father. We NEVER thought it would ever come to anything. I mean, WHO would marry such an elderly man, right? But miracles happened. Can you believe it? A 40 year old woman agreed to the marriage. I was flummoxed by the development. My grandfather remarried when I came back from Australia at the end of my 2nd year in med school. (At least, he waited for me to come home before he tied the knot). I was by his side when he pronounced the akad. I had accepted (reluctantly) that it was his decision to marry and maintain his own household.
My father increased the monthly allowance that he gave to my grandfather so that my grandfather could provide for his wife. A small house was bought where they could live together, so that my grandfather didn’t have to pay the rent. My step-grandmother is a full time housewife and DOES NOT have to work to support my elderly grandfather. My parents were in charge of all my grandfather’s appointments with doctors and did not simply leave the care of my grandfather to his new wife.
Mrs. H was not as lucky as my step grandmother. Mrs. H was the financial provider, the carer and the maid, all in one. (It’s like being a mother to a big toddler, ain’t it?)And on top of that, her 20 year old son who is still a student resented her marriage and did not get along with her new husband. If I were the son, I would resent the whole situation too. Here’s an elderly man taking advantage of his mother! If his mother disobeyed this elderly man, the religious line “I am your husband. You must obey me,” would be flung around. Isn’t it ironic when a dayus husband insisted to be obeyed? It’s a trick designed to make the wife feels guilty, in order to deflect his own inadequacies. His mother was better off not marrying that man. When she married him, her life deteriorated right before her son’s eyes. It violates all sorts of social-exchange theory I have learned. In this marriage, the risk-benefits assessment skews in GREAT favour for the elderly man and a HUGE disadvantage for Mrs.H.
I couldn’t bear it if I were the son. I would probably perform some serious rebellion and would say “You have to choose between your son or your husband.”. (Hahah. I am a dramatic diva like that.)
But here lies the problem. Talak is NOT in the woman’s hands.
That’s why when an elderly man remarries, his children don’t feel that they have lost their father as much. In fact, they would feel like they have gained a free carer for their father. A man holds all the executive decision making. So, his children won’t feel that they have lost their father so completely. If they want, they could influence their father to make any decision that would favour them against their step-mother and the father would say, “Okay, I have made my decision. My children were right. I am your husband, so you must follow me.”
But when an elderly woman remarries, the children would feel the lost acutely. Now THEIR MOTHER who they have known their whole lives is the new wife of a complete stranger. The happiness of their mother lies in the hand of someone they are not sure they can trust. And this stranger holds the power on their mother. Even if the children could influence their mother for a specific decision, what can the mother do if her new husband disagrees? Even if eventually their mother wants to be free from the marriage, talak was not even in her hands.
So a mother remarrying would be taken as a loss for her children, because like Mrs H, now her whole life and energy revolves around the new husband… as a breadwinner, a maid, a nurse! What’s left of herself for her children?
The bottom line is: The elderly man’s life becomes easy when he remarries. The elderly woman’s life becomes harder when she remarries.
And therefore my mother was right to decide never to remarry should anything happens to my father. (I wouldn’t allow it, anyway. I would be very forthright about it too.)
Of course, there is context to everything. Just like there is an exception to every rule. For example, the elderly woman could have married a richer guy, right? Haha. But then putting my self in the shoes of the richer guy, I might as well marry a young woman instead of an elderly one (haha, just trying to think like a man). So MOST OF THE TIME, an elderly woman ends up with a poor elderly man whose children might or might not provide financial support for their father to enable him to provide for the new wife.
So in general, my mother hit the nail on the head when she declared her epiphany.
Imagine if your elderly mother remarries? Can you bear the thought? I am not talking about young mothers, but elderly mothers! What benefit do they get from such marriage? Would you advise your elderly mother to remarry? Am I (and my mother and sisters) the only one who think like this, I wonder?
So that day, after Mrs. H finished telling me that she was now a free woman, and she was going back to KL, I smiled at her and said, “I wish you all the happiness in the world. Don’t hesitate to come back should you need anything else. If you need to talk to me about anything, just call the clinic. You know, I will always take a call from you.”
Since then, she had called me twice.
We kept in touch.
Disclaimer: Some details are hidden, altered or disguised to preserve Mrs. H’s privacy. But the gist of the case remains the same. This is not only the story of Mrs. H, but also the tales of many other women, even when they marry as a young woman. When they marry as an elderly woman, it gets even worse. Take care of your elderly mother. Never make her feel like she has to marry again for companionship. In most cases, it’s just not worth it.