A Clinical Case Study
Betty Stockley


INTRODUCTION

Mrs. Alexander first contacted our office in July of 1991. In this initial contact, and during subsequent visits, Mrs. Alexander indicated that there had been a series of sudden and/or agonizing, prolonged deaths in her family of origin. She further indicated that her family had been, and continued to be, beset with serious illnesses, illnesses which she believed would result inevitably in a further early facing of death. The illnesses and resultant deaths which Mrs. Alexander discussed covered the interval 1980-1991. A further death has occurred during the period of our consultations with her. It became readily apparent to this therapist that Mrs. Alexander was suffering from extreme stress as a result of the serious illnesses and unusual number and types of deaths in her family of origin.


DETAILS OF ILLNESSES AND DEATHS IN MRS. ALEXANDER'S FAMILY OF ORIGIN

Although we believed that it would be emotionally difficult for her to do so, we asked Mrs. Alexander to provide us with a detailed outline of the deaths of family members in her family of origin, the dates of these deaths, the circumstances surrounding the deaths, an outline of her family structure, and her position in that family, including the role she was asked to assume during each of these family crises. We further asked her to provide us with details of the health status of surviving family members and some indication of the status of her own physical health and that of members of her own immediate nuclear family.


Role Played by Mrs. Alexander

This sister had been somewhat of a surrogate mother figure to Mrs. Alexander. There was a very close bond between the two sisters. The other family members turned to Mrs. Alexander for advice and support.


Role Played by Mrs. Alexander

Mrs. Alexander had to view the body of her brother in Toronto before shipment to his home town for burial. She was asked to make the decision for the family as to the relative trauma involved for other family members in the choice of an open or closed casket. This decision had to be made due to the extreme deterioration of the lower jaw and the attempted cosmetic rebuilding. This office was contacted at the time of this brother's illness and we provided a liaison between the various hospitals, the funeral parlour, and Mrs. Alexander, who was then in England. Mrs. Alexander made two (2) trips to Toronto - one at the doctor's request as the demise of her brother became imminent, and the other to view the body, with this therapist present, before accompanying her brother's remains to their home town for burial. A clergy of the Church stationed in the Metropolitan area was contacted by this office at that time. This individual was extremely helpful in aiding our office with funeral parlour arrangements, and with later caring contact with the elderly parents.


Role Played by Mrs. Alexander

From January to March 1990 she confided the heartrending details of her sorrow to Mrs. Alexander by long distance telephone contact. She had no one else to turn to, no one else who she felt would understand the depth of her grief and the enormity of her need. The daughter died and Mrs. Alexander's sister, left totally alone with her heartbreak again talked out her heartbreak to her sister in British Columbia. Mrs. Alexander was the sole source of strength for her sorrowing sister.


Role Played by Mrs. Alexander

Mrs. Alexander received news of her father's death, and flew home alone for the funeral, staying with her widowed sister, the still grieving mother of the dead son. Together, they visited the funeral parlour on the day of Mrs. Alexander's arrival. The funeral was postponed an additional day due to weather conditions. Mrs. Alexander, very tired from her trip, talked with her sister. She listened as the sister spoke of her loss/losses. Evening came and the sisters retired, prepared to attend the father's funeral the next day. The following morning, Mrs. Alexander walked into her sister's bedroom to call her and found her dead. Doctors and the police were called. Some attempt to assist Mrs. Alexander was made then and again a few days later. These local, medical and police officials, aware of the post-trauma involved in such a situation, provided Mrs. Alexander with an opportunity to discuss her shock, her sense of horror, and they attempted to help her relieve the horror of the accumulative traumas by talking about them. The father's funeral was postponed yet another day. Mrs. Alexander again was looked to for advice and solace and had to call upon her now depleted reserves of strength. This sister died on February 14, 1991 -on her childís birthday, and a little less than a year before the anniversary of her death. There had been a much earlier death in Mrs. Alexander's family--the death of a four-year-old nephew, tragically killed in a car accident. The funeral of this child occurred as well on February 14th. Mrs. Alexander, who was then ten (10) years of age, remembers this event with great clarity. She remembers seeing the child's blood on the road, the sound of her father's sobs, etc.

 

*Therapistís Note: Specific dates, particularly dates that are prominent on the calendar--dates such as February 14, Valentine's Day, create an especially poignant problem for survivors of traumatic events. Because their whole immediate world is celebrating Valentine's Day, the day cannot be ignored by the survivor. He/she, suffering from an Anniversary Reaction1 really does not want to remember. However, life goes on and the survivor wishes to celebrate the event with his/her spouse and children. So the day has forever a bittersweet quality, one always tinged with trauma and one associated with devastating loss. February 14th can no longer be thought of by Mrs. Alexander in a benign light. Nightmares, flashbacks, memories of the event/events are more likely to recur on such a date.


Early 1992 - Disposal of Sister's House and Personal Effects

Mrs. Alexander, as the executrix of her sister's estate, was forced by circumstances to revisit her hometown--a town which by now had come to symbolize illness and death--to examine and distribute her sister's effects, to consult with her sister's attorney, to dispose of the estate, and to again be a source of strength and support for her remaining siblings. Again, she relived the horror of the event as she returned to the house where death had come so suddenly and so horrifically. All three members of a family that had been particularly kind to Mrs. Alexander, to her husband, to her children, were gone.


Role Played by Mrs. Alexander

Mrs. Alexander again returned to her hometown for the funeral. Again, her advice was solicited. Again she was a source of solace and strength.


FAMILY OF ORIGIN - SURVIVING MEMBERS - HEALTH PROBLEMS

Mrs. Alexander has four remaining siblings. Both sisters suffer from high blood pressure from time to time. Both brothers have heart problems with blockages in the arterial walls. The activities of the brothers are severely limited.


Role Played by Mrs. Alexander

Mrs. Alexander contacts or is contacted regularly by her siblings with respect to their health status. Again, she is a source of strength and comfort and a symbol of integrity for the remaining members of her family of origin.


MRS. ALEXANDER - PSYCHOLOGICAL PROFILE

Mrs. Alexander presented as an intelligent, well-integrated, intensely private individual. At the time of her contact with this office, she stated that she then had recently been transferred to the Metropolitan Toronto area, in part due to medical concerns over the state of her physical health.

Death is a part of life. However, as Mrs. Alexander presented this office with the detailed outline of the number and types of deaths in her family--deaths which covered an eleven year period--it was clear that death in her family had presented itself with unusual facets of horror, horror that included the number of deaths, types of deaths, overlapping hospitalizations, overlapping deaths, suddenness of deaths, etc. It was clear, too, that because of her position in her family, due to the intense value she places on the innate right of all individuals to privacy, each family member, although older than she was, had depended on her and trusted her with their joys, sorrows, and heartrending confidences. This outpouring of confidences had been ongoing throughout the years but had accelerated after 1980 and had steadily increased throughout the ensuring decade, reaching new heights in January of 1990 and continuing throughout 1992 and into 1993.


DIAGNOSIS

Mrs. Alexander suffers from Posttraumatic Stress Disorder.


MRS. ALEXANDER'S PRESENT NUCLEAR FAMILY

Mrs. Alexander's daughter has been suffering severe pain over the last two years, pain which makes the child frequently come home after school and retire to her bed: pain which makes tears roll down her face as she visits her physician. An appointment has been made with a specialist for further investigation of the child's presenting problems. Needless to say, given the family history, both parents and their daughter are extremely worried about the possible results of this further investigation.


MRS. ALEXANDERíS PHYSICAL HEALTH

After her return to British Columbia in 1991, Mrs. Alexander's cholesterol count was found to be extremely high. Heart problems were suspected, given her physical condition and her family history. An angiogram was performed. At that time there were no blockages in her arterial walls. However, given her family and personal medical history, she was informed she suffered a much higher level of risk for eventual heart disease than the general population. She was instructed to watch her dietary intake; to embark on an exercise program; to subject herself to little or no stress. She was informed that she must take care of herself.

Authorities in the church in British Columbia were aware of the overlapping deaths of Mrs. Alexander's father and sister. They were further informed of Mrs. Alexander's health status. Mrs. Alexander is very grateful to the church for their prompt attention to her situation and for their decision to transfer her and her family to the metropolitan area, where church personnel felt she could obtain more comprehensive medical attention.

Mrs. Alexander gradually began to build up her support systems in the city with the help of this office.


THE ROLE OF MR. ALEXANDER--ALEXANDER NUCLEAR FAMILY COHESIVENESS

We have met briefly with Mr. Alexander and with their two children, Paul and Patricia.

The Alexanders present as a very close, loving family. Mr. Alexander presents as an individual with a high level of personal integrity; he presents as a highly intelligent, deeply sensitive and caring, yet quiet individual. He is clearly an individual possessing a deep sense of commitment to his chosen profession. Because of Mr. and Mrs. Alexander's positions as clergy, they were often posted far afield when the above enumerated tragedies occurred. Due to financial restraints and due to Mr. Alexander's responsibilities, Mrs. Alexander made the majority of these trips to the scenes of death, sudden, horrifying, and otherwise--alone. No one was there at the scene to support her as she gave her support to others.


PRESENCE OF DENIAL MECHANISMS

It is the considered opinion of this office that, as the deaths and diagnosed heart conditions mounted, as Mrs. Alexander continued her journeys to the scenes of family deaths; as Mrs. Alexander's cholesterol level soared; as she went for intrusive diagnostic heart investigations; as she suffered periodic chest pains; as father and mother were informed that their children should visit a physician for cholesterol testing, Mr. Alexander, on some level, went into a form of denial. With the enormity of all of these illnesses possibly affecting his immediate family, a family which he loves more than he loves life itself, Mr. Alexander's mind unconsciously focused on the improvements his wife was making. His mind, overburdened by secondary trauma, no longer wanted to consider the severity of her earlier health problems and her occasional relapses. Neither did Mrs. Alexander want to burden further her already overburdened husband. She herself now became afraid of further medical testing. She, too, went into a form of denial.

The children, too, we believe, loving their mother dearly and loving their lives together, no longer wanted to believe that Mom was under stress, that Mom had any health problems or potential health problems. Neither did they want to pursue any medical testing for themselves until this issue was forced by the daughter's now near-constant pain.

Denial is not an unusual defence mechanism. Denial acts as a protection mechanism in cases where the traumas bombarding a family have been as frequent, as sudden, as prolonged, as horrific and as complex as the traumas affecting this family. Denial on the part of all family members set in. No family member wished to conceptualize that any further personal disaster could, or would, occur. Denial is one of the components that has kept this family functioning as effectively, as lovingly, and as supportively as they have.


MRS. ALEXANDER'S TREATMENT PLAN

This therapist has talked weekly with Mrs. Alexander. When she initially presented at this office, she was suffering from sleep deprivation, nightmares, flashbacks and fears of the impending death of loved ones. Her movements were slow and lethargic. Her voice was benumbed, shocked, deadened. She tired very easily. She had frequent chest pains and suffered from a painful and sometimes debilitating sinus condition.

As is usual in survivors of trauma, she had become hyper-vigilant. She awakened and checked her husband and children frequently at night to see if they were still living. She would often awaken her husband to see if he was still living. She was having flashbacks to the scene of her sister's death and had intense memories of the death and intense memories, too, of her sister's confidences to her and her desperate need of her.

Gradually, Mrs. Alexander began to improve. A more intense program was instituted. Mrs. Alexander was encouraged to enroll at University. A marked change in her trauma-induced numbness occurred at this time. Her voice contained more vitality as she wrestled intellectually with new ideas; as she explored subjects that were new and challenging--subjects that held no content specifically related to her traumas.

Since mid-1992, she has been involved in a rigorous exercise program (three evenings a week). She has developed contacts in the city that have been, and continue to be, helpful to her in this area. This program has helped her immensely in the enhancement of her physical well-being.

Gradually she has, with help, developed a strong support system outside her family and work circles.


NEW STRESSOR--RETURN OF TRAUMA STATE

Mrs. Alexander and her husband received word from their church that they were to move to a new pastorate outside the metropolitan area. The move was to occur within four to six weeks.

The community to which they were told to proceed is a small, isolated community located by the ocean. Mrs. Alexander's "home of origin" and "home of trauma" was a town with very similar characteristics. The location, the isolation: these ever present "triggers" of place made Mrs. Alexander feel very anxious.


PRESENT HEALTH STATUS

Mrs. Alexander's health deteriorated over the next two weeks. Her voice showed signs of numbness. On some levels, she felt immobilized; her walk again slowed to a near crawl. She suffered from sleep deprivation and intensified fear for her fami1y's physica1 we11-being and physica1 survival.. Again, she began experiencing chest pains. Since stress is a prime component in heart disease, given this lady's family history, premature strain on her physical and emotional systems could be deadly.

Although Mrs. Alexander had made marked progress on her journey out of trauma, it was apparent to this office that news of a possible move outside the sphere of her support systems catapulted her back into the trauma state. Her emotional health was too fragile to withstand another change of residential location, of vocational position at this time. Thus the previous symptoms returned with the stressor.

 

RECOMMENDATIONS

This office contacted the national head of the church. It was the considered opinion of this office that Mrs. Alexander urgently needed to remain in the metropolitan area so that all of her support systems could remain intact. We did not believe that it would serve anyone's purpose for this lady's health to further deteriorate.

It was the hope and belief of this office that the church, with its humane approach to the needs of its personnel, would make any necessary arrangements to allow this woman and her family to maintain the necessary support systems which would make it possible for Mrs. Alexander and her family to continue their journey of healing through the pain which the past decade of prolonged trauma had created.


CONCLUSION

The church cooperated. The couple remained in the metropolitan area for a further year. Therapy, education and support systems continued. One year later, the church offered them a promotion, a position of higher authority. The couple were ready to move to a new location. Mrs. Alexander's PTSD Symptoms were under control. The other family members had also reached resolution and healing.  

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