I will sit with you, Lettie

LETTIE, sick with Aids, is referred to me by the clinic nurse. My clinical notes start with the poem Report from the Hospital by Wisława Szymborska:

We used matches to draw lots: who would visit him.
And I lost. I got up from our table.
Visiting hours were just about to start.

When I said hello he didn’t say a word.
I tried to take his hand — he pulled it back
Like a hungry dog that won’t give up its bone.

He seemed embarrassed about dying.
What do you say to someone like that?
Our eyes never met, like in a faked photograph.

He didn’t care if I stayed or left.
He didn’t ask about anyone from our table.
Not you, Barry. Or you, Larry. Or you, Harry.

My head started aching. Who’s dying on whom?
I went on about modern medicine and three violets in a jar.
I talked about the sun and faded out.

It’s a good thing they have stairs to run down.
It’s a good thing they have gates to let you out.
It’s a good thing you’re all waiting at our table.

The hospital smell makes me sick.

Lettie is 42 years old. She carries her head low, mouth slightly open, white tongue, body visibly shivering, big jacket, slippers, small, bare, brown ankles, sweatpants that are too short and too red and too bright for everything else. I ask her why she is here. She says that she is cold and tired. She cannot eat, has not been able to keep food down for almost a month. I say to her that she looks sick. Is she sick?

“I came with a lift. I stay in Factory Street."

Is she in bed all the time?

“I get up a little. If the sun shines, I get up. Then I sit in the front room. The lying down works on my sides."

She does not look at me. Her head stays low. I open her file. The last inscription reads:

Make appointment with Lou-Marié.

1. Prepare client for death.
2. Talk to her about gratitude. She has a supportive family.
3. Repentance about promiscuous life.

Before that the list of her most recent physical symptoms:

Complaint of bad cough. Vomiting. Productive cough. Yellow bile. No appetite. Temperature: 39.4°C. Weight: 50kg. Respiration: bilateral crepitus.  Candidiasis in mouth. Referred to hospital with pneumonia. Admitted emergency unit.

I ask to be excused and go next door to find the sister. I tell her the client referred to me seems very ill, too ill to do a session with me.

“Oh yes, Lettie," she says. “Her count is 92, too low for treatment. It went down overnight. Such a pity. She comes from such a good family. There is always a vrot kolletjie [rotten spot]. I will come and look at her; we probably will have to hospitalise her again."

Behind the nurse’s desk, beneath a poster advertising female condoms, a handmade poster with a picture of a nurse’s cap and a stethoscope: “Save one life, you’re a hero, save 100 lives, you’re a nurse."

I go back to Lettie. “Vrot kolletjie". I put one of the clinic blankets around her shoulders. I wait for the nurse. In the meantime, I do what I usually do — I ask questions. History. Her father was a builder and her mother a housewife. She is the youngest of nine children, seven brothers and one sister. It is the sister she is staying with in Factory Street. Her own children are 25, 12 and 8. The younger two live with their father in Worcester. The oldest son is a cabinet maker and “my girl works at Kekkel en Kraai. They take care of me, the children."

She struggles to talk, I struggle to listen. I watch the movements of her white tongue. She says she got divorced four years ago. Her ex-husband initiated the divorce. “And Lettie, do you have someone new?"

“I now have a boy, Koos Swart. He is also positive." Her sentences are short. She is not interested in the conversation.

Three violets in a jar.

She is still trembling. “I am just tired and I can’t get warm."

So much for the history.

“To get a history is to get the longitudinal information," I teach my university psychology students. “The mental status exam is the cross-sectional picture. Both kinds of information inform the diagnosis and the formulation, and ultimately the treatment plan." I think about what I will write down for Lettie’s mental status exam:

Affect: Blunted (disturbance in affect manifested by severe reduction in the intensity of externalised feeling tone).
Motor behaviour: Anergia (abnormal lack of energy).
Disturbances in speech: Poverty of speech (restriction in the amount of speech used; replies may be monosyllabic). Non-spontaneous speech (verbal responses given only when asked or spoken to directly, no self-initiation of speech).
Levels of memory: Immediate, recent and remote intact. Cruelly so, it seems.
Insight (ability to understand the true cause and meaning of a situation, such as a set of symptoms): Impaired.

Who is dying on whom?

There will be no diagnosis. No formulation. And certainly, no treatment plan. I tell her that she seems very sick and that the sister will examine her, but she will most probably be hospitalised.

Her face changes for the first time during the session: “The last time I went to the hospital, I sat there, waiting, for six hours. Later, I was lying in the corridor, crying. It was so cold. I don’t want to go."

It’s a good thing they have gates to let you out.

I do not know what happened to Lettie. I never saw her again.

In writing about my failure to help, I realised that when I left Lettie I was filled with shame. I was ashamed to be a psychotherapist, ashamed that I could do nothing, ashamed that I was looking forward to leaving the clinic for my warm house, two blocks away from the hospital where Lettie would probably lie shivering in the corridors. Lettie, sitting with me, might have felt, in Szymborska’s words, “embarrassed about dying" in this way. Ashamed. I don’t know. She was perhaps in too much physical agony to feel anything. The nursing file reads like a litany of shame.

I do think, however, that our metaphors helped us in the session, whether intended or not. In her few sentences about the hospital, Lettie succeeded in telling me about how very cold and stark and lonely the world had become for her, how very cold her future seemed. How she did not “want to go". I believe this allowed me to understand something about her emotional world, without her saying anything directly.

I also realise that the only useful thing I did in the session was to call the nurse, to put the thin clinic blanket around Lettie’s shoulders and to sit with her, waiting. In turn, I used metaphors to say to her: I hear you are cold. I can do almost nothing. I will sit with you. I am sorry.

This is a case study from Kruger's haunting book Of Motherhood and Melancholia, published by University of KwaZulu-Natal Press in 2020.

♦ VWB ♦

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