Tuesday, July 27, 2010

Beating the Odds?

I’m writing a second piece on the same patient, for a change – because Soukaina’s story isn’t finished. In the weeks since I posted my initial description of her, she has truly and amazingly come alive. She has cast off her shadows, and seems to have beaten the depressing psychiatric odds with which I ended that first post.

It began with laughter. A kind of bubbling energy she simply could not keep inside. An entire Thursday morning meeting once played itself out to the underlying soundtrack of Soukaina’s bursts of hilarity. Like a steady rhythm, she accompanied other patients’ words, sighs, and tears with her own uncontrollable snorts, giggles, and whinnies. The same impulse would get the better of her when out and about on the ward; the tiniest odd sound could set her off. She tried to hold it in, she really did – hands shielding her mouth like a prison door, the head pressed tightly into her knees, she did her best to maintain an internal sense of order. But to no avail; she seemed beset by an effervescence too large for her small frame.

Her laughter then paved the way for words. Cautious utterances at first: a tentative “mezyane” (good) or “nglis?” (can I sit?). But with every passing day, her voice grew stronger and her communicative overtures bolder. And last week, this development culminated in an actual conversation. She and I sat side by side on a bench in the sun, my hand in hers, as she asked me question after question. Where was I from? Where were my parents? Did I have brothers and sisters? Where did I live now? Did I live alone? What was my job at the hospital? How old was I?

This conversation likewise had its own laugh track. Everything I said prompted a burst of giggles. Maybe, I remember thinking self-consciously, it’s my horrible pronunciation of Arabic. Maybe it’s my strange blonde hair, or the way I look at her. But maybe it’s simply her own joy at the lifting of that mental cloud – and maybe it’s all of those things at once.

But mostly, I remember, I simply had the urge to giggle along with her. I responded to each of her questions with one of my own, and I reveled – as she sat there with her eyes full of recognition; as she revealed her self to me. I reveled in the possibility of being able to actually listen to her.

There was an urgency to it all. We talked as though we were making up for lost time – or perhaps as though we were afraid this window might close up just as quickly as it had opened. But the next morning, when I found her again in the courtyard, our conversation simply continued.

This time she requested to see photographs of my family. I took her with me to the doctor’s office, opened up my laptop, and showed her a collection of pictures. Again, her reaction was strong and fizzy. It was the details that seemed to strike her most – the color of my sister’s dress, my father’s glasses, a can of coke in the background somewhere. It all met with an explosion of laughter, and constant, repetitive requests for me to explain what was shown in the picture.

After lunch on that same day, it was she who dragged me back to the doctor’s office. I once again opened up the pictures of my family – but that’s not what she wanted, this time.

“Show me pictures of the king of America,” she now demanded.

I smiled, toyed briefly with the idea of interpreting that creatively, then connected to the internet and searched for a few pictures of Barack Obama.

Soukaina showed a decided preference for a set of photos depicting the president along with his family. Old wedding pictures, or professional portraits of the Obamas with their kids. Again Soukaina responded with laughter, and endless requests for me to identify each individual in the frame.

Her favorite photo of all showed Obama’s two young daughters, gleaming on a stage somewhere – a snapshot moment during the campaign trail, no doubt. Soukaina stared at it for a while, as though caught by something; then pointed to Malia’s dress and looked me in the eyes.

“what do you call that color in French?”

“Rose,” I responded. “Like your pajamas.”

Soukaina looked down at her own chest, looked back up at the picture, then turned to me.

“Rose,” she repeated, and once more burst into laughter. She leaned in, hugged me close, then kissed me on the cheek. I couldn’t help but laugh with her. I was mystified by the connection she had just somehow made, the recognition she had found in that picture of two unknown girls –

… but I loved it.

And I hope with all hope that she holds on to this clarity and joy…

Tuesday, July 13, 2010

An impossible Choice

Wherever the action is, there you’ll find Soukaina. She spends her days strolling along the ward’s courtyard, observing life as it is lived by her fellow patients. Not yet 15 years old, she is always dressed in the same stained pair of pajamas; her feet drag along a pair of pink plastic slippers, and her hair is haphazardly covered by a disheveled headscarf. She makes her rounds at a steady pace, arms swaying heavily by her side, shyly looking around at her passers-by. She halts in the occasional doorway, quietly watching as other women are having coffee with their visitors. Then she moves on to investigate what’s going on at the end of the hallway there, where her doctor is conversing with an anonymous face. She makes a u-turn, stopping briefly to poke her head inside the nurses’ office, then fixes her attention on what the gardeners are doing to the bed of roses in the courtyard. She finally ends her tour by settling down beside the group of women seated on a bench, basking in the morning sun.

Soukaina always maintains a bit of distance. She does not like to be touched; any well-intentioned attempt to shake her hand, or make an offering of candy, invites a subtle dance of evasive shifts and shakes of the head. Soukaina has a voice, but prefers to parcel out her words in great moderation; any verbal overture is shyly answered with a quick and tiny smile. At every Thursday morning ijtima’, Soukaina’s doctor performs the ritual of trying to coax out a phrase or two. “Kif bqiti?” she’ll ask, her voice sweet as honey – how have you been? Each week, these questions hang suspended in the air, lonely and heavy with awkwardness, until a few other patients decide to speak up on Soukaina’s behalf. “Oh, the other day she was so chatty!” they’ll say. “Soukaina loves to talk with me, we were laughing and crying together all afternoon!”


Soukaina has been on the ward for as long as I can remember. She was there when I first arrived in November and has been a stable presence ever since, quietly strolling through the corridor as other patients come and go around her – like a fixed point of light within a changing image. Over the course of these long months she and I have made slow but steady progress in the buildup of a communicative routine. By January she began to return my greetings with a smile; by February she developed the habit of sitting down beside me as I wrote up my notes, occasionally stretching out a cautious but pioneering finger to get a physical impression of my notebook. By March she began to ask me for the time – always a rapid whisper, barely audible, but words nonetheless! – and by April, she took to following me as I made my own rounds across the ward.

It was around this time that Soukaina was briefly discharged. Her absence did not last long, however; she had spent not four weeks at home with her family before she returned to the hospital and once again took up residence in her old room, as though nothing had ever changed.

Yet something had changed.

I had always thought of Soukaina as an empty notebook; as a set of pages without a story. Beyond the smiles, her eyes were blank – an infinite whiteness that led me to see Soukaina as a moving body without emotions, a conscious mind without thoughts.

This new, re-hospitalized Soukaina remained mute, but now the light seemed to have been turned on behind her eyes. The blankness of before had made way for images, for bright colors in broad brush strokes. I saw an abstract painting, now; a palimpsest of stories each racing out to envelop the beholder.

For a few days, the entire ward reveled in what we thought of as a very pleasant change in Soukaina. Her smiles had become broader, her voice more solid, and her eye-contact more eager. Real communication had begun to seem like a possibility.

Then, from one day to the next, the smiles disappeared. I arrived on the ward one Monday morning to find her sobbing in the courtyard. She saw me as I entered, ran over, and grabbed my hands. For the next three hours, she refused to let go. She dragged me along as she walked restlessly through the corridors, drawn mostly toward the exits – as though she was waiting for someone, or something. The stories in her eyes had become jarring, glaring, frightening in their blackness.

Apparently it had been this way all weekend. “Meskina,” the nurses sighed. “The poor thing – she’s suffering from horrible anxieties and hallucinations.” Whatever had turned on the light behind Soukaina’s eyes had also unleashed something sinister – a monster seemed to have emerged from the shadowy recesses of her mind and now haunted her without reprieve.

Whatever it was, it had exhausted Soukaina’s small body; whenever I managed to sit her down for a moment, her head would begin to loll with the heaviness of sleep, her entire body heaving in yawns of primordial force. Yet she refused to lie down in her bed for a nap, no matter how sweetly our coaxing – and how potent the sleeping pill she’d been made to swallow. It seemed that circling around the ward was Soukaina’s only source of comfort at the moment.

As she pulled me along, I tried to ask her what the matter was. “Yak la bas?” What’s wrong? And Soukaina would simply look at me, a heart-wrenching urgency in her eyes. Her mouth would move, but the sounds remained stuck in her throat. Breathing heavily with the weight of anxiety, she simply pulled me closer, grabbing my forearms now, as the tears ran down her cheeks.


Soukaina has schizophrenia, but the autism she was born with has pushed the mute button on her suffering. She is haunted by terrifying delusions and hallucinations that she is unable to communicate to the outside world; she is imprisoned in the tower of her own mind, with a monster in her cell.

Soukaina had always been on Clozapine, a relatively old anti-psychotic drug usually prescribed only as a last resort for those who don’t respond to anything else – because while highly effective, Clozapine comes with a high risk of potentially life-threatening side effects. The drug had pulled a heavy blanket of sedation over what little communicative ability Soukaina had had. But at least, her doctor reminisces, it had gotten rid of the hallucinations - and it had left her calm, content, “gérable."

Soukaina’s parents, however, had not been satisfied. They remembered Soukaina as she had been before illness laid claim to her mind – peculiar, yes, but nevertheless talkative, receptive, capable even of going to school. Hoping for a better outcome, her parents had convinced Soukaina’s doctor to re-hospitalize her and try a new approach to treatment.

“But do you see what happens when you mess with something that works?” The doctor sighs. “All we’ve managed to do is de-stabilize the patient.” Hopefully, she adds, the parents will now realize that Clozapine really wasn’t all that bad.


What I find saddest of all about Soukaina’s story is that the doctor has a point. While it may be tempting – worthwhile, even – to dream of perfect cures, there are times or cases in which the reality of psychiatric treatment forces one into an impossible choice between two very imperfect options. While listening to the doctor talk, I had the urge to protest. Could “calm and manageable” ever be a desirable outcome for anyone, given the beauty and creativity that the human brain is capable of producing? Is it ever acceptable to accord someone a fate of diminished mental capacity, if the trade-off is a reprieve from psychiatric symptoms?

It isn’t. Yet I realize that this is not what the doctor is arguing for. She does not see “gérable” as the ideal end-result of Soukaina’s treatment. Not in the least. But in her capacity as a psychiatrist, she is nevertheless compelled to play the role of the realist. And the heart-wrenching reality of this situation quite simply is that Soukaina has to choose between freedom from hallucinations, and freedom of communication.

Monday, July 5, 2010

Freedom of Expression

It is Thursday morning, and the patients and doctors of the open women’s ward are gathering in the lounge for the weekly ijtima‘ – an hour or so of sharing stories, experiences, and impressions of life at the hospital. As the women take their seats on the couches – traditional design, but with a modern twist – the hum of excited whispers hangs in the air. There’s been conflict in the corridors this week, and the patients are expecting the issue to come to a head at today’s meeting.

This morning I sit next to Nadia, a woman in her fifties who has been hospitalized for treatment of depression. She’s been here for a few weeks now, and is clearly doing better. She no longer isolates herself in her room, and she’s become more talkative of late. She’s gotten back into the habit of applying eye make-up in the morning, and the curl has returned to her short, auburn hair.

She is slightly restless this morning as she listens to her fellow patients’ stories. The group’s anticipation has been satisfied; the two women engaged in conflict have indeed brought their issue to the meeting. It’s a dispute over religious freedom: whereas one party claims her right to religious expression (in her case, the vocal recitation of Qur’anic verses in the ward’s corridors), the other argues for her right of protection from religious indoctrination (especially at ten o’clock at night, when she would prefer to be sleeping). With building emotion, the two women explain their viewpoints to the group; the doctors are barely able to maintain a sense of order.

It is a heavy topic for any group of Moroccan women to stomach on a given Thursday morning. Yet it’s not the content, but the form of the argument that prompts Nadia to lean in and whisper a question in my ear.

“Can you follow all this Arabic?”

I smile, make a gesture with my head to imply that I’m getting the gist, and suggest we try to listen. But Nadia isn’t done yet. She leans over again, seeking understanding in my eyes.

“I have a really hard time understanding Arabic,” she confesses. “I’m not used to it at all.”

And indeed; when it’s Nadia’s turn to talk, she makes a point of announcing that she’d rather speak French. She cannot express herself as freely in Arabic, she explains to the doctor – whose nod of the head indulges Nadia in her request. And so Nadia begins, noticeably changing the tone of the meeting as she informs her audience, in that soft lyrical French of hers, that she had a good week. A few women shift in their seats, straightening their spines, and a subtle sense of formality seems to have impregnated the air around us. All disruptions have come to an end; even the bickering party is now silently listening. And then – just like that, in a blink of an eye that completely negates the gravity of her original request, Nadia downshifts back into Arabic, formulating her closing statements in the local dialect.


Nadia identifies herself as Moroccan, and as a Muslim; she says she is proud of her cultural heritage and of her family’s illustrious history. Nevertheless, her words and behavior always betray an apparent need to separate, to distance herself, from mainstream Moroccan consciousness. Contradiction and juxtaposition weave themselves continuously in and out of her autobiography; they are the backbone to her stories’ continuity. She was born to a conservative family and raised in Fes, that bastion of tradition – but she was educated at the French mission’s schools, and walked around her neighborhood’s streets in pigtails and short skirts. Her siblings all followed in her father’s footsteps by pursuing degrees in theology – but Nadia chose instead for a career in medicine. Arabic is the language of her country and her family – but Nadia prefers French, the language of international sophistication. And finally, her sisters have all been unhappily married for upwards of 25 years – while Nadia is a divorcée who’s had several long-term boyfriends.

The status of being divorced exerts a major gravitational pull on her narrative of juxtaposition. It is the dominant cause of her sense of difference; all other facets of her identity revolve around the epicenter of its force, twisted and bent in their own path of expression. Nadia tells me several times that divorced women are “très mal vues” in Morocco; on the scale of status, they rank lower yet than donkeys. She feels that other women – her doctor included – are both unable and unwilling to understand her lifestyle of sexual independence. Utterly incapable of imagining how that kind of freedom might taste, these women cower away in fear of transgressing such moral boundaries themselves. As we sit in the ward’s courtyard, Nadia points to a handful of other patients walking around: these individuals refuse to talk to her, she says; they treat her like a leper. “They must have been married as virgins,” she concludes with a sigh.

Men are not much more capable of comprehension, Nadia laments during our next conversation; sadly, she does not derive much fulfillment from the “amis” she’s had. Moroccan men do not understand her needs. However enlightened or “moderne” they may have claimed to be, her boyfriends nevertheless all expected to be wined and dined – “by me, a doctor, for goodness’ sake!” Nadia exclaims in lingering outrage – without providing much in the way of commitment in return.

To Nadia, Moroccan culture is the source of her illness. Her depression was born of suffocation; a case of asphyxiation by the insurmountable baric pressure of cultural mores and taboos. She spent a few years in France, and remembers it as a place of lightness and air, without a care in the world to weigh her down. The thick, winter blanket of sadness did not descend upon her until she returned to her native land, 15 years ago. I thus begin to wonder if her preference for speaking French might simply be driven by the need to breathe. Perhaps that speaking Arabic – a language indelibly linked to and thus bound by Moroccan standards of (expressive) propriety – feels to her like breathing air deprived of oxygen. Might French then be her escape hatch, a seam in the tightly spun fabric of moral codes? A helium balloon that lifts her high beyond the reach of Moroccan gender expectations?

Regardless of her feelings about Arabic, however, Nadia also speaks French, quite simply, because that is how she was trained. After an education at Morocco’s French schools, a medical degree, and a life lived in Morocco’s elite social circles, it is no surprise that Nadia is more easily able to express herself in French than Arabic.

To her, in any case, this linguistic preference in no way precludes her identification as a Moroccan woman. Though Nadia may take issue with what she sees as certain outdated standards of propriety, she eagerly joins in on conversations about local cuisine, asserts herself as an expert on traditional wedding attire, and confidently proclaims that, even if she does agree that Qur’anic recitation should be reserved for the privacy of one’s room, she believes in the Holy Book’s absolute truth. Nadia’s Moroccanness may be a little particular, a pick-and-choose sampling of the full available menu – but it is nevertheless genuine.

To other patients, however, Nadia’s frenchness signals a pollution – a threat, even, to the authenticity of the ward’s Moroccan identity. And like Marwa before her, she elicits the occasional hostile reaction.

In one such case, the hostility came from Halima, a fellow patient who happened to overhear Nadia in conversation with the parents of a newly admitted young woman. Nadia had eagerly asked the French mother of this young patient where she was from, and then began to share her own pleasant memories of time spent in that particular city. Halima had been standing nearby, and now approached to hiss at Nadia, in French:

“Stop bothering these people, they’re here for their daughter; they don’t want to talk to you!”

Nadia looked at her calmly. “I’m just trying to be friendly, Halima,” she explained. “I just want to make them feel welcome.”

The couple in question listened in slightly disconcerted silence as the two women continued their argument over their heads. Halima had retorted that this couple had no need for a welcoming committee; they’d been living in Morocco for years now. Upon which Nadia had responded that it is always nice to exchange memories of other places, and to hear about familiar cities in France.

Halima, at a loss for a witty retort, responded with an angry look and then grumbled, in the local dialect: “well, I’m Moroccan, and I’m Muslim. I’m proud of it, and I’m going to speak Arabic.”

“But that would be impolite,” Nadia responded in French, calm as ever.

“Not at all,” Halima corrected, still in the local tongue. “These people live in Morocco; they understand Arabic perfectly.” And with that, she walked away.

Nadia turned to the couple, and offered them an apologetic smile. Then she looked at me.

“Do you see these Moroccan women?” she asked. “They’re so short sighted, they don’t understand any lifestyle that doesn’t resemble their own.”