Dynamic Consultations with Psychiatrists. Jason Maratos

depressive disorder. Her current medications included fluoxetine 40 mg daily, Deanxit (mixed medication of flupentixol and melitracen) 1 tab daily, zopiclone 3.75 mg at bedtime when necessary, and propranolol 10 mg twice a day as necessary. She achieved remission again after 1 month after medication adjustments. She was keen on psychological intervention for relapse prevention, reducing reliance on medication, and learning relaxation techniques.

      She was seen a few times and reported that her greatest concern at this stage was reliance on sleeping pills. Sleep hygiene was discussed, and she successfully cut down the use of hypnotics. She reported no other distress at this moment. Further work would be needed to focus on relapse prevention for her.

       Consultation

JM congratulated the doctor for the excellent presentation. JM first focused on the timing of Mrs. A's remission after the onset of medication and whether the remission could be pharmacologically explained or if the timing was related to some other factor. The doctor believed that the timing of her improvement was earlier than what would be expected pharmacologically. JM then asked about the significance of this early remission. The doctor wondered whether this was related to a placebo effect. JM then asked about the nature of the therapeutic factor, which was called “placebo.” The doctor found it difficult to respond to this question, and JM suggested that a doctor is not expected to know all the answers but when a matter like this confronts a patient and doctor, then it is worthwhile exploring it with the patient. For example, JM suggested that the doctor mentions to Mrs. A that they have noticed that her recovery occurs earlier than medication had time to have effect and whether doctor and patient could explore this and come to a shared insight. That exploration would help the patient to start thinking more psychologically and less organically. The doctor repeated that Mrs. A's understanding was that it was the medicine that was making her better, and JM pointed out to the doctor that he was aware that the build‐up of serotonin in the synaptic cleft takes longer than the first 2 or 3 weeks to make a clinically significant improvement.

      JM then asked now that it was established that her mental state improvement took place before the biochemical effect of medication, do we have a better understanding of the therapeutic factor? The doctor pointed out that Mrs. A had said that when she tried to speak with her son or daughter, they only offered reassurance that seemed quite facile. Mrs. A felt that her children could not understand her illness. Mrs. A explained that she felt that the professionals at the hospital had a better understanding of her condition. JM then asked, “what was the reassurance given by the healthcare professionals?” The doctor responded that Mrs. A was probably not offered reassurance, but it was the opportunity to talk with professionals at a different level to that of the discussion with her own children.

      JM then asked if the doctor had any thoughts of what the qualitative difference was in the communication with the healthcare professionals and with her children. The doctor replied that Mrs. A felt that doctors could understand her illness better and that the doctors could be more effective in helping her by adjusting the medication. JM then suggested that Mrs. A was given a sense of security on a false premise. The false premise being that it was the change in medication that would get her better. JM pointed out that although the premise was false, it was nevertheless effective. The therapeutic factor was that Mrs. A had a feeling that she was in the right hands and that she would receive the right and effective treatment. The contact with the hospital gave her the security that she needed and that was the therapeutic factor.

      JM then raised the issue of whether it would be appropriate to disabuse Mrs. A of this false assumption and deprive her of a sense of security or whether the doctor should leave this “false assumption” unchallenged. The decision will depend on whether the doctor's assessment is that Mrs. A can cope with the new reality. JM pointed out that for some people this is the best that one can hope for: That they live with the belief that every now and then, events will overwhelm them and they will become depressed (meaning clinically depressed) and that they will then be sorted out by adjustment in medication by specialist doctors.

      Only after the doctors form the opinion that Mrs. A can cope with being disabused—of losing a system of beliefs that she had to date found helpful—can one proceed with a more psychological exploration. For example, only then could she be asked why being short and being less successful than her fellow churchgoers is something that is depressing for her. For an exploration of the relationship among religion, spirituality, and mental health, see the excellent recent review by Dein (2018).

      Mrs. A could be asked to reexamine the way she evaluates herself. For example, we do know that the value of people is not measured by a tape measure. Why is Mrs. A rating herself according to height rather than as a human being? Mrs. A was depressed at the thought of appearing at her children's wedding being as short as she is. Why has Mrs. A not gained a realistic evaluation of herself despite her height? JM then repeated the issue that if the doctors felt that Mrs. A could cope with this kind of exploration, this is one issue that they could begin to look at again with her.

JM then pointed out that Mrs. A rates herself by comparing herself to her “fellow churchgoers” on the dimensions of height, wealth, and career. JM asked the doctor about other dimensions along which Mrs. A could begin to rate herself so that she develops a more realistic evaluation of herself. The doctor pointed out that Mrs. A could begin to value herself as the mother of three good children, that the children are independent, they have good jobs, and they contribute to society. JM then pointed out that Mrs. A may feel that she has not been as good a mother because none of her children are high‐achieving professionals nor are they great earners. JM asked how the doctors could anticipate this depressive slant that Mrs. A is likely to give to her achievements. The doctor responded that the value of a job is not measured by the amount of money they earn but on the worth of the contribution to society. JM confirmed this as a useful line to follow with Mrs. A. JM then added that this was an excellent idea because the doctors could apply the same evaluation to how she values herself. For example, bringing up three children who are useful members of the society is of enormous value even though it brought no income to her. The doctor also added that the children's emotional development was also largely positive in the sense that they had not presented with any psychiatric conditions although they were reserved. It could be pointed out that with her husband, they raised three children who have not become a burden to society, who have not become dysfunctional, and who are dealing with the stages in their lives (like developing a career and personal relationships) constructively. Mrs. A has a good reason to feel proud of this achievement.

      JM then asked the doctor if Mrs. A had good reason to feel proud in her role as a wife. The doctor pointed out that Mrs. A could feel proud of the dedication that she showed to her husband, especially through the last difficult years of his illnesses. JM then summarized that Mrs. A could value herself as a good mother and as a good wife and that she has contributed to society in that way.

      JM pointed out that once Mrs. A felt secure in the relationship with a therapist, the therapist can invite her to reexamine the dimensions that she values herself and think not only of the limitations of her achievements but also of the positive contributions. This would enable her to have a more global, balanced, and realistic view and evaluation of herself and not judge herself only by comparing herself negatively. JM then summarized that contact with the professionals enables her to have a more realistic view of herself and also to develop a shared “understanding.”

      JM then expanded a little on the notion of understanding by pointing out that people feel understood only if the other person shares the same belief or the same view as they do. JM pointed out that young people particularly often accuse their parents of not understanding when their parents see the same events in a different perspective. The security of the relationship with a professional enables patients to reexplore their understanding of and their own interpretations of events or of themselves. In Mrs. A's case, the shared understanding that was based on a false premise was helpful in treating the individual episodes but was not helpful in preventing a relapse. Challenging the original shared understanding would lead to an improved evaluation of herself and an increased personal strength and resilience to face challenges and threats to her self‐esteem. Put more simply, only if she values herself more as a person will she