Dynamic Consultations with Psychiatrists. Jason Maratos

with follow‐up. Since attending the hospital, she had tried various antidepressants, which she felt had doubtful therapeutic effect and considerable unwanted effects.

      Mrs. C was limping and walking slowly supported by a walker. Mrs. C continued being worried about her progressive bilateral osteoarthritis of her knees, with varus knee, and back pain affecting her mobility. Mrs. C has suffered from dyspepsia, hypertension, hyperlipidemia, empty sella syndrome (which was thought to be nonsignificant at follow‐up), spinal stenosis with left foot drop, and obesity.

      Mrs. C had been on a waiting list for total knee replacement since 2015 but claimed that she had been advised that she needed to wait until 2018 for it to be done. Last year, Mrs. C also developed hypertension and felt more concerned about her failing health. Her knee pain and poor mobility had limited her from pursuing her interests, such as hiking and doing volunteer work. However, old case notes reported she had previous plans of hanging herself in the mountain, but Mrs. C denied it during current psychiatric clerking. She claimed that since her husband's stroke, she had already completed the bank account rearrangements and written her final notes in case something was to happen to her.

       Present Treatment and Management of Case

      Mrs. C had been advised to accept inpatient admission, but she strongly refused. She was referred to a clinical psychologist for grief therapy and to a community psychiatric nurse for community supervision; she was started on fluoxetine 30 mg daily. She was referred to PGDH for daytime engagement and support. Mrs. C is sensitive to the side effects of antidepressants and she often complained of fatigue.

Mrs. C had started attending PGDH in July 2017 with the aid of transportation service. She had been reluctant to attend at first, but after joining, she started to enjoy the activities (including physiotherapy and occupational therapy) and liked chatting with other patients. Mrs. C claimed that she had made friends and liked listening to other's problems She is receiving meals on wheels at home and would also do volunteer work at the city society for the aged around once a week whenever her knee and hip pain is better. She had continued receiving cognitive behavioral therapy (CBT) from a clinical psychologist and felt that she had ruminated less about her husband and had resolved some of her anger regarding his death. Mrs. C was not keen to have further psychiatric medication because she was concerned about their side effects. Mrs. C felt that her primary difficulty was her mobility. She had also been referred to the district elderly community center for further support. She also applied for medical fee waivers because she is financially dependent on her daughter only and old aged allowance.

       Consultation

      The doctor expressed the feeling that, as a clinician, she felt helpless; as a psychiatrist she was in no position to improve Mrs. C's mobility (could not hasten the knee replacement operations) or address the other physical problems and medical treatment, which was within her field of expertise (antidepressants).

      JM summarized the case as a case of a woman of 68 who had led an active and creative life, who became married, supported her husband, developed a good relationship with her husband, and had three children who they raised. The children have now moved and live in different countries and so, she had no role in caring for them; this was a major loss for her. The death of her husband is an additional major loss; the other enormous loss was that of her physical fitness. Mrs. C relied on her fitness to be helpful to others and also to be able to enjoy her life (as, for example, in hiking). Mrs. C has not readjusted her ideas and feelings to fit with her present life situation as an elderly, widow, and a woman whose children do not need her anymore and who can contribute little to the wider community.

      JM then added that although doctors and therapists pay considerable attention to feelings of sadness and loss, we do not pay as much attention to unpleasant feelings of anger. JM acknowledged that the anger toward doctors had been addressed somehow because she had expressed anger because they did not save her husband's life and because they had not given her adequate advice on how to help him and telling her to be careful was not good enough. The doctor added that she had acknowledged her anger at not being told on how she could prevent further strokes taking place—something that was likely to happen. The doctor added that Mrs. C had also expressed anger that the doctors did not save her husband from what was a febrile illness. JM raised the issue of anger toward her husband who inflicted part of the illness on himself by smoking. The doctor added that her husband's father had made that comment that he had brought the stroke on himself. The doctor added that she felt that her husband did not deserve to have a stroke despite his smoking because there are many people who smoke and do not suffer strokes. The doctor added that Mrs. C was forgiving toward her husband. JM added that it seemed to him that Mrs. C was idealizing her husband whom she loved.

JM referred to Mrs. C's hallucinations of widowhood (Dewi Rees, 1971; Olson et al., 1985). This was referring to Mrs. C imagining that she had been visited by her husband after his death. The doctor pointed out that she was aware of the various forms of pathological grief. JM pointed out that widowhood is, at that age, one of the most stressful events that could happen to a person (regarding mortality of widowhood, see Parkes & Fitzgerald [1969]). JM added that the only life event that could be more stressful than widowhood is the death of a child. JM then pointed out that the couple had had a good life together. They brought up their children together and they brought them up well; she was tolerant of her husband's little faults, like his gambling, which was measured (not excessive). Before the husband became ill, they had managed to have savings and some small property; they had been a well‐functioning couple and it was difficult for her to readjust her thinking so that she could look forward to a future. The doctor added that having spent all their savings Mrs. C was now left with few resources and she was dependent on her daughter from whom she receives the equivalent of US300 a month which is a small sum—a sum barely adequate to cover her needs. JM pointed out the predicament of having to live alone, aged, with difficulties and with little support from family. JM asked if Mrs. C receives any support from the Buddhist community of the city. The doctor pointed out that although she does have several friends, her mobility restricts her from visiting them. The doctor also pointed out that a visit to a Buddhist temple was not mentioned. The doctor added that it was not only her physical disability but also some reluctance to go out and meet people; she was concerned how she would appear to her peers walking with a walker. The doctor added that it would also be difficult for her to invite people to her home because the living space is limited.

      JM repeated that the task for Mrs. C was to readjust her thinking on how to live the rest of her life as an elderly, physically compromised, lonely woman. JM invited the doctor to imagine what prospect could this woman have for her life in the following, say, 20 years. The doctor replied that if she were in that position, she would place most of her hopes on a knee operation taking place in the immediate future because if her mobility improved she would be able to go out a bit more and engage more in the activities that will improve her emotional state. Maybe she will be able to do some hiking again—something that she enjoyed in the past; she may be able to do some voluntary work or meet up with some of her friends. JM questioned how realistic the prospect of hiking would be for Mrs. C and asked if Mrs. C was also overweight. This was confirmed by the doctor. JM pointed out the vicious circle of arthritis limiting movement, and limitation of movement leading to increased weight, which in turn limits movement even further.

      JM, having questioned the realistic level of the expectation of hiking, then moved on to invite the doctors to consider what would be a realistic prospect and asked the doctor if Mrs. C's hopelessness had become her own hopelessness as well. JM then introduced the psychoanalytic concept of countertransference (Heimann, 1950; Kernberg, 1965; Winnicott, 1960). JM made a summary of the concept as follows: Countertransference refers to the feelings that the therapist develops that arise not from the therapist's own experience or the result of an independent assessment, but they represent the adoption of the patient's feelings, which are seen by the therapist as their own. JM pointed out that in the case of Mrs. C, her own hopelessness became the doctor's hopelessness. JM asked the doctors whether the appropriate thinking and action for Mrs. C was to end her life because there was no realistic future for her. As this was not the case, JM started