Dynamic Consultations with Psychiatrists. Jason Maratos

not to express her feelings to others. She stopped studying after the first year of secondary education and started working. She recalled that she never had plans to study further or get married because her father kept telling her that she should stay at home to care for her parents. During this time, her siblings moved out of the family home one by one after having their own families; Mrs. Z continued to live with her parents.

      Mrs. Z's mother died 10 years ago (2007) from breast cancer, and her father died of a heart attack 6–7 years ago (2011). Although she put much effort in taking care of her parents when they became ill during their final years, she never received any gratitude from her father until the last moments of his life. Yet, she continued to take care of her parents and never considered abandoning them.

      After her parents died, her younger sister moved back to live with her because she was having marital problems and was in the process of divorcing. After several years, her younger sister remarried and her husband moved in to live with them. As it was inconvenient to live with her brother‐in‐law, she moved to her second elder brother's home 3 years ago. Her second elder brother's family had already emigrated, and they returned to visit the city several times a year. She described that whenever her second elder brother returned to the city that he criticized her daily for being useless and told her to go to die so that she would not be a burden to this world, although she would prepare meals for her brother's family when they were in the city. Her brother's wife and children seemed not to notice the criticism at all. Mrs. Z stopped working 5 or 6 years ago (2012).

      Past Psychiatric History

      Mrs. Z is new to psychiatry; she has no history of violence or suicide attempt. There is no family history of mental illness.

      Past Medical History

      Mrs. Z suffered from bilateral knee pain and was diagnosed with osteoarthritis. She had operations on her knees (bilateral knee replacement carried out in a private hospital in 2013), but the pain persisted, making it difficult for her to walk normally. Mrs. Z also suffers from hypertension, hypercholesterolemia, and allergic rhinitis; there is no known drug allergy.

       Mental State Examination

      Mrs. Z is an obese lady walking slowly with a stick; she is neat and tidy, wearing a surgical mask, calm and settled; she made fair eye contact and showed no psychomotor disturbances. Mrs. Z's mood was low and her affect congruent. There were no psychotic symptoms, and she denied any active suicidal ideas; she was orientated to time, place, and person. Mrs. Z. had good insight.

       Diagnosis

      Dysthymia, which was perpetuated by poor stress coping strategies.

       Consultation

      The consultation was started with the request to clarify a few points of history. Mrs. Z. started earning at the age of 14–15 years. She is obese with a body mass index (BMI) of 30. Her intelligence was considered to be slightly below average. She had undertaken semi‐skilled jobs. The siblings were “well off” with one sibling running their own business and a sister being a housewife.

      The therapeutic contract was not clear, but it involved the use of antidepressants (on account of low mood and anxiety); the medication was not significantly helpful but had led to some “partial improvement.” The improvement had been noticed to take place 3 to 4 weeks after onset of medication. The staff noticed that she demonstrated fewer crying spells, fewer temper outbursts, less self‐harming‐harming, and fewer ruminations but no change in interest in activities. Her sleep was normal when brother was absent but problematic when he lived with her. Mrs. Z did not complain of anhedonia and did not demonstrate any diurnal variation of mood.

      The use of antidepressants was justified based on the sleep disturbance. This was questioned because the sleep disturbance was conditional on her brother's presence. The next question was, if the presence of her brother is so unsettling, why did she continue living with him? Could she not live in a place of her own?

      The provisional formulation was that this was a woman who was depressed because she was being criticized by her brother, was submissive, and had been previously criticized by parents.

      Mrs. Z did not see herself as the agent of her own predicament but that she was at the mercy of other people's wishes and actions. The doctor clarified that the arrangement by which she lived was not a necessary part of the culture prevailing in the city and was unfair to her as a younger sister. The doctor added that this arrangement was not the result of Mrs. Z's generosity but an expression of her being taken advantage. There was no doubt that she was being exploited. It seemed that this woman of limited ability was in an unfortunate position in which the only resort of comfort for her was to (over)eat.

In conclusion, Mrs. Z was exploited and was not in a position to take charge of her own life. She had a serious difficulty in becoming the agent of her own predicament. Therefore, the therapeutic intervention needed was the provision of a professional (counselor or social worker) who would support her and direct her in establishing a way of living that was fairer to her and which would secure her human rights. The counselor may mediate on her behalf with key family members. Mrs. Z. could be supported to improve her physical health (she needs to lose weight because her obesity limits her ability to move and restricts her independence).

      It is unlikely that analytical therapy would be appropriate for her. Mrs. Z. is more likely to respond to a continuous intervention that would have realistic (and finite) expectations for change of a pattern of a lifetime. Ambitious therapeutic objectives can only lead to failure in the patient and disappointment in the therapist. The services of occupational therapy may provide support, socialization, and a program toward some work in the final years before retirement.

      One can see how her early life experience of being psychologically and emotionally abused led her to see herself as a person of lesser value and as one who is not entitled to fair treatment because she was not as able as her siblings. Mrs. Z unfortunately continued relating to her family (and possibly to others) in the same way that had been established in her family of origin from a young age.

      Any change in her approach needs to be gradual and coupled with considerable amount of support and small increments of interpretations. She may be helped by comments like: “Even if you are not as able as your siblings, this does not give them the right not to respect you and certainly does not mean that exploiting you is justified.” Mrs. Z could also be given opportunities to build her self‐esteem by being engaged in tasks that carry a realistic chance of success, which will then be demonstrated that she (and her work) is valued. A simplistic example is she may be given a chance to carry out a job that is not too intellectually demanding and is attainable by her despite her knee disability—perhaps something like answering the phone at a center. Being useful and successful can only help to improve her self‐esteem and the confirmation by colleagues and seniors may help consolidate this improvement.

Ms. B

      Ms. B is a 21‐year‐old single unemployed woman living with her family in a public housing unit.

      Presenting Condition

      Ms. B was voluntarily admitted to the hospital on 21 May 2018 because of unstable emotions, following a suicidal gesture after an argument with her boyfriend.

      History of Present Complaint

      Ms. B has had a stormy relationship with her boyfriend ever since they started courting when they were Form 3 classmates (7 to 8 years previously). Over the years, they broke up many times and, in between, Ms. B also had many short‐lived relationships. Ms. B would throw temper tantrums and employ self‐harming behaviors when she expected to be abandoned by her boyfriend. In January 2018, they reunited. The couple agreed that they