Читать книгу Dynamic Consultations with Psychiatrists - Jason Maratos - Страница 61

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 pointing out the positive elements of Mrs. C's predicament. For example, she still had her mind (she was not dementing) and still had a desire to be independent, caring, and giving. JM pointed out that Mrs. C based her relationships on her ability to offer. JM invited the doctors to consider how people who retire from active life adjust to this new pattern (Wu et al., 2016). Generally, older people are less able to offer and less able to earn. The first element on which they can rely is their history. They have a memory of a full life. This lady can have a memory of surviving adversity, coping with numerous changes, enjoying a good relationship with her husband, and fulfilling herself by bringing three children up. Mrs. C can rely on this history to feel that her life has not, to date, been wasted. That is a thought that is not depressing and is realistic.

One can be sympathetic to this woman who has lost her ability to function because of widowhood, disability, and poverty. It is going to be difficult for her to make this adjustment, but it is not impossible to use the residual resources that she has, which are her intellectual ability and her personality. Once she develops a more realistic approach to her future, she is more likely to accept help to engage in interaction with other people such as the interaction arranged at the psychiatric day hospital. Some other organizations, not related with provision of care, could perhaps be approached for her to participate as an equal member and not as a recipient of service. Mrs. C needs to value that she can be useful as a presence not only as somebody who does a job for others or somebody who offers a service. Any expectations of her offering work would be frustrated and, therefore, unrealistic. She could value the realistic expectation of offering herself for who she is and not for what she can do for other people. She could make some people happier by just spending time with them. This, in return, could make her feel happier and more useful. This would increase her own sense of self‐worth. The doctor confirmed that Mrs. C feels better when she is with other people at the day hospital. JM asked if the local Buddhist community has any programs to engage isolated members of the Buddhist community. The doctor undertook to explore this avenue. JM also pointed out that a physical objective within her reach could be some reduction in her body weight. JM suggested that she could be put in touch with a dietician and perhaps an exercise program appropriate to her disability could be devised.

JM concluded that the central focus of a treatment would be for the treating doctor and all the staff to resolve the feeling of hopelessness and replace it with one of realistic expectations for Mrs. C. The doctor concluded that Mrs. C does enjoy interaction with other people and that she is able to come forward with ideas that make other people feel better. JM added that this experience, that she has a positive effect on other people, could be pointed out to her and encourage her that she is still useful to others, and she should not write herself off because she is appreciated by others as a person and not as a job.