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.
References
1 Dewi Rees, W. (1971). The hallucinations of widowhood. British Medical Journal, 4(5778), 37–41.
2 Heimann, P. (1950). On countertransference. The International Journal of Psycho‐Analysis, 31, 81–84.
3 Kernberg, O. F. (1965). Notes on countertransference. Journal of American Psychoanalysis Assessment, 13, 38–56.
4 Olson, P. R., Suddeth, J. A., Peterson, P. J., & Egelhoff, C. (1985). Hallucinations of widowhood. Journal of the American Geriatrics Society, 33(8), 543–547.
5 Parkes, C. M., Benjamin, B., & Fitzgerald, R. G. (1969). Broken heart: A statistical study of increased mortality among widowers. British Medical Journal, 1, 740–743.
6 Winnicott, D. W. (1960). Countertransference. The British Journal of Medical Psychology, 33, 17–21.
7 Wu, C., Odden, M. C., Fisher, G. G., & Stawski, R. S. (2016). Association of retirement age with mortality: A population‐based longitudinal study among older adults in the USA. Journal of Epidemiology and Community Health, 70(9), 917–923.
2 Postnatal Depression
Margaret
Presenting condition
Margaret is a 28‐year‐old married housewife, mother of two (a boy aged 3.5 years and a girl aged 2 months), who lives with her husband and children in a rented subdivided room. Her infant daughter is mainly breastfed. She was referred by Maternal and Child Health Centre with an Edinburgh Postnatal Depression Scale score of 27 out of 30 in January 2018.
History of present complaint
Margaret presented with low mood with suicidal ideas. She was new to the mental health service. She delivered a baby girl on November 19, 2017, via vaginal delivery with no complications. She had multiple stressors from before her daughter's birth. These included her husband indulged in gambling and, recently, even online gambling; he would disappear for a few days a month in the past 3 years. The debt had increased to the point that the debt was paid using credit cards, and the debt now totals about US$30,000. The second source of stress was her son's problematic behavior since she became pregnant. The third source of stress is the crowded living environment. She had decided to live in the city because this would enable her son to attend kindergarten year 1 from January 2018. Margaret has limited support from her family of origin.
Margaret developed low mood, with a sense of worthlessness and helplessness. She would look at her children and become worried about their future; she felt that they were poor. Since giving birth, her mood further deteriorated, with her experiencing reduced energy and poor concentration at work. Her sleep was also disturbed by childcare. Margaret experienced appetite loss and lost 1–2 kg. She does not enjoy activities, feels the lack of money, and has no time for any entertainment; they do not even have a television set at home. Previously, she had fleeting suicidal ideas of jumping from heights, but these became less frequent since she moved to the city. In the city, her husband tended to stay at home most of the time. Margaret denied having a concrete suicide plan, had not acted on any suicidal impulses, was remorseful, and still cared about and worried for her children. Margaret denied alcohol or substance use and denied the existence of any psychotic symptoms. Occasionally, she would hit her son with bare hands or with a hanger; however, she would feel remorse afterward. There were no previous hypo‐manic or manic episodes.
