more so, in a different country. JM had no wish to intervene in the hierarchy that has to exist in a well‐functioning hospital with the inevitable lines of accountability and responsibility. Furthermore, supervision would be against the ethos of arriving at a new insight via collaboration of professionals of varying experiences in different fields. For example, the doctors in training were more aware of the culture of their patients and often taught consultant (JM) quite bit but who was also not ignorant of their culture and history. The consultations were meant to be and were, indeed, a two‐way process. JM feels that he benefited from the process at least as much as the consultees.
A local doctor took the initiative to organize this series of consultations that would be available to psychiatrists in training at their hospital. Successors in her role took up the torch with enthusiasm. In this way, consultations between hospital trainees and JM were established monthly and were conducted via video conferencing.
The hospital's ethical committee approved the project. The hospital authority insisted that extra care be taken to preserve patient confidentiality. No case was discussed without the patient's consent. Furthermore, the names of patients were fictitious, the names of doctors and of hospitals were withheld, and any reference to the country was deleted.
JM was impressed by the high standard of practice at the hospital, by the receptiveness of the trainees to analytical concepts, and by their willingness to learn from the experience. It is a credit to all participants that, over the years, only one or two consultations were canceled, and these were for good reasons. The coronavirus disease 2019 (COVID‐19) pandemic was an unavoidable interruption. The trainees were not able to meet as a group because of the risk of increasing the transmission of the virus. Due to the commitment of the doctors, a Zoom account was established, and the meetings restarted with each participant engaging via their own terminal.
It was thought that many other psychiatrists, who are expected to treat traumatized and disturbed patients, could benefit from the study of the history of such cases and the consultation that followed if they had access to a transcript of these consultations.
The doctors started submitting the text of their presentations in a standardized format. We thought that a full and proper exposition (according to the Maudsley Hospital standard) would take too much space and time and should be sacrificed for the sake of a more focused, reader‐friendly, and less time‐consuming presentation. Each presented case is of a person with a dysfunction on the severe end of the spectrum. The aim of the consultations was not to offer or get patients to engage in psychoanalysis or other form of dynamic psychotherapy but to use analytical concepts to gain a deeper understanding of the patients' “disorder” and to adjust, through this understanding, their psychiatric management. Being aware of the possibility of development of an antagonism between approaches, JM was particularly mindful to make sure that the consultations are seen as complementary to the treatment provided by the hospital and the services of that country as a whole. There is no implication that one approach is “better” or more suitable than the other.
The presentation of each case, and particularly of the consultation, is meant to demonstrate the process by which insights were gained. The consultation was audio‐recorded, and JM, based on this recording, dictated the content aiming to preserve the interaction that led to the gained insights. Searching for more details of this therapeutic interaction is part of this process and should not be seen as criticism of the material presented by the trainee. JM has not forgotten his days as a trainee, the stressfulness of encountering a new patient in crisis, and of having to come up with a helpful measure that would make a difference. JM is still practicing and knows that the work of a practicing clinician does not always permit perfection but always demands a helpful conclusion.
The consultation is written in plain English with deliberately avoiding terminology, especially that of psychoanalytic jargon. In the consultations, the reader may detect the presence of the psychoanalytical concepts even though reference to them is descriptive and using language understood by all mental health professionals. There are several reasons for avoiding terminology; at first, jargon often leads to misunderstandings and, second, makes the flow of reading harder to those not familiar with it. If terminology were to be included, it would make the text incomprehensible for those who it is written. A particular effort is made to explain what is meant by the occasional inevitable use of terminology.
We are grateful that the appropriate ethical committee approved the recording of the consultations with a view to publication. Naturally, all identified features of the patients have been deleted or changed so that patients' privacy is not compromised. The author is grateful to the hospital for agreeing to fund this series of educational events consistently over many years. We are encouraged by the fact that only few patients withheld their permission, and we, naturally, have respected their wishes and have made no mention of them in this book.
The structure of the book is not according to a diagnosis but according to “presenting problem” or to the most prominent feature. Presenting problem in this context is the first impression that the doctors formed on either being referred the patient or on seeing them. Presenting problem is not meant to replace “diagnosis,” which is important in a different context. Indeed some cases could be allocated to different diagnostic groups. The philosophy of this book is to present how a doctor is faced with a patient who is suffering in their own particular way and gradually, after a painstaking process, the clinician gets to develop a deeper understanding of their predicament. The doctor will try to make sense of the patient's present state in the context of their personal history, present family situation, intimate relationships, work situation, understanding of their future, and the cultural context (historical and contemporary) in which they live. The sections of this book do not correspond to any diagnostic category, although diagnoses are inevitably in the author's mind and are occasionally mentioned in the text.
The reader of this book will gain a sense of the wide range of difficulties doctors encounter and the challenges they face both in their personal emotional well‐being and in their relationships with the other professionals (seniors of the same discipline and those of other disciplines, such as psychology, nursing, and the various therapies) both within their hospital and also with other agencies.
The ordering of the sections is arbitrary and does not imply order of severity or importance. The doctors have presented some but few patients with psychosis, though they have presented patients with psychotic and borderline symptomatology. The author has not engaged in an exhaustive consideration of the “right” diagnosis nor has he entered in the extensive professional dialogue (which justifiably exists) about the epistemological standing of various diagnostic categories, such as that of Borderline Personality Disorder. Where appropriate, mention of “borderline features” has been made.
The reader may feel that some of the details in the histories is redundant. They may be right, but the histories are included that so that there is a seamless exposition, as much as possible, of how the conclusions of the consultation have been reached. The author hopes that the readers of this book will feel that they become part of the journey that the consultation process represents and may be able to use similar activities in their own work setting.
Although this work has been developed with hospital psychiatrists, other mental health professionals such as psychologists, mental health nurses, occupational therapists, and social workers may find it useful because it is and, more so, as a prompt to develop similar activities in their work setting.
Jason Maratos
1 Depression
Ms. A
Introduction
Ms. A is a 60‐year‐old woman, divorced housewife, and living with her daughter in her
