Past psychiatric history
Margaret is new to the mental health service.
Present treatment and management
On the first consultation in February, Margaret was found to have low mood and to be calm and settled, even though she was weeping. She presented within the normal range. Her speech was coherent and relevant and was of normal tone and tempo. She claimed that she had been troubled by fewer suicidal ideas. No psychotic features were detected. She had no violent ideas or any harmful ideas toward her children.
The overall impression was that Margaret was suffering from a moderate depressive episode whose onset was well before the birth of her last child and which was related to multiple stressors. Margaret felt initially relieved to live away from her family of origin but found that since moving to the city she was facing more problems, such as financial stress and stress in relation to the care of the children, with limited social support.
Treatment options were discussed with Margaret who was then started on Sertraline 25 mg and was referred to a medical social worker and to the community psychiatric nurse service. The issue of the use of benzodiazepines while breastfeeding was also considered.
Consultation
JM acknowledged that this was a thorough and thoughtful presentation. JM addressed the question of why Margaret developed depression after the second child and not after the first. The doctor responded that Margaret had to change her living environment on this occasion so that her son could attend the nursery in the city. This move brought greater financial stress on the family. It was clarified that Margaret had lived in the country with her first child and her husband. It was therefore made clear that the family is under stress because of the opinion that the children would have a better education in the city than in the country. The doctor pointed out that Margaret was familiar with the city where she lived from her early teenage years. Furthermore, Margaret had been working in the city while living in the country for quite a few years. The doctor pointed out that quite a few families do this as a matter of course. The doctor also pointed out that many people who live in the country believe that the city offers better education, better social care, and better health care.
JM pointed out the disappointment that Margaret must have felt when she was expecting the move to the city to represent an improvement in her family life and living conditions and found quite the opposite. The doctor pointed out that the family had taken steps to make their stay in the city permanent, such as applying for an identity card for her husband and expecting their son to continue making improvement and a good adjustment at the nursery. They expect that after the identity card is obtained, the husband will be able to work and, therefore, contribute to the family finances. The doctor added that this was a realistic plan, but also noted that employment in the city is difficult to obtain.
JM then inquired about the debt. The doctor clarified that the debt had accumulated because of the husband's gambling. The doctor added that husband was gambling his own and his wife's savings. JM inquired further about husband's gambling, and the doctor added that there is an indication that husband is still gambling online from home. The doctor further added that husband is likely to be given an identity card in a few months' time.
JM then asked, because there probably was a group of county people who worked without an identity card in the cash economy, in the black market, or simply manual jobs for lesser money but cash in the city, why the husband wasn't doing something of the sort. JM pointed out that the family situation is not an adequate explanation for husband's staying at home and gambling instead of going out to earn a living to support the family. JM then inquired further about the husband's role in the family and, in particular, whether he was supportive of his wife in other ways.
JM summarized that the basis of Margaret's depression is her view of her own future as without hope of something getting better. JM inquired whether her feeling of hopelessness was based on the absence of any active steps that her husband could be taking to improve their situation. In this sense, her view of the future was realistic; that is, that things are not going to get better if the husband continues to behave the way that he has been.
JM then shifted the focus to Margaret's psychopathology. As the eldest child, she was brought up to feel that she was responsible for supporting the family. She may have carried the same expectation—the expectation that her parents had for her—as her expectation of herself now and, as such, had low expectations of receiving help from her husband. In other words, she expected that everything was her responsibility, and that if things were not going well, she had only herself to blame. Therefore, one of the early therapeutic objectives would be to alter Margaret's expectations of herself and of her husband. In other words, they should share more balanced expectations, but at the moment, she has to give priority to the care of a 3‐month‐old child. And, instead of wasting family resources by gambling, her husband, who has much more free time, should go out and earn money for his family.
JM then shifted the focus to Margaret's perception of the future. Although under the present dynamics, it did not look optimistic, they were not inevitable or unalterable. It was not inevitable that the husband would not pull his weight and that their finances would not improve. These may change if the correct support and direction was given to this family by the involved professionals. By professionals, I mean not only the clinical psychologist but also the social worker who would give them more directive advice. The likelihood is that her husband will get an identity card and, therefore, will be able to obtain legal employment. This would give the family a better living standard to which they can improve their predicament. They could be helped to have a more long‐term perspective and accept that, although in the immediate future finances will be tight, they do not have to be so in the long term. Margaret could be helped to see herself in a few years; time, when both children are at school, when both parents are employed, when the debt will have been repaid, and they will be able to pour the fruits of their labor into making a better family life for themselves and their children. The reality is that they are both healthy and young, and they can make a good life for their family in the city. They also have the alternative of possibly settling in the country and working in the city like so many people do. The point is to give Margaret the ability to have a more realistic perspective of the future rather than the present perspective, which is one of hopelessness.
JM summarized that these were the two dimensions of therapy; the first dimension is her internal dynamic and the expectations that she has of herself (as shaped by the abusive parenting of which she was subjected) and others, and the second dynamic is to develop a more realistic and more long‐term perspective of her future. For further study on effect of physical abuse on parenting see (Buist, 1998a; Buist, 1998b; Lang et al., 2010).
The doctor then added the dimension of parenting skills. Margaret sometimes hits her children physically and then feels remorseful about this. She feels unhappy that she is repeating the pattern with which she was brought up and is keen to give her children a different family experience. The doctor pointed out that although she wants to give her children a different family experience, when she is distressed and angry, she acts impulsively and hits them. JM responded to the doctor's added dimension by inviting her to focus on the reasons why her son was misbehaving. The doctor suggested that her son may be feeling jealous that much more attention was being given to his infant sister. JM suggested that it would be helpful to find out more about how her 3‐year‐old son developed the troubling behavior that he has and what is the feeling that drives this behavior. More particularly, the exploration needs to be directed to whether these parents give direction and proper attention to their son or whether they are neglectful of him because they are absorbed in other activities, some of them necessary, such as the care of their infant daughter, and some unnecessary, like the husband's online gambling. JM invited the doctor to explore the role of the father with his son and, in particular, whether the father actually spends a reasonable amount of time in some enjoyable or creative activity with