Doctors and psychotherapists generally don't like it when their patients don't get better. But the fact is that lots of patients elude our clinical skill and therapeutic cleverness. That's often when the trouble starts.
Weeping in my office one day, he explained that he was depressed because he was a failure and a whiner. "Even my therapist agreed with me," he said. "She said that maybe I don't want to get better."
I could well imagine his therapist's frustration. She had been working with him for nearly three years without significant progress, and she was now doing what many clinicians do when the chips are down: blame the patient for failing to improve.
"I think he has an unconscious desire to remain sick," she told me.
About a month later, I saw this patient respond remarkably well to a novel treatment. Free of depression at last, he was joyful and relieved — an odd reaction, you must admit, from someone who secretly wished to be ill.
Not just that, but he no longer felt like a failure and was much more upbeat about his future prospects.
I decided to challenge him. "How come you're feeling so much better despite the fact that nothing in your life has really changed in the past few weeks?"
"Well, I guess I just think like that when I'm down."
Exactly. His sense of worthlessness was a result of his depression, not a cause of it. It's easy to understand why the patient couldn't see this: depression itself distorts thinking and lowers self-esteem. But why did his therapist collude with the patient's depressive symptoms and tell him, in effect, that he didn't want to get better?
For an all too human reason, I think. Chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it's easier — and less painful — to view the patient as intentionally or unconsciously resistant.
I recall an elderly woman who was referred by a colleague for intractable depression, in which I have a special interest. I was eager to help her. Several months and many treatments later, I began to get frustrated that she was no better and noticed that my thinking about her shifted. I wondered whether there was something about the sick role that she found rewarding.
After all, she had constant visits from friends and family members, not to mention an army of medical experts who were all trying, in vain, to cure her. If she got better, she might lose all that care and attention.
Then one morning, shortly after starting a new combination of antidepressants, she called. I did not recognize the cheerful voice. "I'm feeling really good," she told me. "Not depressed at all."
My delight aside, I felt chagrined that I had begun to write her off as a help-rejecting crank.
Of course, it makes good medical sense for therapists to rethink the diagnosis and treatment of any patient who fails to improve. But this is a double-edged sword.
Another patient, a young woman with unstable moods, was recently hospitalized with a diagnosis of bipolar disorder. When she failed to respond to two mood stabilizers, the staff began to entertain a diagnosis of borderline personality disorder, which involves emotionally chaotic relationships and impaired ability to function in the world.
"She's pretty aggressive and demeaning, and we think she has some serious character pathology," one of the residents told me.
But partly treated bipolar disorder can mimic borderline personality disorder, and after she received a third mood stabilizer, her "personality disorder" melted away, along with her provocative behavior.
This patient had frustrated her clinicians with her lack of response to treatment. In turn, her doctors reacted by changing her diagnosis to a personality disorder. The change in thinking shifted the blame from the clinicians to the patient herself, who was now viewed more as bad than sick.
To be sure, some patients really do want to be sick. People with Munchausen syndrome, for example, deliberately produce physical or psychological symptoms for the express purpose of assuming the sick role. And they will go to extraordinary means to defeat doctors who try to "treat" them.
But a vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let's keep the blame on the disease, not the patient.