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Blame the Illness, Not the Patient

Therapy and Therapists - Psychology, Psychiatry, Psychotherapy, and Health: Blame the Illness, Not the Patient Beyond Blue November 9, 2012 One of the most hurtful comments made to me ...

 

  1. #1

    Blame the Illness, Not the Patient

    Blame the Illness, Not the Patient
    Beyond Blue
    November 9, 2012

    One of the most hurtful comments made to me during the worst of my depression was this: “You must not want to get better.”

    I know that person didn’t intend to be spiteful or mean. She’s just plain ignorant regarding mental health issues. (But I still haven’t let it go, obviously.)

    Comments like that are why I’m so passionate about educating folks on mental illness and eliminating the isolating stigma of our condition. Because it’s hard enough fighting all the negative intrusive thoughts within our head. We don’t need additional insults and negative opinions–confirmation of our weakness–from folks who have never wanted to die and consider all suicidal thoughts self-absorbed and pathetic.

    But boy do we hear a lot of them, even from the persons who are supposed to be on our side: our doctors and psychotherapists.

    Richard Friedman, M.D. penned a compelling, salient piece for the New York Times awhile back on why so many doctors and psychotherapists blame their patients if they don’t get better. It beats blaming themselves!

    Friedman writes:

    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.

    I met one such patient not long ago, a man in his early 30s, who had suffered from depression since his teenage years. In six years of psychotherapy, he had been given nearly every antidepressant under the sun, but his mood hadn’t budged.

    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.”


    You can’t see me, but I’m nodding right now, as I read that. Because I’ve been there, done that, bought the t-shirt, and shrank it in the wash. I can honestly say that my current doctor, number seven, is the only psychiatrist who didn’t look at me with some speck of skepticism in her eye, as if I might be playing sick to prove that she should have never graduated from med school when she doesn’t know a thing about the brain, or how she and the entire field of psychiatry is a sham–a well-contrived conspiracy to get the people’s money, or that I just was on a mission to make her miserable. Because … I have nothing else to do?

    One therapist told me that he knew people who wanted to get well, and he knew people who wanted to stay sick. It’s no wonder, then, that he couldn’t understand why I lost control of myself during a panic attack, why I couldn’t access that “happy place” in my brain, to stop me from shaking, losing my grip of the steering wheel, and ultimately finding myself with a flat tire up on the curb of main road in Annapolis. In retrospect I know exactly why that happened: I wanted to stay sick!

    Thank God for doctors like Friedman and Dr. Smith who honestly get it–they realize that their patients don’t get anything out of misery. In fact, the misery is miserable! Dr. Smith has never once looked at me with scorn after I’ve had a setback–like I framed it to get on more Zoloft because that drug is sooo good for my sex life.

    The patient that Friedman described above finally responded to a treatment. Free from his depression, the guy no longer felt like a failure. Friedman writes:

    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.


    Friedman goes on to say that he believes that some patients do really want to be sick. According to Friedman, some “go to extraordinary means to defeat doctors who try to ‘treat’ them.”

    I don’t think the patient wants to defeat the doctor. I think he is merely too sick to get well, meaning he can’t do all the hard work that’s required to maintain recovery when his feet are cemented in his disease. That cycle–which I know all too well–is a pernicious one that I no longer judge.

    Or maybe some folks are just more driven and more disciplined to get to Sanity Island. Either way, I’d like to blame the illness, not the patient. Friedman does, for the most part, too. He concludes the article with this: “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.”

  2. 5 members thanked David Baxter for this post:

    Cat Dancer (November 9th, 2012),forgetmenot (November 11th, 2012),Lost_In_Thought (November 9th, 2012),rdw (November 9th, 2012),W00BY (November 9th, 2012)

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  4. #2

    Re: Blame the Illness, Not the Patient

    When All Else Fails, Blaming the Patient Often Comes Next
    By RICHARD A. FRIEDMAN, M.D., New York Times
    October 20, 2008

    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.

    I met one such patient not long ago, a man in his early 30s, who had suffered from depression since his teenage years. In six years of psychotherapy, he had been given nearly every antidepressant under the sun, but his mood hadn’t budged.

    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.

    Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.

  5. 2 members thanked David Baxter for this post:

    Cat Dancer (November 9th, 2012),rdw (November 9th, 2012)

  6. #3

    Re: Blame the Illness, Not the Patient

    Wow. That is a good article. I totally blame myself for my illnesses. I DO feel like I'm choosing to stay sick. I know I do have self defeating behaviors that might be proof of that.

    i can't see why anyone would want to be like this on purpose though.

  7. Re: Blame the Illness, Not the Patient

    It is good to see that there are some in the professional field that do get it that understand oh god i wish there were more of them.

    The article brings me to tears because i think too the struggles are so hard and sometimes the fight before a person is so difficult that one can get overwhelmed with all that is in front of them so they are pushed down again. I too believe that the illness is to blame.
    Ones in power should never say statements of negativity it only pushes a person self esteem even lower. One should never take away hope or say things that are hurtful I know they are humans too these professionals but if they cannot say something positive then for god sake don't say anything at all.
    Stay still and listen learn to really listen ok Words use your words wisely and carefully A person that is is sick needs compassion and guidance and if they finally get that they will learn to trust and they learn that perhaps they are worth the fight

    The ones that want to be sick well that is a illness that needs treatment to they are missing something

    People should not judge others really unless one has been in their shoes then don't judge try to listen and be still and just be there
    I myself don't know if i will be able to beat this sadness but i know with caring professionals i can at least face one day at a time

  8. #5

    Re: Blame the Illness, Not the Patient

    Thank you for a great article. I was told so many times that I did not want to get better, but of course it was misdiagnosis and the wrong medications that were the culprit.

  9. #6

    Re: Blame the Illness, Not the Patient

    This is an amazing article and responses.
    One thing I have trouble understanding is OCD literature with lots of descriptions of patients who don't get better "refusing to give up the behavior" or being "unwilling to let go of the thoughts". The words refusing and unwilling are like a poison dagger in my heart.
    Also acknowledging little accomplishments can be very healing for a patient. I felt a lot of blame and frustration from one therapist and I told him nervously that I had a secret wish for positive reinforcement. He said sarcastically "You're not a DOG you don't need reward and punishment." I felt stupid and humiliated for my shameful craving for positive acknowledgments or reinforcement.

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