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.
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