This morning’s *New York Times* includes an article: “When All Else
Fails, Blaming the Patient Often Comes Next” by Richard A. Friedman, M.D.

The author note states: Richard A. Friedman is a professor of psychiatry
at Weill Cornell Medical College.

Here are some excerpts:

[begin excerpts]

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.

<snip>

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.

<snip>

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.

[end excerpts]

The article is online at:
<http://www.nytimes.com/2008/10/21/health/21mind.html?ref=health&gt;.

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