Query

A few weeks ago I tried a new approach with one of my patients. He's affected with a particularly debilitating illness; I'd been treating him for what appeared to be a garden-variety depression. I started him on medication and did what mild cognitive–behavioural therapy I felt comfortable doing. He progressed reasonably well — better able to concentrate, having more energy, feeling less guilty for being ill, feeling less like he was a failure, having a better appetite, getting a better sleep.

But then the progress stopped. My patient stayed stuck — he still had all the cardinal symptoms of depression, only at a lesser severity. At first I increased his medication, then supplemented it, but he could make no further progress. I asked if he was actually taking his medication and was told Yes.

Whenever I reach a plateau when treating an illness, I wonder about what I'm not doing, what the patient might not be doing, or if, indeed, this is as good as things are going to get. I look back at all the previous visits and try to see what's missing. And when I did that in this patient's case, I recognized that, although there were many psychotherapy sessions spent on relationship problems, on work problems, on grief issues, and on sexuality, I had failed to ask a simple but crucial question.

How do you feel about yourself?

The response I got was remarkable. Suddenly he began to tell me of how inadequate he felt in every sphere of his life, about how he never felt good enough or worthy enough to be the recipient of someone else's affection, about how he avoided making social contacts out of a chronic fear of rejection. He felt he was a bad person who deserved to feel depressed.

It was that last comment in particular that caused me to realize that this person's recovery was arrested by his inability to let go of depression. He was actually hanging on to his disease because he felt it was a necessary part of his existence.

I did the usual things, telling him that he was a useful human being, that he deserved to get better, but at each point I was met with a shrug or a shake of the head. It was clear that he wasn't going to let go of his disease without some prodding.

“Do you think you deserve to be sick?”

“Well, not when you put it that way s…”

“How much do you think your depression is actually the result of your need to be sick?”

I challenged him as much as was safe to do and then gave him some homework. I told him to do three things each day that would nurture him, that would be for himself only — something like taking a walk in a park or sitting down and having a random and extended cup of coffee. I told him his depression was partly due to self-laceration, that he was making himself depressed through self-abuse, and that he needed to take care of himself before he could hope to get better. I added that he deserved to get better, and still that was met with a shake of the head. I told him to do his homework anyway, even though he might not believe in it.

Though low self-esteem is not a DSM-IV mental illness, patients like this one affirm in my mind how powerful a disease it can be. It doesn't matter whether the depression or the low self-esteem came first; both need treatment, and one may not improve without the other. Though I don't prescribe self-care on a prescription pad, I believe it's as powerful a directive as an SSRI.

It was gratifying when I saw my patient in follow-up today and he had begun to get better — grudgingly. — Dr. Ursus