What is Patient Demoralization?

This post is a summary of the informative article “Brief Psychotherapy at the Bedside: Countering Demoralization from Medical Illness” by Griffith and Gaby in 2010.  

Demoralization is the helplessness, hopelessness, confusion, low self-esteem, and subjective incompetence felt by a person who believes they are failing their own or others expectations in coping with life stressors (Griffith & Gaby, 2005). 

Demoralization is frequently confused with depression. In contrast to depression, responsively of mood is maintained. Moreover, demoralization does not respond to antidepressant medication and is best treated by removing stressors or improving the patient’s resilience to stress.

Griffith & Gaby summarize, “Demoralization in medically ill patients can be usefully regarded as the compilation of different existential postures that position a patient to retreat from the challenges of illness. When different existential postures blend together, they give rise to a sense of subject incompetence that has been regarding as the distinguishing feature of demoralization.”

The existential postures of vulnerability and resilience to illness are as follows:

Confusion vs. Coherence

Confusion is the inability to make sense of one’s situation. This occurs in patients who become encephalopathic, or those receiving conflicting medical information from various providers. In this situation the clinician should seek to strengthen the patient’s coherence by asking “how do you make sense of what you are going through?” or “To whom do you turn to help when you feel confused?”

Isolation vs. Communion

Isolation refers to being segregated physically and emotionally from others. This occurs in patients due to stigma, disfigurement, or fears of contagion. To improve resilience, the clinician attempts to strengthen the patient’s sense of communion by asking, “What you have difficult says, with whom do you talk,” and “Do you feel the presence of God and what does God know about your experience that others cannot understand.”

Despair vs. Hope

Despair is hopelessness. To mobilize a sense of hope, the clinician should ask, “Who have you known in your life who would no be surprised to see you stay hopeful amid adversity? What did this person know about you and that other people may not have known?”

Helplessness vs. Agency

Agency is the perception that one can make meaningful actions and that these actions matter. Questions to ask include: “what is your prioritized list of concerns? What concerns you most?” and “How have you kept this illness from taking charge of your entire life?”

Meaninglessness vs. Purpose

“Suffering without meaning is unbearable” (Griffith & Gaby, 2005). To mobilize a sense of purpose, the clinician should ask, “For whom, or for what does it matter that you continue to live?” and “What do you hope to contribute in the time you have remaining?” 

Cowardice vs. Courage

Courage is the ability to persist despite feeling of intense fear. The clinician should help the patient perform small acts of courage which will motivate further courageous acts.  Clinicians should ask “Have there been moments when you felt tempted to give up but didn’t’? How did you make a decision to persevere?”

Resentment vs. Gratitude

Gratitude prevents anxiety and depression. The clinician can mobilize gratitude by asking “what are you most deeply grateful?” and If you could look back on this illness from some future time, what would you say that you took from the experience that added to your life?”

The clinician should first identify which existential posture has consumed the patient’s experience of illness and then tailor questions and interventions toward these themes. The role of the clinician is to improve existential postures of reliance by “witnessing, validating, and normalizing the patient’s personal experience of illness” (Griffith & Gaby, 2005).

Download the “Brief Psychotherapy at the Bedside” PDF