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Psychotherapy Casebook


Dean Schuyler, MD

Published: September 3, 2015


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Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is a psychiatrist and a member of the palliative care team at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.

Prim Care Companion CNS Disord 2015;17(5):doi:10.4088/PCC.15f01858

Published online: September 3, 2015.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (

Funding/support: None reported.

Potential conflicts of interest: None reported.

Many of us have used the word demoralized. We know what it means: a loss of purpose or meaning. Some of us have felt demoralized when something important doesn’ t work out as we intended. It is typically transient, and many of us know how to recover from a state of demoralization.

Demoralization features helplessness, hopelessness, and existential distress. It is often associated with a feeling of greater dependency on other people. It may include a sense of being a burden to others. It represents a loss of courage, a lost sense of effectiveness, and a loss of morale.

The association of demoralization with serious medical illness should be obvious, especially to providers of palliative care. Articles have attested to this association.1 Once a patient is diagnosed with, for example, cancer, life typically enters a new stage. Thought is given to what one is used to doing that one can no longer do. If these activities impinge on the patient’s sense of effectiveness, demoralization is a common result.

Demoralization is not depression, although they may share a number of features. There is no pill to treat demoralization. Treatment requires conversation, and the talk focuses on what the patient can do. Support is offered to the patient for speaking his or her mind. Pessimistic predictions are often challenged. Suggestions may be made for how to think, for example, about the future. Support from the family may be mobilized. A "moralizing" lecture might be given. Within the confines of a relationship, much can be done to help. I was reminded of this recently when Mr A was admitted to the hospital after a visit to the oncology clinic. I was asked to see him before he was moved to a room on a medical floor. I didn’ t know it then, but I would speak with him 6 more times before he was discharged home.


Mr A is a 70-year-old white man who was brought to the hospital by his brother and mother. He has been married 3 times and has 5 children, all girls. He was presently single and lived alone. His original family is large: 5 boys and 5 girls. He is the fifth eldest child.

Mr A is a high school graduate, who then served in the US Army. He worked a series of odd jobs, abused alcohol and drugs, but retained a close relationship with his mother and 1 brother. Ten years ago, Mr A abruptly stopped smoking and drinking and has not returned to either habit. Mr A fashions himself a "battler," and he has had a significant amount of success in this regard.

Two months ago, he noted the onset of abdominal pain associated with nausea, vomiting, and significant weight loss. He came to the medical clinic, and gastric cancer was suspected but could not be proven. He was noted to be mildly jaundiced with an elevated bilirubin level. Mr A was admitted to the hospital for further evaluation and treatment.


A team of surgeons came to see Mr A after tests confirmed a diagnosis of cholangiocarcinoma. When asked what treatment they suggested for him, he was told to speak with "a chaplain and hospice." Apparently, little thought was given to how Mr A might understand this suggestion. He saw it as "giving up on me." He described himself as a "fighter" who wanted to be told what could be done for him. He complained that, after the doctors left his room, he had no one to talk with and quickly was left alone with his thoughts. He praised a student nurse who sat on the edge of his bed and talked with him.

It became readily apparent that the confirmation of the medical diagnosis was demoralizing for him. I listened first to his complaint. "There was no one to speak up for me," he said, "and there was nothing for me to do. I was given a death sentence with no options."

I told Mr A how important it was for him to tell the providers what he thought and what he needed. His response was "Usually, I don’ t speak up. My brother or my mother speaks for me." At this point, I began my moralizing lecture. In the hospital, I told him, a patient needs to let providers of care know what he or she thinks and what he or she needs. If not, the patient is likely to be ignored, and others would instead be the recipients of time and attention. I told him that he needed a plan. Who would take care of him once he left the hospital? Where would the necessary money come from? What did he want the doctors to do for him? He was grateful and promised that he would think about it.

I returned to see Mr A 2 days later. He greeted me with, "No one has ever spoken to me the way that you did. I asked my brother if I could stay at his home after I left the hospital, and he promised to take care of me. I talked with the surgeons, and they scheduled me for surgery later this week. I arranged to get the money owed to me that I had not done that much about." I emphasized to him that he had done his job well. He had expressed himself and action had followed.

I next saw Mr A the day before surgery. "I didn’ t sleep last night because of nervousness," he said. We spoke about what he could and could not control. I emphasized that he had done all that he could do. We spoke about the meaningful relationships that he had established. We spoke about the successes he had experienced. I planned to see him the day after surgery.

When we were next together, Mr A related to me that he had told the surgeons to speak in detail with his brother about what they found and not with him. During the surgery, a feeding tube was placed. Mr A assured me that now he had a plan, and that he was following his plan. He spoke also about "crystal balls." I suggested that he not allow himself to think too far into the future. Rather, he might see how he felt and then plan his time on that basis. His anxiety was now minimized. He was no longer demoralized, and he was not depressed.

The last time I saw Mr A, we spoke in detail about this stage of his life: what he could do and what he could not do. He seemed to have a good understanding of his illness, and he knew that no provider could predict his day-to-day course at this point.

When he was spoken to initially, Mr A responded with demoralization. There was nothing he could do, and he interpreted what he was told as there was nothing anyone could do. When he took charge of his life, he found that there were a number of things he could do and that others would respond if he spoke up for himself. Within the context of a good relationship, he could be encouraged to defeat his demoralization.


1. Kissane DW, Clarke DM, Street AF. Demoralization syndrome: a relevant psychiatric diagnosis for palliative care. J Palliat Care. 2001;17(1):12-21. PubMed

Volume: 17

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