Tag: psychotherapy

Do We Really Need Artificial Intelligence to Help People Who Are Demoralized?

I was just going through the many files on one of my old thumb drives that I still keep after I retired from consultation-liaison psychiatry over 5 years ago. I found a file that I must have typed from a source on how to help medically ill persons who are demoralized. Demoralization is not the same thing as depression or adjustment disorder. What I have copied from the original source is below, along with the reference.

Treating Demoralization

Ask first: “how are your spirits today?”  Then ask “what is the most difficult thing for you now?”

Coherence Versus Confusion

1.  How do you make sense of what you’re going through?

2.  When you are uncertain how to make sense of it, how do you deal with feeling confused?

3.  To whom do you turn for help when you feel confused?

4. (For religious patient) When you feel confused, do you have a sense that God has a way of making sense of it?  Do you sense that God sees meaning in your suffering?

Communion Versus Isolation

1. Who really understands your situation?

2.  When you have difficult days, with whom do you talk?

3.  In whose presence do you feel a bodily sense of peace?

4. (For religious patients) Do you feel the presence of God?  How?  What does God know about your experience that other people may not understand?

Hope Versus Despair

1.  From what sources do you draw hope?

2.  On difficult days, what keeps you from giving up?

3.  Who have you known in your life who would not be surprised to see you stay hopeful amid adversity?  What did this person know about you that other people may not have known?

Purpose Versus Meaninglessness

1.  What keeps you going on difficult days?

2.  For whom, or for what, does it matter that you continue to live?

3. (For terminally ill patients) What do you hope to contribute in the time you have remaining?

4. (For religious patients) What does God hope you will do with your life in days to come?

Agency Versus Helplessness

1.  What is your prioritized list of concerns?  What concerns you most?  What next most?

2.  What most helps you to stand strong against the challenges of this illness?

3.  What should I know about you as a person that lies beyond your illness?

4.  How have you kept this illness from taking charge of your entire life?

Courage Versus Cowardice

1.  Have there been moments when you felt tempted to give up but didn’t?  How did you make a decision to persevere?

2.  If you see someone else taking such a step even though feeling afraid, would you consider that an act of courage?  (If so) Can you imagine viewing yourself as a courageous person?  Is that a description of yourself that you would desire?

3.  Can you imagine that others who witness how you cope with this illness might describe you as a courageous person?

Gratitude Versus Resentment

1.  For what are you most deeply grateful?

2.  Are there moments when you can still feel joy despite the sorrow you have been through?

3.  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?

Griffith, J. L. and L. Gaby (2010). “Brief Psychotherapy at the Bedside: Countering Demoralization From Medical Illness.” Focus 8(1): 143-150.

There are a couple of resources I routinely used as a psychiatric consultant in the general hospital. One of them was the general outline of how to recognize and help someone who is demoralized (above). Another was a free online (non-AI) cognitive behavioral therapy resource that is still available called The MoodGym.

These are not the same thing as Artificial Intelligence (AI), which I think in some cases might be the wrong way to help someone with depression and anxiety that is more reactive to situational and medical stressors. AI can also be harmful to some people.

I have seen the brief psychotherapy guide above published and referenced in different articles on the web, one of them published as recently as 2025. Griffith and Gaby first published the guide to help those who are demoralized in 2005. It’s been around for 20 years and in my opinion is better than AI will ever be.

References:

James L. Griffith, Lynne Gaby,

Brief Psychotherapy at the Bedside: Countering Demoralization From Medical Illness,

Psychosomatics,

Volume 46, Issue 2,

2005,

Pages 109-116,

ISSN 0033-3182,

(https://www.sciencedirect.com/science/article/pii/S0033318205701006)

Abstract: Bedside psychotherapy with medically ill patients can help counter their demoralization, which is the despair, helplessness, and sense of isolation that many patients experience when affected by illness and its treatments. Demoralization can be usefully regarded as the compilation of different existential postures that position a patient to withdraw from the challenges of illness. A fruitful interviewing strategy is to discern which existential themes are of most concern, then to tailor questions and interventions to address those specific themes. Illustrative cases show how such focused interviewing can help patients cope assertively by mobilizing existential postures of resilience, such as hope, agency, and communion with others.

https://psychiatryonline.org/doi/full/10.1176/foc.8.1.foc143

Alyssa C. Smith, Jonathan S. Gerkin, Diana M. Robinson, Emily G. Holmes,

Consultation-Liaison Case Conference: Management of Demoralization in the Medical Setting,

Journal of the Academy of Consultation-Liaison Psychiatry,

Volume 67, Issue 1,

2026,

Pages 71-78,

ISSN 2667-2960,

(https://www.sciencedirect.com/science/article/pii/S2667296025005087)

Abstract: Demoralization has important implications for patients’ health, but consultation-liaison psychiatrists may be less familiar with diagnosis and management due to limited inclusion in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. We present the case of a multivisceral transplant patient who experienced demoralization due to complications from her posttransplant course. We discuss the diagnosis of demoralization, including differential diagnoses to consider, followed by a discussion of management of demoralization in the inpatient setting using acceptance and commitment therapy. We then discuss the consultation-liaison psychiatrist’s role in assisting with management of teams’ counter-transference to difficult patient cases, including the possibility of teams experiencing their own demoralization.

Keywords: demoralization; transplantation; transplant psychiatry; acceptance and commitment therapy; consultation-liaison psychiatry

An Anecdote About “Supportive” Psychotherapy

I just read Dr. George Dawson’s excellent blog post on supportive psychotherapy (“Supportive Psychotherapy—The Clinical Language of Psychiatry.” If you’re looking for an erudite and humanistic explanation of supportive psychotherapy, I think you’re unlikely to find anything superior to Dr. Dawson’s essay.

Now, about my take on “supportive” psychotherapy—there’s a reason why the word supportive is wrapped in quotes. It’s because I have a sort of tongue in cheek anecdote about it based on my experience with a staff neurologist in the hospital. It was long enough ago that I’m not sure what level of training I was in exactly. I was either a senior medical student or a resident doing a rotation on an inpatient neurology unit.

Dr. X was staffing the neurology inpatient service and I happened to overhear a brief conversation he had with the psychiatry consultants about what approach to adopt with a patient who he believed had a gait problem due to a psychological conflict. He wanted a psychological approach, preferring something on the psychodynamic side. I remember the psychiatric consultant said flatly, “We’re pretty biological.” I can’t remember what their recommendation was, but he disagreed. Later in the day, Dr. X gathered all of the trainees and we rounded on the patient in his hospital room.

We all crowded into the room with the patient, who had a severe problem walking due to what seemed to be unexplained hemiparesis. This is where the “supportive” element of Dr. X’s approach to psychological treatment came in.

Whether due to a deformity or past injury (I can’t recall which), Dr. X walked with a pronounced limp. He asked the patient if he would be willing to try walking vigorously with him across his room. Dr. X promised to assist him up and made it very clear that, despite his own limp, he was going to walk with the patient as normally as possible, together using both their legs.

The patient was very hesitant. Dr. X offered a lot of reassurance and encouragement—and then hoisted him up out of bed and marched with him across the room, ensuring that the only way this could happen was if he used both legs. The scene was comical, Dr. X limping but strongly moving in one direction while hauling the patient along with him.

The patient did it—twice and with increasing speed while obviously using both legs, never collapsing to the floor while Dr. X effusively praised him. He looked embarrassed and also seemed genuinely grateful for this miraculous cure. I was impressed.

I’m calling this a form of supportive psychotherapy partly in jest, but also to make a point about what support can mean, both literally and figuratively speaking, under certain circumstances according to how differently trained health care professionals might define psychiatric help.

Later in my career as a psychiatric consultant in the general hospital, I often found that many medical generalists and specialists preferred patients with these kinds of afflictions be transferred to psychiatric wards.

I don’t recall Dr. X ever suggesting that.

The personal identities of both doctor and patient were de-identified.

Dirty Dozen on Psychodynamic Psychotherapy in WordPress Shortcode

May is Mental Health Month! Have I said that already? Anyway, this is yet another one of my Dirty Dozen lectures. It’s on Psychodynamic Psychotherapy.

It’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size. If you see weblinks, right click the links to open them in a new tab.

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Dirty Dozen on Interpersonal Psychotherapy in WordPress Shortcode

Hey, because May is Mental Health Month, this is another one of my Dirty Dozen lectures. It’s on Interpersonal Psychotherapy.

It’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size. If you see weblinks, right click the links to open them in a new tab.

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Dirty Dozen on Cognitive Behavioral Therapy in WordPress Shortcode

In keeping with May being Mental Health Month, here’s another slide set on psychotherapy. This one is on the basics of Cognitive Behavioral Therapy. Once again, it’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size.

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Dirty Dozen on Common Elements of Psychotherapy in WordPress Shortcode

In observance of May being Mental Health Month, this is one of my Dirty Dozen lectures. It’s on the elements that are shared among some of the important psychotherapy methods.

It’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size.

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Stop Me If You Heard This One Before

I saw one of my favorite X-Files episodes the other night. It’s titled “Monday.” Mulder goes through the day repetitively doing the same things, including fumbling his chance to thwart a bank robber who blows up the bank and everyone in it, including Mulder. See the Wikipedia for a full spoiler alert but I’m going to spill the beans here anyway.

A lot of people think the idea was stolen from the movie “Groundhog Day,” which I’ve never seen. Actually, it was stolen from a Twilight Zone episode called “Shadow Play,” which I have seen.

“Monday” got good reviews overall, which is saying a lot. I never got the part about how a bank robber (Bernard) who can only land a job mopping floors would be smart enough to build a bomb jacket.

That said, the scenes are mostly everybody going through the day doing the same things over and over. Mulder and Scully both meet Bernard and his girlfriend Pam, who was always waiting outside in the getaway car and is the only one who remembers what has happened each and every time, which is about 50. Pam thinks Mulder is the key to disrupting the endless cycle. She has been trying to get Mulder to change what he does every time he walks in the bank just to cash a check and interrupts Bernard in the process of robbing the bank.

Mulder never gets it right away, but does wonder aloud that he’s getting a sense of déjà vu. Déjà vu is the sense that an experience is something you had before but could not have. The medial temporal cortex triggers the false memory and, normally, the frontal lobe says, “No, this is not a memory.”

Eventually, Mulder gets the idea of repeating to himself over and over that Bernard has a bomb and changes his approach by giving his gun to Bernard and telling him he knows he has a bomb. This approach is based on the assumption Bernard will walk out without setting off the bomb because Mulder will let him go without trying to arrest him.

Then, Scully brings Pam into the bank, and Bernard almost surrenders to Mulder, until he hears police sirens—and tries to shoot Mulder but instead kills Pam because she steps into the path of the bullet. He gives up and doesn’t set off the bomb. Pam changed the ending and notices just before she dies that it never happened in any of the previous enactments.

There’s the brain-based definition of déjà vu and then there’s a more mundane definition, both of which are in the Merriam-Webster dictionary on the web. The mundane definition is “something overly or unpleasantly familiar,” mainly about situations that happen repeatedly (“here we go again”).

We all recognize the second definition. We sometimes say or do something which we would not if we just recognized that it’ll trigger a pattern of events we would like to avoid. Something has to change in order to interrupt the pattern.

Psychiatrists and psychotherapists are usually experts in helping people change repetitive, maladaptive patterns of thought and behavior.

Medications can be helpful, for example in the repetitious thoughts and behaviors of obsessive-compulsive disorder (OCD). Some cases of that may respond better to a combination of psychotherapy and medication.

One of the challenges is that there are not enough helpers to help those who need it. Another challenge is that the ones who need help often don’t recognize they need it. That’s called lack of insight.

The cycle of lack of insight and unpleasantly familiar, repetitive patterns sometimes resulting in explosive consequences is ubiquitous in our society.

Can somebody please bring Pam into the consulting room?