Psychiatric Patients Who Do Not Believe They Deserve to Get Better

Seven years ago, our clinical research group began to
work in our hospital’s partial hospital program. Patients
are most commonly referred to the partial hospital because
they are in crisis, are being transferred from a more intensive
level of care (ie, inpatient services), or are referred from
outpatient settings because they have not responded to
treatment. While the average length of stay in the partial
hospital program is approximately 2 weeks, a minority of
patients are treated for more than a month. During the
course of prolonged admissions, some patients make little
change in their behavior and do not experience much
improvement in symptoms or functioning despite intensive
psychotherapy and ongoing pharmacotherapy. In trying to
understand the reasons for the lack of progress, we learned
that some patients asserted that they did not believe that they
deserved to feel better. It has been our clinical impression
that the patients who did not believe that they deserved to
feel better were less responsive to treatment.
We are unaware of any studies of psychiatric patients’
beliefs as to whether they merited feeling better. This is
understandable because it is reasonable to assume that
patients seeking treatment in an ambulatory setting are doing
so because they wish to get better. While desired clinical
improvement is usually the primary reason that patients
seek treatment, patients also come for treatment for extrinsic
rather than intrinsic considerations. The encouragement (or
requirement) of family, friends, school officials, employers,
or the legal system are some external factors that may be
responsible for patients coming for treatment. Incentive to be
discharged sooner from inpatient settings and the desire not
to be hospitalized when seen in the emergency department
are some other motivations for patients to present for care in
ambulatory settings. Such dynamics likely influence patients’
opinions of whether they want or need treatment. However,
our focus in this commentary is not on whether patients
want treatment, or want to get better, but instead on patients’
internalized belief of whether they deserve to feel better.

We examined the prevalence of the belief of
undeservingness and the demographic and clinical
features that characterized patients who held this belief.
In working with patients in the partial hospital, it was our
clinical impression that patients with depression, a history
of trauma, and borderline personality disorder were more
likely to question whether they deserved to feel better. We
also hypothesized that patients who did not believe that they
deserved to feel better would more frequently drop out of
treatment and, if they stayed in treatment, would have a
greater length of stay in treatment…