When I see a clinically depressed patient who is temporarily unable to work, I fill out disability paperwork, usually the California SDI form. Such forms always ask me to estimate when the patient will be able to resume working. With proper treatment, most depressive episodes significantly improve in less than three months, so that is what I usually estimate. I consider this a little on the generous side, as I want my patient to have the disability benefit he or she deserves. However, unlike recovery from pneumonia or a broken leg, recovery from depression varies widely. Some patients are back to baseline in less than a month, others take much longer than three. I have long been fascinated by the dynamics of predicting recovery. Depression, almost by definition, leads to pessimism. For this reason, my three-month estimate often strikes the depressed patient as too soon — too soon to hope to be well, perhaps too soon for me to expect much improvement of them. Yet part of helping someone overcome depression is to lend optimism and hope. I’d rather err on the side of quick recovery than to pessimistically assume long-term disability. Indeed, when I’ve sometimes overestimated the recovery time, and the patient feels well in three weeks instead of three months, I feel I’ve made the more serious error.
A small subset of patients I see are, for want of a better term, “professional patients.” It is their identity to be ill and disabled. It is their defining characteristic, the first way they introduce themselves. Saying it this way risks “blaming the victim,” as these people did not choose to be sick. They are not malingering (intentionally faking illness). However, even unwanted illness can assume a purpose for itself. Disability becomes a calling card to see a variety of doctors, to call the crisis line and talk, to try a shopping bag full of medications. It becomes a ready answer to that very difficult question: Who am I? Some patients remain psychiatrically disabled because it is a way to be in the world, the only way they find comfortable or familiar. It can be challenging to explore the meaning of such disability in therapy. Patients sometimes complain that I don’t “believe” them, that I should take their disability on face value. I prefer to help them find more options in life, as sometimes disability itself is a state of mind.
From the psychiatric perspective, there is a fine line between assertiveness and undue personal entitlement. On the one hand, it is healthy and strong to assert one’s needs, to make a place for oneself in the world. On the other, diagnostic terms like “narcissism” apply to people who feel, without reason, they are so special they need not obey the same rules as everyone else. As described in my last post, some claims to keep pets in “no pets” housing, or to bring them to work or shopping for “emotional support,” seem to cross over this line. Since narcissism is ego-syntonic (not seen as a problem by the patient himself), it is frequently difficult to address in psychotherapy, or to interest the patient in therapy at all.