Clinical Social Work Journal

, Volume 47, Issue 3, pp 266–275 | Cite as

Demoralization During Medical Illness: A Case of Common Factors Treatment

  • Douglas BehanEmail author
Original Paper


A serious physical illness can become the defining aspect of a person’s life. If a belief develops that the illness cannot be resolved, either through medical care or one’s own coping efforts, then a person can develop demoralization, which is defined as a pervasive feeling of defeat, hopelessness, and powerlessness. Demoralization involves a depressed mood but differs from a major depressive episode in that demoralization does not exhibit the generalized anhedonia found in major depression. Instead, demoralization has a singular precipitating factor causing the patient’s hopelessness, the illness. A patient’s demoralization typically remits if some form of hope is restored. The experience of being hospitalized for an illness, which is often overwhelming and difficult for patients, can adversely impact hope and foster or exacerbate demoralization, leading to adverse outcomes. A brief approach to treating demoralization in the hospital environment, emphasizing interpersonal engagement over pharmacological interventions, is described through a case example. The approach is based on the common factors approach to effective psychotherapy and is well suited for use within fast-paced medical settings.


Demoralization Common factors Hopelessness Helplessness Serious illness 


Compliance with Ethical Standards

Conflict of interest

Douglas Behan declares that he has no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. Ahn, H. N., & Wampold, B. E. (2001). Where oh where are the specific ingredients? A meta-analysis of component studies in counseling and psychotherapy. Journal of Counseling Psychology, 48, 251.CrossRefGoogle Scholar
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Washington, DC: American Psychiatric Publications.CrossRefGoogle Scholar
  3. Blount, A., Schoenbaum, M., Kathol, R., Rollman, B. L., Thomas, M., O’donohue, W., & Peek, C. J. (2007). The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research and Practice, 38(3), 290.CrossRefGoogle Scholar
  4. Brown, J. (2015). Specific techniques vs. common factors? Psychotherapy integration and its role in ethical practice. American Journal of Psychotherapy, 69(3), 301–316.CrossRefGoogle Scholar
  5. Cheng, C., Lau, H., & Chan, M. (2014). Coping flexibility and psychological adjustment to stressful life changes: A meta-analytic review. Psychological Bulletin, 140(6), 1582–1607.CrossRefGoogle Scholar
  6. Clarke, D., Cook, K., Coleman, K., & Smith, G., & (2006). A qualitative examination of the experience of ‘depression’ in hospitalized medically ill patients. Psychopathology, 39(6), 303–312. Scholar
  7. Clarke, D. M., & Kissane, D. W. (2002). Demoralization: Its phenomenology and importance. Australian and New Zealand Journal of Psychiatry, 36(6), 733–742.CrossRefGoogle Scholar
  8. Clarke, D. M., Kissane, D. W., Trauer, T., & Smith, G. C. (2005). Demoralization, anhedonia and grief in patients with severe physical illness. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 4(2), 96–105.Google Scholar
  9. Connor, M. J., & Walton, J. A. (2011). Demoralization and remoralization: A review of these constructs in the healthcare literature. Nursing Inquiry, 18(1), 2–11. Scholar
  10. deFigueiredo, J. (1993). Depression and demoralization—phenomenological differences and research perspectives. Comprehensive Psychiatry, 34(5), 308–311. Scholar
  11. Drisko, J. (2004). Common factors in psychotherapy outcome: Meta-analytic findings and their implications for practice and research. Families in Society: The Journal of Contemporary Social Services, 85(1), 81–90.CrossRefGoogle Scholar
  12. Drisko, J. (2013). The common factors model: Its place in clinical practice and research. Smith College Studies in Social Work, 83(4), 398–413.CrossRefGoogle Scholar
  13. Finset, A., Steine, S., Haugli, L., Steen, E., & Laerum, E. (2002). The brief approach/avoidance coping questionnaire: Development and validation. Psychology, Health & Medicine, 7(1), 75–85.CrossRefGoogle Scholar
  14. Frank, J. D., & Frank, J. B. (1993). Persuasion and healing: A comparative study of psychotherapy. Baltimore: JHU Press.Google Scholar
  15. Galiana, L., Rudilla, D., Oliver, A., & Barreto, P. (2017). The short demoralization scale (SDS): A new tool to appraise demoralization in palliative care patients. Palliative & Supportive Care, 15, 1–8.CrossRefGoogle Scholar
  16. Griffith, J. L., & Gaby, L. (2014). Brief psychotherapy at the bedside: Existential neuroscience to mobilize assertive coping. Psychiatric Times, 31(11), 1–6.Google Scholar
  17. Hojat, M. (2016). Empathy in health professions education and patient care. Cham: Springer. Scholar
  18. Hughes, B. M. (2001). Psychology, hospitalization and some thoughts on medical training. European Journal of Psychotherapy, Counselling & Health, 4(1), 7–26.CrossRefGoogle Scholar
  19. Jacobsen, J. C., Maytal, G., & Stern, T. A. (2007). Demoralization in medical practice. Primary Care Companion to the Journal of Clinical Psychiatry, 9(2), 139–143.CrossRefGoogle Scholar
  20. Katon, W. J. (2003). Mood disorders and medical illness: Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54, 216–226. Scholar
  21. Kazdin, A. E. (1986). Comparative outcome studies of psychotherapy: Methodological issues and strategies. Journal of Consulting and Clinical Psychology, 54(1), 95–105.CrossRefGoogle Scholar
  22. Kimmel, R. J., & Levy, M. R. (2013). Brief psychotherapy for demoralization in terminal cancer: A case report. Psychosomatics, 54(1), 84–87. Scholar
  23. Kissane, D. W. (2014). Demoralization: A life-preserving diagnosis to make for the severely medically ill. Journal of Palliative Care, 30(4), 255–258.CrossRefGoogle Scholar
  24. Kissane, D. W., Wein, S., Love, A., & Lee, X. Q. (2004). The demoralization scale: A report of its development and preliminary validation. Journal of Palliative Care, 20(4), 269.CrossRefGoogle Scholar
  25. Lambert, J. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 139–193). New York: Wiley.Google Scholar
  26. Lolak, S. (2004). Bedside psychotherapy. Current Psychiatry, 3(8), 11–20.Google Scholar
  27. Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T. P., Berman, J. S., Levitt, J. T., & Krause, E. D. (2002). The dodo bird verdict is alive and well—mostly. Clinical Psychology: Science and Practice, 9(1), 2–12.Google Scholar
  28. Mangelli, L., Fava, G., Grandi, S., Grassi, L., Ottolini, F., Porcelli, P., & Sonino, N. (2005). Assessing demoralization and depression in the setting of medical disease. Journal of Clinical Psychiatry, 66(3), 391–394.CrossRefGoogle Scholar
  29. Miciak, M., Gross, D. P., & Joyce, A. (2012). A review of the psychotherapeutic ‘common factors’ model and its application in physical therapy: The need to consider general effects in physical therapy practice. Scandinavian Journal of Caring Sciences, 26(2), 394–403. Scholar
  30. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48(1), 98–102.CrossRefGoogle Scholar
  31. Robinson, S., Kissane, D. W., Brooker, J., & Burney, S. (2015). A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: A decade of research. Journal of Pain and Symptom Management, 49(3), 595–610.CrossRefGoogle Scholar
  32. Robinson, S., Kissane, D. W., Brooker, J., & Burney, S. (2016). A review of the construct of demoralization: History, definitions, and future directions for palliative care. American Journal of Hospice and Palliative Medicine®, 33(1), 93–101.CrossRefGoogle Scholar
  33. Rosenberger, P., Jokl, P., & Ickovics, J. (2006). Psychosocial factors and surgical outcomes: An evidence-based literature review. Journal of The American Academy of Orthopaedic Surgeons, 14(7), 397–405.CrossRefGoogle Scholar
  34. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6(3), 412–415.CrossRefGoogle Scholar
  35. Sagi, A., Joels, T., Scharf, M., & Van Ijzendoorn, M. H. (2002). Disorganized reasoning in holocaust survivors. American Journal of Orthopsychiatry, 72(2), 194–203. Scholar
  36. Sansone, R. A., & Sansone, L. A. (2010). Demoralization in patients with medical illness. Psychiatry (Edgmont), 7(8), 42.Google Scholar
  37. Shamai, M., & Levin-Megged, O. (2006). The myth of creating an integrative story: The therapeutic experience of Holocaust survivors. Qualitative Health Research, 16(5), 692–712. Scholar
  38. Slavney, P. R. (1999). Diagnosing demoralization in consultation psychiatry. Psychosomatics, 40, 325–329. Scholar
  39. Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32(9), 752.CrossRefGoogle Scholar
  40. Stewart, M., Brown, J. B., Donner, A., McWhinney, I. R., Oates, J., Weston, W. W., & Jordan, J. (2000). The impact of patient-centered care on outcomes. Journal of Family Practice, 49(9), 796–804.PubMedGoogle Scholar
  41. Tecuta, L., Tomba, E., Grandi, S., & Fava, G. A. (2014). Demoralization: A systematic review on its clinical characterization. Psychological Medicine, 45(04), 673–691. Scholar
  42. Temple, S., & Stuart, S. (2010) Psychotherapy for the hospitalized medically ill patient. Psychosomatic Medicine. Scholar
  43. Trappler, B. (2002). Holocaust survivors in a primary care setting: Fifty years later. Psychological Reports, 2, 545–552.CrossRefGoogle Scholar
  44. Wampold, B. E. (2015). How important are the common factors in psychotherapy? an update. World Psychiatry, 14(3), 270–277. Scholar
  45. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. London: Routledge.CrossRefGoogle Scholar
  46. Wissow, L., Anthony, B., Brown, J., DosReis, S., Gadomski, A., Ginsburg, G., & Riddle, M. (2008). A common factors approach to improving the mental health capacity of pediatric primary care. Administration and Policy in Mental Health and Mental Health Services Research, 35(4), 305–318. Scholar
  47. Zeidner, M., & Aharoni-David, E. (2015). Memories of holocaust-related traumatic experiences, sense of coherence, and survivors subjective well-being in late life: Some puzzling findings. Anxiety, Stress and Coping, 28(3), 254–271. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of Social Work, RutgersThe State University of New JerseyNew BrunswickUSA

Personalised recommendations