John M. de Figueiredo

Depression and demoralization : phenomenologic differences and research perspectives

Demoralization may be viewed as a combination of distress and subjective incompetence. The main problem in demoralization is the sense of incompetence experienced by the demoralized individual; this sense of incompetence results from uncertainty as to the appropriate direction of action. By contrast, the major difficulty in endogenomorphic depression is a decreased magnitude of motivation even when the appropriate direction of action is known. This distinction is important not only because demoralization appears to be a major public health problem, but also because subjective incompetence appears to influence the course and worsen the prognosis of both nonpsychiatric and psychiatric disorders.

Subjective Incompetence, the Clinical Hallmark of Demoralization

Abstract Subjective incompetence is self-perceived incapacity to perform tasks and express feelings deemed appropriate in a stressful situation. Subjective incompetence together with distress is demoralization, the common feature of all conditions psychotherapy attempts to relieve. While scales for subjective incompetence are lacking, an overview of research suggests that subjective incompetence and distress will occur together when assumptions relevant to self-esteem are disconfirmed by the stressful situation or social bonds are inadequate. We distinguish subjective incompetence from other concepts, e.g., mastery, orientation of locus of control, learned helplessness, self-efficacy, and neuroticism.

Diagnosis and Measurement of Subjective Incompetence: The Clinical Hallmark of Demoralization

Background: This article presents the development and application of a method to diagnose and measure subjective incompetence, the clinical hallmark of demoralization. Methods: The subjects (n = 112) were patients with cancer at a consultation clinic of a cancer center. They completed a questionnaire on general background information, the Brief Cope Scale, and a newly developed scale to measure subjective incompetence. The development and psychometric properties of this scale were studied. Data analysis included both univariate and bivariate statistical tests and an examination of the intercorrelations between the subjective incompetence scores and the scores on the Brief Cope Scale. Results: The scale for subjective incompetence was found to have adequate reliability and validity. Conclusions: The proposed scale will allow us to determine if the distinction between depression and demoralization has practical implications and to what extent and to further clarify the role of demoralization in the etiology and pathogenesis of both physical illnesses and mental disorders. The combined use of this scale with the existing criteria and scales for demoralization will highlight the role of subjective incompetence in converting what might have been a normal response to stress into an abnormal state requiring intervention.

Demoralization and Psychotherapy: A Tribute to Jerome D. Frank, MD, PhD (1909–2005)

psychotherapies share at least four effective features: a therapeutic alliance between the helper and the sufferer; a context or healing setting; a rationale, conceptual scheme or myth that provides a plausible explanation for the patient’s symptoms; and a ritual or procedure that requires the active participation of the healer and the sufferer and that is believed by both to be the means of restoring the patient’s health. According to Frank, these four features are the nonspecific ingredients of the process of healing [1] . Frank recognized that improvement in psychotherapy is multidimensional and he broke the ground for the scientific study of psychotherapy by using comfort, effectiveness and self-understanding or self-awareness as outcome criteria [2] . Soon he noted that the key element in improvement is the patient’s own restorative process rather than the specific form of psychotherapy. This led him to study the attributes of patients that determine their responsiveness to presumed common features of all forms of psychotherapy [3] . A natural phenomenon is often recognized from a convergence of diverse lines of inquiry. Historically it appears that the aggravating role of demoralization was already apparent to Pinel when he noted that patients with chronic mental illnesses hospitalized at the Bicêtre became calmer after he broke their chains and helped them function in the community. Demoralization had been In 1949, when Jerome D. Frank, MD, PhD, first started investigating the active ingredients of successful psychotherapy, he faced the herculean task of finding common trends among a number of different competing schools, all of which claimed to be the true pathway to wisdom. To address this problem, he developed the Psychotherapy Research Unit at Johns Hopkins leading a group of investigators whose pathfinding discoveries started a revolution in psychiatry. To his surprise, Frank noted that the commonalities among these various methods of psychotherapy were far greater than their differences. He also noted that those who sought psychotherapy used similar expressions to describe their suffering. He proposed the term ‘demoralization’ to characterize the state of mind of persons seeking psychotherapy. He noted that the dictionary meaning of ‘demoralize’ is ‘to deprive a person of spirit, courage, to dishearten, bewilder, to throw a person into disorder or confusion’ and that these terms ‘well describe the state of candidates for psychotherapy, whatever their diagnostic label’. Moreover, he pointed out that all

The law of sociocultural demoralization

SummaryResearch in psychiatric epidemiology has consistently revealed that the mere exposure of a community to sociocultural change cannot be invariably associated with an increase in the prevalence of demoralization in that community. Rather, at a given rate of sociocultural change, the prevalence of demoralization is inversely associated with the sociocultural integration. This fundamental law of social psychiatry has important implications for health planning.

Distress, demoralization and psychopathology: Diagnostic boundaries

Background and Objectives: The objectives of the manuscript are: (a) to review the understanding of demoralization and its assessment; (b) to describe its clinical progression; (c) to explain the differences between demoralization and other form of psychological distress; (d) to propose a set of criteria for future research on demoralization. Methods: A MEDLINE search using the keywords distress, subjective incompetence, depression, demoralization, helplessness, hopelessness and psychopathology was conducted. This was supplemented by a manual search of the literature. Results: Demoralization can be distinguished from passing or transient distress, nonspecific distress, sub-threshold depression or anxiety, and certain mental disorders. Demoralization can be a risk factor for the manifestation of psychopathology, the prodromal phase of a mental disorder, or a trigger for exacerbation or recurrence of psychiatric distress symptoms. The domains of distress and demoralization are described and research diagnostic criteria for demoralization are presented. Conclusions: The scales discussed in this article differ in their time frames and have not yet been applied to the same population at the same time. The role of demoralization as a risk factor for mental disorders is just beginning to be understood. The domains and the diagnostic criteria for demoralization presented in this article need to be confirmed by epidemiological and empirical studies. Future research should continue to clarify its role in the pathogenesis of both mental disorders and physical illnesses and identify appropriate interventions for its arrest or prevention.

Explaining the ‘immigration advantage’ and the ‘biculturalism paradox’: An application of the theory of demoralization

Background:Recent immigrants have better mental health than the natives (‘immigration advantage’). Biculturals have better mental health than the monoculturals (‘biculturalism paradox’).Material:Mexican immigrants have lower rates of psychopathology than the US population. This is less true for Cubans and not true for Puerto Ricans. The ‘advantage’ also occurs in other groups. Biculturals have better mental health and endorse both cultures.Discussion:The theory of demoralization predicts that borrowing values from both cultures and applying them judiciously are more conducive to mental health than indiscriminately subscribing to either culture.Conclusion:The findings are consistent with the theory of demoralization.Background: Recent immigrants have better mental health than the natives (‘immigration advantage’). Biculturals have better mental health than the monoculturals (‘biculturalism paradox’). Material: Mexican immigrants have lower rates of psychopathology than the US population. This is less true for Cubans and not true for Puerto Ricans. The ‘advantage’ also occurs in other groups. Biculturals have better mental health and endorse both cultures. Discussion: The theory of demoralization predicts that borrowing values from both cultures and applying them judiciously are more conducive to mental health than indiscriminately subscribing to either culture. Conclusion: The findings are consistent with the theory of demoralization.

Prediction of use of psychiatric services: application of the CART algorithms

A computerized recursive partitioning program called Classification and Regression Trees (CART) was used to identify potential high users of services among low-income psychiatric outpatients. Sociodemographic variables, clinical variables (e.g., psychiatric diagnosis and type of presenting complaint), source of referral and the most recent psychiatric treatment setting used were studied. Discharge from inpatient psychiatric treatment right before admission to outpatient psychiatric treatment was found to be the most consistent, the most powerful and the only necessary predictor of high use of outpatient psychiatric services.A computerized recursive partitioning program called Classification and Regression Trees (CART) was used to identify potential high users of services among low-income psychiatric outpatients. Sociodemographic variables, clinical variables (e.g., psychiatric diagnosis and type of presenting complaint), source of referral and the most recent psychiatric treatment setting used were studied. Discharge from inpatient psychiatric treatment right before admission to outpatient psychiatric treatment was found to be the most consistent, the most powerful and the only necessary predictor of high use of outpatient psychiatric services.

Prevention of demoralization in prolonged bicultural conflict and interaction: The role of cultural receptors I – Description of a natural experiment

Background: This article examines how symbols and sentiments are exchanged to produce a synthesis of two cultures in the context of prolonged bicultural conflict and interaction, thereby minimizing or preventing sociocultural disintegration and the resulting demoralization. This process will be shown to be anchored on the discovery of certain thematic areas (cultural receptors) in which social roles or cultural mandates are missing, unclear, ambiguous or congruent. Material: The setting of this research is the history of Goa, a former Portuguese state on the western coast of India, where the exchange between the Portuguese and Indian cultures lasted longer than four centuries (1510–1961). Both published and unpublished sources were studied. Discussion: From 1510, the year of the beginning of the Portuguese rule, until 1540, the local traditions and leadership patterns were respected. This was followed by a period of religious intolerance during which attempts were made to encourage Hindus to convert to Christianity and to wipe out the bicultural interaction. Finally a new era of tolerance and cultural integration started around 1773 and continued until 1961. The bicultural interaction persisted and a hybrid culture developed around cultural receptors. Conclusions: The history of Portuguese Goa is a natural experiment that allows us to examine the role played by cultural receptors in the adaptation to acculturative stress.Background: This article examines how symbols and sentiments are exchanged to produce a synthesis of two cultures in the context of prolonged bicultural conflict and interaction, thereby minimizing or preventing sociocultural disintegration and the resulting demoralization. This process will be shown to be anchored on the discovery of certain thematic areas (cultural receptors) in which social roles or cultural mandates are missing, unclear, ambiguous or congruent. Material: The setting of this research is the history of Goa, a former Portuguese state on the western coast of India, where the exchange between the Portuguese and Indian cultures lasted longer than four centuries (1510–1961). Both published and unpublished sources were studied. Discussion: From 1510, the year of the beginning of the Portuguese rule, until 1540, the local traditions and leadership patterns were respected. This was followed by a period of religious intolerance during which attempts were made to encourage Hindus to convert to Christianity and to wipe out the bicultural interaction. Finally a new era of tolerance and cultural integration started around 1773 and continued until 1961. The bicultural interaction persisted and a hybrid culture developed around cultural receptors. Conclusions: The history of Portuguese Goa is a natural experiment that allows us to examine the role played by cultural receptors in the adaptation to acculturative stress.

Adaptive strategies for the prevention of demoralization in prolonged bicultural conflict and interaction

The objectives of this research are to present certain adaptive strategies used by the members of a society when exposed to conflict and interaction with a different culture for decades or centuries and to demonstrate that the use of these strategies minimizes or prevents sociocultural disintegration and the resulting demoralization. The setting of the study is the Christianization and ‘westernization’ that took place from 1510 till around 1773 in three districts of Goa, a former Portuguese state on the western coast of India. Information on the history of Portuguese India was studied in the archives and libraries in Goa, the United States, Portugal and other European countries. Five adaptive strategies were used by Hindus who converted to Christianity, by Hindus who refused to convert and by Europeans, including Catholic missionaries, who were in charge of the conversions. They are called transformational mapping, privatization, individuation, cohesiveness and pragmatism. Examples of each strategy are gi...The objectives of this research are to present certain adaptive strategies used by the members of a society when exposed to conflict and interaction with a different culture for decades or centuries and to demonstrate that the use of these strategies minimizes or prevents sociocultural disintegration and the resulting demoralization. The setting of the study is the Christianization and ‘westernization’ that took place from 1510 till around 1773 in three districts of Goa, a former Portuguese state on the western coast of India. Information on the history of Portuguese India was studied in the archives and libraries in Goa, the United States, Portugal and other European countries. Five adaptive strategies were used by Hindus who converted to Christianity, by Hindus who refused to convert and by Europeans, including Catholic missionaries, who were in charge of the conversions. They are called transformational mapping, privatization, individuation, cohesiveness and pragmatism. Examples of each strategy are given. By themselves or combined with each other, these adaptive strategies allowed the Goans to continue to function as a community, thereby preventing or minimizing sociocultural disintegration and the resulting demoralization. In the process, a vibrant hybrid culture was created and became a mark of distinction of Portuguese Goa.