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Personal Accounts: How Guilty Am I?
Marianne Straumfjord, M.D.
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.11.1233
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In 1965, when I started medical school, the big question in allowing the four women into our class was whether we would contribute enough postgraduation to warrant training us. The admissions committee questioned us exhaustively about our plans for marriage and motherhood. The pressure was on. This concern has haunted me for 34 years now. Not that it stopped me from marrying and having a child. It did keep me from taking a three-month leave of absence when my son was born, and it also kept me on my toes during his childhood, making me feel guilty when I took time off to be with him. Certainly that was on top of feeling guilty about not being a good enough mom because I worked so much during his childhood. But there was a more deadly guilt awaiting me.

I have bipolar disorder. I have been hospitalized numerous times and find the rapid cycling and psychotic symptoms to be my hardest test of courage. On two occasions early in my career, I had to give up a family practice. On these occasions I was hospitalized for severe depression for periods lasting up to several months. After one of these episodes I found myself unable to practice for two years. Now I really had something to feel guilty about. I certainly am not stay-at-home-wife material. I couldn't hold a candle to the housekeepers I had employed to help me while I practiced, something even my long-suffering husband commented on. I missed the feeling of competence that a medical practice can awaken. I missed the closeness I had developed with peers, both other doctors and the nursing staff. By this time my son had grown to love his longtime babysitter and missed the friendships he had formed through her. I simply was not the kind of mother he had become so used to having. That is when I rallied my forces and started a psychiatry residency program.

By that time I was actively hallucinating, but I developed coping mechanisms that kept me working, except during times that my husband (who is a psychiatrist), my psychiatrist, and I agreed that I needed to back off for everybody's safety. I have always been careful to keep my patients' well-being in mind, sometimes to a fault. My superiors and peers always knew my diagnosis, and I was sensitive to their feedback. I was, however, turning into a good general psychiatrist. I went into a private practice that I found rewarding and avoided hospitalization for about 15 years, although the symptoms of auditory hallucinations and occasional suicidal ideation still occurred. I did find those symptoms difficult to manage, especially at night, because they interrupted regular sleeping habits.

Ten years ago I stopped private practice and became the medical director of a growing child and adolescent residential program. I loved my work, and my superiors were a dream come true. The volume of work grew exponentially as the organization merged with two other residential programs in a city about 70 miles away. I rapidly became responsible for providing care to about 200 inpatients as well as developing outpatient and alternative school programs. My administrative skills were tapped, and I reveled in it. I was doing a good job and got the feedback to prove it.

Then started the slippery slide. My husband retired, and we divided our time between two homes, one near my work and one about 100 miles away in a wonderfully small and beautiful community in the mountains. I was working three days a week at a job that was easily a five-days-a-week production and traveling 500 miles a week between campuses at work and trips to the "cabin," our main residence, on long weekends. Once again the guilt ate at me. I was denying my husband his retirement by remaining professionally active. I needed to spend more time at work.

A crazy nightmare ensued, and I responded in kind, becoming more and more depressed with interspersed episodes of hypomania. I can't say I was aware of the depths of my depression until about two years ago, when I realized that I was unable to safely see patients anymore. I did only administrative work for six months, then took a leave of absence, and finally resigned entirely. But that decision only made things worse. I not only grieved about losing my work but also was increasingly suicidal. The hallucinations were beginning to consume my time and attention.

In my case the morbidity of depression played out quite dramatically. I had a heart attack, the damage from which (but not the cause) was shown on angiography. Now I had something else to feel guilty about. Finally my psychiatrist suggested that I consider going into a hospital that could work with me over a longer period than the few days offered by our local units. Those hospitals were 3,000 miles away, but we decided to take the plunge.

By then I was dreadfully ill. It was a relief to go into the hospital and have care available at all times. I didn't want to kill myself, yet I was actively planning it. Things were at the emergency level. Medications failed miserably, and electroconvulsive therapy was the only viable option. For that I was transferred to a regional medical center, because of my heart disease. I had 16 sessions of electroconvulsive therapy before responding sufficiently to be discharged.

At the beginning of my hospitalization in the second unit, a physician said something to me that influences me to this day. It is one of the few things I can remember about that miserable time when guilt consumed me. One of the weekend physicians saw me for a short visit and said the fateful words: "You are just in this for the secondary gain. As a psychiatrist you should know better than that." He said this after seeing me for only about five minutes and without benefit of my history or mental status. His words echo in my head to this day. I cannot shake them. I felt—and still do feel—so guilty about the whole experience that his words burned into my very being. As many times as my family and other doctors have told me how unprofessional this man was, and although I know intellectually that what he said was grossly inappropriate, his words still come back to haunt me. I heard them when we had to refinance our home to pay the $90,000 hospital bill that insurance did not cover. I heard them when I was required to give up my license until I was considered psychiatrically stable. I heard them when I was eligible for Social Security Disability Insurance. I heard them when my long-term disability payments from work ended. And I still hear them when I try to get up the guts to re-enter the field of medicine. How do I know I am not making all this up? How guilty am I?

So that is where I am now. As I struggle to establish remission of my illness, the guilt of a lifetime of serious illness lives on. And that one comment has sealed my fate. Even the voices I hear—the ones that no one else can hear—repeat that physician's words over and over. I wonder how often I have negligently said something that a patient has had to struggle with for the rest of his or her life. I am sure, as psychiatrists, we all must have committed such errors—hopefully not as thoughtless as this man's statement, but nonetheless meaningful to the patient. How important it is to be aware of how powerful we can be in shaping a person's future life. Perhaps the dictum "do no harm" is true. We are stewards of a priceless entity: a patient's innermost feelings. We must be careful how we handle our responsibility.

Dr. Straumfjord lives in Camp Sherman, Oregon. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.

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