Episode 257: How to Overcome Guilt: Break Free from Unreasonable Expectations with Jennifer Reid, MD
Jennifer Reid, MD and David Puder, MD
Transcript editing: Joanie Burns, PMHNP-BC and Amy Dunn
By listening to this episode, you can earn 1.0 Psychiatry CME Credits.
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What Causes Guilt? Why It’s So Common in 2025 (0:00)
Puder:
Welcome back to the podcast. I am joined by Jennifer Reid. She's a psychiatrist and has written a recent book called Guilt Free [Guilt Free: Reclaiming Your Life from Unreasonable Expectations]. She has a podcast that is called A Mind of Her Own, which I was able to listen to. And she talks about different topics such as guilt. I'm excited to get into this and really get your perspective on it, what you think we can do to decrease it. The book is written for women, but all mental health providers have experienced guilt. And so, why don't we start with how you got excited about this. Tell me a little bit about guilt.
Reid:
Yes. So, you know, as a practicing psychiatrist, when you're sitting across from patients, thousands of patients over the years, you start to hear patterns of challenges or complaints or ways that they're suffering or struggling. And guilt was one I just kept hearing over and over again from my patients. And I also heard it from friends and family, and I certainly felt it myself. I think, in particular, sort of COVID and beyond just this sense of never feeling like you're doing enough, never feeling like you can get caught up, not feeling organized enough to, to be perfect in all your roles. And I was struggling with how to guide patients because I didn't feel like I knew how to break it down. I like to try and simplify as much as I can so that people can examine their own lives, you know, as opposed to, here's this broad concept and “good luck to you.”
Reid:
And so, I started writing about it because I really wanted to understand it and wanted to have some resources to give to my patients when they were really struggling. And the research on it has been really helpful, informative, and writing this book and editing it has really helped me with my own guilt and being able to use these tools in my own life. So I really hope it does work for others, but I think that it is this ubiquitous feeling—why are we struggling so much? That was the answer I wanted to figure out.
Guilt vs Shame: What’s the Difference? (02:19)
Puder:
So differentiate, maybe, guilt from shame. How would you differentiate those?
Reid:
Yes, I mean, I think there are certainly places where it can be difficult because there is some overlap, but guilt really in a broad sense is, “I've done something wrong or I've not done something I should have done.” And so it's more, “This was my behavior, this was my action, this was something that I did.” As opposed to shame, which can become, maybe they've done something wrong, but that then defines their entire person. “I am bad.” Right? “I am worthless. I am a bad person in general.” Simply because I did something small, made a mistake, or had some particular challenge. So shame is more kind of all encompassing you as a person. Whereas guilt, I mean, guilt at its most adaptive is highlighting a situation where maybe you've made a mistake or done something that may have harmed someone or upset someone. You recognize that you feel badly about it, and you work to repair. So that's adaptive guilt. And we've had that for eons. We evolved to have that to stay connected with our community. It's just this maladaptive broad generalized guilt, which is, “I'm responsible for everything and I'm failing at everything,” that really causes problems. And I think that can shift into shame because there's this sense, “If I can't do any of these things perfectly, then I'm just not a worthwhile person. I don't have value.”
Healthy Guilt: Benefits and When It’s Normal (03:45)
Puder:
Yes. Okay. So yeah. What are the adaptive qualities of guilt? Like healthy guilt?
Reid:
Right. So really, interpersonally, right? We know how important our interpersonal relationships are. We know as mental health providers that [interpersonal relationships] really affect our mood, and affect our longevity, for that matter. And so we really need that ability to say to someone else, “I noticed that some harm has come to you” (Identify “you” as another person—this is why it takes you to age three or four to start having these abilities to identify you as someone else). “I see that you're hurting” (I may feel empathy towards you. I feel what you are feeling). And I say, “I don't like that you're feeling that way. I want to try and do something to make it better.” So you're identifying to that other person or those people, “I care about you, I see what I did wrong, and I want to make a repair so that it doesn't happen again, and we can move forward with connection and support.”
Reid:
So that's where it's adaptive, right? We don't want someone to be absolutely without any guilt or shame, for that matter. That is sort of pathological to say, “Well, I may have just cut you off in traffic and [caused] you to crash your car, but whatever, I don't feel anything.” Of course we're going feel guilty if we made a mistake. But I think where it becomes maladaptive is where it's just broadened and generalized, sort of similar to anxiety, right? If you have a particular anxiety that you can then address, that's one thing. But if you just feel generally anxious all day long in all your different activities, that's where it can become really difficult to cope with and limit your life in a number of ways.
Do Narcissists Feel Guilt? (05:19)
Puder:
Do you think people with psychopathy or narcissism have less guilt in general?
Reid:
I think that certainly with narcissism, it can be difficult to empathize, it can be difficult to see someone as other than you, because the focus is very much on self. The focus is on how I sort of shore up some of these insecurities through bluster and all the different ways that someone with some narcissistic personality traits does. So I definitely think that they can struggle with a sense of guilt, because that implies I see you, I noticed you as a person, you have value, and I'm feeling badly that you're hurting. And I do think that there can be more trouble with that in someone with some of those traits, certainly.
Puder:
Yes. I see, I see. People with narcissism are organized around protecting against this feeling of shame, right? But sometimes the guilt is actually kind of like a developmental success if they're doing therapy and they're able to have some guilt, like interpersonal guilt.
Reid:
That's a good way of putting it. I agree. I think that is a step in a direction where there can be some change and they may see there's something I could do differently that could actually affect those around me in a positive way. And that is progress, certainly.
Guilt as a Symptom of Depression and Anxiety (06:40)
Puder:
So, okay. How about with someone who's more, I'm thinking of like the Big Five [see also episodes 92 and 95], high neurosis, kind of like neurotic traits. You know, those people seem to be higher in guilt, or someone with depression is higher in guilt. So when you're thinking about treating guilt or, or helping someone with guilt, when do you focus on this singular issue that they're struggling with to target versus this is more of a constellation of issues and guilt is one piece of it?
Reid:
That's interesting. I mean, I think certainly it's one of our diagnostic symptoms for depression and for major depressive disorder, this feeling of kind of nebulous broad, generalized guilt. So I certainly want to look for the other symptoms around that, right? Which is sort of a persistent low mood, changes in sleep, changes in appetite, poor concentration, maybe thoughts of helplessness, hopelessness, worthlessness. So certainly, looking at that in neurosis or more anxiety and the other pieces that might go along with that—really feeling kind of keyed up on edge, trouble resting, restless, those kinds of symptoms. But I think for me, really it's looking at, even if you ask yourself the question, “Okay, what did you do wrong?” What is it that you did wrong? And I think what is difficult and where you can find this really broad guilt is when someone says, “I just didn't do enough”, or “I just feel like I'm not getting anything right.”
Reid:
As opposed to, “What did you do wrong?” “Oh, I forgot to pack my son's lunch.” Okay. Right. Let's address that specific instance. Your son was disappointed. He was able to get some food from one of his friends, you apologize to him, and the next day you're very likely to remember it. That's very different than, “I forgot his lunch. And that just means I'm not getting anything right. And I've just destroyed him. He is never gonna get over this.” These sort of broad generalizations, catastrophizing and cognitive distortions, right?
Reid:
And so I think when it becomes really broad and it's almost more difficult to identify a particular something that they're feeling guilty for, that's where you start to see, okay, this is a broader issue. And also when I see people making decisions based on that guilt repeatedly. “I didn't really want to go and visit my family. But they said, ‘You know, you never come. You're always so busy.’ So I felt so guilty. I went to visit them even though I was kind of resentful the whole time and really was frustrated.” Right? Like, that kind of decision making based on guilt can also highlight where it's becoming a problem because they're not making decisions based on what they want and need in those situations.
Childhood Roots of Adult Guilt (9:25)
Puder:
I think about parentification, you know, when parents kind of talk to kids in a way that puts them out of the kid role. And I think about the guilt that sometimes parents put on kids even from a young age. Do you think that that leads to the kids later in life having an experience of guilt as adults or do you see a developmental trajectory to guilt from that or from other things?
Reid:
Yes, great question. I think socialization comes up so much in this from a young age. And I think, for example, in women, there might be this expectation that they should take care of everyone in their orbit. And a parent might say to them, for example, “Your brother seems kind of sad today. You know, why don't you go and see if you can cheer him up or make him feel better”, right? Or, “Your mother is really having a tough day. Maybe you could just not go and do what you were planning to do and just spend time with her instead.” So this sense that not only should you caretake for those around you, and caretake even for adults when you're a child, but that you have the ability to actually become accountable, be responsible for someone else's emotional experience. “Go make her happy.”
Reid:
“Go make him feel less lonely. Or less sad.” And so those kinds of things are some of these major expectations that I've discovered. These main categories of expectations that are so commonly associated with guilt, which are the sense of constant caretaking that “I must be doing that otherwise I'm not doing enough.” That I'm hyper-accountable for other people's emotions. Again, we know as therapists, if we could just say , “Here, feel this,” and they did, okay, that'd be a quick session. Of course we can't do that. And the other two I found were just the sense of seeking perfection—that short of perfection in things we’re not valuable, we’re not, you know, worthy of love. And the final one is a sense of being able to have it all: balancing it all, having all these different ways that we're demonstrating our success and our happiness.
Reid:
So I think those different expectations can be placed on us from a very young age. Certainly in a situation where there's that parentification, there is a sense of responsibility that far exceeds that child's control. And children naturally do that, right? If our parents, my parents got divorced when I was younger, and I really believed that it was something that I had done wrong. There's this personalization that's very common in kids. So you're emphasizing what's already a really challenging experience for that child to say, “I did this.” Like this is something that I failed at, and that can really cause problems over time.
Therapist & Doctor Guilt: Burnout and Identity in Helping Professions (12:14)
Puder:
Right. Okay. So there's that. I would put it in the category of as a kid, you often attribute things that are going on, to yourself. Which kind of puts you in some control over an uncontrollable situation, which can have some advantages in and of itself, right? To imagine yourself in control of these things that are happening right around you. And then you talked about parentification and these kinds of messages that you should be able to make your parent feel happy. And maybe you do, maybe that's the role you play in your family of origin. I've seen a lot of therapists with that narrative. They started being a therapist when they were really young to some degree, and they did play that role of peacemaker and helping out their family of origin to maybe have more peace, more functionality. Any thoughts on that weightiness? And have you worked with therapists who have had that weightiness, and how do you help them overcome that?
Reid:
Certainly therapists. I definitely hear it a lot in healthcare providers. This sense that we have what we call an interpersonal therapy, something called reflected appraisals, which is we view ourselves in the way that it was reflected back to us as a kid. Like you said—I was the peacemaker. I was the academic one. I was a success in the family. I was the black sheep of the family. And those kinds of blueprints, we might then carry those into our adult life and see that is what gives us our value. That, because I keep the peace, therefore I'm valuable to my family. And so anything that veers away from that, or where maybe they feel like, “If I actually said what I wanted or set limits or boundaries in my own life, I would no longer be the peacekeeper because that would upset my family members—they want me to be doing what they expect me to do, then I lose my whole value or my identity because that's how I see myself.”
Reid:
And so, I think that can be really challenging. And anyone who enters caring fields—whether it's teaching or social work, other healthcare fields, therapy—those individuals may say, “This is what gives me value, and therefore I need to make sure that I am, at all times, giving, giving, giving to try and make those things happen.” But guess what, negative outcomes occur. We have patients that don't do well. We have situations where we might lose a patient in medicine, and we have to figure out, “How do I maintain my identity and my sense of self in the absence of perfection in this way that I see myself?”
Puder:
Okay. So something about your sense of being able to help people, it's almost like identity gets wrapped around that. So talk more about that.
Reid:
Yes. Well, I think identity is so important and we're socialized, like I said, in healthcare and mental health care that the identity is we're this altruistic person who takes the knowledge that we're given and goes and helps everyone. And I think certainly there are many aspects of that that are positive, but I think the challenge is when we start to have things like moral injury as we were hearing about during COVID [see also episodes 48 and 146]. For example, “I know what would help this patient, but I don't necessarily have the equipment or the staffing or the ability in this particular situation to do what I think needs to be done,” or, “Someone else is really forcing me to do something that I don't feel like is the appropriate choice.” And that really can create this complexity in our identity because there's this sense of, “I'm being asked to do things that I don't believe in, or I'm forced to care for patients in a way I don't think is optimal.”
Reid:
And being able to still maintain that “I'm a good person” and “Who I am is not based on what the outcomes are”, and “Who I am, or not, is not based on these external factors, but how am I trying to show up. How am I trying to give back.” So, I think you can hear that a lot with burnout and people needing to take a break from the caretaking fields because there's this sense that, “If I can't do this, if I can't be present, if I can't give back, I literally don't exist.” Like, that is their whole point of existence, almost. And I think that could really be such a struggle because people may not take the breaks that they need, or they may not be able to set limits on that. I certainly had patients who were struggling with grief, that ended up taking on more and more shifts because it just helped them to be distracted. And then they got more and more burned out and they weren't sleeping and becoming more depressed. And it's this sort of vicious cycle. But guess what, there are not that many people in healthcare that will say to you, “Stop and take a break and take care of you.” They may say that, but it's not always demonstrated in how you're treated as an employee.
How to Stop Feeling Guilty About Referring Unsafe Patients (17:21)
Puder:
Right. The employer often has a bias to rejoice in your working excessively. My mind is going to a therapist who recently was murdered by a patient. I don't know if you heard about this case, Rebecca White. She [practiced] in Winter Park. I drive by this location frequently. This is a couple blocks from my office here. A patient came in at 9:00 PM and wanted to talk to her. She said no. The patient pulls out a knife and stabs her to death. Another patient, I think somewhere in the waiting room, or maybe it was in session, I don't know, was trying to help and ended up getting stabbed, as well. [The patient is] not dead, but stabbed 10 times. And my community around here is feeling this.
Puder:
The therapists I know are really upset about this and also kind of scared. So I think that's kind of in the background of this conversation. I'm not sure how that relates to guilt necessarily, but I think sometimes we feel like we need to be able to help every patient. And some people are just really hard to help, you know? I mean, this person was obviously very, very ill. I don’t know if this is bringing up anything for you. Did you hear about this story?
Reid:
I didn't hear about this particular story. I'm so sorry that that happened. And that must be just so frightening for those in the community. I mean, it's scary to hear about very far off where I am, but it's not the first time, you know, you've heard about. I've had a number of colleagues, even back in training, who were assaulted by patients. Not necessarily to this degree. So, you know, whether or not there's guilt that comes out of that. Maybe that survivor guilt of the part that, “Gosh, why did I get lucky? And that hasn't happened to me and that's happened to someone else who's just trying to help people.” But I think it's just, it's a reality of the work that we do, that there are vulnerabilities in that, and that we are caring for people that we don't always know what's going to happen or how things are going to go.
Reid:
I think for me, that it is more based around anxiety and how am I going to approach my patients. you know, with equanimity, even though there is that potential risk. And so, this isn't guilt related, but I definitely find myself, I remind myself of the people that are doing work that does have a risk to it, and being courageous enough to do that. You think about firemen who were trying to put out those fires in LA [California]. You think about the police force, who are out on the streets trying to care for people. EMTs who are going to people's homes. Those in the military who are putting their lives at risk. I think reminding ourselves that, yes, there is an inherent vulnerability in the work that we do, both for our own mental health, but also our physical safety. And so how do we still approach this and frankly recognize that it's courageous to do so, and reminding each other of that, and that we are showing up in the face of a changing world?
Puder:
Okay. So I associated, while you were talking, to why I think this relates to guilt. So, I run cohorts. I teach mental health professionals psychotherapy and reflective function [see episodes 185, 205, 213, 239, and 249], mentalization [see episodes 206 and 227], psychodynamic [see episodes 29, 164, 144, and 244] type of stuff. And a couple people come to mind, clinicians, who have felt incredible guilt about not wanting to see a particular person that they felt was dangerous. Specifically, I'm thinking of female [providers]. And the common thread is, “Well, I feel like I should be able to help this person despite, for whatever reason, I don't feel very safe.” And you know, I think there is a place of working through countertransference [see episodes 41, 170, 250, and 254] and our reaction to people. But I like to tell clinicians, “If, for whatever reason, especially if you're a female clinician, there's something about this particular person that makes you feel very unsafe, it's okay to refer them out. You don't need to feel guilty about that. You don't need to feel guilty about referring them to a male colleague.” Any thoughts on that in particular?
Reid:
Yeah, that's a really good point. I think if you're looking at guilt in that situation, because I think of guilt as sort of this difference between our expectations of ourselves in a setting versus our perceived reality. So what do we see ourselves as doing? And I think if you're looking at your expectations in that situation, and as a female therapist, I absolutely have done this. And I've asked for different accommodations in a particular clinic because I remember distinctly being in a far back removed clinic without anyone around and had some patients coming in that I didn't feel like that was the appropriate setting. And so, I had to speak up. And that was really hard because I thought I should be able to, you know, be tough or handle this. So I think really examining our expectations in that setting— “I should be able to see all patients that come my way, even if I don't necessarily have the setup or the tools or the safety there to see them.”
Reid:
That if I don't do that, then I'm not being a good doctor—broadly—as opposed to, “What is it that really allows me to do my best work?” And I think you can even broaden this to maybe individuals who don't want to see a particular patient. Because, it doesn't excite them. It doesn't light them up. They find them much more difficult. They worry about them a lot more and they lose sleep over them. So it's like, how do you find the patients that you really want to work with because that's where you do your best work? And you really see how that resonates and that gives you energy and is sustainable for you as the provider. Because I think there's this sense that we should be giving all selflessness and anything other than that is selfish. These two, this sort of, yin or yang, that's it.
Reid:
I think it's really reminding individuals that it's also about how you are able to show up and if there's fear, there's discomfort with a particular patient, or you just find them exhausting and just think, “I just can't do it. After that, I have to go take care of myself much more than usual.” That's really important information. And it's not selfish to say, “How can I show up in the best way? What are the ways that I can really help others and show up in that environment?” Because there are going to be people that maybe could work with a more challenging patient in a setting where they have support. Right? I'm thinking of a DBT program where you have peer supervision, you have groups, you have a lot of support. You have an after hour call. There's a contract. The patients know how often they can reach out. All these things in place. That's a very different setting than someone out alone in private practice trying to manage the severity. I've gone through my own guilt about this and going from working in an academic center at Penn and then doing private practice. It did change the complexity of patients I felt comfortable seeing. It was a lot of telehealth and for really complex medication issues that was not going to be the safest place for them either. But there was guilt. There still is about that.
Puder:
I've had to grow in this myself. I feel like there's a big part of me that wants to be able to take care of anyone that comes through my door. And I think, only recently, have I been like, “I'm not set up to take care of this particular person.” Whether they're coming in on three controlled substances, and the first thing they say is, “Oh, by the way, I don't want any of these changed and I want that as an agreement as I establish care with you.” And I'm like, “No, that it's not gonna work for me.” Right? Yes,this patient's coming in with a stipulation that I am not able to adjust medications if I deem necessary.
Puder:
Or, sometimes they'll call and they'll say, “I am coming in on this dose, which is two times the FDA recommended dose of Adderall, and I want this continued.” I'm sorry. I'm not going to start the relationship with a preconceived notion that this is the correct dose for you without getting to know you. Right? I can think of a bunch of different situations like that, but coming back to just safety with some of my female colleagues. I think it is very important that they feel safe with their patients. And if they get this kind of gut feeling, I want them to tune into that and listen to that and respond to that.
Setting Boundaries to Reduce Guilt and Prevent Burnout (26:39)
Reid:
Right. I mean, we are taught to respond to any countertransference. And I think in that situation, it does indicate that they need a higher level of care and they need a different level of care. That's really diagnostic. It's helpful. It's our “spidey sense”—it’s something we've honed over time. And I think not listening to that in any way, to understand someone's depression severity, their anxiety, and certainly their threat level, I think that we're not doing them any good either because we're not able to optimally treat them in that setting. If I'm scared of a patient or if I'm intimidated significantly by a patient that I can't suggest a change in med or I don't know what, you know, I'm afraid to say what I think is actually the case, I'm not able to care well for that patient. I really do remind myself and trainees of that a lot. And that finding a colleague that might just be their wheelhouse, their absolute sweet spot. They do a great job with it. They have resources set up and therefore we're all a team. We're all on the same team trying to help these people. But we, as an individual player, may not be the best fit.
Puder:
I like how you said earlier, if there is guilt [that] this particular patient is draining you, [but you still feel] that you should continue to treat them, yet this is the one patient that maybe they drain you so much that, for whatever reason, it's impacting your sleep, all your other patients. Recently I had a therapist I was doing some supervision with, giving supervision too, who had a patient like that. And I said, kind of what you were saying, which is, “Hey, maybe this person isn't the best fit for you. And I think that there could be someone out there. It's not a bad thing that for whatever reason this is going on. Let's find a better fit for this person.” Right? But I think with providers, what would you say if they felt so guilty about that? Let's say they're listening to this right now, and they're thinking of that one person, but they feel incredible guilt. What do you say to that person? How do you help them?
Reid:
Well, I think it's sort of this broader question of boundaries. And I've been thinking about that a lot around guilt because I think people are afraid to set boundaries in relationships. And this is true in healthcare as well, because it seems like it's selfish. I'm putting my needs before theirs. And in this situation, my need for not having one patient take up 40% of my brain space is “selfish.” And I think that's where really thinking about what boundaries provide [is important]. And yes, they do set limits on your time, your energy, your attention, but they also allow you to better connect to the people in your life because you have a sustainable path toward that. You don't feel resentment every time you see them. You don't feel exhausted and drained afterwards so that the next time you're less likely to spend time with them. Boundaries actually help you connect and bring you together.
Reid:
Even in your practice. My husband is an orthopedic surgeon and I certainly talk with him about it. [He’ll tell me,] “I really want to see this patient that has this really complicated case, but I'm in this community hospital where we don't have the facilities for that.” It's easy for me to say, “Well, refer them to the academic center where that exists.” But for him, it's like, “I'm failing in some way.” Of course, it's easy to see that in someone else, but I think in ourselves, recognizing that those boundaries sustain us, help us connect, help us be better, and better doctors. The more often I really see patients that I love working with and I really feel like I can help, I feel great.
Reid:
And they do better. I believe personally, I mean, have I done a randomized control trial? No. But I think I am also able to sustain and still feel good about myself because I'm showing up and I'm giving my best. There's this book by Parker Palmer, who I had on my podcast, that's called Let Your Life Speak [Let Your Life Speak: Listening for the Voice of Vocation]. And he talks about going into organizing and grassroots organizing and realizing even though he thought he should do it, and that it was really good for society, and it was an altruistic thing, that it was really hard for him. It drained him. It made him feel anxious and exhausted and depressed. And he said, “You know, you can learn just as much about yourself based on what you don't want to do or what doesn't work for you as you can [doing] something that you're really excited about.” And I think I've been thinking about that too, because we're socialized not to have any limitations that way, but I think you really can learn from me [,as an example,] working in fast-paced ER psychiatry, where I briefly meet someone, stabilize them, and clear them out, that that would never work for me because that's not how I want to engage with people. But some people love that. It really does take all kinds. So how do we allow ourselves to show up in the most authentic way because it's the way that's going to sustain us?
CBT for Guilt: How to Challenge Guilt Thoughts (31:47)
Puder:
Talk to me a little bit about the cognitive behavioral therapy [see episode 202] approach for guilt. How do you use that?
Reid:
Yes. Well, I think that you're going to find cognitive distortions present with this maladaptive, broad guilt. I was just reading this really interesting paper about, they showed a number of physician scenarios with guilt, like in Grey's Anatomy and some other television shows, and talked about some of the distortions that were on display, like personalization, as we spoke about earlier. This sense that, “I am at fault if anything happens.” [In one scene,] the whole team was taking care of this trauma patient. The patient didn't make it. “It's because I messed up. It's because I'm at fault.” Right? So you have those kinds of cognitive distortions. You have outcome-related distortions. Whereas, if this bad thing happened, even if I did everything I could to try and prevent it, then that means that I'm messed up. I've messed up. I should feel guilty. So I think it's the way that our brains interpret a situation that is beyond that specific setting, and it's to a greater degree than that specific setting calls for.
Reid:
And I think in healthcare that happens a lot—this distortion of, “I should be omnipotent. I should be able to, not only like is hindsight is 20/20, but my foresight should be 20/20. I should have known. I should have anticipated that finding was going to show up on CT and treated them before I even knew about it.” This kind of false idea of omnipotence. Which, I don’t know about you, but I feel like we, in healthcare, we kind of nurture that a bit in others. Like, it’s nice for people to think that we know what we’re doing and that we can really save everyone. But it doesn’t necessarily serve us to do that, because obviously we can’t. And, you know, death and taxes are sort of the inevitabilities in our lives. And so we’re pushing against that. And if we see those as failures, personal failures, when we lose a patient, for example, or someone doesn’t do well on a medication we want to try, or someone has a negative outcome in their family and then they’re really struggling with their depression, again, to blame ourselves or to see that we should have known or should have anticipated or should have prevented places us in a situation where guilt is really common.
Puder:
Okay. Yes. So cognitive distortions. Personalization is one [form] of all-or-nothing thinking. Overgeneralization, generalizing from one bad situation to all situations. Mentally filtering out the positive. Right? We don't think about all the positive impacts we're having during the day. We think about the couple of negative, bad interactions. Right?
Reid:
Right. And that point with what I call the “guilt equation”, where it’s the expectations minus our perceived reality. Our perceived reality is shaped by our tension. It’s shaped by what we are paying attention to—we only see the things that we didn’t get right, we don’t see the things that we’re doing well, all the different ways we’re showing up. You know? Like a parent who says, “I’m the worst parent.” And you go through, and they say, “I got my kids up, and I made them breakfast, and I got them to a safe school where they are learning something, and I picked them up.” You know, every day we’re all doing so many different things and I think [we should give] that some attention, because otherwise we don’t see reality as it is. We see it as we view it, and the attention we give it. So I think that piece is really important too in helping to lower guilt. It lets me shift what I see, because I’m not paying attention to all the things that could really help support me.
Role-Play (35:30)
Puder:
Okay. Do you ever do role plays on your podcast? I like to do role plays. Are you down to try one?
Reid:
I certainly do it in my sessions on my podcast. Sure. I mean, let's do it.
Puder:
Okay. Let's say I'm a therapist coming to see you. Okay? I'm going to pick something about guilt, okay? I'm waking up in the middle of the night on a regular basis and it's not like there's a specific patient that I'm waking up to over and over again, but it's different ones. So I wake up at two in the morning and I will have thoughts like, “Should I have said that? Should I have drawn this insight into this person? And did they react poorly to it? Are they reacting poorly to it? Are they going to pull away? Maybe I shouldn't have said that.” Those kinds of thoughts.
Reid:
Yes. So when you're having those kinds of thoughts, what do you think you might be expecting of yourself? Let's think about if there's one particular patient we'll use as an example in this setting. Share with me what your expectation is in a session. What do you think you should be doing with that patient?
Puder:
Okay. So this one person I'm thinking of, I'm worried that if I don't get it right, if I'm not able to help him, he's going to start using drugs again. And so I think my expectation of myself is that he stays sober. Like, if I do my job right, he'll stay sober.
Reid:
So, it sounds like if you were to sort of quantify, let's say the amount of control you have over that decision, let's just think about the timeline. How many hours of the day are you with him?
Puder:
Not even an hour. I mean, he comes in maybe every one, every two to four weeks, you know, for like 25 minutes. It's more of a medication management person, you know.
Reid:
Okay. So as far as checking in with him on how he's feeling and how he's coping, and is he taking his medication, how often do you know what he's doing day to day?
Puder:
Not much.
Reid:
But if you really were to think, like, what's your belief about how much you could control his decisions moment by moment? How would you describe that?
Puder:
I don't think I can control, now that I think about it. I don't think I can control much of what his decisions are. But I'm worried that I said something that made it worse.
Reid:
Okay. Tell me more about it.
Puder:
I, well, I was challenging his narrative on something. And I'm worried that made it worse. So I'm kind of ruminating at two in the morning on this. I don't know why it is always two in the morning, you know?
Reid:
I have the same thing lately. For me it's been 4:00 AM.
Puder:
Okay.
Reid:
You know, I think that we, throughout the day, in this attention economy, rarely have the time and the space to allow these things to come up. The sense of the omnipotence is there in the middle of the night, but not the sort of ability to take action? Right? You're going back and rehearsing over something that you said. But I think also looking at the intention is important. Okay. So I'm thinking about, let's say this, as we role play this specific thing that you said, this challenging of the narrative, what was your intention in doing? Were you trying to get him to relapse?
Puder:
Oh, no. I was trying to get him to not see himself as a villain. He starts to kind of see himself as a villain.
Reid:
Okay. Well, let's do a brief self-compassion exercise. Which I do with myself. I find it very helpful. Let's say you're talking to me…
Puder:
Okay.
Reid:
Or another colleague or friend. And I'm saying, "My goal was to really help my patient not feel like such a villain.” And so I tried a technique.
Puder:
Yep.
Reid:
What would you say?
Puder:
I think you were being creative and I think you were trying to get to the core of what is keeping him using drugs and you don't really know if it worked or didn't work. It sounds like you really care about this person and you're trying hard.
Reid:
Yes. I think that's another important piece, keeping in mind that when we do worry, when we do get caught up in patients, it is because we care, because we are showing up, because we really want to make their lives better. And there's no clear manual for what to say every minute. I mean, thank goodness, because that would just be boring as all get out. But we are using our creativity. We are using our common humanity, our compassion, and our training, all coming together and trying to make choices. If our expectation is that every word we say is just like liquid gold, they take it and it makes them better, and every medication we try, and every technique we suggest is going to work perfectly, every day is filled with a sense of guilt and disappointment.
Puder:
I think, if I'm gonna be honest with you, I think the guilt got worse actually when he didn't show up to his last appointment. It was a no show. And then it's like, I don't know if he was upset at me or if he was just using again and wanted to avoid trying to get sober.
Reid:
Well, I think that might be an example of that personalization, right? He didn't show up. Therefore, it's because I said the wrong thing last time. And I think you are, obviously, coming up with these other reasons that could be the case. And I think really being careful that the personalization isn't the most likely reason in your mind. That somehow this is my fault. Because I imagine we could list a number of different reasons that he had no showed. And in part, his challenge, his addiction is going to increase risk of that kind of behavior. Right?
Puder:
I'm feeling guilty now that my personalization is…that narcissistic of me to personalize?
Reid:
No, because this is what we are encouraged to do and reminded to do over and over and over again. “Doctor, that's your patient. You need to take care of them. This is your patient. You need to figure out some strategies for that individual.” We are really encouraged to take responsibility far outside our locus of control in healthcare. In mental healthcare, particularly.
Reid:
People sometimes think that if I speak to you, I can change your whole life circumstances. I can lower your stress about finances, about being unstably housed, about difficult relationships, about a history of trauma. I can't do any of those things. What are the tools I have in front of me and how can I try and use those tools that I have to best offer you a chance at recovery? I can't control whether you take it, whether you show up. I may say something that is objectively brilliant and it may not resonate with you.
Puder:
That would be more of the narcissism. Okay. “I'm so brilliant. I'm so wonderful.” Yes.
Reid:
But you might think you've said something that seemed really helpful and then they come back and say something entirely different than you said.
Puder:
No, I'm joking.
Reid:
Yeah. We're joking about something and you're like, I still remember that.
Puder:
Yes. I'm always surprised when a patient will say, “You know, when you said this, three years ago, that made an impact.” And I'm like, “Did I say that?” Or, “Oh, wow. That was the thing that helped that I would've never guessed.” Okay. So, one of the other things, and I'm curious. I'm still in the role play, by the way. I know this sounds very irrational, but in the middle of the night when I'm having this thought, I'm also worried, “What if this guy sues me over this?” Or, “What if things don't go well and then some lawsuit comes at me?”
Reid:
Yes. Well, I think anytime my patients have a thought or I have a thought that starts with “what if”, we just start from a place, “That's an anxious thought.” That's what it is. That's not reality. That's the anxious thought. So let's try and address that directly. And especially, in the middle of the night, we can have that anxious thought and either try to just cut it off or distract ourselves or think about something else, or that thought just goes again and again and again. We ruminate, right? But it's sort of like Sisyphus continuing to try and climb the hill. We never actually get over and get to the other side. And so one exercise that I use, and that I help with patients use with anxiety, is to say, “Rather than ‘What if,’ say, ‘if then.’”
Puder:
Okay. If then….
Reid:
If then, so what if he sues me based on this one comment I made trying to help him not feel like as much of a villain? That's where we're at. Okay. If he does sue me in that situation, what will I do?
Puder:
If then. What will I do? Well, I imagine being on the stand and I would be cross examined by some person that would be asking me why I made that comment. What evidence I had to back it up. And then, I go in this anxious loop of researching how I would back that up. So, you notice….
Reid:
You're jumping to….
Puder:
Is that what we're talking about? I don't think this is the answer you're looking for though. I feel guilty that I'm not getting your…
Reid:
No, I think…
Puder:
I'm not doing this right.
Reid:
It is an absolutely very common and understandable approach. And notice that you're jumping to this most stressful moment of the potential outcome. Again, “What if it's me on the stand trying to justify what's happening,” as opposed to, “Okay, what are the first steps I would take if I were to be named in a lawsuit.” Right? Confirm that I have malpractice insurance, for example.
Puder:
Speak…
Reid:
To someone about the situation. Right?
Puder:
Okay.
Reid:
Because you're already jumping to the fact that you've gone through all of this. Someone believes they can truly bring a suit against you. You've gone through all the other mediation, everything else with your malpractice, and here you are in front of a jury, I don't know, on the stand, being quizzed, like that sort of TV version of what being sued looks like. Right? And I think again, that worried thought, “What if I have to go on the stand and justify why I said the statement that I made?” And you can do that for any treatment. Any treatment, of course, I think being able to try and do the “if then” and actually think through some of the boring details, calms that anxiety down a bit. Because there's a big space between being named in a lawsuit and being on the stand like Tom Cruise asking you if you ordered the code red. You know what I mean? That's a big jump. How can we look at the details leading up to that? Like, I'm afraid if I'm late for this meeting, then I'm gonna be fired and then I'm gonna be homeless and then I'm gonna be alone. And that, you know, like this sort of jumping to kind of the worst, the catastrophic outcomes.
Reid:
Yes. So I think checking with that. In a broader sense though, from a malpractice standpoint in the work we do, I always remind myself that the only providers that are not at risk of those kinds of situations are those that are not caring for patients. Pure and simple. Period. So that would be the choice. If your choice is to continue, why are you doing that? What are the ways that it benefits you, benefits those around you? How do I keep going in the face of, again, same with that vulnerability of being in a situation where we can assure that we're going to be safe, but we can't do that anywhere. We can't do that in the grocery store, movie theater, what have you, these days. So I think, how do we move forward despite and in the setting of “What is it we're moving toward?” Right? And as you're continuing to see patients, even when you have some nights where you're waking up in the middle of the night worrying, “Why am I continuing to do so?” Because I have a choice.
Puder:
A choice. What is my choice?
Reid:
Your choice is to…
Puder:
My choice is to say…
Reid:
I'm not gonna take this risk anymore.
Puder:
Oh.
Reid:
I'm gonna go do something else.
Puder:
I'm not gonna be a therapist anymore. Okay. And then, it's interesting because I'm starting to feel guilt even when I'm talking to you. That I'm not getting it right and I'm not doing it right the way that I've been doing it. But I know that's probably not what you're intending, I know you're not intending to have that happen here.
Reid:
Well, we'll recognize that I don't know anything about what you're doing with individuals. So the idea that I would be telling you, “You're getting it wrong.”
Puder:
Oh, no. I don't think you are telling me I'm getting it wrong. I think I'm getting it…. Well, I don't think that you are telling me I'm getting it wrong with patients. I want to clarify that.
Reid:
What do you think is happening then?
Puder:
I think I'm getting it wrong with how I'm talking to myself in the middle of the night.
Reid:
Oh.
Puder:
But I am getting it wrong. Because if I was getting it right, I wouldn't be doing that. Right?
Reid:
It's interesting that that brings up guilt, as opposed to a sense of opportunity. You know?
Puder:
Yes. I should have some opportunity.
Reid:
Yes. There's something about that. If you're saying, ”Okay, maybe I'm not doing this the way that I want to keep doing this.” I mean, this was something when I was reading about sort of sleep and insomnia, just reading again and again and again. The more you stress about sleep, the harder it is to fall back to sleep. And so every night when I wake up at 4:00 AM it's like, well, this is interesting. Here I am awake. Maybe I'll just get up now. But like the idea of being able to just say, “This is just what it is. This just exists. This doesn't mean anything broader than this particular situation. Me waking up at 2:00 AM and worrying about a patient, it's emotional reasoning to say that means I've done something wrong.” Right? That I'm using my emotion to describe for me what the reality is. Because I'm worrying about it, I must have said something bad. I do that after social gatherings too. Like, “Oh my God, why did I say that? That sounds ridiculous. I feel really embarrassed now.” So therefore it must have been something embarrassing. But again, that's a cognitive distortion and just pointing out we all have them. Those of us that treat people with them still have them. This is not a matter of it just goes away. Talking and writing about guilt doesn't mean I don't have guilt.
Puder:
Oh. It just…
Reid:
Means I'm beginning to understand it.
Puder:
It probably means you have more guilt, or you started with more guilt.
Puder:
Hopefully it's helped you. Okay. We could pause the role play. I think that the thing that I appreciated that you did was asking how we start to look at it differently, right? How do we start to look at what's happening differently? Whether it's adding in, can you identify the cognitive distortions that are going on? Which I think that, to generate the story, I was thinking of some different providers I've been talking to. There's something about sleep and kind of being between sleep, which our brain is not fully functioning, right? Or we don't have our full frontal lobe online when we are just kind of in those lighter stages of waking up and thinking about these things.
Puder:
And so you're kind of like calling forth, right? With this way of putting on some of the cognitive behavioral therapy techniques, calling forth more of an executive function, looking at these guilty things like are you overly personalizing your ability to help with limited contact with this person, right? Are you using emotional reasoning where because you feel anxious, then it really is as bad as you feel it is, right? Or [that because] you fear some legal consequences, that you're actually going to have legal consequences. Or, you have this kind of nightmarish scenario where you have the worst case scenario, right? You're in court, you're being cross examined and so it's become anxiety, it's become guilt. It's become all of these things, right? And it's magnified, it's blown up. The non-judgmentalness that you talked about, I think that's good, as well. The waking up is not necessarily a bad thing. We're going to have some nights that we wake up thinking about clients. It's just the way it is. That's the profession we're in.
Reid:
Right? And that's what sleep is. You wake up throughout the night. Sometimes you're aware of it, sometimes not. That's just biology. The other thing I want to point out is when I'm working with residents who are transferring from working with patients in the hospital to working in an outpatient setting, there's a lot of anxiety about, “You mean that person's just roaming around the world and I'm telling them what to do, but I can't guarantee that they're doing it. I don't have any nurse that told me they took the pill.” Right? That's a big transition that creates a lot of anxiety. And I think we live with that as outpatient providers. Perpetually. And we maybe kind of bury it, but that's the reality. It's also like having kids. My kids are off roaming around and I don't have full control over what they're doing. And that understandably triggers some anxiety sometimes. So I think recognizing, again, these are valid feelings. They're not unusual, but that doesn't mean that they indicate a true reality or that I'm getting it wrong.
Puder:
Yes. I think I knew I was becoming a difficult patient, and so I apologize for becoming a difficult patient by feeling more guilt, based off getting it wrong, not doing the correct CBT techniques. Now I'm feeling guilty about that. I'm feeling guilty that I'm even talking to you about this today. So I feel like that can happen as well when we talk to patients. Right? That the here and now experience of the inner critic comes out.
Reid:
But there's value to that. If you can actually share that inner critic or push back against your therapist or challenge them. Or say, “I don't think you've quite got that right.” Or, “Now I'm feeling worse.” Those are all really important and valid things to bring up in therapy. I think the fear of being a bad patient can actually hold people back. [The patient may say,] “Okay, yeah, sure. No, I definitely feel better,” Well, if they don't, then [the client/therapist should] actually dig into that. Right? The fact that you had more guilt as we're talking is really helpful information to think about when you wake up at two in the morning and bring back in the next week. What came up? What sort of thoughts? Let's try and understand that a little bit more. That's just all part of the process of therapy.
Practical Ways to Reduce Guilt Every Day (57:12)
Puder:
And then I know you talk about “shoulding" and you know, guilt has a lot of “shoulds”. Right? I can create a “should” for you here: “I should be able to combat this guilt.” I don't know if you noticed that. That was awesome—me being difficult, which is pleasurable for me. I had someone send me a nice email the other day and was like, “Please do not stop the role plays. I really appreciate them. I could tell you really enjoy them.”
Reid:
I think they're really helpful. I use them in therapy often.
Puder:
Yes.
Reid:
Yes.
Puder:
That's fun. Okay. So we're going to wrap things up in a couple minutes here. What are some of the other things that we haven't covered about guilt that you think you’d want to leave the people that listen to this with?
Reid:
Well, I think sometimes it's hard because you may understand where the guilt is coming from, but you really want to have some practical strategies to make a difference. We sort of practiced one here, a self-compassion strategy, which is, let's pretend you're speaking to a friend. Right? So if you're really struggling to be compassionate with yourself, pretending that you're speaking to a friend about that particular situation, what would you say to a friend who would be messed up in that way or felt like they let someone down or missed something? And it gives you just that hint of objectivity, just a little bit of a bird's eye view into your own experience. I think positive psychology has a lot of benefits in boosting that sort of perceived reality of things that are going well. The three good things exercise or three blessings. It has different names. Really, at the end of the day, writing down three things that went well that day and why. Sounds really simple, but otherwise it's us up at the middle of the night [thinking of] three things that went poorly that day. Right? Five things, a hundred things that went poorly that day. That's where our brain might tend to go. We're in the habit of that, right? So I think this is a shift. I actually do it sometimes with my family around the dinner table.
Puder:
Yeah.
Reid:
And it's fun, because my kids will say something other than, “I liked lunch.” They'll be like, “I helped a friend with a math problem,” or “I did really well in this situation,” or “a teacher said something nice about me.” It prompts us to think that way. And I think we do need practice in that. I think that there's practice in finding the positive things. That's why gratitude journals are so commonly recommended. Sometimes that works for people, maybe not. But those kinds of strategies. How do we shift our attention? And then lastly, attention is really important in thinking about social media. Thinking about comparisons. Thinking about hearing terrible things on the news. And from that, extrapolating that the whole world is bad, is going down the tubes, is on fire. Like there's so many negative things out there.
Puder:
Oh, so much.
Reid:
And that then creates guilt. Because I “should” be trying to make it better. I “should” be out protesting or I “should” be making these changes. I think also reminding ourselves of things that are going well. And personally, that's why I started my own podcast. Because I wanted to talk to people that were doing good things. Because I needed to know. I needed to hear about it. I needed to remind myself of the people that are really doing positive things in the world because those aren't getting the headlines. So you have to find your own sources for that. And I think that can help with the skill. And then maybe taking small actions within your community that seem reasonable as opposed to, “I feel guilty because I can't solve the world's problems.” Because, again, we're expected to do so as providers. But it gives us no more control than anyone else.
Puder:
Right? It's like, what is some small impact you can make? You know? And that, rather than just punching your fist into the air over and over about all of the chaos in the world, what is some small change you can make? I like how you, in your own life, you start your own podcast and like you told me before, you edit your own podcast, which is very, very, very masochistic of you. We're going to work on that.
Reid:
We'll deal with that next session.
Puder:
We'll deal with that next session. The self-compassion, the role play, right? Where it's like, okay, pretend you are your friend talking to you about this, right? And I think that is very helpful. I think we could do that as well. Like, pretend you're a therapist friend of yourself trying to give yourself some input on this, like some objectivity. What would you say? I think that's great. And I think also just having colleagues who you can discuss things with, as well. I think that's very powerful to have some reality checks. The more I talk with colleagues, the more I realize like we're all experiencing a lot of this together. Right?
Puder:
I don't know any mental health professional who doesn't have moments of guilt about what they do and are the patients getting well fast enough and if there's a bad outcome. I think it really weighs on them. And you mentioned moral injury. Moral injury is something that we have to deal with as professionals because moral injury is like if we have this outcome that we don't want and we think that we could have done something better, were we kind of forced into a system? Especially a lot of the professionals I talk to, they're in a system where they may not have enough time with clients that allow them the outcome that they want. Insurance doesn't allow the time. Insurance doesn't allow them medications maybe that will give them the outcome that they want. So that can be tough as well.
Guilt in Mental Health & Healthcare Systems (01:03:19)
Reid:
Yes. And we exist in a system of, “What do we have pharmacologically to use?” We didn't develop these meds and we may be prescribing medications that have side effects that we very much don't want our patients to experience, and yet, we're forced to make a choice. Do we start a second generation antipsychotic knowing that weight gain is very likely [and] other metabolic issues are very likely? Increasingly we have some treatment options but it doesn't work for everyone. So we're forced into that setting where we don't control the meds available to us, but those are the tools we have to work with.
Puder:
This is good. I appreciate you and I appreciate you coming on here. For those of you who found this helpful, I highly recommend checking out her book, Guilt Free, and her podcast. Jennifer Reid, I appreciate you coming on. Check out her podcast. It's called, A Mind of Her Own. She also has a Substack newsletter. I'm sure she would love it if you followed her on Substack and you're on Instagram as well?
Reid:
Yeah. Occasionally.
Puder:
Jen Reid, MD
Reid:
Yes.
Reid:
Thank you for having me on. This has been a really fascinating conversation. I love that we got to do some role play and cover some of these topics. And it's always fun to speak to a colleague, like you said, peer supervision I find incredibly helpful.
Puder:
Where are you licensed? What states?
Reid:
In Pennsylvania and New Jersey.
Puder:
Pennsylvania and New Jersey. Okay. That's good. I don't know if I know anyone up there that's a psychiatrist. So it's good. It's good knowing I can refer someone to you if I get an email. Pennsylvania and New Jersey, guys. Jennifer Reid, thank you for coming on. We'll leave it there for today.
Reid:
Thanks for having me.