Psychiatry & Psychotherapy Podcast - How to Overcome Guilt: Break Free from Unreasonable Expectations with Jennifer Reid, MD

Episode Date: February 6, 2026

In this episode, we welcome psychiatrists Dr. Jennifer Reid (author of Guilt Free: Reclaiming Your Life from Unreasonable Expectations) who explores why guilt feels so overwhelming amid post-COVID pressures, perfectionism, and endless roles. Dr. Reid and Dr. Puder differentiate guilt from shame, highlighting adaptive healthy guilt for repairing relationships versus maladaptive generalized guilt tied to depression, anxiety, burnout, and cognitive distortions. The discussion covers childhood roots like parentification and socialization, narcissism's reduced guilt, therapist/doctor identity struggles with moral injury, and practical strategies like boundary-setting, reframing expectations, and safely referring unsafe patients without guilt. Ideal for anyone battling unreasonable self-expectations, mental health providers seeking tools to manage guilt in patients and themselves, or listeners wanting to break free and reclaim emotional freedom through self-compassion and realistic accountability.   By listening to this episode, you can earn 1.0 Psychiatry CME Credits. Link to blog Link to YouTube video

All right, welcome back to the podcast. I am joined with Jennifer Reed. She's a psychiatrist. She has written a recent book called Gilt Free. 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. The one I listened to is on Gilt since we're talking about that today. I'm excited to get into this and get into really kind of your perspective on it, what you think we can do to decrease it. The book is written for women, but we were talking before it, I think it's true. Like, if you're a mental health provider, you have experienced guilt yourself. And so, yeah, why don't we start with how you got excited about this and tell me a little bit about guilt? So, you know, as a practicing

psychiatrist, as you know, 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 with 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 be perfect in all your roles. And I was, 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. 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. And, and, 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 and why are we struggling so much? That was the answer I wanted to figure out. So like differentiate maybe guilt from shame. How would you differentiate those? Yeah. 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 some 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. 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 can shift into shame because there's a sense that like if I can't do any of these things perfectly

then I'm just, I'm not a worthwhile person I don't have value. Yeah, okay, so yeah, what are the adaptive qualities of guilt, like healthy guilt? Right. So really interpersonally, right? We know how important

our interpersonal relationships are. We know as mental health provides, that really affects our mood and affects our longevity for that matter. And so we really need that ability to say to someone else, like I'm saying, like, I notice that something, some harm has come to you. So I identify you as another person. This is why it takes you to, say, three or four to start having these abilities. Identify you as someone else.

I see that you're hurting. I may feel empathy towards you. I feel what you're 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. So that's where it's adaptive, right?

We don't want someone to be absolutely without any guilt or shame for that matter. If that sort of is pathological to say, well, I may have just cut you off in traffic and you crashed your car, but whatever, I don't feel anything. Of course. We're going to 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 you think people with psychopathy or narcissism have less guilt in general? I think that certainly with narcissism, there can be a difficult, 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 can 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, you know, I'm feeling badly that you're hurting.

And I do think that there can be more trouble with that and someone with some of those traits, certainly. Yeah, I see people with narcissism are like 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 in a personal guilt. Yeah, 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. So, okay, how about with someone who's more, I'm thinking with like the Big Five high in neurotic neurosis, kind of like neurotic traits, you know, those people seem to be higher in guilt or someone

new with depression, hiring guilt. So when you're thinking about treating guilt or helping someone with guilt, when do you focus on this is a 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? That's interesting. And I think certainly it's one of our diagnostic symptoms for depression, for major depressive disorder, is 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 or helplessness, hopelessness, worthlessness. So certainly looking at that or in kind of neuroses or more anxiety,

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 does you do wrong? Right? 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, I didn't do enough or I just feel like I'm not getting anything right 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 know, 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 like destroyed him. He is never going to get over this, like these sort of broad generalizations, catastrophizing that we have. Disstortions, right? A lot of cognitive distortions. And so I think when it becomes really broad and it's almost more difficult to identify a particular, you know, 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 those kinds of decision making based on guilt can also highlight where it's becoming a problem because they're not making decisions based on what we want to need in those situations. I think about parenthification, you know, when parents talk to kids in a way that, you know, puts them out of maybe 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? you know, as like adults or like, do you see like a developmental trajectory to guilt from that or from other things? Yeah, great question. I mean, 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, you know, 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. Like maybe you could just not go and do what you were planning to do and just, spend time with her instead. So the sense that you can, not only that you should caretake for those around you and caretake,

even for adults when you're a child, but that you have the ability to actually, you know, become accountable, be responsible for someone else's emotional experience. Go make her happy. 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 and things were not valuable, we're not, you know, worthy of love. And the final one is a sense of being able to have it all. bouncing at all, having all these different ways that we're demonstrating our success and our happiness. 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 my parents got divorced when I was younger and I really believe 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've failed at and that can really cause problems over time. Right. Okay. So, yeah, there's that I would put in the category of like as a kids,

you often attribute things that are going on to yourself, which is kind of like, you know, puts you in. some control over uncontrollable maybe situation, which can have some advantage in and of itself, right, is to imagine yourself in control of these things that are happening around you. And then you talked about the prentification and this kind of these messages that can be, you should be able to, you know, make your parent feel happy. And maybe you do.

Maybe you, maybe that's the role you play in your family of origin. I've seen a lot of therapists with that narrative, you know, and 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 maybe have more peace, more functionality. Yeah. Yeah. Any thoughts on like that weightiness,

and have you worked with therapists who have had that weightiness, and how do you help them overcome that? Certainly therapists. I definitely heard a lot in health care 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 kind of blueprints, we might then carry those into our adult life and see that 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. And so I think that can be really challenging. And anyone who enters the sort of caring fields, whether it's teaching or social work, other health care fields, therapy, that 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. Yeah. Okay, so something about identity gets like your sense of being able to help people. It's almost like identity gets wrapped around that. And so talk more about that. Yeah, well, I think the identity, I mean, it's so important. And we're socialized, like I said, in health care, in mental health care. 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, 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 a sense of I'm being asked to do things that I don't believe in or that I actually, I'm forced to care for patients in a way I don't think is optimal and being able to still maintain that I'm a good person and that who I am is not based on what the outcomes are and who I am or not, it's 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,

a lot with burnout and people needing to take a break from the caretaking fields because there's a 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 my whole point of existence almost. And I think that can 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 mean, I've certainly had patients who, you know, when struggling with greed, 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? They're 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.

Right. The employer has often a bias to rejoice in your working excessively, right? Right. Yeah. You know, I'm like, 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 in winter park. So this is like I drive by this location frequently.

I drive, you know, this is like a couple blocks from my office here. The patient comes in 9 p.m. 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 ends up getting stabbed as well. It's not dead, but a stab ten times. And my community around here is feeling this.

the therapists I know are really, like, really upset about this. And also kind of scared, scared, you know. 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 beyond, like, this person was very ill. very, very ill. I don't know. Is this bringing up anything for you? Did you hear about this story?

Gosh, 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 those kinds of things, you know, you've heard about that, that there, I've had a number of colleagues, even back in training, who at least, you know, were assaulted by patients, not necessarily to this degree. So, You know, whether or not there's guilt that comes out of that, maybe the 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 do 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. I think for me that's the more basis around like just anxiety and how am I going to. 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, which are, you know, you think about firemen that we're trying to put out those fires in L.A. You think about the police force who's out on the streets, trying to care for people, EMTs 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 and 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. Yeah. Yeah. 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 like psychotherapy and reflective function mentalization, you know, psychodynamic 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 therapists, nurse practitioner. 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 like countertransference and, you know, 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. Like you don't need to feel guilty about that. You don't need to feel guilty

about referring them to a male colleague, you know? So any thoughts on that in particular? Yeah, that's a really good point. I think if you're looking at guilt in that situation, because I think of guilt is 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, you know, 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 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. 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 even can broaden this to maybe individuals who don't want to see a particular patient because it's just, 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 a provider because I think there's this sense that we should be giving selflessness and anything other than that is selfish.

These two, this sort of, you know, Yan or Yang, that's it. And I think really reminding individuals that it's also about how you're able to show. 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. 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, as opposed to, because there are going to be people that maybe could work with a more challenging patient in a setting where they have support. I'm thinking of a DBT program where you have peer supervision, you have groups, you have a lot of support, you have after our call planning. There's a contract that 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 that severity. So I've gone through my own guild 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, you know? Yeah. I've had to, I've had to grow in this myself. I feel like, like, there's a big part of me that wants to be able to take care of anyone that comes to my door. And I think, like, only recently have I been like, I'm not set up to take care of this particular person, you know? Whether it's like they're on, 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 kind of like as an agreement as I establish care with you. And I'm like, no, that's not going to work for me, right? Like you are coming in, this person, this patient's coming in with the stipulation that I am not able to adjust medications if I deem necessary. Or like sometimes they'll call and they'll be like, I am coming in on this dose, which is two times the FDA recommended dose of Adderall. And I want this continued. It's like, I'm sorry, like 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? And so 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, right? And if they get this kind of gut awful feeling, you know, I want them to tune into that and listen to that and respond to that. Right. I mean, any countertransference we're taught to respond to. And I think in that situation, it does indicate that they need a higher level of care.

They need a different level of care. It's that's really, it's diagnostic, it's helpful. It's our spidey sense is something we've honed over time. And I think not listening to that in any way, not listening to that to understand someone's depression severity, their anxiety, and certainly their kind of 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. They're 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 in the same team trying to help these people.

But we as an individual player may not be the best fit. I like how you said earlier, if this, there can be guilt, if this particular patient is draining you, that you should continue to treat them yet. This is the one patient that maybe they drain you so much that it's like, for whatever reason, and it's impacting all your sleep, all your other patients. Recently had a therapist I was doing some supervision with,

kind of giving supervision to who had a patient like that. And I said kind of what you were saying, which is like, hey, like, 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. And so let's find a better fit for this person, right? Absolutely. But I think with providers, like, 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 an incredible guilt. What do you say to that person? How do you help them? 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 do boundaries provide. 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 lives. 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. That boundaries actually help you connect and bring you together. I think having boundaries in your practice in whatever capacity, my husband's an orthopedic surgeon,

and I certainly talk with him about, I really want to see this patient that has this really complicated case, but I'm in this community hospital where that's not, we don't have the facilities for that. It's like, 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 by not having the appropriate machine.

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. Like, the more often I really see patients that I love working with and I really feel like I can help, I feel great, and they do better, I believe, personally. I mean, have I done a randomized control trial? No,

but I think I also unable 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. And he talks about him going into organizing and like grassroots organizing and realizing, even though he thought he should do it, and then it was really good for society and it was an altruistic thing, it was really hard for him. He drained him. It made him feel anxious and exhausted and depressed. And he really 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, 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 for me

working in like fast-paced ER psychiatry where I briefly meet someone, stabilize them and clear them out, that would never work for me because that's not how I want to engage with people, but some people love that. Like it takes, it really does take all kinds. So how do we allow ourselves to show up the most authentic way? Because it's the way that's going to sustain us. Talk to me a little bit about the cognitive behavioral therapy approach for guilt. Like how to use that? Yeah. Well, I think that you're going to, find cognitive distortions present with this maladaptive, this broad guilt. I was just reading this really interesting paper about they showed a number of physicians' settings with guilt in like

Gray'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, the sense that I am at fault, if anything happens. The whole team was taking care of this trauma patient. The patient didn't make it. It's because I messed up because it's 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 should, I 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. And I think in,

health care, that happens a lot, this distortion of I should be omnipotent. I should be able to, not only like this hindsight is 2020, but it should be, my foresight should be 2020. I should have known. I should have anticipated that that finding was going to show up on CT and treated them before I even knew about it. These kind of like this false, this idea of omnipotence, which I don't know about you, but I feel like we in health care, we kind of do 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

of 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. Okay. So yes, so cognitive distortions, personalization is one, all or nothing thinking, overgeneralization, generalizing from one bad situation to all situations. mental filter filtering out the positive right we don't we don't think about all the positive impacts we're having during the day we think about the couple negative bad interactions right right and that's that

point with what i call the guilt equation where it's like the expectations minus our perceived reality our perceived reality is shaped by our attention it's shaped by what are we paying attention to and if we have this sort of we only see the things that we didn't get right we don't we don't see the things that we're doing well, all the different ways we're showing up. You know, a parent who says, I'm like the worst parent and you go through and they're like, well, yeah, I got my kid up and I made him breakfast and I got them to a safe school where they are learning something and I pick them out, you know, like every day we're all, we're doing so many different things. And I think giving that some attention, because otherwise, you know, we don't see reality as it is. We see it as 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 is let me shift what I see, like what is because I'm not paying attention to all the things that could really help support me. Okay. Do you ever do role plays on your podcast? I like to do some role plays. Are you down to try one? I certainly do it in my sessions on my podcast.

Sure. I mean, let's do it. Okay. I'm a, let's say I'm a therapist coming to see you. Okay. So let's say this is, I don't know. I'm going to pick something about guilt. Okay, I, I'm waking up in the middle of the night on a regular basis.

And it's not like I'm, there's like a specific patient that I'm waking up over and over again, but it's like different ones. Okay. So we get about like two in the morning and, um, I will have thoughts like, oh, I, um, you know, it should, Should I have said that? Should I have drawn this insight into this person? And like, did they react poorly to it? Are they reacting poorly to it? Like, are they going to pull away?

Are they going to, like, maybe I shouldn't have said that. Those kind of thoughts. Mm-hmm. Yeah. 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 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? 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 was, I think my expectation is that he stays sober of myself. Like if I do my job right, he'll stay sober. 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 timeline. Like how many hours of the day are you with him?

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. Okay. So as far as checking in with him on every day, 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? Um, not much, yeah. Okay.

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, what would you describe that? Yeah, I don't, I mean, 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. I'm worried that I said something that made it worse. Okay. Tell me more about it. Well, I think I was challenging his, this person's narrative on something.

And I'm worried that that made it worse. So I'm kind of like ruminating at two in the morning on this. Yeah. Yeah. And I don't know why. why is it always two in the morning, you know? I have the same. Lately for me, it's been 4 a.m.

Okay. 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. And I think there is this 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 rehearsing over something that you said. But I think also looking at the intention is important. So I'm thinking about, let's say, this specific, as we roleplay, this specific thing that you said, this challenging of the narrative, what was your intention in doing so? Were you trying to get him to relapse? 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 Okay Okay Well let's do a brief self-compassion exercise Which I do with myself, I find very helpful Which is let's say you're talking to me Okay 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 Yep What would you say? 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.

Yeah, it sounds like you really, you care about this person and you're trying hard. Yeah. I think that's another important piece is keeping in mind that when we do worry, when we do get caught up in patience, it is because we care, because we're 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 I'll 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 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. I think if I'm going to be honest with you, I think the guilt got worse, actually, when he didn't show up. to his last appointment, it was like a no-show. And then he, it's like, I don't know if he no-shod because he was upset at me or if he was just using it again

and didn't, and wanted to avoid trying to get sober. 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're, you know, obviously coming up with 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? I'm feeling guilty now that my personalization is like, is that narcissistic of me to personalize? 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 constable. control in health care, in mental health care, particularly. 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, you know, is objectively brilliant, and it may not resonate with you. That would be more of the, that might be more of the narcissism, okay. I'm so brilliant.

I'm so wonderful. Yes. But you might think you've said something that seemed really helpful, and then they come back in something entirely different that you said. Maybe you just were joking about something. And they're like, I still remember that. Yeah, 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 have never guessed. Okay, so, you know, one of the other things, and I'm curious how, I'm still in the roleplay, by the way, is, I know this sounds very irrational. But in the middle of the night when I'm having this thought, I'm also worried like, man, what if, like, what if this guy sues me over this? Or what if, like, you know, things don't go well and then, like, some lawsuit comes at me, you know? So that's, it's like, that's there, right? Yeah. 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, okay, 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. 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, patients use with anxiety, is to say, rather than what if, say, if If then. 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? If then, what will I do? Yeah. Well, I imagine, like, being on the stand and I would be like, you know cross-examined by like there would be some like person that would be asking me why I made that comment or what evidence I had to back it up and then and then I so then I go in this anxious loop of like researching like how would I back that up yeah but then yeah so but you notice you're jumping to

is that what we're talking about is I don't think this is the answer you're looking for though I feel guilty that I'm not getting your no I think I'm not doing this right absolutely very common and understandable approach and notice that you're jumping to this kind of the 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 speak to someone about the situation. Okay.

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, I guess, a jury. I don't know, on the stand being quizzed. Like that's sort of that TV version of what being sued looks like, right? And I think, again, that's 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 sort of being on the stand, like Tom Cruise asking you if you ordered the code red. You know what I mean? Like we're not, that's a big jump. How can we go and look at the details leading up to that. Like, I'm afraid if I'm late for this meeting, then I'm going to be fired,

and then I'm going to be homeless, and then I'm going to be alone. And, you know, like this sort of jumping to kind of the worst, the catastrophic outcomes. Yeah. And so I think checking with that, in a broader sense, though, from a malpractice standpoint,

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? 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't assure that we're going to be safe.

But we can't do that anywhere. 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. A choice. What is my choice? Your choice is to say... I'm not going to take this risk anymore.

Oh. I'm going to go do something else. I'm not going to be a therapist anymore? Yeah. Okay. And then... Okay. Well, I'm also like, 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 that's probably like not what you're intended. I know you're not intending to do that or to have that happen here. Yeah. 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. Oh, no, I don't think you're telling me I'm getting it wrong. I think I'm getting it. I'm, well, I don't think that you are telling me I'm getting it wrong with patience. Yeah, I want to clarify that. Yeah. What do you think is happening then? I think I'm getting it wrong with how I'm talking to myself in the middle of the night. Oh. But I am getting it wrong. because if I was getting it right, I wouldn't be doing that, right? It's interesting that that brings up guilt

as opposed to a sense of opportunity, you know? Yeah, I should have some opportunity. Yeah, that there's something about that if you're saying, okay, maybe I'm not doing this a 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 a.m., it's like, well, this is interesting.

Here I'm awake. Maybe I'll just get up from 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. I mean, waking up at 2 a.m. 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.

is like because I'm worrying about it, I must have said something bad. I do that after like social gatherings too. Like, oh my gosh, 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. It just means I'm beginning to understand. understand it. It probably means you have more guilt than most people, or you started with more guilt. Perhaps, right? Research. I mean, yeah, I think, I think, yeah, I think that hopefully it's helped. Hopefully it's helped you. Okay, we could, we could pause the rolefully. I think, I think that the the thing that I appreciated that you did was kind of like, how do we start to look at it differently, right? How do we start to look at what's

happening differently, whether it's adding in, like, okay, can you identify the cognitive distortions that are going on? Which I think that when people, like, you know, to generate the story, I was thinking of some different providers I've been talking to, who like, there's something about sleep and kind of being between sleep, which our brain is not fully functioning, right? Or we have, we don't have our full frontal lobe online when we just kind of are in those lighter stages of waking up and thinking about these things. 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 a executive function looking at these guilty things. Like are you overly personalizing, right, 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 if you fear some legal consequences, 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. You know, 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. And then the non-judgmentalness that you talked about, I think that's good as well. It's like, how do you like remove the, you know, waking up is not necessarily a bad thing. It is, right? Like 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.

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, like, when I'm working with residents who are transferring from working with patients in the hospital to working 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,

you know, a true reality or that I'm getting it wrong. Yeah. I think I knew I was becoming a difficult patient, and so I apologize for becoming a difficult patient by like feeling more guilt based off of like, you know, getting it wrong, not doing the correct CBT techniques. Now I'm feeling guilty about that, or I'm feeling guilty that I'm even talking to you about this today,

or I'm feeling guilty, you know. 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. Yeah, so. 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. Like, 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. It's like, okay, yeah, sure. No, I definitely feel better. Well, if you don't, then let's actually dig into that. 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, to think about 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.

Yeah. And then I know you talk about shitting and, you know, guilt has a lot of sheds, right? So then I was kind of like, okay, I can create a shit from you here. Like I should be able to combat this skill. I don't know if you noticed that. That was awesome me being difficult, which is pleasurable for me. It's like, I had someone sent me a nice email the other day and was like, please do not stop the role plays. I really appreciate them that I can tell you like really enjoy them.

I think that's really helpful. Again, I use them in therapy. often. Yeah. Yeah. That's fun. Okay, yeah. So we're kind of, you know, we're going to wrap things up in like a couple

minutes here. What are some of the other things that we haven't covered about guilt that you think you'd still want to leave the people that listen to this with? Well, I think sometimes it's hard because you may understand where the guilt's coming from, but you really want to have some actual, like, practical strategies. to make a difference. We sort of practice one here, one self-compassion strategy, which is, you know, 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 miss 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 another one positive psychology has a lot of benefits in, like I said, boosting that sort of perceived reality of things that are going well. The three good things exercise or three blessings that has different names, really at the end of the day, writing down three things that went well that day and why. Yeah. Sounds really simple, but otherwise it's us up at the middle of the night 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. So I think this is a shift. I actually do it sometimes with my family around the dinner table. Yeah, yeah. And it's fun because my kids will say something other than like 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. Like, it just, it prompts us to think that way. And I think we do need practice in that.

I think 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 kind 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. Oh, so much. And that then that creates guilt because I should be trying to make it better.

I should be out protesting or I should be, you know, making these changes. I think also reminding ourselves with 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 this guilt. 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. Right. It's like what is some small impact you can make, you know, and that rather than just, you know, punching your fist into the air over and over about all of the chaos in the world, right? It's like what is some small change you can make? I like how you, you know, in your own life, you start your own podcast.

and like you told me before you edit your own podcast, which is like very, very, very masochistic of you, which we're going to work on that. Yeah, we'll deal with that next session. We'll deal with that next session, yeah. The self-compassion, the role, kind of the role play, right, where it's like, okay, pretend you are your friend, you know, talking to you about this or pretend, you know,

what would you say, right? And I think that that is very helpful. I think we could do that as well. Like pretend you're a therapist friend of yourself, right? Trying to like give yourself some input on this, like some objectivity. What would you say? Mm-hmm. I think that's great.

And I think also like just having colleagues who can, you know, you can discuss things with as well. I think that's very powerful to kind of like have some reality checks. And the more I. talk with colleagues, you know, the more I realize, like, we're all experiencing a lot of this together, right? Like, I don't know any, I don't know any mental health professional who doesn't have moments of guilt about what they do and, you know, their patients and are the patients getting well fast enough? And if there's a bad outcome, like, I think it really weighs on them. And that you mentioned moral injury, and moral injury is something that we have to deal with

as professionals, because it doesn't, because we, moral injury is like, if we have this outcome that we don't want, then we think that we're, you know, could we have done something better, where we kind of forced into a system, especially a lot of the professionals I talk to there in a system where they may not have enough time with clients that allow them the outcome that they want, right? Insurance doesn't allow the time. Insurance doesn't allow the medications maybe that give them the outcome that they want. So that can be tough as well. Yeah, 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 other metabolic issues are very likely. Increasingly we have some treatment options, but not. 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. Yep. So this is good.

I appreciate you and I appreciate you coming on here. For those of you who found this helpful, I highly recommend, you know, checking out her book, Guilfrey and her podcast, Jennifer Reed. I appreciate you coming on. check out our podcast. It's called, um, once again, a mind of her own. She also has a substack news letter. I'm sure she would love if you followed her on substack. And you're on what Instagram as well? Yeah. Gen. G. Gen. Occasionally. Yeah. Oh, I know. I post like 10 times a

year now. It's like, uh, yeah. Well, thank you for having me on. This has been really fast. 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. Where are you licensed? What states? In Pennsylvania and New Jersey. Pennsylvania and New Jersey. Okay. That's good. I don't know if I know anyone up there, or that's a psychiatrist. So it's good knowing I can refer someone to you if I get a, I get an email Pennsylvania and New Jersey, guys. Jennifer Reed, thank you for coming on. We'll leave it there for today. Thanks for having me.