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Introspections   |    
Going for the Gold
Dinah Miller, M.D.
Am J Psychiatry 2006;163:13-13. doi:10.1176/appi.ajp.163.1.13
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A young woman comes in for a psychiatric consultation. She is fresh out of an Ivy League university where she was a talented musician who graduated magna cum laude. In the fall, she will continue her studies at a prestigious graduate school. She suffered symptoms of depression earlier in the year after a breakup with a boyfriend, but her mood is now euthymic, and her anxiety is what remains most salient. By all accounts, she has everything going for her and a future that is likely to be as luminous as her past. However, she confesses, she carries with her the sense that she is a fraud who somehow does not deserve all the accolades she has earned.

A gentleman is seen for treatment of recurrent major depression at the request of his wife. During the initial evaluation, I ask if there was any notable trauma or loss during his childhood. He proceeds to tell me that as a teenager he was a nationally ranked athlete and was favored for a spot on the U.S. Olympic team. He missed making the team by fractions of a second and felt he had "choked" under pressure. His struggles with depression interfered with his training and ended the possibility of future Olympic competition. Although he went on to have many successes and a loving family, he has lived life framed in the silhouette of his failure.

Finally, a young woman seeks treatment after a devastating accident that nearly took her life. She has, after months of rehabilitation, made a full recovery. She soon returns to work as a waitress, a temporary job while she looks for a position that will use the skills she mastered in college. She has difficulty finding such employment and, despite her young age, spends much time in therapy talking about how disappointed she is that she has not lived up to her potential—the expectations that were set when she graduated high school as valedictorian—and she sees her life as a failure. Her family supports this with mixed messages: constant reminders to "take it easy" after the accident along with pressure to find a more prestigious job and a constant barrage of wisdom about how she should live her life.

Success is relevant, I suppose, and depends on the standards we set. By the simplest measure, all of these patients have achieved some degree of success: They are all college graduates who are supporting themselves financially, none has spent time in jail or become addicted to substances, and they all have families who cherish them. Their stories remain mostly unwritten, although you wouldn’t know that to listen to them. Would the athlete, I wonder, be any happier if he’d won an Olympic gold medal, or would he be left with the sense that life had peaked at 17? Where does one go from there? It’s a funny world we live in where even a silver medalist may see himself as a failure and where we count in advance how many gold medals we expect top athletes to bring home, well aware that one might not be enough.

Life is no different for psychiatrists. Have our careers turned out the way we planned? Do we measure career success in the terms we thought we would—money, material possessions, academic position, grant dollars, or the Nobel Prize? Is it enough to go to the office every day and hope we ease the suffering of our patients? It seems that happiness, for both ourselves and our patients, is found not so much in attaining a goal but in the act of striving for it—yearning, planning, and trying. Of course, it’s wonderful to achieve a goal, but once the yacht (or gold medal) arrives, aren’t we obliged to move the bar and seek something new? I doubt it is ever enough to bask in the glory of one accomplishment for too long.

The musician came in for a half-dozen therapy sessions. She was relieved to express her sense of being a fraud and to have a chance to look at it. She left feeling she’d gotten something useful out of this brief psychotherapy. The waitress has just given notice to her employer, and I’m hopeful she will find more gratifying employment. I have made some progress in convincing her family that it is fine to accept her—and even feel proud of her—as she is. Despite the medications we have used to stabilize her mood, she remains left with the sense that she is a failure who has wasted her life. At 25, her story remains to be told, and she has a long way to go with therapy. The athlete has just begun treatment. He is restarting the medications that have been helpful to him in the past and is talking about concerns in his present life as well as difficulties from the past. It is a time for both of us that remains full of hope.

Address correspondence and reprint requests to Dr. Miller, the Rotunda, 711 West 40th St., Suite 322, Baltimore, MD 21211; dmill004@umaryland.edu (e-mail).

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