Case discussion: disease as punishment.

"A 62-year-old woman has sustained a left hemiplegia while recovering
from elective hip replacement for osteoarthritis. She refuses all
treatment including physical therapy. She tells you in confidence that
she is being punished for having committed adultery about 25 years ago,
and that she should not have had the hip replacement. She feels that the
osteoarthritis also was a punishment. She does not want her husband or
other health care professionals to know about it. The woman is
competent."

This case raises a number of questions: What is going on? What does this patient need? Should the clinician agree to keep her secrets? What should be the clinician's own moral or spiritual stance?

She is resisting therapy and wants to guard her privacy, so that exploring her distress probably needs to be both tactful and targeted. A possibility that could help guide might be depression. Irrational guilt and hopelessness about the future are hallmarks of major depression, a condition that is more common after a stroke. An inability to respond to a sympathetic interview could indicate that she is severely depressed, possibly psychotically so. Are other symptoms of significant depression present, or is the picture more consistent with an acute adjustment to sudden incapacity? In other words, does it seem likely to resolve as she improves physically, and/or integrates her condition into a previously intact sense of self? A third possibility is that her faith is prominent in her approach to life, and that this has become more problematic. Is she a spiritual or religious person? What does she think God is like? Does she tend to view God as ready to criticize and condemn rather than to love and forgive her? (The researcher Ken Pargament might describe this as negative religious coping.) Still other possibilities are that her illness has unearthed a longstanding propensity to self-blame, or unresolved guilt for having violated her conscience. Has she never sought forgiveness, or has she been unable to find it?

Each of these possibilities would suggest a different approach. A sensitive conversation might itself be therapeutic by helping her to unburden herself, feel understood or forgiven by another person, or alerted to new possibilities. If she is depressed, explanation and beginning treatment could offer her hope. If she is adjusting, a life review (1) could help her regain perspective and morale. If feeling punished by God is her major concern, one would want to know if she has a pastor with whom to talk, or if she is willing to speak with a hospital chaplain. If not, it may be helpful to explore why not, and to identify a trauma or other reason for estrangement from sources of spiritual support that could be constructively addressed as a focus in brief psychotherapy. Similarly, if unable to find forgiveness, she may benefit from therapy or pastoral counseling on the reasons why.

[ILLUSTRATION OMITTED]

Should a clinician agree to keep her secrets in the process of making these plans? If she is competent and safe, she has a right to keep them, but establishing this takes an assessment. If she continues to refuse therapy, will she be safe to send home? Is she feeling so guilty that she is suicidal? If so, the rest of the treatment team, and perhaps her family, need to know at least the plan for mental health treatment, though not necessarily the details of her concerns. There may be good reasons for her keeping her secrets (fear of hurting her husband, or of being hurt by him if he is abusive), but there also may be reasons to encourage her to share them with other professionals treating her. Helping her to move beyond her guilt and toward a better relationship with her husband requires her to be open with someone.

In taking any of these positions to help her, a clinician would be expressing value judgments about what is good for her--ie, to be safe, to have a chance to heal, and to avoid making things worse for herself. Her clinician might also have to draw on his or her own moral, or religious convictions to confront her insistence that she deserves to be punished (ie, "I can't agree that you deserve to be sick any more than anyone else"). But rather than explicitly suggesting how forgiving he or she believes God to be, it will more likely be helpful to examine the question within her own system of belief: Is it really true, for example in the Judeo-Christian tradition that adultery always has to be severely punished? Or that illness is always a punishment from God? What about the healing and forgiveness that are a part of every tradition?

Patients who say they are being punished are often overwhelmed, desperate and withdrawn. They challenge us personally and professionally to engage them in considering what is really going on, how much they need their secrets, and what keeps them from finding physical, emotional, spiritual and moral healing.

References

1. Viederman M, Perry SW 3rd. Use of a psychodynamic life narrative in the treatment of depression in the physically ill. Gen Hospital Psychiatry 1980;2:177-185.

2. Pargament KI. The Psychology of Religion and Coping: Theory, Research, Practice. New York, Guilford Press, 1997.

3. Peteet JR. Approaching spiritual problems in psychotherapy: A conceptual framework. J Psychother Pract Res 1994;3:237-245.

Among those whom I like or admire, I can find no common denominator, but
among those whom I love, I can: all of them make me laugh.
--W. H. Auden

John R. Peteet, MD

From the Dana-Farber Cancer Institute, Boston, MA.

Reprint requests to John R. Peteet, MD, Dana-Farber Cancer Institute, 44 Binney Street, Gossman 411, Boston, MA. Email: [e-mail]