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When I was a younger psychiatrist in training, I had the pleasure to meet a remarkable woman named Sarah. Here’s what happened. Sarah grew up in an immigrant family. She was the youngest of six children, all girls. She told me that when she was born, her father cried and cried because he so wished for a boy. As a result, young Sarah became quite active in sports, a tomboy they called her back then. She was tough. Nobody messed with her. But she certainly had a feminine side. Boys were attracted to her - and at the age of 19, when she saw a tall young man giving a speech, she orchestrated events so they would meet. And soon they married. Sarah wanted children, lots of children, and in quick order the pregnancies came: six beautiful kids in eight years. Life moved on and all was well. Yes, there were the inevitable tensions and dysfunctional moments that afflict most families but for the most part the young kids played and consumed each others’ energy. It was a pretty stable home. And then something happened. At the age of 31, two years after giving birth to her sixth child, Sarah began to act differently. It started subtly enough, with Sarah requiring less sleep. She then started buying all sorts of stuff, unnecessary stuff like 30 beach towels, each one a different color. She started yelling at her husband and kids for no reason. Sarah became a sea of unstoppable energy and she wouldn’t listen to reason. Her husband, frustrated and concerned, took her to the hospital. She signed herself in to the psychiatric ward “to show everyone that I’m ok”, she said. And so we met. I was a psychiatric resident in training, and assigned to do the initial interview of Sarah. She told me lots of things about herself, like how she used to dance with the Native Indians during their summer festivals; how she memorized the entire Scrabble dictionary; how the Queen of England was awaiting her visit. Sarah spoke nonstop, fast, rambling, switching from topic to topic. Clearly she was in the thick of a manic episode. But I also noted Sarah’s strength, her inquisitive mind, constantly challenging me. She was not an easy, compliant patient. And I liked that about her. I presented Sarah’s case to the psychiatrist in charge who said we should immediately medicate her. As anticipated, she flatly refused. Sarah told me that a doctor once advised her to have her tubes tied so that she wouldn’t have any more children. “How nutty is that”, she told me, “doctors playing God. I don’t trust them, none of them. I’m not even sure that I trust you.” Sarah then went on a hunger strike. She said that she would refuse to eat as long as we kept offering her medication. Her treatment course became a silent battlefield: every day she would be offered the medication and every day she would not eat a thing. It was Sarah against the psychiatric attending, the administration, the whole psychiatric bureaucracy. She wasn’t aggressive or violent; she was simply determined and quietly defiant. After three days of this, the hospital authorities couldn’t take it anymore. They stopped offering Sarah medication. Sarah’s persistence, a lifelong skill, had won the day. In the next couple days, her manic symptoms naturally and slowly decreased. The psychiatrist in charge agreed to discharge her as long as she would follow up - with me - at least once a year. With that, Sarah went home, turned to her husband and said “See, I told you. I’m fine “. (As an important caveat, please know that most people with significant manic episodes do require medication treatment. Without it, they can lack so much insight and judgment that they can engage in very dangerous activities.) Sure enough, Sarah held to her word and we met once a year. She was as spunky as ever. She did have a couple more manic episodes, but they happened just once a decade - and again resolved naturally. Her husband never took her to the hospital again. Sarah never touched a medication for mania. She continued to raise and adore her children. She went back to school and got a PhD. And she continued to have a mind of her own. Years later, and a few months after our annual appointment, I learned that Sarah had fallen ill and suddenly passed away. Her family called me with the sad news. As I sat, frozen and quietly crying, they told me that one of Sarah’s last requests was that I attend her funeral. At the funeral service, I could not hold back my tears as each of her children spoke with so much love and adoration for their remarkable mother. “Always a twinkle in her eye”, they said. “She loved us for being who we are“. “She taught us to never give up”. “Her life was all about her children and grandchildren - she put a bumper sticker on her car that said, ‘Foxy Grandma’.” Yes, there was nostalgia, sweet memories, tears and laughter. And I especially smiled when her daughter shared that Sarah never lost a game of Scrabble. Sarah was Sarah, resolute and tenacious. She showed the world how to live life with a confidence not dependent on the approval of others. And her spirit, her soul will never fade away.

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