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When PsychiatrieResidents Treat Medical Students

Passage Through Idealization and Overidentification

Jerald Kay, M.D.

Coordinator ofMedicu1 Student Educution, Department ofPsychiatry, University of Cincinnati College ofMedicine,
Cincinnati, Ohio

Abstract: The author describes a survey of psychiatrie resi- experience is not instrumental in a student’s deci-
den ts and faculty supervisors inquiring as to problematic aspects sion to enter psychiatry. Because approximately
of the psychotherapy of medical students when treated by 25% of medical students engage in some form of
residents. Medical students’ idealization of and identification psychotherapy before their graduation and in light
with their resident-therapist werefound toproducea significant of the disconcerting decline in the number entering
amount of discomfort for the trainee. Difficulties in the
psychiatry (7), a description of some inherent diffi-
psychotherapies were also attributed to the numerous pos-
culties in the treatment of this special group of
sibilities of identification by the residents with their medical
patients is timely.
student patients. The varied forms of identification are detailed
through the use of clinical vignettes submitted by respondents. A recent study (8) of medical students’ mental
Zt is the author’s contention that psychotherapies involuing health services in this country revealed that approx-
these “special patients” provide a window for examining many imately two-thirds (67.3%) of al1 psychiatry de-
issues in the development of the resident’s professional self. partments (60 responding) indicated that their
Given the increasing number of medical students electing some residents were involved in the delivery of such ser-
form of personal psychotherapy and the declining number enter- vices. The University of Cincinnati Department of
ing psychiaty residency training, the timeliness of this issue is Psychiatry, for example, relies very heavily on ad-
noted. vanced residents to provide this care. It has been
the author’s experience, however, that residents
often have a difficult time with their medical stu-
An extensive literature describes the emotional dent patients, and, moreover, there appear to be
stresses concomitant with medical student years some clearly definable problem areas in these
(1-5). Many authors underscore the usefulness of therapies that are easily lessened by appropriate
psychotherapeutic experiences in assisting the stu- teaching and supervision.
dent through those trying times. Surprisingly little,
however, has been written on the actual conduct of
psychotherapy with these students outside such Description
issues as establishing a conducive environment for
psychotherapy within the medical school and con- To study the extent and nature of the problems
fidentiality among therapist, student, and medical most frequently encountered in the psychotherapy
school administration (6). of medical students by residents, the author
Few would argue that a positive psychotherapy queried advanced residents and supervisors in the
Department of Psychiatry at the University of Cin-
cinnati. The questionnaire sent to residents in-
The author wishes to thank Drs. Paul H. Ornstein and Donald G. quired about how many students had been seen
Langsley for their suggestions in preparing this manuscript.
both diagnostically and for treatment. It further
Presented at the 133rd annual meeting of The American Psychiatrie asked for a rating of the efficacy of treatment ex-
Association, San Francisco, California, May 9, 1980. periences. Thirdly, it asked what particular prob-

Genera/ Hospital Psychmtry 3, 89-94, 1981

0 Elsevier North Holland, Inc., 19Rl 89
52 Vanderbilt Avenue, NW York, NY 10017 ISSN 0163-8343181/o20089-06/$02.25
J. Kay

lems were encountered in treating these students. sulted in a break in empathy, in which residents
Given the resident’s stage of training, was it felt that became overly sympathetic with how bad things
there were unique problems in treating medical were, for instance, on the clinical services for their
students? If so, what were they? Lastly, the resi- medical students. Not surprisingly, overidentifica-
dents were requested to describe a brief clinical tion was often accompanied by the residents’
vignette illustrating a problematic aspect of the minimizing a student’s psychopathology as wel1 as
diagnosis or treatment of the medical student. The having unrealistic expectations of the “student as
supervisors were asked to complete a similar form patient.” Some supervisors noted that the latter
about the number of residents supervised who might be attributed to the residents’ greater ease
were treating students, the effacacy of those treat- and facility with acute and short-term problems as
ment experiences, particular problems encountered opposed to long-term psychotherapy. Other su-
in supervising these cases, and, from their supervi- pervisory comments indicated that residents
sory experiences, whether there were any unique tended to doubt their confidence more with this
problems in residents treating medical students. group of patients, frequently illustrated by the resi-
The supervisors were also asked to supply a clinical dent’s need to present himself to both the super-
vignette illustrating the supervisory problems visor and patient as “knowing al1 the answers”
and/or problematic aspects of a resident’s treating rather than adopting an open, investigative posture
or diagnosing a medical student. of evocative listening. Only one supervisor could
recall a resident having assumed an inappropriate
relationship vis-a-vis the medical school adminis-
tration in which a breach of confidentiality trans-
Nine advanced residents and 28 supervisors re- pired.
sponded to the questionnaire. Responses from res-
idents indicated there had been diagnostic contact
Unique Problems Encountered in the
with ten students and therapy experiences with
twelve others. Five cases were considered to have Treatment of Medical Students
been terminated successfully and five more moder- Resident and supervisory responses to the question
ately so. Two of the treatments were described as as to whether there were unique problems in treat-
unsuccessful. Only one of the nine residents felt ing medical students were more detailed and il-
there were no unique problems in treating stu- luminating. Over three-quarters of the supervisors,
dents. The 28 faculty supervisors responding indi- for instance, listed more than five items. In general,
cated that they had supervised, over the past 5-10 however, both groups agreed that the resident-
years, 137 different residents in their student dyad provided a microcosm for issues that
psychotherapy with medical sutdents (total might be subsumed under the rubric of the resi-
number of cases, 155). Supervisors rated 42 of those dent’s “development of the professional self.” Al-
cases as successful, 87 as moderately successful, though similar problems occurred in treating other
and 26 as unsuccessful. patients, they were clearly more frequent and in-
tense with the medical student patient.
Genera1 Problems Encoun tered in
Medical Student Psychotherapy Resident Responses
Residents noted several problems in their clinical As noted above, residents stated that their patients’
work with medical students: “excessive in- idealization of and overidentification with them
tellectualization” on the part of the students, unre- produced the more intense discomfort. Two-thirds
mitting fears of breach of confidentiality, and un- of resident respondents indicated that given their
comfortable instances of strong identification with stage of training, this was a unique problem in
and idealization of the resident. Of the three areas, treating this group of patients. Therapists confided
the last apparently gave residents the most diffi- they would frequently “debunk” the admiration
culty. Supervisors, on the other hand, referred these patients demonstrated by informing them of
repeatedly to their perceptions that residents very reality issues pertaining to the field of psychiatry
frequently overidentified with their student pa- and the stress inherent in psychiatrie training. To
tients, thereby causing a loss of therapeutic stance. illustrate, a resident reported the following
As an example, this overidentification often re- vignette:

Psychiatrie Residents Treat Medical Students

1 was treating a third-year woman student who not sicker and that they, the residents, might be needed
infrequently told me how much she was impressed in capacities beyond their therapeutic skills. The
with my intellectual ability to understand her. Medical following vignette illustrates this issue:
school was so unrelentingly trying for her that she
often thought of me as a model and a source of A first-year medical student presented to her sixth
strength that permitted her sometimes to get through therapy hour with me in a dissociative state. Her
the worst of the clerkship days. The patient viewed me mood, markedly in contrast to a previous depression,
as a “very together” person who seemed not to let the was elated. She laughed inappropriately, sat childlike
“system” get the best of me. Her compliments and in the chair, and appeared totally unable to recall or
yearnings to be like me were so troublesome to me at connect with material that we had expressed in previ-
times that 1 found myself anxious and on many occa- ous sessions. She repeatedly stated, “It al1 seems to be
sions told her that 1 was not as perfect as she pictured a game.” (1 now view this as having been a defense
me. For instance, 1 related that 1, like everyone else, against disintegration anxiety which was aroused by
had problems adjusting to medical school and that my having touched upon her experience of herself as
being a resident was no picnic; in fact, things seemed being worthless, unwanted, and defective.) At any
worse at times now than in medical school. Invariably, rate, my anxiety was such that 1 was unable to “be with
these interventions produced a noticeable depression her” in this feeling state. Instead of providing the
in the patient and sometimes an angry reaction. It was calmness which 1 would with any other patient, and
not until much later in the therapy before the patient which she clearly needed, my anxiety pressed me into
could admit to me that when 1 gave those responses, activity. 1 asked her numerous questions in an attempt
whe experienced them as a chastisement. She felt that to get her to assure me that she was really “O.K.”
1 was saying to her: “Keep a stiff upper lip and stop Fortunately, the overall course of the 6-month therapy
being a crybaby.” My supervisor was most helpful to was reasonably good, although 1 remained disap-
me in pointing out how uncomfortable 1 had been in pointed in myself for several major therapeutic errors.
permitting the idealizing transference to unfold and Certain therapeutic skills temporarily were lost due to
that my reality-oriented comments tended to drive a lack of proper therapeutic distance on my part and
underground some significant feelings in the patient. subsequent inability to tolerate this young woman’s
affect. Also, it is clear that my expectations of her went
far beyond the reality of her own ego strength. 1
Two residents spoke openly of their medical stu-
wanted to view her as healthier than she actually was,
dent patients who made the decision to enter
and my failure to recognize her vulnerability led to a
psychiatry-decisions that were not examined
therapeutic approach that precipitated a temporary
thoroughly in the therapy, but accepted at face fragmentation. Fortunately, it was short lived.
Approximately one-half of the residents felt that One-third of the residents noted that “competi-
their identification with the student was so great at tion between patient and therapist seems to be
times as to interfere with the psychotherapy. more difficult to handle in therapy.” These resi-
Vignettes clearly portrayed that analogous difficul- dents cited examples of their patients’ needing to
ties in training, as wel1 as in the developmental demonstrate their recently acquired knowledge and
tasks of young adulthood, caused frequent “blind expertise in psychopathology, which often took on
spots” on the part of the therapist. One resident a rather highly challenging character. Patient
commented: “1 was having feelings of despair and doubts about their residents’ clinical expertise
doubt in my own work and often the student’s tended also to be unnerving at times for the young
similar situation would mobilize these feelings for resident.
me right in the therapy hour.” Conversely, yet
another resident reported that “My student was so
Unique Problems as Sem by the
vehemently tearing down every resident he had
contact with on the wards that 1 became defensive;
after all, 1 too am a resident.” Another noted that As a group, supervisors were strongly convinced
“Overexposure of the therapist to the student that a unique problem for the treatment situation
through teaching activities in the junior clerkship under discussion was overidentification with the
was quite sticky for me.” patient. The comment that the resident was often
Two of the nine residents mentioned that they “too close to the student’s experiences” appeared
experienced difficulties in tolerating their students’ frequently. One incident was related of the resident
intense affect because it invariably left them with a who was unable to be helpful to his patient, a
feeling that these special patients were becoming second-year student overwhelmed with anxiety

J. Kay

about examining patients in his new physical diag- brilliant, superficially formed smooth social relation-
nosis course. The student was troubled by fantasies ships, but confided in treatment the coldness and
of examining patients’ bodies as wel1 as fears of contempt he felt for patients, peers, and faculty. The
missing some important physical findings. Another resident experienced a great deal of distress as he tried
to envision the student functioning as a physician, and
vignette described a resident’s discomfort in treat-
unconsciously began trying to “steer” his patient into
ing a beginning medical student struggling with
an area of medicine where the resident-therapist felt
feelings about working on a cadaver. Yet another the student-patient would “do the least damage.”
faculty member spoke of his resident’s failure to Some might argue that the resident was doing the
explore his student-patient’s intense shame over appropriate thing and in the long run would be the
having to repeat the second year in medical school. best for everyone concemed. As a supervisor, 1felt the
Supervisors noted that residents were more apt resident was abandoning his role as therapist and was
to be troubled by wishes to “protect” their patients denying his patient the unique opportunity of
by breaking their professional role and intervening psychotherapy to understand his problems and to
for the medical student vis-a-vis the dean’s office. come to his own decisions.
Six of the 28 supervisors related examples of resi-
dents who actively encouraged their student- Four supervisors noted that a complication arose
patients to act out hostility toward the medical at times when both the resident and his patient
school administration. were completing their training concomitantly.
The “specialness” of the patient was also noted
The resident was terminating the program at the same
by many to be particularly troublesome to the resi-
time the medical student was terminating his
dent. By specialness, supervisors alluded to the
psychotherapy and graduating from medical school,
residents’ feeling that these students were “valu- which brought into closer alignment a common feeling
able patients,” that the residents’ therapy would state. The result was that the resident intellectualized
have high visibility in the medical community if the termination and sidestepped for some time intense
things went poorly, and that psychiatrie faculty affective issues in his patient’s termination.
would be looking more closely at their work with
these patients. This was most often manifested in Lastly, mention should be made of competitive
the supervisors’ comments that residents “seemed situations likely to arise. The caseload of many
to have an inability to tolerate regression on the part residents may be overrepresented by supposedly
of the patient for fear of poor school performance less suitable patients for intensive psychotherapy.
resulting in dismissal of the patient from medical A bright, young, successful, and verba1 student,
school.” That the resident was treating perhaps his therefore, may be a jolting experience for many
first colleague often interfered with adopting a pro- residents. They often find themselves making
fessional stance. One resident, for instance, found mistakes that they long ago discarded from their
himself spending 2.5 hours for the first diagnostic professional conduct. A number of supervisors com-
meeting with a senior medical student. His usual mented that residents are more apt to enter in-
practice was to see a new patient for 50 minutes and tellectual struggles with these student-patients and
schedule a second appointment. frequently try to teach them psychodynamics rather
Difficulties with definition of roles also received than allow the understanding to evolve within the
some comments. A number of supervisors related context of the psychotherapeutic relationship. This
that residents failed to examine the complexities of was particularly likely to take place if the student
their patients’ decision to enter psychiatrie training. was perceived by the resident as being too scien-
One resident admitted to her supervisor that she tific and biological in orientation. Yet, another
felt very confused because she wanted her patient, type of competition was noted in the following
whom she felt would be an excellent resident, to vignette:
come to our residency program. She was troubled
because she felt this was an improper feeling to A third-year male resident discouraged a fourth-year
express in the therapy. In a different vein, a super- male medical student from applying to the Institute
visor reported the following vignette: Consultation Clinic for a low-fee psychoanalysis be-
cause he enjoyed having him as “his patient” and,
A 24-year-old male senior medical student had a se- secondly, the resident was waiting to enter analysis
vere narcissistic personality disorder recognized by himself. He seemingly did not want the student to
both the supervisor and resident. The student was have something that he didn’t have as yet.

Psychiatrie Residents Treat Medical Students

prevalent as had been expected. In a similar vein,

Discussion only two supervisors commented that they had
The reader wil1 note the relative absente of the term encountered instances wherein one resident had
“countertransference,” a quite purposeful omis- strong negative feelings about women physicians
sion. Many of the comments and vignettes submit- and another about blacks that had interfered in the
ted by residents and supervisors reflected more the patients’ psychotherapy. An unexpected issue was
sense of inadequate skills and knowledge on the that when completion of psychotherapy and resi-
part of the resident than the operation of uncon- dency training coincided, it was likely to produce a
scious conflicts, although certainly these were situation in which the patient’s termination was not
present as well. Often in the past, lack of adequately worked through. This is helpful to note
psychotherapeutic progress has been too narrowly because the contingenties of medical school and
and perhaps inaccurately attributable to counter- residency training demand frequent shifts in
transference alone, leaving the resident with the therapy and often impose time limitations for the
sense either that he was not very insightful or that treatment. Lastly, of the 28 responding supervisors,
he needed to seek further personal psychotherapy. only one voiced the concern that “the medical
This produced a sense of helplessness and needless school was gambling with quality by permitting
doubt in the young therapist. On the other hand, if residents to treat medical students.”
the discomfort expressed with patient idealization,
for instance, were seen in light of readily explain-
able transference phenomena, this would permit
the resident to learn more of the specific process In conclusion, this survey has illustrated how fre-
rather than view his anxiety about being idealized quently the treatment of a medical student by a
as merely a sign of inability to tolerate close feelings resident is characterized by complexity. Indeed, it
from the patient. often turns out to be a microcosm of significant
A number of striking trends are brought forth by professionalization issues for the resident. Without
this survey. Issues of identification between patient question, it is a valuable opportunity for the resi-
and therapist, and vice versa, presented as most dent and can provide an important learning experi-
problematic for the resident-therapist. Because of ence in treating medical colleagues. Supervisors,
the strong similarity of life-cycle issues and de- then, have an important role to play in assisting the
velopment of professional identity, a number of young therapist to fee1 more comfortable by under-
problems were more likely to transpire in therapy standing more of the intricacies of this special
between residents and medical students than with treatment situation.
other patients. Therapists noted how easily their Recent and highly significant contributions to
own feelings of helplessness, both about medical self-psychology (9-ll), while beyond the scope of
school days and current residency training, were this paper, nevertheless provide supervisors with
mobilized by patient material. This at times blocked an alternative teaching approach to the phenome-
the therapist’s ability to recognize certain themes non of idealization. Kohut’s elucidation of a distinct
and conflicts and deal with them adequately within “idealizing transference” permits idealization and
psychotherapy. Moreover, it not infrequently led to identification to be viewed not exclusively as defen-
the resident’s breaking his therapeutic stance and sive operations, but indeed as pathways to health
combatting the helplessness with inappropriate ac- and, therefore, favorable prognostic signs. Idealiza-
tivity. This was more likely to take place when tion is no longer conceptually restricted to the for-
therapists feared the student was becoming more mative years of personality development but persists
dysfunctional in medical school performance. The throughout life and is most certainly activated in
perceived responsibility for this “valuable” patient every psychotherapy experience regardless of the
facilitated residents’ inappropriately spelling out patient’s age. Supervisors need to instruct residents
their patients’ dynamics for them in the hope of that their patient’s idealization is not something to
staving off a regression which would further com- be eliminated through correcting the patient’s
promise the student’s functioning in school. transference distortions.
While some supervisors reported the tendency For supervisors to approach the therapeutic
of their supervisees to unconsciously promote the problems related to idealization and overidentifica-
students’ acting out of aggressive impulses toward tion only as countertransference issues overlooks
faculty and administration, it was not nearly so recent developments in the field, and it is also less

J. Kay

productive for the trainee. Supervisors would do stances, it wil1 result in the selection of residency
better in their preceptorships and clinical confer- training in psychiatry.
ences to remind residents how frequently strong
similarities between patient and therapist evoke
significant anxiety that may black the therapist’s
empathy for his patient (12). 1. Bojar SA: Psychiatrie problems of medical students.
In Blaine GB, McArthur CC (eds). Emotional Prob-
There is genera1 agreement that life experiences
lems of the Student. New York, Appleton-Century-
and, in particular, a psychotherapy experience are Crofts, 1961, pp 217-231
significant factors in career selection. The psychiat- 2. Funkenstein DH: The learning and personal de-
rit specialty has recently witnessed a dramatic de- velopment of medical students and the recent
cline in students electing psychiatry. It is therefore changes in universities and medical schools. J Med
Educ 43:883-897, 1968
quite timely that more attention should be given to
3. Glaser RJ: The adaptation of the student to medical
the psychotherapy of medical students by school. J. Med Educ 31:17-20, 1956
resident-therapists. The coercion, however, no 4. Pitts FN et al: Psychiatrie syndromes, anxiety symp-
matter how subtle, of a patient by his therapist to toms and responses to stress in medical students. Am
enter psychiatrie training is most certainly not being J Psychiatry 118:33340, 1961
5. Saslow G: Psychiatrie problems of medical students. J
advocated. Such a practice is unethical and coun-
Med Educ 31:2733, 1956
terproductive and provides no assistance as a spe- 6. Snow LH: Preliminary observations of the
cific recruitment technique. For most medical stu- psychotherapy of medical students. Am J
dents, more engaging and clinically meaningful Psychother, 23:293-302, 1969
undergraduate teaching wil1 ultimately prove to be 7. Pardes H: Why students are not entering psychiatry.
Res Staff Phys April, 1979, pp 54-58
the most effective lure to the field. Yet, to deny that
8. APAINIMH Survey of Medical Students Mental
these unusual treatment situations have little im- Health Services, 1979 (unpublished)
pact on student career decisions is naive. Assisting 9. Kohut H: The Analysis of the Self. New York, Inter-
psychiatrie residents, through increasingly sophis- national Universities Press, 1971
ticated supervision, to perform the most com- 10. Kohut H: Restoration of the Self. New York, Interna-
tional Universities Press, 1977
prehensive psychotherapy with their student-
ll. Ornstein PH: On Narcissism: Beyond the Introduc-
patients additionally provides two minor, but not tion, Highlights of Heinz Kohut’s Contributions to
insignificant, benefits, particularly to students con- the Psychoanalytic Treatment of Narcissistic Person-
templating careers in psychiatry. First, highly ef- ality Disorders. In The Annual of Psychoanalysis
fective psychotherapy enhances the residents’ pro- 2:127-149. New York, International Universities
Press, 1974
fessional selves, an enhancement undoubtedly
12. Shore MF: The per& of homology. Int J Psychoanal
transmitted to their patients as an assuring clinical Psychother 7:480485, 1978-79
stance of professional conviction. This is particularly
valuable during a period when the psychiatrie spe-
cialty appears to be in flux and having some major Direct reprint requesfs to:
professional identity concerns. Second, the best Jerald Kay, M.D.
possible psychotherapy experience allows student- Department of Psychiatry
patients a definitive firsthand appreciation of psy- University of Cincinnati
chiatry’s most centra1 skill. Such psychotherapy College of Medicine
wil1 indirectly contribute to students’ autonomous 231 Bethesda Avenue
career decisions, and it is hoped that in some in- Cincinnati, OH 45267