A PREVENTATIVE ILLNESS
APPROACH TO EMOTIONAL IN PSYCHIATRIC RESIDENTS E. M. Waring, M.D.
Emotional illness in psychiatric residents and its relationship to psychiatric post-. graduate training is examined. First, the pertinent literature is reviewed. Psychological and social factors which predispose, precipitate, and perpetuate these emotional disturbances are discussed. The significance of emotional illness in psychiatric residents to the teaching and learning of psychiatry and to the psychiatric profession is darified. Second, the currently unresolved dilemma of the psychiatric resident "Teach or Treat?" is presented. It is the author's contention that by redefining "treatment" in terms of the goals and philosophy of public health this dilemma can be resolved to the satisfaction of resident, faculty', and the psychiatric profession.
E M O T I O N A L ILLNESS IN PSYCHIATRIC RESIDENTS It has been suggested that Freud suffered from an obsessivecompulsive neurosis. Wilhelm Reich, following his brilliant contributions to "character analysis," died in prison suffering from a chronic psychosis. Psychiatrists and psychiatric residents are, after all, human. Although selfevident, the simple fact remains, and thus it should come as no surprise, that we all are susceptibIe to developing emotional disorders. The question, then, is whether or not psychiatric residents are more or less susceptible to developing psychiatric illness than the general population? What forms do these emotional disturbances take? What are the factors responsible for such disturbances? What is the significance o f these emotional illnesses, particularly in light of the old adage, "physician heal thyself," and how do they influence postgraduate training? Merklin and Litde, 1 in 1967, discussed "Beginning Psychiatric Training Syndrome." They stated: "The psychological response of the resident to his first year of psychiatric training may be characterized by temporary neurotic symptoms, psychosomatic symptoms, and symptomatic behaviour." They described a prodrome characterized by a change in the resident's attitude to his peers, patients and instructors. T h e resident often becomes preoccupied with paper work and conferences at the expense of patient Dr. Waring is Assistant Professor of" Psychiatry, University of Western Ontario. Reprint requests should be addressed to Dr. Waring at Victoria Hospital, London Ont. PSYCHIATRICQUARTERLY,VOL.49(4) 1977
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contact. An absorption in neurology or biochemistry was frequently noted. The manifest syndrome showed no specific pattern of clinical symptoms, although most had difficulty with authority, were easily distracted, and showed specific learning blocks. The authors related the development of symptoms to premature resignation from postgraduate training programs. Halleck and Woods support the existence of emotional illness in psychiatric residents. 2 They state: "The impact of the various stresses upon the psychiatric resident is most often manifest by the occurrence of clinical or subclinical symptomatology or in an impairment of the professional development." T h e y feel that few residents have gone through the residency period without having experienced, somewhere along the line, moderate to severe anxiety or depression. Holt referred to "The typical slump---a period of vague dissatisfaction occurring during the first year. ''a He also reported that 65% of the residents in his study sought personal psychotherapy, perhaps an indicator of a high prevalence of emotional illness. Sadock and Kaplan 4 suggest that there is "between the first and second year of r e s i d e n c y . . , a period when recognition of the limitations in psychiatric knowledge often causes disillusionment and personal disequilibrium." They felt this "second year slump" was characterized by (1) vague dissatisfaction, (2) persistent complaints, and (3) formal protests. H u n t e r describes his experience in supervising groups of residents. 5 Three phases occurred in the groups' natural history. The first phase was characterized by anxiety and bewilderment, the second by criticism of hospital policy, organization, and staff; and the third phase by resolution of conflict or the development of "counterattitudes" suggesting deep personality difficulties. Ungerleider referred to the first year of training as "that most difficult year" and discussed the development of defences against helplessness and anxiety. 6 Pasnau and Bayley gave the Minnesota Multiphasic Personality Inventory (MMPI) to two consecutive classes of first-year psychiatric residents and found a marked increase in scores on the depressive scales when compared to medical school graduates applying for psychiatric training. 7 Kelly suggested that suicide during psychiatric residency was not rare. 8 The author, in a crosscultural prevalence study, demonstrated that 16.2% of psychiatric residents in a total combined British and Canadian sample of 173 scored greater than 12 on the General Health Questionnaire suggesting a high probability of nonpsychotic emotional illness 9 This prevalence did not differ greatly from that found in the combined sample of residents in medical specialties other than psychiatry. Contrary to the previous literature, the prevalence was not greater in the first year of training than in later years. Foreign medical graduates were found to be at no greater risk for development of emotional illness than native-born graduates.l°'11
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ETIOLOGICAL FACTORS Halleck and Woods 2 state: "The psychiatric residency is a time of extraordinary emotional stress in the life of the prospective psychiatrist, a stress which may have a profound effect upon both his personal well-being and his subsequent professional adequacy." In discussing factors which may contribute to emotional illness, I shall focus on three areas: (1) the resident, (2) problems inherent in residency training, and (3) factors specific to psychiatric residency. Although separated for the purpose of discussion, it is obvious that these areas are interconnected and overlapping. The resident
Who are these medical school graduates who decide to enter postgraduate training in psychiatry? Why have they chosen psychiatry? What personality features and life experiences may predispose them to the development of emotional illness during psychiatric residency? Walton suggests that the attitudes of students toward a psychiatric career are already well defined before instruction in psychiatry and are relatively little influenced by the training provided. 1~ A positive attitude to psychiatry as a career is an indicator of a "psychological-mindedness"; the students who express a negative career attitude to psychiatry tend to be more organically oriented. T h e most important of the four personality dimensions tested by Walton in relation to psychiatric career attitude is "reflectiveness"; that is, the students who favor abstract ideas are positive, and the students who prefer ideas with practical application are negative about psychiatric career. "Complexity" and "the capacity to tolerate ambiguities" can be correlated to a positive attitude toward a psychiatric career. Extroversion-introversion has been shown to be of no importance and neuroticism to have only a very minor relationship to psychiatric career. Determinants other than personality factors influence doctors to become psychiatrists, and need to be explored. Halleck and Woods 2 state: "Many psychiatrists have the subjective impression that the choice of psychiatric specialization may also be determined by the presence of significant emotional conflict." The impression that some applicants use training as an entry into therapy is widespread. ~a Unfortunately, there has been little research in this area. Finally, a myth has grown in medical schools that the student who chooses psychiatric postgraduate training tends to be "odd, eccentric, and an underachiever." If true, could this predispose to development of emotional illness during residency? A recent study by Pasnau and Bayley 7 seems to dispel this myth. Their eighteen medical school graduates who applied for postgraduate training in psychiatry shared the following characteristics: (1) higher than average Medical College Admission Test
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scores; (2) personality traits described by teachers as "well-liked, community interest, enthusiastic, pleasant, sensitive, dedicated, and thoughtful"; and (3) high level of extracurricular activities, the group of applicants included most of the major class officers and leaders. Kardener and associates 14 described a "personal, patient-centered, help-giving orientation." Unfortunately, there have been no studies correlating personality features of psychiatric residents with the presence or absence of emotional illness in residents. Residency as a Factor in Emotional Illness in Residents
Merklin and Little 1 have referred to several factors which exist in all postgraduate residency programs which may predispose to the development of emotional illness in residents. Peer group competition is one. Competition for resident positions and anxiety related to examinations may generate hostility. The individual may be unable to cope with this hostility, and isolation from those who could provide support during residency may result. Conflicts related to both the individual's relationship to authority figures and to increasing medical responsibility may arise. Halleck and Woods 2 have paid particular attention to the psychiatric resident and his family. They feel the resident's wife is in a particularly vulnerable position and state: "Since the majority of residents have married during medical school training, the wives have visualized the context of their future lives as including many of the traditional living arrangements of a medical family. T h e resident's wife often finds, however that the entire milieu in which she or her husband move is radically different from what she had experienced before or had anticipated." These authors felt the long hours absent from the home and the frequent upsets and often personality changes occurring in the resident led to breakdowns in seemingly adequate marriages and a high incidence of symptomatology amongst residents' wives. Factors Specific to Psychiatric Residency
Halleck and Woods 2 state: "The two major emotional stresses of the first year concern the resident's struggle to achieve identity as a psychiatrist, and the impact of the anxieties attendent upon the development of psychological-mindedness." Several authors 1~'1s have discussed the psychiatric residency experience as a "transitional crisis" particularly with reference to "role identity." T h e y question the tradition of the resident beginning his service in an inpatient setting with seriously disturbed patients. Here the resident is given enormous responsibility at a time when his clinical knowledge is limited. T h e psychiatrist resident may become preoccupied with his loss of identity as a medical physician. The isolation of the traditional psychiatric hospital, coupled with frequent skepticism and even
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insults and deprecating jokes from his medical colleagues, may predispose to such preoccupations. Secondly, the development of "psychological-mindedness" is difficult because of (1) identification with the psychopathology of the patient; (2) the impact of psychotherapy and psychotherapy supervision; and (3) the therapist's quest for omnipotence. As the resident becomes familiar with his patients, he cannot help but become aware of feelings, impulses, and conflicts which he, himself, may have experienced. The patient's problem may become his own. Secondly, the resident's first attempt at psychotherapy often occurs in unfavorable circumstances. His first patient is often poor and of low socioeconomic dass--a group traditionally unresponsive to psychotherapy. The resident frequently rotates clinical services; thus he rarely sees long-term changes or improvement. Frustration and disillusionment may result. Individual supervision, especially bad supervision, may predispose to the development of emotional illness. Halleck and Woods 2 state: "While supervision is the most useful tool in the teaching of psychotherapy, it can also be a most significant contributing factor in the emotional decompensation of a psychiatric resident." This is in part due to the supervisor's divided loyalties between resident and administration, in which he is both educator and evaluator. The resident faces the realistic absence of the securities inherent in a "therapeutic alliance," knowing the supervisor has realistic power over the success or failure of his residency. Countertransference in the supervisor may result in the failure to recognize emotional illness in residents or in the "acting out" of unresolved conflicts from their own training through the resident. Finally, Sharaf and Levinson 19 have studied the "quest for omnipotence" in the psychiatric resident. They describe the emotional problems that develop as residents attempt to work through this "quest," or "wish to cure." The anxiety produced may lead to a radical selfexamination producing further anxiety or depression or to a massive identification with his supervisor which precludes further growth.
SIGNIFICANCE OF E M O T I O N A L ILLNESS IN PSYCHIATRIC RESIDENTS Merklin and Little 1 suggest: " . . . recognition of the 'Beginning Psychiatric Training Syndrome' as a transient, and often valuable adaptation response may lessen its intensity and encourage both the resident and his instructors to deal with it more constructively." Generally, psychotherapy supervisors have looked upon such illnesses as natural events or even as a favorable occurrence leading to greater self-awareness and empathic understanding. Here we see a paradox. On the one hand, candidates for postgraduate training in psychiatry are often refused acceptance because of preexisting emotional disorder. On the other hand, the development of neurotic,
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psychosomatic, or behavioral symptoms during the residency experience may lead to greater self-awareness. However, even those who adhere to this doctrine admit that in a certain percentage, the anxiety and depression linger on and require treatment! The presence of neurotic, psychosomatic, and behavioral symptomatology may be evidence of emotional illness in psychiatric residents. The failure to prevent, recognize, and treat such illness results in: 2°'21 (1) severe psychiatric decompensation in some cases; (2) premature and impulsive resignations from training programs; (3) development of therapeutic nihilism which may never remit, i.e. cynical, unbelieving, and chronically dissatisfied psychiatrists; and (4) possibly a contribution to the relatively high incidence of suicide, drug addiction, and marital discord amongst psychiatrists. T H E PSYCHIATRIC RESIDENT: "TEACH OR TREAT" Emotional difficulties can impede or inhibit the learning of new skills being taught to the resident during his psychiatric training. As R. C. A. H u n t e r s has suggested in an unpublished paper, "The Psychiatric Resident: Teach or Treat," the recognition of such emotional difficulties in the student inevitably imposes on his teachers an obligation to help him, at least up to a point. The question is "... up to what point?" H u n t e r states: "Although the educational function of the Department of Psychiatry is teaching and not treatment, they cannot be sharply separated since both aim to produce modification in the student." Should such help be called "counseling," "supervision," or "psychotherapy"? What sort of help should be offered? Suggestions have ranged from "modified analysis" to more intensive supervision oriented toward reducing resistences to learning. It is the purpose of the second part of this paper to show that the "teach or treat" dilemma has arisen because traditionally "help" was offered to the psychiatric resident with emotional illness in the form of psychotherapy, either within or outside of supervision. By redefining "treatment" in terms of the goals and philosophy of public health, i.e., primary, secondary, and tertiary prevention, the occurrence of emotional illness in residents can be reduced and, through early detection and intervention, the resistences to learning can be minimized. PRIMARY PREVENTION Primary prevention, as defined in this paper, is the promotion of mental health and the lowering of the risk of mental disorder in residents through interfering with pathogenic forces within the resident and in their psychological and social environment before the appearance of identifiable pathology. T h e focus of primary prevention shifts from the individual to
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the community of the resident. Although this paper emphasizes primary prevention, it does not imply a belittling of the importance of secondary and tertiary prevention, but that the preoccupaiton with the latter in the form of psychotherapy has led to the "teach or treat" controversy. The discussion of primary prevention of emotional illness in psychiatric residents will examine issues related to: (1) research, (2) education, and (3) alteration of pathogenic forces within residency training.
Research into Pathogenic Factors within Psychiatric Residency It is interesting to note that despite the large literature on emotional illness in psychiatric residents, Halleck and Woods z state: "There are no reliable statistics available as to the cause of failure in residency training programs. Information as to the incidence of anxiety attacks, depression, suicide, psychosis or serious acting out is also unavailable." These authors suggest that the failure to adequately study these problems may reflect guilt arising from a sense of responsibility for these casualties, as well as the nebulous qualities of selection precedures and a sense of inadequacy about successfully meeting the residents emotional needs. Numerous suggestions are raised in the lkerature regarding pathogenic factors in psychiatric residency. However, these must be substantiated before changes in postgraduate training are implemented rather than postulated. For example, three factors are mentioned in the literature which could lead to psychopathology in psychiatric training: (1) identification with the psychopathology of the patients; (2) the impact of psychotherapy supervision with the development of "psychologicalmindedness"; and (3) a shift from the authoritarian medical model to a more passive psychological role. T h e literature indicates that these three factors have the greatest impact during the first year of training. However, in our study of British and Canadian residents, emotional illness was shown to be no more frequent in the first year of training than in subsequent years. This would suggest that the above factors are of only minor significance in the development of emotional illness and that the main problem is that personality and life experience that the resident brings with him into training. Thus the above mentioned factors may only be precipitating or, more likely, perpetuating factors, and the high prevalence rate frequently suggested for psychiatrists in middle life may not be related to a greater prevalence of illness but to their inability, and that of psychiatric residents, to get adequate psychiatric care? 1,~2 Finally, the significance of emotional illness in psychiatric trainees to their training, careers, and personal health remains problematic. Although it is suggested that the presence of anxiety and depression are necessary for the development of a competent and empathic psychiatrist, other authors suggest that they are symptoms of psychiatric illness which may be related to premature termination of training, poor training performance, and cyncial and negativistic attitudes to psychiatric practice. In an attempt to an-
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swer some of these questions, we have given the General Health Questionnaire, Strong Vocational Inventory Blank, Eysenck Personality Inventory, and Minnesota Multiphasic Personality Inventory to a group of psychiatric residents at the University of Toronto and the University of Western Ontario in the first month of their residency. These groups are being followed-up to assess whether these tests are predictive of premature termination of training, type of practice, and various parameters of success or failure during postgraduate training.
Education Supervisors and residents should be aware of the possibility of emotional illness developing during psychiatric residency. Halleck and Woods 2 state: "We believe this (identification with patient's psychopathology) to be an extremely common phenomenon and a powerful source of anxiety in first-year residents. It is also our impression that supervisors frequently fail to recognize the often subtle expressions of the resident's concern." They emphasize that the supervisor-resident relationship itself is a strange one, almost inherently conflictual and ambiguous. It is hoped, acquainting the supervisor with the existence of such problems may help him to cope with "empathetically remembered experience engendering his own anxiety and avoidance mechanisms". He should be aware of the possibility that he may too easily slip into the role of "quasi-therapist" in supervision and, on the other hand, the resident may attempt to convert supervision into psychotherapy. The author, from his cross-cultural prevalence study of residents in England and Canada and also the personal follow-up study mentioned above, suggests that the anxiety an dysphoria of the "Beginning Psychiatric Training Syndrome" is a normal, emotional response to the first year of training in psychiatry. 11 However, it is important to note that the response of supervisors to these adjustment reactions can lead either to a "universalization" and to a positive experience in self-understanding for some residents, or to a defensive withdrawal from psychiatry and psychotherapy, or into treatment situations which are unnecessary. T h e above study suggests that despite this normal emotional response psychiatric educators and supervisors should be prepared to face the possibility that psychiatry attracts some individuals with a vulnerability to emotional illness. Their sensitivity and awareness, both in recognizing and assisting the trainee to deal appropriately with such reactions may influence the success of his training, professional career, and personal adjustment.
Alteration ~ Pathogenic Forces Within Residency Training Several factors are referred to repeatedly in the literature as being potentially pathogenic for the development of emotional illness in psychiatric residents: (1) predisposition of the individual resident; (2) iden-
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tity conflicts; (3) peer group hostility; (4) psychotherapy supervision; and (5) the resident's family. Each factor will be discussed, and a method of interfering with the pathogenic force will be offered,
Predisposition of the Resident. Crown et al. 2a suggest that neuroticism and motivational factors are the most important variables in the difficulties of university students. Unfortunately, there is no simple test that can predict which applicants to a psychiatric training program will develop emotional illness. However, the Strong Vocational Interest Blank (SVIB) does predict success in residency training. 24 Burdock, Cheek, and Zubin found the SVIB more successful than faculty admission ratings from individual interviews in predicting success of 88 applicants to a psychoanalytical training program. 25 These findings are of particular note because Merklin and Little suggest emotional illness is correlated with failure in training programs, particularly, with premature withdrawal from training programs. These findings suggest that more information regarding the screening of applicants, particularly whether emotional illness produces training failures is essential for the proper functioning of university admission policy. Furthermore, individual residents could potentially use such tests for counseling purposes. Identity Conflicts. Halleck and Woods 2 have suggested one stress in the resident's first year is his struggle to achieve identity as a psychiatrist. Traditionally, the resident's first year is spent in an inpatient mental hospital setting. He faces seriously disturbed patients at a time when he has the least clinical knowledge. He is often physically isolated from his medical colleagues. He often watches his accumulated knowledge slip away. He develops psychological-mindedness while dealing with patients often from a socioeconomic group different from his traditionally present unusual difficulties. These considerations suggest that perhaps the first year of psychiatric residency should take place in the general hospital setting. This would ease the transition from the medical model to a more psychological model without the isolation of the psychiatric hospital and the chronicity and severity of its patients. Peer Group Hostility. It is the author's contention that an ongoing group training seminar is the optimal method of preventing the development of emotional illness amongst psychiatric residents and identifying resistences to learning. T h r o u g h group experience, anxiety produced by developing "psychological-mindedness" can be recognized as universal among residents, and peer group hostility can be effectively met through mutual support, the sharing of experience, and solution of disagreement. Sadock and Kaplan 4 report on long-term intensive group psychotherapy with residents as part of a residency program: "The group experience enables the resident to become aware of his emotional problems and correct them." They claim it eases the transition between the first and
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second year when recognition of limitations in psychiatric knowledge often cause disillusionment and personal disequilibrium. Berger suggests such an experience enhances real cohesiveness and cooperation among the resident staff, as well as decreasing disruptive and destructive conflicts and competitiveness among them. 26 Sherman and Hildreth 27 (both residents) describe an ongoing group seminar as a model for the prevention of emotional illness in residents. First the group leader must be a consultant from outside the hospital. This avoids the evaluator-supervisor conflict, and prevents the subtle coercion of the influential teacher seducing the unwilling resident into therapy. Second, in view of the therapeutic potential of such an experience, a clear "teaching-learning alliance" must be explicit from the onset and participation must be voluntary. Finally, the group leader in a training group should prescreen the candidate. T h e r e have been several recently reported tragedies due to assuming "the myth of the healthy candidate" in psychiatric residents entering sensitivity training. 28
PsychotherapySupervision. A controversy exists as to whether supervision is or is not psychotherapy and whether or not it should be. Escoll and Wood 15 explain: "Since supervision involves intimate discussion between two individuals, discussions often focusing on one individual's personal experiences in his work, the similarities to psychotherapy are many." The controversy revolves around two different viewpoints of supervision with historical roots in psychoanalysis and social work, respectively. On the one hand, Ekstein and Wallerstein advocate focusing on the residentsupervisor relationship itself as a method of exploring the resident's learning block or deficiency of technique in dealing with a patient. 29 This comes close to psychotherapy. On the other hand, Tarachow feels the preceptor should offer himself as a transference figure for identification but keep to the position of teacher? ° Supervision which becomes psychotherapy may be a pathogenic force in the development of emotional illness in psychiatric residents. The absence of a "therapeutic alliance," the supervisor-evaluator conflict and countertransference problems discussed above disqualify the supervisor as a psychotherapist. Escoll and Wood 1~ provide an answer to the question posed earlier of "up to what point does the teacher have an obligation to help the resident?" T h e y state: as "The supervisor should point out the resident's personal problems only as related to his work experience, such as his ability to do therapy with a patient or his capacity to learn." T h e decision regarding treatment for these emotional difficulties must remain with the resident. Research into the transactions of students and teachers may help resolve the supervision controversy. A step has been taken in this direction by Muslin and Carmichael, who report observing the teaching of clinical psychiatry by filming teacher-student dyads followed by group supervision of the teachers involved? 1
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The Resident's Family. The psychiatric resident works long hours, is frequently away from home, and receives litde pay in relation to his nonresident colleagues. These factors may perpetuate an emotional illness or contribute to such illness. Tradition seems to impede interference with these factors, but it is a fertile area for further studies. Halleck and Woods 2 state: "While again there are no data available as to the amount and seriousness of psychiatric symptomatology among resident's wives, it is our subjective impression that serious disability occurs with some regularity." Some form of groups, dubs, or social gatherings of a formal or informal nature for the spouses of residents might lend to the sharing of experiences and to the decrease of isolation and instability felt by many as their spouses go through residency.
SECONDARY AND TERTIARY PREVENTION Secondary prevention implies the early recognition and treatment of psychiatric residents with emotional illness. T h e provision in postgraduate psychiatric training programs of screening procedures and ongoing group process seminars will facilitate the early recognition of severe psychopathology as will educating supervisors and residents to the occurrence of such disorders. Treatment may be through any modality but must be tailored to the specific needs and resources of the psychiatric resident and his family. Tertiary prevention implies intervention to reduce the disabilities of sequela of emotional illness in psychiatric residents. Here, for example, the resident who develops crippling anxiety through developing "psychologicalmindedness" could be counseled to enter areas of psychiatry where his anxiety would be minimized.
SUMMARY The literature on emotional illness in psychiatric residents has been reviewed. Factors within the resident, residency, and psychiatric residency which may predispose, precipitate, or perpetuate emotional illness were discussed. The significance of these disorders to the resident and the psychiatric profession were presented. The author contends that by applying the goals and philosophy of public health, particularly primary prevention, the occurrence of emotional illness can be reduced and by early identification and treatment the resistances to learning can be minimized. Research into the pathogenic forces contributing to emotional illness in psychiatric residents is essential. The author advocates more careful screening of candidates for training, education of all concerned regarding the occurrence and manifestation of such illness, ongoing group process seminars, and interference with
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p a t h o g e n i c f o r c e s w i t h i n p s y c h i a t r i c t r a i n i n g p r o g r a m s as a s t a r t in t h e d i r e c t i o n o f r e d u c i n g e m o t i o n a l illness i n p s y c h i a t r i c r e s i d e n t s a n d t h e i r families.
REFERENCES 1. Merktin L, LittleR: Be~nning psychiatry training syndrome.AmJ Psychiatry 124:193-197, 1967. 2. Halleck S, Woods S: Emotional problems of psychiatric residents. Psychiatry 25:339-346, 1962. 3. Holt R: Personality growth in psychiatric residents. Arch Neurol Psychiatry 81:203-215, 1959~ 4. Sadock BJ, Kaplan HI: Long-term intensive group psychotherapy with psychiatric residents as part of residency training. Am J Psychiatry 126(8): 1138-1143, 1970. 5. Hunter RCA: The psychiatric resident: teach or treat. Unpublished paper, 1972. 6. Ungerleider J: That most difficult year. AmJ Psychiatry 122:542-545, 1965. 7. PasnauRO, BayleyS: Personalitychangesinthefirstyearofpsychiatricresidencytraining. Am J Psychiatry 128(1):79-83, 1971. 8. Kelly WA: Suicide and psychiatric education. AmJ Psychiatry 130(4):463-467, 1973~ 9. Goldberg DP: The detection of psychiatric illness by questionnaire. Maudsley Monograph. Oxford, Oxford University Press, 1972. I0. Waring EM: Emotional illness in psychiatric trainees. BrJ Psychiatry 125:10-11, 11974. 11. Waring EM: Beginning psychiatric training syndrome: A cross-cultural prevalence study. CanJ Psychiatry 20:533-536, 1975. 12. Walton H J: Personality correlates of a career interest in psychiatry.BrJPsychiatry 115:211219, 1969. 13. Rakoff V. Director of Postgraduate Training, University of Toronto. Personal communication. 14. Kardener S, Fuller M, Mensh I, et al: The trainees' viewpoint of the psychiatric residency. Am J Psychiatry 126:116-122, 1970. 15. Escoll P, Wood H: Preception in residency training. AmJ Psychiatry 124:187-193, 1967. 16. Fleckles CS: The making of a psychiatrist in the resident's view. Am J Psychiatry 128(9): 1111-1115, 1972. 17. Scanlan JM: Physician to student: The crisis of psychiatric residency training. Am J Psychiatry 128(9): 1107-1110, 1972. 18. Tischler GL: The transition into residency. Am J Psychiatry 128(9): 1103-1106, 1972. 19. Sharaf M, Levinson D: The quest for omnipotence in professional training: The case of the psychiatric resident. Psychiatry 27:135-149, 1964. 20. Editorial: Suicide among doctors. Br MedJ March 28, 1964. (Leading article p. 789.) 21. Freeman W: Psychiatrists who kill themselves. AmJ Psychiatry 124(6):846-847, 1967. 22. Waring EM: Psychiatric illness in physidans: A review. CommunityPsychiatry 15(6):519530, 1974. 23. Crown S, Lucas CJ, Supramaniam S: The delineation and measur~ement of study difficulty in university students. BrJ Psychiatry 122:381-393, 1973. 24. Tucker A, Strong E: Ten-year follow-up of vocational interest scores of 1950 medical college seniors. J Appl Psychol 46:81-86, t 962. 25. Burdock EI, Cheek F, Zubin J: Predicting success in psychoanalytical training. In Hoch PH, Zubin J (eds): Current Approaches to Psychoanalysis. New York, Grune & Strattan, 1960. 26. Berger MD: Experimental and diathetic aspects of training in therapeutic group approaches. Am J Psychiatry 126(6):845-850, 1969. 27. Sherman RW, Hildreth AM: A resident group process training seminar. AmJ Psychiatry 127:372-275, 1971.
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28. Stone WN, Tieger ME: Screening tor T-groups: The myth of healthy candidates. Am J Psychiatry 127:1485-1490, 1971. 29. Ekstein R, Wallerstein R: The Teaching and Learning of Psychotherapy. New York, Basic Books, 1958. 30. Tarachow S: An Introduction to Psychotherapy. New York, International Universities Press, 1963. 31. Muslin HL, Carmichael HT: Exercises in self-observation: A workshop for instructors in psychiatry. Am J Psychiatry 124(2):198-202, 1967.
APPROACH TO EMOTIONAL IN PSYCHIATRIC RESIDENTS E. M. Waring, M.D.
Emotional illness in psychiatric residents and its relationship to psychiatric post-. graduate training is examined. First, the pertinent literature is reviewed. Psychological and social factors which predispose, precipitate, and perpetuate these emotional disturbances are discussed. The significance of emotional illness in psychiatric residents to the teaching and learning of psychiatry and to the psychiatric profession is darified. Second, the currently unresolved dilemma of the psychiatric resident "Teach or Treat?" is presented. It is the author's contention that by redefining "treatment" in terms of the goals and philosophy of public health this dilemma can be resolved to the satisfaction of resident, faculty', and the psychiatric profession.
E M O T I O N A L ILLNESS IN PSYCHIATRIC RESIDENTS It has been suggested that Freud suffered from an obsessivecompulsive neurosis. Wilhelm Reich, following his brilliant contributions to "character analysis," died in prison suffering from a chronic psychosis. Psychiatrists and psychiatric residents are, after all, human. Although selfevident, the simple fact remains, and thus it should come as no surprise, that we all are susceptibIe to developing emotional disorders. The question, then, is whether or not psychiatric residents are more or less susceptible to developing psychiatric illness than the general population? What forms do these emotional disturbances take? What are the factors responsible for such disturbances? What is the significance o f these emotional illnesses, particularly in light of the old adage, "physician heal thyself," and how do they influence postgraduate training? Merklin and Litde, 1 in 1967, discussed "Beginning Psychiatric Training Syndrome." They stated: "The psychological response of the resident to his first year of psychiatric training may be characterized by temporary neurotic symptoms, psychosomatic symptoms, and symptomatic behaviour." They described a prodrome characterized by a change in the resident's attitude to his peers, patients and instructors. T h e resident often becomes preoccupied with paper work and conferences at the expense of patient Dr. Waring is Assistant Professor of" Psychiatry, University of Western Ontario. Reprint requests should be addressed to Dr. Waring at Victoria Hospital, London Ont. PSYCHIATRICQUARTERLY,VOL.49(4) 1977
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contact. An absorption in neurology or biochemistry was frequently noted. The manifest syndrome showed no specific pattern of clinical symptoms, although most had difficulty with authority, were easily distracted, and showed specific learning blocks. The authors related the development of symptoms to premature resignation from postgraduate training programs. Halleck and Woods support the existence of emotional illness in psychiatric residents. 2 They state: "The impact of the various stresses upon the psychiatric resident is most often manifest by the occurrence of clinical or subclinical symptomatology or in an impairment of the professional development." T h e y feel that few residents have gone through the residency period without having experienced, somewhere along the line, moderate to severe anxiety or depression. Holt referred to "The typical slump---a period of vague dissatisfaction occurring during the first year. ''a He also reported that 65% of the residents in his study sought personal psychotherapy, perhaps an indicator of a high prevalence of emotional illness. Sadock and Kaplan 4 suggest that there is "between the first and second year of r e s i d e n c y . . , a period when recognition of the limitations in psychiatric knowledge often causes disillusionment and personal disequilibrium." They felt this "second year slump" was characterized by (1) vague dissatisfaction, (2) persistent complaints, and (3) formal protests. H u n t e r describes his experience in supervising groups of residents. 5 Three phases occurred in the groups' natural history. The first phase was characterized by anxiety and bewilderment, the second by criticism of hospital policy, organization, and staff; and the third phase by resolution of conflict or the development of "counterattitudes" suggesting deep personality difficulties. Ungerleider referred to the first year of training as "that most difficult year" and discussed the development of defences against helplessness and anxiety. 6 Pasnau and Bayley gave the Minnesota Multiphasic Personality Inventory (MMPI) to two consecutive classes of first-year psychiatric residents and found a marked increase in scores on the depressive scales when compared to medical school graduates applying for psychiatric training. 7 Kelly suggested that suicide during psychiatric residency was not rare. 8 The author, in a crosscultural prevalence study, demonstrated that 16.2% of psychiatric residents in a total combined British and Canadian sample of 173 scored greater than 12 on the General Health Questionnaire suggesting a high probability of nonpsychotic emotional illness 9 This prevalence did not differ greatly from that found in the combined sample of residents in medical specialties other than psychiatry. Contrary to the previous literature, the prevalence was not greater in the first year of training than in later years. Foreign medical graduates were found to be at no greater risk for development of emotional illness than native-born graduates.l°'11
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ETIOLOGICAL FACTORS Halleck and Woods 2 state: "The psychiatric residency is a time of extraordinary emotional stress in the life of the prospective psychiatrist, a stress which may have a profound effect upon both his personal well-being and his subsequent professional adequacy." In discussing factors which may contribute to emotional illness, I shall focus on three areas: (1) the resident, (2) problems inherent in residency training, and (3) factors specific to psychiatric residency. Although separated for the purpose of discussion, it is obvious that these areas are interconnected and overlapping. The resident
Who are these medical school graduates who decide to enter postgraduate training in psychiatry? Why have they chosen psychiatry? What personality features and life experiences may predispose them to the development of emotional illness during psychiatric residency? Walton suggests that the attitudes of students toward a psychiatric career are already well defined before instruction in psychiatry and are relatively little influenced by the training provided. 1~ A positive attitude to psychiatry as a career is an indicator of a "psychological-mindedness"; the students who express a negative career attitude to psychiatry tend to be more organically oriented. T h e most important of the four personality dimensions tested by Walton in relation to psychiatric career attitude is "reflectiveness"; that is, the students who favor abstract ideas are positive, and the students who prefer ideas with practical application are negative about psychiatric career. "Complexity" and "the capacity to tolerate ambiguities" can be correlated to a positive attitude toward a psychiatric career. Extroversion-introversion has been shown to be of no importance and neuroticism to have only a very minor relationship to psychiatric career. Determinants other than personality factors influence doctors to become psychiatrists, and need to be explored. Halleck and Woods 2 state: "Many psychiatrists have the subjective impression that the choice of psychiatric specialization may also be determined by the presence of significant emotional conflict." The impression that some applicants use training as an entry into therapy is widespread. ~a Unfortunately, there has been little research in this area. Finally, a myth has grown in medical schools that the student who chooses psychiatric postgraduate training tends to be "odd, eccentric, and an underachiever." If true, could this predispose to development of emotional illness during residency? A recent study by Pasnau and Bayley 7 seems to dispel this myth. Their eighteen medical school graduates who applied for postgraduate training in psychiatry shared the following characteristics: (1) higher than average Medical College Admission Test
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scores; (2) personality traits described by teachers as "well-liked, community interest, enthusiastic, pleasant, sensitive, dedicated, and thoughtful"; and (3) high level of extracurricular activities, the group of applicants included most of the major class officers and leaders. Kardener and associates 14 described a "personal, patient-centered, help-giving orientation." Unfortunately, there have been no studies correlating personality features of psychiatric residents with the presence or absence of emotional illness in residents. Residency as a Factor in Emotional Illness in Residents
Merklin and Little 1 have referred to several factors which exist in all postgraduate residency programs which may predispose to the development of emotional illness in residents. Peer group competition is one. Competition for resident positions and anxiety related to examinations may generate hostility. The individual may be unable to cope with this hostility, and isolation from those who could provide support during residency may result. Conflicts related to both the individual's relationship to authority figures and to increasing medical responsibility may arise. Halleck and Woods 2 have paid particular attention to the psychiatric resident and his family. They feel the resident's wife is in a particularly vulnerable position and state: "Since the majority of residents have married during medical school training, the wives have visualized the context of their future lives as including many of the traditional living arrangements of a medical family. T h e resident's wife often finds, however that the entire milieu in which she or her husband move is radically different from what she had experienced before or had anticipated." These authors felt the long hours absent from the home and the frequent upsets and often personality changes occurring in the resident led to breakdowns in seemingly adequate marriages and a high incidence of symptomatology amongst residents' wives. Factors Specific to Psychiatric Residency
Halleck and Woods 2 state: "The two major emotional stresses of the first year concern the resident's struggle to achieve identity as a psychiatrist, and the impact of the anxieties attendent upon the development of psychological-mindedness." Several authors 1~'1s have discussed the psychiatric residency experience as a "transitional crisis" particularly with reference to "role identity." T h e y question the tradition of the resident beginning his service in an inpatient setting with seriously disturbed patients. Here the resident is given enormous responsibility at a time when his clinical knowledge is limited. T h e psychiatrist resident may become preoccupied with his loss of identity as a medical physician. The isolation of the traditional psychiatric hospital, coupled with frequent skepticism and even
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insults and deprecating jokes from his medical colleagues, may predispose to such preoccupations. Secondly, the development of "psychological-mindedness" is difficult because of (1) identification with the psychopathology of the patient; (2) the impact of psychotherapy and psychotherapy supervision; and (3) the therapist's quest for omnipotence. As the resident becomes familiar with his patients, he cannot help but become aware of feelings, impulses, and conflicts which he, himself, may have experienced. The patient's problem may become his own. Secondly, the resident's first attempt at psychotherapy often occurs in unfavorable circumstances. His first patient is often poor and of low socioeconomic dass--a group traditionally unresponsive to psychotherapy. The resident frequently rotates clinical services; thus he rarely sees long-term changes or improvement. Frustration and disillusionment may result. Individual supervision, especially bad supervision, may predispose to the development of emotional illness. Halleck and Woods 2 state: "While supervision is the most useful tool in the teaching of psychotherapy, it can also be a most significant contributing factor in the emotional decompensation of a psychiatric resident." This is in part due to the supervisor's divided loyalties between resident and administration, in which he is both educator and evaluator. The resident faces the realistic absence of the securities inherent in a "therapeutic alliance," knowing the supervisor has realistic power over the success or failure of his residency. Countertransference in the supervisor may result in the failure to recognize emotional illness in residents or in the "acting out" of unresolved conflicts from their own training through the resident. Finally, Sharaf and Levinson 19 have studied the "quest for omnipotence" in the psychiatric resident. They describe the emotional problems that develop as residents attempt to work through this "quest," or "wish to cure." The anxiety produced may lead to a radical selfexamination producing further anxiety or depression or to a massive identification with his supervisor which precludes further growth.
SIGNIFICANCE OF E M O T I O N A L ILLNESS IN PSYCHIATRIC RESIDENTS Merklin and Little 1 suggest: " . . . recognition of the 'Beginning Psychiatric Training Syndrome' as a transient, and often valuable adaptation response may lessen its intensity and encourage both the resident and his instructors to deal with it more constructively." Generally, psychotherapy supervisors have looked upon such illnesses as natural events or even as a favorable occurrence leading to greater self-awareness and empathic understanding. Here we see a paradox. On the one hand, candidates for postgraduate training in psychiatry are often refused acceptance because of preexisting emotional disorder. On the other hand, the development of neurotic,
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psychosomatic, or behavioral symptoms during the residency experience may lead to greater self-awareness. However, even those who adhere to this doctrine admit that in a certain percentage, the anxiety and depression linger on and require treatment! The presence of neurotic, psychosomatic, and behavioral symptomatology may be evidence of emotional illness in psychiatric residents. The failure to prevent, recognize, and treat such illness results in: 2°'21 (1) severe psychiatric decompensation in some cases; (2) premature and impulsive resignations from training programs; (3) development of therapeutic nihilism which may never remit, i.e. cynical, unbelieving, and chronically dissatisfied psychiatrists; and (4) possibly a contribution to the relatively high incidence of suicide, drug addiction, and marital discord amongst psychiatrists. T H E PSYCHIATRIC RESIDENT: "TEACH OR TREAT" Emotional difficulties can impede or inhibit the learning of new skills being taught to the resident during his psychiatric training. As R. C. A. H u n t e r s has suggested in an unpublished paper, "The Psychiatric Resident: Teach or Treat," the recognition of such emotional difficulties in the student inevitably imposes on his teachers an obligation to help him, at least up to a point. The question is "... up to what point?" H u n t e r states: "Although the educational function of the Department of Psychiatry is teaching and not treatment, they cannot be sharply separated since both aim to produce modification in the student." Should such help be called "counseling," "supervision," or "psychotherapy"? What sort of help should be offered? Suggestions have ranged from "modified analysis" to more intensive supervision oriented toward reducing resistences to learning. It is the purpose of the second part of this paper to show that the "teach or treat" dilemma has arisen because traditionally "help" was offered to the psychiatric resident with emotional illness in the form of psychotherapy, either within or outside of supervision. By redefining "treatment" in terms of the goals and philosophy of public health, i.e., primary, secondary, and tertiary prevention, the occurrence of emotional illness in residents can be reduced and, through early detection and intervention, the resistences to learning can be minimized. PRIMARY PREVENTION Primary prevention, as defined in this paper, is the promotion of mental health and the lowering of the risk of mental disorder in residents through interfering with pathogenic forces within the resident and in their psychological and social environment before the appearance of identifiable pathology. T h e focus of primary prevention shifts from the individual to
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the community of the resident. Although this paper emphasizes primary prevention, it does not imply a belittling of the importance of secondary and tertiary prevention, but that the preoccupaiton with the latter in the form of psychotherapy has led to the "teach or treat" controversy. The discussion of primary prevention of emotional illness in psychiatric residents will examine issues related to: (1) research, (2) education, and (3) alteration of pathogenic forces within residency training.
Research into Pathogenic Factors within Psychiatric Residency It is interesting to note that despite the large literature on emotional illness in psychiatric residents, Halleck and Woods z state: "There are no reliable statistics available as to the cause of failure in residency training programs. Information as to the incidence of anxiety attacks, depression, suicide, psychosis or serious acting out is also unavailable." These authors suggest that the failure to adequately study these problems may reflect guilt arising from a sense of responsibility for these casualties, as well as the nebulous qualities of selection precedures and a sense of inadequacy about successfully meeting the residents emotional needs. Numerous suggestions are raised in the lkerature regarding pathogenic factors in psychiatric residency. However, these must be substantiated before changes in postgraduate training are implemented rather than postulated. For example, three factors are mentioned in the literature which could lead to psychopathology in psychiatric training: (1) identification with the psychopathology of the patients; (2) the impact of psychotherapy supervision with the development of "psychologicalmindedness"; and (3) a shift from the authoritarian medical model to a more passive psychological role. T h e literature indicates that these three factors have the greatest impact during the first year of training. However, in our study of British and Canadian residents, emotional illness was shown to be no more frequent in the first year of training than in subsequent years. This would suggest that the above factors are of only minor significance in the development of emotional illness and that the main problem is that personality and life experience that the resident brings with him into training. Thus the above mentioned factors may only be precipitating or, more likely, perpetuating factors, and the high prevalence rate frequently suggested for psychiatrists in middle life may not be related to a greater prevalence of illness but to their inability, and that of psychiatric residents, to get adequate psychiatric care? 1,~2 Finally, the significance of emotional illness in psychiatric trainees to their training, careers, and personal health remains problematic. Although it is suggested that the presence of anxiety and depression are necessary for the development of a competent and empathic psychiatrist, other authors suggest that they are symptoms of psychiatric illness which may be related to premature termination of training, poor training performance, and cyncial and negativistic attitudes to psychiatric practice. In an attempt to an-
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swer some of these questions, we have given the General Health Questionnaire, Strong Vocational Inventory Blank, Eysenck Personality Inventory, and Minnesota Multiphasic Personality Inventory to a group of psychiatric residents at the University of Toronto and the University of Western Ontario in the first month of their residency. These groups are being followed-up to assess whether these tests are predictive of premature termination of training, type of practice, and various parameters of success or failure during postgraduate training.
Education Supervisors and residents should be aware of the possibility of emotional illness developing during psychiatric residency. Halleck and Woods 2 state: "We believe this (identification with patient's psychopathology) to be an extremely common phenomenon and a powerful source of anxiety in first-year residents. It is also our impression that supervisors frequently fail to recognize the often subtle expressions of the resident's concern." They emphasize that the supervisor-resident relationship itself is a strange one, almost inherently conflictual and ambiguous. It is hoped, acquainting the supervisor with the existence of such problems may help him to cope with "empathetically remembered experience engendering his own anxiety and avoidance mechanisms". He should be aware of the possibility that he may too easily slip into the role of "quasi-therapist" in supervision and, on the other hand, the resident may attempt to convert supervision into psychotherapy. The author, from his cross-cultural prevalence study of residents in England and Canada and also the personal follow-up study mentioned above, suggests that the anxiety an dysphoria of the "Beginning Psychiatric Training Syndrome" is a normal, emotional response to the first year of training in psychiatry. 11 However, it is important to note that the response of supervisors to these adjustment reactions can lead either to a "universalization" and to a positive experience in self-understanding for some residents, or to a defensive withdrawal from psychiatry and psychotherapy, or into treatment situations which are unnecessary. T h e above study suggests that despite this normal emotional response psychiatric educators and supervisors should be prepared to face the possibility that psychiatry attracts some individuals with a vulnerability to emotional illness. Their sensitivity and awareness, both in recognizing and assisting the trainee to deal appropriately with such reactions may influence the success of his training, professional career, and personal adjustment.
Alteration ~ Pathogenic Forces Within Residency Training Several factors are referred to repeatedly in the literature as being potentially pathogenic for the development of emotional illness in psychiatric residents: (1) predisposition of the individual resident; (2) iden-
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tity conflicts; (3) peer group hostility; (4) psychotherapy supervision; and (5) the resident's family. Each factor will be discussed, and a method of interfering with the pathogenic force will be offered,
Predisposition of the Resident. Crown et al. 2a suggest that neuroticism and motivational factors are the most important variables in the difficulties of university students. Unfortunately, there is no simple test that can predict which applicants to a psychiatric training program will develop emotional illness. However, the Strong Vocational Interest Blank (SVIB) does predict success in residency training. 24 Burdock, Cheek, and Zubin found the SVIB more successful than faculty admission ratings from individual interviews in predicting success of 88 applicants to a psychoanalytical training program. 25 These findings are of particular note because Merklin and Little suggest emotional illness is correlated with failure in training programs, particularly, with premature withdrawal from training programs. These findings suggest that more information regarding the screening of applicants, particularly whether emotional illness produces training failures is essential for the proper functioning of university admission policy. Furthermore, individual residents could potentially use such tests for counseling purposes. Identity Conflicts. Halleck and Woods 2 have suggested one stress in the resident's first year is his struggle to achieve identity as a psychiatrist. Traditionally, the resident's first year is spent in an inpatient mental hospital setting. He faces seriously disturbed patients at a time when he has the least clinical knowledge. He is often physically isolated from his medical colleagues. He often watches his accumulated knowledge slip away. He develops psychological-mindedness while dealing with patients often from a socioeconomic group different from his traditionally present unusual difficulties. These considerations suggest that perhaps the first year of psychiatric residency should take place in the general hospital setting. This would ease the transition from the medical model to a more psychological model without the isolation of the psychiatric hospital and the chronicity and severity of its patients. Peer Group Hostility. It is the author's contention that an ongoing group training seminar is the optimal method of preventing the development of emotional illness amongst psychiatric residents and identifying resistences to learning. T h r o u g h group experience, anxiety produced by developing "psychological-mindedness" can be recognized as universal among residents, and peer group hostility can be effectively met through mutual support, the sharing of experience, and solution of disagreement. Sadock and Kaplan 4 report on long-term intensive group psychotherapy with residents as part of a residency program: "The group experience enables the resident to become aware of his emotional problems and correct them." They claim it eases the transition between the first and
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second year when recognition of limitations in psychiatric knowledge often cause disillusionment and personal disequilibrium. Berger suggests such an experience enhances real cohesiveness and cooperation among the resident staff, as well as decreasing disruptive and destructive conflicts and competitiveness among them. 26 Sherman and Hildreth 27 (both residents) describe an ongoing group seminar as a model for the prevention of emotional illness in residents. First the group leader must be a consultant from outside the hospital. This avoids the evaluator-supervisor conflict, and prevents the subtle coercion of the influential teacher seducing the unwilling resident into therapy. Second, in view of the therapeutic potential of such an experience, a clear "teaching-learning alliance" must be explicit from the onset and participation must be voluntary. Finally, the group leader in a training group should prescreen the candidate. T h e r e have been several recently reported tragedies due to assuming "the myth of the healthy candidate" in psychiatric residents entering sensitivity training. 28
PsychotherapySupervision. A controversy exists as to whether supervision is or is not psychotherapy and whether or not it should be. Escoll and Wood 15 explain: "Since supervision involves intimate discussion between two individuals, discussions often focusing on one individual's personal experiences in his work, the similarities to psychotherapy are many." The controversy revolves around two different viewpoints of supervision with historical roots in psychoanalysis and social work, respectively. On the one hand, Ekstein and Wallerstein advocate focusing on the residentsupervisor relationship itself as a method of exploring the resident's learning block or deficiency of technique in dealing with a patient. 29 This comes close to psychotherapy. On the other hand, Tarachow feels the preceptor should offer himself as a transference figure for identification but keep to the position of teacher? ° Supervision which becomes psychotherapy may be a pathogenic force in the development of emotional illness in psychiatric residents. The absence of a "therapeutic alliance," the supervisor-evaluator conflict and countertransference problems discussed above disqualify the supervisor as a psychotherapist. Escoll and Wood 1~ provide an answer to the question posed earlier of "up to what point does the teacher have an obligation to help the resident?" T h e y state: as "The supervisor should point out the resident's personal problems only as related to his work experience, such as his ability to do therapy with a patient or his capacity to learn." T h e decision regarding treatment for these emotional difficulties must remain with the resident. Research into the transactions of students and teachers may help resolve the supervision controversy. A step has been taken in this direction by Muslin and Carmichael, who report observing the teaching of clinical psychiatry by filming teacher-student dyads followed by group supervision of the teachers involved? 1
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The Resident's Family. The psychiatric resident works long hours, is frequently away from home, and receives litde pay in relation to his nonresident colleagues. These factors may perpetuate an emotional illness or contribute to such illness. Tradition seems to impede interference with these factors, but it is a fertile area for further studies. Halleck and Woods 2 state: "While again there are no data available as to the amount and seriousness of psychiatric symptomatology among resident's wives, it is our subjective impression that serious disability occurs with some regularity." Some form of groups, dubs, or social gatherings of a formal or informal nature for the spouses of residents might lend to the sharing of experiences and to the decrease of isolation and instability felt by many as their spouses go through residency.
SECONDARY AND TERTIARY PREVENTION Secondary prevention implies the early recognition and treatment of psychiatric residents with emotional illness. T h e provision in postgraduate psychiatric training programs of screening procedures and ongoing group process seminars will facilitate the early recognition of severe psychopathology as will educating supervisors and residents to the occurrence of such disorders. Treatment may be through any modality but must be tailored to the specific needs and resources of the psychiatric resident and his family. Tertiary prevention implies intervention to reduce the disabilities of sequela of emotional illness in psychiatric residents. Here, for example, the resident who develops crippling anxiety through developing "psychologicalmindedness" could be counseled to enter areas of psychiatry where his anxiety would be minimized.
SUMMARY The literature on emotional illness in psychiatric residents has been reviewed. Factors within the resident, residency, and psychiatric residency which may predispose, precipitate, or perpetuate emotional illness were discussed. The significance of these disorders to the resident and the psychiatric profession were presented. The author contends that by applying the goals and philosophy of public health, particularly primary prevention, the occurrence of emotional illness can be reduced and by early identification and treatment the resistances to learning can be minimized. Research into the pathogenic forces contributing to emotional illness in psychiatric residents is essential. The author advocates more careful screening of candidates for training, education of all concerned regarding the occurrence and manifestation of such illness, ongoing group process seminars, and interference with
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p a t h o g e n i c f o r c e s w i t h i n p s y c h i a t r i c t r a i n i n g p r o g r a m s as a s t a r t in t h e d i r e c t i o n o f r e d u c i n g e m o t i o n a l illness i n p s y c h i a t r i c r e s i d e n t s a n d t h e i r families.
REFERENCES 1. Merktin L, LittleR: Be~nning psychiatry training syndrome.AmJ Psychiatry 124:193-197, 1967. 2. Halleck S, Woods S: Emotional problems of psychiatric residents. Psychiatry 25:339-346, 1962. 3. Holt R: Personality growth in psychiatric residents. Arch Neurol Psychiatry 81:203-215, 1959~ 4. Sadock BJ, Kaplan HI: Long-term intensive group psychotherapy with psychiatric residents as part of residency training. Am J Psychiatry 126(8): 1138-1143, 1970. 5. Hunter RCA: The psychiatric resident: teach or treat. Unpublished paper, 1972. 6. Ungerleider J: That most difficult year. AmJ Psychiatry 122:542-545, 1965. 7. PasnauRO, BayleyS: Personalitychangesinthefirstyearofpsychiatricresidencytraining. Am J Psychiatry 128(1):79-83, 1971. 8. Kelly WA: Suicide and psychiatric education. AmJ Psychiatry 130(4):463-467, 1973~ 9. Goldberg DP: The detection of psychiatric illness by questionnaire. Maudsley Monograph. Oxford, Oxford University Press, 1972. I0. Waring EM: Emotional illness in psychiatric trainees. BrJ Psychiatry 125:10-11, 11974. 11. Waring EM: Beginning psychiatric training syndrome: A cross-cultural prevalence study. CanJ Psychiatry 20:533-536, 1975. 12. Walton H J: Personality correlates of a career interest in psychiatry.BrJPsychiatry 115:211219, 1969. 13. Rakoff V. Director of Postgraduate Training, University of Toronto. Personal communication. 14. Kardener S, Fuller M, Mensh I, et al: The trainees' viewpoint of the psychiatric residency. Am J Psychiatry 126:116-122, 1970. 15. Escoll P, Wood H: Preception in residency training. AmJ Psychiatry 124:187-193, 1967. 16. Fleckles CS: The making of a psychiatrist in the resident's view. Am J Psychiatry 128(9): 1111-1115, 1972. 17. Scanlan JM: Physician to student: The crisis of psychiatric residency training. Am J Psychiatry 128(9): 1107-1110, 1972. 18. Tischler GL: The transition into residency. Am J Psychiatry 128(9): 1103-1106, 1972. 19. Sharaf M, Levinson D: The quest for omnipotence in professional training: The case of the psychiatric resident. Psychiatry 27:135-149, 1964. 20. Editorial: Suicide among doctors. Br MedJ March 28, 1964. (Leading article p. 789.) 21. Freeman W: Psychiatrists who kill themselves. AmJ Psychiatry 124(6):846-847, 1967. 22. Waring EM: Psychiatric illness in physidans: A review. CommunityPsychiatry 15(6):519530, 1974. 23. Crown S, Lucas CJ, Supramaniam S: The delineation and measur~ement of study difficulty in university students. BrJ Psychiatry 122:381-393, 1973. 24. Tucker A, Strong E: Ten-year follow-up of vocational interest scores of 1950 medical college seniors. J Appl Psychol 46:81-86, t 962. 25. Burdock EI, Cheek F, Zubin J: Predicting success in psychoanalytical training. In Hoch PH, Zubin J (eds): Current Approaches to Psychoanalysis. New York, Grune & Strattan, 1960. 26. Berger MD: Experimental and diathetic aspects of training in therapeutic group approaches. Am J Psychiatry 126(6):845-850, 1969. 27. Sherman RW, Hildreth AM: A resident group process training seminar. AmJ Psychiatry 127:372-275, 1971.
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28. Stone WN, Tieger ME: Screening tor T-groups: The myth of healthy candidates. Am J Psychiatry 127:1485-1490, 1971. 29. Ekstein R, Wallerstein R: The Teaching and Learning of Psychotherapy. New York, Basic Books, 1958. 30. Tarachow S: An Introduction to Psychotherapy. New York, International Universities Press, 1963. 31. Muslin HL, Carmichael HT: Exercises in self-observation: A workshop for instructors in psychiatry. Am J Psychiatry 124(2):198-202, 1967.
