Acad Psychiatry DOI 10.1007/s40596-014-0068-0
COLUMN: “DOWN TO EARTH” ACADEMIC SKILLS
Supervising the Tearful Trainee: Opportunities for Professional Growth and Learning Adam M. Brenner
Received: 4 September 2013 / Accepted: 23 February 2014 # Academic Psychiatry 2014
Abstract Trainees in psychiatry sometimes become tearful during supervision, and this presents the supervisor with significant challenges and also opportunities for the development of professionalism. This paper describes two major anxieties of trainees: first, that they will be unable to control their feelings during their clinical work and that this will derail the fulfillment of their duties; second, that that their feelings stem from an identification with some aspect of the patient or the patient's circumstances and may fear that this exposes them to the stigma of mental illness. The author describes how the trainee’s potential for shame can be greatly mitigated by supervisory interventions that treat this as a ‘teachable’ moment and opportunity for growth in professionalism. The author outlines effective interventions including didactic instruction and education, role modeling of empathic connection in the context of a boundaried relationship, and sensitive referral to mental health services for unresolved emotional issues or psychiatric symptoms. Suggestions of specific wording of interventions are provided throughout. Keywords Residents . Medical students . Supervision . Psychiatric education . Professionalism Through the years, I have had a repeated experience when meeting with medical students, psychiatry residents, and even rarely psychiatry residency applicants. I expect this is an experience that is likely to be common to most educators in psychiatry. The trainee is discussing something that is clearly of great importance to him/her. It might be an experience with a patient that particularly disturbed or inspired them. It might be something about their own personal experience or an
A. M. Brenner (*) University of Texas Southwestern Medical Center, Dallas, TX, USA e-mail: [email protected]
experience of their family or a close friend that involved psychiatric suffering and behavioral illness. At some point, as the trainee allows him/herself to experience the depth of their connection to the material, he or she becomes visibly emotional (i.e., tearful, flushed, shaken). At this point, something notable often happens—the trainee becomes embarrassed and apologizes. They may feel ashamed of having ‘lost control’ of their emotions. They sometimes feel that they have done something professionally inappropriate and may express concern that they have burdened me unfairly. Sometimes they express the worry that this show of emotion might be seen as a contraindication to a career in psychiatry. These moments of intense feeling may be uncomfortable for the supervisor as well, but they provide a rich opportunity for professional development. They are part of the broader task of developing competence in professionalism, which includes establishing a professional identity, defining one’s clinical boundaries, and maintaining an authentic empathy within these boundaries. The milestones for psychiatry specifically require that a resident demonstrate the capacity for empathy and self-reflection, and that this be paired with attention to the maintenance of professional boundaries [1]. My aim here is to provide beginning educators some framework of understanding why moments of tearfulness carry so much anxiety and embarrassment for the trainee and then to offer some suggestions of useful ways to manage the encounter so that development of professionalism is effectively fostered. I would like to suggest two primary concerns of the trainee. First, they may believe that any show of feeling will lead to being overwhelmed by affect and rendered helpless and useless. Second, they may fear that empathic identification with mentally ill patients will result in a kind of secondary stigmatization of the trainee. Both of these concerns may be intensified when their clinical experience touches on their own (sometimes untreated) psychiatric condition, and that this
Acad Psychiatry
condition will disqualify them from potentially treating psychiatric patients.
The Anxiety of Being Overwhelmed by Emotions Medical students and beginning residents can be surprised by the depth to which they are touched or disturbed by the experience of their patient. The trainee may feel concerned that these feelings will hinder their capacity to function as a clinician. They may worry that it will be impossible to “close the floodgates” and that they will be overwhelmed by affect. This would then result in being unable to effectively think and communicate professionally. They may be worried that if this emotional experience recurs in the presence of the patient, the patient will lose confidence towards them or will feel the need to take care of them, thereby reversing the usual roles of caregiver and care receiver, as well as the dynamics of power. Some fear that any loss of self-control demonstrates confirmation of their fear that they are frauds who lack the requisite character and maturity to become a physician. Finally, they also worry that they will be unable to contain the experience to their professional life, so that they will be unable to avoid “taking their work home with them.” This anxiety of being overwhelmed by their feelings can be unintentionally supported by academic environments that neglect the emotional lives of trainees. Shapiro has argued that not enough attention is given to the emotional lives of medical students and that as a result they are often afraid they will be overwhelmed by their feelings towards patients and feel helpless [2, 3]. Since one of the appeals of a career in psychiatry is the extent to which the personal relationship and empathic encounter with patients are so central this anxiety may be even more relevant in our specialty [4]. I have often been struck in reading psychiatry residency applicants’ essays how many report that they are drawn to psychiatry because they understand that an empathic connection with the patient will not only provide the context for the treatment but also will be an active ingredient of the treatment itself. However, there is another side to this experience. Cutler and colleagues [5] surveyed medical students and found that many are concerned about the intense interactions psychiatrists have with their patients and worry that a career in psychiatry will lead to feeling overwhelmed by empathy.
Concern About the Stigma of Identifying with Psychiatric Patients The idea of identifying with psychiatric patients carries more challenges than identifying with other kinds of patients. This can be seen as early as the medical school admissions process. Medical school applicants frequently write about some
experience of injury or illness that they have suffered and how it taught them something about the experience of the patient role, or perhaps about the value of the patient-doctor relationship. In my experience on our medical school’s admissions committee, these confessions are generally seen as appropriate disclosures that are entered into the ‘plus’ column in assessing the applicant’s suitability for medicine. However, disclosures about experience with a psychiatric illness are received with much greater ambivalence. Along with acknowledging the potential deepening of the patient’s empathy, there is likely to be some anxiety among medical school faculty. Does someone who has suffered from a psychiatric disorder have the necessary balance, discipline, and resilience to manage the stresses of medical school and the demands of patient care? The concern about having common ground with psychiatric patients seems to persist throughout the curriculum. Reflection papers written during the psychiatry clerkship reveal anxiety about the possibility of identifying with patients [6]. Cutler et al. found that an important aspect of students’ perceptions of the stress of psychiatry involved the tendency to identify with the patients. This stigma was still apparent in a more recent study using structured interviews [7]. Almost a third of students described their clerkship experience with psychiatric patients as disturbing, and 20 % were concerned about the personal impact of working with such patients, or as one student put it, “Working with crazies will make you crazy.” Part of the difficulty is that, along with the intrinsic challenge of understanding and modulating this identification, the stigma of mental illness persists among medical providers and even among mental health professionals [8].
Suggestions for Supervisors Even in the face of these anxieties, moments of tearfulness (or other shows of feeling) represent critical and highly valuable opportunities to psychiatric educators. They provide a signal that the student or resident is engaged at the deepest levels of the heart and mind, around issues of boundaries, professional identity, and empathy. The trainee is vulnerable at these moments, and at a crossroad—they may find their way to significant professional growth, or they may retreat into a more rigidly defended posture. As a beginning, it may help to provide some basic education on the issues outlined above [9] and to offer conceptual frameworks that can help organize the trainee’s difficult experiences. Cutler and colleagues advise explicitly instructing medical students that psychiatry may involve intense interactions with patients and the tendency to identify with them, but that practicing psychiatrists are able to empathize without feeling overwhelmed [6]. One could say, for example, “Most of our interactions with patients in psychiatry are fairly straightforward—we provide the
Acad Psychiatry
patient with a compassionate and knowledgeable doctor and the patient responds positively to this. However, our field also includes experiences where patients will invoke intense feelings that can be very disturbing. It’s natural as a beginner to be worried that you’ll be overwhelmed, but with practice and supervision we learn to identify troubling feelings without becoming lost in them.” I have found it helpful to tell trainees that there is a significant difference between simply feeling something painful with/about a patient and having that painful affect become so intense and consuming that has a detrimental effect on patient care. It is of course possible for a clinician’s own affect, particularly in the aftermath of acute loss or severe trauma, to prove overwhelming, generate panic or sobbing, and make it impossible to think or speak clearly. This would be more than most patients could or should bear, and it becomes the professional’s duty to recognize that he or she is unable to continue caring for patients and to make appropriate arrangements. However, while this possibility looms large in the minds of trainees, it is quite rare in practice, either for trainees or for experienced psychiatrists. In contrast, most experienced clinicians have at times felt so moved by a patient that a tear wells up in our eyes; this is very rarely a problem for the patient, and more often is felt by the patient as a therapeutic experience of validation or connection. (When it does cause anxiety to the patient, this is generally tolerable and can often be discussed and made good use of therapeutically.) In our program, we instruct the trainee, if asked by the patient, to acknowledge straightforwardly that he or she is feeling something in response to the patient’s narrative or presentation, while refraining from self-disclosure about any possible connections to the trainee’s own history or internal life, and while returning the focus to the patient’s experience. For example, the trainee might say “Yes, what you have been describing really has touched me. I think this might mean that we are talking about something that is really important to you (or painful to you, or confusing to you, etc.). Can you tell me more about your own thoughts and feelings about this?” Beyond instruction, however, there is also an opportunity for role modeling and demonstrating a set of values that may be even more valuable [9–12]. Learning to acknowledge a painful feeling, bear it, and put into perspective is no less crucial for the developing clinician than it is for the patients they will work with over the course of their career [13]. The opportunity for role modeling is furthered when we provide this education from a position of a real empathic connection with the learner. First, when we acknowledge a trainee’s affect, resonate with it, and then engage them in discussion about it, we are directly modeling the professional expression of empathy. Second, if we succeed in facilitating the trainee’s articulation of their feelings, we will often see the student become calmer and more comfortable. We have then demonstrated for the student something that is at the core of all
psychotherapeutic encounters—that sharing a disturbing feeling with an expert helper can allow that feeling to become less threatening. As the trainee moves forward in their own professional work, they will often be called upon to help patients learn that dialogue is an effective means of affect regulation and containment. Their capacity to do this will depend on their confidence in this kind of intervention and in the range of affect in themselves that they are capable of tolerating. How do we make sure that this kind of mentoring does not inadvertently cross over the boundary into a psychodynamic psychotherapy? Unlike in psychotherapy, the supervisor does not explore the origins of the trainee’s affect, nor does she interpret any resistance the trainee is having to the situation or to their own affect. In therapy, the goals may include following the affect to explore disturbing memories or thoughts and allowing associated and painful affects to rise to consciousness. The supervisor, by contrast, is focused on helping the trainee acknowledge that they had a feeling, decreasing their shame over this universal human experience, and helping them contain their affect within an appropriate professional demeanor and role. “I can see you’re feeling something powerful. You know, it’s not uncommon for a psychiatrist to have our work stir our own hearts. It’s OK with me that you’re feeling something important during our meeting. I don’t want to pry into your personal life, but maybe we can put words to what you’re feeling. This may help you feel confident that you can continue to maintain your balance with your patient. Would that be OK with you?” The demonstration of affect may also represent a rare opening where the trainee allows himself or herself to acknowledge that something personal has been troubling them for some time. The range of problems is wide and what follows is only a sampling drawn from my own experience—unresolved grief over the death of a parent; the trainee’s previously untreated or now recurring depression, bipolar disorder, eating disorder, etc.; ongoing concern for a family member’s serious mental illness; death by suicide of a family member or friend; childhood trauma; recovery from sexual assault; unresolved feelings related to pregnancy, miscarriages, and abortion. However, regardless of the nature of the difficulty, the professional anxiety is similar—will acknowledgement and exploration of this area of struggle deepen and enrich their care of patients, or will it derail it? Dunn and colleagues suggest that the culture of academic medicine has fostered too sharp a division between caregivers and care receivers, and as a result asking for help or treatment may be viewed as a weakness [14]. The opening to make a referral for a trainee may turn out to be one of the most important educational and training interventions we can provide. There is probably no small number of psychiatrists who can trace the origins of their decision to enter the field to an experience with an empathic and effective psychiatrist in the student mental health service. In making such a suggestion, it is helpful to
Acad Psychiatry
place it in a normalizing context: “Your clinical experience is touching on something in your own life that is still very painful (or frightening). It is so important in medicine that we take care of ourselves, or else ultimately we can’t take the best care of others. Many in our field have found it extremely valuable to have their own experience of treatment during training. If you’d like, I can help you find the right person/ place.” And yet, while personal experience of psychiatric symptoms and their treatment may be a deep source of motivation for some clinicians, trainees experience anxiety in acknowledging such experience in a way that is different from the acknowledgment of ‘physical’ illnesses. There are several things we can do to mitigate this stigma. For those of us who have had similar experiences, judicious self-disclosure can be valuable in normalizing the trainee’s experience [14]. We might also let the trainee know that there are many physicians (and specifically psychiatrists) who have suffered episodes of significant psychiatric illness and have been able to successfully return to practice in the context of professional support and careful self-monitoring. It may be helpful to recommend or loan the trainee some of the many powerful memoirs of psychiatric illness and subsequent recovery (An Unquiet Mind; The Center Cannot Hold; Darkness Visible, etc.) [15–17]. Research in social psychology suggests that the most effectively destigmatizing experience occurs when we have an experience of sharing productive work with members of the stigmatized group [18]. Extending this concept, we might emphasize clinical training venues where medical students and beginning residents can form a treatment alliance with patients who are productively engaged in their own recovery, something we are now emphasizing in our program. Even when their moments of tearfulness are treated with respect and affirmation by the supervisor, some trainees nonetheless remain anxious that this event will have a negative impact on their evaluation. In other words, they may think that we are being kind but will ultimately still consider this shared event to be a problem. This anxiety is unfortunately likely to go unspoken. So, it can helpful to say something in conclusion like, “Just in case you have any concerns that your show of feeling will have a negative impact on your evaluation, I want to be clear that I believe that it is a real strength for a psychiatrist to be in touch with the deeper roots of his/her connections with patients. To be able to experience and learn from our own most vulnerable and sensitive feelings is only a ‘plus’”.
Conclusions Moments of tearfulness present a critical opportunity for psychiatric trainees and educators. At such moments the trainee is directly in touch with something important, something that matters a great deal to them, and this has become
associated with an experience in their training. This is a teachable moment. And yet, it is also a moment that carries great vulnerability for the trainee—a risk of having embarrassed themselves through loss of self-control or through identification with stigmatized and marginalized patients. If we as supervisors remain aware of these vulnerabilities and anxieties, we can provide invaluable service to our trainees. We can teach them what they need to know to tolerate, understand, and make use of their own feelings— both by direct instruction and by role modeling. Our acceptance of their affect and our capacity to empathize with them while maintaining the frame of the educational relationship may teach them that intense feelings do not have to be shameful, disorganizing, or stigmatizing. Implications for Educators • Medical students and residents may experience anxiety when they become tearful during meetings with supervisors. Two frequent concerns are that: • They will be overwhelmed by their feelings and be unable to fulfill their professional role. • They will be stigmatized by their identification with the experience of psychiatric patients. • Supervisors can have a profound influence in diminishing shame and fostering professional development during these moments by: • Normalizing the experience and providing instructions about how to manage experience of one’s own affect while with patients. • Role modeling empathic acceptance of the trainee’s affect and confidence that putting feelings into words will help contain and integrate them. • Suggesting or facilitating a mental health referral when the trainee has unresolved emotional issues or untreated psychiatric symptoms that could benefit from attention.
Disclosures The author states that there is no conflict of interest.
References 1. https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/ PsychiatryMilestones.pdf 2. Shapiro et al. How do physicians teach empathy in the primary care setting? Acad Med. 2002;77:323–328 3. Shapiro J. Does medical education promote professional alexithymia? A call for attending to the emotions of patients and self in medical training. Acad Med. 2011;86:326–32. 4. Feifel D, Moutier CY, Swerdlow NR. Attitudes toward psychiatry as a prospective career among students entering medical school. Am J Psychiatry. 1999;156:1397–402. 5. Cutler JL et al. Medical students’ perceptions of psychiatry as a career choice. Acad Psychiatr. 2006;30:144–9. 6. Brenner A. What medical students say about psychiatry: results of a reflection exercise. Acad Psychiatr. 2011;35:196–8. 7. Cutler J et al. Discrediting the notion “working with ‘crazies’ will make you ‘crazy’”: addressing stigma and enhancing empathy in medical student education. Adv Health Sci Educ. 2009;14:487–502. 8. Peris TS et al. Implicit and explicit stigma of mental illness: links to clinical care. J NERV MENT DIS. 2008;196:752–60.
Acad Psychiatry 9. Louie AK, Coverdale J, Roberts LW. Emotional intelligence. Acad Psychiatr. 2006;30:1–3. 10. Bowers MB. Supervision in psychiatry and the transmission of values. Acad Psychiatr. 1999;23:42–5. 11. Radden J, Sadler J. Character virtues in psychiatric practice. Harv Rev Psychiatr. 2008;16:373–80. 12. Winseman J, Malik A, Morison J, Balkoski V. Students’ views on factors affecting empathy in medical education. Academ Psychiatr. 2009;33:484–91. 13. Rako S, Mazur H. Semrad: the heart of a therapist. Northvale: Jason Aronson Inc; 1980.
14. Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatr. 2008;32:44–53. 15. Jamison KR. An unquiet mind: a memoir of moods and madness. New York: Vintage Books; 1995. 16. Saks E. The center cannot hold: my journey through madness. New York: Hyperion Press; 2007. 17. Styron W. Darkness visible: a memoir of madness. New York: Random House; 1995. 18. Wolfe C, Spencer S. Stereotypes and prejudice. Am Behav Sci. 1996;40:176–85.
COLUMN: “DOWN TO EARTH” ACADEMIC SKILLS
Supervising the Tearful Trainee: Opportunities for Professional Growth and Learning Adam M. Brenner
Received: 4 September 2013 / Accepted: 23 February 2014 # Academic Psychiatry 2014
Abstract Trainees in psychiatry sometimes become tearful during supervision, and this presents the supervisor with significant challenges and also opportunities for the development of professionalism. This paper describes two major anxieties of trainees: first, that they will be unable to control their feelings during their clinical work and that this will derail the fulfillment of their duties; second, that that their feelings stem from an identification with some aspect of the patient or the patient's circumstances and may fear that this exposes them to the stigma of mental illness. The author describes how the trainee’s potential for shame can be greatly mitigated by supervisory interventions that treat this as a ‘teachable’ moment and opportunity for growth in professionalism. The author outlines effective interventions including didactic instruction and education, role modeling of empathic connection in the context of a boundaried relationship, and sensitive referral to mental health services for unresolved emotional issues or psychiatric symptoms. Suggestions of specific wording of interventions are provided throughout. Keywords Residents . Medical students . Supervision . Psychiatric education . Professionalism Through the years, I have had a repeated experience when meeting with medical students, psychiatry residents, and even rarely psychiatry residency applicants. I expect this is an experience that is likely to be common to most educators in psychiatry. The trainee is discussing something that is clearly of great importance to him/her. It might be an experience with a patient that particularly disturbed or inspired them. It might be something about their own personal experience or an
A. M. Brenner (*) University of Texas Southwestern Medical Center, Dallas, TX, USA e-mail: [email protected]
experience of their family or a close friend that involved psychiatric suffering and behavioral illness. At some point, as the trainee allows him/herself to experience the depth of their connection to the material, he or she becomes visibly emotional (i.e., tearful, flushed, shaken). At this point, something notable often happens—the trainee becomes embarrassed and apologizes. They may feel ashamed of having ‘lost control’ of their emotions. They sometimes feel that they have done something professionally inappropriate and may express concern that they have burdened me unfairly. Sometimes they express the worry that this show of emotion might be seen as a contraindication to a career in psychiatry. These moments of intense feeling may be uncomfortable for the supervisor as well, but they provide a rich opportunity for professional development. They are part of the broader task of developing competence in professionalism, which includes establishing a professional identity, defining one’s clinical boundaries, and maintaining an authentic empathy within these boundaries. The milestones for psychiatry specifically require that a resident demonstrate the capacity for empathy and self-reflection, and that this be paired with attention to the maintenance of professional boundaries [1]. My aim here is to provide beginning educators some framework of understanding why moments of tearfulness carry so much anxiety and embarrassment for the trainee and then to offer some suggestions of useful ways to manage the encounter so that development of professionalism is effectively fostered. I would like to suggest two primary concerns of the trainee. First, they may believe that any show of feeling will lead to being overwhelmed by affect and rendered helpless and useless. Second, they may fear that empathic identification with mentally ill patients will result in a kind of secondary stigmatization of the trainee. Both of these concerns may be intensified when their clinical experience touches on their own (sometimes untreated) psychiatric condition, and that this
Acad Psychiatry
condition will disqualify them from potentially treating psychiatric patients.
The Anxiety of Being Overwhelmed by Emotions Medical students and beginning residents can be surprised by the depth to which they are touched or disturbed by the experience of their patient. The trainee may feel concerned that these feelings will hinder their capacity to function as a clinician. They may worry that it will be impossible to “close the floodgates” and that they will be overwhelmed by affect. This would then result in being unable to effectively think and communicate professionally. They may be worried that if this emotional experience recurs in the presence of the patient, the patient will lose confidence towards them or will feel the need to take care of them, thereby reversing the usual roles of caregiver and care receiver, as well as the dynamics of power. Some fear that any loss of self-control demonstrates confirmation of their fear that they are frauds who lack the requisite character and maturity to become a physician. Finally, they also worry that they will be unable to contain the experience to their professional life, so that they will be unable to avoid “taking their work home with them.” This anxiety of being overwhelmed by their feelings can be unintentionally supported by academic environments that neglect the emotional lives of trainees. Shapiro has argued that not enough attention is given to the emotional lives of medical students and that as a result they are often afraid they will be overwhelmed by their feelings towards patients and feel helpless [2, 3]. Since one of the appeals of a career in psychiatry is the extent to which the personal relationship and empathic encounter with patients are so central this anxiety may be even more relevant in our specialty [4]. I have often been struck in reading psychiatry residency applicants’ essays how many report that they are drawn to psychiatry because they understand that an empathic connection with the patient will not only provide the context for the treatment but also will be an active ingredient of the treatment itself. However, there is another side to this experience. Cutler and colleagues [5] surveyed medical students and found that many are concerned about the intense interactions psychiatrists have with their patients and worry that a career in psychiatry will lead to feeling overwhelmed by empathy.
Concern About the Stigma of Identifying with Psychiatric Patients The idea of identifying with psychiatric patients carries more challenges than identifying with other kinds of patients. This can be seen as early as the medical school admissions process. Medical school applicants frequently write about some
experience of injury or illness that they have suffered and how it taught them something about the experience of the patient role, or perhaps about the value of the patient-doctor relationship. In my experience on our medical school’s admissions committee, these confessions are generally seen as appropriate disclosures that are entered into the ‘plus’ column in assessing the applicant’s suitability for medicine. However, disclosures about experience with a psychiatric illness are received with much greater ambivalence. Along with acknowledging the potential deepening of the patient’s empathy, there is likely to be some anxiety among medical school faculty. Does someone who has suffered from a psychiatric disorder have the necessary balance, discipline, and resilience to manage the stresses of medical school and the demands of patient care? The concern about having common ground with psychiatric patients seems to persist throughout the curriculum. Reflection papers written during the psychiatry clerkship reveal anxiety about the possibility of identifying with patients [6]. Cutler et al. found that an important aspect of students’ perceptions of the stress of psychiatry involved the tendency to identify with the patients. This stigma was still apparent in a more recent study using structured interviews [7]. Almost a third of students described their clerkship experience with psychiatric patients as disturbing, and 20 % were concerned about the personal impact of working with such patients, or as one student put it, “Working with crazies will make you crazy.” Part of the difficulty is that, along with the intrinsic challenge of understanding and modulating this identification, the stigma of mental illness persists among medical providers and even among mental health professionals [8].
Suggestions for Supervisors Even in the face of these anxieties, moments of tearfulness (or other shows of feeling) represent critical and highly valuable opportunities to psychiatric educators. They provide a signal that the student or resident is engaged at the deepest levels of the heart and mind, around issues of boundaries, professional identity, and empathy. The trainee is vulnerable at these moments, and at a crossroad—they may find their way to significant professional growth, or they may retreat into a more rigidly defended posture. As a beginning, it may help to provide some basic education on the issues outlined above [9] and to offer conceptual frameworks that can help organize the trainee’s difficult experiences. Cutler and colleagues advise explicitly instructing medical students that psychiatry may involve intense interactions with patients and the tendency to identify with them, but that practicing psychiatrists are able to empathize without feeling overwhelmed [6]. One could say, for example, “Most of our interactions with patients in psychiatry are fairly straightforward—we provide the
Acad Psychiatry
patient with a compassionate and knowledgeable doctor and the patient responds positively to this. However, our field also includes experiences where patients will invoke intense feelings that can be very disturbing. It’s natural as a beginner to be worried that you’ll be overwhelmed, but with practice and supervision we learn to identify troubling feelings without becoming lost in them.” I have found it helpful to tell trainees that there is a significant difference between simply feeling something painful with/about a patient and having that painful affect become so intense and consuming that has a detrimental effect on patient care. It is of course possible for a clinician’s own affect, particularly in the aftermath of acute loss or severe trauma, to prove overwhelming, generate panic or sobbing, and make it impossible to think or speak clearly. This would be more than most patients could or should bear, and it becomes the professional’s duty to recognize that he or she is unable to continue caring for patients and to make appropriate arrangements. However, while this possibility looms large in the minds of trainees, it is quite rare in practice, either for trainees or for experienced psychiatrists. In contrast, most experienced clinicians have at times felt so moved by a patient that a tear wells up in our eyes; this is very rarely a problem for the patient, and more often is felt by the patient as a therapeutic experience of validation or connection. (When it does cause anxiety to the patient, this is generally tolerable and can often be discussed and made good use of therapeutically.) In our program, we instruct the trainee, if asked by the patient, to acknowledge straightforwardly that he or she is feeling something in response to the patient’s narrative or presentation, while refraining from self-disclosure about any possible connections to the trainee’s own history or internal life, and while returning the focus to the patient’s experience. For example, the trainee might say “Yes, what you have been describing really has touched me. I think this might mean that we are talking about something that is really important to you (or painful to you, or confusing to you, etc.). Can you tell me more about your own thoughts and feelings about this?” Beyond instruction, however, there is also an opportunity for role modeling and demonstrating a set of values that may be even more valuable [9–12]. Learning to acknowledge a painful feeling, bear it, and put into perspective is no less crucial for the developing clinician than it is for the patients they will work with over the course of their career [13]. The opportunity for role modeling is furthered when we provide this education from a position of a real empathic connection with the learner. First, when we acknowledge a trainee’s affect, resonate with it, and then engage them in discussion about it, we are directly modeling the professional expression of empathy. Second, if we succeed in facilitating the trainee’s articulation of their feelings, we will often see the student become calmer and more comfortable. We have then demonstrated for the student something that is at the core of all
psychotherapeutic encounters—that sharing a disturbing feeling with an expert helper can allow that feeling to become less threatening. As the trainee moves forward in their own professional work, they will often be called upon to help patients learn that dialogue is an effective means of affect regulation and containment. Their capacity to do this will depend on their confidence in this kind of intervention and in the range of affect in themselves that they are capable of tolerating. How do we make sure that this kind of mentoring does not inadvertently cross over the boundary into a psychodynamic psychotherapy? Unlike in psychotherapy, the supervisor does not explore the origins of the trainee’s affect, nor does she interpret any resistance the trainee is having to the situation or to their own affect. In therapy, the goals may include following the affect to explore disturbing memories or thoughts and allowing associated and painful affects to rise to consciousness. The supervisor, by contrast, is focused on helping the trainee acknowledge that they had a feeling, decreasing their shame over this universal human experience, and helping them contain their affect within an appropriate professional demeanor and role. “I can see you’re feeling something powerful. You know, it’s not uncommon for a psychiatrist to have our work stir our own hearts. It’s OK with me that you’re feeling something important during our meeting. I don’t want to pry into your personal life, but maybe we can put words to what you’re feeling. This may help you feel confident that you can continue to maintain your balance with your patient. Would that be OK with you?” The demonstration of affect may also represent a rare opening where the trainee allows himself or herself to acknowledge that something personal has been troubling them for some time. The range of problems is wide and what follows is only a sampling drawn from my own experience—unresolved grief over the death of a parent; the trainee’s previously untreated or now recurring depression, bipolar disorder, eating disorder, etc.; ongoing concern for a family member’s serious mental illness; death by suicide of a family member or friend; childhood trauma; recovery from sexual assault; unresolved feelings related to pregnancy, miscarriages, and abortion. However, regardless of the nature of the difficulty, the professional anxiety is similar—will acknowledgement and exploration of this area of struggle deepen and enrich their care of patients, or will it derail it? Dunn and colleagues suggest that the culture of academic medicine has fostered too sharp a division between caregivers and care receivers, and as a result asking for help or treatment may be viewed as a weakness [14]. The opening to make a referral for a trainee may turn out to be one of the most important educational and training interventions we can provide. There is probably no small number of psychiatrists who can trace the origins of their decision to enter the field to an experience with an empathic and effective psychiatrist in the student mental health service. In making such a suggestion, it is helpful to
Acad Psychiatry
place it in a normalizing context: “Your clinical experience is touching on something in your own life that is still very painful (or frightening). It is so important in medicine that we take care of ourselves, or else ultimately we can’t take the best care of others. Many in our field have found it extremely valuable to have their own experience of treatment during training. If you’d like, I can help you find the right person/ place.” And yet, while personal experience of psychiatric symptoms and their treatment may be a deep source of motivation for some clinicians, trainees experience anxiety in acknowledging such experience in a way that is different from the acknowledgment of ‘physical’ illnesses. There are several things we can do to mitigate this stigma. For those of us who have had similar experiences, judicious self-disclosure can be valuable in normalizing the trainee’s experience [14]. We might also let the trainee know that there are many physicians (and specifically psychiatrists) who have suffered episodes of significant psychiatric illness and have been able to successfully return to practice in the context of professional support and careful self-monitoring. It may be helpful to recommend or loan the trainee some of the many powerful memoirs of psychiatric illness and subsequent recovery (An Unquiet Mind; The Center Cannot Hold; Darkness Visible, etc.) [15–17]. Research in social psychology suggests that the most effectively destigmatizing experience occurs when we have an experience of sharing productive work with members of the stigmatized group [18]. Extending this concept, we might emphasize clinical training venues where medical students and beginning residents can form a treatment alliance with patients who are productively engaged in their own recovery, something we are now emphasizing in our program. Even when their moments of tearfulness are treated with respect and affirmation by the supervisor, some trainees nonetheless remain anxious that this event will have a negative impact on their evaluation. In other words, they may think that we are being kind but will ultimately still consider this shared event to be a problem. This anxiety is unfortunately likely to go unspoken. So, it can helpful to say something in conclusion like, “Just in case you have any concerns that your show of feeling will have a negative impact on your evaluation, I want to be clear that I believe that it is a real strength for a psychiatrist to be in touch with the deeper roots of his/her connections with patients. To be able to experience and learn from our own most vulnerable and sensitive feelings is only a ‘plus’”.
Conclusions Moments of tearfulness present a critical opportunity for psychiatric trainees and educators. At such moments the trainee is directly in touch with something important, something that matters a great deal to them, and this has become
associated with an experience in their training. This is a teachable moment. And yet, it is also a moment that carries great vulnerability for the trainee—a risk of having embarrassed themselves through loss of self-control or through identification with stigmatized and marginalized patients. If we as supervisors remain aware of these vulnerabilities and anxieties, we can provide invaluable service to our trainees. We can teach them what they need to know to tolerate, understand, and make use of their own feelings— both by direct instruction and by role modeling. Our acceptance of their affect and our capacity to empathize with them while maintaining the frame of the educational relationship may teach them that intense feelings do not have to be shameful, disorganizing, or stigmatizing. Implications for Educators • Medical students and residents may experience anxiety when they become tearful during meetings with supervisors. Two frequent concerns are that: • They will be overwhelmed by their feelings and be unable to fulfill their professional role. • They will be stigmatized by their identification with the experience of psychiatric patients. • Supervisors can have a profound influence in diminishing shame and fostering professional development during these moments by: • Normalizing the experience and providing instructions about how to manage experience of one’s own affect while with patients. • Role modeling empathic acceptance of the trainee’s affect and confidence that putting feelings into words will help contain and integrate them. • Suggesting or facilitating a mental health referral when the trainee has unresolved emotional issues or untreated psychiatric symptoms that could benefit from attention.
Disclosures The author states that there is no conflict of interest.
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