PAUL.
new will we nal
techniques in the evaluation of our own trainees that benefit medical education as a whole. The fact that have been unable to do this adequately so far is the fiand perhaps most disturbing conclusion of this paper.
REFERENCES I. Halleck 5, Woods 5: Emotional problems of psychiatric residents. Psychiatry 25:339 346. 1962 2. HoIt R. Luborsky L: Personality Patterns of Psychiatrists. New York. Basic Books. 1958 3. Pasnau R. Bayley 5: Personality changes in the first year of psychiatric residency training. Am I Psychiatry 128:79-84, 1971 4. DufTy J, Litin E: The Emotional Health of Physicians. Springfield, Ill, Charles C Thomas. 1967
The BY
Affective PALL
G.
Experience \I.1).,
COTTON,
of Residency
A\I)
KYLE
The comm unity setting aro uses disturbing anxiett’, loneliness, anger, and disappoin resident in a manner that is both unique constructivejor
his
development feelings
1).
PRL’ETT,
of these
in the
supervisory
and through the resident’s
peer supervision is crucial work in the community.
The
of
AS THE FIEL.L) OF community psychiatry has matured, some experience in this area has become a recommended part of most approved psychiatric residency programs. In addition, an increasing number of reports on relevant training issues for new practitioners have appeared in the literature ( 1-3). However, in reviewing the literature on training programs, we have found that relatively little attention has been paid to certain complex and subtle subjective experiences that have a major impact upon the resident’s growth and development. These are the affec-
At the time this work was done, the authors were residents in psychiatry at Tufts-New England Medical Center Hospitals. Boston, Mass. Dr. Cotton is now Director of’ the Ambulatory Community Service, Cambridge
Somerville
setts vard
Department Medical
Yale
Child
partment
Cambridge,
Study of
Mental
of Mental School. Dr.
Center.
Psychiatry.
Mass.
02139.
Health
and Retardation
Center,
Lives
KY I.E D. PRUETT
of Physicians.
Springfield,
F: Factors relating to selection of psychiatric residents. J Educ47:145-147, 1972 7. Kelly W: Suicide and psychiatric education. Am J Psychiatry 130:463-468, 1973 8. Gurel L (ed): A Descriptive Directory of Psychiatric Training Programs in the United States, 1972-73. Washington, DC, American Psychiatric Association, 1973 9. Pasnau R, Russell A: Psychiatric resident suicide: an analysis of five cases. Am I Psychiatry (in press) 10. American Medical Association Division of Medical Education: Directory of Approved Internships and Residencies, 1972-73. Chicago, AMA, 1972 II. American Psychiatric Association Division of Manpower Research and Development: Personal communication, 1973 12. Taintor Z: Group sensitivity’ training for psychiatric residents. Journal of Psychiatric Education (in press)
Med
in Community
Psychiatry
\I.D.
setting
to the success
J: Emotional Issues in the Ill, Charles C Thomas, 1970
DufTy
ANI)
6. Garetz
Training
feelings (of tmen 1) within the and potential/i’
as a clinician.
examination
5.
G. COTTON
Massachu-
Health, and Instructor in Psychiatry, HarPruett is Clinical Instructor in Psychiatry, Address reprint requests to Dr. Cotton, DeCambridge Hospital, 1493 Cambridge St.,
tive, intrapersonal issues that are discussed in traditional psychotherapy supervision between supervisor and resident under the heading of “countertransference feelings.” In practical terms this usually means the resident’s personal reaction to a given psychotherapeutic situation. We view the community psychiatric experience as a unique opportunity to examine a group of these feelings. In this paper we will outline the setting and supervision of our training experience, describe some of these feelings, give an example of the community experience, and conelude by considering some of the possible long-range effects that the community experience has had on our overall growth and development as clinical psychiatrists.
THE
SETTING
The Tufts Mental Health Center, a part of the Massachusetts system of community mental health centers, consists of an affiliation of I 7 agencies already existing in the South Boston-North Dorchester community. At the same time it is an integral part ofthe training activities of the Tufts Department of Psychiatry, a dynamically onented training center of Tufts Medical School and the New England Medical Center Hospitals. Residents in psychiatry spend their first year working primarily on the inpatient psychiatric unit of the TuftsNew England Medical Center Hospitals. During the second year they work with inpatients and outpatients of
Ami
Psychiatry
132:3,
March
/975
267
AFFECTIVE
EXPERIEN(’E
OF
COMMUNITY
TRAINING
Tufts Mental Health Center. The residents work in pairs. For six months one resident is the ward physician on one of three inpatient wards at the Austin Unit of Boston State Hospital, while his alternate works in the.area of the community that admits patients to the ward. At midyear the residents switch positions. It was our community work in the South Boston subdivision of our catchment area that generated our thoughts for this paper.
THE
AFFECTIVE
EXPERIENCE
The major affective experiences in our community training fall into four categories: anxiety, loneliness, anger, and disappointment. Obviously, these feelings are also central to the traditional psychotherapy situation in which the therapist is called upon to examine these feelings as they arise in his relationship with his patient. However, we wish to call attention to a similar need to acknowledge and examine them in the community expenience, although the nontraditional roles and settings here can make this analysis more difficult. Just as the failure to acknowledge and work through these feelings can lead to an inappropriate disruption in a psychotherapeutic relationship, it can also lead to misunderstandings and unnecessary failures in community efforts. The anxiety we are discussing was specifically related to the ambiguity that characterized the community training experience. This ambiguity was particularly striking when we contrasted it with our experience in a traditional inpatient setting where patients, clearly defined as such, came with complaints to us as residents in psychiatry. In community settings it is rarely as clear who is the patient, what is the role of the physician, and what constitutes treatment and improvement or cure. The ambiguity in the role of the physician extended from our vague perception of what skills we had to offer to the confused cxpectations of the people with whom we would work in the community. Loneliness was experienced because the community work itself was often done in relative isolation from othen medical colleagues and away from the main hospital facilities. We especially felt the loss of a shared sense of purpose with our colleagues. We missed our teachers in the office nearby. There was no such thing as a “coffeepot consultation.” Our anger was aroused by the suspicion and skepticism that we encountered in the people we met. They questioned our motives, reliability, and usefulness and distrusted even our “sacred” position as helping professionals. We were angry at this challenge to our professional self-images. A final
issue
we experienced, munity work amount and were clearly
much munity
268
is the
which itself. quality not met.
particular
stems First,
kind
from our
of work Second,
of
we hoped to it is necessary
more trial-and-error, setting than in the
preparatory more defined,
Am J Psychiatrt’
March
132:3,
disappointment
the nature fantasies
1975
of the comof both the accomplish to perform
work in a comstructured set-
ting time
of the hospital. and effort was
Initially, we not productive.
felt that much We felt fallow.
ol’ our
SUPERVISION
We now turn our attention to the role that two modes of supervision played in facilitating our awareness of the feelings previously described. The first was a traditional supervisory meeting held weekly between each of us and our clinical supervisor, a full-time member in our department who had had significant experience in community psychiatric work. These sessions dealt primarily with the more technical aspects of the consultation rather than the more subjective issues previously discussed. Although it is not the focus of this paper, we had a great deal to learn about the principles and mechanics of consultation. This learning took place primarily in the traditional supervisory sessions. The second mode of supervision developed out of our working relationship, which was fostered by the structure of the residency program that paired the second-year residents.
In
order
to establish
some
continuity
between
our experience on the ward and in the community, we scheduled a formal weekly meeting in which we discussed aspects of the community psychiatry experience. These meetings continued through the year regardless of which of us was working in the community. We noticed that these meetings evolved into discussions of our more personal reactions to the community work. We discovered that our personal reactions came up more fully and more frequently in these meetings than in our traditional supervisory meetings. There were some obvious problems in our traditional supervisory meetings. Not only do residents often pay selective attention to those areas in which they do well, but also their ability to talk with a supervisor about interpersonal concerns varies widely with each resident-supervisor mix. Two residents who have known and worked with each other for more than a year have the potential for a trusting relationship that can allow access to their positive as well as negative personal reactions to their work. Most concretely, in this case we found it easier to tell each other that we were at different times anxious, lonely, angry, or disappointed. It was very valuable for our personal growth as well as for the success ofour work to discover and examine the common situations that led to these feelings. In retrospect this seemed crucial to the success
THE
of the
AFFECTIVE
community
EXPERIENCE
We selected the experience in order previously outlined. After discussion to attempt to develop high school located time there was no
consultation.
IN
THE
COMMUNITY
following case from our to illustrate the aflective with
community experiences
our staff supervisors, we decided a consultation with the large urban within our catchment area. At that formal consultation with the school:
PAUL
however, its staff had expressed an interest in receiving some help from the mental health center. During the summer one of us (P.G.C.) visited the school to speak with the headmaster, the assistant headmaster, and the master in charge of the ninth-grade annex. At that time he introduced himself and expressed an interest in the possibilities of working together. He was received with some skepticism. The headmaster described how previous mental health workers had been more interested in their own training than in helping the high school. Another story was told about a group of mental health workers who had stopped coming to the high school when their own research project was finished. Despite these feelings the group oflered to meet again at the beginning of the school year. At that point in the first meeting it seemed that the school staff had accepted the offer to work together, and the resident became more active. Responding in part to the group’s skepticism, he defined his time commitment approximately one morning each week during the school year-and suggested that the group and he decide together what work could be done during that year. This gave a focus for the first meetings, allowed him to remain flexible, and gave him the opportunity to discover the main problems of the school as presented by the staff. As he left this meeting the resident felt good about the prospects for the fall. The resident returned to the high school shortly after the beginning of the school year. Finding the front door locked, he rang the bell, and a teacher who had been sitting at a desk behind the door asked him who he was and what he wanted. After he introduced himself, she asked him for identification to prove that he was a physician working for the mental health center. She then telephoned the assistant headmaster’s office and asked permission for him to enter. 1-Ic was then admitted to the building. I-Ic walked into the headmaster’s office, which was crowded and obviously very busy. 1-Ic announced his arrival to the secretary, who asked him to be seated. After he had waited for some time he was seen by the assistant headmaster, who said he was very busy since it was the beginning of the school year. The assistant headmaster suggested that the resident return the following week since he did not have anything specific to talk about with him. A similar series of events took place at the next two meetings. After several mornings of this, the resident began to get angry. Different teachers were assigned to the front door of the school on a rotating basis. They were all suspicious, probably based on their unpleasant experiences with outsiders coming into and disrupting the school. This was the first time during his residency that the author had been mistaken for an interloper. He commented to his colleague that there might be more truth in this message than he was willing to admit. At this point he was also disappointed. He had spent several mornings working in the community, and he still had difliculty getting in the front door. His anxiety was heightened by the continual lack of defined tasks. In con---
G. COTTON
AND
KYE.E
D. PRUETT
trast to his expectations, he had accomplished very little. He was also very lonely. He sensed that he was not wanted. The “enemy” was all around him. There were no friendly supervisors in the next office with whom to share these feelings. It seemed that the isolation of the setting heightened his feelings of anxiety, anger, disappointment, and loneliness. It became clear in our discussions with each other that the recognition and understanding of these feelings were the prerequisite for our further work with the school. If the feelings had been projected onto the school, which was seen as rejecting, our efforts could have floundered. When we accepted the feelings as our own and began to explore them, we were able to develop means of dealing with the difficulties. For example, we planned to deal with the staff’s suspicions by having the resident currently working with the school introduce himself to the teachers and guidance counselors, talking with the school nurse, and continuing to appear each week. We wanted to show them that their fears of him were unfounded. As he confronted the suspicion, the loneliness became less of a problem. By the fourth week the assistant headmaster was talking with him and the teachers and guidance counselors began to greet him when they saw him. Eventually, over a period of about three months, he was able to apply his clinical skills. The assistant headmaster focused on behavior problems. The guidance counselors consulted him about difficult emotional problems. Occasionally, when a teacher was interested in making a particular point about mental health, he would ask the resident to sit in on the class. Then the resident discussed
the
presentation
with
him.
From
time
to
time
he saw individual students. The other resident (K.D.P.) enjoyed a similar relationship with the staff. There is a large body of literature on school consultation (4-8). Many of these observations were useful to us in the later aspects of our work in the school. However, we must reemphasize that the success of this work was dependent upon the attention we paid to the feelings generated in our initial contacts with the school.
CONCLUSIONS
Our experience in the community has given us the opportunity to acknowledge and analyze some of the differences between working in that setting and in the traditional mental health institutions and to examine some of our feelings when presented with these differences. We have found that the analysis of these feelings was crucial in terms of the effectiveness of our community work and was relevant to our personal growth as clinicians. The process of doing on it is a response in drives toward independence cian can learn in another ful analysis of the nature both from himself and community work. Am
community work and reflecting some sense to the professional and competence. The clinisetting the importance of careof clinical material as it emerges from the problems particular to
J P.syc’hiatrv
/32:3,
March
/975
269
CONTROVERSIES
IN PSYCHIATRIC
FI)UCATION
5. Trickett
REFERENCES I.
Morrison AP, Shore MF, Grobman J: On the stresses of community psychiatry. and helping residents to survive them. Am J Psychiatry 130:1237 1241. 1973 2. Pattison EM: Residency training issues in community psychiatry. AmJ Psychiatry 128:1097 1102, 1972 3. Scherl DI: Training for community psychiatry’ in the general psychiatric residency. Massachusetts Journal of Mental Health 1:16 23, 1970 4. Lambert NM, Bower EM. Caplan G. et al: The Protection and Promotion of Mental Health in Schools, Mental Health Monograph 5. Public US Government
Health Service Publication Printing Office. 1964
Controversies BY
JOHN
1226.
in Psychiatric
F’. GREI)EN,
.SNl)
MI).,
Washington,
DC,
Education: JORGE
A Survey
1. CASARIE(;O,
orien
ted
p.st’chotherapi’.
authors conclude that substantial changes required in the core curriculum ofresidenc.s’ the prediction that tomorrow’.s p.si’chiatrist complete p.st’chobiologist is to be fulfilled.
PSYCHIATRISTS
ARE
Read tion,
at the Detroit,
127th annual Mich., May
The these
meeting ofthe 6 10, 1974.
Am J Psychiatry
132:3,
American
Psychiatric
cally
if
Associa-
Dr. Greden was Director of Psywas a third-year resident, DepartWalter Reed Army Medical Cenis now Assistant Professor of Medical Center, Ann Arbor, Mich. Psychiatry Clinic, 130th Station
March
/975
Todd
DM:
The
social
environment
of the
of Residents’
Attitudes
modalities and (10), the wisdom the future imporand neurochemistry ( I 3). psychiatric residents regarding
of psychoanalysis
perceptions issues
are
of important
for
a variety
of
reasons.
First,
residents are the consumers of our educational policies; as such, their perceptions may provide quality control information about the type of product our medical schools are turning out. Second, residents constitute a numeri-
with a multitude of consuch diverse issues in psychiatric for internships (I), the benefits of residency (2), the desirability of liaison with neurology (3-8), the by psychiatric organizations (9),
At the time this study was conducted. chiatric Research and Dr. Casariego ment of Psychiatry and Neurology, ter, Washington, D.C. Dr. Greden Psychiatry. University of Michigan 48104. and Dr. Casariego is Chief, Hospital, Heidelberg, Germany.
270
tance
STRUGGI.ING
troversies pertaining to education as the need psychotherapy during the medical model or value of social activism
JG,
the relative merits of various therapeutic the ideologies on which they are based of periodic recertification (I I, 12), and
The
will be education will be a
Kelly
M.D.
The authors administered a questionnaire including statemen 15 regarding con tro versie.s in psychiatric education to 86 residents in six programs in the Washington. D.C/Baltimore, Md., area. The residents were askedfor their opinions on educational policies. ideological is.sue.s in psi’chiatr’i’. their identification with traditional areas ofmedicine. andfuture regulatori’ practice.s for p.si’chiatrs’. The data gathered sho w some shifts in attitudes amongfir.st-. second-. and third-year residents. They also show a marked inclination toward dynamic-analytical/i’
EJ,
high school: guidelines for individual change and organizational redevelopment, in Handbook of Community Mental Health. Edited by Golann SE, Eisdorfer C. New York, Appleton-Century-C rofts, l972,pp33I 406 6. Pearson GHJ: The most efTective help a psychiatrist can give to the teacher, in Orthopsychiatry and the School. Edited by Krugman M. New York, American Orthopsychiatric Association, 958. pp 3 22 7. Bloch HS: Experiences in establishing school consultation. Am I Psychiatry 129:63 68, 1972 8. Vanderpol M. Waxman HS: Beyond pathology: some basic ideas for effective school consultation. Psychiatric Opinion 11(4): 18 24, 1974
substantial
and
outspoken
segment
of
the
profes-
sion; their support for contemplated changes in educational policies can be crucial. For this reason, and because residents appear more formative and flexible than established practitioners, rhetorical arguments often seem to be directed their way. Third, residents are the future leaders of the profession. There is no guarantee that their viewpoints will remain stable in ensuing years, but residents’ perceptions today may provide clues as to where psychiatry is headed tomorrow. For these reasons, we sought to determine how psychiatric residents in one part ofthe United States perceived some of the philosophical-methodological controversies
M ETHO
being
at all
levels
of psychiatry.
[)
In May questionnaires programs
discussed
and in the
June 1973, we to 86 psychiatric Washington,
personally residents
D.C./Baltimore,
The 86 respondents represented dents enrolled in the six programs.
77
administered in six residency Md.,
area.
percent of all resiEight of the residents
new will we nal
techniques in the evaluation of our own trainees that benefit medical education as a whole. The fact that have been unable to do this adequately so far is the fiand perhaps most disturbing conclusion of this paper.
REFERENCES I. Halleck 5, Woods 5: Emotional problems of psychiatric residents. Psychiatry 25:339 346. 1962 2. HoIt R. Luborsky L: Personality Patterns of Psychiatrists. New York. Basic Books. 1958 3. Pasnau R. Bayley 5: Personality changes in the first year of psychiatric residency training. Am I Psychiatry 128:79-84, 1971 4. DufTy J, Litin E: The Emotional Health of Physicians. Springfield, Ill, Charles C Thomas. 1967
The BY
Affective PALL
G.
Experience \I.1).,
COTTON,
of Residency
A\I)
KYLE
The comm unity setting aro uses disturbing anxiett’, loneliness, anger, and disappoin resident in a manner that is both unique constructivejor
his
development feelings
1).
PRL’ETT,
of these
in the
supervisory
and through the resident’s
peer supervision is crucial work in the community.
The
of
AS THE FIEL.L) OF community psychiatry has matured, some experience in this area has become a recommended part of most approved psychiatric residency programs. In addition, an increasing number of reports on relevant training issues for new practitioners have appeared in the literature ( 1-3). However, in reviewing the literature on training programs, we have found that relatively little attention has been paid to certain complex and subtle subjective experiences that have a major impact upon the resident’s growth and development. These are the affec-
At the time this work was done, the authors were residents in psychiatry at Tufts-New England Medical Center Hospitals. Boston, Mass. Dr. Cotton is now Director of’ the Ambulatory Community Service, Cambridge
Somerville
setts vard
Department Medical
Yale
Child
partment
Cambridge,
Study of
Mental
of Mental School. Dr.
Center.
Psychiatry.
Mass.
02139.
Health
and Retardation
Center,
Lives
KY I.E D. PRUETT
of Physicians.
Springfield,
F: Factors relating to selection of psychiatric residents. J Educ47:145-147, 1972 7. Kelly W: Suicide and psychiatric education. Am J Psychiatry 130:463-468, 1973 8. Gurel L (ed): A Descriptive Directory of Psychiatric Training Programs in the United States, 1972-73. Washington, DC, American Psychiatric Association, 1973 9. Pasnau R, Russell A: Psychiatric resident suicide: an analysis of five cases. Am I Psychiatry (in press) 10. American Medical Association Division of Medical Education: Directory of Approved Internships and Residencies, 1972-73. Chicago, AMA, 1972 II. American Psychiatric Association Division of Manpower Research and Development: Personal communication, 1973 12. Taintor Z: Group sensitivity’ training for psychiatric residents. Journal of Psychiatric Education (in press)
Med
in Community
Psychiatry
\I.D.
setting
to the success
J: Emotional Issues in the Ill, Charles C Thomas, 1970
DufTy
ANI)
6. Garetz
Training
feelings (of tmen 1) within the and potential/i’
as a clinician.
examination
5.
G. COTTON
Massachu-
Health, and Instructor in Psychiatry, HarPruett is Clinical Instructor in Psychiatry, Address reprint requests to Dr. Cotton, DeCambridge Hospital, 1493 Cambridge St.,
tive, intrapersonal issues that are discussed in traditional psychotherapy supervision between supervisor and resident under the heading of “countertransference feelings.” In practical terms this usually means the resident’s personal reaction to a given psychotherapeutic situation. We view the community psychiatric experience as a unique opportunity to examine a group of these feelings. In this paper we will outline the setting and supervision of our training experience, describe some of these feelings, give an example of the community experience, and conelude by considering some of the possible long-range effects that the community experience has had on our overall growth and development as clinical psychiatrists.
THE
SETTING
The Tufts Mental Health Center, a part of the Massachusetts system of community mental health centers, consists of an affiliation of I 7 agencies already existing in the South Boston-North Dorchester community. At the same time it is an integral part ofthe training activities of the Tufts Department of Psychiatry, a dynamically onented training center of Tufts Medical School and the New England Medical Center Hospitals. Residents in psychiatry spend their first year working primarily on the inpatient psychiatric unit of the TuftsNew England Medical Center Hospitals. During the second year they work with inpatients and outpatients of
Ami
Psychiatry
132:3,
March
/975
267
AFFECTIVE
EXPERIEN(’E
OF
COMMUNITY
TRAINING
Tufts Mental Health Center. The residents work in pairs. For six months one resident is the ward physician on one of three inpatient wards at the Austin Unit of Boston State Hospital, while his alternate works in the.area of the community that admits patients to the ward. At midyear the residents switch positions. It was our community work in the South Boston subdivision of our catchment area that generated our thoughts for this paper.
THE
AFFECTIVE
EXPERIENCE
The major affective experiences in our community training fall into four categories: anxiety, loneliness, anger, and disappointment. Obviously, these feelings are also central to the traditional psychotherapy situation in which the therapist is called upon to examine these feelings as they arise in his relationship with his patient. However, we wish to call attention to a similar need to acknowledge and examine them in the community expenience, although the nontraditional roles and settings here can make this analysis more difficult. Just as the failure to acknowledge and work through these feelings can lead to an inappropriate disruption in a psychotherapeutic relationship, it can also lead to misunderstandings and unnecessary failures in community efforts. The anxiety we are discussing was specifically related to the ambiguity that characterized the community training experience. This ambiguity was particularly striking when we contrasted it with our experience in a traditional inpatient setting where patients, clearly defined as such, came with complaints to us as residents in psychiatry. In community settings it is rarely as clear who is the patient, what is the role of the physician, and what constitutes treatment and improvement or cure. The ambiguity in the role of the physician extended from our vague perception of what skills we had to offer to the confused cxpectations of the people with whom we would work in the community. Loneliness was experienced because the community work itself was often done in relative isolation from othen medical colleagues and away from the main hospital facilities. We especially felt the loss of a shared sense of purpose with our colleagues. We missed our teachers in the office nearby. There was no such thing as a “coffeepot consultation.” Our anger was aroused by the suspicion and skepticism that we encountered in the people we met. They questioned our motives, reliability, and usefulness and distrusted even our “sacred” position as helping professionals. We were angry at this challenge to our professional self-images. A final
issue
we experienced, munity work amount and were clearly
much munity
268
is the
which itself. quality not met.
particular
stems First,
kind
from our
of work Second,
of
we hoped to it is necessary
more trial-and-error, setting than in the
preparatory more defined,
Am J Psychiatrt’
March
132:3,
disappointment
the nature fantasies
1975
of the comof both the accomplish to perform
work in a comstructured set-
ting time
of the hospital. and effort was
Initially, we not productive.
felt that much We felt fallow.
ol’ our
SUPERVISION
We now turn our attention to the role that two modes of supervision played in facilitating our awareness of the feelings previously described. The first was a traditional supervisory meeting held weekly between each of us and our clinical supervisor, a full-time member in our department who had had significant experience in community psychiatric work. These sessions dealt primarily with the more technical aspects of the consultation rather than the more subjective issues previously discussed. Although it is not the focus of this paper, we had a great deal to learn about the principles and mechanics of consultation. This learning took place primarily in the traditional supervisory sessions. The second mode of supervision developed out of our working relationship, which was fostered by the structure of the residency program that paired the second-year residents.
In
order
to establish
some
continuity
between
our experience on the ward and in the community, we scheduled a formal weekly meeting in which we discussed aspects of the community psychiatry experience. These meetings continued through the year regardless of which of us was working in the community. We noticed that these meetings evolved into discussions of our more personal reactions to the community work. We discovered that our personal reactions came up more fully and more frequently in these meetings than in our traditional supervisory meetings. There were some obvious problems in our traditional supervisory meetings. Not only do residents often pay selective attention to those areas in which they do well, but also their ability to talk with a supervisor about interpersonal concerns varies widely with each resident-supervisor mix. Two residents who have known and worked with each other for more than a year have the potential for a trusting relationship that can allow access to their positive as well as negative personal reactions to their work. Most concretely, in this case we found it easier to tell each other that we were at different times anxious, lonely, angry, or disappointed. It was very valuable for our personal growth as well as for the success ofour work to discover and examine the common situations that led to these feelings. In retrospect this seemed crucial to the success
THE
of the
AFFECTIVE
community
EXPERIENCE
We selected the experience in order previously outlined. After discussion to attempt to develop high school located time there was no
consultation.
IN
THE
COMMUNITY
following case from our to illustrate the aflective with
community experiences
our staff supervisors, we decided a consultation with the large urban within our catchment area. At that formal consultation with the school:
PAUL
however, its staff had expressed an interest in receiving some help from the mental health center. During the summer one of us (P.G.C.) visited the school to speak with the headmaster, the assistant headmaster, and the master in charge of the ninth-grade annex. At that time he introduced himself and expressed an interest in the possibilities of working together. He was received with some skepticism. The headmaster described how previous mental health workers had been more interested in their own training than in helping the high school. Another story was told about a group of mental health workers who had stopped coming to the high school when their own research project was finished. Despite these feelings the group oflered to meet again at the beginning of the school year. At that point in the first meeting it seemed that the school staff had accepted the offer to work together, and the resident became more active. Responding in part to the group’s skepticism, he defined his time commitment approximately one morning each week during the school year-and suggested that the group and he decide together what work could be done during that year. This gave a focus for the first meetings, allowed him to remain flexible, and gave him the opportunity to discover the main problems of the school as presented by the staff. As he left this meeting the resident felt good about the prospects for the fall. The resident returned to the high school shortly after the beginning of the school year. Finding the front door locked, he rang the bell, and a teacher who had been sitting at a desk behind the door asked him who he was and what he wanted. After he introduced himself, she asked him for identification to prove that he was a physician working for the mental health center. She then telephoned the assistant headmaster’s office and asked permission for him to enter. 1-Ic was then admitted to the building. I-Ic walked into the headmaster’s office, which was crowded and obviously very busy. 1-Ic announced his arrival to the secretary, who asked him to be seated. After he had waited for some time he was seen by the assistant headmaster, who said he was very busy since it was the beginning of the school year. The assistant headmaster suggested that the resident return the following week since he did not have anything specific to talk about with him. A similar series of events took place at the next two meetings. After several mornings of this, the resident began to get angry. Different teachers were assigned to the front door of the school on a rotating basis. They were all suspicious, probably based on their unpleasant experiences with outsiders coming into and disrupting the school. This was the first time during his residency that the author had been mistaken for an interloper. He commented to his colleague that there might be more truth in this message than he was willing to admit. At this point he was also disappointed. He had spent several mornings working in the community, and he still had difliculty getting in the front door. His anxiety was heightened by the continual lack of defined tasks. In con---
G. COTTON
AND
KYE.E
D. PRUETT
trast to his expectations, he had accomplished very little. He was also very lonely. He sensed that he was not wanted. The “enemy” was all around him. There were no friendly supervisors in the next office with whom to share these feelings. It seemed that the isolation of the setting heightened his feelings of anxiety, anger, disappointment, and loneliness. It became clear in our discussions with each other that the recognition and understanding of these feelings were the prerequisite for our further work with the school. If the feelings had been projected onto the school, which was seen as rejecting, our efforts could have floundered. When we accepted the feelings as our own and began to explore them, we were able to develop means of dealing with the difficulties. For example, we planned to deal with the staff’s suspicions by having the resident currently working with the school introduce himself to the teachers and guidance counselors, talking with the school nurse, and continuing to appear each week. We wanted to show them that their fears of him were unfounded. As he confronted the suspicion, the loneliness became less of a problem. By the fourth week the assistant headmaster was talking with him and the teachers and guidance counselors began to greet him when they saw him. Eventually, over a period of about three months, he was able to apply his clinical skills. The assistant headmaster focused on behavior problems. The guidance counselors consulted him about difficult emotional problems. Occasionally, when a teacher was interested in making a particular point about mental health, he would ask the resident to sit in on the class. Then the resident discussed
the
presentation
with
him.
From
time
to
time
he saw individual students. The other resident (K.D.P.) enjoyed a similar relationship with the staff. There is a large body of literature on school consultation (4-8). Many of these observations were useful to us in the later aspects of our work in the school. However, we must reemphasize that the success of this work was dependent upon the attention we paid to the feelings generated in our initial contacts with the school.
CONCLUSIONS
Our experience in the community has given us the opportunity to acknowledge and analyze some of the differences between working in that setting and in the traditional mental health institutions and to examine some of our feelings when presented with these differences. We have found that the analysis of these feelings was crucial in terms of the effectiveness of our community work and was relevant to our personal growth as clinicians. The process of doing on it is a response in drives toward independence cian can learn in another ful analysis of the nature both from himself and community work. Am
community work and reflecting some sense to the professional and competence. The clinisetting the importance of careof clinical material as it emerges from the problems particular to
J P.syc’hiatrv
/32:3,
March
/975
269
CONTROVERSIES
IN PSYCHIATRIC
FI)UCATION
5. Trickett
REFERENCES I.
Morrison AP, Shore MF, Grobman J: On the stresses of community psychiatry. and helping residents to survive them. Am J Psychiatry 130:1237 1241. 1973 2. Pattison EM: Residency training issues in community psychiatry. AmJ Psychiatry 128:1097 1102, 1972 3. Scherl DI: Training for community psychiatry’ in the general psychiatric residency. Massachusetts Journal of Mental Health 1:16 23, 1970 4. Lambert NM, Bower EM. Caplan G. et al: The Protection and Promotion of Mental Health in Schools, Mental Health Monograph 5. Public US Government
Health Service Publication Printing Office. 1964
Controversies BY
JOHN
1226.
in Psychiatric
F’. GREI)EN,
.SNl)
MI).,
Washington,
DC,
Education: JORGE
A Survey
1. CASARIE(;O,
orien
ted
p.st’chotherapi’.
authors conclude that substantial changes required in the core curriculum ofresidenc.s’ the prediction that tomorrow’.s p.si’chiatrist complete p.st’chobiologist is to be fulfilled.
PSYCHIATRISTS
ARE
Read tion,
at the Detroit,
127th annual Mich., May
The these
meeting ofthe 6 10, 1974.
Am J Psychiatry
132:3,
American
Psychiatric
cally
if
Associa-
Dr. Greden was Director of Psywas a third-year resident, DepartWalter Reed Army Medical Cenis now Assistant Professor of Medical Center, Ann Arbor, Mich. Psychiatry Clinic, 130th Station
March
/975
Todd
DM:
The
social
environment
of the
of Residents’
Attitudes
modalities and (10), the wisdom the future imporand neurochemistry ( I 3). psychiatric residents regarding
of psychoanalysis
perceptions issues
are
of important
for
a variety
of
reasons.
First,
residents are the consumers of our educational policies; as such, their perceptions may provide quality control information about the type of product our medical schools are turning out. Second, residents constitute a numeri-
with a multitude of consuch diverse issues in psychiatric for internships (I), the benefits of residency (2), the desirability of liaison with neurology (3-8), the by psychiatric organizations (9),
At the time this study was conducted. chiatric Research and Dr. Casariego ment of Psychiatry and Neurology, ter, Washington, D.C. Dr. Greden Psychiatry. University of Michigan 48104. and Dr. Casariego is Chief, Hospital, Heidelberg, Germany.
270
tance
STRUGGI.ING
troversies pertaining to education as the need psychotherapy during the medical model or value of social activism
JG,
the relative merits of various therapeutic the ideologies on which they are based of periodic recertification (I I, 12), and
The
will be education will be a
Kelly
M.D.
The authors administered a questionnaire including statemen 15 regarding con tro versie.s in psychiatric education to 86 residents in six programs in the Washington. D.C/Baltimore, Md., area. The residents were askedfor their opinions on educational policies. ideological is.sue.s in psi’chiatr’i’. their identification with traditional areas ofmedicine. andfuture regulatori’ practice.s for p.si’chiatrs’. The data gathered sho w some shifts in attitudes amongfir.st-. second-. and third-year residents. They also show a marked inclination toward dynamic-analytical/i’
EJ,
high school: guidelines for individual change and organizational redevelopment, in Handbook of Community Mental Health. Edited by Golann SE, Eisdorfer C. New York, Appleton-Century-C rofts, l972,pp33I 406 6. Pearson GHJ: The most efTective help a psychiatrist can give to the teacher, in Orthopsychiatry and the School. Edited by Krugman M. New York, American Orthopsychiatric Association, 958. pp 3 22 7. Bloch HS: Experiences in establishing school consultation. Am I Psychiatry 129:63 68, 1972 8. Vanderpol M. Waxman HS: Beyond pathology: some basic ideas for effective school consultation. Psychiatric Opinion 11(4): 18 24, 1974
substantial
and
outspoken
segment
of
the
profes-
sion; their support for contemplated changes in educational policies can be crucial. For this reason, and because residents appear more formative and flexible than established practitioners, rhetorical arguments often seem to be directed their way. Third, residents are the future leaders of the profession. There is no guarantee that their viewpoints will remain stable in ensuing years, but residents’ perceptions today may provide clues as to where psychiatry is headed tomorrow. For these reasons, we sought to determine how psychiatric residents in one part ofthe United States perceived some of the philosophical-methodological controversies
M ETHO
being
at all
levels
of psychiatry.
[)
In May questionnaires programs
discussed
and in the
June 1973, we to 86 psychiatric Washington,
personally residents
D.C./Baltimore,
The 86 respondents represented dents enrolled in the six programs.
77
administered in six residency Md.,
area.
percent of all resiEight of the residents
