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a publication of

The American Journal of Psychiatry and the

APA Committee of Residents and Fellows

June 2009 Volume 4 Issue 6

This Issue

Paul P. Christopher, M.D.
Department of Psychiatry and Human Behavior, Brown University

1 Introduction
Paul P. Christopher, M.D.

2 Residents in Psychotherapy:
Where Have All the Hours
Paul P. Christopher, M.D.

3 The Making of A Good

Therapist: One Resident’s
Amy Yang, M.D.

4 Manifest Similarities: More

Than Skin Deep
C. Joy Somberg, M.D.

Participation as a patient in individual psychotherapy is often cited as an important

6 Committee of Residents and
aspect of psychiatry residency training. In this issue, we take a closer and more per-
sonal look at the perspectives and experiences of residents in psychotherapy. The first
article examines the extent to which psychiatry residents seek psychotherapy while
in training, their reasons for doing so, and how these trends may have changed over
time. Two personal essays written by residents about their own experiences in psycho-
therapy are also featured. I hope you will agree that their narratives make a compelling
case for why personal psychotherapy continues to be a central force in our develop-
Editor-in-Chief: Sarah B. Johnson, M.D. ment, not only as psychiatrists but as healthier individuals.
Issue Editor: Paul P. Christopher, M.D.

Staff Editor: Angela Moore


Residents in Psychotherapy: Where Have All the Hours Gone?

Paul P. Christopher, M.D.
Department of Psychiatry and Human Behavior, Brown University

Competence in psychotherapy is among whether to enter psychotherapy and, if References

the more difficult skills psychiatry resi- so, what kind of psychotherapist to see
1. Macran S, Shapiro DA: The role of per-
dents must acquire during their training. as well as the duration of the therapy.
sonal therapy for therapists: a review. Br J
While the groundwork for this may begin Not surprisingly, though, the residents
Med Psychol 1998; 71:13-26
in the classroom or with a textbook, of programs in which psychotherapy is
mastery is only achieved through the ex- encouraged or supported report higher 2. Kaslow FW: Psychotherapy with Psycho-
therapists. New York, Haworth Press, 1984,
perience of being a psychotherapist. But participation rates (3, 5).
pp 22-26
how do residents make the transition The current research suggests that fewer
from playing the role of psychotherapist 3. Weintraub D, Dixon L, Kohlhepp E, Wool-
residents are choosing to enter their own ery J: Residents in personal psychotherapy: a
to being competent and confident in their therapy, relative to past years (3, 4, 6-8). longitudinal and cross-sectional perspective.
abilities? Likely explanations include the decreased Acad Psychiatry 1999; 23:14-18
In other fields of medicine, trainees learn emphasis on psychodynamic training, 4. Daly KA: Attitudes of U.S. psychiatry
by observing experienced doctors at work, robust development of pharmacologic residencies about personal psychotherapy for
by being observed as they perform an ac- treatments, and costs of being in therapy psychiatry residents. Acad Psychiatry 1998;
tivity, and by receiving feedback on their (4). 22:223-228
performance. But for many reasons—e.g., Still, residents of a substantial per- 5. Fogel SP, Sneed JR, Roose SP: Survey of
the intimacy of the work, the multitude centage continue to enter their own psychiatric treatment among psychiatric resi-
of acceptable strategies, the protracted psychotherapy, although perhaps for dif- dents in Manhattan: evidence of stigma. J
treatment—psychotherapy is often a ferent reasons than in the past. In a survey Clin Psychiatry 2006; 67:1591-1598
poor fit for this model. To approximate of residents from three training programs 6. Casariego JI, Greden JF: Perceptions of
the approach, many residents audiotape (3), psychotherapy participation rates treatment value, therapeutic orientation, and
therapy sessions and share them with ranged from 6% to 60%. Among those actual experience of psychiatric residents.
their supervisors, while others choose to residents in psychotherapy, 78% cited Compr Psychiatry 1978; 19:241-248
summarize and discuss what they iden- personal reasons as their motivation. 7. Greden JF, Casariego JI: Controversies in
tify as important issues from each session. Another survey (5) reported that among psychiatric education: a survey of resident’s at-
Unfortunately, residents rarely have the postgraduate II, III, and IV residents in titudes. Am J Psychiatry 1975; 132:270-274
opportunity to observe seasoned psycho- Manhattan, 56% indicated that they were 8. Weissman S: American psychiatry in the
therapists doing therapy. And when they in psychotherapy. Of these, 60% stated 21st century: the discipline, its practice, and
do, it is usually only for a few sessions. “personal issues” as their primary motiva- its workforce. Bull Menninger Clin 1994;
Historically, another way for residents tion; 22% reported “educational value;” 58:502-551
to learn psychotherapy was to enter into and 18% reported both personal issues 9. Hoop JG: Hidden ethical dilemmas in
their own treatment. Besides the benefit and educational value. Irrespective of ini- psychiatric residency training: the psychiatry
of directly observing a psychotherapist, tial motivation, residents in both studies resident as dual agent. Acad Psychiatry 2004;
residents could learn what it was like to reported that being in psychotherapy had 28:183-189
be a patient, develop a deeper empathy a positive influence on their training and 10. Martini S, Arfken CL, Churchill A, Balon
for those they treated, and hone their professional development. B: Burnout comparison among residents in
therapeutic skills. In their own individual different medical specialties. Acad Psychiatry
The reality that large numbers of resi- 2004; 28:240-242
therapy, residents can also develop a bet- dents seek psychotherapy because they
ter sense of themselves and address issues identify it as potentially helpful in their
11. Pilkinton P, Etkin M: Encountering sui-
that will affect their professional and per- cide: the experience of psychiatric residents.
personal lives is, at once, reassuring and Acad Psychiatry 2003; 27:93-99
sonal lives (1). sobering. It suggests that despite the
12. Pitt E, Rosenthal MM, Gay TL, Lew-
At one time, personal psychotherapy greater emphasis on biological treat-
ton E: Mental health services for residents:
was all but required of residents in train- ments, many residents recognize the
more important than ever. Acad Med 2004;
ing (2). Today, few programs, apart from benefits that psychotherapy offers. It also 79:840-844
those with a strong psychoanalytic or serves as a reminder of the many stresses
psychodynamic focus (3), mandate that residents face while in training (9-12).
trainees enter psychotherapy (4). Instead, Dr. Christopher is a fourth-year resident
residents are left to decide for themselves and the Editor for this issue.

The Residents’ Journal 2

The Making of A Good Therapist: One Resident’s Perspective

Amy Yang, M.D.
Department of Psychiatry and Human Behavior, Brown University

“As a resident, I sometimes worry about my innate talent to be a therapist.”

In The Unbearable Lightness of Being, of, and disparaged by my therapists. I giving me unsolicited advice. Even so, I
Milan Kundera (1) describes how physi- have never felt that one was like a mother learned how to express myself during one
cians are defined by a curiosity to know or father figure, though. I don’t always of the least creatively stimulating times
all there is about the human condition, leave therapy feeling well, and it an- of my life. In many ways, medical school
something that goes deeper than talent noys me when people teach that therapy deadened the artistic energy I had taken
or skill. To some extent, this is true and always brings about relief and “your pa- so many years to cultivate in high school
not true for psychiatry. It takes a certain tients should leave sessions feeling good.” and college. Thank goodness that is over.
finesse to be a psychiatrist, which cannot I’ve had as many easy sessions as hard, And I made it through partly because of
always be learned and is not completely and some of the best therapy sessions left Susan. For what it is worth, I owe her a
accounted for by “curiosity.” To varying me feeling awful. hand.
extents, all physicians have to work at My first therapist was a graduate student The therapist I see now, “Audrey,” works
it, but there is something about a good in psychology. I was a sophomore in col- within a circle of practitioners in my town.
therapist that appears to be innate. It’s lege and had just transferred from one I rarely run into her outside of our ses-
difficult to define. “You either have it or small school near my home to a larger sions, although our town is small. But her
you don’t” is what has been explained to one in the city. The dormitory I lived in influence quite often works its way into
me many times by experienced therapists. was specifically for transfer students. I the therapy sessions I have with my own
Without this idealistic view of a thera- wouldn’t be surprised if a lot of us were in patients. For example, when I’m at a loss
pist, I might not feel so challenged on therapy that year. for words, I’ll use Audrey’s. Sometimes it
a daily basis in my work. A lot of this What I remember most about my thera- works. Other times it is a non-sequitur, a
comes from my own forays into therapy. pist, “Cindy,” was that she never made deviation from my natural response that
As a neurotically introspective individual, eye contact. To this day, I still don’t know distracts both me and my patient. It takes
I view therapy less as treatment and more why. Was she testing some new method an effort to suppress Audrey’s voice from
as lifeblood. in managing countertransference? Or overshadowing my own therapy voice, es-
Over the past 10 years, I’ve been in some was she just too nervous to meet my eyes? pecially if I’m feeling tired or uncertain.
sort of talk therapy or another. Even Nonetheless, together Cindy and I made In conclusion, it is important to note that
during breaks when I wasn’t seeing a some headway into my dysphoria, sorting all of my therapists have played a role in
therapist, I had discussions with friends out some of my difficulties in assimilating who I am today: still neurotic but more
as well as journals, writings, and poems to a new school and city. My tendency is appreciative of it and always self-aware.
to be later unearthed. Once, I went for 3 to ruminate. Cindy helped me turn some In the future, I’m likely to feel as com-
years without talking to a therapist. Those of those ruminations into self-reflection. fortable sitting in front of the couch as I
years were the easiest for me emotionally By the end, I didn’t even notice that she have on it in the past.
because I wasn’t reflecting on a whole lot. never did look me straight in the eye.
It was the aftermath that was a little more My least effective therapist never played Reference
involved. It was during this period when I by the rules. I saw her very briefly in 1. Kundera M: The Unbearable Light-
discovered that an “unwatched” pot does medical school, during my second year. ness of Being (English translation by
boil. Somewhat scatterbrained, “Susan” was Heim MH). New York, Harper Peren-
I have cried in therapy and laughed in constantly putting on makeup, eating her nial, 1999
therapy and been attracted to, frightened lunch during our therapy sessions, and

Back issues of the Residents’ Journal are available at


The Residents’ Journal 3

Manifest Similarities: More Than Skin Deep

C. Joy Somberg, M.D.
Department of Psychiatry and Human Behavior, Brown University

“The trouble with people is not that they don’t know, but
that they know so much that ain’t so.” –H.W. Shaw

I’m on my third interview and it’s only escence that the similarities between us was no way anyone could know I was de-
been 2 hours. do not end with our gender and training: pressed. I just didn’t fit the mold.
It is another busy call day during my that we both suffer from major depres- What I believed to be working for me,
month of nights. For now though, time sion. The difference between us is only a and what ultimately did me harm, was
has slowed. I am sitting across from Dr. matter of degrees. the stereotyped idea of depression. All
P. She is a second-year surgery resident Most people who meet me would say psychiatric diagnoses are essentially ste-
who was brought in by a friend because that I am cheerful to a fault, outgoing, reotypes (by its strictest definition): a
of a comment she had made during an and carefree; however, I have been in formulaic conception or image of what
argument. treatment for major depressive disorder it means to have a particular disorder. Of
“So what’s been going on?” I ask. since January 2007. The course of my course our stereotypes are different than
illness likely precedes this diagnosis. I those of popular media; ours are based on
“It’s been hard for a while now.” She looks started with months of cognitive behav- evidence. People who are depressed tend
away toward the frosted window of the ioral therapy, was transitioned to schema to have poor appetites, have little en-
interview room. I imagine she is look- treatment, and have been referred for ergy, and are fatigued. They wake in the
ing for a way out. I stay quiet. Her tears medication management. Until recently, early morning hours and can’t get back to
are welling. She is finally forced to blink, the true extent to which I have been sleep. Depending upon the severity of ill-
and the tears roll down. She takes a deep impaired at any one time has only been ness, they may even appear disheveled or
breath and sits back in her chair utterly known to me and to my therapist. poorly groomed. They isolate themselves,
defeated. “I’ve been practicing what I’d do stay at home, and hide under their blan-
in my head….I’d go out into the woods At first, I believed myself to be clever.
Sure I was a few minutes late here and kets. They are despondent. Tearfully, they
and take a bunch of pills. Then I would speak softly and slowly about hopeless-
numb my wrists and I’d take a scalpel and there. But whatever it was that I had to
handle, I left it at home. I couldn’t get ness, worthlessness, guilt, and sometimes
I’d cut down to my radial artery….” Her suicide. Often, this is what we see, but the
eyes meet mine. They are expressionless, up to be at work on time everyday to
save my life, but I always made sure to same can be said for any stereotype. They
blank behind the veil of tears; her voice have to come from somewhere. However,
is barely audible: “I’d make sure I wasn’t use a cold compress on both eyes to get
rid of the swelling. I had been spending we miss a great deal when we mistake ste-
coming back.” Slowly, she looks back reotypes for reality.
down at her hands folded in her lap. She my daily commutes to work ruminating,
is still, save for her right thumb picking at but by blasting music on my car radio What I didn’t realize was that my lack of
her left cuticle. and singing loudly, I could drown out adherence to this construct was really be-
the thoughts. Once I was at the hospi- side the point; there was something about
The silence between us lengthens. “It tal, the symptoms would slowly fade, and my manner that just wasn’t right. Even
must be so painful to feel that way, by midday, I would feel normal. On the though no one could give me specifics
that….” I fumble for the word, “desper- days it was hard to focus, I used the man- (besides my lateness), attendings noted
ate.” She looks up at me; she is listening. tra “I’ll think about it later.” Gradually, I there was something wrong with me.
“To feel that it is impossible to get up out repeated it less and less, and there were Suddenly, I found myself under a micro-
of bed, to carry on with everyday, to live.” fewer and fewer days I needed it. scope. The lateness was now under strict
Something in my words strikes a chord. In the back of my mind, there was a surveillance. All I had to do was come in
There is a resonance between us, and I nagging suspicion that it was all pre- on time, but it seemed even harder. More
feel exposed. I’ve said nothing profound tend—that I would be unmasked and and more, things became increasingly
or revealing, but to me the self-disclosure seen for what I was: a charlatan. But then difficult. Basic responsibilities (going to
is apparent. She shifts slightly in her I would examine the evidence: I cared lecture, remembering supervision, fin-
chair and with some effort leans toward about my patients. My patients got better. ishing notes) were now proving to be
me. Her gaze is penetrating. I fight not I got the work done. I took comfort in the monumental challenges. As the details
to shrink from it. I am an impostor, and fact that at least I could do my job. Soon were enumerated, they grew in number.
she has seen through me to the truth. Any the days I needed compresses dwindled
action now would be an admission, acqui- and that doubt began to subside. There continued on page 5

The Residents’ Journal 4


continued from page 4 picion, the specter that haunted the back As I sit across from Dr. P, I feel her eyes
halls of my mind, was real, had been real, on my skin, my safe veneer of “doc-
The truth is I was dissolving into a role. continues to be real. It’s not the depres- tor” stripped away, flesh exposed, nerve
I was becoming the “delinquent resident.” sion; I’ve been incompetent all along. endings raw and tender. I hope that my
A well-groomed, smiling person is not That is where my struggle lies, where face remains expressionless, yet empa-
depressed. A well-groomed, smiling per- my roles as doctor and as patient con- thetic. I try not to move, breathe, speak,
son who cannot get to work on time is tinue to clash. While the depression is a fearing that anything more would only
unprofessional. A well-groomed, smiling dark cloud capable of blinding me to my further reveal my weakness. As my anxi-
person who starts to miss meetings and own condition, it is a gateway to under- ety mounts, it occurs to me that she too
lectures is irresponsible. A well-groomed, standing the individuals I treat. Knowing has experienced this doubt, this vulner-
smiling person who cannot get her notes patterns delineated by DSM-IV, being ability, perhaps even now. We look at
done in a timely manner is not fit to prac- able to put a name to the disorder from each other for what seems like an eter-
tice. The depression insinuated itself into which patients suffer, while important nity, when, finally, she breaks the silence:
all aspects of my life and gained ground. for treatment, often says little about their “What should I do?” Her eyes are now
Depression was no longer a problem I quotidian existence. pleading, hoping against hope I have the
was having. I was the problem. That sus- answer. With that, the balance is restored.
My secret is safe, and I do my job.

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Committee of Residents and Fellows

The Committee of Residents and Fellows (CORF) is a permanent Since 1971, the Committee has represented resident opinions and
standing committee of APA. The Committee is composed of seven issues within the Association and has established effective and
psychiatry residents, each representing one of the seven geographic meaningful liaisons with many components of APA, as well as
areas into which APA divides the United States and Canada. Ad- with many other organizations that are involved in training and
ditionally, representatives from APA’s three fellowship programs the profession.
participate as active members. Each member is nominated by his/
her residency training program and serves a 3-year term.

Area 1 Area 5 Mentor

Teo-Carlo Straun, M.D. Sarah Johnson, M.D. Paul O’Leary, M.D.
University of Massachusetts University of Louisville University of Alabama
c.s08873@gmail.com sbjohn01@gwise.louisville.edu pjoleary@uab.edu

Area 2 Area 6 APA Minority Fellow

Stacey Yearwood, M.D. Shirley Liu, M.D. Icelini Garcia-Sosa, M.D.
The Zucker Hillside Hospital University of Massachusetts SUNY Downstate Medical Center
smylein05@yahoo.com shirley.liu@umassmemorial.org icelini@hotmail.com

Area 3 Area 7 APA/Bristol-Myers Squibb Fellow

Jessica Kettel, M.D., Ph.D. Rachel Davis, M.D. Sharon Kohnen, M.D.
University of Pittsburgh University of Colorado University of Pittsburgh
ketteljc@upmc.edu rachel.davis@UCHSC.edu kohnens@upmc.edu

Area 4, Chair Liaison from ACOM

Molly McVoy, M.D. Joshua Sonkiss, M.D.
University Hospitals- University of Utah
Case Medical Center joshua.sonkiss@hsc.utah.edu

The Residents’ Journal 6