Holly Crisp-Han

Recruiting Researchers in Psychiatry: The Influence of Residency vs. Early Motivation.

BackgroundThe declining numbers of clinician-researchers in psychiatry and other medical specialties has been a subject of growing concern. Residency training has been cited as an important factor in recruiting new researchers, but there are essentially no data to support this assertion. This study aimed to explore which factors have influenced motivation to conduct research among senior psychiatry residents.MethodsThe authors surveyed senior residents, inquiring about their level of interest in research, demographics, background, research experiences, and factors influencing motivation for research. The authors had confirmed participation from 16 of 33 residency programs with a class size of 10 or more. They received 127 responses, a 67% response rate, from participating programs.ResultsResidents with high stated interest in research differed from those with low and moderate interest in their research-intense post-residency plans. They were more likely to have graduate degrees. Those planning research careers had a consistent pattern of interest and involvement in research, starting well before residency. The majority of residents had had research exposure in college, but research involvement of those with very high versus lower interest diverged sharply thereafter. Those with high research interest were overwhelmingly male and tended to have lower debt than those with less interest.ConclusionThe great majority of residents appear to have decided whether or not to pursue a research career by the time they reached residency, and few of those with less than the highest research interest were enrolled in research tracks. Efforts to increase recruitment into research should center on identifying early developmental influences, eliminating barriers specific to women, and ensuring adequate funding to provide secure careers for talented potential researchers.

Teaching Professional Boundaries to Psychiatric Residents

ObjectiveThe authors demonstrate that the teaching of professional boundaries in psychiatry is an essential component of training to prevent harm to patients and to the profession.MethodsThe authors illustrate overarching principles that apply to didactic teaching in seminars and to psychotherapy supervision.ResultsThe teaching of boundaries must be based in sound clinical theory and technique so that transference, countertrans-ference, and frame theory are seen as interwoven with the concept of boundaries and must use case-based learning so that a “one-size-fits-all” approach is avoided.ConclusionThe emphasis in teaching should be on both the clinician’s temptations and the management of the patient’s wish to transgress therapeutic boundaries.

Impact of the Information Age on Residency Training: Communication, Access to Public Information, and Clinical Care

Access to technology in practice helps physicians manage information, communicate, and research topics; however, those in training receive almost no formal preparation for integrating web-based technologies into practice. One reason for this is that many faculty—aside from junior faculty or those in recent generations—did not grow up using Internet communication, may use it minimally, if at all, in their own practices, and may know little about its forms and varieties. This report presents a case to illustrate how these disparities may play out in the supervisory situation and makes suggestions about helping supervisors integrate technology-awareness into their teaching.

Survey of Threats and Assaults by Patients on Psychiatry Residents

ObjectivesThe authors sought to determine the prevalence of threats and assaults by patients on psychiatry residents, their consequences, and the perceived adequacy of supports and institutional responses.MethodsAuthors conducted an anonymous survey of 519 psychiatry residents in 13 psychiatry programs across the United States. The survey questionnaire inquired about residents’ experiences of threats and assaults by patients during their residency training.ResultsThe response rate for this survey was 39% (N=204). Residents were most commonly threatened (N=175; 86%), physically intimidated (N=145; 71%) or received unwanted advances (N=118; 58%). One-quarter (N=51; 25%) were physically assaulted. Most of the incidents occurred in inpatient settings (N=92; 45%).ConclusionThis study, like previous studies on this topic, calls attention to the high number of residents that are affected by violence during their training, and it underscores the need to protect the safety of psychiatry residents and to support those who have been victimized.

Teaching Psychiatry Residents to Teach: A National Survey

ObjectiveBecause there have been no previously published national surveys on teaching psychiatry residents about how to teach, the authors surveyed United States psychiatry program directors on what and how residents are taught about teaching.MethodsAll psychiatry training programs across the United States were mailed a semistructured questionnaire; 95 responded (response rate: 53%). The survey included questions on what, if anything, was provided in the way of formal instruction; the number of seminars offered each year; texts and other materials that were used for teaching; and how seminars were evaluated.ResultsThe majority (N=69, 73%) of all responding programs provided formal instruction to residents about how to teach. Topics most commonly taught included evaluation and feedback (N=57; 60%), lecturing skills (N=43; 45%), small-group skills (N=40; 42%), learning theory (N=37; 39%), and problem-based learning (N=36; 38%). Instructional methods used were predominantly group discussion (N=62; 65%), lecturing (N=59; 62%), reading of relevant literature (N=35; 37%), role-playing (N=33; 35%), and audiovisual instruction (N=32; 34%). There was a heterogeneity of texts and materials used for teaching. Few of the programs utilized formal validated and reliable tools for evaluating their teaching.ConclusionAlthough most programs provided formal teaching, there remains a need to further develop teaching programs and to create model ones.

The many faces of narcissism.

Although the term narcissism is widely used in psychiatric discourse, there is much confusion about its precise meaning. The term is most often used pejoratively to refer to someone with excessive vanity or an urgent need for validation and praise. There is a continuum of narcissism, and the point where healthy self‐esteem ends and pathological narcissism begins is highly arbitrary. A further complication is that some individuals who have elements of pathological narcissism may have sectors of their personalities that are characterized by generosity towards others. It is unfortunate that a false dialectic between narcissism and altruism is in common usage. The two entities regularly co‐exist. Vaillant1, in his longitudinal study of healthy males, found that altruism increases significantly in the second half of life – not simply because we become more selfless as we age, but rather because helping others becomes more rewarding to us. A neuroimaging study2 demonstrated that those who are altruistic directly benefit from their altruism. Participants had to choose to endorse or oppose societal causes by anonymous decisions to donate or refrain from donating to real charitable organizations. The mesolimbic reward system was engaged when one donated money in the same way as it was when one received monetary awards. In other words, altruism activates brain centers that are associated with selfish pleasures like sex or eating. A further complication is that the term narcissism is used as a clinical entity as well as a way of denoting cultural trends, as in C. Laschs book The Culture of Narcissism 3, describing a cultural phenomenon in the 1970s in which the growing role of the media promoted a lack of substance and depth in the culture. In our decade, we are in the midst of another cultural awakening as the constant interaction with technology and social media is impacting the cultural perspective of the self. Members of the millennial generation live in a constantly connected, technologically visible, self‐oriented public space. Time captured this cultural moment by referring to the “Me Me Me Generation”. S. Turkle4 described how the smartphone generation is populated by people who are losing the art of human interaction. A radical new self is emerging, one that is shaped by what we want others to see. One can receive validation, praise and self‐esteem enhancement within seconds after pressing “send” or posting a “selfie”. In a study by Stinson et al5, there were nearly three times the number of persons in their twenties meeting criteria for narcissistic personality disorder than in the age group over 65. However, we must question the idea that the current generation is developing such a vastly higher number of narcissists. The overlap between cultural shifts and individual pathology must be more complex than simply following a list of diagnostic criteria. Moreover, the constant connection to social media has also led to altruism in this new generation. Indeed, they are dedicated to service projects, are socially aware and contribute to charity at a higher rate than their elders6. Not only do we need to consider the false dialectic between narcissism and altruism in individuals; we must also consider it more broadly in the culture. In the midst of this confusion, how do we distinguish healthy self‐interest from pathological narcissism, usually referred to as narcissistic personality disorder? The time‐honored indices of “to love and to work” are problematic in this context, because some of the most successful individuals from an economic perspective are also highly narcissistic7. Their narcissistic need for acclaim and recognition may motivate them to succeed. On the other hand, the capacity for mutuality and reciprocity in love relationships may be useful in identifying narcissistic personality disorder. Others are often used up and discarded, existing only to serve the narcissistic individuals needs. While problems in human relatedness are central to narcissistic personality disorder, clinicians must be alert to the fact that narcissistic individuals may have considerable variability in their ways of relating to others. There is a spectrum of narcissistic personality disorder, not necessarily reflected in the official nomenclature. Psychoanalytic debates about narcissistic patients stemmed from differences noted by Kohut8 and Kernberg9. While Kohuts formulation was based on a self‐deficit model, causing patients to be highly sensitive to narcissistic injury, Kernberg emphasized the aggressive and destructive aspects of these patients. Further research has documented the existence of two subtypes of narcissistic personality disorder: the grandiose and oblivious variant and the hypervigilant or fragile subtype7. More recent research10 detected a further high‐functioning variant, which is outgoing, energetic and articulate, with an exaggerated sense of self‐importance. The fact that narcissistic personality disorder is not a monolithic entity creates challenges for the diagnostician and the psychotherapist. In keeping with the notion that the key to diagnosis lies in the quality of love relationships, we suggest that a careful examination of modes of relatedness is crucial7. As Kohut stressed, some patients who are narcissistically organized tend to idealize others so that they can bask in the reflected glory of an idealized object. They may insist on the most famous psychotherapist or pick a romantic partner purely on his/her looks so that others will be impressed. Denial of the romantic partners autonomy may be a central strategy for some narcissists. They are wounded if their love object acts or thinks independently. The fantasy of control serves to defend against ongoing anxiety of losing the one they love. However, it also represents a common problem with narcissistic individuals – namely, they cannot mentalize the internal experience of the other. Hence, they are unable to empathize with the partners need for agency, autonomy, and freedom from control. Another common mode of relatedness is to deny all pain or conflict in the love relationship, thus turning away from reality. Narcissistic patients are desperately attempting to manage their vulnerability. Hence denial of dependency, sometimes referred to as “pseudo‐self‐sufficiency”, is another strategy in their repertoire. If they do not need anyone, then they cannot be hurt by losing someone. Another way that narcissistic individuals will relate to love objects is to see the other as completing the self. It is as though there is a “hole” in their sense of self that requires another person to perform missing functions for them. A common form of this occurs in patients who cannot soothe themselves and need their romantic partner to comfort them, tell them they are wonderful, and provide empathy for their pain. The relationship may end when the partner is not consistently providing the admiration or praise the patient requires. Narcissism is pervasive in its normal and pathological variants. While some presentations are quickly apparent in treatment, as in the oblivious subtype, others may take longer to manifest in the clinical relationship. A person with the high functioning variant, who presents with energy, gregariousness and self‐importance, may be initially charming to the psychiatrist and hence it takes longer to detect clinically significant narcissism. Only over time does the lack of relatedness and low self‐esteem become clear. Narcissistic patients may feel understood if the clinician focuses on self‐esteem struggles and vulnerability beneath the grandiose surface. Some patients may not be able to tolerate any confrontation at first, and may need long periods of empathic validation in order to preserve a therapeutic alliance. A subset of these hypervigilant patients may never be able to tolerate confrontation or rupture, and may instead use the treatment over months and years to shore up a shaky sense of self‐esteem and build validation. Timing is everything in making an impact through interventions, and it is advisable to wait for openings in which the patient lets the therapist know that he or she is hurting and yearning for help. The psychiatrist must be attentive to countertransference issues. Kernberg9 described that the therapist can feel consigned to a “satellite existence”, which can lead to boredom and distance impacting the therapy. In addition, therapists must be alert to contempt and enactments of judgment and criticism. Finally, patients with narcissistic problems can require some of the longest treatments in a therapists caseload. Consultation is recommended in conflicted or difficult cases. Glen O. Gabbard, Holly Crisp‐Han Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA

The Early Career Psychiatrist and the Psychotherapeutic Identity.

We now practice in an era where “split treatment” is the order of the day. Psychiatrists are increasingly relegated to prescribing while psychotherapy is assigned to non-psychiatrist mental health professionals. To avoid a descent into biological reductionism, we feel it is essential for psychiatry to stay in touch with a broader identity than “prescriber.” Psychiatrists are, or should be, the integrators par excellence of the biopsychosocial model in medical practice. To retain this model, the co-authors of this contribution, a senior psychiatrist and an early career psychiatrist, feel it is essential for our younger colleagues to emerge from training with an identity that includes “psychotherapist” to meet the challenge of that integrative model. The two of us teach a year-long case conference on psychotherapy to PGY-III residents to instill this conceptual framework in the minds of trainees and to help them grasp the complexities of integrating psychotherapeutic models with biological and sociocultural models. To make a case for this approach to training, we will focus on four broad themes: the person with the illness; the contribution of the psychotherapeutic experience to the development of the psychiatrist’s own sense of professional role; the usefulness of psychotherapeutic principles in all psychiatric settings; and the myth of the med check.

THE “ME AND WE” OF PSYCHOANALYSIS: A COMMENTARY ON STEPHEN D. PURCELL'S PAPER

While reading Dr. Purcell’s professional memoir, “Becoming Related: The Education of a Psychoanalyst,” I was moved by his reflections on his first exposure to analytic ideas in a psychiatric hospital, mentored by a nurse who, though not psychoanalytically trained, was psychoanalytic in her approach. Hence in his description of Sybil, he formed an idea of how an analyst might think and work. Purcell had met a person who was sensitively attuned to the patient Tommy’s needs as well as to Purcell’s own needs. In Purcell’s efforts to come close to Tommy, he came to know him as a person, not only as a patient. As he was drawn inexorably into the patient’s feelings of love and hate, Purcell experienced the power of closeness in relationships, a formative influence that he would eventually carry over into his psychoanalytic understanding. In musing on what I might write as a discussant of this paper, I recognized that my formative experiences followed a somewhat different arc than Purcell’s and started much earlier in my development. I imagine each of us follows a different path, one that winds and twists through the course of our lives and has both conscious and unconscious determinants. Like Purcell, I can look back at moments in my life that were