Teaching is at the core of my being and always has been. Sometimes I think I'm out of step with the times. We live in an era of shrinking budgets for academic centers. The emphasis is now on soliciting donations from philanthropists, obtaining research grants, and increasing clinical revenues to survive another day. No one seems to be able to pay for education these days. One of my colleagues on the West Coast asked her chairman about reimbursement for the time she spent preparing her seminar for the residents. She was told that there was no money available. Her chairperson clarified that "teaching is something we do out of the goodness of our hearts. It's part of the Hippocratic Oath." Those who commit themselves to teaching may seem a bit like Don Quixote, striving to see the world as it should be, rather than as it is. So why do I teach? In this communication I will offer a personal answer to that question. I will tell the reader why I teach, without any implication that this is why the reader should teach. Each teacher of psychiatry will develop his or her own justification, but my reflections may stimulate others to consider their own motivations.
When one embarks on a career path to become a psychiatric educator, there is much to discourage one from the journey. John Maynard Keynes (British economist; 1883–1946) is said to have defined education as "the inculcation of the incomprehensible into the indifferent by the incompetent." At least once or twice a month, I arrive in the classroom to find that only 5 out of 14 residents have shown up. We sit for a few minutes, and then I ask them whether they did the reading. Silence ensues. They break eye contact with me. I try to avoid shaming them, so I go ahead and cover the reading in my lecture. During the lecture, they whisper to each other and sometimes doze off. I return to my office, questioning my commitment to teaching and wondering whether I'd be better off in private practice. So I return to the question of what motivates me to teach. It IS, in fact, written in the Hippocratic Oath, but that's hardly a major reason. Preparing this article engaged me in an effort to articulate what it is that keeps me in the classroom. I obviously derive some pleasure out of it. My motives can't be so noble and pure that it's simply a matter of masochistically enduring the teaching experience for the benefit of others.
Shortly after I received notice that I had won the Vestermark Award, I was beginning my work on this lecture while flying home to Houston, Texas, after I did some teaching in Santiago, Chile. I was reading Irv Yalom's book, Staring at the Sun (1), and I came across a heartbreaking passage about an extraordinary woman who cared for African children with AIDS. She ran a shelter with very little help from others. Children were dying every day, and someone asked her how she eased the dying children's terror. She responded that there were two things she did: "I never let them die alone in the dark, and I say to them, ‘you will always be with me here in my heart (p 132).’" When I read that passage, I found myself suddenly overwhelmed with the sensation that I was going to start sobbing. My eyes welled up with tears, and I was struggling to keep my composure. A flood of memories then went through my head:
I flashed on an episode from my third year in medical school when I said goodbye to a 71-year-old woman patient I had taken care of in the hospital during a complicated endocrine work-up. She was to be discharged that day, and as I walked out of her room, she called to me and said, "Dr. Gabbard, I'll never forget you and your kindness to me." I got choked up, nodded to her, and stumbled out of her room. I started to walk down the hospital corridor, but I stopped myself. I returned to her room. I stood in her doorway and said to her, "I just wanted to say that I won't forget you either."
I then recalled another memory. The first time I had my own personal psychotherapy was when I was an undergraduate, struggling with an Eriksonian identity crisis, trying to figure out who I was and what I wanted to do. I was fortunate to find an unconventional psychiatrist in the student health service who helped me a great deal. My mind flashed to something he said to me in the last session of my therapy: "No matter where you go in life or what you do, you'll know that I'll be here thinking about you from time to time and feeling good about the work we did together."
My next memory was a note I received from a resident I was mentoring and supervising near the end of her time in residency: "You truly have had an amazing impact on me as a person and as a psychiatrist. At this point, I am unable to capture it in words in an adequate way. You could be out there using your name and reputation to make lots of money, and have far fewer headaches, but you choose to be here mentoring people like me and making a difference that is far more lasting because I carry you into every therapy session, and you will always be there with me."
It became clearer and clearer why I was so moved by the words of the courageous woman in Africa. It was about remembering and being remembered. As these memories flashed before me, I was still sitting on the plane, fighting off tears. I had to regain my composure because the flight attendant was serving dinner and was just about to reach my row. When she arrived, she looked at me, and asked if everything was all right. I said, "Yes, I was just thinking about the airline food, and I started crying." She laughed and went on her way. When I finished my microwaved "mystery sandwich" and the four M&Ms provided for dessert, I had some time to reflect on what had moved me.
On Remembering and Being Remembered
When my therapist had said that he'd be thinking about me from time to time, I was surprisingly touched. As I became a psychiatrist and psychoanalyst, I soon learned that one of our patients' greatest fears is that they will not be remembered. I treated a young man in analysis long ago who was consistently hateful (2). Nothing I did was right. He treated me with contempt when I tried to make an observation about what I saw, and, at one point, he explained himself: "I know you think I'm assaultive, but it's because of the way you treat me. You make me pay for these sessions; you don't answer questions I want to know about you, and you rigidly enforce the end of the hour even if I'm in the middle of a thought. I see you as assaultive, so I react with hostility." Hence, he viewed his hatred of me as completely justified. These tirades recurred throughout the treatment. In the last week of his analysis with me, having made many improvements, he made a poignant confession to me. He revealed that his worst fear was that I would not remember him. He imagined that some day he would call me when he needed to discuss something with me, and I would not know who he was. Despite his contempt, I had actually grown quite attached to him, having seen the painful insecurity beneath the attacks on me. I told him that it would be impossible to forget him.
It is not only our patients who wish to be remembered. They are simply reminding us of a universal need. We all want to be remembered. I think this is one of the reasons I teach. Life is brief and mysterious. We do not want to think of ourselves as merely a flash of light between two darknesses. I'm reminded of an apt quotation from one of my favorite playwrights, Samuel Beckett, in Waiting for Godot (3): "Astride of a grave and a difficult birth, down in the hole, lingeringly, the grave-digger puts on the forceps (p 58)."
One component of my wish to teach, then, is an immortality strategy. When you teach, you throw a pebble into the water and the ripples from that pebble create an endless ring of concentric circles in such a way that you never know when your influence ends. Of great importance in my own thinking has been the brilliant Pulitzer Prize-winning work of Ernest Becker, The Denial of Death (4). Challenging the Freudian view, Becker said, "It is the immortality motive and not the sexual one that must bear the larger burden of our explanation of human passion (p 142)." My passion for teaching is very much linked to the immortality motive. Maybe I can pass something on to those I teach that will make a difference in their lives. And maybe they too will pass it on to their students and/or children, so that still others benefit, and, ultimately, maybe generations of patients will benefit from what has been passed on.
The Dalai Lama is said to have observed: "Share your knowledge. It is a way to achieve immortality." Maybe—just maybe—it's possible to make a difference in the lives of others during our brief sojourn on this planet. That's why I became a physician in the first place.
The note I mentioned before from the resident I was supervising is the kind of gift that comes to a teacher from time to time and makes it all worthwhile. When she said she had internalized me to the extent that I was always in the room with her while seeing a psychotherapy patient, she was telling me that I had become a part of her. It reminds me of an e-mail I received from a young psychiatrist I had mentored a few years ago, when my mother passed away. She said, "The residents all knew your mother indirectly because she is alive in you, and we learned from her as you did."
Neural-network theory has greatly enhanced our knowledge of internalization (5). If a boy is loved by his father and hugged every night before he goes to bed, a set of neurons fire together that create a network involving a loving father and a loved son. A set of representations are laid down in the synapse, and "what fires together wires together." We internalize the way that people in our lives have related to us. To be more precise, we also internalize how we were with them. As Fairbairn (6) once emphasized, from a more psychoanalytic perspective, in the course of development, we don't simply internalize an object. We actually internalize an object-relationship. Indeed, as we take in the memories of our interactions with others, we wire our cortex with these memories. Those who are significant figures in our lives become part of us. What we consider the "self" is memory. In that regard, those we remember, those who are important to us, those who give of themselves to teach and mentor us in a way that we value, become part of us.
Whenever I am receiving contemptuous comments from a patient because I have said something that he or she doesn't really want to face, I hear the voice of my first supervisor saying, "Psychotherapy is not a popularity contest. We take people to places they don't really want to go." We learn through our mentors, supervisors, and teachers. They inhabit us and help us get through the day. They may be dead, but they are not gone. And now, my students and supervisees learn from me what I learned from my teachers. And so it goes on and on.
My writing is simply an extension of this same wish—to make an impact that others will treasure and remember. My textbooks allow me to broaden my influence, even to those whom I have never met. I was teaching residents in Europe not long ago when an intelligent young trainee told me that he often remembered something he had read in my psychotherapy textbook: "When in doubt, be human (7)." He said it had served him well. For my former students, my texts are transitional objects that help them bridge the transition between resident and graduate psychiatrist. Not long ago, I received an e-mail photo from a former mentee, who showed me that my textbook, Psychodynamic Psychiatry in Clinical Practice (8) was positioned right under her credit-card machine. The implication was that I had helped her make a living. It was intended to be humorous, but there is truth in jest, and it meant a lot to me.
Much of what is valuable between a professor and a resident is also valuable between a therapist and a patient. In both, we make profound connections with people under emotionally powerful situations. There are differences, of course. An old professor of mine once quipped that the main difference between teaching students and treating patients is that the students actually get better. There are few pleasures in our professional lives as gratifying as mentoring. We are witness to the birth of knowledge in the face of the mentee—the first time they grasp what you mean by "transference" or "the unconscious" or "the therapeutic alliance." I'll never forget when a supervisee stopped by my office at the end of the day when I was preparing to leave the Baylor Psychiatry Clinic, where I train residents to do psychotherapy. She said, "I finally get what transference is. My patient told me that I am the mother she always wanted. I'm 28 and she is 45. Yet she sees me as her mother."
For me, there is a wonderful form of vicarious gratification when one sees one's former students succeed and come into their own. Although aging certainly has its downside, one of its real pleasures is sharing in the triumphs of those we have mentored. Those who are narcissistically organized and riddled with envy do not age well because they cannot enjoy the success of those who will replace them someday. I have particularly enjoyed those moments when someone I have taught is teaching others what they have learned from me. One of my talented supervisees struggled in therapy with how to manage the erotic transference feelings that emerged in her male patient. After many supervisory discussions of this challenge, she emerged with a self-confidence and skill that was impressive. Some time later, she was sensitively teaching a predominantly female class of beginning residents. She told me how she was helping them navigate the difficult waters of male patients who complimented them on how they looked and wanted to walk behind them rather than in front of them as they went from the waiting room to the office. I was delighted to see how my previous supervisee had come into her own as a teacher and role-model for younger colleagues.
Another aspect of mentoring that parallels the therapist–patient relationship is watching the impact of having someone believe in you. A few months back, a quiet and gentle man in our residency program came to my clinic at the beginning of his third year. I asked him to come to my office so that we could get to know each other a bit. He told me about his work in South Dakota with wayward youths in the Native American community there. He himself is a member of the Cherokee Nation, and he told me that he was a good storyteller, since part of the Cherokee tradition was to paint a picture of one's life by telling a story to others in the tribe. I told him that if he could tell a story, he could also write a story. I encouraged him to write up his account of working with one of the troubled kids on the reservation and think about publication. He turned in a beautifully written narrative to me, and I helped him revise it a bit for publication (9). He later told me that it was his first publication, and he never would have written anything if I hadn't encouraged him to do so. I told him that I became a writer in the same way. I never imagined I could publish until a mentor convinced me to try. My first paper, written when I was a third-year resident, was on stage fright (10). My mentor, who encouraged me to write it, told me to send it to the International Journal of Psychoanalysis; I told her that was a waste of time. She said, "You don't know that unless you try. Even if they reject it, you may receive some useful comments to revise it and submit it elsewhere. You have nothing to lose." I submitted it, and it was accepted. I was floored. Like my third-year resident from the Cherokee Nation, I would never have published a word unless my mentor believed in me and pushed me to do something that I wasn't sure I could do. Young psychiatrists-in-the making are insecure. The last thing they need is someone to shame them and humiliate them on the basis of the dubious notion that embarrassing them will motivate them. What they do need is someone who can see the person they will become, and who believes that they can do things that they themselves doubt deep in their hearts.
My greatest moments as a teacher are when one of my mentees has internalized my belief in them so they can face a patient with the courage of their convictions and say what needs to be said without fear that they will make a fool of themselves. I sense at those moments that something has been passed on, something that will survive this moment and this time. Much of what I'm describing here is part of the so-called "hidden curriculum" (11). These internalizations are only partly related to formal classroom teaching and supervision. Residents identify with who we are and how we relate to others in a variety of settings: how we respond to their e-mails, how we answer the phone, how we interact with them when they interrupt us in our offices with a question, or how we listen to a patient on hospital rounds. In this regard, we can't take off the mantle of educator. There is not a moment of the day when we are not viewed as teachers.
Altruism and Self-Interest
This discussion of what I get out of teaching and mentoring underscores the fact that when we teach, it is not a self-sacrificing act of altruism that will leave us burned out and demoralized. On the contrary, the giving of ourselves to our students is the surest way to feel fulfilled. Altruism is commonly regarded as a mature defense (7). Anna Freud (12) noted that altruism may grow out of hatred and aggression in one's heart. But that version of altruism is a limited, reductive one. Altruism is also genetically programmed in all of us. Our mirror-neurons have been finely honed over years of evolution to help us empathize with our fellow creatures on the planet—human and otherwise. The mirror system allows for an immediate and direct understanding of the inner world of another person (13). Altruism is the manifestation of the most noble feature of homo sapiens. In the Harvard Study of Adult Development, where college-age men were followed prospectively throughout their lives, Vaillant (14) found that altruism increases significantly in the second half of life. Mature love is often defined as living for others instead of oneself. However, this shift does not occur simply because we become more selfless as we age. It occurs because helping others becomes more rewarding to us. Our state of well-being throughout the life-cycle depends on balancing altruism and self-interest (I avoid the word narcissism here because it carries too much jargonistic baggage).
The view of altruism as a defense has shifted dramatically in recent years. We now have neuroimaging studies demonstrating convincingly that those who are altruistic directly benefit from their altruism. Moll et al., at NIH (15), designed a study to evaluate whether reward systems were activated by altruistic activity. Nineteen participants chose to endorse or oppose societal causes by anonymous decisions to donate or refrain from donating to real charitable organizations. A robust finding in this research was that the mesolimbic reward system was engaged when one donated money in exactly 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 eating or sex; in brief, generosity just feels good. We are hard-wired to be altruistic, and helping other people has a self-interest component that is undeniable. A long time ago, my mother taught me that the key to happiness is giving to others without expecting anything in return. I always thought there was some wisdom in this axiom, but I'm afraid she might have been a little "off" on this one. What we get back in return for giving is inherent in the act of giving, itself.
Another reason I teach is to learn. Indeed, one of the greatest gratifications in being a psychiatrist is that we are always learning. We are always getting better. We don't peak at 30 (like physicists and mathematicians!). As we age, we become wiser, provided we continue to learn. The next patient I treat will probably receive better treatment from me than the last. We don't simply learn a body of knowledge and then apply it to those we treat. Rather, we treat patients to learn.
I think the same complementary relationship exists between teaching and learning. You don't simply learn a body of knowledge and then teach it to your students. You teach students to learn. I have been enriched by what I have learned from my students. Two of my African American mentees recently taught classes with me on racial issues in psychotherapy. As they described their experiences of encountering subtle and not-so-subtle forms of racism in psychotherapy and in life, I realized how much I, as a white person, didn't truly understand about the impact of the "microtraumas" of everyday life for black psychiatrists or for those who are members of other minority groups. I thought I had understood their experience, but my knowledge was cerebral. As my mentees were teaching, I was learning about the emotional impact of that experience in ways that I had only partly appreciated. I was internalizing their experiences and their teaching, just as they had internalized mine. When I teach, I am also forced to clarify what it is I think. Like writing, teaching demands that one be clear. You have to be able to articulate your point of view on issues of relevance to your students. When I sit with patients, images, memories, words, and feelings march through my mind in a kaleidoscopic procession. Preparing a lecture to students allows me to make order out of the chaos in the same way that writing a chapter in a book helps me to clarify my point of view on a controversial topic.
In recent years, another motivation for my dedication to teaching has been related to my alarm at the prospect that the teaching of psychotherapeutic skills may become a lost art. In my travels to various training programs around the country and abroad, I encounter residents who think they don't need to learn psychotherapy to be a psychiatrist. They are assigned supervisors in their residency, but never make an appointment to see them. They say they are more interested in neuroscience and psychopharmacology, and they don't need to learn therapy, no matter what the Residency Review Committee mandates. They will practice "med checks" when they get out in the real world of practice, and they won't need to know about therapy. I wish them luck. There is no area of psychiatry that can be divorced from the use of psychotherapeutic skills. We are currently in an era in which neurobiological reductionism threatens to undermine the core science of psychotherapy in psychiatric training. Visits to office-based psychiatrists that include psychotherapy declined from 44.4% in 1996–97 to 28.9% in 2004–2005 (16). There are insidious effects of these trends in the training of psychiatrists. One result is a disconcerting lack of curiosity about what is happening inside the patient and how it relates to what is happening inside the psychiatric resident. In recent years, I have noted a particular educational variation on what British psychoanalyst Wilfred Bion (17) called "attacks on linking." When Bion used the phrase, he was referring to a clinical observation in working with disturbed patients. When the patient tried to project parts of his personality into the therapist, these parts were refused entry by the therapist. No linking between patient and therapist was allowed. The variation on this phenomenon that I have been observing involves the refusal or inability of some psychiatric residents in the clinical setting to allow the patient to get "under their skin," or "colonize" them. There is a defensive need to disavow a connection with the patient. These trainees, terrified of what they might find if they look inward, prefer to think of themselves as a Healthy doctor examining a Sick patient, much like a specimen, scrutinized for its psychopathology. There is no awareness that there are two "patients" in the room, not one.
We all grow up with imperfect families, struggle with internal conflict, and suffer from the scars of development. We have a common humanity that allows us to understand even the most disturbed patient. Another observation that worries me is the lack of curiosity many residents have about themselves. By turning inward and examining what it is that we feel, we know the patient in a way that other people know the patient, and we discover truths that are not available in a brain scan. We study the life of the mind. The exploration of interiority, subjectivity, and uniqueness is the very essence of psychiatry. But I fear that we are losing it. Hence, another reason I teach is to preserve a flame—a spark of humanity that links patient and clinician. I am trying to rescue a way of thinking from extinction. In the flurry of excitement about neurotransmitters and functional imaging, we are at risk of losing the soul. We must never equate the self-with what we see on a brain scan (8). The scanning technologies provide a convenient way to externalize problems by saying that there is something wrong with my "brain" instead of something wrong with "me" (18). I teach to preserve the idea that we don't just treat disorders—we treat a person. William Osler (Canadian physician, scientist: 1849–1919) was quoted as saying, "It is more important to know the patient with the disease than to know the disease the patient has."
And so, when I teach, I think of myself as the bearer of a flame—a flame that illuminates the darkest recesses of the human psyche and kindles a spark of curiosity in the student—because each time we enter a classroom, begin a supervision, or mentor a protégé, we are witness to something transcendent. We internalize and we are internalized. We teach and we learn. We give to others while enriching our own lives. We remember and are remembered. We become a part of our students, and they become a part of us. We are wired together forever. And in the ebb and flow of conversation about ourselves, our patients, and our field, we make a small contribution to the world, and we both part the wiser for it. For everything we leave behind, we take something with us. And we never forget.