Dr. Elizabeth Bromley, like all psychiatry residents, must learn the science and art of our field. This difficult task requires residents to assimilate the empirical base of psychiatry, while developing empathy and learning the tact, timing and dose of psychotherapeutic interventions.
Dr. Bromley’s day begins with personal psychotherapy, which helps her burgeoning psychiatric identity. While personal psychotherapy is not required in psychiatric training, it is frequently recommended, especially in residencies that emphasize psychotherapy training. Dr. Bromley is surely learning firsthand about psychodynamics and psychotherapeutic technique for all patients, even those treated by medication alone, and gaining an understanding of herself that will facilitate her access to countertransference reactions.
In her clinical encounters, Dr. Bromley faces several challenges. Using pattern recognition, she listens to her first patient’s report of symptoms with the ear of a pharmacologist who considers medication changes for residual symptoms. Yet Dr. Bromley has developed the ear of a psychotherapist who listens for pattern recognition in the events, conflicts and reactions that may have precipitated changes in the patient. Integrating these two tasks is sometimes difficult, even for experienced psychiatrists. Dr. Bromley is learning to help the patient identify feelings, symbolize them with words, and share them with another human being. Through empathic understanding, she facilitates greater openness and new options for feeling, reacting and behaving. Supervision plays an important role in shaping Dr. Bromley’s understanding of her patients. The one-on-one supervision she describes is key in learning to conduct psychotherapy. Dr. Bromley also learns a great deal from her discussions with colleagues.
A hallmark of maturity is recognizing one’s strengths and limitations. Mature psychiatrists must balance hope and belief that treatment will help with the recognition of limitations in our treatments. Treatment refractory patients threaten our sense of power and our desire to help others. Dr. Bromley has worked with her patient with depression through the roller coaster of trying to understand the etiology of his oscillations, select treatments that are informed, resist the feeling further improvement is not possible yet be able to accept limitations, and know when to seek consultation.
On a similar note, Dr. Bromley struggles to understand what research really tells us. Rating scales and research studies can be comprehensive and precise, yet are more limited than is open clinical treatment. On the other hand, open clinical treatment is difficult to study because of all of the variables involved. The need for researchers to obtain funding and demonstrate results is on Dr. Bromley’s mind as she lives in an ever-increasing evidence-based world.
Every resident experiences graduation jitters. This milestone represents a loss of innocence and the excitement of becoming an adult, professionally speaking. For many it is the first entry into the work world without the familiar cloak of student status. Dr. Bromley is beginning this phase of transition, yet the preparation for it begins with the commitment to healing and learning and the personal qualities necessary to withstand medical school and residency. Dr. Bromley has reason to be apprehensive, as the responsibilities of a physician continue throughout one’s career. She is firmly committed, however, to the lifelong learning process necessary for graduation, and that will be her benchmark.
Drs. Bromley and Mellman are affiliated with New York State Psychiatric Institute, New York, NY.