Medical students have been observed to experience the psychiatry clerkship as emotionally stressful and professionally difficult (1). Although countertransference responses of many sorts exist across clerkships and throughout the professional lifespan of all physicians (2), students in the psychiatry clerkship often face the particular stress of caring for interpersonally challenging patients as they simultaneously work to establish their own professional identities (3, 4). For this reason, aspects of countertransference that relate to role-expectations, including expectations of patients and of themselves as healthcare providers, loom especially large.

We have developed an approach to help students understand and manage feelings relating to role-expectations in the therapeutic relationship. At the outset of the psychiatry clerkship, in describing differences between psychiatric and medical/surgical services, we advise students that they may find the clerkship emotionally stressful and encourage them to share their emotional responses to patients with their supervisors. We discuss the “differential diagnosis” of such reactions and their clinical utility. We employ an “empathic spectrum,” ranging between extremes of over-identification and disengaged lack of empathy/withdrawal, to conceptualize students’ typical struggles to find a balance that fosters both empathic connection and professional distance (1).

In a group-reflection session later during the clerkship, we introduce a framework for exploring role-expectations in emotionally stressful clinical situations. This session forms part of an across-clerkships course on the patient–doctor relationship and reflective practice, an increasingly prominent theme in medical education (5). We ask students to submit a written reflection, describing an experience that evoked an “intense emotional response.” Students’ responses are then discussed in a seminar centered on recognizing countertransference and using this understanding to achieve a more balanced, empathic stance.

The framework depicted in Figure 1 has served as a helpful reference during this discussion. Focusing on the contribution of role-expectations to students’ emotional responses, the framework schematizes students’ views of their patients’ and their own roles and responsibilities in the therapeutic relationship. The vertical axis represents the patient’s agency with regard to his or her psychiatric illness. At one end, illustrated at the top of the axis, students view patients as fully accountable for their symptoms. At the other end, students view patients as subject to, or eclipsed by, their illnesses, and not held responsible (6). The horizontal axis represents students’ views of their roles, ranging from, at one end, “owning” patients’ problems and bearing responsibility for fixing them, to, at the other end, allocating responsibility to the patient and supporting patients’ struggles (7). Students in the “ownership” position are vulnerable to rescue fantasies, where, in the extreme supportive position, students may feel impotent and unfulfilled. Although represented graphically as continua, the dimensions depicted on the vertical and horizontal axes may be more helpfully viewed as dialectics, or opposing principles, challenging students to embrace both poles simultaneously. Although the framework’s concepts are familiar to doctors, particularly psychiatrists, they may be more novel for medical students just beginning to assume clinical responsibility.

In reviewing students’ reflective writings and in the group discussion, it has been our experience that their emotional responses in difficult clinical encounters often relate in part to the underlying role assumptions depicted in Figure 1. Students who report frustration or anger with their patients often feel thwarted in their attempts to fix the problem by the patient’s behavioral choices. Holding patients responsible for causing their problems while holding themselves responsible for solving them places students in the upper-left quadrant of the framework. Patients signing out of the hospital prematurely, suffering a relapse of a substance-use disorder, or sabotaging the pass they had been eagerly anticipating often evoke this response in their healthcare providers. Students who feel guilty or dutiful regarding their care of the patient or are drawn toward overextending themselves to protect their patients can be conceptualized as being in conflict with the patient’s illness, as represented by the lower-left quadrant. Students who feel sad or helpless are most often viewing the patient as being in the grip of the illness, and themselves as displaced to the sidelines, able only to witness the patient’s struggle. This is depicted in the lower-right quadrant. Patients with intractable illnesses or histories of trauma and deprivation often elicit this response. Students who see their patients beginning to emerge from their illnesses, and themselves in a primarily supportive role, may initially eagerly anticipate the patient’s full recovery and have difficulty coping with the uncertainty of the outcome, as shown in the upper-right quadrant. Nonetheless, they may ultimately feel more comfortable and settled, finding meaning in supporting the patient’s own struggle.

An illustrative case (see Table 1) depicts one student’s emotional responses and role-assumptions with regard to one of her more challenging patients during the clerkship. In this case, the student progresses through the emotions and conflicts represented by all four quadrants, in a counterclockwise fashion, ending in the upper-right quadrant. In the cases students bring to the session, however, there is no fixed pathway or endpoint. Students and physicians move in different fashions through the roles and emotions depicted by the framework. At particular moments, they may even find themselves simultaneously experiencing feelings characteristic of more than one quadrant. We believe it is useful for students to use their emotional responses as clues to their underlying assumptions regarding their and their patients’ roles and, having identified their assumptions, to examine and question them.

This framework was designed to emphasize typical negative emotions or experiences that students may find troubling; however, these various perspectives may also be associated with particular positive emotions or experiences. Students in the upper-left quadrant may experience a sense of mastery and control; in the lower-left quadrant, the traditional satisfaction of the good doctor; in the lower-right quadrant, a deep solidarity with the suffering patient; and, in the upper-right quadrant, a faith in the patient’s own drive toward recovery. The student may feel professional competence and hope for the patient in any of the quadrants, enhanced by awareness of the underlying dialectics regarding patient and student roles. It is also notable that patients, as well as their doctors, have role-expectations in the therapeutic relationship, and disparities between their respective assumptions may be reflected in overt or covert conflict.

The introduction of this framework in the psychiatry clerkship is intended to enable students to use feelings to identify underlying role-assumptions and to explore their effects on the therapeutic process. Moreover, students may better understand the challenges presented by these role-definitions: coping with anger when they experience patients as willfully acting out, finding the humanity in their patients overwhelmed by illness, accepting failure when they expect themselves to be able to cure, and feeling effective in the supportive position. The latter may be particularly relevant for students in clinical clerkships, who strive to progress from a “supporting” to a “fixing” role, sometimes failing to appreciate all they contribute by supporting the patient and the team. The ultimate goal is not to find the right spot in the framework, but rather to fully embrace the dialectic (8). In order to work effectively with patients, students must first simultaneously appreciate the illness and not lose sight of the person, and, second, both assume responsibility to intervene and respect that the problem ultimately belongs to the patient. Finally, regarding professional roles, students must struggle to empathize with even the most difficult patients, while at the same time stepping back sufficiently to avoid boundary-confusion such that they feel merged with the patient. Similar to a patient’s process of self-discovery in psychotherapy, students who become aware of their previously implicit assumptions regarding their patients’ and their own roles and responsibilities in the clinical encounter are able to become more flexible in their approach and, as seen in our illustrative case, become better able to achieve a balanced empathic stance in the therapeutic relationship.

The authors thank Joslyn Nolasco, M.D., and Kerry Vaughan for their contributions to the illustrative case.

Dr. Devlin receives royalties from Guilford Press. Dr. Cutler receives royalties from Oxford University Press. Dr. Harper reports no competing interests.

This work was partially supported by grants K07 HL082628 and R25 HL108014 from the National Institutes of Health.