In many clinical settings in psychiatry, journal writing plays an important role. From survivors of sexual abuse sharing diary entries in groups (1) to cognitive behavior therapists assigning writing exercises and using personal essays in 12-step programs, journal writing has often helped patients in group or individual psychotherapy.
Could journal writing play a role in psychiatric residency training? For many residents, this question might provoke a groan of protest. Overburdened by writing exercises of numerous kinds—from long histories, physicals, and progress notes to endlessly proliferating correspondence with insurance companies—perhaps only a few residents would brighten at the prospect of using journal writing in their clinical training. However, attempting to make sense of the emotionally intense and potentially overwhelming experiences that constitute the training process through journal writing may be enriching, if not enjoyable.
Journals and the Learning Process
For some residents, writing journal entries relieves stress. For others, writing e-mails to friends in off-hours or recording humorous riffs about call nights in a resident book stashed away from the prying eyes of attendings might serve the same function (2). Journal writing attempts to go one step further than a “locker room wall” type of semipublic exposé as a forum for thoughtful and sustained reflection.
As a form of stress relief, writing a personal journal carries less personal risk and risk of exposing others than other more formal types of autobiographical writing about the residency experience, such as Samuel Shem’s House of God and Mount Misery (3, 4) and Stephen Hoffman’s Under the Ether Dome (5). Journal entries are by definition private scribbles, excluded from the medical record and appropriately discarded when it is time to launder one’s white coat. The experiences they record need not be relived or even discussed with others. Standing separate from the process notes used in psychodynamic supervision, which formally document the events of each psychotherapy session, journal entries are a safe place to “spill” in a field where the ability to contain and modulate one’s emotions is prized.
In most psychiatric residency programs, writing process notes for psychotherapy supervision is still an important aspect of training. Journal entries may help residents mediate between being expressive and learning to function as a mental health professional. Considerations of safety are important as residents come to understand their own countertransference reactions, for example. It takes skill to appreciate what is appropriate and what is not and what can be discussed in professional supervision. Erotic or aggressive countertransference reactions, while theoretically important topics, can be uncomfortable to process fully in supervision, particularly as one is getting to know (and trust) a supervisor. Journal entries may serve as a bridge from the encounter with a patient to a resident’s personal psychotherapy. Journal entries written after therapy sessions may conversely act as a bridge back to professional supervision, making it easier to identify how given moments of a session with a patient may be influenced by the countertransference acknowledged and explored in personal therapy. Keeping brief journal entries may also be beneficial for developing skills in expressive writing, which may be of further use in writing process notes that capture both clinical events and feelings.
“Limbic music” (6) is much broader than countertransference and extends to objective clinical material. It may be most easily understood as raw data, the wordless yet powerful feelings and reactions that underlie the words by which both patients and psychiatrists attempt to shape their impressions of each other. Perhaps the concept is best summarized by Murray (7):
The limbic system is involved with motivation, attention, emotion and memory … [It] mediates gender role, territoriality, and bonding. For example … the limbic system mediates how one feels about family, rights, “keep off the grass,” and other areas that have a spatial or relational component. In bonding, the limbic system mediates strongly how one bonds to one’s spouse, family, father, country, flag, religion—in sum, loyalty (p 26).
Limbic music is a term that denotes the existential, clinical, “raw feel” emanating from the patient. It is a more true reading of the patient’s clinical state than articulate speech. Limbic music never lies (p 28).
The journal entries sampled here (Appendix 1) were written during the emergency psychiatry rotation of a resident (CB). When read with an eye for details that might give clues to the limbic music played by each patient, teaching experience, or clinical encounter from the call night, the entries are quite revealing (perhaps more so than the writer intended).
With regard to these journal entries, the expressions of countertransference, exploratory observations about possible limbic music, venting for stress relief, and identifying personal fears all remained in the private domain. However, some medical training programs have found journal entries useful in public assessment. One academic geriatrics program for medical interns (8) uses a narrative journal writing exercise as part of formal assessment. Many family practice training programs use journal writing to enhance resident reflection in a formal way, almost like process notes for nonpsychiatrists (9). Journal entries have also been used to evaluate supervisor-resident interactions in internal medicine (10).
At Massachusetts General Hospital (MGH), the tradition of autognosis rounds, supported by the Department of Medicine, encourages residents to write anonymous journal entries in a public book nicknamed the Red Book (3). The concept of autognosis was developed by the late Edward Messner (11), an MGH staff psychiatrist who used the term to describe how residents can learn to observe their own emotional reactions to a patient and then use those reactions to better understand the patient’s experiences. Messner conducted autognosis rounds for residents learning emergency psychiatry. In these rounds a resident would talk directly about how a patient evoked feelings of anger and frustration without fear of being judged or regarded negatively. Once these feelings were voiced, the resident and his or her classmates would be invited to analyze how and why the case might have caused that reaction. Encouraging residents to learn from, rather than suppress or merely contain, their emotions was Messner’s method of teaching both compassion and objectivity, because the ability to read one’s own feelings is a helpful first step to setting them aside and becoming a more astute, neutral reader of the patient’s feelings and needs.
Messner’s teachings were applied to the weekly intensive care unit rounds in the Department of Medicine, where internal medicine residents, in the absence of their attending supervisors and with the support of consultation-liaison psychiatrists, reflected about patient cases and their feelings in a similar way. These rounds often stimulated residents to write expressive, anonymous entries in a collective journal (3).
The privacy of journal writing allows it to escape both the medical record and the record of one’s progress in psychiatric training. But even when journal writing is private or anonymous and, above all, a safe place to “spill,” it can still help residents communicate their interests to training directors. Residents’ journal entries and other expressive writing (including reflective personal essays published in a residency newsletter) may lead to productive discussions between residents and teaching faculty. An example of one coauthor’s (EB) initiatives included actively encouraging residents in expressive writing that would support a career in academic psychiatry, and suggesting how these expressive exercises could be polished into academic articles.
Finally, given the potential benefits of journal writing for learning emergency psychiatry and for residency training in general, medico-legal aspects must be considered. A review of the literature did not yield any specific case laws regarding the status of resident journal entries. Numerous first-person accounts of residency training, both fictionalized (4, 5, 12) and factual (13–15), have used journal material of one kind or another without incurring legal problems. In the absence of case law, journal entries may be discoverable, but residents are not obligated to preserve them as they would a note in the chart. Personal journal entries written in a fragmentary form, particularly if they avoid or disguise identifying details of patients, may be discarded along with other notes that residents make—from to-do lists and lists of important phone numbers to nonsensical doodling accumulated in Grand Rounds or morning didactics.
The seminal work of the linguistic psychologist Pennebaker (16, 17) used expressive writing in therapy with different populations (e.g., substance-using adolescents, sexual abuse survivors, and communities joined by post 9-11 grief). Self-disclosure (18, 19) has a powerful role in healing and growth. In learning emergency psychiatry, journal writing may play a similar role.
The role of journal entries in psychiatric residency training requires further exploration; in the mean time, some residents at least will surely continue to write down their thoughts and impressions and learn from them.
The authors gratefully acknowledge Dr. Kathy Sanders, residency training director at the MGH-McLean program, for generously providing free time to Dr. Bhuvaneswar for the independent conception and writing of this article during her second and third postgraduate training years and for making comments about the completed, accepted version of the article.
Manuscripts authored by an editor of Academic Psychiatry or a member of its editorial or advisory board undergo the same editorial review process, including blinded peer review, applied to all manuscripts. Additionally, the editor is recused from any editorial decision making.
At the time of submission, the authors disclosed no competing interests.