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Institutional transference and the psychiatric resident
Institutional Transference and the Psychiatric Resident By STEPHEN
R. GOLDSMITH
P
SYCHIATRIC RESIDENCY TRAINING PROGRAMS frequently pay too little attention to the importance of the concept of institutional transference, and thereby seemingly lose sight of the admonition of William Osler: “To be of any value an education should prepare for life’s work.“1 Institutional transference is a meaningful concept with respect to those patients for whom it may be the variable which figures most prominently in their recovery. Transference to institutions by psychiatric residents and patients has considerable relevance to the trainees development of professional competence. Norman Reider has described a group of patients where the transference was to the clinic and not to their therapists, i.e., it is the process of “cathecting an organization rather than a person. “2 He implies that the therapist can be but an incidental agent in the treatment of some patients. As stated by Harris, “ . . . the clinic has become invested with parent-like qualities furnishing them (the patients) with emotional s~pport.“~ According to Saperstein, institutional transference “. . . consists of an emotional attachment to the institution with a concomitant detachment from particular individuals who consitute the institution.“* Thus, some patients demonstrate a definite inability to enter into an intense relationship with an individual therapist. These patients come to the clinic or institution, but not to the doctor. They may be schizoid people who are unable to tolerate the vulnerability which is associated with a close personal relationship, but may have an immense need for narcissistic supplies which can only be safely obtained from institutions. Others must utilize various distancing maneuvers to avoid the type of relationship which could expose and undermine a defensive paranoid system. While schizoid and paranoid patients because of the nature of their illnesses may have the “need” to develop transference to institutions, most patients regardless of their symptoms can obtain some benefit from the multiple resources potentially available in institutions other than the individual therapists. In those centers where therapeutic relationships are routinely terminated for administrative reasons, e.g., when residents have to transfer patients because of rotation onto a new service, both members of the therapeutic alliance may guard against the development of a strong individual transference. Not uncommonly, transference reactions may be shared with many members of the clinic or hospital staff. There are a large group of “. . . patients who in spite of having sustained a psychotic break, retain a sufficient reservoir of basically sound object relations that they can, after the acute episode is passed, seek, stimulate and utilize the human warmth in the environment whether it comes from the charwoman, fellow patients, the nurses or the psychiatrist.“” STEPHENR. GOLDSMITH, M.D.: Resident in Psychiatry, University of Cdif~dt~ Angeles Neuropsychiatric Institute, Los Angeles, Calif. 256
COMPREHENSIVEPSYCHIATRY,VOL. 11, No. 3 (MAY),
at LOS
1970
INSTITUTIONAL
TRANSFERENCE
257
“Psychiatry is a unique experience in medicine, one in which the practitioner’s personality is a prominent, and at times, the only treatment modality.“6 As stated by Halleck and Woods, “There are few comparable situations in medicine in which a physician is given so much responsibility in an area where he starts out with so little knowledge.“5 If he is dishonest with himself, he will see change and improvement (in his patients) where little exists, only to be later frustrated and disappointed. If he is scrupulously honest, he may be plagued by self-doubt and concerns regarding his abilities. The neophyte has no assurance that he will ever become accomplished enough to help patients improve.“’ Quite commonly residents suffer from lapses in self-esteem which can be offset by “success experiences” with individual psychotherapy, but cast in doubt by their subsequent impression that their role may be relatively inconsequential compared to that of the institution in the recovery of some patients. The expressed and actual needs of many patients may appear to be in conflict with those of the psychiatric residents. In one study a questionnaire was responded to by 93 patients during the week prior to their discharge from a university psychiatric hospital inpatient service (UCLA, NPI). Fortyfive per cent of the patients did not mention their physicians as having been of help to them in response to the question, “What has helped you the most during your hospital stay ?“, This type of data may contribute to the residents’ need for omnipotence as described by Sharaf and Levenson.” According to Mandell, “Psychotherapeutic process theorists engage in theory construction partially to organize and feel secure in an atmosphere of tension and anxiety.“lO Some trainees may seek to allay their anxiety by becoming “bandwagon residents,” i.e., latching onto popular philosophies and endowing them with the status of fact.6 Not uncommonly in the resident’s eagerness to identify with a particular theoretical model, the model and its application may be misconstrued. For example, there may be a tendency to identify with the caricature of the psychoanalyst, i.e., the “. . . inhumanly stone-faced, rigidly, silent mirror interested only in sex is too well known to require further comment.“” In seeking to identify with the skilled therapist who can approach patients with reassuring directness, the resident may identify with the caricature and become the “. , . bludgeoning insulter only interested in hostility.“” An inexperienced resident attempting to treat a schizophrenic who has an exaggerated need for people and a fear of them as potential “violators” may “ . . . assume that the patient needs warmth and therefore will attempt to establish closeness,” while the patient is desperately seeking to make a “safe” emotional attachment to the institutiom4 “Many courtships end in disillusion because one party feels smothered by the other’s effusive expression of love and tendemess.“4 Dynamic psychiatry and the principal agent in its therapeutic armamentarium, intensive individual psychotherapy, often has a value connotation, i.e., in many training centers it stands for everything that is alive, active and important.ll For a practitioner not to be dynamically oriented implies that he has a less desirable static view.12 Not surprisingly, there is a desire among most residents for “fresh cases” for intensive individual psychotherapy. Some displeasure may be expressed about having to provide supportive treatment for
258
STEPHEN
R. GOLDSMITH
“old, uninteresting patients.“13 However, excessive concentration in developing the techniques to practice intensive one-to-one psychotherapy with “new” patients loses sight of the fact that most patients are only “new” for a brief segment of their illness and many patients are unable to benefit from, or even tolerate an intense individual relationship. Earlier it was mentioned that the needs of the residents may appear to be in conflict with the needs of many of their patients. In actuality there should be no conflict as in a psychiatric residency program the trainees have the “need” to become proficient at whatever modalities of treatment are applicable to the mentally ill whom they seek to help. Although most trainees continue to shun full-time institutional work as a career choice and enter private practice in psychiatry following the completion of a residency program, approximately 60 per cent of private practitioners devote a portion of their time to research, teaching, or working in a clinic.14 Since the aforementioned professional activities generally are pursued in an institutional setting, it would appear that an adequate preparation for one’s life work should include learning about an often neglected factor in treatment in this setting, i.e., the institutional transference. It would appear that everybody associated with a psychiatric institution may play a role in making it possible or impossible for some patients to find a “. . . safe spot under the umbrella of a powerful, if not almighty benevolent and personal protector who cares and helps.“4 Freud appreciated the importance of the concept of institutional transference. In 1912 he wrote, “The outbreak of negative (institutional) transference is a very common occurrence in institutions; as soon as he is seized by it, the person leaves uncured or worse.“15 It is suggested that psychiatric residents having become acquainted with the concept of institutional transference could participate in a potentially gratifying experience in “community psychiatry.” They could participate in a program designed to educate the institution’s personnel about institutional transference and how its positive potential may be maximized, thereby contributing to the return to functioning of many patients. This type of program could be expected to have the important ancillary benefit of adding to the residents frequently challenged self-esteem by giving them a much needed r&son d’&tre with respect to this segment of the mentally ill population. One of the beginning psychiatrist’s primary developmental tasks is to establish a flexible therapeutic style. This should include a comfortably “expandable ego” which can incorporate the environment, i.e., hospital and personnel, into the therapeutic image. Hopefully with the development of an “expandable ego” rather than a threat, the ancillary intrapersonal environment can become part of the therapeutic challenge. Learning about a concept and then teaching about it can give trainees confidence in their ability to manipulate and control some of the various parameters affecting treatment, thereby adding to much needed feelings of mastery. Residents develop a transference to their institutions, which if positive fosters professional development and relatively atraumatic separation from the institution after completion of the program. However, not unlike children who, having had unresolved conflicts at given stages of psychosexual development, are prone to having difficulties during subsequent phases, those residents who have not developed satisfactory
INSTITUTIONAL
z.59
TRANSFERENCE
techniques to master their environment can be expected to have doubts about their ability to function professionally outside of the institution. SUMMARY
The concept of institutional transference is defined and the literature on this subject reviewed. Emphasis is placed on the importance of this type of transference with respect to the return to functioning of many psychiatric patients. Residents develop a transference to their institutions, the nature of which is influenced by their degree of success in effectively coping with the institutional environment. Those residents who are unable to develop feelings of mastery in this area may be expected to have more difficulty in separating from the institution. REFERENCES 1. Keyes, T. E.: Osler on the teaching and study of medicine. Proc. Inst. Med. Chicago 26: 125, 1966. 2. Reider, N.: A type of transference to institutions. Bull. Menninger Clin. 17:58-63, 1953. 3. Harris, H.: Drop-out of Negative Institutional Transference. Amer. J. Psychother. 20: 664-668, 1966. 4. Saperstein, S. L.: Institutional transference. Psychiat. Quart. 41:557-566, 1967. 5. Lichtenberg, J. D.: Untreating in the therapy of certain schizophrenics. Brit. J. Med. Psychol. 36:311-31’7, 1963. 6. Goldsmith, S. R.: Some aspects of development in a first year resident as seen by . . a participant observer. Presented at the Seventh International Congress on Mental Health, London, August 1968. 7. Halleck, S. L., and Woods, S. M.: Emotional problems of psychiatric residents. Psychiatry 25:339-346, 1962. 8. Zaslove, 51. O., Ungesleider, J. R., and Fuller, XI.: How psychiatric hospitalization
helps. Patient views vs. staff views. J. Nerv. Ment. Dis. 147:567-576, 1966. 9. Sharaf, M. R., and Levinson, D. J.: The quest for omnipotence in professional training. Psychiatry 27: 135-149, 1964. 10. Mandell, A. J.: Golf and psychotherapy: The function of theory construction. Arch. Gen. Psychiat. 16:430437, 1967. 11. Goldsmith, S. R., and Mandell, A. J.: Amer. J. Psychiat. 125:1738-1743, 1969. 12. Stengel, E.: The origins and status of dynamic psychiatry. Brit. J. Med. Psychol. 27: 193-200, 1954. 13. Keith, C.: Multiple transfers of psychotherapy patients. Arch. Gen. Psychiat. 14: 185-189, 1966. 14. Mental Health Manpower. Current Statistical Activities Report 9. Occupational and Personal Characteristics of Psychiatrists in the United States, 1965. Bethesda, Md., NIMH, 1966, p. 9. 15. Freud. S.: The dynamics of transference. In Collected Papers, Vol. 2. Iondon, Hogarth, 1924, p. 320.
R. GOLDSMITH
P
SYCHIATRIC RESIDENCY TRAINING PROGRAMS frequently pay too little attention to the importance of the concept of institutional transference, and thereby seemingly lose sight of the admonition of William Osler: “To be of any value an education should prepare for life’s work.“1 Institutional transference is a meaningful concept with respect to those patients for whom it may be the variable which figures most prominently in their recovery. Transference to institutions by psychiatric residents and patients has considerable relevance to the trainees development of professional competence. Norman Reider has described a group of patients where the transference was to the clinic and not to their therapists, i.e., it is the process of “cathecting an organization rather than a person. “2 He implies that the therapist can be but an incidental agent in the treatment of some patients. As stated by Harris, “ . . . the clinic has become invested with parent-like qualities furnishing them (the patients) with emotional s~pport.“~ According to Saperstein, institutional transference “. . . consists of an emotional attachment to the institution with a concomitant detachment from particular individuals who consitute the institution.“* Thus, some patients demonstrate a definite inability to enter into an intense relationship with an individual therapist. These patients come to the clinic or institution, but not to the doctor. They may be schizoid people who are unable to tolerate the vulnerability which is associated with a close personal relationship, but may have an immense need for narcissistic supplies which can only be safely obtained from institutions. Others must utilize various distancing maneuvers to avoid the type of relationship which could expose and undermine a defensive paranoid system. While schizoid and paranoid patients because of the nature of their illnesses may have the “need” to develop transference to institutions, most patients regardless of their symptoms can obtain some benefit from the multiple resources potentially available in institutions other than the individual therapists. In those centers where therapeutic relationships are routinely terminated for administrative reasons, e.g., when residents have to transfer patients because of rotation onto a new service, both members of the therapeutic alliance may guard against the development of a strong individual transference. Not uncommonly, transference reactions may be shared with many members of the clinic or hospital staff. There are a large group of “. . . patients who in spite of having sustained a psychotic break, retain a sufficient reservoir of basically sound object relations that they can, after the acute episode is passed, seek, stimulate and utilize the human warmth in the environment whether it comes from the charwoman, fellow patients, the nurses or the psychiatrist.“” STEPHENR. GOLDSMITH, M.D.: Resident in Psychiatry, University of Cdif~dt~ Angeles Neuropsychiatric Institute, Los Angeles, Calif. 256
COMPREHENSIVEPSYCHIATRY,VOL. 11, No. 3 (MAY),
at LOS
1970
INSTITUTIONAL
TRANSFERENCE
257
“Psychiatry is a unique experience in medicine, one in which the practitioner’s personality is a prominent, and at times, the only treatment modality.“6 As stated by Halleck and Woods, “There are few comparable situations in medicine in which a physician is given so much responsibility in an area where he starts out with so little knowledge.“5 If he is dishonest with himself, he will see change and improvement (in his patients) where little exists, only to be later frustrated and disappointed. If he is scrupulously honest, he may be plagued by self-doubt and concerns regarding his abilities. The neophyte has no assurance that he will ever become accomplished enough to help patients improve.“’ Quite commonly residents suffer from lapses in self-esteem which can be offset by “success experiences” with individual psychotherapy, but cast in doubt by their subsequent impression that their role may be relatively inconsequential compared to that of the institution in the recovery of some patients. The expressed and actual needs of many patients may appear to be in conflict with those of the psychiatric residents. In one study a questionnaire was responded to by 93 patients during the week prior to their discharge from a university psychiatric hospital inpatient service (UCLA, NPI). Fortyfive per cent of the patients did not mention their physicians as having been of help to them in response to the question, “What has helped you the most during your hospital stay ?“, This type of data may contribute to the residents’ need for omnipotence as described by Sharaf and Levenson.” According to Mandell, “Psychotherapeutic process theorists engage in theory construction partially to organize and feel secure in an atmosphere of tension and anxiety.“lO Some trainees may seek to allay their anxiety by becoming “bandwagon residents,” i.e., latching onto popular philosophies and endowing them with the status of fact.6 Not uncommonly in the resident’s eagerness to identify with a particular theoretical model, the model and its application may be misconstrued. For example, there may be a tendency to identify with the caricature of the psychoanalyst, i.e., the “. . . inhumanly stone-faced, rigidly, silent mirror interested only in sex is too well known to require further comment.“” In seeking to identify with the skilled therapist who can approach patients with reassuring directness, the resident may identify with the caricature and become the “. , . bludgeoning insulter only interested in hostility.“” An inexperienced resident attempting to treat a schizophrenic who has an exaggerated need for people and a fear of them as potential “violators” may “ . . . assume that the patient needs warmth and therefore will attempt to establish closeness,” while the patient is desperately seeking to make a “safe” emotional attachment to the institutiom4 “Many courtships end in disillusion because one party feels smothered by the other’s effusive expression of love and tendemess.“4 Dynamic psychiatry and the principal agent in its therapeutic armamentarium, intensive individual psychotherapy, often has a value connotation, i.e., in many training centers it stands for everything that is alive, active and important.ll For a practitioner not to be dynamically oriented implies that he has a less desirable static view.12 Not surprisingly, there is a desire among most residents for “fresh cases” for intensive individual psychotherapy. Some displeasure may be expressed about having to provide supportive treatment for
258
STEPHEN
R. GOLDSMITH
“old, uninteresting patients.“13 However, excessive concentration in developing the techniques to practice intensive one-to-one psychotherapy with “new” patients loses sight of the fact that most patients are only “new” for a brief segment of their illness and many patients are unable to benefit from, or even tolerate an intense individual relationship. Earlier it was mentioned that the needs of the residents may appear to be in conflict with the needs of many of their patients. In actuality there should be no conflict as in a psychiatric residency program the trainees have the “need” to become proficient at whatever modalities of treatment are applicable to the mentally ill whom they seek to help. Although most trainees continue to shun full-time institutional work as a career choice and enter private practice in psychiatry following the completion of a residency program, approximately 60 per cent of private practitioners devote a portion of their time to research, teaching, or working in a clinic.14 Since the aforementioned professional activities generally are pursued in an institutional setting, it would appear that an adequate preparation for one’s life work should include learning about an often neglected factor in treatment in this setting, i.e., the institutional transference. It would appear that everybody associated with a psychiatric institution may play a role in making it possible or impossible for some patients to find a “. . . safe spot under the umbrella of a powerful, if not almighty benevolent and personal protector who cares and helps.“4 Freud appreciated the importance of the concept of institutional transference. In 1912 he wrote, “The outbreak of negative (institutional) transference is a very common occurrence in institutions; as soon as he is seized by it, the person leaves uncured or worse.“15 It is suggested that psychiatric residents having become acquainted with the concept of institutional transference could participate in a potentially gratifying experience in “community psychiatry.” They could participate in a program designed to educate the institution’s personnel about institutional transference and how its positive potential may be maximized, thereby contributing to the return to functioning of many patients. This type of program could be expected to have the important ancillary benefit of adding to the residents frequently challenged self-esteem by giving them a much needed r&son d’&tre with respect to this segment of the mentally ill population. One of the beginning psychiatrist’s primary developmental tasks is to establish a flexible therapeutic style. This should include a comfortably “expandable ego” which can incorporate the environment, i.e., hospital and personnel, into the therapeutic image. Hopefully with the development of an “expandable ego” rather than a threat, the ancillary intrapersonal environment can become part of the therapeutic challenge. Learning about a concept and then teaching about it can give trainees confidence in their ability to manipulate and control some of the various parameters affecting treatment, thereby adding to much needed feelings of mastery. Residents develop a transference to their institutions, which if positive fosters professional development and relatively atraumatic separation from the institution after completion of the program. However, not unlike children who, having had unresolved conflicts at given stages of psychosexual development, are prone to having difficulties during subsequent phases, those residents who have not developed satisfactory
INSTITUTIONAL
z.59
TRANSFERENCE
techniques to master their environment can be expected to have doubts about their ability to function professionally outside of the institution. SUMMARY
The concept of institutional transference is defined and the literature on this subject reviewed. Emphasis is placed on the importance of this type of transference with respect to the return to functioning of many psychiatric patients. Residents develop a transference to their institutions, the nature of which is influenced by their degree of success in effectively coping with the institutional environment. Those residents who are unable to develop feelings of mastery in this area may be expected to have more difficulty in separating from the institution. REFERENCES 1. Keyes, T. E.: Osler on the teaching and study of medicine. Proc. Inst. Med. Chicago 26: 125, 1966. 2. Reider, N.: A type of transference to institutions. Bull. Menninger Clin. 17:58-63, 1953. 3. Harris, H.: Drop-out of Negative Institutional Transference. Amer. J. Psychother. 20: 664-668, 1966. 4. Saperstein, S. L.: Institutional transference. Psychiat. Quart. 41:557-566, 1967. 5. Lichtenberg, J. D.: Untreating in the therapy of certain schizophrenics. Brit. J. Med. Psychol. 36:311-31’7, 1963. 6. Goldsmith, S. R.: Some aspects of development in a first year resident as seen by . . a participant observer. Presented at the Seventh International Congress on Mental Health, London, August 1968. 7. Halleck, S. L., and Woods, S. M.: Emotional problems of psychiatric residents. Psychiatry 25:339-346, 1962. 8. Zaslove, 51. O., Ungesleider, J. R., and Fuller, XI.: How psychiatric hospitalization
helps. Patient views vs. staff views. J. Nerv. Ment. Dis. 147:567-576, 1966. 9. Sharaf, M. R., and Levinson, D. J.: The quest for omnipotence in professional training. Psychiatry 27: 135-149, 1964. 10. Mandell, A. J.: Golf and psychotherapy: The function of theory construction. Arch. Gen. Psychiat. 16:430437, 1967. 11. Goldsmith, S. R., and Mandell, A. J.: Amer. J. Psychiat. 125:1738-1743, 1969. 12. Stengel, E.: The origins and status of dynamic psychiatry. Brit. J. Med. Psychol. 27: 193-200, 1954. 13. Keith, C.: Multiple transfers of psychotherapy patients. Arch. Gen. Psychiat. 14: 185-189, 1966. 14. Mental Health Manpower. Current Statistical Activities Report 9. Occupational and Personal Characteristics of Psychiatrists in the United States, 1965. Bethesda, Md., NIMH, 1966, p. 9. 15. Freud. S.: The dynamics of transference. In Collected Papers, Vol. 2. Iondon, Hogarth, 1924, p. 320.