When PsychiatrieResidents Treat Medical Students
Passage Through Idealization and Overidentification
Jerald Kay, M.D.
Coordinator ofMedicu1 Student Educution, Department
Cincinnati, Ohio
Abstract: The author describes a survey of psychiatrie resi-
den ts and faculty supervisors inquiring as to problematic aspects
of the psychotherapy of medical students when treated by
residents. Medical students’ idealization of and identification
with their resident-therapist werefound toproducea significant
amount of discomfort for the trainee. Difficulties in the
psychotherapies were also attributed to the numerous pos-
sibilities of identification by the residents with their medical
student patients. The varied forms of identification are detailed
through the use of clinical vignettes submitted by respondents.
Zt is the author’s contention that psychotherapies involuing
these “special patients” provide a window for examining many
issues in the development of the resident’s professional self.
Given the increasing number of medical students electing some
form of personal psychotherapy and the declining number enter-
ing psychiaty residency training, the timeliness of this issue is
noted.
An extensive literature describes the emotional
stresses concomitant with medical student years
(1-5). Many authors underscore the usefulness of
psychotherapeutic experiences in assisting the stu-
dent through those trying times. Surprisingly little,
however, has been written on the actual conduct of
psychotherapy with these students outside such
issues as establishing a conducive environment for
psychotherapy within the medical school and con-
fidentiality among therapist, student, and medical
school administration (6).
Few would argue that a positive psychotherapy
The author wishes to thank Drs. Paul H. Ornstein and Donald G.
Langsley for their suggestions in preparing this manuscript.
Presented at the 133rd annual meeting of The American Psychiatrie
Association, San Francisco, California, May 9, 1980.
Genera/ Hospital Psychmtry 3, 89-94, 1981
0 Elsevier North Holland, Inc., 19Rl
52 Vanderbilt Avenue, NW York, NY 10017
ofPsychiatry, University of Cincinnati College ofMedicine,
experience is not instrumental in a student’s deci-
sion to enter psychiatry. Because approximately
25% of medical students engage in some form of
psychotherapy before their graduation and in light
of the disconcerting decline in the number entering
psychiatry (7), a description of some inherent diffi-
culties in the treatment of this special group of
patients is timely.
A recent study (8) of medical students’ mental
health services in this country revealed that approx-
imately two-thirds (67.3%) of al1 psychiatry de-
partments (60 responding) indicated that their
residents were involved in the delivery of such ser-
vices. The University of Cincinnati Department of
Psychiatry, for example, relies very heavily on ad-
vanced residents to provide this care. It has been
the author’s experience, however, that residents
often have a difficult time with their medical stu-
dent patients, and, moreover, there appear to be
some clearly definable problem areas in these
therapies that are easily lessened by appropriate
teaching and supervision.
Description
To study the extent and nature of the problems
most frequently encountered in the psychotherapy
of medical students by residents, the author
queried advanced residents and supervisors in the
Department of Psychiatry at the University of Cin-
cinnati. The questionnaire sent to residents in-
quired about how many students had been seen
both diagnostically and for treatment. It further
asked for a rating of the efficacy of treatment ex-
periences. Thirdly, it asked what particular prob-
89
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J. Kay
lems were encountered in treating these students.
Given the resident’s stage of training, was it felt that
there were unique problems in treating medical
students? If so, what were they? Lastly, the resi-
dents were requested to describe a brief clinical
vignette illustrating a problematic aspect of the
diagnosis or treatment of the medical student. The
supervisors were asked to complete a similar form
about the number of residents supervised who
were treating students, the effacacy of those treat-
ment experiences, particular problems encountered
in supervising these cases, and, from their supervi-
sory experiences, whether there were any unique
problems in residents treating medical students.
The supervisors were also asked to supply a clinical
vignette illustrating the supervisory problems
and/or problematic aspects of a resident’s treating
or diagnosing a medical student.
Results
Nine advanced residents and 28 supervisors re-
sponded to the questionnaire. Responses from res-
idents indicated there had been diagnostic contact
with ten students and therapy experiences with
twelve others. Five cases were considered to have
been terminated successfully and five more moder-
ately so. Two of the treatments were described as
unsuccessful. Only one of the nine residents felt
there were no unique problems in treating stu-
dents. The 28 faculty supervisors responding indi-
cated that they had supervised, over the past 5-10
years, 137 different residents in their
psychotherapy with medical sutdents (total
number of cases, 155). Supervisors rated 42 of those
cases as successful, 87 as moderately successful,
and 26 as unsuccessful.
Genera1 Problems Encoun tered in
Medical Student Psychotherapy
Residents noted several problems in their clinical
work with medical students: “excessive in-
tellectualization” on the part of the students, unre-
mitting fears of breach of confidentiality, and un-
comfortable instances of strong identification with
and idealization of the resident. Of the three areas,
the last apparently gave residents the most diffi-
culty. Supervisors, on the other hand, referred
repeatedly to their perceptions that residents very
frequently overidentified with their student pa-
tients, thereby causing a loss of therapeutic stance.
As an example, this overidentification often re-
90
sulted in a break in empathy, in which residents
became overly sympathetic with how bad things
were, for instance, on the clinical services for their
medical students. Not surprisingly, overidentifica-
tion was often accompanied by the residents’
minimizing a student’s psychopathology as wel1 as
having unrealistic expectations of the “student as
patient.” Some supervisors noted that the latter
might be attributed to the residents’ greater ease
and facility with acute and short-term problems as
opposed to long-term psychotherapy. Other su-
pervisory comments indicated that residents
tended to doubt their confidence more with this
group of patients, frequently illustrated by the resi-
dent’s need to present himself to both the super-
visor and patient as “knowing al1 the answers”
rather than adopting an open, investigative posture
of evocative listening. Only one supervisor could
recall a resident having assumed an inappropriate
relationship vis-a-vis the medical school adminis-
tration in which a breach of confidentiality trans-
pired.
Unique Problems Encountered in the
Treatment of Medical Students
Resident and supervisory responses to the question
as to whether there were unique problems in treat-
ing medical students were more detailed and il-
luminating. Over three-quarters of the supervisors,
for instance, listed more than five items. In general,
however, both groups agreed that the resident-
student dyad provided a microcosm for issues that
might be subsumed under the rubric of the resi-
dent’s “development of the professional self.” Al-
though similar problems occurred in treating other
patients, they were clearly more frequent and in-
tense with the medical student patient.
Resident Responses
As noted above, residents stated that their patients’
idealization of and overidentification with them
produced the more intense discomfort. Two-thirds
of resident respondents indicated that given their
stage of training, this was a unique problem in
treating this group of patients. Therapists confided
they would frequently “debunk” the admiration
these patients demonstrated by informing them of
reality issues pertaining to the field of psychiatry
and the stress inherent in psychiatrie training. To
illustrate, a resident reported the following
vignette:

1 was treating a third-year woman student who not
infrequently told me how much she was impressed
with my intellectual ability to understand her. Medical
school was so unrelentingly trying for her that she
often thought of me as a model and a source of
strength that permitted her sometimes to get through
the worst of the clerkship days. The patient viewed me
as a “very together” person who seemed not to let the
“system” get the best of me. Her compliments and
yearnings to be like me were so troublesome to me at
times that 1 found myself anxious and on many occa-
sions told her that 1 was not as perfect as she pictured
me. For instance, 1 related that 1, like everyone else,
had problems adjusting to medical school and that
being a resident was no picnic; in fact, things seemed
worse at times now than in medical school. Invariably,
these interventions produced a noticeable depression
in the patient and sometimes an angry reaction. It was
not until much later in the therapy before the patient
could admit to me that when 1 gave those responses,
whe experienced them as a chastisement. She felt that
1 was saying to her: “Keep a stiff upper lip and stop
being a crybaby.” My supervisor was most helpful to
me in pointing out how uncomfortable 1 had been in
permitting the idealizing transference to unfold and
that my reality-oriented comments tended to drive
underground some significant feelings in the patient.
Two residents spoke openly of their medical stu-
dent patients who made the decision to enter
psychiatry-decisions that were not examined
thoroughly in the therapy, but accepted at face
value.
Approximately one-half of the residents felt that
their identification with the student was so great at
times as to interfere with the psychotherapy.
Vignettes clearly portrayed that analogous difficul-
ties in training, as wel1 as in the developmental
tasks of young adulthood, caused frequent “blind
spots” on the part of the therapist. One resident
commented: “1 was having feelings of despair and
doubt in my own work and often the student’s
similar situation would mobilize these feelings for
me right in the therapy hour.” Conversely, yet
another resident reported that “My student was so
vehemently tearing down every resident he had
contact with on the wards that 1 became defensive;
after all, 1 too am a resident.” Another noted that
“Overexposure of the therapist to the student
through teaching activities in the junior clerkship
was quite sticky for me.”
Two of the nine residents mentioned that they
experienced difficulties in tolerating their students’
intense affect because it invariably left them with a
feeling that these special patients were becoming
Psychiatrie Residents Treat Medical Students
sicker and that they, the residents, might be needed
in capacities beyond their therapeutic skills. The
following vignette illustrates this issue:
A first-year medical student presented to her sixth
therapy hour with me in a dissociative state. Her
mood, markedly in contrast to a previous depression,
was elated. She laughed inappropriately, sat childlike
in the chair, and appeared totally unable to recall or
connect with material that we had expressed in previ-
ous sessions. She repeatedly stated, “It al1 seems to be
a game.” (1 now view this as having been a defense
against disintegration anxiety which was aroused by
my having touched upon her experience of herself as
being worthless, unwanted, and defective.) At any
rate, my anxiety was such that 1 was unable to “be with
her” in this feeling state. Instead of providing the
calmness which 1 would with any other patient, and
which she clearly needed, my anxiety pressed me into
activity. 1 asked her numerous questions in an attempt
to get her to assure me that she was really “O.K.”
Fortunately, the overall course of the 6-month therapy
was reasonably good, although 1 remained disap-
pointed in myself for several major therapeutic errors.
Certain therapeutic skills temporarily were lost due to
a lack of proper therapeutic distance on my part and
subsequent inability to tolerate this young woman’s
affect. Also, it is clear that my expectations of her went
far beyond the reality of her own ego strength. 1
wanted to view her as healthier than she actually was,
and my failure to recognize her vulnerability led to a
therapeutic approach that precipitated a temporary
fragmentation. Fortunately, it was short lived.
One-third of the residents noted that “competi-
tion between patient and therapist seems to be
more difficult to handle in therapy.” These resi-
dents cited examples of their patients’ needing to
demonstrate their recently acquired knowledge and
expertise in psychopathology, which often took on
a rather highly challenging character. Patient
doubts about their residents’ clinical expertise
tended also to be unnerving at times for the young
resident.
Unique Problems as Sem by the
Supervisor
As a group, supervisors were strongly convinced
that a unique problem for the treatment situation
under discussion was overidentification with the
patient. The comment that the resident was often
“too close to the student’s experiences” appeared
frequently. One incident was related of the resident
who was unable to be helpful to his patient, a
second-year student overwhelmed with anxiety
91
J. Kay
about examining patients in his new physical diag-
nosis course. The student was troubled by fantasies
of examining patients’ bodies as wel1 as fears of
missing some important physical findings. Another
vignette described a resident’s discomfort in treat-
ing a beginning medical student struggling with
feelings about working on a cadaver. Yet another
faculty member spoke of his resident’s failure to
explore his student-patient’s intense shame over
having to repeat the second year in medical school.
Supervisors noted that residents were more apt
to be troubled by wishes to “protect” their patients
by breaking their professional role and intervening
for the medical student vis-a-vis the dean’s office.
Six of the 28 supervisors related examples of resi-
dents who actively encouraged their student-
patients to act out hostility toward the medical
school administration.
The “specialness” of the patient was also noted
by many to be particularly troublesome to the resi-
dent. By specialness, supervisors alluded to the
residents’ feeling that these students were “valu-
able patients,” that the residents’ therapy would
have high visibility in the medical community if
things went poorly, and that psychiatrie faculty
would be looking more closely at their work with
these patients. This was most often manifested in
the supervisors’ comments that residents “seemed
to have an inability to tolerate regression on the part
of the patient for fear of poor school performance
resulting in dismissal of the patient from medical
school.” That the resident was treating perhaps his
first colleague often interfered with adopting a pro-
fessional stance. One resident, for instance, found
himself spending 2.5 hours for the first diagnostic
meeting with a senior medical student. His usual
practice was to see a new patient for 50 minutes and
schedule a second appointment.
Difficulties with definition of roles also received
some comments. A number of supervisors related
that residents failed to examine the complexities of
their patients’ decision to enter psychiatrie training.
One resident admitted to her supervisor that she
felt very confused because she wanted her patient,
whom she felt would be an excellent resident, to
come to our residency program. She was troubled
because she felt this was an improper feeling to
express in the therapy. In a different vein, a super-
visor reported the following vignette:
A 24-year-old male senior medical student had a se-
vere narcissistic personality disorder recognized by
both the supervisor and resident. The student was
92
brilliant, superficially formed smooth social relation-
ships, but confided in treatment the coldness and
contempt he felt for patients, peers, and faculty. The
resident experienced a great deal of distress as he tried
to envision the student functioning as a physician, and
unconsciously began trying to “steer” his patient into
an area of medicine where the resident-therapist felt
the student-patient would “do the least damage.”
Some might argue that the resident was doing the
appropriate thing and in the long run would be the
best for everyone concemed. As a supervisor, 1felt the
resident was abandoning his role as therapist and was
denying his patient the unique opportunity of
psychotherapy to understand his problems and to
come to his own decisions.
Four supervisors noted that a complication arose
at times when both the resident and his patient
were completing their training concomitantly.
The resident was terminating the program at the same
time the medical student was terminating his
psychotherapy and graduating from medical school,
which brought into closer alignment a common feeling
state. The result was that the resident intellectualized
the termination and sidestepped for some time intense
affective issues in his patient’s termination.
Lastly, mention should be made of competitive
situations likely to arise. The caseload of many
residents may be overrepresented by supposedly
less suitable patients for intensive psychotherapy.
A bright, young, successful, and verba1 student,
therefore, may be a jolting experience for many
residents. They often find themselves making
mistakes that they long ago discarded from their
professional conduct. A number of supervisors com-
mented that residents are more apt to enter in-
tellectual struggles with these student-patients and
frequently try to teach them psychodynamics rather
than allow the understanding to evolve within the
context of the psychotherapeutic relationship. This
was particularly likely to take place if the student
was perceived by the resident as being too scien-
tific and biological in orientation. Yet, another
type of competition was noted in the following
vignette:
A third-year male resident discouraged a fourth-year
male medical student from applying to the Institute
Consultation Clinic for a low-fee psychoanalysis be-
cause he enjoyed having him as “his patient” and,
secondly, the resident was waiting to enter analysis
himself. He seemingly did not want the student to
have something that he didn’t have as yet.

Discussion
The reader wil1 note the relative absente of the term
“countertransference,” a quite purposeful omis-
sion. Many of the comments and vignettes submit-
ted by residents and supervisors reflected more the
sense of inadequate skills and knowledge on the
part of the resident than the operation of uncon-
scious conflicts, although certainly these were
present as well. Often in the past, lack of
psychotherapeutic progress has been too narrowly
and perhaps inaccurately attributable to counter-
transference alone, leaving the resident with the
sense either that he was not very insightful or that
he needed to seek further personal psychotherapy.
This produced a sense of helplessness and needless
doubt in the young therapist. On the other hand, if
the discomfort expressed with patient idealization,
for instance, were seen in light of readily explain-
able transference phenomena, this would permit
the resident to learn more of the specific process
rather than view his anxiety about being idealized
as merely a sign of inability to tolerate close feelings
from the patient.
A number of striking trends are brought forth by
this survey. Issues of identification between patient
and therapist, and vice versa, presented as most
problematic for the resident-therapist. Because of
the strong similarity of life-cycle issues and de-
velopment of professional identity, a number of
problems were more likely to transpire in therapy
between residents and medical students than with
other patients. Therapists noted how easily their
own feelings of helplessness, both about medical
school days and current residency training, were
mobilized by patient material. This at times blocked
the therapist’s ability to recognize certain themes
and conflicts and deal with them adequately within
psychotherapy. Moreover, it not infrequently led to
the resident’s breaking his therapeutic stance and
combatting the helplessness with inappropriate ac-
tivity. This was more likely to take place when
therapists feared the student was becoming more
dysfunctional in medical school performance. The
perceived responsibility for this “valuable” patient
facilitated residents’ inappropriately spelling out
their patients’ dynamics for them in the hope of
staving off a regression which would further com-
promise the student’s functioning in school.
While some supervisors reported the tendency
of their supervisees to unconsciously promote the
students’ acting out of aggressive impulses toward
faculty and administration, it was not nearly so
Psychiatrie Residents Treat Medical Students
prevalent as had been expected. In a similar vein,
only two supervisors commented that they had
encountered instances wherein one resident had
strong negative feelings about women physicians
and another about blacks that had interfered in the
patients’ psychotherapy. An unexpected issue was
that when completion of psychotherapy and resi-
dency training coincided, it was likely to produce a
situation in which the patient’s termination was not
adequately worked through. This is helpful to note
because the contingenties of medical school and
residency training demand frequent shifts in
therapy and often impose time limitations for the
treatment. Lastly, of the 28 responding supervisors,
only one voiced the concern that “the medical
school was gambling with quality by permitting
residents to treat medical students.”
Conclusion
In conclusion, this survey has illustrated how fre-
quently the treatment of a medical student by a
resident is characterized by complexity. Indeed, it
often turns out to be a microcosm of significant
professionalization issues for the resident. Without
question, it is a valuable opportunity for the resi-
dent and can provide an important learning experi-
ence in treating medical colleagues. Supervisors,
then, have an important role to play in assisting the
young therapist to fee1 more comfortable by under-
standing more of the intricacies of this special
treatment situation.
Recent and highly significant contributions to
self-psychology (9-ll), while beyond the scope of
this paper, nevertheless provide supervisors with
an alternative teaching approach to the phenome-
non of idealization. Kohut’s elucidation of a distinct
“idealizing transference” permits idealization and
identification to be viewed not exclusively as defen-
sive operations, but indeed as pathways to health
and, therefore, favorable prognostic signs. Idealiza-
tion is no longer conceptually restricted to the for-
mative years of personality development but persists
throughout life and is most certainly activated in
every psychotherapy experience regardless of the
patient’s age. Supervisors need to instruct residents
that their patient’s idealization is not something to
be eliminated through correcting the patient’s
transference distortions.
For supervisors to approach the therapeutic
problems related to idealization and overidentifica-
tion only as countertransference issues overlooks
recent developments in the field, and it is also less
93
J. Kay

productive for the trainee. Supervisors would do stances, it wil1 result in the selection of residency
better in their preceptorships and clinical confer- training in psychiatry.
ences to remind residents how frequently strong
similarities between patient and therapist evoke
References
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cialty appears to be in flux and having some major Direct reprint requesfs to:
professional identity concerns. Second, the best Jerald Kay, M.D.
possible psychotherapy experience allows student- Department of Psychiatry
patients a definitive firsthand appreciation of psy- University of Cincinnati
chiatry’s most centra1 skill. Such psychotherapy College of Medicine
wil1 indirectly contribute to students’ autonomous 231 Bethesda Avenue
career decisions, and it is hoped that in some in- Cincinnati, OH 45267

94