Training Groups: An Integral Part of the Psychiatric Residency

Robert D. Bennett, M.D.

Training groups can play an important role in the transition from medical resident to psychiatrist. Psychiatry, as a medical specialty, has in psychotherapy its central, unique tool. Psychiatrists, like other specialists, have somatic and pharmacologic treatments, which are soundly based on the medical model. This type of approach, however valuable, does not easily lend itself to the teaching or learning of psychotherapy. It is my contention that learning psychotherapy is at the heart of the process of becoming a psychiatrist and that the T-group can materially assist in making the necessary shift in mindset. Specifically, I will deal with the T-group-related increase in self-awareness, the positive focus on the topic of empathy, and the changes from a directive to a collaborative interviewing style. This presentation does not presume to be inclusive regarding the necessary experiences to become a therapist. Most residency programs assign a caseload of patients and supervision. There is also didactic course work and encouragement to proceed with personal analysis—be that in psychoanalysis, psychotherapy, or through introspection. It is difficult to separate the utility and effectiveness of any single aspect of the various training programs. I shall try to focus on what seems to be T-group-related effects and welcome any questions and discussion of my hypothesis.

Many types of groups are subsumed under the rubric “training group.” Not included in the concept of a resident’s T-group are psychoanalytic groups, sensitivity training groups (i.e., Esalen), gestalt groups, TA groups, and psychodrama. The T-group requires a voluntary membership with an emphasis on group process focus from the vantage point of participant/observer. The group leader should be from outside the residency program and be explicitly excluded from the residency evaluation procedures. The initial contract should encourage interpersonal honesty and direct feedback. Other specific uses for the group can be negotiated. The T-group from which this paper stems was composed of psychiatric residents, psychology interns, and a group leader. I will resort to an avowedly subjective account of the stages I perceived this T-group to go through in order to communicate a sense of the experience.

The initial phase of the T-group was marked by the sense of its being a sanctuary from the stresses of the PGY-2 training program. Group members eagerly attended and unabashedly attempted to attain gratification of dependency needs. The group norms and goals were established. The norms allowed for a confidential exploration of personal issues as they related to professional activities and staff relationships. The goals included examining communication styles and attending to group process. The group leader initially maintained an active role and made most of the process comments. The topics discussed were primarily “outside of the group” issues such as patient and staff conflicts.

The middle phase of the group might best be called the negotiation phase. The negotiations revolved around 2-3 basic issues. The first was for either greater or lesser interpersonal closeness; the second consisted of vying for more or less power, including attempts to get certain needs met in the group. This development was predicated on each member becoming more trusting and familiar with the setting. Group members lowered the façade of self-satisfied, competent therapist; this allowed for their preferred role in the group to surface more clearly and for the exchange of perceptions of one another’s style of relating. Group members became more involved with group issues and less with inpatient unit problems. Group members joined the leader in making process observations.

The final phase of the group entailed the working through of the sadness of losing this supportive setting and the individuals involved, as well as the anger at some failed expectations.

This type of experience is especially important early in a resident’s career because of the confusing disarray of approaches to psychotherapy. Whether one hails from the objective/descriptive, the psychoanalytic, the interpersonal, or the existential school of psychotherapy, there is agreement that psychotherapy is an interactional event and agreement on the value of increasing one’s awareness of his/her impact on the process. Towards this end, the T-group offers a setting unique to medical education. In a peer group, the individual’s character structure can be seen as another factor that must be considered in the interaction with the patient—i.e., to identify IF and HOW it interferes with treatment. The fact that we all have idiosyncratic responses is accepted without being labeled as evil or threatening us with expulsion. For example, it was frequently noted that I tended to mediate disputes, which is not an uncommon role for me to take, as I reflected on my position in my nuclear family.

A frequent predicament for the beginning therapist is his/her tendency to invite certain defense mechanisms and then to label this as stemming from the patient’s defensive structure. In line with my role as mediator, I would frequently elicit intellectualizations in my attempt to spread oil on the troubled waters and avoid expressions of anger. You may be wondering how one can ferret out whether these effects are attributable to T-group experience rather than to other training experiences. Martin Lakin has noted the powerful effect of the emotional immediacy—i.e., the vividness of the group interaction as well as the group perceptions as mutative factors in group therapy. He states, “While many heads do not necessarily come up with solutions to problems, they provide alternative perspectives on them.”

Ultimately, I find that in pondering this question my experience stands out as the most persuasive argument. Being fortunate to have had the opportunity to be in psychoanalysis while in the residency group, I found there to be a qualitative different exploration of the issues of competition, sibling rivalry, and authority figures in T-group interactions than in psychoanalysis.

In the previous section, I noted the importance of being aware of the impact the therapist has on the process of psychotherapy. Now I would like to turn our attention to the equally important idea that the therapist is impacted BY the process. The novice therapist often encounters difficulties with the strong emotions stimulated in him/her during sessions. The frequent tendency is to invalidate these seemingly foreign emotions or, because of problems with certain feeling states, to have perceptual distortions and not accurately perceive these communications. This paper does not address the methodology of teaching empathic perception, a topic deserving many papers on its own. A recent review article in the Journal of American Psychoanalytic Association by Michael Basch, M.D., on this topic is highly recommended. Dr. Basch stressed that empathy is not simply affective resonance but a complex capacity, similar to syllogistic reasoning. He takes exception to the common translation of the German word Einfuhlung, or empathy, as “feeling with.” This “emphasizes the affective resonance to the exclusion of inference, judgment, and other aspects of reasoning thought which are equally important to the concept of Einfuhlung.”

It has been observed by such people as Lewis, Schafer, and Greenson that successful use of psychotherapy requires alternating emotional arousal on the part of the therapist with increasing interpersonal distance for contemplating, hypothesizing, and evaluating. This model lends itself to defining two types of empathy: cognitive and affective (Lewis). Cognitive empathy is the capacity of the therapist to perceive the feelings of the patient accurately. Affective empathy is described as the feelings aroused in the therapist as he/she attempts to be with the patient emotionally. J.M. Lewis, M.D., asserts that, in training psychiatric residents, cognitive empathy is easily taught. However, affective empathy is not and depends upon the level of ego functioning of the trainee. In discussing cognitive empathy, Dr. Lewis described six “detachment skills.” They are:

To listen for associations
To identify major themes and affects
To recognize signs of conflict—voice, unusual words, blushing, etc.
To identify mechanisms of defense
To observe nonverbal behavior
To construct a clinical formulation

Learning these skills can be accommodated by the T-group. The best way to summarize its ability to teach cognitive empathy is to note the group process focus. This includes noting associations, major group themes, and commenting on sudden changes in topic or tone of meetings. Probably the most potent source of the group’s power lies in the fact that group members are able to validate these emotional communications and correct perceptual distortions.

A final supposition for your consideration is that the T-group facilitates change form a “directive” to a “collaborative” interviewing style. In the medical school selection process and training, with its emphasis on objectivity and authoritarian power base, directive exchanges are the norm. Since the interviewing style frames the relationship, attention to this aspect of interaction is well rewarded. In his book, Psychotherapy and Growth—A Family Systems Perspective, Robert Beavers, M.D., states that collaboration, among other basic attitudes, is inherent in healthy families and conceptualizes the healthy family as a useful model for growth-promoting psychotherapy. As with the two previously mentioned capacities, increased self-awareness and empathy, the T-group initiates the shift toward establishing a collaborative alliance.

The group leader exerts a strong influence in his/her maintenance of a collaborative style. This occurs via the sharing of power and in respecting personal boundaries. The pivotal role of group leader, initially thrust upon him/her by the group, must give way to the more peripheral role of a group member with expertise in group interaction.

The fluidity of power alignments was seen most graphically in my T-group by the increasing comments on group process by group members. The group reality was treated as subjective and negotiable. Individual, distinctive ways of feeling, describing, and responding to this reality were tolerated.

I have submitted aspects of a T-group that aid in the transition from medical resident to psychiatrist and have defined this transition as the addition of the role “psychotherapist.” The path can be torturous, since the resident must contend with interference from personal issues, the authoritarian M.D. role model, and the diversity of approaches to psychotherapy. The T-group can transcend these difficulties and deal with basic aspects of therapeutic interactions.

Thank you.

TRAINING GROUP BIBLIOGRAPHY

Basch, M. F. Empathic Understanding: A Review of the Concept and Some Theoretical Considerations. Journal of the American Psychoanalytic Association, 31:101, #1, 1983.

Beavers, R. W. Psychotherapy and Growth—A Family Systems Perspective. New York: Brunner/Mazel, 1978.

Greenson, R. Empathy and Its Vicissitudes. International Journal of Psychoanalysis, 41:418-424, 1960.

Lakin, M.

Lewis, J. M. To Be a Therapist: The Teaching and Learning. New York: Brunner/Mazel, 1978.

Schafer, R. Generative Empathy in the Treatment Situation. Psychoanalytic Quarterly, 28:342-373, 1959.