Facilitating Ego Mastery in Brief Psychotherapy with Medical Students J E F F R E Y L .BINDER, P H . D . * SUSAN WEISSKOPF, Ed.D.f Four dents

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The University of Michigan Medical School provides psychotherapeutic services to its students with a primary goal being the prevention of major academic dysfunction caused by emotional conflict. These services are free and easily accessible. Increasingly, students seek help before emotional turmoil has resulted i n a major disruption of academic functioning. The therapist often works with his eye on an externally imposed deadline—impending examinations or the general necessity of not getting too far behind in course materials—before which he hopes previous levels of performance can be regained. For about one-third of the students who seek help, adequate functioning can be restored within one to five sessions. Working within this time period is a result of goal limiting and time limiting ( 1 ) . We have done this most expeditiously by gearing brief therapeutic techniques to the ego-adaptive and defensive modes characteristic of the patient. This paper reports on several related techniques which are well suited to an adaptive and defensive style particularly characteristic of medical students. I n general, the basic principles of brief psychotherapy include early formulation of a problem and focusing on a delimited area of conflict (2, 3 ) . The aims are to foster progressive ego-adaptive and synthetic functioning (4) and problem solving (5), in order to restore the individual to his prior level of functioning, or better. The techniques used in brief therapy are numerous and vary i n complexity. They range from information giving and manipulation to interpretation ( 2 ) . I n general, the therapist takes an active, sympathetic, and friendly approach, thereby utilizing the positive transference to achieve rapid improvement (6, 7 ) . A n intricate technique may involve a particu* Neuropsychiatric Institute, University of Michigan, Medical School, 1405 E . Ann St., Ann Arbor, Mich. 48104. t University of Michigan Medical School.

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lar set toward the patient stemming from a specific theory of personality, such as focusing on empathy with and interpretation of "preconscious trends" (8). On the other hand, there are innumerable simpler and more pragmatic techniques ranging from counterconditioning, to exhortation, to inhalation of carbon dioxide-oxygen gas that are used because they seem to work under specific conditions (9). However, regardless of theoretical orientation, a therapeutic technique should be designed to meet the needs of the patient and it should be carefully defined so that its effects can be assessed (10, 11). Generally, techniques have been developed which fall into three categories. There are those designed to meet the needs of individual's encountering a specific kind of situation. Lindemann's (12) use of brief therapy to facilitate healthy mourning among those who had lost loved ones in the Cocoanut Grove disaster is a good example of this type of intervention. Techniques are also developed to deal with different sorts of psychopathologic syndromes like depression, severe somatic conditions, and depersonalization ( 6 ) . Thirdly, there are techniques designed to meet the special characteristics and problems of distinct ethnic, racial, sociocultural, and socioeconomic subgroups ( 9 ) . The appropriateness of particular techniques to particular patterns of ego functioning is an important criterion within all of the general categories. Bellak and Small (6) have forcefully explained the imperative of assessing areas of ego weakness and disruption, as well as areas of ego strength. They emphasize that a clear conception of ego strengths available to a patient can lead to the use of these strengths as allies in facilitating therapeutic goals. Unfortunately, they do not elucidate the ways in which specific therapeutic techniques can be interdigitated to specific ego functions. Adaptive and Defensive Styles of Medical

Students

I n doing brief and emergency psychotherapy with a population that shares a certain characteristic pattern of ego functioning, therapy will be more successful if the ego pattern is well understood and techniques are used that take advantage of the strengths inherent in that pattern. Medical students as a group tend to share a common set of ego-adaptive and defensive modes which are found with sufficient frequency among this population to make expedient the development of techniques that capitalize on them. They tend to have an ego-adaptive style that deals with emotional conflict or stress through intellectual mastery and action rather than living with or fleeing it, and a defensive style that favors intellectualization and isolation. When burdened with uncomfortable feelings they tend to translate these feelings into ideas and then intellectually manipulate the ideas, often ignpring the original feelings (13-15).

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This style of adaptation and defense is well suited to medicine, where much knowledge must be learned and kept available for recall in the emotionally stressful context of illness, suffering, and death. However, i t can become a liability when the student is faced with psychic experiences that do not make rational sense to him. Even relatively mild symptoms and relatively restricted forms of ego-dystonic acting out can cause great distress, because the student cannot logically understand these phenomena; they, therefore, directly challenge his favored adaptive and defensive structures. Such a situation threatens the very foundation upon which the student's sense of reality mastery rests. A n acute sense of helplessness may be precipitated which serves to exacerbate the problem. The result can be an upsurge of intense depression, anxiety to the point of panic, a painful loss of self-esteem, and self-doubts about whether the student is suited to a medical career. A dramatic collapse in academic functioning often follows. Facilitating

Ego Mastery through

Intellectualization

A psychotherapeutic technique which capitalizes on these potentially very effective adaptive and defensive modes would be one that helps the student to directly face at least the immediate source of uncomfortable feelings and intellectually understand them in a way that can lead to planful remedial action. I n this effort the student's impressive knowledge i n a variety of areas, his problem-solving skills, his appreciation of facts and details, and his abstracting and integrating capacities are enlisted. Further, this intervention tends to reactivate and reinforce the student's defensive use of intellectualization and, to some degree, isolation, and can lead to a mastery of his intense, traumatic sense of helplessness. Intellectualization as a therapeutic technique has tended to be disvalued among psychoanalytically oriented therapists as well as others. Therapists working with medical students in medium and long-range therapies generally feel that the students' tendency to utilize intellectualization inhibits true emotional insight (16-18). Yet, some psychoanalytic therapists have stated that i t is a useful technique in brief intervention (6, 19, 20). While not given much formal recognition in the literature, in fact intellectualization is used quite commonly by therapists. I t is used intuitively and spontaneously i n all sorts of brief interventions with individuals who have the style of adaptation and defense described here. A brief vignette will illustrate how this may be done: A well-known natural scientists became quite depressed while undergoing a lengthy and tedious hospital convalescence after a serious accident. Normally an active, ebullient man, Professor B. found himself irritable and cranky at best. Frequently he found himself unable to sleep, lacking appetite and generally depressed. An old friend, a classically trained analyst, visited him in the hospital.

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After talking with him for several minutes he remarked, "But of course you are depressed," and went on to add that Freud had said that psychologic states had biologic bases, and as yet our ability to pin down these biologic factors was underdeveloped. When the analyst left, the scientist realized that he felt enormously relieved. He was reassured because now he felt there was a "real" reason for his depression which, if the technology was available, one could identify the source of. He no longer needed to be concerned that his depression was caused by fuzzy, murky, and uncontrollable emotional pressures. I t is our contention that following the sound brief psychotherapeutic principle which dictates that techniques be geared to the needs and characteristics of the patient population, intellectualization can be a most valuable asset in the brief therapy of medical students, given, of course, that the selection of the patients is appropriate. I n brief psychotherapy the initial interview often combines the beginning of a diagnostic work-up with the first session of treatment. With this format, the process of clinical inference through which a decision is made about what form of brief intervention to provide and what conflict area to focus on is not well understood. There are general guidelines for deciding on brief therapy, which include acute onset of symptoms, adequacy of previous adjustment, circumscribed complaints, and environmental stability (3, 11, 21). While such guidelines are valuable in practice, they offer little insight into the subtle and intuitive process by which a skillful clinician comes to empathize with a patient's emotional state and proceeds to decide upon an area of focus which is most likely to foster progressive ego readaptation. The clinical research neglect of this inferential process in brief therapy certainly needs to be redressed. I n the meantime, we have had to rely on the same sorts of relatively molar and practical guidelines as mentioned above. We have chosen students for our intellectualization techniques who appear with relatively circumscribed and acute symptoms or problems. They also must feel satisfied with their prior functioning, and this satisfaction must reasonably correspond to their actual prior behavior in work and play. Most importantly, their presentation in the first session must make it possible for the therapist to focus on a circumscribed area and to formulate at least in his own mind a dynamic hypothesis that logically explains the symptom picture. I t does not matter how delimited the conflictual area, nor that the conflict may be only a distant derivative of an original childhood conflict. The crucial point is that the student-patient's ego management of his present emotional state allows him to communicate to a therapist enough information to make logical sense of the immediately operative conflict. Further, the therapist must feel that the student is genuinely seeking to understand what is troubling h i m ; the initial interview is not weighted

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down with manifestations of pervasive and entrenched infantile transferences. I f these conditions are met, it is possible in the first few sessions to offer the student a reasonably accurate dynamic formulation about his present emotional state. This gives the student's intellectualizing adaptive and defensive functions a productive area to reorganize around and, thus, facilitates ego mastery. The ensuing reduction in anxiety serves to further the process of restoring adaptive equilibrium. I t should be emphasized that the dynamic formulation must be reasonably accurate with regard to the student's emotional state, as well as to his conscious and unconscious conflicts. Otherwise, intellectualizing coping behavior and defenses are directed toward maladaptive solutions that will soon result in a renewal of difficulties. Consequently, the therapist using brief psychotherapy must be skilled and experienced in intensive dynamically oriented treatment, for that is the knowledge he uses as a framework when doing this form of therapy. I t has been said that use of intellectualizing interventions does not result in useful "dynamic insight" ( 8 ) . Dynamic insight in brief therapy, however, has not really been defined. I t is not the integration of cognitive knowledge and affective experience that comes from thoroughly working through conflicts, because that can only be done i n long-term intensive treatment. We propose that dynamic insight in brief psychotherapy results from an intervention that shifts the balance of unconscious forces in a way that frees progressive ego-coping behavior and defenses, leading to a restoration of adaptive equilibrium. We propose, further, that an intellectualizing interpretation provides dynamic insight by fostering more direct expression of relevant impulses and feelings; it, as well, fosters a more constructive reorganization of ego-adaptive and defensive functions. By this we mean that stress is reduced through intellectual mastery, or unconscious conflicts are partly resolved and partly bound anew with repression, and reinforced with intellectualization, in a manner that allows for more symptom-free functioning. Types of Intellectualization I n this section four types of intervention will be described, each of which attempts to foster ego mastery through intellectual understanding and defensive intellectualization organized around a reasonably accurate formulation of a circumscribed area of conflict or stress. These four approaches are as follows: I . Labeling feelings and placing them within a causal sequence of events that can be understood logically. I I . Labeling feelings and offering a mini-lecture on the nature of a par-

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ticular psychologic syndrome and/or normative developmental process. This enables the student to understand a set of feelings which were intense but foreign to him and which therefore contributed to a sense of impending emotional collapse. I I I . Fostering the student's utilization of available knowledge to modify an anxiety-provoking fantasy. I V . Using a vertical, reconstructive interpretation to diminish specific forms of repetitive behavior associated with traumatic childhood experiences. /. Labeling Case 1

Feelings

Mr. D. was a second-year medical student who was referred to one of the authors by the University Health Service. He had been suffering from fatigue, restless sleep, and tension headaches for about three months. In addition, he was having trouble concentrating, which was beginning to affect his ability to study. The findings of an extensive medical work-up had been negative. Mr. D . was a cherub-faced man who looked depressed and yet had an imperious air about him; he impressed the therapist as someone who felt very sure of himself and needed to have others share that feeling. A brief explanation of his present situation revealed that a girl whom he had been dating and sleeping with left to attend graduate school in another part of the country. Her departure coincided with the onset of his physical symptoms but the student had never connected the two events. I t turned out that while the relationship had been relatively short lived, it had been Mr. D.'s only intimate relationship. Previously, he had had only one other very brief sexual encounter. After the breakup of his latest relationship, he had done only minimal dating. His rationale for this restricted social life was that medical students have to make "sacrifices" for their education. It was evident to the therapist that this student was feeling depressed over the loss of his girl friend who had served as a source of intimacy and sexual gratification. I t was not felt that this connection could simply be asserted because Mr. D. had already made it clear that he would find it hard to tolerate the idea that anyone knew more than he, particularly about himself. Furthermore, his psychosomatic symptoms indicated how prone he was to keep feelings out of awareness. It appeared that he conceived of his therapeutic contact as an extension of his medical work-up—facts would be gathered in order to generate a diagnostic hypothesis. I n the first interview his therapist therefore decided simply to label the depression and its connections to the girl friend. Further, it was offered in the form of a hypothesis for Mr. D. to consider, with emphasis on how he would make sense of it. Additionally, it was pointed out that while it is true that medical students must make sacrifices, once a medical student has experienced and lost a source of interpersonal gratification it often becomes harder to accept this sacrifice. I t was suggested that this might explain Mr. D.'s loss of interest in studying and his concentration problem. Another appointment was made to talk

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further about these ideas, but in the interim the therapist received a handwritten note from Mr. D . The note stated that Mr. D. felt much better and thought the therapist had been on the right track. However, Mr. D . went on to say that he did not think the therapist had been completely accurate, but had catalyzed his own thinking on the subject and he was hard at work analyzing the situation. Mr. D . subsequently had no further academic difficulties.

Psychologic symptoms seem incomprehensible to the student when feelings are kept out of awareness through repression or denial, or are separated from their precipitating source through extensive isolation, displacement, or conversion reactions. His sense of intellectual mastery is shattered, exacerbating the stress already present. When a therapist translates the student's vague feelings and sensations into ideas that can be fitted into a comprehensible, meaningful sequence of events which presents a veridical even if relatively delimited picture of the situation, the student is able to get hold of the problem with the cognitive tools with which he is familiar and skillful. Additionally, intellectualization replaces other defenses, resulting in a higher order defensive stance. This interweaving of adaptive and defensive modes was illustrated by M r . D . going off to improve upon the therapist's initial hypothesis about his depression. I t is conceivable that M r . D may have fled from treatment, but it also could be argued that he obtained what he wanted from the interview and now with an increased sense of mastery was continuing the therapeutic work in his own way. I n brief psychotherapy it certainly is legitimate to let the patient set his own goals (20). 77. Mini-Lectures Case 2

on Affective

Syndromes

Miss P. was a pretty, first-year medical student with a soft, childlike appearance. She presented herself in an acute panic over an impending visit from her parents. She was the youngest of three sibs and the only girl. She and her mother had been dominated by her father, a caring but aggressive and hard-driving man who had been a very successful scholar. However, several months before, the father had suffered a stroke which had severely impaired his mental functioning. Miss P. found herself needing to assist her mother in caring for and setting limits for her father whom previously she had related to in a submissive, dependent way. To add to her stress, Miss P.'s father became overtly seductive sexually with her—behavior which was completely out of character and which clearly resulted from the brain damage he had suffered. The first interview revealed two related sources of Miss P.'s panic over her parents' visit. First was an anticipatory mourning reaction associated with the father's deteriorated condition; second were incestuous urges and fantasies revived from repression by the father's frightening seductive behavior. In the first interview, Miss P.'s manner of relating to her therapist led into

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her anticipatory mourning; she experienced great disappointment that the therapist was not wiser and more distinguished looking, and demanded to see an "older M.D." Her therapist responded by interpreting Miss P.'s attempts to deny the loss of the supportive father of her childhood by seeking to enter into a dependent relationship with an older father figure. This proved to be a meaningful observation for Miss P., who became more active in attempting to understand what she was experiencing. The therapist explained how Miss P. might be undergoing anticipatory mourning because of her father's deteriorated condition. The therapist suggested that Miss P. was frightened that the anger aroused in arguments with her father over limiting his activities, and the anger she felt as part of the anticipatory mourning process, would kill her father. Miss P. spontaneously brought up intense discomfort with her father's new seductive behavior. Her therapist explained how the father's stroke had undoubtedly resulted in emotional as well as intellectual decompensation and assured her that if the father was aware of his behavior be would be mortified. Miss P. was sufficiently relieved to recall a statement the father had made which had frightened her greatly. Once when she had rebuffed his attempt to kiss her in a most unfatherly way, he exclaimed, "You always have disappointed me like that I " The therapist responded by noting that an important and universal source of paternal care and affection is sublimated incestuous impulses, and how the father's decompensation had unearthed this elemental source of genuine affection. Miss P. was greatly relieved by these explanations. A visit the following day revealed that her anxiety had lifted. After her parents' visit, Miss P. called to let her therapist know that all had gone well. We have found that anticipatory mourning can be especially painful and disruptive for medical students. Since they must face illness and death every day, there is no escaping the feelings surrounding this reality. Further, to watch helplessly the deterioration and dying of a loved one strikes at the student's fantasies of omnipotent control over death. O f course such fantasies have to be moderated eventually, but as with any narcissistic fantasy an abrupt confrontation with reality can be traumatic. The result can be intensive anxiety, loss of self-esteem and frequently severe doubts about one's suitability for medicine. Because true mourning does not yet have to be faced, the laborious process of object detachment does not necessarily have to be encouraged in students facing these situations. A very brief intervention can often help reduce anxiety and restore self-esteem. We have used a mini-lecture that describes the nature and cause of the complex of feelings composing the anticipatory mourning syndrome. Since our patients are both young adults and medical students, when the person dying is a parent or parental figure, an explanation of the syndrome is explicitly tied to the adolescent separation-individuation process (22) as well as to the particular concerns these developmental tasks stir up in medical students. This sort of mini-lecture

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provides an intellectually comprehensible framework for vague feelings and worrisome thoughts; i t describes a syndrome that can be understood in the same way—utilizing the same cognitive skills and ego defenses—that other medical syndromes are being understood in the student's coursework every day, except that we emphasize the normal rather than the pathologic aspects of the syndrome. With this approach a minimal amount of interpretive working through is necessary, so i n a very brief time the student can be helped to reintegrate his normal functioning. I n addition, the student can learn much about his own reactions to illness and death and can internalize ways of dealing humanely with these reactions in patients. Utilizing the Student's Knowledge to Modify Fantasies Case 3 A first-year medical student, Mr. N., came to one of the authors complaining of difficulties studying because of a fear that he would die of a heart attack. He had been troubled by these thoughts prior to coming to school since the death a year before from a "heart attack" of a favorite uncle. However, shortly after his admission, he witnessed a neighbor's death from a myocardial infarction and this fear became intrusive and recurrent. I n exploring the circumstances around the uncle's death, it emerged that Mr. N . physically resembled him and after his death his aunt had tried to give him many of his uncle's clothes. Mr. N . began to wonder if he also would inherit the uncle's heart problems. Mr. N . mentioned that when he was ten years old, a heart murmur had been discovered. He "forgot" this until the physician who gave him his medical school entrance physical examination commented on it. The therapist focused on how the uncle's death had stirred up not only Mr. N.'s long repressed knowledge of his heart murmur, but also anxieties about this condition. The therapist noted that Mr. N . must be angry at the uncle who made him remember and also rather guilty over this "irrational" and uncharitable anger. Mr. N . spontaneously recalled that in fact his uncle had died from heart failure resulting from complications associated with chronic emphysema. The therapist and Mr. N . then discussed the latter's confrontation with his own mortality at the age of ten, how helpless he must have felt, and how he was now not allowing himself to apply his medical education in understanding the nature of his heart defect. Within two sessions this student's anxiety had lifted and he once more was able to work effectively. This was made possible by focusing on the derivative conflicts involving the deceased uncle, rather than probing into Mr. N.'s phallicoedipal strivings and accompanying castration anxieties which could have set going a process that would have necessitated a lengthy psychotherapy. When providing brief psychotherapy to the general population, anxiety associated with physical illness or defects usually can be diminished by providing factual information about the physical problem. Medical students tend to be vulnerable to hypochondriacal symptoms—"the medical students'

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disease" (23)—when learning about disease processes. When they actually have a disease or defect, they usually have a great deal of information about i t at their disposal. Frequently, however, anxiety-producing fantasies about the physical problems exist alongside factual information without being influenced by the latter. This is the result of a vertical split in the ego (24), whereby two contradictory bits of psychic reality can exist simultaneously without influencing each other. We hypothesize that this split becomes necessary because the amount of medical information possessed by the students, as well as their predilection for intellectualization, makes i t impossible for repression or denial adequately to defuse the fantasies. I t is possible to encourage increased ego-synthetic functioning without extensive exploration of the unconscious conflicts underlying such fantasies by focusing on the derivative conflicts that have precipitated the present stress; the student can be shown how his anxieties stem from fantasies about his physical problems, fantasies which he surely is not checking against his medical knowledge. As the student faces these fantasies and acknowledges their unreality, the mobilization of ego synthesis and defensive intellectualization will often be sufficient to diminish his anxiety. IV.

Reconstructive Interpretation Case 4 Mr. R. was a second-year medical student who complained of depression and anxiety verging on panic, which made it virtually impossible for him to study. Mr. R.'s girl friend of several years had just left him because she felt that their relationship was not going anywhere. I n addition to feelings of loss and futility, Mr. R. was plagued by sleep difficulties, specifically early awaking. I t was the therapist's impression that the feelings, thoughts, and behavior making up Mr. R.'s response to the loss had a coherence indicative of a traumatic early memory or relationship. In reviewing Mr. R.'s history, several significant experiences emerged. Mr. R., the eldest of five sibs, had suffered from enuresis at the age of three in response to the birth of a sib. Mr. R.'s mother would get up in the middle of the night to take him to the bathroom during this period. After the birth of the next younger sib, Mr. R.'s mother was hospitalized for several weeks for a "nervous breakdown," probably a postpartum depression. From Mr. R.'s description of past romantic relationships, his therapist felt that behind his smug and somewhat aloof attitude toward women lay passive-dependent longings and a profound sense of helplessness about influencing what women were doing to him. Furthermore, the therapist felt that Mr. R.'s present reaction to the loss of his girl friend recapitulated traumatic reactions to the birth of his younger sibs and his mother's hospitalization. His therapist decided that the quickest restoration of Mr. R.'s functioning could be obtained by capitalizing on the latters' conscious self-image as scholarly and capable of mastering most any intellectual problem once all the data were provided. This approach also attempted to confront directly the profound sense of helplessness which was so

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devastating to a man who relied on intellectualization as much as Mr. R. did. The therapist offered a reconstructive interpretation, stating that Mr. R.'s present anxiety and depression were a repetition of the helplessness, terror, rage, and grief which he must have felt in reaction to the emotional loss of his mother each time one of his younger sibs was born and to her physical loss when she was hospitalized for her nervous condition. The therapist pointed out that his conscious desire to show his ex-girl friend how much he really loved her could be seen as a repetition of his childish fantasies about his mother's hospitalization, that is, that his jealousy and anger had injured his mother or driven her away. Further, his insomnia in the early morning hours, relieved only with the sedative left by his ex-girl friend, could be seen as a wish to have his mother's sole attention, as he had during the nocturnal visits to the bathroom with her. Mr. R. was impressed with the cogency of these connections and in the following interview stated that he felt immensely relieved and that his insomnia had disappeared. In the third session, Mr. R.'s improvement had been maintained. Additionally, he had resolved to begin dating again although he felt a certain "adolescent apprehension" about it (indicative, perhaps, of further detachment from incestuous object ties). Mr. R. has had no further academic problems. Case

5

Mr. A. was a second-year medical student referred to one of the authors because of anxiety, depression, and an inability to study. He appeared extremely tense and anxious, almost to the point of agitation. Mr. A. knew that he was reacting to the fact that he was not seeing as much of his girl friend as previously. He had been attracted to her initial playful seductiveness, but as time passed he suffered from her increasingly frequent cold, critical, and rejecting manner. Eventually, Mr. A. decided that he was too dependent on her and moved into his own living quarters after having lived with her for several years. She saw other men, although they saw each other regularly. Mr. A. was furious and jealous that she was giving attention, which used to be solely his, to other men. This student's specific reaction to the semi-breakup with his girl friend suggested to the therapist a compulsive attempt to master some early trauma or traumatic relationship. Consequently, an exploration of his early history was undertaken which revealed that he was the oldest of three sibs, the other two being girls two and six years younger than Mr. A. Both parents were physicians. However, the mother had become pregnant with Mr. A. during her residency and had dropped out, returning only quite recently. Mr. A.'s therapist suggested to him that his mother might have been very ambivalent about having to withdraw from her residency to become a mother, and might have been depressed as well. Such an emotional state in his mother coulc^ have left him with a strong yet vague sense of deprivation and a real doubt as to whether he was loved by her. Furthermore, such a situation also could have left him acutely sensitive to any further loss of his mother's attention and care. Consequently, the arrival of sibs when he was two, and again when he was six, could have been traumatic, evoking intense anger, jealousy, and panic. His current extensive distress could conceivably be a repetition of his childhood reac-

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tion to the loss of his mother's attention and care when his sibs were born. Mr. A. was struck by this formulation, and while it had not occurred to him before that his mother might have been ambivalent and depressed over her role conflict, knowing his mother he felt it certainly was conceivable. Mr. A. felt relieved in this interview and the next. However, his anxiety quickly mounted again and he eventually was referred for intensive psychotherapy where he engaged in a great deal of acting out. Much of this acting out involved seeking to be rescued from any bit of frustration or anxiety by numerous therapists whom he consulted. The neurotic compulsion to repeat a childhood trauma or traumatic early relationships is characterized by a repetitious, complexly patterned set of feelings and behaviors, organized around a fantasy or set of fantasies that arise in association with the traumatic incident or relationship. Further, the nature of the compulsively repetitive behavior ranges from extensive and disorganized to highly organized reactions evoked by specific types of stimuli (25). This continuum can also be related to the degree of ego organization involved, with the more organized and specific sort of behavior characterized by a higher order of ego management. We have found that this latter type of reaction often can be successfully contained in brief psychotherapy with a reconstructive interpretation. Since from an ego perspective the compulsion to repeat is an attempt to master trauma, brief psychotherapeutic intervention should foster more adaptive forms of ego mastery. A vertical, reconstructive interpretation (6, 26) in such circumstances promotes intellectual comprehension of the causal sequence leading from the present, seemingly illogical, behavior to a specific traumatic situation in the past, thus promoting ego synthesis. Further, cognitive mastery of the causal network of events, fantasies, and feelings influencing the student promotes the substitution of defensive intellectualization for more maladaptive acting out. When the student intellectually grasps, even superficially, the dynamics involved in his painful situation, it alleviates his profound sense of helplessness, which in turn diminishes anxiety and depression and restores self-esteem. This is true even when there is a direct interpretation of passive-dependent wishes, as occurred in Case 4. Such an intervention can be "progressive" (27), in the sense of promoting ego mastery rather than regression, because the main thrust of the interpretation is in the direction of encouraging immediate intellectual mastery of the disturbing feelings and behaviors. Consequently, even the awareness of passive-dependent longings is supported by intellectualization; the student experiences it as part of the data with which he can master his problems. I t is worth mentioning again that a brief intervention of this sort is most effective when there is a limited range of stimuli that evoke the compulsion to repeat an early trauma. When acting out is more pervasive be-

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cause; its sources are multiply determined and consequently the ego has less contijol, then more extensive psychotherapy is required. Case 5 illustrates this point. This case and Case 2 also highlight the importance of the medical student's initial transference reaction, which is discussed in detail below. Ego-Ideal

Transference

The impact of the intervention techniques just described involves offering the student-patient an alternative view of his feelings and behavior, a view that makes sense rationally and logically. A stressful situation is seen in a more structured and orderly framework, allowing a synthesis of past (remote and/or recent) and present events, thereby providing a reasonably accurate cause-and-effect sequence. Unclear emotions and sensations are transformed into articulated ideas which the ego can order and manipulate for planned remedial action (28). This process allows the medical student to experience feelings that are modulated, organized, and directed by the intellectualizing ego-adaptive and defensive mechanisms with which he operates best. However, for these techniques to have a significant impact, they must take place in the context of a therapeutic relationship that encourages the student's acceptance of the intervention. Nurturance of positive transference in brief psychotherapy is advocated by many therapists (6, 7, 19). I t strengthens the influence of any intervention, whether i t be interpretation, suggestion, manipulation, education, and so forth, and, consequently, shortens the period of time necessary for significant changes. I n addition, positive transference facilitates the patient's internalization of the therapist as a benign and supportive object, thereby reinforcing adaptive ego skills, diminishing the influence of punitive superego introjects, providing an internal model for social interactions, and so on. When psychotherapeutic services are provided to medical students by faculty members under the auspices of the medical school, students are more likely to feel that using these services is a legitimate part of their medical training. A particularly helpful type of positive transference can then develop. The therapist can become an embodiment of the student-patient's externalized ego ideal; that is, the therapist is idealized as a caring and skillful clinician (equals physician) who can help the patient. The student-patient in turn identifies with the idealized therapist. This reinforces his own vocational ideal and fosters internalization of new ego skills and consolidation of latent skills that can be helpful in clinical work as well as in coping with his own feelings. I n this emotional setting, interventions that seek to reinforce the student's intellectually oriented ego-adaptive and defensive mechanisms can be particularly effective, since in one sense we

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perform a kind of experiential teaching or problem solving that is most effective in a positive relationship in which some idealization is present (29). This ego ideal transference may take two forms which rarely if ever are mutually exclusive but which are presented separately for clarity. First is the therapist as idealized teacher; the student experiences his therapy as an opportunity to learn valuable diagnostic and clinical problem-solving skills under the tutelage of an expert. Second is the therapist as idealized physician; the student comes to realize that symptoms and maladaptations, whether mental or physical, are not a sign of weakness or badness. He further can identify with an approach to patients that harmoniously combines a scientific attitude with humane treatment. For medical students this sort of identification is especially relevant to their future professional activities. These ego-ideal transferences do not always develop automatically. Sometimes the initial transference expression is based primarily on childish object ties and longings. I f interpretation can rapidly diminish these transference reactions, the ego-ideal transference can be freed. I n Case 3, for example, the wish for a dependent, submissive attachment to the father initially impeded that student's ability to work collaboratively with her therapist. A t other times the infantile transference is too entrenched and pervasive to be resolved easily. I n such cases it is unlikely that the brief psychotherapeutic techniques described here will be very effective because the ego-ideal transference is unavailable. This was true i n Case 5, where the student manifested intense ambivalent behavior toward his therapist, attempting both to manipulate himself into a passive-dependent position and to defiantly resist any advice or interpretations. I t is no coincidence that both of his parents happened to be physicians. Not only was the object-oriented infantile transference powerful, but also M r . A . could not easily develop an ego-ideal transference with his medical school faculty therapist, since it was obfuscated by his relationships with both parents. We have found that, in general, brief psychotherapy tends to be more difficult with medical student-patients where one or both parents are physicians. The ego-ideal transference, whether associated with the fantasy of the teacher-student or the doctor-patient relationship, promotes an ego-strengthening experience. The student is not made to feel dependent upon an omnipotent healer who has mysterious powers. Though a good deal of idealization is present, i t results from externalization of the student's own ego ideal of himself as a skillful physician; the student feels capable of learning from his therapist and thereby acquiring the latter's skills for his own. Furthermore, the need to learn is not seen as indicative of weakness or abnormality. Because the therapeutic experience in a significant sense is emotionally equated with the medical education process, the student can be helped to focus not on what he does not know or cannot do for himself,

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but gather on what he is capable of learning. Self-esteem and a sense of reality mastery are strengthened as the student experiences himself working collaboratively with a skillful clinician-teacher. DISCUSSION

The goal of the brief and emergency psychotherapeutic techniques described here is to aid medical students under stress in restoring their previous level of academic performance, or better. Further, a reasonable social adjustment within the limits of the student's present emotional functioning is also aimed for. I n contrast to the goals of long-term, intensive psychotherapy, these may seem like modest aims. But to medical students working under the duress of an exceedingly demanding curriculum, even modest relief from emotional conflict or stress may have a significantly healthy influence on their lives during the four years of medical school. We have found that a therapeutic approach capitalizing on the student's intrinsic ego strengths can restore his sense of confidence in his ability to make it through the system. His feeling of mastery alleviates his perception of victimization by a callous medical education system. Frequently, the less the student feels persecuted by an uncaring faculty, the less likely he in turn will relate to patients insensitively. I t could be argued that the brief therapy techniques described here conceivably might create intractable resistances should the student-patient seek intensive psychotherapy in the future. The argument might run that while the dynamic formulation describes a derivative conflict with reasonable accuracy, it is offered in place of the basic (childhood) conflict. Consequently, intellectualizing adaptive and defensive functions are reinforced by reorganizing them around the derivative conflict, leaving the basic conflict untouched. I n subsequent intensive treatment this basic conflictual area could be walled off from therapeutic exploration by the defenses strengthened in the prior brief therapy. This distinction fuzzes the differences between "incomplete" and " i n exact" interpretation (30). I f in brief psychotherapy it was explicitly or implicitly communicated to the patient that the interpretative work being accomplished was definitive, it could be argued that inexact interpretation (that is, derivative conflicts treated as core conflicts) were creating a situation detrimental to subsequent intensive treatment. However, it is a fundamental tenet of our method (and of most brief psychotherapeutic approaches) that the patient be explicitly informed about the need to focus on a delimited area of conflict; much is left untouched. Under these circumstances, interpretations are "incomplete" in that they deal with circumscribed and derivative conflictual areas. Whether they are sufficient to restore adequate functioning or whether they are preparatory for future intensive therapy is determined by the patient's future behavior. I f in subsequent

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intensive treatment a resistance is encountered which takes the form of the attitude "We need explore this situation no further, because i t was thoroughly understood in my previous therapy," the patient's rational observing ego should be capable of enlistment against this attitude—as is the case with any distortion of reality. I t is our impression that these techniques work best when the precipitating stress is fairly recent. With the passage of time, the student becomes so overwhelmed by the synergic effects of his personal problems and the concurrent demands of medical school that his academic functioning is severely impaired, or he develops an array of maladaptive defensive strategies that are hard to give up. By then, more extensive therapy is usually needed. Over the past three years very few of the students who referred themselves to us have gotten into noticeable academic difficulties, while the number of students we see increases each year. This speaks for the efficacy of providing free and easily accessible mental health services to medical students. From a practical point of view, our experience has been that it increases the efficiency and productivity of the medical school's educational process; such a service contributes to lowering the academic drop-out rate as well as helping to lower the frequency of minor academic difficulties. From a more long-range, philosophical view, the approach offered here provides the student-patient a model for integrating a scientific attitude toward patients with a sensitivity to the human needs of the individual. SUMMARY

I n an educational setting, like a medical school, disruption of academic functioning due to emotional problems often can be avoided with rapid psychotherapeutic intervention. This can be accomplished most expeditiously i f intervention techniques are geared to ego-adaptive and defensive styles characteristic of the patient population. Such styles characteristic of medical students are described which involve a prominent use of intellectual mastery and defensive intellectualization. Also described are four very brief therapeutic interventions that are particularly effective with these adaptive and defensive styles. When therapeutic services provided by the medical school are considered by students to be a legitimate part of training, a helpful form of ego-ideal transference often appears in the therapy. Free and easily accessible psychotherapeutic services for medical students can reduce attrition rates as well as the frequency of relatively minor academic problems. REFERENCES

1. Patterson, V . and O'Sullivan, M. Three Perspectives on Brief Psychotherapy. Am. J . Psychother., 28:265, 1974.

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2. Semrad, E . V., Binstock, W. A., and White, B. Brief Psychotherapy. Am. J. Psychother., 20:576, 1966. 3. Barten H . Brief Therapies. Behavioral Publications, New York, 1971. 4. Gillman, R. D. Brief Psychotherapy. A Psychoanalytic View. Am. J. Psychiat., 122:601, 1965. 5. McGuire, M. T . The Process of Short Term Insight Psychotherapy. /. Nerv. Ment. Dis., 171:83, 1965. 6. Bellak, L . and Small, L . Emergency Psychotherapy and Brief Psychotherapy. Grune & Stratton, New York, 1965. 7. Wolberg, L . R. Short-Term Psychotherapy. Grune & Stratton, New York, 1965. 8. Sarvis, M. A., Dewees, S., and Johnson, R. F . A Concept of Ego-Oriented Psychotherapy. In Brief Therapies, Barten, H., Ed. Behavioral Publications, New York, 1971. 9. Small, L. The Briefer Therapies. Brunner/Mazel, New York, 1971. 10. Alexander, F . and French, T . M. Psychoanalytic Therapy. Ronald Press, New York, 1946. 11. Sifneos, P. E . Short-Term Psychotherapy and Emotional Crisis. Harvard University Press, Cambridge, 1972. 12. Lindemann, E . Symptomatology and Management of Acute Grief. Am. J. Psychiat., 101:141, 1944. 13. Lief, H . J . Young, K., Spruiell, V., Lancaster, R., and Lief, V . F . A Psychodynamic Study of Medical Students and Their Adaptational Problems, Preliminary Report. /. Med. Educ, 35:696, 1962. 14. Schlageter, C. W. and Rosenthal, V . What Are "Normal" Medical Students Like? /. Med. Educ, 37:19, 1962. 15. Keniston, K . The Medical Student. Yale J . Biol. Med., 39:346, 1967. 16. Lief, H . Psychotherapy of Medical Students. In Current Psychiatric Therapies, Vol. 7. Masserman, J . H . , Ed., 1967. 17. Snow, L . H . Preliminary Observations of the Psychotherapy of Medical Students. Am. J . Psychother., 23:293, 1969. 18. Bojar, S. A. Psychiatric Problems of Medical Students. In Emotional Problems of the Student, 2nd ed. Blaine, G. B., Jr. and McArthur, C. C , Eds. Appleton-Century-Crofts, New York, 1971. 19. Schonbar, R. A. Interpretation and Insight in Psychotherapy. In Use of Interpretation in Treatment: Technique and Art. Hammer, E . F., Ed. Grune & Stratton, New York, 1968. 20. Rosenbaum, C. P. Events of Early and Brief Therapy. I n Brief Therapies. Barten, H . , Ed. Behavioral Publications, New York, 1971. 21. Malan, D. H . A Study of Brief Psychotherapy. Tavistock Publications, London, 1963. 22. Bios, P. On Adolescence. Free Press, New York, 1962. 23. Woods, S. M., Natterson, J . and Silverman, J . Medical Students' Disease: Hypochondriasis in Medical Education. /. Med. Educ, 41:735, 1966. 24. Wolfenstein, M. Loss, Rage and Repetition. Psychoanal. Study Child, 24:432, 1969. 25. Stein, M. H . Acting Out as a Character Trait: Its Relation to the Transference. Psychoanal. Study Child, 28:347, 1973. 26. Leavy, S. A. Psychoanalytic Interpretation. Psychoanal. Study Child, 28:305, 1973.

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27. Swartz, J . Time-Limited Brief Psychotherapy. In Brief Therapies, Barten, H . Ed. Behavioral Publications, New York, 1971. 28. Menaker, E . Interpretation and Ego Function. In Use of Interpretation in Treatment: Technique and Art. Hammer, E . F . , Ed. Grune & Stratton, New York, 1968. 29. Mann, J. Time-Limited Psychotherapy. Harvard University Press, Cambridge, Mass., 1973. 30. Glover, E . The Therapeutic Effect of Inexact Interpretation: A Contribution to the Theory of Suggestion. Int. J . Psychoanal, 12:397, 1931.