Original Article
Using the Technique of Journal Writing to Learn Emergency Psychiatry Chaya Bhuvaneswar, M.D., M.P.H., Theodore Stern, M.D. Eugene Beresin, M.D. Objective: The authors discuss journal writing in learning emergency psychiatry. Methods: The journal of a psychiatry intern rotating through an emergency department is used as sample material for analysis that could take place in supervision or a resident support group. A range of articles are reviewed that illuminate the relevance of journal writing for the learning process, including articles about resident resilience, “autognosis,” the learning process in psychiatry, and “limbic music.” Results: Journal writing is a useful tool in consolidating knowledge, and can be used along with traditional exercises for learning psychiatry such as writing chart notes, process notes, and completing required studies for examinations. Conclusion: Psychiatry training should continue to explore the use of journals as residents continue to write them.
I
n many clinical settings in psychiatry, journal writing plays an important role. From survivors of sexual abuse sharing diary entries in groups (1) to cognitive behavior therapists assigning writing exercises and using personal essays in 12-step programs, journal writing has often helped patients in group or individual psychotherapy. Could journal writing play a role in psychiatric residency training? For many residents, this question might provoke a groan of protest. Overburdened by writing exercises of numerous kinds—from long histories, physicals, and progress notes to endlessly proliferating correspondence with insurance companies—perhaps only a few residents would brighten at the prospect of using journal writing in their clinical training. However, attempting to make sense of the emotionally intense and potentially overwhelming experiences that constitute the training process through journal writing may be enriching, if not enjoyable.
Received July 13, 2006; revised July 18 and September 24, 2007; accepted October 10, 2007. Dr. Bhuvaneswar is affiliated with the Department of Psychiatry at the University of Pennsylvania; Drs. Stern and Beresin are affiliated with the Department of Psychiatry at Massachusetts General Hospital in Boston. Address correspondence to Chaya Bhuvaneswar, 3535 Market St., 2nd Floor, Outpatient Psychiatry, University of Pennsylvania, Philadelphia, PA 19104; Chaya.
[email protected] (e-mail). Copyright 䊚 2009 Academic Psychiatry
Journals and the Learning Process For some residents, writing journal entries relieves stress. For others, writing e-mails to friends in off-hours or recording humorous riffs about call nights in a resident book stashed away from the prying eyes of attendings might serve the same function (2). Journal writing attempts to go one step further than a “locker room wall” type of semipublic expose´ as a forum for thoughtful and sustained reflection. As a form of stress relief, writing a personal journal carries less personal risk and risk of exposing others than other more formal types of autobiographical writing about the residency experience, such as Samuel Shem’s House of God and Mount Misery (3, 4) and Stephen Hoffman’s Under the Ether Dome (5). Journal entries are by definition private scribbles, excluded from the medical record and appropriately discarded when it is time to launder one’s white coat. The experiences they record need not be relived or even discussed with others. Standing separate from the process notes used in psychodynamic supervision,
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which formally document the events of each psychotherapy session, journal entries are a safe place to “spill” in a field where the ability to contain and modulate one’s emotions is prized. In most psychiatric residency programs, writing process notes for psychotherapy supervision is still an important aspect of training. Journal entries may help residents mediate between being expressive and learning to function as a mental health professional. Considerations of safety are important as residents come to understand their own countertransference reactions, for example. It takes skill to appreciate what is appropriate and what is not and what can be discussed in professional supervision. Erotic or aggressive countertransference reactions, while theoretically important topics, can be uncomfortable to process fully in supervision, particularly as one is getting to know (and trust) a supervisor. Journal entries may serve as a bridge from the encounter with a patient to a resident’s personal psychotherapy. Journal entries written after therapy sessions may conversely act as a bridge back to professional supervision, making it easier to identify how given moments of a session with a patient may be influenced by the countertransference acknowledged and explored in personal therapy. Keeping brief journal entries may also be beneficial for developing skills in expressive writing, which may be of further use in writing process notes that capture both clinical events and feelings. “Limbic music” (6) is much broader than countertransference and extends to objective clinical material. It may be most easily understood as raw data, the wordless yet powerful feelings and reactions that underlie the words by which both patients and psychiatrists attempt to shape their impressions of each other. Perhaps the concept is best summarized by Murray (7): The limbic system is involved with motivation, attention, emotion and memory . . . [It] mediates gender role, territoriality, and bonding. For example . . . the limbic system mediates how one feels about family, rights, “keep off the grass,” and other areas that have a spatial or relational component. In bonding, the limbic system mediates strongly how one bonds to one’s spouse, family, father, country, flag, religion—in sum, loyalty (p 26). Limbic music is a term that denotes the existential, clinical, “raw feel” emanating from the patient. It is a more true reading of the patient’s clinical state than articulate speech. Limbic music never lies (p 28).
The journal entries sampled here (Appendix 1) were written during the emergency psychiatry rotation of a resident (CB). When read with an eye for details that might give 44
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clues to the limbic music played by each patient, teaching experience, or clinical encounter from the call night, the entries are quite revealing (perhaps more so than the writer intended). With regard to these journal entries, the expressions of countertransference, exploratory observations about possible limbic music, venting for stress relief, and identifying personal fears all remained in the private domain. However, some medical training programs have found journal entries useful in public assessment. One academic geriatrics program for medical interns (8) uses a narrative journal writing exercise as part of formal assessment. Many family practice training programs use journal writing to enhance resident reflection in a formal way, almost like process notes for nonpsychiatrists (9). Journal entries have also been used to evaluate supervisor-resident interactions in internal medicine (10). At Massachusetts General Hospital (MGH), the tradition of autognosis rounds, supported by the Department of Medicine, encourages residents to write anonymous journal entries in a public book nicknamed the Red Book (3). The concept of autognosis was developed by the late Edward Messner (11), an MGH staff psychiatrist who used the term to describe how residents can learn to observe their own emotional reactions to a patient and then use those reactions to better understand the patient’s experiences. Messner conducted autognosis rounds for residents learning emergency psychiatry. In these rounds a resident would talk directly about how a patient evoked feelings of anger and frustration without fear of being judged or regarded negatively. Once these feelings were voiced, the resident and his or her classmates would be invited to analyze how and why the case might have caused that reaction. Encouraging residents to learn from, rather than suppress or merely contain, their emotions was Messner’s method of teaching both compassion and objectivity, because the ability to read one’s own feelings is a helpful first step to setting them aside and becoming a more astute, neutral reader of the patient’s feelings and needs. Messner’s teachings were applied to the weekly intensive care unit rounds in the Department of Medicine, where internal medicine residents, in the absence of their attending supervisors and with the support of consultationliaison psychiatrists, reflected about patient cases and their feelings in a similar way. These rounds often stimulated residents to write expressive, anonymous entries in a collective journal (3). The privacy of journal writing allows it to escape both the medical record and the record of one’s progress in Academic Psychiatry, 33:1, January-February 2009
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psychiatric training. But even when journal writing is private or anonymous and, above all, a safe place to “spill,” it can still help residents communicate their interests to training directors. Residents’ journal entries and other expressive writing (including reflective personal essays published in a residency newsletter) may lead to productive discussions between residents and teaching faculty. An example of one coauthor’s (EB) initiatives included actively encouraging residents in expressive writing that would support a career in academic psychiatry, and suggesting how these expressive exercises could be polished into academic articles. Finally, given the potential benefits of journal writing for learning emergency psychiatry and for residency training in general, medico-legal aspects must be considered. A review of the literature did not yield any specific case laws regarding the status of resident journal entries. Numerous first-person accounts of residency training, both fictional-
ized (4, 5, 12) and factual (13–15), have used journal material of one kind or another without incurring legal problems. In the absence of case law, journal entries may be discoverable, but residents are not obligated to preserve them as they would a note in the chart. Personal journal entries written in a fragmentary form, particularly if they avoid or disguise identifying details of patients, may be discarded along with other notes that residents make— from to-do lists and lists of important phone numbers to nonsensical doodling accumulated in Grand Rounds or morning didactics. The seminal work of the linguistic psychologist Pennebaker (16, 17) used expressive writing in therapy with different populations (e.g., substance-using adolescents, sexual abuse survivors, and communities joined by post 9-11 grief). Self-disclosure (18, 19) has a powerful role in healing and growth. In learning emergency psychiatry, journal writing may play a similar role.
APPENDIX 1. Journal Entries from the Emergency Psychiatry Rotation Entry Love and Suicide The hand-off. But before the pager reaches my hand, it shrieks impatiently—it’s the medicine resident wanting to know when the patient going to psych is going to be taken off his hands. Last night the young man was found shouting hopeless and suicidal thoughts at strangers and asking if any of them would sell him a gun. Now he says he’s fine and only wants to know how his girlfriend is doing, the one whose rejection sent him into the streets. ‘‘I wanted to see if she really cared,’’ he adds. Delirium and Aggression in the Lollipop Club The phone rings—I’m up. It’s a child psychiatrist bringing in a patient. A young girl with no history of violence has started to act ‘‘strange’’ for the past 10 days, ever since being started on an SSRI. She’s striking out at things, is confused, and seeing invisible insects. I’m writing notes, looking up articles, getting ready to do a ‘‘tip of the head to the bottom of the toes’’ workup on this kid. There’s a pleasant humming, cognitive processing going on, but underneath—a sharp, quick stab of pain. Thinking about a family member’s disability, his inability to express himself and how that can make him frustrated. How he too has wanted to strike out. Treat ’em or Street ’em: Middle of the night, off with a nurse to triage, past the open buckets of pungent barbecue chicken the security guards have been gnawing on all night, the smell making me nauseated. The chicken smell is nothing compared to what awaits in triage. Drunk (‘‘off his ass,’’ as one of the nurses says), stinking of urine and dirt, it’s the homeless alcoholic with a history of delirium tremens and seizures, one of which resulted in head trauma that he’s still recovering from. Long ago another of his benders ended by his waking up in an emergency room with bleeding track marks, HIV positive.
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Discussion The way the patient’s words are quoted reveals skepticism. The patient shouts for a gun but doesn’t really want it. He shouts to check whether his girlfriend truly cares for him, but the sense of caring doesn’t exert much of an emotional pull for his caregivers. His medicine resident is impatient to transfer him. The feelings he articulates suggest an unstable, exploratory, adolescent relationship (or borderline personality) with an intensity that is in large part performed. He has not touched his doctors or caused them to be emotionally involved, at least not yet. Here there is literally limbic ‘‘music’’—the humming, the metaphor of a machine working, in this case a resident’s clinical reasoning, wheels turning in ever more familiar ways to work up and admit a patient, to integrate sign-out from the referring physician, while mentally generating a differential diagnosis. There is some satisfaction in this humming, the ability to make the machine work—but at the same time pain, a type of anticipatory grief about the prospect of evaluating a child with a disability because of the similarity to a family member. There is the twinge of pain, already felt before the words form to describe the ‘‘stab of pain.’’ Smells can be powerful stimuli for the limbic system and the memory of a nauseating smell can permeate the visual and verbal memory of a patient who in some way evokes nausea. The smell of chicken and the difficulty in making oneself touch a disheveled, dirty patient—the wish to insulate, to wall off from a contagion— capture some of the ambivalence involved in becoming a doctor. For a resident, it means leaving the ranks of laypeople who are perfectly within their rights to turn away from whatever is difficult to face and to join the cadre of professionals whose job it is to probe, to examine, and to cure.
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The role of journal entries in psychiatric residency training requires further exploration; in the mean time, some residents at least will surely continue to write down their thoughts and impressions and learn from them. The authors gratefully acknowledge Dr. Kathy Sanders, residency training director at the MGH-McLean program, for generously providing free time to Dr. Bhuvaneswar for the independent conception and writing of this article during her second and third postgraduate training years and for making comments about the completed, accepted version of the article. Manuscripts authored by an editor of Academic Psychiatry or a member of its editorial or advisory board undergo the same editorial review process, including blinded peer review, applied to all manuscripts. Additionally, the editor is recused from any editorial decision making. At the time of submission, the authors disclosed no competing interests.
References 1. Bradley RG, Follingstad DR: Group therapy for incarcerated women who experienced interpersonal violence: a pilot study. J Trauma Stress 2003; 16:337–340 2. Stern TA, Prager L, Cremens MC: Autognosis rounds for medical house staff. Psychosomatics 1993; 34:1–7 3. Shem S: The House of God: The Classic Novel of Life and Death in an American Hospital. New York, Dell Publishing, 1978 4. Shem S: Mount Misery. Westminster, Md, Fawcett Books, 1997 5. Hoffman SA: Under the Ether Dome: A Physician’s Apprenticeship at Massachusetts General Hospital. New York, Scribner Book Company, 1986 6. Murray G: Limbic music. Psychosomatics 1992; 33:16–23
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7. Murray GB: Limbic music, in Massachusetts General Hospital Handbook of General Psychiatry. Edited by Stern TA, Fricchione G, Cassem N, et al. St. Louis, Elsevier (Mosby) Publishing, 2004 8. Maurer MS, Costley AW, Miller PA, et al: The Columbia cooperative aging program: an interdisciplinary and interdepartmental approach to geriatric education for medical interns. J Am Geriatr Soc 2006; 54:520–526 9. Kasman DL: “Doctor, are you listening?” A writing and reflection workshop. Fam Med 2004; 36:549–552 10. Rabatin JS, Lipkin M Jr, Rubin AS, et al: A year of mentoring in academic medicine: case report and qualitative analysis of fifteen hours of meetings between a junior and senior faculty member. J Gen Intern Med 2004; 19:569–573 11. Messner E, Gorves JE: Autognosis: How Psychiatrists Analyze Themselves. Chicago, Year Book Medical Publishing, 1989 12. Doctor X: Intern. New York, Harper & Row, 1965 13. Klass P: A Not Entirely Benign Procedure: Four Years as a Medical Student. New York, Putnam, 1987 14. Firlik K: Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside. New York, Random House, 2006 15. Viscott DS: The Making of a Psychiatrist. New York, Arbor House, 1972 16. Ames SC, Patten CA, Offord KP, et al: Expressive writing intervention for young adult cigarette smokers. J Clin Psychol 2005; 61:1555–1570 17. Cohn MA, Mehl MR, Pennebaker JW: Linguistic markers of psychological change surrounding September 11, 2001. Psychol Sci 2004; 15:687–693 18. Kloss JD: An exposure-based examination of the effects of written emotional disclosure. Br J Health Psychol 2002; 7:31– 46 19. Bolton EE: The relationship between self-disclosure and symptoms of posttraumatic stress disorder in peacekeepers deployed to Somalia. J Trauma Stress 2003; 16:203–210
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