THE AMERICAN JOURNAL OF PSYCHOANALYSIS: 37:141-146 (1977)

DO PSYCHIATRISTS HAVE SPECIAL EMOTIONAL PROBLEMS?

Gordon E. Bermak

A questionnaire dealing with the emotional problems involvecl in the practice

of psychiatry was sent to seventy-five psychiatrists residing in the San Francisco
Bay Area. They were all known personally to the author in his role as either
teacher, student, or colleague. The sample was probably somewhat biased in that
the author practices psychoanalysis and psychotherapy in the same geographical
area, and there may be some skewing of the selection in that direction. However,
an effort was made to include representatives of different subspecialties of
psychiatry. One hundred percent of those questioned returned the questionnaire,
with over fifty percent adding a full page of comments. The sample appeared to be
an accurate cross section of therapists in this area, in which the major practice is
made up by psychotherapists. More specifically, twenty nine reported that they
did analytic psychotherapy and psychoanalysis, twenty were doing various forms
of psychotherapy not clearly defined by them as psychoanalytic psychotherapy,
twelve did hospital work primarily, nine spent the major part of their time in
administration, three had left psychiatry for the resumption of the general practice
of medicine. There did not appear to be statistically valid correlations between the
responses and the subspecialty practiced.
The questions and answers were as follows:
1) "Do you think that psychiatrists have emotional difficulties that are special
to them and their work as contrasted with non-psychiatrists?" Sixty eight replied
yes and seven, no. Those who clarified their negative response indicated that they
thought that psychiatrists had no more problems or significantly different ones
than had other physicians or professional persons. These no responses viewed
everyone as having problems. Some members of this group believed that training
and education were designed to prepare a therapist for dealing with the demands
of the field. They believed that sophistication and experience in the field would
eventually alleviate difficulties.
2) "If you believe that psychiatrists have special emotional problems, do you
believe that these problems come from the kind of person who went into the field
or from the type of work itself?" Forty five stated that the problems originated in
the personality of the psychiatrist, but fifteen of these forty five thought that
problems also were contributed by the work itself. Sixty stated that the problems
originated in the work primarily, but of this group thirty also concluded that the

G. E. Bermak, Assistant Clinical Professor, Department of Health Sciences, University of California,

Berkeley.

141
142 GORDON E. BERMAK

personality played a role. (The overlapping of the figures beyond the total number
of the sample is accounted for by the fact that various people weighted these
factors differently, and this was taken into account in the rating of the answers.)
3) "For those who believe that special problems do exist, exactly what do you
think are the special difficulties?" Although respondents were encouraged to
supply key words and phrases alone, in the interest of making a minimal demand
upon their time, about ninety percent chose to write at least a paragraph, and
many wrote more than one page. The answers given are summarized below.
Isolation was referred to by thirty-eight people. Twenty three of this group
made special reference to the actual physical aloneness in the practice of
psychiatry. One quoted the hole-in-one joke wherein God punishes the minister
who plays golf on the sabbath by giving him a hole in one, the punishment being
that he cannot tell anyone what he has accomplished. Six said that the need for
intimacy was not satisfied in the office. Five felt that inability to communicate with
others about patients because of the need to preserve confidentiality created a high
degree of isolation. Four believed that personality problems interfered with the
ability to achieve intimacy outside the office.
The need to control emotions was regarded as a burden by twenty one. The
feelings of the therapists were stimulated by patients. Several specified that these
feelings were primitive in nature. Ten spoke directly of difficulties dealing with
countertransference, and many others alluded to this problem using different
terminology. Five specifically mentioned that the practice of psychiatry produced
an increased awareness of deep emotional issues in oneself, and that this was a
source of strain.
Omnipotent wishes and the frustration thereof was listed by seventeen respond-
ents. Therapists often had a great need to help and rescue others. This was seen
as concealing great wishes to receive love. When the need to be an all-powerful
rescuer was thwarted, a sense of helplessness was felt. Six referred to a high ego
ideal and exaggerated demands upon the psychiatrist's performance, with conse-
quent guilt when unable to meet such standards. Although these responses ap-
peared related more to matters of conscience and guilt, the sense of mission and
rescuing self-image seemed related to the omnipotent theme.
Ambiguity in the field itself was listed as a major source of distress by sixteen
psychiatrists. Nine mentioned ambiguity specifically, and seven mentioned the
impossibility of validation of results. Some felt ambiguity of the field was more an
issue for residents in training, and others observed the problem of validation more
as an issue in the midlife crisis years.
The following problems, although still specified often enough to be discernible
as shared concerns, were not as frequently and clearly stated as the above. The
emotional drain of constantly being empathic was a specific problem for twelve
people. Three of this group said the obsessiv~e-compulsive character structure
present in the vast majority of psychiatrists made their task of empathy particularly
draining for them. Some spoke of being sucked upon and did not see it as a
countertransference problem but as a literal physical drain upon their energies.
 DO PSYCHIATRISTS HAVE SPECIAL EMOTIONAL PROBLEMS? 143

They experienced this as going home and needing to be replenished. However,

they often had to give more when they arrived home because of the realistic needs
of their family.
Physical inactivity and enforced physical passivity was regarded as a strain by
six.
Struggles with one's professional identity was regarded as a problem by fifteen.
Of these fifteen, eight stated that the problem was specifically that of rejection by
nonpsychiatrists. Six felt that the confusion with nonpsychiatric psychotherapists
produced an identity problem, and one felt that the rejection by society of the
whole psychiatric profession was a severe issue.
The long delay in achieving results in the treatment of patients was mentioned
by eight. This was related to a lack of immediate gratification. It was noted that
pleasure from rapid cures was suspect because they were seen as transference
cures and thus could not be accepted as a source of guilt-free gratification.
The need to have a normal image in the observing eyes of society was a
problem specifically mentioned by five. Psychiatrists and their families were seen
as living examples by society of the nature of their practice and of proof of their
skill as therapists. These respondees felt that psychiatrists had to demonstrate that
they knew how to achieve mastery over the art of living, be mature, and usually
not too fun loving if they were to have a good professional reputation. Their
families had to live up to these standards as well.
Hostility and the problems of dealing with it, as stimulated in the psychiatrist
and as experienced from the patient, was mentioned by eight people. Not being
allowed to retaliate to the angry patient was a particular problem.
The obsessive-compulsive personality structure of the psychiatrist was viewed
as threatened by twelve individuals. The obsessive personality was seen as defen-
sive and therefore its threat provoked anxiety.
Exposure to depressive people made psychiatrists depressed. Two of this group
believed that such exposure to suicide in patients caused therapists to consider
this as a solution for their own problems.

Separation anxieties produced by the termination of therapy with patients with

whom the therapist has met for many years was regarded as a particular source of
sadness for psychiatrists. Two individuals specified this.
The literature on the subject of the problems of psychiatrists reflects the main
themes described by the respondents to this questionnaire. RossI and Satir2 men-
tion isolation and lack of support systems. Wheelis 3 speaks of isolation in terms of
strivings for intimacy and disappointments in the gratification of intimacy, particu-
larly when the patient is ungrateful and hostile. Marmor 4 also speaks of isolation
and the need for psychiatrists to learn to be alone. Wheelis 3, Kernberg s, and
Menninger 6 speak of the psychiatrist's struggles with his sense of identity on the
professional level as well as the need to have identity problems resolved before
entering practice. Kernberg and Menninger emphasize the importance of profes-
sional training in maintaining and developing a sense of professional identity.
144 G O R D O N E. BERMAK

Many of the psychiatrists in this survey reported a sense of isolation and various
forms of lack of intimacy as a special problem. This complaint is heard frequently
from people in all walks of life. Work can offer sublimated gratification of needs
for intimacy, but in order to do so, there must be a capacity for sublimation. In
psychiatry it can come from contact with patients through participation with them
in the solution of their difficulties and in mutual sharing and discovery. Nonsub-
limated forms of intimacy in life must be experienced with friends and, finally,
with lovers. Attempts to meet these other needs in psychiatric work are inevitably
frustrated. At the same time, the sublimated gratifications from the work are
frustrated because the work is no longer effective due to its present-day unsubli-
mated quality. Those who have problems achieving unsublimated gratification of
need for intimacy outside their work will find the sublimated gratification in the
job insufficient. It appears to be this group which is often referred to as the
introspective practitioners who suffer from isolation. These people will find the
literal lack of contact with friends, acquaintances, and love objects during the
work day a special problem.
Psychiatry has been described as having an identity crisis. Once again, this
does not seem to be a description special to psychiatrists. A sense of identity is
based upon an internal sense of self and upon the confirmation of this self by the
society. As with all workers, psychiatrists must have a work, or professional iden-
tity, which is added to and part of a previously achieved sense of self. Professional
training develops this identity. It includes an awareness of the complexity of
mental phenomena, a sense of psychic determinism, an acknowledgment of the
importance of affects, a fundamental sense of the unconscious, and an awareness
of the importance of the genetic point of view. In addition, the psychiatric profes-
sional identity involves a sense and understanding of the vicissitudes of empathy
and basic integration of the body-mind dichotomy. This combination of previ-
ously developed sense of self and newly developed professional self provides a
solid professional stance. If either part of this combination is lacking, the psychia-
trist is vulnerable to and threatened by claims of other groups not similarly trained.
It follows that crises of identity in psychiatrists are best remedied by personal
therapy which treats the problems with personal identity and by further training
and collaboration which treats the problems with professional identity.
A psychiatrist must be able to tolerate ambiguity. The professional must have
personal insight into the origins and nature of fears of uncertainty. The anxiety
over the ambiguity of the field may be related to obsessive character traits in many
psychiatrists, resulting in problems of doubting. Those who have strong needs to
rescue people and have powerful wishes to deal with their underlying feelings of
helplessness by mastering them through striving toward omnipotence, are particu-
larly vulnerable because of the lack of ready validation of results and the length of
time before results can be seen. Unresolved needs for immediate gratification
exacerbate the frustration that is basically inherent in the long waiting periods for
results of therapeutic efforts. Narcissistic personality types will be much affected
by the lack of support that society offers. Such individuals respond to the lack of
 DO PSYCHIATRISTS HAVE SPECIAL EMOTIONAL PROBLEMS? 145

external support with depression and in some instances with an actual sense of
threat to their sense of self. The ambiguity and long delay tend to provide much
opportunity for fantasy and possible distortions of reality in the therapist, with
resultant sense of being overwhelmed from within. Those who have a particular
proclivity to fantasy may suffer from the long periods of introspection when work-
ing alone. One's psychiatric education makes it clear that the field does have great
complexities and uncertainties. Undue anxiety may be manifested by identifying
with the critics of psychiatry w h o seek to make psychiatrists responsible for the
ambiguity.
Empathizing is work. Maintaining objectivity is work. In some instances this is
emotionally draining. This is particularly true of the treatment of patients who use
projective identification and of patients who seek the destruction of their helpers.
They can produce in their psychiatrists states of mind to which other professionals
are not exposed. However, even in these situations, the availability to the psychia-
trist of intellectual understanding arrived at through the continuation of profes-
sional training, as well as the resource of personal therapy, can bring to these
occupational hazards some perspective. A sense of having worked hard is realis-
tic. Listening and sitting in the office is a most active existence. One's families and
certainly critics from the nonpsychiatric society often seem to believe that psychi-
artists have been doing nothing but sit all day and thus should not feel drained
when they come home. Families tend to believe that their parent and spouse
should be able to produce much more than they do. A psychiatrist who does not
fully recognize the professional dimensions of the problems of empathy may side
with his or her critics and in fact deny that real work effort is involved. Such denial
of the real work could lead to a self-devaluation of the work, with propensity to
wild innovation and to handing the job over to the nonprofessional.
Most of the psychiatrists in this questionnaire believed that the profession had
special emotional problems. It is the author's opinion that these difficulties should
be approached in two ways. First, it is important to maintain high levels of train-
ing, including continuing education with peer supervision. Second, personal ther-
apy should be postively and persuasively encouraged for all in the field. There
appears to be much ambivalence in recommending therapy for ourselves and our
residents. One can only assume that, as with our patients, when we are in pain we
will resist because of our anxieties. Such resistance can be lessened by the profes-
sion as a whole taking a stance in favor of therapy as training and treatment for the
professional.

References

1. Ross,M. Suicide among physicians. Dis. Nerv. System 34:145-50, 1973.

2. Satir, V. Personal communication.
3. Wheelis, A. The Quest for Identity. New York: Norton, 1958, pp. 206-247.
146 GORDON F. BERMAK

4. Marmor, J. (ed.). Psychiatrists and Their Patients. Joint information service for APA,
1975.
5. Kernberg, O. Some effects of social pressure on the psychiatrist as a clinician. Bull.
Menn. 32:144-159, 1968.
6. Menninger, R. The psychiatrist's identity: quo vadis? Bull. Menn. C1 32:139-43, 1968.

Reprint requests to 281~1 College Ave., Berkeley CA 94705