Dr. Aftab is a PGY4 Chief Resident for Education and Research at Case Western Reserve University/University Hospitals Cleveland Medical Center (CWRU/UHCMC) psychiatry residency program. Dr. Dery is a PGY2 psychiatry resident at CWRU/UHCMC.
Erik Erikson, a highly influential psychoanalyst responsible for introducing the notion of “identity crisis” into popular vernacular, is best known for his psychosocial stages of ego development from infancy to late adulthood. He proposed 8 stages of development, each associated with a specific crisis, the resolution of which leads to acquiring associated virtues. Erikson’s stages are epigenetic, ie, they occur in a well-defined sequence, and each stage must have a satisfactory resolution. Failure to resolve a crisis in one stage is reflected in all subsequent stages.
Here we offer a lighthearted exploration of extending Erikson’s stages to the development of psychiatry residents during their training. While this piece builds on personal experience and observation, it is more of playful analogy that is cognizant of its limitations while aspiring to be of metaphorical value. Unlike Erikson’s stages, we do not consider these stages to be strictly epigenetic. Not all crises may be experienced; they may be experienced in different orders; and they may be experienced simultaneously.
1) Trust vs. Mistrust
Existential Question: Can I trust the training environment?
At the initiation of their training, residents quickly develop a sense of trust if their early interactions with the training directors, coordinators, and senior residents demonstrate reliability, fairness and genuine concern for their well-being. In an unstable and unpredictable training environment, mistrust develops. Trust leads to an optimism that—in a reliable, caring environment—future challenges will be overcome.
2) Autonomy vs. Shame and Doubt
Existential Question: Is it okay for me to be the trainee that I am?
Trainees at this stage develop a basic command over clinical skills and some semblance of independence. The attendings and senior residents assume the role of metaphorical parents (their task is to be 'a good enough parent') who provide an encouraging environment in which trainees can test their skills. The environment is tolerant of failure. Mistakes are expected but mechanisms are in place so that these mistakes do not have devastating consequences and instead serve as opportunities of learning. Excessive control – or complete lack thereof – at this point foils the development of trainee's sense of internal mastery.
3) Initiative vs. Guilt
Existential Question: Is it okay for me to take decisions and act independently?
This is the stage at which trainees begin to assert themselves, grow more curious, and begin to question the information they are receiving. If this tendency is excessively criticized or punished, the trainees may develop feelings of guilt; when addressed in a balanced manner, a sense of purpose follows.