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A lighthearted exploration of Erikson’s stages through residency training.
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.
4) Industry vs. Inferiority
Existential Question: Can I survive and flourish in this program?
Trainees may experience a need to gain the approval of superiors and peers by achieving tasks that are valued in the program, and with their successful accomplishment, develop a sense of internal pride. Failure to live up to standards of competence can lead to a sense of inferiority.
5) Identity vs. role confusion
Existential Question: What is my identity as a psychiatry resident, and what will be my identity as a psychiatrist?
Residents go through a period of intense self-exploration of what their place in the program is and how they contribute value to it. This self-exploration is paralleled at a higher level as they canvas the field of psychiatry and try to determine what their professional goals are during training and afterwards.
Efforts to resolve role confusion may lead trainees to seek clinical exposure to an array of different settings to a degree that is beyond what is expected in the program.
6) Intimacy vs. isolation
Existential Question: Can I develop intimate, meaningful relationships with my peers?
This stage concerns the social life of trainees within the residency program. Close, fulfilling friendships and relationships develop with other residents, which contribute to overall meaningfulness and well-being; their absence may lead to loneliness and dissatisfaction.
7) Generativity vs. stagnation
Existential Question: Can I make my residency count? What and how much can I achieve?
Building on a sense of competence, residents engage in productive ventures and work to establish their place in the program. Leadership roles-such as acting attendings and chief residents – are pursued. There are active contributions to education, research or administrative aspects of the program. Failure to be productive may lead to a sense of stagnation.
8) Ego integrity vs. despair
Existential Question: Is it okay to have been me as a psychiatry resident?
Confronting the end of training is in some ways akin to confronting one's mortality; an important phase of life is coming to an end, and residents will look back at what they have accomplished, relationships they have developed, and the legacy they are leaving behind. The wise survive this encounter with acceptance and closure, ready to face the challenges of the next step in their professional lives.