Psychiatric residency training has changed dramatically over the years. Psychodynamic training, once central to the curriculum, is now frequently eclipsed by a neurobiological focus. More recently, concerns over the erosion of psychotherapy training in residency (1) led the Residency Review Committee for Psychiatry to affirm the importance of psychotherapeutic competencies. Training guidelines emphasize skills that enable the training psychiatrist to build a therapeutic alliance with patients, learn about the unconscious and the ways in which it impacts patients’ behavior, be attuned to the therapeutic relationship, and utilize transference and countertransference in the service of the treatment (2). Historically, personal psychotherapy has been viewed as an important experiential learning tool for the development of psychotherapeutic competence in these areas. Personal therapy experiences were believed to help therapists better manage irrational reactions to patients (3) and have fewer blind spots, experientially learn about the patient role to promote greater sensitivity to the patients’ experience, and help improve emotional functioning and alleviate the stresses involved in training (4, 5). For these reasons, many training programs once incorporated personal analysis or therapy into the residency training structure.
Studies from the 1950s (6) into the 1980s (7) showed two-thirds of residents seeking therapy during training. However, the rate of residents seeking therapy sharply dropped after 1990 (8). It is unclear if this trend has continued. This survey examines the current place of personal therapy in psychiatric training. Is personal psychotherapy still valued in psychiatry training? If so, why and for what? Do training directors perceive problems with personal therapy during residency? How often do residents seek personal therapy? What administrative and financial practices support personal therapy for residents? What program characteristics contribute to a culture in which residents more commonly seek personal psychotherapy experiences?
A 29-item, anonymous questionnaire was mailed to 182 U.S. training directors identified using FREIDA online and was followed up after 2 weeks by e-mail and after 4 weeks with an electronic version of the questionnaire.
Nine questions assessed program characteristics, including geographic location, patient setting, and program support for personal therapy. Multiple-choice questions examined the specific nature of financial support that the department makes available for residents and the estimation of the percent of residents in personal therapy. Additionally, 15 seven-point Likert-type questions assessed the attitudes and practices of training directors regarding personal therapy (Table 1).
The geographic distribution of this sample was compared with that of the national sample to assess whether programs offering support to reduce the cost of therapy beyond providing personal insurance varied across geographic location. Chi-square was used for these analyses. Assessment of mean differences in geographic location and percent of residents in therapy were analyzed by one-way analysis of variance (ANOVA). We also used ANOVA to examine if the directors’ belief and encouragement for personal therapy, for both personal crisis and as an educational tool, varied across geographic locations. An independent samples t test was used to compare the percentage of residents in therapy for programs with financial support beyond personal insurance with programs without financial support beyond personal insurance. We used a two-way ANOVA to assess whether geographic location moderated the effect of financial support on the percentage of residents in therapy. We calculated a partial correlation to assess the association between the directors’ encouragement of personal therapy, for both educational and health reasons, and the percent of residents in therapy while controlling for geographic location. Two-tailed tests were used throughout. The significance level was fixed at 0.05.
Eighty-six training directors (47%) completed and returned the questionnaire. The returns were geographically representative of the national sample (χ2=3.41, df=4, 86, p=0.64).
Is Personal Psychotherapy Still Valued In Psychiatry Training? If So, Why?
Almost all training directors agreed that personal therapy is overall useful and specifically valuable as an educational tool. The majority of training directors agreed that therapy is useful for dealing with premorbid psychopathology and helps residents deal with training stresses. Most also agreed that personal therapy is useful for learning about the experience of being a patient, managing emotional reactions toward patients, learning therapeutic technique, developing empathic skills, developing a professional identity, and improving patient care skills.
Is Personal Therapy Valued More for Health or Educational Reasons?
Almost half of residency directors (45%, n=38) always encouraged personal therapy when a resident is in crisis, whereas only 21% (n=18) always encouraged therapy as an aspect of training. While virtually all training programs (99%, n=85) at least sometimes encouraged personal therapy for residents in crisis, fewer than two-thirds (65%, n=55) regularly encouraged personal therapy as an aspect of training.
What Problems Did Training Directors Perceive About Personal Therapy?
Thirty-eight percent of respondents agreed that regression could be a risk of resident therapy, and one-half (47%) thought that stigma was a concern for residents. Moreover, 45% of training directors thought that residents were interested in psychotherapy, while 36% did not. Although the majority of training directors (80%) thought that the outcome of therapy justified the financial cost, time costs of therapy were more of a concern, with 36% agreeing that personal therapy could conflict with residents’ duties.
How Often Do Program Directors Think The Residents Seek Personal Therapy?
Most training directors (59%, n=48) estimated that fewer than 30% of their residents seek personal therapy. One-third (33%, n=27) estimated that 30% to 70% of the residents seek personal therapy, and a minority (7%, n=6) estimated that more than 70% of their residents seek personal therapy.
What Are Common Administrative and Financial Practices, If Any, to Help Support Personal Therapy for Residents?
Approximately 20% (n=17) of training directors offered no financial support for personal therapy. Most (73%, n=63) supported personal therapy by offering medical insurance. Nearly one-third of training programs (31%, n=27) offered financial support through a contractual arrangement for low-fee care or similar arrangements to reduce the cost of therapy. Only seven programs (8%) provided training program stipends.
What Program Characteristics Contribute to a Culture in Which Residents More Commonly Seek Personal Psychotherapy Experiences?
An ANOVA demonstrated a significant difference in the percentage of residents in therapy among different geographic regions (F=7.11, df=4, 75, p<0.001), with Northeast and West Coast training programs having a higher percentage of residents in therapy. In those same areas, training directors were more likely to recommend therapy for personal crisis (F=2.62, df=4, 80, p=0.04), as an aspect of training (F=2.94, df=4, 80, p=0.03), and to offer support beyond personal insurance to reduce the cost of therapy for residents (χ2=12.4, df=1, p<0.001, N=86).
Thirty-five programs (41%) offer financial support beyond personal insurance; these programs have a greater proportion of residents in therapy (t=4.15, df=57.15, p<0.001). A two-way ANOVA was calculated to determine if geographic location had an effect on the relationship between finances and the percentage of residents in therapy; the interaction was not significant (F=0.29, df=3, 71, p=0.83).
Training directors’ beliefs and encouragement for personal therapy, for both personal and educational reasons, were correlated with a greater percentage of residents in therapy. While controlling for geographic location, active encouragement of personal therapy for personal crisis (r=0.52, p<0.001) or as an aspect of training (r=0.46, p<0.001) is correlated with a higher percentage of residents in therapy. While controlling for geographic location, training directors’ beliefs that therapy is overall useful to residents is significantly correlated to the percentage of residents in therapy (r=0.40, p<0.001).
The statement “Therapy is overall useful to residents” does not distinguish if the belief is for health or educational reasons. Additional tests determined that the percentage of residents in therapy was not correlated to the belief that personal therapy is overall valuable as an educational tool (r=0.14, p=0.23). However, the percentage of residents in therapy was correlated with specific belief questions regarding the usefulness of personal therapy for health reasons: dealing with premorbid psychopathology (r=0.31, p=0.005) and the stresses of training (r=0.39, p<0.001).
Usefulness of Therapy for the Personal Lives of Residents
Our findings suggest that program directors think, overall, that personal therapy is helpful for residents in crisis, whether due to premorbid psychopathology or stresses of training. Personal therapy for trainees may be particularly important in psychiatric residencies because psychiatrists may have higher levels of emotional distress than physicians in other specialties, and psychiatrists in training may be particularly vulnerable (9, 10). This is not simply because psychiatry attracts residents with particular vulnerabilities (7, 11), but also because psychiatric residency provides unique emotional stresses not present in other fields (12–14).
At least two-thirds of therapists in previous studies (5, 15–19) reported their therapy experience to be beneficial, noting improved self-esteem and work performance, improved social and romantic life, and character change (16). Though personal therapy allows disturbed residents to grow and have more successful careers than those not receiving therapy (20), it is also clear that therapy will not “turn a sow’s ear into a silk purse” (21).
That 38% of program directors in our study believed that personal therapy could exacerbate residents’ distress is not surprising, given that psychotherapy is a medical procedure that carries the risk of a negative outcome. In prior surveys of therapists and residents, 14% to 40% reported some negative experiences (15, 16, 22, 23). Dubovsky et al. (24) argued that personal therapy carries the danger of pathologizing a phase-appropriate stage, namely, the “beginning resident syndrome.” One wonders if the risk of stigmatizing residents in therapy would be less if personal therapy were viewed as a tool for experiential learning rather than remediating problematic symptoms or character traits. Other risks of therapy for residents include a boundary-blurring identification with patients, aggravation of self-scrutiny, worsening of mood symptoms, and exacerbation of marital conflict. These risks likely account for some training director reluctance to actively encourage residents to seek therapy (11).
Usefulness of Therapy for Education
Program directors appear more likely to encourage personal therapy for health than for educational reasons. This parallels Henry’s (22) finding that therapists found personal therapy to be more helpful in their personal than in their professional lives. Macaskill (15) described trainees seeking therapy more often for personal than professional reasons (though finding it helpful regardless their motives). Still, in the present study, program directors value personal therapy as an educational tool, particularly for learning about countertransference, therapeutic technique, and empathy. To a lesser extent, they also thought it helped residents develop a professional identity and an understanding for the patient role and deliver better patient care.
Previous evidence concerning the impact of personal therapy on therapists’ skills shows why training directors might be more enthusiastic about therapy for health reasons than for educational reasons. Patients seem not to be able to tell the difference between therapists who have had therapy and those who have not (25, 26). Furthermore, some professional benefits that therapists derive from their own therapies may not show up until after residency. Strupp (27–29) found that experienced therapists were more empathic when they have undergone personal therapy, while inexperienced therapists were initially less empathic. Nonetheless, therapists who have had therapy have been shown to be better at containing countertransference reactions (30), are more adaptable, and are better able to interpret transference, independent of the therapist’s level of experience (30, 31). These benefits may be of particular interest to training directors, who are charged with promoting core competencies including professionalism (e.g., empathy and countertransference containment) and medical skills (e.g., ability to use interpretation competently).
Greater Resident Participation in Personal Therapy
Nationally, training directors estimate that 10% to 29% of residents are in therapy, approximating a recent survey study (32) showing that one-third of resident respondents received therapy during training. In the Northeast and the West coast, a higher proportion of residents sought personal therapy, also approximating findings that a majority of New York residents seek therapy (33). This pattern may reflect the influence of the larger culture, in which therapy is a normative approach to both personal problems and personal growth.
Program characteristics promoting personal therapy include the training director’s belief that therapy helps residents deal both with premorbid psychopathology and the stresses inherent in psychiatric training as well as active encouragement by the training director to use therapy for health and educational aims. Notably, the belief that personal therapy is a valuable educational tool is not, in itself, sufficient to foster an increased use of psychotherapy among residents. Instead, active encouragement to use therapy translates into increased use of therapy for educational purposes. The availability of financial/contractual support to minimize the cost of therapy to residents was another potent factor. Programs that offered a stipend for personal analysis or made arrangements for low-fee or free treatment had a substantially greater proportion of residents in therapy. It may even be that programs offering only insurance for personal therapy provide disincentives, because insurance raises a host of practical quandaries: Will the resident be labeled and stigmatized? Does payment for therapy give the resident a “preexisting condition”? Is it ethical to have insurance pay for what may largely be an educational experience?
Training programs found several ways to lessen the financial burden of therapy on residents. Programs that provided financial support beyond simply offering health insurance made agreements with local practitioners, psychotherapy training programs, or psychoanalytic institutes for low-fee psychotherapy; gave credit toward the time commitment required for academic appointment for faculty providing pro bono or low-fee therapy; made arrangements for partial reimbursement through the Resident’s Union; and/or offered a significant psychotherapy stipend. Perhaps the most creative solution was the psychiatry program that worked with the institution’s Medical Education Office to create a fund for the therapy of the psychiatric residents. The psychiatric residents offered reduced-fee therapy to trainees in other disciplines. In return, each department made a contribution to the psychotherapy fund for the psychiatric residents.
This study has a number of limitations. The return rate of the questionnaire was 47%, raising questions about whether there were significant differences between responders and nonresponders that could introduce bias into the results. The geographic distribution of our sample is similar to that of the original sample of training programs, suggesting that there is not an overrepresentation from any geographic area that could skew the results. It is possible that training directors who had more negative attitudes about therapy were less likely to respond. Furthermore, the conclusions about program characteristics that promote resident engagement in therapy are based on training director estimates and not on objective measures of trainees’ involvement in therapy or resident self-reports. Given that stigma is an issue experienced by some trainees in therapy (33), it is likely that training directors are underinformed about the actual numbers of residents in therapy, especially in programs demonstrating less enthusiastic attitudes toward personal therapy. Nonetheless, training director assessments seem to approximate (but slightly underestimate) reported percentages of residents in therapy from both national and regional samples. Finally, this study did not address the important question of the actual educational or health value of personal therapy during training but, rather, assessed the attitudes, perceptions, and practices of training directors and training programs.
Personal therapy does seem to be less a part of psychiatry than it was even 15–20 years ago. This is despite widespread agreement among training directors that personal therapy is overall useful to residents for both the promotion of mental health and also the development of professional competencies. Some training director attitudes about the usefulness of therapy seem to influence resident behaviors in seeking out personal therapy experiences, though training director practices are more potent. Encouragement to residents to pursue personal therapy and financial/contractual support to lessen the financial toll of therapy promote an environment in which residents are more likely to seek personal therapy during training. The overall culture outside of the program seems also to have an impact, with more residents from Northeast and West Coast residencies seeking therapy during training. Given the renewed focus on the development of competencies, our field may benefit from further research to assess whether personal therapy does indeed promote aspects of professionalism (e.g., empathy and ability to manage countertransference) and improvement of patient care.
The authors would like to thank the participants of the AADPRT Workshop “Is Personal Psychotherapy Still Relevant to the Culture of Psychiatric Training in the 21st Century?” in San Juan, Puerto Rico, March 10, 2007, for the thoughtful discussion that helped deepen our understanding of the complexities of this issue.
At the time of submission, the authors declared no competing interests.