Psychiatric practice and residency training in the United States have changed dramatically over the past 50 years. An explosion of knowledge; increased understanding of the neurobiology of psychiatric illness and treatment; and changing methods of payment, treatment, and service delivery, including the advent of the “split” treatment model, have led residency training programs to reevaluate the core curriculum and residency requirements. Although learning psychotherapy has been reaffirmed as a core competency for residents (1) and continues to be an essential part of psychoanalytic training, its place in residency training has diminished substantially (2). Many educators have concerns that this trend will contribute to lowered expectations for psychiatric residents’ skills in forming and maintaining a therapeutic doctor-patient relationship.

Studies from the 1950s to the 1970s showed that 52% to 67% of residents were in personal psychotherapy (3–5). In 1994, a survey of all postgraduate-year 4 (PGY-4) residents found that 50% were in psychotherapy, but the response rate of that survey was only 20% (6). A more recent national survey of chief residents and training directors found that in almost 50% of programs, fewer than 25% of residents were estimated to be in psychotherapy; only 10% of programs had more than 50% of their residents in psychotherapy (7). Another study in 1999 found that 28% of current residents in the Louisville area were in psychotherapy, while a subsample of previous graduates found a rate of 74% (8). Most recently (2006), Fogel (9) surveyed residents in PGY-2 to PGY-4 in Manhattan programs and found that 57% were in psychotherapy. This study’s aims were to provide more current and nationally representative data regarding residents’ experiences with and views of personal psychotherapy. In particular, the study investigated rates and types of psychotherapy and the perceived barriers and attitudes toward personal psychotherapy.

Study Participants

Residency programs in both general and child and adolescent psychiatry were selected using a random number generator from the American Association of Directors of Psychiatric Residency Training’s regional list of training programs. Two general and three child programs were chosen from each of the seven regions defined by APA. Training directors were contacted to provide a list of each program’s residents and their e-mail addresses. Thirty-seven programs were contacted, and 25 responded (67%). Residents from these programs were sent e-mails personally addressed to them with an explanation of the study and a request for participation. The letter included a direct link to the anonymous, web-based survey, which was a 21-item questionnaire designed to investigate residents’ experiences with and attitudes toward personal psychotherapy, including perceived barriers to pursuing it.

The survey included questions about the residents’ demographic characteristics, personal experiences with past or present psychotherapy, and opinions about psychotherapy and its helpfulness for personal and professional growth, as well as factors encouraging or hindering their pursuit of psychotherapy. Responses included Likert scales, ranked items, and answers to closed- and open-ended questions. The survey was developed by the authors (JH, a resident, and DK, a training director), with additional input and review by two experienced psychiatric educators, and is available upon request. The study received institutional review board approval.

A total of 390 residents were contacted in February, 2006. Over the following 2 months, up to two additional e-mails were sent to nonresponders. The chief resident of each program was also contacted by phone after the second mailing. Of the 390 residents asked to participate, a total of 107 residents (27%) completed the survey.

Statistical Analysis

Data were analyzed with SPSS 13.0 for Windows. Descriptive statistics included mean, median, standard deviation (SD), and frequency. Chi-square analyses and Spearman’s correlations were used in data analyses using nonparametric data.

Respondent demographic characteristics are summarized in Table 1, and survey responses regarding personal psychotherapy experiences are summarized in Table 2. Approximately one-third of respondents were currently in psychotherapy; the majority of respondents were in psychoanalytic psychotherapy (n=20, 58.8%,). Forty-two percent of respondents had been in psychotherapy at some time in the past; the majority sought supportive (n=15, 33.3%) or psychoanalytic (n=11, 24.4%) psychotherapy. Being a resident in a program affiliated with a psychoanalytic institute was associated with a greater likelihood of currently being in therapy (χ²=8.60, df=1, p<0.003). Of the 34 participants (32.1%) who were currently in therapy, 28 came from affiliated programs (82.4%). In contrast, being a resident in a program affiliated with a psychoanalytic institute was not related to whether respondents had previously sought therapy. Attending a U.S. or international medical school was not related to current therapy attendance, but it was significantly related to being in psychotherapy in the past (χ²=17.82, df=1, p<0.001).

Participants’ year in training was significantly associated with current therapy (r_s=0.20, df=107, p<0.04) and previous therapy (r_s=0.19, df=107, p<0.05), such that advanced training was associated with being in therapy both currently and previously.

Respondents were also asked to rank reasons for which they initiated therapy during their training. Respondents indicated their top two reasons as “for personal issues or problems outside of training” and “to improve my skills as a psychotherapist.”

Respondents were asked to rate on a 7-point scale (1=not at all, 7=very much so) and to place in rank order to what degree they experienced several barriers to pursuing psychotherapy during their training. Both “cost” and “training demands make it difficult to find time” were rated over 6 and consistently cited as the top two barriers. Those who sought therapy were asked to rate how helpful current therapy was to their professional development and how helpful previous therapy was to their personal and professional development on a 7-point scale (1=not at all helpful, 7=very helpful). Most respondents currently in psychotherapy found it to be helpful to their professional development (mean=6.0±1.2). Previous therapy was reported as somewhat less helpful to professional development (mean=5.1±2.0).

In our study nearly one-third of respondents were currently in psychotherapy and 43% had been in the past. Given the low response rate and likelihood of response bias (i.e., programs and residents who endorse personal psychotherapy for residents could be expected to have responded at higher rates), these are likely significant overestimates of a representative sample. Even given this, the percentages are substantially lower than rates shown in the past. Not surprisingly, they are also lower than the rates found by Fogel (9).

The low response rate could reflect a generally diminished interest in this issue among training directors and residents, although the response rate is slightly higher than the only other nationally representative sample addressing this issue (6). It would be helpful to compare these rates with those obtained in studies during the height of popularity of psychoanalysis, but there are no nationally representative studies from that era. These past studies used more limited samples and hence may not be comparable.

Generally, residents have been in psychodynamic psychotherapy, and few pursue cognitive behavior approaches. This may reflect a traditional and stronger endorsement of psychodynamic psychotherapy by supervisors and faculty. Other factors might include the goals that residents had (i.e., more for personal growth, self-understanding, and professional development than for treatment of specific disorders) or lack of availability of competent cognitive behavior therapists.

Both advanced training and affiliation with a psychoanalytic institute were positively correlated with having a personal psychotherapy experience. This is consistent with previous studies and reflects both selection bias by residents (i.e., residents interested in psychotherapy are more likely to apply to programs affiliated with psychoanalytic institutes) as well as increased support for personal psychotherapy at these programs.

The primary barriers to personal psychotherapy were time and money. This is also consistent with stated reasons found in previous studies. Although residents did not perceive stigma or attitudinal barriers to pursuing psychotherapy, programs may be able to further encourage their trainees to enter psychotherapy in many ways, including providing greater support for residents’ involvement in psychotherapy by explicitly discussing the issue or including a policy in the program manual, providing a list of recommended psychotherapists in the community, and arranging for reduced fees or providing reimbursement with educational funds.

Limitations

Conclusions from this study are limited by the response bias. Twenty-five of 36 program training directors responded, and fewer than one-third of residents who were contacted completed the survey. It is likely that programs which view personal psychotherapy as important responded to the request for resident information. In parallel, residents who have an interest in the issue of psychotherapy or who are in psychotherapy may have been more likely to respond.

Although the sample was representative of the current demographics of psychiatric residents (gender, age, ethnicity, and number of U.S. versus international medical graduates) a disproportionate number of child and adolescent psychiatric residents responded to the survey. Because these are more advanced residents, the overall percentage of residents in psychotherapy likely increased.

In this limited sample of current residents in psychiatry, a significant minority have been or are currently in psychotherapy. These percentages appear to be lower than in past cohorts of psychiatric residents. Psychodynamically informed psychotherapy was the treatment of choice for residents pursuing psychotherapy, and few selected a cognitive behavior approach.

At the time of submission, the authors disclosed no competing interests.