Academic Psychiatry 22:223-228, December 1998
© 1998 Academic Psychiatry
Attitudes of U.S. Psychiatry Residencies About Personal Psychotherapy for Psychiatry Residents
Karen A. Daly, M.D.
Dr. Daly is a staff psychiatrist in the Department of Mental Health at Naval Medical Clinic, Pearl Harbor, Hawaii. Address reprint requests to CDR Daly, MC, USN, Mental Health Department, P.O. Box 121, Naval Medical Clinic, Pearl Harbor, HI 96860–5080.
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ABSTRACT
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This study examined the current attitudes and policies of U.S. psychiatry residencies about psychotherapy for psychiatry residents. The survey was distributed to program directors and chief residents at 196 psychiatry residencies in the United States in 1995–1996. The author received 257 responses, representing 86% of all programs. Results are described and comparisons analyzed by contingency tests. Forty-two percent of U.S. psychiatry residencies recommended psychotherapy for residents, while a smaller percentage of residents engaged in therapy. The psychoanalytically oriented and other psychodynamic programs recommended therapy more often, had more residents in therapy, and perceived therapy as more helpful than the biologically oriented programs.
Key Words: Psychotherapy • Residents • Residency Training
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INTRODUCTION
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Should personal psychotherapy be part of the training of psychiatry residents? This is a controversial question, since the focus of psychiatric treatment and residency training continues to shift toward biologic modalities in contrast to traditional psychotherapeutic techniques as medical technology advances.
Personal psychotherapy during training has been encouraged and sometimes required for psychiatrists and other mental health care professionals since Sigmund Freud recommended it in 1912 (1–10). It is mandatory for psychotherapists who pursue postgraduate psychoanalytic training. Studies have shown its benefits can include therapists becoming more responsive to the therapeutic needs of their patients, but therapists may also become less spontaneous and more self-conscious in their work (2,4,11). Personal therapy has been found beneficial for psychiatry residents with emotional and personal difficulties (12–14).
The 1994–1995 Graduate Medical Education Directory's list of special requirements for residency education in psychiatry does not address the issue of personal psychotherapy (15). The 1994–1995 American Psychiatric Association's (APA) Directory of Psychiatry Residency Training Programs stated that 44% of the programs in the United States offered personal therapy (16).
A 1975 study of 86 psychiatry residents in the Washington, D.C., area showed that 52% rated psychotherapy as extremely important and that 52% were in personal therapy by their third year of training (17). The number of general psychiatry residents who obtain personal psychotherapy appears to have declined over the years. The Group for the Advancement of Psychiatry suggests one factor may be the cost of therapy (2). Another factor may be the decreased emphasis on psychodynamic and interpersonal techniques and increased emphasis on neurobiologic and psychopharmacologic modalities in psychiatry residency training (2,9,18).
This study attempts to describe the current attitudes and policies of U.S. psychiatry residencies regarding psychotherapy for residents and discuss the factors that influence residents to obtain therapy.
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METHODS
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Subjects
Study subjects were the program directors and the chief residents at the 199 psychiatry residencies in the United States and Puerto Rico listed in the APA's 1994–1995 Directory of Psychiatry Residency Training Programs. Three directors responded that their programs currently had no residents, leaving 196 active residencies. A total of 257 responses (66%) were received, representing 69% of program directors, 62% of chief residents, and 86% of residencies. Four percent of the respondents were military, representing 100% of military residencies.
Questionnaire
The study questionnaire was constructed based on a literature review (19–26). Other items were suggested by faculty and residents during the pilot testing of the questionnaire. The final questionnaire was derived from revisions based on feedback from the pilot testing. The questionnaire consisted of 18 items, including 17 multiple-choice questions and one Likert scale. The questions focused on the residency program's location, size, medical school affiliation, psychiatric orientation, and policy toward therapy, in addition to the percentage of residents in therapy, educational background of therapists, type of therapy received, and frequency, funding, and outcome of therapy.
Statistical Analysis
Data were described by histograms of categories. Where contrasts between the groups were posed, contingency tables were provided and tested by Fisher's exact test or chi-square when the number of categories was large (26).
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RESULTS
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Ninety percent of the respondents' programs were affiliated with medical schools. Sixty-five percent of the programs had 10–30 residents (Table 1). Seventy-one percent of the respondents described their program's psychiatric orientation as eclectic.
Forty-two percent replied that their program recommended psychotherapy for residents. Forty-eight percent of the respondents stated 0%–25% of residents were in therapy, 20% said 26%–50% of residents, and 20% were uncertain.
Six percent stated their programs provided therapists within the program, 24% provided a listing of therapists outside the program offering services at reduced fees, 27% provided a listing of referral therapists without fee information, 24% provided no assistance, and 20% stated assistance was arranged individually. Seven percent responded that therapy was funded by the program, 11% stated insurance was used, 26% stated the resident paid for therapy, and 49% reported a combination of funding sources.
Ninety-four percent of the programs replied that the resident chose the therapist. Twenty-three percent of therapists were psychoanalysts, 41% were psychiatrists, 19% were psychologists, and 7% were licensed clinical social workers. Fourteen percent of therapy received was analytic, 63% was psychodynamic or interpersonal, and 10% was cognitive–behavioral. Fifty percent of the respondents replied that the average frequency of therapy was 1 hour per week, and 38% were uncertain.
Of those responding to a Likert scale, 46% replied therapy was mostly helpful, and 38% stated it was moderately helpful. Sixteen percent did not respond to this question, often adding the outcome was unknown. Regarding outcomes, 33% of the responses noted "an improvement in professional practice," and 45% stated psychotherapy was "personally helpful."
There were no significant differences between the responses of program directors and chief residents regarding a program's policy toward therapy for residents, percentage of residents in therapy, or treatment outcome. There were no significant differences in program orientation, policy toward therapy, percentage of residents in therapy, or funding based on U.S. location.
There were significant associations between a program's policy toward therapy and the percentage of residents in therapy, assistance given to finding a therapist, funding, and outcome (Table 2). The programs that mandated or recommended therapy for residents had a higher percentage of residents in therapy, provided more assistance in finding a therapist, provided more funding for therapy, and their residents perceived therapy as more helpful than the programs that were neutral or discouraged therapy. Of the 43% of the programs that mandated or recommended therapy, 23% had 51%–100% of residents in therapy, 41% provided therapists within the program or at reduced fees, 13% provided funding, and 60% perceived therapy as mostly helpful. Of the 49% of programs that were neutral and that 1% discouraged therapy, 5% had over 50% of residents in therapy, 32% provided assistance finding a therapist, 3% provided funding, and 33% perceived therapy as mostly helpful.
There were also significant associations between a program's psychiatric orientation and its policy toward therapy for residents, percentage of residents in therapy, assistance in finding a therapist, and outcome assessment. One hundred percent of the analytic programs, 69% of the psychodynamic programs, 43% of the eclectic programs, and 32% of the biologic programs recommended therapy. Over 50% of the residents were in therapy in 33% of the analytic programs, 31% of the psychodynamic programs, 11% of the eclectic programs, and 6% of the biologic programs. Fifty-three percent of the analytic and psychodynamic programs, 33% of the eclectic programs, and 39% of the biologic programs provided assistance in finding a therapist within the program or at a reduced fee. Therapy was perceived as being "mostly helpful" by 100% of the residents in the analytic and psychodynamic programs, 90% of those in the eclectic programs, and 52% of those in the biologic programs.
There were significant associations between the percentage of residents in therapy compared with the size of the program and the funding available. The larger residencies had a greater percentage of their residents in therapy. Sixty-five percent of the programs with more than 30 residents had more than 50% of residents in therapy, compared with 28% with fewer than 20 residents and 40% with 20–30 residents. A larger percentage of residents were in therapy when funding was provided by the program rather than by insurance or resident resources. Fifty percent of the programs that funded therapy had 51%–100% of residents in therapy vs. 11% of programs where therapy was funded by insurance, 9% where therapy was paid for by the resident, and 15% where therapy was funded by a combination of sources.
The military respondents were composed of 37.5% Army, 37.5% Navy, and 25% Air Force. There were no significant differences between the services regarding program orientation, policy toward therapy, percentage of residents in therapy, funding, or treatment outcome. There were no significant differences between the military and civilian respondents regarding program orientation, policy toward therapy, or treatment outcome. There were significant differences in the following areas. A smaller percentage (50%) of the military programs are affiliated with medical schools. Fifty-five percent of the military programs have greater than 50% of their residents in therapy vs. 32% of the civilian programs, with 73% of personal therapy funded by the program and 18% by the resident. In the civilian programs, 4% of therapy was funded by the program, 12% by insurance, 27% by the resident, and 50% by a combination of sources.
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DISCUSSION
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A significant percentage of U.S. psychiatric residencies continue to recommend psychotherapy for residents, particularly residents who experience difficulties personally or professionally. A small number of the programs have formal systems established for providing therapy. Factors that influenced residents obtaining therapy included a recommendation from their program, an analytic or psychodynamic orientation, therapists provided within the program or at reduced fees, and program funding. Such programs were also more likely to perceive the therapy as helpful. The biologically oriented programs were less supportive and had fewer residents in therapy.
Military psychiatry residencies were rather similar to their civilian counterparts. The differences regarding funding may reflect military residents being ineligible for medical insurance, unless their spouses are privately insured. They are also ineligible for TRICARE government benefits that cover dependents.
The results of this study may not be applicable to the 14% of the programs not responding to the survey. These 28 nonrespondents were spread diversely throughout the country. Nonparticipation may reflect attitudes regarding therapy for residents.
In comparing findings from this study with prior research, some similarities and differences were noted. The 1975 Washington, D.C., study stated that 52% of the residents were in therapy (17); 68% of the respondents in my study reported that less than 50% of the residents in their programs were in therapy. The APA noted that 44% of the responding residencies "offer" therapy for residents (16); my study noted 43% recommend therapy, but few provide assistance. While dynamic therapy may be taught less often in residencies and in some cases is being supplanted by cognitive therapy and interpersonal therapy, 77% of the residents nevertheless receive analytic or dynamic therapy when they seek personal treatment. Personal psychotherapy for residents continues to be an important aspect of training in many programs and for many trainees, despite the changing face of psychiatry.
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ACKNOWLEDGMENTS
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The author thanks Robert Riffenburgh, Ph.D., and Kenneth J. Brodeur, Ph.D., for their assistance with the statistical analysis of this study.
The Chief, Navy Bureau of Medicine and Surgery, Washington, DC, Clinical Investigation Program sponsored this study (#S–95–113), as required by HSETCINST 6000.41A. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.
This work was presented at the Braceland Seminar, May 4, 1996, during the American Psychiatric Association meeting in New York. This work also won the U.S. Navy Hogan Award for 1996.
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ABSTRACT
INTRODUCTION
