Academic Psychiatry 23:14-19, March 1999
© 1999 Academic Psychiatry
Residents in Personal Psychotherapy
A Longitudinal and Cross-Sectional Perspective
Daniel Weintraub, M.D.,
Lisa Dixon, M.D., M.P.H.,
Elizabeth Kohlhepp, M.D. and
Janet Woolery, M.D.
Dr. Weintraub is Assistant Professor of Psychiatry at the University of Louisville School of Medicine. Dr. Dixon is Associate Professor of Psychiatry and Residency Training Director at the University of Maryland School of Medicine. Drs. Kohlhepp and Woolery are currently in private practice. Address correspondence and reprint requests to Dr. Weintraub, Norton Psychiatric Clinic, 200 E. Chestnut St., Louisville, KY 40202; e-mail: danielweintra{at}alliant.org
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ABSTRACT
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The authors tested the following hypotheses: 1) that current psychiatry residents engage in personal psychotherapy less frequently than did former residents; 2) that there are interprogram differences with respect to engagement in personal psychotherapy among current residents; and 3) that attitudes about the professional utility of personal psychotherapy and toward psychodynamic therapy as a form of treatment are related to participation in personal psychotherapy. A 66-item anonymous questionnaire was sent to 119 current residents at three local residency training programs and 209 former residents of one of the training programs. The questionnaire gathered information on the residents' participation in insight-oriented personal psychotherapy and attitudes toward personal therapy and toward psychotherapy as a treatment for patients. Current residents (20%) partake less frequently in personal psychotherapy during training than did former residents (70%) (P<0.0001). Among those in therapy, current residents have less frequent sessions than former residents. There are differences in participation in personal psychotherapy among current residents of different programs, ranging from 6% to 60% (P<0.0001). Residents in personal psychotherapy are more likely to acknowledge professional utility in personal therapy and to believe that residents should learn how to deliver insight-oriented therapy. These findings suggest that there has been a recent decline in the use of personal psychotherapy during residency training and a concomitant lower value assigned to psychodynamic therapy by trainees. This lower utilization may be the cause and/or the effect of the lower valuation. If confirmed, these findings reflect significant changes in the training experience of psychiatrists and have implications for the delivery of psychiatric care.
Key Words: Treatment • Psychotherapies • Residents
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INTRODUCTION
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The tradition of the therapist obtaining personal psychotherapy began with Sigmund Freud, who wrote, "But where and how is the poor wretch to acquire the ideal qualifications which he will need to in his profession? The answer is in an analysis of himself" (1). To become a psychoanalyst, one must undergo a personal analysis, but personal therapy is not required of psychiatrists.
Few studies to date have evaluated the use of personal psychotherapy by psychiatry residents. Holt and Luborsky reported that 67% of 238 residents surveyed from 1946–1952 at the Menninger School of Psychiatry had received or sought psychoanalysis or psychodynamic psychotherapy (2,3). Casariego and Greden's survey of 112 residents at six Baltimore–Washington residency training programs found that 52% were in personal therapy by their third year of training (4). Weissman reported that 50% of postgraduate year PGY-4 residents surveyed from around the country in 1994 reported being in psychotherapy, and about 10% were in psychoanalysis; however, only 20% of the 1,442 surveyed residents responded (5).
We studied the participation in personal psychotherapy by current (those in training during 1994–1995 academic year) residents at three local residency training programs (hereafter referred to as Programs A, B, and C) and former psychiatry residents (those who completed training between 1970 and 1994) at one of the programs (Program C). We hypothesized that there has been a decline in participation in personal therapy by residents in recent years, that there are interprogram differences with respect to engagement in personal therapy, and that there are attitudinal differences about personal therapy and insight-oriented therapy as a form of treatment between those residents who are in personal therapy and those who are not.
The study's goals were to determine 1) the change over time in the rate of participation in individual insight-oriented psychotherapy during training, 2) the rates of participation in personal therapy among current residents of different programs, and 3) the attitudes of current residents concerning personal psychotherapy and insight-oriented psychotherapy as a form of treatment. "Therapy" or "psychotherapy" hereafter refer to individual insight-oriented or psychodynamic psychotherapy, as the personal therapy of psychiatrists has traditionally been of a psychodynamic (i.e., insight-oriented) nature.
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METHODS
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A 66-item anonymous questionnaire that took 15 minutes to complete solicited the respondents' demographics, name of training program, year residency training was completed, educational debt, participation in insight-oriented personal therapy, attitudes toward personal therapy, and attitudes toward psychotherapy as a treatment. If the respondent was in therapy, the type of therapy and therapist, frequency of sessions, when therapy was started, percentage of gross income spent, and reasons for seeking psychotherapy were also determined. Those not in therapy were asked the reasons for not seeking therapy. Former residents not in therapy during training were asked about postresidency participation in personal therapy.
The survey was sent by mail in the fall of 1994 to all 119 current residents at the three local psychiatry residency programs and to 209 former residents of one of the psychiatry training programs for whom addresses could be obtained through the residency training office and the American Psychiatric Association Directory. As mailed questionnaires generally have a low response rate, we chose to target former residents only at the training program where we were located and knew the most graduates. Respondents were told that the survey was part of an academic project to determine the rate of participation in personal psychotherapy by residents during training. Numeric coding of the surveys with no linkage to names available to the analytic team assured anonymity.
A total of 96/119 (81%) current and 114/209 (55%) former residents returned surveys. Overall, the respondents were 84% (172/204) American medical graduates (AMGs), 78% (162/207) Caucasian, and 56% male (114/205). Sixty-one percent (126/208) of the respondents reported having educational debt at the time of training. Table 1 shows the demographic characteristics of groups defined by period of training and program.
We conducted two sets of comparisons of rates of participation in personal therapy. First, we compared current and former residents in the same program. Second, current residents in different programs were compared with each other. We initially did bivariate analyses, using chi-square for categorical data and analyses of variance for continuous data, to determine factors associated with therapy participation. We then conducted additional multivariate analyses to control for factors such as country of medical school training (international medical graduates [IMGs] vs. AMGs) in therapy participation. A similar strategy was used to determine the attitudes associated with therapy participation. Statistical significance was defined as P<0.05, and all tests were two-tailed.
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RESULTS
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Comparison of Former and Current Residents at Program C
Former residents were more likely than the current residents to use therapy during residency training (79/113 [70%] vs. 11/54[20%],  2=34.1, df=1, P<0.0001). Bivariate analysis suggested that the AMGs were more likely than the IMGs (81/131[62%] vs. 8/31[26%], 2=13.14, df=1, P<0.0001) and that Caucasians were more likely than non-Caucasians (77/126 [61%] vs. 13/39 [33%], 2=9.27, df=1, P=0.002) to participate in therapy. Logistic regression covarying for period of training (current vs. former), race (Caucasian vs. non-Caucasian), gender, educational debt (none vs. any), and country of medical school training (IMGs vs. AMGs) showed that the former residents were more likely than the current residents to have received therapy (odds ratio=6.1, Z=4.2, 95% confidence interval =2.6–14.4, P<0.001). In the full model none of the other covariates (i.e., race, gender, educational debt, country of medical training) were significantly associated with therapy participation.
When the former residents were divided into 5-year blocks and compared with each other, there were no differences among these groups in the use of personal psychotherapy: 67% (8/12 for 1970–1974), 81% (13/16 for 1975–1979), 78% (14/18 for 1980–1984), 72% (21/29 for 1985–1989), and 61% (23/38 for 1990–94).
Of concern was the possibility of underestimating the participation of current residents in therapy, since they might still enter personal therapy during the remainder of their residency. One way to address this issue is to assume that the proportion of residents in therapy who started prior to training would be similar for current and former residents. Forty-three percent (34/79) of the former residents in therapy started therapy prior to training. Seven current residents started therapy prior to training. If these 7 residents eventually constituted 43% of the total current residents in therapy by the end of training, then 16 current residents (30%) would be in personal therapy by the end of training. Even if this projection was correct, current residents remain less likely than former residents to participate in personal therapy (2=20.76, df=1, P<0.001).
We are, however, aware that this assumption might be incorrect. Current residents may be more or less likely to start therapy while in training than former residents. For the rate of participation in therapy between current and former residents to be equivalent, almost two-thirds (28/44) of the current residents not presently in therapy would have to start therapy before the end of residency. Since at least 8 of the current residents were about to complete training without having been in therapy, over three-quarters (28/36) of the remaining residents would have to start therapy during training to produce equivalent rates of participation. This scenario seemed highly unlikely.
Looking at those residents who did start therapy during training, 49% (22/45) of former residents began during their PGY-1 or PGY-2, and 51% (23/45) started in their PGY-3 or PGY-4. Of the four current residents who started therapy during training, two began in each the PGY-2 and PGY-3. Of the current residents in therapy, five were PGY-4s, three were PGY-3s, two were PGY-2s, and no PGY-1s were in personal therapy.
When comparing the frequency of therapy, former residents were more likely than current residents to have been in twice per week psychotherapy (former: 24/79 [30%] vs. current: 1/11 [9%]) or psychoanalysis (former: 32/79 [41%] vs. current: 0/11 [0%] [2=16.09, df=2, P<0.001]). There were no differences between the current and former residents in type of therapist seen (psychoanalyst vs. nonanalyst), percentage of gross income spent on therapy, and reasons for seeking therapy (both groups overwhelmingly listed personal reasons as the primary reason for seeking therapy, with professional or other reasons a distant second and third). Table 2 lists the changes over time in participation in and frequency of personal therapy at Program C.
The resident groups differed in the reasons listed for not receiving personal psychotherapy. The current residents not in therapy were more likely to list cost (current: 23/41 [56%] vs. former: 8/33 [24%]), whereas the former residents not in therapy were more likely to list time (current: 7/41 [17%] vs. former: 11/33 [33%]) or other factors (current: 11/41 [27%] vs. former:14/33 [42%]) as the primary reason for not seeking psychotherapy (2=7.73, df=2, P<0.05). A minority (3/34 [9%]) of the former residents not in therapy during training started therapy postresidency.
Comparison of Current Residents at Programs A, B, and C
Sixty-five percent (62/96) of the current residents at the three programs reported never having been in therapy of any sort, 28% (27/96) reported engaging in individual personal therapy, and 8% (7/96) reported being in non-insight-oriented therapies. Bivariate analyses revealed that training program and country of medical school training (AMG vs. IMG) were associated with personal therapy participation; year of training, ethnicity, age, gender, marital status, and educational debt were not. Sixty percent (15/25) of the residents at Program A were in personal therapy, compared with 6% (1/17) in Program B and 20% (11/54) in Program C. Post-hoc analyses revealed that residents at Program A were more likely to engage in therapy than residents in either Program B or C (2=18.3, df=2, P<0.0001), and there were no differences in therapy participation between Programs B and C. AMGs (35% [25/72]) were more likely to receive personal therapy than IMGs (9% [2/22] [2=5.4, df=1, P=0.02]). Logistic regression controlling for training program and country of medical school training showed that only the training program was significantly associated with involvement in personal therapy (odds ratio=1.93, 95% confidence interval =1.1–3.4, P=0.02).
For those residents engaged in personal therapy, 70% (19/27) began prior to residency training, whereas the other 30% (8/27) began sometime during their residency. Most (17/27, 63%) had been in therapy for more than 2 years, 22% (6/27) for between 1 and 2 years, and 15% (4/27) for less than 1 year. Seventy-eight percent (21/27) listed personal reasons as the main reason for engaging in personal therapy, whereas 22% (6/27) cited professional reasons (i.e., to improve overall psychiatric skills or to improve psychotherapy skills). About one-half (13/27) of the residents were in therapy with a psychoanalyst. Most residents (81% [22/27]) were in therapy one session per week, 15% (4/27) were in twice a week therapy, and 1 resident was in psychoanalysis (4% [1/27]).
For those residents who reported never being in personal therapy, 45% (31/69) cited cost as the primary reason, 25% (17/69) listed lack of time, and 16% (11/69) believed that personal therapy would not be helpful. Fourteen percent (10/69) endorsed other reasons.
We found differences in attitudes toward personal therapy and psychotherapy as a treatment between current residents engaged and those not engaged in personal therapy. After controlling for training program, the residents in therapy were more likely to endorse the beliefs that personal therapy helps a psychiatrist to function professionally (F=7.09, df=1,90, P<0.001) and that residents should be taught to deliver insight-oriented therapy (F=4.67, df=1,90, P<0.05). The residents engaged in personal therapy were also more likely to endorse the statement that prior to training they wanted to learn how to deliver insight-oriented therapy (F=4.10, df=1,90, P<0.05).
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DISCUSSION
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To our knowledge, this is the first study to examine the change over time in the use of personal psychotherapy by psychiatry residents at one training program and to compare rates of personal psychotherapy among current residents at different training programs. The major conclusions reached were that 1) residents engaged in personal therapy at a high rate over the past 25 years, with a signficant decrease among current residents (i.e., those who entered residency after 1990); 2) current residents engage in personal therapy at a low rate, and there are interprogram differences; and 3) attitudes about personal therapy and whether psychiatrists should learn how to deliver psychotherapy are associated with engagement in personal therapy.
The reasons for the decline in personal therapy over time are not clear, but possible explanations can be roughly grouped into two categories: those that are program-specific and those that may reflect a national trend. Factors specific to Program C might include changes in the curriculum, the inevitable change in faculty over the years (including a new departmental chairman and two new training directors), changes in availability or cost of psychotherapy for residents, and time restriction. When asked about their reasons for not being in personal therapy, the current residents most frequently listed cost as the determining factor, yet presence of educational debt was not a factor statistically in predicting therapy participation. It is possible that other aspects of cost not measured by this survey (e.g., changes in insurance coverage for psychotherapy) may be important factors in determining therapy participation, or there may be other unacknowledged reasons that current residents do not enter psychotherapy. Of note, there is partial reimbursement of personal therapy for current residents (50% of reasonable cost for 50 sessions per year), and reduced-fee psychotherapy and psychoanalysis is available.
Other possible factors for the decrease in the use of personal therapy that are not specific to Program C include dilemmas over use of insurance reimbursement for personal psychotherapy (i.e., possible jeopardization of future insurability); use of non-insight-oriented therapy such as cognitive-behavioral or interpersonal therapy; use of nonpsychotherapy means, including medication, to gain understanding of oneself or to alleviate distress; the move toward managed care with the resultant deemphasis of psychotherapy skills for psychiatrists; and the recent shift in psychiatry toward a biological focus and away from a psychodynamic approach, which may have led to the recruitment of residents with a decreased interest in psychodynamic therapy.
How do we begin to explain the differences observed among Programs A, B, and C? The orientations of the programs have traditionally differed. Program A has the greatest emphasis on psychodynamic psychiatry, Program B the greatest emphasis on biological psychiatry, and Program C is by reputation somewhere in between. It is possible that interested residents may have selected Program A because of its greater emphasis on psychodynamic psychiatry and that those residents were also more likely to engage in personal therapy. This argument is supported by the fact that 70% of the current residents in therapy started their therapy prior to residency training, thus indicating an interest in psychodynamic therapy that predated psychiatric specialization. Only 8% (8/96) of the residents responding from the three programs reported starting therapy while in training, so it is possible that the programs do not convey the message that personal therapy is of potential value to a training psychiatrist.
Finally, current residents in therapy differed from those not in therapy in placing a greater professional value on personal therapy and in believing that learning how to deliver psychotherapy should be a part of psychiatry training. It is not clear if the experience of being in personal therapy led those residents to place a greater value on psychiatrists' ability to deliver psychotherapy. At this time, it is impossible to substantiate the belief of those in personal therapy that the experience makes one a more effective psychiatrist.
There are several limitations to this study. In spite of our efforts to provide anonymity, some respondents may have been concerned about confidentiality. Our response rate was lower for former residents, and it is possible that nonrespondents were less likely to have been in therapy. The precipitous drop in personal therapy among current residents may reflect an artifact or an underestimate, as some current residents are likely to enter personal threrapy during their remaining years of training. Also, there is no way to know if the association of favorable attitudes toward psychotherapy and engagement in personal therapy reflects a cause, an effect, or both. Finally, the data over time represent one program's experience, so it is unclear if this represents a nationwide trend, and the current data represent the experiences of trainees in only one city. Future studies should prospectively follow residents through their training and attempt to survey a wider distribution of residents, both over time and geographically. It is also important to determine the impact of personal therapy on the personal and professional lives of psychiatrists.
If our findings are validated, they have implications for the training of psychiatrists and for the field of psychiatry as a whole. Psychiatry is now in great flux, and there is increasing pressure to diagnose and treat patients quickly, with an emphasis on nosology and psychopharmacology at the expense of psychological understanding. There are fewer skilled faculty available to teach and supervise psychotherapy, and treating patients in long-term psychodynamic therapy during training has been deemphasized by residency programs or limited by managed care. Many psychiatrists complain about their loss of autonomy and dissatisfaction with changes in the delivery of mental health treatment.
Where does personal therapy fit into this picture? Has it become an anachronism in an era of biological psychiatry? Or should training programs recognize and encourage it as being of potential value to psychiatric residents, particularly at a time when the foundation of psychiatric training is shifting? If not, future psychiatrists will be practicing psychiatry, and perhaps delivering psychodynamic therapy, without having had the experience of personal therapy to help understand themselves and their patients.
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REFERENCES
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Freud S: Analysis terminable and interminable (1937), in Complete Psychological Works, Standard Edition, Vol 23. Translated and edited by Strachey J. London, UK, Hogarth Press, 1964, p. 246
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Holt RR, Luborsky L: Personality Patterns of Psychiatrists, Vol I. New York, Basic Books, 1958, pp. 63–67
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Holt RR, Luborsky L: Personality Patterns of Psychiatrists, Vol II. Topeka, KS, The Menninger Foundation, 1958, pp. 20–27
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Casariego JI, Greden JF: Perceptions of treatment value, therapeutic orientation, and actual experience of psychiatric residents. Compr Psychiatry 1978; 19:241–248[Medline]
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Weissman S: American psychiatry in the 21st century: the discipline, its practice, and its work force. Bull Menninger Clin 1994; 58:502–551[Medline]
This article has been cited by other articles:
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C. Mace
Personal therapy in psychiatric training
Psychiatr. Bull.,
January 1, 2001;
25(1):
3 - 4.
[Full Text]
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ABSTRACT
INTRODUCTION
