Sacramento Street Psychiatry

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Therapy for Therapists

Should therapists have therapy themselves?

Tara Parker-Pope of the New York Times blog Well featured my prior post, on the feelings some patients have as they imagine whether their psychotherapists have been in therapy themselves. My post was about patients' fantasies, not the reality of therapy for therapists. Nonetheless, many of the comments argued for the great value of such therapy, and one or two expressed amazement that such therapy is not universally required. I agree that psychotherapists have much to gain from personal therapy, and in this follow-up post I'll offer some reasons why.

Is therapy required in order to become a therapist? In the U.S., generally not. According to Geller, Norcross, and Orlinsky [1]: "In most European countries, a requisite number of hours of personal therapy is obligatory in order to become accredited or licensed as a psychotherapist. In the United States, by contrast, only analytic training institutes and a few graduate programs require a course of personal therapy."

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A "training analysis" is required to become a psychoanalyst. I.e., one must be analyzed oneself. However, in the U.S. personal therapy is not required to practice other schools of psychotherapy, nor to obtain licensure in mental health disciplines such as psychiatry, clinical psychology, etc. Specific training programs within a discipline may require it, and certainly a large number of programs recommend personal psychotherapy for their trainees. Indeed, many strongly encourage it by offering referrals to therapists, low-fee therapy, time off from training to attend therapy, and so forth. In a 1994 survey of psychologists by Kenneth Pope and Barbara Tabachnick, 84% reported having had psychotherapy themselves, although only 13% had attended a graduate program requiring personal therapy for therapists-in-training [2]. Whether by mandate, urging, or independent choice, many practicing psychotherapists can claim experience in "the other chair."

At the most commonsense level, a therapist who knows what it is like to be a patient may be more empathic, and may anticipate unstated feelings more readily than a therapist without this first-hand knowledge. For example, vacation breaks can feel extraordinarily disruptive to patients, a fact that can be taught in lectures or textbooks (or blogs), but may not be fully appreciated until it is experienced oneself. Transference in general is better understood experientially than learned academically. Even non-analytic therapists can benefit by recognizing transference and other common "real-time" emotional reactions, conscious and unconscious, in their patients or clients; these can affect rapport, treatment adherence, and so forth. Psychodynamically informed practice is a hallmark of psychiatry, even when psychodynamic treatment is not offered. The same, I would argue, is true of other mental health disciplines. Psychologists conducting CBT and clinical social workers leading support groups should know about psychodynamics too. And the best way to learn dynamics is experientially, in one's own psychotherapy.

The argument is even stronger for therapists who practice traditional psychodynamic therapy, where transference and countertransference are essential treatment tools. As I wrote last year, it takes self-knowledge to use countertransference therapeutically. Without this self-knowledge it would be impossible to sort out the patient's issues from one's own. In seminars for psychiatry residents, I point out that our field has no blood test or brain scan to directly measure thoughts and feelings in the interpersonal space. Our own feelings, countertransference broadly defined, is the sensitive instrument we bring into the consultation room. The therapist's own psychotherapy "calibrates the instrument" so he or she can better trust its readings when applied to patients.

To me, this is the main reason to recommend therapy for therapists. In addition, others have argued that it normalizes and destigmatizes being in therapy (assuming the therapist discloses his or her personal therapy to the patient); that it improves one's performance as a therapist non-specifically, by relieving stress and tension; and that it may give the therapist "a valuable perspective on what works and what doesn't." Several commenters on the NY Times blog believe the therapist's own therapy encourages humility, and may decrease errors based on hubris and unexamined countertransference:

We are to be one of the self monitoring professions, responsible in a unique way as the stewards of our treatment with our clients.... Having our own issues worked with ... goes a long way toward ensuring a unique quality of care.

I would be very wary of a therapist who had never sought therapy for him or herself. To me it would smack of an "I don't need it - it's for messed up folks like you" attitude.

I am also frequently shocked by the stories my patients will tell me about being in therapy with someone who clearly hasn't worked on their issues. It can be very damaging to a patient...

A personal psychotherapy does not guarantee that a therapist will be caring, non-abusive, technically proficient, or effective. But there is little in psychotherapy, or in life, that is guaranteed. Psychotherapeutic work, particularly the psychoanalytic and psychodynamic varieties, seems closely tied to the therapist's self-knowledge and willingness to self-reflect. If we are to use our own perceptions and reactions as sensitive instruments in the consultation room, we are well-advised to take good care of the equipment.

[1] Geller JD, Norcross JC, and Orlinsky DE, The Psychotherapist's Own Psychotherapy: Patient and Clinician Perspectives, Oxford University Press, 2005.

[2] Pope KS and Tabachnick BG, "Therapists as Patients: A National Survey of Psychologists' Experiences, Problems, and Beliefs" Professional Psychology: Research and Practice, 25(3), pp 247-258.

© 2011 Steven Reidbord MD.  All rights reserved.

Steven Reidbord, M.D., is a psychiatrist and psychiatric educator, and chairs the Continuing Medical Education Committee at California Pacific Medical Center.

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