Psychotherapist who abstain from personal theraphy
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Psychotherapist who abstain from personal theraphy Psychotherapist who abstain from personal theraphy Document Transcript

  • Brief Report Psychotherapists Who Abstain From Personal Therapy: Do They Practice What They Preach? m John C. Norcross University of Scranton m Denise H. Bike Loyola College in Maryland m Krystle L. Evans and Danielle M. Schatz University of Scranton The authors examined the attitudes and reasons of 119 American psychologists, counselors, and clinical social workers who had never sought personal therapy. Nontherapy seekers, compared to therapy seekers, expressed less-positive attitudes toward its value as a prerequisite for clinical work and for ongoing professional development. Women, men, and members of all three professions were equally likely to have sought therapy, but cognitive–behavioral therapists and academics were significantly less likely to do so. Top reasons for not undergoing personal therapy entailed dealing with stress in other ways, receiving sufficient support from friends and family, believing coping strategies were effective, and resolving the problem before therapy was needed. The likelihood of seeking personal treatment in the future as well as reasons for doing so are discussed. & 2008 Wiley Periodicals, Inc. J Clin Psychol 64:1368–1376, 2008. Keywords: personal therapy; psychotherapists; clinical psychology; social workers; counselors‘‘But where and how is the poor wretch to acquire the ideal qualification whichhe will need in this profession? The answer is in an analysis of himself, with whichhis preparation for his future activity begins.’’ Thus Freud (1937/1964, p. 246)The authors gratefully acknowledge the participation of the 727 psychotherapists who made this studypossible.Correspondence concerning this article should be addressed to: John C. Norcross, Department ofPsychology, University of Scranton, Scranton, PA 18510-4596; e-mail: norcross@scranton.eduJOURNAL OF CLINICAL PSYCHOLOGY, Vol. 64(12), 1368--1376 (2008) & 2008 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20523
  • Psychotherapists Who Abstain From Personal Therapy 1369asked—and answered—in Analysis Terminable and Interminable. Following hisexhortations, at least 75% of mental health professionals in the United States(Norcross & Guy, 2005) and in Europe (Orlinsky, Rønnestad, Willutzki, Wiseman,& Botermans, 2005) have undergone personal therapy on one or more occasions.Several studies (e.g., Dearing et al., 2005; Gilroy, Carroll, & Murra, 2002; Holzman,Searight, & Hughes, 1996) suggested that the prevalence may be even higher amongcontemporary graduate students in clinical and counseling psychology. And theimpact of personal therapy is typically profound: More than 90% of clinicians reportconsiderable personal improvement, and more than 75% relate a strong professionalinfluence on their development as therapists (Orlinsky, Norcross, Rønnestad, &Wiseman, 2005). In fact, personal therapy has been consistently found to rankamong the top three sources of positive influence on professional development, onlyfollowing direct experience with patients and formal case supervision (Orlinsky,Botermans, & Rønnestad, 2001). The centrality of the psychotherapist’s own psychotherapy and its ubiquity inpsychology training programs have led many to wonder about those psychothera-pists who have not undergone the experience themselves. Do they practice what theypreach? Researchers have consistently found that 20–25% of therapists abstain frompersonal therapy. This percentage remains stable across training levels (Farber, 2000;Holzman et al., 1996) and across professions (Gilroy et al., 2002; Liaboe, Guy,Wong, & Deahnert, 1989; Mahoney, 1997; Pope & Tabachnick, 1994) with onepossible exception: Marriage and family therapists may be significantly less likely toseek personal therapy than therapists in other professions (Norman & Rosvall,1994). In the past, women, psychoanalytic, and humanistic therapists were more likely toseek personal therapy than their male and cognitive–behavioral counterparts.Studies of American psychotherapists have typically, but not uniformly, found ahigher prevalence of personal treatment among female therapists than among maletherapists (e.g., Mahoney, 1997; Norcross, Strausser-Kirtland, & Missar, 1988; Pope& Tabachnick, 1994), but studies among international samples suggested that anydifferences between genders were small and inconsistent (Orlinsky et al., 2005).Reviews of personal therapy studies conducted in both the United States (Norcross& Guy, 2005) and internationally (Orlinsky et al., 2005) arrive at similar conclusionsregarding theoretical orientation: Psychoanalytic clinicians had the highestprevalence and cognitive-behavioral the lowest. Fewer studies have intentionally sought specific information unique topsychotherapists who abstain from personal therapy. The handful of studies thathave probed further, examining the factors affecting the decision to not undergopersonal therapy, have been largely restricted to small samples and interview studies.Nontherapy-seeking psychotherapists and graduate students most commonlyreported that they either have no need for therapy or that they receive adequatesupport from other sources (Gilroy, Carroll, & Murra, 2001; Holzman et al., 1996;Liaboe et al., 1989). For others, concerns about credibility, confidentiality, and costkeep them from seeking personal therapy (Farber, 2000; Norman & Rosvall, 1994).These reasons remain consistent among student trainees (Holzman, et al., 1996;Liaboe et al., 1989; Strozier & Stacey, 2001) and seasoned psychotherapists(Deutsch, 1985; Gilroy et al., 2002; Norman & Rosvall, 1994). This study was designed to investigate, in a larger and multidisciplinary sample,additional questions about psychotherapists who do not seek personal therapythemselves. How do psychotherapists who abstain from personal therapy differ from Journal of Clinical Psychology DOI: 10.1002/jclp
  • 1370 Journal of Clinical Psychology, December 2008those who do undergo therapy? What are their reasons for not using personaltreatment? How likely are they to seek therapy in the future? What circumstances, ifany, would lead them to consider seeking personal therapy? MethodQuestionnaireWe adapted a 6-page questionnaire used in a 1987 study (Norcross, Strausser, &Faltus, 1988; Norcross, Strausser-Kirtland, et al., 1988) for the present study byretaining most items, reducing it to 5 pages by reformatting the document andremoving many questions on professional activities, and adding a few new questions.Page 1 covered demographic, training, and professional characteristics. Pages 2–4were devoted to personal therapy in detail (see Bike, Norcross, & Schatz, 2005, andNorcross, Bike, & Evans, 2008, for those results). We addressed the final page of thequestionnaire to therapists who had never sought personal therapy. Thesepsychotherapists rated 17 potential reasons for not seeking therapy (derived fromDeutsch, 1985; Farber, 2000; Holzman et al., 1996; and Norman & Roswall, 1994)on a 5-point, Likert-type scale. Participants who had never sought personal therapywere also asked to indicate the likelihood of seeking it in the future and to cite onecircumstance that would probably lead them to do so.Procedures and ParticipantsWe mailed the questionnaire, a cover letter, and a stamped return envelope to 2,100randomly selected American mental health professionals: 700 psychologists from theNational Register of Health Service Providers in Psychology, 700 social workersfrom the National Association Social Workers (NASW) Register of Clinical SocialWorkers, and 700 counselors from the American Counseling Association (ACA).One month after the initial mailing, we mailed a follow-up to nonrespondents. Wereceived responses from 736 participants; however, 9 did not complete thequestionnaire. We secured usable returns from 727 psychotherapists—261 psychol-ogists, 234 clinical social workers, and 232 counselors—for a response rate of 35%. Our samples appeared demographically representative of their respectivepopulations with the exception of an underrepresentation of ethnic/racial minoritypsychotherapists. The National Register reported 42% women, the NASW Register82%, and the ACA 73%; our samples contained 45%, 82%, and 79% women,respectively. Our respondents’ age distribution corresponds closely to the publishedinformation for the three professional organizations as well. The National Registerreported 45% of its members were 61 years and older, NASW 23%, and ACA 12%;our samples contained 42%, 24%, and 13%, respectively. As a final example, theNational Register reported 9% ethnic/racial minority members, the NASW 11%,and ACA 11%; our corresponding samples contained 5%, 6%, and 5%. ResultsAll told, 119 or 16% of our sample had never obtained personal therapy. Table 1summarizes the respondents’ characteristics, comparing those who underwentpersonal therapy and those who did not. Therapist age, race, profession, degree,and employment site did not differ significantly between those who had usedpersonal therapy and those who had not. Although men (19%) appeared slightly Journal of Clinical Psychology DOI: 10.1002/jclp
  • Psychotherapists Who Abstain From Personal Therapy 1371Table 1Comparison of Psychotherapists Who Have and Who Have Not Sought Personal TherapyVariable Nontherapy Seekers (n 5 119) Therapy Seekers (n 5 608)Age (M, SD) 52 (12.2) 53 (10.1) % %Gender Female 62 68 Male 38 32Ethnicity Caucasian/White 87 93 African American/Black 6 3 Multiracial/Other 6 3 Asian American 1 1Profession Psychology 33 36 Social Work 35 32 Counseling 33 32Terminal degree PhD 36 36 MSW 29 29 MA, MS 24 25 PsyD 7 6 Other 4 4Theoretical orientation Cognitive 36 24 Eclectic 23 24 Behavioral 15 9 Systems 9 9 Humanistic/existential 7 9 Psychodynamic 2 12 Interpersonal 2 3 Psychoanalytic 1 4 Other 5 6Professional self-view Clinical practitioner 68 81 Administrator 9 6 Academician 10 4 Consultant 2 2 Other 11 7Employment site Private practice 40 45 Community clinic 10 10 University 10 8 Hospital setting 8 7 Other outpatient setting 8 6 Other 24 24more likely to have abstained from personal therapy than women (15%), this wasnot a statistically significant difference. Therapy seekers and nonseekers did differ significantly in terms of theoreticalorientation and professional self-view. Fully 26% of all cognitive–behavioraltherapists in our sample did not seek personal therapy. This percentagediffers significantly, w2(2, N 5 701) 5 28.51, po.001, from both humanistic and Journal of Clinical Psychology DOI: 10.1002/jclp
  • 1372 Journal of Clinical Psychology, December 2008psychodynamic/psychoanalytic therapists, of whom only 15% and 3% did not seektherapy, respectively. In addition, a greater percentage of self-identified academi-cians (32%) and administrators (22%) did not seek therapy. Clinicians andconsultants were far more likely to have sought personal therapy, w2(7,N 5 723) 5 17.19, po.01.Attitudes Toward Personal TherapyThe groups differed robustly in their attitudes toward the value of personal therapy.We asked participants to rate on a 5-point scale (1 5 very unimportant, 3 5 neutral/undecided, 5 5 very important), the importance of personal therapy under threeconditions: as a prerequisite for clinical work, as a source of ongoing developmentduring a clinical career, and as a condition of continuing or resuming practice forclinicians disciplined by licensing boards. In each case, nontherapy users’ ratingswere consistently lower than those of therapy users. Specifically, therapists who havenever sought personal therapy gave a significantly lower rating of the importance oftherapy as a prerequisite for training (M 5 2.78, SD 5 1.09) compared to therapistswho had sought personal therapy (M 5 4.23, SD 5 1.04), t(720) 5 13.57, po.001.Nontherapy-seeking therapists rated therapy as a source of ongoing developmentduring one’s career a mean importance of 2.85 (SD 5 1.09) compared to theirtherapy-seeking counterparts’ rating of 3.81 (SD 5 1.00), t(720) 5 9.30, po.001.They also devalued personal therapy as a condition for discipline by a licensingboard, rating it at 3.28, compared to 3.87 for therapists who had sought therapy,t(718) 5 4.45, po.001.Reasons for Not Using Personal TherapyAs captured in Table 2, nonseekers rated the importance of 17 reasons for notpursuing personal therapy. Among the highest rated reasons were ‘‘I dealt with mystress in other ways’’ and ‘‘I received sufficient support from friends, family, orcoworkers’’ (both M 5 4.04). Coping effectively with challenges, resolving problemsbefore therapy was undertaken, and having no need for personal therapy wereranked third, fourth, and fifth, respectively. The lowest-rated considerationspertained to the inability to find a therapist with whom they would feel comfortable,inability to locate a good therapist, and discouragement due to peers’ unsatisfactoryexperiences. Table 2 also presents the results of previous studies for comparative purposes. Asshown there, several of the top reasons for not initiating therapy were not even listedin the previous studies. The most frequent reasons in two previous studies wereranked fifth and seventh in this study. Profession and gender related to the reasons that psychotherapists did not seekpersonal treatment. Psychologists were significantly less concerned about the cost oftherapy, F(2, 109) 5 5.33, po.01, than were social workers and counselors. Womenwere significantly more likely to report the lack of time, F(2, 109) 5 5.62, p 5 .02,whereas men were significantly more likely to cite their ability to cope effectively ontheir own as a reason for opting out of personal therapy, F(2, 109) 5 5.59, p 5 .02.Circumstances Under Which Therapists Might Initiate TreatmentWe asked nontherapy-seeking psychotherapists to answer an open-ended question:What one circumstance would lead you to probably seek personal therapy? Journal of Clinical Psychology DOI: 10.1002/jclp
  • Psychotherapists Who Abstain From Personal Therapy 1373Table 2Factors Affecting Therapists’ Decision to Not Seek Therapy Rank Order Mean Present Deutsch Norman & Gilroy et al.Factor (SD) study (1985) Rosvall (1994) (2002)I dealt with my stress in ways other 4.04 1 (Tie) NR NR 2 than therapy. (0.86)I received sufficient support from 4.04 1 (Tie) 2 NR NR friends, family, or coworkers. (1.00)I coped with challenges effectively on 3.87 3 NR 2 NR my own. (0.89)I resolved my problems before therapy 3.49 4 3 NR 1 was undertaken. (1.25)I did not need personal therapy. 3.42 5 NR 1 NR (1.28)No one recommended therapy to me. 2.79 6 NR NR NR (1.66)I knew all of the acceptable therapists 1.90 7 1 NR 4 in my locale. (1.28)I lacked the time for personal 1.89 8 NR NR NR therapy. (1.16)I thought personal therapy was too 1.69 9 6 (Tie) NR 8 expensive. (1.02)I was not sure personal therapy 1.64 10 12 NR 10 would be helpful. (1.09)I did not want to invest the energy in 1.50 11 6 (Tie) NR 7 the undertaking. (0.91)I believed that, as a therapist, I 1.49 12 6 (Tie) NR NR should work out my own problems. (0.90)I was afraid of exposure. 1.47 13 4 (Tie) NR 6 (0.93)I had concerns about confidentiality. 1.44 14 4 (Tie) 3 5 (0.85)I was unable to find a therapist with 1.37 15 NR NR NR whom I could be comfortable. (0.87)I was unable to locate a good 1.34 16 NR 5 3 therapist. (0.90)I was discouraged from seeking 1.10 17 NR NR NR personal therapy due to my peers’ (0.37) unsatisfactory experiences.Note. NR 5 not reported.Ninety-four percent (112 of 119) of the psychotherapists responded. They listed atotal of 112 circumstances. Two trained undergraduates constructed 13 mutuallyexclusive categories (including Other) by reviewing all responses, creating andrevising the categories in a recursive process, and obtaining 90% or better intercoderreliability on category assignment. The most frequent circumstances under which these therapists would seekpersonal treatment are shown in Figure 1. Six circumstances recurred: personal orprofessional dysfunction (n 5 37), death of a loved one (n 5 26), stress overwhelmingtheir coping (n 5 10), marital difficulties or divorce (n 5 7), perception that therapywould be useful (n 5 2), and requirement of a licensing board (n 5 2). Journal of Clinical Psychology DOI: 10.1002/jclp
  • 1374 Journal of Clinical Psychology, December 2008 Personal dysfunction 25% Death of a loved one 33% Perception that it would be effective Training requirements 9% Marital difficulties Stress overwhelm coping 6% 2% Other reasons 23% 2%Figure 1. Future circumstances under which psychotherapists may seek personal treatment. Participants also rated the likelihood of their seeking personal therapy in thefuture. On a 5-point, Likert-type scale where 1 was very unlikely and 5 was verylikely, the mean rating was 2.66 between somewhat unlikely and undecided. Only 31%indicated that they were somewhat or very likely to seek personal therapy in thefuture. Younger participants, r(109) 5 .543, po.01, and concomitantly those withfewer years of clinical experience, r(109) 5 .472, po.01, were more likely to indicatethat they would seek personal therapy in the future. DiscussionOur results were generally consistent with previous research on the relations oftherapist gender, theoretical orientation, and professional self-view to abstainingfrom personal treatment. Male therapists were as likely to avoid personal therapy aswomen were, a finding corresponding to recent conclusions of small and inconsistentgender disparities (Orlinsky et al., 2005). Behavior and cognitive therapists were lesslikely to enter personal therapy than therapists endorsing other theoreticalorientations, including psychodynamic, psychoanalytic, interpersonal, humanistic,and eclectic. Academicians were far less likely to engage in personal therapy compared toclinical practitioners and those with other professional self-views. Parallel findingsemerged in a study of 88 training directors of clinical psychology programs and 231clinical practitioners; sharp attitudinal differences were found between theacademicians and practitioners on 22 of 26 survey items concerning the value ofpersonal therapy (Voigt, 1998). These patterns hark back to the original Henry,Sims, and Spray (1973) study that found academics and administrators were lesslikely to seek personal therapy than practitioners—be they psychiatrists, clinicalpsychologists, or psychiatric social workers. Academicians and training directors can exert substantial impact on graduatestudents’ attitudes and behaviors—both as models through personal interaction andas standard setters though program requirements. Graduate students have citedstigma and the potential for negative ramifications among their top reasons for notseeking personal therapy (Farber, 2000; Holzman et al., 1996). As seen in our results,therapists who did not seek personal treatment placed far less value on it as acomponent of training. Journal of Clinical Psychology DOI: 10.1002/jclp
  • Psychotherapists Who Abstain From Personal Therapy 1375 Past research suggested that the primary reasons psychotherapists give for notentering therapy were confidentiality concerns, financial expense, fear of exposure,time constraints, and difficulty locating a skilled therapist outside their network(Gilroy et al., 2001; Liaboe et al., 1989; Norman & Rosvall, 1994; Pope &Tabachnik, 1994). By contrast, our research, with a larger, multidisciplinary sampleusing structured ratings, demonstrated other, higher-ranking concerns. Expense fellto a ranking of nine, and fear of exposure, confidentiality concerns, and finding atherapist to be comfortable with dropped to 13, 14, and 15, accordingly. Perhaps themore widely accepted use of personal therapy as a self-care strategy for mentalhealth professionals has reduced its stigma, resulting in less fear of exposure andfewer confidentiality concerns. Time constraints, sufficient coping skills, and othersources of adequate support topped the reasons for not initiating personal treatmentin the present study. Mental health professionals hold respectable reasons for not seeking personaltherapy as well as the presence of mind to acknowledge the circumstances that mayprompt them to seek it in the future. Perhaps their belief that they cope well withoutpsychotherapy sheds light on why Stevanovic and Rupert (2004) found that menwere significantly less likely than women to identify the contribution of personaltherapy (as a career-sustaining behavior) and why fewer depressed malepsychotherapists (61%) in Gilroy et al.’s sample (2001) sought personal therapythan did women psychotherapists (73%). Past behavior is not entirely predictive of future choices in our sample ofnontherapy seekers. Almost a third (31%) of our respondents who had never enteredpersonal therapy, particularly the younger psychotherapists, related that they mayseek therapy in the future. We then asked a question never, to our knowledge, askedbefore in the research literature: What one circumstance would lead you to probablyseek personal therapy? The anticipated circumstances all centered around loss: lossof adequate functioning, loss of a loved one, loss of necessary coping, or loss of closerelationship/marriage. These reasons are nearly identical to the presenting problemsof psychotherapists actually receiving personal treatment (Bike et al., 2008), with theexception of grief, which was less prevalent in the present study of nontherapyseekers. ReferencesBike, D.H., Norcross, J.C., & Schatz, D. (2008). Processes and outcomes of psychotherapists’ personal therapy: Replication and extension 20 years later. Manuscript submitted for publication.Dearing, R.L., Maddux, J.E., & Tangney, J.P. (2005). Predictors of psychological help-seeking in clinical and counseling psychology graduate students. Professional Psychology: Research and Practice, 36, 323–329.Deutsch, C.J. (1985). A survey of therapists’ personal problems and treatment. Professional Psychology: Research and Practice, 16, 305–315.Farber, N.K. (2000). Trainees’ attitudes toward seeing psychotherapy scale: Development and validation of a research instrument. Psychotherapy, 37, 341–353.Freud, S. (1937/1964). Analysis terminable and interminable. In J. Strachey, (Ed. and Trans.), Complete psychological works of Sigmund Freud: Volume XXIII. London: Hogarth.Gilroy, P.J., Carroll, L., & Murra, J. (2001). Does depression affect clinical practice? A survey of women psychotherapists. Women & Therapy, 23, 13–30. Journal of Clinical Psychology DOI: 10.1002/jclp
  • 1376 Journal of Clinical Psychology, December 2008Gilroy, P.J., Carroll, L., & Murra, J. (2002). A preliminary survey of counseling psychologists’ personal experiences with depression and treatment. Professional Psychology: Research and Practice, 33, 402–407.Henry, W.E., Sims, J.H., & Spray, S.L. (1973). The public and private lives of psychotherapists. San Francisco: Jossey-Bass.Holzman, L.A., Searight, H.R., & Hughes, H.M. (1996). Clinical psychology graduate students and personal psychotherapy: Results of an exploratory survey. Professional Psychology Research and Practice, 27, 98–101.Liaboe, G.P., Guy, J.D., Wong, T., & Deahnert, J.R. (1989). The use of personal therapy by psychotherapists. Psychotherapy in Private Practice, 7, 115–134.Mahoney, M.J. (1997). Psychotherapists’ personal problems and self-care patterns. Profes- sional Psychology: Research and Practice, 28, 14–16.Norcross, J.C., Bike, D.H., & Evans, D.H. (2008). The therapist’s therapist: A replication and extension 20 years later. Manuscript submitted for publication.Norcross, J.C., & Guy, J.D. (2005). The prevalence and parameters of personal therapy in the United States. In J.D. Geller, J.C. Norcross, & D.E. Orlinsky, (Eds.), The psychothera- pist’s own psychotherapy. New York: Oxford University Press.Norcross, J.C., Strausser, D.J., & Faltus, F.J. (1988). The therapist’s therapist. American Journal of Psychotherapy, 42, 53–66.Norcross, J.C., Strausser-Kirtland, D., & Missar, C.D. (1988). The processes and outcomes of psychotherapists’ personal treatment experiences. Psychotherapy, 25, 36–43.Norman, J., & Rosvall, S.B. (1994). Help-seeking behavior among mental health practitioners. Clinical Social Work Journal, 22, 449–460.Orlinsky, D.E., Botermans, J., & Rønnestad, M.H. (2001). Toward an empirically grounded model of psychotherapy training: Four thousand therapists rate influences on their development. Australian Psychologist, 36, 139–148.Orlinsky, D.E., Norcross, J.C., Rønnestad, M.H., & Wiseman, H. (2005). Outcomes and impacts of the psychotherapists’ own psychotherapy: A research review. In J.D. Geller, J.C. Norcross, & D.E. Orlinsky, (Eds.), The psychotherapist’s own psychotherapy. New York: Oxford University Press.Orlinsky, D.E., Rønnestad, M.H., Willutzki, U., Wiseman, H., & Botermans, J. (2005). The prevalence and parameters of personal therapy in Europe and elsewhere. In J.D. Geller, J.C. Norcross, & D.E. Orlinsky, (Eds.), The psychotherapist’s own psychotherapy. New York: Oxford University Press.Pope, K.S., & Tabachnik, B.G. (1994). Therapists as patients: A national survey of psychologists’ experiences, problems, and beliefs. Professional Psychology: Research and Practice, 25, 247–258.Stevanovic, P., & Rupert, P.A. (2004). Career-sustaining behaviors, satisfactions, and stresses or professional psychologists. Psychotherapy, 41, 301–309.Strozier, A.L., & Stacey, L. (2001). The relevance of personal therapy in the education of MSW students. Clinical Social Work Journal, 29, 181–195.Voigt, H. (1998, August). Practitioners and academics disagree: Personal therapy as a clinical training requirement. Poster presented at the annual convention of the American Psychological Association, San Francisco, CA. Journal of Clinical Psychology DOI: 10.1002/jclp