Personal therapy for therapists: Professional and ethical issues

Preface

In 2018 I was asked to revise my chapter on personal therapy for therapists for a third edition of the Handbook of Professional and Ethical Practice for Psychologists, Counsellors and Psychotherapists edited by Rachel Tribe and Jean Morrissey, which I gladly agreed to. I think that the two editors have done an excellent job of collating thoughtful and expert discussions on a wide range of ethical issues that confront mental health practitioners in a diverse range of settings. In the process of revising the chapter the editors made suggestions and re-wrote a number of parts of the chapter, some of which I was happy to include and others that I thought did not accurately represent my thoughts. With the publication deadline approaching, we were not fully able to agree on some of the changes and additions that the editors wished to make that they felt were important to maintain a balanced perspective. Because the published edition contains those changes, I have decided to publish below the version that I would have wished to have published. Readers may form their own opinion as to the relative merits of each version.

Andrew Grimmer, 2019

Introduction

In the last 15 years there has been considerable research published about personal therapy for psychological therapists, including a book (Geller et al., 2005) and a dedicated edition of the Journal of Clinical Psychology. In recent years this activity has slowed considerably, for whatever reason, perhaps because the subject has reached theoretical saturation, or the issue has become either institutionally settled or redundant due to changes in the practice and training of therapists. This chapter sets out to provide a critical overview of the literature on the subject, including recent research, which continues to be prolific, although it should be noted that much of the recently published work has tended to replicate existing studies with a different population or slight change in methodological emphasis and has produced broadly similar results to previous findings (e.g. Hadjipavlou et al., 2016; Wilson et al., 2015). 

International surveys suggest that between 66–90 per cent of practising psychological therapists will have had at least one episode of personal therapy (Norcross & Guy, 2005). The personal therapy of therapists is, however, an enormously varied experience, as demonstrated in even a relatively small-scale qualitative study (Grimmer & Tribe, 2001) where participants reported personal therapy of varying duration, frequency, timing, or fidelity to their preferred therapeutic approach. The number of episodes of therapy, the qualifications or experience of the therapy provider, and the motivation to attend also varied considerably. The role of personal therapy in the UK as a structural training requirement (i.e. a minimum number of hours) has become less common as the nature of the psychological therapy workforce changes. NHS England’s Improving Access to Psychological Therapies (IAPT) service is the largest employer of psychological therapists in the country, with the full-time equivalent of 5990 psychological therapists and practitioners and 780 trainees, of which roughly a third are low intensity practitioners and two-thirds high intensity (NHS, 2015). Of the high intensity workforce 61% were cognitive behaviour therapy (CBT) practitioners whereas 27% were offering additional modalities, such as interpersonal therapy, dynamic interpersonal therapy, couple therapy for depression, counselling for depression and behavioural activation (NHS, 2015).

Personal therapy is not a formal requirement of CBT training in the UK, though recent publications on CBT training have increasingly focused on the development of reflective practice as an integral input into training (e.g. Bennett-Levy et al., 2014).  In 2005 the British Association for Counselling and Psychotherapy (BACP) discontinued its accreditation requirement for applicants to complete 40 hours of personal therapy in order to ensure parity for therapists from theoretical orientations that do not view personal therapy as an essential part of training. It was replaced with the requirement to demonstrate ‘self-awareness activities’ and how they apply to one’s therapeutic practice (O’Neill, 2014). In contrast, the United Kingdom Council for Psychotherapy (UKCP) still expects all trainees to undertake a personal therapy of the same modality, duration and frequency as they intend to offer in their practice (UKCP, 2012). For example, the Institute of Psychoanalysis (IOP) requires all students to have been in analysis five times a week with a training analyst of the British Psychoanalytic Society for a minimum of a year before starting lectures and seminars and for the duration of the training (IOP, 2018). Likewise, a specific competence for counselling psychologists is to ‘understand therapy through their own life-experience’ (HCPC, 2015: 23), which is usually interpreted as a requirement for personal therapy. Despite considerable overlap in competencies there is no corresponding requirement for personal therapy for clinical psychologists (Rake, 2009).

Rationale for personal therapy 

The desirability of personal therapy for therapists has been described as ‘one of the most firmly held and cherished beliefs’ among psychotherapists (Norcross, 2005: 841). It has been traced back to the injunction inscribed on the Temple of Apollo at Delphi to ‘Know thyself’, and to Socrates’ dictum that the unexamined life is not worth living. In a more contemporary vein, Rizq (2009:570) claims the scientific status of psychological therapy depends at least in part on ensuring that therapists are not ‘characterologically susceptible’ to the temptation to exploit the vulnerable and thus preserves the hope that there are ‘safe, reliable practitioners … on whom we can trust and depend’. 

Brooks (2011: 185) describes personal therapy as psychoanalysis’ ‘pedagogical imperative’, referring back to Freud’s ([1937] 1943: 248) frequently quoted remarks from Analysis Terminable and Interminable that personal analysis will have been successful if ‘it gives the learner a firm conviction of the unconscious, if it enables him, when repressed material emerges, to perceive in himself things which would otherwise be incredible to him’. In addition, it would give the learner ‘a first sample of the technique which has proved to be the only effective one in analytic work’ (ibid.: 248). Freud perceived that practising analysis held such dangers that the analyst might retreat into defences and thus analysts should submit to a further analysis at least every five years (ibid.). 

In 1988 Norcross et al. identified six recurring commonalities in the functional goals of personal therapy for therapists and its proposed mechanisms of change that are still influential today (Murphy et al., 2018): These are:

1) Improved emotional and mental functioning making the therapist’s life less neurotic and more gratifying. 

2) A more complete understanding of personal dynamics, interpersonal elicitations, use of self, and conflictual issues, that enables therapy to be conducted with clearer perceptions and reduced counter-transference potential. 

3) Alleviating emotional stresses and burdens, enabling practitioners to deal more successfully with challenging work.

4) Providing a profound socialisation experience that establishes conviction about therapy’s effectiveness and facilitates internalisation of the healer role. 

5) Experience of being a client, which sensitises therapists to the interpersonal reactions and needs of their own clients. 

6) Direct modelling of clinical methods through first-hand, intensive experience. 

Prevalence of personal therapy

While the prevalence of therapists entering therapy is consistently high, there is limited research on the relative prevalence across different mental health professions, though there is substantial evidence that it varies according to theoretical orientation (Orlinsky et al., 2011; Norcross & Guy, 2005; Orlinsky, Rønnestadet al., 2005;). Therapists who have had personal therapy were more likely to have had previous personal therapy, had been in therapy for longer hours, had suffered longer (but not more severe) distress, and rated their self-help as less successful (Norcross & Prochaska, 1986). Reasons for not entering therapy are robustly consistent: confidentiality concerns, financial expenses, exposure fears, self-sufficiency desires, time constraints, and difficulties locating a suitable therapist outside their immediate professional and social network (Norcross & Connor, 2005). Over 40 years ago, Burton (1973) suggested that other, less immediately accessible, reasons may contribute to reluctance, for example, that those therapists most convinced of its efficacy also have the greatest doubts; the belief that self-analysis is sufficient, having been good enough for Freud; that therapists narcissistically fear giving up power to others through personal regression; and, that there is a profound shame in becoming a fellow sufferer of those one treats. 

More recently, Norcross and Connor (2005) point out that the presenting problems of therapists correspond to those of the general population and are indicative of the emotional toll of the profession, even though the most likely source of distress was problems in the personal lives of therapists, rather than problems that arose from professional concerns or pressures. The three most frequent presenting problems are: depression, relationship conflicts (including emotional under-involvement with family) and anxiety. Other problems include loneliness, critical life events, substance abuse, and emotional depletion. A client problem (such as client suicide) was a precipitant in only a tiny number of cases. Occupational stressors related to supervision, policies, promotions, salaries etc. were also reported. Encouragingly, Schroeder et al. (2014) reported that a psychologist’s disclosure of being in personal therapy did not influence colleagues’ intentions to refer to that psychologist, suggesting that there was no professional stigma attached to using therapy to manage personal difficulties.

Therapists’ opinions of personal therapy 

There is now an extensive body of research on the experience of personal therapy and its perceived outcomes on therapists’ personal satisfaction and professional functioning. Consistent with the six rationales cited above (Norcross et al., 1988), Orlinsky et al. (2011) conclude that research generally supports the notion that personal therapy enhances professional development through: increasing sensitivity and empathy; experiential learning of therapeutic skills; understanding one’s own conflicts, beliefs and values, and the ability to use self-awareness in therapy. They also point out that there is a ‘small literature’ (ibid.: 831) concerning possible dangers of personal therapy, in particular, where there are ethical and health risks associated with a structural requirement for therapy in training. The following section will briefly review the current state of our knowledge. 

Internationally, studies report that between 78–93 per cent of therapists who had received personal therapy reported having at least one that they found ‘highly beneficial’ (Orlinsky, Norcrosset al., 2005), with the suggestion being that it gave the therapist a direct experience of the potency of therapy that is communicated to clients. Unsatisfactory outcomes have also been reported to varying degrees, with studies reporting between 1 and10 per cent of therapists stating that their therapy was either unhelpful or harmful (ibid.). One survey (Grunebaum, 1986) clustered harmful therapy experiences under five themes: distant and rigid therapists; emotionally seductive therapists; poor patient–therapist match; explicitly sexual therapists; and, multiple involvements with therapists. Pope and Tabachnick (1994) found the experiences most frequently reported as harmful were: attempted or actual sexual acts by therapists; incompetence; sadistic or emotionally abusive behaviour; general failure to understand the client; and, non-sexual dual relationships and boundary violations. In two studies the clients of younger and less experienced therapists had poorer outcomes (Norcross et al., 1992; Norcross et al., 1988).

Contribution to professional development

Despite the assumption that personal therapy contributes to professional development Macran and Shapiro (1998: 19) state that three major reviews of the outcome literature all conclude: ‘There is no evidence that either receipt of personal therapy or length of personal therapy is positively related to various measures of client outcome.’ Claims that personal therapy reduces the likelihood of active forms of unethical behaviour (Farrell, 1996) are not supported in studies of therapist abuse that show personal therapy appears not to prevent or predispose to boundary violations when they occur (Gabbard, 1997). 

Nonetheless studies consistently find that therapists perceive their own therapy as valuable in facilitating clinical effectiveness and preventing burnout, and in improving self-awareness, self-esteem, relationships and therapeutic effectiveness (Orlinsky et al., 2011). Orlinsky, Norcrosset al. (2005) suggest that it might be difficult to detect the influence of personal therapy on client outcome because therapist factors contribute to a relatively small proportion of the variance in client outcome relative to the characteristics and resources of the client. Other factors include methodological issues and confounding factors such as therapist experience, motivation to attend, and diverse reasons for entering therapy (Beutler et al., 1994) in a context where research has failed to demonstrate evidence that professional training as a whole has a consistently good effect on outcome for clients (Christensen and Jacobsen, 1994). 

Qualitative accounts of personal therapy

Macran and Shapiro (1998) argue that the lack of a clear relationship between personal therapy and improved client outcomes make it more useful to research process issues. There are now a number of qualitative studies that include detailed accounts from the recipient’s perspective. In early research, Mackey and Mackey (1993) found that the therapist became a potent role model. In a replication with UK counselling psychology trainees and recent graduates, Grimmer and Tribe (2001) found that socialisation and modelling were central components: participants reported that negative therapy experiences served as a potent reminder of what not to do, while at other times trainees adopted therapist behaviours they had experienced negatively themselves, because they saw them of being to the benefit of the client in the longer term, such as the ability to tolerate silence. 

Some years later, in a study of 20 experienced psychoanalytically oriented therapists, Bellows (2007) reported that therapists who viewed their personal therapy as having most influence on their practice were also more likely to view their own treatment as promoting personal psychological change. This group reported the fewest harmful effects of therapy and saw psychological stress as a purposeful, inherent part of treatment. They tended to value their former therapist as a role model and thought about him or her when unsure what to do in a clinical situation. Personal therapy was seen as enhancing professional identity and improving interpersonal relationships, whilst focusing on the working alliance and addressing problems between themselves and their patients were central to their practice of therapy. Bellows (2007) also reported that a perceived treatment benefit was self-acceptance mediated by the therapist’s acceptance of the client’s fallibility. Therapists reported being able to admit mistakes and be corrected, which was associated with the respectful treatment of clients and greater self-acceptance. The manner in which therapy was terminated, including feedback about the progress of therapy, was associated with the extent to which the former therapist was internalised as a good role model with whom the practitioner continued to have an internal dialogue. Unresolved or unhappy terminations of treatment led to feelings of ambivalence about continuing this inner therapeutic dialogue with the former personal therapist. 

Rizq and Target (2008) identified five ‘master themes’ in their interpretative phenomenological analysis of nine senior professional counselling psychologists’ accounts of personal therapy: that personal therapy: provides an arena for intense self-experience; establishes self–other boundaries; provides an arena for professional learning; is integral to training; and, makes self-reflexivity significant. Rake and Paley (2009) noted three major themes for therapists who had an obligatory training therapy: ‘I learnt how to do therapy’, ‘I know myself much better’ and ‘a very dissolving process’. The latter theme was seen as detrimental and destabilising with participants reporting that self-absorption could have a negative impact on relationships; that the obligatory nature of therapy ‘spoiled’ the experience; and that particular unhelpful comments had a lasting impact, even after 20 years. 

Therapy as a mechanism of change

The idea that receipt of personal therapy is a straightforward moderator of desirable professional outcomes or interpersonal skills, even when perceived as highly beneficial, is unduly simplistic. Until recently there was a noticeable absence of theorising about what factors in personal therapy might mediate the favourable outcomes that many therapists perceive. Rizq and Target (2008) propose a mechanism of change linked to Fonagy and Target’s psychodynamicall-orientated, developmental model of mentalisation (cited in Rizq & Target, 2008), which refers to the maturing child’s experience of, and reflection on, strong emotion that increases their capacity to manage intense affect. They suggest that therapy can replicate this process. Through the experience of ‘being seen’ and understood by their therapist, the capacity to see, identify and empathise with clients is developed through the recognition that ‘subjective experience is a representation of, rather than indistinguishable from, reality’ (ibid.: 43). They suggest that developing this mentalising stance is responsible for the perceived emotional resilience that participants attributed to personal therapy and that the effects of successful therapy may be seen most prominently when working with challenging clients who have the potential to elicit the greatest negative emotion. 

Wigg, Cushway and Neal (2011) developed a model to describe how practitioners “progress to greater levels of reflexivity, assisted through the experience of personal therapy” (p354). Their reflective practice model notes the following themes across studies that focused on process issues: personal reflections (processes that encourage personal growth and development to occur); professional reflections (the development of greater skill and accuracy through the honing of the professional self as the tool of therapy); extended reflections (the benefits of prolonged therapy as an ongoing process to meet different demands at different points in the professional life of the practitioner); and, meta-reflections (a diverse category that encompasses the development of authenticity in the personal and professional selves along with self-acceptance, awareness and coherence). The model describes a process whereby each level of reflection builds on the former to produce increasingly abstract and thus generalizable principles that have applicability across a wide range of professional situations. The authors acknowledge that their proposal raises questions as to whether it is necessary to have reflected in a personal manner before reflecting in a professional manner, and whether therapists need to reflect personally, professionally, and over an extended period, before being able to reflect on their reflections.

Bennett-Levy (2006) provides an alternative account of the mechanism by which experiential learning (including personal therapy and self-practice/self-reflection exercises) moderates a degree of variance in the effectiveness of cognitive behavioural therapy trainees. The theory describes an information-processing model whereby reflection (conceived of as a content-free process analogous to working memory) mediates between interpersonal skills and declarative and procedural memory structures. In this account, therapy skills practised on the self become represented in two memory structures: the self-schema and the self-as-therapist schema. As a consequence, experiences are processed at greater depth, dual retrieval pathways improve access to memory systems, and the impact on self- schema directly improves interpersonal skills. 

Those three theories suggest that reflection and self-reflection could be conceived of as the capacity to hold in awareness and evaluate multiple perspectives (client experience, self experience, and contextual variables) while under emotional strain from the impact of client behaviour. The positive reciprocal influence of increased reflective capacity and emotional regulation skills could facilitate a non-defensive, empathic and inquisitive stance towards the client’s experience. This mechanism is implicit in some qualitative research, for example, increased capacity to tolerate a client being distressed and crying (Grimmer and Tribe, 2001). The relationship between reflection, emotion regulation and socialisation could be developed in further research that focuses on therapists’ actual in-session reflections and responses during difficult therapeutic encounters. There are, however, some potential obstacles to objective or in-depth research, not least because, whether one has had a positive or negative experience, it is often emotionally highly charged. Rizq and Target, (2008) describe the emotional consequences of personal therapy as contributing to a general lack of theorising about the functions of personal therapy whereby ‘the very strength and intensity of participants’ experiences within personal therapy, indexing a subjective sense of conviction about its utility within training programmes, may nonetheless militate against attempts to investigate its aims and potential benefits’ (2008: 45; italics in original). 

In future research perhaps, as researchers and practitioners, we might endeavour to set aside our deeply held and strongly felt opinions to avoid producing more ‘bland, descriptive accounts’ (ibid.: 45) or ‘vacuous assertions’ about the role of personal development in training (Irving & Williams, 1999: 520). This chapter argues that we could benefit from a more decentred perspective that examines findings in the light of wider psychological knowledge including: the operation of heuristics, confirmation bias, attitude polarisation, cognitive dissonance, social identity formation, and group conformity processes. Social psychology and related disciplines could help us to understand similarities and differences between personal therapy and other, highly affect-laden rituals, such as religious conversion experiences or rites of passage. For example, increased self-awareness through personal therapy is presumed to lead to a lower likelihood of unethical behaviour because increased reflective awareness could inhibit the urge to act unprofessionally that might arise in response to the intimacy of the therapeutic relationship. It has been argued that reflective judgement follows a developmental pathway with increasing capacity to manage ‘ill-structured problems’, i.e., those with no clear-cut right or wrong answer. However, theories of bounded rationality also suggest that our actions are influenced not just by reason and reflection but through applying simplified decision-making (heuristics) in response to preconscious neurological processes that generate automatic emotional responses in social environments that have the power to influence actions in unethical or unprofessional directions (Kitchener, 2013). Assumptions about the necessity and sufficiency of personal therapy therefore need to be contextualised within a balanced and bounded appreciation of its impact and research should be sensitive to the benefits and limitations of personal therapy through a greater understanding of its mode of action. 

Future directions 

Norcross (2005) advocates strongly for practitioners of all orientations to engage in personal therapy as an ‘emotionally vital, interpersonally dense, and professionally formative experience’ (ibid.: 848) that should be central to one’s professional development. He argues for: 

“integration of the person of the psychotherapist, integration of science and practice, and integration of diverse approaches to behavior change … let us avoid fragmentation and commit to the seamless acquisition and simultaneous integration of both technical competence and personal formation. Decades of training experience, empirical evidence, and practitioner reports converge on this message.”

(ibid.: 847)

Rather than a universal structural requirement Norcross suggests a range of measures to increase access to affordable personal therapy. These include: trainee selection based on interpersonal skills in addition to academic prowess; enthusiastic recommendation of personal treatment for trainees; maintaining lists of local practitioners offering reduced fees; class meetings to emphasise consistent reports of its multiple benefits and infrequent negative outcomes; lecturers modelling openness to personal therapy as a lifelong process; more research on specific moderators and mediators of successful outcomes; active disputation that returning to therapy is a failure; and advancing the cause of practitioner self-care more generally. 

Traditionally a structural requirement for mandatory personal therapy has polarised proponents and sceptics into seemingly implacable camps (see, e.g. Macaskill, 1999, and Sinason, 1999). Despite its centrality and history in psychoanalytic approaches, other approaches, for example CBT, which draws on specific treatment protocols, see personal therapy for therapists as unnecessary. Practitioners from a psychodynamic background would view the idea of trainees wishing to practice therapy whilst being unwilling to experience it themselves as raising serious professional and ethical issues and would argue that training programmes will prepare trainees in a variety of ways. For some training programmes personal therapy is, and will likely remain, the sine qua nonof professional and personal development. Murphy et al. (2018) are therefore less concerned with whether personal therapy should be a mandatory part of training and more with how it is managed when it is a structural requirement. They argue that mandatory personal therapy should be positioned as an intensive form of experiential learning, not as a course requirement to ‘fix’ individual deficiencies and that trainees should be able to choose when they wish to begin therapy and to choose the frequency, length and intensity themselves whilst also being allowed to explore alternative methods for personal development. Murphy et al.argue that risks must be communicated clearly and readiness should be assessed as a part of an overall duty of care to the trainee. The author would ague that there is value in the plurality of our approaches to therapy and in the continuing development of a diverse professional community that celebrates both the range of personal development experiences and of our chosen ways of trying to be of psychological assistance to distressed and vulnerable people. This pluralist position respects both those traditions that choose to mandate personal therapy (with appropriate safeguards for the trainee) and those approaches that develop reflective practice by other means (with appropriate safeguards for clients). 

Conclusion

As we have seen, personal therapy is still a valued experience for many psychological therapists, even as it becomes a less common requirement of training in certain modalities and training organisations. The majority of therapists who have had a personal therapy believe that it enhanced their therapeutic skill, although this effect has not been demonstrated reliably. In conclusion, it is probably safe to assume that personal therapy for therapists serves four main purposes: 1) to ameliorate personal distress, as for any client; 2) to increase awareness of personal vulnerabilities, sensitivities or blind spots that could interfere with forming, maintaining and ending a therapeutic relationship; 3) to socialise the practitioner to the norms and conventions of therapeutic practice; and 4) to facilitate the development of a firmly held belief in the efficacy of one’s own chosen model and/or of therapy itself. In so far as personal therapy does have a positive effect on practitioners and their practice (and negative effects have also been reported) it probably does so because positive therapeutic relationships and better therapeutic outcomes (Lambert & Barley, 2001) are more likely to be achieved by interpersonally sensitive, less distressed and more self-aware therapists who practise according to accepted guidelines that they have seen modelled for them, and who have a firm belief in the efficacy of their treatment that creates powerful expectancy effects in clients. 

Reflective questions

1) In what way do you think personal therapy has had an impact on your personal and professional development? Give an example. If you have not had personal therapy what do you imagine that you might be missing?

2) What are your views about therapists practising who have never had personal therapy? 

3) How would you respond to a trainee who says he/she is only having therapy because it is part of the course requirements? 

4) What other means of personal development or distress management are important to you and how might they complement or conflict with personal therapy? 

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