Therapists as Patients:
A National Survey of Psychologists' Experiences, Problems, and Beliefs
Abstract: A survey of 800 psychologists (return rate = 59.5%) found that of 84% who had been in therapy, only 2 described therapy as unhelpful, 22% found it harmful, 61% reported clinical depression, 29% reported suicidal feelings, 4% reported attempting suicide, 26% reported being cradled by a therapist, 20% reported withholding important (mostly sexual) information, and 10% reported violations of confidentiality. Women were more likely than men to report sexual material in therapy; psychodynamically oriented respondents were more likely to report sexual material. Of those who had terminated, 63% reported recent consideration of resuming therapy. Most believed that therapy should be a requirement of graduate programs and licensure, but only about a third believed therapy mandated by licensing boards for resuming practice after violations of professional standards to be clearly or even likely effective.
The idea that it may be beneficial, perhaps even necessary, for those who provide therapy to become patients can be traced to Freud, who wrote, "Every analyst ought periodically ... to enter analysis once more, at intervals of, say, five years, and without any feeling of shame in doing so" (Freud, 1937/1963, pp. 267-268). In part, this notion rested on the premise that the therapist's personal problems may, if unidentified, unexamined, and unaddressed, interfere with the ability to conduct effective therapy. Fromm-Riechman (1950) believed that attempting to be a therapist without first being a patient "is fraught with danger, hence unacceptable" (p. 42). Guntrip (1975) quoted one of his own therapists (Fairbairn) as stating a rather extreme opinion about the relationship of personal problems with the motivation to be a therapist: "I can't think what could motivate any of us to become psychotherapists if we hadn't got problems of our own" (p. 145).
Relatively little research information exists about the types of problems that may have prompted psychologists who are therapists or therapists-in-training to seek therapy. As late as 1986, Millon, Millon, and Antoni noted that "there are no systematic data specifying which variants of psychopathology are most prevalent among psychologists and other mental health professionals" (p. 119). A subsequent survey of 379 members of a midwestern state psychological association found that "approximately 10% of our sample reported distress across a variety of dimensions: depression, loneliness, relationship dissatisfaction, recurrent physical illness, and recognition of drinking problems" within the past year (Thoreson, Miller, & Krauskopf, 1989a, p. 15 ; see also Thoreson, Miller, & Krauskopf, 1989b).
A substantial literature has emerged that addresses special considerations in the provision of therapy to therapists (e.g., Greenberg & Staller, 1981; Kaslow, 1984, 1986). These thoughtful works have paid particular attention to potential pitfalls. Fleischer & Wissler (1985), for example, wrote
"Certainly, the role of being a "therapist's therapist" provides marked narcissistic appeal, akin to being a "lawyer's lawyer, " or a "physician's physician."... The therapist may experience strong wishes to collude with the patient's need for perfection and omniscience in the treater, resulting in excessive and unrealistic expectations about one's capacities as a therapist.... A highly negative and destructive pitfall of this seduction is the failure to analyze the developing positive transference and the identification with the therapist. Thus, both the patient and the therapist may have difficulty acknowledging the patient's negative reactions including hostility toward and dissatisfaction with the therapist." (p. 589).
Individual autobiographical accounts and case studies of patients' experiences provide vivid portrayals of therapists' experiences in therapy (e.g., Guntrip, 1975; Roazen, 1986). Reik (1956), for example, began his account of becoming Freud's patient with the statement, "Then already an analyst of many year's experience, I found myself on the analytical couch as a patient of Freud. It was an extraordinary situation, and became an emotional and intellectual experience which I shall treasure to my last day" (p. 214).
Research focusing on the experiences, problems, and beliefs of therapists
as patients, however, has been rare, with three notable exceptions. Shapiro's
(1976) survey of graduates of a specific psychoanalytic training program
focused specifically on the training analysis. He found that "the vast majority
[of the 121 analysts who returned completed questionnaires] viewed their
therapeutic gains favorably, despite the complications posed in analysis
concurrent with training" (Shapiro, 1976, p. 36). Kaslow and Friedman's
(1984) interview study of 14 clinical psychology graduate students who were
in therapy while they were in training found that personal therapy tended
to be more influential than supervision in the development of clinicians.
The students were asked to rank order the educative value of outside readings,
academic course work, clinical practice, supervision, and personal treatment.
The results were that "only one student ranked 'reading's at the top of
the list. The others, regardless of number of years of training, ranked
clinical practice, personal treatment, and supervision, in descending order,
as having had (or having) the most impact on them as clinicians" (Kaslow
& Friedman, 1984, pp. 43-44). Finally, a brief report by Guy, Stark,
and Poelstra (1988) found that only 18% of 318 psychologists practicting
as therapists had
"never received any form of personal psychotherapy at
any time" (p. 475).
This present study had three purposes. The first was to gather exploratory data, based on a national sample, about therapists' beliefs about, problems leading to, and experiences in therapy and to examine relationships among these and other (e.g., demographic) variables. A major aspect was to discover the degree to which the participants reported that various feelings, behaviors, or events occurred in their therapy.
A second purpose was to determine whether confirmation of the three findings from previous studies noted above would emerge (e.g., would participants tend to view their experiences in therapy favorably, would they view personal therapy as a valuable resource in their development as therapists, and would a large majority report that they had been in therapy) despite differences in scope and methodology.
A third purpose was to gather data to address additional hypotheses or questions: (a) Do a majority of therapists believe that personal therapy should be a requirement of graduate training programs and of licensure? (b) Do a majority believe that licensing boards should be able to mandate therapy as a condition of therapists continuing or resuming practice (e.g., for those who have violated professional standards), and is therapy mandated under such conditions viewed by a majority as clearly, or at least likely, effective? (c) In light of Thoreson et al.'s (1989a, 1989b) findings that a minority of psychologists experienced depression and other difficulties within the past year, do a much larger proportion of therapists (perhaps a majority) report experiencing clinical depression at least once over the life span? (d) What is the major problem, distress, dysfunction, or issue addressed in therapy? (e) What do participants report as the most important benefit of therapy (if any) and as the cause of the most serious harm from therapy (if any) and as the cause of the most serious harm from therapy (if any)? (f) Would a factor analysis of the feelings and behaviors that may occur in therapy yield six well-defined, internally consistent factors; sexual material therapist (un) kindness, patient sadness, therapeutic errors, emotionality, and expressiveness? (g) Would a majority of participants report keeping an important secret from their therapists, and would a majority of secrets involve sexual issues? (h) Would only a small minority of participants report that their therapists cradled or held them? (i) Would the respondents tend to report continuing psychological with their therapists after termination and to think about resuming therapy?
A cover letter, survey form, and return envelope were sent to 800 psychologists (400 men and 400 women) randomly selected from the American Psychological Association's (APA) Divisions 12 (Division of Clinical Psychology), 17 (Division of Counseling Psychology), 29 (Division of Psychotherapy), and 42 (Division of Psychologists in Independent Practice) as listed in the APA Membership Register. [ footnote #1.] Replacements were sent out for forms returned by the postal service as undeliverable.
The questionnaire requested participants to provide information about (a) demographics (age, sex, and theoretical orientation); (b) whether they were currently or had previously been in therapy; (c) whether their graduate training program had required therapists-in-training to enter personal therapy; (d) the parameters of their personal therapy (e.g., age when they began therapy, number of therapists they had worked with, total months or years they had been in therapy, and number of months or years that had passed since their last session if they were no longer in therapy); (e) the degree to which their experiences in therapy, taken as a whole, had been helpful and the most important benefit, if any, gained from therapy; (f) the degree to which their experiences in therapy, taken as a whole, had been harmful and the cause of the most serious harm, if any; (g) whether there had been anything important that they had kept secret and refused to disclose to any therapist and, if so, what the secret was; (h) the degree to which they had considered, within the past year, resuming therapy with a previous therapist or with a new therapist, if they were no longer in therapy.
The questionnaire also asked participants who had been in therapy to report (a) to what degree, if at all, at least one therapist had engaged in 19 behaviors; (b) to what degree, if at all, participants had experienced or engaged in 8 feelings or behaviors; and (c) to what degree, if they were no longer in therapy, participants, during the past year, had daydreamed about a former therapist, had dreamed (while asleep) about a former therapist, had felt intense anger at a former therapist, or had experienced sexual feelings or fantasies about a former therapist.
Four questions were included about required therapy. Participants were asked to indicate the degree to which they believed that (a) personal therapy should be a requirement in psychology graduate schools for students who are training to be therapists, (b) personal therapy should be a requirement for the licensure of therapists, (c) licensing boards should be able to require therapists (e.g., those who have violated professional standards) to obtain therapy as a condition of their continuing or resuming practice, and (d) therapy mandated by licensing boards as a condition of therapists continuing or resuming practice tends to be effective.
Four hundred and seventy-six psychologists returned usable forms, for a return rate of 59.5%. As the results in Table 1 show, there was a slight majority of female therapists in the sample, despite equal numbers of surveys sent to men and women. most often were in their 40s. Table 2 contains participants' theoretical orientation, in decreasing order of frequency.
|40 and under||73||17.2|
Note: Percentages do not add up to 100% because of missing data.
Note: Other includes all orientations listed by fewer than 3 therapists. Percentages do not add up to 100 because of missing data.
Involvement in Therapy: Beginning, Duration, and Number of Therapists
Most of the respondents (400 of 476) reported having been a patient or client in therapy. The median number of therapists worked with was 3, with a mode of 2 (108 of the 396 who responded to the question). One respondent reported having 15 therapists, 1 had 20 therapists, and a 70-year-old respondent reported 50 therapists, having begun therapy at age 18. There was no statistically significant correlation between respondent age and number of therapists.
The median time in therapy was 4 years (398 therapists responding), with a median time of 15 years having passed since the last session for the 289 therapists responding to that question. One hundred respondents reported that they were currently in therapy. The median age for beginning therapy was 26 years. Current age was moderately correlated with age at which therapy began and time since last session, r (375) = .44 and r (276) = .39, respectively, p < .01. There was no reliable association between age and time spent in therapy.
Involvement in Therapy as a Function of Age, Sex, and Theoretical Orientation
A logistic regression analysis evaluated status as a therapy client or patient as a function of age, sex, and theoretical orientation (psychodynamic, eclectic, cognitive, or other). Patient status was predicted by a model that included sex, theoretical orientation, and age, but by none of the interactions among them, goodness-of-fit χ2 (17, N = 433) = 14.32, p = .64 . Women were more likely to have been in therapy (89.6%) than were men (79.7%), F (1, 426) = 5.08, p = .02. Psychodynamic therapists were most likely to have been in therapy (94%), followed by 87% of eclectic therapist, 79% of other therapist, and 71% of cognitive therapists, F (3, 426) = 7.10, p = .0001.
Status as a therapy patient decreased with age. Whereas 92.9% of therapists 40 years or under were or had been patients, only 84.5% of therapists in their 40s were or had been, decreasing to 81.3% of therapists over age 50, F (1, 426) = 3.10, p = .05.
Major Focus of Therapy
Participants were asked to reveal the major problem, distress, dysfunction, or issue that they addressed in their personal therapy. Some indicated more than one major focus of therapy. Table 3 contains the 35 categories representing the 640 responses.
|Focus||No. of times mentioned|
|Depression or general unhappiness||120|
|Marriage or divorce||94|
|Self-esteem and self-confidence||57|
|Career, work, or studies||45|
|Family of origin||38|
|Loss or abandonment||18|
|Sexual conflicts, behavior, or functioning||9|
|Sexual assault or abuse||9|
|Focus on participant's mother||8|
|Participant's parenting role or duties||7|
|Focus on participant's father||7|
|Awareness or management of feelings||7|
|Trauma or post-traumatic stress disorder||7|
|Obsessive thoughts or behavior||6|
|childhood events or issues||4|
|Substance abuse or addiction||4|
|Feelings of inadequacy||4|
Beneficial Aspects of Therapy
Asked to indicate whether their experiences with therapy, taken as a whole, were "not at all helpful, " "somewhat helpful, " "very helpful, " or "exceptionally helpful, " 342 (85.7%) of the 399 participants responding to this question reported that their experiences with therapy were very or exceptionally helpful. Only 2 respondents reported that the experience was not at all helpful.
Responding to an open-ended question that asked for the most important benefit, if any, of their experience with therapy, participants mentioned 517 benefits in 38 categories, as shown in Table 4.
|Benefit||No. of times mentioned|
|Self-awareness or self-understanding||133|
|Self-esteem or self-confidence||98|
|Improved skills as a therapist||77|
|Better understanding of or relationship with family of origin||17|
|Support provided by therapy||17|
|Openness to and acceptance of feelings||17|
|Understanding of or impovement in relationships (general)||13|
|Decrease in or management of depression||13|
|Decrease in or management of anxiety||13|
|Increased sense of control||11|
|Improved marital relationship||9|
|Increased sense of perspective||7|
|Sense of inner peace||6|
|Accomplishment of a specific goal||6|
|Survival (e.g., therapy "kept me alive")||4|
|Increased capacity and skills for intimacy||4|
|Greater sense of life's options||4|
|Provision of an outside opinion or perspective||3|
|Greater sense of freedom||2|
|Greater ability to be flexible||2|
|Clarification of values||2|
|Better physical health||2|
|Greater sense of humility||2|
|Promotion of stability||2|
|Increase in assertiveness||2|
|Relationship with the therapist||2|
|Happiness and joy||2|
|Decrease in or management of anger||2|
|Development of patience||2|
Harmful Aspects of Therapy
Asked to indicate whether their experiences with therapy, taken as a whole, were "not at all harmful, " "somewhat harmful, " "very harmful, " or "exceptionally harmful, " 9 therapists (2.3%) of the 398 who responded to this question reported that their experiences were very or exceptionally harmful. Most (309;77.6%) found the experience not at all harmful.
Responding to an open-ended question that asked what caused the most serious harm, if any, of their experience with therapy, participants mentioned 144 causes of harm in 25 categories, as shown in Table 5.
|Cause||No. of times mentioned|
|Therapist's sexual acts or attempted sexual acts with participant||16|
|Sadistic or emotionally abusive therapist||12|
|Therapist's (general) failure to understand the patient||11|
|Nonsexual dual relationships and boundary violations||10|
|Therapist's mishandling of marital issues||7|
|Inattentive or uncaring therapist||7|
|Narcissistic or self-centered therapist||6|
|Therapist's dogmatic reliance on theory or preconceived notions||5|
|Poorly handled termination||5|
|Therapist's tendency to blame patient||4|
|Therapist's overlooking of abuse issues||4|
|Violations of confidentiality||3|
|Therapist's encouraging of inappropriate dependence||3|
|Therapy being generally a waste of time||3|
|Participant's learning that therapist had engaged in sex with another patient||2|
|Therapist's substance abuse||2|
|Therapist's creating undue and nontherapeutic emotional turmoil||2|
|Therapist's mishandling of medication issues||2|
|Therapist's pressuring the patient to do something||2|
|Therapist's overlooking patient's medical illness or condition||2|
|Therapist's lack of belief in patient||2|
Benefits and Harm in Relationship to Duration of Therapy
A 2 x 3 weighted means analysis of variance assessed the relationship between time in therapy and how helpful and harmful the therapy was rated to be. Harm was dichotomized into not at all harmful and the other categories combined. Help was categorized into (a) not at all or somewhat helpful, (b) very helpful, and (c) extremely helpful. Because of heterogeneity of variance and highly unequal sample sizes, alpha was set to .01. The sample size with responses to all three items was 392. Both main effects for time in therapy and helpful or harmful ratings were statistically significant, but not their interaction. The higher the rating of helpfulness, the longer the patients were in therapy, F (2, 386) = 10.50, η 2 = .05 .Those who found therapy to be not at all or somewhat helpful were in therapy an average of 3.5 years, those who found therapy very helpful were in therapy an average of 4.5 years, and those who found therapy extremely helpful were in therapy an average of 6 years. Those who rated therapy harmful (somewhat, very, or extremely) were in therapy longer (M = 6.7 years) than were those who rated it not at all harmful M = 4.57 years , F (1, 386) = 20.33, η 2 = .05 .
Information Kept Secret From the Therapist
Of the 392 participants who responded to the question, 80 (20%) reported that there was something important they had kept secret and refused to disclose to any therapist. Invited to disclose the nature of the secret if they felt comfortable doing so on this anonymous survey, participants reported 49 secrets in seven general categories: sexual issues (25), feeling about the therapist (5), their own history of abuse (4), their engaging in substance abuse (3), their eating disorder (2), the identity of third parties whom they mentioned in therapy (2), and miscellaneous (8).
Experiences During and After Therapy
The survey form invited participants who had been in therapy to indicate to what degree, if at all, a therapist had engaged in 19 behaviors, and to what degree, if at all, the participants had engaged in 8 behaviors. Participants who had been in therapy but were no longer in therapy were invited to report how often, if at all, they had recently (i.e., within the past year) daydreamed about a former therapist, dreamed while asleep about a former therapist, felt intense anger at a former therapist, or experienced sexual feelings or fantasies about a former therapist. Table 6 contains the participants' ratings on these 31 items.
Ratings: 0 = never; 1 = once; 2 = rarely (2-4 times); 3 = sometimes (5-10 times); 4 = often
In your own personal therapy, how often (if at all) did your therapist: (N=400)
Cradle or hold you in a nonsexual way
Touch you in a sexual way
Talk about sexual issues in a way that you believe to be inappropriate
Seem to be sexually attracted to you
Disclose that he or she was sexually attracted to you
Seem to be sexually aroused in your presence
Express anger at you
Express disappointment in you
Give you encouragement and support
Tell you that he or she cared about you
Make what you consider to be a clinical or therapeutic error
Pressure you to talk about something you didn't want to talk about
Use humor in an appropriate way
Use humor in an inappropriate way
Act in a rude or insensitive manner toward you
Violate your rights to confidentiality
Violate your rights to informed consent
Use a course of psychotropic medication as part of your treatment
Use hospitalization as part of your treatment
In your own personal therapy, how often (if at all) did you (N=400)
Feel sexually attracted to your therapist
Tell your therapist that you were sexually attracted to him or her
Have sexual fantasies about your therapist
Feel angry at your therapist
Feel that your therapist did not care about you
Make a suicide attempt
Feel what you would characterize as clinical depression
If you are no longer in therapy, how often (if at all) have you recently (within the past year): (N=295)
Daydreamed about your former therapist
Dreamed, while asleep, about a former therapist
Felt intense anger at a former therapist
Experienced sexual feelings or fantasies about a former therapist
NOTE: Percentages do not add up to 100 because of missing data.Factor analysis of experiences.
The 27 experiences reported on by all therapists who had been patients or clients in personal therapy (i.e., the first 27 items in Table 6) were subjected to a factor analysis. The analysis was based on 372 cases; 28 cases were missing data on one or more of the items. The two items with more than 95% of the responses in a single category were dropped from the analysis. Items with a preponderance of responses in an extreme category were dichotomized; response categories were combined for several items with only a few responses in adjacent categories.
The principal factor analysis with varimax rotation yielded three factors, accounting for 75% of the total variance in the ratings. All three factors were internally consistent and well defined by the variables; the lowest of the squared multiple correlations for factors from variables was .79. However, variables were not well represented by the factors. As the results in Table 7 show, communalities tended to be low. With a cutoff of .45 for the interpretation of a loading for a factor, 15 of the 25 analyzed items loaded on one of the three factors. Factor 1, interpreted as Therapist Unkindness or Errors, was defined by 7 variables. The second factor, interpreted as Therapist Sexual Material, was defined by 5 variables. Three variables loaded on the third factor, interpreted as Patient Sexual Material. Table 7 shows only the 15 variables that loaded on one of the factors.
|Factor 1: Therapist Unkindness or Errors (percentage of variance = 3.21)|
|Did your therapist express disappointment in you?||.62||.42|
|Did your therapist act in a rude or insensitive manner toward you?||.61||.39|
|Did your therapist make what you consider to be a clinical or therapeutic error?||.58||.38|
|Did you feel that your therapist did not care about you?||.57||.35|
|Did you feel angry at your therapist?||.55||.48|
|Did your therapist express anger at you?||.54||.35|
|Did your therapist use humor in an appropriate way?||.46||.25|
|Factor 2: Therapist Sexual Material (percentage of variance = 2.84)|
|Did your therapist seem to be sexually aroused in your presence?||.71||.52|
|Did your therapist seem to be sexually attracted to you?||.70||.53|
|Did your therapist disclose that he or she was sexually attracted to you?||.66||.47|
|Did your therapist talk about sexual issues in a way that you believe to be inappropriate?||.61||.41|
|Did your therapist touch you in a sexual way?||.52||.28|
|Factor 3: Patient Sexual Material (percentage of variance = 2.32)|
|Did you have sexual fantasies about your therapist?||.80||.69|
|Did you feel sexually attracted to your therapist?||.78||.70|
|Did you tell your therapist that you were sexually attracted to him or her?||.72||.57|
Note: Other includes all orientations listed by fewer than 3 therapists. Percentages do not add up to 100 because of missing data.
The second factor was defined by questions in the first set of items, beginning with the stem, "How often (if at all) did your therapist ...?" The third factor was defined by items in the second set, beginning with the stem, "How often (if at all) did you ...?" The first factor was defined by items that spanned the two parts of the questionnaire about therapy experiences.
Experiences associated with ratings and duration of therapy.
A 2 x 3 weighted means multivariate analysis of variance (MANOVA) was used to examine the association between ratings of helpfulness and harmfulness and factor scores. Harmfulness was dichotomized into (a) not at all harmful and (b) all other harmfulness categories combined. Helpfulness was divided into three categories: (a) not at all or somewhat helpful, (b) very helpful, and (c) extremely helpful. Because of heterogeneity of variance and highly discrepant sample sizes, multivariate effects were evaluated at a = .01.
By Hotelling's T 2 criterion, the main effect of harmfulness was statistically significant (Tabachnick & Fidell, 1989), multivariate F 3, 359 = 29.34, p < .0001, η 2 = .20 . Neither the main effect of helpfulness nor the interaction reached statistical significance.
Univariate analysis (with a = .017) revealed that ratings of harmfulness were associated with all three factors. Those who felt the therapy was at least somewhat harmful were more likely to score high on items reflecting Therapist Unikindness or Error, F (1, 361) = 58.00, η 2 = .14 . Univariate analyses also produced higher scores on items reflecting sexual material on the part of patients' therapists, F (1, 361) = 22.33, η 2 = .06, as well as on item reflecting sexual material on their own part, F (1, 361) = 6.68, η 2 = .02 .
The relationship between time in therapy and factor scores representing experiences was investigated with standard multiple regression. Time in therapy was significantly related to the set of three factors, F (3, 366) = 44.04, p < .001; the relationship was moderate R 2 =.27 . With a criterion a = .017, Factors 1 and 3 were related to duration of therapy. Patients who were in therapy longer were more likely to report unkindness or errors on the part of their therapists (β = 0.278), F (1, 366) = 38.27, and more likely to report sexual material on their own part (b = 0.398), F (1, 366) = 78.45.
Experiences and patient characteristics.
A 2 x 2 x 2 weighted means MANOVA examined factor scores (Therapist Unkindness or Errors, Therapist Sexual Material, and Patient Sexual Material) as a function of sex, age (47 years or younger, and over 47 years), and theoretical orientation (psychodynamic vs. others). All main effects were adjusted for each other, as were all two-way interactions.
By Hotelling's T 2 criterion, the results showed statistically significant main effects for sex, multivariate F (3, 331) = 10.34, p < .0001, η 2 = .09, and for theoretical orientation, multivariate F (3, 331) = 9.97, p < .0001, η 2 = .08 . There was also a small, but statistically reliable, three-way interactions, multivariate F (3, 331) = 2.77, p = .04, η 2 = .02. None of the two-way interactions was significant.
Significant univariate effects were tested at α = .017. Sex of patient was associated with sexual material on the part of the therapist (Factor 2) and the patient (Factor 3). On both factors, men produced lower standard scores than did women, F (1, 333) = 11.74 for Factor 2 and F (1, 333) = 17.02 for Factor 3. That is, the experiences that defined the factors were more likely to occur to female therapists as patients than to male therapists as patients. Theoretical orientation was associated only with Factor 3, F (1, 333) = 26.16. Factor 3 experiences (sexual material on the part of the patient) were more likely to occur for psychodynamically oriented therapists in the role of patients.
Although the three-way interaction reached statistical reliability during multivariate analysis, all of the univariate tests exceeded the criterion significance level.
Logistic regression was used to examine the predictability of respondents keeping secrets from their personal therapists. Predictor variables were age, sex, theoretical orientation (psychodynamic vs. other), ratings of helpfulness and harmfulness of therapy, duration of therapy, and the three factor scores representing experiences in therapy. Although a model had an acceptable level of fit, goodness-of-fit χ2 (320, N = 330) = 325.16, p = .41, only the rating of helpfulness of therapy significantly added to predictability by itself, F (1, 320) = 4.20, p =.04 . The higher the rating of helpfulness, the less likely that information was withheld from the therapist, B = -0.44.
Continuing Psychological Involvement
Of the 297 respondents who had been but were no longer in personal therapy, 117 (39%) reported at least some continuing psychological involvement in therapy, answering positively to one or more of the following items: have you recently day dreamed about a former therapist; dreamed, while asleep, about a former therapist; felt intense anger at a former therapist; or experienced sexual feelings or fantasies about a former therapist. Two-group logistic regression analysis examined whether respondents were still psychologically involved in their former therapy as a function of age, sex, time since termination, ratings of helpfulness and harmfulness of therapy, whether a secret was kept from the therapist, and the three factor scores representing experiences in therapy. Model fit was acceptable, goodness-of-fit χ2 (227, N = 241) = 258.73, p = .07 . Continuing psychological involvement was related to scores on Factors 1 and 3. Therapist Unkindness or Errors (Factor 1) predicted greater likelihood of continuing involvement, F (1, 227) = 11.01, p = .001, B = 0.67 . Sexual material on the part of the patient (Factor 3) also predicted greater continuing involvement, F (1, 227) = 17.00, p = .0001, B = 0.81.
Thoughts About Returning to Therapy
Among the 300 respondents who had been but no longer were in therapy, 188 (63%) had considered resuming therapy. Of these, 81 reported considering resumption only with a new therapist, and 44 reported considering resumption only with a former therapist. Logistic regression analysis was used to evaluate differences in those who considered resumption with a new or former therapist on the basis of scores on the three experience factors, ratings of helpfulness and harmfulness of therapy, whether secrets had been kept from a therapist, and whether there was continuing psychological involvement with a former therapist. The fitted model showed a relationship between predictors and whether resumption was considered with a former or new therapist, goodness-of-fit χ2 (104, N = 112) = 118.03, p = .16 . By itself, only rating of helpfulness predicted therapist resumption, F (1, 104) = 11.01, p = .0013 . The greater the rated helpfulness, the more likely resumption of therapy was considered with a former rather than with a new therapist.
Beliefs About the Desirability and Effectiveness of Requiring Therapy
Of the 464 participants who responded to the question, 62 had studied in graduate programs that required therapists-in-training to enter personal therapy. Table 8 contains the responses to questions about requiring therapists to participate in personal therapy.
A weighted means 2 x 2 x2 x 2 MANOVA explored the beliefs presented in Table 8 as a function of age (47 years and younger, and over 47 years), sex, theoretical orientation (psychodynamic vs. other), and having been in personal therapy. Third- and fourth-order interactions were not evaluated becaue of small sample sizes in some cells (e.g., n = 1 each for male and female psychodynamically oriented therapist who were 47 years or younger and had not been in personal therapy).
Note: 1 = absolutely yes; 2 = probably; 3 = don't know; 4 = probably not; 5 = absolutely not.
|Should personal therapy be a requirement in psychology graduate and professional schools for students who are training to be therapists?||39.7||30.0||2.5||17.0||10.1|
|Should personal therapy be a requirement for licensure of therapists?||30.7||23.7||4.8||20.2||20.0|
|Should licensing boards be able to require therapists (e.g., show have violated professional standards) to obtain therapy as a condition of their continuing or resuming practice?||62.0||25.2||3.8||2.9||5.5|
|Do you believe that therapy mandated by licensing boards as a condition of therapists continuing or resuming practice tends to be effective?||5.3||28.8||49.6||12.2||3.8|
Note: Percentages do not add up to 100% because of missing data.
By Hotelling's T 2 criterion, statistically significant multivariate effects were found for main effects of theoretical orientation, F (4, 413) = 3.70, p = .0057, η 2 = .03 , and status as a patient, F (4, 413) = 19.27, p < .0001, η 2 = .16 . One two-way interaction was statistically reliable: Theoretical Orientation x Patient Status, F (4, 413) = 4.19, p = .0025, η 2 = .04 .
Associations between the effects and individual opinions were evaluated through step-down analysis, with opinion about requirements for therapy in graduate training given highest priority, followed by requirement for licensure, then by requirement as a condition for continuing practice, and finally by belief in the effectiveness of this requirement as a condition for continuing practice. Family-wise Type I error rate was kept to 5% by evaluating each step-down effect with α = .0125.
Respondents who had been patients supported therapy a requirement in graduate programs (M = 2.07 on an increasingly negative scale ranging from absolutely yes = 1 to absolutely not = 5) more strongly than did respondents who had never been therapy patients (M = 3.62), F (1, 416) = 64.18. After that opinion was adjusted for, respondents who had been patients also more strongly supported personal therapy as a requirements for licensing (adjusted M = 2.72) than did respondents who were not patients (adjusted mean = 3.20), F (1, 415) = 9.11. Psychodynamically oriented therapists were more likely to endorse a requirement for personal therapy in graduate training (M = 1.87) than were therapists of other orientations (M = 2.53), F (1, 416) = 8.96.
Theoretical orientation interacted with patient status in endorsement of personal therapy as a condition for therapists continuing or resuming practice (i.e., after having violated professional standards), after an adjustment for opinions about requiring therapy for graduate training and licensing. Psychodynamically oriented therapists and therapists of other orientations who had been patients had virtually the same opinion (adjusted M = 1.66 and 1.69, respectively). However, psychodynamically oriented therapists who had not been patients were less likely to endorse therapy as a condition for continuing practice (adjusted M = 2.57) than were therapists of other orientations who had not been patients (adjusted M = 1.24).
In keeping with the findings of Guy, Miriam, and Poelstra (1988), these findings suggest that the overwhelming majority (84%) of participants had entered therapy, although only 13% had attended a graduate program requiring personal therapy for therapists-in-training. [Please follow this link to [ footnote #2.] Slightly over one in five of all participants reported that they were currently in therapy. The following sections highlight a few of this survey's findings and implications. However, consideration of these findings and implications must be guided by the caution warranted by an unreplicated study. The sources of potential error in any survey are many, and the results of a single survey always warrant caution. Responses may be vulnerable to social demands (Edwards, 1957), forces that influence the accuracy of memory (Feldman-Summers & Pope, 1994; Freyd, in press-a, in press-b ; Herman, 1992, 1994; Loftus, 1993; Neisser, 1982; Pope, 1994; Stangor & McMillan, 1992), and other threats to survey validity (Lessler & Kalsbeek, 1992).
Therapy as a Requirement in Graduate Training and Licensure
All participants, regardless of whether they had been in therapy, were asked to respond to questions concerning mandated therapy. A surprising finding, especially in light of the fact that only 13% had been required by their graduate programs to enter therapy, was that a substantial majority (70%) believed that psychology graduate and professional schools should "probably" or "absolutely" require therapy for therapists-in-training. A smaller majority (54%) believed that state licensing boards at least "probably" should make personal therapy a requirement for licensure.
These beliefs seem linked to some extent to participants' experience (or lack of experience) as patients: Participants who had been in therapy were significantly more likely to favor graduate training programs and licensing boards mandating therapy. These beliefs may also reflect, to some extent, participants' experienced-based views that (a) they are likely to encounter periods of clinical depression for which therapy is warranted, (b) therapy in most instances produces important benefits (one of the most common of which is that it improves the patient's skills as a therapist), and (c) the self-awareness and self-understanding that appear to be the most frequently mentioned benefit of therapy may enable therapists to better handle self-disclosure, self-expression, boundary issues, sexual dynamics, and other frequently mentioned (by participants) aspects of therapy. Each of these topics is discussed in a subsequent section.
Although therapy was mandated by graduate and professional schools for only a small minority of participants, younger therapists were significantly more likely to have entered therapy. Whereas about 1 in 5 therapists (19%) who were over 50 years old had never been in therapy and about 1 in 7 (15%) who were in their 40s had never been in therapy, only about 1 in 14 (7%) who were under 40 years old had never been in therapy.
An intriguing finding is that although a majority (87%) favored enabling licensing boards to require therapists (e.g., those who violate professional standards) to obtain therapy as a condition of their continuing or resuming practice, only about a third believed that therapy mandated under such conditions either "certainly" (5%) or "likely" (29%) is effective. This majority conclusion may be due in part to the difficulty of finding any therapy or rehabilitation research in this area that meets 11 fundamental validity criteria (Pope, Butcher, & Seelen, 2000, pp. 207-224; see also Pope & Vasquez, 1998) as well as the nature of licensing board actions (Pope, 1993). The failure of research, theory, and other factors to convince more than a third of the professional community that such interventions by licensing boards are effective seems to warrant a rethinking of policy and practice in this area and to invite renewed efforts of researchers.
Depression and Unhappiness
One of the surprising findings was the degree to which participants reported suffering from unhappiness and depression. Almost one out of five revealed that depression or unhappiness was the major problem, distress, dysfunction, or issue that they addressed in therapy, A majority (61%) reported that, regardless of the major focus of therapy, they had experienced at least one episode of what they would characterize as clinical depression. Over one out of four (29%) disclosed that they had felt suicidal, and almost 4% reported having made at least one suicidal attempt.
These findings suggest that training programs may need to pay much more attention to clinical depression as a phenomenon that most psychologists are likely to experience at least once. Psychologists-in-training may need education to learn how to recognize and respond to the onset of depression, assurance that such experiences are not inherently discordant with their professional identity (i.e., experiencing clinical depression does not imply that one must seek another career), opportunities to discuss how to fulfill the ethical responsibility to "refrain from undertaking an activity when they know or should know that their personal problems are likely to lead to harm" (APA, 1992 , Principle 1.13. p. 1601) [ footnote #3 ] and adequate access to support and other forms of help should depression or similar distress occur in the course of training.
The Self-Disclosing and Self-Expressive (but Often Unfunny) Therapist
In sharp contrast to the view of the therapist as a blank screen or passive listener are participants' reports of their therapists' behavior. Almost all (96%) disclosed that at least one of their therapists offered encouragement and support, and a majority (64%) reported that at least one therapist explicity told the participant that he or she cared about the patient. Not all of the sentiments were positive. Over one third (39%) noted that at least one therapist expressed anger at them, and slightly less than a third (32%) reported that a therapist expressed disappointment in them. About the same percentage (31%) indicated that a therapist had acted rudely or insensitively toward them.
One of the most surprising findings was that relatively few participants (23%) reported that their therapists used humor appropriately. Not only was appropriate humor generally absent during the course of therapy, but inappropriate humor was amazingly prevalent, reported by almost 94% of the participants. Participants described some dismaying instances of hurtful jokes and related put-downs. One participant, for example, wrote that her therapist joked about her being suicidal; another described how her therapist belittled her for her fear during a biopsy for her fear during a biopsy for breast cancer. Such findings suggest that graduate training programs might devote more time to exploring the uses and misuses of humor in therapy.
Three well-defined, internally consistent factors, accounting for three fourths of the total variance, emerged from the first 27 items listed in Table 6 . In planning the research, we had hypothesized that there would be six factors: sexual material, therapist (un)kindliness, patient sadness, therapeutic errors, emotionality, and expressiveness. The results showed that unkindness and therapeutic errors loaded on the same factor, suggesting at least two possibilities. It is possible (but, in our view, unlikely) that patients tend to blend the experiences of unkind behavior and (supposedly unintentional) mistakes. It is also possible that therapists who are unkind are more likely to make therapeutic errors (and perhaps that unkindness itself is experienced as a therapeutic error).
Sexual material formed two orthogonal factors, depending on whether the sexual, feelings or expressions were on the part of the therapist or the client. This intriguing finding is consistent with the notion that there may be a substantial independence between the sexual feelings of the therapist and of the client (e.g., see Pope, Sonne, & Holroyd, 1993 ; Pope & Tabachnick, 1993). Such an interpretation suggests that a client's sexual feelings or expressions do not generally evoke sexual feelings or expressions on the part of the therapist, and vice versa.
The gender of the client appears to be significantly linked to the two orthogonal sexual factors. Women tended to assign higher ratings to items on both Factor 2 (Therapist Sexual Material) and Factor 3 (Patient Sexual Material). At present, there is insufficient research to understand completely why these factors are associated more with female clients than with male clients (Pope, Sonne, & Holroyd, 1993; Pope & Tabachnick, 1993). This finding may reflect the likelihood that most participants were heterosexual and that women are more often patients of male therapists than men are patients of female therapists. It is also possible that sex role bias and stereotyping play a role, as they appear to when therapist-client sexual contact occurs (e.g., Hare-Mustin, 1974; Holroyd, 1983; Holroyd & Brodsky, 1977), but this is speculation. A complete understanding must take account of the full context, including "unique developmental experience and life processes" (Bernay & Cantor, 1986, p. 3; see also Brown, 1994). Therapist-patient sexual dynamics deserve more extensive research and have significant implications for understanding this phenomenon and providing adequate training (Pope, Sonne, & Holroyd, 1993), particularly in light of the possible link between sexual issues in training programs and subsequent sexual behavior between therapist and patient, a link for which there is some empirical support (Pope, 1994; Pope, Levenson, & Schover, 1979).Help, Harm, and Errors
A large majority (86%) of participants who had been in therapy found it helpful, which is consistent with the findings of Shapiro (1976) . The most frequently mentioned benefit (26%) was not the accomplishment of a specific behavioral goal but rather was an increase in self-awareness or self-knowledge. Because such a concept tends to be difficult to operationalize or measure, therapy research that explores the processes by which and the extent to which such benefits are accomplished may be extremely difficult. Interestingly, the third most frequently mentioned benefit was that therapy improved the participants' skills as therapists (i.e., they learned what it was like to be a patient and what sorts of interventions seemed to be helpful or useless), in keeping with the findings of Kaslow and Friedman (1984) .
Therapists who tend to worry that their own fallibility will likely be a cause of disaster for their patients can take comfort in the findings that although 79% reported that their therapists had made clinical and therapeutic errors, only 2% reported that therapy had been "very" or "exceptionally" harmful. Nevertheless, the finding that over one in five (22%) reported that their experiences with therapy, taken as a whole, had been at least somewhat harmful must be taken into account as the profession thinks through such policy issues as providing adequately informed consent to patients (5% reported that a therapist had violated their rights to informed consent) and requiring therapists-in-training to enter therapy (a topic discussed in a subsequent section).
Unlike helpfulness, harmfulness was significantly related to the three factors presented in Table 7; like helpfulness, harmfulness emerged as positively associated with the duration of therapy (i.e., longer therapy tended to be associated with more extreme ratings for harmfulness and helpfulness). The helpful or harmful effects can be viewed in terms of both their intensity and their duration. As mentioned above, some participants emphasized that being patients had enhanced their skills as therapists, yielding benefits over the course of a career. Some participants also emphasized the lasting effects of harm (e.g., "[A] therapist I worked with for 2 years threatening to throw me out of her office because I said she had hurt my feelings once. Ten years later this still undermines my ability to relax and trust.").
Secrecy, Confidentiality, and Boundaries
About one in five of those who had been in therapy reported that there was something important that they had kept secret and refused to disclose to any therapist. In light of the trust involved in therapy, it is not surprising that successful therapy tended to be statistically associated with an absence of secrets withheld from the therapist. Interestingly, when participants revealed the topic of the secret, a majority involved sexual issues.
Patients who are joining or are already a part of the community of therapists may have heightened concerns about confidentiality. If the therapist does not keep the material shared by and relevant to the patient secret, at least within accordance of the patient's rights, not only will the patient's trust and rights be violated, but potentially sensitive or damaging information about the patient may become the focus of gossip and misunderstanding among the patient's colleagues, perhaps damaging personal relationships, reputation, and career. Some therapists, for example, may wish it to be their own decision, rather than their therapist's, whether and how to reveal to colleagues that they have taken psychotropic medications or that they have been hospitalized in conjunction with therapy, as reported by 15% and 4%, respectively, of the participants who had been in therapy. Similarly, some form of abuse (sexual assault or abuse, child abuse, or general abuse) was identified 16 times as the central issue in therapy. Abuse issues may have special salience and implications for confidentiality because of the cruel stigma that exists, which often influences the ways in which those who have experienced abuse are viewed (Herman, 1981, 1992 ; Walker, 1979, 1984 , 1994 ), because of the substantial percentages of psychologists who have experienced abuse (Pope & Feldman-Summers, 1992) and because of the degree to which therapy may serve as the occasion for psychologists to remember abuse that they had previously forgotten (Feldman-Summers & Pope, 1994). In this regard, it is both surprising and disturbing that 1 out of 10 participants who had been in therapy reported that a therapist had violated his or her rights to confidentiality. Such violations may be not only a cause of possible harm for patients but also a potential barrier to others needing or wanting therapy. One participant who had never entered therapy wrote that "if I did I would feel extremely constrained because of public positions I've held in the local psychology community."
The clarity and reliability of boundaries to the flow of information (e.g., secrets and confidential communications) are part of the more complex array of issues in establishing and maintaining boundaries when therapists-in-training become patients. That the patient is a member or a soon-to-be member of the community of therapists creates numerous opportunities for dual relationships and other blurrings of bounderies (which was the fifth most frequently mentioned cause of harm in therapy). These boundary issues may become acute within the context of training programs, regardless of whether the program mandates the therapy. Describing the cause of harm in therapy, a participant focused on the graduate program's boundary violations and enmeshment, as the therapists were also graduate faculty. Another participant wrote, "My first therapist not only promoted a dual relationship (shared personal info, asked me to watch her pets, etc.) but also reacted inappropriately to my disclosure that I was sexually involved with the director of my clinical training program (e.g., she was excited by this and never pursued the exploitation or violation of ethics)." Policy discussion about the role of therapy in the training, development, and support of psychologists is in need of increased research and attention focusing on such boundary issues.
About 1 in 20 (6%) reported that the therapist touched the patient in a sexual way, a phenomenon that has received much attention in the therapeutic literature during the past 2 or 3 decades (e.g., Bouhoutsos, Holroyd, Lerman, Forer, & Greenberg, 1983; Feldman-Summers & Jones, 1984; Gabbard, 1989; Hare-Mustin, 1974; Holroyd & Brodsky, 1977; Pope, 1994; Pope, Sonne, & Holroyd, 1993). It is important to note that the APA's code of conduct states, "Psychologists do not engage in sexual intimacies with current patients or clients" (APA, 1992 , Section 4.05, p. 1605). Slightly larger percentages reported encountering therapists who exhibited sexual responses that did not involve physical contact. About 14% reported that a therapist seemed to be sexually attracted to them, and about 8% reported that a therapist seemed to be sexually aroused. About 7% reported that a therapist disclosed his or her sexual attraction to the patient, and about 8% reported that the therapist talked about sexual issues in a way that the participant believed was inappropriate.
One of the surprising findings concerned the use of nonsexual physical touch in the form of cradling or holding. Slightly over one fourth (26%) of participants who had been in therapy reported that a therapist had cradled or held them in a nonsexual way. That so many participants had been cradled or held by their therapists was surprising, in part, because of the attention paid, by both the public and the profession, to sexual contact. In light of the harm and penalties associated with sexual violations, it might be hypothesized that therapists would tend to avoid forms of physical contact such as holding and cradling (i.e., those beyond a handshake, reassuring touch, and other brief and limited forms of making contact). The finding is also somewhat surprising given the relevant lack of therapy research literature on the effects of nonphysical touch. That at least one fourth of the participants reported having been cradled or held by their therapists suggests that this form of therapist-client relationship deserves increased attention in systematic studies, graduate training programs, and continuing education courses. (Additional research data regarding various forms of nonsexual contact between therapist and patient are provided by Holroyd & Brodsky, 1977, 1980; Pope, Tabachnick, & Keith-Spiegel, 1987; Pope & Tabachnick, 1993).
Continuing Involvement Posttermination and Thoughts of Resuming Therapy
Finally, the findings suggest that for many participants termination does not mark the end of cognitive and emotional involvement with the therapist and of considerations of additional therapy. Of those who were no longer in therapy, almost one out of three (31%) had daydreamed about a former therapist during the previous year. Over 1 in 10 had dreamed while asleep (14%) about a former therapist and had experienced intense anger (11%) at a former therapist. About 1 in 20 (6%) had experienced sexual feelings or fantasies about the former therapist. In the past year, most (63%) had considered returning to therapy; twice as many considered resuming only with a new therapist as those who considered resuming therapy with a former therapist. As might be expected, helpfulness was significantly related to thoughts of returning to a former therapist (i.e., the more helpful the therapy had been, the more likely the participant was to consider returning to the former therapist). These findings suggest that researchers and psychology training programs devote more attention to the exploration of how termination processes can best address issues relating to the client's continuing psychological involvement with the therapist after termination and to thoughts of resuming therapy. Although sexual involvement with a former therapist has been explicitly addressed in the current ethics code (APA, 1992), a richer array of research is needed to help practicing therapists and training programs adequately understand the nature, processes, and implications of the client's experience after termination, particularly with regard to the psychological relationship to the former therapist and the course of therapy.
NOTE: Some references have been updated since publication of the original article.
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Footnote #1: Specific divisional membership (i.e., Division 12, 17, 29, and 42, in which most members practice as therapists) has been used in this study, as in previous surveys, as a useful and approximate, though imperfect, approach (i.e., some members do not provide therapy) to the selection of a representative sample of psychologists who provide therapy. [Back to body one]
Footnote #2: Although the methods of data collection and variables examined are so different as to make attempts at comparison risky at best, the difference between the 13% of participants in this study reporting graduate school mandated personal therapy and the 4% of APA-approved clinical training programs requiring therapy, as reported by Wampler and Strupp (1976), seems to suggest that there may have been an increase in the number of training programs that require therapy. [Back to body two]
Footnote #3: The profession may need to devote much more attention to the potential difficulties in fulfilling this ethical mandate. Psychologists may be well aware, from their formal education and the ethics code itself, that the experience of depression, should it become debilitating, obligates them to refrain from practicing in a way that may lead to harm to patients. However, severely depressed therapists, faced with the loss of patients and income, if in independent practice, or with the potential loss of a badly needed job, if employed, may wonder whether their training program devoted sufficient time to the exploration of how to resolve constructively such dilemmas. [Back to body three]