Psychotherapists-In-Training Evaluate Their Personal Therapy:Results of a UK Survey

Norman Macaskill and Ann Macaskill

SUMMARY. A national survey of the personal therapy experiences of UK Senior Registrarsin Psychotherapy found that 87% reported their personal therapy had a moderate to verypositive effect on both their work with patients and in their personal lives. Positive effectsincluded increased self-awareness (76%), increased self-esteem (47%) and reduction insymptoms (43%). The most common primary goals for personal therapy were personalgrowth and the resolutions of personal problems.

No trainees reported purely negative outcomes for their therapy but 38% reported somenegative effects from their therapy. The main negative effects were psychological distress (29%) and marital or family stress (13%).

These results are discussed in relation to previous research on personal therapy.

Introduction

A recent review of the exclusively American empirical research on the effects ofpersonal therapy (Macaskill 1988) revealed that approximately 66% of therapists rated theirpersonal therapy as satisfactory. However 15-40% reported negative outcomes or negativeeffects, and no evidence was found to support the view that personal therapy enhancedtherapeutic effectiveness.

The current study of personal therapy experience of UK psychotherapists-intrainingwas undertaken to determine whether the American findings are applicable in a BritishNHS setting.

Method

All twenty-seven current senior registrars in psychotherapy in the UK were sent asixteen-item questionnaire eliciting the details of and their views of their personal therapyexperience. Q1-3 elicited the location, planned duration and theoretical orientation of theirtraining course. Q4-6 elicited the planned duration, duration to date and session frequencyof their personal therapy. Q7-9, 10, 11 and 12 asked trainees to describe, and rank in orderof importance, their goals for their therapy and whether these goals were discussed andagreed with their therapist. Q8 and 6 asked trainees to rate their initial and current degree ofenthusiasm for their personal therapy. Finally, Q13 and 14 asked trainees to rate anddescribe the effects, either positive or negative, on their work with patients and theirpersonal life.

ResultsTwenty-five trainees (93%) returned questionnaires.

Dr N Macaskill is Consultant Psychiatrist in the Department of Psychiatry, Whiteley Wood Clinic,Woofindin Road. Sheffield S1O 3TL. Dr Ann Macaskill is Senior Lecturer in Psychology, HealthResearch Centre, Sheffield Hallam University.

British Journal of Psychotherapy, Vol 9(2), 1992© The authors

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Training CourseFourteen trainees (52%) have their training in the London area: the remainder are

scattered throughout the country.Twenty of the courses (74%) are planned to last three or more years and twenty-two of

the courses (81%) are described as psychoanalytic in orientation.Two are described as eclectic and one as Jungian.

Characteristics of Personal Therapy

(a) Planned durationFor twenty trainees (74%) therapy was open ended. For the remaining five trainees, therapywas planned to last between two and a half years and three years.(b) Duration to dateSixteen trainees (64%) had already been in therapy for over three years. Eight had been intherapy for one and a half years to three years. One had been in therapy for less than sixmonths. (The responses of this trainee were not included in the evaluation of therapyoutcomes.)(c) Frequency of therapy sessionsSixteen trainees (64%) were in therapy more than twice a week. Five had therapy twice aweek and three had therapy initially once a week, later changing to twice a week. Onetrainee had therapy once a week.(d) Contractual natureTwenty-one trainees (78%) indicated therapy was obligatory. The remaining four traineesstated therapy was optional.

Attitude Towards Personal Therapy

(a) Initial level of enthusiasmSixteen trainees (64%) rated themselves as `very enthusiastic', six as `moderatelyenthusiastic' and three as initially having `little or no enthusiasm' for their personal therapy.(b) Current level of enthusiasmNineteen trainees (70%) now rated themselves as `very enthusiastic', four as `moderatelyenthusiastic' and two as having `little or no enthusiasm'.(c) Comparison of initial and current levels of enthusiasmFourteen trainees (51%) remained unchanged at moderate to high levels of enthusiasm.Seven trainees (26%) had increased their ratings while four had decreased their ratings. Allthree trainees who initially rated low levels of enthusiasm increased their ratings tomoderate or high levels.

Goals for Personal Therapy

Ten trainees (37%) ranked personal growth as their primary goals and nine trainees (33%) ranked resolving personal problems. Three rated fulfilling course requirements, tworated increasing therapeutic effectiveness and one rated having the experience of being apatient as their primary goal.

Norman Macaskill and Ann Macaskill 135

Summed rankings for the group showed a generally similar pattern with personalgrowth > overcoming problems » improving efficacy as therapist > having the experienceof being a patient > fulfilling course requirements.

Negotiation of GoalsThirteen trainees (48%) explicitly discussed their goals for therapy with their analyst

and, of those that did, seven (54%) judged these to have been mutually agreed.

Effects of Personal Therapy(a) Overall outcomes (see Table 1)Twenty-one trainees (91%) reported purely positive outcomes for their therapy. Twenty-one reported moderate to very positive effects on their personal lives and a similar numberreported a moderate to very positive effect on their work with patients. Twenty trainees (87%) reported a moderate to very positive effect on both their personal lives and work withpatients.

No trainee reported purely negative outcomes for their personal therapy. Two traineesreported mixed outcomes. One reported a moderately positive and a slightly negativeoutcome in work with patients and a moderately positive and very negative outcome in hispersonal life. One reported a slightly positive outcome in work with patients and amoderately positive and slightly negative outcome on his personal life.

(b) Positive effects of therapyTwenty-one trainees described the positive effects personal therapy had produced (seeTable 2). Six trainees reported 1-2 positive effects while fifteen trainees (71 %) reported 3-5 positive effects.

Increased %ell awareness was reported by 76%. Other improvements commonly

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reported were increased self esteem, increased work competence, improved personalrelationships and a reduction in symptoms.

(c) Negative effects of therapy (see Table 3)Nine trainees (38%) reported therapy as having some negative effect. Four trainees (17%)reported two or more negative effects.

The commonest negative effect was psychological distress (7) amounting in some casesto overt episodes of depression. Several trainees (3) reported substantial marital or familystress and two reported therapy had led to them being too reflective and avoiding dealingwith significant life issues.

Three trainees reported substantial decreases in their enthusiasm for personal therapyand this is included as a negative effect.

StressTwelve trainees (50%) commented that financial costs and time constraints were a

substantial stress, but indicated they did not feel this was necessarily a negative effect. Fivetrainees (22%) reported psychological distress as an effect of their therapy but indicatedthis was a necessary aspect of their therapy and not something they considered a negativeeffect.

Therapy Outcomes and Personal Therapy Characteristics78% of London-based trainees reported very positive outcomes for their personal

therapy compared with 44% of non-London-based trainees. In addition only 28.5% ofLondon-based trainees reported a negative effect in their therapy compared with 56% ofother trainees. Due to the small sample size, however, none of these figures achievesstatistical significance.

78% of London-based trainees had personal therapy more than twice a week comparedwith 45% of non-London-based trainees and, similarly, 86% of the Londonbased traineeshad been in therapy for more than three years compared with 44% of non-London-basedtrainees. Again, however, these figures are not statistically significant.

Discussion

This study is the first to survey the characteristics and effects of personal therapy onUK psychotherapists-in-training. The general picture that emerges is that personal

Norman Macaskill and Ann Macaskill 137

therapy is an integral, intensive, expensive and time-consuming component of thetherapists' training. It typically continues over three years, occurs more than twice a weekand produces very substantial personal and professional benefits for nearly all trainees,although sometimes at a considerable emotional cost. It seems clear that, from the trainee'spoint of view, the gain is generally well worth the pain.

How do these findings compare with the findings from previous American studies?(1) The overall high positive outcome - 87% of all trainees rate personal therapy as leadingto moderate to very positive changes compares very favourably with other outcome studies.Henry et al (1971) found that 60% rated their personal therapy as satisfactory, whileShapiro (1976) found that 85% similarly rated their therapy experience positively.(2) As in other studies, e.g. Buckley (1981), the range of positive effects of personaltherapy reported by trainees in this survey was quite wide. Changes were noted particularlyin terms of self-esteem, work competence, personal relationships, symptoms and also,although far less frequently, in areas such as creativity and spontaneity.

However, the percentage of trainees reporting improvements in these areas wassubstantially less - generally 50% of the rates reported by Buckley (1981). The onlyexception to this was in improvement in self-esteem which was reported equally frequentlyin both studies.(3) UK trainees rate therapy as having had a moderate to very positive effect on both theirwork and personal lives. In contrast Henry et al (1971) reported that therapists ratedtherapy as having a significantly greater impact on their personal lives than in their workwith patients. Thus, the results of this study are the most favourable to date for the overalleffects of personal therapy, particularly in relation to its positive effect on work withpatients.(4) The striking finding in this study in comparison to previous UK surveys was that therewas no evidence that personal therapy was overall a harmful experience. No traineesreported therapy as having overall negative outcomes and two trainees reported a mixtureof both positive and negative outcomes. This general finding is reassuring given theminimal rate of 18% unsatisfactory outcomes reported by Henry et al (1971) and Shapiro (1976).(5) For most (87%) therapists in the present study the experience of personal therapymaintained or increased their level of enthusiasm for personal therapy as a training andtherapeutic experience. It seems likely, therefore, that the current cohort will underline theimportance of personal therapy as a training requirement when they in turn become trainersof the next generation of psychotherapists.

In this study the trainee's commonest goals for personal therapy were personal growthand the resolution of personal problems. Whether this finding is unique to this cohort isunknown, but may partly explain the initial and continuing high levels of commitment topersonal therapy, which trainees reported on their scores on enthusiasm for personaltherapy. As with patients, the relief of personal distress may be an important factor inmotivating trainees to enter and persevere with personal therapy. This clearly does nottotally explain the positive evaluation of personal therapy as some (10%) trainees, whoentered therapy with low levels of enthusiasm and less personal goals for therapy, increasedtheir levels of enthusiasm as a result of the therapy experience and indicated positiveChanges in work performance and in their personal lives.

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(6) The overall very positive changes reported in this study were nonetheless frequently (51%) accompanied by psychological distress, thus confirming the old adage that 'there's nogain without pain'. Trainees clearly found personal therapy a powerful and unsettlingexperience, 29% describing their distress as a negative effect, while a further 22% reporteddistress but did not rate it as a negative effect.

The overall 39% rating for negative effects in personal therapy in this survey, includingepisodes of depression and marital distress, does not suggest, however, that one ought to becomplacent about the emotional cost/benefit ratio of personal therapy for trainees. To whatextent anything can be done to reduce the pain while retaining the gains remains anunanswered and important question.

In any study of the type reported here, i.e. a consumer-based evaluation particularlywhere the sample size is relatively small, any conclusions that may be drawn have to bedrawn very cautiously. In particular, subjective reports need to be supplemented byobjective outcome measures before the very positive results reported here can be fullyaccepted. Nonetheless, the results reported in this study of beneficial effects of personaltherapy in both work and professional therapy for the great majority of trainees, in theabsence of negative outcomes for any trainees and a moderately low rate of negativeeffects, represents a significant endorsement for an activity that has, almost since itsintroduction, had its share of vociferous supporters and critics.

References

Buckley, P., Karasu, T.B. & Charles, E. (1981) Psychotherapists view their personaltherapy. In Psychotherapy Theory, Research, Practice 18, pp. 299-305.

Crown, S. (1983) Contra-indications and dangers of psychotherapy. In British Journal ofPsychiatry 143, pp. 436-441.

Henry, W.E., Sims, J.H. & Spray, S.L. (1971) The Fifth Profession. San Francisco: JosseyBass.

Macaskill, N.D. (1988) Personal Therapy in the training of the psychotherapist: Is iteffective? In British Journal of Psychotherapy 4(3), pp. 219-226.

Shapiro, D. (1976) The analysts' analysis. In Journal of the American PsychoanalyticAssociation 24, pp. 5-42.