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Clinical and Research Reports |
Received May 20, 2000; revised September 5, 2000; accepted September 14, 2000. From the Department of Psychology, University of Scranton, Scranton, Pennsylvania, and the Department of Psychiatry, Yale University, New Haven, Connecticut. Address correspondence to Dr. Norcross, Department of Psychology, University of Scranton, Scranton, PA 18510-4596. E-mail: norcross{at}uofs.edu
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Abstract |
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Key Words: Psychotherapy of Psychotherapists • Boundary Issues
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Introduction |
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In the first article,1 we introduced our methodology and presented some preliminary normative data regarding the prevalence of conducting psychotherapy with fellow mental health professionals. Three-quarters of respondents replied that they had treated mental health professionals and professionals-in-training in the past 3 years; this population constituted 3% to 7% of their caseloads. Practically all of the therapist-patients were self-referred, and 85% received individual therapy. The psychotherapist-patients tended to be psychologists (37%) or social workers (29%) of diverse theoretical traditions, with the exception of biologically oriented clinicians. In that article, we also called for the development of a knowledge base that could effectively guide the work of psychotherapists who are selected to be the therapists of fellow mental health professionals.
At the center of our first article was the identification of satisfactions and stressors that a national sample of the American Psychological Association Division of Psychotherapy identified as being specific to the psychotherapy of therapists. In several important respects, the respondents echoed the sentiments expressed by a handful of therapist's therapists in clinical case reports.2–6 They shared the view that common clinical dilemmas are activated or intensified when a patient is also a mental health professional. In particular, our data suggest that treating a colleague increases the probability that psychotherapists will feel more anxious and self- conscious about their technical choices, stylistic preferences, and emotional reactions to the potential conflicts of the treatment situation. Many of our respondents also emphasized that there are narcissistic rewards and pitfalls unique to the treatment of therapists—for example, winning the praise or criticism of one's peers and contributing to the advancement of the profession. As Kaslow7 and Freudenberger8 recognized, and our initial results1 reaffirmed, treating colleagues is characteristically difficult, even for seasoned clinicians.
Clinical and empirical investigations of the psychotherapy provided to mental health professionals are clearly needed. Even though the majority of mental health professionals have been or are in psychotherapy, and are of the opinion that personal therapy is a beneficial or even a necessary adjunct to clinical work, scant attention has been devoted to the experience of conducting therapy with therapists and the linkages between their receiving and conducting therapy. Furthermore, three-quarters of psychotherapists are treating mental health professionals, but they have little training or empirical knowledge to assist them in doing so. What other population of psychotherapy clients, accounting for 3% to 7% of our daily work, has been so neglected in the literature and training?
As an extension of this line of inquiry, the present study takes as its focus the following four questions:
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METHODS |
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The sample was demographically and geographically representative of the entire Division of Psychotherapy: 38% were female; 5% were ethnic minorities; their average age was 54 years (SD=10); academic degrees held were Ed.D. (4%), Psy.D. (4%), and Ph.D. (91%); and the predominant theoretical orientations were eclectic (23%), psychodynamic (21%), cognitive (17%), and interpersonal (9%). Most of the psychologists were primarily employed in private practice (64%), with some others in university settings (14%).
The sample was also representative with respect to history of personal therapy. In replication of previous findings, 89% of the psychologists reported having been patients in therapy/analysis. Additionally, 16% stated they were currently in therapy or analysis. In our sample, as in previous studies of psychologists,9,10 the mean and median number of discrete episodes of receiving personal therapy was 3 (SD=1.6). Almost all (96%) had undergone some individual therapy, with a median of 150 hours and a mean of 370 hours. The large standard deviation reflects the large variability, ranging from a few hours to 5,200. Thirty-four percent of the psychologists had undergone group treatment, and when they did so, it was for a mean of 58 hours (SD=268). Exactly half (50%) of the respondents underwent couples/family treatment, which averaged 22 hours (SD=59.7).
Psychologists characterized the outcome of their only or most recent personal therapy on a seven-point, Likert-type scale (1=very harmful, 4=no change, 7=very helpful). Only 2% rated the therapy as harmful (very, moderately, or somewhat), 3% no change, 12% somewhat helpful, 25% moderately helpful, and 58% very helpful. As in previous studies,9–11 the vast majority of respondents reported that their experiences with personal therapy were moderately or exceptionally helpful.
This article summarizes the findings from the last two portions of the questionnaire. Therapy Experiences consisted of a series of 78 questions on conducting psychotherapy with psychotherapists. The questions were clustered into six subsections identified as treatment formats, general therapeutic style, therapy process, termination issues, treatment outcome, and post-therapy relationships (Table 1). The first section, consisting of nine items, asked respondents to describe the treatment formats employed with therapist-patients as compared with non–mental health professionals. The second subsection requested a characterization of therapeutic style. These 14 items factorially represent four dimensions12: efficacy (
=0.72 for two items), caring (=0.82 for four items), directive (=0.71 for five items), and reserved (=0.69 for three items). The 46 items in the third subsection were written to secure information about the following domains: negotiation of a therapeutic contract, techniques used, conversational foci of therapeutic dialogue, and the subjective experiences of therapists that are commonly referred to as countertransference reactions. Three items assessed the termination process, and four items focused on the frequency and nature of post-therapy contacts. Two items reflecting the distinction between symptom relief and enhanced self-understanding were used to assess treatment outcome.
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In each subsection, psychologists were asked to rate the extent to which their therapeutic approach differed when conducting psychotherapy with psychotherapists or therapists-in-training than with non–mental health professionals of comparable intelligence, socioeconomic status, and diagnosis. Ratings were made in five- point, Likert-type format (1=much less frequently with psychotherapists, 3=the same frequency with psychotherapists, 5=much more frequently with psychotherapists).
The last portion of the questionnaire consisted of a free response item regarding advice on conducting psychotherapy with fellow psychotherapists. Specifically, psychologists were asked to "offer two brief pieces of advice for fellow psychotherapists to help them conduct effective psychotherapy with psychotherapists."
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RESULTS |
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As shown in Table 1, the sample as a whole reported that in many clinically important respects their work with therapists and laypersons was similar: 55 of the 78 items fell into the equivalent category. Of the 23 items that differentiated, 10 were in the less frequent and 13 in the more frequent direction.
In terms of treatment format, therapist-patients are more likely to be offered individual therapy. Concomitantly, they are less likely to attend couples therapy and group therapy. Relative to laypersons of comparable education and diagnosis, therapist-patients are less likely to be hospitalized, medicated, referred to support groups, and recommended to self-help books as part of their ongoing treatment.
In terms of therapy process, responding psychologists indicated that while they are equally concerned about protecting the confidentiality of all their patients, they are more likely to limit the information contained in their therapist-patients' therapy notes. They indicated that they felt less detached from and friendlier toward their therapist-patients and, as they reported to us, the therapists enjoy being with therapist-patients more than with nontherapist patients. In several important respects the respondents reported that they do not self- disclose more to one group than the other, yet they are more likely to discuss research and professional matters relevant to the profession with therapist-patients.
Whereas the participants relate feeling comparably effective and skillful with their therapist and nontherapist patients, they are more likely to "worry about treatment effectiveness" and are more concerned about "patients being critical of their work" when the patient is a fellow therapist. The participants report using the same techniques with both categories of patients, but they are aware, at the same time, of being more self- conscious of their techniques and more likely to attend to their countertransference reactions when the patient is a mental health professional.
In terms of treatment outcome, the results suggest that the therapists in our sample are no more ambitious in their efforts with therapist than nontherapist patients, and that they do not discern differences in the extent to which therapist and nontherapist patients realize positive therapeutic outcomes in terms of behavior change and symptomatic relief. On the other hand, they are more likely to discern positive therapeutic outcomes in terms of self-understanding and insight among their therapist-patients.
Finally, in terms of post-therapy experiences, the respondents related having a greater frequency of contact with their therapist-patients than with laypersons following termination. However, the increased post-termination contact with therapist-patients is not accompanied by increases in the probability of social relationship or return for further psychotherapy.
Impact of Theoretical Orientation
Respondents' theoretical orientations were grouped for these analyses into five superordinate orientations: cognitive-behavioral, eclectic, humanistic (encompassing gestalt, existential, humanistic, and person-centered), psychoanalytic/psychodynamic, and interpersonal.
For this and subsequent analyses, the alpha level was set at 0.05 (bidirectional). Although it might be argued that the multiple analyses performed in this study should dictate a Bonferroni correction or a lower alpha, we decided that the exploratory nature of the study warranted the bidirectional examination of a wide range of possible relationships among the variables.
There were no differences found in terms of the four broad therapeutic styles. In terms of the 78 practice items, only 5 items discriminated as a function of theoretical orientation. These were closely and obviously allied with theoretical prescriptions—for example, psychoanalytic therapists were more likely to conduct longer therapy, cognitive-behavioral therapists were more likely to recommend self-help books, and interpersonal therapists were more likely to discuss patients' work stress. The broader conclusion was that theoretical orientation did not exert a powerful effect on therapist's differentiation between treatment of mental health professionals and non–mental health professionals.
Therapist's Therapists
We were intrigued by the possibility that the personal and professional histories of psychotherapists might influence the manner in which they treated fellow mental health professionals. In the exploratory tradition, we statistically explored a number of variables that might have affected respondents' clinical practices in conducting psychotherapy with psychotherapists. Psychologist age, gender, and experience did not show any significant pattern of relationship. But self-characterization as "a therapist's therapist" did.
Practitioners rated themselves on a five-point, Likert-type scale on the degree to which they considered themselves "a therapist's therapist" (1=yes, definitely; 5=definitely not). Sixteen percent responded that they definitely considered themselves a therapist's therapist, 25% said probably, 28% said maybe, 26% said probably not, and 6% said definitely not. The sample was then divided into "therapist's therapists" (yes, definitely) and others.
The 16% who were self-described therapist's therapists were demographically similar to the others but reported significantly more successful outcomes in their own personal therapy (t=2.1, mean=6.6 vs. 6.2; all bidirectional <0.05). Theoretical orientation also bore a significant relationship (
2=10.6) to self-designation as definitely a therapist's therapist: 35% of responding humanistic therapists responded as such compared with a low of 9% of cognitive therapists and 10% of interpersonal therapists. In between were 14% of eclectic/integrative and 11% of psychoanalytic/psychodynamic therapists. Congruent with their self-designation, these therapist's therapists reported treating about twice the number of fellow therapists in their caseloads compared with the other respondents (t=4.3, mean=14.2% vs. 7.3%).
The therapist's therapist designation statistically differentiated responses on 16 of the 78 items related to clinical practice. In terms of treatment format, therapists' therapists were less likely than other respondents to conduct short-term therapy (t=2.9, mean=2.4 vs. 2.8). In terms of general therapeutic style, therapists' therapists were less detached (t=2.6, mean=2.5 vs. 2.8) and less guarded (t=3.2, mean=2.5 vs. 2.9), but more effective (t=2.3, mean=3.3 vs. 3.1) and warm (t=2.1, mean=3.3 vs. 3.1), with their psychotherapist patients compared with therapists without the self-designation. In terms of the therapy process, responses by self-designated therapist's therapists indicated that, compared with other respondents, they were more likely to share the responsibility for creating a therapeutic contract (t=2.2, mean=3.5 vs. 3.3), apologize for mistakes or errors (t=2.7, mean=3.2 vs. 3.0), attend to countertransference reactions (t=2.3, mean=3.6 vs. 3.3), be task-centered (t=2.5, mean=3.2 vs. 3.0), discuss current issues and research in the field (t=2.8, mean=3.8 vs. 3.4), and disclose information about their own personal therapy (t=2.0, mean=3.4 vs. 3.1). However, they were less likely to have canceled sessions (t=2.9, mean=2.3 vs. 2.7) or to feel like emotionally withdrawing from the patient (t=2.0, mean=2.7 vs. 2.9). In terms of termination, therapist's therapists were more likely to arrive at a mutually agreed upon termination (t=2.4, mean=3.4 vs. 3.2) than their fellow therapists. In terms of treatment outcomes, therapist's therapists reported a higher probability of experiencing a positive therapy outcome in self-understanding/enhanced insight (t=3.3, mean=3.7 vs. 3.3), but not in behavior change. Finally, therapist's therapists avowed more frequent contact with patients post therapy (t=4.1, mean=3.7 vs. 3.2) than non–therapist's therapists.
Advice to Fellow Psychotherapists
Psychotherapists offered a generous amount and an impressive variety of advice to help others conduct effective treatment with fellow mental health professionals. The total number of pieces of advice was 415, and these were content-coded into 28 mutually exclusive categories, including "other." Coding was completed by two of the authors; when disagreement surfaced, it was resolved by mutual discussion.
The most frequent advice is summarized in Table 2. As can be seen, broadly speaking, two types of advice were offered; those that are and those that are not unique to the psychotherapy of psychotherapists. The former type largely revolved around the centrality of expressing empathy, conveying respect, establishing mutual goals, and articulating a treatment contract.
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DISCUSSION |
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The satisfactions and stressors cited by our respondents, the advice they offered colleagues, and their descriptions of their clinical practices vis-à-vis therapist and nontherapist patients all point to the centrality of boundaries in the psychotherapy of therapists. First and foremost, the participants' advice was to not dilute the therapy of therapists by overidentifying or by overemphasizing the collegial aspects of the work. The patterning of the findings further suggests that one should not begin treating therapists until the ability to remain empathically involved with and committed to patients who diminish or question the efficacy of one's approach to doing therapy is firmly in place.
Similar patterns of statistically significant relationships were evident for self-characterization as a therapists' therapist. Responses of those with this self-designation indicated that they were
It is one thing to treat mental health professionals rarely or infrequently. It is quite a different order of things to be known as a "therapist's therapist." Acquiring this role and identify bestows a special status on a clinician. Special expectations and meanings are attached to this identity by patients and therapists alike. For example, therapist's therapists unavoidably become role models, powerfully and implicitly influencing how their therapist-patients, especially those who are in training, conduct themselves as practitioners.
Mental health professionals rarely receive formal training and supervision in treating fellow mental health professionals. In one sense this is not surprising or disconcerting, since graduate education does not focus on treating any particular occupational group. In another sense, however, it is not clear when it is ethically and professionally appropriate for a mental health professional to accept the responsibility of treating a colleague in the absence of specific training or supervision. The age distribution of our respondents suggests that therapists do not usually treat other therapists until they have achieved a certain level of seniority in their professional communities.
Using a survey method, we sought to give voice to the experience of psychotherapists treating fellow psychotherapists. Several limitations of such a methodology should be borne in mind. The response rate was 35%, perhaps an overrepresentation of people with histories of personal therapy or treating psychotherapists in their practices. This possibility is supported by a higher incidence of personal therapy among our sample (89%) than is found in general samples of psychologists.9,10,13 Therapist's therapist designation was self-reported, and there is probably a socially desirable pull toward so designating oneself. And, of course, the data are based on a single mental health profession and on anonymous self-reports, with the inescapable virtues and limitations of such self-characterizations.
Although this study cannot provide specific information on handling moment-to-moment therapeutic challenges, it can identify empirical trends that suggest the directions clinical research should take in order to provide information that improves treatment quality. Accordingly, we conclude with a representative list of researchable questions: What particular aspects of their personal therapies are therapists most likely to repeat with their own patients? Is accepting a fellow therapist for treatment without specific training and supervision analogous to the ethical violation of working outside of one's area of competence? What distinguishes the treatment of therapists who undergo therapy at different stages of their careers? What criteria can a therapist rely on to distinguish countertransference-based doubts about professional competence from the reality of overextending oneself? What special considerations, if any, attend to the decision to medicate or hospitalize a mental health professional? And, What are the additional burdens and special problems posed by therapists mandated to receive treatment by professional authorities?
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Acknowledgments |
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