Clinical Impact Statement: This manuscript discusses the prevalence, attitudes, and research surrounding engagement in personal psychotherapy for the psychology graduate student trainee. Varying opinions regarding advantages and disadvantages of therapy during training, as well as barriers to care, are expressed. Suggested solutions are provided to assist training programs in establishing positive guidelines and cultures surrounding personal psychotherapy for their students.
Given that mental health professionals lead lives outside the therapy room, they are not invulnerable to the impact of psychosocial life stressors. In addition, working with distressed patients is a complex and demanding task that requires the service provider’s devoted mental resources. Graduate student trainees in applied psychology programs are arguably prone to even greater stress as a result of the multiple demands of graduate school, including academic coursework, assistantship responsibilities, research, clinical training, qualifying exams, and financial constraints. Further stress may arise in relation to performance anxiety, competition among students, ongoing evaluation of competency, and lack of experience (Badali & Habra, 2003). Graduate students must also navigate hierarchies of professional relationships within their training program and clinical training sites, appearing both appropriately self-confident and deferent to authority figures concurrently. Thus, students must strike a balance between fulfilling multiple roles and expectations, while also developing and practicing the skills necessary to provide therapeutic services to others (Myers et al., 2012).
Despite the numerous challenges encountered by psychology graduate students, workload, stress, and health among students are not well understood. Of the few studies conducted, one found that out of 281 clinical psychology trainees, 75% reported being moderately or very stressed as a result of training (Cushway, 1992). A more recent survey conducted by the American Psychological Association (APA) of Graduate Students found that 70% of graduate students reported impaired functioning due to stress stemming from finances, academics, relationships, and health (El-Ghoroury, 2011). Similarly, 119 graduate students in APA-accredited doctoral programs in clinical and counseling psychology reported that either graduate school (60.0%) or their current financial situation (16.4%) was the most stressful aspect of their life. In regard to physical health symptoms, at least half of the sample reported experiencing each of the following biweekly or more: headache, back pain, feeling easily fatigued, and irritable bowels. Additionally, 49% of students reported three or more symptoms of anxiety as occurring multiple times per week, while 39% reported five or more symptoms of depression as occurring multiple times per week.
In view of these significant stressors, graduate students are encouraged to practice self-care, defined as engagement in behaviors that maintain and promote physical and emotional well-being (e.g., sleep, exercise, social support, emotion regulation strategies, and mindfulness practice; Myers et al., 2012). Self-care may also include personal psychotherapy. Assuming that virtually all students experience stressors, it may be expected that clinical training programs would have an interest in providing students with the opportunity to receive mental healthcare. However, there is much diversity in the personal therapy experiences available in conjunction with graduate training. There is also little consistency on matters of whether therapy is mandatory, recommended, or simply not discussed in a trainee’s program.
This article discusses the advantages and disadvantages stated in the research and in the opinions of the authors of receiving personal psychotherapy as a psychology graduate student trainee. We also explore the barriers to receiving treatment, the confusion in personal clinical decision-making, and possible suggestions and solutions for graduate training programs and for trainees.
Advantages and Disadvantages of Receiving Psychotherapy as a Trainee
A number of advantages to receiving psychotherapy as a trainee have been illuminated in the literature. From the psychoanalytic perspective, personal analysis serves to enhance the trainee’s ability to conduct therapy as a more unbiased clinical observer whose countertransference potential has been mitigated (Nierenberg, 1972). Other rationales for personal therapy have emerged more recently, and apply to various therapeutic approaches (Grimmer & Tribe, 2001). The first includes improved emotional and mental functioning of the trainee, which is presumed to lead to the provision of more effective therapy. Personal therapy may also function as a socialization experience and lend credibility to the student’s belief in the psychotherapy process. Furthermore, receiving therapy firsthand offers a unique model of how (or how not) to conduct therapy and can result in one’s own mastery of technique. Finally, Gold and Hilsenroth (2009) state that personal therapy can lead to increased awareness of and respect for a patient’s needs and struggles, increased emphasis on the therapeutic relationship, increased therapist genuineness and capacity for empathy, and ultimately to the development of a professional sense of self. They found, for example, that graduate clinicians who had received personal therapy rated agreement about the goals and tasks of therapy with their own clients higher than did students who had not received therapy. In addition, these students felt more confident providing therapy, felt their patients were more committed and confident in therapy, and delivered treatments that were twice as long as therapists who did not have personal therapy.
Research examining disadvantages of receiving personal therapy while in training discusses a potential limiting of the trainees’ openness to a variety of therapeutic models (McEwan & Duncan, 1993). Students may also endure added emotional and financial stress that could impact academic success. For students mandated to therapy, the lack of choice may counteract its potential efficacy. Students may also continue with unsatisfactory therapy only to comply with program requirements. Importantly, there is a lack of conclusive evidence that personal therapy is an effective method of training professional helpers. In contrast, some argue that in the case of a mature, well-balanced individual, supervision from a competent therapist is enough to make personal therapy unnecessary, as it provides both satisfactory emotional support for the trainee and socialization to the profession.
Attitudes About and Prevalence of Trainee Personal Therapy
Throughout the past few decades, some research has been conducted on prevalence, attitudes, and effectiveness of receiving personal therapy during graduate training. Wampler and Strupp (1976) conducted a study with representatives from 87 clinical training programs on their views of how to best provide students with opportunities for personal growth and how students in their programs obtained therapy if desired. Department responses ranged from benign neglect (e.g., department assumes no responsibility for helping students find therapy) to the actual requirement of a therapy experience. A majority of departments (67%) actively encouraged students to seek therapy without actually requiring it. Availability of therapy resources varied widely depending upon the region of the country and proximity to a city. Size of the university was also a factor, with larger institutions more likely to have a student counseling center functioning independently of the training program. Clinical directors were almost unanimously opposed to requiring students to attend therapy (the three training programs that did require therapy only required short-term participation). Some also expressed concern that enthusiastic encouragement to participate in therapy could be perceived as an implicit coercive demand. However, a lack of encouragement may lead a student to fear that entering personal therapy would be taken as an admission of poor psychological health or be regarded as evidence of unfitness to conduct therapy.
In a survey of graduate students in APA-accredited programs, most (74%) had received psychotherapy during graduate school and reported positive experiences (Holzman, Searight, & Hughes, 1996). Respondents reported believing their confidentiality was protected in therapy and felt it was important for practicing as a therapist. However, attitudes about the importance of personal therapy in graduate school varied as a function of theoretical orientation. Specifically, 90% of students with a psychodynamic orientation chose a rating of very important versus only 60% of students with a cognitive-behavioral orientation. Reasons for seeking therapy included personal growth (70%), desire to improve as a therapist (65%), adjustment or developmental issue (56%), and depression (38%). The most frequently cited reason for not seeking therapy was having no need for it (56%) and finances (53%).
Another survey of 959 psychology graduate members of APA (Dearing, Maddux, & Tangney, 2005) found that 47% had engaged in therapy during graduate school. Student attitudes toward seeking personal therapy were generally very favorable and most agreed about the necessity of therapy for training. Those with a favorable attitude toward personal therapy and endorsement of therapy as an important component of training were more likely to have received personal therapy. Students who indicated a perceived need for therapy (but did not seek therapy) reported greater concerns about cost and confidentiality than did students who reported they neither needed nor entered therapy. Perception of a favorable faculty attitude about students in therapy was also related to positive student attitudes toward personal therapy and to the belief that therapy is integral to training.
In the most recent study found on trainees receiving psychotherapy, utilization of psychotherapy services as a coping mechanism was endorsed by only 19% of a sample of 119 doctoral students in APA-accredited counseling and clinical psychology programs (Rummell, 2015). This prevalence rate is significantly lower than previous studies, perhaps due the use of a smaller sample size. It is also possible that engagement in personal psychotherapy by psychology trainees is declining. Further research examining stress and wellness in psychology graduate students is needed, in addition to studies investigating the current prevalence and efficacy of personal therapy in relieving stress, improving functioning, and enhancing clinical skills in therapist trainees.
Barriers to Receiving Personal Psychotherapy
Even when programs encourage students to seek treatment, there are inevitable privacy-related, logistical, and financial barriers that students face. For example, confidentiality tends to be a concern, especially in smaller universities and communities (El-Ghoroury, Galper, Sawaqdeh, & Bufka, 2012; Rummell, 2015). Psychology student trainees may feel they cannot seek services at their campus counseling centers because they work there as a provider themselves or have existing professional relationships with the providers. This can be problematic if graduate student healthcare policies limit these students to using university-based services and/or do not cover many community providers. Similarly, such psychology programs could have strong ties with outside providers in the community (e.g., external practicum sites, client referrals, alumni), making the anonymity limited.
Logistically, applied psychology students are often working upwards of 60 hours per week, balancing roles in research, teaching, assessment, and therapy (Willyard, 2012). Thus, students may feel that both the search process for an in-network provider not affiliated with the school and the obligation of traveling off campus for a weekly therapy appointment is too time-consuming. The financial burden of co-pays tied with less than ideal healthcare plans may deter graduate students from seeking personal therapy as well. Ultimately, the student is left to decide whether adding a commitment of therapy to the week would be more or less stressful than not getting treatment at all.
Additionally, for trainees in programs where personal therapy is perceived as taboo, students may feel uncomfortable seeking treatment. Some students may believe that seeking personal therapy is something they should not need or that it indicates instability and lack of fitness to be a therapist. The existence of such biases within a field that is training individuals to fight against stigma is upsetting and serves to prevent distressed graduate students from reaching out for help. Thus, faculty and administrators should consider taking steps to counteract these biases.
Personal Clinical Decision-Making
If a graduate student has considered the advantages and disadvantages of receiving personal psychotherapy and is willing and able to overcome barriers to care, more decision-making lies ahead. Specifically, one must grapple with choosing a provider. First, the question arises of which degree type (e.g., PhD, PsyD, LCSW, MHC) a student would like to see. Students hoping to experience therapy as a model for personal practice may wish to work with a provider of the same degree type. However, lower tier insurance policies may limit accessibility to a doctoral level provider. The student must also consider the desired theoretical orientation and/or treatment approach. Students may feel uncertain about whether it would be more beneficial to see someone with the same theoretical leaning or someone with an orientation distinct from one’s own.
Once a student has selected a provider, questions may arise about how to discuss training and research knowledge with the clinician. For example, a student with in-depth knowledge of psychotherapy research, alliance formation and outcome, routine outcome monitoring, and so forth may be overly observant and/or critical of therapist behaviors. Students may feel uncertain about how to broach these topics, especially with providers with less research training. Constantly analyzing the therapist’s style and technique, even with positive intentions of learning, may also harm the therapy. In addition, students may question if it is appropriate and ethical to discuss one’s own patients with the therapist, either for emotional support or in a supervisory manner. Finally, students may wonder what types of interventions would be best suited for them. For example, they likely do not need psychoeducation or basic rationale explanations of a treatment model or technique. Thus, it seems difficult to determine what interventions would be most helpful for psychology graduate students and what an ideal therapeutic experience would entail.
The Ethical Principles of Psychologists and Code of Conduct (APA, 2017) require that psychologists “take appropriate measures” (p. 5) when personal problems impede on competent work performance. Thus, it seems important for clinical faculty, supervisors, and mentors to educate trainees regarding appropriate pathways to seek self-care and to establish concrete and consistent messages regarding personal therapy. Indeed, in Rummell’s (2015) survey study, 44% of students reported dissatisfaction with the emphasis placed on self-care by their program faculty. Students wished for more modeling of appropriate self-care, more psychoeducation about self-care strategies, and more empathetic understanding about the difficulty of balancing the demands of being a graduate student. Therefore, it is important that faculty members highlight opportunities for students to enter therapy, convey information about the potential benefits and risks of therapy, and openly encourage students to engage in self-care and/or enter therapy if the student believes it would be beneficial.
Logistically, it may also be helpful for programs to establish a list of referrals that are not affiliated with the university, which would eliminate the arduous process of searching for a provider. A compilation of readily available resources also allows students experiencing distress to access providers immediately, without having to disclose such matters to the faculty to request recommendations. As financial burden has been strongly endorsed as a student barrier to mental healthcare, training departments might consider potential means of reducing costs. For example, schools could develop a cooperative agreement with local counseling centers whereby clinicians without an affiliation with the university would offer services to students for a reduced fee or on a sliding scale arrangement.
For students, receiving therapy can be an important source of support during the demanding training period. Therapy can function not only to treat distress and enhance development, but also to provide a valuable experiential learning that complements formal supervision and education (Holzman et al., 1996). Therefore, Dearing et al. (2005) suggested that graduate students evaluate their own attitudes and beliefs regarding personal therapy in service of uncovering biases preventing them from seeking out support. Before applying to graduate school, prospective students may want to consider whether therapy is a requirement of the program and to take into account any financial considerations related to personal therapy (e.g., whether the program has any means of offsetting the costs of therapy). Students should consider the potential personal and professional benefits to be gained from engaging in therapy and should be aware of the importance of self-care to minimize the effects of stress.
Cite This Article
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