Introduction
Psychotherapy is widely viewed as a key component in the delivery of comprehensive and holistic mental health care. Worldwide, best practice guidelines consistently recommend so called ‘combination approaches’ (combination of medication and psychotherapy) as the gold standard in most affective and anxiety-based disorder treatments (e.g. Cuijpers et al. Reference Cuijpers, Sijbrandij, Koole, Andersson, Beekman and Reynolds2014; Davidson Reference Davidson2010; National Institute for Health and Clinical Excellence 2009; CANMAT 2016).
Given the importance of psychotherapy in the management of most mental health conditions, psychiatrists and psychiatry trainees are expected to possess reasonable levels of knowledge and understanding of the different therapeutic modalities on offer to their patients. Therefore, most psychiatry training programs and accrediting bodies worldwide have minimum requirements regarding trainees’ achievement of core competencies in psychotherapy.
In the USA, psychotherapy training is considered a ‘defining feature and core value of psychiatric education’ (Calabrese et al. Reference Calabrese, Sciolla, Zisook, Bitner, Tuttle and Dunn2010, p. 13). The most recent program guide of the Accreditation Council of Graduate Medical Education (ACGME 2020) requires residents to develop competence in managing and treating patients using both brief and long-term supportive psychotherapeutic modalities.
In Europe, the Union Européene des Médecins Spécialistes’ (UEMS) charter for training in psychiatry has long considered ‘experiential training in psychotherapy’ as a ‘compulsory component of psychiatry training’ (Brittlebank et al. Reference Brittlebank, Hermans, Bhugra, Pinto da Costa, Rojnic-Kuzman, Fiorillo, Kurimay, Hanon, Wasserman and van der Gaag2016, p. 161), adding ‘it is crucial for psychiatry…that all psychiatrists are qualified to use psychotherapeutic interventions in everyday treatment of psychiatric patients’ (Union Europeenne des Medecins Specialistes 2004).
The UK’s Royal College of Psychiatrists (RCPsych) curriculum for core training in psychiatry highlights the importance of psychotherapy in its clinical skills section, and argues that trainees must ‘demonstrate appropriate psychotherapeutic capabilities through having delivered treatment in a minimum of two psychotherapeutic modalities over both short and long durations’ which is appropriately supervised ‘under the governance of the Medical Psychotherapy Tutor’ (Royal College of Psychiatrists 2022, p. 9). The Irish College of Psychiatrists’ curriculum (2016, p. 13) similarly states that ‘psychotherapy is a key aspect of psychiatric practice’ allowing psychiatrists to ‘develop and maintain therapeutic alliances with patients’.
In acquiring required psychotherapy knowledge and skills, trainee psychiatrists are typically expected to both attend didactic psychotherapy teaching and participate in some form of practical learning such as delivering psychotherapy to patients under supervision.
Another widely recognized way to enhance one’s knowledge and understanding of psychotherapy is by experiencing one’s own course of psychotherapy (Brenner Reference Brenner2006). Most European organizations and training bodies thus consider personal therapy a valuable resource for psychiatry trainees. The European Federation of Psychiatric Trainees (EFPT) views ‘personal psychotherapeutic experience’ as a ‘valuable component of training’ (EFPT statement, 2014-2015, p. 4). Similarly, UEMS include ‘personal therapeutic experience’ in the section covering the ‘content considered essential for training in psychotherapy as part of training for psychiatry’ (Union Europeenne des Medecins Specialistes 2004). According to Johnson (Reference Johnson2017) ‘a strengthened statement regarding the crucial place of personal therapy’ was introduced to the UK curriculum in 2015 (Royal College of Psychiatrists, 2010/2015a), arguing that ‘to develop and maintain the ability to bear and think with people who experience extreme mental disturbance’ it is crucial for psychiatrists to have a ‘reflective space in which to examine their own emotions in response to the people who come to them’.
Ample evidence exists that mental health care providers across several disciplines including psychiatry, view personal therapy as ‘an indispensable element of both their continued personal well-being and their ongoing professional development’ (Bike et al. Reference Bike, Norcross and Schatz2009, p. 19), and clinicians who engage in personal therapy tend to report ‘more personal growth and positive changes, and less burnout’ (Linley & Joseph Reference Linley and Joseph2007, p. 392). By engaging in their own psychotherapy therefore, specifically vis-à-vis psychoanalytic or psychodynamic oriented psychotherapy, trainees can develop the capacity to recognize and understand the impact of their work on the self and the effect of unconscious identifications with their patients (Brenner Reference Brenner2006).
Objective
Given the reported value and benefits of personal therapy outlined above, one might hypothesize that high numbers of psychiatrists and trainees elect to have personal therapy. This systematic review was conducted to assess whether this is true.
The objective of this review was thus to identify and evaluate the findings derived from all available survey-based studies reporting quantitative data regarding psychiatrists’ and psychiatry trainees’ experiences with and opinions of personal therapy.
Methods
Search strategy
A systematic review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines (Page et al. Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann and Mulrow2021). A literature search was conducted across the following four databases and platforms: PubMed platform, Scopus, Embase and EbscoHost platform from inception to 15 May 2022.
We used two search concepts: ‘personal therapy’ and ‘psychiatrist’/‘psychiatry trainee/resident’, linked by the Boolean operator ‘AND’. Search terms included relevant synonyms, truncations and Mesh terms. Full details of search terms used for the PubMed search are shown in Appendix 1. A similar search was conducted with the other databases and search platforms.
Inclusion/exclusion criteria
Inclusion criteria were that studies had to report data on the use of personal psychotherapy amongst psychiatrists or psychiatry trainees. Studies were required to have been published as peer-reviewed research papers. The publication date was restricted to the last 30 years (May 1992–May 2022), as this was deemed to be sufficiently representative of contemporary trends in psychiatric practitioners’ use of personal therapy. Studies were excluded if they were not written in English. Studies were also excluded if they were not concerned with medical professionals specializing in psychiatry. Studies were included if they reported on the personal psychotherapy experiences of other categories of clinicians as long as psychiatrists were included among the sample of participants surveyed.
Study selection
The primary reviewer (RA) screened all titles and abstracts and identified articles as being either ‘potentially relevant’ or ‘irrelevant’ to the research question based on the inclusion and exclusion criteria described above. Full-text copies of articles identified as potentially relevant were retrieved and individually assessed for inclusion in the review stage. Further exclusion criteria were applied to determine suitability for inclusion in the final list of included studies (see Fig. 1). Further articles were identified through citation searching and review of relevant gray literature. Discrepancies were resolved by consensus achieved through the supervision process of this study.
PRISMA 2020 flow diagram depicting the selection process of included studies.
Data extraction
Data from the included studies were extracted and inserted into a table using the following headings: authors and date, study location, objectives, study methods and design, sample size and demographic characteristics of participants, response rate and results/key findings.
Data synthesis
Meta-analysis is defined as a type of statistical analysis in which the multiple quantitative effect estimates extracted from different studies are grouped together to produce an overall effect estimate. In this review, meta-analysis statistical synthesis was considered inappropriate because the majority of included studies did not report effect estimates along with a measure of precision, such as confidence interval or standard error. There was also considerable heterogeneity in the included studies in terms of methods, participants and survey instruments used. As a result, a narrative approach to synthesis was considered more suitable. The included studies thus underwent quality appraisal followed by a structured narrative synthesis.
The article selection flow diagram based on the PRISMA guidelines (Page et al. Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann and Mulrow2021) is shown in Figure 1.
Results
206 articles in total were identified by the search strategy outlined above. After removing 67 duplicates, titles, and abstracts of 139 studies were screened and 106 excluded for the following reasons: no full-text articles (n = 9) or irrelevant study (n = 97). 33 full-text articles were sought for retrieval, among which 4 were unable to be retrieved and 29 underwent further screening; 14 were excluded for the following reasons: reason 1: study not concerned with psychiatrists (n = 4), reason 2: study not reporting quantitative data about psychiatrist and/or psychiatry trainees’ use of personal therapy (n = 6) or reason 3: data included in study already reported in another article by same author (n = 4). 15 articles fulfilled all requirements and were included in this review. Table 1 summarizes the key findings of each included study.
Summary of characteristics of included studies
PT, personal therapy; MH, mental health; UK: United Kingdom; USA: United States of America; NZ: New Zealand; ROI: Republic of Ireland; DPCCQ: Development of Psychotherapists Common Core Questionnaire; CRN: Collaborative Research Network; CBT, Cognitive Behavioral Therapy; CAT, Cognitive Analytic Therapy; SHO, senior house officer; PTC, Psychiatric Trainees’ Committee; RCPsych, Royal College of Psychiatrists, UK; PLC, psychotherapy long case; AMG, American medical graduate; IMG, international medical graduate; IPT, interpersonal therapy. CT, core training; ST: specialist training; PGY: post-graduate year; APA, American Psychiatric Association.
Quality appraisal
Quality assessment of the 15 included studies was conducted using the quality assessment checklist for survey studies in psychology (Q-SSP) (Protogerou & Hagger Reference Protogerou and Hagger2020) (see Table 2), a study quality tool specifically designed for appraising studies using survey designs. Based on the number of applicable items, studies are attributed an overall ‘acceptable’ quality score when receiving a ‘yes’ score on at least 75% of applicable items. However, it was found that using a 60% threshold resulted in better consensus between experts (Protogerou & Hagger Reference Protogerou and Hagger2020).
Where necessary, items or scoring scheme were modified to fit the design of included studies. Firstly, noting that most studies set out objectives or aims rather than specific research questions or hypotheses, the former were also accepted as eligible statements for item 3. For item 8, the term ‘response rate’ was substituted for ‘attrition rate’. For item 9, to obtain a YES score, studies had to mention whether they used any strategies to minimize non-response (see Phillips et al. Reference Phillips, Reddy and Durning2016 for a description of recognized strategies). For item 11 to obtain a YES, it was sufficient to state that a copy of all measures was available upon request (by contacting authors). For item 12, it was deemed sufficient to provide a comment on validity or lack thereof of questionnaire used, and/or to provide information about validity of existing tools that the survey instrument included. For item 16, to obtain a YES, it was sufficient for studies to include at least two of the following key demographic characteristics: age, gender, nationality or ethnicity and/or years or level of training/experience as a psychiatrist. For item 19 (participant debrief), as included studies did not involve any form of participant deception, the ‘not applicable’ code was used for all studies.
Quality assessment checklist for survey studies in psychology (Q-SSP)
Results of quality assessment conducted for the 15 included studies are summarized in Table 3.
Quality assessment of included studies using the quality assessment checklist for surveys in psychology (Q-SSP)
A, acceptable quality; Q, questionable quality.
Despite the modifications made to the Q-SSP items, over a third of included studies (6/15) failed to reach the 75% threshold originally recommended for ‘acceptable’ quality, however none of the studies fell below the more consistently rated 60% threshold.
The six areas where most studies fell short related to information about the following: measurement description, measures against non-response bias, validity of survey instrument used, survey participants’ provision of consent, person(s) collecting the data, and disclosure of funding sources or conflict of interests. Overall, given the observational and descriptive nature of the included studies and the specific factors contributing to the quality ratings, the quality of evidence was considered acceptable for the purpose of the syntheses carried out in this review.
Discussion of key findings
This review brings together findings from 15 survey-based studies which collected data on the proportion of psychiatrists who received personal therapy. Over half of the studies reviewed had this as their primary objective (Dover et al. Reference Dover, Beveridge, Leavey and King2009; Haak & Kaye Reference Haak and Kaye2009; Emmerich et al. Reference Emmerich, Cabaniss, Caligor, Forand, Luber and Roose2004; Hadjipavlou et al. Reference Hadjipavlou, Halli, Hernandez and Ogrodniczuk2016; Kovach et al. Reference Kovach, Dubin and Combs2015; Orlinsky et al. Reference Orlinsky, Schofield, Schroder and Kazantzis2011; Sathanandan & Bull Reference Sathanandan and Bull2013 and Weintraub et al. Reference Weintraub, Dixon, Kohlhepp and Woolery1999), while the remaining studies only discussed personal therapy as part of a larger investigation into psychiatric practitioners’ experiences with and attitudes towards psychotherapy training and/or their experiences and opinions regarding delivering psychotherapy.
Trends in personal psychotherapy use: variations across time and location
Most included studies were conducted in North America (Bodkin et al. Reference Bodkin, Klitzman and Pope1995; Emmerich et al. Reference Emmerich, Cabaniss, Caligor, Forand, Luber and Roose2004; Haak & Kaye Reference Haak and Kaye2009; Hadjipavlou et al. Reference Hadjipavlou, Halli, Hernandez and Ogrodniczuk2016; Kovach et al. Reference Kovach, Dubin and Combs2015; Lanouette et al. Reference Lanouette, Calabrese, Sciolla, Bitner, Mustata, Haak and Dunn2011 and Weintraub et al. Reference Weintraub, Dixon, Kohlhepp and Woolery1999). Three studies took place in the UK (Ball et al. Reference Ball, Collins, Harrison, Le Grice, McGrady and Slater2021; Dover et al. Reference Dover, Beveridge, Leavey and King2009 and Sathanandan & Bull Reference Sathanandan and Bull2013); and one each in New Zealand (Kazantzis et al. Reference Kazantzis, Calvert, Orlinsky, Rooke, Ronan and Merrick2010), Israel (Shachar et al. Reference Shachar, Mendlovic, Libi Hertzberg, Baruch and Lurie2016) and South Korea (Bae et al. Reference Bae, Joo and Orlinsky2003). Two studies sought to gather data from multiple countries (Orlinsky et al. Reference Orlinsky, Schofield, Schroder and Kazantzis2011; Gargot et al. Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova, Silva and Sönmez2017).
1995–2009
Bodkin et al.’s (Reference Bodkin, Klitzman and Pope1995) survey sought to investigate the treatment orientation (biologically vs. psychotherapeutically oriented) and associated characteristics (including use of personal therapy) of North American academic psychiatrists. There was significantly higher frequency of reported engagement in personal psychotherapy in psychotherapeutically oriented psychiatrists (86%) compared to biologically oriented psychiatrists (44%). Considering the known rise of biological psychiatry since the 1990s, it is possible this could account for some of the declining engagement rates in personal therapy reported in subsequent studies included in this review.
By the start of the 21st Century, engagement in personal therapy by psychiatry residents was clearly on the decline in the USA. Weintraub et al. (Reference Weintraub, Dixon, Kohlhepp and Woolery1999) found that current residents were much less likely (20% vs. 70%) to engage in personal therapy than former residents.
Using data collected as part of Orlinsky et al. (Reference Orlinsky, Ambühl, Rønnestad, Davis, Gerin and Davis1999) collaborative international study on development of psychotherapists, Bae et al. (Reference Bae, Joo and Orlinsky2003) sought to describe demographic characteristics, professional identification, training, theoretical orientation, career status, as well as personal therapy engagement in a sample of 538 South Korean psychotherapists in various mental health professions, including psychiatry. Overall, only 32.1% of psychiatrists who responded to this survey indicated engaging in their own personal therapy, however in the sub-sample of respondents who had at least 10 years of practice, this proportion increased to 52%. This again seems to align with the emerging trend that psychiatry trainees in more recent years are less likely to engage in personal therapy.
Emmerich et al. (2004) gathered survey data about proportions of Manhattan based psychiatry residents availing of personal psychiatric treatment. Over half (57%) of respondents indicated they were receiving personal psychiatric treatment. Of those, 68% indicated they were receiving individual psychotherapy alone, 17% reported receiving a combination of psychotherapy and medication, and fewer than 1% reported receiving medication alone.
Haak & Kaye (Reference Haak and Kaye2009) conducted a survey investigating current American psychiatric residents’ experience with and opinions about personal psychotherapy. Fewer than one-third of residents (31.8%) reported receiving current therapy, while 42% reported receiving therapy at some point in the past. Dover et al. (Reference Dover, Beveridge, Leavey and King2009) surveyed UK core psychiatry trainees in a similar time period, finding that only 16% were engaging in personal therapy, again suggesting this downward trend was occurring across different geographic regions.
2010-present
Orlinsky et al. (Reference Orlinsky, Schofield, Schroder and Kazantzis2011) conducted an international survey on experiencing personal therapy among 3,995 psychologists, counselors, social workers, psychiatrists, and nurses in 6 English-speaking countries, including Ireland. Among the 163 psychiatrists who completed the questionnaire, 29.4% indicated never experiencing personal therapy, representing the second lowest prevalence of personal therapy among mental health professions after nursing. Only one psychiatrist among the limited Irish sample indicated that they had received personal therapy in the past but were not currently receiving therapy.
Using data collected as part of Orlinsky et al.’s study, Kazantzis et al. (Reference Kazantzis, Calvert, Orlinsky, Rooke, Ronan and Merrick2010) investigated New Zealand psychiatrists’ and mental health nurses’ use of didactic teaching, supervision of case-work and personal therapy. The vast majority of respondents (89%) experienced personal therapy at some point previously. However, when compared to participants in the larger Orlinksy et al. (Reference Orlinsky, Schofield, Schroder and Kazantzis2011) survey, New Zealand psychiatrists spent least time in therapy (Mean = 4.8 years) and had the lowest proportion of current engagement in personal therapy (16%).
Lanouette et al. (Reference Lanouette, Calabrese, Sciolla, Bitner, Mustata, Haak and Dunn2011) conducted a survey aiming to examine psychiatry residents’ attitudes towards learning psychotherapy, practicing psychotherapy in the future, and their overall identification as psychotherapists. The questionnaire contained four questions relating to the use of personal therapy. Approximately half of the respondents (47%, n = 118) reported previous or current personal therapy; 49% (n = 122) had never been in psychotherapy, and 4% (n = 7) did not respond.
Sathanandan & Bull (Reference Sathanandan and Bull2013) sought to identify numbers of psychiatry core trainees from the University College London Partners (UCLP) training scheme engaging in personal psychotherapy and to explore trainees’ views regarding the value of personal psychotherapy in their psychiatric training. Only 31.3% of trainees reported having undertaken personal therapy previously or were currently having personal therapy. Nonetheless, this represents nearly double the proportion of London based core trainees who reported being in therapy four years earlier (Dover et al. Reference Dover, Beveridge, Leavey and King2009), which can be seen as somewhat of an outlier in relation to the observed trend.
In their 2015 survey, Kovach et al. investigated American residents’ participation in and characterization of personal therapy, including their reasons for entering therapy and barriers to seeking personal therapy. They found that only 26.5% of residents were in personal therapy at the time of the survey, which indicates a further decrease when compared to rates of receiving personal therapy reported by residents in several older USA studies.
The EFPT aimed to evaluate actual provision of psychotherapy training for European psychiatry trainees as compared to UEMS guidelines. From 2013 to 2015, the EFPT collected 574 responses from trainees of 23 European countries by online surveying (Gargot et al. Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova, Silva and Sönmez2017). While this large-scale study was more generally focused on how psychotherapy training was delivered for psychiatry trainees across Europe (Ireland was not included), it also enquired about receiving personal therapy, results indicating that personal psychotherapy was received by only 41% respondents despite both UEMS and EFPT statements recommending such experience (Gargot et al. Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova, Silva and Sönmez2017).
Hadjipavlou et al. (Reference Hadjipavlou, Halli, Hernandez and Ogrodniczuk2016) conducted a national survey of all Canadian psychiatry residents to investigate their experiences with and perspectives on personal therapy during their residency training. Results indicated that 55.3% received personal therapy at any time, and 42.8% received personal therapy during residency, (much higher compared to USA figures).
Shachar et al. (Reference Shachar, Mendlovic, Libi Hertzberg, Baruch and Lurie2016) explored attitudes of psychiatrists in Israel regarding psychotherapy and psychotherapy training during residency, including use of and attitude towards personal therapy. The study made comparisons between residents vs. specialists, practicing in peripheral versus central institutions, and mental health vs. medical centers. 65.3% of residents surveyed (n = 47) reported receiving personal therapy compared to 77.7% (n = 122) of the specialists. Despite higher overall rates of receiving personal therapy by psychiatry residents in Israel, this finding parallels US results in suggesting a downward trend in receiving personal therapy by newer generations of psychiatrists.
More recently, Ball et al. (Reference Ball, Collins, Harrison, Le Grice, McGrady and Slater2021) surveyed UK psychiatry trainees nationally regarding the quality of psychotherapy long-case (PLC) training experience during their ‘core training’ years (i.e. before advancing to higher speciality training). The survey used in this study also contained several questions about receiving personal therapy during their PLC. They found that only 13.4% of respondents received personal therapy while completing the PLC, 2.5% preferred not to answer these questions, and the remaining 84% reported no therapy while completing the PLC. While 13.4% seems low, it must be noted that there is no obligation for core trainees to engage in personal therapy. Also, in higher speciality training in the UK there are six higher specialities and three further sub-specialities, and only the higher speciality ‘Medical Psychotherapy’ requires trainees to participate in regular personal psychotherapy during training.
Therapy modalities
Several studies investigated the modalities of psychotherapy experienced by psychiatrists and trainee psychiatrists for their personal therapy. Emmerich et al. (Reference Emmerich, Cabaniss, Caligor, Forand, Luber and Roose2004) found that among residents who engaged in psychotherapy, 77% were in psychodynamic psychotherapy, 13% were in psychoanalysis, 9% described their psychotherapy as eclectic and only 1% indicated receiving supportive therapy. No residents were in CBT or IPT. In Dover et al. (Reference Dover, Beveridge, Leavey and King2009), psychiatry trainees similarly reported most commonly engaging in psychodynamic psychotherapy. In Haak & Kaye (Reference Haak and Kaye2009) study, most respondents were in psychoanalytic psychotherapy (58.8%,) while the next most popular choice was supportive psychotherapy, which was selected by 17.6% of respondents. In Kovach et al. (Reference Kovach, Dubin and Combs2015), the majority of residents also indicated being in psychodynamic psychotherapy (87.9%) while only 3% indicated being in CBT. Similar results were found in Hadjipavlou et al. (Reference Hadjipavlou, Halli, Hernandez and Ogrodniczuk2016), with nearly three quarters of respondents indicating they received psychodynamic psychotherapy and approximately one quarter availing of supportive psychotherapy. Only 8.9% of respondents indicated receiving CBT. No other modality was selected by more than 1% of respondents.
Reasons for engaging vs. not engaging in personal therapy
Half the studies included in this review contained some exploration into the reasons psychiatrists and psychiatry trainees chose to undertake personal therapy and/or the reasons for not engaging in therapy (Bodkin et al. Reference Bodkin, Klitzman and Pope1995; Weintraub et al. Reference Weintraub, Dixon, Kohlhepp and Woolery1999; Dover et al. Reference Dover, Beveridge, Leavey and King2009; Haak & Kaye Reference Haak and Kaye2009; Kovach et al. Reference Kovach, Dubin and Combs2015; Hadjipavlou et al. Reference Hadjipavlou, Halli, Hernandez and Ogrodniczuk2016; Sathanandan & Bull Reference Sathanandan and Bull2013). Bodkin et al. (Reference Bodkin, Klitzman and Pope1995) reported 52% of survey respondents sought therapy for a diagnosable disorder while 66% sought therapy for ‘other reasons’ (these were not specified). In their survey of current and former American residents, Weintraub et al. (Reference Weintraub, Dixon, Kohlhepp and Woolery1999, p. 16) found that both groups ‘overwhelmingly listed personal reasons as the primary reason for seeking therapy, with professional or other reasons a distant second and third’.
Dover et al. (Reference Dover, Beveridge, Leavey and King2009) also found that most (48%) of the psychiatry trainees who responded to their survey indicated seeking personal therapy for personal reasons. However, a significant portion (39%) indicated undertaking personal therapy for both training and personal reasons, and 13% for training alone. In Sathanandan & Bull (Reference Sathanandan and Bull2013) survey, only one-third of respondents indicated starting personal psychotherapy for purely personal reasons while 60% reported starting therapy for both personal and professional reasons. Only one respondent indicated seeking therapy for professional reasons alone. In Haak & Kaye (Reference Haak and Kaye2009) study, American psychiatry residents indicated their top two reasons for engaging in personal therapy were ‘for personal issues or problems outside of training’ and ‘to improve my skills as a psychotherapist’. Kovach et al. (Reference Kovach, Dubin and Combs2015) found that self-awareness and understanding were the most commonly reported reasons for engaging in personal therapy. However, a significant proportion of American residents (44.5%) listed personal stress, substance abuse/dependence, or mood symptoms, anxiety or other mental health problems as the primary reasons for seeking personal therapy (Kovach et al. Reference Kovach, Dubin and Combs2015). Most Canadian residents listed the pursuit of personal growth, a need for self-understanding and enhancing professional development as being among their main reasons for personal therapy engagement. Approximately one-third also reported anxiety, depression or another mental health problems as their primary reason for seeking personal therapy (Hadjipavlou et al. Reference Hadjipavlou, Halli, Hernandez and Ogrodniczuk2016).
When it came to exploring reasons for not receiving therapy, Weintraub et al. (Reference Weintraub, Dixon, Kohlhepp and Woolery1999) found that cost and time were the most commonly listed reasons. Interestingly, current residents were more likely to list cost as the primary reason preventing them from seeking personal therapy, while former residents were more likely to list time. Financial cost and time were consistently cited as survey respondents’ primary reasons for not engaging in therapy in several other studies (Haak & Kaye Reference Haak and Kaye2009; Kovach et al. Reference Kovach, Dubin and Combs2015; Hadjipavlou et al. Reference Hadjipavlou, Halli, Hernandez and Ogrodniczuk2016).
Psychiatrists’ opinions and attitudes regarding the value of personal therapy
Several studies found that psychiatry trainees who had received personal therapy tended to express more favorable opinions towards psychotherapy in general (in terms of its importance as a form of patient treatment, and as a valuable skill for residents to develop during their training), and particularly personal therapy, in terms of impact on personal and professional development. Weintraub et al. (Reference Weintraub, Dixon, Kohlhepp and Woolery1999) found that current residents who received personal therapy (as opposed to those who did not) placed greater professional value on it and were more likely to believe that psychiatry training should include learning to deliver psychotherapy.
In Lanouette et al. (Reference Lanouette, Calabrese, Sciolla, Bitner, Mustata, Haak and Dunn2011) survey, respondents with personal psychotherapy experience were consistently more positive about psychotherapy in responses to questions relating to identity as a psychotherapist. For instance, they were more likely to express pride in being a psychotherapist, to believe that being a psychotherapist is integral to a psychiatrist’s identity, and to report that practicing psychotherapy is the most rewarding aspect of their work.
In Kazantzis et al. (Reference Kazantzis, Calvert, Orlinsky, Rooke, Ronan and Merrick2010), New Zealand psychiatrists considered personal therapy to be highly influential in their professional development as psychotherapists when compared to formal didactic training. Kovach et al. (Reference Kovach, Dubin and Combs2015) found that residents who had received personal therapy tended to view this as having a more important role in their training compared to those who had not. Similarly, Hadjipavlou et al. (Reference Hadjipavlou, Halli, Hernandez and Ogrodniczuk2016) found that residents who experienced personal therapy generally reported more confidence in their psychotherapy skills than those who had not.
Strengths, limitations and areas for further research
This review represents the first known effort to provide a synthesis of available international survey-based data concerning use and characterization of personal therapy by psychiatrists and psychiatry trainees over the last three decades. Adherence to PRISMA 2020 guidelines (Page et al. Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann and Mulrow2021), use of several recognized databases, and the reporting of all eligible peer-reviewed survey studies are among the strengths of this review.
A limitation of this review is that in order to maximize the data available for synthesis, not all included studies were primarily focused on questions related to receiving personal therapy by survey respondents. Some studies only contained a few questions about the proportion of respondents who received therapy while the remainder of the survey was concerned with the aim of investigating broader topics such as attitudes towards psychotherapy and psychotherapy training. As a result, it was difficult to make comparisons between studies.
Another related limitation concerns the quality of included studies. In particular, none of the studies seeking to investigate the use of personal therapy as their main objective utilized the same standardized questionnaire. This additional heterogeneity in the data may have limited the validity of comparisons made between different populations and settings.
Another limitation is that most studies did not specify whether personal therapy was considered a mandatory component of participants’ training programs. Indeed, whether or not psychotherapy was seen as mandatory may have influenced the proportions of participants engaging in personal therapy during their training years, as well as the reasons they gave for engaging in personal therapy. As mentioned above, Medical Psychotherapy is recognized as a distinct sub-specialty of Psychiatry in the UK and trainees who choose this training pathway are required to engage in their own personal therapy. Further research on the opinions of this specific cohort as regards the impact of personal therapy on their ability to provide psychotherapy would offer valuable additional insights.
Finally, restricting the inclusion criteria to reports written in English may inevitably have led to a proportion of data being overlooked, thus limiting the fully ‘international’ aspirations of this review. In addition, while data was gathered from multiple geographical regions, formulating hypotheses relating to the potential presence of culturally mediated differences accounting for the variation in rates of psychotherapy engagement between studies was beyond the scope of this review. While the authors did not find among the included studies any mention of particular barriers or facilitators to psychotherapy access that could be considered culture or context specific, investigating this further could present an area for future research.
Conclusion
Despite its limitations, this review represents the first known attempt to collect and synthesize data aimed at providing insights into past and current worldwide trends in psychiatrists’ use of personal therapy. Rates of receiving personal therapy varied greatly from country to country, and depending on whether participants were asked about current or previous personal therapy engagement.
Across many studies, trainees who had received personal therapy tended to express more favorable opinions towards psychotherapy in general and particularly personal therapy, in terms of impact on personal and professional development. This warrants further investigation, particularly the impact of burnout in this cohort and the potential of engagement in one’s own personal psychotherapy to help alleviate this concern.
Although beyond the scope of this paper, many psychiatry training programs encourage trainees to participate in Balint groups; when facilitated by a senior clinician with experience in psychotherapy and group dynamics, this can provide a safe space for trainees to explore with curiosity the complex dynamics at play within clinician-patient interactions. This in turn may act as a stepping stone to trainees seeking out personal therapy for themselves.
Despite covering data from across four continents over a 30-year time period, this systematic review did not identify any studies concerned with trends in personal therapy receipt by psychiatrists and/or psychiatry trainees based in Ireland, thus exposing a significant gap in the literature.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ipm.2024.14.
Acknowledgments
None.
Financial support
None.
Competing interests
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
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