Personal Psychotherapy Prepares Trainees to Be Better Psychiatrists, Educators Say

Abstract

Back to table of contents Previous article Next article Education & TrainingFull AccessPersonal Psychotherapy Prepares Trainees to Be Better Psychiatrists, Educators SayMark MoranMark MoranSearch for more papers by this authorPublished Online:30 Nov 2022https://doi.org/10.1176/appi.pn.2022.12.12.17AbstractThe number of residents who avail themselves of psychotherapy during training is hard to determine, but those who seek it are probably the exception rather than the rule.iStock/SDI ProductionsFor Sasha Narayan, M.D., a third-year psychiatry resident at Johns Hopkins University School of Medicine, her personal psychotherapy is, at least in part, a way of ensuring that when she treats patients, she leaves her own history at the door.“Part of my motivation in seeking out therapy was explicitly because I know I am a person with a history and my own experiences,” she told Psychiatric News. “I wanted to ensure that those prior experiences did not affect the decisions I made for my patients. I want to understand patients’ history through their own lens, being able to put my own history aside.”Narayan is no stranger to psychotherapy, having come from a family that encouraged it. Even before entering medical school, while working in a hospital emergency department (ED), she pursued psychotherapy as a way to help process some of what she was seeing in the ED. This included children and teenagers who had been assaulted or otherwise traumatized, encounters that were especially troubling because of Narayan’s own history of trauma.“I saw a lot of very acute situations, and one of the most concerning is the presentation of a young person after being assaulted,” she said. “It’s very emotionally charged for many parties involved. For me, I wanted to be sure I was making decisions for that patient in front of me—not based on my own history or what I might have wanted for myself, but really thinking about what the patient needs and wants.”Educators who communicated with Psychiatric News said they encourage residents to seek out personal psychotherapy during their training—certainly if they are having a mental health crisis, but more generally because it can be essential to being a good psychiatrist. And as in the case of Narayan, even those who seek out therapy to be a better psychiatrist have a world of issues of their own to explore.“I certainly feel strongly about residents seeking their own psychotherapy during training as it helps them develop who they are and understand their own biases,” said Sallie De Golia, M.D., president of the American Association of Directors of Psychiatric Residency Training (AADPRT). She is also associate chair for clinician educator professional development and associate residency director of the Adult Psychiatry Residency Program at Stanford University.“It should not just be for residents in crisis or residents interested in becoming psychotherapists, but rather for [trainees pursuing] any career path. As a leader, having a good handle on who you are, knowing what you bring to the table, and understanding interpersonal dynamics are all essential to becoming an effective leader, whether in research, program development, advocacy, teaching, or administrative work.”Having Therapists Unaffiliated With Program CriticalThe number of residents who avail themselves of psychotherapy during training is hard to determine, but they may be the exception rather than the rule. A 2015 paper in Academic Psychiatry reported that of 133 residents who responded to a survey of 14 programs in three states (Delaware, New Jersey, and Pennsylvania), just 34 (26.5%) were in personal psychotherapy.Donna Sudak, M.D., says training programs, at a minimum, need to provide insurance that covers psychotherapy with reasonable copaysMost residents in the survey described their psychotherapy as psychodynamic, once weekly, with a private practitioner not affiliated with the resident’s academic center. “Self-awareness and understanding” was the most commonly reported primary and contributing reason for being in psychotherapy. Close to half of the respondents (44.5 %) listed personal stress, substance dependence, mood, anxiety, or other psychiatric symptoms as the primary reason for seeking personal psychotherapy. The most common reasons for not entering psychotherapy were time and finances. Half of all respondents reported that their program recommends psychotherapy.In a much earlier day when psychoanalysis was preeminent in psychiatry, it was pro forma for trainees to seek their own psychotherapy. As the field became more biologically focused, that tradition waned. Donna Sudak, M.D., a professor of psychiatry and vice chair of education in the Department of Psychiatry at Drexel University College of Medicine, suggested as well that while psychodynamic psychotherapy has always put a premium on the therapist obtaining personal psychotherapy to understand his or her own reactions in a therapeutic situation, that has not been the case for therapies such as cognitive-behavioral therapy.But Sudak believes the availability of psychotherapy is important for all trainees, regardless of specialty or type of practice, as medicine wrestles with wellness and burnout among physicians. “Young adulthood is a period during which many people navigate substantial changes in their lives,” she said in an interview. “Often, they are sustaining losses for the first time—parents die, relationships end during medical training. And it happens in the context of an incredibly stressful, high-demand job.”For psychiatry programs, providing robust support to residents seeking psychotherapy is of paramount importance, she said. “Being a psychiatrist requires people to listen to things that are often quite disturbing and that stress them beyond what clinical supervision [of their outpatient caseload] can be helpful with, because of what it stirs up for them and because of the issues they have in their own histories,” Sudak said.Personal Psychotherapy Elective OfferedSo, what does robust support look like? Sudak said that at a minimum, programs should provide insurance that covers psychotherapy at a reasonable percentage of the fee or else subsidize the cost of psychotherapy. Also crucial is providing time for trainees to meet psychotherapy appointments—a factor that is frequently a significant barrier to residents pursuing therapy.Anne Ruble, M.D., says that training programs should foster a culture of openness about psychotherapy.At the University of California, San Diego, the psychiatry training program offers no-cost, no insurance psychotherapy for PGY-3 and PGY-4 trainees with carefully selected voluntary faculty, who provide the service pro bono without the use of an electronic health record. “We call it an elective as not everyone is interested, but we feel it is an important part of training to be the best clinician one can be,” said program director Sidney Zisook, M.D.Voluntary faculty provide the service in exchange for teaching credit that allows them to maintain their voluntary faculty appointment. “It saves them having to come to the clinical site to teach or the requirement for hospital credentialling,” Zisook explained. “Many of our more senior analysts in San Diego prefer this mode of teaching and the residents love it, especially since it is so difficult and expensive to find available therapists in the community. If the pair want to continue working together after the academic year, they can shift into a more traditional patient-therapist model.”To be sure, the ability to provide this kind of support is a luxury of larger, better resourced institutions. Sudak added that another benefit not necessarily available in smaller programs located away from major cities is the presence of therapists in the community who aren’t affiliated with the training program. “Trainees are not going to see someone who is connected with the training program,” she said.APA Director of Education Vishal Madaan, M.D., pointed to yet another layer of complexity involving international medical graduate (IMG) trainees, who have traditionally made up approximately 30% of psychiatry trainees. “IMG trainees often bring in a separate set of cultural nuances, values, and vulnerabilities that may make it harder to identify a culturally informed psychotherapist,” he said.Culture of Openness, Support NeededAnne Ruble, M.D., chair of the psychotherapy committee of AADPRT, agreed that programs need to proactively support psychotherapy and give residents the time to commit to it. “The culture of the program needs to be open about supporting this practice, and faculty need to be open about how psychotherapy has helped them—even for psychiatrists who won’t necessarily be doing formal psychotherapy.” She is director of psychotherapy training and associate training program director at Johns Hopkins.That culture of openness is important, Narayan said, because she believes that outside her own institution, stigma around help-seeking among physicians exists. “I would say the culture of medicine is still so stigmatized against medical professionals having any kind of illness of their own,” she said. “Unfortunately, psychotherapy is still rooted in that category of illness treatment, not necessarily as a prophylactic or preventative measure, which is how I see it.”Her advice to educators about trainees seeking psychotherapy? “It can only be a benefit to residents—their training, their resilience, their well-being. It’s a great thing to encourage, but not to require.” ■Resources“Use and Characterization of Personal Psychotherapy by Psychiatry Residents” ISSUES NewArchived