The extant rationale for mandated therapy during psychotherapy and counselling training: a critical interpretive synthesis

ABSTRACT

Attending personal therapy sessions is a requirement in many counselling and psychotherapy trainings worldwide. More research is needed to establish why the requirement is essential and what it is intended to achieve. This study focused on the question, what is the rationale for mandated self-development requirements in therapy trainings? From a selective literature search, 19 highly relevant papers were found which formed a sampling frame. The papers included qualitative studies, mixed method reports, review and opinion papers. Research participants across all reports included therapy and psychiatry trainees (N = 1134), and current therapy practitioners (N = 194) totalling 1328 participants. The papers were analysed using Critical Interpretive Synthesis method to devise a synthesising statement. The analysis resulted in a synthesising statement about the rationale for personal psychotherapy during training, and the stated risks of this requirement as reflected in the materials consulted. A strong coherent rationale exists for the recommendation that trainee therapists undertake personal psychotherapy. However, the risks of mandating this requirement present multiple challenges, and the evidence for the intended outcomes of personal psychotherapy undertaken during training is weak.

KEYWORDS:

• Career development
• career education
• psychotherapy

Introduction

Attending personal therapy sessions is a requirement in many counselling and psychotherapy trainings worldwide. However, there is no accepted agreement on whether this should be required for all trainee therapists. For example, The British Psychological Society (BPS) does not require trainees in the Clinical Doctorate to attend personal therapy, but students in BPS accredited counselling psychology trainings must attend 40 hours of personal therapy. In Greece, all counselling students must attend 40 hours of personal therapy. The rationale provided is that,

… besides getting to know themselves better, it [personal therapy] will sensitize them to the feelings, thoughts and expectations a client might experience during the therapeutic process. (Malikiosi-Loizos, 2013)

For the British Association for Counselling and Psychotherapy experience of personal therapy is not a requirement to be qualified to practice, but it can be used to meet criteria for accreditation as a therapist including as a contributor to documented ongoing professional development requirements.

Attending personal psychotherapy during training is conceptualised as providing opportunities for students to learn about use of the self within therapeutic work. Students have the opportunity in personal therapy to develop and refine their capacity to use insight. Therapy trainees learn to manage their experiences in interaction with the client through employing what has been described as a reflective stance (Rizq & Target, 2008), or engaging reflective function (Ensink et al., 2013).

The ability to both discern one’s own reactions and feelings and to use these to reflect upon the interpersonal dynamics occurring is a key element in expert practice within interpersonal psychodynamic therapy (Bateman & Fonagy, 2011). In a discussion of mandatory individual psychotherapy during training Kumari identified that:

A heightened awareness of the self is seen as a fundamental aspect of the majority of approaches to therapy, particularly those that aim to help clients change their behaviour or cognitive processes … Adequate self-awareness is also essential to ensure that the therapist does not become completely overwhelmed by seeing clients who are often extremely distressed. (2011, p. 213)

In an empirical study of 25 therapists who treated 1001 patients it was shown that reflective function of the therapist and the therapist’s attachment history had mutual impact. The researchers found that ‘ … [s]ecure attachment compensated somewhat for low reflective functioning and high reflective functioning compensated for insecure attachment’ (Cologon, Schweitzer, King, & Nolte, 2017, p. 1). Individual personal therapy during training is intended to achieve gains in the use of reflective function but this learning is impacted by the students’ attachment style (Rizq & Target, 2010a).

Self-learning as a requirement of therapy training

Enhancing insight is a goal of personal therapy (Lacewing, 2014). It is described in psychotherapy and counselling literature as a way of perceiving what is happening in therapy that is distinct from an intellectual understanding or theoretical interpretation (e.g. Casement, 1985; Jørgensen, 2004). As Jørgensen has indicated:

Part of what the good therapist has to offer is different perspectives on the self and reality—perspectives that open up new forms of behavior and new ways of relating to others … Classic psychodynamic theory has conceptualized parts of this process in terms of the patient’s gaining insight into her history and intrapsychic function and concomitantly developing the observing ego. (2004, p. 529)

One of the claims of psychotherapy is that the early attachment relationship is re-activated (Schore, 2001). By exploring their attachment history the client has the opportunity to address and resolve unsatisfactory internalised aspects of the first relationship. There is evidence to indicate that rates of insecure attachment are similar among cohorts of therapy trainees and the general population (Rizq, 2011). It is therefore possible to predict that, for at least some insecurely attached trainees attending psychotherapy, painful, distressing and discomforting feelings could be experienced for the duration of the work.

A key finding from research about trainee experiences of mandated personal therapy is the problematic cost. An analysis of interviews with eight participants in a counselling psychology training pointed to the paradox that the stress of the cost and burden of time to participate in therapy for trainees was likely to militate its effectiveness (Kumari, 2011). In one study there were multiple ‘reactions to the cost including “a worry”, “stressful”, “a burden”, and “a nightmare”’ (Moller, Timms, & Alilovic, 2009, p. 378).

Research with practicing professionals reflecting on their personal therapy during training or as a complement to practice have reported mixed experiences. For example, a survey of 95 senior psychiatric trainees across Australia and New Zealand in 2003 found only 22% of respondents considered personal therapy essential (Foulkes, 2003). In a survey of 48 psychiatric trainees in London, one third of respondents had attended personal psychotherapy and reported it as beneficial, and the majority of the remainder indicated they would consider attending psychotherapy (Sathanandan & Bull, 2013). Of 25 psychotherapy registrars in the UK who responded to a survey (Macaskill & Macaskill, 1992), 15 reported negative effects from their therapy. The main negative effects for these respondents were psychological distress (29%) and marital or family stress (13%).

In a study of 400 psychiatry residents in Canada, self-reports about the value of psychotherapy impacted confidence of trainees in applying professional skills.

… residents who had received personal therapy rated themselves as better able to understand what happens moment by moment during therapy sessions, detect and deal with patients’ emotional reactions, and make constructive use of their personal reactions to patients. (Hadjipavlou, Halli, Hernandez, & Ogrodniczuk, 2016, p. 35)

It has been proposed that the requirement for mandated personal therapy during training for people who are well is ‘neither intellectually nor ethically coherent’ (Atkinson, 2006). An alternative view has suggested that:

Stated in ethical terms, the debate concerns the proposition that undertaking personal psychotherapy while training to be a psychotherapist is ethically responsible because it maximizes therapeutic functioning while minimizing the possibility of harming clients or acting in ways that are not in their best interests. (Ivey, 2014, p. 92)

In the contemporary student-as-customer ethos increasingly permeating the higher education sector (Lynch, 2010) if students do not appreciate or like a certain aspect of a course, or cannot see the benefit to them, a strong evidence-based rationale is needed to support its retention. Not all trainees reflecting on their experiences in learning to become a therapist report personal therapy as essential, but as Heathcote has described,

… what is needed is for trainers and supervisors to help trainees to develop their own understanding regarding the importance and significance of commitment to their in-depth psychotherapy journey. Experience suggests that as trainees develop this understanding, continued commitment to their own growth and psychotherapy is a natural outcome. (2009, p. 245)

Von Haenisch (2011) noted that participants’ later reflections on their experience of mandatory psychotherapy in training reported in her study were similar to those of Rothery (1992) almost two decades prior. Both studies reported that with hindsight the participants were positive about the benefits of individual psychotherapy. However, some respondents had felt unwilling to engage and use the opportunity at the time of training (Von Haenisch, 2011).

A study of 37 trainees in three counselling and psychology courses across the UK found that respondents believed that ‘ … making personal therapy a requirement of training made it potentially less effective, and that the requirement assumed that the trainee needed personal therapy’ (Moller, et al., 2009, p. 380). However, it was concluded that ‘there are always personal issues to be dealt with, thus there is a tension between what might be termed the “don’t need it/everyone needs it” positions’ (p. 380).

Reflexivity: the stance of the researcher

This research was prompted by concerns raised by students and management in a course I previously led about the role and function of personal therapy for students. I have elsewhere stated how,

… without better evidence and theoretical support as to the need for a personal development component in therapy training, and without a pedagogical rationale for its implementation, it is difficult to progress a convincing argument to managers within the customer focussed university context as to a. why individual psychotherapy is required, and b. if it is required, why students should pay for it. (Edwards, 2013, p. 221)

The requirement to attend personal psychotherapy can be difficult to justify within a higher education institution because pedagogical clarity over-rides the way we have always done things argument.

A student’s feeling of being overwhelmed can sometimes be linked to the materials taught and required to be considered in such programmes. Some examples include child sexual abuse, trauma and stressful and potentially traumatising life events such as divorce, death and bereavement. Students may be additionally stressed by the emerging realisation of the unmet needs of their current and future clients (Edwards, 2013). Personal therapy is intended to offer a way to process and integrate some of these difficulties, within a confidential and safe space provided for the working through of issues as they arise.

However, although I hold a positive view as to the value of personal therapy during training I must admit to concern about the implications of endorsing a personal psychotherapy requirement for students who are not aligned with the dominant culture, for example in relation to race or sexuality. The sinewy, embedded nature of Eurocentrism across therapy work, social sciences and research findings underpin psychotherapy practice (Joseph, 2015). The symbolic violence of the misrecognition of the client’s culture and sensitivity to their world view is increasingly considered a site needing remediation within professional associations and training courses (e.g. Moon, 2011). This has tempered my previously more strongly held view about the value of requiring personal therapy in training.

There are multiple examples in the literature that give cause for concern that some therapists have so little understanding of the impact of their behaviour on the client (e.g. Trimboli, Keenan, & Marshall, 2016). Students are potentially seeking out and paying for professional support from people who could behave as per these problematic examples which, as the paper’s title worryingly indicates, are considered common. These point to potential serious dangers to trainees, and in the wider therapy field. This additional risk is challenging for the course team to manage. Of course the competent practitioner uses self-reflection and the supervisory process to consider mistakes and rectify them, but it is not clear this happens in every situation. How would the student learn what to do should such a mistake occur in their own behaviour when providing therapeutic support to another?

It is my view that a culturally competent therapist not associated with the course can play an important role in listening carefully and empathetically to the student. They can help the students to consider other points of view if they experience upset during the course. Attending therapy is one way for the student to be supported to manage their trajectory through the demands of an intensive therapy course. Individual therapy can help students develop greater knowledge and respect for the therapeutic process; not as something one superior expert provides to a vulnerable and needy person but rather a process which aims to build capacity through mutuality, and a trusting partnership.

Aim of the research

This study aimed to critically review the current research and literature to further explicate the underlying reasoning for the inclusion of self-development in therapy trainings. The guiding question was what is the rationale for mandated self-development requirements in therapy trainings? Rather than treating the topic as controversial, the paper engaged the ways in which this issue is presented in the relevant research literature. By focusing on how the rationale for inclusion of personal therapy in training is positioned, it was intended to highlight hidden assumptions, and to reveal common areas of agreement and disagreement.

Method

Critical interpretative synthesis (CIS) was chosen to conduct this meta-synthesis. CIS offers a process by which new findings can be gleaned from a large number of complex, diverse sources. The fluidity and flexibility of the method was additionally attractive (Dixon-Woods et al., 2006).

CIS method was originally founded as a way to conduct a literature-based study to better understand the complexity of issues in access to healthcare (Dixon-Woods et al., 2006). Critical is used in the description of the method to reflect the expectation that the researcher will undertake the review with ‘emphasis not only on summary of data reported in the literature but also on a more fundamental critique, which may involve questioning taken-for-granted assumptions’ (Dixon-Woods et al., 2006). The goals of applying CIS method can be multiple. However, usually the intent is to create ‘a transformation of the underlying evidence into a new conceptual form’ (Dixon-Woods et al., 2006). The reviewer is encouraged to take ‘a critical and reflexive approach to the literature, including consideration of contradictions and flaws in evidence and theory’ (Dixon-Woods et al., 2006). The researcher is expected to identify and interrogate underlying assumptions in their own values and beliefs as well as those represented in the materials included in the review (Dixon-Woods et al., 2006); including normative assumptions, and societal and cultural expectation implicit in the study’s use of terms, and reference to participants, services and others.

Literature search

Nineteen papers were found that met the inclusion criteria (see below). The CIS literature search process aims to provide an adequate number of relevant papers to achieve what is described as the sampling frame (Dixon-Woods et al., 2006). An initial search was conducted using EBSCO host (including Medline and Cinahl), and PubMed. Keywords used in the search included ‘self-development’ and ‘psychotherapy training’, ‘counselling’, ‘counsel*’, ‘training’ and ‘self-development’. A further PubMed search with the MeSH term counselling/education was undertaken. Similarly to the experience of Dixon-Woods et al. (2006), a large number of papers were found (N = 1189) most of which had little or no relevance to the topic.

Useful results were more successfully found by hand-searching the reference lists of the first relevant papers found. Using the PubMed similar articles function also revealed further papers. Some publisher databases through which certain papers were accessed provided linked articles in side menus which were read and, if relevant, included. Additionally, using the citations function in google scholar revealed further studies citing the studies already in the reference list. The only quality criteria applied was that the research was published in a peer reviewed journal. As the purpose of the research was to explore the underpinning rationale for requiring therapy attendance during training as a therapist, it was important that the representation of the issues had been scrutinised by peers.

Inclusion criteria – Only papers published in English were included. Papers which examined therapy students’ self-development during training by active methods designed to facilitate self-development such as individual personal psychotherapy, rather than tacit processes, were included. Papers which included comparisons between students where personal psychotherapy was not mandated were also included.

Exclusion criteria – papers were excluded which referred to students who were not training in psychological therapies, for example nursing students, or were not primarily verbal psychotherapies, for example creative arts therapy reports. Papers which concerned the experience of therapy practitioners as therapy clients were also excluded. Studies or reports of self-development experiential processes facilitated by a member of the course team were excluded, and also papers where it was not specified who facilitated the experiential work. Papers researching or providing reviews of the role of group work processes for trainees were also not included. There were also some brief opinion reports for or against mandated personal therapy that were excluded.

The CIS process

The process of completing the CIS involved (1) Identifying an adequate pool of relevant abstracts, (2) Selecting papers from these that were the most relevant and adequately in-depth with regards exploration of the topic of self-development in therapy training qualitatively or empirically, (3) Reviewing the papers recording the method, the main rationale exposed, and any critical statements, and (4) Undertaking and reporting the synthesis.

No specific date range was used in conducting the search but one paper prior to 1980 was removed. After exclusion of duplicates, 19 papers were found that met the criteria for inclusion published between 1996 and 2016. A majority of the papers were published during or after 2011. At a later stage a few further relevant papers were found. These were cited but not included in the analysis as the sample was considered adequate, the analysis had progressed substantively and they did not add any further unique rationale statements or findings.

The included papers fell broadly into three types. (1) Literature-based reviews of the topic, (2) Surveys or interviews with current practitioners reflecting on their personal therapy experiences during training and (3) Survey- or interview-based qualitative studies with current trainees undergoing personal therapy. The participants included therapy and psychiatry trainees (N = 1134), and current therapy practitioners (N = 194) totalling 1328 research participants.

Analysis of the materials

Each paper was read carefully and examined for instances of descriptions or statements that provided a rationale for mandated self-development in therapy training. The papers were summarised in terms of participants, method, rationale for mandated personal therapy and any critical or alternative perspectives or cautions stated explicitly or tacitly in the paper (see Table 1). Each of the rationale statements was compared. Where rationales included more than one rationalising statement these were separated.

Table 1. Summary of papers included in the critical interpretive synthesis.

Paper	Method	Participants	Rationale – summary	Critical concepts identified by the author/s
1. Edwards (2013)	Literature review	N/A	Personal therapy undertaken during training is a way to (1) Experience what the client experiences and (2) To learn techniques directly through modelling the therapist’s actions.	Psychotherapy training without a personal therapy component might be possible where a person has spent adequate time addressing issues through personal psychotherapy in the past.
2. Hadjipavlou, Halli, Hernandez, and Ogrodniczuk (2016)	Questionnaire	N = 400 psychiatry trainees in Canada	Personal therapy consistently has been shown to be one of the most highly ranked positive influences that psychotherapists’ indicate influences their professional development  … residents who had received personal therapy rated themselves as better able to understand what happens moment by moment during therapy sessions, detect and deal with patients’ emotional reactions, and make constructive use of their personal reactions to patients	… personal therapy may interfere: with the ability of inexperienced trainees to provide psychotherapy  … with marital harmony And may aggravate normal professional development crises
3. Wigg, Cushway, and Neal (2011)	Systematic literature review – six exploratory studies and four review studies included	N/A	Personal reflections can be seen as those processes which encourage personal growth and development to take place, including how personal issues impact on practice, what it is like to be a client, knowing one’s boundaries and intense self-experiences in PT. This theme also includes personal reflexivity, insight and acceptance of the self.	… assumption that therapists’ self-reported improved skills and well-being impact positively on clients … there is only indirect evidence of increased empathy and therapist warmth to support this suggestion.
4. Ivey and Waldeck (2014)	Qualitative interviews	Nine trainee therapists studying at graduate level who were at internship stage	Personal therapy helps students with difficult aspects of their training. Being in personal therapy specifically helps with understanding of the processes and dynamics of psychotherapy, specifically experiences of transference, interpretation, termination, and therapy techniques …	Trainees start out with the idea that having to attend therapy is a personal attack
5. Kumari (2011)	Qualitative interviews – analysed via IPA	Eight counselling psychology trainees – IPA	Enhancing understanding of client role.  … therapists who undertake personal treatment are likely to make major gains, both with their clinical work and in their personal lives, although this is sometimes associated with substantial emotional distress.	… trainee therapists’ skills become negatively affected when they participate in personal therapy and carry out clinical work at the same time. Accessing therapy while training is hard – especially financially. This stress is likely to reduce the effectiveness of the therapy.
6. King (2011)	Qualitative content analysis of interview transcripts	Eight therapists providing sessions to psychotherapy trainees	Therapists can only take clients to the depths they have been themselves. Personal therapy during training is a key element of eventually being a competent practitioner.	Where students struggled with using therapy effectively during training this may be an indication of their lack of suitability for psychotherapy practice in the future.
7. Murphy (2005)	Semi-structured group interview analysed using Grounded Theory	Master of Counselling students	Four key capacities are enhanced through personal therapy: reflexivity, growth, authenticity and prolongation
8. Moller et al. (2009)	Qualitative thematic analysis	N = 37 Eleven trainee Clinical Psychologists, 13 Professional Doctorate in Counselling 13 counselling Diploma trainees – all participated during first two weeks of commencing training	Having therapy is supportive and makes completing training more likely. Seeing therapy from the side of the client helps empathy with the client experience. Using personal therapy to promote mental health is likely to have a positive impact on client outcomes.	Students were unclear the rationale for needing to undertake therapy.
9. Von Haenisch (2011)	IPA	Six psychologists post training with between one and six years experience in the field	Therapy is needed so that trainees can sort out ‘troubled pasts’.	Participants in this study reported they did not have traumatic early life experiences and did not need therapy to address such issues. Nonetheless they found it helpful.
10. Ivey (2014)	Literature based discussion paper	N/A	Not having benefitted from being the recipient of therapeutic caring could hamper psychotherapists’ ability to foster caring relationships with their own clients. Balancing the ethical care of trainees with their rights needs to occur judiciously.  … given that psychotherapy is known to enhance the interpersonal competences and virtues required to work therapeutically, that it sensitises trainees to the experience of the client role, that it fosters self-reflectivity, personal integration, and belief in the therapeutic efficacy of the healing relationship, there are good ethical grounds to insist that all trainee psychotherapists experience this singular process in the course of their training.	Is it ethical to impose psychotherapy on someone who is not suffering, displays no pathological behaviour, and feels no need for treatment? Mandated personal psychotherapy may not be inherently unethical but imposing it with no alternative may be.
11. Rizq and Target (2008)	IPA analysis of interviews	Nine qualified therapists who had attended therapy	The intensity of attachment to the therapist described by some participants equated to an experience of parenting; others spoke about the various ways in which the therapist's willingness to engage in a ‘real’ relationship sponsored in them a sense of emotional authenticity and a capacity to become more real and present for their clients. For others, however, a concern with psychological safety and boundaries emerged in order to contain, or even perhaps defend against, the perceived potential risks engendered by the intensity and authenticity of the therapeutic encounter.	Participants believed strongly that therapy during training should be obligatory but were unable to identify the purposes or aims of this work.
12. Grimmer and Tribe (2001)	Grounded theory	Seven trainee therapists and seven qualified therapists.	Personal therapy helps clients because the therapist reduces the blind spots and likelihood of unethical behaviour towards the client … is protective against the harmful belief that the therapist is superior to the client • Developing reflexivity • Validational experiences • Normalisation	Trainees can be preoccupied with their own emotional turmoil if receiving therapy during training. Trainees can still gain from therapy even if they do not have a presenting problem.
13. Gold, Hilsenroth, Kuutmann, and Owen (2015)	Measures pre and post analysed statistically. Interviews.	14 graduate/trainee clinicians	Although other self-development processes can improve insight and empathy personal psychotherapy during training is the optimal choice.	Findings suggest that how trainees rate their personal therapy alliance impacts on their clients rating of the outcomes of therapy
14. Holzman, Searight, and Hughes (1996)	Survey	1018 graduate students of clinical psychology were approached to complete the survey – response rate 50%	Personal therapy enhances empathy and reduces opportunity for harm.	Where therapy is optional students may fear seeking help as an indicator they are unfit to practice.
15. Strozier and Stacey (2001)	Descriptive statistics	148 Master of SW faculty; 139 MSW students	Students who access personal therapy voluntarily see it as foundational to being able to practice effectively Personal therapy allows students to deal with their current issues and provides increased self-awareness	Faculty members reported lower value of therapy than students. [NB this may be because they are aware of other ways self-development can be fostered].
16. Rizq (2011)	Secondary analysis of former study of 12 graduates	N/A	Early attachment experience may be one of the factors relevant to understanding how a mandatory training therapy is perceived and experienced by trainees	Personal therapy for trainees is seen as a type of indoctrination Research is sometimes in the style of ‘press reports’ Quantitative research is inadequately detailed regarding experiences of trainees Psychotherapy during training is necessarily insipid because the client conforms to the ‘good child’ role
17. Wilson, Weatherhead, and Davies (2015)	Narrative analysis of interviews about experiences of therapy during training	10 clinical psychologists – all female	… outcomes from personal therapy can be broadly grouped into: emotional support, enhanced self-awareness and professional development.  … therapists who relate positive experiences of their therapy during training indicate it allowed them to become better therapists, and they are enthusiastic about similar opportunities being available to all trainee clinical psychologists	Personal therapy during training can be a burden – especially regards relationship difficulties, time and financial restraints, and preoccupation with personal conflicts. [but it is not known how much of this is due to the mandatory nature of the requirement].
18. Rizq and Target (2010b)	IPA study of responses/outcomes of the Adult Attachment Interview – plus interview about therapy experiences	12 BPS chartered psychologists	Personal therapy during training improves reflective functioning but secure attachment is a requirement	Reflective functioning (the skill to be developed through personal therapy in training) is not always helpful because for some candidates this can ‘trip over’ into anxious/depressive ruminations
19. Chaturvedi (2013)	Literature review – critical commentary	N/A	… being in the client's chair is a humbling experience that allows therapists to recognise personal issues	… studies relying on self-report offer an overwhelmingly favourable view of personal therapy.  … making therapy mandatory relies on an exclusivist position of therapy as the only acceptable means of change and growth.  … personal therapy is perceived, by many course leaders and therapists, to be a valuable element of therapy training, although there is no objective or empirical evidence confirming the veracity of these claims.  … some practices may be rooted in tradition rather than supported by empirical evidence  … students with legitimate concerns about the value of therapy may be interpreted as resistive or needing a break from the training – trainees must either comply or risk not qualifying

Note: IPA = Interpretive Phenomenological Analysis.

Initially it was intended to seek out differences between traditions of therapy. Given the small number of papers found, and the contrary actions and opinions about personal psychotherapy even within some aligned traditions it was decided to focus on the papers without reference to the psychological tradition of the training. Not all papers referred to mandated personal psychotherapy. It was sometimes not clear whether personal therapy was a course requirement, a requirement of the professional association or optional. Therefore the mandated aspect was only loosely referred to during the analysis.

The process of analysis involved moving back and forth between the synthesising statements and the original paper, comparing concepts between papers, and describing in detail the rationales that appeared in the paper, or were able to be derived from the points of view about self-development in therapy training. Each of these rationale statements were copied in full based on the text in the paper (see Table 1). They were then broken down into around 60 meaning units (see Table 2) with a single rationale for the benefit of personal psychotherapy during training identified in each of these; for example, ‘increased empathy for the client role’. General enthusiastic statements about potential gains in undertaking personal psychotherapy during training which did not point to any specific outcomes were removed. These meaning units – or first order statements – were then compared for similarities and grouped (see Table 3).

Table 2. First order statements directly from rationales in the papers – meaning units derived from rationales within the papers identified for analysis.

Personal psychotherapy during training helps the trainee to –

o Experience what the client experiences  o Learn techniques directly through modelling the therapist’s actions.  o Have experiential evidence of effectiveness of therapy  o Increase empathy based on experiencing the client role  o Increase their self-awareness  o Reduce stress  o Be encouraged to engage in personal growth and development  o Understand how personal issues impact on practice  o Experience what it is like to be a client  o Know one’s boundaries  o Experience first-hand the intense self-experiences that can occur in personal psychotherapy  o Develop personal reflexivity  o Develop capacity for insight  o Increase acceptance of the self.  o Manage difficult aspects of their training  o Understand the processes and dynamics of psychotherapy  o Enhance experiences of transference  o Enhance experiences of interpretation  o Enhance experiences of termination  o Enhance experience of therapy techniques  o Enhance understanding of client role  o Make major gains, both with their clinical work and in their personal lives  o Understand that therapists can only take clients to the depths they have been themselves  o Engage a key element of eventually being a competent practitioner  o Enhance reflexivity  o Enhance growth  o Enhance authenticity  o Enhance prolongation (staying the course to experience the benefits)  o Experience therapeutic support  o Be more likely to complete the training  o Enhance empathy with the client experience  o Enhance personal mental health which is likely to have a positive impact on client outcomes.  o Sort out any aspects of ‘troubled pasts’  o Foster caring relationships with their own clients.  o Enhance their interpersonal competences and virtues required to work therapeutically  o Be sensitised to the experience of the client role  o Foster their self-reflectivity  o Foster their personal integration  o Enhance their belief in the therapeutic efficacy of the healing relationship  o Undertake an ethical requirement of training and future practice  o Be more in tune with their own experience as a client in therapy  o To know that having therapy can be beneficial for everyone therefore students will benefit  o Have the experience of being parented effectively  o Have an experience of the ‘real’ relationship in therapy which sponsors emotional authenticity and a capacity to become more real and present for their clients.  o Reduce blind spots  o Reduce likelihood of unethical behaviour towards the client  o Be protected against the harmful belief that the therapist is superior to the client  o Develop empathy  o Enhance empathy  o Reduce opportunity for harm.  o Deal with their current issues  o To develop increased self-awareness  o Receive emotional support  o Enhance self-awareness  o Contribute to their professional development.  o Have a humbling experience  o Enhance recognition of personal issues

Table 3. The rationale for (mandated) personal psychotherapy during training.

Personal psychotherapy during training is required because it can:

Enhance the trainee’s capacity for empathy towards the client

experience what the client experiences – what it is like to be a client – Enhancing understanding of client role – it sensitises trainees to the experience of the client role – be more in tune with their own experience as a client in therapy

Enhance the trainee’s knowledge of techniques and capacities for use in practice

learn techniques directly through modelling the therapist’s actions – enhance experiences of transference – enhance experiences of interpretation – enhance experiences of termination – enhance experience of therapy techniques – knowing one’s boundaries – understanding of the processes and dynamics of psychotherapy – enhances the interpersonal competences and virtues required to work therapeutically – the ‘real’ relationship in therapy sponsors emotional authenticity and a capacity to become more real and present for their clients.

Reduce the likelihood of future harm towards clients

the therapist reduces their blind spots – reduces likelihood of unethical behaviour towards the client – reduces opportunity for harm – Therapists can only take clients to the depths they have been themselves – helps trainee ability to foster caring relationships with their clients – is protective against the harmful belief that the therapist is superior to the client

Contribute to the trainee’s personal growth

increased self-awareness – reduced stress – encourage personal growth and development – personal reflexivity – insight – acceptance of the self – helps with difficult aspects of their training – Enhance reflexivity – Enhance growth – enhance authenticity – supportive – makes completing the training more likely – helps trainees sort out ‘troubled pasts’ – Using personal therapy to promote personal mental health is likely to have a positive impact on client outcomes – fosters self-reflectivity – fosters personal integration – the experience of parenting through the relationship with the therapist – Provides a way to deal with their current issues – provides increased self-awareness – emotional support – enhanced self-awareness – is a humbling experience – enhances recognition of personal issues

Help the trainee gain deeper insight into therapeutic processes

Trainee gains experiential evidence of effectiveness of therapy – how personal issues impact on practice – the intense self-experiences that can occur in personal psychotherapy – enhance prolongation (staying the course to experience the benefits)

Afford wider implications and benefits

Is an ethical requirement – promotes belief in the therapeutic efficacy of the healing relationship – having therapy can be beneficial for everyone therefore students will benefit – is part of professional development

The second order statements resulted in the following rationale – Personal psychotherapy during therapy training is required because it can: enhance the trainee’s capacity for empathy towards the client; enhance the trainee’s knowledge of techniques and capacities for use in practice; reduce the likelihood of future harm towards clients; contribute to the trainee’s personal growth; help the trainee gain deeper insight into therapeutic processes; afford wider implications and benefits.

Critical statements from the literature were then examined using a similar process as for the rationale above (see Table 4). This resulted in the following critical statements – Personal psychotherapy during training is problematic because: it is disputed whether personal psychotherapy is warranted for well, untroubled trainees; other self-development pathways apart from mandated personal psychotherapy should be considered; although there is some evidence for the benefit of personal psychotherapy, claims for the benefits of personal psychotherapy over-reach the existing evidence; trainees’ resistance to engaging therapy is not dealt with optimally; personal psychotherapy during training is hard and expensive and can disrupt effective work with clients; the rationale for personal psychotherapy is not adequately clear.

Table 4. First order statements raising concerns about the value of personal psychotherapy for therapy trainees.

Personal psychotherapy during training is problematic because –

It is disputed whether personal psychotherapy is warranted for well, untroubled trainees

Participants in this study reported they did not have traumatic early life experiences and did not need therapy to address such issues. Nonetheless they found it helpful.

Is it ethical to impose psychotherapy on someone who is not suffering, displays no pathological behaviour, and feels no need for treatment?

Trainees can still gain from therapy even if they do not have a presenting problem.

Other self-development pathways apart from mandated personal psychotherapy should be considered

Prior experience may be adequate

Mandated personal psychotherapy may not be inherently unethical but imposing it with no alternative may be.

Faculty members reported lower value of therapy than students. [NB this may be because they are aware of other ways self-development can be fostered].

… making therapy mandatory relies on an exclusivist position of therapy as the only acceptable means of change and growth.

Psychotherapy during training is necessarily insipid because the client conforms to the good child role

Although there is some evidence for the benefit of personal psychotherapy, claims for the benefits of PP over-reach the existing evidence

How trainees rate their personal therapy alliance impacts on their clients rating of the outcomes of therapy

… studies relying on self-report offer an overwhelmingly favourable view of personal therapy.

… personal therapy is perceived, by many course leaders and therapists, to be a valuable element of therapy training, although there is no objective or empirical evidence confirming the veracity of these claims.

… assumption that therapists’ self-reported improved skills and well-being impact positively on clients … there is only indirect evidence of increased empathy and therapist warmth to support this suggestion.

… some practices may be rooted in tradition rather than supported by empirical evidence

Research is sometimes in the style of ‘press reports’

Quantitative research is inadequately detailed re-experiences of trainees

Trainees’ resistance to engaging therapy is not dealt with optimally

Trainees start out with the idea that having to attend therapy is a personal attack

… students with legitimate concerns about the value of therapy may be interpreted as resistive or needing a break from the training - trainees must either comply or risk not qualifying

Where therapy is optional students may fear seeking help as an indicator they are unfit to practice.

Personal psychotherapy during training is hard and expensive, and can disrupt effective work with clients

… trainee therapists’ skills become negatively affected when they participate in personal therapy and carry out clinical work at the same time.

Trainees can be preoccupied with their own emotional turmoil if receiving therapy during training.

Normal professional development crises can be aggravated

Accessing therapy while training is hard – especially financially. This stress is likely to reduce the effectiveness of the therapy.

Where students struggled with using therapy effectively during training this may be an indication of their lack of suitability for psychotherapy practice in the future.

Personal therapy during training can be a burden – especially regards relationship difficulties, time and financial restraints, and preoccupation with personal conflicts. [but it is not known how much of this is due to the mandatory nature of the requirement].

The rationale for personal psychotherapy is not adequately clear

Students were unclear the rationale for needing to undertake therapy.

Participants believed strongly that therapy during training should be obligatory but were unable to identify the purposes or aims of this work.

Personal therapy for trainees is seen as a type of indoctrination

Refutational synthesis

The refutational synthesis within CIS is focused on the main points of disagreement evident in the research (Dixon-Woods et al., 2006). These are interrogated further through reflecting on commonalities and tensions. This process occurred throughout the synthesis. However, a common area of disagreement across different papers concerned the reasons students have difficulties with attendance at personal therapy during training. Therefore this was the focus of a small stand-alone refutational synthesis.

The explanations provided in the studies as to why students struggle with therapy can be simplistically described as placing students into a win–lose scenario. The win can include the positive help they gain from personal therapy with the loss that it may, for example, clarify and exacerbate the source of relationship tensions. Additionally they may win the course requirements procedure by taking the good child stance in the therapy and therefore lose the benefits of an in-depth interpersonal process.

The outcomes of therapy engagement may not be useful for their completion of their training. For example, students who raise concerns about the value of personal therapy may be perceived as unsuitable for therapy practice. They can risk not qualifying. However, the critical capacities the trainee demonstrates by being able to perceive difficulties in a bigger picture way could be a positive indicator of a counsellor or psychotherapist. Perceiving the difficulties of the client through a more holistic and ecological lens can be an advantage to supporting positive change for a therapy client.

The main reasons given as why students have difficulties attending personal therapy were either located in the processes and outcomes of therapy, and/or located in the student’s circumstances. The outcomes of therapy that were seen to disrupt trainee progress included, (1) preoccupation with self, making the student less available for reflection on client distress, (2) the risk of anxious/depressive rumination – a negative extension of reflective function, (3) difficulties can indicate whether or not student is suitable as a future therapy practitioner. The personal circumstances indicated as problematic for the trainee included, (1) financial difficulties, (2) crossover between the training period and personal developmental milestones and (3) existing intimate relationship stress.

Further critical reflection fundamental to the CIS process was then undertaken by (a) contemplating all statements generated through the synthesis, (b) writing out responses to the statements and (c) seeking further literature relevant to personal psychotherapy during training. This resulted in a final synthesising argument presented and discussed below.

Discussion

The current rationale for personal psychotherapy as part of therapy training is summarised in the following critical synthesising argument:

In spite of the minimal evidence to show the benefits to the trainee, or their future competence in practice, of engaging personal psychotherapy during training, there are multiple published reports to show that even when trainees do not appreciate personal psychotherapy at the time of undertaking it they later reflect back on it as key to their growth and eventual competence in the field. There are strongly held beliefs that underpin the use of personal psychotherapy as an essential self-development process during training. These include: the reduction of harm to the client, the personal growth of the trainee, and the development of new insights and skills needed to be an effective therapist in the future. The strongest rationales about the outcomes of personal psychotherapy is that the process will assist the trainee to have more empathy with the client, will challenge and obviate any stigma the trainee holds about those who attend therapy, and will reduce the risk of harm through the trainee having lived experience of the vulnerability of being in client role. However, these beliefs must be mitigated with the caveat that there is also a range of opinion, again without any substantive evidence, which expresses concern about the value of exploring one’s own issues deeply while providing this same deep experience for someone else, and the difficulties in being able to provide support to highly distressed people while (possibly) experiencing distress from one’s own issues being explored in personal psychotherapy.

Further additional concerns raised through undertaking this review is that students may not have adequate knowledge of therapy and the therapy role to know when boundary violations are occurring. Students are at risk of being traumatised in therapy through empathic mis-steps that the therapist is not adequately skilled to identify and address. The CIS process exposed a number of identified risks that need to be managed by the course, the profession and the student. These are summarised as follows:

If there are issues that arise for the student during personal psychotherapy that are difficult for them to manage, or actually disrupt the training process for them, the only options are to either continue attending sessions, or to leave and risk not completing the qualification. Consideration of options for the student to complete a supportive self-development process by another means should be engaged.

There could be value in expecting students to have engaged in personal psychotherapy prior to enrolling to study to become a therapist. If they would like to engage in further personal therapy during their training that would be entirely their own decision and responsibility. However, cautions must be taken not to create a situation in which future applicants feel compelled to have therapy when they have no need of it, or undertake the pre-course requirement with a minimal commitment to opening their lives to change. The usefulness of personal therapy during training can be impacted by multiple aspects of the student experience. As Malikiosi-Loizos (2013) has indicated,

… training … is a mentally and emotionally charged activity: students are trying to master new skills, establish a professional identity and a sense of self–efficacy as a therapist and deal with the personal issues that arise from the experiential nature of the training itself.

Limitations

Interpretations of this research must be applied with caution. This was a secondary analysis of existing research studies. The studies were heterogeneous. They varied in their methodology and training orientation. Some studies included surveys either undertaken during and following training. Studies which reported the experiences of students varied in whether the students were at entry level in their first counselling training, or were taking a higher degree such as the Clinical Doctorate in Psychology, or Master of Clinical Social Work. Some studies recruited students from different training programmes with differing therapeutic practice orientations.

Meta-synthesis is not intended to achieve consensus. Rather, the interpretations of a researcher applying a critical interpretive process are reported. Although the aim of congruence has been met, there may be some idiosyncratic aspects of the findings that belong to the author’s unique perspective based on reflections on her experiences of providing training.

Conclusion and future directions

The rationale for attending personal psychotherapy during training is strong, the risks challenging and the evidence for its immediate and long term benefit weak. There is more to be done to evaluate the claims underpinning the rationale for personal psychotherapy during training, whether it is mandated or recommended. This further research should:

1. Create comparator studies between courses to evaluate outcomes for students.

2. Engage in longitudinal and/or post-hoc research to examine outcomes of trainees who have positive experiences of their in-training psychotherapy, and those who don’t.

3. Compare personal therapy with other training dimensions that promote reflective function.

Additionally, course teams and professional associations should engage in conference presentations and discussion groups – perhaps also online – that can allow a wider discussion of the issues underpinning personal development during training.

It is noteworthy that there is evidence that mentalisation training significantly enhances trainee therapists’ capacity to engage reflective function (Ensink et al., 2013). Further understanding of how personal therapy achieves gains for the trainee, especially with regards the essential skill of reflective function is needed. The means by which this knowledge could be acquired in alternative ways requires further consideration.

Course teams need to further reflect upon and document their methods of supporting and advising trainees who attend psychotherapy. Students need clear information from their course prospectus and from the professional association as to what they should ideally expect from attendance at therapy, including any potential risks. Further research will help course teams and professional associations to carefully deliberate the costs and gains of personal therapy as part of training.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes on contributor

Jane Edwards is an Associate Professor in Mental Health at Deakin University in Victoria, Australia. She is a qualified creative arts therapist with expertise in child and family mental health.