Psychotherapy trainees’ experiences of their own mandatory personal therapy raise “serious ethical considerations”

By Christian Jarrett

Many training programmes for psychotherapists and counsellors include a mandatory personal therapy component – as well as learning about psychotherapeutic theories and techniques, and practising being a therapist, the trainee must also spend time in therapy themselves, in the role of a client. Indeed, the British Psychological Society’s own Division of Counselling Psychology stipulates that Counselling Psychology trainees must undertake 40 hours of personal therapy as part of obtaining their qualification.

What is it like for trainees to complete their own mandatory therapy? A new meta-synthesis in Counselling and Psychotherapy Research is the first to combine all previously published qualitative findings addressing this question. The trainees’ accounts suggest that the practice offers many benefits, but that it also has “hindering effects” that raise “serious ethical considerations”.

David Murphy and his colleagues at the University of Nottingham conducted a systematic review of the literature and found 16 relevant qualitative studies up to 2016, involving 139 psychologists, counsellors and psychotherapists in training who had undertaken compulsory personal psychotherapy as part of their course requirements. Most the studies involved interviews with the trainees about their experiences; the others were based on trainees’ written accounts.

Murphy and his team identified six themes in the trainees’ descriptions. Some were positive. The trainees talked about how therapy had helped their personal and professional development, for example raising their self-awareness, emotional resilience and confidence in their skills. Personal psychotherapy also offered them a powerful form of experiential learning in which they got to see for themselves how concepts like transference play out in therapy, and they obviously experienced what it is like to be a client. They also learned about “reflexivity” – how to reflect on themselves and the way their own “self material” contributes to the dynamics of therapy.

Another positive theme was therapeutic gains – some trainees saw their personal therapy as a form of “explicit stress management”; they said it helped them work through issues from their past; and also helped them to become their authentic selves, and accept their strengths and weaknesses.

But the remaining themes were more concerning. The first – Do no harm – referred to the fact that many trainees spoke of the stress and anguish that the therapy caused them, and the way it affected their personal relationships. In some cases this left them feeling unable to cope with their client work (in which they were the therapist). Another theme – “Justice” – summarises the burden that trainees felt the mandatory therapy imposed on  them, in terms of time and expense, and the pressure of being assessed and of their lost autonomy.

Finally, under the theme “Integrity“, the researchers said some trainees talked about how their therapist was unprofessional, yet it was difficult to change them; that they felt coerced into therapy and that the mandatory nature of it prevented them from truly opening up – in fact there was a sense of some trainees simply jumping through hoops in a functional way to complete their course requirement.

Murphy and his team end their paper calling on regulatory and training institutions to consider the issues raised by their findings. Although the “hindering factors” they identified raise serious ethical issues, they believe that it may be possible to address them: “We envisage that programmes that attend to the points raised in this study will provide the best learning opportunities, compared with courses that do not regularly critically reflect upon, assess, and evaluate mandatory psychotherapy within the course.”

A systematic review and meta-synthesis of qualitative research into mandatory personal psychotherapy during training

Christian Jarrett (@Psych_Writer) is Editor of BPS Research Digest

20 thoughts on “Psychotherapy trainees’ experiences of their own mandatory personal therapy raise “serious ethical considerations””

  1. When does a problem become a problem? Answer; when the psychotherapist says you have a problem.

    I spent thirty years in psychiatry, pigeon- holing patients into diagnostic- labelled straight -jackets and trying to convince them that the psychiatrist was right about the source of their ‘problems’ – schizophrenia/ borderline personality disorder, depression, alcohol and substance abuse, bi polar disorder, anorexia. It was my job to, ensure ‘patients’ took their tablets or ECT and weren’t a danger to themselves or others. In short I was perpetuating the medical -model strategy of symptom management. Every one of those people were individuals and there was considerable variation in the assessed ’causes’ of their ‘illness’ even when the symptoms were similar.

    I have come to think that we forget things that cause us emotional pain and deep distress for a reason – a mental defence mechanism and that trawling for causation is not the way to address the symptoms of that pain.

    None of us can change what happened in the past, only our response to it,

    Psychotherapy has the power of authority (source credibility) attached to it, not only, to bring to consciousness painful events form our past which must be forcefully re-lived, but also to implant false memories and explanations for causation that do not exist.

    In my experience, psychotherapy is a very dangerous scalpel to wield no matter whether as a patient or as a potential therapist and has the potential to cause more harm than to do good. I therefore, welcome this article questioning the ethics of its use for anyone..

    1. ” trawling for causation is not the way to address the symptoms of that pain. ” amen, bro.

  2. This is an interesting article and I look forward to reading the full research. There is a need for far more research in this area, as having undertaken training with significant requirements for individual personal therapy, I think it is essential if you are going to practice professionally that you have experience of it personally because of the nature of the profession and the potential for a therapist without ‘good enough’ self-awareness to potentially cause harm to a client unknowingly. Perhaps it’s not psychotherapy per se that is the problem, but the minimal requirement for it which leaves trainees with issues less resolved than they could be.

    I think the other commenter here confuses psychiatry and psychotherapy, and well trained therapists would be very aware of the ethics of ‘implanting’ false memories and just wouldn’t do this. So, if anything, the lack of rigour in some trainings and the very few requirements placed on trainees to undergo therapy, could have more to do with the hindering factors found in the research. In my opinion we need to understand these experiences in relation to the type (and modality?) of training and length of therapy. And maybe it’s helpful for people to know therapy isn’t easy, and it involves change, for both client and therapist.

    1. While I myself found the process interesting, sitting on the other side of the room and experiencing it for the first time, I was left with concerns. I agree that the minimal requirement may leave trainees with unresolved issues especially if they are doing it to meet the requirements and cannot continue afterward because of finances, time, etc.

      Then, my cohort was asked to complete these 40 hours by the end of the second year and show proof of this. That also caused some discomfort because one feels rushed rather than the process unfolding naturally and allowing for active and voluntary engagement. While I understand the need for therapists to develop some self-awareness and this experience provides this, the mandatory nature concerns me as I believe therapy should be voluntary. In this way, it seems to be causing harm by forcing students/trainees to become vulnerable, expose themselves within a very structured time period. One may feel as they are doing it for the course rather than themselves. As a therapist, I would not force someone to seek therapy.

      Perhaps we should consider the number of hours and the time requirement. I wonder if it would be sufficient for students to demonstrate to their programme that they are indeed engaging in therapy via a letter from their therapist? In this way, they can develop their awareness at their own safe pace. Further, there seems to be no evidence for the 40 hours? What if they were have a breakthrough in the 39th session or were going to have one on the 41st but ended therapy because of finances? We would be left with an uncontained trainee. For a field that encourages the use of evidence, it’s a bit confusing that this requirement is not supported by such.

      I welcome dialogue.

      1. In therapy the client sets the pace anyway. You can make very little headway in 40 hours, or you can make huge leaps. It’s really up to the client.
        If a clinical psychology student is not working at being self-aware and more vulnerable, then they are definitely not ready to be therapists.

      2. Why would someone wishing to be a psychotherapist be reluctant to undergo therapy? I would be worried about anyone who did wish to ‘bypass’ this step setting themselves up as a therapist. Managing projection and bias etc. require any therapist to have high levels of self awareness so they can at least bring what is unconscious to consciousness. However if someone already had done therapy previously, does that count as part of training? Should it? Should ‘top up sessions’ while undergoing training (as training in itself can bring up issues) be adequate if one has already undertaken therapy. Good point re the ’40 hours’ and how that number is arrived at.

      3. I have been a practising psychotherapist for the past 17 years and I am appalled at the idea that anyone would be allowed to practise without first having undergone a period of therapy themselves.
        I trained in the Republic of Ireland and the course requirement was for 120 hours minimum and a letter from the therapist affirming that the process had been completed satisfactorily. In some instances a longer period could be required.
        Any person who has unresolved issues from their period of mandatory psychotherapy should not be seeing clients. The issue is not the comfort or discomfort of trainee therapists but the protection of the general public.
        The ethical imperative is for psychotherapy training courses to carefully assess and select trainees and to ensure that they fully understand the personal and psychological demands such a course will make on them.

  3. Shrinking the shrink, what could possibly go wrong? A Cardiovascular Surgeon who has gone to Medical School as a student is never asked to go through open heart surgery as a pre requisite to becoming a Surgeon themselves. To ask Psychotherapists to go through Psychotherapy themselves is “sick and twisted,” a form of Medevil medicine in some respects.

    1. I often wondered if anyone doing medicine should be required to undergo some sort of ‘treatment’ and experience life as a patient – even what it is like to be lying on a bed and being interviewed by a ‘team’. Some ‘non-invasive’ but slightly uncomfortable procedures? (slightly tongue in cheek).

  4. Never trust a therapist who hasn’t been a therapy client for an extensive period of time (40 hours is the absolute minimum). The most important skill a therapist has is that they know themselves; otherwise they are unable to recognize counter-transference, projection and the many ways they harm their clients through assumptions and unexamined biases.

  5. Unfortunately there is scope for abuse. One example is that most trainings require the prospective trainee to be in analysis two, three, or four times a week for a year before starting, so the analysis needs to have started before they are accepted for training. That creates a problem if the prospective trainee is turned down, especially if that is because of the processes of the training organisation (for example, if the training is over-subscribed).

    There’s also a real problem if the trainee goes to a highly experienced, and therefore aged, training analyst. All-being-well, there is great experience to draw on, but a potential problem if the training analyst start to lose capacity through age — a trainee might well soldier on for fear that the interruption caused by the change of analyst would delay their training, where someone not in analysis for the purposes of training might say “this is not working” and either leavel analysis, or change analyst much earlier.

    There’s also a problem if the analyst in training feels they can’t mention something — in the past there were stories of gay people in training analysis feeling the need to conceal their sexual orientation.

    1. I agree with the part that trainees might “soldier on” so as to not cause interruption as I have witnessed this myself. Trainees have been uncomfortable but because of the programme’s requirements, the list of available therapists has been short leaving the trainee with little option. Then, they do not wish to restart the process.
      I also agree with the problem of trainees not feeling comfortable with revealing certain things. I have also noticed where the pool of therapists is so small and connected to the training institution that the trainee chose to withhold. Sure, they understood the rules of confidentiality but the degrees of separation seemed too little for comfort. They were concerned with they would be found out through process of elimination.

  6. I am currently a psychotherapy trainee in my 3rd year of 4. We are expected to undertake 40 sessions of personal therapy per academic year throughout the entire course. It has been the cornerstone of my learning and without this as an integral part of the course I would be a far less competent therapist. Yes it does stir things up to work through your own stuff whilst learning (and adds HUGE expense). However, what you gain from sitting in the other chair is immeasurably rich as a learning resource and in helping to gain awareness of your own process. Also it is an amazing support for the times when therapy training, placements etc get tough.

    So many of our clients will be expected to undergo intense therapy whilst also holding down jobs, families, educational courses etc. If we have no idea how to balance these different elements of lives ourselves, how can we support our clients to do the same? How would we recognize when someone is experiencing ‘normal’ therapeutic turbulence or if the therapy is actually doing more harm than good?

    I would never, ever work with a therapist who hasn’t undergone personal therapy themselves. 40 hours wouldn’t be enough for me, but as a minimum it seems fair.

    When I did my counselling diploma I had the horrendous experience of sitting in skills practice with several trainee counsellors (all in placements and working with actual clients) who had never undergone counselling themselves. Each session was like a cross between having a chat with a friend, an agony aunt preaching at me about how to fix my problems, and a car crash. They didn’t have a clue what they were doing and boundaries were terrible, because they had never been through the process themselves, and had no empathy or insight as to what the client would be feeling.

    Would you trust a driving instructor who had never learned to drive, but considered themselves qualified to teach, just by having watched a lot of traffic footage on tv and read the highway code?

    I certainly would not!

    1. all of this training, time and expense and while the average driving instructor might be a better driver than the average driver or maybe not? is the therapist any better at living life than the average person? probably not – long before psychotherapy we have had an entire history of human beings harming and helping each other – but now after around 100 years of modern psychology, psychiatry, psychopharmacology are we seeing a rise in wellbeing. mental health and human thriving? NO in fact its the exact opposite suffering grows year in year out and we are encouraged to see more and more systemic causes of suffering as personal problems or disorders.

      What do the critics of psychotherapy research tell us? that its largely rubbish and the entire industry is completely oversold but is nonetheless now embedded within the culture and reinforced through self interest and self promotion and the cult of self.

      I think of equal importance for any ‘therapist’ is to read the critics and be very humble about what they believe they can achieve from a few hours of talking to someone in distress from the isolated confines of a therapy room, imbued with power imbalance, largely devoid of context with both parties operating from their own bias, blind spots and ignorance.

      Human beings are in constant dynamic interaction with self and world both of which we have only a sliver of awareness about – we are also contained within vast powers of economy, ideology, media, education, class – all of this and more and we think a few hours of talking/exploring/homework/techniques is going to be anything other than a temporary fleeting offer of comfort, clarification and encouragement?

      It seems clear we have significant cultural level or systemic disorders that are shaping us all and cause our distress but we have mental (ill) health systems that re-frame this as personal distress and heaps the person with responsibility to change themselves so they can continue to simply get on with it – how about we strive as David Smail suggested not for empty insight but outsight and seek to change the world to make it a place fit for human thriving not just struggling to get buying.

      If you are a therapist working in primary or secondary care in the UK you will likely to be stressed through the overwhelming work load and focus on meaningless targets linked to equally pointless outcome measures.

      this chap has done a thorough review of the research

      there are other critics a good summary can be found here – The Therapy Industry: The Irresistible Rise of the Talking Cure, and Why It Doesn’t Work, Paul Maloney.

      and anything by David Smail is a must

Comments are closed.