Therapy for therapists?

We see periodic flare ups - among psychologists and psychotherapists - of a debate about the importance of personal therapy for therapists. If you want to work in this business providing it to others, the central question goes, is it imperative that you undergo your own? The debate usually gets hot headed, perhaps because it is actually a form of culture clash between very different types of professional psychology. Across the spectrum of the "psy professions," the requirements vary. Many (most?) psychotherapy training courses mandate it. Others don't. It is constitutive of what it means to a psychoanalyst that you are someone who has been psychoanalysed. Meanwhile, most courses in clinical psychology will not insist that their trainees receive any sort of therapy.

It seems easy to argue that personal therapy has value for several rather banal reasons: the experience of being in the “hot seat” (being encouraged to divulge personal details, opening up about your insecurities) can give you a sense of what you are asking people to do. The opportunity to discuss feelings about the ways your work affects you personally is also a way to ward off professional fatigue and "burn out." The privacy of the whole situation (it's hard to see what a therapy session is like without actually sitting in one) also makes personal therapy seem an attractive introduction to how the process ought to look - a sort of apprenticeship. 

There are also arguments that the case in favour of personal therapy is overdone. It is a very resource intensive requirement, hitching entry to the profession to a large financial outlay that some more "hard headed" clinicians argue is simply unnecessary. I sought therapy when I was training to be a therapist, but whatever value it had for me as a person, it was not the only (and maybe even not the best) source of insight about the intersection of my personal and professional development. Intensive supervision on the other hand was profoundly helpful. I had the fortune to meet with supervisors who took a granular interest in the blow to blow of the sessions, and who were not afraid to tell me when they thought I was avoiding material from my own anxieties, or getting wrapped up in a response that was more aimed at gratifying me than helping the person I was meeting. 

Looking at my colleagues I hesitate to suggest personal therapy is essential. Some of them were the most gifted and emotionally insightful people I have met, but I suspect this was principally a result of their temperament, interests and life experiences. Many psychologists seem conscientious and rather neurotic, making them good candidates for extensive self-examination in or out of therapy. Others I have met seem somewhat emotionally unaware despite years of personal therapy. Hardly a convincing advert. 

It may be that this is a case (one of many in my view) in which the psychoanalysts have made an accurate diagnosis of a problem (therapists without personal insight are a bad thing!), but don’t have a monopoly on the remedy. Much as “mindfulness” is actually a description of a wide ranging mental state, which can be facilitated in many ways other than those that have been made popular since the advent of professional meditation training, so "emotional insight" does not only need to arise from a particular form of two way conversation that became popular in the 20th Century. The flip side of this is that therapy is not a precise science and has no guaranteed outcomes anyway. It would seem weird therefore to put too much store by it as some sort of royal road to clinical wisdom. 

How could we settle the question? Apart from examining the efficacy of therapist therapy on outcomes (those who worry about the value of personal therapy for trainees often ask to see the evidence that it "works"), the most interesting way of looking at the problem would be a straightforward “taste test”. You could (for instance) take a panel of senior psychotherapy teachers who run therapy courses mandating personal therapy and have them interview a sample of psychotherapy trainees, some of whom have had at least a year of therapy and some of whom have had none. Would the trainers be able to discern the “analysed” from the “unanalysed” cases? If the trainers’ judgments about who had had therapy were no better than chance then that would seem a significant challenge to the dogma that personal therapy is doing something clinically relevant.

Ultimately the dispute is so intractable because what is at stake is two conflicting visions of the ways that it is possible for us to deceive ourselves. For the cognitively minded, a salient sort of self deception might arise from the various self-justifying biases that are tied up with the insistence upon personal therapy: that it may seduce you into thinking that you’ve got (that it is possible to get) your own psychological house in order; that it bestows an unchallengable authority on the figure of the "well analysed" therapist ("I have the requisite sort of insight - you do not"), and that it is an arrangement principally suited to keeping psychotherapists in business through a steady flow of trainees who need to sit on the couch.

For the psychoanalytically inclined, the relevant self deception is tied up in the hubris of embarking on "the work" without sufficient knowledge of what lurks in your own unconscious. Enter the room as a psychoanalytic naïf and you will be hit by a storm of transferential and counter-transferential responses that you can’t make sense of. You will likely be pulled into a range of potentially harmful enactments with the people you’re trying to help. You'll be lucky to avoid causing harm to the client and to yourself, let alone providing help. I find this way of thinking fairly compelling. The rampant abuse of patients by mental-healthcare professionals (who didn’t – I assume – enter their field as aspirant sadists) looks like striking evidence of how harmful and surprising our unconscious motivations can be. Personal therapy - under the psychodynamic conception - is a way to start looking at the darkness that lies within you so you can stop it from wreaking havoc on those you work with.

The point of raising these two types of consideration is not to try and arbitrate between them, but to diagnose the whole problem with the debate as it is currently constituted. Both sorts of concern seem valid to me. I am convinced of the fact that therapists bring things into therapy that will impact on the work in potentially profound ways. I am also convinced that therapists are motivated to preserve their professional identity by appeal to the special significance of their hard-won clinical insight, and that this can often be overblown. If different sides can retreat from their favoured assumptions, a new way of asking the question might emerge.  

Psychoanalysis' unlikely innovator

There is a popular narrative about the history of psychoanalysis and schizophrenia; that it involved little more than the invocation of schizophrenogenic parents and equated to victim blaming. This version of history is sometimes raised to engender doubts about any psychological theorizing in this area and shut it down.  It’s intellectually healthy to raise such doubts. Contemporary psychoanalysts - worried about repeating historical mistakes - have grappled with them too. Here is an excellent essay, by a psychoanalyst warning his colleagues to heed the "cautionary tale" of the schizophrenogenic mother theory.  

But historical reality is more nuanced than the narrative that runs "psychoanalytic theory bad; biomedical revolution good": Frieda Fromm-Reichmann’s “schizophrenogenic mother” idea has come to symbolise the theoretical chauvinism of the age, but her legacy is more complex. She didn’t focus on aetiology as much as on therapy. Her heroic efforts are documented in Gail Hornstein’s fantastic biography.

More overtly anti-mother was the work of Theodore Lidz, who devoted a large part of his career to studying the dynamics of families of those diagnosed with schizophrenia. His descriptions of two schizophrenia-creating family patterns (skewed families locate all of the power in one parent while schismatic families split it between them in a perplexing civil war) contain toe-curlingly misogynistic descriptions of mothers. These ideas stuck around a long time. As late as 1994 the notion of schizophrenogenic parenting was still doggedly advocated by some authors, with no attention to the idea’s serious evidential shortcomings.

But there was a more subtle and integrative idea at large during the psychoanalytic heydey of American Psychiatry. Sandor Rado was a peculiar figure in American psychoanalysis. Although an elder statesman of the field (he had known Freud well and was selected by him to edit two early psychoanalytic journals), he was cast out from the orthodox New York Psychoanalytic Society for his belief that psychoanalytic knowledge could not be separated from a sound understanding of neurology and genetics. “I believe that the influence of genetics, especially biochemical genetics, is going to be so enormous that it would be bootless to try to outline it.” Rado once said (see page 141 in this)

Rado coined a term that has become ubiquitous in modern academic psychiatry: schizotype. This portmanteau (a collapsing of “schizophrenic genotype”) was used to designate an individual genetically vulnerable to a psychotic decompensation. For Rado (who outlined his ideas in a 1953 paper) a psychotic breakdown represented a combination of this genetic predisposition and the very human process of adapting to the world in light of that predisposition. Although highly speculative and somewhat vaguely couched, Rado’s paper on schizotypy is notable for its almost Laingian level of phenomenological detail. His ideas about the relationship between the constitutional factor (an “integrative pleasure deficit”) and the dynamic contents of the mind were supposed to be the start of a serious mind-body theory of psychosis. But it wasn’t to be.

Although some theorists took note (Paul Meehl brought the concept to academic clinical psychology where it slowly began to gain traction), American psychoanalysis at the time - which is virtually to say American psychiatry at the time - entirely ignored Rado’s idea. In fact “ignored” might be too suggestive of indifference.Some have gone so far as to suggest that Rado’s influence on psychiatry was repressed: “Rado and his collaborators were shunted out of the mainstream psychoanalytic journals and largely vanished from even their references and citations” (p.975 here). Instead American psychoanalysis became committed to ever more dogmatic assertions of the role of parenting in the development of schizophrenia. It's tantalizing to imagine how different it could have been.