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P s y c h o t h e r a p is t s ’ P e r s o n a l P s y c h o t h e r a p y

and I t s P e r c e iv e d I n f l u e n c e o n C l in ic a l P r a c t ic e

A dissertation submitted in partial fulfillment o f the requirements for the


degree of Doctor of Philosophy

Karen F. Bellows-BIakely

Smith College School for Social Work


Northampton, Massachusetts

April 1999

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UMI Number: 9945612

Copyright 1999 by
Bellows-Blakely, Karen F.
All rights reserved.

UMI Microform 9945612


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Copyright by
Karen F. Bellows-BIakely
1999

ii

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A cknow ledgm ents

The completed product of any dissertation is the creation of numerous

psychological “parents.” This project is no exception. The idea for it was conceived from

an awareness o f the often subtle, sometimes profoundly experienced influences of personal

therapy on my own clinical work. The project has taken on a life of its own and has

proven personally enlightening beyond my expectations.

I owe a debt o f gratitude to many who have generously shared their knowledge,

time, and talents. First and foremost, I thank the 20 clinicians who shared their personal

psychotherapy journeys with such candor. Their stories were at once unique and yet

offered a universal resonance with the poignancy of struggling toward psychological

growth. There would have been no “study” without their willingness to offer their

experiences so openly.

The dissertation committee members each provided an invaluable function.

Donald B. Colson, Ph.D., former Chief Psychologist o f The Menninger Clinic generously

offered timely input and guidance, yet intuitively allowed the investigator sufficient

psychological space to struggle productively with the essential aloneness of dissertation

work. To Roger R. Miller, D.S.W., Research Chair, Smith College School for Social

Work, I extend considerable appreciation for believing in the project since its inception

and for invariably helping me “find daylight” when my vision was routinely obscured

through the myopic lens of living in the thick of the research. James W. Drisko, D.S.W.,

Professor, Smith College School for Social Work, encouraged me to enjoy the discovery

iii

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aspects of research and flexibly offered his considerable knowledge about qualitative

research design, without ever imposing his ideas.

To Barbara Berger, Ph.D., I wish to extend special thanks for our many years of

friendship, which apparently remains intact, despite the long hours of free advising

I sought. Her extensive knowledge o f research methodology, her capacity to think clearly,

and her generosity are appreciated beyond words.

I wish to thank my therapist friends who have thoughtfully encouraged my

continued focus on the work at hand, amidst the many distractions in living life-Amy

Holbrook, M.S.W., Ellen Safier, M.S.W., April Stein, Ph.D., Helen Stein, Ph.D., Barbara

Ruggles, M.S.W., Nancy Jones, M.S.W., and Peg Donley, M.S.W.

Thanks also to Smith College School for Social Work colleagues whose friendship

and commiseration has long and deeply sustained me-Judith Batchelor, Ph.D., Carol

Cohen, M.S.W., John Giugliano, M.S.W., Craig Soloman, M.S.W., Marian Harris, Ph.D.,

and AnnMarie Glodich, Ph.D.

Thanks to Menninger colleagues who have provided invaluable input and

encouragement in reading parts o f the manuscript or advising about data analysis-Mary Jo

Pebbles Kleiger, Ph.D., and Glen O. Gabbard, M.D. For her continued supportive

interest, my thanks also go to Kathryn Zerbe, M.D.

Appreciation is extended to Judy Kash and Marcy Schott of the Menninger

Professional Library for their expertise in computerized literature searching and to Barbara

Hauschild and Barbara Reed for their professionalism in the transcription o f interviews.

Grateful acknowledgment is due Norine Kerr, Ph.D., for her early editorial suggestions

iv

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and to Mary Ann Clifft, M.S., for excellence in the final editing. Special thanks to

Aleta Pennington for typing near perfection.

To Gerry Schamess, M.S.S., Professor, Smith College School for Social

Work, I extend special appreciation for many years of encouragement and for his capacity

as a social work mentor in both clinical work and scholarship.

Thank you to Jennifer Kennedy, M.D., from whom I have learned much about

myself and about the nature of the two-person collaboration of psychotherapy. She-and

our work together-truly were “good enough.”

I wish to thank my mother, Jeanne Bellows, for her long years of encouragement

and for believing in me, even when I have doubted myself. She is a lifelong model of what

a woman can do when she puts her mind to it. Deep thanks to my sister, Kathy

Gunderson, whose steadfast support has sustained me to keep going. I extend appreciation

to my father, Kirk Bellows, who has modeled the courage to choose your own goals and

the diligence to achieve them. Thank you especially to David, Ben, and Sarah for

supporting me as I followed my dream, even when it meant sacrificing parts o f our

“wonder years” together. And to other family members, friends, and colleagues, thank you

for your support, ideas, and understanding during the years I have worked on this project.

You are all invited to share in this moment.

K.F.B.B.

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Table of C ontents
Pape
Copyright......................................................................................................................... ii
Acknowledgments........................................................................................................... iii
Table of Contents............................................................................................................ vi
List of Tables.................................................................................................................... viii
Abstract............................................................................................................................ ix
Chapter I: Introduction................................................................................................. 1
Statement of the Study Issue.................................................................... 1
Rationale..................................................................................................... 4
Chapter II: Prior Relevant Work and Research Implications........................................ 8
Literature Review....................................................................................... 8
Theoretical Assumptions and ResearchQuestions.................................... 60
Chapter III: Research Design and Sample...................................................................... 64
Methodological Assumptions ............................................................. 64
Sample Selection........................................................................................ 65
Sample Size................................................................................................ 66
Sampling T echniques................................................................................. 66
Method for Securing D ata......................................................................... 68
Pilot Study................................................................................................. 70
Results of Pilot Study................................................................................ 70
Developing the Interview Questions........................................................ 71
Ethical Issues.............................................................................................. 72
Data Analysis Procedures.......................................................................... 74
Chapter IV: Findings........................................................................................................ 77
Data Analysis: Phase 1
Identifying and Categorizing Themes in the Narrative Data 77
Data Analysis: Phase 3
Association of Perceived Influence of Personal Therapy with
Perceived Benefits, Risks, and the Interpersonal Relationship 191
Chapter V: Discussion................................................................................................... 258
Distillation of Major Findings................................................................... 258
Summary of Findings................................................................................. 259
Implications of the Findings...................................................................... 266
Limitations of the Study............................................................................ 275
Implications of Results for Clinical Practice and Future Research 282
References........................................................................................................................ 287

vi

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Table of C o n t e n t s (con tinued)
Pape
Appendix A: Initial Contact Letter............................................................................... 294
Appendix B: Mail-In Response to Initial Contact L etter...............................................295
Appendix C: Informed Consent Form: Written Explanation to Participants............... 296
Appendix D: Statement o f Informed Consent by Research Participant...................... 297
Appendix E: Demographic Questions........................................................................... 298
Appendix F: Interview Questions...................................................................................299
Appendix G: Ordinal Rankings of Questions Assessing Perceived Influences of
Personal Therapy on Conducting Psychotherapy................................ 301
Appendix H: Level of Influence Scores: Perceived Positive Influence of
Personal Therapy on Conducting Therapy......................................... 303
Appendix I: Data Analysis: Phase 2
Matrix of Findings: Outline of Categories, Themes, & Subthemes.... 304

vii

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L is t of Tables
Page
Table 1: Perceived Level of Influence of Personal Therapy on
Clinical Practice............................................................................................. 232

Table 2: Perceived Benefits o f Personal Therapy Compared with


Level of Influence........................................................................................... 233

Table 3: Perceived Risks of Personal Therapy Compared with


Level of Influence.......................................................................................... 235

Table 4: Perceived Overall Effectiveness of Personal Therapy


Compared with Level of Influence..................................................................237

Table 5: Perceived Interpersonal Relationship and Posttermination


Psychological Involvement Compared with
Level of Influence.......................................................................................... 238

Table 6: Gender and Professional Affiliation of Participant and


Treating Therapist and Choice or Assignment of Therapist
Presented by Level o f Perceived Influence.....................................................250

Table 7: Professional Affiliation and Level of Perceived Influence................................ 254

Table 8: Variables Related to Time Conducting Psychotherapy,


Time Receiving Psychotherapy, Years of Postgraduate
Experience and Time Posttermination, Compared with
Levels of Perceived Influence of Personal Treatment on
Clinical Work................................................................................................. 257

viii

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A b st r a c t

This qualitative study explored psychotherapists’ perceptions of the influence of

their personal therapy on their clinical practice with patients. Twenty psychoanalytically

oriented therapists were interviewed in single audiotaped interviews. Participants included

experienced clinical social workers, psychologists, and psychiatrists who had terminated

from their most recent personal therapy.

The interview schedule was based on aspects of personal therapy deemed relevant

after reviewing the professional literature and conducting a pilot study. The semistructured

interview probed four areas o f personal therapy valued by therapists: benefits, risks,

influence on clinical practice, and the interpersonal relationship between former treater

and patient.

Data analysis consisted of identifying and categorizing themes in the narrative data,

then comparing them with the literature model for thematic relevance. Responses were

then ranked in high, middle, or low levels of influence and these subgroup responses were

then compared with the other areas-reported benefits, risks, and the interpersonal

relationship.

Major findings include that participants perceiving the highest level of influence

of personal therapy on their clinical practice most clearly viewed their treatment as

promoting psychological change, valued their former therapist as a professional role

model, and thought about the former treater during moments of clinical uncertainty.

Problems with the working relationship became the central focus of treatment only in the

high level-of-influence group. The working through of negative aspects o f both

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transference and the “real relationship” apparently contributes to a positive identification

with the former therapist as a professional role model. Those reporting the highest level of

influence most clearly wished to continue the therapeutic dialogue and had most frequently

sought contact with their former treater. Participants also reported that personal therapy

helped modify their perfectionistic traits, which influenced their clinical work. The

termination phase of personal therapy was especially important to the fate of

internalization o f the treatment relationship. To contextualize the findings, clinical practice

characteristics and personal treatment history variables of participants are presented.

Findings support that the extent to which the former treater is seen as a positive

role model is associated with the extent to which treatment relationship conflicts were

actively addressed by the treatment dyad.

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Ch a p t e r !
I n t r o d u c t io n

Statement of the Study Issue

The purpose of this exploratory study was to examine psychotherapists’

perceptions of how their personal psychotherapy experience has influenced their clinical

practice as a psychotherapist. This project explored, through interviews, the personal

psychotherapy experience o f multidisciplinary psychodynamic psychotherapists. The intent

was to describe both the perceived personal benefits and the harmful effects of their

psychotherapy experience and to compare these with its perceived effect on subsequent

work with patients. The “therapist’s therapist,” as a dual role model for both personal and

professional identification and learning, has the potential to serve as an enduring and

influential internalized relationship. Hence, aspects of the perceived interpersonal

relationship and continued psychological involvement with the former therapist were also

explored and compared with the perceived influence of personal therapy on clinical work.

Recent research on this topic has centered on whether personal therapy can be

shown to have any measurable effect on the psychotherapist’s personal adjustment and

professional functioning (MacDevitt, 1987). Findings range from an absence of any clear

evidence of enhanced professional effectiveness (Greenberg & Staller, 1981), to the

position that personal therapy is correlated with greater verbal effectiveness (Strupp,

1955) with particular patients. McEwan and Duncan (1993) have suggested that personal

therapy during training may be detrimental because it interferes with the empathic

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functioning o f inexperienced therapists. Rigorous efforts to operationalize these complex

concepts and to measure change in therapists’ personal functioning as a result o f personal

therapy are in their infancy. Despite the difficulty in developing a body of empirical

evidence on the benefits of therapy for this population, there is general optimism in the

literature that therapy for psychotherapists is personally beneficial, regardless o f the reason

for seeking help.

Factors that influence the personal benefits of therapy for psychotherapists include

the personality and interpersonal adjustment of the psychotherapist or trainee.

A concomitant belief is that the clinical work of impaired professionals will benefit from a

personal psychotherapy process (Deutsch, 1985; Nierenberg, 1972). Impairments viewed

as potentially amenable to personal therapy include personality or intrapsychic difficulty,

symptoms o f addiction, sexual boundaty violations, interpersonal problems, and problems

in adjustment to the developmental tasks of the life cycle (Deutsch, 1985; Pope &

Tabachnick, 1994). “Environmental” factors may also cause the psychotherapist to benefit

from seeking personal therapy; these may include the stress inherent in the work itself,

either during training or later, which can result in professional “burnout” (Farber, 1983).

Finally, the desire for personal growth and self-understanding in this articulate, self-

reflective, insight-oriented group of individuals is not only a source of motivation for

personal therapy but also indicative of the high value generally placed on it by

psychodynamic psychotherapists (Prochaska & Norcross, 1983). Notwithstanding the

difficulties in measuring such complex phenomena, if personal therapy does benefit the

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adjustment o f the psychotherapist, what evidence is there that it translates to better

professional practice?

Controversy surrounds whether personal therapy affects the psychotherapist’s

professional competence. Do therapists who have sought personal psychotherapy function

differently than those who have not? Those grappling with this question must confront the

issue of how to compare basic ideological and personality differences between individuals

who do or do not seek personal therapy. Although complex variables make it virtually

impossible to capture the essential factors in question, several researchers have found

evidence of a continuum o f influence of personal therapy in the therapist’s future clinical

work (MacDevitt, 1987; Peebles, 1980). One such finding is that the greater the duration

of personal therapy and the more recently it was experienced, the more the therapist

consciously accesses it in his or her own work with patients.

These complex questions about the efficacy and influence of personal therapy for

the psychotherapist remain largely unanswered. To promote further inquiry into these

issues, this study explored specific aspects of the therapy experience to determine which

are valued and which are viewed as harmful, and whether there are conscious evocations

of the therapist’s own therapy while working with patients.

The plan for presenting the study follows: A statement of the rationale for

undertaking this study is followed by a review of prior relevant work. The prior work has

been organized into the following six sections: (1) prevalence of personal therapy for

psychotherapists; (2) rationale for recommending personal therapy; (3) subjectively

perceived benefits and harm from psychotherapy; (4) effects of personal psychotherapy on

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4

professional functioning; (S) internalization of the personal therapy relationship; and

(6) the role o f self-analysis and posttermination involvement with personal therapy as a

source of help in professional functioning. Following this review of the literature, the

theoretical assumptions of the study and research questions are presented, concluding this

chapter.

Rationale

The majority of psychodynamically trained psychotherapists seek personal therapy.

Most of them report a high level of satisfaction with, and perceived benefit from, personal

therapy (Buckley, Karasu & Charles, 1981; Shapiro, 1976). Supervised conduct of

psychoanalysis, didactic learning, and personal analysis are the three cornerstones of

psychoanalytic training. The influence of the “therapist’s therapist” as a role model for

personal and professional identification and learning is widely referred to in the

psychoanalytic training literature (Mackey & Mackey, 1994). This historic valuing of

personal therapy by psychoanalysis continues to influence training expectations in the

mental health professions o f psychiatry, clinical psychology, and clinical social work

(Liaboe, Guy, Wong & Deahnert, 1989).

Although there is broad agreement among mental health professionals that their

personal therapy is valuable, both personally and professionally, there is a surprising

absence of knowledge about how the experience of personal therapy affects the conduct

of psychotherapy with patients. Specifically, what is it about their personal therapy that

therapists draw on in conducting psychotherapy themselves? That is the focus of this

study.

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Geller and Farber’s work (Geller, Cooley & Hartley, 1982; Geller & Farber,

1993), on the modes and factors influencing the process of internalization in

psychotherapy, suggests that therapists who have been in therapy consciously evoke

memories o f their own therapist as a source of help while conducting therapy with others.

There is also evidence that the personal therapy experience is drawn on differentially,

depending on whether the therapist is currently engaged in personal psychotherapy or has

terminated, and depending on the therapist’s level of experience. Therapists who are still

early in their career are often engaged in concurrent training and personal psychotherapy,

so are in a position to experience the influences of their personal treatment quite vividly

and differently than the experienced therapist who is returning to psychotherapy or

analysis after a lengthy hiatus or who terminated personal therapy long ago. Evidence for a

continuum o f influence of personal therapy in one’s work with patients supports the

further exploration o f the possibility of the evolving and enduring function of personal

therapy for psychodynamic psychotherapists as a whole.

In addition, professional group affiliation and training of individual

psychotherapists may influence the personal therapy experience. The majority of studies in

this area have sampled a single professional discipline, such as psychiatrists, psychologists,

or psychoanalysts (Norcross, Strausser-Kirtland & Missar, 1988b; Pope & Tabachnick,

1994; Shapiro, 1976). Mackey’s (1994) research is the sole published study to specifically

examine clinical social work therapists’ experience of personal therapy.

Several studies have sampled an interdisciplinary cohort (Buckley et al., 1981;

Norcross, 1990), but have relied on questionnaire data. Questionnaires provide the

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6

advantage of anonymity in this sensitive area and may avoid certain social response biases

inherent in personal interviews. In addition, they are generally cost-efficient and

nonintrusive. But questionnaire data cannot capture the richness and intricacy o f meanings

in individual responses obtained via in-depth interviews. The flexibility of the interview

allows for motivations, meanings, memories, and interpretations to be captured that are

possible only through face-to-face contact (Anastas, 1994). Hence, this study will not only

be interdisciplinary but will also rely on interviews.

This study was an exploratory effort at inquiry into a complex phenomenon,

focusing on the perceived benefits and risks of personal therapy and the uses that

therapists make of their personal psychotherapy in their professional practice. The results

have implications for understanding the identity development of psychotherapists, for

therapists who treat other therapists, and for psychotherapy research in general, regarding

which aspects of the psychotherapy relationship are valued, utilized, and “passed on” in

other complementary relationships.

The relevance o f this study to the profession of social work has both historical and

contemporary implications. The heart of social work always has been the relationship

between client and social worker. Charlotte Towle (1935) charged fellow social workers

to learn the impact that transference and projection had on their work with clients, noting

that “self-ignorance has defeated many highly trained, well-informed, and widely

experienced social caseworkers” (p. 43).

Clinical social work has come of age in the past 25 years as an accepted discipline

providing mental health services in direct social work practice. Clinical social workers

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provide advocacy, casework, and psychotherapy services to their clients through direct

practice with individuals, families, and groups. Since the late 1970s, the number of clinical

social workers who provide psychotherapy services to the public has grown considerably

faster than that o f other disciplines (Golman,1985). This trend is expected to continue,

resulting in increasing numbers of psychotherapists whose professional identity is in social

work.

Towle’s early discussion of the benefits of personal therapy for social workers has

gained recent attention within social work circles (Mackey, 1994). Despite growing

acceptance by social workers of the value of personal therapy, and the long-held regard

for it within psychoanalytic circles, little research has been conducted in this area by social

workers. In 1918, Mary Jarrett addressed the question of professionalism in a talk to the

first class at Smith College School for Social Work:

Our new discipline, psychiatric social work, holds two possibilities: we could think
o f ourselves as assistants in psychiatry, working under the direction of
psychiatrists, or we can develop a profession in our own right, bringing to
psychotherapy the social outlook and skills which would require our thinking for
ourselves and would place us alongside psychiatrists as another, but different,
allied professional. (Reynolds, 1963, p. 62)

As autonomous professionals, clinical social workers are responsible for researching

clinical issues and exploring questions that affect the quality of service they provide.

This research was intended as a step in that direction.

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C h a p t e r II
P r io r R e l e v a n t W o r k a n d R e s e a r c h I m p l ic a t io n s

Literature Review

Prevalence

The majority of contemporary American psychotherapists-between 65% and 80%

(Henry, Sims & Spray, 1973; Norcross, 1990)-have obtained personal treatment for

themselves. Although personal therapy is rarely required by training programs, aside from

psychoanalytic institute training, it is considered a desirable experience by clinical

practitioners and training programs alike (Greden & Casareigo, 1975; Norcross &

Prochaska, 1982; Shapiro 1976; Wampler & Strupp, 1976). A recent study of the personal

therapy experiences o f 800 psychologists (Pope & Tabachnick, 1994) found that the

overwhelming majority (84%) had entered therapy, although only 13% had attended a

graduate program requiring personal therapy. Slightly more than 1 in 5 o f all participants

reported that they were currently in therapy. Another survey of psychologists practicing as

psychotherapists found that only 18% had never received any form of personal

psychotherapy at any time (Guy, Stark, & Poelstra, 1988). Thus practicing

psychotherapists do, in fact, utilize the very service they provide.

Psychotherapists cite their personal psychotherapy as being second only to

practical experience as the most important contributor to their professional development

(Henry, Sims & Spray, 1971; Rachelson & Clance, 1980). Similarly, Kaslow and

Friedman’s (1984) interview study of 14 clinical psychology graduate students who were

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in therapy while in training found that personal therapy tended to be more influential than

supervision in their development as clinicians. Another questionnaire survey (Prochaska &

Norcross, 1983) on the personal therapy experience sampled 400-plus members of the

American Psychological Association, Division 29 (psychotherapy). When asked to rate the

importance of personal psychotherapy as a prerequisite for their work, nearly half stated

that it was very important, while fewer than 1 in 10 thought it not important at all. Those

entering personal treatment before graduation also tended to use it after entering clinical

practice. Such studies support the view that psychotherapists highly value personal

therapy as part of their professional training.

Several studies that examined the therapy-seeking patterns of psychotherapists

after completion o f formal training found that a majority do seek it: 52% of psychoanalysts

(Goldensohn, 1977), 55% of psychotherapists (Grunebaum, 1986), and 62% of

psychologists (Guy & Liaboe, 1986). Similarly, Liaboe, Guy, Wong & Deahnert (1989)

found that a significantly higher percentage of psychotherapists enter personal therapy

after completing graduate training. Rarely is this use o f psychotherapy a component of

formal postgraduate training. In their studies of psychologists, psychiatrists, social

workers, and counselors, Norcross et al. (1988a, 1988b) asked whether recent personal

therapy was initiated for personal reasons, professional purposes, or both. The majority o f

respondents (55%) indicated that their reasons were primarily personal, a finding that

replicated the earlier work o f Henry et al. (1971, 1973). Only 10% replied that their

treatment was largely for training reasons, but 35% reported entering therapy for both

personal and professional growth. These findings indicate that the majority of practicing

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10

psychotherapists seek personal therapy after formal training for personal reasons or for a

combination o f personal and professional reasons.

Studies providing data about duration of personal therapy for psychotherapists'

show that more experienced therapists (those with more than 10 years in the profession)

tend to have accrued more treatment hours than their less experienced, and likely younger,

colleagues (349 vs. 234 hours), which indicates that therapists continue to use personal

therapy during the course o f their career (Prochaska & Norcross, 1983). In a study by

Guy, Stark & Poelstra (1988), the choice o f a psychoanalytic or psychodynamic

theoretical orientation accounted for the greatest variance in the number of hours of

therapy. When Norcross (1990) studied the treatment experiences of 500-plus

psychotherapists from the professions of social work, psychiatry, and psychology, the

average number of discrete treatment episodes was 2.3. The sample was about equally

divided in reporting one personal therapy, two therapies, or three or more. Norcross also

found that having a psychoanalytic or psychodynamic orientation was significantly related

to duration of personal therapy. No differences between females and males were found on

incidence, type, or duration o f personal therapy, yet women rated personal therapy as a

significantly more important prerequisite for conducting psychotherapy (Prochaska &

Norcross, 1983). These findings support the view that psychoanalytic and psychodynamic

therapists continue to seek personal therapy during the course of their career, that most

therapists have engaged in multiple personal therapy processes, and that therapists from a

psychoanalytic or psychodynamic theoretical orientation engage in longer treatment than

do therapists of other orientations.

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The amount of personal psychotherapy received by clinicians after entry into the

profession is influenced not only by their theoretical orientation and years of experience,

but also by the number of hours of individual psychotherapy that they themselves conduct

weekly. Those who tend to provide the greatest amount of individual therapy for clients

also receive the greatest amount of individual treatment themselves (Guy, Stark, &

Poelstra, 1988). The tendency of therapists specializing in individual psychotherapy to

obtain individual personal treatment more often suggests several possible interpretations.

Such individuals may recognize the importance of their own emotional health for the

integrity o f the treatment they provide. Those preferring to explore the individual issues

and problems o f their clients may also be more interested in better understanding their

own. On the other hand, the greater the number of hours of individual treatment provided,

the greater may be the negative impact on the personality of the therapist, who may

require more personal therapy as a result. Or perhaps the personal distress necessitating

treatment may also have compelled these therapists to escape through their work, leading

to more hours o f therapy conducted per week (Guy, Stark, & Poelstra, 1988). These

findings stress the highest utilization of personal therapy by those who are most engaged

in it as practicing professionals.

From whom do these therapists seek help? Several studies have demonstrated the

importance of demographic matching between therapist-patients and their chosen

therapists (Kaslow & Friedman, 1984; Norcross, 1990; Norcross et al., 1988a). Pertinent

factors include theoretical orientation, professional affiliation, gender, and ethnicity. The

psychotherapist’s theoretical orientation has been shown to be predictably related to his or

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12

her psychotherapist’s orientation (Grunebaum, 1983). In addition, Norcross’ (1990) study

of therapist choice showed that the majority of therapists of any theoretical orientation

undertook personal treatment with psychoanalytic (41%) or psychodynamic (18%)

psychotherapists.

Regarding professional affiliation, psychotherapists seek treatment from

psychiatrists, then psychologists, social workers, counselors, and lay analysts, in that

general order. However, there are definite preferences on the basis of professional

discipline. In Norcross’ study (1990), 36% of the psychologists received treatment from

fellow psychologists, while 35% turned to psychiatrists. Psychiatrists routinely sought out

other psychiatrists-82% of the time. Social workers were the only group more likely to

enter treatment with a therapist of a discipline different from their own. There is evidence

that this pattern in social work is changing, though, given the increasing availability of

clinical social workers who are specializing in the practice of individual psychotherapy

(Norcross et al., 1988a; Sailer, 1992). Kaslow and Friedman (1984) found that clinical

psychology doctoral students, citing the importance of professional role modeling, have a

strong preference for seeking personal therapy from a competent therapist within their

own discipline.

Demographic factors such as gender and racial heritage o f the chosen

psychotherapist also exert a strong influence. Norcross et al. (1988a) noted the ubiquitous

practice of therapist-patient demographic matching on these variables and provided

evidence of an increasing tendency for mental health professionals to be treated by

members of their own gender and professional discipline. On the positive side, such

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treatment experiences can enhance personal validation and professional socialization.

Conversely, these emerging patterns of similarity can promote professional indoctrination

and theoretical “inbreeding.” Altogether, these findings offer evidence of how important it

is to psychodynamic psychotherapists to select a personal therapist similar in theoretical

orientation, professional affiliation, gender, and ethnicity.

In addition to demographics, several other factors have emerged as important in

selecting a personal therapist. That psychotherapists select their own therapist primarily on

the basis of clinical acumen and interpersonal qualities is supported by evidence from two

pioneering studies (Grunebaum, 1983; Norcross et al., 1988a). Both identified four

essential criteria that therapist-patients keep in mind as they search for a personal

therapist. Two essential factors are perceived professional competence and interpersonal

warmth. In addition, Grunebaum’s sample noted that a treater with an active, talkative

style, outside the therapist’s professional and social network, was usually sought.

Norcross’ sample listed clinical experience and professional reputation as being important

to therapist choice. With regard to these factors, interprofessional differences evident in

the selection criteria existed between social workers, on the one hand, and psychologists

and psychiatrists on the other. Social workers accorded more weight to treatment cost,

therapist flexibility, interpersonal warmth, active style, and openness. Overall, these

findings reflect the importance o f perceived competence, interpersonal warmth, clinical

experience, and professional reputation as factors that influence a therapist’s choice of

personal therapist. Such choices also appear to be made within the demographic matching

of such characteristics as theoretical orientation, professional affiliation, and gender.

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In summary, research on the therapy-seeking behavior of psychodynamic

psychotherapists indicates that both trainees and experienced psychotherapists use services

similar to those they themselves provide to others. As a group, they value personal therapy

as a significant contributor to their professional development, and they continue to seek it

after completing their formal training. However, the majority of experienced

psychodynamic psychotherapists seek personal therapy not so much for professional

reasons as for personal reasons, or for a combination of the two. Most have seen two or

more therapists in a significantly lengthier process than have therapists o f other theoretical

perspectives. Also, the more hours of engagement in psychotherapy practice, the more

likely it is that the therapist will utilize personal psychotherapy at some point. And, finally,

psychodynamically oriented therapists tend to seek personal therapists whose theoretical

orientation, professional affiliation, gender, and ethnicity resemble their own.

Rationale for Recommending Personal Psychotherapy

The recommendation that therapists undergo personal therapy grew out of Freud’s

discussion of countertransference, a concept first introduced in 1912 in Recommendations

to Physicians Practising Psycho-Analysis: “Everyone who wishes to carry out analyses on

other people shall first himself undergo an analysis by someone with expert knowledge”

(p. 116). Freud was concerned with the counterproductive effects of neurotic problems in

the therapist. Unresolved conflicts and characterological problems that are not dealt with

in a therapeutic manner may render a less-than-adequate therapist.

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15

Freud based his injunction on technical considerations, but he came to subscribe to

the view that an analyzed therapist is a better therapist. In addition to illuminating the

therapist’s personal conflicts and bringing them under control, the training analysis

(initially called didactic analysis) was designed to give the young therapist firsthand

experience with personal psychodynamics, to increase self-awareness, to deepen

understanding o f therapeutic techniques and augment their impact, and, in general, to

strengthen the therapist’s ability to withstand the stresses of therapeutic work (Strupp,

1975).

Freud’s recognition of the importance of the psychotherapist’s personal therapy for

personal and professional functioning can also be found in his later injunction in Analysis

Terminable and Interminable: “But where and how is the poor wretch to acquire the ideal

qualifications which he will need in his profession? The answer is in an analysis of himself,

with which his preparation for his future activity begins” (Freud, 1937/1964, p. 248).

In the same paper, Freud suggested that analysts should regularly reinitiate personal

treatment because intense therapy continually exposes the therapist to the impact of

patients’ unconscious processes. “Every analyst should periodically-at intervals of five

years or so-submit himself to analysis once more, without feeling ashamed of taking this

step. This would mean, then, that not only the therapeutic analysis of patients but his own

analysis would change from a terminable into an interminable task” (Freud, 1937/1964,

p. 248).

A decade after Freud’s death, Fromm-Reichmann (1949) echoed this imperative

for those who wish to provide intensive psychotherapy:

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And so it is, because of the inter-relatedness between the psychiatrist’s and the
patient’s interpersonal processes and because of the interpersonal character of the
psychotherapeutic process itself, that any attempt at intensive psychotherapy is
fraught with danger, hence unacceptable, where not preceded by the future
psychotherapist’s personal analysis, (p. 378)

Since Freud’s time, no training requirement for the psychoanalytic psychotherapist

has been considered more vital than personal analysis. The curricula o f psychoanalytic

training institutes have traditionally been built around this requirement. In clinical

psychology training programs, departmental attitudes toward personal therapy for students

range from benign neglect, to reticent helpfulness, to active encouragement, and-rarely-to

a requirement that trainees undergo personal therapy (Wampler & Strupp, 1976).

Graduate schools o f social work have been conspicuously silent on the issue, although the

profession as a whole recognizes that self-awareness is critical to good clinical practice

(Mackey, 1994).

Henry (1971) has pointed out that the extent to which therapists have themselves

undergone therapy is a motivating factor for entering the profession of psychotherapy.

A common property in this set of professions, and of the cultural values o f training, is the

prompting to study the self and others to determine psychological motives for behavior.

The figures on personal psychotherapy may therefore reflect the prevalence o f both the

interest in this form o f inner contemplation and the use of personal therapy as a form of

socialization that provides practice in the art of examining inner values and experiences.

Strupp (1975) noted several benefits of personal therapy. Chief among them was

that personal therapy is “a process for coming to terms with one’s personal and

professional identity” (p. 11). In so doing, the therapist-patient also learns “about

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psychodynamics, psychoanalytic technique, insight, and therapeutic change” and confronts

“the basic problems o f human existence and the nature o f human relations in a manner

unequaled by any other learning experience” (Strupp, 1975, p. 11).

A specific rationale for personal therapy is the therapist’s need to discover and

appreciate the power of the unconscious. The issue of training analysis for analytic

candidates can be enlarged to cover other psychotherapists in training, who must choose

whether to deal with the unconscious of their patients, even in a nonanalytic situation.

On this subject, Silverstone (1970) wrote that “the primary purpose of a personal

psychoanalytic experience for student analysts is, in fact, not the eradication of personal

problems, but the personal validation by the student analyst of something which must be

experienced as foreign to him-the existence of the unconscious in himself’ (p. 284).

The unconscious is not only not conscious but also difficult for a person with intact

defense mechanisms to accept. Ekstein and Wallerstein (1958) echo this position,

suggesting “that one can only work with the unconscious of another person when he has

learned to work with his own, has relived his infantile neurosis, freed himself from its

terrors, and has resolved his basic conflicts” (p. 248). In a similar vein, Glass (1986)

noted: “It is this narcissistic wound that every [psychotherapist] who has experienced his

own unconscious remains ever mindful that more is going on than meets the eye in not

only his patient but himself as well” (p. 306). These writers have emphasized discovery of,

and respect for, the power of the unconscious as a primary benefit of personal therapy.

Understanding how one’s own defenses can interfere with the therapeutic process

is another core rationale for personal psychotherapy. Meissner (1973) stated that self-

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understanding is necessary for psychotherapists to better understand others and to be able

to react in an empathic, objective manner. In his own analysis, for example, he thought of

himself as normal, but he was soon able to identify obstacles to his personal and

professional development that he would not have seen otherwise, since these obstacles

were nonetheless adaptive. Meissner’s therapy process enabled him to evolve both as a

person and as a psychotherapist. Similarly, Glass (1986) has noted that the “personal

baggage” one brings into therapy cannot but influence the dynamic process o f the

therapeutic relationship. Further supporting the view that understanding one’s defenses is

important, Rubenfine (1971) has said that analysis teaches the therapist to know “when his

own defenses interfere with the therapeutic process and, at the very least, this knowledge

should ensure the patient against becoming a target for the therapist’s own unconscious

anger and hostility” (p. 230). These writers thus view an increased awareness o f one’s

defenses as leading to a greater understanding of oneself and others that mitigates against

the therapist’s destructive aggression with patients.

A comprehensive summary o f the reasons for personal psychoanalysis or

psychotherapy has been provided by Nierenberg (1972): (1) to enhance the analyst’s

ability to conduct therapy as a more sensitive and unbiased clinical observer whose “blind

spots” and countertransference potential have been mitigated; (2) to give therapists a

personal sense of conviction about the validity of the theory and the method of treatment

they are using, by demonstrating their personal relevance; (3) to learn about technique via

a firsthand modeling experience; and (4) to make the therapist’s life less neurotic and more

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gratifying, so that the stress of conducting therapy can be tolerated better. These gains are

often regarded as sufficiently great so as to make the experience indispensable.

The presumed benefits of personal therapy for the therapist thus include growth in

both personal and professional identity. This growth occurs through experiential learning

about the power of unconscious processes, understanding one’s own defensive patterns,

mastery of technique as a result of increased self-awareness, gaining a sense of conviction

about the validity o f the therapeutic model, exposure to a role model, and resolution of

personal problems or “emotional baggage” that could interfere with one’s therapeutic

effectiveness.

In general, the authors who support personal therapy for the therapist in training

do not insist on it as a requirement. Rather, they strongly suggest or encourage

undertaking a personal therapy process, espousing the view that no therapist can go

further in the therapy of a patient than what the therapist’s own obstacles permit.

Obviously, there are exceptions, including the fact that certain individuals may become

excellent clinicians without being analyzed (Glass, 1986).

Problems of Mandated Psychotherapy

Another group of authors is neither totally for nor against personal therapy for

therapists in training; the majority would still encourage but not require it. Arguments

against such an experience include the risk of limiting the trainees’ openness to a variety of

therapeutic models, emotional and financial stress on trainees (Clark, 1986; Macaskill,

1988), and the possibility that motivation would be diminished if the individual did not feel

the need to change. With insufficient anxiety, the trainee might lack the motivation to

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withstand the rigors of personal therapy and, hence, the student would acquire only a

superficial knowledge of psychoanalysis or psychodynamic psychotherapy. It is also

frequently argued that the competence of a therapist cannot be judged on the basis o f the

successfulness of a personal therapy. According to several studies (Garfield & Bergin,

1971; Glass, 1986; Kaslow & Friedman, 1984), psychotherapy concurrent with training

may have a detrimental effect on the functioning of therapists in training. One explanation

for this reaction is that, although these problems are often of short duration, the increased

awareness of previously repressed inner feelings that occurs during personal therapy may

interfere with the trainee’s ability to be empathic toward patients. In summary, cautions

against mandatory psychotherapy concurrently with clinical training include the risk of

indoctrination to single therapeutic models, emotional and financial stress, insufficient

motivation to change, and self-absorption with the personal treatment that may detract

from clinical empathy.

Another contraindication to personal therapy is the possibility of overidentification

with the personal therapist, which might contribute to the future psychotherapist’s rigidity.

This is a concern because it is the more flexible individuals who have, in fact, developed

new therapies and made new discoveries. In addition, those who are analyzed may be

viewed as having more insight, but they are not necessarily the best therapists. So

engaging in personal psychoanalysis or other types of personal therapy is not sufficient for

becoming a good therapist, because of the potential that doing so may reinforce

maladaptive traits o f either the therapist-patient or the personal therapist and the lack of

clear correlation between insight and therapeutic effectiveness (Glass, 1986).

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Leader (1971) has noted that the motivation for personal psychoanalysis often

derives, in part, from the anxiety and insecurity of the beginning therapist, and that the

desire for a personal psychoanalysis may diminish during the course of training with

teaching and supervision. He asserts that a good training program with well-selected

candidates under competent supervision should be sufficient for understanding and dealing

with anxiety or other training-related problems. Leader emphasizes that analysis or any

other type o f therapy is indicated only for students with personal problems. He stresses

that empathy with others develops out of trainees’ real-life experiences and growing

maturity throughout the training process. Thus, in his view, empathy is not necessarily

related to personal psychotherapy. As a result, Leader suggests that those beginning

therapists who really need psychotherapy will find the means to pursue it voluntarily.

Several factors contribute to the need for personal therapy among experienced

psychotherapists, while others often prevent its use (Bermak, 1977; Greben, 1975; Guy,

Stark & Poelstra, 1988; Will, 1979). Many psychotherapists may be negatively affected by

factors inherent to the practice of psychotherapy, including physical and psychic isolation

and repeated feelings o f loss and abandonment as a result of planned and unplanned

terminations. To this list o f specific problems, Bermak (1977) adds a frustrated need for

intimacy, the need to control emotions, the frustration of omnipotent rescue wishes and

the helplessness that ensues, ambiguity in the field, and the emotional drain of constantly

being empathic. Depleted emotional reserves resulting from the professional practice of

psychotherapy can have negative consequences for the therapist’s interpersonal

functioning with family members and friends. It may also be that psychotherapeutic

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practice actually exacerbates emotional and interpersonal problems already present in the

therapist (Henry, 1973). Because of the inherent stress in the practice o f psychotherapy,

these writers recommend that personal therapy should be positively and persuasively

encouraged by all in the field, in addition to maintaining high levels of continued training

and education with peer supervision.

It is beyond the scope of this study to review the extensive body of literature

regarding treatment that may be necessary for impaired professionals with underlying

psychopathology who are in training or practice. According to Campbell (1982), between

4% and 22% of psychiatry residents have either a minor or a major psychiatric problem.

The role of stress during the training period should be looked at more closely, because it

may lead to an increase in minor, often temporary, problems. The literature suggests

several ways of helping maladjusted trainees, as well as practicing therapists, such as

through individual psychotherapy (Gabbard, 1995; Garetz, 1976; Glass, 1986).

Reasons for Seeking Personal Therapy

Therapists give a variety of reasons for seeking personal therapy. In a number of

survey studies that have asked about the presenting problem (Guy et al., 1988; Pope &

Tabachnick, 1994), psychotherapists most frequently reported interpersonal conflicts,

depression, and anxiety. These modal complaints are consistent with other research

indicating that clinical practice exacts a toll on the practitioner, particularly in the form of

emotional underinvolvement with family members, moderate depression, and problematic

anxiety (Bermak, 1977; Cray & Cray, 1977; Deutsch, 1985; Farber, 1983; Looney,

Harding, Blotcky & Barnhart, 1980; Pope & Tabachnick, 1994).

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The pervasiveness o f these struggles for practicing psychotherapists is supported

by Deutsch (1985), who investigated therapists’ personal problems and treatment in a

study of250-plus nonmedical, doctoral, and master’s level psychotherapists. It is

noteworthy that over three fourths of these subjects (82%) reported having experienced

relationship difficulties and that almost half (47%) had sought therapy at one point for

relationship problems. The figures for depression also were substantial, with 57%

reporting depression at some time in their lives. Over one fourth of the sample had been in

therapy for depression, and 11% had taken antidepressant medication. Despite these

symptoms o f distress, which may interfere with personal and professional functioning,

most psychotherapists utilized the resource of personal therapy as a result of their personal

awareness o f their own internal processes, and made an active decision to enter therapy in

response to a personal evaluation, rather than in response to external factors or specific

precipitating events (Deutsch, 1985).

Therapist Resistance

Although personal psychotherapy is accepted by most clinicians as being helpful

for the therapist in training, stigma nevertheless still seems to be attached to the role of

patient for the experienced therapist (Glass, 1986). Factors that may prevent experienced

therapists from using the services they provide include resistance to entering the patient

role because o f a sense o f professional superiority and omniscience that hinders the ability

to identify one’s own need for psychotherapy. Guy and Liaboe (1986) concluded that the

majority of experienced psychotherapists appear to resist entering personal therapy, even

during times o f distress when it could prove both useful and appropriate. Concern about

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confidentiality is an issue for some therapists, particularly those in small professional

communities. Experienced therapists may also resist therapy because o f expectations that

therapists should give rather than receive help. Even during times of distress, many

therapists do not seek psychotherapy. Rather, they minimize the severity of their struggles

and favor other sources for dealing with personal stress.

In summary, the rationale for personal therapy includes experiential learning about

the power of unconscious conflict and intrapsychic processes, mastery of technique,

exposure to a role model, and resolution of personal problems. Conversely, the argument

against required psychotherapy concurrent with clinical training includes the potential

indoctrinating effects, both from theoretical approaches and from the personal

idiosyncrasies of the therapist’s therapist, emotional and financial stress, insufficient

motivation to change, and self-absorption, which may detract from clinical empathy.

Motivation for personal therapy may diminish with time, as trainees become more secure

in their professional role. Although personal therapy encourages insight, this is not

sufficient cause. But since the stress of psychotherapeutic practice may exacerbate

emotional and interpersonal problems in the therapist, personal therapy should perhaps

also be encouraged for experienced therapists. A substantial number o f psychotherapists

suffer from interpersonal conflicts, depression, and anxiety, yet most seek personal therapy

only if they become aware of their internal processes. However, an internalized sense of

superiority and omniscience can lead experienced therapists to minimize their personal

struggles to such an extent that they will avoid entering the patient role.

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Therapists* Perceptions o f Personal Therapy

Although the literature indicates that psychotherapy generally produces positive

changes in patient adjustment, little research has focused on how a personal therapy may

affect the psychotherapist’s adjustment. At present, there is no existing empirical evidence

that personal therapy enhances therapist adjustment. However, there is considerable

indirect evidence, both through the subjectively perceived benefits and through the harmful

effects of personal therapy for psychotherapists, in several existing surveys. Prior work

related to therapists’ perceptions of the personal benefits and risks of their own

psychotherapy has focused as well on interpersonal factors related to the “fit” between the

therapist as patient and his or her therapist.

Overview

Studies surveying psychiatry and psychology trainees’ perceptions of the value of

personal therapy have found that the majority of trainees rate their personal therapy highly,

from very desirable to essential (Coryell & Wetzel, 1978; Macaskill, 1992). Shapiro’s

(1976) landmark study of graduates from one psychoanalytic training program focused

specifically on the training analysis. He found that “the vast majority [of the 121 analysts

who returned completed questionnaires] viewed their therapeutic gains favorably, despite

the complications posed in analysis concurrent with training” (p. 36).

Studying experienced social work therapists, Sailer (1992) asked respondents to

rate the overall success of their most influential personal therapy experience. Eighty-nine

percent rated their therapy as beneficial, 10% rated it as somewhat beneficial, and just one

respondent rated it as both a harmful yet beneficial treatment experience.

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Pope and Tabachnick’s (1994) large survey of practicing psychologists found that

85% o f the respondents described their personal experience with therapy as very helpful or

exceptionally helpful. Only two respondents reported that it was not at all helpful.

Seventy-eight percent found the experience not at all harmful, but 2.3% reported that it

was very harmful or exceptionally harmful. Those who believed that their therapy was at

least somewhat harmful were more likely to perceive their therapist as being unkind or as

making errors.

Findings from these studies of single professions are consistent with Buckley,

Karasu & Charles’ (1981) multidisciplinary review of psychotherapists’ perception of the

value o f their personal therapy which found the lowest outcome measure to be a 73% level

o f improvement. Overall, these studies concur that the great majority o f respondents

received considerable personal benefit from treatment, and that the few harmful therapy

experiences were associated with particular respondent perceptions about the treating

therapist.

Perceived Benefits

As a result o f personal therapy, psychotherapists report significant benefit in

multiple areas. These include perceived improvement in self-understanding or self-

awareness; self-esteem or self-confidence; interpersonal relationships; characterological

conflicts; improved therapeutic skills; and, to a lesser extent, symptom severity (Buckley

etal., 1981; Norcross, 1990; Pope & Tabachnick, 1994; Shapiro, 1976).

Some individual psychoanalysts have provided accounts of their personal therapy

(e.g., Guntrip [1975] has written of his separate analyses with Fairbaim and Winnicott,

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contrasting their different personalities and therapeutic styles). But there has been no

systematic investigation o f multidisciplinary psychotherapists’ experience in therapy until

Buckley et al. (1981). The positive benefits of treatment reported by the 71 experienced

psychotherapist respondents occurred on a broad front and involved improvements in self­

esteem, interpersonal relations, work functioning, and character change. Symptom

alleviation was also considered important but ranked least among these variables. The

study concluded that the majority of respondents received considerable personal benefit

from their treatment. These benefits occurred in ways that are difficult to measure, such as

improvement in self-esteem and interpersonal relations. The significance o f such change

for the individual, however, should not be underestimated. This study stressed a reliance

on the subjective report o f the person who actually experienced the therapy as an

important aspect o f what it is that intensive psychotherapy or psychoanalysis does in the

way o f effecting therapeutic change. In particular, Buckley et al. cited the “emotional

tone” of the therapeutic relationship as a key to determining perceived outcome: “The

critical importance o f the positive perception of the therapist corroborates the view that

mutative experiences can only occur in the context of a positive patient-therapist

relationship” (p. 304).

A more recent study of trainees’ perceptions of the benefits and risks o f their

personal therapy is Macaskill’s 1992 questionnaire survey. In it, 87% of the British

psychotherapy trainees who evaluated their personal therapy reported that it had a

moderate to very positive effect both on their work with patients and in their personal

lives. Positive effects included increased self-awareness (76%), increased self-esteem

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28

(47%), and a reduction in symptoms (43%). The most common primary goals for personal

therapy were personal growth and the resolution of personal problems. The general

picture that emerged from Macaskill’s study is that personal therapy is an integral,

intensive, expensive, and time-consuming component o f training. It typically consists of

more than twice-weekly sessions, lasts more than three years, and produces substantial

personal and professional benefits for nearly all trainees, although sometimes at

considerable emotional and financial cost. From the trainees’ point of view, the gain is

generally well worth the pain (Macaskill, 1992).

In Sailer’s (1992) survey study o f 67 licensed clinical social work psychotherapists,

respondents reported on the accomplishments of their personal therapy. In order of

importance, they offered four main reasons for participating in therapy: (1) to gain

personal insight; (2) to learn more about the therapeutic process; (3) to improve self­

esteem; and (4) to alleviate symptoms.

Although such positive perceptions of the benefits of personal therapy are

impressive, the possibility exists that therapists will overestimate the therapeutic results of

their personal treatment, especially given the therapist’s professional stake in highly

valuing his or her own investment in the product of psychotherapy. As a practitioner, the

therapist-patient has an inevitable bias toward viewing psychotherapy in a positive light.

In addition, favorable self-assessment could be based, in part, on positive transference

attachments to the therapist (Shapiro, 1976).

In summary, various studies show that a large majority of therapists who have

been in personal therapy have found it helpful in many different areas of their lives.

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The most frequently mentioned benefits are not the accomplishment of specific behavioral

goals but, rather, such concepts as enhanced self-awareness or self-understanding and

improved self-esteem. These concepts tend to be difficult to operationalize or measure.

In addition, psychotherapy research that explores the processes by which (and the extent

to which) such benefits are accomplished is made even more difficult by the inevitable bias

in the therapist-patient’s stake in personal therapy. Even so, these subjectively perceived

benefits should not be underestimated with regard to what intensive psychotherapy does in

effecting therapeutic change. Nonspecific factors related to the emotional tone of the

interpersonal relationship between therapist-patients and their therapists appear crucial to

perceived benefits.

Perceived Harmful Effects

A minority of respondents in each of the studies reviewed did report negative

outcomes or actual harm as a result of personal treatment (Buckley et al., 1981; Pope &

Tabachnick, 1994; Sailer, 1992; Shapiro, 1976). In these studies, from 8% to 24% of the

respondents reported that their therapy or analysis had been harmful in some way.

The most common reason for a harmful treatment experience appeared to be a rigid,

distant, and uninvolved therapist who promoted a therapeutic relationship lacking in

mutual positive regard. Less common, but nevertheless detrimental, were specific

boundary violations by the treating therapist.

One fifth o f Buckley’s (1981) respondents, for example, reported that their

treatment was somehow “harmful.” Comments ranged from treatment being “deleterious

to my marriage,” to “allowing destructive acting out,” to “fostering too much withdrawal

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from the outside world.” These reportedly harmful effects were not significantly correlated

with therapist factors such as a lack of warmth or empathy or not being understood by the

therapist. The most significant correlates for harmful effects included: dreaming about the

therapist; feeling that during the course of therapy, the therapist was the most important

person in one’s life; feeling that the therapist was not neutral about his or her behavior;

and feeling sad that sessions with the therapist had ended. These findings suggest that, at

least in this group of respondents, specific unresolved transferential factors are an

important component in the subjective experience of a harmful effect. It is of interest, too,

that the mean scores of items related to these “transference residues” were all significantly

lower in the no harmful effects subgroup. Those in this group appear to have been able to

successfully work through transference to a greater extent. This finding would tend to

confirm the belief of most practicing psychotherapists that management of transference

should be a central focus of treatment (Buckley et al., 1981).

In contrast, harmful results of therapy were significantly related to particular

therapist factors in Pope and Tabachnick’s (1994) study of practicing psychologists.

Therapist unkindness or errors, therapist sexual material, and patient sexual material were

all correlated with perceived harmfulness. One out of 10 participants who had been in

therapy reported that a therapist had violated confidentiality. That the patient is a member

or a soon-to-be member of the community of therapists creates numerous opportunities

for dual relationships and other blurred boundaries (which was the fifth most frequently

mentioned cause o f harm). The most serious harm, however, resulted from the therapist’s

attempted or actual sexual acts with the respondent, clinical incompetence, sadistic or

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31

emotionally abusive actions, general failure to understand the patient, nonsexual dual

relationships, and boundary violations (Pope & Tabachnick, 1994).

Despite such problems, none of the trainees reported purely negative outcomes

for their therapy (Macaskill, 1992), but 38% reported some negative effects. The main

negative effects were psychological distress (29%) and marital or family stress (13%).

Half the sample commented that financial costs and time constraints in general were a

substantial stress, but they also indicated that these two factors were not necessarily

negative. Approximately one fourth reported feeling psychological distress because of

their therapy, but they viewed it as a necessary aspect of therapy and not as something

negative.

The social work subjects (Sailer, 1992) were also asked if any aspect of their

personal therapy had been harmful. Their responses are in keeping with those from other

studies (i.e., from 70% not harmful, to 24% harmful). Six percent of the social workers

were unsure whether some aspect of their personal therapy had been harmful. Recurring

themes o f harmful characteristics included problems with psychoanalytic theory being

applied too rigidly by the therapist and boundary violations of therapists.

The five most common factors that Shapiro (1976) found to be associated with

significant problems in psychoanalysis during training included: (1) characterological

problems of the candidate; (2) countertransference not related to the analyst’s role as a

training analyst; (3) evaluative or reporting aspects of the analyst’s dual role; (4) personal

attributes of the analyst; and (5) overestimation of, or excessive identification with, the

analyst.

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In summary, a substantial minority of psychotherapists view their personal therapy

as having been somehow harmful. But, overall, trainees appear to accept that being able to

deal with psychological, interpersonal, and financial stresses associated with personal

therapy is important to becoming a professional. Nonspecific factors associated with

perceived harm relate more to the treating therapist’s rigidity, perceived emotional

underinvolvement, and lack of neutrality toward the patient. Less commonly reported

were specific therapist behaviors involving boundary violations (e.g., confidentiality,

sexual acting out). Specific, unresolved transference residues appear to be an important

and widespread component in the subjective experience of a harmful effect.

Interpersonal Factors

Significant correlations with a series of therapist variables were revealed in

Buckley et al’s. (1981) analysis o f outcome factors. Improvement in all areas positively

correlated with “mutual liking”-the feeling of liking and being liked by, the therapist.

Eschewing any mention of an affectionate bond, Greenson (1967) has defined the

“therapeutic alliance” as what occurs between the patient’s reasonable ego and the

analyst’s analyzing ego. The significant correlation of mutual “liking” with every outcome

variable in Buckley et al’s. study suggests that, at least for this group of respondents, the

therapeutic alliance may necessarily include elements of an affectionate bond. The feeling

of being understood by the therapist also correlated with all positive outcome factors

except alleviation of symptoms. Improved self-esteem significantly correlated with

perceived therapist empathy and warmth. Thus Buckley and colleagues hypothesized that

the emotional “tone” of treatment is of critical importance to a positive outcome. These

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therapist factors would appear to be the sine qua non of an effective treatment and it is

noteworthy that they are nonspecific.

Related to emotional “tone” is the issue of the stylistic and characterological “fit”

between analyst and analysand. Seldom addressed in the literature, this factor is an

apparently crucial element in the therapeutic outcome experienced by many analysands:

A ‘good fit’ between analyst and candidate should reflect reciprocal role
expectations (the analyst believes the candidate will make a good analyst some
day, the candidate accepts the training analyst as a good role model) and
compatible professional convictions and philosophies, a fit of compatible cultural
and social values and mutual respect to the distinctive ethnic and other
sociocultural differences, and an unconscious congruence of reciprocal personality
dynamics and transference-countertransference configurations and personal
attributes. (Shapiro, 1976, p. 27)

The roles of interpretation and insight as therapeutic agents of change remain

controversial; each has been questioned as a key curative factor in psychotherapy. Data

from the reviewed studies suggest that specific technical procedures of the therapist

related to the appropriate management of transference phenomena are critical to a positive

outcome. Such factors may be central to a positive therapeutic exchange resulting from

psychoanalysis or intensive psychotherapy, provided that they are implemented within the

context o f a positive therapeutic relationship (Buckley et al., 1981).

Thus interpersonal factors, characterized by the emotional tone of the treatment,

appear vital to the perceived therapeutic outcome for therapist-patients. The factor of

“mutual liking” correlates with a broad range of perceived improvements. A “good fit”

occurs when both members of the dyad believe in the competence of the other and have

compatible professional convictions, respect for personal differences, and an “unconscious

congruence” of personality and transference-countertransference dynamics. Technical

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34

factors, such as the role of interpretation, are also important to respondents within the

context of a positively experienced therapeutic relationship.

In summary, the literature indicates that most therapists perceive their personal

therapy to have been beneficial. Benefits tend to be global in nature, however, so are

difficult to measure. Nonspecific factors inherent to the interpersonal relationship appear

crucial to perceived benefits. A minority of psychotherapists report that their personal

therapy was somehow harmful. Nonspecific harmful factors were related to the

respondents’ characterological struggles and to the treating therapist’s rigidity or

emotional underinvolvement. Less common, but even more detrimental, were therapist

boundary violations involving confidentiality and sexual acting out. Unresolved

transference residues, which left the respondent feeling unfinished with the relationship,

were frequently implicated in the subjective experience of a harmful effect. In contrast, a

therapeutic relationship characterized by mutual respect for the competency and similarity

to and difference from the other, as well as by a mutual liking, appears vital to perceived

positive outcome. These interpersonal factors may be associated with more transference-

focused treatments, which enable the therapist-patient to better resolve the transference

neurosis.

Effects on Professional Practice

Despite finding in one study that supervisors observed no difference in clinical skill

between analyzed and unanalyzed psychiatry residents, Demer (1960) later recommended

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35

unequivocally that personal therapy would probably be helpful to the professional

functioning o f therapists:

To judge a priori who will be a good therapist by the use o f personal therapy
experience as a major prediction criterion is questionable. The best way to judge
whether a person can be a therapist or not is to allow him to become involved in
the intimacy o f the therapeutic relationship. If his humanness can be put at the
disposal of the patient, he will probably be a successful therapist. And one way to
increase the possibility of his allowing his humanness to be at the patient’s disposal
is for a personal therapy experience to increase the therapist’s self-understanding
and skillfulness at relating. If one was of such good fortune that he was bom with
parents who helped him develop with minimal distortions in interpersonal
relationships and his life from that point on continued to be of such a nature that he
could relate well to others, personal therapy could well be dispensed with. Most of
us, however, will be better therapists as our self-understanding and ability to relate
to others is increased by our own therapeutic experience.. .. Let me state on faith
and theoretical grounds, but not verified by research, that the training of a
psychotherapist should include some therapy experience for the therapist
himself. . . . The therapist as the therapeutic tool must be able to relate on a
conjunctive level with his patient and he may need personal therapy to become
skilled at conjunctive relatedness. (Demer, 1960, p. 134)

Demer’s position highlights the conclusions of a number of other authors who

found conflicting evidence about the significance of personal therapy for professional

functioning and development. The following review of these studies is organized into five

sections: (1) an overview of the evidence; (2) findings from studies of the subjective

valuation o f personal therapy on professional functioning; (3) findings from patient-

therapy outcome studies; (4) findings from studies measuring changes in the therapist’s

functioning; and (5) conclusions.

Overview

There is considerable controversy in the literature about whether personal

psychotherapy-before, during, or after training-is a prerequisite for being a good

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36

therapist. Three major views have emerged: (1) it is indispensable: (2) it is necessary for

some therapists sometimes: and (3) it has limited usefulness or is altogether unnecessary.

The first view is that personal therapy is either indispensable to, or very helpful in,

providing effective treatment (Buckley et al., 1981; Fromm-Reichmann, 1950; Peebles,

1980; Rubinfine, 1971). Those who take this position cite a variety of expectable

professional benefits: experientially derived knowledge of what it is like to be a patient,

reduced tendency to develop undetected countertransference problems, enhanced listening

ability as a result of ffeed-up defenses and increased cognitive flexibility, and more stable

and elevated self-esteem. Nevertheless, the therapist-trainee’s personal treatment can have

some temporary negative effects on any treatment he or she is simultaneously conducting.

These negative consequences arise by virtue of the anxiety that sometimes floods

therapist-trainees in treatment. But such temporary difficulties are later compensated for

by the improved functioning o f the therapist-patient as the personal treatment progresses.

The second position, that personal therapy is necessary only for some therapists at

some times (Burton, 1973; Leader, 1971), would mandate that therapists enter treatment

only when feeling stressed by their personal lives to the extent that they are unable to cope

effectively. For those individuals with satisfactory coping abilities, however, such

treatment would not be necessary.

The third view, o f personal therapy as having either limited utility or being

altogether unnecessary, emanates from several studies with conflictual findings (Holt &

Luborsky, 1958; Katz, Lorr, & Rubinstein, 1958; McNair, Lorr, & Callahan, 1963).

In their study of psychiatric residents at the Menninger Foundation, Holt and Luborsky

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37

found no relationship at all between supervisors’ ratings o f residents’ clinical competency

and the existence or length o f the residents’ personal treatment history. In commenting on

this study, however, Fisher and Greenberg (1977) questioned the extent to which

supervisory ratings can be regarded as valid indices of therapeutic competency. Finally,

in other studies focusing on patient improvement rates (Katz et al., 1958) and premature

termination rates (McNair, Lorr, & Callahan, 1963), a positive correlation was found

between treatment outcome and therapist’s experience level, but not between treatment

outcome and therapist’s personal treatment history.

For purposes of the present review, empirical evidence on the effect of personal

therapy on professional practice has been organized into three areas: (1) subjective

valuations-studies of the therapist’s own evaluation of his or her personal therapy;

(2) patient therapy outcome-studies that evaluate the effects of personal analysis by

comparing analyzed versus nonanalyzed therapists via subsequent patient outcomes; and

(3) therapist functioning-studies that evaluate the effects of personal analysis by

comparing the effects of analyzed versus nonanalyzed or less analyzed therapists on

particular measures of in-session functioning.

Subjective Valuations

Perceived Benefits. Several studies have sought to understand what benefits of a

personal therapy relate to how therapists conduct clinical practice (Kaslow & Friedman,

1984; Mackey & Mackey, 1994; McEwan & Duncan, 1993; Norcross, 1990; Pope &

Tabachnick, 1994). A number of common benefits have been noted to promote change

and growth in the therapists’ professional functioning. Variations on five beneficial themes

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38

appear in most o f these studies: role modeling, enhanced empathy, increased

understanding of therapeutic process, greater self-awareness, and personal and

professional development.

A particularly valued aspect of personal therapy for both trainees and therapists

early in their career is that it gives them an opportunity to learn about the process of

therapy from a seasoned professional role model (Kaslow & Friedman, 1984; McEwan &

Duncan, 1993). Studies of the therapy experiences of psychology interns and of

experienced social workers (Mackey & Mackey, 1993; Sailer, 1992) particularly

emphasize this benefit.

A second benefit related to the therapist’s professional functioning is the

enhancement o f empathy that comes from personal therapy. That is, the therapist-patient

learns the importance o f warmth, empathy, and the personal relationship. Personal therapy

also teaches empathy by increasing the therapist-patient’s appreciation of what it means to

be in the role of patient, hence increasing respect for the struggles of patients (Mackey &

Mackey, 1993).

Enhanced understanding o f the therapeutic process is a third benefit often cited. It

includes increased confidence and trust in the process and increased understanding of

which interventions and specific techniques are or are not helpful. It also promotes

improved therapeutic skills, in particular, decreasing the therapist’s need to “do for”

patients and increasing the ability to instead “be with” them (Kaslow & Friedman, 1984;

Mackey & Mackey, 1993).

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39

A fourth benefit, that of enhanced self-awareness, translates into a greater ability to

use countertransference reactions more effectively with patients in sensitive areas of the

therapeutic process. Pope and Tabachnick’s (1994) subjects, in particular, reported that

their increased self-awareness and self-understanding enabled them to better handle issues

of self-disclosure, self-expression, and boundary issues.

Closely tied to this benefit is personal and professional development: the

perception that therapy is, in the long run, a growth-promoting process in and of itself.

Included here are such responses as working through one’s own issues, putting one’s

humanness in the service o f the therapeutic work, and gaining an increased capacity to

differentiate one’s affective states from those of patients (Mackey & Mackey, 1993;

Sailer, 1992).

In summary, these studies report beneficial aspects of personal therapy for the

psychotherapist that translate into enhanced self-awareness, personal and professional

development, and professional functioning in the areas of learning from the therapist as a

professional role model, gaining empathic understanding of the patient’s role and

understanding the therapeutic process. The consensus that emerges supports Ford’s

(1963) notion that the “developing psychotherapist acquires large portions of his own

personal identity and self-concept collaterally with his acquisition of professional and

therapeutic role and identity” (p. 476). In short, clinical training and psychotherapeutic

treatment simultaneously stimulate the process of continued internal development in both

students and experienced psychotherapists.

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Perceived Risks and Negative Effects. In addition to perceived benefits, personal

therapy also poses a number of perceived risks or negative effects for professional

development. In McEwan’s (1993) study of psychology interns, therapy was seen as being

detrimental to professional development by providing poor role models or by

“indoctrinating” students into only one therapeutic model. Overgeneralization and

projection of the trainees’ own responses onto future clients were also mentioned as risks.

Similarly, several of McEwan’s respondents commented that personal therapy might instill

a false sense of confidence by conveying the impression that, as a result of being

“therapized,” the student is therefore in good psychological health and has the necessary

professional skills to work as a therapist. Risks imposed by dual relationships were also

cited in this study, as well as in others (Kaslow & Friedman, 1984; Norcross, 1990). The

data show that when therapy is included in a graduate training program, dual relationships

have been the norm, and these open-ended comments indicate awareness of such inherent

problems.

Trainees are aware o f negative effects on their clinical work as a result of being in

concurrent training and treatment. Overidentification with the patient role, for example,

can become a problem. In addition, despair about the efficacy of clinical work may surface

whenever the trainee feels at an impasse in personal therapy. More commonly, however,

students faced with increased affect, newly freed in treatment, find that it reduces the

capacity to think clearly and attend well to patients. Finally, having to invent a facade of

competency and adequacy in order to manage the work with patients can produce

overwhelming stress (Kaslow & Friedman, 1984). This problem seems to indicate that

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41

having to perform a function not yet fully mastered, while attending graduate school and

undergoing the affectively stimulating experience of personal treatment, is often just too

much.

Another complication involves manifestations of trainees’ struggles with

differentiation. Kaslow and Friedman (1984) described students’ inhibitions about openly

discussing with their therapists those areas of their professional lives where they

presumably differ. These areas typically include trainees’ theoretical orientation,

therapeutic techniques, personal style, and career goals. Most studies categorize the

therapy experience as a mixed blessing for trainees because it entails both risk and benefit.

Attention should therefore be paid not only to the potential benefits of this training

experience, but also to the risks involved.

Patient Outcome Studies

No Significant Differences. A number of studies have correlated the therapist’s

use of personal therapy with measures of change in patients. Since the prime goal of

personal therapy is the production o f better therapists, from a clinical point of view, these

studies may legitimately be considered the most significant test of the effect of personal

therapy. With regard to patient improvement, studies by Katz et al. (1958), Holt and

Luborsky (1958), and Demer et al. (1963) all fail to show differences between the

analyzed and nonanalyzed groups. Numerous methodological problems exist with these

studies, however, including poor design, inadequate or vague process and outcome

measures, and small sample size, leading to provisionally acceptable conclusions.

Nevertheless, their attempt to measure change in clients, as a consequence o f treatment by

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42

an analyzed therapist, found no direct evidence that personal therapy has a positive effect

on outcome. In addition, length of therapy did not correlate with outcome.

Negative Outcomes. Evidence for negative effects of the therapist’s personal

therapy on the outcome of therapy for patients can be found in two recent studies, one of

which (Wheeler, 1991) investigated therapist orientation and its relationship to the

therapeutic alliance developed with eating disordered patients. A surprising finding was

the significant negative correlation between the amount of personal therapy of the

respondents and the extent o f their therapeutic alliance with patients. Personal therapy

correlated negatively, particularly with therapist’s predictions about the therapeutic

alliance; that is, with increasing amounts of personal therapy, therapists were increasingly

negative about their alliance with patients. This pattern implies a lack o f confidence about

ability to predict a good alliance. Wheeler notes that the negative correlation of personal

. therapy and alliance could have a more positive meaning. Perhaps more personal therapy

gives the therapist more confidence to allow the development and expression of a negative

transference, which is a more reality-based relationship than one seen through rose-

colored glasses.

Another study giving evidence of a negative relationship between patient outcome

and the therapist’s personal therapy is Garfield and Bergin’s (1971) exploration of the

relationship of the amount of personal therapy to three measures of change in clients. The

18 therapist participants in this study were advanced graduate students (4 with no personal

therapy, 7 with 80-175 hours, and 7 with 200-450 hours). No information was provided as

to the type o f personal therapy or the theoretical orientations of the therapists. The results

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43

indicated that patients of therapists with no personal therapy showed the greatest change.

These results were independent of differences in the therapists’ level of disturbance. But

the small sample precluded statistical tests of significance and no information was obtained

on the severity level o f initial distress for patients of the therapists by duration o f personal

analysis. The inexperience of these therapists suggests a possible differential effect for

personal analysis that occurs at different points in the therapist’s career. The lower patient

improvement in the treated group of young therapists could be explained by the fact that

they were still in the throes of the usual turbulence attendant to being analyzed and thus

were blocked in therapeutic efficacy by a current preoccupation with their own problems.

Strupp (1973) has suggested that this problem of blocked therapeutic effectiveness

is a temporary phenomenon, however, because his data also show that after many years of

experience, therapists who have been analyzed are (as a group) far more empathic than

unanalyzed therapists. Strupp’s finding would suggest the possibility that the advantage in

favor of subjects with a low amount of personal therapy revealed by Garfield’s data is a

transient one that would have been reversed if experienced therapists had been used.

These findings challenge the assumption that personal analysis and concurrent practice of

psychotherapy for the beginner can safely proceed simultaneously.

Positive Outcomes. A positive relationship was noted in the Menninger Clinic

project headed by Kemberg (1973). Therapists with many years of experience who had

completed analysis obtained greater patient improvement than relatively inexperienced

therapists still undergoing analysis. Unfortunately, this study did not factor out the

therapist’s experience as an influence on outcome. Thus, although the findings are

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44

consistent with a positive personal therapy effect, they do not rule out the possibility that

experience is an important factor in outcome.

Measurable Differences in Therapist In-Session Functioning

Evidence that personal therapy influences the therapist’s in-session functioning was

found by Strupp (1955), Peebles (1980), and MacDevitt (1987). Their findings have

significance for the present investigation and are summarized below.

Strupp’s (1955) work, which used therapy analogues, focused on the therapist’s

therapeutic approach. Contrary to prediction, personal analysis seemed to lead to greater

rather than to diminished activity on the therapist’s part. Compared to unanalyzed

therapists, analyzed practitioners tended to be more active, as evidenced by a significantly

smaller number of silent responses. In dealing with transference phenomena, analyzed

therapists tended to prefer interpretations, silence, and structuring responses. The results

for the unanalyzed group were inconclusive. This evidence suggests that analyzed

therapists have learned to introduce reflective distance between their immediate emotional

reactions to a patient and their verbalizations, which enable them to be more empathic and

less punitive and disapproving. Strupp concluded that personal analysis has a demonstrable

effect on the therapist’s verbal behavior, independent of the therapist’s level o f experience.

Supporting Strupp’s findings that personal therapy changes some aspect of the

therapist’s functioning is a study by Peebles (1980) on the ability of clinical psychology

trainees to display empathy, warmth, and genuineness. She used independently rated

sample tapes o f therapy sessions to determine whether the number of hours o f personal

therapy could be positively associated with this ability. Comparisons were significant for

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45

empathy and genuineness, using Truax and Carkhuff Scales for Accurate Empathy (Truax

& Carkhuff, 1967). Peebles concluded that personal therapy works on therapists by

altering their manner of perceiving themselves and the world around them, and that this, in

turn, affects their cognitive and affective capacities for displaying empathy, warmth, and

genuineness. It could thus be reasoned that the primary effects of personal therapy are on

one’s cognitive style. Given these findings, future research should perhaps examine the

effects of personal therapy by looking at variables more closely related to therapists’

functioning than at therapeutic or patient outcome measures.

Findings from MacDevitt’s study (1987) offer further evidence that personal

therapy influences the therapist’s in-session functioning by altering perceptions o f self and

other, which in turn affects cognitive and affective capacities, thus enhancing therapeutic

effectiveness. In this survey of 185 doctoral-level psychologists averaging 16 years’

experience, respondents answered questions about their personal therapy history, then

gave their professional reactions to 24 hypothetical psychotherapy situations. The results

suggest that awareness o f countertransference issues is highly significantly and positively

related to the amount-and rated professional value of-personal therapy received. This

connection might be explained as due to self-reflective therapists not only scoring high on

countertransference awareness but also finding personal therapy valuable professionally.

MacDevitt also concluded that personal therapy may be more valued by those whose

exclusive function is providing therapy and who therefore conduct more therapy weekly.

MacDevitt concluded that the number of hours of personal therapy makes its own

sizable and independent contribution to countertransference awareness and to the

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46

perceived professional value of therapy. These findings lend support to the notion that

personal therapy is an experience that leads to greater professionally relevant self-

awareness and better professional functioning. There is some support in the data for

hypothesizing a tendency or ability to be introspective or some similar variable as a

significant determinant of the professional value of personal therapy. Other pertinent

questions suggested by MacDevitt’s study are: Besides increasing professional self-

awareness, how does personal therapy contribute to the therapist’s practice? Is the

modeling effect important? Does the experience create better empathy or more social

savvy regarding the patient role?

In summary, these studies have attempted to measure various aspects of therapist

in-session functioning due to varying amounts of personal therapy experience. The results

o f these three investigations must be viewed with some caution, however, because two of

them are based on experimental analogues rather than on actual therapy interactions.

Nonetheless, they do suggest that therapists who have had personal therapy may be more

responsive in some ways to the therapeutic needs of patients. The responses of analyzed

therapists, for example, were seen as being more consistent with recommendations in the

literature as to the optimal way to handle various therapeutic situations. In addition, the

behavior of therapists with personal therapy was more in keeping with recent findings

about the importance of transference interpretations and the need for increased therapist

activity in dealing with seriously disturbed patients. These findings suggest that internal

change in the therapist is translated into enhanced empathy with patients, increased self-

awareness, and increased sensitivity to countertransference. Overall, the findings from

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Al

these three studies of altered therapist functioning support evidence from the literature on

therapists’ subjective valuations of the beneficial aspects o f their personal therapy.

Conclusions

These studies suggest a number of possibilities that are tempered by design

difficulties. It is extremely difficult to design a study in which the variable of personal

therapy is not influenced by some other variable, such as the therapist’s experience or

personality. And particularly in outcome studies, patients treated by all the therapists

would need to be sufficiently similar to be compared. Since isolating the personality of the

therapist as a variable is such an unsolved problem, the therapy versus no therapy group

design is probably not the way to test this question. The evidence already gathered

indicates that some therapists can be effective without having had personal psychotherapy.

It also indicates that personal therapy can affect the practice of psychotherapy, although

not always as expected. The effects that occur appear complex and reflect not only when

the personal therapy took place within the therapist’s practice career but also specific

therapeutic skills, such as empathy. It may be that it is only during therapy with a

particularly disturbed patient or a borderline patient who elicits substantial

countertransference reactions that the effects of a personal analysis are likely to be most

evident, or equally in the psychotherapeutic training o f the substantially disturbed trainee

who has a tendency toward counterproductive countertransference responses. Although it

may be possible to design a study that attempts to account for the individual contribution

of personal therapy, the clinical relevance of the results would certainly be questionable,

given the highly intercorrelated nature of the variables.

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48

Despite clear limitations in the available data, these studies imply certain effects of

personal therapy:

1. Personal therapy seems to affect a therapist’s verbal behavior. Clinicians may

become more appropriately responsive to patient needs as a result of having been in

therapy themselves.

2. Personal therapy, when combined with clinical experience, has been found to

have some positive effects on the therapist’s subsequent professional relationships.

Empathic ability, for example, may be facilitated in therapists who have undergone therapy

themselves. Some evidence also suggests that a personal therapy experience makes it less

likely that a clinician’s dislike of a patient will produce a negative treatment.

3. Personal therapy seems to lead to increased self-awareness and, hence, to

enhanced awareness of countertransference.

4. Undergoing therapy and doing psychotherapy at the same time may be

antitherapeutic for inexperienced trainees, but this situation appears to be a temporary

problem that reverses with clinical experience.

5. There is no evidence to indicate that psychotherapists who have undergone

psychotherapy themselves will be seen as superior trainees or will have more successful

careers than their untreated colleagues.

6. In general, the data linking personal therapy with outcome are inconclusive.

Among the respondents in the subjective valuation and therapist in-session

functioning studies, therapy appeared to nurture the development of personal qualities

essential to effective clinical practice to produce a caring, respectful, and accepting use of

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self with clients. Therapy also enhanced the development o f empathy as a professional

skill, including integration of cognitive and affective dimensions in relationships

characterized by balancing connectedness with separateness. Therapists attributed these

gains, along with a deeper understanding of the therapeutic process, to identification with

their therapist, which appeared to become increasingly selective over the course of

treatment. Many o f the perceived risks of personal therapy are associated with the

trainee’s role as learner. The potential for personal and professional growth through

identification with a competent therapist who is a “good enough” role model appears more

prevalent than the harm that comes from an incompetent therapist’s therapist, who would

make a poor role model. However, most trainees acknowledge the inherent risks of

personal therapy concurrent with clinical training.

Most of these studies do not focus on the meaning o f personal therapy for one’s

professional practice. The outcome studies touch only indirectly on the relationship

between personal therapy and the development of professional identity. On the basis of

research to date, relatively little is known about the relationship between personal therapy

and the psychotherapist’s sense of a professional self. We do know, however, that those

who have undergone personal therapy view it as helping them to be more effective in their

professional work.

Internalization of Personal Therapy

Several studies previously reviewed have emphasized the importance of

identification with the therapist’s own therapist in the development of personal and

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50

professional identity formation (Kaslow & Friedman, 1984; Mackey, 1994; Shapiro,

1976). Articulated directly by almost everyone in Kaslow and Friedman’s (1984) study of

psychology graduate students was the wish to have a professional role model with whom

to identify. Mackey (1994) also noted the theme of therapist as model, stating that

respondents talked of wanting to emulate their therapists in their professional lives. These

identifications were based on relational or “nonspecific” factors observed in therapists who

offered trusting, secure, and safe environments wherein professionals could explore their

inner world. This identification was more pronounced among therapists early in their

careers who were struggling to find themselves and felt “incomplete” or “unfinished.”

They often viewed their therapist as someone to emulate and with whom they could

identify. Mackey (1994) found that, as professionals progressed in therapy, the mode of

identifying with therapists took on a character different from earlier, more holistic

identifications. This new dimension of modeling involved more selective identifications

and often included both positive and negative qualities. Along the same lines, Shapiro

(1976) noted that “the [therapist’s] necessity for identifying with the analyst in his work as

part of the development o f a new role is universally acknowledged” (p. 28). He also cited

the tendency in a number of his respondents to overidentify with the training analyst,

which can pose real problems o f dependency versus autonomy for the graduate’s

postanalytic working-through period. These researchers all noted the importance of the

therapist’s therapist as a positive professional role model.

Although frequently used in the literature, terms such as professional role model

and ego ideal are rarely defined. Part of the difficulty with defining the professional role is

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51

the variety of human developmental stages used as analogies to this professional

development process. Reference to a specific developmental stage is not necessary if we

suppose that the common thread to these analogies is that they contain progressively

higher levels of introjection, identification, and ego integration (Roy, 1992).

Pfeffer (1963) emphasized the conflictual but progressive nature of aspects of

identification:

In the course of the analysis, the person of the analyst becomes, and after the
analysis remains, a permanent intrapsychic image intimately connected with both
the regressively experienced conflicts and the resolution o f these conflicts in the
progression achieved. . . . In analysis, conflicts are organized around the person of
the treating analyst and, with interpretation, these are resolved. However, the
treating analyst remains, perhaps forever after, an important intrapsychic
representation for the patient and a point of anchorage for the resolution of
infantile conflicts, (p. 230)

According to Geller and Farber (1993), the concept of internalization encompasses

introjection and identification, whereby individuals transform personally experienced

events into networks of emotionally charged representations of self and others.

Introjection is primarily responsible for the construction of emotionally charged

representations o f the self in relation to others, whereas identification entails the

modification of self-representations. Individuals model themselves after, or identify with,

the representations of others that are brought into existence by the process of introjection.

Identification refers to the processes whereby individuals increase their felt resemblance to

other persons. Like imitation, identification aims toward sameness or likeness. Geller and

Farber (1993) assume that identifying with another person requires the modification of

one’s self-representations so that they more closely resemble mental representations of the

other person’s characteristics, roles, and functions.

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The work of Geller, Cooley and Hartley (1982) and of Geller and Farber (1993)

holds considerable significance for the current investigation. That research involved an in-

depth examination of the internalization process in psychotherapy with subjects who were

all psychotherapists themselves. Factors affecting the recall, forms, themes, and

phenomenological properties o f internalized representations of the psychotherapist and the

psychotherapeutic relationship were investigated in a sample o f 206 current or former

therapist-patients (Geller & Farber, 1993). Responses on the Therapist Representation

Inventory (TRI) indicated that representations are most likely to be evoked when painful

affect is experienced; that regardless o f when therapy was terminated, the greater the

number of therapeutic sessions, the greater the likelihood that patients will use

representations of the therapist to continue the work of therapy after termination; and that

among both current and former patients, positive therapeutic outcome is significantly

associated with the tendency o f representations to reflect a wish to continue the

therapeutic dialogue. These findings indicate that the history and continuing influence of a

psychotherapy relationship can be discerned in the functions and qualities patients ascribe

to representations of themselves in relation to their therapist. Finally, almost 1 in 5

therapist-participants in Geller and Farber’s study was aware of bringing to consciousness

the representations of their own therapist when conducting therapy with others.

Consistent with the view that the process of internalization makes a vital

contribution to the therapeutic action o f psychotherapy, Geller and Farber’s (1993)

findings indicate that these representations potentially serve a wide range of adaptive and

reparative functions. In contrast to merely “remembering” information about their

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53

therapist, patients also bring forth representations of themselves in relation to their

therapist to regulate painful affects, assuage feelings of loneliness, and facilitate problem

solving and conflict resolution. For example, by reuniting the patient with calming and

soothing images of the therapist and the therapeutic relationship, these representations can

attenuate the negative consequences of a self-deprecating self-image.

One goal of psychoanalytic psychotherapy is to promote the development and

stability o f the capacity for self-analysis. This attribute is frequently cited as a criterion of

termination readiness, and its development is usually seen as being mediated by the

patient’s identification with the analyst’s “analyzing functions.” Among other things, these

functions refer to the therapist’s knowledge, creativity, and problem-solving and decision­

making abilities. Geller and Farber’s (1993) data indicate that the ability to engage in

internal dialogues with one’s therapist-both during therapy and after termination-is

significantly correlated with self-perceived outcome. This finding confirms Loewald’s

(1960) belief that the very essence of psychotherapy is the patient’s internalization of the

therapeutic dialogue.

Some theorists argue that, with increased maturity, the patient gives up

“dependence” on the felt presence of the therapist; others contend that continued access to

that felt presence may serve highly adaptive functions. In the absence o f normative data, it

is impossible to determine whether the use of introjects is a transitional mode en route to

autonomous self-regulation or whether their continued use is necessary to autonomous

self-regulation. The current study inquired about the use of such evocations of the

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54

therapist’s therapist during clinical work, in an attempt to contribute to an understanding

of the role that introjects play in professional functioning.

In summary, a number of psychoanalytic theorists and researchers concur on the

importance of the therapist’s therapist as a potent role model professionally. Implied in

some o f the literature is a developmental progression through distinct stages. A more

useful concept may be the recognition of aspects of intemalization-introjection,

identification, and ego identity-at progressively higher levels. There is evidence that, even

after termination, the analyst remains an important intrapsychic representation and an

anchor for the resolution of internal conflict. To identify with another person requires

modifying one’s self-representations so that they more closely resemble mental

representations of the other person’s characteristics, role, and functions. Geller and Farber

(1993) stated that the history and continuing influence of a psychotherapy relationship can

be discerned in the functions and qualities that patients ascribe to representations of

themselves in relation to their therapist. These representations potentially serve a wide

range o f adaptive and reparative functions. The development and stability of the capacity

for self-analysis is related to the patient’s internalization of the therapeutic dialogue. It is

not clear whether the use of introjects is a transitional mode en route to more autonomous

self-regulation or whether their continued use is vital to autonomous self-regulation. In an

effort to promote this inquiry, the current study addressed questions about evocations of

the therapist’s personal therapy while conducting psychotherapy.

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55

Self-Analysis and Posttermination Intrapsychic Involvement

The findings o f Geller et al. (1982, 1993) identify the internalization process of the

personal therapy relationship as an important source of influence on the therapist-patient’s

professional practice o f psychotherapy, which will be pursued in the current study. This

internalization process continues after termination of psychoanalysis or psychotherapy and

may be related to the capacity for self-analysis.

The recognition that the patient has acquired a capacity for self-analysis is a

generally acknowledged reason for considering termination. This self-analytic function is

regarded as a capacity that develops during the course of analysis, in that the patient’s ego

identifies with the analyzing functions of the analyst (Norman, Blacker, Oremland &

Barrett, 1976). Describing the challenges to preserving the intrapsychic changes,

posttermination, that psychotherapy promotes, Geller et al. (1982) quoted Edelson:

The problem o f termination is not how to get therapy stopped, or when to stop it,
but how to terminate so that what has been happening keeps on ‘going’ inside the
patient. The problem of termination is not simply one of helping the patient to
achieve independence in the sense of willingness to function in the physical absence
of the therapist. More basically it is a problem of facilitating achievement by the
patient of the ability to ‘hang on’ to the therapist (or the experience o f the
relationship with the therapist) in his physical absence in the form of a realistic
intrapsychic representation (memories, identification associated with altered
functioning) which is conserved rather than destructively or vengefully abandoned
following separation, thus making mastery of this experience possible, (p. 127)

Although psychoanalytic theory has historically emphasized the interpretive resolution of

the transference neurosis as fundamental to the analytic process, more recent findings

consistently demonstrate that transference persists beyond termination (Gabbard & Lester,

1995).

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In his pioneering study of postanalytic follow-up, PfefFer (1963) reported on

individual case studies o f patients who were interviewed within 5 years of termination.

Satisfactorily analyzed patients reacted to the follow-up interviews as though in analysis,

with transient regressive revival of the transference neurosis and reexperiencing of the

symptomatology and character difficulties for which they had first sought analysis. PfefFer

posited that the investigator became a new transference figure who mobilized both

transference residues and partly resolved infantile conflicts. In subsequent work, published

30 years later, PfefFer (1993) notes that the former analyst is represented as both an old

object (a residual displacement from past figures) and a new object (on the basis of new

integration of conflicts integral to the transference neurosis). He stressed that both mental

representations remain indefinitely.

That many former patients make consistent use in fantasy o f the “benign presence”

of the former analyst to facilitate conflict resolution after analysis is reported in the

literature (Buckley et al., 1981; Norman et al., 1976; Schlessinger & Robbins, 1974).

These authors share the view that analysis does not obliterate the transference neurosis.

They also note that each patient experiences varying degrees of control over the

transference neurosis, or that it could be viewed as a new psychic structure under the

purview o f the unconscious ego (Gabbard & Lester, 1995).

In reviewing these contemporary views o f the fate of the transference neurosis

after termination, Gabbard and Lester (1995) found that, although the transference

dispositions persist, as a result of analysis they are much more thoroughly understood and

mastered. Although transferences are not necessarily resolved, they are modulated to the

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57

point that patients can deal with them more effectively. Transference wishes remain, but

the expectation of how others will react to those wishes is significantly altered.

A contemporary and relevant study on posttermination follow-up is the work of

Kantrowitz, Katz & Paolitto (1990). This study examined the relationship between the

extent of resolution of the transference at termination and the characteristics of the

analyst-patient match. The interdigitation o f the personal characteristics of the analyst with

the particular difficulties and characteristics of the patient was a crucial factor in

determining a facilitating or an impeding match. For the majority of patients interviewed

5 to 10 years after termination, the researchers found that the analyst-patient match played

a role in the outcome of analysis. Whether factors related to the perceived match would be

discernible in the current study and whether these are associated with perceived influences

of personal therapy on the professional conduct of psychotherapy, was a focus of this

study.

Evidence o f continued psychological involvement in therapy posttermination

comes from Pope and Tabachnick’s (1994) study of psychotherapists. O f 297 respondents

who had been in personal therapy, almost 40% reported at least some continuing

psychological involvement. That is, they answered positively one or more of the following

questions: Have you recently daydreamed about a former therapist? Dreamed, while

asleep, about a former therapist? Felt intense anger at a former therapist? Or experienced

sexual feelings or fantasies about a former therapist? Continuing psychological

involvement was related to therapist unkindness or errors. Pope and Tabachnick’s findings

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58

support the idea that unanalyzed aspects of both erotic and aggressive transference may be

involved in continued posttermination psychological involvement.

In exploring the effects of passage of time on posttermination intrapsychic

involvement, Buckley et al.’s. (1981) study is an important reference. Their data indicate a

changing response over time in “transference residues” in the posttreatment period. The

ratings o f both the outcome factors and nonspecific items (e.g., “warmth” and “mutual

liking”) did not differ significantly, however, with time since termination. Forty percent of

the group who had terminated treatment within 4 years responded that their treatment had

been harmful somehow, as opposed to only 12% of the posttreatment group that had

terminated 11 to 20 years earlier. This difference may reflect a gradual working through of

unresolved transference issues with the passage of time. Analysis of the data also revealed

that thoughts about the therapist reach a peak, then wane, 5 to 10 years after treatment.

All respondents in this period reported experiencing thoughts of returning to analysis or

therapy. They voiced concerns, such as the “wish to see the therapist again,” and they

viewed the therapist as a “friendly spirit” (all rated significantly higher in this group), so

this period would seem to be a critical time in posttherapeutic development. Thoughts of

returning to treatment may eventually lose their urgency, especially as life conflicts are

successfully traversed. How the passage of time influences posttermination psychological

involvement with the therapist may also bear on the perceived influence of personal

therapy on the therapist’s professional conduct of psychotherapy.

Findings from these studies suggest that termination does not mark the end of

cognitive and emotional involvement with the therapist or of consideration of additional

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therapy. These posttermination follow-up studies also support the importance of

considering whether images or introjects of the therapist’s therapist function as a

transitional mode en route to more autonomous self-regulating, or whether their continued

use is vital to self-regulation. The findings regarding self-analysis and posttermination

psychological involvement with therapy have direct bearing on the current study, given the

significance of the therapist’s therapist as a “permanent intrapsychic representation,” and,

therefore, one with potentially great impact on the therapist-patient’s continued

professional practice of psychotherapy.

In conclusion, there is considerable evidence that the internalization of the

therapist’s therapist is an ongoing developmental process that changes over many years

after termination. This process involves the self-analytic function, or the capacity to keep

the therapeutic process alive inside the former patient. The current investigation explored

the relationship between the subjects’ perceptions of an internal therapeutic dialogue and

its potential usefulness for conducting clinical work. Aspects of the perceived therapist-

patient match or “goodness of fit” were also explored through interview questions. Based

on findings in prior work, ongoing internalization of the personal therapy relationship is

seen as an important developmental process with lasting implications for the therapist-

patient’s professional conduct o f psychotherapy.

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Theoretical Assumptions and Research Questions

Statement of Learning Goals

The investigator’s interest was to learn more about how reported benefits and risks

o f psychotherapists’ personal therapy are related to its perceived influence on conducting

their professional work. Also, how does the reported level of overall effectiveness of

personal therapy affect its reported influence in the conduct of psychotherapy? This

investigator found a body of literature suggesting that specific aspects of personal therapy

are valued by psychotherapist-patients, while other aspects are viewed as potentially

negative or riskier. This study was designed to confirm or disconfirm previously reported

findings about benefits and risks of psychotherapists’ personal therapy, especially given

that these have not been systematically compared with the perceived influences of

psychotherapists’ personal therapy on their professional conduct of psychotherapy.

The literature also suggests that complex but nonspecific “process” variables may

influence how psychotherapists perceive their personal therapy. These processes include

various aspects of the interpersonal relationship between therapist-patients and their

psychotherapists and continued posttermination psychological involvement with the

former therapist. This study compared the level of reported influence of the participants’

personal therapy on conducting psychotherapy with perceived benefits and risks of

personal therapy, with perceived overall effectiveness of personal therapy, and with

perceptions of the interpersonal relationship with their therapist.

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The Philosophy of Science Employed in the Study

In articulating the philosophy of science from which this study emanates, the

author finds several tenets o f “fallibilistic realism” relevant. This philosophy incorporates

the critiques of logical positivism without abandoning entirely the concept of “knowable

reality” (Anastas, 1994). Fallibilistic realism is a model of science that emphasizes the

complexity of the actual research situation and views the relationships between data and

concepts as reciprocal. The personal and theoretical lenses through which the researcher

views reality and theory, and the impingements of the social context onto the research

enterprise, are considered important in this model of science. Both description and

explanation are the purposes of this approach. The central goal is to describe how

phenomena react or change in the presence or absence of other specific elements in an

open system.

Development of Research Questions

This researcher conducted in-depth interviews with psychotherapists to assess

three related issues: (1) how therapists perceive the benefits and risks of their personal

therapy experience; (2) how therapists perceive their interpersonal relationship and their

posttermination psychological involvement with the former treater; and (3) how these

perceptions compare with their perceptions about the influence of their personal therapy

on conducting psychotherapy. Although there are obvious limitations in using therapist-

patients’ subjective accounts alone as a measure of outcome, these data are central to any

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62

meaningful understanding of exactly what it is that intensive psychotherapy does in the

way of effecting personal and professional change.

Within the reviewed literature, certain central themes emerged. In general,

psychotherapists have reported that their personal therapy has helped them in the

following ways:

1. Enhanced self-understanding and self-awareness.


2. Enhanced self-esteem and self-confidence.
3. Improved interpersonal relationships.
4. Enhanced therapeutic skills (empathy, in using countertransference, in
structuring their treatment, in understanding the process of psychotherapy).
5. Reduced characterological conflicts and enhanced symptom alleviation.

Likewise, certain risks o f personal therapy have been identified as:

1. Stress and psychological distress.


2. Related to alliance problems.
3. Related to treatment errors.
4. Related to over or underidentification with therapist.
5. Blocked therapeutic effectiveness due to role confusion (being both patient and
therapist, concurrently, in training).

The themes o f reported influences of personal psychotherapy on the conduct of

psychotherapy that were reported in the literature include:

1. Different activity, verbal level.


2. Different way of dealing with countertransference.
3. Therapist as role model.
4. Functions o f therapist as mentor-introject.

The present study compared the perceptions of practicing psychotherapists with

the literature model in order to determine the relative congruence or incongruence with

the model, to determine relationships within the various areas of the model, and to account

for possible variations in participants’ experience within the model elements by comparing

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63

them with the perceived influences on conducting psychotherapy. This was done by

seeking to advance an understanding of the following questions:

1. Will particular themes of benefits, risks, and relationship variables be associated

with particular reported influences of personal therapy on their clinical work?

2. Will therapists who report more particular benefits and fewer specific risks in

their personal therapy also report greater influence of their personal therapy on their

conduct o f psychotherapy than will therapists who report fewer specific benefits and more

specific risks in their personal therapy?

3. Will therapists who report higher overall effectiveness of their personal therapy

report greater influence of their personal therapy on their conduct o f psychotherapy than

will therapists reporting less overall effectiveness of their personal therapy?

4. Will therapists who report having experienced an interpersonally highly

significant relationship with their own therapist also report more particular benefits, fewer

risks, and a higher level of perceived influence of personal therapy on their conduct of

therapy, compared with those who report an interpersonally less significant relationship?

5. Will therapists who report more evidence of continued posttermination

psychological involvement with their therapist report more particular benefits, more risks,

and higher levels of perceived influence of personal therapy on the conduct of therapy than

will those who report less evidence of continued posttermination psychological

involvement?

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C h a pter m
R e s e a r c h D esig n a n d S a m p l e

Methodological Assumptions

This study combined aspects of a concept-driven, deductive method of data

collection with a flexible method o f data analysis, in order to study emerging data not

encompassed in the conceptual model derived from the literature. Flexible method

research is used both for verification of theory and for attempting to generate new

“theory” about a topic.

Qualitative approaches are advantageous for studying subjectively experienced

phenomena, such as a person’s experience of his or her psychotherapy process.

A prevailing ideology in psychotherapy research has prejudiced the acceptance of studies

o f this type, under the guise of “external validity.” Several studies (e.g., Beutler &

Mitchell, 1981) have discerned that therapists’ self-reports of behavior do not correlate

well with outside observers’ ratings of activity. The preponderance of research has gone to

external observation, rating, and coding of therapist behavior. Although this approach has

considerable merit, psychotherapists’ phenomenology should not be so easily dismissed.

Imposed, externally defined dimensions of therapist behavior may say more about the

researcher’s phenomenology than about the clinician’s experience. Moreover, externally

generated behavior may be considered irrelevant by participants (Bern & Allen, 1974).

The question of “valid” therapist behavior is not simply an empirical one; rather, it is a

deeply personal and philosophical issue concerning “reality” and perceived meaning

64

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65

(Wogan & Norcross, 1985). Although qualitative modes are no better at dealing with

complex questions o f validity and reliability than are other modes, they do provide space

within a fairly defined structure for in-depth exploration of the significance of personal

psychotherapy for professional practice. When analyzed collectively through the

identification o f themes, such explorations may deepen our understanding of the potential

connections between these variables.

In summary, the goals of the research called for a deductive study, using a fixed set

of questions that still left room for the discovery of new findings. This study drew on the

literature for a model against which to compare study findings. Such a theoretical model

provided a schema against which data were analyzed and interpreted. In addition, the

study used a flexible approach to summarize and code findings within each area of the

study and then compared them with levels of perceived influence o f personal therapy on

the conduct o f psychotherapy.

Sample Selection

The study was limited to therapists who have engaged in, and currently conduct,

psychodynamically oriented individual psychotherapy, given the theoretical importance

paid to the therapist-patient relationship as a vehicle for change in this kind of therapy.

Sustained focus on the treatment relationship is not emphasized in other theories of

psychotherapy, such as systems or behavioral treatments, and hence was beyond the scope

of this study.

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66

The sample for the study included professional staff at The Menninger Clinic in

Topeka, Kansas, and other licensed psychotherapists in the local community who met

selection criteria and were willing to participate. By professional affiliation, participants

included psychoanalysts affiliated with the Topeka Institute for Psychoanalysis and

psychodynamically oriented psychiatrists, psychologists, and clinical social workers.

All participants were licensed therapists who met the following inclusion criteria:

(1) have practiced individual psychotherapy for at least 5 years, in order to report a well-

grounded experience of themselves as psychotherapists; (2) have concluded a personal

psychodynamic psychotherapy or psychoanalysis process at some point in their lives; and

(3) have identified a significant part of their professional work as providing individual

psychotherapy or psychoanalysis to adults.

Sample Size

The researcher planned to conduct a single in-depth interview with 20 to 24

therapists, depending on the variability of their individual responses. Relying on a principle

of flexible method research, the researcher determined that, after interviewing

20 participants, the variation in their responses was sufficiently broad as to likely yield

little new information by continuing to interview more participants.

Sampling Techniques

Given the variability in training among the three mental health professions sampled,

it seemed vital to include a roughly equal number of members from each discipline in this

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67

nonrandom sample, as a dimension of sampling on the basis of concepts that have proven

theoretical relevance.

With only 20 participants, purposely stratifying the sample by length of time in

personal therapy and clinical practice was not feasible. The literature indicated that time

since termination is a variable that affects a therapist’s perceptions of its influence

(Kantrowitz, 1990). These differences were limited by interviewing only therapists who

had terminated their personal therapy, and only therapists with a minimum of 5 years

postgraduation experience. This approach focused on better understanding the long-term

influences that personal psychotherapy casts on professional functioning. The investigator

hoped to interview a significant number of therapists 5 to 10 years posttermination from

personal therapy, since the literature indicates that this is a crucial time for internalizing

the therapy (Kantrowitz, 1990). By happenstance, half the study sample fell into this

posttermination time range. In the final stage of the data analysis, their responses were

compared with those of the other respondents.

Since many participants had sought multiple psychotherapies, their most recent

psychotherapy or psychoanalysis received the primary focus. This decision was based on

findings from a pilot study conducted by this researcher in which the cumulative “effects”

of the participants’ multiple therapy processes were available for recall by focusing on the

current or most recent therapy.

To strengthen the trustworthiness of the study, the investigator looked for

disconfirming evidence for the model by asking in the interviews whether the questions

captured what was essential in the participants’ personal therapy and what other

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68

significant aspects o f their personal treatment were not addressed in the interview.

Considering that the literature findings reveal that 20% o f therapists report some degree of

harm from their personal treatment (Buckley, 1981), it was deemed important to interview

some psychotherapists who reported specific risks and negative effects of their treatment,

as well as to interview therapists who believe that their personal therapy has had little

influence on their practice of psychotherapy.

Method for Securing Data

Prospective participants were therapists listed as providing individual outpatient

psychotherapy or psychoanalysis at The Menninger Clinic, or those in the Topeka

community who were so identified through their local telephone directory listing.

On completion of the Institutional Review Board approval process at Menninger, the

researcher sent 18 o f the randomly chosen prospective participants (6 from each of the

3 professions being studied) a letter of introduction (Appendix A). Included was a

response form to the initial contact letter (Appendix B) and a self-addressed, stamped

envelope. If an affirmative response was returned, the prospective participant was

contacted by telephone, at which time the researcher further described the study,

confirmed its purpose and nature, and answered any questions. If the prospective

participant met the study criteria and remained willing to participate, a specific

appointment for an interview was scheduled. A written explanation of the study was given

at the actual interview (Appendix C), as well as a copy of the informed consent form

(Appendix D), which both the participant and researcher signed. This process allowed

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69

time for any uncertainties to be resolved so that consent was truly informed. In all,

54 prospective therapists were contacted about participating in the study in order to obtain

the 20 participants who were interviewed. Five therapists expressed an interest in

participating, but did not meet the study criteria, and another agreed to participate, but

then was repeatedly unavailable. Two therapists wrote to express regret in declining

participation, citing their dual relationship with the dissertation adviser, which created

confidentiality concerns for them. Hence, 27 therapists did not respond to the initial

contact letter.

The researcher conducted one semistructured, audiotaped interview with each

participant at a site convenient to both, usually the office of the participant or researcher.

Several participants preferred to be interviewed in their home, given their need to do so

after working hours. After the confidentiality and informed consent issues were discussed,

the investigator asked each participant information about their years of postgraduate

clinical practice experience, their current weekly hours conducting individual

psychotherapy, and their own treatment histoiy (i.e., number of discrete treatments,

approximate hours in personal therapy, and amount o f time posttermination from their

most recent treatment) (Appendix E). The interview questions (Appendix F), developed

over the course of the pilot study and review of the literature, were then employed. The

length of the interviews averaged about 90 minutes, and ranged from 1 hour to 2.5 hours.

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70

Pilot Study

To determine the feasibility of this study, a pilot study was conducted earlier

by this researcher, who interviewed 11 psychodynamically oriented psychotherapists.

Specifically, its purpose was to determine whether psychotherapists would be willing

to candidly share, through an in-depth interview, their experiences of personal therapy?

Given the highly personal nature of the study questions, would the narrative accounts

enable the researcher to examine influential aspects of their personal treatment

experiences? Would the content of the interviews point to identifiable themes? Conducting

the pilot study helped to determine what kind o f coding methodology might be appropriate

as well. Early interview questions for the pilot study were less structured, to assist subjects

in describing their “lived experience” of psychotherapy. Participants in the pilot study both

appeared and reported feeling at ease, and were candid in sharing their personal

experiences.

Results of Pilot Study

Themes that emerged as important to pilot study respondents in their personal

therapy included the structural aspects of the treatment, such as time management, and the

availability, reliability, and predictability of the analytic environment. Technique-related

aspects, such as the timing of interventions and the perceived responsiveness and

involvement o f the therapist, were valued, as was the communication o f accurate empathy

in supporting self-esteem. Enhancement of personal self-confidence and competency was

also valued as a benefit of personal therapy by the pilot study respondents.

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71

How the therapist’s mistakes were dealt with and how the inevitable

misunderstandings in the dyadic relationship were worked through was significant.

The respondents valued seeing their therapist as “someone who owned her mistakes,” or

as being “a real person who let his vulnerability show.” The pilot study raised questions

about the conditions under which therapists’ mistakes have proven harmful to the

participant and his or her clinical work, or are used to promote psychological growth.

The importance of the interpersonal relationship with the treater was noted.

It often contributed to a deepened understanding of transference and countertransference

phenomena. Also prevalent as an important aspect of the interpersonal relationship was

the valuing of spontaneity, flexibility, and even departure from strict analytic technique

by the respondent’s therapist.

Aspects of identifying with the therapist as a mentor to be at times imitated, to be

differentiated from, and with whom to compare oneself as a therapist also emerged in the

pilot data. Prior therapy deemed unsatisfactory by participants provided a negative model

with which participants apparently dis-identified in their professional conduct. These

themes were further probed in the subsequent study.

Developing the Interview Questions

The pilot study and the model elements described in prior cited work were used to

develop the following interview format. The researcher asked the first question and

allowed the participant to respond fully before inquiring about the specific elements of that

part o f the model. This format was used for the second and third areas of the model as

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72

well. The specific questions asked are presented in Appendix F. The questions used to

explore the areas of benefits and risks are straightforward, and therefore do not require

explanation here. Two questions about the perceived overall effectiveness of personal

therapy were included as global appraisals of the value o f personal therapy. These

questions also replicated those asked in studies reported in the literature (Kantrowitz,

1990; Mackey, 1994; Shapiro, 1976). Questions in the third area, about influences of

personal therapy on conducting therapy, reflect some elements of the findings of prior

studies, and in addition asked about aspects of role modeling and introjection or imitation,

which have not been well studied. What kinds of responses would be generated by these

questions, or how they actually would reflect the model elements that they sought to

probe, was unclear at the outset. The final set of five questions inquired about continued

psychological involvement and the perceived interpersonal relationship with the personal

therapist. The review of prior work and the author’s own pilot study findings suggested

these two processes as being explanatory for some of the variations in the participants’

perceptions of the benefits, risks, and reported influences or uses of personal therapy in

conducting psychotherapy.

Ethical Issues

Several ethical issues were deemed important to consider from the initial stage of

this project. According to principles outlined in the Code o f Ethics o f the National

Association o f Social Workers Pertaining to Research and Knowledge Development

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73

(1990), relevant issues include potential harm to subjects, limits of confidentiality, and the

recording or maintenance o f data.

Participants in this study typically would not be considered a vulnerable

population, given their level of professional education or training, socioeconomic status,

and overall psychological strengths requisite of those providing psychotherapy services to

others. However, they were asked to reflect on personal therapy experiences that

potentially could provoke painful psychological material. The researcher’s sensitivity to

this potential distress and respect for the autonomy o f the individuals being interviewed

was one safeguard against any untoward psychological distress. As described in the

consent form (Appendix D), subjects had the right to refuse to answer specific questions,

the right to end the interview at any point, and/or the right to retract consent to participate

in the study.-These issues were discussed during the initial telephone contact and again at

the beginning o f the interview.

Protection of the privacy of subjects was safeguarded by not interviewing subjects

who were involved in close relationships with this researcher or her dissertation adviser.

In addition, the identity o f subjects has been, and will continue to be, disguised in all

written and oral presentations of findings.

The researcher also informed potential participants prior to scheduling an interview

that the on-site dissertation adviser, with whom carefully disguised interview data would

be discussed, was Donald B. Colson, Ph.D. This was deemed especially important as

Dr. Colson served as Chief of Psychology at Menninger at that time. This approach

addressed the potentially varying interests of the participants and the researcher, given the

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need to discuss the unfolding data with the advisor, as well as to inform participants of this

limitation on confidentiality.

Participants also were asked for permission to audiotape the interview. Transcripts

of interview data were typed by one of two clinical research transcriptionists, hired by the

researcher, who were experienced with confidentiality standards in clinical research. Their

identities were told to the participants prior to the interview, in order to ensure that the

participant did not know the transcriptionist, so that voice recognition on the tape would

not compromise their confidentiality. Once the recording of an interview began, the

researcher did not address the participant by name. Materials were securely stored in the

researcher’s home office in locked files. On all transcripts, participants were identified by

an assigned number rather than by name or initials, in order to further protect anonymity.

Data Analysis Procedures

As in most flexible method studies, the proposed data analysis procedures and

those actually executed were in some variance. In an attempt to best describe and compare

the nature o f the findings as they unfolded, the researcher made some modifications in the

plan. The proposed plan called for three aspects of data analysis, which included:

(1) comparing the study sample with the model from the literature for thematic relevance;

(2) describing which themes of reported benefits and risks relate to reported influences on

personal therapy in conducting psychotherapy; and (3) explaining how reported benefits,

risks, and influences o f personal therapy on professional functioning relate to various

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aspects of the interpersonal relationship and to continued posttermination involvement

with one’s therapist.

The implementation o f the actual data analysis involved first identifying and

categorizing themes in the narrative data of each participant’s responses. These categories

o f themes and subthemes were organized by aggregating the responses of every

participant for each of the 27 questions on the interview schedule. Included in this

summary are quotations from the participants that illustrate those themes. This process

was followed by the second phase of the data analysis, which entailed mapping and

counting the number of subjects who responded that a particular theme was relevant.

These data were displayed in the form of a data matrix outline (see Appendix I). Each

participant’s responses in the major categories of each interview question were recorded

and displayed for each of the four domains (perceived benefits, risks, influence on

professional conduct, and interpersonal relationship).

Considering that the primary goal of the research was to better understand the

influences o f personal therapy on therapists’ clinical practice, the final stage o f the data

analysis involved comparing the individual results in this area of inquiry with the other

three areas o f the study: benefits, risks, and interpersonal relationship. In looking at the

individual questions in this third area of the model and at the aggregate responses of

participants, the investigator decided to rank the participants’ reported influence of

personal treatment on clinical work into high-level, middle-level, and low-level groups

(see Appendix G). A comparison was then made by looking for patterns of association

between the three groups’ responses in each of the other areas (perceived benefits, risks,

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76

and interpersonal relationship). This comparison created a composite picture o f the

variations between the perceived benefits, risks, and interpersonal relationship for group

members at the three levels of perceived influence, which made up the third and final

phase of the data analysis. The goal here was to identify and summarize differences in the

various levels of influence that emerged in the responses of members. A summary of these

findings is then reported as integrated responses in each of the four domains. This

summary is followed by a visual display in chart form of the variations between the levels-

of-influence group in each domain. Conclusions of this phase o f the data analysis are then

presented.

The presentation of findings ends with a description of two unanticipated themes

that emerged from the data, followed by an effort to contextualize the findings by

presenting variations in the study participants’ years of clinical experience, professional

affiliation, and personal treatment history, compared with the level o f perceived influence

of personal therapy on their conduct of psychotherapy.

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C h a p t e r IV
F in d in g s

Data Analysis: Phase 1


Identifying and Categorizing Themes in the Narrative Data

The first phase o f the data analysis involved identifying and categorizing the

aggregate responses for each of 27 questions on the interview schedule. Eveiy response

from each participant was reviewed and themes were identified and organized according

to patterns o f response. The patterns of response for each question are presented with

selected verbatim narrative data that support the development of the categories and

themes. During this process, the researcher recorded the participants’ code number, in

order to map each participant’s specific response categories. These code numbers have

been removed from the first phase of the data presentation, to facilitate reading the

document.

The interview began with an open-ended exploratory question about the benefits

of personal therapy. The responses were deemed to merit particular weight, since they

were provided before the interviewer probed the specific categorical questions. Thus, it is

believed that these responses were less likely to be influenced by what the participant

perceived as a desirable response. For this reason, more space is given to responses on the

first question, as well as to the one other similarly structured question that introduced the

perceived risks section of the interview. The percentages of respondents who mentioned

particular themes of benefits in the first question were calculated and are displayed.

77

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Participants’ responses to open-ended question 1. (Please describe w hat has

been beneficial to you in your personal therapy or analysis?) were categorized into

the following themes, followed by the percentages o f respondents who spontaneously

addressed each category:

1. Enhanced self-understanding and self-awareness (55%)

2. Enhanced separation-individuation related to family of origin (40%)

3. Improved interpersonal relationships with contemporaries, including intimate

relationships (40%)

4. Symptom alleviation (40%)

5. Enhancement o f professional work with patients (35%)

6. Improved self-esteem and self-acceptance (30%)

7. The importance of the interpersonal relationship with one’s analyst (20%)

8. Initial treatment unhelpful, subsequent treatment sought (10%)

Responses to this initial open-ended question were organized into the above themes and

are further described below:

Enhanced Self-Understanding and Self-Awareness

Responses related to enhanced self-understanding included comments describing a

gradual growth in introspection and self-awareness, such as: “I valued the opportunity to

examine my inner world and workings for a period of time in a very regular way,” and

“It helped me trust my ability to be introspective and I became much more comfortable

with my inner feelings.”

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Perceived growth in self-understanding revealed implications for understanding

others differently in one participant’s statement: “I gained a deeper awareness of how

powerfully issues affect people’s lives, through my own experience. And I know that

everybody else is also under the sway of the kinds of matters that I discovered within

myself.”

The view that self-understanding is relatively situated, in an existential sense, is

reflected in one participant’s response that he was left “with the sense being reinforced

that most o f the time, we live in the questions and not the answers.” He implied, however,

that his analysis has left him feeling more comfortable in living with these uncertainties.

Enhanced Separation-Individuation Related to Family o f Origin

Spontaneous responses related to parent-child separation-individuation themes

were organized into two subgroups. Three participants spoke of their adaptation to

traumatic separation and loss of one or both parents in childhood, due to illness or death.

Each o f these participants described themselves as being resilient in their capacity to elicit

care from substitute caretakers. This group seemed to value their analytic experience as a

place to rework the meanings and impact of such profound childhood loss. The second

group, reared in intact families, spoke of “coming to terms with who my parents are and

who I am because of the family I came from.” Several of these participants described

having unresolved emotional issues that trace back to their family of origin and are an

indelible part of who they are and how they relate. Two respondents referred to “oedipal

conflicts” in competitive struggles with their same-sex parent during separation in late

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adolescence and early adulthood. Both spontaneously offered that their analysis helped

them find new solutions through which to experience their competency as adults, both

similar to, and yet different from, their parent.

Improved Interpersonal Relationships

The capacity for relating differently to others, which has generally enhanced their

interpersonal relationships, was spontaneously noted by seven participants in the open-

ended question about the global benefits of psychotherapy. One participant noted that,

“As a result of the process, I experience myself differently and I relate differently, not just

as a professional, but as a human being. The most important aspect was I learned how to

be in a relationship in a different way that has profoundly affected the way I relate to

people now.”

The perception that their personal therapy enhanced their interpersonal

relationships was described by participants in terms of deepening both their capacity for

commitment and their tolerance for the humanness of others. Several participants noted

their prior struggles to make commitments in intimate relationships, while one quipped

that his spouse tells him he is a better partner since his analysis. This same participant

observed that analysis has helped him become “more tolerant of people and not just o f

patients.” Finally, another participant noted that having worked on dynamic issues related

to her relationship with her parents has had a lasting impact on her interpersonal

relationships, with both men and women. She then noted that she “tends to expect or

allow imperfection or humanity much more in relationships” than she used to.

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Symptom Alleviation

Approximately half the participants mentioned a reduction in symptomatology as

a benefit of their personal therapy. Their symptoms included fairly severe depression,

generalized anxiety and guilt, obsessiveness, self-consciousness and anger. In the group

of 8 who mentioned benefits o f symptom reduction, 4 participants noted that they entered

personal analysis in large part because of depression, anxiety, or guilt, and the remaining

4 expressed pleasant surprise in noticing well into, or after their, analysis that their

presenting symptoms had abated. One participant explained, “I realized after termination

that a lot o f nervous habits I’d had had disappeared.”

Enhancement of Clinical Work with Patients

Seven participants spontaneously spoke o f the beneficial influences of their

personal therapy on their clinical work with patients. One participant noted that therapy

was close to the best thing she has done for herself and one of the best things she has done

for her patients. Another participant who noted the ongoing influence of his treatment on

his clinical work commented that he continues to use the analysis, that is, he can think

about himself with certain skills and techniques that he learned there and continues to use

now.

Several participants also mentioned enhanced awareness and attunement to

multiple levels of the treatment process with their patients as a benefit of personal therapy.

One participant noted:

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It’s made me much sharper as a treater, because I do have a grasp of the process,
of how things that you cannot be aware of are still very much a part of your life
and propelling you and get played out in relationships and in transference. I know
from firsthand experience and can extrapolate from that and pick up on things
much more astutely and quickly in relating with people, as well as working with
patients. I’m much more aware o f the implications of seemingly insignificant
behaviors in general. I hear metaphor and can conceptualize it more immediately to
implications for levels of functioning and personality organizations, for better or
worse, with friends, family, and with patients.

The value of engaging in personal therapy concurrently with their clinical training

was mentioned by two participants in response to the initial question about general

benefits. One participant noted the value of “engaging in a lot of work with patients

concurrently, having a chance to see how that was resonating. It helped me examine, in

vivo, what was happening to me in response to patients.” Another participant observed

that the dual roles of her analyst, who also taught in her clinical training program,

encouraged her to bring her clinical cases into their analytic work. She noted that she

“learned a lot o f theory and didactic stuff as well, within the context of the analytic

relationship.”

Improved Self-Esteem and Self-Acceptance

Improvements in self-esteem were described by three participants in such

comments as: “Generally, I felt better about myself. My perception of who I am and what

I am capable of is probably what’s changed the m ost. . . my own self-view, self-concept,

changed in that I learned to like myself, and that wasn’t any small achievement.” The

notions o f feeling both better about oneself and more confident about one’s capabilities

can also be seen in a participant’s comments that her analysis helped her “learn not to be

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so scared and get much more sense of my own competence. Toward the end o f my

analysis, I had a much stronger sense of really trusting myself, listening to what I felt and

believing it and going with it.” She noted that this self-confidence was particularly true of

her clinical work.

Enhanced self-acceptance as a perceived benefit is reflected in several participants’

expressions o f progressively viewing themselves as “good enough” and feeling entitled to

be how they are. One participant noted being “more comfortable with who I am, not

feeling like I should try to be different or that I shouldn’t have particular feelings, feeling

more self-acceptance, and feeling more entitled to whatever I feel.” With enhanced self­

acceptance came an increased capacity for self-comforting, as one participant explained:

Because o f a lot o f premature losses early in life, from the analysis, I came to feel
not so alone because I became my own friend in a way I hadn’t been before . ..
I came to accept and view myself in a way I hadn’t before, through his acceptance.
So I’ve had an inner peace since my analysis that I never had before, which is
invaluable, and this feeling has grown since we terminated.

Enhanced self-acceptance can also be heard in the comment made by one participant who,

with therapy, became increasingly aware of the harshness of his “superego”: “It

tremendously reduced my self-criticism, which I was not aware was even there. I had no

idea that I was talking that way to myself, treating myself so critically.”

Benefits of the Relationship with One’s Analyst or Therapist

Four participants mentioned the relationship with their analyst or therapist as a

valuable benefit o f their treatment. Two of them, both men, described the importance of

developing a close relationship with a man, in light of their early father loss or a strained

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and distant relationship with their father. Both noted this as an “educational” benefit of

their treatment. Their references to being taught related primarily to the help they received

from their analyst in learning, first, about being a competent man, and second, about

becoming a competent psychotherapist. Hence, the analyst as a model for gender-role

identification was relevant to these participants, both of whom had experienced early

parental object loss. The importance of such closeness and containment is revealed in this

participant’s initial description o f his relationship with his analyst:

My analyst and I had a funny relationship. He was helpful to me, a sort of father
figure. We had quite a bit o f postanalytic contact. He liked me and was surprised
by the fact that I had the capacity to regress deeply and then pull myself together
quickly. I was able to make good use of the process because I felt contained by
him. In fact, it was his work with me that made me feel confident in myself. The
containing or holding environment is very important.

Another participant noted the importance of being treated like a colleague in his

second analysis, which was very reinforcing to his self-esteem and professional

competence. Unfortunately, he had had a different experience in his first analytic

encounter.

Finally, another participant who offered comments specifically related to her

relationship with her analyst emphasized the value of the unique intimacy of the analytic

relationship, noting:

Though it cleared up a lot of conflicts, what I most value about my experience was
and is the relationship. I don’t think I’ve ever experienced the level of intimacy
with another human being that I did with my analyst. That can be a double-edged
sword, because I longed for that in other relationships and it’s possible to have, but
this was a very unique kind.

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Initial Treatm ent Not Helpful, Subsequent Treatm ent Sought

Two participants noted that their first psychoanalysis was not helpful. One sought

a subsequent analysis, which proved highly satisfactory and contributed favorably to his

own career path as an analyst. He said that he felt his first analyst didn’t like him and that

he felt quite differently with the second one. The other participant who spontaneously

reported that his psychoanalysis was not helpful noted that his analyst not only

underdiagnosed him, but also was “struggling, too; I felt I had to take care of him. He had

political problems in the institution and this felt to me like a traumatic reenactment of my

own parents’ intense marital conflicts.”

In summary, the participants in this study responded to the initial open-ended

question about the general benefits of their personal therapy with accounts that were

highly congruent with the model developed from reviewing the literature. The various

categories are valued very similarly, with the exception that symptom alleviation was

perceived as a more frequently mentioned benefit by this study sample than reported in the

literature. The significant addition to the model would be the study participants’

perception o f the relationship with their analyst or therapist as a beneficial aspect of

treatment unto itself, rather than viewing the treatment relationship merely as a means to

an end. These study results suggest the importance of the therapist’s therapist as a

continued “real object” for the participants, long after termination of the treatment

relationship.

Responses to question 1. a. (How useful was your therapy in enhancing your

awareness and understanding of yourself?) have been organized into the following five

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predominant subthemes related to enhanced self-awareness: (1) improved understanding

o f one’s psychodynamics: (a) based on understanding oneself in the context o f relatedness

with one’s original, infantile objects, and (b) based on perceived contemporary ego

functioning; (2) related to the relationship with the analyst; (3) regarding needs for both

connectedness and separateness of self and others; (4) regarding effects on one’s

professional development; and (5) concerning disappointments or limitations in the

enhancement of self-awareness.

The theme of reported improvements in self-understanding and self-awareness

related to understanding oneself in the context of early object, or familial, relationships

included responses by several participants. Exemplifying these were comments such as,

“My analysis reinforced my strong self-awareness and intuition, which had been stifled in

my growing up-I reclaimed part of me.”

Reported enhancement in self-understanding also was related to the participants’

self-reported contemporary ego functioning and appreciation of their dynamic intrapsychic

conflicts, defensive functioning, coping style, and adaptation to the demands o f reality.

One participant noted that it stimulated his curiosity about his dreams and he wondered

who he would have been without his analysis. He believed that he would be more action-

oriented and more prone to live “on the surface.” Another participant observed that, with

his increased self-awareness, he could see that he had coped with loss through looking for

stimulation or getting a little hypomanic.

Dynamic issues related to growing self-awareness about narcissistic vulnerabilities

was reflected in the comments of several participants, such as: “My analysis was too short.

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I wasn’t aware o f the extent o f my narcissistic problems, which left me with anger and

isolation as symptoms. I wish I’d have continued in the analysis, to work more o f that

out,” and “I became more aware of how reactive I can be to breaks in attunement to me,

to anticipation o f loss. That increased my observing ego and led to less reactivity to my

own dynamics.”

Closely related to the perceived changes in narcissistic vulnerabilities is the theme

o f increased competence, self-confidence, or self-esteem in response to the question about

increased self-awareness. Participants noted that analysis helped them feel more competent

and better able to think about their self-concept and problems with self-esteem.

A second subtheme o f response to the question about the usefulness of therapy in

enhancing self-awareness and self-understanding relates to the relationship with the

therapist and includes transference and identifications with the analyst. One of the two

participants who described at least one negative psychotherapy experience noted that he

and his last psychiatrist were a very good match and that it was a helpful treatment.

Another participant noted that he didn’t choose his analyst, however, he felt that he had

“lucked out” in getting the one he got.

Several respondents noted the importance of being able to develop a negative

transference to their analyst, as a painful but necessary part o f the work, evidenced by

such comments as: “I was surprised at my level of rage. My analyst wouldn't let me avoid

it in the transference work.” Another participant related: “I needed to and was able to

experience a negative transference in the analysis, which was unpleasant but necessary and

helpful.”

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Developing identifications with the analyst as a new object was observed in

comments by several participants. One noted that she developed some healthier

identifications with her mother and some new feminine identifications that her mother

doesn’t have. This participant recalled wanting her analyst to “put his foot down” on her

behalf with her mother by helping her learn to set limits with her mother, which he

wouldn’t do. But, she noted, he did “put his foot down in a different way with me

(in setting limits around self-disclosure of his personal life), and it hurt my feelings, but

now I see maybe it was helpful in helping me learn to set limits with my [intrusive]

mother.” Another participant noted that his analysis changed his “sense of self and perhaps

it has to do with identification with her [his analyst]. Perhaps, because o f my identification

with her, I could conceive of myself as a practicing mental health professional. So in that

sense, my psychotherapy changed my representations of myself in a major way.”

A third subtheme o f responses to the question about the usefulness of personal

therapy in enhancing self-awareness and self-understanding relates to autonomy and

relatedness in object relationships. On the side of promoting separation-individuation, one

participant noted that his analysis increased his autonomy and his ability to self-soothe

through self-analysis and through reading psychoanalytic theory: “I have continued to read

psychoanalytic theory and it has come much more alive for me. Bibliotherapy is part of my

ongoing self-analysis.” Another participant noted her sense of enhanced self-reliance

through learning how to carry out a procedure on herself. She observed:

I think I refined a model or a procedure for how you go about gaining insight.
It has to do with allowing myself to focus on a particular thought or affect, rather
than run away from it, to not be afraid of it. And to simply trace that affect or
thought back to the point where it started and then see what was happening in my

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life that would help me gain insight into it. And also to just let my mind free-
associate to the event that had triggered it to see where, in the past, I might be able
to get insight from other situations. And then to try and sort out how much of the
current affect was a realistic response to my current-day reality and how much of it
came from past things. And if it came from current day, what did I need to do to
rectify the situation? So I came to appreciate that emotions are really kind of
crucial messages I ’m sending myself and to think about them. This was
phenomenally powerful!

An example of relatedness can be found in the report of one participant who noted:

“I was already intuitive and this helped me put words to my experience and gave it some

validity. It was very powerful for me to be able to put words to my experience and then

not to feel isolated in my own narrow understanding of things.” Another participant

explained: “It gave me an introduction to the world of feelings and relationships and a

greater appreciation for subtleties.”

A fourth subtheme o f responses to inquiry about self-awareness and self-

understanding relates to the ongoing development of professional identity. Several

participants addressed this in their comments. One respondent noted that her enhanced

self-awareness has affected her clinical practice, “by helping me believe that everything

people do is understandable-there are reasons for what they feel and why they do what

they do.” Another participant noted feeling more self-aware and more differentiated with

her patients in her observation:

I became aware of my issues and hopefully more sensitive about not putting my
issues into my patients, being able to separate them-using my own experience to
understand them, but not putting my issues on them.

A third participant noted the usefulness of the self-understanding he gained from his

second analysis, particularly in his work with analytic patients:

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I think if I had tried to do analysis based on my first analytic experience, I would


have felt very little freedom. I experienced my second analyst as being comfortable
with being gentle and approving. He was a model of what I needed and what
I wanted and I think that that probably affected the way I work because I had very
little confidence in the way I worked. I thought I was too much of a pushover and
too softhearted. So it changed my whole view of myself as a therapist. I had been
doing better therapy than I realized. So it had a powerful affect on me. I feel best
about myself as a therapist in the last few years than I’ve ever felt before.

Finally, a fifth subtheme of responses to inquiry about the perceived significance of

enhanced self-understanding and self-awareness as a benefit of personal therapy relates to

limitations regarding this dimension, as noted by several participants. One participant said:

“it’s not perfect, there were some disappointments and a sense o f ‘unfinishedness,’ yet

both came at good stages of my life.” Another respondent reflected: “It didn’t change my

life profoundly, but it stirred things and helped me live deeper, and at a less superficial

level.”

In summary, the range o f responses to inquiry about perceived enhancement of

self-awareness and self-understanding stemming from personal therapy reflects several o f

the benefits reported in the model from the literature, particularly improved self-esteem,

improved interpersonal relationships, and enhanced therapeutic skills. The participants’

responses further emphasize the importance of the relationship with their analyst or

therapist as an identification figure and the analytic process as one promoting the

development o f enhanced separation-individuation, including through experiencing

negative transference reactions.

Responses to question 1. b. (How useful was your therapy in enhancing your

self-esteem and self-confidence?) fall into two categories-those who experienced their

self-esteem as being clearly enhanced by their therapy and those with mixed or equivocal

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responses. In both categories, responses reflect changes in both personal and professional

self-esteem and self-confidence. Numerous participants mentioned the therapeutic activity

of their treater, which promoted or hampered the development of their self-esteem and

self-confidence. The aggregate results of this question will be presented by category, with

reported personal and professional changes in self-esteem followed by perceived

therapeutic actions by the treater associated with these changes.

Over half the participants reported that their analysis or therapy had clearly

enhanced their self-esteem and self-confidence. Their responses reflect both enhanced

personal and professional self-esteem. Perceptions of improved self-confidence and self­

esteem in their personal life include such comments as, “My analyst’s confidence that

I could have a healthy relationship with a man was really important to me.”

Although several participants noted that their struggles with self-esteem remain

incompletely resolved, they nevertheless found their personal therapy to be quite helpful.

One participant noted:

I ’m still not what you’d call ‘Mr. Assertive,’ by any means. I ’m still very much
a quiet person and shy at times, but I am much more comfortable with myself.
So it really sparked my self-esteem in terms of catching myself being negative or
defeatist and saying, ‘Wait a second, I can do this,’ and do it. It made a big
difference.

Within the category o f those participants who felt positive about the benefits to

their self-esteem and self-confidence, seven identified perceived benefits to their

professional identity or clinical practice. Included in their responses were such comments

as, “I would have perceptions validated as making sense and my clinical work as being

solid, so that nudged me along in self-esteem.” Another participant observed that the

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benefits to his self-esteem were relative, considering where he had started, yet very

helpful: “From my personal history, issues of self-esteem and self-confidence are still

incompletely resolved. But the analysis was enormously useful in clarifying what the issues

were and helping me arrive at a better sense o f who am and of my right to be doing this

work and to be able to see it as valuable to other people.” One participant noted that she

went through several job promotions during her analysis and would play out whether it

was okay for mother, father, and analyst if she took each new step. She observed that her

analyst helped her contain her anxiety about her success and competition and helped her

deal with her fear of shame if she failed to win in the competition. Finally, one participant

very eloquently described her dilemmas with professional competence and what she

learned about herself in her analysis:

I can remember the minute I said in analysis, after I had just done a videotape with
a family and had to watch myself with my supervisor, then going into my analytic
hour, and feeling, ‘You know, she’s not perfect, but she’s okay.’ And it was a very
powerful thing to think, ‘I don’t have to be perfect to have something to
contribute; I don’t have to know everything to be helpfiil-that I know something
and that can be found by my patients in a way that is helpful.’ So my analysis
validated my self-confidence. One o f the things that I learned in my analysis that is
very powerful in my clinical work and I use a lot is that, if the standard that you’re
striving for is perfection, all that does is isolate you. And that, really, it’s by our
imperfections that we’re really allowed to connect. So when ‘good enough’ is
better than perfect, is the theme that I walked away with. It’s given me permission
to just be who I am and then I feel like I can turn around and try and help patients
do the same thing. You don’t have to be perfect to be lovable or accepted.

The therapist’s role in promoting personal self-esteem and self-confidence is a

theme that is reflected in numerous participants’ comments. One person noted that

“a couple of things in the therapy helped with my self-esteem. One was how he made me

feel, or the feeling I got. I just felt totally respected. I’d never experienced this feeling of

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incredible respect, with this person listening to you, concentrating on you. It was

amazing!”

Almost half the participants reported mixed or equivocal changes in their self­

esteem, which they associated with their personal therapy. One participant noted,

“My analysis was not very helpful to my self-esteem and self-confidence, although

I always kept a good sense of myself as a therapist somehow.” However, this participant

added that a later psychotherapy process had been quite helpful with his self-confidence.

Two participants, in particular, noted the benefits to their professional functioning with

their second treatment experience. One participant’s mixed responses reflected his

experience of a therapeutic mismatch with his first analyst, which left him feeling less self-

confident after his initial therapeutic analysis, but then he availed himself of a training

analysis, with much more positive results for his self-esteem. Another person whose

description falls into the mixed results category described his first analysis as helping him

reduce symptomatology and function better in some ways, but he noted that it was a very

frustrating process, followed by one that he felt supported his self-esteem:

There were things left undone [in the first analysis] and it didn’t have a traditional
termination phase, where I left feeling I had significantly resolved a lot of issues.
I thought it just petered out a bit toward the end, and I terminated because
I thought I couldn’t do more. Whereas my second analysis was very helpful,
because it focused so directly on issues of self-esteem and earlier narcissistic
injuries in childhood, and it gave me the courage to make a career change and to
go into clinical work, which I’ve enjoyed a great deal, and since it worked
specifically on that issue, it was very helpful.

Two other people in this mixed results group regarding self-esteem spoke of not having

much of a problem with self-esteem or self-confidence before their analysis yet, over time,

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94

seeing that it helped some of their self-perceptions about their confidence level to become

more realistic.

Finally, three participants noted mixed results for their self-esteem due to

limitations in the analytic process itself. One noted that her self-esteem eventually did

benefit but could have been helped much more quickly if her analyst had confronted,

rather than only explored her unrealistic and very burdening sense of responsibility for

others. She added that she plans to tell him this someday. Another participant noted his

own increased and unabating anxiety, confusion, and bewilderment throughout analysis,

by virtue o f doing something as difficult as “being forced to face your deepest fears.” He

added that he now thinks it was probably good for him, although it certainly shook his

self-confidence during the entire analysis. A third participant noted that while the analytic

process made him “more reflective, less action-oriented, and more receptive to looking at

things” in himself, he observed certain doctrinaire aspects of analysis. He reported,

“disdaining the analytic rigidity that mimics religion, the closed attitudes in buying only

into drive theory, for example. On the one hand, analysis can open you up, can enhance

your sense o f discovery of the patient. This participant appeared to develop self-

confidence in his professional convictions through differentiating his theoretical beliefs

from classical psychoanalytic drive theory, to which he felt his own analyst subscribed.

In summary, the range of responses to inquiry about perceived enhancement of

self-esteem and self-confidence associated with personal therapy reflects the participants’

varying capacities to acknowledge and work on their narcissistic vulnerabilities within the

context of their particular treatment relationship. Therapeutic action that was described as

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beneficial to self-esteem included the analyst’s ability to help contain anxiety about both

success and failure in issues related to competition, the patient’s experience o f being

respected by the analyst, helping the patient resolve unrealistic and defensive

perfectionistic strivings, technical aspects of analysis of resistance (such as the timing of

silence and interpretation), and the therapist’s perceived comfort and expertise in helping

the analysand work on painful issues related to early narcissistic injury. Limitations in the

therapeutic action that were associated with mixed results or unimprovement in reported

self-esteem and self-confidence include a perceived therapeutic mismatch, perceived

constraints in the analyst’s method or technique, including not structuring the termination

phase of treatment, and inherent limitations in the psychoanalytic process itself.

Responses to question 1. c. (How useful was your analysis or therapy in

improving your interpersonal relationships?) cluster into two broad groups: those for

whom personal therapy was perceived as clearly helpful to their interpersonal

relationships, and those for whom the implications for their relationships were more

complicated, with enhancement in some relationships but no clear improvement in others.

The “clearly improved” interpersonal relations group of responses is presented first,

followed by the “mixed results” group. Within both groups, specific themes are presented.

Over half the participants reported that their interpersonal relationships improved

with treatment. Their responses cluster in three thematic areas: (1) their own enhanced

capacity to form “healthy” relationships; (2) enhanced relations with significant others,

including family of origin, romantic or marital partnerships, and friendships; and

(3) enhanced professional relationships. Several respondents who perceived that their

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capacity to develop positive interpersonal relationships was enhanced by treatment

described themselves as less self-preoccupied, less self-referential, and better at listening.

Two believed their analyses made them “less superficial,” more introspective, and

reflective, which they viewed positively. Yet another participant noted that her analysis

helped her become less defensive about what was her responsibility and what was other

people’s responsibility in her interpersonal relationships.

Eight participants reported enhanced relationships with significant others, including

family-of-origin, romantic or marital relationships, and friendships. Their comments

included the following: “The quality of my friendships have changed as a result of my

analysis. It’s made a significant difference in my ability to approach my family members,

individually and collectively. I don’t think I ’d be as content with my family relationships as

I am, not having experienced the analysis.” Another commented, “I’m sure it’s made some

relationships richer, particularly relationships with other men.” A female participant noted,

“It was useful in helping me to clarify a lot of anger I’ve had in relationship to men and

with my father. . . and it helped me feel like I could have a relationship with a man and

stay clear about who I was.” Two male participants noted that during their analyses, they

finally extricated themselves from an “unhealthy” relationship and met the woman they

would later marry. Both these individuals described their marital relationship as rich and

fulfilling and credited their analytic work with helping them move into a committed

intimate relationship with a mature partner.

Two participants in the “clearly beneficial to interpersonal relationships” group

described examples of enhanced professional relationships. One observed that he became

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clearer about the senior analysts whom he admired and wanted to emulate and that he

cultivated mentoring relationships with them. He also became aware of who he did not

respect, “teachers that were too doctrinaire, too much like priests at the temple.” He

found his capacity to thus differentiate himself to be quite helpful overall to his

professional identity.

O f the eight participants reporting “mixed results” for their interpersonal

relationships, the responses o f the five female participants shared a common theme-that

their treatment helped them clarify the boundaries of their personal responsibility in

relationships. Two o f these women noted changes in their relationships generally, which

they eventually connected with changes in their relationship with their mother. One

participant noted:

What’s useful is that I don’t feel so much like I’m totally responsible for how a
relationship goes. So some of my relationships are improved and some o f them
aren’t, but I don’t see it as my total job to improve them. I think my relationship
with my mother is improved a lot. Partly because I’ve just accepted the fact that
she really is a difficult person and it’s not just me or our interaction, and I think in
large part I ’ve quit trying to make her into the kind of mother I might want, and
I think we’re just easier with each other this way.

Another participant noted that her therapy helped her a lot:

Yet there are some ways that it actually disenhanced my relationships . . . I think
I was a much nicer person before my analysis. I think that I am much more up
front with my aggression now. I tend not to welcome everybody into my life.
I guess I would say that I don’t try and please people as much, so I have deeper
friendships, but I don’t have as many people. I think I became a more assertive
daughter in a lot of w ays... . And I learned in my analysis that my mother has
more to lose by holding on too tight. I can leave and it’s made it a lot easier.

And, finally, another female participant noted her struggles with significant others during

her analysis:

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During the process of analysis, it probably was not terribly helpful. I went through
it being married, being a mother, dealing with parents going through elderly crises
and I think I was self-centered and irritable with the distractions of other people’s
issues. It was probably hard for them to understand my self-centeredness. In the
heat o f the analysis, for an extended period of time, I was less pleasant to spend
time with, to put it mildly. But, ultimately, I think my interpersonal relationships
were greatly enhanced. Having gone into the analysis realizing I was kind of angry
and guilt-ridden and kind of neurotic in a number of ways and resolving some of
that, I was less irritable and impatient and irrational in my relationships with other
people.

Two o f the three men in this group of “mixed responses” regarding interpersonal

relationships noted that their spouses encouraged them to seek analysis and supported the

results for their marital relationship. One noted, “At the time, I didn’t see that it had much

effect, but my wife would say it improved me a lot.” Another male participant noted:

“I think that is an area that is clearly improved. In some ways, interpersonal relationships

would be the clearest benefit, clearer than internal changes, like self-esteem. The

interpersonal relationship with my wife is clearly improved.” However, this same

participant went on to state:

A cost of going through an intensive psychotherapy process is that you don’t


suffer a lack o f insight in others, including your friends as well. If you feel your
friends are stuck, it’s very difficult to have the relationship continue for years and
years and if they don’t get into therapy for various reasons, your threshold for
friendships changes and is more exclusive, to a higher threshold, which makes it
a little harder to form close friendships.

Finally, the “mixed responses” of these participants include a theme of change in

professional relationships. A female participant noted: “I’m more direct in work situations.

I’m less fearful about telling people when I disagree. I don’t think I always do it with as

much equanimity as I would like. .. . I’m passionate, but I’m much more able to be direct

and care less about the outcome o f it.” A male participant noted that during his analysis,

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he had more conflicts with patients than before and that a number of patients didn’t want

to be treated by him, but that has changed in recent decades. He observed: “I think my

analysis helped me, that it had some significant effect on my capacity to establish a

therapeutic relationship with patients. And that’s one thing I emphasize now with

trainees-is the importance o f building a relationship with their patients. It’s more

important than getting rid of symptoms or other problems.”

The “mixed response” for interpersonal relationships group themes are thus

separable by gender, with women describing themselves as developing clearer boundaries

between self and other, and becoming less “people-pleasing.” Male respondents seemed to

be saying that they have become easier to get along with, especially in marriage, although

more discriminating in relationships generally. Reported changes in professional

relationships involved a sense of greater personal assertiveness, less anxiety about

disagreeing with others, and the view that establishing a therapeutic relationship is a

process that requires careful attention by the therapist.

In conclusion, the “clearly improved” relationships group described beneficial

changes in their capacity to form positive interpersonal relationships with implications for

relating to their significant others and in professional situations. Their responses focused

on feeling they had improved in their capacity to relate to others, which did not seem to

create interpersonal conflict for them. The “mixed response” group, however, noted that

their desired personal changes often met with opposition or created interpersonal conflict

for them, at least for a period o f time.

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Responses to question 1. d. (How useful was your therapy in enhancing your

therapeutic skills?) have been organized into three broad groups for presentation. The

groups include responses related to: (1) perceived changes in oneself that have

implications for one’s professional practice of psychotherapy, including greater conviction

and self-confidence as a therapist, greater self-acceptance, and a better capacity to help

patients work with issues similar to one’s own; (2) the importance of the interpersonal

relationship between therapist and patient, including “the real relationship,” transference,

and identification with the analyst or therapist; and (3) learning about the therapeutic

process, including structure, technique, and concurrent treatment and training.

Thirteen respondents noted changes in themselves as a consequence of their

personal therapy, which they perceived as having implications for their clinical practice.

Responses related to changes in oneself also addressed their perceived growth in

conviction and self-confidence as a therapist. These included one participant’s comment

that “My treatment increased my self-confidence to take a clear position o f hope with my

patients when I believe it, like my analyst did with me.” Another participant noted that her

analysis has helped her to trust her intuition and what she was learning, to think that she

“might have something to say or offer . .. feeling that there was something inside to be

able to give and it didn’t have to be perfectly tailor-made at the start. . . that there was a

way to connect with the patient and grapple with issues that was safe for both of you.”

Yet another participant noted that, through her analysis, she “learned, not just at an

empathy level, but also at an intellectual level, which led to a greater sense of conviction

that these phenomena-of resistance and transference-do exist. That they’re complex,

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powerful vehicles for change and also carry some danger for both parties involved.”

Another participant, who noted his analysis has changed how he thinks of himself,

observed that he is very good, in fact, a “crackeijack” with patients with poor self-esteem.

Perceived changes in oneself related to greater self-acceptance included comments

by nine participants. One participant noted: “My perfectionistic tendencies were enhanced

by my training institution . . . but, my analyst gave me permission to be myself.” Another

participant noted some personal things about her analyst that “made me realize that you

could be vulnerable and be a human being and also do very good clinical work, so I’ve

taken a self-acceptance o f my humanness from my analysis.”

Several participants observed that following their personal treatment, they felt

better able to help their patients with similarly conflictual issues. One participant noted:

The more I was able to explore about myself, the less fearful I’ve been about
exploring that [type of issue] with my patients. The more I ’m able to hear what
they’re saying about some things, [I can] get more deeply into it instead of staying
away from it.

Other participants noted the professional benefits of their personal therapeutic work on

specific issues related to shame, trauma, and issues related to loss and mourning and

instilling hope.

Numerous responses to the question, “How useful was your therapy in enhancing

your therapeutic skills?” spoke to the importance of the interpersonal relationship with the

treater. These included aspects of the “real relationship,” transference, and identification

with the analyst or therapist. By the “real relationship,” these respondents were referring

to “objective” qualities o f their treatment relationship, which they distinguished from

transference manifestations. At the core o f this distinction seemed to be the experience of

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being treated with genuine respect, based on common humanness. One participant noted:

“The experience o f the relationship has meant and made all the difference in the way

I practice-I’ve internalized my analyst and the relationship, but it’s automatic.” Another

participant observed, “What’s valuable comes from my analyst being real and it comes

from the heart.”

Almost half the participants noted their enhanced ability to work with transference

as a treater, which they attribute to their personal therapy. One participant observed,

“After you’ve been in analysis, you understand the power of regressive experience and

have an understanding of transference in a way you never could possibly understand if you

haven’t had that experience. And I think then you have an understanding of your patients

that nobody can teach you out of a book.” This belief was expressed by several others as

well. The capacity to better tolerate negative transference manifestations was expressed by

three participants. One participant observed:

It helped me tolerate anger and being hated. It’s made it possible for me to be
much more available to patients, that I don’t have to be warding off the negative
stuff in particular, which I think was hard for me to deal with.. . . I think that was
one difficult area for me, to really be able to tolerate and focus on and go after the
negative transference.

Another theme o f response related to the interpersonal relationship between

patient and therapist concerns identification with the analyst or therapist, which was

reported by seven participants. One noted, “I have identified with my therapist as a

thoughtful, rational person who is also comfortable with affect.” Another participant

observed, “For the first decade or so after my analysis, I could see that much of what I did

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was, in a way, a copy of what my analyst had done, more in terms o f attitude than

technique. I think that had a major impact in my relationship with patients.”

The third theme of responses to the question, “How useful was your therapy in

enhancing your therapeutic skills?” related to learning about the therapeutic process,

including structure, technique, and influences of concurrent treatment and clinical training.

Three fourths of the participants offered comments related to valuing learning about the

therapy process through their personal treatment. Many of them reflected on their growing

patience with, and trust in, the treatment process, a respect for the complexities of change,

and empathy for human struggles. One participant observed:

My analysis has certainly made me more empathic. It has helped me understand


people’s struggles when they didn’t seem reasonable. I knew there was a reason
for it, even though it didn’t look reasonable on the surface. And so I have a respect
for people’s struggles that I don’t think I had before.

Other comments that reflect learning about the treatment process from one’s personal

treatment include a participant’s observation of having gained an “increased appreciation

for the power of knowing somebody over time and of giving people room to react.”

Another aspect of learning about the psychotherapy process from one’s own

treatment relates to the structural aspects of the enterprise, such as the framework of the

setting, time management, and fee arrangements, all of which create the therapeutic

environment. Several participants commented on learning about the treatment structure

through their personal therapy. One participant observed that he has “internalized the fact

that this has to be a safe environment,” while noting his struggles to achieve such an

atmosphere with his patients despite the time pressures of managed health care dictating

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so much about treatment structure. Yet another participant critiqued the 50-minute time

frame of psychoanalytic treatment, stating:

What stands out most is in terms of structure. Analysts, including mine, believe
that everything happens in 50 minutes and that the work is never done. I also think
that not all work happens then and to finish a piece of work is important. So that’s
something very different than what I got in analysis, but I believe in that and it’s
affected how I work.

In contrast, another participant noted specific ways she practices that resemble her

analyst’s techniques with regard to structural aspects o f the treatment:

It continues to astound me how I have consciously identified, by little things I do-


the way I end the hour. I always say things like, ‘well, we need to leave it there.’
I call vacations ‘interruptions.’ I also go downstairs and greet my people, like he
did-I think it’s primarily an identification with him.

Half the participants addressed some aspect of treatment technique in their

response to the question about the usefulness of personal therapy in enhancing their

therapeutic skills. Their responses showed how they value the therapeutic activities of

listening and understanding, interpreting conflict and confronting defenses empathically,

and modeling thoughtful self-disclosure. One participant addressed several o f these points

in her response:

I found myself at times, in almost a humorous fashion, remembering when I was a


little girl and used to put my dad’s shoes on and put his tie around my neck and
walk around the house pretending like I was a business man. And I would have
that experience afier analytic sessions of leaving my own session, going to another
one and hearing the same words come out of my mouth that my analyst had said to
me and having that image in my mind of me in my daddy’s shoes, you know? So it
was kind o f a practicing, a modeling, in identification with him and what he was
doing, so I had the benefit of both my own immediate experience and my reflection
on my immediate experience and identifying with him, so both of them. So it
helped improve technique as well. And it helped me know I could be there without
being overwhelmed by it. ‘Oh, my God! I don’t know what to do. I don’t know
what this means!’ More caught up in my own experience o f not knowing how to

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make sense of my patient than to be able to say “I ’m understanding this and I will
understand it better, if I can listen and remain present.

Another participant observed the importance of feeling understood and communicating it

in her comments:

Where I learned the most is that I felt understood through his interpretations.
It used to make me cry sometimes when I felt understood. It was such a relief.
And it convinced me that understanding is where it’s at. Listening is 75% o f the
road and then 25% is communicating your understanding. So I really work hard to
understand what people are telling me, because it’s a gift that I want to be able to
give them back.

In learning about the technical aspects of interpretation from his analyst, one participant

noted:

My analyst would interpret things as both a resistance and an attempt to develop a


healthy ego, which helped me a great deal and that’s been very influential in my
work-I use that approach when I’m doing interpretive work, if I’m confronting.

With regard to learning about technical aspects of treatment from personal

therapy, participants described themselves as becoming more interested in understanding

intrapsychic conflict than in trying to control symptoms, more comfortable with their

patients’ disturbing feelings and behaviors, and more thoughtful about issues related to

self-disclosure with their patients based on the model of their own treater.

Four participants commented on the influences of concurrent professional training

and personal treatment, noting that while there are risks involved, their increased insight

about themselves and others, and their growing comfort with, and conviction about, the

value of the therapeutic process helped promote their ability as psychotherapists.

In summary, most of the study participants believed that their personal therapy

promoted their belief in the value of the therapeutic enterprise. They described it as giving

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them a firsthand experience with the power of the “humanness” o f the therapeutic

relationship, as the foundation of the change process. Although learning about

transference and treatment technique from one’s therapy process was valued as an

important aspect, it was subsumed in the larger context of the treatment relationship.

Responses to question 1. e. (How useful was your therapy in resolving

characterological issues and alleviating symptoms?) can be categorized into four

groups: (1) Those who found their treatment to be very helpful in alleviating both

symptoms and promoting significant character change; (2) Those who obtained symptom

alleviation, but only attenuation o f characterological issues; (3) Those who did not believe

they had symptoms per se, but noted positive changes in some character traits; and

(4) Those who did not observe any alleviation of symptoms or characterological change.

The group of seven participants who noted positive changes in both their

symptoms and character reported significant improvement in symptoms related to anxiety

and depression and in conflictual issues that included struggles with dependency and

perfectionism. One participant noted:

Before my analysis, I really had the deep-seated belief system that if I did
everything perfectly, if I was a “good-enough girl,” nothing bad would ever
happen, which left me with some anxiety kinds of symptoms. And when I finally
realized, on a gut level, this isn’t in my control and I will just do the best I can to
cope with whatever comes along and if something bad happens, it doesn’t mean
I did something wrong, this was very helpful in getting rid of some of my
underlying, free-floating anxiety.

Nine o f the participants described their personal treatment as helpful in alleviating

symptoms related to anxiety and depression, but resolution of characterological conflicts

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was described as “modified” or “neutralized and made more manageable,” rather than

resolved. One participant observed:

It was very useful, and consistent with a lot of what the research suggests. It’s not
that I am free now o f anxiety and guilt, but they are both somewhat less, because
I do believe, to some extent, conflicts that I had that created those feelings have
been muted. I don’t think they’re ever erased, but I think they’ve been muted.

Other participants in this group observed that traits such as being overresponsible for

others, overcontrolling, and perfectionistic were not resolved, but were instead modified

enough to help them realize when they enact these struggles now and so they can better

modulate them. They each offered some observation that analysis doesn’t turn anyone into

a different person, but instead it lessens vulnerability to one’s own defensive

symptomatology, which is helpful to clinical work. The third category of response found

in the data consists of the responses of two participants who believed that they didn’t have

symptoms as such but that, characterologically, their personal therapy helped them make

more creative and effective use of their aggression by rechanneling it and softening the

intolerant attributes of their character structure.

Finally, the fourth category consists of responses from two participants that reflect

a belief that neither symptoms nor character change occurred as a result o f their personal

treatment. One o f them regretted not being able to go deeply enough into the work so that

more character change was possible, and the other described his analysis as “the wrong

kind of psychosurgery for what ailed [him].”

In summary, over half the participants believed that their treatment helped alleviate

their symptoms, and all but two perceived their characterological conflicts as being

modified or attenuated, although not resolved, following personal therapy. Despite the

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overwhelmingly positive responses of these participants, symptom alleviation was

spontaneously mentioned fewer times than all but one other benefit noted in the initial

open-ended question about benefits of personal treatment, which is congruent with the

model from the literature.

Aggregate results of question 1. f. (Do any other benefits come to mind now

th a t haven’t been addressed?)

About half the participants offered additional thoughts. Their responses reflect

three themes: (1) valuing the treatment relationship and how it promotes change;

(2) gaining a more realistic perception of themselves and their significant relationships; and

(3) perceptions about termination and how “complete” they regard their personal analytic

work.

Five participants addressed the treatment relationship and its contribution to

psychological change. One stated, “I think the relationship with my analyst is probably the

most important in my life.” Another noted, “There is always that other voice in your life to

moderate or titrate situations . .. the message of the analysis and the things that were

helpful stay with you and you kind of step outside and consult with that.” Yet another

participant observed:

It’s quite clear that I’ve internalized her, that there’s a permanent internalization.
I don’t think there’s any question that there’s a soothing internalization and one
which is nice to go through life with, especially professional life, because it’s the
same work, where there’s a legitimizing of doing it.

Other participants observed that psychotherapy is about understanding and valuing the

subjective experience of the person “by wanting to hear their story” and that this is what

can help people change.

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A second theme, that of gaining a more realistic self-perception and a clearer

perception o f significant others, was described by two participants. One found that he had

developed “a real appreciation of the weaknesses and strengths” o f his parents and his

wife that led him to see his relationships in a clearer, more realistic way. Another observed

increased differentiation of herself from her mother’s life, noting her sense of “being

doomed to re-live [her] mother’s life.” She explained that her mother “was a very hard­

working woman who accomplished amazing things, yet could never allow herself an

appreciation of what she could do, instead viewing herself as a second-class citizen.” This

participant recalled her analyst’s helpful response that, unlike the participant, her mother

didn’t have a chance to think things through, to look at things, with help. This comment

gave the participant much hope that she could create something different for herself.

A third theme found in response to the question of additional benefits regarded

termination and the relative completeness of the treatment relationship. Four participants

addressed this concept, through such observations as, “He was much more planful of the

termination than other past treaters I ’ve had. He was attentive to dealing with the issues

that reemerged at termination.” Yet another respondent noted feeling “cleanly

terminated,” despite her analyst leaving the profession after their termination. The two

other respondents who commented about termination were uncertain about the

completeness o f their work, believing they terminated arbitrarily, which left them with the

unanswered question, “Am I done yet?” Both reported that they did not get clear feedback

from their treater about their readiness to end.

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In conclusion, almost half the respondents offered additional comments in

concluding the benefits section of the interview. They seemed to be left with thoughts

about their treatment relationship as an ongoing source of strength, with clearer

perceptions of themselves and their significant relationships, and with definite perceptions

about the relative completeness of their personal therapy.

Perceived Disappointments, Risks, or Negative Effects

As with the benefits questions, the respondents were first asked to describe any

general disappointments, risks, or negative effects of their personal therapy or analysis.

Their responses have been organized separately by “negative effects,” “risks,” and

“disappointments,” since virtually all participants specified which of these categories

characterized their experience. Only one of the 20 respondents described actual negative

effects of his analysis. Seven respondents described at least one perceived risk o f their

personal treatment and 14 described at least one disappointment in theirs. Responses will

be reported by themes and categorized subthemes of negative effects, perceived risks, and

perceived disappointments of personal therapy, in that order.

Perceived Negative Effects

The one respondent who perceived actual negative effects from his analysis related

that his analysis never came close to touching on his issues with alcohol abuse and his

resistance to honestly exposing his vulnerabilities. He believed that he had successfully

kept his addiction hidden from his analyst.

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Perceived Risks

Seven respondents described perceived risks of personal treatment. Subthemes

emerging in their responses included: anxiety related to completing the analysis; issues

about the relationship with the analyst; psychological distress as a consequence of

treatment; and financial costs.

Four respondents reported anxiety related to uncertainty about completing

treatment. Two noted that their analyst’s unavailability due to illness during the course of

treatment, “stirred up premature feelings of loss, uncertainty, and ambivalence,” which

mirrored their anxiety about earlier object losses in their lives. However, both participants

noted eventual growth from dealing with this anxiety, leading them to feel more capable of

living with uncertainty and more accepting of their own and their analyst’s vulnerabilities.

Another participant noted the risk involved in even beginning her analysis,

knowing she was guaranteed only two years of self-sustaining work at the institution

where she was concurrently in training. Had employment opportunities necessitated her

moving immediately after her training was completed, it would have precluded her ending

her analysis “naturally.” A fourth respondent, who did conclude her analysis “naturally,”

observed that having recently ended it, she is aware of experiencing a mourning process,

as if she has become an orphan. She described feeling sad because she can no longer tell

her analyst what has been going on, come Monday morning.

A second subtheme of risk involved the relationship with the analyst. Three

participants spontaneously addressed this theme. One respondent observed that he had

overidentified with his analyst’s working style as a therapist but had gradually freed

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himself: “I decided I was not going to have any superego sitting on my shoulder, telling

me, ‘Dow't do this, do this; don’t say this, do say this.’ So, I ’m at that phase of my work

when I ’m applying different models.” Another respondent noted her ambivalence about

the dual relationship she experienced with her treater, who worked at the same institution.

She observed that although she sometimes felt uncomfortable, she had chosen to see

someone who worked in the same setting, “wishing to integrate my vulnerability and my

strength.” Yet another participant noted as a risk o f treatment the intensity of the negative

transference, leading to the experience of feeling somewhat persecuted by her analyst,

“When I felt miserable about life, myself, and my family, I would feel angry that she was

seemingly trying to make me feel worse, instead of better.”

A third subtheme, that of psychological distress, was described by two

participants. One noted, “the loosening of old defenses, which led to greater pain for

awhile. It opens you up and creates more distress, temporarily.” Another respondent

described her great self-absorption during the analysis, which at times made her feel less

connected to her significant others.

The fourth subtheme of risk concerns the financial cost of treatment. Two

participants described the expense as a real factor in weighing the costs and benefits of

personal therapy.

Perceived Disappointments

About three fourths of the participants reported at least one disappointment in

their therapy, with several of them naming two or three subthemes. The subthemes o f

reported disappointment have been categorized into four groups listed by frequency:

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(1) unresolved psychological issues not experienced as related to limitations of the analyst;

(2) unresolved psychological issues experienced as related to perceived personal

limitations o f the analyst; (3) unresolved psychological issues experienced as related to

limitations in the analyst’s therapeutic technique; and (4) disappointments related to the

wish to be perfected.

About half the participants in the study reported perceived disappointments in their

personal treatment related to unresolved psychological issues that were not described as

related to limitations of the treater. These have been categorized according to several

subthemes: feeling unfinished because of not being able to go further or more in depth

with a number of psychological issues; frustrations in working through issues of early or

preoedipal development related to fears of dependency on the analyst; unresolved issues in

relation to separating from an aging parent; and disappointment that therapy was not more

helpful in resolving sexual issues.

Participants related perceived disappointments in their personal treatment to

personal limitations o f their analyst. One participant described his analyst as being, “too

doctrinaire, too interested in his own narrow perspective.” Yet another participant

observed his analyst was at times too free-wheeling, which made her “a real object and

sometimes too real, for better and for worse.” Two other participants wished their analyst

could have been more helpful in a particular prolonged life situation, such as in dealing

with the illness of a significant other. Finally, one participant observed that she wished her

sexuality had been dealt with differently by her analyst. She felt that it was a limitation in

her analyst that he wasn’t better able to explore it.

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A third category o f response to questions about perceived disappointment in

personal therapy related to unresolved psychological issues concerning limitations in their

treater’s psychotherapeutic technique. Three respondents addressed this area in comments

about their analyst preserving technical neutrality, which they felt slowed their change

process or left them feeling disrespected or misunderstood.

Finally, a fourth category o f response to questioning about perceived

disappointments in personal therapy related to the wish to be perfected. These inevitably

frustrated wishes were expressed by two respondents, both of whom also cited the

benefits of accepting imperfection as part of termination. Their responses reflect that

coming to terms with disappointment in the wish to be perfected has profound

consequences, both personally and professionally. This theme is further discussed in the

final stage o f the data analysis.

In summary, the participants responded to the initial open-ended question about

the general disappointments, risks, or negative effects of their personal therapy with

responses that only partially concurred with the model developed from reviewing the

literature. If the concept “psychological distress” includes the risks o f anxiety about

completing analysis, as well as responses directly addressing temporary self-absorption

and loosening of defenses, the literature model concept of psychological distress as a risk

o f personal therapy is fairly congruent with the study responses.

The concept of “the working relationship,” as found in the literature model, refers

to the rational parts of the patient’s ego that collaborate with the treater to accomplish the

goals o f treatment. If both “objective reality” and transference are seen as affecting this

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115

collaboration, then the “risk” of a perceived dual relationship increases the potential for

complications in the working relationship. The literature model concept o f “treatment

errors” was somewhat congruent with the study findings in this open-ended question,

given that three participants spontaneously noted the untoward effects of preserving

technical neutrality “at the expense of the patient.”

Only one respondent spontaneously described untoward effects on his work of

overidentifying with his analyst while in training. Hence, the spontaneous responses of

these participants lacked congruence with the model concept of “adverse identification

with one’s treater.” None o f the participants spontaneously mentioned that they perceived

their effectiveness as a therapist was blocked because of confusion in being both a patient

and a therapist at the same time.

The study results of this open-ended question differ from the model elements most

substantively in the emphasis that almost half the respondents placed on their

disappointment in experiencing unresolved psychological issues after termination, which

they perceived as not related to personal limitations in the analyst or the therapeutic

technique.

Participants responses to question 2. a. (To what extent did you experience

excessive stress o r psychological distress as a consequence of your personal

therapy?) fall into four categories: (1) those who reported there was nothing excessively

stressful about their therapy and offered no further elaboration; (2) those who reported

nothing excessively stressful, yet offered anecdotes about “nonexcessive” stress related to

their personal therapy; (3) those who acknowledged some “excessive stress” or

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116

“psychological distress” as a consequence of personal therapy, yet viewed it as an

inherent, necessary, or inevitable part of their experience, which in the end was a

meaningful part of the therapy process; and (4) those who acknowledged that their

treatment was “excessively stressful” but did not view that stress as an essential,

meaningful, or purposeful part of their treatment process.

Four participants reported nothing stressful about their personal therapy. One

participant in this group elaborated, noting, “I found it to be extremely luxurious and

stress reducing. That tells you how anxious I was, when I came in!”

About half the participants reported nothing excessively stressful in their therapy,

but offered anecdotes about nonexcessive stresses associated with their treatment. Their

comments included the wish to have been referred for antidepressant medication and their

preoccupation with the analysis as initially unbalancing. Several noted that they acted out

some things that were related to the transference, but this did not cause any kinds of

trouble in their external functioning. The comments of one participant capture a number of

these subthemes:

It was mostly a relief. I would certainly get stirred up by it I never had to leave
work. I would get embarrassed because I cried a lot. I was embarrassed because
I’d rage in the analytic hours, and I ’m sure every training analyst and my
colleagues heard me. I had a lot of affect, but I could always pick myself up and go
on with my day and be fully engaged in my work. But it is a very self-solipsistic
world. I’d go home and then I’d tell him about all the sessions we’d have in my
mind and all the things I’d say. But I functioned great! I functioned better and
better. I didn’t have to take meds, I didn’t have to be hospitalized, I didn’t lose
sleep. Work went well. Initially, I did go into a flight into health-I felt so relieved
by being in treatment. And I liked it.

The third group is comprised of the responses of six participants who

acknowledged some “excessive stress or psychological distress” as a consequence of

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personal therapy, yet viewed this stress as an inherent and essential part of a meaningful

treatment process. The comments of two participants addressed their perceived self­

absorption with the analytic process, which had repercussions for other relationships.

One participant related:

A couple of times, I was upset to the point of having difficulty concentrating on


work. O r even more, when I would go home and you have a family and kids there,
they really don’t let you concentrate on your problems, so maybe that’s useful.
It didn’t affect my ability to meet my kids’ immediate needs, though there may
have been times where I was a little bit out of tune with them, because I was
preoccupied with something that I was upset about in the analysis.

Other participants noted that their excessive stress was related to distressing life events

during the analysis, such as the illness or death of a family member, during which time the

analyst’s active support was especially needed; to core psychological issues around

separation and loss; and, in one case, to the participant’s experience of his analyst as

acting out countertransference issues at the time of termination:

The only time [I felt excessive stress] was when I was terminating. Despite my
overall very positive feelings about him, I was distressed about the fact that he
strongly urged me not to break off the treatment. I perceived a significant amount
of anger and countertransference on his part when I wanted to leave. [But over
time, this issue was worked through, in part, by the analyst taking responsibility for
his part in creating the impasse, while keeping clear professional boundaries.]
And that’s one thing that’s influenced my own work: How to make use of your
personal reactions in psychotherapy, but be very careful of the boundaries while
you do it. Revealing certain aspects of yourself in a careful, measured way for the
purposes of using it for the benefit of your client in psychotherapy. It had a strong
reparative effect on our work. One of the issues I was dealing with related to needs
for perfection. And he was pointing out to me how it’s important to be able to
recognize mistakes one makes and not need to be perfect, and that you can benefit
sometimes more by recognizing your limitations.

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The comments of this group thus reveal that ultimately the excessive stress or

psychological distress they experienced has meaningfully promoted their psychological

maturity.

Finally, the fourth group of two participants experienced their analysis as

excessively stressful, and not directly promoting their psychological growth. One

described extreme psychological distress, noting, “I did not decompensate psychotically,

but I was a mess.” The other participant felt that he began to explain everything within the

context of the analysis and he wished to be free of it because it was sometimes repetitious.

He reported an internal struggle with his readiness to terminate, wanting the analyst’s

approval and eventually coming to terms with his decision, yet without a sense of

collaboration with his analyst.

In summary, the range o f responses to inquiry about perceived excessive stress or

psychological distress as a consequence o f personal therapy reveals that the vast majority

o f respondents viewed the stress they experienced as either not excessive or, if excessive,

as necessary to the process of achieving their therapeutic goals. The nonexcessive stress

group described less intense transference reactions and noted their continued ability to

function well at work. The “excess stress” themes included being self-absorbed by the

analytic process, being preoccupied with the transference relationship, and dealing with

core issues especially related to separation and loss at termination. The two participants

whose excessive stress from treatment did not appear to have ultimately promoted their

psychological growth both described a sense o f extreme isolation in their analytic

relationship.

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The responses to question 2. b. (Did you experience any problems with the

working relationship with your analyst?) fall into two major categories that have been

further subdivided for clarity of presentation. Nine respondents indicated that they

experienced no problems with the working relationship with their treater. O f this group,

four gave no evidence of any complications to the working relationship. One described

“a mutual liking and a good fit,” and another offered her definition of a good working

relationship, which included having a treatment goal, a method to arrive at it, faith in the

process, and a respectfulness in the relationship as a vehicle for the treatment, all of

which she perceived her treatment was to contain. The five other respondents in the

“no problems” group each added a qualifier to their response which implicated the

therapist or themselves as a source of some complication to their treatment alliance.

Several individuals found some flaw in their treater, despite their denial o f a problem with

the working relationship. These included a belief that their analyst was “too nice,” which

prevented one participant from exploring his anger and identification with his father’s

meanness without feeling overwhelming shame. Another believed his therapist was not

forthcoming enough with her understanding about the patient. He wanted more feedback

from his treater, which eventually, she did provide. The third participant noted that her

analyst’s chronic five-minute lateness helped her “learn to take imperfect men to task.”

The fourth participant viewed himself as the source of complications in his working

relationship with his analyst. He noted a problem with experiencing her as being

emotionally important in his life because of his early object loss. Finally, the fifth

participant noted that the dual relationship inherent in being treated by a person with

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whom he had professional contact contributed to his regretfully not being able to go

deeper into the work, although his analyst invited him to. These respondents seemed to

experience the complications they mentioned as not overriding their sense o f a good

therapeutic alliance with their treater, and it is noteworthy that all of them believed they

had worked in some depth on analyzing these issues.

The second major category of response to this question consisted of respondents

who replied that they did experience some problem with the working relationship with

their therapist. Over half of the participants perceived some problem in this category.

Their responses are related to four subthemes, which included: (1) the perception of the

analyst as vulnerable and in need of the patient’s care, due to the life circumstances of the

analyst; (2) perceptions of the analyst’s personality traits, such as being oversensitive to

criticism or being very serious or formal; (3) the therapeutic action or technique, due to

the analyst’s nonadherence to the treatment frame by starting the sessions chronically late,

to perceived “lack o f neutrality,” and to a lack of understanding of a psychodynamic issue

by the therapist; and (4) the participant’s perceived resistance to treatment.

The perceived effects of these problems with the working relationship on the

participants can be categorized as either contributing to a positive identification with, or

a dis-identification with, the analyst’s working style. It is noteworthy that the respondents

who accepted and identified with their analyst’s way of handling a conflictual situation in

their treatment-such as charging fees for missed appointments, even due to life-

threatening illness-reported that the conflict was discussed at length in their treatment,

with the analyst eventually making a statement about his or her position on the issue or

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121

assuming responsibility for his or her part in contributing to the problem. In comparison,

the respondent who reported that she dis-identifies with how her analyst handled a

particular situation stated that he never explained why he operated in a particular way.

It thus seems that the participant’s perception of the analyst’s willingness to discuss why

the analyst acted in a particular way determines the identification influence o f resolving

conflict in the working relationship for this group.

In contrast is the experience of the participant who reported a highly beneficial

analysis, yet noted an unresolved problem in her working relationship with her analyst on

the issue o f names, which she saw as a metaphor for maintaining an unhelpful formality in

their relationship:

Before we knew each other in this role, I knew him as a supervisor. He called me
by my first name and I called him by his first name. Then we started analysis and he
called me Dr. and I still called him by his first name-and did, throughout the
treatment. And I said, ‘This is phony! Stop it!’ and he’d grunt and say, ‘Dr. [her
last name]’ and he would analyze it with me, but he never said why he believed it
should remain on a last-name basis.

In summary, responses to this question fell into two approximately equal groups,

with about half the respondents claiming no problems with their working relationship and

half acknowledging some relationship problem with their former treater. Of the group who

reported no problems, half qualified that there were, however, some complications to the

working relationship created by the therapist’s foibles, the respondent’s foibles, or the

existence of a dual relationship. The 11 respondents who acknowledged that they did, in

fact, experience a problem with the working relationship implicated such issues as role

reversal with their treater, perceived flaws in the therapist’s practice techniques, or their

own resistance to treatment. A conscious identification or dis-identification with the

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122

former treater’s working style was associated with whether the perceived problems were

openly discussed in treatment, with the therapist acknowledging his or her contribution to

the relationship problem or explaining his or her therapeutic actions.

Responses to question 2. c. (To your way of thinking, did your analyst or

therapist make treatment errors in your work together?) have been organized into

four main categories: (1) those decisively reporting no treatment errors; (2) those claiming

no treatment errors, but who were left with questions about their analyst’s understanding

o f them or acting out of personal needs that did not advance the treatment enterprise;

(3) those acknowledging treatment errors that were not experienced as impeding the

treatment process; and (4) those experiencing treatment errors that were perceived as

impeding the treatment process.

Five participants reported experiencing no treatment errors. One noted the

difference between the analyst having human foibles and making treatment errors. Another

added that she and her analyst were a good match, linking the concept of interpersonal

match with the participant’s perception of treatment errors.

Another group of seven participants reported no treatment errors, yet offered

evidence o f grappling to resolve such internal questions during and after their analysis.

These questions included one participant’s wondering whether his analyst fully understood

the impact o f chronic family stress on the participant’s life throughout the analysis.

Another participant believed that his analyst had been remarkably dedicated to the

treatment and he was amazed by her memory and capacity for well-timed interpretations.

Rather than not feeling well-enough understood, he related that his “narcissistic needs

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were not being fulfilled in a traditional analysis.” Yet another participant observed an

unfinished issue in wondering whether his analyst believed he was competent to have

pursued taking on more professional training after being denied admission into one

program. The issue o f the analyst’s perception of the analysand’s competence was also

observed in the comments o f another participant. He felt humiliated when his analyst

spontaneously chuckled at his admission of erotic feelings toward her. He acknowledged

his wish to “pull her out of her analytic neutrality,” but considered his momentary success

in this to have proven quite hurtful and stated that he could not explore the erotic

transference thereafter. Another participant noted that while she didn’t view it as a error,

her analyst “didn’t use the best approach in helping [her] work on issues of

overfunctioning in interpersonal relationships.” Two other participants in this group had

grappled with issues concerning the analyst’s management o f the therapeutic frame.

One noted his professional identification with his analyst’s “frequent lateness, yet making

the time up eventually and balancing eveiything out, in the end—playing it loose, which for

better or worse consolidated that style for me.” The other participant in this group

observed that, during the termination stage of their work, her analyst expressed his own

countertransference needs related to liking her, which she felt diminished the power of the

analytic work.

A third group o f three participants responded that their analyst did make treatment

errors, but they described these as not substantively impeding their treatment process.

Included were perceived mistakes related to a limited exploration of variations in the

analyst’s schedule, and one participant’s perception that his analyst liked him “too much,”

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so that it would have been easy to seduce or fool the analyst. The other participant in this

subgroup sensed that her analyst “owned way too much in the intersubjective field,” but

while he made technical errors, she felt they ultimately promoted her growth:

He would [make mistakes] all the time and I would call him on it. Like, ‘Wait a
minute, that’s your free-association, it’s not mine!’ He’s a very lively, passionate
guy and he kind o f got ahead of himself. And that was the other pattem-he would
be so excited about how we were finally dealing with, you know, penis envy, in
Freudian terms, or aggression and, I mean, given my fear of it, he would go too
quickly and then I would get scared and backpedal and then that would take some
repairing the rupture. So it was very well understood by both of us that when he
did something, I had the strength to call him on it. And it didn’t feel as though
I was being a noncompliant analysand. He owned way too much. I just felt like,
‘Just shut up and let me get a word in edgewise,’ towards the end.

Finally, a fourth pattern o f response was the acknowledgment of treatment errors

that were experienced as hurtful or as impediments in the participant’s treatment process.

Seven respondents described such mistakes, which included one participant’s perception

that his analyst failed to understand him diagnostically. Another participant experienced

her analyst as maintaining neutrality at the expense of reacting supportively during a brief

health crisis she experienced, which left her angry and clearly dis-identifying with him

professionally:

He was very neutral about [my thinking I might well have a life-threatening illness]
and I raised holy hell! I said, ‘Don’t you want to know?’ There were a few times
I really called him on t hat . . . I said, ‘I can’t believe this. If this is what
psychoanalysis is, I not only don’t want to be in treatment, I don’t want to practice
it. Period!’

Three participants reported mistakes related to limited exploration of their

psychodynamic issues, including insistence on analyzing preoedipal material to the

exclusion of oedipal problems; inadequate exploration of one participant’s sexual identity;

and inadequate analysis of a participant’s marital relationship to a person suffering from

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125

substance abuse. Each o f these participants felt that such oversights compromised their

treatment.

Harmful countertransference enactments were described by two participants, one

of whom related having her verbal hostility toward the analyst returned in kind, which hurt

her feelings and made her ever careful of not expressing anger at her analyst except in a

very restrained manner. She felt it further inhibited her development in coming to terms

with asserting and exploring her aggression, which was already a conflictual issue for her.

The second participant, in describing harmful countertransference enactments, noted that

his analyst was overly sensitive to criticism, reacting too quickly and with premature

interpretations because of his own narcissistic limitations.

The technical aspect o f timing interpretations was a final issue mentioned by

participants in this subgroup o f treatment errors experienced as harmful or detrimental to

the treatment process. One participant noted this theme in her comment that her analyst

“could be a little bit wild in her interpretations, maybe not doing enough groundwork.”

She noted a particularly infuriating interpretation her analyst made that reinforced her

problem of feeling overly responsible for everything that happens to everyone around her,

resulting in an experience o f not being understood.

In summary, more than half the respondents reported no perceived treatment

errors or expressed doubt about whether true errors had been made. Those who were

unequivocal in their response noted their analyst’s humanity and the goodness of the

character match. Those participants who reported no errors but who still questioned some

aspect o f their treatment that remained unfinished seemed unsure about how their analyst

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understood them and their needs: their level of stress, their suitability for analysis, their

professional competence, their personal attractiveness, and their need for analytic

neutrality. Those who acknowledged errors but felt them not to be detrimental to the

treatment process described the analyst as never explaining his idiosyncratic practice of

scheduling the 50-minute sessions at 10 minutes past the hour, and countertransference

positions of being either too active in the session or too fond of a participant, which made

the participant believe he could have “fooled” or seduced his analyst. Those who

acknowledged that treatment errors may have been detrimental to their therapy process

described the analyst’s failure to understand their dynamic conflicts or diagnostic picture

and technical errors in treatment, such as poorly timed interpretations or rigid adherence

to neutrality during a life crisis, as well as engaging in harmful countertransference

enactments.

The results of question 2. d. (Do you think you have identified with your

therapist in some way that has affected you adversely?) have been organized into four

categories of response: (1) those who replied that they have not consciously identified

with their analyst in any way that affects them negatively; (2) those who reported that they

have not identified in any way that affects them negatively but elaborated on ways they

consciously identify with positive aspects of their therapist; (3) those who reported that

they dis-identify with negative aspects of their therapist; and (4) those who believe that

they have identified with their therapist in some way that has affected them adversely.

Seven participants reported succinctly that they do not think they have identified

with their treater in any way that has affected them negatively.

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127

A second group o f five participants reported no adverse identifications but

spontaneously added their perceived positive identifications. O f this group, two

respondents briefly noted long-term positive identifications with their analyst’s excellent

therapeutic style and professional attitude. Another participant related that his

identification with his analyst as an immigrant has been helpful to his self-esteem and

professional self-confidence. Another participant, in analysis concurrently with training,

noted that her identification with her analyst as a new kind o f father figure-one who was

kind and generous-led her to think of this as the therapeutic ideal with all her patients,

which then led her to need to learn about also setting appropriate limits and boundaries

with different types of patients. Finally, another participant believed she walked away from

her analysis with a sense of empowerment about her own thoughts, feelings, and beliefs.

She noted no pull to be like her analyst, but viewed the two of them as “kindred spirits,”

as people who shared similar spiritual convictions. She chose her analyst believing that

they would be a good match and noted that, in her professional experience, it has been

hard to make a truly deep connection in the treatment relationship with people who have a

contrasting world view.

The third group o f participants responded that they have dis-identified with

negative aspects of their therapist. One participant from a different culture noted his

analyst’s lack of sensitivity to cultural contexts. He believed that he learned a lot about

examining where his orientation to a patient comes from through experiencing his own

analyst’s lack of sensitivity. The second participant observed that his analyst didn’t take

good care of her physical health, although she gave a lot to others. After noting his

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128

similarity to her in ambition and commitment to working long hours with patients, he

noted his own intention to begin getting regular physical exercise, unlike his analyst.

The fourth group of six participants believed that they had identified with their

therapist in some way that had affected them adversely. Four participants described an

identification with their analyst’s neutrality that affected their personal and professional

sense o f self. Their comments included one participant’s noting that she has become less

playful since her analysis and considers undertaking a future analysis, “just to free [her] up

a bit more.” Another participant observed his wish to loosen up more with his child cases,

in particular, while still another noted identifying with her analyst’s reserved personality

style and her sense of their shared difficulties in forming intimate relationships, which she

sees as more pronounced as a result of identifying with him. Yet another participant noted

the adverse effect o f her analyst’s neutrality on a particular issue in her treatment, which

she believes has limited her clinical effectiveness with her patients who present with the

same issue. A fifth participant observed his similar personality traits of arrogance and

pontificating, as well as an old habit of smoking cigars, like his analyst. He related with

mortification his repudiation of “stinking up others’ airspace.”

Finally, the sixth participant noted his identification with his analyst’s annoying

verbal mannerism. This participant also noted the power of multigenerational analytic

voices as identificatory “ghosts” that can sometimes haunt the dyadic relationship:

He had a little verbal mannerism that I found mystifying and totally annoying. The
mannerism was that he would make a therapeutic point to me and say, for instance,
‘I think we can see how that affects your relationship with so-and-so, hmm?’ That
little ‘hmm’ felt odd, maybe a little too presumptive. Like, ‘Well, we both know
that, right?’ It had a quality of being an alien voice and now that I think about it,

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129

I wonder if it was his analyst’s, because now, I do it and I hate it! But I can’t stop
it. It’s like just there, the shadow on my ego.

Many in the group o f participants who believed they had adversely identified with their

analyst spoke o f the influence o f analytic neutrality on inhibiting some o f their spontaneity

and playfulness or their effective expression of aggression. The adverse identifications

involved experiencing these libidinal derivatives as undesirable. Two participants noted

that likely there are numerous unconscious identifications with one’s analyst, which can

only be known at the surface level.

In summary, 12 of the 20 participants did not believe they had consciously

identified with their analyst in any way that affected them negatively and almost half of

them spontaneously mentioned their perceived positive identifications. Only two

participants noted a specific conscious dis-identification. Almost one third of the

participants noted some adverse conscious identification with their analyst that was

predominantly related to the perceived inhibiting influences of analytic neutrality.

Responses to question 2. e. (In your view, was your effectiveness as a therapist

ever blocked due to confusion in being both a patient and a therapist at the same

time?) have been categorized into four groups, consisting of (1) respondents who

succinctly reported no perceived adverse effects on their clinical work due to concurrent

clinical work and treatment, and offered no other details; (2) those who reported no

adverse effects but added that, in fact, their clinical work had been enhanced by being in

personal treatment concurrently; (3) those who perceived no blockage in their therapeutic

effectiveness, but experienced some complications with concurrent clinical work and

treatment; and (4) those who experienced some blockage in their therapeutic effectiveness

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130

due to confusion about being concurrently engaged in clinical practice and personal

treatment.

Two respondents briefly commented on not being aware of having felt any

confusion in concurrent clinical work and treatment, which might have blocked their

effectiveness with their patients. Both of these participants were engaged in postgraduate

clinical training during their treatment.

The second group of 10 participants noted that they did not think their

effectiveness as a therapist was blocked due to their concurrent treatment and clinical

work, adding that it was only helpful to the latter. Three subthemes were identified, which

included comments that their treatment served the function of containment-that is, giving

the participant a place to discuss and explore their experiences as a therapist and a

patient-in the context o f a therapeutic relationship. Most o f these respondents were

engaged in postgraduate clinical training concurrently with their personal treatment.

A second subtheme involved the participants’ enhanced sensitivity, empathy, and

identification with their patients, based on knowing what it feels like to be a patient.

Illustrating this were comments about an increased awareness of similarity with their

patients, and the common experience of their humanness. The third subtheme was related

to enhanced technical skills as a therapist, consequent to concurrent treatment and clinical

work. One participant observed: “The transition from patient to therapist was never a

problem. It sharpened my attunement to the depths of process and metaphor.”

A third group of five participants perceived no blockage in their therapeutic

effectiveness with patients, but reported some complications with concurrent clinical work

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131

and personal treatment. Three of these participants engaged in personal treatment

concurrently with postgraduate training. Most added that despite the complications

involved, they perceived that their therapeutic skills were, in fact, enhanced by their

concurrent clinical work and treatment. One participant commented that, “If anything,

[concurrence was] helpful because it made it easier to identify with the patient, which

sharpened my interventions. I would ask myself, how would it feel if my therapist said

this?” Three subthemes of complications were identified. The first subtheme consisted of

participants who noted being preoccupied with their own psychological issues to the point

that it was difficult to be truly present for their patients. One participant reflected on her

own unresolved narcissistic vulnerabilities, given her embarrassment and shame that some

o f her analytic patients would see her leaving her training analyst’s office and realize that

she also was a patient. A second subtheme involved the complications of making the

transition from being the patient to being the therapist. One participant noted: “It was

hard, because I used to do them, time-wise, very close. Yet I oftentimes pulled on what

felt to me was his wisdom, in knowing how to respond to patients, so I don’t think my

experience was of being blocked.” A third subtheme noted in this group addressed the

issue of anxiety related to competition with one’s own analyst, in “being in his chair and in

his place.” This participant added that her analyst not only survived her success in

becoming an analyst, but has seemed to revel in it. She went on to describe him as

“a different kind of mother” to her, in this sense.

The fourth group of participants perceived that they did, in fact, experience some

blockage in their therapeutic effectiveness due to confusion in being engaged in concurrent

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132

clinical work and personal treatment. Only one of them was engaged in postgraduate

clinical training and personal treatment concurrently. Two participants in this fourth group

observed that, at the time, they were unaware of these adverse effects, and that it was only

later that they could perceive the adverse effects on their work. One of them noted her

occasional difficulty in making the transition from being the patient to being the therapist,

“because it was hard to leave behind stirred-up feelings about my analysis. This led to my

not being fully present with my patients a few times.” The other participant in this group

noted that, very early in her training and her treatment, she had had a countertransference

enactment of abruptly terminating with a patient who had issues similar to her own.

She reported that this event led her to intensify her training efforts, so as not to make

treatment decisions that hurt people out of her own countertransference reactions.

In summary, 17 of 20 participants believed that engaging in personal treatment

concurrently with clinical work did not block their therapeutic effectiveness with their

patients. Half the participants in the study believed that their personal treatment was

actually helpful to their clinical work, a finding that is supported in the professional

literature (Mackey & Mackey, 1994). These participants specified as helpful the

containment function o f their treatment, the promotion of empathic identifications with the

role of patient, and their learning of technical skills from their therapist. Thirteen of the 20

engaged in their target analysis concurrently with postgraduate clinical training. Those few

participants who perceived their therapeutic effectiveness to be blocked due to confusion

in being both a patient and a therapist at the same time noted such issues as anxiety over

competitive wishes and fears about replacing their analyst, or being so self-preoccupied

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with intense affects related to personal therapy that it detracted from optimal attunement

to patients, or being affectively stirred up by personal treatment that colored their

perceptions o f their patients’ material. Whether or not they perceived their therapeutic

effectiveness as being influenced adversely by concurrent personal treatment and clinical

work, many of the participants observed that their self-awareness about this issue may

have been quite limited at the time of their treatment.

Responses to the first question about perceived overall effectiveness of personal

therapy 1. (Overall, how well do you believe your therapist understood you and

communicated his o r her understanding to you?) have been categorized into four

groups, ranging from (1) those who felt very well understood and offered no further

elaboration; to (2) those who felt very well understood and added specific supporting

details; to (3) those who felt generally well understood, but added a qualifier or exception

to feeling understood; and, finally, to (4) those who reported they did not feel well

understood by their therapist.

Three respondents replied that they felt very well understood but did not elaborate

further.

Nine respondents reported that they felt very well understood and elaborated with

supporting details. The quality o f experiencing a common humanness and intersubjectivity

with their treater permeated their responses, which have been categorized into three

subthemes: (1) the therapist treated the participant as though he was important; the

therapist was not seen as being elitist-he didn’t hold himself above the participant; (2) the

therapist had his human flaws and didn’t always understand the participant, but he was

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reliably striving for understanding, which was highly valued; and (3) the participant gave

himself or herself some personal credit for developing the kind o f treatment relationship in

which he or she felt well understood.

Seven respondents reported feeling generally well understood but added a qualifier

or exception to this statement. Their responses have been organized into the following

four subthemes: First, there was the need for more direct communication from the treater

o f his understanding of the patient’s material. The absence of this additional explication

left three participants feeling anxious, uneasy, or “cheated” in not knowing their treater’s

impressions. Second, two respondents noted that certain aspects of the treatment

relationship were not explored as thoroughly as the participant would have wished. One

described his analyst as being “too nice” and not helping him more thoroughly explore his

preoedipal rage. Third, another participant observed that his analyst overvalued theoretical

neutrality, which left him too aloof and detached, and too concerned with maintaining

“a priestly appearance,” which mitigated against the support and encouragement the

participant felt would have better promoted his growth at the time. Finally, one participant

noted that, despite her overall feeling of being quite well understood, her treater had been

befuddled by her unremitting depression and failed to refer her for antidepressant

medication.

Only one respondent believed that, overall, his analyst did not understand him

very well. This participant reported that his analyst did not understand the role played

by traumatic separation and loss during his adolescence or the role of ongoing substance

abuse in his life. He said that his analyst seemed to know that the participant was

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135

deteriorating, but not that psychoanalysis was an inappropriate treatment for him at

that time.

In summary, over half the participants said they felt overwhelmingly positive about

being understood by their analyst and having that adequately communicated. Another third

o f the participants, while feeling generally well understood, noted a lack of feeling

understood with such issues as wanting more feedback from their treater that would tell

them what the therapist thought about their material or that would explore a transference

relationship issue in more depth. Maintenance of analytic neutrality at the expense of

supportive engagement with the participant was also mentioned here. Only one respondent

believed that his analyst failed to understand him, a feeling that the participant based on his

perception of being in the wrong form of treatment at the time. Hence, the vast majority of

participants in this study perceived that they were very well understood by their treater

and that the therapist’s understanding was, for the most part, communicated adequately.

Responses to the second question about the perceived overall effectiveness of

personal therapy 2. (Overall, how successful or satisfactory do you believe your

psychotherapy or analysis was?) have been organized in the following four categories:

(1) respondents who stated only that it was quite successful, or gave supporting evidence

related to benefits to their professional work, or added that it was their own clarity of

goals initially that contributed to their satisfaction; (2) respondents who stated that their

personal therapy was quite successful, especially by helping them come to terms with their

perfectionism; (3) respondents who described their therapy as quite successful or

satisfactory, with one disappointing exception, related either to their own personality

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limitations or to limitations of the analytic process; and (4) respondents who stated that

their personal therapy was unsatisfactory.

Seven respondents replied that their psychotherapy or psychoanalysis was highly

successful or satisfactory and gave further elaboration that involved either crediting their

clarity o f therapeutic goals or the benefits of therapy to their professional work.

Six respondents described their psychotherapy or psychoanalysis as very

successful, an opinion they supported with descriptions of coming to better terms with

their struggles with perfectionism. Subthemes related to this perfectionism involved being

less self-critical as well as more accepting of the foibles of others; becoming convinced

that being “good enough” is an improvement over one’s perfectionistic strivings; and

relating personal progress with this issue directly to repercussions for their own clinical

work. The response of one participant addressed several of these subthemes, particularly

in using the relationship with her analyst to come to terms with her own and her analyst’s

imperfectibility:

I think it really was very helpful, despite the problems and the misunderstandings
and the hurt feelings and the anger. In some ways, that was real valuable, to go
through that with somebody and to have somebody acknowledge that part o f the
problem was their problem, to see that I didn’t destroy that person and didn’t
destroy the relationship and didn’t get destroyed myself. That we all came out of it
better, I think. And that issue o f just being able to accept all three of those areas as
being imperfect, but still worthwhile. She didn’t have to be perfect. She made her
goofs, but she was still able to be helpful, in the long run. And my life isn’t perfect,
but it’s a work in progress.

The third category of response to this question consists o f six respondents who

described their therapy as overall quite successful or satisfactory, with one disappointing

exception, related either to their own personal limitations or to limitations of the analytic

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process. The four participants who expressed disappointment in themselves offered

descriptions of needing, but not pursuing, continued treatment for relationship issues; of

an internal struggle with allowing sufficient dependency on the analyst to deepen the

work; and o f some sadness in deciding that, given the perceived pervasiveness and depth

o f their problematic personality traits, the treatment was quite satisfactory.

Despite reporting an overall successful or satisfactory treatment experience, two

participants expressed disappointment in the analytic treatment process itself. One

described psychoanalytic theory as an inadequate explanation for understanding all mental

processes and human behavior. Yet this same participant observed that the positive

outcome of treatment for him was to expand his world view, thereby differentiating

himself from the perception he had of his analyst’s self-limiting theoretical world view.

The other participant in this group noted his disappointment in having to prematurely

terminate from his analytic work, due to his analyst’s career move. Being near enough to

his own sense o f readiness to end, he chose not to engage with another analyst, yet felt he

could have benefited from further work with his analyst and a termination that was attuned

to his readiness rather than to the external realities of his analyst’s life.

Finally, only one participant responded that his personal analysis was

unsatisfactory. He stated that his analyst and the psychoanalytic institute where he trained

mistook his excellent education for brilliance and for psychological stability. He added that

psychoanalysis was not the appropriate treatment for him but that subsequent

psychotherapy o f a more supportive nature had been quite helpful.

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In summary, all but one of the participants in the study perceived their personal

treatment to have been quite successful. Two thirds of the respondents believed that their

personal therapy helped them clarify their personal goals and helped them modify their

perfectionistic strivings, with good consequences for their professional psychotherapy

work. Another one third reported a successful personal therapy experience, yet one with

disappointing exceptions, which were attributed to their own limitations, such as conflicts

about dependency on the analyst or other resistances to treatment. Limitations related to

the treatment process included the perceived limitations of psychoanalytic theory as an

adequate framework for understanding human motivation and behavior. Premature

termination was cited as another limiting factor by one participant. The sole participant in

the study who found his personal treatment to be unsatisfactory believed that he had been

misdiagnosed and that an exploratory, psychoanalytic treatment process was not

appropriate for him at that time.

Perceived Effects of Personal Therapy on Conducting Therapy

Responses to question 3. a. & b. (Do you believe you work differently with

your patients or clients as a consequence of having received your own therapy? If so,

in w hat ways: which aspects of your therapy do you think you draw upon?) have

been separated by those who expressed uncertainty about their personal treatment

influencing their clinical work from those who perceived that they work differently with

patients subsequent to their personal therapy. Only three participants reported that they

were not sure whether their personal therapy informs their clinical practice of

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psychotherapy. They each noted that their clinical practice has been more influenced by

experience doing the work itself, by their formal education and by life experiences in

general. However, one participant in this group acknowledged some effect:

It’s hard to know [how much influence my personal therapy has had on my clinical
work], because I never did this work before my analysis. I don’t know if it’s from
treatment or experience doing the work, but I believe that ultimately it’s the
patient who does the w ork.. . . [My personal treatment has] given me more
freedom to know that psychotherapy is very hard and there’s a certain emotional
security you take away from your own therapy, knowing it’s hard and slow and it
gives you an anchoring in your clinical work.

Seventeen respondents said they believed that their personal psychotherapy or

analysis influenced their work with patients. Reported aspects of personal treatment that

they draw on have been organized into the following five categories: (1) enhanced

awareness of the importance of the treatment structure; (2) ability to draw on a broader

range of interventions; (3) enhanced confidence in the therapeutic process; (4) deepened

conviction about the value of the treatment relationship as an important vehicle for psychic

change and growth; and (5) greater acceptance of the realistic limitations of the

therapeutic enterprise. Each of these categories has been further organized by subthemes,

which are presented with occasional substantiating quotations. Learning about the

importance of the treatment structure was addressed by one participant, who noted her

therapist’s careful attention to ruptures in the session schedule, which she has drawn upon,

especially in treating patients with a history of inconsistent early caretaking.

Drawing on a broader range of clinical interventions consequent to personal

treatment was reported by two participants. One observed that she “validates the patient’s

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reality more and is less neutral” with her patients who have a trauma history than she

believes she would have been without personal treatment.

Enhanced confidence in the therapeutic process was reported by eight participants.

Their responses have been organized into three subthemes. The first subtheme is that

feeling confidence in one’s personal therapy process leads to instilling confidence in one’s

patients. The second involves an underscoring of the importance of listening and

understanding. This subtheme includes the patient’s experience of the therapist as actively

listening and as making a sustained effort to understand. The therapist also listens for

latent as well as manifest content and views the sustained effort at understanding the client

as the central therapeutic action, instead of experiencing significant internal pressure to

react immediately to the patient’s material. The third subtheme in this category is greater

patience with the slow evolution of psychic change reported by one participant as a

consequence of personal therapy.

The fourth category of response to this question relates to a deepened conviction

about the treatment relationship as the vehicle for psychic change and growth, reported by

about three fourths of the participants. Three noted feeling greater empathy for their

patients’ struggles to change, based on their identification with the role of the patient.

Their responses included comments about being more open than their analyst in expressing

empathic understanding to patients and having the analyst model “a loving acceptance,”

which helped with issues related to shame.

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Using the treatment relationship to promote the patient’s self-esteem is yet another

subtheme in the category o f the treatment relationship as a vehicle for psychic change. One

participant noted:

My treatment impressed upon me the benefits o f the psychotherapeutic approach


that can effectuate changes in self-esteem and functioning, even when underlying
conflicts remain ‘on the books.’. . . Self-esteem is an overarching concept that may
be more important than any particular manifestations o f psychopathology.

Understanding and using transference and countertransference from a personal

treatment experience to promote treatment with patients is another subtheme identified by

eight respondents in this category. Respondents noted feeling more aware of, and more

respectful of, the power of transference. One participant noted gaining an appreciation

from her analyst “that the most effective interpretations are not always transference

interpretations. He was very good with that-knowing when to do which and his

transference interpretations were very, very powerful and focused.” Another participant

noted that by virtue o f the work she has done in her personal analysis, struggling with

issues of her analyst’s reactions to her growth, she is sensitive to patients’ issues around

growth:

And attuning myself to nuances of the transferences that are indications of their
struggle with me about can they grow? Can they have a different life? I think
I hear that and by focusing in on those conflicts and struggles, there is a permission
to grow.

Six participants noted an enhanced understanding of, and use of, their

countertransference responses to promote their psychotherapy •with patients. Several

related that they draw on how a sensitive issue was understood in their personal analysis

and use that to explore the patient’s experience. Two participants observed that their

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142

analyst modeled sharing his countertransference reactions and that they similarly share

their reactions to patients when they believe it will promote a patient’s self-understanding.

Five participants observed that their personal treatment enhanced their

understanding of psychotherapy as a two-person psychological process or as an

intersubjective experience. Four observed that their own contributions as a treater in the

therapeutic enterprise are bathed in a brighter light following their own treatment

experience. One said that, as a psychotherapist, “nothing is neutral about a human being,”

and that it’s the studied use of one’s subjectivity that is used for the patient’s benefit.

Another participant noted the profound subtlety of discovering through her analysis that

she could be both herself and a good therapist.

A fourth subtheme in this categoiy, noted by two participants, addressed the type

o f therapeutic relationship viewed as curative. The two models described by participants

regard the therapist as a developmental partner for preoedipal reparenting and as a

collaborator in alliance with the “reasonable” part of the patient’s ego.

A fifth subtheme, related to gaining a deepened conviction about the treatment

relationship as the vehicle for psychic growth, involved the responses of five participants

who noted that they draw on the analyst’s personal qualities as a model for clinical

effectiveness. These respondents revealed conscious attempts to draw on and emulate

helpful personal qualities of the analyst, such as his sense of humor; her capacities to admit

her misunderstanding and be corrected by the patient; his reveling in (vs. being damaged

by) the participant’s successes, thereby giving her permission to grow and surpass him;

and her sustained, thoughtful focus on the patient. Two participants described an

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identification with their analyst as an ego ideal in comments such as, “My analyst was the

first sane adult in my life,” and “my treaters have all been part o f ‘the committee’ of

helpers upon which I draw in my life and in my work.”

Finally, the fifth major category of response to this question addressed the

participants’ acceptance of the realistic limitations of the psychotherapy enterprise. Five

participants commented that accepting limitations in their personal treatment has positively

influenced their clinical work. This sense of greater realism included feeling more

compassionate with, and respectful of, patients in their struggles, given the difficulties

inherent in the process of psychic change, and a greater comfort in admitting one’s own

personal limitations in being of help to others. These participants appear to have come to a

greater acceptance of the inevitable limitations of this unique human psychotherapy

relationship, based on gaining greater patience, compassion and acceptance of the foibles

o f both themselves and their patients.

In summary, only three respondents were doubtful about the influence of their

personal therapy on their clinical work, citing other more clearly influential sources. Of the

17 respondents who perceived influences of their personal therapy on their psychotherapy

practice, 14 noted the deepening of their conviction that the treatment relationship is an

important vehicle for psychic change and growth. Frequently mentioned subthemes of this

category included gaining a better understanding of, and using concepts of, transference

and countertransference to promote clinical treatment, valuing personal treatment as

promoting an understanding of psychotherapy as a two-person, intersubjective process,

and drawing on the analyst’s personal qualities as a model for clinical effectiveness.

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Another major category identified by almost half the participants in this group is an

enhanced confidence in the usefulness o f the therapeutic process, which included concepts

such as having patience with the slow pace of change, listening actively, and

communicating one’s understanding to patients.

The other prevalent category that was mentioned by about one third o f the

participants involved the increased acceptance of realistic limitations of the psychotherapy

enterprise. This reaction was based on their acceptance of the human foibles o f both

treater and patients, which diminished the participants’ perfectionistic strivings.

The responses to question 3. c. (i) (To what extent has your analyst or

therapist served as a role model for you in conducting psychotherapy) have been

organized into three categories: (1) those participants who reported that their analyst had

served as a role model for their work and who cited only examples of positive

identification with the analyst; (2) those participants who reported that the analyst had

served as a role model yet cited examples o f both positive identifications and ways they

viewed themselves as practicing differently from their former treater; and (3) participants

who reported that their analyst was not a significant role model for their work.

The 12 participants who experienced their treater as a significant role model for

conducting psychotherapy and who cited only examples of positive identifications

addressed both technical aspects of conducting therapy and how their treater related to

them as a human being. The therapeutic techniques noted by five participants included

using questions or comments similar to those o f the analyst to help their patients explore

dilemmas similar to ones the participants had dealt with in personal analysis. These

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participants noted feeling more confident about helping their patients explore these issues,

due to a belief that the exploration can be of help. Another participant observed that his

first analyst “loosened [him] up by modeling playfulness as a therapist, without losing sight

o f the basic goal o f the work,” whereas his second analyst helped him become more

comfortable with being reserved and in giving patients room to experience discomfort

without rushing in to provide comfort that might stymie the treatment goals. Another

participant identified with his analyst’s capacity to use his free-associations to promote the

treatment. Noticing his own comfort level in using free-associations to interpret a

psychotic patient’s material, the participant linked this capacity to his analyst’s “never

sharing his personal associations, but obviously being usefully attuned to them.” Two

other participants cited their respect for how their analyst “went about his work.”

Seven participants gave examples of identifying with their treater’s qualities of

human relatedness, after which they consciously model themselves. This sense is captured

in one participant’s comment that, “I’ve internalized him as a person, as well as an

analyst.” Qualities o f their treater that they admired, found personally helpful, and strived

to emulate included the analyst’s integrity and flexibility with his neutrality and his

support, such as by laughing at one participant’s jokes. This mirroring is echoed in another

participant’s words, “I probably act, smile, and laugh like him. It’s a pleasure to see his

photo [on a wall, at work], I feel like he’s smiling at me-I have a sense of affirmation.”

Two participants cited their analyst as a role model for treating people humanely, with

respect and dignity, by giving them time and staying with them in treatment. One

participant admired his analyst’s willingness to engage with him on a level “that

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146

acknowledged and allowed [him] to explore [his] experience of the analyst’s humanness.”

He believed that his analyst had “the courage to be honest and the courage to be human,

including acknowledging her personal flaws.”

The second category o f responses to this question includes those of six participants

who viewed their personal treater as a significant role model, yet cited examples not only

of identifications with the treater, but also of differences in how they practice

psychotherapy. The valued aspects of the treater, which the participants desire in

themselves as therapists, included the analyst’s sensitivity to the meaning of ruptures in the

treatment, presentation as “a well-trained, good human being,” acceptance o f people and

compassion and empathy for whatever the patient is experiencing, and concepts and ways

o f thinking about patients.

The areas of differentiation from the treater include the experience of the treater as

not revealing as much o f her conceptual thinking to the patient as would have been

helpful, which the participant noted he does differently with his own patients. Closely

related to this difference was another participant’s awareness of her therapist as being too

inhibited about sharing her own experience. This participant noted that she does not want

to practice that way, but realizes it is helpful in containing some patients. Two female

participants who cited their stylistic differences with their male analyst as being at least

partially gender based described themselves as being more animated and their analyst as

more reserved. One believed that her analyst’s classical training was the main source of

this difference, however. This same participant noted:

I think he gave me permission to be different. I don’t think he would disapprove of


how I do it. But I learned from him that you have to do what feels right to you, in

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order to make a real connection with patients. Otherwise, you’re kind of playing
a role.

That these perceived differences can promote differentiation in the participants, which can

positively influence their clinical work, is exemplified by one participant’s observation.

Despite having a different frame of reference and not working the same as her analyst, she

found that:

If your heart’s in the right place, and you’re basically kind and accepting o f people,
and not critical, and if you take them seriously, they can accept a lot. Because then
they can accept you for who you are, and I think that’s a corrective experience in
their other relationships, as well as in their most basic relationship with their own
self. And coming to accept yourself for who you are and how you are.

The third category of response to this question is the response of two participants

that their treater was not a significant role model for them in conducting psychotherapy.

One participant noted that he might find “helpful bits and pieces” of his analyst, but he

reported “a collective contribution of so many other people” that he has encountered. The

other participant responded that his analyst was somewhat o f a model, then he added that

he subsequently has learned about other models of treatment that include self-disclosure

on the therapist’s part, which have been more important to him professionally.

In summary, responses to this question about the personal treater as a professional

role model revealed that 18 o f the 20 participants experienced their treater as a significant

role model for conducting psychotherapy. Of the one third o f this group who also cited

differences between how they and their treater practice, a few noted feeling that these

differences were supported by their treater, while the others also eventually used their

differences to promote their own individuation in “becoming their own person” as a

psychotherapist. The two participants in the group who reported not experiencing their

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148

analyst as a significant role model in conducting psychotherapy revealed that while some

aspects of their treater might be helpful, other people have better exemplified models that

more clearly match their ideals for professional conduct.

Responses to question 3. c. (ii) (W hat do you perceive as being your analyst’s

o r therapist’s limitations or mistakes which have influenced your work with your

own patients?) have been categorized into those who report no limitations or mistakes,

instead offering only what was helpful, and those who did report some type o f limitation

o f their treater that they believed influenced their own clinical work. Nineteen responses

are reported, as the interviewer omitted asking this question of one participant, due to an

oversight. Of the four respondents who reported no limitations and instead focused on

what was helpful, responses included the analyst’s genuineness and authenticity, and the

analyst’s modeling that a “good enough” therapist does not have to be perfect or without

personal limitations or misfortunes to do good work.

Of the 15 participants who acknowledged some limitation or mistake on the part of

their analyst, three themes emerged, including: (1) limitations due to theoretical biases,

which at times led to developmental or situational issues not being understood as well as

the participant had hoped; (2) limitations perceived as being related to the analyst’s

technique; and (3) limitations perceived as being related to the analyst’s human foibles.

The perceived limitations or mistakes due to the analyst’s theoretical biases

included one participant’s perception that her analyst had “a classical Freudian view of the

oedipal struggle as explaining everything,” which led him to miss helping her explore the

wonders of her pregnancy during her analysis from other than a phallocentric view of

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149

development. She reported feeling hurt that he didn’t sufficiently value this experience,

which was unique to her as a woman. Another participant noted o f his analyst that

classical psychoanalytic theory 20 years ago, during his analysis, appeared blind to the

influences on them o f their different cultures, social classes and native languages. This

participant assigned responsibility for this “culture blindness” to the then-prevailing

psychoanalytic views and the particular psychoanalytic institute more than to his analyst.

He added that, whenever possible, every effort should be made to match the analysand

with a treater from his or her own culture.

Another six participants noted that theoretical biases led to their analyst not

understanding a particular developmental or situational issue with which they struggled.

These issues included the analyst not referring the participant for antidepressant

medication; not understanding the challenges the participant faced in coping with a

spouse’s chronic illness; lacking sensitivity to the complexities of parental anxiety

regarding a child’s chronic illness; and bypassing a thorough analysis o f preoedipal issues

in the analysand in favor of focusing on oedipal interpretations. Several participants

believed that their analyst’s limited understanding was also a consequence o f personal

inexperience with the issues, such as by not being a parent or never having faced chronic

illness in a spouse. In the face of such unfamiliarity, the analyst reverted to a classical

theoretical understanding, which prevented helping the participants find more satisfying

solutions to their dilemmas.

The second theme that emerged in this group of participants who acknowledged

some limitation or mistake by their treater relates to the analyst’s technique. Six

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150

participants observed a technique-related limitation. Two participants viewed their analyst

as valuing adherence to classical technique over the human relationship. Both saw

themselves as being more flexible with technique, in favor of putting the human

relationship first. However, both viewed their analysts and themselves as products of the

times in which they were trained. Another participant believed that her analyst “too

directly confronted [her] defenses,” which reinforced them, and that the analysis of her

core issue with dependency was thereby encumbered. She has since learned that initially

joining the patient’s defenses “promotes movement to the other side of the conflict,” that

is, it enables the patient to explore issues more safely without having to resist premature

confrontation from the analyst. Other participants cited such limitations as their treater not

giving them enough direct feedback. Another participant noted that his treater did not take

control of directing the sessions, which left him without a model for doing so in his own

work. Two of these participants added, however, that their analysts were following

acceptable psychoanalytic technique and that they admired their analyst’s principled

adherence, despite the perceived limitations. One participant noted, “One person can’t do

everything.” Finally, one participant in this group perceived that a limitation from her

analysis is that she strongly identified and agreed with her analyst’s view of the importance

o f neutrality, which precludes her working well with patients with a severe trauma history

who may need their therapist to affirm their perceptions of reality in ways that this

participant would not feel comfortable doing.

The third and final theme observed in the group of participants who perceived a

limitation or mistake by their treater that influences their own practice involves limitations

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related to the analyst’s human foibles. These included the perceptions that the analyst was

overly sensitive to personal criticism; allowed his personal issues with separation and loss

to color the termination process; was habitually late for sessions; and was self-disclosing in

ways that sometimes distracted from the participant’s analytic work. These participants

noted that when they discussed these relationship issues in their treatment, with the

therapist acknowledging his or her personal flaw or error, the treatment process was

promoted, and they subsequently gained more confidence in working through difficult

interactions with their own patients.

In summary, three fourths of the respondents noted some limitation or mistake by

their treater. Of the five participants who reported no limitations or mistakes, three alluded

to their treater’s humanness, genuineness, and authenticity as being central to their not

perceiving the analyst’s flaws as harmful, but as an inevitable and even useful part of the

process with which they identify professionally. Of the 14 respondents who noted some

limitations or mistakes, participants either dis-identify with their treater’s perceived

limitations, as harmful pitfalls to be recognized and avoided, or they tend to view their

analyst’s mistakes as inevitable and as both personally and professionally helpful to their

own clinical work. Those in the latter group revealed that their treater modeled that his

inherently flawed humanness could be acknowledged forthrightly and the participant’s

reactions to it could be carefully discussed as to its meaning to the participant and for the

treatment relationship. This, paradoxically, left the participants with greater confidence in

being similarly able to accept their own humanness and yet view themselves as being able

to help others in the therapeutic enterprise.

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Responses to question 3. d. (i) (Do images or thoughts of your therapist ever

come to mind while you’re conducting psychotherapy or psychoanalysis?) have been

organized into three main categories: (1) those who reported that they do not currently

have thoughts or images of their treater(s) during sessions and who did not think that they

had, in the past, during the course of their treatment; (2) those who could not recall having

thoughts o f their past treater(s) while conducting psychotherapy at present, but reported

that they have had them during sessions in the past; and (3) those who reported currently

having thoughts or images of their treater(s) while conducting psychotherapy. Responses

of 19 o f the 20 participants are reported here, as the interviewer mistakenly omitted asking

this question to one participant.

Six participants responded that neither currently nor in the past have they ever had

thoughts o f their former therapist(s) while conducting psychotherapy sessions. Three of

them noted that thinking of one’s therapist may be an unconscious process, so they would

not be aware of it. Two participants noted that at times outside of sessions they have

thought about their therapist. One recalled wondering, when he was reflecting on his work

outside a session, what his therapist would have said to a particular patient. The second

one noted that he has evoked vicarious experiences of relating to his now-deceased analyst

by imagining the two o f them having a drink together, which he felt represented his greater

sense of safety in closeness with men since his analysis. He added that this ability to

visualize such an interaction has had both personal and professional benefits.

Four participants responded that they do not currently have thoughts or images o f

their treater(s) while conducting psychotherapy, but that they have had them in the past.

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One participant noted two types of occurrences of these images. One entailed her actively

questioning, “What would he be making of what this patient is saying?” And the second

type was after the fact, “When I found myself saying something to a patient without any

conscious thought of what he would say, but it sounded just like him. I’d have an image

of him in my mind.” Echoing the concept of actively evoking helpful images of one’s

therapist during clinical sessions is another participant’s comment that he would hear his

analyst’s voice inquiring in a particular direction:

These images make me feel like I’m directly modeling or connected to her or
calling upon that memory at a particular moment. Doing that thing and it feels like
this is a good thing when it happens. It feels pleasant and like it’s something that’s
going to be helpful to the patient. It’s not intrusive thoughts.

Another participant in this group noted that while engaging in long-term treatment with a

very difficult character-disordered patient soon after terminating his analysis, he thought of

his analyst especially to help him safeguard from boundary violations, as the patient spoke

of her sexual arousal during sessions. He observed that his analyst was an “ethical

representative” for him.

Nine participants responded that they continued to have thoughts or images of

their treater(s) while conducting psychotherapy. One of these participants also noted

actively wondering what her analyst would say or ask or do at a particular moment with

a particular dilemma. Another respondent revealed experiencing the after-the-fact

identification previously described: “Every now and then, I find myself putting something

exactly the way he would have, which feels good. Images, little anecdotes. He just stays

with me. Little flashes of things.” At termination she gave her analyst a small painting that

had some significance for them both, and then she got herself a small sketch of the same

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thing, so she could see it also. She noted that “It’s a nice connection that is reminiscent.

I deliberately want his work to keep informing mine, so I’ve kept that [sketch] in view.”

Two participants reported having thoughts about their former analyst related to

therapeutic technique. One noted that when “subterranean issues” are going on with her

patients, that is when she draws on her own free-associations and will then think of

something helpful her analyst said to her. She observed that she identifies with what her

analyst was doing with her-drawing on his free-associations to promote understanding of

his patient. The other technique-related comment came from a participant who noted that

he thinks about his most recent therapist whenever he is talking too much in a session and

he feels that he needs to be quiet and listen more.

Four participants in this group who reported having thoughts or images of their

therapist while conducting psychotherapy addressed a relational aspect of their experience

with the former therapist. Included here are observations of one participant who noticed

that she made the same noises her analyst did and that she had become more relaxed and

casual in her style, like her analyst. This participant felt that this emulation was beneficial,

given her “internalized, rigidly high standards” from earlier in life. Another participant

recalled his analyst’s style of external detachment, but internal connectedness. He noted

his difference in that he strives to connect, to have a “personal encounter” with his

patients, unlike what he experienced with his former analyst. Another participant noted

that when she is perplexed in a session, she finds herself thinking of her former analyst, or

when she finds herself sitting in a particular way, she wonders if her analyst also sat that

way, behind the couch, in their sessions. Finally, one participant recalled her analyst’s very

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reserved style, which she emulated in their sessions, thinking that that was the proper

analytic style. Then, far into her analysis, while in a playful mood, she joked with her

analyst and he spontaneously laughed. She related:

Making him laugh was very powerful to me. It showed me he really was
emotionally with me. That he could let himself spontaneously be delighted showed
me something vital about his resonating with me. And when I ’m with my patients,
there’s a line in my mind that I dance close to and away from. Often, it’s around
how separate am I from them and how much do I actually just join them in the
experience of being human? And having been in treatment, I ’m more comfortable
with feeling very close.

In summary, about one third of the participants in the study did not recall ever

thinking about their former therapist while conducting psychotherapy. However, half of

this group noted that drawing on experiences from one’s personal treatment may remain

an unconscious process and hence out of awareness. Two others added that they think

about their former analyst at other times, even to draw on the analyst as a source of

clinical help, yet not while conducting psychotherapy sessions. One fifth of the participants

report that they used to consciously think about their analyst while conducting treatment,

but do not do so currently. In the past, they thought of the analyst by actively evoking or

drawing on thoughts or images of him or her, as well as after the fact, discovering

similarities to the analyst in some way through their own patients. This phenomena might

have occurred during clinical dilemmas of uncertainty or risk for the participant as

therapist. About half the participants reported that thoughts or images of their former

treater do currently come to mind while they’re conducting psychotherapy. They also

observed aspects of both actively drawing on helpful images of the former treater, as well

as after-the-fact discovery of identification with the former therapist. Participants in this

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group noted that both technique-related and personal qualities of their former treater come

to mind, as if they were attuned to an often-preverbal level of object relatedness. They

mentioned pleasurable feeling states of being with, or in the presence of, the therapist as a

powerful maternal presence on whose strength the participant can draw for steadiness in

providing therapeutic relatedness to their own patients.

Responses to question 3. d. (ii) (Do you remind yourself of your analyst while

you’re working? If so, can you describe any such moments, or any particular clinical

circumstances?) have been organized into two main categories: (1) those participants

who report not reminding themselves of their analyst; and (2) those who do find

themselves in some way to be like their analyst while working. Only two participants

reported that they neither think they are like their analyst while working nor remind

themselves o f their former treater. One noted that this differentness is partly because he

has not treated neurotic, high-functioning professional people in a number of years

(e.g., people who are like him as a patient and who would evoke countertransference

reactions similar to those his analyst likely experienced with him).

O f the 18 participants who reported that they do remind themselves of their former

treater in some ways while conducting psychotherapy, three themes o f perceived similarity

to the former treater emerge in the areas of: (1) therapeutic technique; (2) style of

interpersonal relatedness; and (3) theory of what is curative in psychotherapy.

Half the participants in this group offered that they perceived similarities between

their own and their treater’s therapeutic techniques. Two participants said that they

reminded themselves of their former analyst when it came to the structure of beginning or

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ending the sessions and the handling of interruptions. Another noted that he emulated the

body language o f his former female analyst in cross-gender clinical situations when he

wanted to convey safety with sexual tension. He observed his body posture “as not always

being exactly [his] own” and as signaling his attentiveness in a nonaggressive way.

Another participant eloquently asserted:

I think we want to be most like our treaters when we are the most perplexed or
we’re starting out with a new case; when we want to feel and we need to put on
the suit o f armor, to take in the strength. It’s like the warriors who used to drink
the blood o f the animal before going into battle.

One participant pointed out that, for her, it is a conscious process of drawing on the

memory o f something her treater said that she now uses with her own patients. She also

knows that the developmental level of the patient contributes to her drawing on her

memory of her first therapist. When she is treating an adolescent, she is inclined to be

most like the treater she had as an adolescent-to become as “unflappable” with her

patients as he was with her. Another participant cited that, at times, he usefully reminds

himself to talk less and to listen more to his patients, just as his therapist did with him.

Four participants noted the importance of techniques that respect the patient’s pace of

doing the work. This technique-related knowledge respects the need for balance in

providing connection with, and separateness from, the patient, respect for both the

patient’s resistance and adaptive strengths, and appreciation for the very slow pace of

psychic change that requires both supportive and expressive work, encompassing respect

for the need for flexibility yet holding clear limits and knowing when each is needed to

promote psychic growth in the patient. Participants cited these technique-related aspects

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o f balance and pacing as similarities between themselves and their former treaters in that

the participants draw on their memory of this type of experience with their own treater.

Six participants noted some similarity with their former treater’s style of

interpersonal relatedness. These similarities include the capacity to relate authentically

with patients. Another participant noted herself becoming more self-accepting because of

the work in her personal analysis and in now accepting her patients for who they are. She

added, “There was some basic core of how he felt about me that I’ve intemalized-it’s now

me. And how I feel about myself and people is different!” Echoing this is another

participant’s observation that his analyst helped him to stop being so hard on himself by

giving him a very natural human response. He noted that sometimes he observes himself

using her same phrasing when his patients are struggling with similar dilemmas. He views

this emulating as a human response that she modeled with him. Another participant noted

that he catches himself repeating his former analyst’s phrase to patients about “entering

the complexity of the world of relationships and how one can not like somebody’s

behavior and yet feel very close to them.” Another aspect of similar relatedness with

patients is noted in a participant’s observation of the special type o f love she felt for her

analyst, which she felt was reciprocated and well boundaried. She expressed that she has

felt similar bonds with a few of her long-term patients and believes that her former analyst

“is an anchor in [her] work with [her] patients.” Finally, one participant in this group

reflected on the progression of internalizing his former analyst’s style of relatedness:

I thought I always wanted to be like him in the way I made people feel, but I didn’t
want to adopt his mannerisms per se. I wanted to be myself, to tty to work myself
into doing that sort of thing. I think probably early on, I might have tried to adopt
some of his mannerisms and I would say now, looking back on it and thinking

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about it, I just want to integrate or adopt his attitudes into the way I am. But,
certainly, early on, I wanted to almost mimic, like a little kid mimicking their
parent. I wanted to mimic his thoughtful, understanding style.

Three participants reported a similarity between their own and their former

therapist’s theories of what is curative to patients. One participant cited their common

understanding o f a need to regress “in the service of the ego,” under the stress o f psychic

growth. Another noted the importance of challenging patients to shift from “an

experiencing to an observing ego” at times, in order to see opportunities for making

conscious choices that can promote psychic growth and reveal resistances to it. A third

participant cited her similarity to her former analyst in her capacity to nurture the patient’s

attempts at mastery over resignation in even the most bleak situations, such as dealing

with life-threatening illness or the effects of chronic childhood sexual abuse.

In summary, nine tenths of the participants in the study believe they are in some

way similar to their former therapist while conducting psychotherapy. Half of this group

perceived a similarity with their former therapist’s technique in such ways as handling

structural aspects of beginning and ending the hours or in handling interruptions in the

work. Similarities with body language or nonverbal behavior were noted, as well as

consciously drawing on the former therapist’s words or exact phrases. The developmental

level of the participant’s patient may influence the content and form of these memories.

Identification also occurs with the former therapist’s ability to use restraint by listening

and limiting verbalizations in order to give the patient ample space to do the work.

A balanced approach of technique, which both respects the difficulty of psychic change,

and yet flexibly provides both supportive and expressive interventions, was valued by

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these participants and reportedly modeled by their former treaters. Identifications with the

therapist’s style o f relating included seeing oneself as similar in authenticity, acceptance of

self and others, appreciation for the complexity of intimate interpersonal relationships, and

experiencing a unique kind of love in the therapist-patient relationship. This process of

internalization appears to move through stages of mimicking words and behaviors to

identifying with the analyst’s attitude and style of relatedness. Several study participants

also identified with what they perceived as their treater’s theoiy of what is curative for

psychotherapy patients, consciously taking it into their own clinical work.

Responses to question 3. d. (iii) (Which, if any, personal attributes of your

therapist or analyst do you find yourself most identifying with in your work?) have

been organized into three main categories: (1) respondents who reportedly identify with

how their former therapist conducted his or her life outside the treatment relationship;

(2) respondents who reportedly identify with admirable personal character traits of their

former therapist; and (3) respondents who reportedly identify with the therapist’s

capacities or abilities in conducting treatment. The responses of 19 of the 20 participants

are included in this analysis, as the investigator mistakenly omitted asking the question of

one participant.

Four respondents described admiring and identifying with how their former

therapist lived his or her personal life outside the therapeutic relationship. Two

participants noted their former therapist’s ability to assert differences from others yet stay

connected simultaneously, thus modeling the capacity to make desired changes in a

powerful, proactive way. These changes involved one analyst’s changing his work

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environment and another analyst’s publicly advocating for health care reform. Another

participant observed his former analyst’s integrity in how he conducted his life, even in the

way he lived as he was dying, some time after the participant had terminated. The fourth

participant noted her identification with her former analyst’s “style in the world”:

It’s nonverbal. I just like his style in the world. He was kind of laid back. It’s just
kind o f an atmosphere of him that I’m comfortable with. It wasn’t like coming
along copying, it was just that I found myself to be the same kind o f way and that’s
comforting, or pleasant.

A second group of four participants described admirable personal character traits

of their former therapist, that had a powerful impact on them as a patient and with which

they identify as a therapist. These characteristics included the analyst’s calmness and soft-

spokenness, which one participant believed he shares as a therapist with his patients, and

qualities o f personal warmth, kindness, and “a caring from the heart,” which were

expressed by two participants. Another participant in this group described his analyst as

“remaining [his] ego ideal for the traits of honesty, patience, and hard work, dependability,

and deep caring.” He added that his admiration of her as “a first-class individual,” who

was also very beautiful, made for an idealized, erotic transference which, to some degree,

limited his analytic work, but which has also sensitized him to the power of covert

transferences in treating his own patients. The emphasis in these responses was on the

personal qualities of the former treater.

The third category o f 11 respondents emphasized identification with the former

therapist’s capacities to do the treatment. Their responses focused less on the influence of

how the therapist is as a person, and more on what the therapist did or how the therapist

behaved, (i.e., how the therapist’s capacities and abilities influenced the conduct of

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therapy with the participant.) The responses have been divided into four subthemes, which

include the capacity to: (1) respect the patient; (2) appreciate what is humorous and laugh

with the patient; (3) take the work itself very seriously; and (4) be engaged with the

patient yet maintain clear personal boundaries. Five respondents noted that their former

therapist showed respect for them as a patient through such capacities as maintaining

impeccable ethics, acknowledging mistakes, and interpreting painful material without

being sadistic. Three participants identified with their analyst’s capacity to appreciate what

is humorous and to share laughter with the patient. One of these participants noted:

“I learned from him that life is too damned sweet to take too seriously, which only gets in

the way o f really being able to savor it.” Four participants noted that their analyst took the

work seriously and was quite absorbed in it. An additional three participants observed that

their therapist was immersed in the work, yet kept good personal boundaries by always

keeping the work focused on the patient.

In summary, it is noteworthy that all the participants in the study responded that

they experienced some conscious identification with personal attributes of their former

therapist. They identified with how their former therapist apparently lived life, and with his

or her character traits or relational capacities in conducting treatment. Noted as admirable

in how the therapist lived in the world were abilities to cope with separation and loss, that

is, to take a stand that differentiates oneself when needed and to live with integrity, even

while facing death. Personal traits such as calmness, warmth, kindness, and genuine caring

contributed to positive identifications, which several participants observed as evidence of

their “idealized transference.” Relating respectfully to the patient was valued as a positive

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capacity for conducting psychotherapy by more than half the participants. This respect was

communicated by the therapist’s ability to maintain impeccable ethics, acknowledge

mistakes, and interpret without sadism. In addition, a willingness to appreciate what is

humorous, yet to take the work seriously, while maintaining clear personal boundaries was

admired and consciously identified with.

Perceived Interpersonal Relationship and the Process of Continued Psychological


Involvement with the Therapist

Responses to question 4. (1.) (How would you describe the interpersonal

match or fit between you and your most recent therapist?) have been divided into

three categories: (1) respondents who initially experienced a good interpersonal match that

later deteriorated; (2) respondents whose initially poor interpersonal match with their

therapist later became good; and (3) respondents who initially experienced a good

interpersonal match that remained good.

Only one participant reported that the interpersonal match initially felt good, but he

later viewed it more negatively. This attitudinal change occurred when he discovered that

he was in the wrong form of treatment with an aging, declining analyst, of whom he felt

compelled to take care.

Several participants reported that initially the interpersonal fit between them and

their therapist felt poor but that, over time, they came to develop a good match. The

reasons offered for these “mismatches” include one participant’s experiencing a sharp

contrast with his previous therapist’s warm style, as well as with his own personal style of

relating. Another participant found her analyst to be “too different from [her] oedipal

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father,” and also noted struggles to work on feminine identity issues with a male treater,

while the third participant observed that, initially, she found her analyst to be “a cold,

computer-like person who merely spit out correct interpretations.” She added that

weathering a very lengthy negative transference toward her analyst was probably one of

the most helpful parts of her analysis. This participant observed that she was able to get

into some issues that she had been blocked on in previous therapy processes. Each of

these participants observed a change in their initial sense of mismatch, based on working

directly with these feelings in the analysis. They believed that this working through process

contributed something important to their own therapeutic acumen, as evidenced by one

participant’s comments:

We found each other, despite those initial external impediments. And in that sense,
I think it was very important not only personally, but in working as a therapist, in
being less quick to think of a therapeutic mismatch as a fatal problem.

Finally, the participant who initially struggled with working with “a different kind of father

figure,” also noted that she never would be able to do the kind of intensive transference-

based clinical work she does without having first had that relationship with her analyst.

Interestingly, each o f these participants was assigned to their analyst by the institution

where they were treated.

Sixteen of the participants reported experiencing an initially good interpersonal

match that remained good between themselves and their treaters. This group is further

divided into those respondents who emphasized the similarities between themselves and

their treater and those who emphasized the differences between them. Ten participants

believed that the match with their former therapist initially was good and remained good

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emphasized similarities they experienced. Their responses contained three subthemes:

comfort with having a similar personality style with their treater, admiration o f the

therapist’s personality traits and aspiration to be more like the treater, and the perception

o f sharing certain values and life experiences with the treater. Emphasizing the complexity

of aspects o f what makes for a perceived good fit is one participant’s observation:

The fit between me and my second therapist was a very good fit, I felt intuitively,
from the beginning. The things I wanted to achieve and be like, I saw in him and
yet some of the traits I perceived that were negative within myself, I also perceived
in him. In fact, these tended to play out somewhat that way. Some of the things
I became angry with him about, at the end-a certain type of manipulativeness-are
things I struggle with within myself. So in some ways, I felt it was a
disconcertingly good fit and stirred up a lot.

It is noteworthy that only three of the 10 participants in this group chose their

therapist. The institution matched the other seven, who nevertheless emphasized their

perceived similarity with their treater. Results indicate that o f the three participants who

chose their treater, they all viewed their own style as similar to the treater’s personality

style, two reportedly aspired to be like their treater, and one of them reported sharing

values and experiences in common with the treater. These results suggest that therapists

who chose their treater and experienced a high degree of similarity with their therapist’s

relational style reported that the interpersonal match remained good throughout the course

o f their treatment.

O f the seven participants in this group who did not choose their treater four

described similarity with their treater’s personality style, two described admiring the

therapist and aspiring to be like him or her, and four reported sharing values and

experiences in common with their former treater. It would thus appear that for those

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participants who did not choose their treater, feeling a similarity with the therapist’s

personality style and having a perception of sharing common values and experiences is

important for experiencing a good interpersonal match throughout treatment.

Six participants emphasized the differences between themselves and their former

therapist in describing the initially good interpersonal match that remained good. Two

described their differences as complementary and as promoting their treatment. One

participant observed:

It was an excellent match, but we’re as different as night and day. He’s quiet,
thoughtful, reserved, intellectual. I’m brash, excitable, full of affect, petulance,
reactivity. It overtly sounds like oil and water, unless you believe opposites attract,
which apparently they did in our case.

It is noteworthy that both o f the participants who described their perceived differences

with their former treater as complementary chose their own therapist, knowing something

beforehand about his or her clinical working style and reputation.

Four participants who described the match as being good and remaining good

emphasized the differences between themselves and their therapist as related to the

inherent vulnerability of being in the patient role. One noted his own resistance to doing

the work, another observed his need to idealize his therapist in order to preserve a fantasy

image of the analyst as “a really good person,” and a third, a physically petite woman

observed her initial anxiety about her analyst’s great physical stature, which apparently

represented a threat of being overpowered. A fourth participant noted instability in his

analyst’s mood and behavior that sometimes created an unsafe therapeutic environment.

Despite these differences, which led to feeling vulnerable, the participants viewed the

interpersonal match between themselves and their treater as a good one that remained so.

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It is noteworthy that none o f these four participants selected their analyst; rather, the

match was assigned by the institution where they were treated.

In summary, 19 o f 20 participants in the study reported experiencing a good

therapeutic match as their treatment unfolded. Only three participants initially experienced

a poor fit between themselves and their therapist. Each of these three experienced negative

transference to the personal style of their analyst, which was in sharp contrast to what they

initially believed they needed. Four fifths of the participants initially viewed the

interpersonal match as a good one that remained good throughout the treatment. Those in

this latter group described the ongoing goodness of fit either in terms of their perceived

similarities to, or their perceived differences from, their former therapist. Similarities

included sharing a similar interpersonal style, aspiring to be like the treater, and having

values and life experiences in common. Perceived differences between the participants and

their former therapist included different, but complementary, personality traits and

differences in the level and kind of vulnerability experienced in the patient role versus the

therapist role.

Responses to question 4. (2.) (To what extent did you like your most recent

therapist, or feel fondness and affection for him or her and experience th at he or she

liked you? Did you sometimes dislike him or her, or feel disliked?) have been

organized into four categories: (1) respondents who reported liking and being liked

throughout their treatment and who reported no experience of disliking; (2) respondents

who reported liking and being liked by their treater, yet sometimes disliked their treater

but did not think their treater disliked them; (3) respondents who reported that by the end

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168

o f the treatment, they liked their treater, but earlier on, they had experienced a mutual

disliking; and (4) respondents who reported not liking their treater, but experienced being

adequately well liked by the treater.

Over half the participants reported an overall experience of liking their treater and

being liked throughout their treatment with no experience of being disliked or feeling

disliked. All these respondents noted feeling a real fondness or affection for their treater,

and two o f them mentioned experiencing loving feelings toward or from their treater. Nine

o f the 11 participants in this group reported experiencing some negative reaction toward

their treater. These included feeling angry sometimes with their treater, fearing that the

treater was bored with the participant, and experiencing distance and aloofness from the

treater. Three participants in this group reported their awareness of experiencing idealized

or eroticized transference reactions and three reported the fear of becoming disliked. It is

noteworthy that, despite experiencing anxieties about intense negative affects, these

participants perceived an overall mutual liking and an overall absence of disliking.

Six participants reported an overall outcome of liking and being liked by their

treater, yet at times during the process, they disliked the treater, but did not think the

treater reciprocated their dislike. All participants in this group reported a mutual fondness

and affection, with one o f them adding that she experienced a mutual loving, and half of

them valued being able to safely “fight” with their treater. Only two of these six offered

specific examples of what they disliked about their treater. One described his treater’s

narcissistic need for admiration, and the other disliked her analyst’s neutrality and distance

at a point in her life when she was experiencing a health crisis. The other four participants

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merely affirmed their temporary anger, hostility, or negative transference enactments.

While denying feeling actually disliked, four of the participants perceived that their treater

did experience some negative affect toward them, as evidenced by the treater’s

acknowledgment o f irritation, mere tolerance for the participant’s negativity, or expressed

anger at the furious participant. What stands out in all these accounts is that the upsetting

issues were worked on within the relationship and resulted in an eventual outcome of the

participant feeling liked and being liked, yet consciously remembering and reporting the

experience of disliking, while in the treatment process.

Two respondents reported that, by the end of treatment, they had experienced a

mutual liking, but at some time earlier, they had felt a mutual disliking. Specific reasons

they offered for disliking their treater included finding the treater to be cold and computer­

like or not helpful and not giving the participant her money’s worth. These participants felt

disliked because o f the treater’s lack of personal relatedness and because they felt withheld

from and not helped enough during “long, rocky moments.” Both noted that it was only

through long and difficult work with their treater on these intense relationship issues that

they eventually came to experience a mutual liking.

Finally, one participant reported being left at the end of treatment with the sense of

not liking his most recent treater, although he himself felt well enough liked. This

experience stood in contrast to his earlier analysis. Nevertheless, he noted that he had been

helped by both treatment processes, and he addressed subtle differences between being

helped by and liking his treater.

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In summary, over half the participants in the study reported experiencing a mutual

liking and no disliking of or from their treater, despite having consciously experienced

negative emotions toward the treater. The one third who reported an outcome of mutual

liking, but who sometimes disliked their treater during the process, reportedly worked

through upsetting relationship issues. A working through o f difficult treatment relationship

issues was also described by those respondents who eventually experienced a mutual

liking, but who had felt a mutual disliking during the process. Only one participant overall

was left with a sense of not liking his most recent therapist, despite having benefited from

the treatment. This reaction had to do with his doubts about the therapist’s integrity and

trustworthiness, despite his skill as a therapist. It thus appears that the participant’s

experience of a fundamental honesty in the treater, as well as the working through of

relationship impasses, is intrinsic to being left with a sense o f mutual liking.

Responses to question 4. (3. a.) (Regarding the match between you and your

most recent therapist: Did you think of your therapist as professionally competent?

Do you think your therapist thought of you as professionally competent?) have been

organized into three main categories: (1) respondents who replied affirmatively to both

parts of the question; (2) respondents who perceived their therapist as professionally

competent, but who expressed uncertainty about their therapist’s view of the participant’s

competence; and (3) respondents who expressed uncertainty about their therapist’s

professional competence but believed that the treater viewed them as professionally

competent.

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Over three-fourths of the participants (16) responded affirmatively to both parts of

this question. Some participants related that they definitely felt their therapist was

competent, and they elaborated on their sense that their therapist also regarded the

participant as competent. One participant observed that his analyst did not oppose the

numerous personal “life changes” he made during his analysis, which he took as tacit

support o f his personal and professional competence, while another noted that his

therapist affirmed the participant’s professional competence at a time when he felt

extremely vulnerable and was temporarily unable to work due to depression. Two

participants in this group observed that their analysts implicitly validated their clinical

work when it came up in analysis by conveying an attitude of respect for their

interventions. One of these two was in a training analysis and one was in a therapeutic

analysis. Finally, three participants commented that their analyst seemed to credit them

with more professional competence than they credited themselves with at the time.

A second group of two respondents perceived their treater as professionally

competent, but expressed some uncertainty about their therapist’s view of the participant’s

competence. Both participants were graduate students at the time of their treatment, in the

same professional discipline as their treater, and both noted how exquisitely sensitive they

were to wanting their treater’s approval. Both added that, although they got no direct

feedback, their treater probably did respect their professional competence, yet their own

anxiety about their budding professional skills colored their perceptions.

A third group of two participants related that they sometimes questioned their

treater’s professional competence during the course of the treatment but believed that the

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172

treater viewed them as professionally competent. The first described these doubts as

stemming from the perceived rigidity of the treater, while the other participant viewed

them as coming from doubt about his own competence, which he thought he had

projected onto the analyst. This participant addressed his view of his analyst’s competence

as being intimately intertwined with his own dynamic issues:

I had questions about whether she was professionally competent. She was a
candidate and a woman. I’m saying that tongue in cheek, because those two issues
take me pretty quickly to the whole issue of safety and competence and
consistency in relation to the losses I shared with you and the inconsistencies in my
background. So, essentially, I’m saying a lot of the treatment was about my
resistance to experiencing her as real, and questions about her being competent
constituted a fair amount of the treatment.

Both of these participants added that, by the end of their treatment, they had come to view

both themselves and their analyst as professionally competent, and their views on this

point changed only by working on these painful issues related to their early struggles with

trusting in the goodness of caretakers.

In summary, it is noteworthy that four fifths of the participants in the study were

definite in their affirmation of professional competence, both in their view of their treater

and in their treater’s view of them. It appears that the realistic external circumstances of

the participants as vulnerable, often youthful trainees in the early stages of learning to

conduct psychotherapy, as well as persons less experienced in making life decisions,

contributed to the significance of both wanting and believing in the therapist’s affirmation

professionally. Those few participants who questioned whether their treater viewed them

as competent also described their vulnerability as students and consciously recalled their

self-doubts, which they believed were at times readily projected onto their idealized,

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173

experienced therapist. An interesting question is posed as to whether these participants

were unable to internalize any existing affirmation that was intended by the treater and to

what extent analytic neutrality precluded the treater’s imparting even implied support of

the participant’s professional competence. The very small minority o f participants who

doubted their treater’s competence also noted treatment relationship issues that they

viewed as involving highly transference-laden images of primary caretakers as rigid and

unbending or unavailable and inconsistent. These participants noted that much of their

work in therapy entailed working in the transference on their dynamic conflicts related to

trusting in the capacity of significant others to be consistent, caring, and authentically

affirming. Over time, they came to believe both in their own and in their therapist’s

professional competence.

Responses to question 4. (3. b.) (How compatible were your professional

convictions?) show that all the participants replied that they perceived their professional

convictions and their former therapist’s professional convictions to be compatible.

Nineteen o f the 20 participants’ responses are included in this analysis, as the interviewer

unintentionally omitted asking the question of one respondent. Responses to this question

have been organized into three categories: (1) respondents who emphasized the mentoring

role o f their treater; (2) respondents who described only similarities between their own and

their treater’s professional convictions; and (3) respondents who described differences as

well as similarities between their own and their analyst’s professional convictions.

In describing their professional convictions, three respondents emphasized the

mentoring role o f their treater. Two of these respondents were new trainees as they began

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174

their personal treatment, and they observed that their treatment was a place to process

how de-skilled they felt and to have modeled for them what a good psychotherapist was.

The other participant in this group was an experienced, analytically trained therapist when

he sought his most recent treatment. He noted that his therapist, who held more o f an

existential view, broadened his horizons and taught him some of the validities o f another

perspective.

Just over half of all the respondents (11) described only similarities between their

own and their therapist’s professional convictions. Three themes of responses were found

in their answers: (1) respondents who perceived their clinical approach to patients as being

similar to their therapist’s; (2) respondents who noted personal similarities with their

former treater in holding high ethical standards, while living a very full and enjoyable

personal life; and (3) respondents who replied affirmatively about their professional

compatibility but did not elaborate on their perceived similarities.

Participants in this group commented on the similarity between their clinical

approach to treatment and that of their therapist. Their comments were further

categorized into perceptions that they hold similar views about what is curative to

patients, they hold similar theoretical beliefs, and they share similar clinical interests,

which may include a preference for working with the same patient populations.

Two respondents observed personal similarities with their former treater with

regard to holding high ethical standards, while living a full personal life.

Two respondents replied that they felt a similarity with their treater’s professional

convictions but did not specify more details about those similarities.

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175

Finally, five participants described differences as well as similarities between their

own and their therapist’s professional convictions. Three themes emerged in the area of

perceived similarities with professional convictions in this group. First, three participants

noted their shared respect for, and belief in, the therapeutic process and an approach that

values understanding the patient and puts a premium on a respectful therapeutic

relationship as curative. Second, two respondents perceived that they and their treater

shared a quest for seeking answers to existential questions that in one led to an emphasis

on growth in spirituality. Third, one respondent noted his and his treater’s shared

convictions about the usefulness of traditional ego psychology as a model for

understanding psychic phenomena.

Three themes also emerged in the perceived differences between professional

convictions in this group. First, three participants commented that they have less

conviction about the exclusive usefulness of a classic psychoanalytic theoretical approach

than did their former therapist. One of them noted that he has added a self-psychology

approach, and another stated that his convictions about the usefulness o f psychoanalytic

theory, unlike those of his former analyst, are not steady but are instead in a process of

evolution and change. Second, one participant observed that, unlike her former analyst,

she cannot put the practice o f psychoanalysis as preeminent, instead believing that

psychotherapy is as important and valuable a mode o f clinical practice. Third, one

participant noted that her former treater emphasized a spiritual base in their work more so

than she does with her patients.

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176

In summary, all the participants in the study described compatibility between their

own and their treater’s professional convictions. Over half of the respondents cited only

similarities of convictions. The most frequently cited conviction was a similar clinical

approach to treatment, particularly shared beliefs about the interpersonal nature of cure in

psychotherapy. The most frequently reported perceived difference between professional

convictions was the lower priority given by participants to the exclusive usefulness of a

classic psychoanalytic approach to treatment. Several respondents also described their

former therapist as a mentor. These results offer strong evidence that perceived

professional compatibility between the participants and their former therapist is based on

the relational aspects of the treatment enterprise.

Responses to question 4. (3. c.) (Did you feel respected by your therapist and

do you think your therapist felt respected by you?) have been organized into three

categories: (1) respondents who succinctly replied yes to both parts of the question but did

not elaborate; (2) respondents who replied yes to both parts and elaborated; and

(3) respondents who replied yes to both parts, but qualified how their treater felt respected

by them. Nineteen of the 20 participants’ responses are included here, as the interviewer

mistakenly did not ask this question of one participant.

Eleven participants responded succinctly in the affirmative with such responses as

“yes, to both.” Five respondents replied in the affirmative with elaboration. Two of these

participants described an idealizing transference to their treater early in the process. One

of them commented that the termination phase of her work was a very rich time in the

treatment. She added that it had been important to her to terminate “with dignity and not

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Ml

to be encouraged by her treater to feel only the loss of the relationship.” Yet another

participant observed that he felt respected by his analyst, except for some moments in

reaction to her repeated lateness. He added that this was just his analyst’s “humanness and

it wasn’t a big deal. I could be forgiving, especially when a person admits a mistake.”

Three participants observed that while they felt respected by their treater

throughout the treatment, there was a period when their analyst most likely did not feel

respected by them. Two of them acknowledged that because of their being distressed by

their analyst’s withholding style, the analyst may not have felt respected by the participant

early in the process. Both of these participants felt certain, however, that their treater did

feel respected by the end of treatment. Another participant noted that, despite elements of

disliking and being angry with his therapist, he respected the therapist: he acknowledged,

however, that during their rocky termination, the therapist may have felt disliked or

disrespected beyond what the participant actually experienced.

In summary, it is noteworthy that all the participants reported feeling respected by

their treater and only one participant noted feeling disrespected by his analyst’s “human

foible” o f lateness, o f which he was forgiving. Three participants, who were disappointed

by some aspect o f their interpersonal relationship with their treater, believed that their

therapist might not have felt respected at some point in the treatment. Themes connected

with mutual respect point to how idealizing transference was worked with in the

treatment, whether the analyst’s neutrality was perceived as unhelpfully withholding, and

how the termination phase was handled, especially in reference to respecting the

participant’s need for autonomy.

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Responses to question 4. (3. d.) (How compatible were your personality

styles?) have been divided into three major categories: (1) respondents who perceived that

they were compatible because of similarities with their treater’s personality style;

(2) respondents who perceived that they were compatible because of differences between

their own and their therapist’s personality style; and (3) Respondents who perceived that

they were compatible, despite the differences between their own and their therapist’s

personality style. Responses from 19 of the 20 participants are included in this analysis, as

the interviewer mistakenly omitted asking the question of one participant.

Respondents described their sense of similarity with their former therapist in

assessing compatibility with their treater’s personality style. These similarities involved

three themes, including character traits, such as affective intensity or social

gregariousness. Similarity o f professional practice was another theme. It included similar

clarity about ethics, boundaries, and the nature of the therapeutic contract, as well as a

shared love for the profession of psychotherapy and shared “profoundly positive

institutional transferences to Menninger.” The third theme of perceived similarity involved

shared cultural interests in the performing or visual arts.

Some respondents perceived that they were compatible because of differences

between their own and their therapist’s personality style. Two themes emerged in their

responses, including a perceived complementarity of personality traits, which helped the

participant feel more emotionally contained and better able to modify intense affect that

inhibited rational thinking. Conversely, a second subgroup of respondents in this group

perceived a complementarity of personality that lowered the participant’s inhibitions and

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179

usefully encouraged the experiencing and exploring of internal affects. The

complementarity involved having a therapist whose quietness was helpful to the

participants in finding their own voice, or whose perceived forcefulness of character

usefully modeled a self-assuredness with which the participant identified.

Finally, half the participants perceived compatibility between their own and their

therapist’s personality style, despite some differences. Two themes that emerged in their

responses included a perception that the differences in personality style were benign to the

therapeutic process, that is, that the differences were neither enhancing nor interfering

with the participant’s treatment. These respondents mentioned such traits as the analyst’s

perceived extroversion, compared with the participant’s introversion, and the opposite

(i.e., a more animated, self-revealing participant with a reserved, stoic analyst). Also in this

group were comments by one participant about his analyst being from a different part of

the country than himself, and by another of her experience o f her analyst as being from a

wealthier, more culturally sophisticated background. The participants in this subgroup all

experienced these differences as benign to their therapeutic process and as not particularly

detracting from, or enhancing o f their sense of compatibility with their therapist’s

personality style.

The second emerging theme involved a perception that the differences in

personality style increased the participant’s resistance to treatment. These respondents

described such traits as the therapist’s rigidity, because o f his or her inexperience as an

analyst. Therapeutic techniques that were either perceived as too withholding or too

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180

supportive were also mentioned as personality style differences that interfered with the

therapeutic process by increasing the participant’s resistance.

In summary, it is noteworthy that all participants experienced a basic compatibility

with their therapist’s personality style. This compatibility was reported not only by the

minority o f participants who noted just the similarities between their personality style and

that o f their treater, but also by the vast majority of 15 participants who cited differences

in the two personality styles. These stylistic differences were viewed as complementary

and contributing to the perceived compatibility of the personality match between the

participant and therapist by one third of those who emphasized the differences in their own

and their therapist’s personality style. One half of the participants in the study viewed the

personality differences as either benign to, or as somewhat inhibiting of, their treatment

process, the latter by increasing their resistance. Despite these variations, the participants

described perceived compatibility of personality as the norm, whether in regard to

similarities, complementary differences, benign differences, or more inhibiting differences

in personality style.

Responses to question 4. (4.) (Do you sometimes find yourself thinking about

your therapist or wishing to talk with your therapist? If so, under what

circumstances?) have been organized into three categories: (1) respondents who reported

ambivalence in thinking about, or wishing to talk with, their therapist; (2) respondents

who reported thinking about and wanting to talk with their former therapist primarily

about matters of professional practice; and (3) respondents who reported thinking about

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181

and wanting to talk with their former therapist primarily about matters in their personal

life.

Four respondents reported significant ambivalence in thinking about, or wishing to

talk with, their former therapist. In two cases, there was a premature termination due

either to the participant’s or the therapist’s career move. The other two participants

reported that, after termination, their former therapist left the institution involuntarily,

“under a cloud,” which did not negate their prior analytic work but which saddened them.

These participants were acutely attuned to the fact that their former analyst had been

forced out, which made for their considerable ambivalence about continuing contact with

the former treater. The participant in this group who left his treatment early to pursue

advanced clinical training noted his anger with his therapist during their termination phase.

He linked his anger to struggles with leaving while the erotic transference remained so

strong.

Six participants reported thinking about and wanting to talk with their former

therapist, primarily about matters of professional practice. However, wishes to speak with

the former therapist about clinical matters invariably were intertwined with the

participant’s personal life, as exemplified by the following response:

Both of my former treaters are now deceased. However, I think of them both often
and often wish that I could talk with them about treatment issues that come up, or
issues o f professional life. Because they know me so well and because I ’ve
respected them both so much, I wish I had them as colleagues, as friends, to share
some perspectives o f the world, managed care, transference-countertransference
paradigms, just name it. They are the people most centrally involved in my
personal and professional development. I had concluded by the age of 14 that
I wanted to be an analyst.

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These respondents indicated that they wished to consult with their former treater

at times o f uncertainty about clinical dilemmas with patients. Four of them wondered what

their analyst would say about their dilemma and reported drawing on a helpful internal

conversation-a “mini-session”-with their former therapist. In this group, only one

participant had, in fact, spoken to her former therapist about clinical dilemmas after

terminating. Two reported significant postanalytic contact with their treater and one

returned for a one-time consultation during a relationship crisis with a partner.

Finally, half the participants (10) reported thinking about and wanting to talk with

their former therapist, primarily about matters in their personal life. Their responses have

been organized into two subcategories, which included both what the respondents wished

to talk about with their treater after termination and what they had, in fact, spoken about

with their former treater.

Seven of the 10 participants articulated a wish to speak with their former treater

about both exclusively or primarily personal and secondarily, professional matters. The

personal issues included three subthemes: (a) marital relationship issues; (b) developmental

stage issues, such as struggling with child-rearing concerns, or the death of an elderly

parent; and (c) situational crises, including “emotional struggles” and health-related crises.

The professional issues related to a wish on the part of the participant who had only

recently terminated to report how a particular legal situation came out, and wishes to

discuss impending career changes with the former therapist, including career development

and retirement plans.

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183

Describing posttermination psychological change as a continuing process set in

motion by his treatment, one participant in this group commented:

As time progressed, after ending the treatment, I could look back and see things
that were continuing to change in my life, as a consequence of the process with
him that had set things in motion. I could tell you about my relationship with my
therapist, maybe right after I got out of therapy. But in terms of the relationship
with my father, there were things that happened between my father and I, four or
five years later, and it was like the process had been started with my therapist.
And I would think, ‘God, I wish I could tell him about this!’

Five of the 10 respondents in this category had, in fact, spoken with their former

treater about exclusively personal or primarily personal and, secondarily, professional

matters. The personal issues involved: (a) marital relationship issues; (b) developmental

“growth” issues, such as becoming a grandparent or purchasing a new home; and

(c) situational crises, including difficulty with pregnancy. The professional issues involved

having collaborated on the clinical treatment of patients and calling the former treater for

an informal consultation on systemic, organizational issues at work, or being in an analytic

study group together.

Addressing the posttermination relationship with her therapist as an evolving

process, one participant in this group noted:

It’s really something to sit back and realize that there have been a number of
phases in the postanalytic relationship between us. I’ve gone back for consultations
and I used to see him every six months just to keep him posted. Now he comes
over to the house. We have a study group together and I got brave this week and
even talked about my analysis, in the sense that I ’m talking to you about people
having to own their stuff and make their own decisions, with him right in the
room! I thought that it was very brave. And I think he took it very well. He gave
me a hug afterwards.

In summary, fourth fifths of the participants in the study (16) reported thinking

about and wanting to talk with their former therapist about personal or professional issues.

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The few respondents who reported ambivalence about posttermination contact reported

issues of premature termination or conflictual feelings about the former treater’s apparent

loss o f credibility within the psychoanalytic community. The respondents who emphasized

their wish to consult with the former therapist primarily about clinical practice sought

guidance at times of uncertainty. Half the study participants reported wanting to speak

with their former therapist about issues related to their personal life, including their marital

relationship, developmental stage issues, or situational crises. Half this group of 10 who

wished to speak with their former therapist during stressful times about personal or

professional issues had never initiated any contact posttermination. Only about one third

o f the study participants have maintained some sustaining postanalytic contact with their

former therapist. Posttermination psychological change and relatedness to one’s former

therapist were described as an evolving process by several participants. It thus appears

that, for the majority of respondents, continued psychological involvement with their

former therapist takes place as an internal object relationship that sustains them in both

their clinical practice and personal life.

Responses to question 4. (5) (In your conduct of psychotherapy, do you ever

engage in an internal dialogue with your therapist? If so, under w hat

circumstances?) have been organized into three categories: (1) respondents who replied

that they have engaged in an internal dialogue with their former therapist while conducting

therapy; (2) respondents who replied that, while not having consciously engaged in an

internal dialogue with their former treater while conducting therapy, they have

experienced other types o f psychological relatedness with their treater during clinical

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185

sessions; and (3) respondents who replied that they do not presently engage in an internal

dialogue with their former treater while conducting psychotherapy, but believe they may

have done so in the past.

Four respondents replied that they have engaged in an internal dialogue with their

former therapist while conducting psychotherapy. Three indicated that this internal

dialogue has occurred when they feel uncertain of how to understand the patient’s material

or the process between their patients and themselves, and they have actively wondered

what their former treater would say. Two noted that when patience with letting the

process unfold is called for, they have thought o f their former treater. This is elucidated in

one participant’s comments:

The most powerful example of this is that a lot of times, what I hear in my mind
from him is that often it’s okay to say nothing. And to just sit with the patient.
So that’s probably the most powerful dialogue that I get from him, because I tend
to err on the side of talking too much. And so he helps me practice some restraint,
to be quiet. So he’s very much there.

The other circumstance identified as a reason to dialogue internally with the former

treater was when the patient’s material touches very closely on one’s own dynamic issues,

which was noted by two participants. One said that when she evokes her former analyst’s

help to sort out the patient’s material and “to say the right thing,” she has felt helped by

“almost a spiritual sense that [her] analyst’s unconscious, [her] own unconscious, and

[her] patient’s unconscious-all three-are connected in some primary process way that is

therapeutic.” The other participant observed that in reflecting on this question, he learned

something new about what his former analyst was trying to tell him and what he thinks he

has perhaps unconsciously drawn on.

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One participant in this group of four noted that he thinks about his former analyst

more when he considers who has influenced him and the ideals for which he strives, than

when he is with patients. He described his first analyst as an influential person who helped

form his ego ideal in a more fundamentally personal way than as merely an influence on his

clinical work. This same participant described the notion of internal dialogue as an

evolving but only partially conscious process that changes over time, posttermination:

With my second therapist, not so much in recent years, but for the first few years
after, I often had kind of an internal dialogue with him. He made a veiy vivid
impression on me and we’re a lot alike. So in more recent years, I don’t so often
do that. Though nothing specific comes to mind, over the years, there have been a
half dozen or so instances when I’ll find myself saying something and
remembering, ‘That’s almost precisely what he said to me.’

Half the study participants (10) replied that they have never engaged in an internal

dialogue with their former treater while conducting therapy, yet most report experiencing

other types o f internal relatedness. Although two participants offered only that this internal

relatedness does not occur in their experience, several subthemes emerged in the group

overall. One participant who had terminated only recently observed her wish to continue

the actual therapeutic dialogue with her treater only when she is feeling personally

stressed. Two participants offered that they believe they have internalized their former

treater’s careful listening and therefore are not focused on a separate dialogue while with

patients. One participant mentioned the self-analytic function that he carries from his

analysis, describing it as part o f himself that takes place during clinical sessions when he

experiences particular countertransference reactions:

Rather than having an internal dialogue with him, I do a lot of self-analysis. For
example, if I’m feeling inadequate in understanding the patient, it used to be that
I believed that generally. Now I’m apt to say, ‘This is countertransference. What

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187

am I contributing and what is the patient contributing?’ I think that’s a skill I’ve
developed, and it’s so much a part of me that I don’t think about it, but it’s there.
Because I know that if I went to see my analyst and talked about that, I’d probably
engage in some self-reflection as to what set off those feelings, and I’m pretty sure
that I know what does, regarding a loss or competition.

Four participants reported that they do not have an internal dialogue with their

former treater during clinical sessions, but they do experience “verbal memories” of their

analyst during sessions. They may remember what the analyst might have said or may find

that they are “using his words.” The contents of these verbal memories were related to

appreciating the power of the analyst’s simple statements as a good clinical model and the

importance of interpretations being made from a position of feeling supportive rather than

critical of the patient. Finally, one participant addressed the internalization process of her

analytic work as contributing to her identity as a therapist, noting that she did not engage

in an internal dialogue with her former therapist during sessions but did rely on the essence

o f his presence:

It’s more capturing the feeling tone of words than concrete incidents. It’s not
like thinking about him and thinking what he might have said. It’s much more
interwoven into the fact o f how I work and how I think.

Finally, six respondents replied that while they do not presently engage in an

internal dialogue with their former treater while conducting psychotherapy, in the past

they may have done so. It is noteworthy that these participants who were quite clear that

they do not presently engage in an internal dialogue, noted that it “makes theoretical

sense” that this may have happened in the past, but they have no specific, subjective recall

o f it, only a dim awareness. Two in this group of six conjectured that such dialoguing

might have happened in the past during times of clinical uncertainty. The lack o f specificity

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188

in their responses may reflect a fading awareness of a process of internalizing the object

relationship and being left with little conscious recall of doing so, as reflected in this

participant’s comments:

I think, early on, I might have dialogued with my analyst when I would be
uncertain, like ‘Jeez, what do I do now?’ When I was into something that just was
really overwhelming. I think I’ve kind of moved away from that at this point.

In summary, only one-fifth of the participants in the study (4) reported having

engaged in an internal dialogue with their former treater while conducting psychotherapy.

Situations of clinical uncertainty tend to actively evoke an image of the former therapist

and how she or he would intervene. These evocations might serve to give the participant

some needed patience and respect for the slow process of psychological change.

In addition, when the patient’s material is uncomfortably similar to the participant’s own

dynamic struggles, an image of dialoguing with the former therapist may provide direction

in the analytic enterprise. The very limited internal dialogue during clinical sessions

described by these participants appears to have served the function of providing clinical

guidance during uncertainty but only relatively early after termination from personal

treatment.

Evoking memories of their former therapist through an internal dialogue was

considerably less prevalent than were other types of reported internal relatedness. More

prevalent was identifying with the analyst’s careful style of listening or recalling “verbal

memories” of what the former treater said in particular situations and, thus, how she or he

modeled good clinical intervention. Interestingly, only one participant described his

continued self-analysis of countertransference paradigms as a form of connectedness with

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189

his former analyst. There was considerable evidence that memories o f discreet interactions

with the former treater fade over time, leaving the emotional tone of the treatment as the

substrate through which evocative memories are filtered. The study participants described

an evolving and only partially conscious process of identification that leaves them feeling

as if their personal treatment experience is indeed woven into how they work and think

and who they have become as a psychotherapist.

At the conclusion of the interview, each participant was asked to offer any

additional thoughts about the research topic. Six participants added comments. One

observed that, rather than traditional psychotherapy, the Twelve Steps of Alcoholics

Anonymous is the best blueprint for personal reconstruction. Another respondent

addressed the differences between analytic treatment relationships in a small, close mental

health community, such as where this study was conducted, and in large cities, where

patients might never know the background of their therapist. She wondered how the

current study results would be influenced by the small, “hothouse, fraternity” feeling in this

close analytic community. Four participants elaborated on the importance of personal

therapy in coloring their life, both personally and professionally. One noted being further

convinced of the importance of having been a patient before trying to work therapeutically

with patients. Another participant, who had responded generally doubtfully throughout the

interview as to whether his clinical work had been influenced by his personal treatment,

added:

Once we got going, it was clear to me that it’s had some influence. More than
I’ve thought, once I got talking about it and followed the leads of your questions.
And it’s kind of too bad, in some ways, although I wouldn’t want to belong to a
discussion group to obsess about that necessarily. It’s kind o f too bad that at least

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190

I probably don’t take time to think about that veiy much. I think it would be
important to do that. So I think the process here, for me, but also your research,
is veiy useful in that sense. Maybe other people do a lot more of that and I just
don’t, particularly in terms of influence on my work. As we talked about it, I can
see other influences on me as a person and, consequently, on my work.

In summary, approximately one fourth of the respondents offered their additional

thoughts at the conclusion of the interview. Their comments included one participant’s

view that a 12 step program was more helpful than traditional psychotherapy for personal

change. Another respondent noted that the sociocultural context of this study in a small

psychoanalytic community might bear heavily on the results. Five of these six respondents

elaborated on the positive influences of their personal therapy, both personally and for

their professional work.

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Data Analysis: Phase 3


Association of Perceived Influence of Personal Therapy with Perceived Benefits,
Risks, and the Interpersonal Relationship

The data analysis involved first identifying and categorizing themes in the narrative

responses of each participant to the interview questions developed from the literature

model. In the second phase of data analysis, the aggregate responses were then outlined

(see Appendix I). The third and final phase of the data analysis sought to identify

relationships within the various areas of the model by determining whether particular

themes o f benefits, risks, and aspects of the interpersonal relationship would be associated

with varying levels of reported influence of an individual’s personal therapy in informing

the clinical work. The level of data from the outlined results which was analyzed in this

final phase of comparing themes, includes only the major categories of response for each

question in the model. It was determined to be a reportable level of analysis, given

limitations on the volume o f data that can be effectively compared without computer

assistance.

The first step was to display the individual responses of each participant’s

categorized results in each o f the study’s four areas: benefits, risks, influence on practice,

and interpersonal relationship. This arrangement enabled the researcher to begin

identifying patterns of response in each of the four model areas.

The goal of this phase o f data analysis was to compare participants’ perceptions of

the influence of their personal therapy on clinical practice with their responses in the other

areas o f the model. This process called for organizing the various themes in the third area

of the model-the reported influences of personal therapy on the professional conduct of

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192

psychotherapy. After reviewing the outlined responses to the six questions on the

interview schedule that evaluated perceived influences of personal therapy on conducting

psychotherapy, the investigator determined that the descriptive responses could be

effectively ranked into levels of relative influence. For example, responses to question

3. d. (i) (“Do images or thoughts of your therapist ever come to mind while you’re

conducting psychotherapy?”) resulted in three basic response variations with implied

ordinal levels of ongoing influence: (1) no current or past thoughts of treater; (2) no

current but past thoughts of treater; and (3) ongoing, continued thoughts o f treater, now

and in past.

The five remaining questions in this section produced thick descriptive data.

Nevertheless, the responses can be usefully quantified, with the addition of qualitative

themes within categories to capture their intended meaning. For example, responses to

question 3. a. and b. (“Do you believe you work differently with your patients as a

consequence of having received your own therapy? I f so, in what ways; which

aspects of your therapy do you think you draw on?”) were categorized as:

(1) uncertain that personal therapy informs clinical work; and (2) yes, personal therapy has

influenced my work with patients. There were five identifiable themes of influence in the

affirmative responses in the latter category. These consisted of: (a) enhanced awareness of

the importance of the treatment structure; (b) drawing on a broader range o f interventions;

(c) enhanced confidence in the therapeutic process; (d) deepened conviction about the

treatment relationship as an important vehicle for psychic change and growth; and

(e) increased acceptance of the realistic limitations of the psychotherapy enterprise.

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Of the six questions in the perceived influences section, only the final one was

entirely qualitative in nature. Question 3. d. (iii) (“Which, if any, personal attributes of

your therapist do you find yourself most identifying with in your work?”) garnered

three themes o f response, with participants identifying with: (a) how the therapist

conducted his or her life outside the treatment relationship; (b) admirable personal

character traits of the former therapist; or (c) the therapist’s capacity to conduct

treatment.

The researcher then assigned a rank to the categories of response to all except the

final question in the section on perceived influence. Individual responses were ranked

according to the strength o f the participants’ perception that personal therapy had had a

significant and positive influence on their clinical work. For example, responses to

question 3. c. (i) (“To w hat extent has your therapist served as a role model for you

in conducting psychotherapy?”) fell into three rankable categories. These consisted of:

(1) the analyst had been a significant role model and only positive identifications were

described; (2) the analyst had been a significant role model and the participant offered

both positive identifications with, and differences from, how the analyst practiced; and

(3) the analyst was not perceived as a significant role model in conducting psychotherapy.

That the second category, in which participants offered areas of differentiation, actually

describes less positive identifications can be discerned by examining the differentiation

subthemes in the treater’s practice conduct. These points of differentiation include a

perception o f the former treater as withholding useful conceptual thinking or emotional

relatedness. Therefore, the first category contains the most positive responses and is

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194

ranked “2,” the second category is ranked “ 1,” and the third category is ranked “0”

(see Appendix G).

Using the outline o f responses coded for each participant in the prior phase of the

data analysis, the researcher calculated each participant’s categorized responses to each of

the six questions in the section. The scores fell between -1 and 7. This range was divided

into equal thirds, with the levels of influence termed “low level,” “medium level,” and

“high level.” The “low level” of influence consists of two participants whose combined

rankings on the six questions fell between -1 and +1. The “medium level” of influence

consists of nine participants whose rankings fell between 2 and 4. The “high level” of

influence consists of nine participants whose rankings fell between 5 and 7.

The responses of one participant exemplify this process. This participant’s

responses are ranked after each abbreviated question:

3. a. & b. Work differently because of personal therapy? If so, how? (2) Yes = 1
d) deepened conviction about importance of therapy relationship;
e) increased acceptance of realistic limitations of psychotherapy

3. c. (i) To what extent was treater a professional role model?


(1) Significant and only positive identifications noted = 2

3. c. (ii) What do you perceive as being your therapist’s limitations or mistakes that have
influenced your work with your own patients?
(2) Limitations that influence my work = -1
due to: a) theoretical biases of analyst

3. d. (i) Do images or thoughts of your analyst ever come to mind while conducting
psychotherapy?
(2) Yes, currently and in past = 2

3. d. (ii) Do you remind yourself of your analyst while you’re working? If so, describe.
(2) Yes, I do = 1
a) similar with analytic technique

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3. d. (iii) Which, if any, personal attributes of your analyst do you find yourself most
identifying with in your work?
(2) admirable personality traits of analyst

Adding the rankings in the first five questions gives a response of 5: (1 + 2 +

[-1] + 2 + 1 = 5) as the assigned level of positive influence of personal therapy on

conducting psychotherapy described by this participant. This process was undertaken for

each participant (for results see Appendix H). Both the high and middle levels-of-positive-

influence groups consist o f nine members each, with only two members making up the low

influence group.

After determining the relative reported level o f positive influence for each

participant, the researcher examined the participants’ responses within each o f these three

levels-high, middle, and low-to discover whether clusters or patterns existed in intragroup

responses. An analysis of these intragroup responses is followed by an analysis comparing

the patterns of response in the high, middle, and low level-of-influence groups within each

of the other areas of the model (i.e., benefits, risks, and the interpersonal relationship with

the treater). The results of this data analysis are presented in the following section.

Patterns of Response in Perceived Influences of Personal Therapy on Conducting


Psychotherapy

3. a. & b. Do you believe you work differently with your patients as a consequence o f

having engaged in your own therapy? I f so, in what ways; which aspects o f your

therapy do you think you draw on?

In both the high and middle level-of-influence groups, there was practically

unanimous reporting o f working differently as a consequence of personal treatment, with

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196

all but one individual in both groups emphasizing increased conviction about the

importance of the treatment relationship. Over half the middle-level group noted that

treatment increased confidence in the treatment process. Conversely, both members in the

low influence group expressed uncertainty that their personal therapy informs their clinical

work, noting that their practice has instead been more influenced by experience doing the

work itself, by formal education, and by life experience.

3. c. (i) To what extent has your therapist served as a role m odelfor you in conducting

psychotherapy?

All but one of the high level-of-influence group members reported that their former

treater was a significant role model and that they had only positive identifications with

their former therapist. The sole participant who reported that her analyst was a significant

role model, but then offered evidence of both positive identifications and areas of

difference, noted that the differences concerned benignly experienced, unavoidable,

gender-based, stylistic variations in one’s degree of reserve with patients.

In contrast, the middle level-of-influence group’s results were evenly divided, with

about half the participants experiencing the therapist as a significant role model-with only

positive identifications-and about half experiencing the therapist as a significant role

model but one with both positive identifications and areas of difference. Those who cited

areas o f positive identification as well as areas o f difference described their therapist as

well-trained, compassionate, and empathic, yet with an occasionally withholding style.

One participant in the low-level group described his former therapist as a

significant role model, citing evidence of his identification with her capacity to listen

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197

carefully, yet differing from her in that he was more forthcoming with his own patients.

He experienced his analyst as withholding her conceptual thinking from him, which he

believed prolonged his treatment unnecessarily. The other participant did not experience

his former analyst as a significant professional role model.

3. c. (ii) What do you perceive as being your therapist's limitations or mistakes that

have influenced your work with your own patients?

Responses to this question were about evenly divided between “no perceived

limitations and only positive comments offered” and those who described limitations that

they thought had, in fact, influenced their clinical work. The praises o f the former group

included perceived genuineness and authenticity in the treater and a belief that the “good-

enough therapist” does not have to be perfect or without personal limitations or

misfortunes to do good work. The most common limitation involved perceived theoretical

biases o f classical psychoanalytic theory. None in this group reported limitations due to

their analyst’s countertransference errors or human foibles.

Unlike participants in the high level-of-influence group who were evenly divided

on this question, respondents in the middle level-of-influence group all experienced

limitations in, or mistakes by their analyst that they believe influenced their own clinical

practice. In turn, these limitations were about evenly divided among those caused by the

treater’s perceived theoretical biases or limitations due to technique, and limitations due to

the analyst’s personal vulnerabilities.

Both participants in the low level-of-influence group reported limitations that

affect their clinical work. These involved the analyst’s theoretical biases and inability to

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198

structure the direction of the hour as much as the participant believed would have been

helpful. One participant noted the analyst’s perceived vulnerability (i.e., being overly

sensitive to personal criticism). Both participants remarked on their ongoing attempts to

navigate these issues differently with their own patients.

3. d (i) Do images or thoughts o f your therapist ever come to mind while you ’re

conducting psychotherapy?

Three fourths of the participants in the high level-of-influence group of nine

reported that thoughts of their analyst have come to mind, both now and in the past, while

they are conducting psychotherapy. These thoughts tend to occur whenever a patient

presents puzzling material. In contrast, three participants said that they had not currently,

nor in the past ever had conscious thoughts of their former treater while conducting

therapy. But two of these three observed that they identified with their former analyst in

that he or she was a very thoughtful listener who focused exclusively on their material

during sessions and that they strived to provide the same kind o f active, focused attention

to their patients. Consequently, they believed that conscious thoughts of other

relationships-even with their former therapist-would not tend to enter their awareness in

the consulting room.

Unlike those in the high level-of-influence group, respondents in the middle level

were about evenly divided among three groups: (1) those not currently, nor in the past,

having thoughts or images of their former therapist while conducting psychotherapy;

(2) those reporting that not currently, but in the past, they had had thoughts or images of

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199

their treater while conducting therapy; (3) and those continuing to have thoughts or

images o f their former treater while conducting psychotherapy.

Both participants in the low level-of-influence group responded that they do not

currently have thoughts or images of their treater while conducting sessions and that they

do not think they ever have had in the past, even during the course of their own treatment.

One of them added that perhaps this process is unconscious and hence, does not reach his

awareness.

3. d (ii) Do you remind yourself o f your psychotherapist while yo u ’re working? I f so,

can you describe any such moments, any particular clinical circumstances?

All nine respondents in the high level-of-influence group reported that they do

remind themselves of, or think they are similar to, their former analyst in how they

conduct psychotherapy. Over half linked the similarity to technique-related aspects of

conducting therapy.

Eight of the nine participants in the middle level-of-influence group reported that

they do remind themselves of, or think they are similar to, their former analyst. Their

responses were about evenly divided among perceived similarities in therapeutic

technique, interpersonal style, and theories about what is curative.

Responses were mixed in the low level-of-influence group, with one of the two

respondents there reminding himself that he sometimes used an aspect of his former

therapist’s technique while conducting treatment. This mirroring involved emulating her

nonintrusive, nonseductive body language, in cross-gender treatment relationships.

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3. d (iii) Which, if any, personal attributes o f your therapist do you fin d you rself most

identifying with in your work?

In both the high and middle level-of-influence groups, responses to this question

were about evenly divided between those who reported identifying either with the personal

traits o f the analyst and how he or she apparently conducted his or her life outside the

consulting room or with the analyst’s capacities in conducting treatment. No readily

apparent pattern was observed with this variation.

Both respondents in the low level-of-influence group replied that they identify with

their former therapist’s capacity in conducting treatment by taking the work very seriously

and being very absorbed in it. It is noteworthy that neither participant included as

identifications the treater’s personal qualities or perceptions about the therapist living life

outside the analytic hour.

In summary, the patterns that emerge in the high level-of-influence group include

increased valuing of the treatment relationship between the therapist and patient. They

noted only positive identifications with their former therapist as a professional role model.

When asked about their former treater’s limitations or mistakes, they instead described the

treater’s genuineness and authenticity and their belief that their treater modeled being

good enough (i.e., not without personal limitations) to do good clinical work. The

majority believed that their former analyst might feel puzzled at times by their patients’

material. All reported reminding themselves of, or thinking they are similar to, their former

therapist while conducting psychotherapy, mostly with regard to therapeutic technique.

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201

Patterns that emerged in the middle level-of-influence group similarly include the

greater valuing of the treatment relationship between the therapist and patient, as well as

increased confidence in the treatment process. About half this group noted positive

identifications, as well as areas of differences, such as an occasionally withholding

relational style that was viewed as unhelpful. Unlike the high level-of-influence group, this

group experienced limitations in, or mistakes by, their analyst that they believe have

influenced their clinical practice. No clear patterns emerged regarding thoughts about their

former treater while conducting psychotherapy, but virtually all o f them believed that they

are similar to their former treater.

Finally, patterns emerging in the low level-of-influence group (of two) include

expressed doubts about working differently with patients after a personal therapy. One

respondent did not experience his former therapist as a significant professional role model,

while the other revealed that his analyst is a professional role model, but he dis-identifies

with her tendency to withhold her conceptual thinking and strives to avoid doing this with

his own patients. Both cited personal limitations in their analyst or his or her practice

conduct from which they strive to differentiate themselves professionally. Neither is aware

o f currently or previously having thoughts of their former therapist during clinical hours,

although one did acknowledge identifying with an aspect of his former therapist’s

technique related to body language. In contrast to the two higher level-of-influence

groups, both respondents identified with their former analyst’s absorption in the clinical

work, but not with the therapist’s activity as a person in the world.

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202

An integrated comparison of the responses of these three groups indicates that the

low level-of-influence group differs from the two higher ones in that the participants do

not view personal therapy influencing their clinical work. There is, in fact, a progressive

decrease in reported positive identifications with the therapist as a professional role model

from high to middle to low level. In addition, their perceptions of mistakes and limitations

in the treater differed greatly among the three groups, as did thoughts about the former

treater during moments of clinical uncertainty. Interestingly, all three groups reported

thinking that they work similarly to their former treater, in at least some circumscribed

way.

Comparing Levels of Influence o f Personal Therapy on Clinical Practice with


Associated Benefits of Personal Therapy

After identifying the intragroup patterns of response within the various levels of

perceived influence of personal therapy on conducting psychotherapy, the researcher

analyzed the data in the first section o f the interview, the perceived benefits, by seeking

associated patterns of response for each of these three levels of influence. As in the prior

section, the findings are presented for each of the six questions that make up the benefits

section of the study. Summarized results of associated benefits for each level of influence

conclude this section.

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203

1. Please describe what has been beneficial to you in your personal therapy or

analysis?

About half the members of both the high and middle level-of-influence groups

identified increased self-understanding and alleviation of symptoms as benefits. The high

level group also noted benefits of enhanced clinical work and improved self-esteem and

self-acceptance, while the middle level group reported improved interpersonal

relationships. The two participants in the low level-of-influence group both spontaneously

reported that their self-understanding was promoted by their personal therapy.

1. a. How useful was your therapy in enhancing your awareness and understanding o f

yourself?

About two thirds of the respondents in both the high and middle level-of-influence

groups reported an improved understanding of their psychodynamics after personal

therapy. About half o f those in the high influence group also noted the importance of their

relationship with their former treater in promoting self-awareness. Both members of the

low level-of-influence group reported improved understanding of their psychodynamics as

a subtheme o f enhanced self-awareness and self-understanding.

1. b. How useful was your therapy in enhancing your self-esteem and self-confidence?

Eight of the nine respondents in the high level-of-influence group believed their

personal therapy clearly enhanced their self-esteem and self-confidence. Over half of them

identified enhancement of their professional identity as a component of their improved

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204

self-esteem. Almost half also emphasized the therapist’s role in promoting their self­

esteem.

No clear pattern of response emerged in the middle group, with about half the

respondents there reporting that their therapy clearly enhanced their self-esteem and self-

confidence and the other half reporting mixed or equivocal results.

Both participants in the low level-of-influence group described mixed or equivocal

results regarding enhancement o f self-esteem and self-confidence as a benefit of their

personal therapy.

1. c. How useful was your therapy in improving your interpersonal relationships?

The majority of respondents in both the high and middle level-of-influence groups

responded that their treatment was clearly helpful in improving their interpersonal

relationships with significant others. However, just under half the members in the high

level-of-influence group(all women) believed it was equivocally helpful to their

relationships (e.g., by enabling them to clarify relationship boundaries, which created some

interpersonal conflict but resulted in greater mutuality).

One participant in the low level-of-influence group described his personal therapy

as clearly enhancing his interpersonal relationships, while the other noted mixed results for

his interpersonal relationships.

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1. d. How useful was your personal therapy in enhancing your therapeutic skills, fo r

example, with empathy, in using countertransference, in structuring treatment, in

understanding the process ofpsychotherapy?

Over three fourths of the members in both the high and the middle level-of-

influence groups reported that their personal treatment led to psychological changes

promoting changes in their clinical practice. Members in both groups also noted that their

personal treatment aided them in learning about the therapy process. Over half commented

on the importance o f the treatment relationship with their former therapist in promoting

their therapeutic skills. Within the subtheme o f learning about the therapeutic process,

both participants in the low level-of-influence group described enhancement of their

therapeutic skills.

1. a How useful was your therapy in resolving characterological issues and alleviating

symptoms?

Three fourths o f the participants in the high level-of-influence group reported

that their treatment helped alleviate psychological symptoms, but only modified their

characterological issues. The rest believed their treatment both alleviated symptoms

and resolved their characterological issues.

Although symptom alleviation was experienced by virtually everyone

in the middle level o f influence group, a minority o f them indicated significant shifts

in both symptoms and character.

Interestingly, both participants in the low level-of-influence group reported their

treatment to be beneficial both with symptom alleviation and with resolving or modifying

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206

characterological issues. It is noteworthy that even in this small group of respondents who

report the least influence o f their personal treatment on their clinical work, symptom

alleviation was nevertheless experienced as a clear benefit. Symptom alleviation was

valued across the spectrum of participants.

In summary, several patterns emerge in analyzing the benefits of personal therapy

that were reported by members of the high level-of-influence group: (1) improved

understanding of their own psychodynamics; (2) enhancement of self-esteem and self-

confidence, as well as promotion of their professional identity; (3) psychological changes

that affected clinical practice; and (4) symptom alleviation. The somewhat mixed results of

benefits to interpersonal relationships stem from the female participants’ noting

temporarily increased interpersonal conflict as they clarified their personal boundaries.

Reported psychological changes that resulted in changes in clinical practice were also very

prevalent in this group, as were an emphasis on the value of learning about the treatment

process and the treatment relationship within the context of enhancing therapeutic skills.

This entire group reported symptom alleviation, with either modification of, or resolution

of, characterological issues.

A summary of emergent patterns of benefits associated with the middle level-of-

influence group includes a similar valuing o f self-understanding and a crediting of the

treatment relationship with promoting self-awareness. No clear pattern emerged, however,

regarding self-esteem and self-confidence. Nevertheless, these participants emphasized

that their relationships with significant others were improved with personal treatment

more so than did those in the high level-of-influence group. This group also valued the

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207

usefulness of their personal therapy in enhancing their therapeutic skills and in alleviating

symptoms, but no clear pattern regarding characterological change could be identified.

Finally, a summary of the patterns of benefits reported by the low level-of-

influence group includes a similar valuing of self-understanding and a crediting of the

treatment relationship with contributing to self-understanding. Both participants described

mixed or equivocal results about enhanced self-esteem and self-confidence. Reported

benefits to interpersonal relationships offer no emergent pattern in this group. As a sub­

theme o f enhanced therapeutic skills, both participants valued learning about the

therapeutic process. Both reported symptom alleviation and resolution or modification of

characterological issues.

An integrated comparison of these results reveals that the high level-of-influence

group reported benefits in all categories of inquiry. Both the middle and low level-of-

influence groups reported benefits similar to those of the high level-of-influence group

with regard to valuing self-understanding, learning about conducting psychotherapy, and

alleviating symptoms. The apparent differences lie in the category o f enhanced self-esteem,

where the middle and low level-of-influence groups report a relative absence of enhanced

professional identity. The other area of difference lies in the perceived enhancement of

their interpersonal relationships, where the low level-of-influence group reports no clear

pattern o f benefit.

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208

Comparing Levels of Influence of Personal Therapy on Clinical Practice with


Associated Risks and Disappointments o f Personal Therapy

2. Please describe any disappointments, risks, or negative effects o f your personal

therapy or analysis.

Responses to this question show a similar pattern for both the high and middle

level-of-influence groups, with the vast majority o f participants noting some

disappointment in their therapy and only a few acknowledging risks of treatment.

Surprisingly, the single participant in the study who reported a negative effect of personal

treatment was a member of the middle level-of-influence group, whereas the members of

the low level-of-influence group reported only a risk of, or disappointment in treatment.

2. a. To what extent did you experience excessive stress or psychological distress as a

consequence o f your personal therapy?

Three fourths of the members of the high level-of-influence group reported no

excessive stress as a consequence of their personal treatment. Most, however, noted some

“nonexcessive” stresses. The few who noted excessive stress viewed it as an inherent,

meaningful part o f treatment. The patterns of response in the middle level-of-influence

group were similar except that one participant believed the stress he experienced was not a

necessary and inherently purposeful part of his psychological growth. One member of the

low level-of-influence group reported no excessive stress or distress consequent to

treatment. The other participant at that level related the excessive stress he experienced as

due to a lack of mutuality in discussing his readiness to terminate, which left him feeling

that his treatment was unfinished.

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209

2. b. D id you experience any problems with the working relationship?

Surprisingly, two thirds of the high level-of-influence group reported problems

with the working relationship with their former treater. These participants described

complications related to their perceptions of the therapist as vulnerable and in need of

protection (due to a sudden relationship loss), as overly sensitive or too focused and

serious, or as having flaws in technique, (e.g., nonadherence to the time frame, with

chronic lateness), or lacking in neutrality. Only one participant noted her own resistance

as contributing to the perceived problem in the working relationship.

The majority o f those in the high level-of-influence group who experienced

problems with the working relationship added that working actively on these problems

eventually led them to a positive identification with their analyst as a professional role

model. Discussing the issue as part of their therapeutic work led to an acceptance of the

analyst’s way o f working, which had initially created conflict. For example, discussing at

length one analyst’s persistence in charging for missed sessions during the participant’s

illness, or another analyst’s personal problem with lateness was cited as contributing to

positive identifications and helping to resolve the perceived difficulty in the working

relationship. The one participant in this group who described a dis-identification with

her analyst’s working style revealed that her analyst never did explain why he persisted

in calling her by her surname, although she had long requested that he address her less

formally.

In fact, the responses o f the middle level-of-influence group rank more positively

than do those o f the high level group. In this group, over half the respondents noted no

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210

problems in their working relationship. Of the four participants who did report

experiencing problems, unlike in the high level group, only one respondent reported

focusing actively on the conflict, with the analyst’s help, in treatment. It thus appears that

participants who believed that their problems with the working relationship became a

central focus of the therapeutic dialogue ultimately became more positively identified with

their former therapist as a professional role model than did those participants who do not

report that problems in the working relationship were thoroughly discussed in treatment.

One of the two members of the low level-of-influence group reported no problems

in the working relationship, but still viewed his therapist as not being forthcoming enough

about her thoughts, which extended his treatment unnecessarily. The other participant at

this level perceived his analyst as vulnerable and in need of protection, due to life

circumstances and to a personality trait of oversensitivity.

2. c. To your way o f thinking, did your therapist make treatment errors in your work

together? I f so, please specify.

The responses of the high level-of-influence group were roughly evenly divided

between four categories of responses to this question. Two participants perceived no

treatment errors. Another three reported no actual errors, yet wondered whether their

former analyst fully understood them (e.g., the amount of their family relationship stress),

or questioned the analyst’s loose management of the therapeutic time frame, or differed

with the analyst’s move away from analytic neutrality at termination.

The high level-of-influence participant who noted a minor treatment error not

substantively detrimental to his treatment process (time management) nevertheless

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211

wondered why it was uncharacteristically not open for exploration with his analyst.

Three other participants in this group experienced treatment errors they viewed as

detrimental. These mistakes involved incompletely exploring the participant’s dynamic

issues, using flawed analytic techniques (e.g., mistiming interpretations, which was

experienced as hurtful ,or rigidly maintaining neutrality), and enacting harmful

countertransference reactions.

The middle level-of-influence group’s responses to this question are again more

apparently positive. Only one participant noted experiencing treatment errors detrimental

to his process, based on the analyst failing to accurately diagnose the extent of the

participant’s psychological problems.

One member o f the low level-of-influence group described no treatment errors, but

questioned whether he could safely explore issues related to his sexual competence, given

his erotic transference to his female analyst. The other member of this group described

treatment errors related to harmful countertransference enactments by his analyst, which

he experienced as detrimental to his treatment process.

2. d. Do you think you have identified with your therapist in some way that has

affected you adversely?

The responses o f the high level-of-influence group were also fairly evenly divided

among the four levels o f overall responses. Two participants reported that they did not

experience adverse identifications, but instead noted some positive ones. Three in this

group simply replied that they experienced no adverse identifications, while one described

a dis-identification with a negative aspect of his analyst, whose failure to take good

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212

physical care of herself influenced his resolve to begin exercising regularly. Three

participants believed they identify with their former analyst in some way that affects them

adversely: (1) identifying with the analyst’s neutrality to such an extent that it stifles the

participant’s clinical spontaneity and playfulness; (2) feeling “defensively stuck in

neutrality”, like an analyst whose neutrality limited his clinical effectiveness with a

particular dynamic issue in treatment; and (3) suffering an adverse identification, or a

“multigenerational influence of the negative” by adopting the former analyst’s annoying

verbal mannerism. All of these adverse identifications relate to the analyst’s conduct of

professional practice, rather than to his or her personal life.

Again, the middle level-of-influence group described more apparently positive

results on this question than did the high level-of-influence group. Seven of the nine

experienced either positive identifications or at least no adverse identifications. O f the two

respondents in this group who did experience an adverse identification with their treater,

one noted that he shares similar distasteful personality traits with his analyst, and the other

observed that her identification with her analyst’s reserved, cautious personality style has

contributed to her difficulty in forming friendships. Unlike those in the high level-of-

influence group, these two participants report the adverse identifications to be on a

personal rather than a professional level.

Both members of the small cohort of low level-of-influence described negative

aspects of their treatment relationship. One cited a dis-identification with his former

analyst’s cultural insensitivity, believing that it enhanced his own. The other participant

noted an adverse identification with his former analyst, in which his experience of his

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213

analyst’s neutrality has resulted in making him feel less spontaneous and playful as a

treater.

2. e. In your view, was your effectiveness as a therapist blocked due to confusion in

being both a patient and a therapist at the same time?

About half the participants in the high level-of-influence group responded that their

clinical work was enhanced by being in personal therapy concurrently. One participant

simply stated that there were no adverse effects. Three others denied any perceived

blockage in their therapeutic effectiveness with patients yet acknowledged complications

(e.g., preoccupation with one’s own psychological issues that made it occasionally difficult

to attune to patients; the struggles to transition from being the patient to being the

therapist; and competitive anxieties about being in the analyst’s chair). The one participant

in this group who did perceive blockage in her therapeutic effectiveness was just beginning

her clinical training and thought she had engaged in a countertransference enactment that

led to premature termination with a patient struggling with issues similar to hers.

The middle level-of-influence group’s responses to this question cluster much like

those of the high level-of-influence group. The exception is that one more participant in

this group reported experiencing blocked effectiveness. One participant cited such adverse

effects as feeling overwhelmed by engaging in personal therapy concurrently with rigorous

postgraduate training, which made it difficult to transition from being the patient to being

the therapist, because of feeling too stirred up to attune well to patients at times.

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Interestingly, both members o f the low level-of-influence group believed that then-

personal treatment promoted their clinical work by serving a containing function, which

enhanced their sensitivity, empathy, and identification with their patients.

In summary, several patterns emerge in analyzing the disappointments and risks of

personal treatment which were reported by members of the high level-of-influence group.

The majority noted some disappointments, rather than actual risks, but none in the group

noted true “negative effects.” The few who acknowledged excessive stress viewed it as an

inherent, meaningful part of in-depth psychological treatment. Surprisingly, well over half

the high level-of-influence participants reported problems with the working relationship

with their former treater. These complications were due to perceptions of the analyst as

personally vulnerable and in need of protection, or to perceived flaws in analytic

technique, especially with regard to a lack of analytic neutrality. Noteworthy is that a large

majority of participants in this group who experienced working relationship problems

spontaneously added that they had actively worked on them as a central part of the

treatment process. This apparent “working through” contributed to an eventual positive

identification with the analyst as a professional role model. A range of experiences

regarding perceived treatment errors was found in this group. Those few participants who

reported the most detrimental errors experienced incomplete analytic exploration of their

dynamic conflicts, or flawed analytic technique in mistimed interpretations, rigid

maintenance of neutrality, or countertransference enactments. Their responses were also

evenly divided regarding adverse identifications with the former analyst. The majority did

not experience adverse identifications, but those who did feel they have identified with the

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215

analyst’s neutrality in a way that has stifled clinical spontaneity and playfulness or limited

clinical effectiveness. Rather than blockage of their clinical work, the majority experienced

enhancement o f it. However, several in the high level-of-influence group noted temporary

complications due to a preoccupation with their own psychological issues, especially those

inexperienced therapists engaged in concurrent training and treatment.

A summary o f the middle level-of-influence group’s perceived disappointments and

risks in personal treatment includes some surprising similarities and differences from those

of the high level group. The sole participant in the study who reported a negative effect of

personal treatment belonged to this group. This middle group similarly reported

experiencing some nonexcessive stresses consequent to personal treatment. One

participant in this group experienced excessive stress not conducive to his psychological

growth. Regarding perceived problems with the working relationship, over half the

respondents noted none, which appears to be a more positive response than that of the

high level-of-influence group. However, unlike the former group, of those who did

experience problems, only one reported actively engaging in working on it in the treatment

relationship, as a central part of the therapeutic dialogue. Regarding treatment errors, the

middle level-of-influence group’s responses again appear to be more positive at first

glance. Only one participant noted treatment errors that were detrimental to his process.

This group also responded apparently more positively than did the high level-of-influence

group to the question regarding adverse identifications. However, unlike the high level-of-

influence group, the few respondents here who did report adverse identifications cited the

source as untoward personality traits of the analyst, rather than his or her professional

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216

practice. This group reported similarly positive responses as the high level group

concerning the effects of engaging in concurrent personal treatment.

A summary of the low level-of-influence group’s perceived disappointments and

risks o f personal treatment includes that no actual “negative effects” were initially reported

in the open-ended question by either of the group members. Their responses were divided

on most of the remaining questions assessing risk and disappointment, however. One

participant reported excessive stress, which he felt was not an inevitable part of treatment,

that was related to an “unfinished” termination. The same participant reported no

problems in the working relationship but viewed his therapist as withholding important

feedback. The other member reported problems in the working relationship associated

with his view o f the analyst as vulnerable and in need o f protection. The respondents in

this small cohort were also divided on their experience o f treatment errors, with one

claiming no actual errors, yet longing to have more completely explored questions related

to his sexual competence that were impeded by his “unprocessed” erotic transference. The

other group member acknowledged treatment errors by his analyst’s harmful

countertransference enactments. Both participants also noted adverse identifications with

their former analyst. Noteworthy, however, is that even in this low level-of-influence

group, the participants concurred that their clinical work was promoted by the containing

function served by their personal treatment.

An integrated comparison of these results reveals that the level of perceived

influence o f one’s personal treatment on clinical practice is positively associated with the

extent to which psychological stress was seen as a purposeful, sometimes necessary, part

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217

o f the treatment process. However, a comparison o f the intergroup results on questions

about problems in the treatment relationship and perceived treatment errors offers some

counter-intuitive findings, in that the high level-of-influence group reported the most

problems in the working relationship. Yet in the high level group more than in the others,

these treatment relationship problems became the central focus of the analytic dialogue.

The middle and low level -of-influence groups described a need to side step these conflicts

in order to protect the analyst from their negative experience. This finding suggests that

the level o f influence of personal treatment on one’s clinical work is positively associated

with risking negative feelings about the treatment relationship and, in bringing these

problems into the analytic dialogue, in having a therapist who is receptive to working with

the participant’s negative experience. These participants also experienced their analyst as

thoughtfully considering their own contributions to the problems, while continuing to

analyze the relative contributions of the participant’s transference and resistances. The

high level-of-influence group described treatment errors related to the treater’s analytic

technique, whereas the other groups cited relatively more errors related to their

perceptions o f their analyst’s personal character shortcomings. Finally, the low level-of-

influence group members described having the least well-explored reactions to their

former treater, who was seen as vulnerable to criticism, as vulnerable to the erotic

transference, and as prone to enacting negative countertransference.

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Comparing Levels of Influence of Personal Therapy on Clinical Practice with


Associated Effectiveness of Personal Therapy

1. Overall, how well do you believe your therapist understood you and communicated

his or her understanding to you?

Eight o f the nine participants in the high level-of-influence group felt veiy well

understood by their former analyst. The single participant who felt generally well

understood, with some exceptions, noted that certain aspects of the treatment relationship

with his analyst were not explored in enough depth. Although the middle level-of-

influence group’s responses ranged among all categories, from very well understood to

not well understood, about half of them described feeling well understood. The experience

o f “egalitarianism” and o f recognizing that the therapist, although flawed, reliably strived

to understand the participant contributed to this perceived high level of understanding.

Almost half the middle level-of-influence participants reported feeling generally well

understood, with some exceptions. The most prevalent exception involved the need for

more direct communication from the treater. The single respondent in this group who felt

not well understood believed that his analyst did not appreciate the role played by

traumatic separation and loss during the respondent’s adolescent development. Both

members o f the low level-of-influence cohort responded that they felt generally well

understood, with some exceptions. One participant cited his need for more direct

communication from his treater about the analyst’s understanding of the participant’s

material, and the other observed that his treater overvalued analytic neutrality, which left

him too aloof and detached, and which denied the participant the warmth and support

needed to promote his psychological growth.

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In summary, there is a positive association between findings comparing the level o f

influence o f one’s personal treatment and the participant’s perceptions of being

understood by the treater. Respondents in the high level-of-influence group offered

evidence o f feeling the most thoroughly understood by their former treater. Although all

three groups reported quite high levels of feeling understood, the middle and low level-of-

influence groups offered progressively more evidence of the treater not communicating his

or her understanding to the participant, reportedly either because the analyst misperceived

the participant’s material or more prevalently, because the analyst was seen as overvaluing

analytic neutrality and hence withholding feedback.

2. Overall, how successful or satisfactory do you believe your personal treatment was?

Eight of the nine participants’ responses in the high level-of-influence group

clustered in the “quite successful” category and the “quite successful, especially in helping

with perfectionism” category. The one participant who described his analysis as being

“quite successful, with one disappointing exception” related it to his perceived personal

limitation in needing, but not pursuing, continued treatment after the analysis for ongoing

family relationship issues. Responses of the middle level-of-influence group ranged among

all subcategories with almost one half reporting quite successful treatment and almost all

the rest reporting quite successful treatment, with one disappointing exception. The

majority of these disappointments were related to the respondents’ perceived personal

limitations, which they believed kept them from experiencing greater success with their

treatment. The single respondent in the middle level-of-influence group who reported an

unsatisfactory treatment related it to his underdiagnosis by the therapist and to his belief

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220

that psychoanalysis should not have been the treatment o f choice for him. One member of

the low level-of-influence group reported a quite successful analytic experience but

offered no supporting comments. The other participant in this group believed that his

analysis had been quite successful, despite the limitations in psychoanalytic theory as a

sufficient explanation for understanding human motivation and behavior.

In summary, findings comparing the level of influence of one’s personal treatment

with the participant’s perceptions of treatment success show a positive association.

Respondents in the high level-of-influence group offered evidence of experiencing their

treatment as most successful. Respondents in both the high and middle level-of-influence

groups who revealed a disappointment in their treatment usually attributed it to internal

limitations or resistances that kept them from experiencing greater success. One

respondent in the middle level-of-influence group reported an unsatisfactory treatment

related to the external factor of being incorrectly diagnosed. This respondent also believed

that psychoanalysis had been an inappropriate treatment for him. Responses o f the low

level-of-influence group were divided, with one participant reporting a very successful

treatment and the other being disappointed in the limitations o f psychoanalytic theory. The

perceived success of treatment was thus positively associated with the level of perceived

influence. Perceived disappointments in personal, treatment were negatively associated

with the level of perceived influence. Disappointments were perceived as more internally

located by those respondents who reported higher levels of influence o f personal therapy.

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Comparing Levels of Influence o f Personal Therapy on Clinical Practice with


the Perceived Interpersonal Relationship and Posttermination Psychological
Involvement with the Therapist

4. (1.) How would you describe the interpersonal match or f it between you and your

most recent therapist or analyst?

Results o f both the high level-of-influence and middle level-of-influence groups

indicate that seven of the nine respondents in both groups experienced the interpersonal

match with their treater as good and remaining good throughout the treatment. Two

participants in the high level-of-influence group initially felt the interpersonal match was

not good due to the analyst’s reserve and due to their own manifestations of negative

transference. These participants did not choose their treater. One participant in the middle

level-of-influence group described an initial feeling that the match was good yet, over

time, it changed to not being good. Surprisingly, both members in the low level-of-

influence group described experiencing a good match with their analyst that remained so

over time.

4. (2.) To what extent did you like your therapist, or feelfondness and affection fo r

him or her and experience that your therapist liked you? D id you sometimes dislike

your therapist or fe e l disliked?

Results of both the high and middle level-of-influence groups are similarly

clustered in the high range of mutual liking. Mutual liking and no disliking meant that

participants felt genuine fondness and affection for their treater, which they believed to be

mutual. These participants did, however, report experiencing negative emotions toward

their treater, experiencing idealized and eroticized transference reactions, and fearing that

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222

they would be disliked by the treater. Surprisingly, the sole participant who reported not

liking his therapist by the end o f treatment was a member of the middle level-of-influence

group. This participant reported not liking his former treater’s glibness, which reduced the

level of trust in him. The two respondents who reported a period of mutual disliking that

later changed to mutual liking were also in the high level-of-influence group. They

described a period o f mutual lack of relatedness and withdrawal from one another in the

treatment, that was eventually worked through. Also noteworthy is that the two low level-

of-influence group members described high levels o f mutual liking.

4. (3. c l) Regarding the match: Did you think o f your therapist as professionally

competent? Do you think your therapist thought o f you as professionally competent?

Surprisingly, the high level-of-influence group’s responses ranged lower than did

those of either of the other two groups. Two participants in this group described feeling

uncertain about their therapist’s competence. Their uncertainty involved highly

transference-laden images of significant others as rigid and unbending, or as unavailable

and inconsistent. Much of their therapeutic focus involved working in the transference on

dynamic conflicts regarding the capacity to trust in the steadfastness of authorities, which

led them to eventually view the self and the therapist as professionally competent.

All members of the middle level-of-influence group reported thinking that their therapist

was competent, as well as believing that their therapist considered them likewise.

Interestingly, both members of the low level-of-influence group considered their treater to

be professionally competent.

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223

4. (3. b.) How compatible were your professional convictions?

The high and middle level-of-influence groups gave very similar responses to this

question. In both groups, a majority of respondents emphasized the similarities between

their own and their therapist’s professional convictions, rather than noting both similarities

and differences. These similarities involved mutual clinical interests, theoretical beliefs, and

ethical standards. Those who reported differences mentioned theoretical approaches to

treatment, convictions about the preeminence of classical psychoanalytic theoretical

approaches, and the spiritual basis of treatment. Interestingly, very few participants in

either group described their former therapist as primarily serving a mentoring function;

those who did were new trainees who could talk in treatment about feeling temporarily de­

skilled. The low level-of-influence respondents were divided evenly between those noting

only similarities and those noting both similarities and differences in professional

convictions.

4. (3. c.) Did you fe e l respected by your therapist? Do you think your therapistfelt

respected by you ?

It is noteworthy that in all three levels-of-influence groups, the vast majority of the

respondents felt well respected by their former treater. Only three participants overall, two

of whom were members of the high level-of-influence group, perceived that their former

treater might not have felt respected by them. The third participant was from the middle

level-of-influence group. Both members of the high influence group noted that their upset

with their former treater became a major focus of the analytic work until the relationship

issues were resolved. These issues involved the participant’s distress with the analyst’s

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224

withholding style. Interestingly, respondents who elaborated about the respect felt in both

directions added that early idealization was a factor in the respect issue and that the

therapist’s eventual acknowledgment of the participant’s acceptance o f the therapist’s

human foibles was an important part of that mutual respect. Another participant

expressing mutual respect noted that her dignity and autonomy were respected at

termination.

4. (3. d.) How compatible were your personality styles?

It is noteworthy that every respondent in the study felt that his or her own and

their analyst’s personality styles were compatible. Interestingly, the results o f the high

level-of-influence group are strikingly different than those of the other groups, in that all

but one member of the high level-of-influence group believed the compatibility existed

despite their differences in personality styles. Results were more evenly distributed in the

middle level-of-influence group. This finding suggests that participants reporting a high

level of influence of their personal treatment in their clinical work perceive differences in

personality style not as complementary or as contributing to the perceived compatibility,

but as a potential challenge to compatibility that was overcome.

4. (4.) Do you sometimes fin d yourself thinking about your analyst or therapist or

wishing to talk with him or her? I f so, under what circumstances?

A significant majority of respondents in the high level-of-influence group reported

that they do find themselves thinking about and wanting to talk with their former therapist,

primarily about matters of personal life. Over half the members in this group have, in fact,

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225

sought out their former therapist for posttermination contact. In the middle level-of-

influence group, about half the members reported wanting to talk with their former

therapist, primarily about matters related to professional practice. Three in this group

initiated posttermination contact with their former therapist. It appears that a high level-

of-influence is associated with participants who readily wish to continue the therapeutic

dialogue with their former treater, primarily on matters of their personal well-being, but

also regarding their professional life. These participants are more likely, in fact, to initiate

posttermination contact than are participants who report a lower level o f influence. The

low level-of-influence group noted ambivalence in thinking about or wishing to contact

their former treater, adding that there was a premature or incomplete termination.

4. (S.) In your conduct o f therapy, do you ever engage in an internal dialogue with

yourform er therapist/analyst? I f so, under what circumstances?

Surprisingly, those in the high level-of-influence group responded overwhelmingly

that they do not consciously experience an internal dialogue with their former treater while

conducting psychotherapy, but they added that they have conscious experiences of “verbal

memories” o f what the therapist said. One observed that his self-analytic function in

understanding transference-countertransference paradigms is a direct connection to the

former analyst, as is a conscious identification with the former analyst’s careful listening.

The middle level-of-influence group offered a wider range of responses, with three

members describing an internal dialogue with their former treater when in need of clinical

patience and guidance or when the patient’s material resonates with the participant’s

earlier dynamic conflicts. Almost half those in the middle level-of-influence group reported

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226

that they may have engaged in an internal dialogue with their former therapist during times

o f clinical uncertainty but do not do so presently. Neither member of the low level-of-

influence group noted internally dialoguing with their former treater, yet one of them

consciously identified with his former therapist’s careful and active listening.

In summary, the vast majority of the high level-of-influence group reported a good

interpersonal match with their treater. They also reported high levels of mutual liking,

despite feeling a range of negative emotions and complicated transference reactions. The

small minority in this group who described a period of mutual disliking noted that these

relationship issues were worked through in the treatment process with the former treater’s

help. Regarding perceived professional competence, the high level-of-influence group’s

responses ranged lower than did those in the other two groups. Their responses also were

related to negative transference-laden views of authority figures. Again, these difficult

issues were described as becoming the central focus of therapy for the high level-of-

influence group members and promoted an eventually more positive view of self and

others regarding professional competence. Regarding compatibility of professional

convictions, a majority of respondents emphasized the similarities of their professional

conviction and de-emphasized their differences. Very few participants in this high level-of-

influence group described their former therapist as serving primarily a mentoring function

unless they were trainees at the time. Although a large majority of respondents felt well

respected by their former treater, for the few who did not, this issue became the central

focus of treatment until it was worked through. Although all respondents in the study

perceived that they had compatible personality styles with their treater, only those in the

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227

high level-of-influence group believed that such compatibility existed despite differences

between their own and their treater’s personality style; thus these differences were not

perceived as complementary, but rather as challenges to be overcome. A significant

majority of respondents in thus group reported that they do think about and often wish to

talk with their former treater, primarily about matters regarding their personal life and

secondarily about their professional life. The majority in this group had, in fact, sought

contact with their former treater following termination. Participants reported that they do

not consciously experience an internal dialogue with their treater while conducting

treatment, but instead have “verbal memories” of what the therapist said during sessions.

This self-analytic function served as a connection with the former treater for a few

respondents.

In summary, as with the high level-of-influence group, most of the members of the

middle level-of-influence group described a good interpersonal match with their treater

throughout psychotherapy. They reported a high level o f mutual liking, except for one

participant, who did not like or completely trust his therapist at termination. All members

of this group described their therapist as competent and believed that their therapist

considered them likewise. This group’s responses to perceived compatibility of

convictions also closely mirrored those in the high level group, with a majority

emphasizing the similarities between their own and their treater’s convictions, yet few

believing that their former treater served primarily a mentoring function. With regard to

mutual respect, all but one member of this group responded affirmatively. Although all

respondents in the study perceived compatibility between their own and their treater’s

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228

personality styles, the source of that compatibility ranged from similarities to perceived

differences or despite perceived differences. In this group, about half the members

reported wanting to talk with their former therapist primarily about matters related to

professional life. However, only one third had initiated posttermination contact. Regarding

an internal dialogue with the former treater, this group again offered a wide range of

responses, such as doing so when clinical patience or guidance was needed. About half of

them report not currently engaging in an internal dialogue with their former treater, but

think that they may have in the past during times of clinical uncertainty.

A summary of the results from the low level group includes that both members

described a good interpersonal match with their analyst and a high level of mutual liking.

These participants also considered their former treater to be professionally competent.

Although they both perceived compatibility, one emphasized differences from, as well as

similarities to, his treater’s convictions. Like the participants in the higher levels of

influence groups, both low level group members felt mutual respect toward their former

therapist and experienced compatibility of personality styles. They noted feeling

ambivalent about thinking about or wishing to contact the former treater, due to a

problematic termination. Neither one noted internally dialoguing with the former treater,

yet one identified with his former treater’s style of actively listening.

An integrated comparison of these results reveals that in all levels of influence, the

majority of participants reported a good match with their former treater, and most

experienced this throughout their treatment. With regard to mutual liking, the high level-

of-influence group is associated with working through any feelings of mutual disliking.

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With regard to the perceived character match, the working through of negative

transference also appeared more centrally in the responses of the high influence group and

is notably absent in the apparently more “positive,” less conflict-ridden responses of the

middle and low influence groups. Compatibility of perceived professional convictions was

similarly high in all groups. Responses to the mutual respect question again showed the

pattern o f positive experience in all groups, yet only in the high level group did any

respondents describe a working through of problems related to mutual respect in the

treatment relationship. Although all respondents in the study reported compatibility with

their treater’s personality style, only the high level influence group showed a clear pattern

of experiencing compatibility despite the perceived differences in personality styles. This

finding again suggests more awareness of, and working through of, negative emotional

reactions in the high level-of-influence group. Another clear pattern is the strong positive

association between level of influence and posttermination psychological involvement with

the treater. Only in the high level-of-influence group was there a universal wish to

continue the therapeutic dialogue with the former treater, whereas ambivalence in thinking

about or actually contacting the former treater grew in the lower level-of-influence

groups. The intergroup patterns of response about engaging in an internal dialogue with

the former treater during clinical sessions showed that few respondents at any level of

influence report doing so. However, other forms of psychological relatedness, such as

recalling “verbal memories” of the former therapist’s words, is positively associated with

level o f influence. These combined results support an overall impression o f a positive

association between level o f influence of personal therapy for one’s clinical work and

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230

working through negative interpersonal experiences in the treatment relationship. The

therapeutic work done on resolving these issues is a common theme in the responses of

the high level-of-influence group. This group also reported the strongest and least

ambivalent posttermination psychological involvement with the former treater. There thus

appears to be a positive association between working through negative emotional

experiences with the treater and the level of posttermination psychological involvement.

These combined results support evidence of a positive association between level of

influence of personal therapy on one’s clinical work and level of posttermination

psychological involvement with one’s former therapist.

Integrated Responses of the Four Domains o f Study

The findings reported in the preceding section were then integrated by comparing

the summarized variations in the response patterns between the three levels in each of the

domains of the study. To illustrate the variations between the responses of high, middle,

and low levels o f influence groups, these results are visually displayed in table form

(see Tables 1-5).

Levels o f Perceived Influences of Personal Therapy on Conducting Psychotherapy

These levels were created by ranking the varied responses o f the participants’

perceptions about how much influence personal therapy has had on their clinical work.

At variance was the belief that the participant works differently as a result of personal

therapy. The degree to which the former therapist is seen as a professional role model also

varied among participants, as did perceptions about mistakes and limitations in the treater,

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231

and thoughts about the former treater during moments of clinical uncertainty.

Yet, all participants believe they work similarly to their former treater, in at least

some circumscribed way. These results are displayed in Table 1.

Levels of Perceived Benefits of Personal Therapy

Those participants reporting the highest level of influence of their personal

treatment on their clinical work also reported the most areas of benefit. Hence, there is an

association between the level o f reported influence and the number o f reported benefits.

The two areas o f benefit that show clear differences in responses between the levels of

influence are self-esteem/self-confidence and interpersonal relationships. Those reporting

the highest influence of their personal treatment on their professional practice also report

the clearest enhancement o f their professional identity as part of increased self-esteem and

self-confidence. Having improved interpersonal relationships as a benefit of personal

therapy was also associated with higher levels of perceived influence of personal treatment

for clinical work. These findings are displayed in Table 2.

Levels of Perceived Risks o f Personal Therapy

The level of perceived influence of one’s personal treatment on clinical practice is

associated with the extent to which psychological stress is viewed as an inherent and

meaningful part o f the treatment process. Surprisingly, the highest level-of-influence group

reported the most problems in the working relationship. However, in this group more so

than the others, the treatment relationship problems became the central focus o f the

analytic work, in the lower level-of-influence groups, these conflicts were more likely to

have been defensively avoided by both members of the therapeutic dyad. Hence, the level

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Table 1
Perceived Level of Influence of Personal Therapy on Clinical Practice
Questions Determining Level-of-Influence Ranking
Perceived Level of Influence High Middle Low

3. a. & b. Work differently Yes, valued Similar and more I don’t think I do
consequent to personal relationship confident in work differently
therapy? If so, how? more highly. treatment process. now.

c. (i) To what extent has All: yes; very Half: therapist was One: analyst not a
your therapist served as a much a a positive professional model.
role model for you in positive professional role One: yes, but I dis-
conducting psychotherapy? professional model. Half: both identify with her
role model. similarities and withholding.
differences from
analyst, who was
withholding, at
times.

c. (ii) What do you perceive No mistakes; Limitations and Limitations were


as being therapist’s my therapist mistakes have been due to therapist’s
limitations or mistakes that was“good influential due to personal foibles-
have influenced your work enough,” therapist’s I strive to be
with patients? which is better theoretical biases, different.
than perfect. flawed techniques,
and personal
foibles.

d. (i) Do images or thoughts Yes, I think (No clear pattems- No, not while
of your therapist ever come about him or results divided.) working.
to mind while conducting her when I’m
psychotherapy? uncertain or
puzzled.

d. (ii) Do you remind Yes, with Yes, I do. (Similar Yes, in a limited
yourself of your therapist regard to to high level way.
while working? If so, how? treatment group’s responses.)
technique.

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233

Table 2
Perceived Benefits of Personal Theraov ComDared with Level of Influence
Level-of-influence Ranking
Perceived Benefits High Middle Low

1. a. Enhanced self- Yes, especially with Similar. Similar.


understanding and psychodynamic
self-awareness? conflicts.

b. Enhanced self­ Yes, professional No clear Mixed,


esteem and self- identity especially pattern. equivocal
confidence? enhanced. results.

c. Improved Mixed, because of More clearly Not clear.


interpersonal female participants’ than in high
relationships? responses. level group:
enhanced
interpersonal
relationships.

d. Enhanced Yes, very much; Similar. Similar.


therapeutic skills? changes in myself led
to changes in my
clinical work;
treatment process
and relationship
taught me a lot about
what is curative.

e. Alleviated Symptom alleviation Similar, but less Similar to


symptoms and occurred. Mixed character high level
changed character? results with modification. group.
character
modification or
resolution.

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234

o f influence o f personal treatment on one’s clinical work is positively associated with

risking negative emotions in the treatment relationship and with experiencing the therapist

as seriously engaging in understanding these problems as the central task o f the analytic

work at that juncture. These participants describe their former treaters as having engaged

in analyzing the impasses as manifestations of negative transference, while also seriously

considering their own relative contributions to the problems in the working relationship.

The level of influence was also associated with differing types of perceived treatment

errors, with those in the lower levels reporting relatively more errors linked to the

therapist’s personality flaws and harmful countertransference enactments. Adverse

identification with the therapist also varied with the level of perceived influence, with

those in the higher groups reporting fewer adverse identifications. These results are

displayed in Table 3.

Levels of Perceived Overall Effectiveness o f Personal Therapy

There was a positive association between level of influence and feeling understood

by the former treater. All three groups reported quite high levels of feeling understood,

but the highest level-of-influence group offered the most evidence that the treater had

communicated his or her understanding to the participant.

Findings that compared the level of influence and the participants’ perceptions of

treatment success also showed a positive association with the highest level group

experiencing their treatment as most successful. Perceived disappointments in personal

therapy were negatively associated with the level of influence and were seen as more

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235

Table 3
Perceived Risks of Personal Theraov Comoared with Level of Influence
Level-of-Influence Ranking
Perceived Risks High Middle Low

2. Any disappointments, Disappointments only. Disappointments, Disappointment and


risks, or negative effects? risks, and one risk; no negative effects.
reported negative
effect.

a. Excessive stress or Little excessive stress; Similar with regard Mixed; one “no,” one
psychological distress? purposeful, necessary to nonexcessive “yes.” Both: “unfinished
stress. stress; one reported termination.”
stress as excessive
and not necessary to
the process.

b. Problems with the Yes; majority had Majority: no Mixed with problems:
working relationship? problems, but worked problems; minority: one, no problems; one,
through them to a yes, problems that yes, but analyst seen as
positive identification were not worked vulnerable, so problems
with analyst as through with treater. not talked about.
professional role
model.

c. Therapist’s treatment Range of responses: More positive: only One: no, but unresolved
errors? most detrimental were said treatment errors transference love. One:
professional practice were detrimental to yes, hurtful
“errors” by three process. countertransference
respondents’ enactments.
therapists.

d. Adverse identifications Majority, no; Majority, no; Yes, to adverse


with therapist or analyst? minority, yes, with minority, yes identifications.
less spontaneity, (regarding
hiding behind neutral­ personality traits of
ity seen as clinical treater).
practice issues.

e. Blocked therapeutic Majority: no, it Similar. Similar.


effectiveness due to helped; minority:
concurrence? temporary
complications due
to inexperience.

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236

internally located by respondents in the group reporting the highest level of influence.

These findings are displayed in Table 4.

Perceived Interpersonal Relationship and Process o f Continued Psychological Involvement


with Therapist

The working through of negative emotions related to disliking the therapist, to

believing the therapist was professionally competent, and to feeling respected by the

former therapist prevailed only in the high level-of-influence groups. Participants in this

group also emphasized differences between themselves and their former treater as

obstacles to compatibility of personality styles, which were apparently overcome. Such

patterns suggest a greater awareness of, and therapeutic work focusing on, the negative

reactions in the interpersonal relationship with the treater. Interestingly, only in this high

level-of-influence group was there a universal wish to continue the therapeutic dialogue.

In contrast, the middle and low level groups lacked a sustained focus on negative

emotional experiences but had considerably more ambivalence about contacting the former

treater. Although there was little evidence that respondents engaged in an internal

dialogue while conducting psychotherapy, other forms of psychological relatedness were

reported. Having verbal memories o f the former therapist’s words was most prevalently

reported in the high level-of-influence group.

These combined results support the existence o f a positive association between the

level o f perceived influence of personal therapy for one’s clinical work and the working

through of negative interpersonal experiences in the treatment relationship, and also of a

positive association between level of influence and posttermination psychological

involvement with the former treater, as displayed in Table 5.

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237

T ab le 4
Perceived Overall Effectiveness of Personal Therapy Compared with Level of Influence
Level-of-influence Ranking
Perceived Overall Effectiveness_____________________________ High Middle Low

1. How well did therapist understand you and communicate


that understanding to you?
Very well. 8 4 0
Generally well, but with exceptions. 1 4 2
Not well. 0 1 0

2. How successful or satisfactory was your personal treatment?


Quite successful 8 4 1
Quite successful, with one disappointing exception. 1 4 1
Unsatisfactory. 0 1 0
Note: Numbers represent number o f respondents.

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238

Table 5
Perceived Internersonal RelationshiD and Posttermination Psvcholocical Involvement Comnared with Level of
Influence
Perceived Interpersonal
Relationship and
Posttermination Psychological Level-of-Influence Ranking
Involvement High Middle Low

4. (1.) Description of Majority: good match Similar. Similar.


interpersonal match or fit. throughout.

4. (2.) Mutual liking or Majority: high levels, High levels, except for one High levels.
disliking? despite negative reactions. who didn’t like therapist
If mutual disliking, this and had bad termination.
was worked through.

4. (3. a.) Therapist Lower than other groups; Yes, more so than in high Yes; yes.
professionally competent? negative transference led to level group; yes.
Therapist thought you working on it in the
professionally competent? treatment and it changed.

4. (3. b.) Compatibility of Emphasized similarities, Similar to high level, Compatible; one:
professional convictions? de-emphasized differences. emphasized similarities, but only similarities;
few said treater was mostly one: both similar
a mentor. and different.

4. (3. c.) Felt respected by Most: yes; few: this Most (8 of 9): yes. Yes.
treater? became the focus of
treatment and it changed.

4. (3. d.) Compatibility of Most (8 of 9): yes, Yes, compatible because of Yes, compatible
personality styles? compatible despite similarities; because of because of
differences. differences; despite differences.
differences.

4. (4.) Think about, wish to All: yes; significant Two: ambivalent; about Both: ambivalent;
talk with former treater? If so, majority: yes, to think half: yes, on matters of termination was
when? about personal matters and professional life; one third problematic.
to talk about professional initiated posttermination
life (most sought contact). contact.

4. (S.) Engages in internal One, yes; others: no One third: for guidance; one No internal
dialogue with treater while internal dialogue but third: no, but other dialoguing, but
conducting treatment? If so, “verbal memories” or self- connections; one third: no, identified with
when? analysis (connection to the but may have in past. treater’s active
former analyst). listening style.

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239

Conclusions

To conclude this report o f findings, the integrated responses o f the high level-of-

influence group are described here, as their responses most clearly illustrate the patterns of

association found between the domains. Following this overview is a description o f the

unexpected findings in the high and low level-of-influence groups.

The high level-of-influence participants were ranked as such because their replies

most definitively indicated that their personal treatment influenced their clinical work.

The members of this group believed that they work differently as a result of their personal

therapy, primarily because it deepened their convictions about the treatment relationship as

an important vehicle for psychic change and growth. They viewed their former therapist as

a very positive professional role model who made few mistakes in treatment. They also

reported having thoughts about their former treater during moments of clinical

uncertainty, unlike participants in the low or middle level-of-influence groups.

The high level-of-influence group reported benefits in all areas. These participants

differed from the others in clearly reporting enhanced self-esteem and self-confidence,

especially concerning their professional identity development. Improved interpersonal

relationships also varied in this group, with greater mutuality experienced eventually,

sometimes after a period of increased interpersonal conflict.

The high level group varied from the others on five of the six questions related to

harm from personal treatment. This group described only disappointments and no risks or

negative effects, unlike the other groups. They reported experiencing little excessive stress

from personal treatment, but unlike the other groups, when they did experience excessive

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stress, they believed it was a purposeful, inherent part of the therapy process. Also

different from the other groups is that the majority of the members of the high level-of-

influence group reported problems in the working relationship with the analyst, which

were resolved well enough to allow a positive identification with the analyst as a

professional role model. They reported a range of treatment errors, which, unlike in other

groups, were not perceived as detrimental to the therapeutic process. The majority of high

level-of-influence respondents did not identify with their former treater in ways that

affected them adversely. However, the few who did report adverse identifications noted

issues related to the analyst’s practice techniques (e.g., one participant viewed himself as

being less spontaneous and as hiding behind neutrality, which his analyst had done on

occasion). In comparison, those in the other groups noted negative personality traits of

their analyst. The three groups offered essentially similar responses about minimally

blocked therapeutic effectiveness due to the concurrence of treatment and clinical work.

The high level-of-influence group reported feeling very well understood because

the therapist communicated his or her understanding well, which was a more positive

response overall than that of the other groups. Only one participant reported an exception

to feeling generally well understood, which involved wanting certain aspects of the

treatment relationship to be explored in more depth. These responses were considerably

more positive than those o f the other groups. As for perceived success and satisfaction

with personal treatment, the high level group reported a quite successful experience,

except for a participant who felt his treatment had been successful despite a disappointing

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241

exception, which involved his personal limitation in needing but not pursuing continued

treatment for relationship issues.

The high level-of-influence group alone reported that the focus of their therapeutic

work became the working through of negative emotions related to the therapeutic

relationship. These areas included mutual liking, working through negative transference

related to the therapist’s professional competence, and mutual respect. This group, more

so than the others, cited compatibility of personality styles despite differences. Yet, only in

the high level-of-influence group was there a universal desire to continue the therapeutic

dialogue, primarily about matters of personal life and, secondarily about professional

dilemmas. Unlike the other groups, most of the members in the high level-of-influence

group have indeed sought contact with their former treater. Although there was little

evidence supporting the presence of an internal dialogue with the former treater while

conducting psychotherapy, memories of what the former therapist said were described as

being sustaining to the participants’ clinical work. Some evidence was offered that

members of this group engaged in self-analysis, which sustained an ongoing psychological

connection to the former therapist.

Unanticipated Findings

Two unanticipated themes emerged from the data to further distinguish the high

and low level-of-influence groups’ perceptions of their personal psychotherapy

experiences. The first of these relates to the wish to be perfected by the treatment and to

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242

the eventual fate o f identification with the analyst in light o f the inevitable disillusionment

of this wish.

The theme of struggling to come to terms with wishes to be perfected, and with

learning tolerance of their own and others’ imperfections, was reflected in many responses

throughout the interviews. Acceptance of their own inevitable human imperfections was

viewed by numerous participants as essential to enhancing their clinical work by increasing

their compassion for their own patients’ struggles and limited ability to change. The theme

of struggling with perfectionistic strivings is particularly reflected in responses to the areas

of inquiry about benefits to self-esteem and perceived disappointments in therapy.

Several participants noted the importance of discovering in their personal

treatment that they could be themselves and yet still be a good therapist. This resolution is

evident in the experience o f the participant who observed:

‘I don’t have to be perfect to have something to contribute; I don’t have to know


everything to be helpful-that I know something and that can be found by my
patients in a way that is helpful.’. . . And that, really, it’s by our imperfections that
we’re really allowed to connect. So when ‘good enough’ is better than perfect, is
the theme that I walked away with. It’s given me permission to just be who I am
and then I feel like I can turn around and try and help patients do the same thing.

That treatment helps modify perfectionistic traits, which participants believe has

benefited their clinical work, appears to have been promoted by identification with the

former therapist’s apparent acceptance of his own fallibility. Noting her former therapist’s

human flaws, one participant observed:

Some personal things about my analyst made me realize you could be vulnerable
and be a human being and also do very good clinical work. My therapist modeled
that ‘good enough’ includes having human imperfections and misfortunes. So I ’ve
taken a self-acceptance of my humanness from my analysis.

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243

This acceptance o f the therapist’s fallibility by the participant may thus be promoted by the

therapist’s capacity to admit mistakes and his willingness to be corrected. This participant

claims a conscious identification with the former therapist’s admirable trait of

acknowledging fallibility. Being perceived as respecting patients by acknowledging

personal mistakes promotes a view o f the former therapist as a professional role model for

clinical effectiveness.

Closely linked with accepting human imperfection in oneself, in one’s patients, and

in one’s therapist is evidence suggesting that a modification of perfectionistic traits

extends to discovering and accepting limitations in what the process of psychotherapy or

psychoanalysis can realistically accomplish. The experiences of two participants in the high

level-of-influence group, at the time of their termination from psychoanalysis, reflect

multiple ways of grappling with accepting disappointments and limitations concerning

imperfection:

The one major disappointment in my treatment was also a benefit: I discovered


that the outcome of the analysis wasn’t going to be that I became perfect.
As termination was on the horizon, I was enormously disappointed as I realized
that my wish to be perfected by the other person was going to be disappointed and
that it really was going to be for me to continue the work, knowing that I, too,
could not perfect myself, but that I could take what was coming up, just as I had
during the analysis, and continue this lifelong process of working at finding more
satisfying solutions to my own stuff. So, on the one hand, this was a great
disappointment, but on the other hand, it was a profoundly important benefit,
because to be under the illusion that I was perfectible would, I think, carry over
into the work in the sense of expecting that I could be a perfecting agent for other
people, or that it would be up to me to make them perfect, or that their having
more limited results than their wishful goals was not something I had to berate
myself for.

The benefits of accepting imperfection as part of termination is also reflected in the

comments of another participant:

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244

One of the things we worked on in termination was the idea that I had to stay in
therapy until my life was perfect and then I would know I was really ready to
terminate. I think part of that was just accepting that chances are pretty good my
life is never gonna be perfect, that there were going to continue to be times, even a
lot of the time, major problems, major worries-that analysis can’t fix everything in
your life. There was a bit of disappointment with that, although I think it was also
therapeutic to realize that. It kind of lifts a burden from you to realize that you
don’t have to be perfect and your life doesn’t have to be perfect.

These results suggest that participants whose struggles with perfectionistic wishes

became a meaningful part of their therapeutic work did experience some useful changes in

their perceptions of self and others related to a greater acceptance o f limitations. There is

evidence in their remarks that, with treatment, acknowledging the limitations of self and

others has become less equated with narcissistic injury. This process seemed to unfold

with the inevitable disappointment in being perfected by the analysis leading the participant

to identify with the therapist’s apparent self-acceptance of his own humanness. By

implication, being able to embrace as “good enough” the imperfectibility o f oneself and

others, and the limitations imposed by an imperfect world, was essential to a readiness to

terminate from the treatment process for these individuals, the majority of whom were

ranked as members of the high level-of-influence group.

This acceptance of imperfection leads to the second unanticipated theme in the

study findings, which appears also to vary with the level of perceived influence of personal

therapy on one’s clinical work. The termination process, per se, was not specifically

inquired about in the interviews. However, the importance of the termination phase of

personal treatment was spontaneously mentioned by numerous participants. Surprisingly,

to the open-ended question about perceived risks o f personal therapy, four participants

offered that they had been cognizant from the beginning of the inherent risk of not being

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245

able to complete treatment, due to the possibility of a premature ending, related to either

their own or their therapist’s career move.

Participants noted the benefits of a good termination and the complications left by

an inadequate termination. Four respondents raised issues related to termination when

asked about any other benefits o f their personal treatment that had not been addressed. In

their responses, the perceived completeness of termination was associated with a clear

termination phase, versus an arbitrary, incomplete ending, where the patient was left

wondering, “Am I done, yet?” A lack of clear feedback from the therapist on the

participant’s readiness to end was apparent in the responses of two participants. However,

disappointments in oneself also contributed to perceived problems with termination. Three

participants (one from each level of influence) felt unfinished, because o f not being able to

go into more depth in their therapeutic work. Each reported that resistance or inability to

deepen the work frustrated and disappointed them.

That an adequate termination phase of treatment can promote autonomy and

mutual respect was attested to by one participant, in describing her termination:

I remember the termination stage to be a very rich time in the treatment. And my
saying how important it was that I terminate with some dignity, that I not throw
myself around his ankles and clutch and say, ‘I’m not going! I ’m not!’ And he kind
of chuckled and he did nothing to provoke any sob scenes. He gave me every
opportunity I wanted to say positive and negative things, but had no need to
reduce me to tears about what a horrible loss it was going to be and allowed me to
leave with a lot o f dignity and it felt very good. And I think he probably also had
some sad feelings around the termination.

There is evidence that how the termination was experienced contributes to

identifying with the former treater as a professional role model. One participant noted his

disappointment in the lack of a structured termination phase, which left him feeling that

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246

the treatment was incomplete. This same participant described his analyst as evidencing

personal struggles with separation and loss, in not wanting the participant to end the

treatment, which complicated the termination process. He reported that he and his

therapist “fought this through” to the point that the analyst eventually apologized for his

countertransference enactment, thus restoring the analytic focus on understanding the

participant’s decision to terminate. The analyst’s acknowledgment contributed to the

participant’s ultimately respecting his analyst, despite moments of disliking him and being

very angry during the termination process. This participant noted his identification with

the analyst’s eventual acknowledgment of his countertransference-induced error, which

makes him consciously strive to model the same courage with his own patients.

Another participant, a member of the high level-of-influence group, described how

the termination process in her personal therapy informs her clinical work. She observed

that while she didn’t consider it a real treatment error, her analyst’s moving away from

neutrality at termination did not enhance the power of the analytic work. She believed that

her former analyst’s fondness for her prompted his slight departure from neutrality when

he gave her a few professional articles to read. Her advice to analysts is, “Adhere to

neutrality to the end, because the analysis is enough.”

Finally, several respondents spontaneously referred to their termination process in

describing posttermination psychological involvement with their former therapist. Of the

only four participants in the study who reported ambivalence in thinking about or wishing

to talk with their therapist (both low level participants and two from the middle level), all

of them connected that ambivalence to problems with termination. Two of these four

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247

participants described a premature termination, one due to his career move, which he felt

precluded his adequately resolving an erotic transference to his female analyst. The other

participant reported a premature termination due to his analyst’s making a career move.

The other two participants who reported ambivalence in thinking about or wishing

to talk with their former therapist, described the analyst as being forced out o f the

psychoanalytic institute, due to either a severe health impairment or an alleged sexual

boundary violation. These unfortunate departures occurred after the two participants had

terminated, yet their disappointment and anger was evident during the interview and was

directed at both the former analyst and at the psychoanalytic institute. Both described

feeling conflicted loyalty toward their former treater, as well as a sense of betrayal by the

analyst’s vulnerability. Neither had initiated postanalytic contact with their former analyst

and both appeared to struggle to maintain a positive image of the former analyst, who had

been censured by the local psychoanalytic community. However, both participants

hastened to add that these unfortunate events did not undo their therapeutic work with

the analyst.

In summary, these findings support the significance of the termination process as

influencing participants’ overall perceptions of their personal therapy experience.

A number of participants were aware, at the outset of treatment, o f the importance of

having a “completed” treatment. The study findings suggest that a “complete” termination

process was associated with a distinct phase of the treatment, in which issues related to

loss and change were central to the therapeutic dialogue. There is some evidence from

these findings that getting sufficient feedback from the therapist about the participant’s

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248

progress and readiness to end is associated with a “complete” ending. There is evidence

that termination poses particular risks for both the participant and the therapist to enact

their personal struggles with separation and loss. One participant each in the middle and

high level-of-influence groups described the analyst’s extraordinary behavior at

termination as being related to countertransference vulnerability to loss. Confronting and

working through these struggles led one participant to respect and identify with his former

analyst’s assumption of responsibility for countertransference errors. Premature

termination from treatment was associated with posttermination ambivalence in thinking

about or wanting to contact the former therapist to continue the therapeutic dialogue.

There is evidence that, even after termination, negative events in the former analyst’s life

have significant meaning for participants’ perceptions of their earlier analytic work with

the former treater.

Variables Related to Personal Treatment History

Concluding this presentation of findings are data about certain variables of the

study sample, which prior published studies have identified as having an impact on

therapists’ use o f personal therapy. These variables include: (1) choice or assignment of

therapist; (2) the match between gender and professional affiliation o f participants and

their former therapist; (3) the participants’ average weekly hours currently engaged in

providing individual psychotherapy to others; (4) their years of postgraduate clinical

experience; (5) the extent o f personal treatment; and (6) time since termination from

personal therapy. These variables are presented according to the perceived level-of-

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249

influence group into which each participant was ranked (see Tables 6-8). They were

compared with the perceived level-of-influence of personal therapy on the participants’

clinical work, in keeping with the overall data analysis plan of looking for patterns of

association between perceived level-of-influence of personal therapy on clinical work and

other variables.

Choice of Therapist: Gender and Professional Affiliation

As noted in this study’s review of relevant prior literature, several studies have

demonstrated the importance of demographic matching between therapist-patients and

their chosen therapists (Kaslow & Friedman, 1984; Norcross et al., 1988a). Pertinent

factors include theoretical orientation, professional affiliation, and gender and ethnicity.

The theoretical orientation of this study sample and that of their psychotherapist is highly

matched in that all the participants identified themselves as either psychoanalysts or

psychoanalytically oriented psychotherapists and sought a therapist with the same

orientation. This finding mirrors those of Grunebaum (1983), in which the

psychotherapist’s orientation was predictably related to his or her psychotherapist’s

orientation, and of Norcross (1990), whose study of therapist choice showed that the

majority of therapists of any theoretical orientation undertook personal treatment with

psychoanalytic or psychodynamic psychotherapists.

Regarding professional affiliation, prior studies show that psychotherapists seek

treatment from psychiatrists, then psychologists, social workers, counselors, and lay

analysts, in that 'order. There are definite preferences on the basis of professional

discipline, however. Norcross (1990) found that psychologists sought treatment equally

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250

from other psychologists or from psychiatrists, while psychiatrists routinely sought out

other psychiatrists. Social workers were the only discipline more likely to enter treatment

with a therapist of a different discipline. The present study’s findings reflect this pattern, in

that seven o f the eight psychiatrists were treated by other psychiatrists, whereas the

psychologists were treated by either another psychologist or a psychiatrist, as were the

social workers (see Table 6).

Table 6
Gender and Professional Affiliation of Participant and Treating Therapist and Choice
or Assienment o f Therapist Presented bv Level of Perceived Influence
Level-of-Influence Ranking
Participant // Therapist: Choice or Assigned High Middle Low

male MD // male MD : assigned 2 3 1


female MD // male MD : chosen 1
female MD // male PhD : chosen 1
male PhD // male PhD : assigned 1
male PhD // female PhD : assigned 1
male PhD // female MD : assigned 1
female PhD // female MD : assigned 1
female PhD // male MD : chosen 1
female PhD // male MD : assigned 1
male MSW // male MD : chosen 1
male MSW // male MD : assigned 1
female MSW // male PhD : chosen 2
female MSW // male MD : chosen 1
female MSW // male MD : assigned 1
Total 9 9 2
Note: Numbers represent number o f respondents.

Demographic factors, such as gender and racial heritage of the chosen

psychotherapist, also exert a strong influence on therapist selection. Norcross (1988)

noted the ubiquitous practice of therapist-patient demographic matching on these variables

and provided evidence of an increasing tendency for mental health professionals to be

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251

treated by members of their own gender and professional discipline. Taken altogether,

these findings offer evidence that psychodynamic psychotherapists prefer a personal

therapist who is similar in regard to theoretical orientation, professional affiliation, gender,

and ethnicity.

However, a factor affecting therapist choice that may well override these apparent

patterns is that this study sample was obtained in a small psychoanalytic community,

where 17 of the 20 participants have engaged in at least one psychoanalysis, a pattern that

is changing only recently. When these participants sought treatment, the predominant

providers o f psychoanalysis were white, male psychiatrists. Thirteen o f the 20 participants

in the study sample did not choose their therapist, but rather were assigned one, which is

standard for therapists seeking psychoanalysis or psychoanalytic psychotherapy through a

psychoanalytic training institute or clinic. The other seven of the 20 chose their most

recent therapist. Given these special parameters on therapist choice, the participant-

therapist matches regarding professional affiliation cannot be compared fairly with prior

studies.

In light o f this “matchmaking” function of the psychoanalytic institute, which

assigned the therapist for the majority of the study sample, how did the participants’

“arranged marriages” compare, regarding similarity or difference of gender and

professional affiliation with their level of perceived influence of personal therapy on

clinical work? Did those participants who chose their treater choose therapists o f the same

gender and professional affiliation and did they perceive a higher level of influence of

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252

personal therapy on their clinical work than did those participants who were assigned a

therapist?

Taking this second question first, four of the seven participants who chose their

most recent treater were social workers, one was a psychologist, and two were

psychiatrists. Only one o f the seven chose a treater o f the same professional affiliation.

Six o f the seven were female participants who chose a male treater and the seventh was

a male participant who chose a male treater. Five of the seven had engaged in a

psychoanalysis. Three of the seven, all of whom had engaged in psychoanalysis, ranked in

the high level of influence of personal therapy on clinical work. The other four

participants, two o f whom had engaged in psychotherapy and two in psychoanalysis,

ranked in the middle level of influence. These results support the prior findings that social

workers, more than those in other mental health professions, seek treatment outside their

own professional affiliation. However, the findings do not support the idea that

psychotherapists seek treaters of a similar gender or professional affiliation. Nor is there

evidence from this finding that choosing one’s treater is associated with a higher level of

perceived influence of personal therapy on one’s clinical work.

Similarity or difference of gender and professional affiliation with one’s therapist

was then compared with the levels of perceived influence o f personal therapy on one’s

clinical work for the 13 study participants who were assigned their therapist. Three

participants in both the high and middle level-of-influence groups were assigned therapists

of both the same gender and professional affiliation, as was one of the two participants in

the low level-of-influence group. At the other extreme, two participants in the high level-

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of-influence group, one participant in the middle level-of-influence and none in the low

level were assigned therapists of both a different gender and professional affiliation. Given

this variability, the patterns do not support an association between the level of perceived

influence of personal therapy on clinical work and similarity o f gender and professional

affiliation with one’s therapist. It would thus appear that factors other than gender and

professional similarity or difference between participants and their treater are at work in

determining the level o f perceived influence of personal therapy on one’s clinical work,

regardless of whether the participant chose his or her treater.

Professional Affiliation and Level of Perceived Influence of Personal Therapy

Prior studies indicate that psychotherapists trained in the three professional

disciplines of psychiatry, psychology, and social work similarly value personal

psychotherapy. When clinical hours engaged in conducting individual psychotherapy are

comparable, there is no evidence that therapists vary by discipline in their valuing of

personal therapy (Deutsch, 1985). Findings in the current study support this view, given

the roughly similar patterns of the perceived influence of personal therapy on clinical work

by the participating social workers, psychologists, and psychiatrists (see Table 7). About

half the respondents from each discipline were ranked in the high and half in the middle

level-of-influence groups. One psychologist and one psychiatrist were ranked at the low

level of influence.

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Table 7
Professional Affiliation and Level of Perceived Influence
Professional Level-of-influence Ranking
Affiliation High Middle Low Total
MSW 2 4 0 6
PhD 3 2 1 6
MD 4 3 1 8
Total 9 9 2 20
Note: Numbers represent number o f respondents.

Number o f Hours Conducting Psychotherapy and Level of Perceived Influence o f Personal


Therapy

Prior studies show that the amount of personal therapy received by clinicians after

entering the profession is influenced by the number of hours of individual psychotherapy

that they themselves conduct weekly. Those who tend to provide the greatest amount of

individual therapy for their clients also receive the greatest amount of individual treatment

for themselves (Guy, Stark & Poelstra, 1988). The results of the current study confirm this

relationship (see Table 8 for details on the participants who currently conduct more

individual psychotherapy and have also received more personal treatment).

In addition, it is noteworthy that both the average number of hours spent treating

individuals and the average hours of personal therapy received are highest in the high

level-of-perceived influence group (22 hours per week, and 1,537 hours, respectively).

The average number of hours currently providing individual treatment and the average

number of hours of personal treatment received is substantially lower in the low level-of-

influence group (12.5 hours per week and 800 hours, respectively). These results suggest

an association between the number of hours spent conducting individual psychotherapy,

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the amount of personal treatment received, and the perceived level of influence of personal

therapy on clinical work (see Table 8).

Amount of Personal Treatment Received and Level of Perceived Influence

Participants in this study averaged 2.1 discrete treatment episodes. This finding

closely mirrors Norcross’ (1990) national sample of 500-plus psychotherapists from the

professions of social work, psychiatry, and psychology, whose average number of discrete

treatment episodes was 2.3. In the current study, the average number of discrete treatment

episodes in the high level-of-influence group, at 2.4, is more than twice that of the low

level-of-influence group average of 1 discrete treatment episode. These results suggest an

association between the number of discrete treatment episodes and the level of perceived

influence of personal treatment in conducting psychotherapy (see Table 8).

Amount of Personal Therapy Received. Average Years Postgraduate Clinical Experience,


and Level of Perceived Influence

Prior findings note a positive correlation between discrete treatment episodes and

time in professional practice, indicating that psychotherapists tend to seek personal

therapy throughout the course of their clinical work (Norcross, 1990; Prochaska &

Norcross, 1983). The current study results support this finding as well. Prior findings also

indicate that the number o f hours of personal therapy is positively correlated with the

therapist’s number o f years of postgraduate clinical experience, which indicates that

therapists continue to use personal therapy during the course of their career (Norcross,

Strausser-Kirtland & Missar, 1988; Prochaska & Norcross, 1983). Findings in the current

study reveal a similar general trend, with participants who reported more hours of

personal treatment also having more years o f clinical practice experience. However, this

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256

trend is not absolutely associated, because participants in the high level-of-influence group

averaged 547 more hours of personal treatment than their middle level-of-influence

counterparts, yet 2.6 years’ less practice experience.

In the current study, both the average number of discrete treatments and the

average number o f years in postgraduate psychotherapy practice were substantially higher

in the high level (2.4 episodes and 20.8 years), compared with the low level-of-influence

group (1 episode and 13 years), as displayed in Table 8.

Time Posttermination from Personal Therapy and Level of Perceived Influence

The average number of years posttermination was lower in the high level-of-

influence group (9.4 years) than in either the middle or low level-of-influence groups

(11.7 and 11.5 years, respectively), as shown in Table 8. Over half the participants in the

high level group had terminated from their most recent treatment five to 10 years prior to

the interview, a time which is crucial to the internalization of the therapeutic work,

according to studies by Kantrowitz et al. (1990). The potential implications of this finding

are further discussed in the discussion section of this study.

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Table 8
Variables Related to Time Conducting PsvchotheraDv. Time Receiving PsvchotheraDv. Years o f
Postgraduate ExDerience and Time Posttermination. Compared with Levels o f Perceived Influence o f
Personal Treatment on Clinical Work
Level-of-Influence Ranking
Psychotherapy Variables High Middle Low
n=9 n=9 n=2 (Mean) (S.D.)

Average Hours Conducting 22 hrs. 19.1 hrs. 12.5 hrs. 20 hrs. (4.39)
Psychotherapy / week.

Time in Personal Treatment


Average Hours o f Psychotherapy 1,537 hrs. * 990 hrs. 800 hrs. 1,145 hrs. (325)
Average Number Discrete Treatment 2.4 2.1 1 21 (0.66)
Episodes

Average Years Postgraduate Experience 20.8 yrs. 23.4 yrs. 13 yrs. 20.7 yrs. (4.90)

Average Years Posttermination from 9.4 yrs. 11.7 yrs. 11.5 yrs. 10.6 yrs. (1.07)
Personal Treatment

* Includes average hours o f treatment f o r 8 o f 9 participants in high level-of-influence group. Only one
p a rticipan t in the entire study had engaged in less than 400 treatment hours. This individual reported
100 treatment hours and w as ranked in the high level-of-influence group. This outlier was not included
in calculating the group mean or the overall mean.

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Ch a pter V
D is c u ss io n

Distillation o f Major Findings

1. Participants perceiving the highest level o f influence of personal therapy on

their conduct o f psychotherapy most clearly reported that their treatment relationship

promoted psychological change. They also most clearly valued their former therapist as a

professional role model and thought about the former treater during moments o f clinical

uncertainty with their own patients.

2. Participants reporting the highest level o f influence o f personal therapy on their

clinical work most clearly described enhancement o f their professional identity and

improved interpersonal relationships consequent to personal treatment.

3. Participants reporting the highest level o f influence o f personal therapy on their

clinical work reported the lowest level of harmful effects from their treatment. However,

psychological stress was seen as a purposeful, inherent part of the treatment process in this

group only.

4. Problems with the working relationship became the central focus of the

treatment in the high level-of-influence group only. The working through of negative

aspects o f both the transference and the real relationship apparently contributes to a

positive identification with the former therapist as a professional role model. Those

reporting the highest level o f influence most clearly wished to continue the therapeutic

dialogue with the treater and most frequently sought contact with their former treater.

258

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5. Acceptance of personal imperfectibility is seen by participants as a benefit of

personal therapy that enhances their clinical work by increasing empathy for the difficulty

o f change, both for themselves and for their patients. The modification of perfectionistic

traits is apparently promoted by identifying with the former therapist’s acceptance of

personal fallibility. The former therapist’s capacity to admit mistakes and to be corrected is

associated with the participant identifying with the therapist’s respectful treatment of

patients and to self-acceptance as a model of clinical effectiveness.

6. Getting sufficient feedback from the therapist about the participant’s progress

and readiness to end treatment contributes to a satisfactory termination. Experiencing a

satisfactory termination is associated with the participant’s identifying with the former

treater as a professional role model. “Good enough” terminations promote the

internalization o f the therapeutic relationship through attempts to keep the therapeutic

dialogue going internally, whereas unresolved treatment relationship problems during

termination contribute to ambivalence about continuing the therapeutic dialogue.

Summary of Findings

The high level-of-influence group developed a positive identification with the

analyst as a professional role model. Those reporting the most influence also believe their

personal therapy most benefited their self-confidence and self-esteem.

Perhaps most striking in the findings was the prevalence of problems in the

working relationship with the analyst reported by members of the high level-of-influence

group. However, only in the high level-of-influence group did treatment relationship

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260

problems become the primary focus of the treatment and were reportedly worked through.

This apparently resulted in a positive identification with the former treater as someone

who was authentic and able to sustain a treatment relationship through tumultuous times

related to the patient’s need to express and work through negative transference

manifestations. This process appeared to result in participants identifying with their former

therapist’s integrity in acknowledging personal human foibles or subjectivity, while

continuing the analytic work of helping the patient to better understand herself or himself

in the context o f the co-created treatment relationship.

Treatment errors were seen as not detrimental to the therapeutic process only in

the high level-of-influence group. Fewer adverse identifications with the former analyst

were noted by those reporting the highest level of influence. The adverse identifications

with the former treater which were reported by the high level-of-influence group involved

unhelpful practice techniques, while those participants in the lower levels o f influence

described more negative personality traits of their former treater.

The level o f influence of personal therapy on conducting psychotherapy was

positively associated with feeling well understood by the former therapist and with

perceived success of, and satisfaction with, personal treatment.

Treatment relationship variables included mutual liking and respect and working

through the negative transference. Level o f influence was positively associated with a

compatibility of personality styles, despite differences with the treater. This suggests that

treatment promoted greater differentiation of self and object as a prelude to more mature

internal object representations.

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Level o f influence was strongly associated with a desire to continue the therapeutic

dialogue and with having sought posttermination contact with the former therapist. Little

evidence supported the presence of participants engaging in an internal dialogue with their

former treater while conducting psychotherapy. However, remembering their therapist’s

words at other times was experienced as sustaining to clinical work. Exploring the extent

of engagement in self-analysis was not a major focus of the study. However, there is some

evidence that self-analysis sustains an ongoing psychological connection to the former

therapist and thus may be associated positively with the level of perceived influence of

personal treatment in conducting psychotherapy. These findings indicate that the

participants believe in the growth-promoting value of ongoing continued psychological

work as represented by their personal treatment relationship.

Unanticipated Findings

A summary o f the two unanticipated findings notes that acceptance of one’s

personal imperfectibility was viewed as enhancing clinical work by increasing the

participants’ compassion for the struggles and limitations of change for both themselves

and their patients. That treatment helps modify perfectionistic traits, which participants

believe has benefited their clinical work, appears to have been promoted by identification

with the former therapist’s acceptance of fallibility. This more realistic and tolerant

experience o f the self appears to be promoted in the treatment by the therapist’s capacity

to admit mistakes and his or her willingness to be corrected by the patient. This, then,

leads the participant to identify with his former treater’s respectful treatment o f patients

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262

and promotes an identification with self-acceptance as a model o f clinical effectiveness.

Discovering and accepting limitations in what the process of psychotherapy or

psychoanalysis can realistically accomplish is closely linked with the acceptance of

personal imperfectibility. The findings also suggest that tolerance of the imperfection in

self and others and an acceptance of limitations in the psychotherapy process itself may be

associated with termination-readiness.

The second unanticipated discovery was that the termination process was

spontaneously mentioned as influencing the participants’ ongoing perceptions about their

personal therapy. Experiencing a “complete” termination was associated with having a

distinct termination phase o f the treatment that focused on separation, loss, and change.

Results suggest that how termination was experienced contributes to identification with

the treater as a professional role model. The findings suggest that unresolved problems

during termination are associated with conflictual internalizations of the treatment

relationship, as evidenced by ambivalence about continuing the therapeutic dialogue.

Getting sufficient feedback from the therapist about the participant’s progress and

readiness to end appears to be associated with a “good enough” ending. Termination is

viewed as a high-risk time for both members of the dyad to enact their personal struggles

with separation and loss. “Good enough” terminations tended to involve an authentic

engagement by both participants around the analytic material that arose. Unsatisfactory

terminations were associated with posttermination ambivalence about the interpersonal

relationship with the former therapist. Satisfactory terminations may promote the

internalization o f the therapy relationship through attempts to keep the therapeutic

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dialogue going inside oneself. Posttermination negative events in the former analyst’s life

appeared to contribute to participants’ ambivalent or conflictual identifications.

In an effort to contextualize the findings, certain variables were compared that

relate to the personal treatment history of the participants. A summary o f these findings

follows.

Personal Treatment History Variables

Choice o f Therapist: Gender and Professional Affiliation

The theoretical orientation of the study sample and that of their psychotherapist

was highly matched, with all participants identifying themselves as psychoanalytically

oriented and as having sought a therapist with this same orientation. However, there was

no overall evidence supporting the idea that psychotherapists seek treaters o f a similar

gender or professional affiliation. Nor was evidence found that choosing rather than being

assigned one’s treater was associated with a higher level of perceived influence of personal

therapy on one’s clinical work.

Professional Affiliation of Participants and Level of Perceived Influence of Personal


Therapy

Findings in the current study support those from the literature (Norcross et al.,

1988) indicating that psychotherapists trained in the three professional disciplines of

psychiatry, psychology, and social work find personal psychotherapy to be useful to their

clinical work.

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Number of Hours Conducting Psychotherapy and Level of Perceived Influence of Personal


Therapy

Results of this study suggest an association between the number of hours spent

conducting individual psychotherapy, the amount o f personal treatment received, and the

perceived level of influence o f personal therapy on clinical work. Those who conduct the

most individual psychotherapy have received the most treatment and are also rated in the

highest level group o f perceived influence.

Amount of Personal Treatment Received and Level of Perceived Influence

Participants in the current study averaged 2.1 discrete treatment episodes,

commensurate with averages reported in the literature (Norcross, 1990). Participants who

rated in the highest level o f influence had sought an average of 2.4 discrete treatments,

compared with an average of only one treatment episode in the low level-of-influence

group These findings raise several possible questions: Are some individuals more prone to

need and therefore to repeatedly seeking an “influential” relationship with a

psychotherapist? If disappointed in an initial treatment process, are some therapist-patients

more likely than others to turn away from seeking subsequent treatment and instead to

seek other sources of growth in professional role identification? Findings in this study

offer inconclusive evidence, one way or the other. Overall, the results suggest an

association between the number of discrete treatment episodes and the level o f perceived

influence of personal treatment in conducting psychotherapy.

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265

Amount of Personal Therapy Received. Average Years Postgraduate Clinical Experience,


and Level of Perceived Influence

In this study, both the average number of discrete treatments and the average

number of years of postgraduate psychotherapy practice were substantially higher in the

high level (2.4 episodes and 20.8 years), compared with those in the low level (1 episode

and 13 years). Given the very small number of participants in the low level-of-influence

group, these findings are difficult to interpret. Future studies might focus on the

experiences o f this group, sampling a larger number of participants who report a perceived

low level of influence of their personal therapy on their clinical work.

Time Posttermination from Personal Therapy and Level of Perceived Influence

Over half the participants in the high level group had terminated from their most

recent treatment between 5 and 10 years prior to the interview, a time that has been found

to be crucial to the internalization of the therapeutic work (Kantrowitz, 1990). There is no

evidence from this study that the level of perceived influence progressively decreases with

continued time, posttermination. It is noteworthy that half the participants in the study had

terminated within this 5-to 10-year period, which Buckley et al. (1981) identified as an

important time because thoughts about the former therapist reach a peak. Of these 10

participants, six were members of the high level-of-influence group and one was a member

o f the low level group. With a sample of 20 participants, it is not possible to know if this

variation occurs merely by chance, or whether during the 5-to 10-year posttermination

phase, there is some particular psychological work of internalizing the former therapy

relationship that contributes to perceptions of higher levels of perceived influence o f

personal therapy on clinical work.

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Implications o f the Findings

From conducting an in-depth review of the literature and undertaking a pilot study,

the investigator discerned a configuration of model elements that have been influential in

the personal psychotherapy of psychotherapists. These elements included themes related

to benefits, risks, influence on professional conduct, and aspects of the posttermination

relationship with the former therapist. As a result, the research project initially sought to

advance an understanding of the following questions:

1. Will particular themes of benefits and risks be associated with particular

reported uses of an individual’s personal therapy to inform clinical work?

2. Will therapists who report more particular benefits then specific risks in their

personal therapy also report more specific influences of their personal therapy on their

conduct o f psychotherapy than therapists who report fewer specific benefits than specific

risks in their personal therapy?

3. Will therapists who report higher perceived overall effectiveness of their

personal therapy report different influences of their personal therapy on their conduct of

psychotherapy than therapists reporting less perceived overall effectiveness of their

personal therapy?

4. Will therapists who report having experienced an interpersonally highly

significant relationship with their own therapist report more particular benefits, fewer

risks, and more specific examples of consciously drawing on their personal therapy

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experience in the conduct o f their own work, compared with those who report an

interpersonally less significant relationship?

5. Will therapists who report continued posttermination psychological

involvement with their therapist report more particular benefits, yet also more risks, and

more specific evidence of consciously drawing on their personal therapy experience in the

conduct of their work than those who do not report continued posttermination

psychological involvement?

Having completed the study, it became clear that several of these questions would

be more relevant if altered. These changes are reflected at the conclusion o f Chapter II.

Following is a discussion of how the findings suggest a reconfiguration of the model

elements that are influential in the personal therapy of psychotherapists.

The first question was changed from looking only for benefits and risks o f personal

therapy to adding the relationship variables as another domain for comparing associated

themes. This change was made to clarify the relevance of influence on clinical work to the

research goals. Since the unfolding data revealed a rankable set of responses in the

influence on clinical work, it became possible to compare the associated variability of

themes within each of the other domains in the model. The complex answers to this first

question are presented in the third phase of the data analysis and have been discussed

earlier in this chapter.

The second proposal question was reworded slightly in the final study, but

remained essentially intact as a query into the relative quantity of the benefits and risks

compared with influence on clinical work. After conducting the literature review and pilot

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study, the investigator surmised that therapists reporting relatively more benefits and

fewer risks would view their personal therapy as exerting more influence on their clinical

work.

Results of the completed study suggest that, rather than quantity or amount of

benefits and risks associated with level of influence, instead particular themes of benefits

and risks support an association with the perceived level of influence of personal therapy

on clinical work. As indicated in the findings, all participants experienced similar

improvements in self-understanding, enhanced therapeutic skills, and symptom alleviation.

What varies by level o f influence is the extent to which the participants’ professional

identity was enhanced by the treatment relationship. This factor related to self-esteem and

self-confidence. There was also variability in improved interpersonal relationships between

the high, middle, and low level-of-influence groups, although clear patterns are less easy

to identify.

Rather than sheer number of benefits, specific benefits related to self-esteem and

interpersonal relatedness appear to be associated with influence o f personal therapy on

clinical work. This finding was also discovered with regard to risks o f personal therapy

and their association with level of influence of personal therapy on clinical work.

In summary, only disappointments, rather than risks or negative effects, were

associated with higher levels o f influence, and psychological stress was viewed as

“meaningful or purposeful,” consequent to being in treatment. Problems in the working

relationship were the most prevalently identified and reported as “worked through” by the

high level-of-influence group. Differences in perceptions about treatment errors exist but

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269

do not suggest clear patterns of variation. Adverse identifications with the former treater

prevailed more in the lower level-of-influence groups, which suggests that psychological

growth was experienced by confronting and working through negative emotion associated

with the treatment relationship, rather than through an absence of risks. This working

through o f negative emotion about the treatment relationship was described most

prevalently by the high level-of-influence group.

The third research question involved comparing the perceived overall effectiveness

o f personal therapy with the level of its influence on clinical work. The wording was

changed from seeking to identify specific influences to identifying levels of influence,

which better reflected the unfolding data. The results show that the high level-of-influence

group members felt best understood by their former treater and, as a group, were most

satisfied with their personal treatment. However, to contextualize these findings, it is

important to note the generally positive responses of 19 of the 20 participants in the study.

For example, the various categories discovered in the therapist understanding question

included: “very well,” “generally well, but with exceptions,” and “not well.” Only one

person, ranked in the middle level-of-influence group, believed that his analyst did not

understand him well. The responses to the success or satisfaction question reflect this

same pattern, with the choices being: “quite successful,” “quite successful, with one

disappointing exception,” or “unsatisfactory.” Only one participant, again in the middle

level-of-influence group, was left with a perception that his analysis was unsatisfactory.

Although twice as many of the high level-of-influence group respondents replied in the

most positive categories as did the middle level group, the overall findings for the entire

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cohort are quite positive regarding overall effectiveness of personal therapy. It may well

be that those who practice psychoanalytically oriented psychotherapy are a self-selected

group who not only value self-awareness and self-reflection, but also are insight-oriented,

thus predisposing them favorably toward utilizing the very services that they themselves

offer.

Possible speculations for this degree of overall positiveness regarding the

effectiveness of personal therapy include a professional “blind spot” in an inherent bias of

psychotherapists toward overvaluing psychotherapy as personally enriching, given the

many years o f professional training and practice of this very activity to which they have

dedicated themselves.

Another possibility for this high degree of belief in their personal psychotherapy’s

effectiveness relates to the self-selection of the participants. There is no way to know

whether the 29 therapists who declined to participate in the study were significantly

different in their view of whether a personal psychotherapy was effective, compared to

those who agreed to participant. Two of them wrote back, declining participation because

o f their collegial relationship with the researcher’s dissertation advisor. However, it is

possible that some who declined to participate did not place the same value in their

personal treatment and hence lacked sufficient incentive to be interviewed. It is also

possible that those not wishing to participate found the nature of the questions to be too

personal. Given the small mental health community from which the pool o f participants

was drawn, resulting in a relative lack o f anonymity with the interviewer, it is quite

possible that those agreeing to participate might have felt less self-conscious about

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271

discussing their personal treatment because they had experienced largely positive

experiences in personal psychotherapy. Thus accessing the “negative case” was perhaps

less likely under such conditions.

By asking many of the participants why they agreed to participate in the study, the

investigator learned that there is apparently a need in some to tell one’s analytic stoiy,

perhaps as a way to continue the therapeutic dialogue with one’s former treater.

Numerous participants noted their enjoyment of the interview experience, citing the

interview as a reconnection with their personal treatment. Several participants noted the

paradox o f their therapy feeling at once both a highly personal and solitary odyssey-

undertaken alone, yet with the help of their analyst-but also a practically universal

experience for psychoanalytically trained treaters. They noted that the interview offered a

generally pleasurable opportunity to partially reexperience the feeling tone of their

treatment. Also, by examining the meaning of their experience through telling their story,

several participants reported “updating” their synthesis of the influence o f personal

treatment on both their personal and professional identity. Several noted that this

reaffirmation was safely done within the context of helping a colleague conduct research

on a topic of mutual interest.

The researcher did occasionally observe “Pfeffer’s phenomenon” (1963), in which

the participants related to the interview process and to the interviewer as though back in

analysis. However, since the method of data collection called for a single, semistructured

interview, this phenomena was less pronounced than in studies in which a number of less

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272

structured interviews were conducted, over time, thus more closely paralleling the actual

analytic situation (Kantrowitz, 1990; Shapiro, 1976).

In summary, in order to further understand overall effectiveness and subsequent

professional influence of personal therapy, it would be important to seek responses from

individuals who report less effectiveness of their personal therapy.

The fourth research question asked whether there is an association between

perceptions of the significance of the interpersonal relationship with the treater and the

other three domains o f the study-perceived benefits, perceived risks, and influence on

professional conduct. This question was changed slightly from the proposal question,

which sought specific examples of the participants’ reporting that consciously drew on

their personal treatment to inform their clinical work. Such discrete examples were quite

rare in the data, as respondents tended to experience the influence of their personal

therapy as integrated into their identity as a psychotherapist.

The decision to focus the data analysis on comparing levels of professional

influence with the other domains was also supported by examining the variability of

themes identified in the interpersonal relationship domain. Variations in subthemes of

responses were often quite subtle and would render less reportable data if the

interpersonal relationship questions were compared with the other domains. For example,

only one participant in the study ended treatment feeling that the interpersonal match with

his treater had not been good. The others either consistently, or over the course of

treatment developed a reportedly good match with their former treater. In addition, all

participants noted that they had felt liked by their former therapist by the end of treatment,

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and only one participant reported not liking his former therapist, when treatment ended.

All the respondents felt respected by their former therapist but only three participants

noted that their former treater might not have felt respected by them. Given this shift in

the data analysis plan, the fourth question, which examined associations between

perceptions of the significance of the interpersonal relationship with the former treater and

the three other domains of the model, was not ultimately pursued.

Reconfiguration of the model based on the current study findings suggests that

developing questions about the perceived interpersonal match with the treater might better

explore Kantrowitz’ findings (1990) about the interdigitation of the personal

characteristics o f the analyst with the particular difficulties and characteristics of the

patient as a crucial factor in determining a facilitating or an impeding match. The current

study found generally positive perceptions of match, based on factors o f mutual liking,

perceived professional competence, perceived professional convictions, mutual respect,

and perceived compatibility of personality styles. However, questions were not asked that

might better have explored aspects of whether there existed an impeding or facilitating

match, (e.g., whether the analyst was perceived as confronting or avoiding the negative

transference) as described by Kantrowitz (1990). The overall findings of the perceived

risks section in this study did support this aspect of Kantrowitz’ findings. However,

incorporating specific questions about how impeding or facilitating the match was, from

the former patient’s perspective could likely enhance the development o f a more accurate

model of character match in the domain o f the interpersonal relationship between

therapist-patients and their former treaters.

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274

The fifth research question concerned the relationship between continued

posttermination psychological involvement with the therapist and perceived benefits, risks,

and influence on professional conduct. The question was reworded slightly as the study

unfolded, to reflect the realities of the levels of influence identified rather than the specific

influences drawn on. Also, continued posttermination involvement was eventually seen as

a relative process, rather than as simply being present or absent.

As in the case of the previous research question, this final one was not analyzed as

originally planned, given the nature o f the unfolding data. There were two questions on

the interview schedule that explored posttermination psychological involvement with the

former therapist. One asked whether the participant thought about or wished to talk with

the former therapist. Only 20% of the sample expressed ambivalence in thinking about or

wishing to talk with their former therapist, with the others reporting clearly more positive,

less conflictual responses. Of the minority who expressed ambivalence, half included the

two respondents comprising the low level-of-influence group of personal therapy on

conducting psychotherapy. The participants who expressed ambivalence noted either a

premature termination from therapy or their analyst’s expulsion from the analytic institute

sometime after the participant’s termination.

The second question probing posttermination psychological involvement with the

former therapist sought to advance an understanding of whether engagement in an internal

dialogue with the former treater occurs while conducting psychotherapy. Geller (1994)

reported that this phenomenon was noted by 20% of his sample. The same frequency was

reported in the present study sample, with occurrences primarily during times of clinical

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275

uncertainty, when guidance was needed. Half the participants noted other forms of

relatedness to their former treater while conducting treatment, although not in dialogue

form. The remaining participants had a dim sense of this phenomenon occurring in the

distant past. As noted previously, however, the study findings do not suggest an

association between internal dialogue and level of perceived influence of personal therapy

on clinical practice. The model could be improved by seeking further information about

the occurrence of reported “verbal memories” of the former therapist during sessions. In

addition, asking about other specific modes of internal representation of the former

therapist during sessions, as described by Geller’s work, might yield additional information

about the forms and functions these internal representations serve for therapists’ clinical

practice. In this area, the present study did not reveal clear findings, perhaps because the

questions were not refined well enough to capture the subtlety of nuance that may exist

regarding this phenomenon.

Limitations of the Study

Given the inconclusive patterns that developed in the data analysis, there is a need

to refine some of the questions in the fourth domain of the study. The two “process

variables” identified as important in the model (the interpersonal relationship with the

treater and posttermination psychological involvement with the former therapist)-could

not be adequately assessed with the questions that were asked. The design o f the study

could be improved by refining some o f the interview questions in the domain of the

interpersonal relationship with the former therapist. These would target the findings in

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276

prior work on impeding or facilitating interpersonal matches (Kantrowitz, 1990) and on

posttermination psychological involvement with the former therapist as evidenced through

a variety o f possible internal representations of the former therapist (Geller, 1994).

Drisko (1997) describes four general interpretive criteria for assessing the

methodology o f qualitative data analysis: credibility, contextualization, confirmability, and

comprehensiveness. The first area of credibility, believability, or truthfulness involves

providing a local context of interpretations and giving authentic and accurate descriptions

of the primary participants. Extensive reporting of raw data in the participants’ own words

is a strength of this study.

The second interpretive criterion is “placing meanings in context” and providing a

sense of the wholeness o f the situation. Establishing context aids in assessing the

transferability of findings. The inclusion of each participant’s treatment history variables

was intended to contextualize the findings in this study.

The third interpretive criterion identified by Drisko (1997) relates to

“confirmability,” which refers to the researcher’s efforts to corroborate data and to

challenge or affirm interpretation or theory. There are both strengths and weaknesses in

this study concerning confirmability. The strengths include the multiple, repeated instances

o f phenomena obtained from the reports of primary sources that were presented in Phase 1

of the data analysis. The researcher attempted to provide extensive original data and

illustrative narrative examples to allow readers to develop their interpretations o f data, to

gauge the suitability o f coding, to understand the data analysis, and to corroborate the

research findings.

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2 77

The confirmatory activities in this study involved sharing the unfolding coding o f

categories with various dissertation committee members. A weakness in confirmability of

findings is that the researcher did not engage in “feedback sessions” with participants to

establish that the codes were accurate, which might have helped confirm the researcher’s

interpretation and enhance the study’s overall credibility.

The final interpretive criterion identified by Drisko (1997) relates to the

“completeness” or comprehensiveness o f both the data collection and analysis. This study

has both relative strengths and weaknesses regarding completeness. The reported data are

comprehensive and many of the descriptions are “thick” and broad. Given the limitations

with the interview schedule already described, the point of saturation was reached when

participants repeated details already provided and added no more to the development of

codes or interpretations. However, the study could have been improved had the interview

questions been altered in the fourth domain of the study to better explore Kantrowitz’s

concepts of impeding or facilitating match and to better assess other forms and functions

o f internalization of the posttermination therapeutic relationship, in addition to the internal

dialogue. Although the researcher did ask participants to say a little more when they

claimed to have said it all and did work on in the face of considerable repetition, adding a

few questions as described above may have resulted in advancing theoretical

conceptualization of the identification process. With respect to data analysis, the coding

scheme did strive for “saturation” to ensure that no data were omitted and that codes were

comprehensive.'

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278

Identifying Biases

Bias in qualitative research refers to influences that impair complete or accurate

sampling, data collection, data interpretation, and reporting. Qualitative researchers

attempt to limit bias through self-awareness, which includes reporting any potential biases

and noting what content areas might be influenced (Drisko, 1997). The inherent

subjectivity o f self-reporting through an interview process is an obvious source of

potential bias in this study’s design and subsequent results. The researcher attempted to

limit biases through self-awareness in sampling.

A possible source of bias in the sampling procedure may exist because of the

researcher’s prior professional acquaintance with 15 of the 20 participants. The researcher

did not interview anyone with whom she had worked closely. However, it is noteworthy

that all nine o f the individuals whose responses ranked in the high level-of-perceived

influence o f personal therapy on clinical work were therapists with whom the investigator

was at least slightly acquainted. Conversely, only five of the individuals in the middle level

and one of the two individuals in the low level groups were therapists with whom the

investigator had prior acquaintance. Whether participants who were acquainted with the

investigator experienced a greater pull to participate initially or to later provide “socially

desirable” responses is a legitimate question. They may have been aware that the

investigator had experienced a personally meaningful analysis that had been experienced as

having a very positive impact on her clinical work. The investigator is left questioning

whether she perceived the responses of acquaintances to be more positive than those of

the minority o f participants who were essentially strangers. There is evidence, however, in

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279

the narrative that those who were acquainted with the investigator were more open and at

ease about exposing their negative transferences and the working through of problems in

the therapeutic relationship, factors which were strongly associated with being ranked in

the high level group of perceived influence of personal therapy for clinical practice.

A bias in data collection existed toward maintaining a fixed interview schedule,

rather than flexibly improving questions in the fourth domain of the study. This bias

occurred in large part because of the novice researcher’s inexperience, which led to the

premature conclusion that probing the concepts of characterological match and internal

dialogue were yielding unclear responses, rather than that the specific questions that

probed these concepts were perhaps inadequate to assess such complex phenomena.

A possible bias in interpreting results may exist because the researcher chose to use

the high level-of-influence group’s integrated responses to illustrate patterns. This

standard was set because o f the relative clarity in observing and contrasting the findings by

emphasizing differences. Given the very small sample size of the low level-of-influence

group, compared with the two others, this comparability may strain the validity of the

intergroup findings. Seeking a larger number of participants who report low levels of

perceived influence of their personal therapy in their clinical work could remedy this

potential limitation. This size limitation was mentioned, however, in the report of study

findings.

On a more personal level, the researcher began the study with a bias that those

individuals perceiving the most influence of their personal therapy on their clinical work

would be able to provide the most vivid and specific examples of how and when they draw

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280

upon it to inform their clinical practice. This expectation was, in fact, not supported by the

data. The researcher had hoped that the participants’ memories o f their personal treatment

would provide data to better understand the context in which such memories are evoked.

Instead, the study results were that these memories occur only during moments o f clinical

uncertainty or perhaps when countertransference is evoked by the patient struggling with

issues familiar to the participant-therapist.

Although clarifying unique situations and specific events is central to the accuracy

and credibility o f a qualitative study, it was nevertheless personally difficult for this

investigator to hear some aspects of certain participants’ accounts of their personal

therapy experiences. For example, the several participants who were left with especially

negative transference manifestations evoked a reaction in the researcher to wish to

intervene “therapeutically.” It was difficult, for example, to hear about participants’ anger

and extreme disappointment in the treatment process when the negative aspects of the

treatment relationship had not become a central focus of the analytic work. Conversely,

one participant appeared to be left with a very idealizing transference. However, she was

ranked in the middle level-of-influence group in large part because of the apparent

countertransference enactment in which her former analyst avoided working through her

negative transference. The researcher experienced a pull with these individuals to provide

the missing experience in their analysis. This reaction stood in striking contrast to that in

interviews with participants whose treatments had been centrally concerned with working

through both transference and “real relationship” struggles in the analytic dyad. In those

interviews, the researcher felt satisfaction on hearing about the drama o f learning to safely

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281

use the treatment relationship as a vehicle for addressing both intrapsychic and

interpersonal conflicts. There was no pull toward engaging in “therapeutic activity” as a

part of listening, but rather a desire to conceptualize the various factors that comprise a

“good enough” personal therapy experience.

In general, the findings have application for the psychoanalytically oriented

treatment o f psychotherapists in which analysis of transference phenomena is central to the

therapeutic action. The results in the domains of benefits and risks generally support the

findings o f prior studies. The domain examining the influence of personal therapy on

clinical work was constructed from prior work and when analyzed for content with this

sample, was determined to provide rankable responses for comparison with the other three

domains. These findings may well have application for evaluating the personal treatment

experiences o f a larger population of psychoanalytic psychotherapists.

Generalizability o f the findings in the domain of the interpersonal relationship and

posttermination involvement is limited, however. Nineteen of the 20 participants had

elected to remain in the locale where they received their personal treatment. Half of the

participants’ former treaters reside locally and remain available for continued consultation

with the participant. These factors appear to influence posttermination psychological

involvement with the former treater and, hence, limit the generalizability of the study

findings to other settings. Perhaps these findings most clearly apply to psychoanalytic

institute settings, where there is a high likelihood of former analysands having

posttermination professional or personal contact with their former treater.

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282

Implications of Results for Clinical Practice and Future Research

Clinical Practice Implications

The findings of this study suggest several implications for the practice of

psychodynamic psychotherapy and psychoanalysis. First, they support common practice

wisdom that analyzing the transference is central to therapeutic outcome. The findings

suggest that therapists as former patients are acutely attuned to their treater’s analytic

attitude toward the coexistence of transference and the “real relationship.” The analysis of

the treatment relationship on both of these levels-as a two-person construction-supports

contemporary shifts in psychoanalytic thinking toward the intersubjectivity o f the analytic

enterprise. Respondents who reported the highest levels of perceived influence of their

personal therapy in their clinical work also experienced their former treater as being

authentic and as not hiding behind analytic neutrality or technique, yet maintaining an

analytic space for the unfolding of the treatment process.

Clinical implications for the personal psychotherapy o f patients who are

psychotherapists include the importance of personal treatment to support the professional

identity o f therapist-patients. Respondents who reported the highest levels of influence

rated this professional growth as a clear benefit of their personal therapy. Acknowledging

disappointments and limitations in oneself and others-including with the therapist-and

working through these disappointments within the treatment relationship, especially as

they involve narcissistic wishes to be perfected, are strongly associated with a high level of

perceived influence o f personal therapy for one’s clinical work. The former patients

appeared to identify with their perception of how their former analyst had resolved similar

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283

disappointments and accepted limitations. Acknowledging characterological differences

and developing a collaborative relationship despite these differences was also associated

with a high level of perceived influence of personal treatment on clinical work.

The findings suggest that the internalization of the treatment relationship is a

process which may change over time, as posttermination life unfolds. Although numerous

participants offered evidence o f a self-analytic function, the internal “therapeutic dialogue”

that several described remained vulnerable to ongoing events in the former analyst’s life,

particularly to traumatic losses represented by the former analyst’s physical or

psychological incapacitation and inability to work. These participants were ranked in the

middle or low level-of-influence group. Respondents in the high level-of-influence group

had largely maintained postanalytic contact with their former treater and continued to

draw on the internalized relationship to resolve ongoing developmental challenges and

crises in their lives. Four of the members of the high level-of-influence group had, in fact,

lost their former analyst-to an untimely death in three cases and to leaving the profession

altogether in another. However, unlike participants reporting lower levels of influence,

these four individuals continued to “internally dialogue” with their former treater as an

aspect of their ongoing self-analysis.

Findings also suggest that the termination phase of treatment has an especially

long-lasting influence on the fate of the ongoing internalization of the therapeutic

relationship. “Good” terminations were associated with a distinct phase of the work

characterized by mourning losses and reworking acceptance of the inevitability of

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284

limitations. These tasks were most often described spontaneously by members of the high

level-of-influence group.

These findings suggest that most participants report an increased differentiation of

self and others consequent to their personal therapy. However, those who were ranked

lower in perceived influence o f their personal therapy on their clinical practice were left to

continue the psychological work of individuation with a less clear sense of the former

therapist as a helpful internal object on whom the participant continues to draw for help in

meeting personal and professional challenges. Those in the high level-of-influence group

offered evidence that their individuation was promoted by the therapy relationship as a

consequence o f focusing on interpersonal conflict within the treatment relationship. Those

in the lower level groups appeared to have less overt conflict in their treatment

relationships generally, yet it would seem that they were then left on their own, without

their treater’s help, to resolve issues of disappointment concerning their treatment.

The wider application of these findings to the general psychotherapy patient

population must be drawn cautiously. They generally suggest that subjectively perceived

benefits, risks, and aspects of the interpersonal relationship with the former treater may

interact to promote greater autonomy of functioning through identification. The extent to

which the former treater is seen as a positive role model may also be associated with the

extent to which the treatment relationship conflicts were actively addressed in a former

patient population o f nontherapists. However, attempts to apply these study findings to a

wider psychotherapy patient population are limited by the complexity of varying influences

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285

and identifications o f being in the same versus a different profession than one's former

treater.

Implications for Future Research

The study findings raise several questions that might guide future research on

aspects of internalization of the psychotherapy relationship. Refinements of questions

related to the fourth domain of the model include incorporating inquiry to take better

advantage of Kantrowitz’s work regarding an impeding or facilitating interpersonal match

between therapist and patient, from the patient’s perspective. In addition, the study

findings suggest pursuing more knowledge about the reported “verbal memories” of what

the former therapist said that remains as a permanent intrapsychic representation for the

former patient. Doing so might involve further incorporating Geller’s work on modes of

representation of the former therapist, with specific questions to advance knowledge about

the functional use of these internalizations for the conduct of psychotherapy. When the

patient is also a therapist, the treatment relationship is presented with both unique

challenges and opportunities for growth through identification with the therapist as a

mentor. The dual functions of promoting both therapeutic and educational goals are

incorporated in the required training analyses of candidates in psychoanalytic institutes.

There are well-documented parallels in other mentoring relationships within the

psychoanalytic psychotherapy field, such as in the supervisory relationship. Could any o f

the findings in the current study be usefully applied to advantage to achieve a better

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286

understanding of identification processes in the supervisory relationship? This question

might be fruitfully pursued.

Another question raised by the current study regards the potential

multigenerational themes or patterns of influence of personal psychotherapy on the clinical

work o f successive generations of psychotherapists. There is an apparent potential for

specific psychoanalytic theories to be passed from therapist to patient, within specific

psychoanalytic institutes. Do identifiable multigenerational processes occur within the

culture o f these psychoanalytic institute “families”? Psychoanalytic institutes are in a

unique position to investigate the potential of multigenerational themes or patterns that

might advance knowledge related to character match or to working through therapeutic

relationship problems that may contribute to overall knowledge about internalization of

personal therapy for therapists.

Finally, this study raises questions as to whether some individual therapists are

“identification hungrier” than others throughout life. That is, are some individuals

inherently more prone to, or more open to, being influenced by authority figures, such as

therapists, teachers, or supervisors with whom they work closely in adulthood? What

developmental processes might be associated with this need? Might specific therapeutic

techniques enhance the patients’ learning about conducting clinical work from their

therapist? These questions have relevance for therapists who treat therapists, given the

tendency for this relationship to reverberate deeply in the therapist-patient’s clinical work.

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287

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A p pe n d ix A
I n it ia l C o n t a c t L e t t e r
(date)

(addressee)

Dear__________ :

I am a doctoral student at Smith College School for Social Work and am writing to inquire
if you would be interested in participating in a study that I am conducting for my dissertation.

The purpose of the study is to explore how psychotherapists feel about their personal
therapy and how it has influenced their professional practice as psychotherapists. I am seeking
participation of psychotherapists with at least five years of practice experience, who have in the
past engaged in individual psychotherapy or psychoanalysis. The intent of the study is to
understand how personal therapy experiences influence one’s own work as a psychotherapist.
I would like the opportunity to discuss your experiences, thoughts, and impressions on this subject
in a face-to-face audio-recorded interview.

The time required for the interview will be approximately 1-1/2 hours. I am aware that
your time is precious and would be willing to meet with you at a time and location most convenient
to you. Unfortunately, I am unable to offer financial remuneration for your participation.

I am very aware that I am asking you to share sensitive material. Your identity will be known only
to me, and all possible steps to ensure confidentiality of the taped material will be taken. Your
name will not appear on any records of the information and will be identified only by a code
number. Following transcription of the interview by a professional research transcriptionist, the
fully transcribed information will be securely stored and accessible only to this researcher.
Segments of the disguised interview results will be discussed with my dissertation committee,
which is chaired by Donald B. Colson, PhD.

I believe that the efficacy of the therapy process will be served by closer examination of
how psychotherapists’ personal therapy experiences inform their personal and professional
development. Your contribution to this effort will be greatly appreciated. If you are interested in
participating, please return the enclosed reply card in the envelope provided. I will then phone you
to further discuss the project and arrange for an interview.

I thank you for considering participation in this study. If you have any further questions, please
feel free to phone me.

Sincerely,

Karen Bellows-Blakely, MSW


Phone (785) 234-6844

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APPENDIX B
M a il -I n R espo n se t o I n it ia l C o n t a c t L e t t e r

I am interested in participating in the research project entitled “Psychotherapists’ Personal


Psychotherapy and Its Perceived Influence on Clinical Practice,” being conducted by
Karen Bellows-Blakely, MSW. I understand qualifications for the study include having a
minimum of 5 years’ postgraduate practice as a psychotherapist and completion of one’s
most recent personal psychotherapy process or psychoanalysis.

Name:_______________________________

Phone #s:____________________________

Best times to call:______________________

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A p pe n d ix C
I n f o r m e d C o n se n t F o r m : W r it t e n E x p l a n a t io n to P a r t ic ip a n t s

I am conducting a study that examines psychotherapists’ experiences o f their personal


treatment and how these have influenced their professional practice of psychotherapy. The
purpose of the study is to gain understanding of how personal treatment contributes to the
development of therapists’ use o f self in the psychotherapy enterprise.

Because you are a practicing psychotherapist who has engaged in personal therapy, your
insights into the nature of this experience are very valuable. I would like permission to
interview you and use the information you share with me in my research, which I am
conducting to complete my doctoral dissertation requirement at Smith College School for
Social Work.

If you decide to participate in the tape-recorded interview, you will be asked a number of
questions about your personal psychotherapy experience and what influences you believe
it has had on your personal and your professional development.

To ensure the confidentiality of the material you share with me, I will take the following
steps. After the interview is transcribed by a professional research transcriptionist, the
verbatim data will be accessible only to me. The typed transcriptions will be identified only
by a code number, and no institutional affiliations will be given. The material in the final
report will be disguised in such a way that it cannot be identified with you. Segments of
the disguised interview material may be shown only to the researcher’s dissertation
committee advisers, chaired by Donald B. Colson, PhD. The other committee advisers are
faculty members at Smith College School for Social Work.

Participation in this study should take approximately 1-1/2 hours of your time. At the
conclusion of the interview, I will ask you about any concerns you may have. You are, of
course, free to terminate the interview at any time. If you withdraw, all information you
have provided will be destroyed. Unfortunately, I am not able to offer financial
remuneration for your participation. I can, however, offer you the opportunity to
participate in what I believe to be a useful study on the efficacy of the treatment process,
and my sincere appreciation for doing so.

The information from this study is being used for educational purposes and may be used
for research publication in the future. You will not be personally identified in any way in
reports or publications that may come out of this research study.

If you have future questions regarding this research, please contact me, Karen Bellows-
Blakely, MSW.
Office address: 522 SW Washburn Ave., Topeka, KS 66606
Office phone: (785) 234-6844

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APPENDIX D
S t a t e m e n t o f I n f o r m e d C o n se n t b y R e s e a r c h P a r t ic ip a n t

I am willing to take part in a research study described to me as “Psychotherapists’ Personal


Psychotherapy and Its Perceived Influence on Clinical Practice,” being conducted by Karen
Bellows-Blakely, MSW, as part of the doctoral dissertation requirements at Smith College School
for Social Work.

I have read the accompanying description of the study. The purpose of the research and the
procedures that will be used for data collection and analysis have been clearly explained. I have
been told that I will be asked questions about my personal psychotherapy experiences, its effects on
me and my professional practice of psychotherapy. I understand that this interview will be
audiotaped.

Any risks and/or benefits I can expect to experience from participation in this study have been
explained to me. Any further questions I may have during or after my participation in this research
study will be answered by the researcher. Also, it has been explained to me that I can discontinue
participation in this research project whenever I wish and without any disadvantage to me.
I understand that I will not be paid for taking part in this research project. 1 understand that if
I have any questions about my rights as a research subject, I can contact the chairperson of the
Menninger Institutional Review Board at (785) 273-7500.

I understand that all of the information I will provide when I take part in this research study will be
confidential. The information will not be shown to anyone except the researcher’s dissertation
advisers, unless it is ordered by a court of law. My name, initials, and institutional affiliation (if
any) will not appear on any records of the information given, even to the research advisers. Such
records will be identified by a code number only. I agree to the use of this information by the
researcher for educational purposes and for research publication, and I understand that I will not
be personally identified in any way in reports or publications that may come out of this research
study.

In signing my name to this form, I am certifying that I understand everything that I have been told
about my part in this research study and that I am willing to participate in it by being interviewed.
My signature on this form does not obligate me to complete the research study nor does it release
the researcher from possible legal responsibility. I understand that I will receive a copy of the
signed consent form for my reference.

(Investigator) (Research Participant)

Date Signed:________

I am interested in receiving overall results of the project. (Please check here):.

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A ppe n d ix E
D e m o g r a ph ic Q u e st io n s

These questions followed a brief introduction of the researcher, further description of the
research study, and a review of the Informed Consent protocol. Participants were then
asked the following questions at the beginning of the interview.

Personal Treatment Processes


For what duration o f time have you engaged in an individual psychotherapy or
psychoanalysis process? How long ago did you terminate your most recent
psychotherapy?_______ Total number of hours of individual psychotherapy:__ .

Professional Training and Experience


Your professional degree: MD ____ PhD ____MSW
Year obtained:______How many years postgraduate practice experience do you have
treating individuals?____
Describe your current clinical practice:

Current Clinical Practice


Which modalities o f clinical work do you currently engage in practicing?
Individual psychotherapy:___ Hours/week:__ .
Psychoanalysis:__ Hours/week:___ .
Couples treatment:__ Hours/week:___ .
Family therapy:__ Hours/week:___.
Group therapy:__ Hours/week:___ .

Your theoretical approach


Please describe your theoretical approach to treatment (i.e., which theory/theories do you
find most informative to your clinical work?).

Your most recent psychotherapist’s theoretical approach


Please describe your understanding of your therapist’s theoretical approach to treatment.

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APPENDIX F
I n te r v ie w Q u estio n s

1. Please describe what has been beneficial to you in your personal therapy or
analysis? This will be asked before prompting with the following questions:

a. How useful was your therapy in enhancing your awareness and understanding of
yourself?

b. How useful was your therapy in enhancing your self-esteem and self-confidence?

c. How useful was your therapy in improving your interpersonal relationships?

d. How useful was your therapy in enhancing therapeutic skills, for example, with
empathy, in using countertransference, in structuring treatment, in understanding the
process of psychotherapy?

e. How useful was your therapy in resolving characterological issues and alleviating
symptoms?

2. Please describe any disappointments, risks, or negative effects of your personal


therapy or analysis. This will be asked, before prompting with the following questions:

a. To what extent did you experience excessive stress or psychological distress as a


consequence o f your personal therapy?

b. Did you experience any problems with the working relationship?

c. To your way of thinking, did your therapist make treatment errors in your work
together? If so, please specify.

d. Do you think you have identified with your therapist in some way that has affected
you adversely?

e. In your view, was your effectiveness as a therapist blocked due to confusion in being
both a patient and a therapist at the same time?

Perceived Overall Effectiveness of Personal Therapy


1. Overall, how well do you believe your therapist understood you and communicated
his or her understanding to you?

2. Overall, how successful or satisfactory do you believe your psychotherapy or analysis


was?

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3. Questions About the Effects o f Personal Therapy on Conducting Therapy


a. & b. Do you believe you work differently with your patients or clients as a consequence
o f having engaged in your own therapy? I f so, in what ways? Which aspects of your
therapy do you think you draw on?

c. (i) To what extent has your therapist served as a role model for you in conducting
psychotherapy?

c. (ii) What do you perceive as being your therapist’s limitations or mistakes which have
influenced your work with your own patients or clients?

d. (i) Do images or thoughts of your therapist ever come to mind while you’re conducting
psychotherapy?

d. (ii) Do you remind yourself o f your psychotherapist(s) or analyst(s) while working? If


so, can you describe any such moments, any particular clinical circumstances?

d. (iii) Which, if any, personal attributes of your therapist or analyst do you find yourself
most identifying with in your work?

Questions about the Perceived Interpersonal Relationship and the Process of


Continued Psychological Involvement with the Therapist
1. How would you describe the interpersonal match or fit between you and your most
recent therapist or analyst?

2. (“Goodness of fit” includes two components-the “emotional tone” or mutual liking


and compatibility of character style). To what extent did you like your therapist, or
feel fondness and affection for him or her and experience that your therapist liked
you? Did you sometimes dislike your therapist or feel disliked?

3. (Regarding character style as a component of the match:)


a) Did you think of your therapist as professionally competent? Do you think your
therapist thought of you as professionally competent?
b) How compatible were your professional convictions?
c) Did you feel respected by your therapist? Do you think your therapist felt
respected by you?
d) How compatible were your personality styles?

4. Do you sometimes find yourself thinking about your analyst or therapist, or wishing
to talk with your analyst or therapist? If so, under what circumstances?

5. In your'conduct of therapy, do you ever engage in an internal dialogue with your


therapist or analyst? If so, under what circumstances?

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APPENDIX G
O r d i n a l R a n k i n g s o f Q uestions A ssessing P e r c e i v e d In f l u e n c e s o f
Pe r s o n a l T h e r a p y o n C o n d u c t i n g Ps y c h o t h e r a p y
3. a. & b. Do you believe you work differently with your patients as a consequence of
having engaged in your own therapy? If so, in what ways; which aspects of your
therapy do you think you draw upon?

(1) Uncertain that personal therapy informs my clinical work = 0


(2) Yes, personal therapy has influenced my work with patients = 1
(a) Enhanced awareness of importance of treatment structure
(b) Broader range of interventions
(c) Enhanced confidence in therapeutic process
(d) Deepened conviction about treatment relationship as important vehicle for
psychic change and growth
(e) Increased acceptance of realistic limitations of psychotherapy enterprise

3. c. (i) To what extent has your therapist served as a role model for you in conducting
psychotherapy?
(1) Significant and only positive identifications noted = 2
(2) Significant and both positive identifications and differences noted = 1
(3) Not a significant professional role model = 0

3. c. (ii) What do you perceive as being your therapist’s limitations or mistakes which have
influenced your work with your own patients?
(1) No limitations, just positives = 1
(2) Limitations that do influence my work = -1
(a) Theoretical biases
(b) Analyst’s technique
(3) Limitations were analyst’s human foibles or countertransference reactions, and
are benign to my clinical work = 0

3. d. (i) Do images or thoughts of your therapist ever come to mind while you’re
conducting psychotherapy?
(1) Not currently; probably not, in past = 0
(2) Not currently; but, yes, in past = 1
(3) Yes, currently and in past = 2

3. d. (ii) Do you remind yourself of your psychotherapist(s) while working? If so, can you
describe any such moments?
(1) Do not remind myself o f him or her while working = 0
(2) Yes, I do remind myself of him or her while working = 1
(a) analytic technique
(b) Interpersonal style
(c) Theories o f cure

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3. d. (iii) Which, if any, personal attributes of your therapist do you find yourself most
identifying with in your work?
(1) With how therapist conducts his or her personal life
(2) With therapist’s personal character traits
(3) With therapist’s capacities in conducting treatment

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A p pe n d ix H
L e v e l o f I n f l u e n c e S c o r e s : P e r c e iv e d P o sit iv e I n f l u e n c e o f
P e r s o n a l T h er a py o n C o n d u c t in g T h er a py

Participant Score Influence Level


1 3 Middle
2 -1 Low
3 3 Middle
4 5 High
5 4 Middle
6 5 High
7 2 Middle
8 7 High
9 3 Middle
10 5 High
11 3 Middle
12 6 High
13 6 High
14 5 High
15 4 Middle
16 1 Low
17 5 High
18 4 Middle
19 5 High
20 2 Middle

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APPENDIX I:
D a ta A n a ly sis : P h a se 2
M a t r ix o f F in d in g s : O u t l in e o f C a t e g o r ie s , T h e m e s , & S u b t h e m e s

Section I: Perceived Benefits of Personal Therapy


1. Please describe what has been beneficial to you in your personal therapy or
analysis.
(1) Enhanced self-understanding: [n=l 1] (2, 4, 7, 8, 9, 13, 14, 15, 16, 19, 20)
(a) Helped me trust in my ability to be introspective (4)
(b) Increased my comfort with my inner world and feelings (4, 8, 9)
(c) Deepened my awareness of how powerfully issues can affect people’s lives (15)
(2) Enhanced separation-individuation related to family of origin: [n=8] (1, 7, 9, 13, 14,
16, 17, 19)
(a) Promoted adaptation to traumatic childhood loss of parent(s) (7, 9, 13)
(i) Viewed self as resilient in eliciting care from substitute caretakers
(b) Helped me come to terms with who I am because of the family I came from
(i) Oedipal conflict with same-sex parent (17, 19)
(3) Improved interpersonal relationships with contemporaries, including intimate
relationships: [n=8] (1, 5, 11, 13, 16, 17, 18, 19)
(a) Deepened capacity for commitment (1, 16, 18)
(b) Increased tolerance for the humanness of others (11, 17)
(4) Symptom alleviation: [n=8] ( 8, 9, 10, 11, 15, 17, 18, 19)
(a) Resolution of depression, anxiety, guilt, and anger (8, 9, 10, 11, 15, 17, 18)
(b) Culture-specific context of meaning of symptoms (9)
(5) Enhancement o f professional work with patients: [n=7] (4, 5, 12, 13, 14, 16, 18)
(a) Personal therapy is one of the best things I’ve done for myself and my patients
(18)
(b) I use the skills and techniques in conducting therapy that I learned there (16)
(c) Enhanced awareness and attunement to multiple levels of the treatment process
with patients (4, 12, 13, 14)
(d) Value of engaging in personal therapy concurrently with clinical training (4, 5)
(6) Improved self-esteem and self-acceptance: [n=6] (6, 7, 10, 14, 15, 19)
(a) Learning to like myself, decreasing my self-criticism (10, 15, 19)
(b) Having a growing sense of my own competence and trusting in it (14)
(c) Feeling more entitled to whatever I feel (6)
(d) Graining an inner peace with the analysis since I became my own friend (7)
(7) Importance o f interpersonal relationship with the analyst: [n=4] (5, 9, 15, 19)
(a) Analyst as a model for male gender-role identification, in light of early loss of
father, or very conflictual relationship with father (9, 19)
(i) Therapist as role model for becoming a competent man and a competent
psychotherapist
(b) Valued the containing or holding function of psychotherapy (9)

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(c) Valued being treated like a colleague as vital to self-esteem and professional
competence (15)
(d) Valued the unique intimacy of the analytic relationship (5)
(8) No or few benefits: [n=2] (3, 10)
(a) First analyst didn’t like me; subsequent analysis much more helpful (10)
(b) Analyst misdiagnosed me; role reversal, with analyst seen as fragile and in need
of care (3)
(i) Analyst’s political problems at the psychoanalytic institute represented a
traumatic reenactment of my parents’ marital conflicts (3)

1. a. How useful was your therapy in enhancing your awareness and understanding
of yourself?
(1) Improved understanding of my psychodynamics: [n=13] (1, 2, 5, 6, 8, 9, 11, 13, 14,
15, 16, 17, 19)
(a) In the context of original, infantile objects (1, 5, 6, 16, 17)
(b) Based on contemporary ego functioning (2, 11, 13, 14, 15, 16)
(i) Increased awareness of narcissistic vulnerabilities (11, 13)
(ii) Increased competence, self-confidence (14, 15)
(2) Related to relationship with analyst: [n=6] (3, 4, 6, 16, 17, 19)
(a) Developing a negative transference important (6, 17)
(b) Identification with analyst as “new object” (16, 17)
(3) Regarding needs for connectedness and separateness of self and object or promoted
separation-individuation: [n=6] (2, 4, 12, 15, 18, 20)
(a) Enhanced my autonomy and ability to self-soothe, through self-analysis and
reading psychoanalytic theory, and enhanced my self-reliance through learning
how to carry out a procedure on myself to gain insight (15, 18)
(b) Powerful to put words to my experience, which validated it and led meto feel
less isolated in my own narrow understanding (12, 20)
(c) Psychoanalytic culture can lead to unhelpful, rigid idealization o f technique and
theory, or can promote further individuation of self (2, 4)
(4) Regarding effects on professional identity development: [n=5] (7, 9, 10, 12, 19)
(a) All human behavior is understandable (9,12)
(b) Increased differentiation of self and patients (7)
(c) Analyst’s implicit approval of me supported my belief in my analytic capacities
(10, 19)
(5) Regarding disappointments/ limitations in the enhancement o f self-awareness: [n=2]
(15, 20)
(a) The work felt unfinished in last treatment (15)
(b) Treatment didn’t change my life profoundly, but it helped me live deeper, less
superficially (20)

1. b. How useful was your therapy in enhancing your self-esteem and self-
confidence?
(1) Clearly enhanced: [n=12] (1, 4, 5, 6, 8, 9, 12, 13, 14, 17, 18, 19)
(a) Personally (1, 8, 9, 14, 18, 19)

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(i) Analyst’s confidence that I could have a healthy relationship with a man was
very important to me (1)
(ii) I became more relaxed, comfortable, less afraid of living, and had less need
to have control over everything (14)
(iii) I’m more comfortable with myself, have better self-esteem, and am less
negative, defeatist with myself (19)
(iv) Promoted my autonomy and competence that I could figure myself out (18)
(b) Professional identity or clinical practice (4, 5, 6, 12, 13, 17)
(i) She validated my perceptions of my clinical work, which nudged me along in
self-esteem (13)
(ii) It was powerful being validated by a male therapist whom I respected, when
I’d had a lot of transference to male authority figures as devaluing of me (5)
(iii) Enhanced my confidence in handling difficult clinical situations (6)
(iv) Issues of self-esteem are still incompletely resolved, but my analyst helped
me clarify who I am and my right to be doing this work and be able to see it
as valuable to other people (4)
(v) Analyst helped contain my anxiety about success and competition and fears
o f failure (17)
(vi) Acceptance of imperfections, when “good enough” is better than perfect is
what I got. It’s given me permission to be who I am and then try to help
patients do the same thing. “You don’t have to be perfect to be lovable or
accepted, or to have something meaningful to contribute.” Setting my own
standards for what I think is meaningful. (12)
(c) Emphasized therapist’s role in promoting self-esteem and self-confidence (1,5,
12, 13, 17, 18, 19)
(i) I felt totally respected, more than ever before (19)
(ii) Analyst’s flexibility in accurately perceiving how much to intervene, how
much to let participant struggle with her own resistance to treatment
promoted self-confidence (18)
(2) Mixed or equivocally enhanced: [n=8] (2, 3, 7, 10, 11, 15, 16, 20)
(a) Therapeutic mismatch with first analyst; second one excellent match; first analysis
left me with many self-doubts, second one helped me feel better about myself
( 10)
(b) Constraints in analyst’s method or technique (3, 15)
(i) Analysis not appropriate mode of treatment; later psychotherapy good (3)
(ii) Lack of structured termination phase (15)
(c) Self-esteem not particularly problematic, but it became more realistic with
treatment (11, 16)
(d) Limitations in the analytic process itself (2, 7, 20)
(i) Self-esteem eventually benefited, but it could have been faster had analyst
more directly confronted one o f her pathological beliefs about herself (7)
(ii) Analytic process very difficult, anxiety-producing in forcing you to face your
deepest fears (20)

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(iii) Analysis helped me to become more self-reflective, yet it can be a


doctrinaire, rigid religion. I subscribe to broader theoretical views as
clinician in practice. (2)

1. c. How useful was your therapy in improving your interpersonal relationships?


(1) Clearly helpful with: [n=12] (1, 2, 4, 5, 7, 9, 10, 12, 13, 15, 19, 20)
(a) Promoting the internal capacity for improved relatedness (2, 7, 9, 12, 20)
(i) Viewed self as less self-preoccupied, less self-referential, and better at
listening to others (2, 7, 12)
(ii) Analysis made me “lesssuperficial,” more introspective and reflective (9, 20)
(iii) It made me easier to live with, gentler, more tolerant of vulnerable people
and less tolerant o f pathological beliefs and behaviors. It made me more
honest, intellectually and emotionally. (9)
(iv) It helped me discover the defensive parts of my overfiinctioning in
relationships and to get a better balance with this (7)
(b) Actual improvements in interpersonal relationships with significant others (1,5,
10, 12, 13, 15, 19, 20)
(i) The quality o f my friendships have changed as a result of my analysis, and
it’s made a significant difference in my ability to approach my family
members, individually and collectively (5, 10, 20)
(ii) It was useful in helping me to clarify a lot of anger I ’ve had in relationship to
men and with my father. And it helped me feel like I could have a
relationship with a man and stay clear about who I was. (1)
(iii) My analysis helped me extricate myself from an “unhealthy’ relationship and
then develop a committed marital relationship with a mature partner (13, 19)
(c) Enhanced professional relationships with patients and colleagues (2, 10)
(i) I became clearer about who my professional mentors were. This led to more
differentiation of myself, professionally. (2)
(ii) I became more secure and confident about my professional abilities and the
analyst helped me learn to trust my intuition (10)
(2) Equivocally helpful: [n=8] (3, 6, 8, 11, 14, 16, 17, 18)
(a) For female participants, clarifying their boundaries in relationships created
interpersonal conflict (6, 8, 14, 17, 18)
(i) Positive changes in my relationship with my mother (6, 17)
(ii) It has disenhanced some of my relationships, because I am more assertive
now, more direct with my aggression, which at times can create conflict. I
have fewer friendships, but the ones I have are more mutual. (17, 18)
(iii) During the analysis, I was irritable with the distractions of my family
members’ issues. But, ultimately, I think my interpersonal relationships were
greatly enhanced, because I became less guilt-ridden, less neurotic, irritable,
impatient, and irrational in my relationships with others. (8)
(b) Spouses pleased with therapeutic results, but other interpersonal relationships
changed, due to less tolerance of others’ foibles (11, 16)
(i) However, a cost o f going through an intensive psychotherapy process is that
you don’t suffer a lack of insight in others, including your friends. Your

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threshold for friendships changes and is more exclusive, to a higher


threshold, which makes it a little harder to form close friendships. (16)
(c) Changes in professional relationships (11, 17)
(i) I ’m more direct in work situations and less fearful about telling people when
I disagree (17)
(ii) During my analysis, I had more conflicts with patients than before, but over
time, I think my analysis has significantly affected my capacity to establish a
therapeutic relationship with patients. (11)

1. d. How useful was your therapy in enhancing your therapeutic skills for example,
with empathy, in using countertransference, in structuring treatment, in
understanding the process of psychotherapy?
(1) Changes in oneself which have implications for clinical practice: [n=13] (1, 4, 5, 6, 7,
8, 10, 12, 14, 15, 18, 19, 20)
(a) Enhanced conviction and self-confidence as a therapist (1, 4, 10, 12, 14, 15, 18)
(i) Increased my self-confidence to take a clear position of hope with my
patients when I believe it, like my analyst did with me. (1)
(ii) Helped me to trust my intuition and what I was leaming-to think that I
might have something to offer and it didn’t have to be perfectly tailor-made
at the start to develop a working relationship with the patient that is safe for
both members. (12)
(iii) Through personal analysis, my conviction increased, at an emotional and at
an intellectual level, that the phenomena of transference and resistance really
do exist and that they carry some danger for both parties involved. (18)
(iv) Analysis has changed the way I think of myself-I know I am a crackeijack
with patients with poor self-esteem. (10)
(b) Enhanced self-acceptance (5, 6, 7, 8, 10, 12, 18, 19, 20)
(i) My perfectionistic tendencies were reinforced by my training, but my analyst
gave me permission to be myself (5)
(ii) I’ve taken a self-acceptance of my humanness from my analyst by seeing his
human vulnerabilities and that he could also do very good clinical work (8)
(iii) My analysis convinced me that parents do their best, and learning not to take
my parents’ imperfections as my failing has helped me work with patients to
likewise love themselves and their parents for who they are and whatever
their weaknesses are (7)
(c) Enhanced capacity to help patients with issues similar to one’s own (1, 4, 5, 6, 7,
10, 12, 14, 15, 18, 19, 20)
(i) The more I was able to explore about myself regarding shame about
competitive issues, the more I ’m able to help patients explore why their
feelings about competition makes them feel awful (6)
(ii) My therapy has helped me professionally by becoming more comfortable
with my own issues related to sexual material, trauma issues, shame, and
issues related to loss, mourning, and instilling hope (1,6, 10, 12)
(2) The importance o f the interpersonal relationship between the therapist and patient,
including: [n=13] (3, 5, 6, 7, 8, 10, 11, 13, 14, 15, 17, 18, 19)

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(a) The “real” relationship, for example, ’’objective” qualities o f the treatment
relationship, being treated with genuine respect (5, 13, 15, 19)
(b) Enhanced capacity to work in the transference (5, 6, 7, 10, 11, 15, 17, 18)
(i) Understanding the power of regressive experience (7)
(ii) Increased tolerance of negative affect from patients (6, 10, 17)
(c) Identification with the therapist (5, 8, 11, 12, 15, 18, 19)
(i) I have identified with my therapist as a thoughtful, rational person who is
also comfortable with affect (19)
(ii) For the first decade after my analysis, I could see that much o f what I did
was a copy of what my analyst had done, more in terms of attitude than
technique. I think that had a major impact in my relationship with patients.
( 11 )
(3) Learning about the therapeutic process: [n=15] (2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 15, 16,
17, 18, 19)
(a) Growing patience with, and trust, in the process, respect for the complexities of
change and empathy for human struggles (2, 4, 5, 7, 8, 12, 18, 19)
(b) Structuring the treatment (3, 8, 16, 17)
(i) Learning about the framework, time management, fee arrangements which
promote the therapeutic goals.
(ii) I practice similarly to my analyst with regarding structuring the enterprise-
being late, ending hours like he did, calling vacations “interruptions” (8, 16,
17>
(iii) I practice differently from my analyst with regards to structuring-not all
work happens in just 50 minutes (3)
(c) Treatment technique (4, 5, 6, 8, 9, 10, 15, 17, 18, 19)
(i) I value the therapeutic activities of listening and understanding, interpreting
conflict and confronting defenses empathically, and modeling thoughtful self­
disclosure
(d) Value of concurrent training and treatment (5, 9, 18, 19)
(i) Though risks exist, increased insight about self and others and growing
comfort with, and conviction about, the value of the therapeutic process
promoted my ability as a psychotherapist

1. e. How useful was your therapy in resolving characterological issues and


alleviating symptoms?
(1) Treatment helped alleviate symptoms and resolve characterological issues [n=7] (1, 5,
10, 12, 15, 16, 17)
(a) Less anxiety and depression, diminished conflicts with dependency and
perfectionism
(2) Treatment helped alleviate symptoms, but only modified characterological issues
[n=9] (2, 4, 6, 7, 8, 13, 14, 18, 19)
(a) I am not free o f anxiety and guilt, but they have been muted (18)
(b) Traits such as being overresponsible for others, overcontrolling, and
perfectionistic have been modified versus resolved; I’m better able to modulate
them, which is helpful to my clinical work (6, 7, 8, 14, 19)

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(3) Treatment produced positive changes in character traits, despite original “lack” of
symptoms [n=2] (9, 11)
(a) Analysis helped me make more creative and effective use of my aggression by
rechanneling it (11)
(b) Analysis softened the intolerant attributes of my character structure (9)
(4) Those who did not observe alleviation of symptoms or characterological change [n=2]
(3, 20)
(a) I regret not having been able to go deep enough into the work to enable more
character change (20)
(b) Psychoanalysis was “the wrong kind of psychosurgery for what ailed me.” (3)

1. f. Have you experienced any other benefits from your personal therapy that you
have not yet described?
(1) Valuing the treatment relationship and how it promotes change [n=5] (2, 4, 5, 8, 16)
(a) The relationship with my analyst is probably the most important in my life (5)
(b) There is always that other voice in your life to moderate or titrate situations. The
message of the analysis and the things that were helpful stay with you and you
step outside and consult with that. (8)
(c) There’s no question that I have a soothing internalization and one which is nice
to go through life with, especially professional life, because it’s the same work,
where there’s a legitimizing of doing it. (16)
(2) Graining a more realistic perception o f self and of significant others: [n=2] (10,12)
(a) I developed a real appreciation of the weaknesses and strengths of my most
significant others and believe I can see my relationships in a clearer, more realistic
way (10)
(b) Increased differentiation o f self and mother (12)
(3) Perceptions about the relative “completeness” of personal therapy or termination
issues [n=4] (1, 8, 16, 20)
(a) Cleanly terminated (1,8)
(i) He was very attentive to dealing with the issues that re-emerged at
termination (1)
(ii) I felt “cleanly terminated,” despite my analyst’s leaving the profession after
I’d terminated (8)
(b) Termination arbitrary, incomplete (16, 20)
(i) I was left wondering, “Am I done, yet?” (16, 20)
(ii) I did not get clear feedback from analyst about my readiness to end (16, 20)

Section H: Perceived Risks. Disappointments and Negative Effects o f


Personal Therapy
2. Please describe any disappointments, risks, or negative effects of your personal
therapy or analysis.
(1) Negative effects of personal therapy: [n=l] (3)
(a) Did not help me acknowledge my alcohol abuse (3)

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(b) Did not help with my resistance to exploring defenses against honesty and
exposing my vulnerability (3)
(2) Risks o f personal therapy: [n=7] (1, 5, 6, 8, 12, 16, 18)
(a) Anxiety about being able to complete the analysis (5, 6, 12, 18)
(i) Uncertainty about completing the treatment (5, 12, 18)
(ii) Ambivalence about having terminated; mourning the loss (6)
(b) Issues about the relationship with the therapist (1,6, 16)
(i) Over-identification with therapist’s working style (16)
(ii) Ambivalence about dual relationship with analyst (1)
(iii) Intensity of negative transference (6)
(c) Psychological distress as a consequence o f treatment (8, 18)
(i) The loosening of old defenses contributes to greater distress, temporarily
(18)
(ii) Great self-absorption contributes to feeling less connected to significant
others, during the treatment (8)
(d) Significant financial cost of treatment (6,16)
(3) Disappointments in personal therapy: [n=14] (2 ,4 ,6 , 7, 9, 10, 11, 13, 14, 15, 16, 17,
19, 20)
(a) Unresolved psychological issues not experienced as related to limitations in the
analyst (6, 9, 11, 13, 15, 16, 17, 19, 20)
(i) Feeling unfinished, due to not being able to go further or in more depth with
a number of issues (16, 19, 20)
(ii) Frustrations in working through issues o f preoedipal dependency (9, 11, 13)
(iii) Unresolved separation issues regarding an aging parent (6, 17)
(iv) Frustrations that treatment was not more helpful in improving sexual
functioning (15)
(b) Unresolved psychological issues experienced as related to personal limitations of
the analyst: (2, 10, 13, 14, 15, 17)
(i) Wishing for more “give and take” or mutuality in the human relationship
(15)
(ii) Perception of analyst as rigid and doctrinaire (2)
(iii) Perception of analyst as too free-wheeling, too “real” at times (13)
(iv) Perception of analyst as not helpful enough with a particular prolonged life
stressor or illness of significant other (10, 14)
(v) Wishing issues about sexuality had been dealt with differently by analyst (17)
(c) Unresolved psychological issues experienced as related to limitations in
psychotherapeutic technique (7, 14, 15)
(i) Analyst preserved technical neutrality, but at expense of patient, who felt
progress was slowed or who felt disrespected or misunderstood (7, 14, 15)
(d) Disappointments in the wish to be perfected (4, 6)
(i) Accepting self as imperfect (4, 6)
(ii) Benefits of accepting personal imperfection for self and for clinical work
(4,6)

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2. a. To what extent did you experience excessive stress/psychological distress as a


consequence of your personal therapy?
(1) Nothing excessively stressful/ no further elaboration [n=4] (9, 11, 12, 16)
(2) Nothing excessively stressful, but commented about “nonexcessive” stresses related
to personal therapy: [n=8] (1, 4, 7, 10, 13, 17, 18, 19)
(a) Wished to have been referred for antidepressant medications (1)
(b) Personal therapy initially “unbalancing” (7,17)
(c) Despite stress o f treatment, always able to do professional work (10, 17, 19)
(d) “Harmless” acting out o f transference (13, 18)
(3) Some “excessive stress or psychological distress,” yet seen as an inherent, essential,
or meaningful part o f treatment process: [n=6] (5, 6, 8, 14, 15, 20)
(a) Self-absorption of analysis had repercussions for interpersonal relationships (5, 6)
(b) Excessive stress related to distressing life events, for example, illness or death of
a family member (14)
(c) Excessive stress related to core psychological issues regarding separation and
loss (8)
(d) Excessive stress related to analytic relationship at termination (15)
(4) Treatment “excessively stressful or psychologically distressing,” but stress not viewed
as an essential, meaningful, or purposeful part of treatment process: [n=2] (2, 3)
(a) Fear of psychotic decompensation (3)
(b) Lack of mutuality in discussing participant’s readiness to terminate (2)

2. b. Did you experience any problems with the working relationship?


(1) No: [n=9]'(l, 9, 10, 11, 13, 16, 18, 19, 20)
(a) No qualifier, or only positive comments (9, 10, 11, 18)
(b) Qualified no; some reported complications in the working relationship (1, 13, 16,
19, 20 )
(i) Therapist’s flaw complicated a good working relationship (1, 16, 19)
(ii) Respondent’s flaw complicated a good working relationship (13)
(iii) “Dual relationship” complicated a good working relationship (20)
(2) Yes: [n= ll] (2, 3, 4, 5, 6, 7, 8, 12, 14, 15, 17)
(a) “Causes” related to:
(i) Perception o f analyst as vulnerable, in need of protection; “role reversal,”
due to life circumstances of treater (2, 3, 14)
(ii) Analyst’s personality traits: oversensitive or too focused and serious (2, 4,
17)
(iii) Therapeutic action or technique by analyst
(a) Non-adherence to time frame-chronic lateness (6, 12)
(b) Perceived “lack of neutrality” (5, 8, 15)
(c) Lack of understanding of a psychodynamic issue (7)
(iv) Respondent’s resistance to treatment (6, 15)
(b) Perceived effects o f problems with working relationship on identification with
analyst
(i) Led to positive identification with analyst’s working style. Discussion of the
issue in therapy led to acceptance of analyst’s way of handling something

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which had created conflict between patient and analyst, for example, fees for
missed sessions, or owning problem with lateness (5, 6, 12, 14)
(ii) Led to dis-identification with analyst’s working style. Analyst did not explain
why he did something which patient had long explored as problematic or
conflictual for her. (17)

2. c. To your way of thinking, did your therapist make treatment errors in your
work together? If so, please specify.
(1) No errors: [n=5] (1, 12, 18, 19, 20)
(a) Noted difference between human foibles and treatment errors (18)
(b) Observation: we were a good match (12)
(2) No errors, yet still questioning certain incidents: [n=7] (7, 8, 10, 11, 13, 15, 16)
(a) Did therapist understand the stressful impact o f chronic illness in my family?(10)
(b) Was a classical psychoanalysis the optimal choice of treatment for my narcissism?
(15)
(c) Did my analyst believe I was competent to be trained as an analyst? (11)
(d) Could I safely explore my sexual competence in the erotic transference? (16)
(e) Analyst took an unhelpful approach with my overfunctioning in relationships (7)
(f) Analyst’s management of the therapeutic frame (8, 13)
(i) “Looseness” with time management of sessions (13)
(ii) Moving away from neutrality at termination (8)
(3) Treatment errors made, but not substantively detrimental to participant’s process
[n=3] (4, 5, 9)
(a) Analyst encouraged limited exploration of variations in his schedule (4)
(b) Analyst liked me too much-I could have fooled or seduced him (9)
(c) Analyst owned too much in the intersubjective field (5)
(4) Treatment errors made and experienced as detrimental to participant’s treatment
process: [n=5] (2, 3, 6, 14, 17)
(a) Analyst failed to understand patient diagnostically (3)
(b) Analyst’s maintenance of neutrality during situational life crisis experienced as
harmful (17)
(c) Mistakes related to incompletely exploring psychodynamic issues (3, 14, 17)
(d) Harmful countertransference enactments (2, 14)
(e) Technical: timing of interpretations hurtful (6)

2. d. Have you identified with your analyst in some way that has affected you
n riv p rc p lv ?
(1) “No”: [n=7] (1, 6, 7, 9, 10, 19, 20)
(2) No, but some positive identifications: [n=5] (5, 8, 11, 12, 15)
(a) My analyst’s excellent therapeutic style and professional attitude (8, 15)
(b) Identification with analyst as an immigrant enhanced my self-esteem and
professional self-confidence (11)
(c) Analyst initially viewed as therapeutic ideal with all my patients, eventually
helped me learn to differentiate between myself and my patients and to consider
diagnostic questions (5)

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(d) Analyst as kindred spirit, mutual identification and good match (12)
(3) Dis-identification with negative aspects of therapist: [n=2] (2, 13)
(a) Analyst’s cultural insensitivity enhanced my cultural sensitivity (2)
(b) Analyst’s not taking good physical care of herself influenced my resolve to begin
regular exercise (13)
(4) Identification with analyst in some way that has affected me adversely: [n=6] (3, 4,
14, 16, 17, 18)
(a) Due to analyst’s neutrality (14, 16, 17, 18)
(i) I’m less playful, less spontaneous (16,17)
(ii) Identification with analyst’s reserved, cautious personality style has
contributed to more difficulty forming friendships (18)
(iii) Analyst’s neutrality limited his clinical effectiveness with an issue in
treatment. Respondent similarly limited in being helpful to her patients,
(stuck with unresolved personal issue.) (14)
(b) Similar distasteful personality traits as analyst’s (3)
(c) Identification with analyst’s annoying verbal mannerism, representing
presumptiveness: “multigenerational influence of the negative” (4)

2. e. In your view, was your effectiveness as a therapist ever blocked due to


confusion in being both a patient and a therapist at the same time?
(1) No perceived adverse effects and no details offered: [n=2] (4, 11)
(2) No perceived adverse effects, instead clinical work enhanced by being in personal
therapy concurrently: [n= 10] (1, 2, 3, 8, 9, 10, 13, 15, 16, 19)
(a) Personal therapy served a containing function-a place to explore and discuss
experiences as both a therapist and a patient in the context of a therapeutic
relationship
(b) Personal therapy enhanced my sensitivity, empathy, and identification with
patients. (2, 8)
(c) Personal therapy helped enhance my technical skills as a therapist (13)
(3) No perceived blockage in therapeutic effectiveness with patients, but some
complications with concurrent clinical work and personal treatment: [n=5] (5, 6, 12,
17, 20 )
(a) Engaged in personal therapy concurrently with postgraduate training (5, 12, 17)
(b) Despite complications, therapeutic skills were, in fact, enhanced by concurrent
clinical work and treatment (5, 6, 12)
(c) Complications
(i) Preoccupation with psychological issues made it difficult to attune to
patients (5, 6, 17, 20)
(ii) Related to transitioning from being the patient to being the therapist (12)
(iii) Related to anxiety about competition with one’s own analyst-being in the
analyst’s chair (17)
(4) Did perceive blockage in therapeutic effectiveness due to confusion with concurrent
clinical work and personal therapy: [n=3] (7, 14, 18)
(a) Engaged in personal psychotherapy concurrently with postgraduate training (18)
(b) Unaware o f adverse effects at time (7, 18)

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(c) Difficulty transitioning from patient to therapist because felt stirred up; difficult
to attune to patients (18)
(d) Countertransference enactment led to premature termination with patient (14)

Perceived Overall Effectiveness o f Personal Therapy


1. Overall, how well do you believe your therapist understood you and
communicated his or her understanding to you?
(1) Those who felt very well understood but offered no details: [n=3] (7, 17, 18)
(2) Those who felt very well understood and provided supporting details [n=9] (5, 6, 8,
10, 12, 13, 14, 15, 19)
(a) The therapist treated the patient as important; therapist seen as egalitarian, not
elitist or holding himself above patient (5, 10, 13, 14)
(b) Therapist had human flaws, didn’t always understand, but reliably strived for
understanding (8, 15, 19)
(c) The participant gave self some credit for developing a treatment relationship in
which she or he felt well understood (6, 12)
(3) Those who felt generally well-understood, but offered exceptions: [n=7] (1, 2, 4, 9,
11, 16, 20)
(a) The need for more direct communication from treater regarding his
understanding of the patient’s material (11, 16, 20)
(b) Certain aspects of the treatment were not explored in enough depth (4, 9)
(c) Analyst overvalued analytic neutrality, was too aloof and detached; treatment
lacked warmth & support which respondent needed in order to grow (2)
(d) Analyst befuddled by respondent’s unremitting depression, did not refer her for
antidepressant medication (1)
(4) Those who did not feel well understood by therapist: [n=l] (3)
(a) Analyst did not understand the role of traumatic separation and loss during
respondent’s adolescence and the role of ongoing substance abuse.
Psychoanalysis not appropriate treatment modality for me, just then! (3)

2. Overall, how successful or satisfactory do you believe your psychotherapy or


analysis was?
(1) Quite successful: [n=7] (1, 4, 5, 12, 16, 18, 19)
(a) No supporting examples (5, 12, 16, 18, 19)
(b) It was successful, in part because of respondent’s own clarity of goals (1)
(c) A great benefit to professional work (4)
(2) Quite successful, especially in regard to help with perfectionism: [n=6] (6, 8, 9, 13,
14, 17)
(a) Became less critical o f self and others (9, 14)
(b) Seeing “good enough” as better than perfect (6, 8, 13,17)
(c) Progress with perfectionism translates to clinical work (17)
(3) Quite successful, with one disappointing exception: [n=6] (2, 7, 10, 11, 15, 20)
(a) Related to perceived personal limitations (7, 10, 15, 20)
(i) Needing, but not pursuing continued treatment for relationship issues (10)

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(ii) Conflicted about depending on analyst enough to deepen the work (20)
(iii) Given own personality structure, treatment quite satisfactory (7, 15)
(b) Related to perceived limitations in the psychoanalytic process (2, 11)
(i) Psychoanalytic theory limited as an explanation for understanding humans
(2 )
(ii) Premature termination due to analyst’s schedule, precluded continued
treatment progress of respondent (11)
(4) Personal treatment was unsatisfactory: [n=l] (3)
(a) Related to misdiagnosis of respondent, psychoanalysis was not the appropriate
treatment. (Subsequently, a supportive psychotherapy process was helpful.) (3)

Section HI. Perceived Influences o f Personal Therapy on Conducting Therapy


3. a. & b. Do you believe you work differently with your patients as a consequence
o f having received your own therapy? If so, in what ways: Which aspects of
your therapy do your think you draw on?
(1) Uncertain that personal therapy informs my clinical work: [n=3] (2, 16, 20)
(a) Clinical practice has been more influenced by experience doing the work itself, by
formal education and life experience
(2) Yes, personal treatment has influenced my work with patients: [n=17] (1, 3, 4, 5, 6, 7,
8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19)
(a) Enhanced awareness of importance of treatment structure (1)
(i) Attention to ruptures due to vacations-this is very important to patients with
a histoiy of inconsistent caretaking (1)
(b) Drawing on a broader range of interventions (1, 18)
(i) I validate reality more or am less “neutral” with my patients with trauma
histories than I would have been before my personal treatment (1, 18)
(c) Enhanced confidence in the therapeutic process (1, 8, 9, 11, 14, 15, 17, 18)
(i) Having confidence in the process leads to instilling confidence in patients (1,
18)
(ii) The importance of listening and understanding (9, 11, 14, 15, 17)
(a) The patient experiences that the therapist is actively listening and
making a sustained effort to understand, which is vital to the process
(11, 15, 17)
(b) Listening for latent not just manifest content (9)
(c) Understanding as “doing,” feeling less pressure to react immediately
(14)
(iii) Greater patience with the slow evolution of psychic change (8)
(d) Deepened conviction about the treatment relationship as an important vehicle for
psychic change and growth (1, 3, 4, 5, 6, 7, 9, 10, 13, 14, 15, 17, 18, 19)
(i) Enhanced empathy for the patient’s struggles to change, based on
identification with the role o f the patient (7, 14, 15)
(a) I tun more open about expressing empathic understanding than was my
analyst. I believe some people need to hear in words that they’re
understood. (14)

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(b) My analyst modeled a loving acceptance o f everything, which opened


me up to sharing my darkest secrets and helped me shift my perspective
o f myself. I try to do this with my patients, as well. (7, 15)
(ii) Using the treatment relationship to promote the patient’s self-esteem (15)
(iii) Understanding and using transference and countertransference to promote
the treatment (1, 5, 7, 9, 10, 14, 17, 18)
Regarding transference (1, 7, 14, 17, 18)
(a) Increased awareness of, and respect for, the power o f transference (1,7,
14)
(b) The most effective interpretations are not always transference
interpretations (18)
(c) Because o f working in the transference with my analyst on struggles to
separate and individuate, I am sensitive to my patients’ struggles with
me on this issue (17)
Regarding countertransference (5, 6, 7, 9, 10, 14)
(a) Drawing on how a sensitive issue was understood in their personal
analysis and using that as a way to explore what the patient might be
experiencing (6, 7, 10, 14)
(b) Analyst modeled sharing his countertransference reactions with
respondent and respondent uses this with patients (5, 9)
(iv) Promoted understanding of psychotherapy as a two-person psychological
process, an intersubjective experience (4,5, 13, 17, 18)
(a) My contributions as treater and the patient’s both are bathed in a
brighter light (4, 5, 17, 18)
(b) There’s nothing neutral about a therapist-it’s the studied use of one’s
subjectivity that promotes the treatment (5)
(c) I discovered in my analysis that I could be myself and be a good
therapist (17)
(d) The type of therapeutic relationship viewed as curative to patients was
experienced in my personal treatment (therapist as mother with child as
new developmental partner, “reparenting,” vs. therapist as collaborator
with rational part of patient’s ego) (18)
(v) Drawing on analyst’s personal qualities as model for clinical effectiveness (3,
6, 7, 17, 19)
(a) Helpful personal qualities include analyst’s humor, capacity to admit
mistakes, willingness to be corrected; his reveling in my successes,
thereby giving me permission to grow and surpass him; his
“thoughtfulness” (6, 7, 17, 19)
(b) Analyst as ego-ideal: “the first sane adult in my life”; “the committee of
helpers” (3, 6)
(e) Increased acceptance of the realistic limitations of the psychotherapy enterprise
(5 ,7 ,1 0 ,1 2 ,1 5 )
(i) Accepting the limitations in personal psychotherapy has positively influenced
my clinical work (5, 7, 10, 12, 15)

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(a) Greater compassion for the struggles and limitations of change for my
patients (7, 15)
(b) Greater acceptance of my own personal human foibles, while perceiving
self as a good-enough therapist (5, 10, 12)

3. c. (i.) To what extent has your treater served as a role model for you In conducting
psychotherapy?
(1) Analyst has been a significant role model and only positive identifications noted:
[n=12] (4, 6, 8, 9, 10, 11, 13, 14, 17, 18, 19, 20)
(a) Modeled good technique in conducting psychotherapy (4, 6, 8, 9, 11)
(i) Respondent uses similar phrasing of questions to explore the patient’s
dilemmas, which are similar to her own, and has greater confidence in the
value of exploration (6)
(ii) First analyst “loosened me up” in modeling therapeutic playfulness; second
analyst helped me learn the value of giving the patient room to struggle, not
rushing to comfort prematurely (4)
(iii) Respondent identified with treater’s capacity to attune to his own free-
associations, to promote the treatment (11)
(iv) Respect for how the analyst “went about his work” (8, 9)
(b) Respondent identified with treater’s capacities for human relatedness (10, 13, 14,
17, 18, 19,20)
(i) Admiration of analyst’s integrity in humane, respectful and dignified
relatedness with patient (14, 19, 20)
(ii) Admiration of analyst’s flexibility within neutrality and spontaneity to offer
support, including mirroring and feeling analyst’s affirmation (10, 17)
(iii) Admiration of analyst’s courage to engage on a human level, acknowledging
own human flaws (13)
(2) Analyst has been a significant role model and offers both positive identification with,
and differences from, how analyst practices: [n=6] (1, 5, 7, 12, 15, 16)
(a) Areas o f positive identification with analyst’s conduct (1, 7, 12, 15)
(i) Analyst’s sensitivity to exploring meanings of ruptures (1)
(ii) Valuing the analyst as a “well-trained, good human being” (5)
(iii) Valuing his acceptance, compassion and empathy for whatever the patient
experiencing (7)
(iv) Valuing his concepts and ways of thinking about patients (12)
(b) Areas o f differentiation from treater’s practice conduct (1, 5, 12, 16)
(i) Withholding conceptual thinking or feedback from patient (16)
(ii) Withholding emotional experience from patient (5)
(iii) Gender-based stylistic differences regarding level of reserve with patients 1,
12)
(3) Analyst not experienced as a significant role model in conducting psychotherapy:
[n=2] (2, 3,)
(a) Many other people have contributed as much or more to my professional ideals
(2, 3)

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3. c. (ii) W hat do you perceive as being your analyst’s or therapist’s limitations or


mistakes that have influenced your work with your own patients?
(1) No limitations or mistakes, instead noted positives: [n=4] (8, 12, 13, 19)
(a) The therapist was genuine and authentic (13, 19)
(b) The therapist modeled that “good enough” includes having human imperfections
and misfortunes (8, 12)
(2) Limitations or mistakes reported that influence respondent’s clinical work: [n=15] (1,
2, 3, 5, 6, 7, 9, 10, 11, 14, 15, 16, 17, 18, 20)
(a) Limitations due to theoretical biases (1, 3, 6, 9, 10, 11, 14)
(i) Analyst had a classical, phallocentric Freudian view-missed the meanings of
participant’s pregnancy (14)
(ii) Psychoanalytic blindness to cultural and class diversity in dyad (11)
(iii) Theoretical biases led to analyst not understanding a developmental or
situational issue (including need for medication, coping with chronic illness
of spouse, parenting stresses, and importance o f analyzing preoedipal level
material) (1, 3, 6, 9, 10, 14)
(b) Limitations due to analyst’s technique (7,15, 16, 17, 18, 20)
(i) Analyst placed technique over relationship (15, 17)
(ii) Analyst too directly confronted defenses around core issue, which increased
respondent’s resistance (7)
(iii) Analyst did not give respondent enough feedback (20)
(iv) Analyst did not take control of sessions, thus respondent has no model for
this in his work (16)
(v) I ’m strongly identified with my analyst’s views of neutrality and, hence,
don’t do well with, and don’t work with female trauma survivors who need
validation of their perceptions (18)
(3) Limitations perceived as related to the analyst’s human foibles: [n=5] (1, 2, 5, 6, 15)
(a) Analyst overly sensitive to personal criticism (2)
(b) Analyst allowed personal issues with separation and loss to color termination
process(15)
(c) Analyst habitually late for sessions (1,6)
(d) Analyst self-disclosed in ways that sometimes distracted from respondent’s
analytic work (5)

3. d. (i.) Do images or thoughts of your therapist ever come to mind while you’re
conducting psychotherapy or psychoanalysis?
(1) Do not currently have thoughts or images of treater during sessions and do not think
they have had, in past, during their treatment: [n=6] (2, 4, 9, 16, 19, 20)
(a) Perhaps an unconscious process-hence, not aware (2, 4, 9)
(b) Have thought about former treater outside o f sessions (19, 20)
(i) What would analyst have said to this client? (19)
(ii) Evokes “vicarious experiences” of relating to former analyst, helpful
personally and professionally (20)
(2) Do not currently have thoughts or images of treater during sessions, but have had, in
past: [n=4] (1, 11, 13, 18)

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(a) Two types of occurrences o f these images (8)


(i) Actively questioning what former therapist would say about patient (8) or
(ii) After-the-fact, noticing a similarity to, or an identification with what the
former analyst would have done (8)
(b) Directly modeling after my former analyst feels like a good thing, pleasant to me
and that it’s going to be helpful to the patient-not intrusive thoughts (13)
(c) Evoking analyst’s memory helpful in treating difficult-to-treat patients with
sexual boundary issues; analyst = an “ethical representative” (11)
(3) Continue to have thoughts or images of treater while conducting psychotherapy, now
and in past: [n=9] (3, 5, 6, 8, 10, 12, 14, 15, 17)
(a) What would former analyst say, ask, or do at a particular moment with a
particular therapeutic dilemma? (6)
(b) After-the-fact identification with analyst: “I find myself putting something exactly
the way he would have!” (8)
(c) Thoughts of former analyst related to technique (14, 15)
(i) Analyst drew on his free-associations with me and I do the same to
understand my patients’ “subterranean issues” (14)
(ii) When I’m too talkative, like my former therapist, I do as he did and remind
myself to be quiet (15)
(d) Thoughts of former analyst are associated with personal relationship with analyst
(3, 5, 12, 17)
(i) I make the same noises he made. I ’ve become more relaxed and casual, like
him-that’s good! (5)
(ii) My analyst was externally detached; I strive to be different with my patients,
to connect, to have a “personal encounter” with them (3)
(iii) When I’m perplexed, I think o f him, or when I sit a particular way, I wonder
if he did also. He really is the primal mother and I think he knows I ’m crazy
about him! (17)
(iv) I emulated his reserved style and then one day, when I made him laugh, I
knew he was emotionally really with me, that he resonated with me. And I
take to my work a question about how separate I am from my patients and
how much to actually join them in the experience of being human. And
having been in treatment, I ’m more comfortable with feeling very close. (12)

3. d. (ii) Do you remind yourself o f your analyst while you’re working? If so, can you
describe any such moments, or any particular clinical circumstances?
(1) Do not remind themselves of former therapist while working [n=2] (2, 11)
(a) Because I work with a different patient population than I fit into as a patient-
different countertransference reactions get evoked (11)
(2) Do remind themselves of former therapist while working: [n=18] (1, 3, 4, 5, 6, 7, 8,
9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20)
(a) Perceived similarity with former therapist’s therapeutic technique (1, 4, 6, 8, 9,
10, 15, 16, 17)
(i) Similar with handling structure of beginnings, endings, and interruptions in
the sessions (1, 17)

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(ii) Emulating nonintrusive body language with cross-gender treatment


relationships (16)
(iii) Drawing on the therapist’s strength, take it in when perplexed or starting
with a new case, or a developmentally difficult client (6, 17)
(iv) Emulating the therapist’s ability to restrain himself, to talk less and to listen
better (15)
(v) Using techniques that respect the patient’s pace for doing the work (4, 9, 10,
15)
(b) Perceived similarity with former therapist’s style of interpersonal relatedness (3,
5, 7, 13, 19, 20)
(i) The capacity to relate authentically with patients (3)
(ii) Enhanced self-acceptance after treatment led to enhanced acceptance of
patients (7, 13)
(iii) Appreciation for the complexity of feelings toward intimate objects (20)
(iv) Experiencing a unique kind of love with the therapist contributed to
experiencing similar feelings with a few patients, which anchors my work (5)
(v) Internalization of therapist’s interpersonal style as a developmental process,
“a family lineage” (19)
(c) Perceived similarity with former therapist’s theories o f what is curative to
patients (12, 14, 18)
(i) We both understood the patient’s need to regress “in the service of the ego,”
to promote psychic growth (14)
(ii) Importance of challenging patient to shift “from an experiencing to an
observing ego,” at times-to see their realistic choices, which can promote
psychic growth (18)
(iii) We’re similar in nurturing the patient’s attempts at mastery over despair in
even the most bleak conditions (12)

3. d. (iii) Which, if any, personal attributes of your therapist or analyst do you find
yourself most identifying with in your work?
(1) Respondents who identify with how the therapist conducted his or her life outside the
treatment relationship: [n=4] (1, 6, 8, 20)
(a) Therapist seen as differentiated from, yet connected with, others, thus modeling
the capacity to make changes proactively (1,6)
• (i) With regard to the changing work setting (1)