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Most mental health professionals seek personal psychotherapy at least once in their careers (Phillips, 2011), and at a much higher rate than the general population (Norcross & Guy, 2005). While one-fourth of the general adult population has received mental health services, three-fourths of mental health professionals have done so (Bike, Norcross, & Schatz, 2009; Norcross & Guy, 2005).
A wealth of studies have explored why psychologists have sought personal psychotherapy — often for the same reason that the rest of the world seeks therapy, such as coping with loss, dealing with depression or anxiety, or struggling with a personal crisis. However, more research is needed about the potential barriers that psychologists may experience when considering such treatment.
In this article, we discuss the research exploring why psychologists may benefit from psychotherapy and report on the findings of our own national survey, which explored independent practitioners' perceived barriers to psychological care.
Risk factors for psychologists
The nature of psychologists' work may predispose them to experience certain problems. Burnout, vicarious traumatization and compassion fatigue, countertransference and a history of personal trauma can all take their toll.
When it comes to burnout, psychologists are at risk for several reasons. Many practitioners, for example, tend to put others' needs before their own. Psychologists also must control their emotions when faced with clients' trauma and intense emotions. They may have a heightened sensitivity to people and the environment and a sense of isolation (O'Connor, 2001).
Negative client behaviors, lack of therapeutic success, and the demands of paperwork and administrative duties can also contribute to burnout (Norcross, Guy, & Laidig, 2007).
The cost of burnout can be quite high. Psychology practitioners in a diminished capacity may experience intense personal distress and may not be able to serve their clients — and could even harm them (Rupert & Morgan, 2005).
Depression is another prevalent symptom of distress in psychologists. Pope and Tabachnick (1994) reported that the majority of the psychologists they surveyed (61 percent of 476) indicated they had experienced at least one episode of clinical depression. In another study, 62 percent of APA Div. 17 (Society of Counseling Psychology) members surveyed identified themselves as depressed, with a sense of withdrawal and isolation from colleagues cited as the most frequent issues associated with the depression (Gilroy, Carroll, & Murra, 2002).
Even more alarming is the rate of suicidal thoughts among psychologists. Pope and Tabachnick (1994) reported that 29 percent of those surveyed indicated they had felt suicidal, and almost 4 percent indicated they had made at least one suicide attempt. Gilroy et al. (2002) found that 42 percent of their respondents reported experiencing suicidal ideation or behavior.
According to the National Institute for Occupational Safety and Health, of more than 230 occupations, male psychologists were the most likely to commit suicide, with an odds ratio of 3.5 times greater than the general public (Ukens, 1995).
Psychologists are also at risk for vicarious traumatization and compassion fatigue (Phillips, 2011), as well as countertransference, the phenomenon that can affect mental health providers' cognitive, affective and behavioral responses to clients (Burwell-Pender & Halinski, 2008). In relation to the general public, for example, psychologists may have a higher-than-normal incidence of childhood trauma, according to Elliott & Guy, 1993; Nikcevic, Kramolisova-Advani, & Spada, 2007.
In light of these risk factors, the potential benefits of personal psychotherapy are substantial. Most psychologists who pursue personal psychotherapy are pleased with the outcome (Bike et al., 2009). Experiential learning through personal psychotherapy may help psychologists better understand the nature of their work and become more effective in meeting their clients' needs (Daw & Joseph, 2007). By having dealt successfully with their own personal issues, psychologists may also gain an enhanced sense of efficacy in their own ability to help others (Pope & Tabachnick, 1994). They may also experience a sort of camaraderie with their psychotherapist that can help diminish feelings of isolation (Coster & Schwebel, 1997).
Deterrents to seeking help
With all those benefits, what keeps psychologists from seeking help? Research has identified several barriers, including:
- Social stigma (Komiya, Good, & Sherrod, 2000).
- Treatment fears (Deane & Todd, 1996; Kushner & Sher, 1989).
- Fear of emotion (Komiya et al., 2000).
- Self-disclosure (Hinson & Swanson, 1993; Vogel & Wester, 2003).
Social norms and self-esteem may also influence the decision to seek psychotherapy (Vogel, Wester, & Larson, 2007). Although some of these barriers exist for almost everyone, others appear to be unique to mental health professionals.
Psychologists may also fear the stigma of seeking therapy, believing they may be viewed negatively by family and friends, as well as by clients, employers and colleagues who may question the ability of a psychologist who is struggling with psychological distress (Barnett, Baker, Elman, & Schoener, 2007).
A psychological diagnosis can also lead to problems in the area of health care and disability insurance, where certain diagnoses can affect the psychologists' ability to get adequate coverage.
Privacy may also be a concern. The fear of being seen sitting in a psychologist's waiting room may be enough to keep some psychologists from seeking help. Though psychologists know about the ethical standards and laws that protect health information, they may have seen other psychologists take these standards lightly, and perhaps wonder how fiercely their personal psychotherapist will honor privilege and confidentiality standards. Violations of privacy for professional psychologists may have dire implications. If a psychologist is perceived to have impaired objectivity, for example, it may become an issue if a future board or malpractice action occurs.
Selecting a personal psychotherapist may also be challenging. When choosing a therapist, all clients consider location, availability, qualifications, language barriers and theoretical orientation. Psychologists seeking care must also think through the possibility of dual relationships since local therapists could be colleagues, peers, mentors, mentees, supervisors or teachers (Deutsch, 1985). Another complicating factor might be competition among practitioners, which could interfere with the psychologist's ability to establish a safe and trusting relationship with his or her psychotherapist.
Lack of time and money may also keep psychologists from seeking mental health care. A psychology career requires working around client schedules, sometimes traveling between practice sites, staying current on scientific literature, pursuing continuing education and carrying heavy client loads. In addition, most early career psychologists are paying off educational loans. In light of these demands, committing the time and financial resources to psychotherapy can be burdensome. Private practitioners may also have health insurance policies that limit or even exclude mental health benefits.
Psychologists' experience with psychotherapy
Perhaps the greatest challenge to discussing obstacles to treatment is that limited systematic research has addressed this issue, and much of the existing research has investigated graduate students rather than practicing psychologists (e.g., Dearing, Maddux, & Tangney, 2005).
To help fill this knowledge gap, we surveyed psychologists to identify the prominent barriers to treatment. We chose 500 randomly selected APA members, including only those who indicated clinical psychology as both their major field and their area of interest on their APA Directory profiles. Participants were contacted with a letter explaining the study, a copy of the survey questionnaire and an addressed, stamped envelope. A $2 incentive was also included.
We had a response rate of 52 percent, including 134 women (52 percent) and 122 men (48 percent). Seventy percent of participants indicated that they are independent practitioners, with the remaining 30 percent fairly evenly divided among community mental health, medical settings, academic settings, government/industry, other or a combination of two or more of these settings.
Respondents reported a mean number of years in practice of 23.7. They reported a mean of 74 appointments per month, with a range from 0 to 250.
Seeking personal psychotherapy
Of the respondents, 86 percent indicated they had participated in psychotherapy at some point in their lives, with a mean of 12.7 years having passed since their last session. Respondents reported taking part in an average of 221.7 sessions and 2.7 courses of psychotherapy. Most reporting past participation in psychotherapy viewed it positively.
When asked if there was a time when they may have benefited from psychotherapy but did not seek it, 59 percent of respondents answered affirmatively. This suggests that although clinical psychologists are open to seeking psychotherapy and usually find it beneficial when they do, there are factors that deter them from doing so.
Deterrents to seeking psychotherapy
Respondents were also asked to rate the degree to which six specific factors have functioned as deterrents in their decision regarding personal psychotherapy. The items having the most impact were, in descending order:
- Difficulty selecting an acceptable therapist.
- Lack of time.
- Lack of financial resources.
- Difficulty admitting distress.
- Professional stigma (might affect professional reputation).
- Personal stigma (my self-view or others' view of me).
Respondents were asked to identify their therapeutic orientation and to indicate the orientation they would prefer in a therapist. The largest group of respondents (38.5 percent) reported that they use a cognitive/behavioral therapy (CBT) approach, and 61 percent of those indicated they would prefer to work with a CBT therapist. The second largest group (29.4 percent) reported using a psychodynamic approach to psychotherapy, and 88 percent of those said they would choose to work with a psychodynamic therapist.
Several respondents (12 percent) indicated that they use more than one therapeutic modality in their work, and 63 percent of those said they would seek a therapist who would use a similarly eclectic approach. A small number (8.3 percent) endorsed a humanistic approach, 86 percent of whom would also seek a humanistic therapist, and another group of similar size indicated they use some other modality than those listed on the survey (e.g., EMDR, biopsychosocial, integrative).
This participation rate of 86 percent is quite similar to the 84 percent rate reported in 2009 by D.S. Bike et al., who speculated that the percentage of mental health professionals who seek personal psychotherapy may be increasing — from just over half in the 1970s to three-quarters in the 1990s and now to the vast majority of mental health professionals.
We also know from past research that psychologists experience positive outcomes from psychotherapy (Bike et al., 2009; Phillips, 2011). Similarly, in our study 84 percent of respondents rated their satisfaction with psychotherapy as a 4 or 5 on a 5-point scale. Psychotherapists in other studies also reported professional gains from participating in psychotherapy (Bike et al., 2009) — something we did not ask about in this study.
Our findings suggest that some barriers are more significant than others, but none are overwhelmingly high. All of the potential barriers we asked about received mean ratings below the midpoint of 3, and issues of stigma were rated extremely low on the scale, indicating stigma is not a substantial barrier for most psychologists.
Still, 59 percent said there was a time when they may have benefited from psychotherapy but did not seek it. This compares with the 34 percent of respondents in the Deutsch (1985) study who indicated they did not seek out psychotherapy or other forms of treatment when needed.
Finding a psychotherapist
A general conclusion of our study — and one that deserves follow-up attention — is that finding a psychotherapist may be the most important obstacle to overcome when professional psychologists perceive a need to seek personal psychotherapy. A similar finding was noted in the Deutsch (1985) study.
Our study participants listed a variety of reasons that finding a therapist was challenging for them, including the youthfulness of available therapists, incompetence, distance, dual relationships, lack of therapists of the same ethnicity and disappointment with previous therapists. Some responses indicated a surprising degree of self-sufficiency ("I feel like I already have the answers and knowledge to treat myself"), while others veered toward narcissism ("I would have a hard time finding someone as good as me!").
To address this problem, it seems that in this age of technology, one or more professional organizations might develop a directory or resource guide to help professional psychologists find a nearby psychologist experienced in working with psychologist patients. Such a directory could be a Web resource or a smartphone application that could promote ease of appointment setting, matching of therapeutic orientation and demographic preferences.
Stigma is not a major problem
It was encouraging to note that personal and professional stigma were identified as having the least impact on seeking psychotherapy, a concern that has been raised in previous literature (Barnett et al., 2007). Though the stigma of participating in psychotherapy seems to still impact the general population to some degree, it appears that, at least within the profession itself, these concerns have been predominantly eradicated.
Professional stress comes in various forms
Our study found that burnout was the most frequent stressor affecting psychotherapeutic effectiveness, though the mean rating was still below the scale's midpoint. Perhaps more telling is that out of 260 surveys returned, 160 respondents wrote in additional stressors they felt had affected their ability to function effectively as a psychologist (an "other" line was provided on the questionnaire). These difficulties varied widely, ranging from suicidal patients to conflicts with co-workers. The bulk of responses fell into four categories: difficulty working with insurance companies, personal losses, family strife and financial difficulties.
The frequency of these unprompted responses suggests that psychologists are consistently operating under the strain of life circumstances that are burdensome and intrusive.
Possible gender differences
Our results suggest that female psychologists are struggling more with the effects of vicarious traumatization and compassion fatigue than are their male counterparts. Though reasons for this are not certain, it may be that women experience a stronger natural caregiver response to their clients, making it more difficult to maintain emotional distance from the impact of traumatic events their clients experience.
Women also reported being affected by some barriers to seeking psychotherapy to a greater degree than men. Finding an acceptable therapist appears to be more problematic for women, as do the challenges of limited time and money.
The explanations for these differences warrant further investigation, but one possibility is that women may have a higher expectation for the rapport between practitioner and client, qualities that can be difficult to establish in an introductory session or through a review of credentials. This premise is supported by research that indicates women tend to be more empathic than men, a characteristic that may lead to higher expectations for this quality in a therapist (DiLalla, Hull, & Dorsey, 2004). Meanwhile, research by Shapiro, Ingols, and Blake-Beard (2008) indicated many women face a career/family double bind in which they are expected to invest in both roles. This conflict would seemingly increase the need for therapeutic help, but it is also likely to make the time commitment of psychotherapy infeasible (Shapiro et al., 2008). Concerns about financial limitations may be related to this as well since women who have more responsibilities at home may work fewer clinical hours than men, resulting in less disposable income.
In addition, greater financial concerns among female psychologists may be related to the disparity in compensation between equally qualified women and men — APA's 2009 Doctorate Employee Survey revealed that the median starting salary for women who received their doctorates in psychology was $8,000 lower than for their male counterparts (Michalski, Kohout, Wicherski, & Hart, 2011).
In spite of these concerns, female psychologists are more likely to engage in psychotherapy at some point in their lives and to participate in more sessions than men. Women are slightly more likely to seek psychotherapy than men (Norcross & Guy, 2005) and rate the importance of personal psychotherapy more highly than men (Bike et al., 2009).
Though there is little research comparing the effectiveness and well-being of therapists who do and do not engage in personal psychotherapy, the wealth of research demonstrating the positive effects of psychotherapy in general suggests that psychologists will benefit both personally and professionally from it.
As a result, graduate training should include discussion of the potential obstacles to finding a psychotherapist. A class on professional issues, for example, may encourage students to seek psychotherapy when the need arises, as well as consider practical matters such as how to find a psychotherapist given the complexities of dual relationships, finances and time demands.
Likewise, self-awareness and self-care for postdoctoral fellows and early career practitioners is important to consider in training and policy discussions. All psychologists should be encouraged to admit when they are distressed and seek therapy for their own health and ability to function effectively as therapists.
Future research directions
We acknowledge that there were limitations with our study. As with any survey study, self-reporting may not be an accurate reflection of actual behavior. Also, sampling bias may be a problem despite the respectable response rate of 52 percent. In addition, the sample was drawn from the APA Membership Directory, and it is possible that psychologists who do not belong to APA may have different experiences from those who do.
Further, the age of the sample was older than a representative sample would be. The age of the current sample was 58.2 years, whereas a recent study by Michalski and Kohout (2011) reported the mean age of psychology health service providers as 53. A similar study of more diverse ethnicity would also be beneficial, as the vast majority of respondents to this study were European-American.
Also, although the current study asked if psychologists had decided not to seek therapy at a time when they needed it, we did not ask when or why they did not seek therapy. Was this choice not to seek therapy made before or after the person became a psychologist? What developmental, personal, professional or financial issues kept them from seeking therapy?
Ideally, longitudinal research could observe the effects of participating in psychotherapy over time. Do psychologists who participate in psychotherapy during training show different levels of career satisfaction or longevity?
It would also be interesting to study readiness for conducting or undergoing psychotherapy. Doctoral trainees who are required to pursue personal psychotherapy sometimes complain that they have no need for therapy. More experienced psychologists may view this as naïve — and it may be. But it is also possible that there are certain critical periods in developing psychotherapists during which personal psychotherapy is maximally beneficial. Perhaps personal psychotherapy during times of personal pain is more useful than mandatory psychotherapy during training, even if it means the psychologist receives psychotherapy later in his or her career. The issue of timing and critical periods for psychotherapy warrants further investigation.
It would also be interesting to know how diversity and cultural variables may influence psychologists' willingness to seek help. Are some psychologists more reticent than others, or might some experience more difficulty than others finding a psychotherapist with whom they can work?
Finally, it would also be interesting to investigate the relationship among burnout, depression and perceived obstacles to psychotherapy. Do psychologists with high levels of stress and burnout tend to perceive or experience more obstacles than psychologists who are functioning at more optimal levels? This question is worthy of further investigation.
Psychology is replete with research on why people do what they do, how it affects them, and how we can better help them address any dysfunction that may be impairing their lives. We are not always so quick to turn the spotlight on ourselves. This study is encouraging insofar as it suggests that many psychologists seek personal psychotherapy and find it beneficial.
Still, some factors impede participation, and most clinical psychologists report having failed to seek psychotherapy at times when they needed it. In light of the relatively high rates of depression and suicidal behavior among psychologists, this is cause for some concern and a worthy topic of consideration in research, practice and training.
Jennifer L. Bearse, PsyD, is a postdoctoral psychology resident at Central Washington University. Mark R. McMinn, PhD, is professor of psychology at George Fox University. Winston Seegobin, PsyD, is director of diversity and associate professor of clinical psychology at George Fox University. Kurt Free, PhD, is a clinical psychologist and an adjunct faculty member at Gerorge Fox University.
- This article is based on “Barriers to psychologists seeking mental health care,” which appeared in the June 2013 issue of Professional Psychology: Research and Practice. To read the full journal article, which includes all references, go to the digital edition.
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