“Know Thyself”: Supporting Personal Psychotherapy During Psychiatry Residency

Inscribed on the ancient Greek temple of Apollo at Delphi was the phrase, “Know thyself.” This ancient maxim is featured in Sophocles’ Oedipus the King and was foundational for Sigmund Freud’s development of psychoanalysis (1). “Know thyself” continues to be an important aphorism that is explored by many patients during psychotherapy. Psychiatry residents should be encouraged to keep this maxim in mind through personal psychotherapy, to hone their skill of self-reflection and to use their own thoughts and reactions as a tool of interpretation during sessions with their patients. Residency programs have an obligation to support and encourage personal psychotherapy as a part of psychiatry training.

The Importance of Psychotherapy Training

Training in the management and treatment of patients by using several psychotherapy modalities is a 2021 psychiatry residency core competency requirement of the Accreditation Council for Graduate Medical Education (2). Learning these modes of therapy prepares residents to “listen with purpose” (3) and allows them to see past the chief complaint and treat the “whole patient.” Psychotherapy training, along with neuroscience and psychopharmacology training, enables psychiatrists to work with patients with extremely complicated problems, particularly with those whose personality structure interferes with medical treatment or otherwise impedes patients from functioning at their full capacity. Psychiatrists are most effective when they are armed with extensive knowledge of the fields of medicine, psychiatry, and psychotherapy, leading to a nuanced understanding and treatment of patients with psychopathology (4).

In addition to preparing residents to work with patients with complicated problems, training in psychotherapy provides an opportunity to develop active listening skills, empathy, and therapeutic alliance when working with patients. Understanding the fundamentals of psychotherapy gives residents a more integrative way to think about all their patients and their mental functioning (3). Participation in psychotherapy during residency was valued even among psychiatrists who chose not to practice psychotherapy in their attending psychiatry careers (5). A recent study demonstrated that only one-third of residents who chose to participate in supplemental psychotherapy training chose to specialize in psychotherapy in private practice (5). Even though few participants chose psychotherapy specialization after graduation, enthusiastic demand for such training persisted, indicating that residents viewed it as a valuable educational experience (5). Learning psychotherapy allows therapists to more deeply understand each patient’s difficulties, which can augment other treatment modalities such as psychopharmacology and interventional psychiatry.

The Value of Personal Psychotherapy

Personal psychotherapy is both a personal and professional endeavor. Psychotherapists have a wide range of skills, and quantifying a “good therapist” remains frustratingly elusive. Recently, Bennett-Levy (6) performed a literature review and created a theoretical framework that highlights the importance of personal psychotherapy in psychotherapy training. Bennett-Levy (6) divided therapist skills into three categories: conceptual, technical, and interpersonal. The first two skill sets are more amenable to didactic training, whereas interpersonal skills require self-reflection and acknowledgment of a lifetime of interpersonal beliefs, attitudes, and behaviors (6).

Therapists who have engaged in personal psychotherapy report reduced psychological distress, greater self-acceptance, better self-care, greater authenticity, improved job performance, and enhanced self-awareness (6), and they hope for similar improvements in their patients. When therapists attain improvements in these attributes, they are then able to better model them during interactions with patients. In addition, enhanced self-awareness is critical when working with patients who have personality disorders or when issues such as countertransference become central to management and treatment. Psychotherapy training sharpens one’s ability to use oneself as a tool for assessment and treatment of patients.

In addition, engaging in personal psychotherapy allows therapists to gain the perspective of “the other side of the couch.” Therapy is inherently difficult and uncomfortable at times. It is painful for anyone to face personal issues, and it takes substantial courage to then make necessary changes to behavior. Experiencing this discomfort increases clinicians’ understanding of the pain and challenges their patients face and fosters their empathy, respect, and compassion for their clients (6). This experience also allows therapists to exert patience, speak with authenticity, and develop a strong therapeutic alliance with patients and to validate their patients’ experiences through shared experience.

Last, engaging in personal psychotherapy is humbling. To ask someone for help in identifying one’s blind spots and problematic patterns of thinking or behavior that are detrimental to personal welfare is hard. Seeking mental health care continues to have significant stigma, although that stigma is lessening. Going through the experience of personal psychotherapy gives clinicians greater respect for the challenges that patients face.

Personal Psychotherapy Practice During Residency

Skill in psychotherapy is an expectation for psychiatrists graduating from residency, and recent research has started to identify how and why personal psychotherapy is important to developing the skills necessary to be an effective psychotherapist (6). Psychiatry residents should engage in their own psychotherapy to develop their skills as therapists. Mounting pressures to train in neuroscience, psychopharmacology, and interventional psychiatry make dedicating time to learning psychotherapy difficult for psychiatry residents; finding time to engage in their own personal psychotherapy is even more difficult.

A 2015 survey of psychiatry residents indicated that time and finances were the most common reasons for residents not to engage in personal psychotherapy (7). Personal psychotherapy is expensive and takes time, but it is vital. Without program support, the process of trying to find a therapist during residency exemplifies the broken mental health system. After many calls to therapists on the insurance list, most cannot see residents weekly to explore personal bias, interpersonal tendencies, repetition of childhood trauma, etc. Many therapists are also unable to accommodate the busy, ever-changing resident schedule. Most therapists with the flexibility and availability to accommodate the typical resident schedule only accept payment out of pocket. A unique issue for residents in an area with a relative dearth of mental health resources is finding someone who is not associated with their training program. These barriers can be insurmountable for residents, who have little bandwidth for basic self-care.

Support for Residents Seeking Personal Psychotherapy

What supports do residents need to engage in personal psychotherapy? Cost and access are significant, practical barriers to engaging in personal psychotherapy for residents. At the most basic level, a list of local therapists who accept the insurance that is offered to residents would be helpful. Because lists provided by insurance companies are usually out of date, a curated list, selected by a residency director, of therapists willing and able to work with psychiatry residents would be most beneficial. An alternative option might be a list of therapists who are willing to work with residents on a sliding scale. This list would substantially lower the activation energy required of residents to engage in therapy. Some programs have started this practice, which has increased the number of residents who engage in personal psychotherapy (7).

In addition to practical solutions, creating a culture of promotion of personal psychotherapy in the resident program is key. Department leaders who encourage the practice of personal psychotherapy can increase the number of residents who engage in it (7). If the importance of personal psychotherapy is emphasized and discussed openly throughout the residency, it will take away the stigma and shame that are sometimes associated with personal psychotherapy. Seeking personal psychotherapy should be encouraged and praised as an important part of training, not viewed as something to do only when there is a problem. Residency directors should talk to residents about the importance of personal psychotherapy as a part of their training.

Last, residency program leaders can respect the time needed to engage in personal psychotherapy. Residents will likely need to engage in personal psychotherapy several times per month. It is imperative to cooperate with residents to ensure adequate time to participate in therapy. The trend of telepsychiatry has lessened the time demand somewhat by reducing commuting time and making long-distance therapy possible. Residents can attend telepsychiatry appointments in a private office on the medical campus, requiring less time away from clinical duties.

Conclusions

Psychiatry is a unique medical field that requires working knowledge of medicine, psychopharmacology, neuroscience, interventional treatments, and psychotherapy. This breadth of knowledge allows psychiatrists to take care of the whole patient and to help patients become the best version of themselves. An essential component of psychotherapy skill development is personal psychotherapy. Psychiatry residency directors can provide lists of available and affordable providers, create a culture that encourages personal psychotherapy, and work with residents to allow time for personal psychotherapy during training. Ultimately, encouraging residents to “know thyself” leads to more competent psychiatrists who are best equipped to work with patients with complicated problems by using myriad interventions.