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The lonely profession: A study of the psychological rewards and negative aspects of the practice of psychotherapy

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The lonely profession: A study of the psychological rewards and negative aspects of the practice of psychotherapy

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Content THE LONELY PROFESSION
A Study of the Psychological Rewards and Negative
Aspects of the Practice of Psychotherapy
, BY
Ray William London
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Education/Clinical Psychology)
June 1976
Copyright (Ray William London) 1976
UMI Number: DP24139
All rights reserved
INFORMATION TO ALL USERS
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and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
UMI DP24139
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
Dissertation Aubi shmg
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789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106- 1346
UNIVERSITY OF SOUTHERN CALIFORNIA
TH E G RADUATE SC HO O L
U N IV E R S IT Y PARK
LOS AN G ELES, C A L IF O R N IA 9 0 0 0 7
This dissertation, w ritte n by
^Y__WILLIAM_ .LONDON.................
under the direction of h..Is.. Dissertation Com
mittee, and approved by a ll its members, has
been presented to and accepted by The Graduate
School, in p a rtia l fu lfillm e n t of requirements of
the degree of
V
E e A
>76
L § H 7
t :
D O C T O R O F P H I L O S O P H Y
Dean
D ate
DISSERTATION COMMITTEE
Chairman
ACKNOWLEDGEMENTS
A special note of appreciation for the profess
ional schools and the graduate school of the University
of Southern California for their clinical training. With
out their assistance, my interdisciplinary studies in
clinical, counseling and medical pyschology; clinical,
medical and psychiatric social work; and psychotherapy
with children, families, adults and groups could not have
been accomplished.
A note for the professors that served and advised
on my committee and studies throughout the years. The
clinical psychologists included Paul A. Bloland Ph.D.,
Joseph Buckhalt Ph.D., Perry London Ph.D., Albert R. Mars-
ton Ph.D., Marvin J. Spiegelman Ph.D., and Milton Wolpin
Ph.D. The counseling psychologists numbered Earl F.
Carnes Ph.D., Fred Moore Ed.D., and Donald R. Schrader
Ph.D. The clinical social workers listed Herman Borenzweig
D.S.W., Howard Hall D.S.W., Carl M. Shafer D.S.W., Bertha
Simos D.S.W. and Barbara Solomon D.S.W. The psychiatrists
were Arnold P. Deutsch M.D., Carl Eisdorfer Ph.D.,
M.D., Edward T. Himeno M.D., and Edward Stainbrook Ph.D.,
M.D. The exceptional child educators and clinicans in
ventoried Leo Buscaglia Ph.D., Marie Paulson Ph.D., and
ii
Eddie Williams Ed.D.
A note for the psychiatrists, clinical psycholog
ists, and clinical social workers that responded to the
inventory and shared their time and feelings.
A note for the physicians, attorneys and pastoral
counselors that took part in the study.
A special note to Bonnie for her listening,
understanding, asserting and caring.
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS......................... il
TABLE OF CONTENTS....................................... iv
LIST OF TABLES • vii
Chapter
I INTRODUCTION .... 1
Background of the Problem • .............. 1
Purpose of the S t u d y ........... 5
Objectives................................... 5
Assumptions........................... 6
Rationale ..................................... 7
Statement of Hypotheses ..................... 9
Importance of the Study-............ 10
Definition of Terms........................13
Delimitations ................................ 14
Summary.......................................15
II REVIEW OF RELATED LITERATURE .................... 16
Rewards of Practice............................ 16
Requirements and Expectations of the
Therapist......................................16
Negative Aspects Related to the Therapist • 22
Negative Aspects Related to Patients . . . 24
External Negative Aspects ••••••••• 28
Related Research Findings .................. 29
Benezra and G o l d ....................... 30
Daniels......................................32
Rdgow........................................34
Henry, Sims and Spray • 35
Critique........................................38
Summary.......................................... 39
III kETHODOLOGY..............................40
Description of Research Methodology .... 40
Research Design .............................. 41
iv
Chapter Page
Null Hypotheses............ . . . . . ; . 43
Operational Definition ................... 44
Pilot Studies.................................... 44
Selection of Subjects- • • .....................45
Population.................................. 45
Sampling.....................................47
Instrumentation .........................49
Data Collection.............................. 5 3
Data Analysis................................ 5 4
Methodological Assumptions .............. 56
Limitations................................ . 56
Summary......................................... 57
IV RESULTS..............................................59
Description of Data Collection . 60
Demographic Data.............................. 6 2
Results on the Psychological Rewards
of Practice.................................. 66
Results on the Psychological Negative
Aspects.......................................66
Total Responses of Psychotherapists
and Other Professions ................ 68
Specific Responses of Psycho
therapists • • • • • 69
Psychotherapists Response Analysis
by S e x ........... 72
Psychotherapists Response Analysis
by Modality of Treatment................74
Psychotherapists Response Analysis
by Context of Practice.................. 76
Results on Dealing with Negative Aspects 80
Nonpredicted Significant Findings ......... 81
Therapeutic Discipline Responses on
the Therapeutic Relationship ......... 81
Modality of Treatment Responses on
the Therapeutic Relationship ......... 84
Context of Practice Responses on the
Therapeutic Relationship .............. 84
Nonpredicted Nonsignificant Findings • • • • 87
Clinical Results .............................. 87
v
Chapter Page
Discussion........................................91
Summary of Results . . . . ................... 9 4
V SUMMARY AND CONCLUSIONS.......................... 96
Methodology.....................................100
Subjects . ............................ 101
Instrumentation ......................... 102
Procedure...............................105
Results......................................... 107
Conclusions.................................. 110
Statistical Analysis .................. 110
Theoretical Understanding ....... Ill
Implications ................................... 114
Recommendations for Further Research .... 115
REFERENCES............................. ................117
APPENDICES
A. Lament of the Psychoanalyst's Wife . . . 124
B. Inventory ... ...............................12 6
C. Inventory Scoring Items .............. . 140
D. Analysis of Variance Tables ............ 14 3
E. Correlation Coefficients ................. 147
vi
LIST OF TABLES
Table
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
XIII
Page
Demographic Data of Subjects Responding
to the Inventory ...............................6 3
The Rewards of the Practice of Psychotherapy
as Reported by Therapeutic Disciplines . . . 67
Significant Mean Negative Aspects Scores
Reported by Psychotherapists and Other
Professions........................................70
Significant Mean Negative Aspects Scores
Reported by the Therapeutic Disciplines . . . 73
Significant Mean Negative Aspects Scores
Reported by the Sex of the Therapists .... 75
Significant Mean Negative Aspects Scores
Reported by the Modalities of Treatment . . . 77
Significant Mean Negative Aspects Scores
Reported by the Context of Practice............ 79
Useful Activities for Dealing with Negative
Aspects of Practice as Reported by
Therapeutic Disciplines ..................
82
Significant Mean Therapeutic Relationship
Variables Scores Reported by the
Therapeutic Disciplines ....................... 83
Significant Mean Therapeutic Relationship
Variables Scores Reported by the Modality
of Treatment......................................85
Significant Mean Therapeutic Relationship
Variables Scores Reported by the Context
of Practice ...... ....................... 86
Analysis of Variance and F Test Results on
the Negative Aspects Variables............... 1^4
Analysis of Variance and F Test Results on
the Therapeutic Relationship Variables . . . 146
vii
CHAPTER I
INTRODUCTION
This study examined the nature of the psycholo
gical* rewards and negative aspects of the practice of
psychotherapy. The responses of randomly selected psychia
trists, clinical psychologists and clinical social workers
were compared with those of physicians, attorneys, and
pastoral counselors. Professionals have too often failed
to investigate the important aspects of their own lives
and environment. Certain components of professional
practice are often ignored or it is simply assumed that it
must be that way. The study attempted to examine the
reflections of psychotherapists and other professionals
in addressing selected issues of their own life experience.
One researcher recently made the statement that "if fish
were to become scientists, the last thing they might dis
cover would be water."
Background of the Problem
The field of psychotherapy is a comparatively
new profession, yet its genealogy includes the family
1
doctor, priest, fortune teller, wizard, shaman, and witch
doctor. The therapist performs many of these functions
and other recently added responsibilities. There is an
extensive literature on human behavior, psychiatry,
psychology, social work and psychotherapy including num
erous schools of thought, professional organizations and
training facilities, but as Jung (1966) maintained,
Neither our modern medical training nor academic
psychology and philosophy can equip the doctor
with the necessary education, or with the means,
to deal effectively and understandingly with the
often very urgent demands of his psychotherapeutic
practice. (p. 190)
The modern therapist has voluminous resources
through which to gain insight into the patient and the
process of therapy. Yet, there is little knowledge of
or research on the therapist. There are some speculations
on why one chooses the field, statements of the personal
characteristics needed in order to be competent, various
codes of ethics to follow, and even some personal state
ments about the rewards of practice. The literature is
relatively silent, however, on the subject of the thera
pist himself or herself. There is even less information
on the psychological stresses, negative aspects and lonli-
ness that therapists experience. This study addresses
these areas.
The present study was motivated by personal
experience, conversations with colleagues, some fleeting
passages found in autobiographical works by therapists,
and a few lines in psychotherapeutic works. The need for
such a study was underscored by studies which have doc
umented high suicide rates among physicians and especially
among psychiatrists (Freeman, 1968, Duffy, 1970). Other
studies show high incidences of alcoholism (Peason and
Strecker, 1960) and drug addiction (Duffy, et al., 1967)
in these professions.
While these are each of vital interest and im
port to - i the. . profession, the present study restricts
itself to the psychological aspects of practicing psycho
therapy .
A common question raised about studying the
negative aspects of practicing psychotherapy was that only
personality factors would be revealed because of the view
that only certain types of individuals select the pro
fession. However, the stereotypic view that therapists go
into the field to solve their own problems has not been
empirically supported.
A therapist’s motivations for going into the
profession may vary from conscious to unconscious, funct
ional to dysfunctional, and complimentary to disdainful.
Some therapists enter the profession because of a desire to
help people who are mentally distressed and an interest in
the problems of mental illness. Some enter the field be
cause it was prescribed or because of personal problems
(Rogtow, 1970). Some therapists select the caretaking role
because of family dynamics assigned such roles to them in
early life (McCarley, 1975).
Henry and his colleagues (19 73) found that psycho
therapists are usually the first born of small families or
last born of large families. This finding is consistent
with the evidence obtained for many other professional
fields. The first and last born tend to go into profes
sions with high responsibility.
Marmor (1953) summarized the issue by explaining that:
there are varied motivations in becoming a therapist. There
is no single type of personality character. The personality
structures of psychotherapists are as varied as those of
practitioners of any other profession. Some may be moti
vated by unconscious drives to solve inner conflicts or may
be seeking prestige. Others may wish to be mothering or
fathering figures, or may.be striving for sublimation of cur
iosities about the private lives of other human beings. Some
therapists enter the field, not because of inner needs, but
because of accidental environmental factors. The choice of
the field is usually based upon a combination of external and
4
inner psychological factors.
Henry, Sims and Spray's (197 3) research found that
there was no evidence to support the position that thera
pists enter the field because of their own problems.
Purpose of the Study/
The purpose of the research was to examine the
positive and negative aspects of the practice of psycho
therapy as reported by professionals in the field. It was
felt that practitioners, educators, students and potential
therapists needed some reasonable information on the psycho
logical rewards and negative aspects.
Vs )1
Objectives
The objectives were to examine the psychologically
negative aspects of the practice of psychotherapy as re
ported by:
1. Psychotherapists, physicians, attorneys, and
pastoral counselors.
2. Psychiatrists, clinical psychologists, and
clinical social workers.
3. Behavior modification, humanistic, existential,
and psychoanalytic psychotherapists.
h
u
ff
4. Practitioners working in agencies, institutions,
group private, and private practices.
The objectives also included examining the:
5. Rewards of practicing psychotherapy.
6 . Reported methods of copying with the pressures of
professional practice and,
7. Variables of the therapeutic relationship and
discipline, modality, and context of practice.
Assumptions
Certain assumptions were made a priori to the
gathering and analysis of the data:
1. There were both positive rewards and negative
aspects of the practice of psychotherapy.
2. There were differences in the negative aspects
of practice as experienced by psychotherapists,
physicians, attorneys and pastoral counselors.
3. There were differences in the negative aspects of
practice as experienced by psychiatrists, clinical
psychologists, and clinical social workers working
with different modalities, in varying contexts of
practice, and of different'sexes.
Rationale
There was no delineated theory on the psychologi
cal rewards and negative aspects of practicing psychother
apy . There were however basic tenets that guided the re
search. The philosophical perspective of Jung's work on
the blending of light and shadow factors, and the existen
tial analysis view on accepting the negative and positive
costs of choices were major principles. Both perspectives
take a position that there are positive and negative aspects
to every choice and situation. The task is to discover the
cost and then decide if it is worth paying the price.
There is no way of making choices with only positive re
wards. One also needs to examine the negative aspects.
The practice of psychotherapy is no exception to this tenet.
A second tenet was based on the concept of
attribution. Human beings are happy or sad, feel good or
bad in the context of what they are doing. A person's
role carries significant psychological importance.
Psychotherapists are often inclined to focus on individual
personality and metapsychology alone. There is a tendency
to view negative aspects as a personal problem (Henry,
Sims and Spray, 1971, 1973), a tendency which ignores
the context of one's work.
The research findings reported by McLean (19 74)
provided further tenets. Kahn (19 74) and French (19 74)
7
determined that professions that involve role conflict, — ^
overload, ambiguity, high responsibility for things and (
people, and external stress produce high levels of stress
and strain.
Role conflict is evidenced by logically incom
patible demands and relations with colleagues characterized
by lack of trust, respect, admiration, and communication.
Overload is a product of having too much to do. Ambiguity
involves nonclarity of work and high expectations. McLean
(1974) found that professions with low degrees of coop
eration and confidence among colleagues and supervisors
have high negative aspects. Stressfulprofessions in
clude those which involve a high need for self control,
threat to super^ego~ideals and constant changes (Levinson,
1970 and McLean, 1974). Such professions also involve
high demands on time, space, and intensity (Selye, 1956).
The literature written by professional therapists
and professional researchers supports these criteria.
The work of Pasamanick and Rettig (1959), Burrow (1926),
Henry, Sims, and Spray (19 7 3), Daniels (19 74), and Marmor
(1953) supports the thesis of role conflict. Henry, Sims
and Spray (1973) , Greenson (1967), and Daniels (1974)
support the concept of overload. Van Kaam (19 66), Swensen
(1971), Greenson (1966), and Lang (1974) explore the tenets
8
of ambiguity and high responsibility. Brody (1971) ,
Ornstein, (1968) and Searles (1966) argue for the ex
ternal stress concept.
Statement of Hypotheses
It was hypothesized that:
1. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
are distinct from those in other professions,
i.e., attorneys, physicians, and pastoral coun
selors.
2. Psychiatrists, clinical psychologists, and
clinical social workers would report differing
psychological negative aspects in their practice
of psychotherapy.
3.„ The psychological negative aspects reported by
male psychotherapists in the practice of psycho
therapy' are distinct from those reported by
female psychotherapists.
4. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
differ with respect to the modality of treatment
employed.
9
5. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
differ according to the context of their practice.
Importance of the Study
This study is significant to three main groups
of psychotherapists: students, practitioners, and educat-
~x
ors. The prospective therapist should have some under- j r
standing of the rewards and the negative costs of pract- f
f
icing psychotherapy. With foreknowledge of the rewards
and negative aspects of practice, students may be able to
make a more intelligent professional choice. While ex
periencing the stresses of training, the student will be
confronted with the prospect of future stresses. The
common self deception that everything will be better when
training is completed will be more difficult to maintain.
The student entering the field expects to be
instructed, hoping to apply the theory learned to the
*
practice of psychotherapy. One often assumes that the
available theory and knowledge is basically equal to the
problems one will face when one is a therapist, however,
this is not necessarily the case. Zucker (1967) proclaims
that one does not know the stress involved in practice
One and one's is used to avoid confusion of he,
-she, him, her and their.
10
\
until one is "well along in it." With foreknowledge of
stress situations one can often take steps to mediate
stresses and negative aspects (McLean, 1974).
The study is also significant to professional
practitioners who are experiencing the stresses of prac
tice. Therapists have a tendency to internalize negative
aspects and to view the world in terms of an individual
y
metapsychology. Few are able to see the inseparable re
lationship of the psychic state and the psychosocial con
dition. Some of the stresses therapists experience may
be inherent in the practice of therapy and not simply
individual neurotic symptoms. With an understanding of
the professional stresses experienced by colleagues, thera
pists may individually and collectively be able function
ally to manage the negative aspects.
At present, therapists only gradually become aware
of the nature of the field. Some respond by hoping that
some new guru has the definitive answer so they continu
ously search for alternatives. Others take what they
have learned and naively attempt to apply it to all situ-,
ations. Some assent to the nature of the subject and try
to find a favorable association. Still others leave the
field or choose another escape (Zucker, 1967).
The study expands some of the options open to
the therapist in responding to professional stresses.
Therapists respond to the isolation and loneliness of
their chosen profession in various ways. Some assume
excessive responsibility for helping their patients. They
consequently spur themselves to greater efforts (McCarley,
197 5). Others decide they have made their contribution
and commit suicide. Some become depressed because their
work has not fulfilled their expectations, while others
become so uninvolved in their own lives that they fail
to recognize their own depressive reactions (Freeman, 1968).
Still others allow their private lives to take a back
seat to their patients' problems and difficulties and stop
living a vital life of their own. Another group of
psychotherapists deal with all of its friendships, family
ties, relationships and social life as analytical and
psychological phenomena (Guggenbuhl;-Craig, 19 71) .
The study is also significant for educators in
the various psychotherapeutic disciplines. Educators
need to be able to provide information and training for
therapists so that they are able to recognize and respond
to the stresses of practice. Some credence must be given
to the concept that to be forewarned is to be forearmed.
Therapeutic training needs to focus on the therapist's
personal needs as well as therapeutic expectations and
patient needs. A knowledge of the strains involved in
the profession can make for better prior selection of
12
therapists, modification of professional lifestyle for
practitioners and more effective preparation programs
(Margolis and Kroes, 1974).
Definition of Terms
The principal terms include psychological negative
aspects, psychotherapists, practice of psychotherapy, other
professions, modality of treatment, and context of practice.
Psychological Negative Aspects: Feelings of
ineffectiveness, isolation, loneliness, excessive demands
and expectations, role conflicts, external pressure,
powerlessness, little attention to personal life, frustra
tion, and lack of gratification.
Psychotherapists: California licensed practi
tioners trained and recognized in the disciplines of
psychiatry, clinical psychology and clinical social work.
Practice of Psychotherapy; The treatment designed
to produce a response by mental and/or behavioral rather
than by physical effects. In includes the use of sugges
tions, persuasion, re-education, reassurance, relationship,
and support (Dorlands, 1965).
Other Professions: Physicians, (Pediatricians,
Family and General Practitioners), attorneys (Trial and
13
General Practitioners) with California licenses, and
pastoral counselors (ministers, priests and rabbis cer
tified by their clinical boards).
Modality of Treatment: Therapeutic orientation
by theory and practice including psychoanalytic, behavior
modification, humanistic, and existential.
Context of Practice: Private practice, group
private practice, agency, and institutional practice.
Delimitation
The scope of the study was arbitrarily narrowed
to include professionals in the urban Southern California
area of Los Angeles and Orange Counties. Consequently,
the findings cannot be appropriately generalized to the
total populations of therapists. However, it should be
noted that this geographic area is a major therapeutic
center in terms of number of therapists, variety of modali
ties utilized and has been used in previous studies (Dani
els, 1974, Rogow, 1970 and Henry et al., 1971 and 1973). /
A second delimitation was that only licensed
professionals were used in the study. It was felt that,
while a great many other professionals in various disci
plines do therapeutic and human services work, the licen
sure criterion established a consistent level of experience,
of legal recognition, and of a right to practice indepen-
14
dently.
Summary
The study examined the nature of the psychological
rewards of the practice of psychotherapy and compared the
psychological negative aspects of psychotherapeutic prac
tice with the negative . aspects reported in other profes
sions. The background of the problem, purpose of the study,
objectives, assumptions, rationale, hypotheses, importance
of the study, definition of terms, and delimitations were
delineated.
Chapter two reviews the literature written
by psychotherapists and four major research studies in the
general problem area. Chapter three explores the research
design, pilot studies, data collection, and analyzes the
data. Chapter four reports the evidence for each hypo
thesis and non-predicted significant findings. Chapter
five presents the summary, conclusions, and recommenda
tions of the study.
15
CHAPTER II
REVIEW OF RELATED LITERATURE
A survey of the literature and research on the re
wards and negative aspects of the practice of psychoterapy
revealed that there were several important issues. These
issues included the rewards of practice, requirements and
expectations of the therapists, negative aspects related
to the therapists and to the patients, and external nega
tive aspects. A summary of related research findings and
a critique conclude the chapter.
Rewards of Practice
There are many functional jrewards in the practice
of psychotherapy. It can provide an opportunity for parti
cipation, personal growth, and participation in intense
psychological processes. It can be a means of participa
ting in a patient's growth (Bugental, 1971). Psychothera
peutic practice provides an individual with a way to help
people while being socially useful. One usually has com
fortable working conditions, status, and an opportunity for
advancement. Therapists usually have a moderate income and
financial security (Rogow, 1970). Lang (1974) considered
an adequate income a gratification of being a therapist.
He also felt that one can obtain some reasonable pride
and a sense of accomplishment. Some therapists obtain a
sublimated voyeurism and an opportunity for exploration.
Clinical practice offers a way of getting to know and
understand other people's inner and outer worlds. While
developing skills, the therapist can work through profes
sional problems and promote personal growth as a therapist.
Psychotherapy is "a terribly rewarding practice."
It is one of the few that combines "art, creativity, and
science." The patients/clients are some of the most inter
esting and creative people. Every patient/client offers
a new world to explore. The work is also needed (Green-
son, 1966).
At the same time however, there are also dysfunc-
tional^rewards. Bugental (1971) explored some of the
possible neurotic gratifications. He maintained that the
practice of psychotherapy can provide a type of one-way
intimacy which is supported by most therapeutic models
and encouraged by professional ethics and professional
organizations. There is a danger of the therapist having
feelings of omnipotence and omniscience and its corollary,
superiority. This latter view is also held by Marmor
(1953) and Sharaf (1964) . The therapist runs a danger of
using the therapeutic process as a means of contingency
17
mastery or a neurotic way of giving or receiving tender
ness, compassion and love. The practice can be a tool
of rebelliousness for the therapist can be in a position'-'"'"'"
to attack authority and tradition.
Requirements and Expectations
of the Therapist
Every school of therapy makes its own unique re
quirements of its practitioners, yet there are a few
general themes. The shortest and most concise list of
requirements was proposed by Van Kaam (196 6) when he
stated that the therapist's crucial characteristics in
clude acceptance, flexibility, gentleness and sincerity.
Swensen (19 71) reviewed twenty years of research
on psychotherapy and concluded that the therapist must
be committed to clients and genuinely care about them.
His review also reported the list of desirable character
istics of the modern psychotherapist prepared by the Ameri
can Psychological Association. The list maintains that
one should be intelligent, sensitive, tolerant, industri
ous, responsible, tactful, cooperative, and ethical. One
should also have originality, curiosity, interest in people,
insight into oneself, warm personal relationships, integri
ty, self control, a broad cultural background, and deep
18
interest in the field.
A study of psychiatrists, psychologists, and social
workers by Spilken and his colleagues (1969) revealed
that the recommended general characteristics included
being objective, dependable, sincere, assured, direct,
responsive, understanding, respectful, interested, and
warm. A similar study by Hamrin and Paulson (1950) , asked
counselors to list the requirements necessary for the
work. The list was presented in the order of frequency
of mention and included understanding, sympathetic attitude,
friendliness, sense of humor, stability, patience, objecti
vity, sincerity, tact, fairness, tolerance, neatness,
calmness, broadmindedness, kindliness, pleasantness,
social intelligence, and poise.
The more competent therapists are self-confident,
outgoing, aggressive, individualistic, nonconforming, spon
taneous while remaining within acceptable social behaviors,
introspective, empathetic, open and consistent with au
thority figures and tend toward inner control rather than
external conformity (Fox, 1962).
Of all the various therapy models, only three ad
dress the issue of therapist characteristics: The Roger-
ian, psychoanalytic, and existential models.
Rogers (1942) maintained that the therapist must
be sensitive to the issues of human relationships, have
19
an objective attitude, be capable of maintaining an
emotionally detached attitude, be willing and able to re
spect the client as the client is, understand ones own
emotional limitations and shortcomings, and have an under
standing of human behavior.
The psychoanalytic perspective is best explained
by Greenson and Lang. Greenson (1966) maintained that
the therapist must have the ability to empathize with
the patient; be able to communicate meaningfully with
words, tone and silence; and be able to safeguard the
working alliance and work with two sets of demands which
are in opposition at the same time. One must have unusual
character, personality, and sensitivity, possess a lively
interest in people, be free of the usual conventionalities
of society, be able to temporarily and partially give up
one's own identity, have the ability to wait and suspend
judgement, have the ability to endure anxiety, depression,
and stress patiently and quietly.
Greenson (1967) further maintained that the therapist
makes a commitment to the patient to guide him or her
into strange new worlds. One must show the patient that
every word and behavior is taken seriously. It is the
therapist's responsibility to safeguard the patient's
sense of dignity and self-respect while working with mu
tually fragile and complex predicaments. In order to
20
accomplish this task the therapist needs to be able to
pursue areas even when it is painful to do so. An under
standing of another person's mind must involve empathy,
emotional closeness, and therapeutic distance. One must
be able to select the right word or language with the
proper timing and have a certain amount of compassion,
friendliness, respect, and warmth. Some of these skills
may be learned, others cannot.
Lang (197 4) maintained that the therapist must:
be natural but not indifferent; warm but not seductive;
tolerant, yet not foster acting out; maintain ones integr
ty and honesty while foregoing gratifications beyond the
therapeutic relationship; and be concerned and empathic,
yet not overly involved.
The existential view of therapist characteristics
includes the ability to maintain selective participation;
be able to accept guilt and be humble; to encounter other
people openly and involve oneself in an evolving concep
tion of oneself, the world, psychotherapy and personality
(Bugental, 1971).
While obeying the Boy Scout Law, the modern thera
pist has a list of requirements and expectations that in
cludes the wisdom of Solomon, the understanding of Socra
tes, and the compassion of Jesus. The high expectations
and the incompatibility of many of the ideals may result
in negative aspects and psychological stresses.
Negative Aspects Related to the Therapist
Some of the negative aspects of practice are rela
ted to the therapist's own situation. After writing an
entire book on the learning of psychotherapy, Bruck (1974)
made a short note about its practice. She stated "doing
psychotherapy is basically a lonely business" (p. 148).
She explained that the practice is totally geared to the
patient's needs requiring the therapist to suspend con
cerns about ones own needs and inadequacies.
Guggenbuhl-Craig (1971, p. 129) argued that "the
greatest curse of the therapist is the isolation."
The practice of therapy affects all areas of the
therapist's life. There is an intimacy with patients
that is different from other relationships, a constant in-
depth detailed look into the socially forbidded aspects
of one's life and rapid succession exposure to different
varieties of intimate personalities and struggles (Bugen
tal, 1973).
The negative aspects of practicing therapy begin
while learning the art of psychotherapy because it is an
anxiety-provoking endeavor. The trainee often has feelings
of loneliness, emptiness, sadness, and anger (Bruck, 1974).
22
The student is given the task of accepting the intense emo
tions of the patient which are frequently directed at the
therapist. One must understand the diverse motives, fanta
sies, and defensive efforts of even the most deeply dis
turbed patients while becoming aware of one's wishes and
feelings and trying to find a balance of emotional involve
ment and distance in relation to the patient (Sharat and
Levinson, 1964). The need for emotional support, and even
renewal of self-understanding, is well acknowledged in the
early years of training. But there is a reawakening of
this turmoil in the last years of training (Allen, 1971).
The stresses do not end when one is licensed,
credentialed and certified. McCarley (1975) took note of
the stresses and needs for support in the latter years of
practice. He explained that the therapist's needs for
support are not yet recognized. The therapist must face
the inherent stresses of practicing psychotherapy while
dealing with the usual stresses of ones own developmental
concerns. The daily emotional load of confrontations with
patients' depressions, rages, nurturance and support de
mands, remain.
After achieving the ego ideal of being a profes
sional, the therapist can experience success and glory in
the public world, but there is often a negative cost of
emptiness and lack of success in the private world. A
lifetime of personal effort and sacrifice in the name of
23
family and public approval can lead to a cycle of success,
glory, emptiness and loneliness.
As with many professions, the therapist is
caught in a struggle to seek and maintain credibility. It
is accomplished by academic honors, professional training,
certification, licensing, and participation in professional
organizations. The credibility struggle requires that one
perpetually sell oneself. This means that the therapist
never really arrives. The struggle takes considerable
. . . . 1 M | | M 1 | | M , ! » ■ f r | | |
energy requiring constant updating and competition. Yet,
the credibility is transitory, for it can evaporate in
stantly. With the first signs of a weak or damaged credi
bility, the "sharks and vultures" are drawn. Some attack
the individual while others attack the discipline or even
the profession (Ehrie, 1974). Thus, tremendous time and
knowledge is demanded of the therapist in order to maintain
professional competence. One also has the accompanying
stresses of family responsibilities, social requirements,
and civic commitments (Duffy and Litin, 1967).
Negative Aspects Related to Patients
Many of the psychological negative aspects of
therapeutic practice are related to the patients. The
areas of personality that the therapist works with range
from the difficult to the impossible and there is no such
24
thing as an easy case. One is seldom able to accomplish
all that one hopes and the therapist has less control over
the subject of the work than practitioners in most other
professions. The basic questions of practice remain un
fathomed. There are meaningful general answers but they
cannot always be applied correctly, with precision and
control. There is a body of useful knowledge, yet the
conditions, expectations, and stresses of practice do not
compare with most other professions. The therapist must
not only be able to apply knowledge, but must also rely on
character, spirit, and personality. Few fields require
such a total and continuous personal response (Zucker,
1967).
The therapistfs psychic energy is concentrated on
the patient's destructive side. One deals with unhappy,
unfortunate, maladjusted people and confronts uncommon
human behavior, emotional outbreaks, and expression of
personal, collective and archetypal shadows (Guggenbuhl-
Craig, 1971).
The therapist-patient interaction often involves
subject areas and feelings that are not socially acceptable,
including hatred, envy, rejection, anger, sex, and guilt.
The more classic forms of therapy exhort the patient to
explore such areas while the therapist's own thoughts and
feelings are never shared. At times, the therapist is
25
powerless to help (Searles, 1966).
The therapist is confronted with personally dis
tressing, infinitely variable, intellectually complex,
and emotionally confusing human material. The work in
volves the lives and happiness of individual patients and
entire families. While challenging, it also involves
emotional trials and legal, if not moral, responsibilities.
The therapist works long hours, with few breaks,
in relative isolation with little direct appreciation or
immediate gratification (Lang, 1974). The therapist spends
many hours in intense relationships that result in a dif
ficult and passive occupation (Zinberg, 1963). The routine
is unusually sedentary with little opportunity for physical
activity or active manipulations of objects in the environ
ment (Tamerin, 19 72). Those who work with groups are
placed in a situation of increased stress with more pres
sing, intense, and immediate pressures (Bernstein et al.,
1963).
While being a psychotherapist affords an opportu
nity for a life of reasonable independence, it can turn
into a life of isolation and loneliness. The rugged indi
vidualist can turn into one compelled by excessive drives
for recognition, power, and prestige. While beginning to
feel that one is indispensable, with the help of trans
ferences from patients, the therapist's life can become a
26
hurried existence where office hours, appointments, poor
eating and sleeping patterns, and family relationships be
come sources of trial and even obstacles (Pearson and
Strecker, 1966).
Most of the therapist's professional life is spent
sitting in the office alone in an isolated kind of exist
ence. When one is reasonably effective in one's work, the
professional isolation increases. Most patients relate
to the therapist not as a human being but as a parent-
figure, shaman, devil, or the embodiment of God. Most
patients expect from the therapist what they themselves
only vainly try to do or solve. Even the most competent,
well trained, and personally civilized therapist cannot
avoid the anxiety, isolation, and loneliness inherent in
the practice of psychotherapy (Marmor, 19 53).
The profession depends on individual performance
with a strong emphasis on prestige and frequent rivalry
with colleagues (Blachly et al., 1963). The therapist,
however, does not have the buffered protection from the
pressures and transferences characteristic of most other
professions. Ministers can displace part of their burden
on God. Attorneys and government officials have the "law,"
policies, protocols, and assistants^(Wheelis, 1958).
The isolation is enhanced by a professional ten
dency to be destructively critical of other colleagues
27
(Pasamanick and Rettig, 1959). Trigant Burrow (1926)
maintained that when any two analysts have a long heart-
to-heart talk they will damn the methods of every other
analyst. This view is not restricted to analysts alone.
The critical tendency is institutionalized by the adherents
of the different schools of therapy. Many of these groups
claim, with religious zeal, that they have the "truth."
Each has its own guru, sacred texts and esoteric private
language. Burrow's view was supported by the research of
Henry and his associates (1973).
Communication between those who adhere to differ
ent therapy models is often very difficult for each group
has a tendency to become self-contained and cult-like.
This makes them relatively immune to outside influences.
These role conflict conditions lead to increased isolation
and loneliness (Marmor, 1953). Even the true believers
and gurus become isolated, lonely, frustrated, and stressed.
External Negative Aspects
The modern psychotherapist is also faced with
sources of external pressures. One is, without willing it,
an agent of social control. Recently the therapist has
become more a part of society's cartaking and behavior-
modifying system (Brody, 1971). Society is demanding that
therapists work with a wider range of problems, more ac
28
countability, and more varied therapeutic services (Orn-
stein, 1968).
There is a disparity between the expectations of
the patients, the public, the government, and the thera
pist's human limitations. The task is to help people live
with a minimum of tension in a complex, contradictory, and
insecure world.
The general American culture values a tangible
job well done. Yet, the work of the psychotherapist is
intangible and is not, in the usual sense, one that is com-
pletable. The measure of success is difficult (Searles,
1966). The only proof is in the experiences of therapists
and patients. Psychic reality cannot totally be grasped
statistically or causally through the classical natural
science research methodology (Guggenbuhl-Craig, 19 71).
The literature provided some insight into the
issues of the positive and negative rewards of practice,
the high expectations of the therapists that must be in
tegrated, the negative aspects of practice related to the
therapists and to the patient, and the external negative
aspects.
Related Research Findings
There have been at least four major research ef-
29
forts that address the psychological negative aspects of
practice. In analyzing research conducted with profession
al psychotherapists it must be recognized that such efforts
are very difficult. Most therapists are "test-wise;1 1 con
sequently the attempts to apply standardized personality
inventories have produced unimpressive results (Heller,
1971).
Benezra and Gold
The most recent research was done by Benezra and
Gold (1974). They mailed questionnaires to 650 psychia
trists in the United States and Canada and received a
response from 240 subjects, a return rate of 36 percent
which was below the rate of previous studies of this type.
The survey revealed that subjects over the age of
50 "indicated feelings of greater rather than less stress"
(p.2). The subjects listed seven conditions of practice
that they felt to be the most stressful. These seven areas
and percentage of those reporting included: (A) Intra
psychic factors including anxiety, depression and conflict
resulting from working with patients -- 23.4 percent.
(B) Hours of work — 18.7 percent. (C) Management of
suicidal patients— 17.1 percent. (D) Doubts about theory
and treatment modalities and concern about positive results
30
— 11.9 percent. (E) The need to maintain one's balance
with emotionally charged material -- 10.9 percent. (F)
The intangible and unmeasurable nature of the work making
the psychiatrist question his professional effectiveness
-- 9.3 percent.
Benezra hazarded an "educated surmise" which has
not yet been established. While he did not study clinical
social workers or clinical psychologists, he maintained
that they do not experience the same amount of stress be
cause they (A) work in agencies, hospitals or mental health
centers. This first point is not substantiated by other
research. Daniels' (1974) work shows that even if this
were true, there would not be less stress. (B) they do
not experience the "on-camera isolation for long stretches"
that psychiatrists experience. If all three disciplines
do essentially the same work in the therapeutic role as
shown by Ekstein and Wallerstein (1958) and Henry, Sims
and Spray (1971, 1973), this second point is questionable.
(C) Responsibility for patient outcome is diffused by
"colleagues, supervisors and medical agency directors."
This point is questionable because the moral and legal
responsibility in terms of malpractice and licensure are
the same for all professions. He made some additional
comments which certainly needed supporting research. (A)
Therapeutic isolation results in continually digging into
31
oneself with self blame. (B) Psychiatrists are finding
ways out of the stresses by new techniques of being more
open, admitting one's own shortcomings, and doing group
therapy.
Daniels
Daniels (1974) studied 152 psychiatrists by using
one and a half to four hour unstructured interviews ending
with a sentence-completion list. The sample included 81
private practitioners and 71 practitioners from organiza
tional settings including 36 in state hospitals and 35 in
military hospitals. The private practitioners were from
undisclosed metropolitan areas in California and eastern
states. The organizational practitioners came from the
Pacific Northwest and an undisclosed Western State. While
no systematic sampling method was used for the subjects,
Daniels argued that the difficulties of "engaging" the
psychiatrists made the method necessary.
Two-thirds of the subjects complained about the
isolation of practice. The complaints were divided into
38 percent who mentioned the structured isolation, 27 per
cent who mentioned isolation from colleagues and 13 percent
who felt isolated because of lack of opportunity to commu
nicate. Both groups of subjects showed that "psychiatric
practice, regardless of setting seems to generate loneli
32
ness" (p. 144).
A second area of concern of the study involved
image and status problems. Three-fourths of all the sub
jects mentioned this area. Fifty percent mentioned that
patients see the therapists as coercive, mysterious, omni
potent, or unreasonable. The view of the therapist being
seen as "God" was mentioned by 18 percent of the subjects.
General image problems were mentioned by 18 percent of the
subjects. Status problems in dealing with medical col
leagues were mentioned by 10 percent. Fifteen percent
of the subjects critically mentioned their colleagues.
A third area of concern was personal strain
created by the work. Three-fourths of the sample mentioned
at least one of four problem areas: the work is too hard,
50 percent response; too much pressure, 25 percent response;
not enough rewards, 26 percent response, and too many
temptations, 16 percent response.
The study showed that psychiatrists are quite
critical of their colleagues. Seventy-eight percent of
all the subjects complained about their colleagues as:
being arrogant, uncommunicative and unfriendly, 66 percent
response; being dependent and over conforming, 33 percent
response; and being mentally ill, 16 percent of the sub
jects. Many of these findings substantiate the positions
taken in earlier sections of this review. In order to
33
obtain a more comprehensive understanding of therapeutic
negative aspects there is a need to use other sampling
techniques and methods to study all three of the psycho
therapeutic disciplines of psychiatry, clinical psychology,
and clinical social work.
Rogow
An earlier investigation by Rogow (19 70) studied
a sample of 149 psychiatrists and 35 medical psychoanalysts.
A questionnaire was mailed to a random sample of the members
of the American Psychiatric Association and the American
Psychoanalytic Association. A total of 490 questionnaires
were mailed with a return of 184, making a 38 percent
response rate. A follow-up was made of those not returning
the questionnaire. The results obtained from 77 nonres
ponding subjects showed similarities to the original 184
respondents. Subjects were asked if they would be willing
to be interviewed. A total of 71 responded affirmatively
with 38 interviews actually conducted.
While the study addressed numerous professional
concerns, it did show that 60 percent of the analysts and
65 percent of the psychiatrists mentioned particular
stresses in their professional lives. The stresses men
tioned by psychiatrists included the tension of constant
attention, a tendency towards isolation from the communi-
34
ty, isolation during working hours, excessive telephone
and paper work, not enough time to do everything, immobili
ty, lack of opportunity to travel, damaging effects on
research by vested interests, and the conflict between
different models of therapy.
The stresses mentioned by psychoanalysts included
loneliness of practice, isolation from social and scienti
fic movements, domination of practice by an establishment,
feelings of inadequacy, discrepancies between efforts and
results, and the passivity and boredom of practice.
Henry, Sims and Spray
The most comprehensive nationwide study of psycho
therapists was done by Henry, Sims and Spray (19 71, 197 3)
who collected data from 4,290 therapists trained in the
disciplines of psychiatry, psychology, social work, and
psychoanalysis. Three hundred four-hour interviews were
conducted with therapists from Chicago, New York City, and
Los Angeles. The interviews also included administration
of a Thematic Apperception Test and an Identity Scale uti
lizing a semantic differential format. The interviewees
were sleeted from highly visible and respected profession
als in the selected communities, the same method used by
Daniels (1974). A quota was then established and subjects
were selected on the basis of obtaining a sample represen
________________________________________________________________35_
tative of each variable, i.e., discipline, orientation,
work setting, sex, and age. The questionnaires were mailed
to 6,629 therapists with a total of 3,990 returns, a 60.2
percent response rate. The therapists were selected by
using the directories of the American Psychiatric Associa
tion, the American Psychoanalytic Association, the American
Psychological Association, the National Association of
Social Ttfork and various other professional directories.
The questionnaires were sent to a sample of the members
listed in each directory.
The 1971 report revealed that there is an accen
tuated blurring of the distinctions between the occupation
al and personal roles of the therapist. The outside life
of the therapist was partially shaped by professional in
fluences. The 197 3 report showed the average work week of
analysts as 57 hours, psychiatrists as 52 hours, psycholo
gists as 47 hours, and social workers as 49 hours.
The report showed that the divorce rate among all
the disciplines was not substantially different from the
divorce rate of the general population of the United States.
Therapists spend varying amounts of time with
spouses: 33 percent spending little time, 41 percent
spending moderate time, 26 percent spending much time with
47 percent reporting the relationship as being very satis
fying, 36 percent reporting it as moderately satisfying,
36
and 17 percent reporting it as unsatisfying. As a coro
llary, 71 percent of the social workers, 49 percent of the
psychiatrists, 41 percent of the psychologists, and 38 per
cent of the analysts reported spending a lot of time with
their children. The majority of the sampled therapists
reported the relationship with their spouse and children
as being calmly positive, generally well worked out, even
satisfying but somewhat dispassionate. The familial
relationships tend to focus on shared intellectual perspec
tives and common recreational activities rather than on
affective communication.
The study (1971) showed that therapists generally
came from small, upwardly mobile familes with both parents
present. The majority came from middle and lower class fami
lies .
The therapists' parents were seen in mixed terms
with the mothers generally described in affective terms and
the fathers seen in cognitive terms. The hypothesis that
a clear relationship exists between early determinants and
later occupational choice remained unproved.
The therapists' childhood was described as posi
tive normalcy in regard to parents and siblings. The des
cription of their childhood and adolescence was remarkably
similar to the developmental norm. The extent and nature
of the relationships with close family relatives was also
37
within the norm. The occurence of mental illness in
therapists' families of origin was similar to that of the
general population. The sexual history was virtually
identical to Kinsey's studies.
While the study did not specifically address it
self to psychological stresses and negative aspects of the
practice of psychotherapy it did present two important
findings: that therapists live in a undimensional
world defined in terms of psychodynamic language and that
language delimits the therapists world. This finding is
poetically expressed in the poem, "Lament of the Psycho
analyst's Wife," (Appendix A).
Critique
While these studies have presented some useful and
important information, they are not above criticism. None
of these studies have utilized comparison groups of other
professions. Consequently there is no way to determine if
the negative aspects experienced by therapists are inher
ent in the practice of psychotherapy or simply a negative
component of being a professional in the twentieth century.
Nor have the studies considered the negative aspects in
terms of the important variables of therapeutic discipline,
sex of therapist, modality of treatment and context of
practice. Not one of the studies addressed the issue of
38
how, if one wanted to avoid certain types of pain, this
could be accomplished. There is no data exploring how
therapists with developmental differences may require dif
ferent solutions to the negative aspects of practice.
None of the studies have explored the therapist's
double bind of feeling responsible for helping patients
to change, yet having to forego public satisfaction for
one's successes. Nor have the studies considered the per
sonally imposed pressures, i.e., the internalized psycho
therapist's ego ideal in relation to external pressures,
such as patient and institutional demands.
Summary
The literature provided a limited base for under
standing the rewards of practice, the requirements and ex
pectations of the therapist, the negative aspects related
to the therapist and to the patients, and the external
negative aspects.
The related research findings and the critique
established a research justification and need for comparing
the responses of psychotherapists with other professions
and examining the variables of disciplines, modalities,
contexts of practice, and sex of therapists.
39
CHAPTER III
METHODOLOGY
The methodology for examining the psychological
rewards and negative aspects of the practice of psycho
therapy involved a field experiment comparing the responses
of randomly selected psychiatrists, clinical psychologists,
clinical social workers, attorneys, physicians and pastoral
counselors. The data was collected by the use of mailed
inventories and unstructured interviews. The inventory
instrument was constructed for this particular study and
was tested for validity and reliability. It was pretested
in four stages. The data were examined by an analysis of
variance using the Wilks Lambda Criterion. A detailed
statement of the approach is presented in the following
sections which include a description of the research
methodology, research design, pilot study, selection of
subjects, instrumentation, data collection, statistical
analysis, assumptions, and limitations.
Description of Research Methodology
The study utilized elements of various research
approaches as explained by Isaac and Michael (1972). It
40
attempted to describe systematically the characteristics ofj
the various therapeutic disciplines, sex, modality of |
i
treatment, contexts of practice. It investigated the !
extent of variations of reported negative aspects as re
ported by psychotherapists and other professionals. The
study also investigated possible cause-and-effeet relation
ships between negative aspects, rewards of practice and
dimensions of the therapeutic relationship.
It was hoped that the results of the study would
lead to the development of new approaches to analyzing and
responding to the psychological rewards and negative aspects;
of practicing psychotherapy.
Research Design
The research was designed as a field experiment
with the principal independent variable of profession and
multiple dependent variables, i.e., responses to an ex
tensive inventory. The principal independent variable was
partitioned in two ways: (a) therapists versus nonthera
pists (attorney, physicians and pastoral counselors) and
(b) partitions within the therapist category, i.e.,
psychiatrists versus clinical psychologist versus clinical
social workers. In sum, the design included both a 1 x 4
and 1 x 3 factorial with no missing cells and no restric
tion regarding equal number of observations per cell.
41
While profession was treated as the principal
independent variable, a series of other independent var
iables was examined: (a) modality of treatment, psycho
analytic versus behavior modification versus humanistic
versus existential versus humanistic existential, with a
1 x 5 factoral; (b) context of practice, agency/institution
versus private versus group private versus mixed private
and agency, with a 1 x 4 factorial and (c) sex of thera
pist, male versus female with a 1 x 2 factorial with no
missing cells and no restriction regarding equal number of
observations per cell.
The design involved the individual administration
of a mailed inventory to a randomly selected sample of
psychiatrists, clinical psychologists, and clinical social
workers and a comparison sample of physicians, attorneys,
and pastoral counselors. Follow-up one hour unstructured
interviews with selected therapists and other professions
were conducted for checks of validity. The statistical
treatment involved an analysis of variance using the Wilks
Lambda Criterion for each of the null hypotheses.
The independent variables were discipline, modal
ity of treatment, sex and context of practice. The depend
ent variables, i.e. the negative aspects, included feel
ings of ineffectiveness, isolation, loneliness, excessive
demands, expectations, role conflicts, external pressure,
42
feelings of powerlessness, little attention to personal
life, feelings of frustrations,and lack of gratification.
Null Hypothesis
The variables of the study were analyzed statis
tically in terms of five null hypotheses:
1. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
are not distinct from those in other professions,
i.e., attorneys, physicians, and pastoral counse
lors .
2. Psychiatrists, clinical psychologists, and clin
ical social workers do not report differing
psychological negative aspects in their practice
of psychotherapy.
3. The psychological negative aspects reported by
male psychotherapists in the practice of psycho
therapy are not distinct from those reported by
female psychotherapists.
4. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
do not differ with respect to the modality of
treatment employed.
5. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
43
do not differ according to the context of their prac
tice .
Operational Definition
All variables were operationalized by self re
port data on the inventory. No attempt was made to opera
tionalize the variables by actual observation of the sub
jects behavior or by utilizing depth oriented techniques.
A subject was presumed to have a particular attitude,
belief or feeling if he/she so stated. The particulars
of how subjects reported on the variables are found in
Appendix C.
The self rating inventory method paralleled pre
vious research methods on professional stress (McLean,
1974; Margolis and Kroes, 1974) and has been used in other
studies of psychotherapists (Daniels, 1974; Rogow, 1970;
Henry, Sims and Spray, 1971, 1973) .
Pilot Studies
Three pilot studies were conducted to make a
preliminary test of the hypothesis, to test the statisti
cal and analytical procedures, to reduce the number of
treatment errors, and to check for concreteness, complete
ness, comprehensibility, consistency and reliability of
the inventory.
44
Three groups of psychotherapist subjects with a
total of ninety were used. Each group included the major
variables of disciplines, modalities of treatment, con
texts of practice and sex. The pilot study subjects
were given the inventory in face-to-face group adminis
trations. The subjects were interviewed and their reaction
to the inventory were noted. Items that were unclear were
eliminated. Thus, the results of the pilot studies modi
fied the instrument and instructions. The inventory was
revised for correction of ambiguity and exactness of defin
ition .
Selection of Subjects
The selection of subjects included definitions of
the population and sampling methodology.
Population
The private and public psychotherapy practition
ers in Los Angeles and Orange Counties were selected as the
total population to be studied. The characteristics of
the practicing psychotherapists population included
licensed psychiatrists, clinical psychologists and clinical
social workers. An investigation of the California State
45
Board of Medical Quality Assurance and the Southern
California Psychiatric directory revealed that there were
1,146 psychiatrists and 1,041 clinical psychologists pres
ently in the study population. The California State Board
of Behavioral Science Examiners maintained that there were
1,369 clinical social workers in the study population.
The sample subjects were drawn from lists of licensed
practitioners maintained by the California State Boards of
Medical and Behavioral Science Examiners. Since psychia
trists are not specifically licensed as a speciality, the
lists of recognized practitioners maintained by the
Southern California Psychiatric Association were also
consulted.
The population included all of the major modali
ties of treatment, contexts of practice, and sex. There
was no method for establishing population characteristics
in the above areas other than absolute measurement of the
entire population. The licensing boards mentioned that
they could not provide this information.
The population for the comparison group included
physicians licensed by the California State Board of
Medical Quality Assurance, attorneys admitted to the
California State Bar and pastoral counselors certified by
Association for Clinical Pastoral Education and/or trained
in clinical settings. The practice specialties for these
46
groups were established by lists provided by the county
and regional associations and boards.
The comparative groups were selected because
each requires post graduate education and licensing or
certification. Members of each group generally have a
high socioeconomic status and hold positions of responsi
bility. They work with people who come to them for pro
fessional assistance. The investigator felt that pastoral
counselors were high in sensitivity to issues of human
suffering and low in personal responsibility. Attorneys
were seen as high in responsibility and tangible measures
and low in sensitivity. Physicians were seen as having
high competency demands, long work hours, and as being
under stress with low introspection. These criteria
established that the comparative groups were similar to
the study group in terms of training requirements, status,
responsibilities, and personal requirements.
Sampling
In order to ensure that the sampling technique
would select therapists representative of the population,
a simple random sample was drawn. Randomness was assured
by use of the Rand random number table. A population list,
including all of the licensed psychotherapists registered
47
as living in the population area was obtained from the re
spective licensing and certification boards. Each pro
fessional was assigned a number according to the list pro
vided. The therapists to be contacted were selected on the
basis of the random number table.
Steps were taken to maximize the inclusion of
the major diverse elements of psychotherapists in the
selected area by the use of a large sample.
Since a major focus of the study was experience
appraisal, strict probability sampling was unnecessary
(Selltz et al., 1959).
Every attempt was made to select randomly those
invited to participate. There was no way of controlling
who would respond affirmatively. Follow-up interviews of
those responding and those not contacted showed that there
was no reason to believe the sample was not representative.
The interview results on negative aspects were s i m i l a r to
the inventory responses. The subjects did not include
friends of the researcher or those from just one institut
ion .
Further follow-up was made with those therapists
not completing the original inventory by requesting that
they complete the professional information part of the
inventory in order to obtain information about the char
acteristics of this group.
48
The same sampling procedure was then used to
select those therapists who were to be contacted for per
sonal interviews. Subjects were randomly selected from
three lists for the interviews. The lists included five
therapists from each discipline returning the inventory,
five from each discipline not returning the inventory and
five from each discipline not included in the study sample.
The same procedure was also used to identify eighteen
control group subjects to be interviewed. A total of two
interviews for each of the three lists was conducted.
A large sample was obtained in order to decrease
the possibility of sampling error and was necessitated
because there were a large number of uncontrolled variables
interacting, the total sample was to be divided into sev
eral subsamples, and the population included a wide range
of variables and characteristics. The details of the
sample characteristics are reported in Chapter IV.
Instrumentation
A thorough review of the literature, including
psychometric tests and interviews with authorities in the
assessment field, revealed that there were no standardized
measures of the selected psychological negative aspects
available. The measures employed by Daniels (1974),
49
Rogow (1970), and Henry, Sims and Spray (19 71, 19 7 3) were
judged inadequate for the present study. Benezra and Gold
(1974) refused to release their instrument. Consequently,
a new inventory was needed.
In addition to the literature and assessment re
views, interviews were conducted with psychiatrists,
clinical psychologists and clinical social workers, in
order to gain their insight into important parameters of
the study questions.
An original item pool of 500 was assembled on
4 x 6 cards. The items included questions and subscales
from the Purdue Therapeutic Relationship study which drew
items from the Usual Therapeutic Practice Scale, Therapist's
Personal Reaction Questionnaire, Barrett-Lennard Relation
ship Inventory, Myers-Briggs Type Indicator, Maudsley
Personality Inventory, Eysench Personality Inventory,
Allport Vernon Lindzey Study of Values, Edwards Personal
Preference Schedule, Guilford-Zimmerman Temperament Survey,
California Psychological Inventory and the Minnesota
Multiphasic Personality Inventory. The item pool also in
cluded items from the Daniels (1974) and Rogow (1970)
inventories and major statements from the literature re
view.
Four phases were followed in selecting the final
inventory items. The first phase consisted of a check for
50
grammar, wording, clarity and social desirability. Those
items not meeting a standard of appropriate grammar,
clarity and construction were reworked or eliminated.
Items with high or low professional desirability were also
reworked or eliminated considering the level of education
and training of the population.
In the second phase the selected items were
evaluated by ten experts in fields of psychiatry, psychol
ogy, social work, clinical research and assessment. Rec
ommendations for inclusion or exclusion were based upon
the area and design of the study including data collection.
The items were evaluated for validity by using the con
tent and internal consistency methods and by assessing
each item for face validity. Any items not judged to be
valid by eight of the experts were eliminated. Since most
of these items addressed the subject’s own perception and
since no other similar measures were available for com
parison, additional tests of validity were not presently
possible.
The third phase consisted of administering the
inventory to one group of 35 therapists and trainees and
a second group of 25 subjects. The final phase involved
a repeat of the first two phases.
The reliability of the final inventory was estab
lished in the third pilot study which included thirty
51
subjects: ten psychiatrists, ten clinical psychologists,
and ten clinical social workers as well as fifteen psycho
analysts, eight humanistic/existental therapists and seven
behavioral therapists. The results of the final pre
testing were analyzed by using the Spearman-Brown formula
for a coefficient of equivalence. The split half method
required dividing the items into two equivalent parts.
Each section was scored separately and the variance of
the two half scores was equal. A reliability coefficient
of .93 was obtained on the final inventory using the
Spearman-Brown Formula.
The completed inventory (Appendix B) consisted
of 49 items ranging from the subjects' disciplines and
modalities to feelings of isolation and loneliness. The
respondents were asked to check items with a response
range for each question which included: total agreement
with the statement, moderate agreement, neutral, moderate
disagreement and total disagreement. A continuum was
selected as opposed to a strict numerical scale because
most of the pilot subjects and experts felt that subjects
would react negatively to having to select a strict
numerical value when there were many input gradations.
Numerical values were used in decoding the responses for
analysis purposes.
52
The inventory was designed so that it was short,
readable, and would not take much time to complete. The
items addressing the negative aspects were close ended
using a continuum scale while the positive aspects were
addressed by using an open ended option. The professional
information section of the instrument included identificat
ion, therapeutic discipline, developmental experience,
modality of treatment and context of practice subscales.
It provided descriptive data which ensured that all of the
subjects were practicing therapists.
The inventory section provided the responses for
analyzing the psychological negative aspects experienced
by therapists.
Data Collection
The data collection procedure included mailed
inventories, telephone calls, and personal contacts. The
inventories included a cover letter, professional informat
ion sheets, and the professional inventory sent with a
pre-stamped and addressed return envelope. Telephone and
personal contact procedures were employed for follow-up of
nonrespondents' and the interviewees.
This method provided a means of obtaining ob
jective and subjective data from a wide range of pro
fessionals whose time is at a premium. It provided
53
necessary checks for reliability, bias, and confidentiality.
Additional methods of data collection included
further requests for the nonrespondent to complete the
inventory or at least the professional information section.
After the data were collected, the material was checked
for completeness, legibility, comprehensibility, con
sistency, uniformity, and inappropriate responses.
The "fixed-alternative" items on the inventory
were scored on a simple checked or nonchecked basis. The
close-ended continuum questions were scored on the basis
of agreement, disagreement or neutral responses. The
scoring included five points for total agreement, four
points for moderate agreement, three points for neutral,
two points for moderate disagreement, and one point for
total disagreement.
The open-ended responses were scored on an in
dividual basis. Those items that added dimensions not
found in the statistical analysis were noted. These re
sponses were totalled by study variables and descriptive
information.
Data Analysis
An analysis of variance was performed to answer
the basic question: Did the various groups, classified by
54
therapeutic discipline, sex of therapist, modality of
treatment, and context of practice, differ in regard to the
psychological negative aspects each experienced in prac
tice? The same statistical test answered this question
for the subjects and for the comparison groups. This
procedure met the requirements of ceteris paribus explained
by Simon (196 9) and permitted an analysis of complex
interrelationships in an efficient design yielding more
reliable conclusions than if the variables had been studied
separately (Selltiz, Jahoda, Deutsch and Cook, 1959).
This test of the null hypothesis is an "extremely versatile
and powerful device" (Ericksen, 1970, p. 188). The test
was further justified because the differences in effect
existed in a small set of treatments, the interest was in
the stated combinations and no others, and the treatment
of immediate interest was included in the study (Hays,
19 63). A homogeneity of variance was established.
The analysis of variance standard criteria of
p less than .05 was employed (p<: .05).
The data were analyzed with the assistance of the
IBM computers at the University of Southern California
Computer Center.
The analysis of variance employed the University
of North Carolina Psychometric Laboratory Analysis of
Variance program. The PRSC update was dated May, 1972.
55
The test of significance utilizing the Wilks Lambda Critercn
was used to analyze two or more dependent variables of sub
jects mean differences. The criterion allowed for group
comparisons of multiple dependent variables of different
sizes taken simutaniously (Kerlinger and Pedhazur, 1973).
Methodological Assumptions
The principal assumptions underlying the use of
the analysis of variance are listed by Guilford (1965) as:
1. The contributions to variance in the total
sample must be additive.
2. The observations within sets must be mutually
independent.
3. The variances within experimentally homogeneous
sets must be approximately equal.
4. The variations within experimentally homogeneous
sets should be from normally distributed pop
ulations.
Each of these assumptions was met.
Limitations
There were some limitations to the methodology
that must be mentioned. As noted by McLean (19 74), it is
56
difficult to assess fully or understand stress reactions.
The subjects were trained in measurement and because they
were asked to reveal some very personal information they
may not have completed the inventory honestly, whether
through conscious or unconscious choice.
It was impossible to control or identify such
behavior even though the inventory was constructed to re
veal blatant abuses. Most of these variables could not
be controlled.
A further limitation involved the sampling pro
cedure. While the subjects were selected randomly for
participation in the study, there was no way of controll
ing who would agree to participate. The data must be seen
in the context of the reliability and validity of the
instruments used and the total research design. With
these appropriate qualifications it was expected that the
study would provide important and useful information.
Summary
The design of the study utilized elements of
survey, descriptive, correlational, comparative, and action
methods. Mailed inventories and personal interviews were
used to collect data from randomly selected subjects.
The inventory had a .93 split half reliability coefficient
57
with content validity established by a panel of clinical
research experts. Three pilot studies were undertaken
to improve the inventory and design. The statistical
test of the null hypothesis involved the University of
North Carolina Psychometric Laboratory Analysis of Variance
computer program.
58
CHAPTER IV
RESULTS
The study established that the practice of psycho
therapy has both psychological rewards and negative aspects.
The subjects reported numerous rewards of practice, many of
which had not been previously mentioned in the literature.
The analysis showed that therapists and other professionals
also reported different levels of negative aspects of prac
tice. Different patterns of negative aspects were reported
by the respondents in terms of the study variables, i.e.,
therapeutic disciplines, modalities of treatment, contexts
of practice and sex of therapists. The therapists reported
various methods of coping with the psychological negative
aspects of practice not previously mentioned in the litera
ture. The therapists, when, categorized by therapeutic
disciplines, modality of treatment, and context of practice,
also reported different patterns in the ways in which they
practice psychotherapy.
The results of the study are reported in sections
which describe the data collectiondemographic data, re
sults on the psychological rewards of practice,
59
results on dealing with negative aspects, nonpredicted sig
nificant findings, clinical findings and summary of re
sults .
Description of Data Collection
Consultations with members of the various boards
and professional organizations and a review of their rec
ords revealed that the population of practicing psycho
therapists included 1,146 psychiatrists, 1,041 clinical
psychologists and 1,369 clinical social workers. A sample
of 960 psychotherapists were contacted for this particular
study including 303 psychiatrists, 269 clinical psycholo
gists and 386 clinical social workers. This contact sample
equaled twenty five percent of the total number of licensed
professionals in each discipline in Los Angeles and Orange
counties.
A total study sample of therapists returning the
inventory included 249 psychiatrists, 221 licensed clinical
psychologists, and 316 licensed clinical social workers.
A total contact return rate of 82 percent was obtained for
the therapists with subgroup return of 82.2 percent for the
psychiatrists, 82.1 percent for the psychologists and 81.86
percent for the clinical social workers. The total study
sample represented 21 percent of the psychiatrists, 21 per
cent of the clinical psychologists and 22 percent of the
60
clinical social workers in the defined population.
The comparison groups for the study included 8 6
physicians licensed by the California State Board of Medi
cal Quality Assurance, 87 attorneys licensed by the Calif
ornia State Bar Examiners and 85 Pastoral Counselors inclu
ding priests, ministers, and rabbis ordained by their
respective faiths and certified by the appropriate boards.
The subjects were randomly selected from lists maintained
by the respective licensing or certifications boards. A
total contact return rate of 86 was obtained for the con
trol group with subgroup return rates of 86 percent for the
physicians, 87 percent for the attorneys, and 85 percent
for the pastoral counselors.
Fifteen inventories were excluded from the study
because they did not meet the criteria of completeness and
legibility while twenty-two inventories provided incomplete
professional information or were not completed at all. Of
those not completing the inventory the reasons given were
that they were too ill to respond, their family stated that
they were deceased, they were retired, or they did not feel
that they had the time. One subject demanded payment. The
nonrespondents were similar in age, discipline, modality
and context of practice to the sample population. Follow-
up interviews of nonrespondents revealed that they were not
different from respondents.
61
Demographic Data
The subjects included licensed and certified mem
bers of the respective professions. The psychiatrists,
clinical psychologists and physicians were licensed by the
California State Board of Medical Quality Assurance. The
psychiatrists included those who had taken psychiatric res
idencies and were board eligible and/or board certified by
the American Board of Psychiatry and Neurology.
The clinical psychologists included 7 8 members cer
tified by the American Board of Professional Psychology.
The number of respondents with a counseling specialty was
so small as to make a separate analysis insignificant.
The clinical social workers were licensed by the
California Board of Behavioral Science Examiners. The
clinical social workers included those with masters degrees,
doctorates, and membership in the Academy of Certified
Social Workers. Of the 26 with doctorates, 80 percent had
their degrees in fields other than social work,
A summary of the demographic data of the subjects
responding to the inventory is noted in Table X. There was
a preponderance of therapists claiming psychoanalytic and
combined modalities; those in agency, institutional, and
private practices; males; and those entering the profession
to help people or because of an interest in mental illness.
About 10 percent of the therapists stated their personal
62
Demographic
Responding
Table I
Data of Subjects
to the Inventory
Variable Total Number Percent
Therapist
Psychiatrists 249 . 32
Clinical Psychologist 221 .28
Clinical Social Workers 316 . 40
Modality of Treatment
Behavior Modification 36 .04
Existential 34 .04
Humanistic 102 .13
Humanistic Existential 14 .02
Psychoanalytic 311 .40
Combination 2 89 . 37
Context of Practice
Agencies and Institutions 306 . 39
Group Private Practice 62 . 08
Private Practice 352 . 45
Part time Combined 66 .08
Sex of Therapists
Male 498 . 63
Female 288 . 37
63
Table I
Demographic Data of Subjects
Responding to the Inventory (Continued)
Variable Mean Hours of Work
Per Week Patient Contact
Psychiatrists 42 32
Clinical Psychologists 42 23
Clinical Social Workers 37 21
Mean Hours of Direct Patient/Client Contact
Behavior Modification 17
Existential 24
Humanistic 23
Humanistic Existential 27
Psychoanalytic 27
Combined 25
Agency and Institution 21
Group Private Practice 26
Private Practice 30
Part time Combined 20
Reason for Entering the Profession Percent
To Help People
Interest in Mental Illness
Prescribed for Them
Personal Problems
Money
229 .29
129 .16
4 . 01
10 .01
7 . 01
64
Table I
Demographic Data of Subjects
Responding to the Inventory (Continued)
. . _ Reason for
Variable
Entering the Profession
(Continued)
Percent
Power or Prestige 7 .01
A Calling 14 . 02
Help People and Interest 180 .23
Prescribed and Calling 2 . 01
Personal Problems and Other Mixes 6 8 .08
Other Mixes 136 . 17
Comparison Groups
Physicians 86
Attorneys 87
Pastoral Counselors 85
Mean Age
Physician 46. 90
Attorneys 42.54
Pastoral Counselors 46.07
Psychotherapists 47.45
65
I
problems as being only part of their reason for entering
the profession.
Results on the Psychological
Rewards of Practice
The practicing therapists responding to the inven
tory and interviews explored various rewards of practice.
A tabulation of the rewards mentioned is given in Table II
by discipline and general topic area including general re
ward statements, patient centered rewards, and therapist
centered rewards.
The psychiatrists reported the highest percent of
those not wanting to do anything else with the clinical
social workers reporting the lowest. The clinical social
workers, however, reported the highest levels of patient
and therapists centered rewards. There was a marked simi
larity of interdisciplinary responses on most of the other
variables.
Results on the Psychological
Negative Aspects
The results of the analysis of responses to the
scales on the psychological negative aspects of practice
corresponded to the five hypotheses of the study. These
included the total responses of
66
Table II
The Rewards of the Practice of Psychotherapy
As Reported by Therapeutic Disciplines
Reward Areas Psychiatrists
n=105
Psychologists
n=lll
Clinical
Social
Workers
n=173
Total
£1=389
Rewards
Would not want to
do anything else .16 .12 .04 38
Work is rewarding .08 .07 .08 32
Patient Centered
Patient's growth/change .11 .13 .20 61
Symptom reduction .06 .06 .03 16
Sharing with patients .07 .08 .11 36
Enjoy patient contact .06 .09 .07 28
Therapist Centered
Financial .06 .07 .06 25
Self Growth .06 .10 .12 39
Learning .07 .05 .03 15
Teaching .05 .05 .07 23
Challenging .06 .05 .04 19
Competency .11 .08 .07 32
Respect/prestige .05 .05 .08 25
Percent 100 100 100 100
Reported by percentage.
67
psychotherapists and other professions,- specific responses
of psychotherapists and other professions, and psychothera<-
pists' response analysis by discipline, sex, modality of
treatment and context of practice.
Total Responses of Psychotherapists
and Other Professions
It was hypothesized that:
1. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
are distinct from those in other professions, i.e.,
attorneys, physicians, and pastoral counselors
The analysis of variance established this hypothesis as
tenable by rejecting the null hypothesis (F = 5.92, df =
7 5/3041, p < .001 using the Wilks Lambda Criterion).
The therapists and other professions do appear to
report distinct scores. The physicians reported the high
est number of areas of negative aspects, followed by thera
pists and then attorneys. An analysis of the specific sub
scales that were shown to be significant at the p < .05 or
higher level revealed that the therapists reported a higher
mean level of isolation. The physicians reported a higher
level of loneliness. The therapists reported a higher
level of the demand of constant attention. The attorneys
68
and physicians reported a higher level of having constant
demands for maintenance of professional competence. The
physicians reported a higher level of too much pressure
expectation, role conflict, and of having a professional
life replete with external pressures. The attorneys re
ported higher levels of being placed in a position of being
an agent of social control conflict. The therapists re
ported higher levels of being responsible for things and
people that they cannot control pressure. The physicians
reported higher levels of being powerless to help their
patient* s/client* s of their personal life taking a back
seat to patient1 s/client1s problems/difficulties and of
not having enough time. The attorneys reported higher
levels of not having enough rewards and of not having
direct appreciation and immediate gratification. Table
III shows the significant variables by experimental and
comparison groups. The analysis of variance table is
noted in Appendix D, Table XII.
Specific Responses of Psychotherapists
It was further hypothesized that:
2. Psychiatrists, clinical psychologists, and clinical
social workers would report differing psychological
negative aspects in their practice of psychothera
py.
69
Table III
Significant Mean Negative Aspects
by Psychotherapists and Other
Scores Reported
Professions
Level of
Significance
Professions
:Therapist -
n=786
Attorneys
n=87
Physicians
n=86
Pastoral
Counselors
n=85
p < .001
M 2.70
Isolation
2.10
(Items 5,10)
2. 30 2.00
SD 1. 30 1.20 1. 34 1.08
p < .001
M 2,. 60
Loneliness
3.20
(Items 3,20)
3.30 2.00
SD 1.30 1.40 _ 1~30 1.08
p < .001
M 3.21
Demands
2.16
(Items 4,17)
2.40 2.60
: sd 1.21 1.18 1. 32 1. 30
p < .0 35
M 3.70 3.86 3. 89 3.50
SD 1.17 1.30 1.21 1.11
p < .005
M 3.11
Expectation
3.33
(Item 1)
3.50 2 .93
SD 1.20 1.20 1.07 1.16
p < .015
M 1.85
Role Conflict
1:91
(Items 8,11)
1.97 1.53
SD 1.02 1.10 1.07 .81
p < .001
M 2. 70 3.23 3.03 2.70
SD 1.24 1.23 1.18 1. 32
p < .001
M 2.40
External Pressure "(Item 13)
2.61 2.81 2.20
SD 1.15 1.28 1. 30 1.06
p < .001
M 2.21
Powerlessness
2.50
(Items 15,22)
2. 83 1. 83
SD 1.21 1.23 1.44 1.11
p < .001
M 4.51 4.04 4.24 4.20
SD 1.11 1. 30 1.18 1.16
70
Table III
Significant Mean Negative Aspects Scores Reported
by Psychotherapists and Other Professions (Continued)
Professions
Level of
Significance
Therapist Attorneys Physicians
n=786 n=87 n-86
Pastoral
Counselor
n=85
£
< .001
M
SD
2.20
1.09
Personal Life
2.50
1.28
(Item 7)
2 . 80
1. 39
1'. 84
.93
£
< .001
M
SD
3.30
1.26
Frus tration
3.65
1.22
(Item 6)
3.76
1.01
3.20
1.29
P
< .016
M
SD
Lack
2.51
1.26
of Gratification
2.61
1.17
(Items 2,21)
2.46
1.22
2.10
1.14
£
< .001
M
SD
2.44
1.25
2.45
1.21
1.92
.95
1.99
1.05
_F = 5.92, df = 75/3041, p < .001, Wilks Lambda Criterion
Analysis used a 1-5 scale with 1 = low and 5 = high
71
The analysis of variance established this hypo
thesis as tenable by rejecting the null hypothesis (F =
3.85, df_ = 44/1524, p < .001, using the Wilks Lambda Cri
terion) . The disciplines do report distinct negative as
pects . An analysis of the specific subscales that were
shown to be significant at the p < .05 or higher level re
vealed that psychiatrists reported the highest levels of
isolation, loneliness, pressure of constant attention,
demand for maintenance of professional competence, contra
dictory and difficult to maintain expectations, external
pressure, intangible and unmeasurable nature of the work
pressure, private life taking a back seat to patients/
clients problems and difficulties, not enough rewards and
lack of appreciation and immediate gratification.
Table IV shows the significant variables by thera
pists disciplines. The analysis of variance table is noted
in Appendix D, Table XII.
Psychotherapists Response Analysis by Sex
It was hypothesized that:
3. The psychological negative aspects reported by male
psychotherapists in the practice of psychotherapy
are distinct from those reported by female psycho
therapists .
72
Table IV
Significant Mean Negative Aspects Scores
Reported by the Therapeutic Disciplines
Level of
Significance
Therapeutic Disciplines
Psychiatrists Psychologist
n=249 n=221
Clinical
Social Workers
n=316
Isolation (Items 5,10)
M 3.10 2.52 2.51
SD 1. 30 1.23 1.30
Loneliness (Items 3,20)
M 2.95 2. 33 2.43
SD 1.28 1.19 1.26
Demands (Items 4,17)
M 3.50 3.05 3.11
SD .97 1.15 1.16
M 4.00 3.53 3.66
SD .97 1.25 1.17
p < .001
p < .001
p < .001
p < .001
p < .001
p < .017
p < .001
p < .002
p < .001
Expectations (Item 12)
M 2.93 2.54 2.58
SD 1.26 1.14 1.24
Pressure (Items 13,18)
M 2.45 2.20 2.41
SD 1.12 1.07 1.22
Personal Life (Item 7)
M 2.40 2.30 1.94
SD 1.14 1.02 1.06
Gratification (Item 2,21)
M 2. 70 2. 30 2.54
SD 1.17 1.09 1.25
M 2. 70 2.20 2.43
SD 1.28 1.14 1.27
JT = 3.84, df = 44/1524, p < .001, Wilks Lambda Criterion
Analysis used a 1-5 scale with 1 = low and 5 = high.
73
The analysis of variance established this hypothesis as
tenable by rejecting the null hypothesis (F = 2,77 df_ =
22/764, p < .001, Wilks Lambda Criterion). There does
appear to be a differential reporting of negative aspects
based on sex. An analysis of the specific subscales that
were shown to be significant at the p < .05 or higher level
revealed that male therapists reported higher levels of
isolation, loneliness, contradictory and difficult expecta
tions , and private life taking a back seat to patient’s/
client's problems and difficulties. The female therapists
reported higher levels of too much pressure expectation.
Table V shows the statistically significant variables by
the sex of the therapists. The analysis of variance table
is noted in Appendix D, Table XII.
Psychotherapist Response Analysis
by Modality of Treatment
It was hypothesized that:
4. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
differ with respect to the modality of treatment
employed.
The analysis of variance established this hypothesis as
tenable by rejecting the null hypothesis (F = 1.6, df =
110/3273, p < .001) using the Wilks Lambda Criterion).
74
Table V
Significant Mean Negative Aspects Scores Reported
by the Sex of the Therapists
Sex of Therapists
Level of ——---------- -------- ----------
Significance Female Male
n=2 83 n=49 8
Isolation (Items 5, 10)
p < .010
M
SD
2. 50
1.28
2. 80
1.27
Loneliness (Items 3, 20)
p < 003
M
SD
2.4
1.26
2. 70
1.27
Expectations (Items 1,12)
p < .017
M
SD
3.25
1. 20
2. 70
1.27
p < .036
M 2.60 2. 80
SD 1.27
Personal
1. 20
Life (Item 7)
p < .001
M
SD
2.00
1. 05
2. 30
1. 09
F = 2.77, df = 22/764, p < .001, Wilks Lambda Criterion
Analysis used a 1-5 scale with 1 = low and 5 = high
75
Different modalities of treatment do appear to report dis
tinct negative aspects.
An analysis of the specific subscales that were
shown to be significant at the £ < .05 or higher level re
vealed that the humanistic therapist reported the highest
mean level of contradictory and difficult to maintain ex
pectations . The existential and humanistic therapists re
ported the highest mean levels of professional role con
flict and often placed in the position of being an agent of
social control. The humanistic existentialist therapists
and the existential and humanistic therapists reported the
highest mean level of having external pressures. The be
havior modification therapists reported the highest mean
level of being responsible for things and people that one
could not control, powerlessness, and not-having-enough-
time frustration.
Table VI shows the statistically significant vari
ables by modality of treatment. The analysis of variance
table is noted in Appendix D, Table XII.
Psychotherapist Response Analysis
by Context of Practice
It was hypothesized that:
5. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
76
Table VI
Significant Mean Negative Aspects Scores
Reported by the Modalities of Treatment
Modality of Treatment
Behavior Existen Human Existen- Psycho- Mixed
Level of
Modifi
cation
tial istic tial analytic
Human
Significance istic
n== 36 n=34 n=102 n=14 n=311 n=289
Expectations (Item 12)
p i .050
M
SD
2.40
1.25
2.62
1.10
2.85
1.04
2.78 2.54
1.18 1.27
2.81
1.26
Foie Conflict (Items 8,11)
p < .003
M 1.50 2.06 2.06 1.93 1.71 1.93
SD .74 1.18 1.05 1.07 .89 1.09
p < .001
M
SD
2.81
1.21
3.35
1.27
3.26
1.12
Pressure
2.93 2.42
1.32 1.18
(Item 13)
2. 70
1.25
p.< .050
M 2.02 2.44 2.54 2.64 2.64 2.43
SD .90 1.13 1.12 1.34 1.14 1.18
Powerlessn'ess
(Item 15)
P < *009
M 2.61 2.10 2.50 2.5 7 2.10 2.24
SD 1.36 1.07 1. 32 1.45 1.12 1.24
Frustration (Item 6)
p < '.025
M
SD
3.58
1.13
3.24
1.18
3.25
1.23
3.21 3.13
1.12 1.28
3.47
1.25
F = 1.6, df = 110/3273, p < .001, Wilks Lambda Criterion
Analysis used a 1-E scale with 1 = low and 5 = high
77
differ according to the context of their practice.
The analysis of variance established this hypothesis as
tenable by rejecting the null hypothesis (F = 2.59, df =
66/2240, p < .001 using the Wilks Lambda Criterion). Ther
apists working in the various settings did appear to report
distinct negative aspects.
The analysis of the specific subscales that were
shown to be significant at the p < .05 or higher level re
vealed that private practitioners reported the highest
levels of isolation, loneliness, and constant demands for
maintenance of professional competence. The agency and
institution practitioners reported the highest levels of
professional role conflicts and being an agent of social
control. The group private practitioners reported the
highest level of external pressures. The agency/institu
tion therapists reported the highest level of intangible
and unmeasurable nature of work pressure and being respon
sible for things and people that they cannot control power
lessness. The private practitioners reported the highest
level of their personal life taking a back seat to pa
tient's and client's problems and difficulties. The agency
and institution therapists reported the highest level of
not enough reward, lack of direct appreciation, and immedi
ate gratification. Table ¥11 shows the statistically sig
nificant variables by context of practice.
78
Table VII
Significant Mean Negative Aspects Scores
Reported by the Context of Practice
Context of Practice
Level of Agency/
Significance Institution
n= 306
Group/Private Private
.n=6‘ 2 n=352
Mixed
n=66
p < .004
M 2.51
Isolation (Items 5,10)
2.61 2.90 2. 73
SD 1.23 i:31 1.31 1.28
p < .003
M 2.40
Loneliness (Items 3,20)
2. 70 2.72 2.56
SD 1.17 1.27 1.33 1. 36
p <0 .006
M 3.69
Demands (Item 17)
3.45 3.78 3. 33
SD 1.07 1.12 1.11 1.26
p < .004
M 2.00
Role Conflict (Items 8,11)
1.87 1.70 1. 89
SD 1.09 1.01 .89 1.19
p < .001
M 2.97 2.85 2.46 2.60
SD 1.23 1.25 1.20 1.24
p < .002
M 2.52
External Pressure (Items
2.53 2.20
13,18)
2.41
SD 1.16 1.13 1.12 1.23
p < .036
M 3. 30 3.08 2.98 3.01
SD 1.21 1.23 1.34 1.35
p < .016
M 2.40
Powerlessness (Item 15)
2.00 2.20 2.03
SD 1. 27 1.13 1.17 1.20
p < .016
M 2.03
Personal Life (Item 7)
2.21 2.30 2.14
SD 1.05 1.16 1,08 1.20
p < .002
M 2. 70
Lack of Gratification (Items 2
2.55 2.33
,21)
2.58
SD 1.19 1.18 1.16 1.25
p < .023
M 2.62 2.30 2.36 2.26
SD 1.23 1.19 1.26 1.34
F = 2.59 df = 66/2240, p < .001, Wilks Lambda Criterion
79
Analysis used a 1-5 scale with 1 = low and 5 = hich
Results on Dealing with Negative Aspects
The literature lists a few means of coping with
negative aspects of the practice psychotherapy. Marmor
(1953) suggests that a personal analysis and contacts with
colleagues and nontherapists are useful measures. Beliak
(1974) suggests mixing the caseload, contacts with other
professions, and physical activity as safeguards. Guggen-
buhl - Craig (1971) mentioned many of the above, but also
added the need for cultural activities.
The results of the inventory tabulations and the
personal interviews showed that the therapists in the sam
ple sought relief from the psychological pressures of prac
tice with family, sexual, and religious activities; teach
ing and administrative duties; alcohol use; social and work
contacts with colleagues; and community involvement.
While the data are not suitable for finite statis
tical analysis, the respondents do show that therapists in
practice utilize coping methods not previously mentioned in
the literature. The subjects reported that these methods
have helped them deal with the pressures of practice.
The clinical psychologists reported hobbies, family,
and community activities as being the most useful activi
ties. The clinical social workers listed family, hobbies
and social contacts with colleagues as most useful. Psy-
chiastrists mentioned family, hobbies and religion as
80
helpful.
A breakdown of the percentages of activities is
noted in Table VIII.
Nonpredicted Significant Findings
The data analysis presented several findings rele
vant to the issue of practicing psychotherapy that were not
predicted in the design of the study.
One set of variables addressed the specific issue
of the therapeutic relationship. They included being
directive and active in therapy sessions/ establishing emo
tionally close relationships with influencing and role
taking with patients/clients, passivity and boredom, a.nd
comparative competence. These variables were analyzed by
therapeutic discipline, modality of treatment and context
of practice using the analysis of variance,
Therapeutic Discipline Responses
on the Therapeutic Relationship
Psychiatrists reported the highest mean level of
passivity and boredom. They also reported the highest
level of negative aspects noted in Table IV. Clinical
social workers reported the highest mean levels of direct
iveness , activity, and role taking. The statistically
significant breakdown is found in Table IX. The analysis
81
Table VIII
Useful Activities for Dealing with the Negative Aspects
of Practice as Reported by Therapeutic Disciplines
Therapeutic Disciplines
Activities
Psychiatrists Psychologists
Clinical
Social Workers
Total
Number
n=112 n=109 n=182 n-403
Family .20 .17 .25 85
Hobbies .19 .27 .20 86
Sex .06 .08 .04 19
Alcohol .07 .09 .10 36
Religion .17 .08 .07 38
Adminis trative .09 .05 .07 26
Colleagues (Social) .08 .08 .13 39
Colleagues (Work) .07 .06 .10 29
Community .07 .12 .04 28
Percent 100 100 100 100
Reported by percentage
82
Table IX
Significant Mean Therapeutic Relationship Variables
Scores Reported by the Therapeutic Disciplines
Therapeutic Discipline
Level of
Psychiatrists Psychologists Clinical
Significance
n=249
Social Workers
n=221 n=316
Directive (Item 55)
p < .001
M 3.53 3.81 3.83
SD 1.11 .93 .96
Active (Item 58)
p < .001
M 3.88
SD 1.00
3.92 4.20
.85 .80
Pole (Item 59)
p < .003
M 2.75 2.66 3.03
SD 1.34 1.27 1.29
Passivity/Boredom (Item 62)
p < .001
M 2.52
SD 1.31
2.15 1.94
1.14 1.16
F = 48.45, df = 26/1522, p < .001, Wilks Lambda Criterion
Analysis used a 1—5 scale with 1 = low and 5 = high
83
of variance table is noted in Appendix D, Table XIII.
Modality of Treatment Responses
on the Therapeutic Relationship
The psychoanalytic therapists reported the highest
mean level of feelings of comparative competence. The
behavior modification therapists reported the highest mean
level of directiveness, influencing of patients/clients and
taking a role with patients/clients. The existential ther
apists reported the highest mean level of activity with
patients/clients, while the humanistic existentialists
group reported the highest mean level of emotionally close
relationship with patients/clients. The breakdown of spe
cific statistically significant levels is found in Table X.
The analysis of variance table is noted in Appendix D,
Table XIII.
Context of Practice Responses
on the Therapeutic Relationship
The private practitioners reported the highest mean
level of feelings of competence. The agency and institu
tion practitioners reported the highest mean levels of
directiveness and activity in therapy and role taking with
patients/clients. The breakdown of the statistically sig
nificant scales is noted in Table XI. The analysis of var
iance table is noted in Appendix D, Table XIII.
84
Table X
Significant Mean Therapeutic Relationship Variables
Scores Reported by the Modality of Treatment
Modality of Treatment
Behavior Existen- Human- Existen- Psycho- Mixed
Level of Modifi tial istic tial Analytic
Significance
cation Human
istic
n== 36 n=34 n=102 n=14 n-311 n=289
Directive (Item 55)
p < .001
M
SD
4.20
.75
4.10
.92
3.98 3.43 3.36
.76 1.16 1.16
Close Relationship (Item 56)
3.95
.81
p < .001
M
SD
3.42
1.23
3.76
.97
3.93 4.10 3.50
.94 1.21 1.17
Influence Patients (Item 57)
3.77
.98
p < .001
M 4.14 3.45 3.47 3.71 3.36 3.82
SD . 83 1.27 1.19 1.14 1.25
Active (Item 58)
1.06
p < .001
M
SD
4.00
.86
4.33
.65
4.20 4.14 3.80
.73 1.03 1.01
Role (Item 59)
4.15
.78
p < .002
M 3.50 3.33 2.94 2.50 2.70 2.83
SD 1.36 1.19 1.27 1.56 1.33
Competence (Item 6 3)
1.28
p < .001
M 4.00 4.21 4.45 4.50 4.56 4.50
SD 1.12 .89 .72 .65 .74 . 82
F = 3.16, df 65/3586, p < .001, Wilks Lambda Criterion
Analysis used a ] L-5 scale with 1 = low and 5 = high
85
Table XI
Significant Mean Therapeutic Relationship Variables
Scores
f
Reported by the Context of Practice
Level of
Significance
Context of Practice
Agency/ Group/Private Private
Institution
n=30 6 n=6 2 n=352
Mixed
n=66
p < .002
Directive (Item 55)
M 3.90 3.81 3.60
SD .92 .97 1.06
3. 74
1.08
p < .007
Active (Item 5 8)
M 4.20 3.90 3.94
SD .72 .93 .99
3.97
.93
p < .001
Roles (Item 59)
M 3.12 3.08 2.60
SD 1.22 1.21 1.36
2. 80
1. 35
p < .003
Competence (Item 6 3)
M 4.37 4.52 4.60
SD .85 .65 .74
4.48
. 83
F = 7.01, df = 39/2218, p < .001, Wilks Lambda Criterion
Analysis used a 1-5 scale with 1 = low and 5 = high
86
Nonpredicted Nonsignificant Findings
In addition to the analysis of variance computa
tions, a correlation coefficients computation was conducted
on every variable of the study utilizing the Statistical
Package for the Social Sciences SPSSH version six which in
cluded the Pearson Correlation Coefficients. It was found
that none of the variables of therapeutic focus, certifica
tion as an analyst, age, personal therapy, years of train
ing and post training experience, hours worked per week,
and hours of patient contact, were significantly correlated
to the .05 level with the psychological negative aspects of
the practice of psychotherapy.
An analysis of the significant correlation coeffi
cients is noted in Appendix E.
Clinical Results
The clinical results were based upon information
obtained by open ended questions and the one hour unstruc
tured interviews with forty-five psychotherapists of the
various disciplines who had completed the inventory, who
had not completed the inventory, and who were not initially
contacted in the mailed study. Their responses were very
similar in terms of areas and depth of response. The
breakdown by discipline, context, and sex. were similar to the
original sample. The interviewees were told
______________ ^ _____________________________________________________87
that the study intended to look at the feelings and atti
tudes of credentialed and licensed professions. Each was
asked to respond to (1) What do you consider to be the re
wards of practicing psychotherapy? (2) What do you con
sider the negative aspects of practicing psychotherapy?
The responses provide a personal dimension to the
issue of the psychological rewards and negative aspects of
the practice of psychotherapy. The following quotations
were typical of the responses given to the question, "What
do you consider the rewards of practice?"
Growth:
I can think of nothing more rewarding than the
privilege of witnessing the process of growth and
development. My own continued personal and pro
fessional growth as a therapist is of unmeasurable
value.
Awareness:
Rewards are immeasurable - The joys of being in
deep intimate relationships, of having self aware
ness constantly renewed, of being a midwife in
trinsically involved in the birth of new growth,
and the constant wonderment at the disclosures of
the nature of human beings.
Interesting:
It is generally interesting and financially re
warding, but sitting still for as long as I have
to makes me edgy— more so as the years go by.
Also I enjoy almost all of'my patients.
Exciting:
1 still find the practice of psychotherapy exciting,
stimulating, creative, joyful, enriching and ful
filling after fifteen years.' 'Private practice
allows me maximum flexibility time wise. I arrange
88
my schedule so that I have all the time I want to
pursue my outside interests as well as to engage
in additional professional training which I have
been doing continually since graduation.
Knowledge:
The opportunity to learn deeply of human related
ness and communication and also to experience one’s
self growth in the process, a growth that is life
long.
Enjoyment:
I once worked in both a clinical and hospital set
ting and chafed under the restrictions and impo
sitions of agency function on my practice. I en
joy private practice because I am responsible for
my work and can deliver higher calibre service
without the restrictions of an agency. Also I
make more money. I do miss daily counsel contact
with colleagues.
Challenge:
Every patient is so unique in personality, be
havior and background that I constantly feel a
challenge, a professional curiosity and an empathy
that enables me to feel the emotions of their ex
periences and in relationship help them to usually
attain a personal identity and resolve problems in
living.
Adventure:
I find therapy an adventure. I know I can not
save anyone, that they must save themselves. I
also know that the more aware of myself I am, then
the more aware I am of another. I need to stay
open, relaxed and available, and I find doing
therapy is fun.
As shown in the statistical analysis, there are
also psychological negative aspects to the practice of
therapy. The following quotations were typical of the re
sponses given to the question, "What do you consider the
89
negative aspects of practicing psychotherapy?1 '
Discouraged:
I am frequently or often discouraged by a lack of
obvious, direct impact of therapy and need to re
mind myself that the effects of therapy may have
an indirect impact years later. At this point in
my career, I am seeking a change in position-~with
some direct patient contact, but with opportunity
to move into program development, training admin
istration, etc. From my conversations with other
colleagues with my experience, I have discovered
I am not atypical in wanting some relief from the
constant intimate demands of being a direct, per
sonal therapist.
Loneliness:
Loneliness and isolation are the main drawbacks
during the work day. I balance them by working
in a teaching setting where there are peers to
talk with and the excitement of residents to teach.
It's important not to look to patients to meet
personal needs wThich should be met by family and
friends.
I find my work largely satisfying, but this may
be because of the great measure of freedom I have
in this agency to practice with few constraints.
The primary negative aspect is the work on the
Psychiatric Emergency Team with grossly psychotic
people for whom little can be done, but that is a
proportionately small percentage of my week. I
would not return to private practice, that is a
lonely existence.
Personally I need to change my pace to be able
to practice. Just seeing my secretary and patients
is lonely. I divide my .professional life into pri
vate practice, training future therapists, teaching
undergraduates and writing and lecturing around
the country.
The frustration of getting patients that pay their
bills. There is little contact with noncompetitive
colleagues. It is taxing, lonely and pressured.
It's getting harder to practice with the restraints
of medicare and medi-cal.
90
Pressured:
Psychotherapy is a pressured life with too much
paper work, expectations of clients and. isolation.
Demands:
Sometimes I really need to talk to someone who
isn't making constant demands on me. It's diffi
cult to meet the responsibilities of patients and
their families.
It is alienating, monotonous, conflicting and de
manding, but I wouldn't leave the field.
Expectations:
I find my work exceedingly satisfying, even though
fraught with stress and tension. It is difficult
to keep up in the field, meet my clients' needs
and be a good parent and spouse. I find myself re
acting to the expectations that patients, families
and supervisors have of me. I find myself discour
aged at the progress I am making. My patients are
often struggling with the same things that bother
me.
Discussion
The purpose of this discussion is to relate the
findings of this research study to its rationale and to the
review of the literature.
The rationale presented the criteria for occupa
tional stress and psychological negative aspects. The
study showed that psychotherapists and other professions do
report statistically significant levels of isolation, lone
liness, pressure, demands, role conflict, social control,
responsibility, not enough time or rewards, and lack of ap
preciation. While the mean responses to the psychological
91
negative aspects were not all in the total agreement to
moderate agreement range it was evident that most of the
upper fifty percent did report general agreement. The
results supported the view that there are psychological
rewards and negative aspects of the practice of psychother-
apy in keeping with the Jungian and Existential world view
of light and shadow aspects and relative costs of one's
choices. The rationale that negative aspects are related
to the practice of psychotherapy and not just to an indi
vidual personality flaw or metapsychology was also support
ed. The results provided information on the rewards of
practice and activities useful in dealing with negative
aspects previously not found in the literature.
There were some similarities between the present
results and the findings presented in the review of the
literature. The results supported Marmor's (1953) conten
tion that there were many reasons for entering the profes
sion. It supported the conclusions of Henry, Sims and
Spray (197 3), that the majority of therapists do not enter
the profession to solve their own problems. Only ten per
cent even listed their personal problems as one of the
reasons for entering the profession while only ten subjects
listed personal problems as their sole reason for entering
the profession. Support was also obtained for Rogow's
(1970) study on the loneliness and isolation of psychia
trists .
92
Mixed support was found for the Benezra and Gold
(1974) study and hypothesis. The present data did not sup
port the age variable they proposed. The view that work in
agencies reduces stress was not supported. Their conten
tion that being more open and admitting ones own short
coming would reduce stress was not supported since the hu
manistic and existential therapists reported more, not
fewer negative aspects.
The Daniels' (1974) data, which indicated that
there is no difference in the isolation experienced by agen
cy and private practitioners and critical colleagues were
not supported. The present data show a significant differ
ence in isolation and other negative aspects by context of
practice. There were, however, significant differences in
the two research designs which may account for the discre
pancy.
The general response to the study by respondents
was supportive as indicated by the favorable responses and
compliments written on the inventory, by the remarks of
those interviewed, and by the number of therapists and con
trol group members requesting a summary of the results.
As with any study, there were a few who did not
like the inventory form, who felt that it was neurotic to
examine the negative aspects of the practice, or who took
the time to ventilate on the nature of the world and sins
of Academe. One therapist refused to complete
9 3
the inventory without payment.
Application of the findings should not be extra
polated beyond reasonable limits. It must be remembered
that the therapists in the sample practiced in the urban
Southern California area. The results should not be extra
polated as though the entire psychotherapeutic community
had responded. There was no way of controlling respon
dents who may not have honestly or who may have overesti
mated or underestimated their responses. Random follow-up
checks were made, however, and there was no evidence that
those who participated in the study were different from
those who did not participate. This was controlled by com
paring the samples of interviews and checks on inventory
respondents. As with any study, the responses must be
viewed in terms of the design and the instruments used.
Summary of Results
The analysis of the results of the study revealed
that a random sample of licensed psychiatrists, clinical
psychologists, clinical social workers, physicians, attor
neys and pastoral counselors did report statistically sig
nificant psychological negative aspects of their practices.
The physicians reported the highest levels of negative as
pects of any of the professions. This pattern continued
when the psychiatrists were compared with other psycho
94
therapists. Male therapists reported higher levels of
negative aspects than female therapists. The "third force"
therapists reported higher negative scores than psychoana'-
lytic and behavior modification therapists. The responses
of therapists in private and public settings revealed that
there were different negative aspects related to each type
of work.
In addition to the issue of the negative aspects of
practicing psychotherapy, the subjects also reported on
what they considered the rewards of practice and methods of
coping with the negative aspects. The subjects also pro
vided important information on how they relate with
patients/clients in the therapeutic process.
95
CHAPTER V
SUMMARY AND CONCLUSIONS
This study examined the nature of the psychological
rewards and negative aspects of the practice of psychother
apy. While there is an extensive literature on human be
havior, psychiatry, psychology, social work and psychother
apy, it is relatively silent on the subject of the therapist
himself/herself as the source of data. There is even less
information on the psychological rewards and negative as
pects that therapists experience. The present effort at
tempted to provide additional information and insight into
the issue for students, practitioners, and educators in the
various therapeutic disciplines. A knowledge of the issues
of practice may make for-more intelligent professional
choices from entry into the field, to changes in work set
tings, to exit from the profession.
It was felt that the best way to explore the psycho
logical issues of the practice of psychotherapy was to
query randomly selected psychiatrists, clinical psycholo
gists, and clinical social workers. Some preliminary work
had addressed the general issue of the psychiatrist's per
sonal responses to practice. But, none of the previous
literature or research had addressed the issues by compar-
96
ing all three of the psychotherapeutic disciplines, modali
ties of treatment, context of practice, and sex of the '
therapists. None of the earlier research had compared the
responses of psychotherapists with other professionals
including attorneys, physicians, and pastoral counselors.
The literature of the past few years had included
some therapists' view that practice can be lonely (Bruck,
19 74) and isolated (Guggenbuhl-Craig, 1971). The practi
tioner may also have feelings of powerlessness (Searles,
1966), little direct appreciation or immediate gratifica
tion (Lang, 19 74). The four major research efforts address-
these issues included Benezra. and Gold (1974), Daniels
(1974), Rogow (1970) and Henry, Sims and Spray (1971, 1973).
Benezfa and Gold found psychiatrists reporting stresses
relating to intra-psychic factors, the hours of work, the
management of suicidal patients, doubts about theory and
modalities, the difficulty of maintaining one's own bal
ance, and the intangible and unmeasurable nature of the
work. Daniels' psychiatrist subjects mentioned isolation,
image and status problems, personal strains, and critical
colleagues. Rogow's psychiatrists and medical psycho
analysts mentioned loneliness, isolation, feelings of inad
equacy, boredom, the tension of constant attention, and
passivity. While Henry's, Sims's and Spray's study involv
ed psychiatrists, clinical psychologists and clinical
social workers, it did not directly address the issue of
97
rewards and negative aspects. It did find a blurred dis
tinction between the occupational and personal roles of
the therapists and that the therapeutic language delimits
the professional world and makes it unidimensional.
Based upon the literature review and extensive
interviews with professionals in the field, it was hypo
thesized that:
1. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
are distinct from those in other professions, i.e.,
attorneys, physicians, and pastoral counselors
2. Psychiatrists, clinical psychologists, and clinical
social workers would report differing psychological
negative aspects in their practice of psychotherapy.
3. The psychological negative aspects reported by male
psychotherapists in the practice of psychotherapy
are distinct from those reported by female psycho
therapists .
4. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
differ with respect to the modality of treatment
employed.
5. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
differ according to the context of their practice.
98
The psychological negative aspects included feel
ings of ineffectiveness, isolation, loneliness, excessive
demands, expectations, role conflicts, external pressure,
powerlessness, little attention to personal life, feelings
of frustration, and lack of gratification. The other pro
fessions comparison group included attorneys, physicians
and pastoral counselors. The sex of therapist variable
included males and females, of course. The modality of
treatment variable consisted of behavior modification,
existential, humanistic, psychoanalytic and mixed modality
therapists. The context of practice involved agency, in
stitutional, group practice, and private practitioners.
In addition to statistically testing the hypotheses,
the study attempted to obtain information in two other
areas. The first was to question, "How do psychotherapists
cope with the negative aspects of practice?" The litera
ture mentions only a .few idiosyncratic methods. The re
sponses of a large number of therapists would provide a
better data base. The second area involved the question
of, "How do psychotherapists in the various therapeutic
disciplines, modalities of treatment, and contexts of prac
tice respond to selected therapeutic relationship vari- ;
ables?" These variables included providing direction,
establishing emotionally close relationships, influencing
patients/clients, activity as a therapist, role taking,
destructively critical colleagues, becoming aware of the
99
stresses of practice only after involvement, passivity and
boredom, and feelings of competence.
It was expected that psychotherapists would report
both psychological rewards and negative aspects in the
practice of psychotherapy. This expectation was based upon
the complaint literature, previous research efforts, and
personal interviews. An argument, based upon the current
literature, could be made for unique and/or more intense
negative aspects for psychotherapeutic practitioners than
other professions. The present study does not support such
an argument. It could also be argued that since psychia
trists, psychologists, and clinical social workers all
practice psychotherapy, the reporting of negative aspects
would also be similar. The present data do not support
this argument. It was expected that there would be differ
ences in the reporting of negative aspects by the variables
of sex of therapists, modality of treatment, and context of
practice. The only contrary literature was the Daniels
(19 74) study of psychiatrists in private practice and in
institutions who reported similar feelings of loneliness.
Methodology
The methodology for examining the psychological
rewards and negative aspects of the practice of psychother
apy involved a field experiement. The responses of randomly
100
selected psychotherapists were compared with attorneys,
physicians and pastoral counselors. Similar comparisons
were done within the variables of therapeutic discipline,
sex of therapist, modality of treatment and context of
practice.
Sub jects
The subjects for the study were drawn from licensed
and certified practitioners in the Los Angeles and Orange
Counties in Southern California. The study sample included
249 psychiatrists, 221 licensed clinical psychologists, 316
licensed clinical social workers, 86 physicians, 87 attor
neys, and 85 pastoral counselors. The subjects were ran
domly selected from lists maintained by the California
Board of Medical Quality Assurance, Psychological Examining
Committee, the California Board of Behavioral Science
Examiners, the California State Bar Examiners and the Asso
ciation for Clinical Pastoral Education. There were- 49 8
males and 288 females in the sample with a mean age of
45. 74 years and an age range from 27 to 82 years old. The
modality of treatment variable included 36 behavior modifi
cation, 34 existential, 102 humanistic, 14 humanistic exis
tential, 311 psychoanalytic, and 289 combined modality
therapists. The context of practice variable included 306
agency and institution, 62 group private practice, 352 pri-
101
vate practice and 66 combined practitioners.
Fifteen inventories were excluded from the study
because they did not meet the criteria of completeness and
legibility while twenty-two inventories provided incomplete
professional information or were not completed at all. Of
those not completing the inventory the reasons given were
that they were too ill to respond, their families stated
that they were deceased, they were retired, or that they
didn’t feel they had the time. One subject demanded pay
ment. The nonrespondents were similar in age, discipline,
modality, and context of practice to the sample population.
Follow-up interviews of nonrespondents revealed that they
did not differ significantly from respondents.
A total contact response rate of 82 percent was
obtained for the therapists and 86 percent for the compari
son group of other professions.
Instrumentation
A thorough review of the literature, including
psychometric tests and interviews with authorities in the
assessment field revealed that there were no standardized
measures of the selected psychological negative aspects
available. Consequently, a new inventory needed to be de
vised. In addition to the literature and assessment re
views, interviews were conducted with psychiatrists, clin-
102
ical psychologists and clinical social workers in order to
gain their subjective insight into important parameters of
the study questions. Items were also selected from a num
ber of inventories and the Daniels (19 74) and Rogow (19 70)
inventories. The inventory was pretested with three dif
ferent groups of therapist subjects.
The selected items were evaluated by ten experts
in psychiatry, psychology, social work, clinical research
and assessment. Recommendations for inclusion or exclusion
were based upon the area and design of the study, including
data collection. The items were evaluated for validity by
the content, face, and internal consistency methods. Any
items not judged to be valid by eight of the experts were
eliminated. Since most of these items addressed the sub
ject's own preception and since no other similar measures
were available for comparison, additional tests of validity
were not possible.
The reliability of the final inventory was estab
lished by the third pilot study which consisted of thirty
subjects. The results of the final pretesting were analyzed
by using the Spearman-Brown formula for a coefficient of
equivalence. A split-half reliability coefficient of .9 3
was obtained for the final inventory using the Spearman-
Brown Formula.
The completed inventory consisted of 49 items rang
ing from inquiries into the subjects' disciplines and modal-
____________________________________________________________ 103
ities to their feelings of isolation and loneliness. The
respondents were asked to check items with a response range
for each question which included: total agreement with the
statement, moderate agreement, neutral, moderate disagree
ment, and total disagreement. A continuum was selected as
opposed to a strict numerical scale because most of the
pilot subjects and experts felt that subjects would react
negatively to having to select a strict numerical value
when there were many input gradations. Numerical values
were used in decoding the responses for analysis purposes.
The inventory was designed so that it was short,
readable, and would not take much time to complete. The
items addressing the negative aspects were close-ended
using a continuum scale while the positive aspects were
addressed by using an open-ended option. The professional
information section of the instrument included identifica
tion, therapeutic discipline, developmental experience,
modality of treatment, and context of practice subscales.
It provided descriptive data and ensured that all of the
subjects were practicing therapists.
The inventory section provided the responses for
analyzing the psychological negative aspects experienced by
therapists.
Those subjects who were selected for interviews
were told that the study intended to look at the feelings
and attitudes of credentialed and licensed professions.
______ 104
Each was asked to respond to (1) What do you consider the
rewards of practicing psychotherapy? (2) What do you con
sider the negative aspects of practicing psychotherapy?
Procedure
In order to ensure that the sampling technique
would select therapists representative of the population,
a simple random sample was drawn. Randomness was assured
by use of the Rand random number table. A population list
including all of the licensed psychotherapists registered
as living in the population area was obtained from the
respective licensing certification boards. Each profes
sional was assigned a number according to the list provided.
The therapists to be contacted were selected on the basis
of the random number table method.
Every attempt was made to select randomly those
invited to participate. There was no way of controlling
for those would respond affirmatively. Follow up inter
views of those responding, not responding and those not con
tacted showed that there was no reason to believe the sample
was not representative. The interview results on negative
aspects were similar to the inventory responses. The sub
jects did not include friends of the researcher or those
from just one institution.
Further follow-up was made with those therapists
105
not completing the original inventory requesting that they
complete the professional information part of the inventory
\
in\ order to obtain information about the characteristics of
1
\
this group.
]
I The same sampling procedure was then used to select
i
those therapists who were to be contacted for personal
interviews.
A large sample was obtained in order to decrease
the possibility of sampling error and was necessitated as
there were a large number of uncontrolled variables inter
acting; the total sample was to be divided into several
subsamples; and the population to be sampled included a
wide range of variables and characteristics.
An analysis of variance was performed to answer the
basic question: Were the various groups, when classified
by therapeutic discipline, sex of therapist, modality of
treatment, and context of practice, different in regard to
the psychological negative aspects experienced in practice?
The same statistical test answered this question for the
subjects and the comparison groups. This permitted an
analysis of complex interrelationships in an efficient de
sign yielding more reliable conclusions than if the vari^
ables had been studied separately (Selltiz, Johada, Deutsch
and Cook, 1959). The test was further justified because
the differences in effect existed in a small set of treat
ments, the interest was in the stated combinations and no
106
others, and the treatment of immediate interest was in
cluded in the study (Hays, 196 3). A homogeneity of vari
ance was established.
The analysis of variance standard criteria of p
less than .05 was employed (p < .05).
The data were analyzed with the assistance of the
IBM computers at the University of Southern California
Computer Center using the University of North Carolina
Psychometric Laboratory Analysis of Variance program. The
PRSC update was dated May, 19 72. A test of significance
utilizing the Wilks Lambda Criterion was used to analyze
two or more dependent variables of subjects' mean differ
ences. The criterion allowed for group comparisons of mul
tiple dependent variables of different sizes taken simul
taneously (Kerlinger and Pedhazue, 1973).
Results
Each of the null hypotheses was rejected at the
p < .001 level. An analysis of variance revealed that:
1. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
are distinct from those in other professions, i.e.,
attorneys, physicians, and pastoral counselors
(F = 5.92, df = 75/3041, p < .001).
2. Psychiatrists, clinical psychologists, and clinical
107
social workers would report differing psychological
negative aspects in their practice of psychotherapy
(F = 3.85, df = 44/1524, p < .001).
3. The psychological negative aspects reported by male
psychotherapists in the practice of psychotherapy
are distinct from those reported by female psycho-
therapists (F = 2.77, df = 2 2/76 4, p < .001).
4. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
differ with respect to the modality of treatment
employed (F = 1.6, df = 110/3273, p < .001).
5. The psychological negative aspects reported by
psychotherapists in the practice of psychotherapy
differ according to the context of their practice
(F = 2.59, df = 66/2240, p < .001).
The analysis revealed the following information:
Professions. The therapists reported higher levels
of isolation, constant attention demands, and powerlessness
scores. Attorneys reported higher social control, lack of
rewards, and appreciation items. Physicians reported
higher loneliness, competence pressure, role conflict, ex
ternal pressure, lack of control, little attention to pri
vate life, and not enough time scores.
Disciplines. Psychiatrists reported higher levels
of isolation, loneliness, pressure of constant attention,
108
competence demands, external pressure, intangible and un
measurable work stress, little attention to personal life,
lack of rewards, lack of appreciation, boredom and passiv
ity items. Clinical social workers reported higher direc
tiveness, activity and role taking.
Sex. Male therapists reported higher levels of
isolation, loneliness, contradictory expectations, and
little attention to personal life scores. Female thera
pists reported higher scores of too much pressure.
Modalities. Behavioral therapists reported higher
scores of not enough time, directiveness, influencing
patients/clients, activity, and role taking. Humanistic
therapists reported higher pressures, emotionally close
relationships with patients/clients, and role conflict
scores. Existentialists reported higher social control
conflict scores. Humanistic existentialists reported a
higher level of powerlessness.
Context. Practitioners in agencies and institutions
reported higher scores of role conflicts, external pres
sure, lack of gratification, directiveness, activeness,
and role taking. Group practitioners reported higher in
tangible stress. Private practitioners reported higher
isolation, loneliness, constant attention, little attention
to private life, and competency scores.
Coping. Therapists sought relief from the psycho
logical pressures of practice with family, sexual, and
________ 109
religious activities; teaching and administrative duties;
alcohol use; social and work contacts with colleagues; and
community involvement.
Rewards. The psychological rewards of practice
included not wanting to do anything else, patient/client
growth and change, symptom reduction, sharing and enjoying
patient/client contact, financial rewards, self growth,
learning, teaching, personal challenges, increased compe
tency, respect and prestige.
Additional Findings. Personal therapy, hours of
work, patient/client contact hours, focus and experience
history were not statistically related to psychological
negative aspects.
Conclusions
The study presented significant findings that can
be grouped to include statistical findings, theoretical
understanding and implications for practitioners, educators
and students.
Statistical Findings
The analysis of variance used to analyze each of
the hypotheses revealed statistically very significant
findings. The sampling of the population was random and
the size of the sample decreased the probability of making
110
Alpha or Beta Errors. The design of the study corrected
many of the errors of the cited earlier research. This
study utilized comparative groups of other professions as
well as the three major psychotherapeutic disciplines.
The variables of sex of therapist, modality of treatment,
%
and context of practice were used, none of which had been
examined before. In addition the study presented ways of
avoiding or limiting the negative aspects of practice.
The issue of therapeutic relationship variables and dis
cipline, context of practice and modality were also shown
to be statistically very significant.
Theoretical Understandings
The results showed that as a group, psychotherapists
did not report as high a level of negative aspects as did
the physicians. It should be noted that physicians and
psychiatrists reported the highest levels of negative as
pects of the various professions. It may be hypothesized
that the medical role, rigors of training, and/or person
ality factors involved in the selection of medicine may be
explanations. The interview data revealed that psychia-
trists often feel they are in the dubious position of being
at the top of the mental health status hierarchy and at the
bottom of and/or excluded from the medical status hier-
111
archy.
It was observed that the medical and legal profes
sions, although ascribed high status and prestige from a
sociological perspective, had numerous psychological nega
tive aspects. While there are rewards, there are also
psychologically negative aspects to possessing high pro
fessional status.
The study provided additional support for the pro
position that not all psychotherapists go into the profes
sion because of their own needs or problems. This is not
to say, however, that there are not some therapists that
have problems.
There are some specific areas that therapists
could consider in evaluating their own lives. Male thera
pists need to attend to the probability of instances of
isolation, loneliness, contradictory expectations and ignor
ing their personal life while female therapists should con
sider the higher levels of too much pressure. Behavior
modification therapists should consider the effects of not
enough time and the impact of directiveness, influencing
patients/clients, activity and role taking in therapy. The
humanistic therapists ought to attend to the felt higher
pressure and role conflicts while the existentialists might
consider the meaning of the social control conflict. The
humanistic existentialists need to attend to the higher
feelings of powerlessness. The findings show that the
w '- '"
negative aspect responses by the existential, humanistic
and humanistic existential groups, while being philosophi
cally consistent in terms of openness, sharing, and mutual
ity, suggest that there is a place for therapeutic distance.
There is a trade off for working in various set
tings. Practitioners in agencies and institutions reported
higher role conflict, external pressure, lack of gratifica
tion, directiveness, activeness and role taking. Group
private practitioners reported more external pressure. Pri
vate practitioners reported more isolation, loneliness,
constant attention, little attention to personal life and
feelings of high competency.
A further findings was that certification as an
analyst, chronological age, personal therapy, years of
training, post training experience, hours worked per week
and hours of patient contact were not significantly cor
related. These rationalizations, optional factors in and
ways of responding to the pressures of practice do not
appear to be effective. The results do present several ways
of responding to the pressures of practice over and above
the traditional response of obtaining more training or go
ing into personal therapy again.
The results of the study added new knowledge by
which to view the effect of doing therapy on the therapist's
life. It has shown that not all of the negative aspects
113
experienced by therapists are the result of counter-
transference or personal failing since there are distinct
patterns reported by various groupings of sex, setting,
method and profession.
In general, it can be concluded on the basis of the
present study that psychotherapy is a very rewarding pro
fession in and of itself involving both patient and thera
pist centered rewards. It can also be demanding; lonely;
isolated; pressured; frustrating with feelings of ineffec
tiveness, excessive expectations, role conflicts, power
lessness, and lack of gratification. One can fall into the
trap of paying little attention to one's personal life.
Implications
The study provides significant implications for
present practitioners, educators in the various disciplines,
and for students training in the psychotherapeutic disci
plines. Present practitioners can review the findings of
the study for support when they are confronted with the
negative aspects of practice or career change decisions.
They can obtain a better understanding of the rewards and
negative aspects of practice as well as identify "additional
coping methods by reviewing the responses of a wide range
of therapists. The practitioner can then be in a better
position to weigh the relative advantages and disadvantages
114
of professional choices.
Educators in the various disciplines can utilize
these research findings in preparing students to understand
the rewards and negative aspects of professional practice
in various contexts of practice and modalities of treat
ment. While training potential therapists in therapeutic
process, techniques, human behavior and psychopathology,
the educator can also focus on the rewards and negative
aspects for the therapists and the effects of therapeutic
focus and relationship.
Students no longer have to wait until they are "well
along" in the field before they learn something of the
psychological negative aspects of practice. Students can
better understand some of the ramifications of key voca
tional choices of discipline, modality and context of prac
tice .
Recommendations for Further Research
The present study is only a beginning of the study
of psychological rewards and negative aspects of practicing
psychotherapy. There are several implications for further
research.
Since there are some data on the negative aspects
of the training period (Bruck, 19 74 and Sharat and Levin
son, 1964) further research efforts could be made to com-
115
pare the trainees in the various disciplines with one
another and with professionals in the field.
The present study could be expanded to include
those therapists in urban and rural areas, in other parts
of the state of California, or in different regions of the
country.
Studies could be instituted to differentiate the
type, quality, and source of the variables found most sig
nificant; for example, loneliness and isolation. However,
the interdisciplinary focus should be maintained.
Follow-up studies could compare the psychological
rewards and negative aspects experienced by mental health
professionals with those experienced by paraprofessionals.
In addition to studies replicating the present de
sign, in depth work could be extended to focus on the nega
tive aspect variables that physicians and attorneys experi
ence .
Work could be extended to other human service activ
ities; for example, educators in secondary or other schools,
psychological and social service personnel in welfare, pro
bation, parole, prison and rehabilitation, and nurses in
various fields of practice.
Similar work could also be undertaken to examine
the study variables as they may relate to administrators at
various levels and in different fields.
116
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12 3
APPENDIX A
LAMENT OF THE PSYCHOANALYSTS 1 WIFE
124
LAMENT OF THE PSYCHOANALYST'S WIFE
Beatrice Allen
I never get mad; I get hostile.
I never feel sad; I'm depressed.
If I sew or I knit and enjoy it a bit
I'm not handy, I'm obsessed.
I never regret; I feel guilty.
And if I should vacuum the hall,
Wash the woodwork and such,
And not mind it too much,
Am I tidy? Compulsive is all.
If I can't choose a hat, I have conflicts,
With ambivalent feelings toward net.
I never get worried, or nervous or hurried,
Anxiety, that's what I get.
If I'm happy, I must be Euphoric,
If I go the the Stork or the Ritz
And have a good time making puns or a rhyme,
I'm manic, or maybe a Schitz.
If I think that a doorman was nasty,
I'm paranoid, obviously.
If I take a drink without stopping to think,
Alchololic B. Allen, that's me.
If I tell you you're right, I'm submissive,
Repressing aggressiveness, too.
And when I disagree, I'm defensive, you see -
And projecting my symptoms on you.
I love you, but that's just transference,
With Oedipus rearing his head.
My breathing asthmatic is psychosomatic
A fear of exclaiming, "Drop dead."
I'm not lonely; I'm simply dependent.
My dog has not fleas - just a tic.
So, if I seem a cad, never mind - just be glad
I'm not a stinker - I'm sick.
Source Unknown
125
APPENDIX B
INVENTORY
COVER LETTER FOR PSYCHOTHERAPISTS
Ray W. London
1125 East 17th Street
Suite E-211
Santa Ana, California 92701
Dear Colleague:
The attached professional research inventory is
part of a doctoral dissertation through the Graduate School
at the University of Southern California, Los Angeles, Ca
lifornia. The general area of the research is a study of
the feelings and attitudes of credentialed and licensed
psychotherapists. You have been selected to participate
because of your training and experience.
The project has received support from members and
officials in the various professional organizations.
The total results of the study will be presented
in the dissertation, a journal article and at a professional
conference, therefore it is very important for you to par
ticipate .
Since you are part of a very select population I
ask you to please complete and return the Professional in
formation Sheet and Professional Inventory as soon as pos
sible .
Since the subject area involves your own attitudes
and feelings as a therapist, I implore you to be as honest
as possible.
The inventory contains forty-nine items which can
be completed in a short period of time. You are being
asked to respond as a professional therapist. The response
range for each question includes: Total Agreement with
the statement to Moderate Agreement to Neutral to Moderate
Disagreement to Total Disagreement. All of your responses
will remain confidential.
12 7
In return for your participation in the study, you
could receive information regarding your "scores" in com
parison to other therapists of various models and disci
plines. Responding to the inventory will also provide you
an opportunity to review your own professional life.
If you would like a copy of your results and/or
further information about the research, please attach one
of your business cards to the inventory.
If you are unwilling to participate in the study
will you please complete and return the professional infor
mation section.
Thank you very much for your time and attention.
Sincerely,
Ray W. London
128
COVER LETTER FOR NONPSYCHOTHERAPISTS
Ray W. London
1125 East 17th Street
Suite E-211
Santa Ana, California 92701
Dear Colleague:
The attached professional research inventory is
part of a doctoral dissertation through the Graduate School
at the University of Southern California, Los Angeles,
California. The general area of the research is a study of
the feelings and attitudes of credentialed and licensed
professionals. You have been selected to participate be
cause of your training and experience.
The project has received support from members and
officials in the various professional organizations.
The total results of the study will be presented
in the dissertation, a journal article and at a profession
al conference, therefore it is very important for you to
participate.
Since you are part of a very select population I
ask you to please complete and return the Professional In
formation Sheet and Professional Inventory as soon as
possible.
Since the subject area involves your own attitudes
and feelings as a professional, I implore you to be as
honest as possible.
The inventory contains twenty-three items which car
be completed in a short period of time. You are being
asked to respond as a professional. The response range for
each question includes: Total Agreement with statement to
Moderate Agreement to Neutral to Moderate Disagreement to
Total Disagreement. All of your responses will remain con
fidential .
129
In return for your participation in the study,
you could receive information regarding your "scores" in
comparison to other professionals of various disciplines.
Responding to the inventory will also provide you an oppor
tunity to review your own professional life.
If you would like a copy of your results and/or
further information about the research, please attach one
of your business cards to the inventory.
If you are unwilling to participate in the study
will you please complete and return the professional in
formation section.
Thank you very much for your time and attention.
Sincerely,
Ray W. London
130
INFORMATION SHEET FOR PSYCHOTHERAPISTS
PROFESSIONAL INFORMATION
This information is for data collection only
be used for subject identification.
It will not
Age Sex Male Female
Training:
Psychiatrist
MD with (a)
(b)
(c)
(d)
Psychiatric Residency
Board Eligible________
Board Certified
Other training
Psychologist:
Ph.D. in (a) Clinical Psychology or
(b) Counseling Psychology or
(c) Licensed as a Psychologist
(d) Board Certified_____________
M.A. or M.S. in psychology___________________
Other Training__________________________________
131
Clinical Social Worker
M.S.W., M.S., M.S.S.W. in Social Work______________
Ph.D., D.S.W. in Social Work________________________
Licensed as a Clinical Social Worker_______________
Academy of Certified Social Workers_________________
Other Training_________________________________________
farcin ,
Please indicate the number of years you have been a
psychotherapist:
In training__________
Post training______________
Please indicate the major setting in which you are
presently functioning in:
(a)x Agency practice _____________
(b) Institutional practice (i.e. hospital)_______
(c) Private practice______________
(d) Group private practice_____________
\ . v
(e) Other: Please specify_______________________
Please indicate the number of hours per week you spend
seeing patients:______________
Please indicate the number of hours per week you
presently work:____________________
Please note the diagnostic category of patients with
which you work with the most:
(a) Neurotic____________________
(b) Psychotic___________________
(c) Character disorder________
(d) Other_______________________
132
Please indicate the modality you use the most:
Individual ________________ Families Groups
Please note your general orientation to therapy:
(a) -Behavior Modification
(b) Existential
(c) Humanistic
(d) Psychoanalytic
(e) Other: Please explain
Please note the number of years of personal or train
ing therapy and the model used:
Individual Group
Behavior Modification ____ ____
Existential_______________ ____ ____
Humanistic________________ ____ ____
Psychoanalytic___________ ____ ____
Are you presently in therapy? Yes_____ No______
Please indicate the type and model:______________________
Number of years:____________________________________________
Please check those that apply:
In general when a patient/client does not get
better, it is the fault of the
(a) Therapist_________________________
(b) Resistance________________________
(c) Restraints of institutions_____
(d) Sabotaging by collaterals_______
I entered the profession because:
133
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Of a desire to help people___
Of a interest in the problems
of mental illness
It was prescribed for me
Of personal problems_____
I wanted to make money__
I wanted to have power
or prestige_______________
Of a calling______________
Check' at the
point of
agreement.
I try to pro
vide direction
in therapy
sessions with
my patient/
clients.
I like to
establish
emotionally
close rela
tionships
with my
patients/
clients
If I feel the
circumstances
call for it,
I will do my
best to in
fluence my
patient/
client one
way or an
other.
I tend to be
active as a
therapist.
Total
Agreement
Moderate
Agreement Neutral
Total
Moderate Disa-
Disagreement greemenij:
134
Total
Check at the Total Moderate Moderate Disa-
point of Agreement Agreement Neutral Disagreement greement
agreement.
I find it
necessary to
play a certain
role with some
patients/
clients.
Many of my
colleagues are
destructively
critical.
I only be
came aware of
the stresses
of practice
after I was
involved in
the field.
Professional
practice en
tails personal
strains crea
ted by pas
sivity and
boredom of
practice.
I feel that I
am at least
equal to most
other thera
pists with
regard to my
clinical
skills.
My work with patients/clients is focused on
Behavior________________
Cognition_______________
Ins ight_________________
Feelings________________
What percentage of your vest friends are psychotherapists?___________%.
_____________________________________________________________________________________________________________________________________________________________________________________135.
INFORMATION SHEET FOR NONPSYCHOTHERAPISTS
PROFESSIONAL INFORMATION
This information is for data collection only,
subject identification.
AGE
Physician:
General Practice _____
Family Practice _____
Pediatrician __________
Other: Please Specify_
Individual Practice __
Attorney at Law:
Trial
General
SEX: Male
It will not be used for
Female
Group Practice
Group Practice
Other: Please Specify____________
Individual Practice________________
Pastoral Counselor:
Please Specify Area of Specialization if any:
Hospital Church Agency Private
Denomination:
Catholic
Pro te s tant_____________
Jewish ________________
Other: Please Specify
What percentage of your best friends are members of your profession?
136
PROFESSIONAL INVENTORY
Please Complete Each Item
Total Moderate Moderate Total
Agreement Agreement Neutral Pisagreement Disagree-
1 ^ vinent
Professional prac
tice entails person
al strains created
by:
a. Too much pres
sure
b. Not enough re
wards
1 1 i i
c. Loneliness
1 1 i 1
d. The pressure
of contant
attention
1 I 1 1
e. Isolation
1 . . I . . 1 1
f. Not enough
time
i 1 1 I
My private life
takes a back
seat to my pati
ents/clients
problems and dif
ficulties .
1 1 1 1
I feel ineffective
' /
with my patients/
cients.
i 1 1 1
The practice of
psychotherapy* is
characterized by
isolation.
1 . I 1_ 1 ...........
Total Moderate Moderate Total
Agreement Agreement Neutral Disagreement Disagree
ment
I am often placed
in a position of
being an agent of i 1
I |
social control. ^ . J |
1 1
The profession * ‘ ' - ' .
has expectations
for its practition
ers which are con
tradictory and dif- | i 1 |
ficult to maintain. j | I 1
My professional
life is replete
with external pres- i i
j 1
sure. j |
1 1
I feel discouraged
about my ability to
help my patients/ *
j 1
clients. | |
1 1
I am responsible
for things
and people that I 1 I j I
cannot control. 1 1 1 j
I can not always
meet the stresses
of family responsi
bilities, social re
quirements and civic • I
1 I
commitments’ . | |
1 1
There is a constant
demand for me to
maintain my profes- I ■
1 1
sional competence. | |
1 1
The intangible and
unmeasurable nature
of the work is a
source of profes-' 1 .
1 1
sional stress. | |
1
138
Total Moderate Moderate Total
Agreement Agreement Neutral Disagreement Disagree-
ment
I am seldom
able to accom
plish all the | 1
I |
things I hope. | |
1 1
The practice of
psychotherapy*
is character
ized by loneli- | I
I |
ness. 1 |
1 1
My practice is
done without much
appreciation and
immediate gratifi- i i
1 |
cation. | |
1 1
At times I am
powerless to
help my patients/ . i
1 I
clients. | |
1 1
I find the following methods of
dealing with the negative aspects
of my profession helpful:
Cultural activities
Mixing caseload
t
Personal therapy
Physical activity
Social life with non-therapists
Other: Please explain
(Please note any comments on the rewards of your practice on the re-
verse side of the attached. Thank you.)
* my profession
139
APPENDIX C
INVENTORY SCORING ITEMS
•140
INVENTORY SCORING ITEMS
Professional Information Items
The therapeutic disciplines were identified with
items 4 to 6 for psychiatrists, 7 to 11 for clinical
psychologists, 12 to 15 for clinical social workers, 101
to 104 for physicians, 105 to 108 for attorneys and 109
to 115 for pastoral counselors.
Developmental experience was determined by items
16 and 17 for length of time practicing psychotherapy,
item 1 for age of therapist, items 2 and 3 for sex. Items'
34 to 4 3 for personal therapy model and items 48 - 54 for
behavioral, items 31, 36, 37 for existential and 32, 38,
and 39 for humanistic, items 24 to 26 for type of patients,
items 55 to 57 for therapeutic relationship, item 64 for
cognitive focus, item 63 for behavior focus, item 65 for
insight focus, item 66 for feeling focus and items 58 and
59 for type of activity.
Context of practice was shown by item 20 for
private, item 21 for group private, item 18 for agency and
item 19 for institutional practice. -
141
Professional Inventory Items
The psychological negative aspects were grouped
by item 9 and 14 for ineffectiveness, items 5 and 10 for
isolation, items 3 and 20 for loneliness, items 4 and 17
for demands, items 1 and 12 for expectations, items 8
and 11 for role conflict, items 13 and 18 for external
pressure, items 15 and 22 for powerlessness, items 7 and
16 for little attention to personal life, items 6 and
19 for frustration and items 2 and 21 for lack of grati
fication .
142
APPENDIX D
ANALYSIS OF VARIANCE TABLES
143
Table XII
Analysis of Variance and F Test Results on
Negative Aspects Variables
the
Significant Negative
Aspects df MS
£ <
F Wilks Lambda
Psychotherapists; and* Other Professions
75/3041 5.92 . 001
Isolation (5) 23.29 14.60 . 001
Loneliness (3) 32. 89 20. 44 . 001
Demands (4) 47.62 31. 84 . 001
Demands (17) 3.73 2. 88 . 035
Expectations (1) 5.79 4. 30 . 005
Role Conflict (8) 3.60 3.50 . 015
Role Conflict (11) 9.95 6. 40 . 001
External Pressure (13) 8. 34 6.10 . 001
Powerlessness (15) 8. 82 11.24 . 001
Powerlessness (22) 16.96 11. 24 . 001
Personal Life (7) 16.37 12. 90 .001
Frustration (6) 9.13 5.90 . 001
Lack of Gratification (2) 4. 90 3.40 . 016
Lack of Gratification (21) 11.91 8.1 . 001
Therapeutic Disciplines
44/1524
3. 84 . 001
Isolation (5) 27.11 17.11 .001
Loneliness (3) 27.81 17.77 ;ooi
Demands (4) 14.53 10.14 . 001
Demands (17) 15.40 12. 65 .001
Expectations (12) 10 . 89 7.28 . 001
Pressure (13) 5.42 ' 4.11 .017
P re s s ure (18) 18.29 11. 32 . 001
Personal Life (7) 15.29 13.30 .001
Gratification (2) 8. 90 6.37 .002
Gratification (21) 16.60 10. 86 .001
4
Table XII
Analysis of Variance and F Test Results on the
Negative Aspects Variables (Continued)
Significant Negative df
Aspects
MS F
E <
Wilks Lambda
Sex of Therapist
22/764
2. 77 .001
Isolation (5) 10.99 6. 72 .010
Loneliness (3) 14. 72 9.12 . 001
Expectations (1) 7.93 5. 72 . 017
Expectations (12) 6.66 4.41 . 036
Personal Life (7) 19. 45 16 . 70 . 001
Modality of Treatment
110/3273
1.60 . 001
Expectations (12) 3 . 35 2. 22 . 050
Role Conflict (8) 3.76 3.71 . 003
Role Conflict (11) 14, 24 9.74 .001
P re s s ure (13) 2.93 : 2.22 . 050
Powerlessness (15) 4. 49 3.0 7 . 009
Frustration (6) 4.04 2.58 .025
Context of Practice
66/2240
2. 59 .001
Isolation (5) 7.26 4.43 . 004
Loneliness (3) 7.50 4.64 . 003
Demands (17) 5.15 4.13 .006
Role Conflict (8) 4. 55 4. 45 . 004
Role Conflict (11) 14.76 9. 82 .001
External Pressure (13) 6. 40 4. 85 .002
External Pressure (18) 4. 72 2. 87 .036
Powerlessness (15) 5.08 3.45 .016
Personal Life (7) 4.07 3.47 .016
Lack of Gratification (2) 7.18 5.12 .012
Lack of Gratification (21) 5. 02 3.21 . 023
The ( ) notes the specific inventorv items 141
Table XIII
Analysis of Variance and F Test Results on the
Therapeutic Relationship Variables
Significant Relationship
Variables
df MS F ' p.. <
Wilks Lambda
Therapeutic
26/1522
Disciplines
48. 45 .001
Directiveness (55) 6.98 6.91 . 001
Active (5 8) 7.13 9.12 . 001
Role (59) 10. 05 5. 89 . 003
Passivity/Boredom (62) 23.58 16 .24 . 001
Modality of
65/3586
Treatment
3.16 .001
Directive (55) 15. 39 16.52 .001
Close Relationship (56) 5.60 4. 89 . 001
Influence Patients/Clients (57) 8.81 6.67 .001
Active (5 8 5.59 7.29 . 001
Role (59) 6 . 35 3.74 . 002
Competence (6 3) 2.6 3 4.19 . 001
Context of Practice
39/2218
. 001
Directive (55) 5.20 5.16 .002
Active (5 8) 3.25 4.12 . 007
Roles (5 9) 18.22 10. 85 .001
Competence (6 3) 2.91 4.75 .003
The ( ) notes the specific inventory items
146
APPENDIX E
CORRELATION COEFFICIENTS
147
Correlation Coefficients:
A Pearson Correlation Coefficient was calculated
on most of the inventory variables. A measure of r >.25
and a p <.001 was done to establish significance. The
statistically significant results will be presented in
terms of negative aspects, therapeutic relationship and
additional correlations.
Negative Aspects:
It was found that feelings of ineffectiveness were
correlated with not enough rewards (r = .28), role conflict
(r = .25) and intangible unmeasurable nature of the work
(r = .29).
Feelings of discouragement about the ability to
help patients/clients was correlated with not enough
rewards (r = .33), loneliness (r = .27), role conflict
(r = .29), isolation (r = .26), external pressure (r = .27)
intangible and unmeasurable (r = .32), seldom able to
accomplish all the things hoped (r = .30) and lack of
direct appreciate and immediate gratification (r = .26).
Isolation was correlated with not enough rewards
(r = .28), loneliness (r = .80), pressures of constant
______ 148
attention (r = .32), contradictory expectations (r = .32),
discouragement (r = .26), intangible and unmeasurable
nature of work (r = .28), external pressure (r = .27) and
lack of immediate gratification and direct appreciation
(r = .29) .
Loneliness was correlated with too much pressure
(r = .25), not enough rewards (r = .32), pressure of
constant attention (r = .30), isolation (r = .80), role
conflict (r = .25), contradictory expectations (r = .28),
external pressures (r = .25), discouragement (r = .27),
intangible nature of the work (r = .33), seldom able to
accomplish all hoped (r = .26), and lack of appreciation
and gratification (r = .27).
The pressure of constant attention was correlated
with too much pressure (r = .41), loneliness (r = .30),
isolation (r = .32), not enough time (r = .25), contra
dictory expectations (r = .26), external pressure
(r = .28 and intangible and unmeasurable nature of work
(r = .33) .
Too much pressure was correlated with the pressure
of constant attention (r = .41), loneliness (r = .25),
social control (r = .25), external pressure (r = .39) and
intangible, not enough time (r = .34) and unmeasurable
nature of the work (r = .32).
149
Feelings of contradictory expectations were
correlated with loneliness (r = .28), pressure of constant
attention (r = .26), isolation (r = .32), role conflict
(r = .31), social control (r = .37), external pressure
(r = .41), not enough rewards (r = .28), discouragement
(r = .28), responsible for things and people that one can
not control (r = .30), powerlessness (r = .30) and the
intangible and unmeasurable nature of the work (r = .28).
Role conflict was correlated with feeling
ineffective with patients/clients (r = .25), contradictory
expectations (r = .31), external pressure (r = .41),
discouragement (r = .29) and loneliness (r = .25).
Social control was correlated with too much
pressure (r = .25), not enough rewards (r = .27),
contradictory expectation (r = .37), and external pressure
(r = . 33) .
External pressure was correlated with too much
pressure (r = .39), not enough rewards (r = .32), pressure
of constant attention (r = .28), not enough time (r = .29),
private life taking a back seat to patients/clients
problems and difficulties (r = .26), role conflict
(r = .41), social control (r = .33), contradictory
expectations (r = .41), discouragement (r = .27),
responsibility without control (r = .25), not being able
150
to always meet family responsibilities (r = .26), discour
agement (r = .27) and loneliness (r = .25).
The intangible and unmeasurable nature of the work
was correlated with too much pressure (r = .32), not enough
rewards (r = .30), pressure of constant attention (r = .33),
isolation (r = .28) feelings of ineffectiveness (r = .29),
contradictory expectations (r = .28), discouragement
(r = .32), seldom able to accomplish all hoped (r = .30),
loneliness (r = .33), and lack of immediate gratification
(r = .35) .
Feelings of powerlessness were correlated with
social control (r = .30) and contradictory expectations
(r = .30). The therapist's private life taking a back seat
to patients/clients problem and not always being able to
meet family rsponsibilities and social/civic committments
were correlated with external pressure (r = .26).
Not enough time was correlated with too much
pressure (r = .34), pressure of constant attention (r = .25)
and external pressure (r = .29) while seldom being able to
accomplish all that was hoped was correlated with discour
agement (r = .30), intangible nature of the work (r = .30)
and loneliness (r = .26).
Feelings of not enough rewards were correlated with
loneliness (r = .32), isolation (r = .28), feelings of in
effectiveness (r = .28), discouragement (r = .33) agent of
social control (r = .27), contradictory expectations
______________________ 151
(r = .28), external pressure (r = .32)r intangible and
unmeasurable nature of the work (r = .30) and lack of
gratification and appreciation (r - .31).
The lack of direct appreciation and immediate
gratification was correlated, with loneliness (r = .27)
isolation (r = .29), ineffectiveness (r = .29), discour
agement (r = .26), the intangible nature of the work (r =
.35) and not enough rewards (r = .31).
Therapeutic Relationship:
The correlation coefficients analysis showed the
correlation between various items of therapeutic relation
ship and the negative aspects variables.
Providing direction in therapy sessions was corre
lated with influencing patients (r = .44), being active as
a therapist (r = .44) and finding it necessary to play
certain roles (r = .30). Establishment of emotionally
close relationships with patients/clients was also corre
lated with being active as a therapist (r = .26).
Providing direction in therapy was correlated with
being in a position of social control (r = .25) While
establishing emotionally close relationships with patients/
clients and influencing patients/clients were correlated
with role conflicts (r = .28). Playing roles with some
patients/clients was correlated with role conflict
(r = .32) and being an agent of social control (r = .28).
152
Becoming aware of the stresses of practice after being in
volved in the field was correlated with too much pressure
(r = .26). Feelings that professional practice entails
strains created by passivity and boredom of practice was
correlated with not enough rewards (r = .28), isolation
(r = .32) and loneliness (r = .28).
The total responses on the therapeutic relationship
scale was correlated with the total responses on the nega
tive aspects scales (r = .31). Specifically, the negative
aspects were correlated with passivity and boredom of
practice (r = .37) and therapeutic relationship was corre
lated with social control (r = .30).
The total score on therapeutic relationship was
correlated with direction (r = .58), close relationship
(r = .48), influencing patients/clients (r = .54), critical
colleagues (r = .45) awareness of stresses (r = .45),
passivity and boredom (r = .43) and feelings of competence
(4 = .29).
The negative aspects total was correlated with
pressure (r = .55), not enough rewards (r = .51), loneli
ness (r = .63), not enough time (r = .41), private life
taking a back seat (r = .33), role conflict (r = .45),
ineffectiveness (r = .44), social control (r = .43), con
tradictory expectations (r = .55), external pressure
(r = .57), discouragement (r = .52), lack of control
_______________________________________________________________ 153
(r = .43), stress of family responsibilities (r = .41),
competence (r = .33), intangible nature of work (.r = .60),
not able to accomplish all hoped (r = .48), lack of gratifi
cation (r = .47) and powerlessness (r = .30).
154

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Asset Metadata

Creator London, Ray William (author)

Core Title The lonely profession: A study of the psychological rewards and negative aspects of the practice of psychotherapy

Degree Doctor of Philosophy

Degree Program Education-Clinical Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, clinical

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c26-450968

Unique identifier UC11247711

Identifier usctheses-c26-450968 (legacy record id)

Legacy Identifier DP24139.pdf

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Document Type Dissertation

Rights London, Ray William

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA