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Psychotherapists and their Families:
The Effect of Clinical Practice on Individual and Family Dynamics
And How to Prevent Therapists' Burnout and Impairment

By Ofer Zur, Ph.D.
 

This is an electronic version of an article published in Zur, O., Psychotherapists and their families: The effect of the practice on the individual and family dynamics. Psychotherapy in Private Practice, 13 (1), 69-95. The Psychotherapy in Private Practice Journal is available online at: http://www.informaworld.com.

 

 

 
Abstract

Psychologists have paid very little attention to the effect their profession has on themselves and have consistently avoided examining its effects on their families. This paper explores the question: Are psychotherapists' families disadvantaged, or are they fortunate to have a therapist-parent who is an authority in the emotional, cognitive, and behavioral domains? Related areas that are explored are the uniqueness of psychotherapists' personalities and the effect of their practice on their personal lives. The paper focuses on the ramifications of the psychotherapists' practice on their own lives and their families', and proposes possibilities for enhancing the positive and preventing the negative effects of their careers on themselves and their intimate connections.

Psychologists have studied the effects of a variety of professions on the professions' practitioners. Physicians, career military personnel, corporate executives, political leaders, and artists are among the many who have been analyzed by psychologists. However, psychologists have failed to systematically study the effect practicing psychotherapy has on their own lives. Similarly, psychologists study the effects of every conceivable kind of family dynamic on children. They have studied the children of alcoholics and schizophrenics, disabled infants, and the children of divorce. They have compiled volumes on baby rats, infant gorillas, puppies, and bunnies. Yet they have consistently neglected to inquire into the dynamics of their own families. They have consistently avoided hypothesizing on the impact of being or living with a person who is an expert in the emotional, cognitive, and behavioral domains.

While limited attention has been given to the effect of psychotherapy on the practitioner, even less has been given to its effect on the practitioner's family. Short of a half a dozen anecdotal articles on families of psychotherapists, even fewer clinical reports on family or group therapy, a single empirical study (Goldney, Czechowicz, Bibden, Govan, Miller, & Tottman, 1979), a page or two on analysts' children in books by leading psychologists, such as Kohut (1977), Miller (1981), and Bettelheim (1976), and a thorough and thoughtful, but extremely anti-therapist biased book by Thomas Maeder (1989) titled Children of Psychiatrists and Other Psychotherapists, the field is suspiciously empty.

The resistance to attending to the complexity of psychotherapists' lives is not only reflected in the lack of comprehensive analysis, but also by the American Psychological Association's governing board and membership's reticence to set up a nationally coordinated program to identify and treat distressed psychologists and prevent burnout. Psychologists, psychiatrists, and counselors have been instrumental in the development of employee assistance programs tailored to serve the needs of other distressed or impaired professional employees. In contrast to psychotherapists, the American Medical Association (AMA) and the American Bar Association (ABA) as well as national organizations of dentists, attorneys, nurses, and pharmacists long ago established avenues for distressed professionals who are seeking help (Kilburg, Nathan, & Thoreson, 1986; Laliotis & Grayson, 1985).

The reasons for this lack of attention to the hazards of the profession are open to speculation. Many therapists claim that their professional lives have no bearing on their personal lives. Therapists may possess a prejudicial sense of grandiosity and invulnerability; they may assume they are capable of helping other professionals, but be incapable of recognizing that they themselves need help. Kottler (1987) attributes their resistance to the illusion that psychotherapy is the pure application of "scientifically tested principles and reliable therapeutic interventions" (p. 26). Other psychologists admit their reasons for not studying themselves stem from defensiveness and the professional practice of focusing all investigations on the patients (Farber, 1983).

This paper maps the complexity of the interaction between the practice of psychotherapy and the personal and familial life of the practitioner. It is based on the author's work in individual, couple, and family psychotherapy with psychotherapists and their families, and on a series of workshops conducted with such families regarding the impact of their clinical practice on their own and their families' lives. Participants were representative of all therapeutic disciplines: psychiatrists, clinical psychologists, clinical social workers, and master level trained counselors.

The clinical data gleaned from these subjects is combined with an extensive review of the literature. Together these provide a map to guide in the exploration of this rarely visited wilderland of therapists' family dynamics. This paper identifies the areas of inquiry, separates myths from realities, and critically examines the existing theories and research. In addition, to specify the strengths and weaknesses the profession brings to psychotherapists' families, the paper suggests ways of enhancing the positive and minimizing the negative effects.

The basic question posed by the paper is: Are psychotherapists' families disadvantaged, or are they fortunate to have a therapist-parent who is an authority in the emotional, cognitive, and behavioral domains?

In order to answer this, three further questions must be thoroughly investigated:

  1. What are the distinguishing characteristics of psychotherapists' personalities, and is there any truth behind the myth of the "wounded healer"?
  2. What aspects of psychotherapists' training and practice are relevant and likely to affect their personality, quality of life, and interpersonal skills?
  3. Do families parented by psychotherapists develop special dynamics due to the parents' profession? And, if yes, what is the impact of the parents' profession on their children?

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The Myth of The Wounded Healer: Are Psychotherapists Injured People?

A commonly accepted belief holds that psychiatrists and psychologists are emotionally injured people using their occupations to heal their own psychic wounds (Adler, 1972; Deutsch, 1984, 1985; Groesbeck & Taylor, 1977; Russel, Pasnau, Zebulon, & Taintor, 1975; Scott & Hawk, 1986). Psychotherapists are a central target of jokes and cartoons, often portrayed as greedy, out of touch with reality, easily outwitted by their crazy patients, prone to creating problems where none exist, and, of course, obsessed with sex, money, and power (Masson, 1988; Redlich, 1950). Psychologists are also accused of narcissism (Maeder, 1989; Mehlman, 1974), over-intellectualizing (Maeder, 1989), and harboring illusions of superiority, omnipotence, and god-hood (Bugental, 1964; Jones, 1951; Masson, 1988; Maeder, 1989; Marmor, 1953; Sharaf & Levinson, 1964). A recent surge of articles, books, and popular media focuses on psychotherapists who sexually exploit their patients (Rutter, 1979). These "doctors of desire" are described as abusive, deviant, exploitative, and above all, willing to betray their patients' trust to satisfy their own desires.

In a 1952 paper, Menninger asserts his theory that most psychiatrists suffer some form of rejection in their family of origin. Hence, their work is necessary to them in order to maintain their mental health. This popular belief that psychotherapists, as compared to the general population, come from emotionally deprived or unstable homes is reflected in several papers (Burton, 1972; Ford, 1963; Groesbeck, 1975; Racusin, Abramowitz, & Winter, 1981). Groesbeck and Taylor (1977) titled their article, "The Psychiatrist as Wounded Physician," and Henry, Sims, and Spray (1973) reveals that more than 60% of the thousands of therapists surveyed report having few friends in high school and feeling somewhat isolated. The claims that psychotherapists have disrupted childhood seem pervasive; however they are based on theoretical speculation or on poorly designed research that did not include a control group to validate its conclusions.

Speculations on additional motivations for becoming psychotherapists range from therapists being drawn to "one way intimacy," to voyeurism, to obsession with others' suffering, to sadism, to an intense need to mother people (Bugental, 1964; Marmor, 1953; Wheelis, 1958). Bugental (1964) also mentions rebelliousness as a potential motivator, pointing out that the clinical setting often permits the discussion of socially tabooed topics, such as sexuality, and thereby challenges authority.

Maeder (1989), interviewing a biased sample of hostile adult children of psychotherapists, concludes, "The field of psychotherapy attracts people with a God complex in the first place, and is nearly custom designed to exacerbate such a condition when it exists" (p. 83). Throughout his book he equates psychotherapists with narcissists and uses the work of Kohut and Alice Miller on narcissistic parents to explain the dynamics of psychotherapists' families.

Studies have provided a few significant variables to indicate where psychotherapists differ from the general population or other professional groups, such as physicians. In the most extensive investigation to date, Henry, Sims, and Spray (1971, 1973) conclude from the 4,300 psychotherapists they studied that no one factor can account for these people's choices of mental health as a career. Other surveys report that prior to their choice of career, future psychiatrists tend to be intellectually flexible and interpersonally adaptive. They are apparently restless and have a low tolerance for routine. They are responsive and function well in settings where autonomy and independence are conducive to success, tend to be psychologically minded prior to their career choice, and are generally introspective. It was also found that even prior to medical training psychiatrists are significantly less authoritarian, less religious, and more liberal than their physician counterparts (Farber, 1983; Henry, 1966; Sharaf, Scheider, & Kantor, 1968).

Research consistently documents physicians' significantly higher rate of depression and suicide as compared to the general population. Psychiatrists have been shown to score markedly higher than physicians (Bergman, 1979-80; Bermak, 1977; Guy & Liaboe, 1985; Ross, 1973). The Task Force on Suicide Prevention of the American Psychiatric Association conducted one of most extensive surveys. In investigating the deaths of approximately 19,000 physicians between 1967 and 1972, the Task Force determined that psychiatrists kill themselves about twice as frequently as other physicians. Furthermore, psychiatrists commit suicide at a younger age than the male population as a whole, and single women are at particularly high risk (Rich & Pitts, 1980). A similar survey of psychologists' death certificates concludes that female psychologists have a rate of suicide three times that of women in the general population (Steppacher & Mausner, 1974). Other important statistical data points to the high rate of alcoholism reported among psychotherapists (Thoreson, Budd, & Krauskopf, 1986).

In contrast to the above findings, Millon, Millon, & Antoni (1986) echo what many other researchers have argued; that there is no data that suggests that psychotherapists differ significantly from comparable professional groups. Indeed, no research to date indicates that psychologists and counselors are as vulnerable to depression, alcoholism, and suicide as psychiatrists were shown to be.

Though some of these conclusions are disputed, they are still valid and merit our attention. They do not necessarily mean that psychotherapists or psychiatrists manifest a significantly stronger tendency toward depression, suicide, and alcoholism prior to their training in and practice of psychotherapy. The alternative argument is that their training and practice increase their vulnerability to depression, suicide, and alcoholism. This second hypothesis leads us to the next area of inquiry.

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Impact Of Training And Practice On Therapists' Lives

As early as 1937, Freud warned about the dangers of psychoanalysis for the practicing analyst. In 1934 Jung alerted practitioners against what he called "psychic infection." More than four decades later, Deutsch, (1984, 1985), Farber (1983), Farber and Heifetz (1981), Freudenberger and Robbins (1979), Kilburg et al (1986), Maslach (1982), Pines and Maslach (1978), and Scott & Hawk (1986) intensified the exploration of the hazards of psychotherapy for the therapists and forewarned that if preventative measures are not taken, burnout becomes inevitable.

Unlike physicians who can wear masks and gloves to protect themselves against infection, or painters who wear masks to protect themselves against toxic fumes, the psychotherapist does not have easy access to protective devices. An atmosphere of isolation permeates the psychotherapist's office, a place where the therapist must listen attentively and be fully present to patients who are almost always in pain, often emotionally demanding, hostile, depressed, or otherwise dysfunctional (Chessick, 1978).

Rolo May, in his book Courage to Create (1983), is quite clear on the dangers facing a practicing psychotherapist. In his view, a therapist entering his office with briefcase in hand is entering into mortal combat. He cautions that in clinical work, armor and defenses must be left behind. Therapists ". . . must go out from our centeredness as far as we dare. In our effort to be open and receptive, to practice with the client in the relationship, to venture forth as far as we are able, we risk loosing our own identity" (p. 81).

Therapeutic encounters are almost always conducted in isolation, an environment conducive to emotional depletion (Marmor, 1982). Not only is the therapeutic setting private; growing numbers of laws and regulations concerning confidentiality exacerbate the sense of loneliness and depletion. Like many other therapists, participants in Farber's (1983) survey report that their work and their subsequent emotional depletion hinders their ability to be genuine, spontaneous, and comfortable with non-mental health professionals or friends. Inevitably, clinical work affects therapists' interpersonal relationships. Many therapists do not seem able to shut off the therapeutic stance, to function in a healthy way with other people and on an equal basis--equal in power, equal in vulnerability (Cray & Cray, 1977; Guy & Liaboe, 1985; Maeder, 1989).

Besides the setting, a number of specific client behaviors were identified as contributing to therapists' depletion and sadness. The behaviors that were ranked highest in causing stress and expectations were: suicidal statements, hostility, agitation and depression, and apathy (Deutsch 1984; Farber 1983; Farber & Heifetz, 1981). Therapists' irrational beliefs, such as "I must be totally competent and able to help everyone," are as significant a cause of stress as patients' behavior and the isolation of the setting (Deutsch, 1985).

A related theme was developed by Adler (1972) in his article "Helplessness in the Helpers." It has been widely reported that therapeutic work with charactologically impaired patients, suicidal and depressed patients, those with diagnoses of borderline, antisocial, or schizotyple, is slow, difficult, and frustrating. Unlike the work of carpenters, gardeners, even physicians, the complex nature of psychotherapeutic work rarely yields immediate, tangible, measurable results. Low sense of efficacy often leaves many psychotherapists frustrated and full of self-doubt about their competence and effectiveness in what Freud (1937) called the "impossible profession."

On the other side of helplessness lie clinicians' feelings of superiority and grandiosity. The therapist's sense of power, authority, competence, and mastery, combined with the patient's often unrealistic, idealized view of the therapist, can exacerbate the clinician's sense of grandiosity and omnipotence (Bermak, 1977; Kottler, 1987; Masson, 1988; Sharaf & Levinson, 1964; Wallerstein, 1981). Marmor (1953) made a detailed argument insisting that the inherent nature of psychotherapy is likely to aggravate a therapist's sense of godhood, which he labels an "occupational hazard." Unlike other professionals, a psychotherapist never fails; unsuccessful therapy is blamed on the patient's "resistance," a convenient excuse that leaves the psychotherapist's sense of omnipotence and superiority intact.

The endless cycle of introducing oneself to new patients, conducting the intense work of psychotherapy, and finally, terminating the relationship, may also leave a psychic scar on the therapist (Bermak, 1977; Guy & Liaboe, 1985; Will, 1979). As therapists often lose all contact with their patients after termination of therapy, this may possibly create feelings of abandonment. Should the therapists then generalize from their professional experience to their personal lives, they might react by avoiding intimate relationships. This, in turn, will increase their sense of isolation and loneliness.

Another related component of psychotherapy that can have a profound effect on the therapist is the dynamic of projection or transference. Regardless of the therapist's orientation and the corresponding amount of emphasis put on working with transference, patients project a wide range of feelings onto the therapist. Jung (1968) warned against what he called "psychic infection":

It is a typical occupational hazard of the psychotherapist to become physically infected and poisoned by the projections to which he is exposed. He has to be continually on his guard against inflation. But the poison does not only affect him psychologically; it may even disturb his sympathetic system. (pp. 172-173)

Psychotherapy is also a unique profession in respect to its private, secretive, and somewhat inexplicable nature (Marmor, 1953; Millon et al, 1986). Unlike most professions, many forms of psychotherapy cannot be standardized, observed, or easily evaluated with any degree of accuracy, a fact that puts in question the scientific basis of psychotherapeutic interventions.

Two main issues dominate this area; how to define the clinical work, and how to evaluate its outcome. The number of therapies offered to patients has expanded from about 60 during the 1960's to 250 during the 1980's. Most of these therapies are ill defined, without a sound theoretical or empirical research base. Psychotherapeutic research consistently reports on the lack of clear definitions and clear measures of therapeutic effectiveness. Combined with the fact that therapists' clientele are not always responsive to interventions, clinicians are led to doubt, confusion, and a sense of ineffectiveness (Bermak, 1977; Daniels, 1974; Deutsch, 1984; Maslach, 1982; Millon et al, 1986; Wallerstein, 1981).

The last, but not the least hazardous effect of the profession on practitioners is the resultant resistance to acknowledging difficulties and to seeking professional help. Millon et al (1986) argue that "Because of the great emphasis on self-reliance and professional autonomy, there exists an unspoken expectation the healers should need no healing" (p. 131). This faulty assumption is reinforced not only by patients, but also by family members and friends whose expectations in regard to the therapist can be quite high. These expectations, compounded by the fear of professional embarrassment, often prevent the therapist from seeking help and aggravate the problem. Additionally, once the psychotherapist seeks help, a whole new set of complexities is likely to emerge (Kaslow, 1984). These special issues, which include boundaries, hierarchies, the use of jargon, and alliances, are beyond the scope of this paper.

Freudenberger (Freudenberger & Robbins, 1979), Kilburg et al (1986), and Pines and Maslach (1978) spearheaded the focus on mental health workers' burnout. They cite many of the basic elements described above as potential causes of practitioner burnout. Maslach asserts that the burnout syndrome is almost always indicated by a change in the individual's perspective on other people; a shift from positive and caring to negative and uncaring. When this shift occurs, "People are viewed in more cynical and derogatory terms, and the caregivers may began to develop a low opinion of their capabilities and their worth as human beings" (1982, p. 17).

Psychotherapists' training and practice can also affect their lives positively. The impact of psychiatric training on the resident has been the focus of several studies. The training, while intense and stressful, seems to induce a number of positive changes in terms of the resident's sense of self; greater self-insight, the ability to form more mature social relationships (Holt & Luborsky, 1958), more psychological mindedness (Pasnau & Bayley, 1971), an increase in self-assurance and humility, and reduced alienation and authoritarianism (Farber 1983; Henry, 1966).

Like the training, the practice of psychotherapy can also promote a therapist's sense of wellness and confidence in interpersonal functioning. Training and practice is likely to sensitize the clinicians to a wide range of human feelings and behaviors (Farber & Heifetz, 1981; Kottler, 1987; Pasnau & Bayley, 1971; Russell et al, 1975). Therapists can become knowledgeable about their own unconscious motivations and drives. This consequently promotes the therapist's personal growth (Burton, 1975; Farber & Heifetz, 1981; Guy & Liaboe, 1985). When the clinical work progresses well, it can provide a therapist with profound satisfaction (Farber and Heifetz, 1981; Rogow, 1970). Farber's survey (1983) concludes that the primary effects of therapeutic practice are increased psychological mindedness, self-awareness, self-assurance, and a greater appreciation of human diversity. He also contends that the majority of his subjects felt they had deeper understanding of and tolerance for other people, and had become more thoughtful in general. In the same vein, Cogan (1978) reports that a majority of therapists surveyed noticed improvement in the intensity, meaning, and openness of their friendships as a result of their practice.

To observe patients respond to therapy, to witness their increased abilities to live their lives with more congruence and less pain, to watch them form healthier relationships, and see increased energy and enthusiasm directed toward their activities can be a highly rewarding experience. Farber (1983) concludes his article on the effect of psychotherapeutic practice on the therapists by stating: "Moreover, in an age where an increasing number of workers experience work as alienation, therapeutic work often generates feelings of personal affirmation and self fulfillment" (p. 181).

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Impact Of The Profession On The Therapist's Family

When Dr. Freud attempted to study his own infants' reaction to excrement, his wife barred the way to the nursery, stating, "Psychoanalysis stops at the door to the children's room" (Freud, 1954). While Freud did not analyze his children when they were young, he did analyze his daughter Anna for several years when she reached her early twenties. Helen Deutsch, a prominent psychoanalyst, analyzed her two-year-old son and published her findings using a pseudonym for the child. Melanie Klein, another Freud disciple and famous analyst in her own right, subjected one son to 370 analytic hours. Biographers assert that prior to World War I, both Carl Jung and Karl Abraham worked analytically with their young daughters and wrote essays based on their observations (Maeder, 1989).

In today's world, analyzing or conducting formal psychotherapy with one's child is a violation of the professional ethical code of psychotherapists, and definitely constitutes a forbidden dual relationship. Officially, psychotherapy stops at the door of the office and the end of the session. Inevitably, psychological knowledge goes on. Psychotherapists are trained to understand and deal with a wide range of human emotions and behavior. Kottler (1987), among others, asserts: "All the powers of observation, perception, sensitivity, and diagnosis are equally useful with clients, family, or friends. The skills we use in our work, such as empathic listening or flexible problem solving, prove invaluable when helping the people whom we love" (p. 25). Systems of psychotherapy have bearing on most aspects of therapists' lives, from the personal to the interpersonal, from the emotional to the behavioral aspects of existence. As such, psychology does not stop and cannot be stopped at the end of the clinical hour. It permeates therapists' lives and inevitably impacts their intimate and familial relationships.

Popular belief tells us that physicians' kids are unhealthy, dentists' kids have decayed teeth, the shoemakers' children go barefoot, and landscapers' offspring play in backyards that are unkempt. It has been shown that every doctor's child developed symptoms and complaints that were dynamically related to their parent's professional interest. By this same token, psychotherapists' children should display psychological impairment in accordance with their parent's expertise. Is the "cobbler's complaint" a valid description of psychotherapists' families? Are these families special due to the occupation of the parent? Maeder (1989), like many other scholars, believes in the uniqueness of psychotherapists' families: "The more one knows about people and is accustomed to dealing with them, the more defenses and techniques one understands, the greater the effect one can have upon another" (p. 109). To deny this power of knowledge is to deny that there is any value to psychotherapy.

Assuming that therapists' skills are indeed relevant and potent in intimate and familial situations, the question then becomes, how does the psychotherapist's power to influence affect the family? The following sections will outline the potential effects, negative and positive, that psychotherapists may have on their families.

Negative Impacts on the Family

Though psychotherapists bring an especially relevant expertise to the home, being a psychotherapist does not guarantee that a person will make an effective parent or supportive spouse. Psychotherapists can negatively influence their families in the following ways:

1. Interpretation:
Undoubtedly, the most pervasive intrusion by psychotherapists on the psychic lives of their family members is interpretation. Numerous partners and children report unsolicited interpretations of their dreams and their relationships with friends and parents. Interpretation, which does not occur within an atmosphere of trust and with impeccable timing, can easily injure. Untimely interpretation, even if correct, can be as devastating as an inaccurate interpretation. While the former makes people feel exposed and unprotected, the latter confuses people regarding their own realities and makes them doubt their perceptions. Along the same line, therapists' family members often hear that all slips have meaning, whether they are slips of the tongue or everyday forgetfulness. Such an attitude on the part of the parent-therapist has the effect of suppressing others' spontaneity and causing them to be excessively self conscious as children or adults (Goldney et al, 1979, Maeder, 1989).

The danger of treating family members as patients cannot be overstated. If the therapist takes on the role of the therapist in the home, the spouse or child will most likely assume the role of the patient. The therapist may be expected to know what the others are feeling whether or not it is expressed, or the 'patients' may ask the 'therapist' to label their emotions and solve their inner conflicts.

2. Questioning and Inquiry:
Most psychotherapists are trained to ask the right questions or to reflect back in a way that facilitates better understanding. Many children and spouses respond poorly to questions, such as "Why do you feel that?" or "Did you consider the consequences?" A child of a psychotherapist interviewed by Maeder (1989) reports that he was regularly hit with the "Freudian whip." One patient, a high school teacher, recalls that his biggest childhood trauma was his therapist father's endless interrogations. Lengthy, clinical discussions were combined with a barrage of questioning that often lasted 50 minutes. He vividly remembers yearning for his father to ground him, yell at him, or even spank him. He longed for his father to lose his cool and become a more real, perhaps irrational, but engaged parent.

3. Emotional Draining:
As described earlier, a major hazard of the profession of psychotherapy with direct impact on therapists' family lives is the emotionally draining nature of psychotherapy. Cameron and Marjorie Cray, a psychiatrist and his wife, state in a joint article:

When the psychiatrist does get home to his family, the very skilled listener is no longer in a mood to listen. He would like to talk for a change. He has been suppressing his feelings all day. He has been suppressing his talking all day. Moreover, the problems of his family seem very trite compared to the problems he has been focusing on. His sensitivity has dulled. (Cray & Cray, 1977, p. 337)

4. Distancing:
Another common complaint among psychotherapists' family members is their parent's or spouse's ability to distance from the emotional realities of the domestic scene (Goldney et al, 1979; Maeder, 1989). According to Henry et al's extensive study (1973), this dispassionate aura, while an important therapeutic mode for some clinicians, is also characteristic of therapists' interaction with spouses and children. The use of jargon as a mean of distancing is usually used as a counter-attack when the therapist feels defensive or uninvolved. Most often, the therapist lashes out with, "You are projecting," meaning, "Your anger has nothing to do with me."

5. Total and Uncritical Understanding:
Children of psychotherapists often say that whatever they did, their parents always accepted it, always understood it. In the psychotherapist's words, they were "just going through a phase." Different versions of this theme are expressed in statements like, "Oh, he's such a pre-teen," or "How typically adolescent," or "It is just your middle age crisis." These comments are demeaning and discounting regardless of the accuracy of the therapist's observations. More to the point are the therapist-parents/partners emotionally involved with their family members, or are they maintaining an analytic distance that keeps them from being truly engaged? The total understanding syndrome often manifests to the extent that therapists tend to excuse all behavior. In their minds, the bully is insecure, the wimp has abusive parents, and the thief comes from a poor family. It may be difficult for children to share their frustrations and anger in the light of their therapist-parents' incredible ability 'to understand.'

6. Labeling and Diagnosing:
These therapeutic techniques pose similar problems to those of interpretation and total understanding. Children and partners of therapists are labeled schizophrenic, paranoid, narcissistic, self destructive, passive-aggressive, borderline, and many other DSM III-R (APA, 1980) diagnostic categories by their therapist-parents. While non-therapists often label as well, psychotherapists have a clear advantage, knowing the appropriate categories and the professional jargon. Labeling is extremely injurious. Calling children "hyperactive" or "accident prone" is likely to encourage hyperactivity and accidents, not minimize them (Goldney et al, 1979; Maeder, 1989). Children learn who they are from their parents. If they are called offensive names, too often they will internalize and incorporate these labels as part of their self-image.

7. Demeaning Tales:
Sharing stories and tales about patients at the dinner table is a common activity in psychotherapists' families. When the stories are not respectful of the patients, when ridicule is prevalent, the potential of adverse effects on other family members, especially the children, is great. Demeaning stories are not only a reflection of a failed alliance between therapist and patient, but an alarming warning to the children about their parents' capabilities to demean others. In the words of a patient who was a therapist's child: "I was afraid that if she talked like that about her patients, she might feel the same way about me. It scared me to death."

8. Jealousy:
Jealousy of patients is another significant experience of psychotherapists' family members. Anonymous and mysterious clients call at all hours, needing to talk or cry. Regardless of how demanding they are, these clients are fully accepted by the therapist-parents. Many therapists' children tell their parents: "You talk to so many people during the day, you have nothing left for me at night." Considering the amounts of time, attention, and the range of privileges patients receive from their therapists, it is no wonder many children of psychotherapists want to grow up to be patients (Maeder, 1989). Children often contend that they never had 50 minutes of focused or continuous attention in a month or a year, while "all those needy and demanding patients" get it at least weekly. These children's sense of deprivation is expressed by wanting to play "patient" with their parents in the therapy room. "I used to lie on the couch and tell my father stories every chance I got," a college professor recalls. "That was the only time I felt I had his full attention."

9. Creating a Crisis:
One of most successful means of getting a psychotherapist's attention is to foment a crisis situation. Psychotherapists are usually at their best in an emergency where people are clearly in need of emotional support. This skill is easily transferable from the therapy room to the home. Acting out or appearing to be depressed seems to evoke the desired response of parental attention (Kaslow, 1984; Rosenthal, 1971-72). After hours of listening to bizarre and dramatic stories, many psychotherapists are not eager to be ardent listeners to complaints about the homework assignment or the car's funny noise. Physical illness, accidents, and other crises often provide, albeit dangerously, the attention that children or spouses of psychotherapists so hunger for.

10. Anonymity and Confidentiality:
Family members of psychotherapists must contend with two other psychotherapeutic issues connected to patients' privacy. The commitment to keep patients' identities anonymous often places psychotherapists in difficult and awkward situations (Cray & Cray, 1977). Children and partners of therapists love to tell embarrassing stories about their parents bumping into their patients in movie theaters, shopping malls, or on the beach. Some feel anxious, unsure what would happen should they discover the identities of these mysterious beings. Paradoxically, what provides safety for patients often creates confusion or even fear in the psychotherapists' family members. Families of mental health workers who work or live in mental institutions, as opposed to families of private practitioners, are not so bewildered by the secrecy of the profession. They better understand who the patients are, the severity of the patients' disturbances, and the nature of their parents' work.

11. The Home Office:
Working out of the home-office adds another dimension to the psychotherapists' already complex family dynamics. Psychotherapists' family members are usually forbidden to see the anonymous patients who are constantly in their homes (Maeder, 1989). Many children are not allowed to play around the house for the last ten minutes of each (clinical) hour. One child expressed a typical confusion; "whether the rules were supposed to protect the patients from my power or protect me from their destructive badness." An eight-year-old girl whose father works out of the home explained that the patients were not allowed to know that she exists in this world because "they might become jealous of me because he is my Dad." Children whose parents work out of a home office seem to be much more resentful of their parents' profession due to the added restrictions of space, time, and noise level imposed by the home-office arrangement.

12. Resistance in Therapy:
When the family dynamic has deteriorated to the point where outside help is sought, the therapist - spouse/parent may further complicate matters by creating obstacles to the healing process. Resistance to family therapy or marriage counseling manifests not only in delays in initiating contact with a provider, due to feelings of shame and attempts to avoid negative exposure, but also through reluctance, once in therapy, to cooperate with the psychotherapist. Competition as to who is the better psychotherapist often interferes with meaningful disclosures and receptivity to interventions (Chessick, 1977). Many patient-therapists use sophisticated jargon during family therapy sessions; clearly an attempt to ally with the hired-therapist (Kaslow, 1984). These unconstructive gestures support the original mistrust the therapist has evoked in the other family members. This often interferes with the course of therapy and may lead to premature termination.

In summary, psychotherapists' skills and knowledge have a profound effect on their families' lives. The misuse of their skills, whether through the employment of jargon, labeling, interpretation, or 'total understanding' is likely to have a negative effect on spouses and children. In response to these feelings, many children and partners of therapists build emotional shields against the therapists' intrusion and disregard (Maeder, 1989). Due to the nature of the profession, many family members experience feelings of exclusion and inferiority in regard to the patients who have the full and undivided attention of the therapist and are treated with utmost patience and courtesy. While some of the elements, such as confidentiality and anonymity, are an inherent part of the profession, other behaviors and responses, such as emotional drainage, intrusive interpretation, and labeling, can be eliminated by the conscientious therapist.

 
Positive Impacts on the Family

While the negative effects of psychotherapists' profession on their families receive limited attention, positive effects receive even less. Following are six important areas where psychotherapists can enhance their families' well being.

1. Knowledge:
Expertise in the emotional, cognitive, and behavioral domains can be an important contribution to the psychotherapist's family life, whether this expertise relates to child and adult development, family cycles, rewards and punishment, motivation, memory, or defense mechanisms. Psychotherapeutic knowledge can be used in a caring way, as in recognizing and attending to the two-year-old's need for increased autonomy or comprehending the delicate balance of dependence and independence in an adolescent. It can help facilitate a spouse's struggle with an aging parent or a sister's post-partum depression. Psychotherapists have the potential to become highly effective parents and partners.

2. Training In and Practice:
The training in and practice of psychotherapy theoretically prepares practitioners to be more adequate parents and spouses. In training, the emphasis on empathy, pro-social behavior reinforcement, communication, the intense practice of active listening, as well as the self-discipline of attending to one's own countertransference issues can provide a foundation for becoming effective parents and sensitive spouses. In his response to a question regarding the danger of psychotherapists becoming therapists instead of parents, Dr. Ginott (1971/2), the renowned child psychologist, stated: "I will give child patients the best I've learned. And that includes properly timed interpretations of unconscious processes. We would not think of interpreting for our children. But, what is sensitive, compassionate, and human changes very little from office to home" (p. 40).

3. Psychologically Minded:
Psychologically aware parents or spouses can help family members attune to their own inner lives, thereby enhancing the quality of life for the whole family (Farber, 1983; Goldney et al, 1979). The "good enough" therapist-parents raise children who are highly aware of their own feelings and inner processes.

4. Cautious Spontaneity:
Spontaneous responses by parents can be harmful or engaging. Part of the complexity that the knowledgeable and conscious psychotherapists bring to their home lives is advanced awareness of their own unconscious (Farber, 1983). Dr. Ginott (1971/2) states clearly that he is not against being spontaneous with one's own child, but adds that: "What I'm against is impulsivity masquerading as spontaneity. There is nothing wrong in parents examining their natural reactions to their children--to separate the chaff from the wheat, to learn what helps and what hurts" (p. 40).

5. Positive Tales:
Stories are at the heart of psychotherapy. The lives of psychotherapists are full of their patients' stories, their inner and outer dramas. By the end of the workday the psychotherapist is saturated with patients' fables and mysteries; stories about girls who won't eat, about boys who love boys, about a woman who has married twelve times, about a man who is afraid of crossing bridges. Schizophrenia, phobias, and compulsions make great tales. Dinner is often a perfect time to share them, to unload the loneliness of the profession at the supper table to a captive audience. While some families do not talk at the dinner table and many others ritualistically watch television, families of psychologists are often regaled with stories about patients. "Our father told us the most incredible stories during dinner," an adult child of a psychotherapist confided to me. "Two themes ran through all his stories--affection and hope. Care, attention, and good will always brought his stories to a happy ending."

6. Observing the Compassionate Therapist at Work:
Watching the therapist, whether on the phone or by listening to the stories, gives members of psychotherapists' households a notion of the diversity of people's problems and intimately acquaints them with concepts of care and hope. It is possible that they will extend this knowledge and become more self-conscious and more aware of their own emotional pain. This acquaintance with psychic pain increases their receptivity to help in general and to psychotherapy or counseling in particular.

The limited literature on psychotherapists' families virtually ignores the positive effects of the profession on the family. This may be a result of the more general professional bias of focusing on the negative -- on what should be healed. This paper suggests that psychotherapist-parents/spouses who use the skills of their trade cautiously and respectfully can create an exceptional home environment where empathy, compassion, and connections are the rule, rather than the exception. These therapists might potentially raise psychologically minded children who are acquainted with the diversity of human experience and not frightened by human pain, whether their own or someone else's. Both spouses and children of these therapists are likely to trust that caring connections can heal, and that relationships are crucial for growth and emotional prosperity.

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Summary And Recommendations

This paper has explored three basic questions in an attempt to understand the complexity of psychotherapists' families. The first question posed was: Is there anything that distinguishes the personality of psychotherapists from other professionals? Or is there truth behind the myth of the "wounded healer"? The answer to this question is that while there are multitudes of myths about psychotherapists, ranging from admiration of their hidden powers to scorn of their craziness, grandiosity, greed, and sexual obsessions, in actuality, only very few variables apply to psychotherapists or the more closely studied psychiatrists that show any significant or meaningful variance from the rest of the population or from comparable professional groups. A small number of studies indicate that before making their career choice psychotherapists are more psychologically minded, more flexible, and more liberal compared to physicians or the general population. Findings that are more consistent, though their validity is still disputed, relate to psychotherapists' rate of suicide and their vulnerability to depression and alcoholism. No other psychological, sociological, or biographical variables seem to differentiate between psychotherapists and any comparable group in the general population. However, it is unclear whether these last three variables are inherent parts of the therapists' personalities prior to their career choice or are caused by the stresses of their practice.

The second question posed was: Is there anything about the training and practice of psychotherapists that is relevant and likely to impact their personality, quality of life, and interpersonal skills? The answer, generated in part by empirical research and primarily by theoretical claims, is definitely affirmative. The nature of the practice of psychotherapy can result in a therapist's sense of isolation, emotional depletion, sadness, hopelessness, sense of ineffectiveness, and depression. Endemic to this line of work is the therapist's vulnerability to feelings of omnipotence and grandiosity. These feelings often carry well beyond the 50-minute session.

On the positive side, psychotherapeutic training and practice may enhance therapists' self-awareness and consciousness, increase their sensitivity, and help them develop empathy to the diversity of human feelings, thoughts, and behavior. The therapist is likely to gain extensive knowledge regarding human development from infancy to geriatrics, and to gain better understanding of how compassion and knowledge enable others to live their lives more meaningfully. Helping others through making authentic connections and empathic bonds can be rewarding peak experiences that give deeper meaning to the therapists' lives.

The exploration of the first two questions provides the basis for the third: do families headed by psychotherapists develop special dynamics due to the parents' profession? Or what is the impact of this profession on spouses and children? The answer to these questions is also in two parts, positive and negative. On the one hand, there are numerous reports of therapists using their skills and knowledge as tools of control and cruelty in the family. On the other hand, therapists who do not operate in a therapeutic mode at home can use their training to promote their families' well being.

Critical to the profession are the dynamics of emotional involvement between therapist and patient, and the consequent emotional depletion of the therapist. The limitations imposed by confidentiality and the demands patients place on the therapist beyond the clinical hour set additional occupational hazards on the therapist. These, in turn, place burdens on the family that must be acknowledged and attended to by all family members.

The effects of the profession on the psychotherapists themselves, and the issue of the wide range of dynamics in the psychotherapists' households naturally leads to the question of what measures should be taken to enhance the positive and minimize the negative effects of the profession on both psychotherapists and their families. The following is a brief guideline which psychotherapists and their families might find useful in preventing therapist burnout and reducing stress in the family.

The measures that psychotherapists should follow to prevent burnout and reduce stress in the family:

Self Analysis: Psychotherapists will find it useful to attend to their emotional lives through their own therapy or, as Freud emphatically recommended, through "self analysis."

Consultation: Psychotherapists should either work under supervision or consult with colleagues, if not on a regular basis, at least when facing a difficult case.

Countertransference: Psychotherapists must conscientiously attend to countertransference issues; feelings of frustration, superiority, grandiosity, sexual attraction, rage, hostility, and emptiness.

Interdisciplinary Approaches: Increased emphasis should be placed on interdisciplinary contacts, such as those between psychotherapists, physicians, social workers, and teachers, in order to reduce the level of isolation. Extending the interdisciplinary approach further, psychotherapists can broaden their theoretical maps by drawing on other theoretical orientations and disciplines, such as sociology, philosophy, law, and education.

Non-Professional Activities: Therapists will benefit from reserving significant time for non-psychology activities, such as sports, meditation, films, reading, or the opera. Similarly, vacations that are not related to professional activities should be scheduled, whether these will be taken with the family, with friends, or alone. Personal relationships with people outside the field are part of an essential non-therapy focus.

Community Involvement: It is important that therapists be active on different levels of the community. Teaching, volunteering, or taking part in political, spiritual, or social causes are reasonable options.

Balance: Ultimately, what is most important is that the therapist find a balance. In the words of Maslach (1982), from her book Burnout-the Cost of Caring.

Balance between giving and getting, balance between stress and calm, balance between work and home--these stand in clear contrast to the overload, understaffing, over commitment, and other imbalances of burnout. To give and give and give until there is nothing left to give any more means that one has failed to replenish one's resources. Unless more fuel is brought to the fire it will eventually use up all that was there to start the flame--and then die out. In a similar way, unless one has fueled oneself (with knowledge, rewards, strength), the fire of compassion can be all consuming, leaving nothing but emotional ashes. (p. 147)

As to how to enhance the quality of life for families of psychotherapists, all family members, and especially the therapist, should strive to become aware of the profound difference between the therapeutic mode and the non-therapeutic or familial mode. While many skills are applied to both settings, there are profound differences between them.

Scope of Relationship: In psychotherapy, relationships are defined by the therapeutic contract. The contract stipulates conditions of time, money, and the agreement that the patient has hired the therapist's services, not visa versa. At home, relationships are more often shared, jointly defined, and open-ended.

Hierarchy and Expertise: While in therapy, regardless of the theoretical orientation, there is a hierarchy and a single "hired expert." At home, the relationships with a spouse are, ideally, equal. Although parents have authority and responsibility over their children, their role is not the expert, but the involved, responsible, and caring parent.

Mutuality and Vulnerability: Whereas the therapist's needs and vulnerabilities are not an integral part of psychotherapy, they are an essential part of a healthy relationship between spouses, and between parents and children. Mutual responsibility, shared vulnerability, and equal investment and commitment are an integral part of a loving relationship, but not necessarily a sound basis for an appropriate therapeutic alliance.

Focus: The focus of psychotherapy is usually on healing psychic wounds, correcting maladjusted behavior, or attending to what causes the patient emotional pain or restricts his or her life. Healthy intimate relationships do not focus on the negative or on pain; it is part of the complexity of intimacy, not its primary concern.

Goals: The goal of psychotherapy is to enhance the patient's sense of well-being or eliminate self-destructive patterns. This is done by means of a variety of methods; inducing regression in order to attend to childhood wounds, correcting faulty thinking, or changing self defeating patterns of behavior. While it is hoped that loving relationships between family members are healing and serve to promote growth, it is not the explicit goal of family relationships to change behavior or heal injuries.

Stance, Posture, and Mode: Psychotherapists at work need to have a map or a model to follow as they work with their patients. No such map exists in the family. Psychotherapy requires some level of detachment on the part of the therapist. Of course this does not mean lack of feelings, empathy, or care. Psychotherapists who stay in the detached analytic mode at home are not engaged, are not involved, and hence cannot be intimate. Certainly, therapists may be thoughtful or sensitive at home, but this will mean that at times they are likely to act irrationally, impulsively, defensively, or angrily, as do all humans who are truly involved. The expression of this wide range of emotions is at the heart of the difference between the appropriate therapeutic and familial modes.

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