Release time: 2020-11-29 17:04

Continuing education: How to help trainees with competency problems

In every psychology training program, there’s at least one student who struggles with an element of professional competence.

In every psychology training program, there’s at least one student who struggles with an element of professional competence, says Linda Forrest, PhD, a professor emerita at the University of Oregon in Eugene and one of the leading researchers on issues related to competency problems. These trainees might be grappling with any number of issues, from protecting professional boundaries to demonstrating empathy to keeping patient information confidential.

Such difficulties don’t necessarily have to derail their clinical practice goals. Most students go on to become skilled and proficient psychologists as long as any competency concerns are identified early and the ­students are guided through a clearly defined remediation process, Forrest says. One such step-by-step approach to remediation appears in Training and Education in Professional Psychology (Vol. 13, No. 4, 2019).

At the heart of any meaningful remediation process is an effort to ensure that it’s fair to the trainee and provides support to both the trainee and the supervisor as they navigate—and ideally avoid—any ethical or legal dilemmas that might emerge.

But to be even more effective and feel less onerous to the trainee, the concept of remediation also should be reframed—beginning early in the educational process—as a potential and valuable component of training, says Evelyn Hunter, PhD, an assistant professor of counseling psychology at Auburn University in Alabama. “Historically, the term ‘remediation,’ even sometimes the way that we talk about it now, has had a really negative connotation,” Hunter says. “It feels like punishment, right? But remediation is really a training tool.”

The goal, she says, is to develop a culture in which remediation is seen as not only a common experience but potentially even a welcome one, so that a struggling student, for instance, might perceive that “faculty members have noticed that I need support and come up with a plan to support me.”

Flagging issues

Accurately identifying when a trainee needs support or professional remediation is a key part of supervisors’ responsibilities, says Rebecca Schwartz-Mette, PhD, an assistant professor of psychology at the University of Maine in Orono, who has studied issues related to professional competence.

APA’s Benchmarks Evaluation System is designed both for psychologists in training as well as for faculty and other trainers. It provides a template of desired competencies, along with a breakdown of the skills students should achieve at various stages, says Schwartz-Mette, who also chairs APA’s Ethics Committee. The system offers guidance on the level of expertise psychologists in training should have in such areas as assessment, ethical decision-making and more. Faculty and trainers can use the system as a way to regularly provide feedback to trainees on how their skills are aligning with those benchmarks, Schwartz-Mette says. “We need to be getting to the students at the very beginning and really articulating what is expected and supporting their growth,” she says.

Along with setting out clear expectations for their trainees, it’s also important for supervisors to request assessments from people other than just faculty members in order to better catch any emerging concerns, Hunter says. “Students are trying their best around us,” she points out. One way to identify trainee competence problems is to gather fellow students’ perceptions of a trainee’s skills. One study that looked at trainer and trainee perceptions of professional deficiency found that students might be more likely than faculty to notice competence problems among their peers. The trainees reported that 21.5% of their peers might be poorly or marginally suited to the counseling field or might be in need of remediation to address problems with interpersonal, emotional, skills-based or other professional fitness issues. Faculty members had a different take, saying that just 8.9% of their master’s-level students needed help. Of those, faculty reported intervening with roughly two-thirds, or 5.8% of all trainees, according to the findings (Gaubatz, M.D., & Vera, E.M., Counselor Education and Supervision, Vol. 46, No. 1, 2006).

Gaining a mix of perspectives also can help guard against unconscious biases that might influence one’s perception of a trainee’s professional competencies, says Nadine Kaslow, PhD, a professor of psychiatry and behavioral sciences at Emory University in Atlanta, who also chairs APA’s Working Group on Trainees With Competence Problems. “There’s no question that diversity considerations need to be taken into account when you’re determining if there’s a competence problem.”

For instance, trainees perceived as being “too quiet” in their interactions with patients might be seen as acting unprofessionally by some supervisors, Kaslow says. “And how much of that ‘too quiet’ is because that’s culturally normative for them?” she asks. For that reason, it’s important to talk to the trainees themselves—or those from similar cultures—about such perceptions and get their feedback, Kaslow says. Otherwise, the risk is that some trainees could get unfairly identified as requiring remediation for perceived professional shortfalls, which would be a loss to the profession. “Our nation is very diverse, and we want the psychology workforce to be very diverse,” she says. “If we get rid of people or slow down people because they behave differently, that’s a serious problem.”

Creating a plan

Once a problem with professional competence has been recognized, the next step is to create a remediation plan. These plans can range in scope from addressing an area as discrete as scoring a cognitive assessment to dealing with much broader concerns such as improving a trainee’s interpersonal skills, Schwartz-Mette says.

Including detail and measurable goals in these plans is essential for successful remediation, Schwartz-Mette says. “Creating a really good remediation plan is what we owe the student,” she says. “If the plan is vague, if the target behavior in question is not well defined, if there’s not a good timeline, if there aren’t effective activities and strategies implemented to help that student attain that competency, then that’s a failure of the trainers.”

It’s also important that the remediation plan explain and track a trainee’s struggles in measurable ways, says Justine Kallaugher, PhD, a Dallas psychologist who has conducted research on how trainees experience remediation. For example, don’t simply tell a trainee to “work on your empathy,” she says. Instead, provide examples of where the trainee could have demonstrated more empathy in sessions. Then set goals, such as requiring the trainee to incorporate at least three empathetic comments in each session.

Schwartz-Mette describes another potential scenario, in which a supervisor becomes concerned that a trainee hasn’t maintained adequate professional boundaries. In that case, she suggests, it could be helpful to assign the trainee skill-boosting activities, such as reading a book or writing a paper to reflect on their strengths and growth areas, or transcribing several sessions and identifying where they did well holding boundaries and where there was room for improvement, she says.

In their article in Training and Education in Professional Psychology (Vol. 13, No. 4, 2019), Kaslow, Kallaugher and their co-authors provide a checklist of the components that a good remediation plan should incorporate beyond the competencies to be corrected. Among them: the specific criteria to be assessed, the time frame, the consequences of success or failure and the signatures of the involved parties.

As the remediation plan is being developed, faculty should consider asking the trainee for input, Schwartz-Mette suggests. “Often those conversations can generate additional solutions or additional growth areas that the faculty was not aware of,” she says. “And the hope is that [trainees] could have a greater sense of ownership over the process and investment in the process if they feel like they’ve been heard.”

In her research with trainees, Kallaugher has found that some of them felt the process was punitive and were frustrated when faculty were not providing regular feedback on how far along they had progressed (Training and Education in Professional Psychology, Vol. 11, No. 4, 2017). That’s why it’s important for remediators to regularly communicate with students about how they’re doing and to check in with them about how they are feeling about the process, she says.

Still, Kallaugher notes, “no matter how hard a trainer works to be collaborative and understanding, that doesn’t necessarily mean that the student will feel that. And defensiveness is a normal human reaction.”

Navigating trouble spots

To reduce remediation pitfalls or confusion, it’s important for institutions and programs to set firm remediation processes and policies before trainee cases arise, Schwartz-Mette says. One potential hazard to be avoided, she says, is speculation about any mental health or substance use issues that might underpin a trainee’s competence concerns.

“That immediately puts us in an unethical dual relationship with the student, where at once we’re training and we are also making judgments about their mental health, which is completely unacceptable,” she says. The focus should be on remediating behaviors that undermine a trainee’s work directly—for instance, in the case of a trainee who arrives at work intoxicated, or one who has been missing class or avoiding group interactions because of anxiety issues.

Still, even when such struggles become apparent, treatment or counseling can only be recommended, not required, as part of a plan, Schwartz-Mette says. (The remediation process outlined by Vacha-Haase et al. in their 2019 Training and Education in Professional Psychology article takes a similar position.)

Clear and consistent communication about professional standards, starting early in the educational process, also will reduce an institution’s legal exposure if the student doesn’t follow through, Forrest says. As one example, Forrest cites a case in which the Minnesota Supreme Court held that a mortuary student could be disciplined for irreverent posts made on social media about a cadaver she was working with during training. While the student argued that her posts were protected by the First Amendment, the court found that the program had been clear about its professional standards, which included respectful interactions with the donated cadavers, and that her posts violated those standards.

What happens if, despite the trainee’s and remediators’ best efforts, the trainee’s competency doesn’t improve? Gaubatz and Vera’s survey of educators’ and trainees’ differing perceptions of competency also indicated that the path at this point might be a bit fraught. Whereas only 2% of the master’s-level students reported that they would pursue legal action if remediation were suggested, nearly 22% said they would do so if targeted for dismissal (Counselor Education and Supervision, Vol. 46, No. 1, 2006).

How well the process and discussion go at this point will vary depending on the degree to which students acknowledge—even to themselves—that they might lack some skills needed to become practicing psychologists, Forrest says. When students are self-aware, they can be encouraged to pursue career counseling to explore other options. If they still want to be psychologists, it’s important that their supervisors be clear about the skills that they are still not developing, even with remediation help, she says.

In some situations, a trainee might be able to transfer to another program at the same institution, Forrest says. For instance, there might be other programs in the educational psychology department that don’t involve clinical interactions with patients. If there isn’t an appropriate alternative, then dismissal might be the only course, she says.

The remediation process, no matter how it resolves, can be anxiety-producing for all players involved, Forrest says. But it’s crucial that trainers don’t flinch from addressing any competence concerns, in order to protect the public from an unqualified psychologist, she says.

“These are difficult conversations to have, but we’ve got to become good at having them,” Forrest says.