Outside practicums

[reluctantPhd01]

I had a question about practicums. I currently RA in a very research heavy Clinical Psychology department. There's a psychological service center within the department, and it's basically entirely staffed by graduate students in the Clinical PhD program.

A friend of mine in another fairly research heavy program (at a different university) also started seeing patients in her 2nd year, and now in her 3rd year, she has several patients in the PSC. But she also has an outside practicum.

In research heavy programs, are there any people that simply ONLY see patients/do clinical work in their PSC and never do an outside practicum? I realize the professional PsyD programs do TONS of practicums, but I am curious more about research PhD programs. Or do most people just do their clinical work through the PSC? What are the factors involved in this?

Could anyone illuminate this process a bit more for me?

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[AcronymAllergy]

I wouldn't doubt that there are students in research-heavy programs whose only clinical experiences occur via their department's psychological clinic. However, I personally would recommend against this; even if you don't gain more hours via an external practicum over the on-campus clinic, the breadth of experience (e.g., treatment modalities, patient populations, site dynamics) will make you much more marketable come internship time, and will also likely provide better training overall.

 

[futureapppsy2]

I'm honestly surprised there would be programs, even very, very research-heavy ones that would allow you to do all your practica in the department clinic, honestly. But I guess it could happen, although you'd probably be at a disadvantage for internship.

 

[reluctantPhd01]

How many outside practicums do you normally do?

 

[cara susanna]

My program is balanced, but if we only saw patients in our department clinic we'd have like ten therapy hours.

 

[Ollie123]

I know some who have managed to land solid internships without venturing outside the school clinic, though these are universally academically-inclined folks. Even as someone who would be perfectly happy to never see a client again after grad school, I wouldn't recommend it.

The number of outside practica will vary widely and can also be misleading. Some of our students do 2-3 a year (research-heavy program). That would be unthinkable at some places where practica is universally 20 hours a week. However, we have a number of sites with a great deal of flexibility with hours where you can get away with doing 4-16 hours at a site. Personally, I'm aiming for variable experiences, doing more practica with a smaller number of hours at each - we'll see how it works out.

 

[stigmata]

Yes and this is the norm....scary

 

[erg923]

I agree here. I know the rationale for this is that heavily supervised, empirically directed treatments is the only appropriate training environment for clinical scientists. However this ideal scenario/environment is simply not representative of real world clinical environments. The real clinical trenches are filled with SMI folks, substance abusers, and understaffed/underfunded programs and facilities. Sheltering one from the realties of the working world doesn't do anyone any favors, IMHO. Even if your goal is academia, this still makes no sense to me. There is nothing worse than the cliche academic psychologist who is has never seen a schizophrenic.

 

[stigmata]

Amen

 

[Ollie123]

I'm not sure I'd say its the norm...my program is pretty much as resesarch-focused as they come, and I can only think of one person offhand who got most of their training in-house. Same goes for friends in other programs. If other clinics are anything like the one here, I think it would be difficult to accrue enough hours that way, even forgoing other benefits. Few supervisors want to be responsible for massive caseloads on top of their other duties and the ratio of therapy/supervision hours is usually too low for it to be practical for anyone planning on graduating in a reasonable timeframe.

I think its good to have some training in that environment because my experiences (and those of many others I know) with what goes on in real world settings is that, frankly, the standard of care is often terrible even in places with good reputations - I can only imagine what is going on elsewhere. Sometimes with good reason (best one can provide given the time constraints/resources) but oftentimes not.

I'd worry just as much about a student whose entire clinical training took place in a tiny facility with limited resources, supervisors with zero experience in EBP who are basically just doing supportive therapy/psychoeducation for short bursts, have little time/ability to adequately supervise, have never seen/heard of a manual, and was flying by the seat of their pants most of the time. Balance is good, especially when it comes to training. Without seeing the real world, its easy to get caught in the ivory tower. Without the ivory tower, standards are unlikely to be raised and its easy to lose sight of the "goal".

 

[thewesternsky]

I am in a research-focused program where most of our training happens in-house. Because of this, we see a lot of mood/anxiety dx clients who are functioning reasonably well. We also see children with a variety of difficulties. There are benefits to this kind of a training model--the most important ones to me are that we get *amazing* (hour-per-hour) supervision. Our supervisors observe each session and then meet with us for an hour afterward to talk about the session and the case. It's pretty much impossible to get that kind of quality training elsewhere.

We also do two four-month external practica (30-40 hours/week for 16 weeks), one near the beginning of the program and one just before we apply for internship. Most people use these to get inpatient/neuropsych/forensic experience, depending on their interests.

Personally, I agree with Ollie and I think this kind of training is ideal. We may not get 1000 face-to-face therapy hours, but we do get extremely good training and some valuable breadth of experience before internship. Nothing wrong with in-house clinics if there's also a way to get some breadth. (Internship can be valuable breadth-wise as well.)

 

[aventurine]

Without the ivory tower, standards are unlikely to be raised and its easy to lose sight of the "goal".

In my program, we saw patients in our university clinic and we did outside practica (simultaneously, until internship). I trained in various private and public settings, and I received high-quality supervision in all of my placements (though there are some dud supervisors everywhere). I did not hear any complaints about low-quality training from my classmates about their training sites. Of course, there are some severely/acutely ill patients who cannot handle more than supportive therapy, but this was decided based on clinical judgment, not a result of poor-quality care and supervision.

I'm sure there are bad outside practica out there, but I don't think this sort of generalization about outside practica is necessarily fair or accurate.

 

[Ollie123]

In my program, we saw patients in our university clinic and we did outside practica (simultaneously, until internship). I trained in various private and public settings, and I received high-quality supervision in all of my placements (though there are some dud supervisors everywhere). I did not hear any complaints about low-quality training from my classmates about their training sites. Of course, there are some severely/acutely ill patients who cannot handle more than supportive therapy, but this was decided based on clinical judgment, not a result of poor-quality care and supervision.

I'm sure there are bad outside practica out there, but I don't think this sort of generalization about outside practica is necessarily fair or accurate.

Oh of course not, things don't fall neatly into one category or another, there is a whole ton of "middle ground" so to speak and I wasn't intending to imply that all outside facilities are like that - many have even more resources than a typical psychology department clinic and it is taken advantage of. I've worked in some of these settings too.

My whole point was that its good to see the full spectrum...it sounded like some people were implying that its bad to get lots of hours in a school clinic and "better" to get those hours in a resource-strapped facility that may or may not be capable of providing ideal interventions for most patients. I'd like to see both.

 

[erg923]

I am in a research-focused program where most of our training happens in-house. Because of this, we see a lot of mood/anxiety dx clients who are functioning reasonably well. We also see children with a variety of difficulties. There are benefits to this kind of a training model--the most important ones to me are that we get *amazing* (hour-per-hour) supervision. Our supervisors observe each session and then meet with us for an hour afterward to talk about the session and the case. It's pretty much impossible to get that kind of quality training elsewhere.

We also do two four-month external practica (30-40 hours/week for 16 weeks), one near the beginning of the program and one just before we apply for internship. Most people use these to get inpatient/neuropsych/forensic experience, depending on their interests.

Personally, I agree with Ollie and I think this kind of training is ideal. We may not get 1000 face-to-face therapy hours, but we do get extremely good training and some valuable breadth of experience before internship. Nothing wrong with in-house clinics if there's also a way to get some breadth. (Internship can be valuable breadth-wise as well.)

I was thinking about much more than just breadth of clinical experince. In fact, I was talking about more than just the clinical aspect of a practicum.

I think one can make a reasonable argument that practicum is, or at least should be, about more than just the training and aquisition of clinical skill sets. IMHO, it should be prepping you/exposing you to the realties of running a clinical service...with all the BS included.

Just one example (I can think of many others):
Calling insurance companies for pre auth for a npsych eval may be a pain the ass, but not only is it good practice for PP (or any job where that will fall on you or one of your staff), but it also slaps you in the face with the financial realties and limitations put on psych services by modern corporate healthcare. Maybe this wont make you a "better clincian" per se, but it will sure as hell make you a more informed one. I think its a shame so many "well trainied" psychologists come out of programs so ignorant of the econmic forces, rationales, and instituitions (HMOs) that affect their livelihood.

Being sheltered from these things as a student doesn't make you a better clinican, only a more sheltered an naive one...

 

[stigmata]

I think one can make a reasonable argument that practicum is, or at least should be, about more than the just training and aquisition of clinical skill sets. IMHO, it should be prepping you/exposing you to the realties of running a clinical service...with all the BS included.

Just one example (I can think of many others):
Calling insurance companies for pre auth for a npsych eval may be a pain the ass, but not only is it good practice for PP (or any job where that will fall on you or one of your staff), but it also slaps you in the face with the financial realties and limitations put on psych services by modern corporate healthcare. Maybe this wont make you a better clincian per se, but it will sure as hell make you a more informed one. I think its a shame so many "well trainied" psychologists come out of programs so ignorant of the econmic forces, rationales, and instituitions (HMOs) that affect their livelihood.[/QUOTE


Again I say Amen !!

 

[Ollie123]

I was thinking about much more than just breadth of clinical experince. In fact, I was talking about more than just the clinical aspect of a practicum.

I think one can make a reasonable argument that practicum is, or at least should be, about more than just the training and aquisition of clinical skill sets. IMHO, it should be prepping you/exposing you to the realties of running a clinical service...with all the BS included.

Just one example (I can think of many others):
Calling insurance companies for pre auth for a npsych eval may be a pain the ass, but not only is it good practice for PP (or any job where that will fall on you or one of your staff), but it also slaps you in the face with the financial realties and limitations put on psych services by modern corporate healthcare. Maybe this wont make you a "better clincian" per se, but it will sure as hell make you a more informed one. I think its a shame so many "well trainied" psychologists come out of programs so ignorant of the econmic forces, rationales, and instituitions (HMOs) that affect their livelihood.

Being sheltered from these things as a student doesn't make you a better clinican, only a more sheltered an naive one...

Ahh okay, I misunderstood your point. I agree with this entirely and do feel its unfortunate that training isn't integrated into the curriculum more (particularly for practice-oriented folks, though agree that in order to translate research into practice, even pure academics would benefit greatly from understanding insurance policies, etc.). I've worked with some pretty intense populations (homeless drug addicts) but its mostly been in settings where billing was a non-issue and that is a definite gap in my training. If I were to open a PP I wouldn't even know where to get started with all that, and my undergrad business degree likely did more to prepare me than any psychology training. Of course, I would likely go back to school for something else before I would ever consider doing that

I was perhaps biased by the discussion in the other thread that seems to be romanticizing certain settings that some seem to view as more "real world" but often provide comparatively weak care.

 

[erg923]

I was perhaps biased by the discussion in the other thread that seems to be romanticizing certain settings that some seem to view as more "real world" but often provide comparatively weak care.

I see what you're saying, and yes, in some cases it is weaker care. Its weaker care because its a weaker enviornment (which is out of your control) and I think you need to know how to deal with it and adjust to it. If you dont, one of two things will happen. You will either burn-out quickly trying to save the world and realizing you cant control state mental health care budgets OR you will become one of those academic snobs who loses touch with what 90% of psychologists have to deal with everyday (ie., budget restrictions, insurance companies, hospital administrators whose job is to keep the lights and who could care less about your last manuscipt, lack of resources, medicare denials, patients with so many diagnoses and medical complications that there is no "manual" designed for them, etc.)

For six month this year I did an intense 20 hour/week practicum at a urban county hospital. I was placed on both the acute medical rehab unit and the long-term skilled nursing unit. This was NOT a quality medical faciltity and it only had 1 full-time psychologist and 1 part-time C/L psychiatrist. Standard of nursing/medical care was poor, IMO. Time was limited. Space was limited. Psychology services was not a priority sevice there. I had to learn how to integrate my services into the patients care with what I had. I had to learn how to do psychotherpay outside the confines of the traditional 50 minute hour...bedside. I had to particpate in medical treatment team meetings and basically "sell" psychology services from the ground up. It was a skill set I didnt learn in my universty PSC. I suppose I could have stuck my Ph.D. nose up at it and said this was not an appopriate enviorment for me to work in. However I figured something was certainly better than nothing for those patients. I certainly learned alot as well.

 

[Ollie123]

In some cases it is out of necessity, I agree, but I'm not convinced that is always true. I believe in gradations of EBP...there is a big difference between working with a tough population and trying to motivate them to change in a short window using established techniques because that is really all you can pull off, and throwing everything we know about psychology and science in general out the window and doing whatever "feels right". Again, this is a continuum so its not black and white, but I actually think sliding towards the latter impairs our ability to get reimbursement. Pretty tough to argue to insurance we are any better at this than anyone else - medication can be standardized and is inherently easier to deal with, but I don't want to see us running in the other direction completely (note: this is why I believe academia needs to push towards mechanism research and flexible manuals).


I agree with a lot (perhaps all) of what you have said now that things are clarified - the above is a debate that will likely depend entirely on context as I doubt you would argue that there are plenty of situations where even with appropriate resources the competency isn't there to provide effective care. Based on my (admittedly fairly limited) experiences, that seems increasingly likely the further you move from academic circles or other large-scale settings. I had misinterpreted your original point as one that encouraged training exclusively in those sorts of environments, which I think is equally problematic.

 

[thewesternsky]

better clincian"[/I] per se, but it will sure as hell make you a more informed one. I think its a shame so many "well trainied" psychologists come out of programs so ignorant of the econmic forces, rationales, and instituitions (HMOs) that affect their livelihood.

Being sheltered from these things as a student doesn't make you a better clinican, only a more sheltered an naive one...

I'm not in the States, so much of this doesn't apply. In fact, we deal more with insurance and financial issues in our in-house clinic than in our community practicums, because the clinic isn't covered by government insurance!

That said, I'm sure there's plenty of other BS involved in running a clinical service that you don't experience in an in-house clinic or academic medical centre... Learning to do the best you can in a less-than-ideal setting is certainly a useful lesson, and it might be best to learn it early in your career when you have plenty of support (supervisory and otherwise).

I'd say that overall, some knowledge and experience of delivering empirically-supported treatments is important, whether this happens in an in-house clinic or another type of service. Experience in more "real world" settings, with difficult populations and limits on session length, interruptions, etc., is also crucial so that you learn to be flexible in your service delivery when necessary. Sound about right?