Gate keeping: Who is actually doing it?

[ExpertHoopJumper]

This is a question and issue I've been kicking around in my mind for several years as I have progressed through training. After reading the recent thread regarding "conversion therapy" I wanted to bring up this topic specifically.

In graduate school, gate keeping mechanisms for the profession were seemingly pretty straight forward and clear. The student must pass comps to progress to the PhD stage, then must defend their dissertation, and finally obtain an APA-accredited internship (among others). As most of the clinical training happened in-house, the faculty had an intimate knowledge of their students' abilities and performance so remediation was, presumably, readily available/possible. However, when I arrived at internship at a large VA with a long training history, I was taken aback when two of the eight interns were clearly unprepared for that level of practice and lacked, in my estimation, understanding of several foundational components of professional psychology. Yet the response to these interns difficulties by the training director and sub-specialty directors was even more surprising. To my knowledge, they did not take actionable steps to remediate the interns' deficiencies, but rather appeared to mitigate their effects themselves via scheduling and case assignments or simply ignored them. It was galling and confusing for these interns to present cases in group supervision or a "research" symposium that were incorrect and uninformed and the faculty not say anything. These interns finished internship and neither has been able to pass the EPPP but they are practicing within the VA nonetheless. How does this happen? How was the proverbial can kicked down the road despite pretty obvious signs that these folk needed help? What can I do as a new clinical supervisor in my first big-boy job if something like this happens?

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[WisNeuro]

As a neuropsychologist, I can't help it, you got to edit it to the correct "gate." I keep thinking of who is watching gaits to determine if someone may have neurological impairment.

 

[HopefulPsych21]

As a neuropsychologist, I can't help it, you got to edit it to the correct "gate." I keep thinking of who is watching gaits to determine if someone may have neurological impairment.

I work with orthopedic doctors and neuropsychologists. Had the same thought 🤣

 

[ExpertHoopJumper]

As a neuropsychologist, I can't help it, you got to edit it to the correct "gate." I keep thinking of who is watching gaits to determine if someone may have neurological impairment.

HA! My bad.

 

[foreverbull]

This is a question and issue I've been kicking around in my mind for several years as I have progressed through training. After reading the recent thread regarding "conversion therapy" I wanted to bring up this topic specifically.

In graduate school, gate keeping mechanisms for the profession were seemingly pretty straight forward and clear. The student must pass comps to progress to the PhD stage, then must defend their dissertation, and finally obtain an APA-accredited internship (among others). As most of the clinical training happened in-house, the faculty had an intimate knowledge of their students' abilities and performance so remediation was, presumably, readily available/possible. However, when I arrived at internship at a large VA with a long training history, I was taken aback when two of the eight interns were clearly unprepared for that level of practice and lacked, in my estimation, understanding of several foundational components of professional psychology. Yet the response to these interns difficulties by the training director and sub-specialty directors was even more surprising. To my knowledge, they did not take actionable steps to remediate the interns' deficiencies, but rather appeared to mitigate their effects themselves via scheduling and case assignments or simply ignored them. It was galling and confusing for these interns to present cases in group supervision or a "research" symposium that were incorrect and uninformed and the faculty not say anything. These interns finished internship and neither has been able to pass the EPPP but they are practicing within the VA nonetheless. How does this happen? How was the proverbial can kicked down the road despite pretty obvious signs that these folk needed help? What can I do as a new clinical supervisor in my first big-boy job if something like this happens?

I’ve heard of supervisors failing interns. It happens, but I think your example suggests that some supervisors are either fearful of doing so or don’t want to have to spend the extra time documenting the situation in case the student challenges it somehow. It’s far easier to greenlight a student than fail them and thoroughly explain why and possibly go through extra meetings, etc.

In graduate programs, the gatekeeping also happens, but students do slip through the cracks. I heard of some folks who got kicked out for extremely unethical behavior (lying about personal hardships, exploiting other students to get work done, trying to date clients, threatening a faculty member, etc.), but sometimes I’ve been surprised at what wasn’t grounds for immediate dismissal (2 students dated but broke up and the 1st student’s passwords were stolen by the ex, the ex was also stalking the other student and was not dismissed—instead the 1st student was told to call the police). Also, some folks who openly exhibited some “isms” got by without issue as well, which makes me wonder how much of a concern programs view this as, if at all, generally.

Clinical deficiency is a problem, certainly, as well. I wonder if faculty in grad programs have more to share about gatekeeping as well.

I would say do your best to maintain integrity, although it will be a challenge to go against the culture of your site. You may also want to consider how your colleagues will respond if you do buck the trend and fail a student who should be failed.

 

[WisNeuro]

I’ve heard of supervisors failing interns. It happens, but I think your example suggests that some supervisors are either fearful of doing so or don’t want to have to spend the extra time documenting the situation in case the student challenges it somehow. It’s far easier to greenlight a student than fail them and thoroughly explain why and possibly go through extra meetings, etc.

In graduate programs, the gatekeeping also happens, but students do slip through the cracks. I heard of some folks who got kicked out for extremely unethical behavior (lying about personal hardships, exploiting other students to get work done, threatening a faculty member, etc.), but sometimes I’ve been surprised at what wasn’t grounds for immediate dismissal (2 students dated but broke up and the 1st student’s passwords were stolen by the ex, the ex was also stalking the other student and was not dismissed—instead the 1st student was told to call the police). Also, some folks who openly exhibited some “isms” got by without issue as well, which makes me wonder how much of a concern programs view this as, if at all, generally.

As much as we may disagree about some of the isms, generally having a removal policy for these is just asking for huge lawsuits. I don't think it's a much as not being concerned about these, as it is, you don't have much ability to do anything is the student is meeting milestones and does not have objectively documented deficiencies.

 

[foreverbull]

As much as we may disagree about some of the isms, generally having a removal policy for these is just asking for huge lawsuits. I don't think it's a much as not being concerned about these, as it is, you don't have much ability to do anything is the student is meeting milestones and does not have objectively documented deficiencies.

True. I suppose the best insurance against this is for supervisors to listen to/watch a broad swath of students’ sessions with different clients to ensure proper practice, which is where the actual harm may lie. Therapy notes don’t always tell the whole story.

 

[WisNeuro]

True. I suppose the best insurance against this is for supervisors to listen to/watch a broad swath of students’ sessions with different clients to ensure proper practice, which is where the actual harm may lie. Therapy notes don’t always tell the whole story.

Yeah, this is why I like programs which do live/one-way mirror supervision. Or at the very least video. So much easier to actually see what is going on and get both verbal and non-verbal cues. Helps for supervising and providing clinical feedback, but also helps in accurately documenting and big problems in a trainee if you have to take more drastic action. Unfortunately, I also know many programs in which supervision consists of a supervisor having the trainee simply describe the session.

As to the OP and what you can do. Document supervision very well. Have a weekly/bi monthly summary of your supervision. It should include what was discussed, any correction items for the trainee, response to feedback, etc. You and the supervisee should review and sign it. Also make sure that it is mostly objective issues which can be operationalized. If you ever have to create a remediation plan, or formally discipline a trainee, that will be key.

 

[Fan_of_Meehl]

Politically-incorrect reply incoming (trigger warning).

It's just an opinion but I think we're seeing the results of a decades-long process of disempowering 'authority figures' in academia/ medicine. The 'old' system had many flaws and needed fixing, to be sure, and we should strive for due process for students and acknowledge that the power differential is real. However, when I was in training, the students/interns feared the supervisors. Now the supervisors fear the students. There has to be a middle ground and I think we may have swung the pendulum a bit too far in the opposite direction.

 

[CheetahGirl]

However, when I arrived at internship at a large VA with a long training history, I was taken aback when two of the eight interns were clearly unprepared for that level of practice and lacked, in my estimation, understanding of several foundational components of professional psychology. Yet the response to these interns difficulties by the training director and sub-specialty directors was even more surprising. To my knowledge, they did not take actionable steps to remediate the interns' deficiencies, but rather appeared to mitigate their effects themselves via scheduling and case assignments or simply ignored them. It was galling and confusing for these interns to present cases in group supervision or a "research" symposium that were incorrect and uninformed and the faculty not say anything.

Did you (as a fellow trainee) say anything?

It is also our responsibility to elevate the level of training among us. I would have called out the inconsistencies and allowed the supervisors to back-peddle, but at least the incompetence would have been revealed at the lower level, rather than letting it slide into the mid to upper levels of training.

 

[Shiori]

I really liked when my supervisors did live supervision or listened to recorded sessions. I know it's labor intensive, but I've gotten a lot of good feedback that way. We could probe why I spoke one way with one client vs another, etc. I've always gotten praise for my approach in therapy which feels nice, but doesn't help break apart what it is I'm doing moment to moment with clients. I've worked with a wide spectrum of folks this year and one supervisor in particular has been really good at helping zone in on tone shifts, noticing when I was being exceptionally deferential, and other little quirks. These are the ways my biases show up in the room, and it is helpful and often healing to process why it's happening. For example, I was a lot less likely to press my older, white, male clients and spoke with a much softer, more passive sounding voice. I hadn't noticed this tendency at all. My supervisor understood the desire to do this, but told me to experiment and make my voice more congruent with how I talk to her or other people. It was immensely helpful. I worry that most supervisors just don't have the support or training to do that kind of work.

I've noticed that students that really struggle to be "naturals" at therapy failed to land prac sites. They were often moved into the experimental psychology programs.

 

[thebalmofhurtminds]

I really liked when my supervisors did live supervision or listened to recorded sessions. I know it's labor intensive, but I've gotten a lot of good feedback that way. We could probe why I spoke one way with one client vs another, etc. I've always gotten praise for my approach in therapy which feels nice, but doesn't help break apart what it is I'm doing moment to moment with clients. I've worked with a wide spectrum of folks this year and one supervisor in particular has been really good at helping zone in on tone shifts, noticing when I was being exceptionally deferential, and other little quirks. These are the ways my biases show up in the room, and it is helpful and often healing to process why it's happening. For example, I was a lot less likely to press my older, white, male clients and spoke with a much softer, more passive sounding voice. I hadn't noticed this tendency at all. My supervisor understood the desire to do this, but told me to experiment and make my voice more congruent with how I talk to her or other people. It was immensely helpful. I worry that most supervisors just don't have the support or training to do that kind of work.

I've noticed that students that really struggle to be "naturals" at therapy failed to land prac sites. They were often moved into the experimental psychology programs.

Side note about this supervision: it's been so great with telehealth to be able to watch/listen to my trainees provide therapy. Mitigates how labor intensive it is in a few ways.

 

[cara susanna]

Politically-incorrect reply incoming (trigger warning).

It's just an opinion but I think we're seeing the results of a decades-long process of disempowering 'authority figures' in academia/ medicine. The 'old' system had many flaws and needed fixing, to be sure, and we should strive for due process for students and acknowledge that the power differential is real. However, when I was in training, the students/interns feared the supervisors. Now the supervisors fear the students. There has to be a middle ground and I think we may have swung the pendulum a bit too far in the opposite direction.

As someone who specializes in PTSD, your trigger warning is triggering me.

 

[StellaB]

I do a fair amount of supervision for interns, and I have to say that I have been shocked in recent years by the poor gate keeping that has been done by more than a few grad programs. Whether it's applicants for internship who do not stand a chance and are clearly unprepared for internship generally, or (far worse) actual interns who demonstrate insurmountable shortcomings in integrity (or ability / willingness to learn), it is quite disheartening. It appears that this is far more common at diploma mills, where the cohorts are so large the DCT does not really know any of the students well. Those schools also have a financial incentive to pass students along, keep taking their student loan money, and don't seem to feel any ownership over the quality of psychologists they're putting out into the field. It feels horrible to have to fail someone on internship when you know the impact this will have on their career, and even worse when you know they have hundreds of thousands of dollars in debt stacked up already. And it's infuriating when it's clear that their grad program screwed them over by just passing them along, either unaware or unbothered by the student's shortcomings. But at the end of the day, our ethical obligation is to pass interns who meet the benchmarks, and fail the ones who don't.

 

[PsyDr]

More idiosyncratic opinions:

Excluding those processes made based upon objective criteria (e.g., failing standardized tests, absentee-ism, etc):

1) Most of the gatekeeping processes are based upon personal preference.
2) There is usually no empirical support for stylistic variations of the administration of professional services.
3) It is hypocritical to espouse the benefits of good boundaries when also asking about a trainee's personal life.
4) Some of the subjective gatekeeping processes are based upon junior high social processes.

 

[foreverbull]

Yeah, this is why I like programs which do live/one-way mirror supervision. Or at the very least video. So much easier to actually see what is going on and get both verbal and non-verbal cues. Helps for supervising and providing clinical feedback, but also helps in accurately documenting and big problems in a trainee if you have to take more drastic action. Unfortunately, I also know many programs in which supervision consists of a supervisor having the trainee simply describe the session.

I hated being observed directly, but I believe it made me a better clinician and also reminded me that I was at the level I should be at in training. I think group supervision was particularly useful in terms of getting a general sense of skill level across students and also getting fresh perspectives from multiple folks on your own cases. Hearing the tapes of others helped me grow too, in terms of theoretical conceptualization and interventions.

My internship site said they used to require a session tape/example as part of the interview application for internship, but that APA stopped letting them. They talked about some infamous standouts: a trainee who used a tuning fork, one who did past life regression hypnosis, etc. The lack of awareness about how that would be perceived by a selection committee boggles the mind.

 

[WisNeuro]

I hated being observed directly, but I believe it made me a better clinician and also reminded me that I was at the level I should be at in training. I think group supervision was particularly useful in terms of getting a general sense of skill level across students and also getting fresh perspectives from multiple folks on your own cases. Hearing the tapes of others helped me grow too, in terms of theoretical conceptualization and interventions.

My internship site said they used to require a session tape/example as part of the interview application for internship, but that APA stopped letting them. They talked about some infamous standouts: a trainee who used a tuning fork, one who did past life regression hypnosis, etc. The lack of awareness about how that would be perceived by a selection committee boggles the mind.

My grad program had the one-way mirrors with A/V setup. We also had tiered clinical teams, so you were part of a clinical team from day one and got a lot of live observation with supervisor commentary well before you ever saw anyone for therapy. I know that setup is something of an outlier, but it was great.

 

[StellaB]

More idiosyncratic opinions:

Excluding those processes made based upon objective criteria (e.g., failing standardized tests, absentee-ism, etc):

1) Most of the gatekeeping processes are based upon personal preference.
2) There is usually no empirical support for stylistic variations of the administration of professional services.
3) It is hypocritical to espouse the benefits of good boundaries when also asking about a trainee's personal life.
4) Some of the subjective gatekeeping processes are based upon junior high social processes.

Where I have seen it (for example, in my grad program), students were dismissed or essentially encouraged out the door for falsifying documentation - fortunately there was a tape to compare the session notes to - and egregious unprofessionalism (e.g., threatening self-harm if not given the assignments one preferred at an externship site). As an internship supervisor, I have seen severe misrepresentations of patient statements, egregious mischaracterization of collateral reports, etc. Point being: there are many ways for a trainee to objectively fail to meet standard.

 

[Ollie123]

At my (name-brand, highly-regarded) internship, we once spent 40 minutes of a seminar reviewing DSM criteria for substance use disorder. I found this shocking and - in my opinion - a waste of our time but in discussion after it was clear this was - literally - the first time some folks had been exposed to the material.

I understand not everyone gets extensive training in SUDs and completely get not having DSM criteria memorized. I'd certainly struggle to spit back the criteria for anorexia given its not something I've ever seen in practice. A 2 minute refresher at the beginning of a lecture is sensible. Having to help people understand what any DSM criteria means at the internship level is....ridiculous.

I firmly believe the DSM is wildly unscientific, bordering on meaningless garbage and not something anyone worth a damn should take very seriously. My program wasn't shy about telling us more-or-less exactly that from the moment we arrived. We had presentations from people on various DSM working groups who made it pretty darn clear they felt the same. So to be clear, I'm far from a DSM fanboy. I'm still utterly confused how one gets to internship without having some level of exposure to this.

That was a pretty jarring moment for me that certainly made me question what exactly is going on with our gatekeeping system. If people are getting that far in their education, I can only imagine what is going on once people are independently licensed, no longer subject to supervision and only receiving further education via whatever number of CE credits their state happens to require.

 

[AbnormalPsych]

At my (name-brand, highly-regarded) internship, we once spent 40 minutes of a seminar reviewing DSM criteria for substance use disorder. I found this shocking and - in my opinion - a waste of our time but in discussion after it was clear this was - literally - the first time some folks had been exposed to the material.

I understand not everyone gets extensive training in SUDs and completely get not having DSM criteria memorized. I'd certainly struggle to spit back the criteria for anorexia given its not something I've ever seen in practice. A 2 minute refresher at the beginning of a lecture is sensible. Having to help people understand what any DSM criteria means at the internship level is....ridiculous.

I firmly believe the DSM is wildly unscientific, bordering on meaningless garbage and not something anyone worth a damn should take very seriously. My program wasn't shy about telling us more-or-less exactly that from the moment we arrived. We had presentations from people on various DSM working groups who made it pretty darn clear they felt the same. So to be clear, I'm far from a DSM fanboy. I'm still utterly confused how one gets to internship without having some level of exposure to this.

That was a pretty jarring moment for me that certainly made me question what exactly is going on with our gatekeeping system. If people are getting that far in their education, I can only imagine what is going on once people are independently licensed, no longer subject to supervision and only receiving further education via whatever number of CE credits their state happens to require.

There is a clinician I know that diagnoses SUD severity by their "gut" since they are in recovery. They also add the 'in early remission' specifier at 90 days sober, no matter what. Even when the symptoms are alarmingly present.

Anecdotally, these are also the people who are not receptive to informal / peer feedback. And highly correlated with attendance at mid levels programs or the unspoken A name schools.

 

[AbnormalPsych]

I hated being observed directly, but I believe it made me a better clinician and also reminded me that I was at the level I should be at in training. I think group supervision was particularly useful in terms of getting a general sense of skill level across students and also getting fresh perspectives from multiple folks on your own cases. Hearing the tapes of others helped me grow too, in terms of theoretical conceptualization and interventions.

My internship site said they used to require a session tape/example as part of the interview application for internship, but that APA stopped letting them. They talked about some infamous standouts: a trainee who used a tuning fork, one who did past life regression hypnosis, etc. The lack of awareness about how that would be perceived by a selection committee boggles the mind.

I am old enough to have been video and/or audio recorded (TAPE recorder...remember those?) at every session until internship. Then on some while there. Live in the same room supervision throughout here and there too. Never been at a place with the mirror though.

Although I hated this, and was given feedback from supervisors which confirmed that I am clearly better without that spotlight on me and the anxiety creeping in, it did help in some ways in the long run. The best by far....was group supervision, as you say.

 

[cara susanna]

At my (name-brand, highly-regarded) internship, we once spent 40 minutes of a seminar reviewing DSM criteria for substance use disorder. I found this shocking and - in my opinion - a waste of our time but in discussion after it was clear this was - literally - the first time some folks had been exposed to the material.

I understand not everyone gets extensive training in SUDs and completely get not having DSM criteria memorized. I'd certainly struggle to spit back the criteria for anorexia given its not something I've ever seen in practice. A 2 minute refresher at the beginning of a lecture is sensible. Having to help people understand what any DSM criteria means at the internship level is....ridiculous.

I firmly believe the DSM is wildly unscientific, bordering on meaningless garbage and not something anyone worth a damn should take very seriously. My program wasn't shy about telling us more-or-less exactly that from the moment we arrived. We had presentations from people on various DSM working groups who made it pretty darn clear they felt the same. So to be clear, I'm far from a DSM fanboy. I'm still utterly confused how one gets to internship without having some level of exposure to this.

That was a pretty jarring moment for me that certainly made me question what exactly is going on with our gatekeeping system. If people are getting that far in their education, I can only imagine what is going on once people are independently licensed, no longer subject to supervision and only receiving further education via whatever number of CE credits their state happens to require.

Being familiar with your internship site... holy cow, that's horrifying.

 

[ExpertHoopJumper]

Did you (as a fellow trainee) say anything?

It is also our responsibility to elevate the level of training among us. I would have called out the inconsistencies and allowed the supervisors to back-peddle, but at least the incompetence would have been revealed at the lower level, rather than letting it slide into the mid to upper levels of training.

I did question and push back during these interns' "research" presentations. One presented on emotional support animals (a big issue in that VA) and when I asked to see the quantitative data/findings, rather than the slick websites of training companies and testimonials, I was accused of being rude among other things. This intern did not understand even correlation and could not competently evaluate scientific literature.

I did not, however, say anything regarding their clinical practice. Both of the interns to which I refer were not in my niche (neuropsych), so that likely made it less pressing to me. Or perhaps I was less confident in my own abilities in those areas at the time. Either way, on multiple occasions basic principles of clinical work were unknown or misunderstood by these interns, and no one said anything publicly.

 

[ExpertHoopJumper]

My grad program had the one-way mirrors with A/V setup. We also had tiered clinical teams, so you were part of a clinical team from day one and got a lot of live observation with supervisor commentary well before you ever saw anyone for therapy. I know that setup is something of an outlier, but it was great.

This is exactly how my grad program was structured as well.

 

[PsyDr]

Where I have seen it (for example, in my grad program), students were dismissed or essentially encouraged out the door for falsifying documentation - fortunately there was a tape to compare the session notes to - and egregious unprofessionalism (e.g., threatening self-harm if not given the assignments one preferred at an externship site). As an internship supervisor, I have seen severe misrepresentations of patient statements, egregious mischaracterization of collateral reports, etc. Point being: there are many ways for a trainee to objectively fail to meet standard.

What in the Days of Our Lives is going on in grad schools?!

 

[Sanman]

Politically-incorrect reply incoming (trigger warning).

It's just an opinion but I think we're seeing the results of a decades-long process of disempowering 'authority figures' in academia/ medicine. The 'old' system had many flaws and needed fixing, to be sure, and we should strive for due process for students and acknowledge that the power differential is real. However, when I was in training, the students/interns feared the supervisors. Now the supervisors fear the students. There has to be a middle ground and I think we may have swung the pendulum a bit too far in the opposite direction.

While I agree that power dynamics shift, I think the core problem is a lack of uniformity in standards compared to other professions. That lack of uniformity means that whichever side has more power can abuse it. It used to be that professors/programs had all the power. Now that business has infiltrated healthcare and education, there is a tide turning and more of a push to protect customers/consumers. I have seen it play out on bot h sides. I have read applications from egregiously unprepared internship applicants and seen significant gaps in the assessment knowledge of several of our trainees. That said, I have also witnessed supervisors/professors attempt to fail trainees despite multiple colleagues reviewing the same work and stating that it was acceptable and professors dropping grad students half way through training despite them meeting all objective (comps, thesis defense) criteria. The system simply needs to be overhauled to require a more universal experience.

 

[Shiori]

I think a more cohesive, organized system could make the process less stressful for everyone. There seems to be a weird dance between programs and training sites based on who is expected to do specific skill building. I know there is an unwritten expectation in my program that the diversity competence building happens during training. It doesn't. Gaining a solid foundation for assessment skills was also tricky. It's clear that there is some baseline for where students should be by the time they hit internship, but conversation may also need to include who is responsible for what in addition to who the gatekeepers are.

 

[cara susanna]

I also think that the gatekeeping needs to be done sooner in the process. It would royally suck for someone to reach the point of internship and then be told that they can't enter the field.

 

[WisNeuro]

I also think that the gatekeeping needs to be done sooner in the process. It would royally suck for someone to reach the point of internship and then be told that they can't enter the field.

Diploma mills aren't going to drive away their cash cows.

 

[Ollie123]

I think a more cohesive, organized system could make the process less stressful for everyone.

Greater standardization throughout would also probably have the downstream (upstream?) effect of helping standardize licensure processes by state.

I'm now in a slightly weird situation where I was independently licensed for several years, moved and am not 100% certain I qualify for licensure in my new state due to slight differences in the language about what does/does not count as clinical activities. The perils of research success as I had to back off clinical work as my funding ramped up. I don't need to be licensed so its not a huge deal, but still a little weird. Coursework and whatnot is easy to rectify, but this is much harder. Was tough enough to justify post-doc the first time, certainly not going to do another one.

 

[deleted106747]

Politically-incorrect reply incoming (trigger warning).

It's just an opinion but I think we're seeing the results of a decades-long process of disempowering 'authority figures' in academia/ medicine. The 'old' system had many flaws and needed fixing, to be sure, and we should strive for due process for students and acknowledge that the power differential is real. However, when I was in training, the students/interns feared the supervisors. Now the supervisors fear the students. There has to be a middle ground and I think we may have swung the pendulum a bit too far in the opposite direction.

Interesting opinion, given our conversation in the VA thread.

 

[Fan_of_Meehl]

Interesting opinion, given our conversation in the VA thread.

Sigh.

Okay, I'll bite.

What contradiction do you think you"ve discovered in my posts that you'd like to point out for me to account for?

 

[DynamicDidactic]

I really view all forms of gatekeeping, starting in undergrad through licensure, as the following: Cut off the super incompetent/unethical and then make the process onerous enough that it gets some people to drop out.

It is really hard to get below a C in most undergrad psych courses. You need to really not care or be unable to deal with college-level responsibilities (due to understandable reasons sometimes). After undergrad, there are a range of doctoral programs and some shhhhiiiiiittttttttyyyyy ones will take almost anyone. If you are willing to pay the tuition and put in the time you can get in. Again as long as you can maintain that B in grad school, do your clinical training without being super unethical, and get through your watered down milestones (e.g., review papers for a "dissertation"), you can get out. Lots of variation in internships with unpaid and unaccreddited at the bottom. Get there, do your time, and get out. Study and take the EPPP as much as needed. Go through the overly complicated licensure practice. Now you are a bona fide psychologist!

If you got the fortitude and are not super incompetent or unethical, you should be able to get through. Though, fortitude is a generally good way to weed out people. However, plenty will get through.

 

[futureapppsy2]

From the faculty POV, it can be an issue of "going broke little by little and then all at once," meaning that it's easy to think that issues can be resolved informally, the student never really quite gets how big of an issue it is or fails to make developmentally appropriate growth (e.g., they perform passably as a first-year but then are still performing at the same approximately level as a third-year), and then when a serious remediation plan needs to be implemented and developed, the student feels blindsided and gets resistant.

 

[StellaB]

What in the Days of Our Lives is going on in grad schools?!

Right?!?

 

[StellaB]

From the faculty POV, it can be an issue of "going broke little by little and then all at once," meaning that it's easy to think that issues can be resolved informally, the student never really quite gets how big of an issue it is or fails to make developmentally appropriate growth (e.g., they perform passably as a first-year but then are still performing at the same approximately level as a third-year), and then when a serious remediation plan needs to be implemented and developed, the student feels blindsided and gets resistant.

This, 100%. I also suspect (at least with regard to the internship I'm involved with) that sometimes the DCT doesn't formally document problems in the early phase - understandable, since you don't want to put unnecessary information into the student's permanent file - so by the time the student is going broke "all at once," the documentation is insufficient to substantiate dismissal, even if everyone involved knows that it's justified.

 

[PsyDr]

There were many abrasive figures in psychology. I wonder how many current day programs would kick them out, if they were around today.

 

[ClinicalABA]

The one standard, objective gatekeeping device that we have in our field (the EPPP) is woefully unrelated to the actual work we perform.

 

[WisNeuro]

The one standard, objective gatekeeping device that we have in our field (the EPPP) is woefully unrelated to the actual work we perform.

The main gatekeeping should occur well before this step. The EPPP, related or not, is not much of a gatekeeper given the high pass rates.

 

[StellaB]

The main gatekeeping should occur well before this step. The EPPP, related or not, is not much of a gatekeeper given the high pass rates.

Also unnecessarily cruel to wait so long into the process that people who are kept out are really up a creek financially.

 

[MCParent]

Also unnecessarily cruel to wait so long into the process that people who are kept out are really up a creek financially.

From the other side (of being admin)…. You really need a lot of evidence to gatekeep. How would faculty do it any faster? Even at the minimum, you’d needed data to identify the problem, give at least one chance at remediation, etc. that is months upon months. I’m not being flippant but genuinely asking. It would be great to do this easy and efficiently, but I also like not being sued.

I do appreciate the emphasis on gatekeeping, though I think some of the suggestions ate not really realistic for the system in which it is occurring.

 

[WisNeuro]

Also unnecessarily cruel to wait so long into the process that people who are kept out are really up a creek financially.

Cruelty indicates willful intent to cause harm, of which there is none in the case of the EPPP. Simply part of a variable system that lacks checks and balances at earlier steps.

From the other side (of being admin)…. You really need a lot of evidence to gatekeep. How would faculty do it any faster? Even at the minimum, you’d needed data to identify the problem, give at least one chance at remediation, etc. that is months upon months. I’m not being flippant but genuinely asking. It would be great to do this easy and efficiently, but I also like not being sued.

I do appreciate the emphasis on gatekeeping, though I think some of the suggestions ate not really realistic for the system in which it is occurring.

Also agree here. Generally speaking, at reputable programs, nearly all of the students are capable of handling graduate level academic work. Being removed for this reason is rare, as it should be given the difficulty of getting into a reputable program. The place where one would start to show deficiencies that would be an issue for public harm would be in their clinical work, which starts to occur later in the process. Particularity as you would need to see this person over a course of time (as very few people are "natural clincicians) to see that they are not progressing or benefiting from corrective feedback. So, really, the earliest there would be ample documentation in most programs would be roughly 3 years in for removal for clinical deficiency reasons.

 

[StellaB]

From the other side (of being admin)…. You really need a lot of evidence to gatekeep. How would faculty do it any faster? Even at the minimum, you’d needed data to identify the problem, give at least one chance at remediation, etc. that is months upon months. I’m not being flippant but genuinely asking. It would be great to do this easy and efficiently, but I also like not being sued.

I do appreciate the emphasis on gatekeeping, though I think some of the suggestions ate not really realistic for the system in which it is occurring.

Oh I fully understand that it’s not always possible or quick - especially when the problems areas are nuanced. But if something is serious enough to warrant direct confrontation with the student, it should be documented. Supervisors should be writing notes after every session, and the supervision contract should have language that clarifies how and when issues will be communicated to the DCT. Supervisors should also be completing standard ratings of trainees at pre-set intervals so that continuous problems can be identified and addressed early and consistently. In my experience, lapses in these basic best practices are often the reason trainees fall through the cracks. Some grad programs aren’t even set up to systematically track their students’ acquisition of relevant knowledge and skills, or their basic integrity and ability to follow the law and/or relevant ethics code(s).

 

[mdwpsyd]

This is a good and important topic. Thank you ExpertHoopJumper for sparking the discussion. In addition to the many excellent responses thus far, here are a couple of observations.

(1) The VA has had problems with not monitoring the performance of clinicians, let alone interns.

Rein, Lisa. “‘Devastating, tragic, and deadly’: VA leaders in Arkansas allowed impaired pathologist to harm hundreds of veterans, watchdog finds.” Washington Post (2 June 2021).

Off. Inspector Gen., Dep’t Veterans Affs. “Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas.” Report No. 18-02496 (2 June 2021).

Off. Inspector Gen., Dep’t Veterans Affs., "Comprehensive Healthcare Inspection Summary Report for Fiscal Year 2019," Report No. 20–01994–18 at 22–23 (24 November 2020). --> “… a significant number of licensed independent practitioners continued to deliver care without thorough evaluations of their practices. Reasons for noncompliance included leadership turnover, insufficient staffing, and lack of attention to detail.”

(2) Along the lines of what Fan_of_Meehl wrote, it seems that fear of attacks from the "woke police" might be a significant impediment these days.

(3) I wonder if VA's infamous risk-averse management ethos leads overseers to overrule internship faculty?

 

[WisNeuro]

As a quick point of clarification, I am no fan of the VA for clinicians. But, I do think that it unfairly gets a bad rap in the media. People look at articles like the ones above and assume that the VA is some hellscape for patients. Fact of the matter is that the VA is by far the most scrutinized healthcare system in the country. The It exists under a microscope that no other healthcare system does, and, as a result, many of it's issues come to light. It also exists as a political football, which magnifies that issue.

Bottom line though, as far as the outcomes literature, as bad as it is, the VA generally outperformed the vast majority of other healthcare institutions. And, having worked in a variety of settings, I can wholeheartedly say that VA patients receive far better care, on average, than any other system I have worked or had care in.

 

[WisNeuro]

This is a good and important topic. Thank you ExpertHoopJumper for sparking the discussion. In addition to the many excellent responses thus far, here are a couple of observations.

(1) The VA has had problems with not monitoring the performance of clinicians, let alone interns.

Rein, Lisa. “‘Devastating, tragic, and deadly’: VA leaders in Arkansas allowed impaired pathologist to harm hundreds of veterans, watchdog finds.” Washington Post (2 June 2021).

Off. Inspector Gen., Dep’t Veterans Affs. “Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas.” Report No. 18-02496 (2 June 2021).

Off. Inspector Gen., Dep’t Veterans Affs., "Comprehensive Healthcare Inspection Summary Report for Fiscal Year 2019," Report No. 20–01994–18 at 22–23 (24 November 2020). --> “… a significant number of licensed independent practitioners continued to deliver care without thorough evaluations of their practices. Reasons for noncompliance included leadership turnover, insufficient staffing, and lack of attention to detail.”

(2) Along the lines of what Fan_of_Meehl wrote, it seems that fear of attacks from the "woke police" might be a significant impediment these days.

(3) I wonder if VA's infamous risk-averse management ethos leads overseers to overrule internship faculty?

1) At least in MH, the VA monitors more than any other system I have seen. In other systems, generally the only thing they are tracking are RVUs.
2) No argument here.
3) I have only ever seen remediation plans and a removal in the VA. The VA is leagues ahead of most places in the training arena. There is actually a nice push to standardize assessment of trainee progress, as well as as provide clear, objective anchors to required APA training points. The VA is still the premier training ground for psychology.

 

[Sanman]

1) At least in MH, the VA monitors more than any other system I have seen. In other systems, generally the only thing they are tracking are RVUs.
2) No argument here.
3) I have only ever seen remediation plans and a removal in the VA. The VA is leagues ahead of most places in the training arena. There is actually a nice push to standardize assessment of trainee progress, as well as as provide clear, objective anchors to required APA training points. The VA is still the premier training ground for psychology.

You know, now that I think about it, that is true for me as well. Two additional thoughts from the supervisor end:

1. Most people are providing clinical supervision do it because A. they enjoy training and/or B. it is a mandated part of their job. The reason for this is that the majority of clinical staff assigned as supervisors are also providers under the gun for meeting their own metrics (quantity of patients seen, never quality). Given all that is required to fail a student, a supervisor needs to put in a lot of uncompensated time and effort in order to fix shortcomings or fail someone. Passing them along is simply the easiest thing to do. As psychologists, we should all understand the inevitable outcome of that behavioral nudge from many facilities.

2. With the way newer PsyD programs are operating (fewer in house clinics, less faculty, more reliance on community placements) there are fewer chances for a cohesive long-term view of the progress of a student by faculty that are paid for this stuff and more reliance on a patch work of clinicians that are busy seeing their own patients and managing their practices and clinics. At the end of the day, there needs to be funding to properly teach students. I try and do so as much as I can in my position, but these days even the VA is hammering people for productivity. Who has time to really ensure quality?

 

[cara susanna]

1) At least in MH, the VA monitors more than any other system I have seen. In other systems, generally the only thing they are tracking are RVUs.
2) No argument here.
3) I have only ever seen remediation plans and a removal in the VA. The VA is leagues ahead of most places in the training arena. There is actually a nice push to standardize assessment of trainee progress, as well as as provide clear, objective anchors to required APA training points. The VA is still the premier training ground for psychology.

Right, those articles mentioned were about services outside of mental health so it's a bit misleading IMO.

 

[Fan_of_Meehl]

Right, those articles mentioned were about services outside of mental health so it's a bit misleading IMO.

I don't think I've ever encountered anything more complicated than mental health service delivery in a VA setting.

With some veterans, when you take 'the foot off the gas' (so to speak) with regard to structure in psychotherapy, they come around, and actually engage more directly in the primary task of therapy (self-reflection/monitoring, self-change).

It's a difficult art to learn, when to apply pressure, when to let up.

And, then...of course, you have the monitors from the rafters rating you on 'progress.'

 

[Mercury in Taurus]

I did question and push back during these interns' "research" presentations. One presented on emotional support animals (a big issue in that VA) and when I asked to see the quantitative data/findings, rather than the slick websites of training companies and testimonials, I was accused of being rude among other things. This intern did not understand even correlation and could not competently evaluate scientific literature.

I did not, however, say anything regarding their clinical practice. Both of the interns to which I refer were not in my niche (neuropsych), so that likely made it less pressing to me. Or perhaps I was less confident in my own abilities in those areas at the time. Either way, on multiple occasions basic principles of clinical work were unknown or misunderstood by these interns, and no one said anything publicly.

In this profession we have committed to, self-development is a continuous process that requires us to take feedback sincerely and self-reflect. During my internship, all of us received some feedback from two supervisors delivered in very harsh ways that at times sounded like insults. Taking feedback personally and sincerely, we had to work through our hurt feelings. With a learning attitude, people would take your feedback sincerely, self-reflect, decide what is helpful, and thank you for helping them identify growth area(s). If your feedback is rejected without self-reflection and exploration of the message, regardless of the perception of the delivery, that is a reflection of the attitude of recipients.

I often receive Amazon deliveries in damaged boxes. As long as the items are good, I throw out the boxes and keep the items. Has anyone ever return their stuff because the boxes were broken? Even a message perceived to be "rude," it may still be helpful.