Practicum Practices: Unethical or just unusual?

[Grenth]

I'm a second-year clinical psych PhD student at a reputable university program Typically students in my program don't start practicum until year 3. However, because I came into my program with some clinical experience I got permission from our clinical director to do a special practicum at a university counseling center 20 hrs (10-12 direct contact) a week. This is not a typical site for practicum as all the staff are master's level only. I'm one of the only students they've had there. I receive supervision from an LMHC once a week and supervision from a psychologist in my department every other week.

Since I've started I've really enjoyed my experience. The staff are kind and supportive and I'm getting a good jump on my contact hours. However, I feel the clients might not be getting evidence-based or even ethical care and I'm uncomfortable with this. I don't want to make a big deal about nothing especially because the other student clinicians (master's level) have told me they think clinical psychology students can come across as snobby.

I'm wondering where is the line between "just not how I would do it" and "this is not acceptable practice" is? Examples of things that concern me
-A licensed staff member advertises as balancing chakras as part of treatment
-A different licensed staff member uses astrology for case formulation and treatment
-A master's level intern gave a case presentation where he was treating a clear-cut (basically by the book) case of MDD as Anorexia based on lack of appetite alone. This is one of many, many examples of almost non-existent knowledge of diagnostic work or treatment planning
-Trauma is treated only with a proprietary workshop based treatment method that is basically not represented in trauma literature (only papers are by the person selling the workshop)
-Diagnoses are actively discouraged as "labels" and "harmful"

I'm not concerned about myself. My own work is mostly CBT/ACT and my supervisors are supportive of my process and give helpful feedback. However, when I brought up my concerns to my psychologist supervisor he basically said "that's just how master's level clinicians are. Just ignore them and act like a psychologist". But I feel uneasy knowing students are seeking help and getting wrong or unscientific help.

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[psych.meout]

Yikes, that sucks.

This kind of thing is why I'm wary of some of the ideas put forth by people in the PCSAS movement. They rightfully complain about the poor rigor, scientific training, and clinical skills from many of the PsyD programs, but then they also complain about the APA and psychologists in general for acting like a "guild" and trying to protect their clinical jobs from mid-levels. They tell psychologists and doctoral students that they should just resign themselves as having lost those jobs, which the PCSAS people don't even really seem to care about in the first place, because they appear to think being clinicians is beneath them.

How can they complain about the PsyD programs, but not apply the same scrutiny when stuff like what you are talking about happens with mid-level practitioners. I'm not saying that all mid-level providers act like this, but they receive far less training in science than PhD or PsyD students to the point that it's difficult to ensure ethical, professional practice. Yeah, we can train them in highly manualized therapies, but without the science training, they don't have the more fundamental basis to prevent them from straying off the farm into this pseudoscience or other unprofessional practices.

 

[Grenth]

Yikes, that sucks.

This kind of thing is why I'm wary of some of the ideas put forth by people in the PCSAS movement. They rightfully complain about the poor rigor, scientific training, and clinical skills from many of the PsyD programs, but then they also complain about the APA and psychologists in general for acting like a "guild" and trying to protect their clinical jobs from mid-levels. They tell psychologists and doctoral students that they should just resign themselves as having lost those jobs, which the PCSAS people don't even really seem to care about in the first place, because they appear to think being clinicians is beneath them.

How can they complain about the PsyD programs, but not apply the same scrutiny when stuff like what you are talking about happens with mid-level practitioners. I'm not saying that all mid-level providers act like this, but they receive far less training in science than PhD or PsyD students to the point that it's difficult to ensure ethical, professional practice. Yeah, we can train them in highly manualized therapies, but without the science training, they don't have the more fundamental basis to prevent them from straying off the farm into this pseudoscience or other unprofessional practices.

Funny you should mention that because I'm actually in clinical scientist identified program, although the talk is of switching to scientist practitioner model. I agree with your points about mid-level providers. I've been told about how therapy is an art not a science so many times by them and it's frustrating. Of course, I know many many good mid-levels but the anti-science or pseudoscience attitude is seemingly pervasive because of the lack of science training leads some to discomfort with and fear of science.

 

[smalltownpsych]

I'm a second-year clinical psych PhD student at a reputable university program Typically students in my program don't start practicum until year 3. However, because I came into my program with some clinical experience I got permission from our clinical director to do a special practicum at a university counseling center 20 hrs (10-12 direct contact) a week. This is not a typical site for practicum as all the staff are master's level only. I'm one of the only students they've had there. I receive supervision from an LMHC once a week and supervision from a psychologist in my department every other week.

Since I've started I've really enjoyed my experience. The staff are kind and supportive and I'm getting a good jump on my contact hours. However, I feel the clients might not be getting evidence-based or even ethical care and I'm uncomfortable with this. I don't want to make a big deal about nothing especially because the other student clinicians (master's level) have told me they think clinical psychology students can come across as snobby.

I'm wondering where is the line between "just not how I would do it" and "this is not acceptable practice" is? Examples of things that concern me
-A licensed staff member advertises as balancing chakras as part of treatment
-A different licensed staff member uses astrology for case formulation and treatment
-A master's level intern gave a case presentation where he was treating a clear-cut (basically by the book) case of MDD as Anorexia based on lack of appetite alone. This is one of many, many examples of almost non-existent knowledge of diagnostic work or treatment planning
-Trauma is treated only with a proprietary workshop based treatment method that is basically not represented in trauma literature (only papers are by the person selling the workshop)
-Diagnoses are actively discouraged as "labels" and "harmful"

I'm not concerned about myself. My own work is mostly CBT/ACT and my supervisors are supportive of my process and give helpful feedback. However, when I brought up my concerns to my psychologist supervisor he basically said "that's just how master's level clinicians are. Just ignore them and act like a psychologist". But I feel uneasy knowing students are seeking help and getting wrong or unscientific help.

Fairly typical of what I have seen with many midlevels. I think your supervisor is basically correct. You could always confront them like some of the other “snobby psychologists in training” have, but that would only serve to validate their pre-existing beliefs. I have found that many midlevels are actually eager to learn and as I gained skill and expertise and demonstrated superior skills as in patient retention and outcomes, as well as clear diagnostic and conceptual skills, then they would begin seeking advice.

 

[Grenth]

Fairly typical of what I have seen with many midlevels. I think your supervisor is basically correct. You could always confront them like some of the other “snobby psychologists in training” have, but that would only serve to validate their pre-existing beliefs. I have found that many midlevels are actually eager to learn and as I gained skill and expertise and demonstrated superior skills as in patient retention and outcomes, as well as clear diagnostic and conceptual skills, then they would begin seeking advice.

Thanks, that's good to hear. I have already seen some evidence of some of the other staff, especially my site supervisor valuing my clinical perspective and seeking me out for complex cases and I would not consider myself anywhere remotely close to skilled, expert, or superior.

 

[MCParent]

Someone needs to make a big deal about it, but I don’t think it has to be/should be you. This sounds like more than an isolated incidence of stupid. It is something the Dean of Students (or whatever Dean oversees the CC) needs to look into with consultation from the director of a CC at a different university. This is much more than a complaint from you is capable of getting at. IMO this sounds like investigation-level malpractice.

I would start by documenting and consulting with your faculty.

 

[temppsych123]

Agreed with MCParent; document document document and consult consult consult. You're new to the environment, and who knows how much backstory there is between this location, their staff, folks affiliated with your program, etc. Your department supervisor should be a useful sounding board to discuss these issues that's not embedded in your training site.

 

[futurecatlady]

Agreed with above. Your DCT or practicum supervisor is probably the best bet for confronting them, if it comes to that.

I was also in a similar experience with a practicum placement in the community that was pitiful. My perspective about ESTs was not valued, and I was seen as the lowly student by the mid-level practitioners who wanted to treat everything under sun with EMDR and validation. However, I was able to demonstrate that I knew my stuff about suicide prevention to the point that they took me up on my offer on giving a few presentations on it. They saw it as a learning opportunity for me with nothing to lose for them.

Maybe you could offer a presentation on something the is clinically relevant for them but doesn't step on their toes? Such a presentation is also a line on your CV...

 

[Grenth]

Thanks so much for the feedback everyone. This is a dumb question but what exactly should I be documenting? Just everything that strikes me as problematic? Of course, I already keep notes for my own clients and supervision.

I'll try to talk about this with my DCT because there is some tense history between my program supervisor and the site supervisor which might explain my program supervisor's attitude.

 

[temppsych123]

For documenting: date, time, location, person you spoke to, what they said (as best as you recall) or what you observed/witnessed, if anyone else was present. If you said or did something, document that, as well as anyone else's responses to you.

 

[deleted343839]

Today, as a licensed psychologist, I would have no problem complaining to institutional administration and to the licensing board for practices like what you described. As a trainee, though, I would have tread more lightly. I would definitely talk to your DCT about how to handle the situation ethically.

IMO these kinds of sites do not make for good first external practica. Of course you could not have anticipated this going in, but for next year look into well established sites that will not only provide cases but will help develop your professional identity as a psychologist. I think it's important, especially in early practica, to work in settings where psychologists are actually part of the delivery system (i.e., you are supervised by an on-site psychologist). You need strong, consistent examples of what TO DO first.

 

[Grenth]

Today, as a licensed psychologist, I would have no problem complaining to institutional administration and to the licensing board for practices like what you described. As a trainee, though, I would have tread more lightly. I would definitely talk to your DCT about how to handle the situation ethically.

IMO these kinds of sites do not make for good first external practica. Of course you could not have anticipated this going in, but for next year look into well established sites that will not only provide cases but will help develop your professional identity as a psychologist. I think it's important, especially in early practica, to work in settings where psychologists are actually part of the delivery system (i.e., you are supervised by an on-site psychologist). You need strong, consistent examples of what TO DO first.

Thank you for the advice. I am going to talk to my DCT.

Next year I plan on applying at sites (AMCs mostly) that are as you describe and have psychologists on site and integral. The site I'm at now is the only one approved by my program that does not meet that standard because typically it's a supplemental practicum. The reason it isn't for me is that I was allowed to take an early placement due to previous clinical experience and so I didn't go through the usual process of selecting and interviewing at different sites but was rather directly assigned this site.

 

[procrastin8r]

-A licensed staff member advertises as balancing chakras as part of treatment
-A different licensed staff member uses astrology for case formulation and treatment

This just made my day! I honestly thought you were trolling at first =) YIKES doesn't begin to cover it. I would talk to DCT, not because I expect any meaningful changes, but because it's important that the sheer unethical incompetence doesn't mar your record. You don't know what kinds of rep the practicum site has and how having worked there may affect you in the future. So, it's important to let your outrage be known, so that it makes for a nice ethical dilemma narrative, and doesn't project the image that you're on board with this. You DCT may also nix this site for future practicum students, saving them a lot of heartache.

 

[MCParent]

not because I expect any meaningful changes

I dunno. Get the DCT to get the Dean to consult w a UCC director at a big, peer uni. There are LOTS of issues about making sure people with suicidal ideation, potential for violence, eating disorders, etc., do not slip through the cracks of UCCs and families sue the uni (on top of the obvious bad stuff that might happen to students). Those practices are going to miss someone some day soon and something bad is going to happen.