Competencies for Psychologists in Academic Health ... - Springer Link

J Clin Psychol Med Settings (2008) 15:18–27 DOI 10.1007/s10880-008-9094-y

Competencies for Psychologists in Academic Health Centers (AHCs) Nadine J. Kaslow Æ Sarah E. Dunn Æ Chaundrissa Oyeshiku Smith

Published online: 6 February 2008 Ó Springer Science+Business Media, LLC 2008

Abstract This paper begins by providing the landscape that undergirds the competency-based movement within professional psychology education, training, credentialing, and performance appraisal. Attention is then paid to the relevance of this culture shift for psychologists working as practitioners, educators, researchers, and administrators in AHCs. In this regard, there is an articulation of the essential subcomponents of each of the core foundational and functional competency domains that are salient for AHC psychologists. Implications of the competency-based movement for professional psychologists in AHCs are offered. Keywords Competencies Academic health centers Psychologists

Kaslow, 2004; Kaslow et al., 2004; Kaslow, Celano, & Stanton, 2005; Peterson, 2003; Rubin et al., 2007), yet there has been a dearth of attention paid to competencies for psychologists in academic health sciences centers (AHCs). In order to foster a culture of competence for AHC psychologists, it is important to have an appreciation of the relevant landscape. Thus, this paper begins by reviewing briefly the competency-based movement within professional psychology. Then, given that the practice of professional psychology in AHCs is influenced markedly by broader changes within the United States health care system (Reed, Levant, Stout, Murphy, & Phelps, 2001), attention shifts to some of these key health care system developments. Competency Movement

Introduction In recent years, the zeitgeist in professional psychology education and training, practice, and credentialing has increasingly become a competency-based culture (Bourg et al., 1987; Bourg, Bent, McHolland, & Stricker, 1989; This paper is based in part on the first author’s plenary address at the Association of Psychologists in Academic Health Centers Midwinter Meeting in Minneapolis, Minnesota, May 2007. N. J. Kaslow (&) C. O. Smith Department of Psychiatry and Behavioral Sciences, Grady Health System, Emory University School of Medicine, 80 Jesse Hill Jr. Drive, Atlanta, GA 30303, USA e-mail: [email protected] S. E. Dunn Department of Psychology, Georgia State University, Atlanta, GA, USA

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Defining competencies, setting competency based standards, and conducting competency-based assessments is congruent with the current emphasis in other health professions (Epstein, 2007; Hoge et al., 2005; Leigh et al., 2007). Psychology as a profession considers competence to be one of its core values. To be considered ethical, psychologists are required to practice within the limits of their competence (American Psychological Association [APA], 2002) and to be certified by credentialing and regulatory boards as being competent and maintaining this competence. A focus on competencies assists the public in understanding the roles and responsibilities of psychologists. Definitions Although it may be easier to ascertain if a person is competent than to describe the construct (Kitchener, 2000),

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considerable attention has been paid to characterizing the term and three definitions that have been useful are the following. First, according to the dictionary (Oxford English Dictionary, 2006), competence refers to a ‘‘state of sufficiency in a given context or environment’’. As such, within professional psychology, it denotes an individual’s capability and demonstrated ability to comprehend and perform certain tasks appropriately and effectively and in a fashion that is consistent with the expectations for an individual qualified by education, training, and credentialing (Kaslow, 2004). It is not an absolute or static process, but rather a dynamic process that entails continual professional development. Second, competence can be viewed as knowledge, skills, and attitudes, and their integration. Third, a more elaborated definition has been presented and is as follows: Competence includes the ‘‘habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served’’(Epstein & Hundert, 2002) (p. 226) ... It involves ‘‘habits of mind, critical thinking and analysis, professional judgment in assessing situations and ascertaining appropriate responses, and evaluating and modifying decisions via reflective practice’’ (p. 227). A competency of a higher order, a metacompetency, has been used to describe the general ability to learn and apply competencies effectively in many difference aspects of a person’s activities (Fleming, 1993). It also refers to the ability to assess what one knows and does not know. This construct plays a key role in the emergence and maintenance of competence. It is necessary to manage the myriad responsibilities involved in ensuring the ongoing acquisition and maintenance of competence through the professional developmental life cycle. Competency refers to the minimal threshold expected for an individual to move to the next level of training or practice rather than proficiency, expertise, or capacity. When determining competency components and performance levels, delineation of the knowledge, skills, and attitudes that comprise the competence (i.e., benchmarks) is required. Benchmarks, behavioral indicators associated with each domain that provide descriptions and examples of expected performance at each developmental stage, are standards of measurement for performance that can be used for comparison and to identify where needs for improvement exist. Benchmarks must be both delineated carefully and measurable concretely to determine if the competence has been reached (Carraccio, Wolfsthal, Englander, Ferents, & Martin, 2002). Recently, the American Psychological Association (APA) commissioned an Assessment of Competency Benchmarks Workgroup to identify essential components, behavioral anchors, and assessment methods for the foundational and functional competencies over

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the formal education and training sequence (Kaslow et al., 2006).

Foundational and Functional Competencies There has been a growing focus on developing competence within the core foundational and functional domains, with attention paid to developmental levels of performance within each domain (Rodolfa et al., 2005). The major foundational domains of competence, depicted in the competency-cube (Rodolfa et al., 2005) and expanded upon since then, may be considered cross-cutting. These include: professionalism (Elman, Illfelder-Kaye, & Robiner, 2005; Stern, 2006), reflective practice (Belar et al., 2001; Elman et al., 2005; Hatcher & Lassiter, 2007), scientific knowledge/methods (Bieschke, Fouad, Collins, & Halonen, 2004), relationships, individual and cultural diversity (APA, 2003, 2004, 2007; Arredondo et al., 1996; Division 44, 2000), ethical-legal standards and policies (de las Fuentes, Willmuth, & Yarrow, 2005), and interdisciplinary systems. There also has been discussion about the definition, education/training, and assessment of competence in the functional domains. The functional core competencies for professional psychology portrayed in the competency cube and added to more recently include: assessment (Krishnamurthy et al., 2004), intervention (Spruill et al., 2004), consultation (Arredondo, Shealy, Neale, & Winfrey, 2004), research/evaluation (Bieschke et al., 2004), supervision (Falender et al., 2004; Falender & Shafranske, 2004, 2007), teaching, administration, and advocacy.

Assessing Competence Considerable attention has been paid to effective strategies for assessing competence (Bandiera, Sherbino, & Frank, 2006; Kaslow et al., 2007b; Roberts, Borden, Christiansen, & Lopez, 2005). Principles to guide the assessment of competence in educational, training, credentialing, and life-long learning contexts have been offered (Kaslow et al., 2007b). These principles highlight the fact that the career-long assessment of competence requires a major culture shift and it is time to embrace a culture of the assessment of competence. Assessing competence fosters learning and provides direction and motivation for future learning and professional development. It evaluates progress, assists in developing curriculum and training program effectiveness, guides the selection of individuals for advanced education and training in professional psychology, and advances the field. Further, assessing competence protects the public by providing quality

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psychologists, serves a gatekeeping function in which individuals with competence problems are screened out if they can not be remediated, and meets public expectations of regulation of the profession (Epstein, 2007). Competencies must be conceptualized as generic, wholistic, and developmentally appropriate abilities. A developmental perspective that is sensitive to individual and cultural diversity and contextual factors must underlie the assessment of competence. Assessments should be repeated and ongoing. Assessments should incorporate formative and summative evaluations of generic and specialty foundational and functional competencies. These evaluations must reflect fidelity to practice and incorporate reliable, valid, and practical methodologies and utilize a multi-trait, multi-method, multi-informant process across a variety of contexts. These strategies may include, but not be limited to, case presentations, competency evaluation rating forms, consumer surveys, faculty/supervisor/peer review, objective structured clinical examinations with or without standardized patients, portfolio reviews, ratings of live or recorded performance, record review, self-assessment, simulations and role play, standardized client/patient interviews, oral examinations, written examinations, and multisource (360°) evaluations (Leigh et al., 2007). Attention must be paid, via multimodal assessments, to interpersonal functioning, professional development, and ethical practice. There should be consistency in the strategies used to evaluate competencies across the various phases of the education, training, and credentialing sequence. Given that self-reflection and self-assessment are key elements of the assessment of competence, these need to be taught and valued highly. In addition to determining whether or not one is competent and meets the minimum threshold expected for an individual to progress to the next level of training or credentialing, it is important to assess for capability (i.e., extent to which competent individuals can adapt their skills to new contexts and situations, generate new knowledge, and continue to enhance performance in the face of challenge) (Fraser & Greenhalgh, 2001; Stephenson & Yorke, 1998). When competence problems are identified through assessment, strategies need to be in place for their remediation and management, an area of burgeoning interest (Huprich & Rudd, 2004; Kaslow et al., 2007c; Lamb & Swerdlik, 2003; Oliver, Bernstein, Anderson, Blashfield, & Roberts, 2004; Rosenberg, Getzelman, Arcinue, & Oren, 2005; Vacha-Haase, Davenport, & Kerewsky, 2004). Finally, evaluators must be trained in appropriate strategies for the ongoing assessment of competence. The literature on the assessment of competence has been mindful of the challenges inherent in shifting towards a culture of competence and its evaluation (Lichtenberg et al., 2007). Key challenges include, but are not limited to,

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the following. There has been an historical lack of consensus with regard to foundational and functional competencies, particularly at the level of essential subcomponents of these competencies. There have been limitations in the assessment armamentarium and a lack of a multi-tiered process of credentialing that incorporates valid and high fidelity assessments. Concerns exist regarding evaluative rigor and inconsistencies, as well as dual roles for educators and trainers. The profession has neglected the assessment of the maintenance of competence of those already licensed. There are limited resources, institutional buy-in, and support for implementing a competency-based approach to education, training, credentialing, and assessment.

Competency Movement and Psychologists in AHCs To date, most of the efforts in the competency-movement in professional psychology have been generic. Only recently, has attention been paid to the essential components of the core competencies in professional psychology specifically relevant to psychologists training and practicing in AHCs. An appreciation of the essential components of the core competencies pertinent for AHC psychologists must be based on an understanding of the current culture in AHCs. Following a brief review of this backdrop, there will be a discussion of competencies for psychologists in AHCs. This will begin with a perspective about the distinctiveness, or lack thereof, of competencies and their essential components for AHC psychologists. Then, there will be a delineation of essential components of the core foundational and functional competencies that may be particularly pertinent for psychologists practicing in AHCs.

Backdrop Health Care System and AHCs The health care system is being transformed in terms of the perceptions of health, wellness, and the prevention of illness. Consumer attitudes, perceptions, and behavior have significantly impacted the health care system (Schulte, Isley, Link, Shealy, & Winfrey, 2004). There is growing recognition of the value of a biopsychosocial perspective for providing health care for the whole person and the need to integrate mental and behavioral health services with medical services to offer a comprehensive, preventive, and cost-effective primary health care system (Frankel, Quill, & McDaniel, 2003; Kaslow et al., 2007a). The passage of the Health Care Safety Net Amendment of 2002 underscores the central role that psychologists, experts in


behavioral health, can play in offering primary care and other medical services. This act redefines psychology to allow increased flexibility in meeting the public’s needs by adding behavior to mental health, replacing the term clinical psychologist with health service psychologist, and defining psychologists as primary care providers. The Health and Behavior Codes now provide reimbursement for psychological services beyond the provision of traditional mental health care. A number of recent reports serve as key elements for the backdrop of conceptualizing the competency-based movement for psychologists based in AHCs (Belar, 2004). For instance, the Commonwealth Fund Task Force on Academic Health Centers, Envisioning the future of academic health centers (The Commonwealth Fund Task Force on Academic Health Centers, 2003) and the Institute of Medicine’s (IOM) report on Academic health centers: Leading to change in the 21st century (Institute of Medicine [IOM], 2003a) provide a framework for transforming the roles of AHCs with regard to education, patient care, and research, as well as for creating an environment for innovation. The IOM report, To err is human: Building a safer health system (IOM, 1999), offered a comprehensive approach to improving patient safety. Ways to alter the education and training of the health care work force to enhance safety and ensure that care is delivered competently and to a high standard were presented in subsequent IOM reports entitled, Crossing the quality chasm: A new health system for the 21st century (IOM, 2001), Health professions education: A bridge to quality (IOM, 2003b), and Improving medical education: Enhancing the behavioral and social science content of medical school curriculum (IOM, 2004).

Other Health Professions and Competencies In addition, there has been an explosion of interest in other health care professions (medicine, dentistry, nursing) with regard to the definition of, training for, and assessment of competencies (Accreditation Council for Graduate Medical Education [ACGME] and American Board of Medical Specialties [ABMS], 2000; Epstein, 2007; Leigh et al., 2007). For example, medicine has agreed upon the following core competencies for residents: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (www.acgme.org/outcome). These have now been adapted for each medical specialty area (Andrews & Burruss, 2004). Further, recommendations for competencies for all health care professionals have been proffered. The Pew Commission recommended competencies for health care

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professionals to meet the changing needs of patients and the public and the 17 competencies are summarized under the following rubrics: care for the community’s health, provide contemporary clinical care, participate in the emerging system and accommodate expanded accountability, ensure cost-effective care and use technology appropriately, practice prevention and promote healthy lifestyles, involve patients and families in the decisionmaking process, and manage information and continue to learn (O’Neill, 1993; Shugars, O’Neil, & Bader, 1991). The IOM has promulgated the following core competencies for all health professions: patient-centered care, informatics, interdisciplinary teamwork, evidence-based care, and improving quality of care (IOM, 2003b).

Competencies for Psychologists in AHCs Distinctive Competencies for AHC Psychologists In considering competencies for AHC psychologists, it is important to address the question of whether or not there are core competencies or essential components thereof that are different for AHC psychologists versus psychologists practicing in other settings. A review of the literature and an examination of practice patterns suggest that the foundational and functional competencies identified as core to professional psychology are the same as those for psychologists in AHCs. There do not appear to be any foundational or functional competencies or essential components of these competencies that are distinctive to psychologists in AHCs. However, it is reasonable to argue that there are essential components of each of the foundational and functional competencies that are particularly important for psychologists in AHCs to possess. Further, certain competency essential components may be more relevant in AHCs than in other settings. In addition, the essential components that are most relevant may vary depending on the psychologists’ particular roles and settings of practice within AHCs (e.g., pediatrics, health, primary care, and neuropsychology).

Foundational Competencies This section first discusses the core foundational competencies and the essential components of each of these competencies that are generic to the overall practice of professional psychology. Then, essential subcomponents that may be especially relevant for psychologists in AHCs are noted. The essential components of professionalism that are generic to all professional psychologists include: integrity,

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deportment, accountability, concern for the welfare of others, and professional identity. AHC psychologists must remember that the core values of professionalism, i.e. the social contract between the professional and society, are scientific expertise and altruism; demonstration of respect, compassion, responsibility, accountability, honesty, and excellence; and respect for the patient’s dignity, privacy, and confidentiality in the delivery of health care. AHC professionals must convey a responsiveness to the needs of patients, their families, and society that supersedes selfinterest; and be accountable to patients, their families, society, and the profession. Psychologists in AHCs must be committed to providing humane, compassionate, and socially responsible care to individuals with medical and mental illnesses and their families and demonstrate concern about health care quality and safety. They must be aware and respectful of the AHC culture and mindful of their roles as AHC psychologists within a medical environment. Under the rubric of reflective practice are the following essential components that are generic to all professional psychologists: self-reflection and self-care. AHC psychologists must routinely engage in self-assessment related to their own competence in delivering services to patients in AHCs, producing scholarship, and educating psychology and other health professional trainees (Belar et al., 2001). These self-assessments should focus on strengths and areas of growth and lead them to seek out and utilize appropriate consultation to bolster their competence. AHC psychologists must apply science to the systematic education, training, and assessment of themselves and to the reflective practice of psychologists and other health care providers. It behooves them to be responsive to and nondefensive about feedback from their interdisciplinary cadre of colleagues and the patients they serve. In addition, psychologists in AHCs should engage in self-care activities that attend to the integration of their physical and mental well-being (Baker, 2003) and manage their personal stress so that it minimizes its negative impact on their work. Scientific mindedness and familiarity with both the scientific foundations of psychology and the scientific foundations of professional practice are the essential components of scientific knowledge-methods that are generic for all professional psychologists. Psychologists in AHCs must locate, appraise, and assimilate evidence from scientific studies related to patients’ health/mental health problems and use critical thinking to guide all professional activities. They must use information technology to support patient care decisions and patient education. In addition, they must serve as a representative on interdisciplinary teams that underscores the relevance of the science base. The requisite essential components for the generic level of practice for the foundational competency domain of relationships include developing and sustaining adaptive

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interpersonal interactions, including intradisciplinary interactions; appropriately managing affect; and effectively communicating. Psychologists in AHCs must create and sustain a therapeutic and ethically sound relationship with patients with medical and/or mental illnesses and their families and utilize a strength-based approach in these encounters. They must communicate effectively and demonstrate caring, humane, and respectful behaviors when interacting with patients and their families, colleagues, and trainees. It is advisable for them to assume a collaborative stance in their interactions with a diverse array of people throughout the AHC setting and develop effective strategies for managing interpersonal conflict. It is imperative that they prioritize the importance of being a good team player. The essential components of the foundational competency domain of individual and cultural diversity that are generic to all professional psychologists are: recognizing that self is shaped by individual and cultural diversity, understanding that others are shaped by individual and cultural diversity, being aware that interactions between self and others are shaped by individual and cultural diversity, and applying their craft in a fashion that takes into account individual and cultural diversity considerations. Psychologists in AHCs must demonstrate knowledge about and sensitivity and responsiveness to patients’ culture, age, gender, sexual orientation, social class, religion, country of origin, and ability status as related to symptom presentation, diagnosis, assessment, intervention, consultation, and health, etc. They must convey an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and interventions. At the generic level of the ethical–legal standards-policy foundational competence, the essential components are ethical, legal, and professional standards and guidelines; ethical decision-making; and ethical conduct. For psychologists working in AHCs, the essential subcomponents of this core competency include familiarity with hospital bylaws, credentialing and privileges, staff responsibilities, documentation, and the standards set forth by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO). It is important for them to understand the rules, regulations, policies, procedures, ethics, etiquette, and traditions of the complex health system environment (Rozensky, 2006). In addition, they must demonstrate a commitment to ethical principles pertaining to the provision or withholding of clinical care, confidentiality of patient information and the Health Insurance Portability and Accountability Act (HIPAA), informed consent, team functioning, and business practices. They also must understand the major ethical dilemmas, particularly those


that arise at the beginning and end of life and those that emerge from the rapid expansion of knowledge of genetics, health care alternatives, etc. Further, they must be knowledgeable about legal issues in health care, mindful of possibilities of shared liability, and practice within the scope of their license. The essential components of the foundational competency of interdisciplinary systems that are generic to all professional psychologists include: familiarity with shared and distinctive contributions of other disciplines, effective multidisciplinary and interdisciplinary team functioning, and productive interactions with individuals from other disciplines. To function productively as a member of an interdisciplinary team, psychologists must be capable of working in primary, secondary, and tertiary medical care contexts (Tovian, 2004). Psychologists in AHCs who demonstrate interdisciplinary system effectiveness are those who discriminate individual from discipline differences, communicate clearly with other health care providers, collaborate with health care professionals from other disciplines to provide patient and family focused care, engage in interdisciplinary team work, and balance confidentiality with cooperation and collaboration. In addition, they partner with health care managers and providers to assess, coordinate, and improve health care and know how these activities can affect system performance. They ensure that the social and community contexts are taken into account in the delivery of health care. Psychologists in AHCs also understand the health needs of the community and how they are prioritized.

Functional Competencies In the following section, the core functional competencies are focused on and the essential components of each of these competencies that are generic to the overall practice of professional psychology are discussed. This is followed by a delineation of the essential subcomponents that may be especially relevant for psychologists in AHCs. In terms of the core functional competence of assessment, the essential components for professional psychologists include knowledge and application of measurement and psychometrics, evaluation methods, multiaxial diagnosis, conceptualization and recommendations, and communication of findings. There are a number of essential subcomponents of the assessment competence that are particularly pertinent for psychologists in AHCs. They need to gather essential and accurate psychosocial information about medically and psychiatrically ill patients, including issues related to diversity characteristics. They need to conduct interdisciplinary assessments that attend to health promotion, health risk, health

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outcome, and quality of life. It is important for them to consider the biological, cognitive, behavioral, developmental, and sociocultural components of health and illness. Also, it is imperative that they be mindful of the interaction of mental and physical health in making assessments and diagnoses and in conceptualizing cases. It is useful for them to bring a focus on strengths, resilience, and wellness to the assessment process. Psychologists working in AHCs must make informed decisions about diagnoses and therapeutic interventions based on patient information and preferences, current scientific evidence, and clinical judgment and they must communicate their assessment findings, diagnosis, and case conceptualizations clearly with patients, families, and their colleagues representing multiple disciplines. Scientific, theoretical, and contextual basis of interventions; planning; implementation; and evaluation are the essential components of the intervention functional competency that are generic to all professional psychologists. Within AHCs, psychologists who are competent at intervention acquire knowledge and skill in implementing evidence-based interventions for the prevention and treatment of the most common psychological problems that cooccur with medical conditions. They attend to patients’ and family members’ beliefs and preferences in determining and carrying out interventions, which includes shared decision-making and more focus on primary prevention. Psychologists in AHCs develop, negotiate, and carry out patient care plans for medically and psychiatrically ill individuals that are mutually acceptable to the patient, family, and health care team, while also making use of the best available evidence. These plans should use conventional and complementary/alternative approaches and embody a holistic viewpoint by considering body, mind, spirit, and all aspects of lifestyle (Kligler et al., 2004). They also should be crafted and implemented in a fashion that is consistent with guidelines related to multiculturalism (APA, 2003), age (APA, 2004), sexual orientation (Division 44, 2000), and gender (APA, 2007). It is essential that AHC psychologists utilize a model of collaborative patient and family health care by providing psychosocial education to medically and psychiatrically ill patients and their families, offering interventions that both enhance motivation and adherence, and presenting interventions aimed at preventing illness and maintaining health. Further, in addition to having key responsibility for the direct provision of interventions, psychologists in AHCs must be involved in the development and implementation of interventions in these settings (Smith, Orleans, & Jenkins, 2004). The essential components of the consultation functional competency domain necessary for all practicing psychologists to possess include knowledge about the role of the

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consultant, assessment of referrals, application of methods, and communication of findings. Within AHCs, psychologists gain exposure to different consultation–liaison models, are knowledgeable about other disciplines integrally involved in the provision of medical care, establish liaison relationships with individuals from different disciplines and departments, engage in interprofessional collaboration, are key members in teams, and aid in care coordination. They co-create an integrated treatment plan; provide a psychosocial framework for conceptualizing and intervening with the patient and family; advocate for integrated, biopsychosocial, quality patient care and collaborative family health care (McDaniel & Campbell, 1996); assist patients in dealing with system complexities; actively aid patients and families with end-of-life decisions; and evaluate consultation outcomes. These psychologists understand how patient care and other professional practices affect other health care professionals, the health care organization, and the larger society. In addition, they know how types of medical practice and delivery systems differ from one another. Further, they provide cost-effective health care and resource allocation that does not compromise quality of care. A scientific approach to knowledge generation and the application of scientific methods to practice are the two essential components of the research/evaluation functional competency domain that all practicing psychologists are expected to possess. The essential subcomponents of this domain particularly valuable for AHC psychologists include the: creation of new knowledge regarding behavior and health, both physical and nonphysical; utilization of evidence-based practice guidelines for individuals with significant medical and/or psychiatric problems (APA, 2006); application of knowledge of appropriate study designs and statistical methods; and the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness to be used in the AHC context. Further, they may conduct research on the interface of mental and physical health and illness and engage in empirical investigations related to health services research and clinical trials. They may be involved in devising developmentally, culturally, and gender informed evidence-based approaches to working with medically ill individuals and their families. In addition, AHC psychologists may participate in the evaluation of the effectiveness of biopsychosocial intervention and prevention programs implemented in their health care systems. Supervision marks the next functional competency domain. Competent supervisors are knowledgeable about supervision expectations, roles, procedures, and processes and apply these effectively. They self-assess with regard to their own capacity to supervise, engage with supervisees in forming a solid working alliance, commit to

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integrating key superordinate values of psychology in their supervision practice, delineate supervisory expectations, identify setting-specific competencies that must be achieved, collaborate with supervisees in devising a supervisory contract, link the contractually agreed upon competencies with the evaluation process, review supervisees’ work, facilitate inquiry that enhances supervisees’ self-awareness, model and engage the supervisee in developing the metacompetence of self-assessment, provide ongoing feedback, encourage and accept feedback, and maintain communication and responsibility (Falender & Shafranske, 2007). Within AHCs, competent supervisors possess effective skills and attitudes related to the supervision of psychology trainees (practicum students, interns, postdoctoral fellows), medical students, residents and fellows, and faculty colleagues from multiple medical disciplines related to behavioral health issues; provide supervision of supervision; ensure that supervision is sensitive to developmental, gender, and cultural factors; offer timely and constructive formative and summative feedback; provide live and on-the-spot supervision; focus on ethical dilemmas and decision-making; and serve as mentors. They facilitate the learning of psychology students so that they can become ‘‘biculturally competent’’, meaning they maintain their identity as psychologists while also functioning well in a heath system that is dominated by medical professionals. They aid their trainees in developing an appreciation of their potential contributions to the assessment, intervention, and consultation of medically and psychiatrically ill individuals and their loved ones (Hoge, Stayner, & Davidson, 2000). Individuals are most likely to be effective supervisors if they have an interest in, and knowledge about, treating the specific medically or psychiatrically ill patient population their supervisees are leaning to treat (Hoge et al., 2000). Familiarity with and the application of theories of learning and teaching are the essential components of the teaching functional competency domain. Individuals working in AHCs train psychology trainees in interdisciplinary and interprofessional care. They also train psychologists and other health care professionals about behavioral sciences, group dynamics, power hierarchies, communication, and conflict management, which are essential to team functioning. Psychologists in AHCs educate other health care professionals about psychosocial assessments and interventions. With the shift in other health care professions to a more competency-based approach to education and training (Leigh et al., 2007), psychologists in AHCs have a central role in assisting other health care professionals in developing and maintaining their core competencies. The essential components of the administrative functional competency domain that are generic to professional


psychologists are leadership and management. Subcomponents of this competency domain that often are key to psychologists’ roles and responsibilities within AHCs include leading interdisciplinary teams, promoting continuous quality improvement activities and serving as role models for these efforts, engaging actively in health policy endeavors, and assuming major administrative roles and responsibilities in health care systems (Belar, 2004). The final core functional competency domain is advocacy and its essential components that are relevant to all professional psychologists are empowerment and systems change. Psychologists in AHCs must advocate effectively for their patients and their families, as well as for psychological services within their settings. Advocacy efforts should be for and within AHCs, as well as geared toward insurance carriers in an attempt to increase reimbursement for behavioral health care services (Kaslow et al., 2005; Tovian, 2004). It is imperative that they assume a leadership role in advocating for policies at the local, state, and federal levels of government that specifically are relevant to AHCs, behavioral health care within this context, and pertinent research funding.

Implications The competency-based movement is gaining momentum within the profession in terms of education, training, credentialing, and performance appraisal. There also are greater practice opportunities available for psychologists in the health care arena. This is particularly true as psychologists increasingly have started to become recognized as health care professionals and primary health care providers, in addition to mental health professionals (Tovian, 2004). Therefore, it is timely to ask what psychologists in AHCs can do to move the competency agenda forward in order to ensure that we remain essential partners within AHCs. Psychologists within the health care system need to define and embrace our roles. It will be beneficial for us to develop agreement in essential subcomponents of each foundational and functional competency and their developmentally appropriate benchmarks for effective functioning in AHCs. Psychologists in AHCs should develop a tool box or portfolio of measures to assess competence akin to those of our medical colleagues (ACGME and ABMS, 2000) that are relevant to AHC competencies, as well as assess practicum students, interns, postdoctoral fellows, supervisors, and colleagues-from a competency-based framework. Effective remediation strategies for individuals practicing within AHCs who are not performing at the level of expected competence should be developed and shared across settings (Kaslow et al., 2007c).

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Psychologists in AHCs should be familiar with and utilize curriculum that have been promulgated for training and educating those interested in working in AHC settings, such as those put forth for professional psychologists in primary care settings (McDaniel, Belar, Schroeder, Hargrove, & Freeman, 2002) and those invested in working with pediatric populations (Spirito et al., 2003). Focus should also be on innovative, competency-based education and training modules, including ones that can be used for continuing professional education. These modules can be shared across settings. These approaches must be designed to meet the challenges for psychologists entering new roles and new settings within AHCs. They also must be continually transformed as the health care system evolves. Moving forward the competency-based agenda for psychologists within AHCs is one response to a recent call for us to articulate our identity, roles and functions, and relationship to the broader health care system (Schulte et al., 2004).

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