Training and Education in Professional Psychology 2011, Vol. 5, No. 3, 175–184
© 2011 American Psychological Association 1931-3918/11/$12.00 DOI: 10.1037/a0024656
Trainees With Professional Competency Problems: Preparing Trainers for Difficult but Necessary Conversations Sue C. Jacobs
Steven K. Huprich
Oklahoma State University
Eastern Michigan University
Catherine L. Grus
Evelyn A. Cage
American Psychological Association, Washington, D.C.
Auburn University
Nancy S. Elman
Linda Forrest
University of Pittsburgh
University of Oregon
Rebecca Schwartz-Mette
David S. Shen-Miller
University of Missouri
Tennessee State University
Kristi S. Van Sickle
Nadine J. Kaslow
Florida Institute of Technology
Emory University School of Medicine
Trainees with professional competency problems, also called problems of professional competence (PPC), are frequently encountered by faculty and supervisors and often are challenging for trainers and educational/training systems. This article underscores the importance of trainers addressing graduate
SUE C. JACOBS, Associate Professor, Training Director, and Ledbetter Lemon Endowed Diversity Professor in Counseling Psychology at Oklahoma State University earned her PhD from the University of Southern Mississippi in 1989. Her interests include issues in ethics, education and training, difficult dialogues, the teaching of psychology, older adults, health, diversity, social justice, disaster response, mindfulness and anger. STEVEN K. HUPRICH earned his PhD in clinical psychology from the University of North Carolina–Greensboro in 1999. He is an Associate Professor of Psychology at Eastern Michigan University, having research interests in personality disorders and personality assessment. He is an Associate Editor of the Journal of Personality Disorders. CATHERINE L. GRUS is the Deputy Executive Director, Education at the American Psychological Association (APA). Dr. Grus received her PhD in clinical psychology from Nova University. At APA, Dr Grus works to advance policies and practices that promote quality education and training in psychology. EVELYN A. CAGE is a Doctoral Candidate in Counseling Psychology at Auburn University. After graduating with a BA in Psychology from Emory University in 2006, Evelyn pursued graduate training and has plans to receive her degree in 2013. Her research interests include training and development, multicultural counseling, and disordered eating in AfricanAmerican women. NANCY S. ELMAN received her PhD from the University of Pittsburgh where she also served for nearly 20 years as training coordinator for the doctoral program in Counseling Psychology. She has served as Chair of the Advisory Committee on Colleague Assistance (Board of Professional Affairs) and the Commission on Accreditation of the American Psychological Association. Her research focuses on psychologists and trainees with professional competence problems. LINDA FORREST, Professor and Associate Director for Faculty Outreach at the University of Oregon Center on Diversity and Community, received her PhD from the University of Washington in Educational Psychology. Her research interests focus on problems of professional competence, and
other professional education and training issues (competency, ethics, international). REBECCA SCHWARTZ-METTE (MA Clinical Psychology) is a doctoral candidate in Clinical and Developmental psychology at the University of Missouri. Her research interests focus on the interpersonal context of adolescent internalizing symptoms and on ethical and training issues in psychology. DAVID S. SHEN-MILLER is an assistant professor of counseling psychology at Tennessee State University. He received his PhD in counseling psychology from the University of Oregon in 2008. His research interests include professional competence issues in training, the psychology of men and masculinity, ecological approaches to supervision and training, and qualitative research methods. KRISTI S. VAN SICKLE received her PsyD in Clinical Psychology from Florida Institute of Technology in 2006, and is currently an Assistant Professor in Florida Institute of Technology’s School of Psychology. Her primary research interests include professional competence, community health, and integrated primary care.; NADINE J. KASLOW, Professor, Vice Chair, and Chief Psychologist (Grady) at Emory School of Medicine Department of Psychiatry and Behavioral Sciences, received her PhD in Clinical Psychology from the University of Houston. Her research is on suicide and mood disorders; family violence; couples and family psychology; and competency-based psychology education, training, and credentialing. AS AUTHORS OF THIS ARTICLE, we are all members of the Trainees With Competence Problems Workgroup under the auspices of the American Psychological Association’s Education Directorate. Except for first, second, third, and last author, authorship order is alphabetical. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Sue C. Jacobs, PhD, Oklahoma State University, School of Applied Health and Educational Psychology, 425 Willard, Stillwater, OK 74078-4024. E-mail:
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JACOBS ET AL. students and interns with PPC for whom regular summative and formative feedback has not been effective by engaging in the often difficult, but necessary, conversations as a first step in many remediation processes. These conversations are framed as an ethical responsibility and suggested as a core competency for trainers. Attention is paid to the myriad barriers that trainers often encounter in engaging in difficult conversations, including personal factors, training setting and systems issues, and the relationship between personal and contextual factors. Strategies are offered with regard to overcoming these barriers. In addition, recommended steps and tools for effective difficult conversations are provided. Implications of this work for trainers and training programs are noted. Keywords: faculty and supervisors, psychology training programs, trainees, professional competence problems, difficult conversations
A program training director, Dr. Jones, has clinical supervision in 45 minutes and needs to prepare for the next morning’s class. She also is in the middle of preparing the Self-Study report for the program’s American Psychological Association (APA) reaccreditation. A junior colleague, Dr. Smith, knocks on her door. He says that he needs to talk to her, although it is really difficult for him. He tells her that Jamie, a second-year student, whom he really likes, appears to be interacting with a client on a regular basis outside of the therapy context. He indicates that Jamie frequently is late to her therapy appointments, writes untimely and incomplete case notes, and sometimes appears resistant to supervision. He says that he feels like he has failed; he thought his supervisory relationship with Jamie was working, but realized differently when another student told him Jamie did not show up for group supervision and that she was talking outside the clinic with one of her clients. Dr. Smith addressed this directly with Jamie, who denied the other student’s allegation and said she just “forgot” group supervision. Dr. Smith then noted that, just a few moments ago, he came back to his office and noticed Jamie with her client, who appeared to be crying. Dr. Smith told Dr. Jones that he was sorry to have let this gone so far and that he recognizes he needed to let her know. He dreaded meeting with Jamie about this, as he was not sure what to say to her. Already feeling the many pressures of her job before Dr. Smith arrived, Dr. Jones did not want to address this and dreaded meeting with the student. She was concerned that she herself had not noticed signs of any troubling behaviors in Jamie, especially because she was her advisee. In addition, she was worried about Jamie because she thought she had overcome her sister’s recent death prior to entering the program. Dr. Jones was equally concerned that Dr. Smith or other faculty members had not come to her before this, and at the moment was frustrated and angry with him for not doing something earlier. She knew that she would need to shift her immediate priorities to effectively and ethically deal with the situation.
This vignette contains many of the elements and complications that make it difficult for trainers (faculty, supervisors, and other individuals involved in the education and training of graduate students and interns) and training programs (graduate programs in professional psychology and predoctoral internship sites) to engage in needed conversations with trainees (professional psychology graduate students and predoctoral interns) who are exhibiting problems of professional competence (PPC). Difficult conversations are necessary when the normal summative and formative feedback given to trainees by trainers has not been effective or when any new problematic behavior emerges. Others have written about how to conduct ongoing evaluations based upon competency benchmarks (Carraccio, Englander, Wolfsthal, Martin, & Ferentz, 2004; Falender & Shafranske, 2004;
Kenkel & Peterson, 2010; Smith, Dollase, & Boss, 2003). In this article, we expand the discussion to the times when ongoing formative and summative feedback is not enough to address emerging problems of professional competence. Our premise is that trainers need to engage in difficult conversations as a necessary first step in remediation, intervention and/or management of trainees with PPC. Indeed, we believe that engaging in these difficult conversations may itself be a core competency for trainers. After providing definitions of the terminology we use in this manuscript, we discuss barriers to trainers and programs engaging in these conversations, offer guidance for effective difficult conversations, and suggest proactive approaches to help overcome both personal and system barriers. Such conversations, in our view, build upon and expand the self-reflection, strategies, techniques, and styles used in giving educational and supervisory feedback.
Difficult Conversations, Background, and Definitions Difficult Conversations Difficult conversations are useful, open dialogues that may address content, such as negative feedback, that is emotionally loaded for one or more of the participants (Lichtenberg et al., 2007; Weeks, 2001). These interchanges should emerge in the context of normative educational and supervisory feedback processes, but as indicated above, often do not. Difficult conversations concerning trainees with PPC involve ethical, personal, setting and systems, and personal-contextual interaction complexities. Barriers to such dialogues are not uncommon.
What Do We Mean by Trainees With PPC? Professional psychology has moved forward in defining and addressing issues surrounding professionals at all levels of development with PPC (Elman & Forrest, 2007; Huprich & Rudd, 2004; Kaslow et al., 2007). Elman and Forrest reviewed the difficulties with previous language and recommended using the terminology, “professional competence problems” or “problems of professional competence” (PPC) (Elman & Forrest, 2007). They suggest that this language captures the three components essential to defining the issue: “(a) the inclusion of the concept that there is a problem with performance, (b) a professional standard, and (c) a focus on competence” (Elman & Forrest, 2007). This replaces, and is much more useful, than the term “trainee impairment” which was used for multiple decades of writing on this topic (Collins et al., 2011;
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Elman & Forrest, 2007; Forrest, Elman, Gizara, & Vacha-Haase, 1999; Schwartz-Mette, 2009; Schwartz-Mette, in press). The terminology we use here, PPC, refers to trainees whose performance or behavior does not meet professional and ethical standards. More specifically, when we refer to the difficulty of many of the necessary conversations surrounding trainees with PPC, we note that they are primarily in the foundational competency domains rather than in the functional domains. Foundational domains include professionalism, reflective practice/selfassessment, scientific knowledge and methods, relationships, ethical and legal practice, individual and cultural diversity, and interdisciplinary systems (Elman & Forrest, 2007; Kaslow, 2004; Kaslow et al., 2004; Kaslow et al., 2007; Rodolfa et al., 2005). Functional competency domains include assessment/diagnosis/ conceptualization, intervention, consultation, research/evaluation, supervision/training, and management/administration. While a trainee’s PPC can occur with respect to both foundational and functional competencies, discriminating along these two dimensions is useful. For example, it may be easier for most trainers to intervene with a trainee who has not mastered a part of the research competency than it is to address professionalism in a trainee with interpersonal deficits (or even a personality disorder) that were missed at program admission and are manifested in problematic professional and/or ethical behavior.
Scope of Problem This is not a new issue. As indicated in previous literature, most training programs have trainees with PPC, and these individuals often are a challenge to manage (Elman & Forrest, 2007; Huprich & Rudd, 2004). Forrest and colleagues (Forrest et al., 1999) found that most faculty and students were able to identify at least one trainee with PPC. In a recent survey of approximately 320 trainees in professional psychology programs, 44% of respondents indicated they were aware of a peer with PPC, with the most common problems being difficulties with professional behavior (58.5%), interpersonal, clinical, and academic skills (48.1%, 42.5%, 31.1%, respectively), and mental health problems (28.3%; Shen-Miller et al., 2011). Unfortunately, the respondents were more confident that faculty and peers were aware of a problem than they were that either would effectively manage it, which reflects a similar pattern reported 20 years earlier (Mearns & Allen, 1991). Also, in a survey of program training directors about trainees with PPC, 342 cases of trainees with PPC were reported across 48 programs, with one program having no cases and four programs reporting over 16 cases (Forrest, Elman, & Huprich, 2010). Further, the directors of clinical training responding reported that 17% of their faculty had “bad to very bad” skills in managing students with PPC, while six reported 50% or more of their faculty had “bad to very bad” skills in answer to this question. This research provides evidence that there are many trainees with PPC and that both trainers and trainees report that trainers do not appear to be managing the problems as well as they could.
The Difficulty in Talking With Trainees With PPC In most programs, trainees receive ongoing feedback from advisors, directors of training, faculty and supervisors. Yet, having conversations with trainees experiencing PPC, such as Jamie,
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remain quite difficult. Why might this be the case? In part, it is because professional psychology previously provided little guidance or discussion of how to orient trainers toward trainees with “problems”. Subsequently, trainees with problems were passed on from one instructor-supervisor-training program in the pipeline to the next (Johnson et al., 2008). There are both personal and contextual or system barriers to having conversations with and about a trainee with PPC; both Dr. Jones and Dr. Smith demonstrated some of these. We believe that the new terminology of PPC, together with the recent consensus articulation of core competencies in professional psychology, will facilitate needed difficult conversations by enhancing trainers’ ability to define specific behaviors of concern for a trainee (McCutcheon, 2008). If trainers can understand, describe, and talk about the problem in specific terms, it may be less emotionally arousing and facilitate a more specific conversation with a trainee exhibiting PPC about what change is needed. Still, discussions with trainees with PPC are not the most pleasant parts of trainers’ professional roles. Many have written about the difficulty, conflict, and painfulness of having to speak with a trainee or other trainers about a trainee with PPC, such as exemplified in the example above (Bemak, Epp, & Keys, 1999; Busseri, Tyler, & King, 2005; Elman & Forrest, 2004; Forrest et al., 1999; Gizara & Forrest, 2004; Vacha-Haase, Davenport, & Kerewsky, 2004; Wheeler, 1996). Problems of professional competence also arise in the context of a system whose due process policies or lack thereof make it difficult to initiate conversations, rather than seeing them as an integral part of the training process (Forrest, ShenMiller, & Elman, 2008; Gaubutz & Vera, 2002). However, it is clear from the empirical and clinical literature that, although common, avoiding a difficult conversation is not an effectiveway to solve the underlying problem (Huprich & Rudd, 2004; Stone, Patton, & Heen, 2000).
Difficult Conversations About and With Trainees With PPC Are an Ethical Responsibility We believe that difficult conversations are not only necessary in managing the trainee’s PPC, but also are an ethical responsibility. Elements of the Ethical Principles of Psychologists and Code of Ethics (American Psychological Association, 2002), hereafter referred to as the APA Code, pertain directly to challenges of trainees with PPC and the requirement to address those challenges. We interpret each of the General Principles of Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, Justice, Respect for People’s Rights and Dignity as they might apply to having difficult conversations with trainees with PPC. To uphold these aspirational principles, trainers responsible for the professional development of trainees need to engage in difficult conversations with trainees who are not upholding these General Principles. For example, when clients are being inappropriately treated by trainees, it is in the interest of both the clients and trainees that the practice of good will and not harming anyone be considered. It may be helpful for the trainer to view engaging in difficult conversations with trainees about competence as part of upholding the Principle of Fidelity and Responsibility. Not having the difficult conversation could be viewed as not being honest with trainees, thus compromising trainers’ integrity. Trainees need to receive feedback about competency problems in order to receive access to
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fair and just contributions to their education in professional psychology. When trainees with PCC see clients without conversations from trainers about their competence they are not treated with the dignity they deserve and may compromise the clients’ rights and dignity. There are also a number of Ethical Standards that are helpful to trainers in having conversations with and about trainees with PPC. Although the language in the Standards refers to the behavior of professional psychologists and does not specifically refer to trainees, we believe that it is important for trainers to view them as pertaining to trainees since it models the behavior that we expect of our graduates as professionals. Standards 1.04 and 1.05 provide guidance for difficult conversations when psychologists believe other professionals have behaved unethically, first by attempting an informal intervention with those colleagues (1.04), and taking further reporting action (1.05) if the behaviors are not appropriate for informal interventions or if those interventions do not resolve the problem. Standard 2.06 directs psychologists to manage personal problems so that they can perform their work related activities in a competent manner. This standard also directs psychologists, when they become aware of personal problems that could affect their work, to obtain professional consultation or assistance and “determine whether they need to limit, suspend or terminate their work-related duties” (American Psychological Association, 2002, p. 1064). These Standards could be helpful and applicable to both Dr. Jones and Jamie in our vignette. Standards 7.02 and 7.06 are specific to education and training and require that trainees receive information about program content and requirements that must be met for successful completion, as well as processes for timely and specific feedback to trainees based on performance on relevant program standards. Standards 7.04 and 7.05 provide direction to trainers regarding the limits and procedures that govern student disclosure of personal information and conditions under which personal psychotherapy as remediation can be mandated. The emphasis is on the relevance of personal problems to performing “. . . activities in a competent manner or posing a threat to the student or others” (American Psychological Association, 2002, p. 1069). The APA Code conveys that trainers have an ethical responsibility for trainees, yet provides limited ethical guidance for managing difficult conversations related to one’s own or others’ competence and only a few standards pertaining specifically to training. Nonetheless, it conveys a general sense that trainers have an ethical obligation to address competency problems. We interpret this to mean that trainers have an ethical obligation to acquire the knowledge, skills, and attitudes to have difficult conversations to facilitate appropriate actions in the training system when competence problems occur. Doing so, however, is often challenging given personal and system barriers to having such dialogues.
Difficult Conversations Barriers and How To Overcome Them Conversations with and about trainees with PPC, especially when they have not occurred early in training, are often experienced as painful and complex, filled with interpersonal conflict, and sometimes avoided by individuals and training programs. We identify both personal and system (or program/institution-specific) barriers to engaging in difficult conversations and provide recom-
mendations for overcoming or reducing them. Inherent in many of our suggestions is the need for trainers to look carefully at themselves when engaging in a difficult conversation. Recognizing one’s own interpersonal style, approach to emotion expression, attitudes and values, skills, and possible deficiencies all require introspection, self-knowledge, and self-awareness, which are essential components of the foundational competency of reflective practice/self-assessment that trainers hope trainees will demonstrate (Fouad et al., 2009). When trainers practice self-reflection, they model professional expectations for trainees. Such conversations then may become less aversive and more integrated into one’s professional identity and functioning (Elman, Illfelder-Kaye, & Robiner, 2005).
Personal Barriers Competency set. Trainers need an integrated set of knowledge, skills, and attitudes to have productive difficult conversations associated with foundational and functional competency domains. In addition, they may need specific knowledge, skills, and attitudes when the trainees’ PPC intersects with diversity issues, as trainers report that diversity issues complicate interactions among trainers and between trainers and trainees (Gizara & Forrest, 2004; Shen-Miller, Forrest, & Elman, 2009). Trainers’ experience, comfort, and expertise may vary based on the type of competence problem and subsequent content of the difficult conversation. This is probably most difficult when the competencies involve personal attributes or behaviors of the trainee (e.g., professionalism) that impact behavior, as opposed to attainment of knowledge in course work. We believe that few programs mentor new trainers on how to engage trainees in conversations about professional competencies; one wonders, in the example of Dr. Smith in our vignette, if any such mentoring or planning had taken place. Real or imagined deficits in conducting productive difficult conversations can act as barriers to initiating the conversations. To overcome these barriers, we suggest that trainers practice having such conversations, consult with colleagues or the literature, and/or obtain pertinent continuing professional education. Avoidance. Few trainers have a positive affective reaction to the idea of a difficult conversation, so it is easy to avoid. As indicated by evidence from psychological research, shying away from uncomfortable emotions and avoiding taking appropriate behavioral steps increases the intensity of avoidance and associated emotions (e.g., fear anxiety; Beck, Emery, & Greenberg, 2005). Trainers experiencing this may find methods effective in overcoming avoidance helpful, such as examining thoughts, feelings, and conflicts about themselves in this situation, being well prepared, role playing, discussing issues with trusted colleagues, and securing appropriate consultation from relevant experts (e.g., legal counsel). Difficult conversations can be opportunities for growth in the professional lives of trainees and trainers and can foster feelings of personal agency and self-efficacy that may be compromised by avoidance. Resentment and fear. Resentment and fear of negative reactions also can act as powerful barriers to difficult conversations and diminish the chances of a positive outcome. Trainers usually do not like having to say something potentially hurtful to a trainee. Furthermore, unresolved anger or frustration about being faced with a difficult conversation, such as Dr. Jones was beginning to
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feel toward Dr. Smith in our vignette, can be insidious in its effects. Trainees may be defensive or argumentative in response to feedback. Anticipating trainees’ negative emotions may incite trainers’ irritation or anger, especially if trainees’ actions and/or deficits consume much time, energy, and attention, or if previous difficult conversations led to unsuccessful outcomes (e.g., trainee’s outright dismissal of the problem, such as with the student Jamie in our vignette). Recognizing and managing feelings of resentment are crucial first steps. Trainers may fear negative emotions, yet know that being comfortable with the range of their own feelings and tolerating and managing their vicissitudes are part of effective, professional functioning. When trainers find these feelings difficult to manage, we recommend peer consultation and/or individual psychotherapy as possibly helpful in overcoming personal obstacles. Moreover, modeling self-examination may foster program-level expectations that influence other trainers and future graduates, who then utilize these skills for initiating difficult conversations. Academic psychology position announcements rarely list “managing trainees with PPC” as a desired quality; however, since such problems are ubiquitous and part of trainers’ job responsibilities, programs may want to discuss this in interviews with potential new trainers. Anticipating such necessary behaviors and creating a culture that expects trainers to act wisely when competency issues arise can minimize their negative impact. Empathy for the parties involved. For trainers, empathy may be both a blessing and a curse when preparing for and having difficult conversations. As trainers we identify with our trainees—we were once them. A strength of trainers is their empathizing with trainees and wanting to nurture and protect them; however, that strength can also lead to overprotective behaviors by trainers that can actually interfere with trainees’ development. Empathy may facilitate favorable outcomes; however, empathy may also evoke strong identification with trainees’ negative emotional reactions, exacerbating trainers’ avoidance. On the other hand, trainers who have little empathy toward trainees with PPC may induce or exacerbate trainees’ anxiety, resentment, or fear. This, in turn, can interfere with trainees’ engagement with the trainer. Thus, it is key that trainers strive to be genuinely empathic, supportive, and understanding, while simultaneously clearly communicating concerns related to professional standards and specific competence problems. These steps are necessary to ameliorate difficulties and to improve outcomes if performance does not meet the developmentally expected benchmarks. Trainee–trainer relationships by definition involve unequal distribution of power, which also may evoke responses in trainees such as fear, defensive reactions of grandiosity, or imperviousness to negative feedback. When trainers recognize their role as authority figures, it may allow them to provide negative feedback with greater sensitivity and respect, making difficult information easier to deliver and to hear. Besides acknowledging the emotions and reactions of trainees or others involved in difficult conversations, trainers need to call upon basic skills in active listening and relationships that can mitigate adverse reactions of trainees to the conversation. Fear of legal action. As trainers, we recognize that trainees may adopt a litigious attitude which also evokes our own fears about depositions, carefully worded replies, attorney consults, court cases, and—in the most extreme—an ethics complaint or
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losing a license or program accreditation. Fortunately, in most cases, the courts have supported training faculty and/or program decisions, if the program has followed its own policies faithfully (Forrest et al., 1999; Gilfoyle, 2008; Huprich & Rudd, 2004). Elsewhere, we have discussed the importance of trainers as gatekeepers and provided guidelines for managing competency problems and minimizing legal threats (Kaslow et al., 2007). Also, trainers often need help deciphering whether guidelines, such as the Family Educational Rights and Privacy Act (FERPA) or the Americans with Disabilities Act (ADA), are relevant to the PPC of particular trainees. For a full discussion of these legal aspects, see the following reviews: Elman and Forrest, 2007; Falendar, Collins, and Shafranske, 2009; Forrest and Elman, 2005; and Gilfoyle, 2008.
Training Setting Issues and System Barriers Training setting factors and program culture both influence the willingness and ability of trainers to engage in difficult conversations regarding trainees with PPC. Here, we discuss several systemic issues and barriers. Program culture. A number of factors may contribute to a culture that decreases the likelihood of identifying competence problems and engaging trainees with PCC in necessary difficult conversations. These include factors such as having a large numbers of adjunct trainers who are not part of the program processes, trainers’ workload and time constraints, concerns about negative evaluations by trainees, lack of established mechanisms for regular program self-assessment, departmental or agency history with avoiding problems or being challenged, and institutional pressures not to intervene (Forrest, Shen-Miller, & Elman, 2008; Gaubutz & Vera, 2002). Program attitudes, beliefs, and unspoken “rules” also exert a strong influence on trainers’ willingness and ability to engage in difficult conversations. If a program’s culture is one of closed communication and secrecy with regard to trainees’ competence issues it may support avoiding such conversations, while generating resentment or fear among trainers (Gizara & Forrest, 2004). Program culture may also include assumptions that ethical responsibility falls at the individual, not program, level, as well as unspoken imperatives that trainees should acknowledge and remediate their own training issues. We believe that the keys to effectively managing a program’s culture to influence the quality of difficult conversations with trainees with PPC are communication and self-examination. It is helpful for program/training directors to model open communication in difficult conversations by leading dialogues at meetings and/or initiating one-on-one discussions with trainers that clarify that these are program faculty responsibilities for producing competent trainees and not a situation in which individual faculty are to be “blamed.” The more frequently open discussions take place in the culture, the more likely it is that difficult conversations will occur when needed and that individuals will become effective in having them. It helps all parties if the leadership clearly and consistently conveys the value it places on the feedback process at all stages of training, including difficult conversations when warranted. One way to establish a program culture that strongly supports difficult conversations when necessary is to have processes in
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place to ensure that multiple trainers are informed of trainees with PPC and any ongoing difficult conversations, when appropriate, so that they can provide perspective for the individual trainers who are actually engaging in such conversations. It also may be helpful for multiple trainers to deliver the feedback in difficult conversations both to convey that this is a programmatic function and to avoid a single faculty member being “blamed” or targeted (Baldo, Softas-Nall, & Shaw, 1997); this also emphasizes the systemic supports available to trainers to address trainees with PPC (Forrest et al., 2008). Program policies (or lack thereof). Programs with poorly defined policies for dealing with trainees with PPC may find it most difficult to initiate conversations (Forrest et al., 2008; Gaubutz & Vera, 2002). Or, programs may have remediation policies in place, but fail to identify difficult conversations as essential, ongoing, part of the remediation process, as is perhaps the case in the program in our vignette (Oliver, Bernstein, Anderson, Blashfield, & Roberts, 2004). We suggest programs explicitly identify difficult conversations as a primary step in the remediation process for trainees with PPC in written policies and that they include guidelines for communicating sensitive information to trainees. Such policies need to be detailed to help trainers attend to varied complexities, particularly around multisystemic involvement (i.e., questions about which trainers or supervisors should be involved if a field training site is the location of the trainee’s difficulties). It is of key importance to discuss program policies and procedures with trainees to proactively reduce potential barriers to difficult conversations. This may be initiated early in training (Forrest et al., 2008; Gilfoyle, 2008; Kaslow et al., 2007). However, it is not sufficient to address these policies and procedures in orientation alone. They need to be discussed throughout training to prepare trainees for potential difficult conversations surrounding peers’ or their own professional competence. Confidentiality. Regulations and program/university/agency policies about confidentiality often render decision-making and communicating decisions about trainees exhibiting PPC complex and challenging (Forrest et al., 2008). FERPA outlines rules for communication of information about student performance in the context of confidentiality, and generally prohibits such communication without the consent of the student (Gilfoyle, 2008). Although there are good reasons to maintain confidentiality during a difficult conversation with a trainee with PPC, doing so may have a negative impact on the system and on the trainee’s peer groups. If trainers within or between programs responsible for trainees (e.g., graduate schools and internships) cannot share information about the process and outcome of difficult conversations, they are not able to provide a systemic and comprehensive approach to training. Also, peers who do not believe that their trainers are adequately addressing trainees with PPC often feel anger and resentment toward their trainers (Oliver et al., 2004; Rosenberg, Getzelman, Arcinue, & Oren, 2005). They also have doubts about the efficacy of licensed professionals and the importance of personal and interpersonal well-being to their work (Gaubutz & Vera, 2006). A multisystemic approach is needed for handling issues surrounding the confidentiality of difficult conversations with trainees with PPC (Kaslow et al., 2009). Boundaries of confidentiality regarding these discussions need to be addressed proactively so
trainers and trainees know what communications will occur among trainers and what will be shared with students (Forrest et al., 2008). Only trainers who “need to know” should be involved in such discussions (Gilfoyle, 2008). However, the definition of “need to know” should be broad and systemically oriented. For example, when students receive training at other institutions (e.g., practicum, internships), programs should obtain in writing and prior to the start of the placement, a consent to share evaluation information (Gilfoyle, 2008). The Council of Chairs of Training Councils (Kaslow et al., 2009; Kaslow et al., 2007) developed structured guidance about communication among multiple systems in situations of trainees who display PPC, including notification when problems are identified, specific steps that will be taken, and guidelines for communicating with the trainees and trainers. In addition, trainers need to communicate that they are responding to concerns related to trainees with PPC through the use of difficult conversations in part, but must do so in a fashion that both respects the privacy of the problematic students and appreciates the “need to know” of the peer groups. Training model/program type. The program’s training model may reflect a setting more or less attuned to the need for and primacy of difficult conversations, depending on the type and content of the identified problem. For example, programs focused on preparing trainees for practice may be more alert to and experienced with addressing trainees with clinical competence problems than research-oriented programs, which may be more attuned to research competence. Moreover, programs that espouse a competency-based approach to education/training and outcomes assessment may have structures that facilitate effective difficult conversations targeted to specific competency concerns and recommended remediation approaches based on evidence. It is helpful if training programs have trainer agreement about the expected level of trainee performance in each competency domain at each stage of development consistent with the program’s training model, to convey this information to trainees, and to have feedback and conversations related to the competencies outlined in the training model. Trainer disagreements. Disagreement among trainers about the need for and nature of a difficult conversation with trainees with PPC can be a major barrier to addressing and remediating the problems (Forrest et al., 1999). Trainers’ reasons for disagreement about the need to initiate difficult conversations include the implications of such a conversation for trainees, beliefs that deficits will improve over time and do not need direct attention, questions about whether the severity or frequency of the problem meets the threshold for intervention, the fact that a trainee has been approved by the doctoral program to go on internship and has been placed in the competitive match process (“It’s too late”), internal or program conflict based on previous experience, or fear about colleagues’ reactions (e.g., no support, overreaction) (McCutcheon, 2008). When differences of opinion among trainers occur, these may reflect the general atmosphere within a training program, specifically the trainers’ problems having difficult conversations among themselves (Gizara & Forrest, 2004). Trainers may need to discuss a recommendation together before initiating difficult conversations with trainees; it is critical for the program and for the identified trainees with PPCs that trainers speak with one voice about their decision and recommendations about competence. If not, the likelihood of a productive conver-
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sation with trainees decreases, as the trainees are provided an implicit opportunity to disagree with remediation recommendations. Speaking with one voice also is essential for minimizing legal risk; in addition, it is a mechanism for ensuring that trainers are addressing relevant competencies and following the program’s own policies and procedures (Gilfoyle, 2008).
Relationships Between Personal and Contextual Factors Because personal and contextual factors are inextricably linked, barriers can arise at the intersections between them. Personal barriers can create obstacles even in exemplary program contexts, and program contexts can exacerbate or reduce personal challenges. For example, in programs without formal or explicit policies, personal anxiety, resentment, and fear can lead to unhealthy engagement or avoidance of difficult conversations with little to no communication among, or intervention from, colleagues. Without formal or explicit policies that necessitate action, the personal barriers and reservations about engaging in a difficult conversation are likely to win the day, despite a clear need for trainer intervention. Instances in which difficult conversations occur and are tainted by trainers’ resentment or lack of empathy toward trainees may heighten potential harm to trainees and diminish chances that encounters will be productive and oriented toward positive professional change. These effects may be exacerbated if programs treat such dialogues as isolated events. Some policies may fail because effective oversight and/or checks and balances are not in place. This could unfortunately communicate that difficult conversations are really not as vital as formal policy indicates. We suggest that programs require documentation of difficult conversations, as with the incidence, assessment, and remediation of problem behavior. Programs and trainers need practice, continuing self-reflection, and program review (Kaslow et al., 2009).
Recommended Steps and Tools for Effective Difficult Conversations Engaging in difficult conversations requires that trainers be mindful of and address the aforementioned personal and system challenges. We recommend that trainers also take appropriate steps to participate effectively in such conversations, using steps and tools such as those which follow. Some steps and tools are drawn from the literature in psychology; human resource/ management models (Weeks, 2001); resources generated by college and university programs designed to promote difficult dialogues about controversial issues (e.g., diversity, pluralism; (http://www.difficultdialogues .org/resources/); and pertinent books, articles, and web pages (Stone et al., 2000), http://www.diffcon.com/; http://www.pon.harvard.edu/ free-reports/the-new-conflict-management-strategies-for-dealingwith-tough-topics-interpersonal-conflicts/).
Engage in Activities To Enhance One’s Competence in Having Difficult Conversations Trainers can enhance their competence in participating in challenging conversations in a number of ways. They can (a) seek naturally occurring opportunities (e.g., regular trainee evaluations)
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to engage in and develop their comfort and experience, (b) consult with experienced colleagues who can provide direction and share their experiences (c) practice conversations with trusted colleagues, and (d) engage in self-directed professional development by referring to the literature on managing trainees with PPC. Create and participate in a supportive and action-oriented culture. Difficult conversations with trainees with PPC are most meaningful, productive, and helpful if they occur within supportive and action-oriented training cultures. It is helpful to have formal mentorship activities for new trainers to help them acquire greater competency in having difficult conversations early in their career (as well as to protect junior faculty who may be most vulnerable in the tenure stream). Senior trainers can educate and mentor others in the training ecosystem about the value and skills for implementing such discussions. Similarly, new programs can benefit from hiring faculty experienced in difficult conversations. We recommend that program policies and procedures that support such conversations be in place and modified as the field evolves and the program has experiences with difficult conversations. It is important that meetings of trainers allow for opportunities to explore the challenges of difficult conversations and the zeitgeist support small group discussions of barriers to initiating, experiencing, and handling the aftermath of such conversations (Gizara & Forrest, 2004). It also is helpful for trainers to develop trusting relationships with trainees, which will sustain the conversations when needed. When there is an agreement among trainers that such conversations are warranted, they can work together to formulate plans for preparing for such conversations when necessary. Prepare for difficult conversations. Once trainers have decided that a difficult conversation is in order, it is essential to prepare. We suggest trainers prepare for difficult conversations when trainees with PPC are identified and standard formative and summative feedback appears insufficient to help the trainee meet the developmentally expected benchmarks within one or more competency domains. In preparing for such conversations, trainers must be clear about the competency domains to be addressed and have realistic expectations regarding the required level of performance. Trainers need to consider what communication strategies are likely to be most effective with specific trainees with PPC based upon their interpersonal, cultural, affective, cognitive, and behavioral styles. Trainers should also ensure that they have all the information needed to address the issues of concern as well as the requisite support from colleagues. Set ground rules. It helps to set ground rules at the outset of difficult conversations. Such rules create an expectancy of honesty and openness, mutual respect, and listening to understand the other’s point of view. They underscore the need to focus on the behaviors rather than the people. Both trainers and trainees might find it helpful to state the issues positively, agree to identify responsibilities of all parties, and consent to small actions. For example, Dr. Smith in our vignette might say to Jamie, “you need to get all your case notes written on the same day you see your client” rather than, “you have not been getting your case notes in on time and that needs to stop.” Communicate thoughtfully. Effective difficult conversations are ones in which trainers employ communication strategies thoughtfully. This means that trainers need to clearly identify and directly communicate the behaviors of concern to trainees with
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PPC. At the same time, it is important that trainers be sensitive to the emotional impact of their words and provide a balance between not being overly blunt and/or overly vague. Effective communication includes moving directly to the topic and not avoiding it by engaging in unrelated discussion. We recommend that trainers adopt a problem-solving approach and engage trainees in a discussion about whether and how they think they can meet expected behaviors to remediate or achieve the professional competence expected. Utilize a psychologically minded interpersonal approach. A psychologically minded interpersonal approach allows for gracefully conducting a difficult conversation. This approach incorporates many of the foundational competencies and their essential components delineated within professional psychology (Fouad et al., 2009). Of course, as reflective of these competencies, trainers need to monitor their own psychological-mindedness as they proceed with the process of a difficult conversation. More specifically, in preparing for, engaging in, and evaluating difficult conversations, trainers need to be cognizant of their own emotional reactions and those of the trainee of concern. Trainers need to anticipate negative reactions, with attention to how they will address the feelings (fear, sadness, anger, disappointment, shame) and reactions (tears, yelling) of the trainee with PPC. It is helpful if trainers are sensitive to the fact that trainees receiving negative feedback may feel ashamed. Trainers should strive to present their perspective by describing their concerns behaviorally and look for possible verbal and nonverbal signs of negative self-judgments on the part of the trainee. When trainees feel ashamed, they are likely to become defensive, and may need more time to process the feedback before they can engage in an open discourse. Such time should be granted as long as it is feasible and realistic. We further suggest that trainers be mindful of differentiating experiences of shame and guilt in the trainee. While the latter may be a somewhat normal reaction to having crossed a professional standard, the former is more attacking of the self, which could be more damaging than helpful. Other strategies for managing strong emotions may also be incorporated. We recommend that trainers meet with trainees for follow-up conversations, in part to address trainees’ emotional reactions as well as to address steps taken subsequent to the conversation. Doing so ensures trainees have the opportunity to process their feelings and to receive appropriate support or assistance in next steps (Forrest & Elman, 2005). Anchor difficult conversations in assessment of competencies. Trainers need to articulate to trainees with PPC the behaviors of concern using program-identified competencies and their essential elements at the appropriate developmental level of the trainee. We recommend this be done in a way that conveys the expected behaviors in observable and measurable terms. Program established standards for successful performance using competency language familiar to trainers and trainees provide a structure for the conversation, and aid inarticulating the assessment methods that have been and will be used to measure the competencies of concern (Kaslow et al., 2007; Kaslow et al., 2009) and to make explicit the time frame for subsequent evaluations. Incorporate conflict management strategies. We further recommend that trainers learn and practice basic conflict management skills. Programs need to support such learning endeavors. Additional resources may be available through Human Resources,
Ombudsman/Mediation, Student Affairs, and Employee Assistance Programs. Consistent with the incorporation of conflict management strategies is the need for trainers and trainees to close the loop after the conversation, summarize, and set next steps. Trainers should check with trainees and other trainers to obtain their comments or feedback on the process. Evaluate the process. There should be follow-up with the trainee to monitor and document progress on the identified competencies of concern. If there is insufficient progress, the trainers need to ascertain what personal and system-level factors may contribute to the trainee’s continued difficulties and if such variables are identified they need to be addressed appropriately. On another note, trainers should self-evaluate their effectiveness and use this information to determine components of foundational and functional competencies they need to enhance to prepare for future difficult conversations.
Future Directions In addition to educating trainers, programs could develop curriculum to better educate trainees regarding difficult conversations and the ways in which they are an integral part of the training and feedback process. This could be accomplished by building on existing curriculum and program activities (e.g., orientation, proseminars and program/internship/postdoctoral residency didactics, ethics courses, and supervision). Training should include why such conversations are important, along with practical skills for having them (Rosenberg et al., 2005). Elevating the issue to the curriculum level makes it more likely that both trainees and trainers perceive and practice difficult conversations as an essential aspect of professional competence. It is also important that trainers evaluate both the efficacy of any such new curricular or program activities, as well as the use of difficult conversations as an integral part of training program policies and procedures. More long term, we hope there are more systematic evaluations of the effect on the level of trainees with PPC in programs in which such training has been instituted. In closing, we believe it is a necessary and ethical obligation to engage in difficult conversations concerning trainees with PPC when warranted. The personal and training system capacity for engaging in conversations related to trainees with PPC are themselves reflections of an integration of essential components of many core competencies in professional psychology. This capacity involves the knowledge that someone, a trainee in this case, is exhibiting PPC and. the requisite skills to assess problematic behaviors and tie them to expected, developmentally appropriate performance of competencies (Fouad et al., 2009). Critically, engaging in difficult but necessary conversations with trainees with PPC is facilitated by both faculty/ supervisor and training director/program awareness and ongoing self-reflection. Effective intervention with trainees with PPC requires that trainers possess the skills and attitudes necessary for engaging in difficult conversations in a thoughtful and interpersonally sensitive way in a context in which all members of the system (trainers and trainees alike) are cognizant of the value and importance of effectively participating in difficult conversations when indicated.
DIFFICULT BUT NECESSARY CONVERSATIONS
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Received September 27, 2010 Revision received March 31, 2011 Accepted June 6, 2011 !
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