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Difficult Interns and Postdoctoral Residents: Identification, Assessment, and Interventions APPIC Pre Conference Workshop Nadine Kaslow, Ph.D., APPIC.

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Presentation on theme: "Difficult Interns and Postdoctoral Residents: Identification, Assessment, and Interventions APPIC Pre Conference Workshop Nadine Kaslow, Ph.D., APPIC."— Presentation transcript:

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2 Difficult Interns and Postdoctoral Residents: Identification, Assessment, and Interventions APPIC Pre Conference Workshop Nadine Kaslow, Ph.D., APPIC Chair Mona Koppel Mitnick, JD, APPIC Public Member Jeff Baker, Ph.D., APPIC Board Member

3 DEFINITIONS Competence Competence –Professional competence is the habitual and judicious use of communication, knowledge, technical skills, reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served (Epstein & Hundert, 2002)

4 DEFINITIONS Historically, the term impairment has been used to describe problematic knowledge, skills, attitudes, and behaviors of trainees and professionals Historically, the term impairment has been used to describe problematic knowledge, skills, attitudes, and behaviors of trainees and professionals The term impairment has a specific meaning within the context of the ADA (e.g., medical or mental health disability) The term impairment has a specific meaning within the context of the ADA (e.g., medical or mental health disability) Therefore, we will focus on trainees with problems, referred to as “difficult” trainees Therefore, we will focus on trainees with problems, referred to as “difficult” trainees Sometimes these trainees also have impairments according to the ADA Sometimes these trainees also have impairments according to the ADA

5 DEFINITIONS (cont.) (Overholzer & Fine, 1990) When supervisees have difficulties it is likely due to: When supervisees have difficulties it is likely due to: –Lack of knowledge –Inadequate clinical skills –Deficient technical skills –Poor judgment –Disturbing interpersonal attributes

6 DEFINITIONS (cont.) (Lamb et al., 1987) Difficult trainees exhibit interference in their professional functioning as reflected in one or more of the following ways: Difficult trainees exhibit interference in their professional functioning as reflected in one or more of the following ways:

7 DEFINITIONS (cont.) (Lamb et al., 1987) –Inability and/or unwillingness to acquire and integrate professional standards into one’s repertoire of professional behavior –Inability to acquire professional skills in order to reach an acceptable level of competency (performance problem) –Inability to control personal stress, interpersonal difficulties, psychological dysfunction, and/or excessive emotional reactions that interfere with professional functioning (conduct or emotional problem)

8 DEFINITIONS (cont.) (Lamb et al., 1987) An trainee’s behavior is considered difficult when characterized by one or more of the following: An trainee’s behavior is considered difficult when characterized by one or more of the following: –The trainee does not acknowledge, understand, or address the problem when it is identified (lack of self- awareness and interpersonal responsiveness) –The behavior is not merely a reflection of a skill deficit that can be rectified by academic or didactic training –The quality of the trainee’s services is sufficiently negatively affected

9 DEFINITIONS (cont.) –The problem is not restricted to one area of professional functioning –A disproportionate amount of attention by training personnel is required –The trainee’s behavior does not change as a function of feedback, remediation efforts, and/or time

10 DEFINITIONS (cont.) (Chapman et al., 2002) Incompetence in clinical skills or inadequate fund of knowledge Incompetence in clinical skills or inadequate fund of knowledge Lack of awareness or disregard for professional behavior and responsibility Lack of awareness or disregard for professional behavior and responsibility Problematic interpersonal issues Problematic interpersonal issues Demonstrates problems in two or more areas Demonstrates problems in two or more areas

11 DEFINITIONS (cont.) These definitions of difficult trainees do not include a trainee’s behavior, attitudes, or characteristics that are developmentally normative, such as: These definitions of difficult trainees do not include a trainee’s behavior, attitudes, or characteristics that are developmentally normative, such as: –Transition issues –Mild performance anxiety –Mild discomfort with diverse client groups –Initial lack of understanding of the facility’s norms – Lack of certain skills sets, but an openness and readiness to acquire them

12 CONTEXT The identification of a trainee’s behavior as problematic needs to take the context into account. It is key to assess if trainee difficulties reflect a mismatch between the: The identification of a trainee’s behavior as problematic needs to take the context into account. It is key to assess if trainee difficulties reflect a mismatch between the: –Philosophy of the site and the trainee’s orientation –Skills and competencies of the trainee and the demands of the site

13 CONTEXT (cont.) A number of contextual factors in the life of the trainee need to be considered when assessing problematic behavior A number of contextual factors in the life of the trainee need to be considered when assessing problematic behavior –Adjustment issues to new setting (not site) –Adjustment to new site –Separate from established support systems –Status change –Personal life events/changes

14 CONTEXT(cont.) (Sherman & Thelen, 1998) Various life events are work factors are associated with different amounts of distress and functional difficulties; personal relationship problems and work with difficult clients are most troublesome Various life events are work factors are associated with different amounts of distress and functional difficulties; personal relationship problems and work with difficult clients are most troublesome People with the greatest number of life events/work factors have the greatest distress People with the greatest number of life events/work factors have the greatest distress Non-work related activities and vacations are the best preventive behaviors Non-work related activities and vacations are the best preventive behaviors

15 CONTEXT (cont.) When the aforementioned issues appear salient, recommend the following When the aforementioned issues appear salient, recommend the following –Suggest options for better stress management and self-care –Provide more support to the trainee

16 PERSONAL RISK FACTORS History of childhood trauma History of childhood trauma Substance use disorders Substance use disorders Major Axis I disorder Major Axis I disorder Axis II disorder Axis II disorder Wounded healer Wounded healer False self False self Attachment difficulties Attachment difficulties

17 PROCESSES ASSOCIATED WITH PROBLEMATIC BEHAVIOR (Lamb et al., 1991) Setting the Stage Setting the Stage Orientation Orientation –Direct communication of the site’s expectations regarding professional standards, skill competency, personal functioning –Communication regarding evaluation guidelines and processes –Provision of Due Process Guidelines

18 PROCESSES (cont.) Reconnaissance and Identification Reconnaissance and Identification –Gathering on-going evaluative information and observing the trainee’s initial response to the setting, training experience, and feedback –Discussion among all training faculty/staff –Identify areas of concern orally and in writing – express concerns as hypotheses and define problem behaviors in concrete and specific terms –Early and continuous monitoring –This process often enough to manage many problems

19 PROCESSES (cont.) Discussion and Consultation when problem behavior persists Discussion and Consultation when problem behavior persists –Discussion among all training personnel regarding other interventions and next steps –Such discussion should consider Actual behaviors of concern (e.g., nature, frequency, severity) Actual behaviors of concern (e.g., nature, frequency, severity) Settings that behaviors occur in Settings that behaviors occur in Negative consequences of the behaviors Negative consequences of the behaviors Trainee’s response to feedback Trainee’s response to feedback

20 PROCESSES (cont.) Discussion and Consultation (cont.) Discussion and Consultation (cont.) –Review of these questions is likely to be time consuming and stressful –Important to thoroughly explore the behaviors in question, full range of interventions, and effects of interventions on all concerned –Interventions (see remediation section)

21 PROCESSES (cont.) Implementation and Review Implementation and Review –Implement intervention plans –Review progress and response to interventions –Communicate with all relevant parties –Provide ongoing feedback –Document all problem behaviors and changes in behavior

22 PROCESSES (cont.) Implementation and Review (cont.) Implementation and Review (cont.) –Ongoing meetings of faculty/staff for review –Consultation from other training personnel –Consideration of possible alternative actions –External consultation

23 PROCESSES (cont.) Anticipating and Responding to Organizational Reaction in Cases of Termination Anticipating and Responding to Organizational Reaction in Cases of Termination –Support trainee and help him/her consider alternatives –Support training personnel –Determine how to communicate what and to whom (e.g., other current and future trainees, staff) –Management of clinical services

24 REMEDIATION CONSIDERATIONS (Lamb et al., 1987) Once problems have been identified, there need to be several meaningful ways to address them. These need to be clearly stated and presented in a written document and the remediation plan needs to be discussed and agreed upon. Possible and perhaps concurrent courses of action designed to remediate problems include, but are not limited to, the following: Once problems have been identified, there need to be several meaningful ways to address them. These need to be clearly stated and presented in a written document and the remediation plan needs to be discussed and agreed upon. Possible and perhaps concurrent courses of action designed to remediate problems include, but are not limited to, the following:

25 REMEDIATION CONSIDERATIONS (cont.) –Increasing supervision, either with the same or other supervisors –Changing the format, emphasis, and/or focus of supervision –Recommending and/or requiring personal therapy in a way that all parties involved have clarified the manner in which therapy contacts will be used in the evaluation process

26 REMEDIATION CONSIDERATIONS (cont.) –Reducing and/or shifting the trainee’s workload –Requiring specific academic coursework –Recommending, when appropriate, a leave of absence and/or a second internship or residency –Collaborating with the graduate department on the remediation plan in accord with the CCTC Communication Guidelines

27 REMEDIATION CONSIDERATIONS (cont.) When a combination of the above interventions do not, after a reasonable time period, rectify the problem, or when the trainee seems unable or unwilling to alter his/her behavior, the program may need to take more formal action in accord with their due process guidelines When a combination of the above interventions do not, after a reasonable time period, rectify the problem, or when the trainee seems unable or unwilling to alter his/her behavior, the program may need to take more formal action in accord with their due process guidelines

28 FORMAL ACTIONS (Lamb et al., 1991) Probation Probation –In writing, Identify specific behaviors or areas of professional functioning of concern Identify specific behaviors or areas of professional functioning of concern Directly relate these behaviors to written evaluations Directly relate these behaviors to written evaluations Provide specific ways deficiencies can be remedied Provide specific ways deficiencies can be remedied Identity specific probationary period Identity specific probationary period Stipulate how functioning will change at site during probation, of applicable Stipulate how functioning will change at site during probation, of applicable Reiterate the availability of due process procedures Reiterate the availability of due process procedures

29 FORMAL ACTIONS (cont.) Giving the trainee a limited endorsement, including the specification of those settings in which he/she could function adequately Giving the trainee a limited endorsement, including the specification of those settings in which he/she could function adequately Terminating the trainee from the program and communicating this to the appropriate parties Terminating the trainee from the program and communicating this to the appropriate parties Recommending and assisting in implementing a career shift for the trainee Recommending and assisting in implementing a career shift for the trainee * All of the above steps need to be documented appropriately and implemented in accord with the due process guidelines

30 TERMINATION (Lamb et al., 1991) Steps to take prior to notifying trainee Steps to take prior to notifying trainee –Review agency and institutional implications of the decision –Letter sent to trainee and other relevant parties reiteration probationary conditions, trainee’s response, and reasons for dismissal –How and when the trainee’s status will change at the site needs to be determined

31 TERMINATION (cont.) Steps (cont.) Steps (cont.) –Trainee must be given the opportunity to appeal in accord with due process guidelines –Proposed action and corresponding written statement should be reviewed in consultation with relevant internal and external parties –Consult with legal counsel at the facility –Notify up the chain of command

32 TERMINATION (cont.) Once these steps have been taken Once these steps have been taken –Hold meeting between the trainee and relevant training and site personnel –Inform trainee of the decision –Provide a written statement –Provide statement of revised responsibilities –Remind trainee of due process guidelines

33 CHALLENGES IN EVALUATING INTERNS & RESIDENTS (Robiner, 1993) Definition and Measurement Issues Definition and Measurement Issues –Lack of clear criteria and objective measures of competence/incompetence in psychology –Lack of clear criteria and objective measures of problematic behavior in psychology –Supervisor awareness of subjectivity inherent in evaluation –Apprehension about defending evaluations due to lack of clear criteria and objective measures

34 EVALUATION CHALLENGES (cont.) Legal and Administrative Issues Legal and Administrative Issues –Concern that negative evaluations may result in administrative inquiry, audit, grievance or litigation –Lack of awareness of internship/residency or institutional policies and procedures involved in negative evaluations –Social and political dynamics – concerns about lack of support from administrators and colleagues

35 EVALUATION CHALLENGES (cont.) Legal and Administrative Issues (cont.) Legal and Administrative Issues (cont.) –Concern that failing to “pass” an intern or resident may result in loss of future training funds or slots or the need to find additional funds to extend the trainee’s training –Concern that failing to “pass” an intern or resident may result in adverse publicity that could affect institutional reputation and the number of applicants

36 EVALUATION CHALLENGES (cont.) Interpersonal Issues Interpersonal Issues –Fear of diminishing rapport or provoking hostility from supervisees –Fear of eliciting backlash from current or future trainees –Anguish about damaging a supervisee’s career or complicating or terminating their graduate training (in the case of an intern)

37 EVALUATION CHALLENGES (cont.) Supervisor Issues Supervisor Issues –Supervisors’ wish to avoid scrutiny of their own behavior, competence, ethics, expectations, or judgment of their clinical or supervisory practices –Limited supervisory experience with problem trainees –Difficulties in imparting negative evaluations –Indifference to personal responsibility for upholding the standards of the profession

38 EVALUATION CHALLENGES (cont.) Supervisor Issues (cont.) Supervisor Issues (cont.) –Inappropriate optimism that problems will resolve without intervention –Preference to avoid the substantial energy and time commitment necessary to address or remediate the behavior of problem interns and residents

39 EVALUATION CHALLENGES (cont.) Supervisor Issues (cont.) Supervisor Issues (cont.) –Discomfort with “gatekeeper” role –Identification with supervisee’s problems –Inadequate attention to supervisee’s performance or problems –Supervisors’ presumption of supervisee competence –Minimization of supervisee’s problem behavior

40 TYPOLOGY OF MENTORSHIP DYSFUNCTION (Johnson & Huwe, 2002) Dysfunction connotes a relationship that is unproductive,characterized primarily by conflict, or is no longer functioning effectively for one or both partners Dysfunction connotes a relationship that is unproductive,characterized primarily by conflict, or is no longer functioning effectively for one or both partners Dysfunction may be rooted in Dysfunction may be rooted in –Behavior or personality features of either person –Contextual factors –Poor matching –Effects of otherwise healthy maturation

41 MENTORSHIP DYSFUNCTION (cont.) Typology Typology –Faulty mentor-protégé matching –Mentor technical incompetence –Mentor relationship incompetence –Mentor neglect –Relational conflict –Boundary violations

42 MENTORSHIP DYSFUNCTION (cont.) Typology (cont.) Typology (cont.) –Exploitation –Attraction –Unethical or illegal behavior –Abandonment –Cross-gender and cross-race issues –Protégé traits and behaviors

43 MENTORSHIP DYSFUNCTION (cont.) Common Self-Defeating Responses to Mentorship Dysfunction Include: Common Self-Defeating Responses to Mentorship Dysfunction Include: –Paralysis –Distancing –Provocation –Sabatoge

44 MENTORSHIP DYSFUNCTION (cont.) Strategies for Preventing and Responding to Mentorship Dysfunction Strategies for Preventing and Responding to Mentorship Dysfunction –Administrative Strategies Create a culture of mentoring Create a culture of mentoring Scrutinize new hires Scrutinize new hires Prepare faculty/staff for the mentor role Prepare faculty/staff for the mentor role Monitor and reinforce mentoring Monitor and reinforce mentoring

45 MENTORSHIP DYSFUNCTION (cont.) Strategies (cont.) Strategies (cont.) –Individual Strategies Slow down the process Slow down the process Honestly evaluate personal contributions Honestly evaluate personal contributions Consider ethical/professional obligations as a mentor Consider ethical/professional obligations as a mentor Be proactive, cordial, and clear in communicating concerns to protégés Be proactive, cordial, and clear in communicating concerns to protégés Seek consultation Seek consultation Document Document

46 TIPS Provide thorough due process guidelines Provide thorough due process guidelines Make expectations clear from the outset Make expectations clear from the outset Identify problems early Identify problems early Provide rationale for change Provide rationale for change Be aware of the consequences of failure to act Be aware of the consequences of failure to act Consult colleagues (internal, external) Consult colleagues (internal, external)

47 TIPS (cont.) Monitor in multiple ways Monitor in multiple ways Document Document Keep the lines of communication open Keep the lines of communication open Inform relevant parties Inform relevant parties Stay informed of current practices Stay informed of current practices Use APPIC’s Informal Problem Resolution Process and Consultation Service as a Resource Use APPIC’s Informal Problem Resolution Process and Consultation Service as a Resource

48 FUTURE DIRECTIONS Guidelines on handling difficult trainees Guidelines on handling difficult trainees Better articulation of assessment strategies Better articulation of assessment strategies More rehabilitation programs for professionals More rehabilitation programs for professionals Greater support for seeking assistance Greater support for seeking assistance Continued education Continued education

49 LEGAL ISSUES AND DUE PROCESS Simple and easy to understand Simple and easy to understand Written and communicated to each intern/trainee/post doc at the time he/she begins the internship or post doc Written and communicated to each intern/trainee/post doc at the time he/she begins the internship or post doc Applied uniformly and in a timely fashion to all such problem or substandard interns/trainees/post docs and to any intern/trainees/post docs complaints about the actions of training program staff Applied uniformly and in a timely fashion to all such problem or substandard interns/trainees/post docs and to any intern/trainees/post docs complaints about the actions of training program staff Applied to all serious performance, conduct, and ethical problems of interns/trainees Applied to all serious performance, conduct, and ethical problems of interns/trainees

50 DUE PROCESS PROVISIONS Description of the types of problems and behavior covered, which should be broad enough to cover all performance, conduct, and ethical deficiencies, as well as any combination of these deficiencies Description of the types of problems and behavior covered, which should be broad enough to cover all performance, conduct, and ethical deficiencies, as well as any combination of these deficiencies Description of the persons covered., making clear that all interns/trainees/post docs, at whatever stage of training, are covered Description of the persons covered., making clear that all interns/trainees/post docs, at whatever stage of training, are covered A clear statement of the time limits at different stages of the process, and whether and for what reasons) such time limits may or may not be waived A clear statement of the time limits at different stages of the process, and whether and for what reasons) such time limits may or may not be waived Both informal and formal procedures for correcting deficiencies, and appealing any dissatisfaction with the program’s compliance with the procedures, the notification of deficiencies and any penalties Both informal and formal procedures for correcting deficiencies, and appealing any dissatisfaction with the program’s compliance with the procedures, the notification of deficiencies and any penalties A clear statement at each stage identifying the decision maker, and the contents of the decision A clear statement at each stage identifying the decision maker, and the contents of the decision A clear statement at each stage of whether and to whom the complainant or training program official may appeal the decision A clear statement at each stage of whether and to whom the complainant or training program official may appeal the decision A clear statement of when the decision becomes final A clear statement of when the decision becomes final

51 SUGGESTIONS FOR DEVELOPING DUE PROCESS Informal Stage Informal Stage Formal Stage Formal Stage

52 INTERN/POSTDOC COMPLAINTS Filing of Informal Complaint Filing of Informal Complaint Decision on Informal Complaint Decision on Informal Complaint Filing of Formal Complaint (ASARC) Filing of Formal Complaint (ASARC) Decision on Formal Complaint Decision on Formal Complaint Appeal from Decision on Formal Complaint Appeal from Decision on Formal Complaint

53 DISABILITY ISSUES A great deal of confusion has arisen among interns/postdoctoral residents and their sites /programs as to what constitutes disability, as defined by the Rehabilitation and Americans with Disabilities Acts; and what, if any, obligation an internship/program site has to provide reasonable accommodation to an applicant or an intern/postdoc after selection A great deal of confusion has arisen among interns/postdoctoral residents and their sites /programs as to what constitutes disability, as defined by the Rehabilitation and Americans with Disabilities Acts; and what, if any, obligation an internship/program site has to provide reasonable accommodation to an applicant or an intern/postdoc after selection

54 CLAIMING AND PROVING DISABILITY Qualified Qualified Responsibility for Determination Responsibility for Determination Toyota vs. Williams Toyota vs. Williams Rehabilitation Act or ADA Rehabilitation Act or ADA Correctible Correctible

55 ACCOMMODATION When and to What Extent Reasonable Accommodation is Required When and to What Extent Reasonable Accommodation is Required –Reasonable Accommodation –Establish Meeting the Definition

56 HANDICAP DISCRIMINATION Avoiding a Successful Claim of Handicap Discrimination Avoiding a Successful Claim of Handicap Discrimination

57 REFERENCES Rehabilitation Act of 1973, as amended (29 U.S.C. sec. 791 et seq.; and Americans with Disabilities Act of 1990 (ADA (42 U.S.C. sec et seq.; 29 C.F.R. sec. 1630; 1997; EEOC Enforcement Guidance on the Effect of Representations Made in Applications for Benefits on the Determination of Whether a Person Is a "Qualified Individual with a Disability" Under the Americans with Disabilities Act of 1990 (ADA) (Feburary 12, 1997); Enforcement Guidance: Reasonable Accommodation and Undue Hardship Under the Americans With Disabilities Act (March 1, 1999). Rehabilitation Act of 1973, as amended (29 U.S.C. sec. 791 et seq.; and Americans with Disabilities Act of 1990 (ADA (42 U.S.C. sec et seq.; 29 C.F.R. sec. 1630; 1997; EEOC Enforcement Guidance on the Effect of Representations Made in Applications for Benefits on the Determination of Whether a Person Is a "Qualified Individual with a Disability" Under the Americans with Disabilities Act of 1990 (ADA) (Feburary 12, 1997); Enforcement Guidance: Reasonable Accommodation and Undue Hardship Under the Americans With Disabilities Act (March 1, 1999).EEOC Enforcement Guidance on the Effect of Representations Made in Applications for Benefits on the Determination of Whether a Person Is a "Qualified Individual with a Disability" Under the Americans with Disabilities Act of 1990 (ADA) Enforcement Guidance: Reasonable Accommodation and Undue Hardship Under the Americans With Disabilities ActEEOC Enforcement Guidance on the Effect of Representations Made in Applications for Benefits on the Determination of Whether a Person Is a "Qualified Individual with a Disability" Under the Americans with Disabilities Act of 1990 (ADA) Enforcement Guidance: Reasonable Accommodation and Undue Hardship Under the Americans With Disabilities Act

58 TYPES OF DIFFICULT TRAINEES Slackers Mild Manipulative Behaviors Personality Disorders Unusual Situations

59 REFERENCES: DEVELOPMENTAL PERSPECTIVE Developmental Issues in Internship & Postdoc Training Developmental Issues in Internship & Postdoc Training –Kaslow, N. J., & Rice, D. (1985). Developmental stresses of psychology internship training: What a training staff can do to help. Professional Psychology: Research and Practice, 16, –Kaslow, N.J., McCarthy, S.M., Rogers, J.H., & Summerville, M.B. (1992). Psychology Postdoctoral training: A developmental perspective. Professional Psychology: Research and Practice, 23, –Lamb, D. H., Baker, J., Jennings, M., & Yarris, E. (1982). Passages of an internship in professional psychology. Professional Psychology: Research and Practice, 13, –Solway, K. (1985). Transition from graduate school to internship: A potential crisis. Professional Psychology: Research and Practice, 16,

60 MODEL BEHAVIOR Model Behavior Model Behavior –Energetic –Responsible –Keeps up in their readings –Keeps appointments, has great foundation in treatment, assessment, and professional behavior –Takes on more responsibilities than expected, but has excellent follow through –Looks for ways to increase their skills and is appreciative of training experience

61 LESS THAN DESIRABLE BEHAVIOR Less than Desirable Behavior Less than Desirable Behavior –Slacker, does less than expected –Hides important information (i.e. has only seen an MMPI in the book, has only read about CBT, etc) –Never volunteers for important tasks (i.e. applicant interviews, lit searches, etc) –Criticizes experience, concerned about how much time they are putting in within the first week of the program –Spends less and less time with other trainees and/or supervisors –Lack of Competence (little or no therapy experience, no assessment experience)

62 DISRUPTIVE BEHAVIORS Disruptive Behaviors Disruptive Behaviors –Mildly manipulative behavior (gets others to do their work, implies they do not recall certain conversations, etc) –Shows up late for supervision –Unprepared for didactics –Unprepared for treatment with patients –Encourages subgrouping and divisiveness among intern/residents –Interpersonal Difficulties (avoids relationships, focuses on own projects, not a team player) –Never attends social functions

63 AXIS I DISORDERS Axis I Disorders Axis I Disorders –Difficult, but some are manageable –Have made it through a rigorous program –Has some strengths and compensatory strategies –Can be disruptive to others –Can lead to withdrawal or break in program –Poor performance may lead to dismissal –Substance Abuse

64 AXIS II DISORDERS Axis II Personality Disorders Axis II Personality Disorders –Passive Aggressive (i.e. misses didactics for dental/dr appointments, uses copier for personal convenience, leaves work early often) –Dependent (overly dependent on others) –Narcissistic (needs constant attention for the smallest of tasks or acts out in other ways) –Borderline (impassioned relationships with colleagues, looking for intense support, ends up destroying any chance of cohesiveness in trainee group) –Avoidant (no desire for relationship with fellow trainees, cannot connect with patients) –Antisocial (substance abuse, walks off with textbooks, etc.)

65 AXIS II DISORDERS (cont.) Combination of Axis II and lack of competence will usually be extremely disruptive to the training program Combination of Axis II and lack of competence will usually be extremely disruptive to the training program

66 UNUSUAL SITUATIONS Unusual Situations Unusual Situations –Pregnancy –Death or serious illness of a child –Death or serious illness of a close relative –Death of a fellow trainee –Serious illness –Chronic medical condition –Acute psychiatric difficulty

67 PURPOSES OF SUPERVISORY EVALUATION Necessary to ensure that training programs achieve educational objectives and produce competent trainees Necessary to ensure that training programs achieve educational objectives and produce competent trainees Provide objective assessment of trainees’ competence and progress Provide objective assessment of trainees’ competence and progress Summative assessment provides input for decisions of warning, probation, or dismissal Summative assessment provides input for decisions of warning, probation, or dismissal

68 EVALUATION DIFFICULTIES Evaluation is an essential aspect of supervision Evaluation is an essential aspect of supervision Develop explicit standards and more uniform expectations regarding the knowledge, skill, and judgment necessary for practice Develop explicit standards and more uniform expectations regarding the knowledge, skill, and judgment necessary for practice Clearer competencies and standards for verifying the readiness of interns for practice Clearer competencies and standards for verifying the readiness of interns for practice

69 EVALUATION OF PERFORMANCE BY SUPERVISORS Greater consensus on evaluation seems possible through research and dialogue within the profession. Greater consensus on evaluation seems possible through research and dialogue within the profession. A procedure for comparison of ratings across supervisors may increase the reliability of evaluation. A procedure for comparison of ratings across supervisors may increase the reliability of evaluation. –Fosters consensual expectations and by exposing personal biases. Robner, W., Fuhrman, M., and Ristvedt, S. (1993) The Clinical Psychologist, Vol 45, 1.

70 Guidelines for Supervision Expectation of meetings (format, frequency and content, missed meetings, etc) Expectation of meetings (format, frequency and content, missed meetings, etc) Goals and outcomes of supervision Goals and outcomes of supervision Establishing expectation of ongoing feedback including strengths and areas of weakness (Both written and verbal feedback) Establishing expectation of ongoing feedback including strengths and areas of weakness (Both written and verbal feedback) Supervisors have an ongoing awareness of the patients who comprise the intern or postdoc’s caseload Supervisors have an ongoing awareness of the patients who comprise the intern or postdoc’s caseload Reviewing and signing co-signing all notes Reviewing and signing co-signing all notes Awareness of agency policies and procedures Awareness of agency policies and procedures Contact supervisor for input regarding all “at risk” patients Contact supervisor for input regarding all “at risk” patients Supervisors are aware of and behave consistently with the Ethical Priniciples Supervisors are aware of and behave consistently with the Ethical Priniciples Supervisors are aware of the power differential that exists Supervisors are aware of the power differential that exists Supervisors and intern or resident keeps supervision notes Supervisors and intern or resident keeps supervision notes

71 IDENTIFICATION OF TRAINEES – USE OF EVALUATION FORMS

72 DETAILED EVALUATION FORM

73 DOCUMENTATION Orientation Orientation –Evaluation Forms (Supervisee/Supervisor) –Suggested Guidelines for Supervision –Due Process/Grievance Documents –Time/Activity Sheets –Ethical/Problematic Situations Expectations of Behaviors (dating, interaction with supervisors, attendance, professional responsibilities Expectations of Behaviors (dating, interaction with supervisors, attendance, professional responsibilities

74 APPIC TRAINING RESOURCES Training Resources Training Resources –By Subject –For Trainers –Reference Lists

75 SUPERVISOR EVALUATIONS

76 MONTHLY ACTIVITY SHEETS Hours of supervision Hours of supervision Contact with diverse populations by ethnicity/age Contact with diverse populations by ethnicity/age Writing (Reports) Writing (Reports) Didactics Didactics Other professional activities (consultations, library research, etc) Other professional activities (consultations, library research, etc)

77 DUE PROCESS GUIDELINES EUGHS 1) an inability and/or unwillingness to acquire and integrate professional standards into one's repertoire of professional behavior, 1) an inability and/or unwillingness to acquire and integrate professional standards into one's repertoire of professional behavior, 2) an inability to acquire professional skills in order to reach an acceptable level of competency, and/or 2) an inability to acquire professional skills in order to reach an acceptable level of competency, and/or 3) an inability to control personal stress, psychological dysfunctions, and/or excessive emotional reactions which interfere with professional functioning. 3) an inability to control personal stress, psychological dysfunctions, and/or excessive emotional reactions which interfere with professional functioning.

78 DUE PROCESS DOCUMENTS – INFORMAL USE OF GRIEVANCE PROCEDURE - UTMB 1. Informal 1. Informal a. After receiving an evaluation which a resident wishes to challenge, the resident should schedule an appointment with the supervisor issuing the Detailed and Frequent monitoring, stating the reason for the appointment. The appointment with the supervisor should be established within five working days following the official evaluation appointment with the Training Director. In extenuating circumstances, where it would be difficult or impossible for the resident or the faculty member to schedule the appointment within the designated time limit, the appointment should be scheduled as soon thereafter as possible, in no case exceeding ten working days from the official date of the posting. a. After receiving an evaluation which a resident wishes to challenge, the resident should schedule an appointment with the supervisor issuing the Detailed and Frequent monitoring, stating the reason for the appointment. The appointment with the supervisor should be established within five working days following the official evaluation appointment with the Training Director. In extenuating circumstances, where it would be difficult or impossible for the resident or the faculty member to schedule the appointment within the designated time limit, the appointment should be scheduled as soon thereafter as possible, in no case exceeding ten working days from the official date of the posting. b. Should the issue fail to be resolved in the meeting with the faculty member to the resident's satisfaction, the resident may request that a conference be scheduled with the Training Director. The conference with the Training Director should be held within three working days of the resident/faculty conference. The resident conference with the Training Director will be held at such a time that the faculty member will be available to participate in the conference. The Training Director shall render an opinion regarding the resident's challenge of the evaluation within one working day of the conference with the resident. b. Should the issue fail to be resolved in the meeting with the faculty member to the resident's satisfaction, the resident may request that a conference be scheduled with the Training Director. The conference with the Training Director should be held within three working days of the resident/faculty conference. The resident conference with the Training Director will be held at such a time that the faculty member will be available to participate in the conference. The Training Director shall render an opinion regarding the resident's challenge of the evaluation within one working day of the conference with the resident. Up to this point, the grievance procedure has been informal with all information being exchanged orally. This guideline should serve to facilitate open communication between the faculty member and the resident without intimidating either party involved. It is hoped that the majority of resident grievances will be resolved at the informal level, with the inclusion of only the essential parties involved and preservation of confidentiality as no formal documentation has been generated. Up to this point, the grievance procedure has been informal with all information being exchanged orally. This guideline should serve to facilitate open communication between the faculty member and the resident without intimidating either party involved. It is hoped that the majority of resident grievances will be resolved at the informal level, with the inclusion of only the essential parties involved and preservation of confidentiality as no formal documentation has been generated.

79 FORMAL GRIEVANCE PROCEDURE - UTMB 2. Formal 2. Formal a. Should the Training Director rule in favor of the supervising faculty member, the psychology resident has the right to appeal to the Ad Hoc Student Grievance and Appeals Committee (the Grievance Committee). The Grievance Committee is made up of four training team members (one whom is appointed chair), none of whom have had direct supervisory responsibility with the resident in question. An outside member will also be appointed to the committee with approval from the psychology resident and the Director of Training. This appeal represents the initial step in the Formal Grievance Procedure. The appeal of the grievance must be submitted in writing by the resident to the Chairperson of the Grievance Committee, stating clearly and concisely the circumstances and particulars relating to the evaluation or circumstance which initiated the grievance. The resident's written report to the Chairperson of the Grievance Committee must be submitted within five working days following the conference with the Training Director. Failure to submit the report within the designated time will nullify the resident's right to challenge the evaluation in question which will stand as assigned. a. Should the Training Director rule in favor of the supervising faculty member, the psychology resident has the right to appeal to the Ad Hoc Student Grievance and Appeals Committee (the Grievance Committee). The Grievance Committee is made up of four training team members (one whom is appointed chair), none of whom have had direct supervisory responsibility with the resident in question. An outside member will also be appointed to the committee with approval from the psychology resident and the Director of Training. This appeal represents the initial step in the Formal Grievance Procedure. The appeal of the grievance must be submitted in writing by the resident to the Chairperson of the Grievance Committee, stating clearly and concisely the circumstances and particulars relating to the evaluation or circumstance which initiated the grievance. The resident's written report to the Chairperson of the Grievance Committee must be submitted within five working days following the conference with the Training Director. Failure to submit the report within the designated time will nullify the resident's right to challenge the evaluation in question which will stand as assigned.

80 OTHER DUE PROCESS AND TRAINING DOCUMENTS APPIC Web site at APPIC Web site at Additional UTMB Web Examples Additional UTMB Web Examples –https://www.utmb.edu/psychology https://www.utmb.edu/psychology

81 VIGNETTES Vignette #1 Vignette #1 –The psychology intern has been slowly withdrawing from their cohorts and you as the TD notice this. When asked, her response is they just seem to be on different wave lengths. You also are getting a couple of complaints from patients that the psychology intern is rude. She seems pleasant to you and has denied this problem with patients and you acknowledge that patients with chronic pain can be difficult to work with. On further inquiry, the secretary in the office notices that the psychology intern is very short with her and other office personnel. What do you do?

82 VIGNETTES Vignette #2 Vignette #2 –The psychology postdoc has very good clinical skills and seems to have very good work habits the first 6 months. You have noticed that he is not taking much initiative lately and seems to be slacking off. He has begun looking depressed and lacks energy. This problem was addressed 1 month ago but the number of sick days have increased substantially and non attendance at grand rounds and other functions has become non existent. He always seems to have a good excuse (dental appointment, need to see physician, etc.). What do you do?

83 VIGNETTES Vignette #3 Vignette #3 –The psychology intern is a quad that ambulates in a motorized wheelchair. She is quite eccentric in her dress (always extra nice) and has fingernails that draw a lot of attention (extra long and ornate). She also has several visible body piercings that she is quite proud of and discusses the importance of her individuality at length. Her skills are average and she has an aide that helps with moving things around (files, test protocols, etc). She has recently received complaints about racing her wheelchair (going at fast speeds) through the hallways of the rehab unit sometimes startling patients. What do you do?

84 VIGNETTES Vignette #4 Vignette #4 –The psychology postdoc has several research projects going on and has not been very good about following through on their responsibilities. You are not sure if they are overwhelmed, just a poor organizer or poor research skills. What interventions might you consider before it becomes a major problem?

85 VIGNETTES Vignette #5 Vignette #5 –The psychology intern has been unusually helpful during the year and has always completed tasks in a reasonable fashion. He is very independent and you sometimes wonder if they are expressing contempt for their colleagues and supervisors. Several things have happened to initiate you taking a closer look: –1) An MMPI was returned by mail from the prison system and he claims the hospital inmate had taken it while they must not have been looking. –2) One patient called to state dissatisfaction with the way she was treated by this intern stating that the intern blew up and lashed out at her by tearing up her MMPI and saying it was just worthless. He states that never happened. –3) The secretary went to lunch with him one day and reported to you, the training director, that the intern had made disparaging remarks about the program, the training director and one supervisor, stating the supervisor had made sexual advances toward the intern. The intern and the secretary met with the TD and the intern claimed they had never made those remarks, that everything was fine. How would you proceed?

86 REMEDIATION OPTIONS Remediation Remediation –Informal Problem Resolution with Supervisor –Contracts that spell out expectations –Formal Sanctions (videotape all sessions, coursework, etc.) –Options

87 MANAGING DIFFICULT TRAINEES Managing Difficult Students Managing Difficult Students APPIC Resources Colleagues Professional Organizations Literature

88 RESOURCES Lamb, Presser, Pfost, Baum, Jackson, & Jarvis (1987) Confronting Professional Impairment During the Internship: Identification, Due Process, and Remediation Lamb, Presser, Pfost, Baum, Jackson, & Jarvis (1987) Confronting Professional Impairment During the Internship: Identification, Due Process, and Remediation Lamb, Cochran, and Jackson (1991) Training and Organizational Issues Associated with Identifying and Responding to Intern Impairment Lamb, Cochran, and Jackson (1991) Training and Organizational Issues Associated with Identifying and Responding to Intern Impairment

89 INFORMAL PROBLEM RESOLUTION Dr. Nadine Kaslow Dr. Nadine Kaslow Department of Psychiatry and Behavioral Sciences Department of Psychiatry and Behavioral Sciences Emory University School of Medicine Emory University School of Medicine


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