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Difficult Interns and Postdoctoral Residents: Identification, Assessment, and Interventions

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. DEFINITIONS. Competence

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Difficult Interns and Postdoctoral Residents: Identification, Assessment, and Interventions

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

  2. DEFINITIONS • 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)

  3. DEFINITIONS • 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) • Therefore, we will focus on trainees with problems, referred to as “difficult” trainees • Sometimes these trainees also have impairments according to the ADA

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

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

  6. 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)

  7. DEFINITIONS (cont.)(Lamb et al., 1987) • 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

  8. 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

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

  10. DEFINITIONS (cont.) • 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

  11. 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: • Philosophy of the site and the trainee’s orientation • Skills and competencies of the trainee and the demands of the site

  12. CONTEXT (cont.) • 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

  13. 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 • 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

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

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

  16. PROCESSES ASSOCIATED WITH PROBLEMATIC BEHAVIOR (Lamb et al., 1991) • Setting the Stage • 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

  17. PROCESSES (cont.) • 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

  18. PROCESSES (cont.) • 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) • Settings that behaviors occur in • Negative consequences of the behaviors • Trainee’s response to feedback

  19. PROCESSES (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)

  20. PROCESSES (cont.) • 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

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

  22. PROCESSES (cont.) • 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

  23. 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:

  24. 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

  25. 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

  26. 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

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

  28. FORMAL ACTIONS (cont.) • 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 • 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

  29. TERMINATION(Lamb et al., 1991) • 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

  30. TERMINATION (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

  31. TERMINATION (cont.) • 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

  32. CHALLENGES IN EVALUATING INTERNS & RESIDENTS (Robiner, 1993) • 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

  33. EVALUATION CHALLENGES (cont.) • 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

  34. EVALUATION CHALLENGES (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

  35. EVALUATION CHALLENGES (cont.) • 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)

  36. EVALUATION CHALLENGES (cont.) • 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

  37. EVALUATION CHALLENGES (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

  38. EVALUATION CHALLENGES (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

  39. 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 may be rooted in • Behavior or personality features of either person • Contextual factors • Poor matching • Effects of otherwise healthy maturation

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

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

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

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

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

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

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

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

  48. LEGAL ISSUES AND DUE PROCESS • 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 • 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

  49. 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 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 • 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 of whether and to whom the complainant or training program official may appeal the decision • A clear statement of when the decision becomes final

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