Christina Carroll-Pavia, Ph.D.

California State University, Fullerton

Brigid Cahill, Ph.D. University of Rochester

Frances Diaz, Psy.D.

University of California, Irvine

Jenny Lybeck-Brown, Ph.D. University of Missouri-Columbia

(Still) Guarding The Gate:

How to Effectively Create & Utilize a Remediation Plan

2013 ACCTA ConferenceSeptember 22, 2013

New Orleans, Louisiana

Today We Will Cover…

• Introductions•Learning Objectives•When to Create a Remediation Plan •How to Create a Remediation Plan•Remediation in a Diverse World•Protecting Yourself and Others•Discussing a Remediation Plan with Relevant Parties•Dealing with the Outcomes of a Remediation Plan•Useful References

We Hope You Learn More About……how and when to initiate, construct, and evaluate the progress of a trainee remediation plan, and how to maximize use of existing systems and resources.

…resources available to assist and support you during a remediation process.

…the potential impact of a remediation process on the trainee, the training cohort, the supervisor, other staff, and yourself.

…the mutual impact of remediation and the internship imbalance, and cultural factors that may impact the remediation process.

…strategies for maintaining positive relationships with trainees and staff, and for appropriate self-care during a remediation process.

Please Check Any Activities You Would Prefer Doing to a Remediation Plan

File taxes. Road trip with a carful of

teenagers.

Swim with leeches Clean toilets Sleep in poison ivy Nothing, remedia-tion plans are an easy part of my

job as TD.

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2013 ACCTA Listserv Survey Resultsn=50 (thank you!)

•70% had put at least one trainee on a remediation plan• (last year 58%)

•Average of two plans (range 1-5 plans)•44% felt it had a positive impact•11% felt it had a negative impact•44% felt it had both positive and negative impacts

When to Implement a Remediation Plan•Clinical performance is subpar – client welfare is at stake• Interpersonal behavior is problematic for the agency•Trainee is not on track to reach the goals necessary for completion of training experience•When your due process guidelines say to!

Variables TDs Consider•From the ACCTA survey•Most commonly cited – same as 2012 survey• Client welfare• Trainee response to informal feedback

•Other variables• Role we serve as gatekeeper• Impact on system, trainee cohort, supervisor(s)• Amount of work involved•Due process procedures

Did I Do the Right Thing?

Considering not implementing a plan? Here are others’ regrets: •38% of ACCTA members surveyed regretted not implementing a plan for at least one trainee•Most commonly cited reasons include (same as last survey):•Lost opportunity for the trainee to grow and change•Recognition that TD’s (or staff’s) inexperience or discomfort interfered with trainee growth possibilities

Constructing a Remediation PlanWithin the guidelines of your own Due Process . . .

• Clearly define problems using concrete, behavioral terms (tie to evaluation items/competencies)

• Brainstorm options of how to remediate problem within training team (include supervisor who raised concern as appropriate)― Consider what is do-able, both for the trainee and the system― Make sure no one is doing all the work (trainee, supervisor, etc.)― Be creative, think outside the box

• Be as behavioral and concrete as possible regarding expectations for change and how this progress will be measured

Constructing a Remediation Plan• Get input from the trainee about

proposed solutions― Increases buy-in― Allows for solutions trainers might not have

considered― Allows for personalization to trainee’s learning style,

cultural background, etc.― Trainee input is not automatically part of the plan but

can be a helpful addition

• Include deadlines and dates for assignments and re-evaluation

Constructing a Plan: Diversity FactorsCultural values and beliefs (of both trainee and

supervisors) may impact the development, implementation, and evaluation of a remediation plan through:• Conceptualization of trainee competence/

performance issues― Distinguishing between cultural mores and skill or

personality factors

• How one gives/receives feedback• Dynamics in the supervisor/trainee

relationship• Some examples

Written Plan Should Include:

•Behavioral descriptions of problem behaviors• “Trainee is not able to articulate a conceptualization based on theory. Trainee is generally not able to describe why s/he chose a particular intervention or what the goal was. Trainee’s interventions are generally micro-skills (reflection and validation).”

•Behavioral expectations for desired outcomes• “Come to supervision prepared with at least one client’s history and a recording cued to a particular event in the session. Review videotapes of your sessions – at least two full ones a week – identifying your interventions and intentions.”

More of What the Written Plan Should Include:•The support the program will offer• “Model reflective practice• Encourage use of supervision to increase reflective practice• Provide immediate feedback when positive changes are observed”

•The limitations on the trainee’s workload• “In order to create time in trainee’s schedule to fully participate in this remediation, (trainee activity) will be eliminated, giving trainee five hours per week of flexible time to dedicate to the aforementioned activities.”

And Even More…•Description of what consequences of failure would be• “Sanctions for unsuccessful remediation in any area may include one or more of the following:• provision of such feedback in formal end-of-year evaluations • refusal to provide future letters of recommendation• additional restrictions on provision of services or professional

activities• probation• termination from (internship/practicum/postdoc)”

•Dates for when the follow up review(s) will happen

CONSULT! CONSULT! CONSULT!• Internal Management Structure• Can provide checks & balance

•ACCTA • Can provide support and samples

•APPIC •Will provide a space for you to verify that you have provided trainee with opportunity for due process

•APA/CoA• Additional source of support if concerns regarding impact on accreditation

CONSULT! CONSULT! CONSULT!• International Office• International trainees & impact on Visa status (home program will also support this process)

•ADA• Ensure that trainee has access to this information & have been included in the processes as appropriate

•HR• Verify that HR due process policies align with training policies

•Campus Legal Counsel•Trainee’s Home Program

Discussing with the Primary Supervisor•Discuss the need for a RP•Discuss each of your roles in the process • who will construct plan, deliver it, how does the process work

•Help Supr manage their reactions; countertransference•Schedule follow-up meetings•Discuss possible interventions. What is Supr willing to do?•Support Supr in giving difficult feedback (e.g.,

articles, modeling, role play). Remind them: this is part of our role•Discuss possible barriers in the supervision relationship•Be sure you’re both on the same page

Impact on Supervisors•Privacy concerns impact ability to discuss specifics•Management of other interns’ anxiety or concerns•Supervisor’s guilt & not knowing how to help•Managing degrees of reactions• Anger, disappointment, desire to do more, sadness, concern, etc.• Impact of their reaction on your relationship with them & role as TD

We’re All on the Same Page…Right?

The impact of the training team and primary supervisor•When you’re on the same page…•When you’re not…•When the supervisor/staff member is the problem (or at least part of it)•Managing the “but Jeremy does it…” response

Discussing with the DCT•Contact DCT early in the process. At the latest—once you’ve decided that RP is necessary • Identify aspects that are possible general program feedback vs. trainee specific concerns•Clearly define expectations• Forms of communication, tracking of progress, what information will be shared

Discussing with the DCT•Share your thoughts and tentative plans•Ask DCT for feedback, ideas, and suggestions • Inquire about DCT’s prior experience with this trainee• Inquire about the academic program’s procedure/ response policy for students on a RP•Emphasize shared desire to help student be successful and shared role as gatekeepers for the profession•Keep DCT informed about any progress or declines

Discussing with the Trainee•Hopefully, not totally a surprise—start giving feedback early•Decide who is the best messenger in earlier stages•TD should likely be involved once the RP is formalized•Be comfortable with the role of the “bad guy” to allow the supervisor to remain a safe person•Explain how you’ve gotten to this place, and why you are initiating a RP•Own any part that may be yours. Model accepting feedback•Emphasize your desire for the intern to be successful, including after they leave internship

Discussing with the Trainee•RP is formalized feedback, plus information to support trainee in being successful•Provide as many specific examples as possible. Use behaviorally-based and competency-based language •Tell them who knows what and who doesn’t•Explain what happens next and the evaluation process•Prepare them to be involved in the development of the RP (if appropriate)• Inform them about contact with DCT (should be outlined in due process of training manual)•Remind them to review their due process and grievance procedures in their manual

Discussing with the Trainee•Help them identify sources of support (intern cohort, academic program peers, personal friends/family, personal therapist)•Be open to questions•Be ready for a variety of intern reactions. Provide empathy, normalization, but remain firm•Encourage them to talk with the other trainees, other staff, if needed and desired•Schedule initial meeting and follow-up evaluation meetings with TD and primary supervisor•Emphasize your desire for the intern to be successful (Again)

Dealing with Ruptures in the Supervision Relationship•Acknowledge this may be inevitable•Be aware the power differential in supervisory relationship becomes very salient (best for supervisor to acknowledge this)•Give trainee invitation and time to process reactions to the process

• Balance between validation of reactions/pain and belief in and support of the process & program supervisors

•Try to keep primary supervisor out of the “bad guy” role as much as possible

• Example• If TD is primary supervisor

•A well-executed process can ultimately strengthen relationships – just not always in the beginning!

Caring for the Cohort•Can be difficult because of privacy and personnel rules/considerations•Ambiguity and privacy considerations can increase cohort anxiety (“Am I next?”)•Address the elephant to the extent possible, especially if intern is dismissed or significantly restricted•Cohort may have a sense of what’s going on, but not know what to do• From their own experience of the intern• Intern may confide in peers (or choose not to)• From the consequences of RP• Through centralized scheduling processes

Caring for the Cohort•May need to just acknowledge generically that the staff is making/has made efforts to support someone who is struggling• May help to talk with intern to see what, if anything s/he has

disclosed to peer group (supervisor may have more access to this)• Take into consideration the intern’s relationships with his/her

peer group• Different interns may have different awareness of what is going

on

•Possibly provide outside facilitator to help them process •Don’t forget to attend to the other trainees in general

Discussing with Non-training Staff • Be attentive to privacy issues• Solicit examples of behaviors (positive & negative) in specific areas• Emphasize both the caring for trainee and duty as gatekeepers• Emphasize that decisions were made by a team, based on patterns of behavior or extreme violations• Encourage a united front. Ask others to trust the process/team• Invite questions, but know that you may not be able to provide certain details• Acknowledge mixed feelings about the process or the results• Publically support the primary supervisor and the Training Team

What Was the Most Difficult Part of Implementing the

Plan?

•Similar to the 2012 survey results•Dealing with the trainee’s reactions (anxiety, defensiveness, anger)•Having to deliver difficult feedback•Getting and keeping all of the training committee on the same page•Creating the plan itself (using behaviorally-based language)

What Would You Do Differently?

• Intervene earlier – most frequent response•Be more specific, detailed, concrete, clear in defining problems and consequences•Get academic program involved early•Be more direct and straightforward (rather than be ‘nice’ and conflict avoidant)•Document more thoroughly•Get support!

From the 2013 Listserv Survey

DOCUMENT!•EVERYTHING!•Document meetings•Communication with intern and supervisors•Begin the documentation early on to help determine if you are moving in the direction of a formal remediation plan•Storage of documentation – if involves ADA or protected information may need to work with HR to protect information storage

Outcomes•When the trainee has met the goals• Acknowledge and celebrate! •Notify academic program•Document

•When the trainee has not made sufficient progress:• Follow your evaluation/due process guidelines• Consult, consult, consult with APA, APPIC, academic program, HR, CoA, legal, •Document

•Consider what is a ‘success’

Separation• In the event that you move towards separation:• CONSULT and work closely with HR, the home program, CoA, campus legal counsel, & APPIC• Consider a leave of absence…no not for you! (depending on factors contributing to challenges)

Impact of the Match Imbalance

•Pressure felt by: • academic programs to get students matched to internships• internship sites to pass interns – impact of failure on future chances

Caring for Yourself•Model good ethics, but also human fallibility•Keep your expectations for yourself and your trainee reasonable•Pace yourself. It’s a process that will likely go on for several weeks, if not longer•Own your part, but don’t take too much responsibility for intern’s shortcomings•Seek support from peers (ACCTA listserv!, local TDs, DCT)•Seek support from your Director and other staff•As much as possible, present a united front. Try to avoid potential for splitting

Caring for Yourself•Don’t do it all yourself. Include your training team (and the trainee, if appropriate) in the creation of the RP• examples of problems, ideas for consequences/training tasks

• Schedule follow-up appts and time to craft plans and evaluation documents well in advance•Use existing examples (check website, ask peers)• Consult with APA, APPIC, HR, campus legal reps, etc. for more serious concerns• Continue to participate in your regular self-care routines (exercise, sleep, nutrition, etc.)• After all is said and done, consider possible changes in your process, policies, procedures, etc. for the future

Selected References (With Comments)Forrest, L., Elman, N, Gizara, S, & Vacha-Haase, T. (1999). Trainee impairment: A review of identification, remediation, dismissal, and legal issues. The Counseling Psychologist, 27, 627-686. Good summary of the literature on remediation plans. Also, good discussion of intersection between impairment and ADA issues.

Hoffman, M. A., Hill, C. E., Holmes, S. E., & Freitas, G. F. (2005). Supervisor perspective on the process and outcome of giving easy, difficult, or no feedback to supervisees. Journal of Counseling Psychology, 52, 3-13.Nice exploration of different factors involved in supervisors’ decisions to give or not to give feedback to doctoral interns in APA-approved UCCs. Includes supervisors’ assessments about the short- and long-term outcomes of their decisions.

Jacobs, S. C., Huprich, S. K., Grus, C. L., Cage, E. A., Elman, N. S., Forrest, L., Schwartz-Mette, R., Shen-Miller, D. S., Van Sickle, & K. S., Kaslow, N. J. (2011). Trainees with professional competency problems: Preparing trainers for difficult but necessary conversations. Training and Education in Professional Psychology, 5, 175-184.Great discussion of barriers trainers encounter when addressing competency issues including suggestions for overcoming these obstacles.

Selected References (With Comments)

McAdams, C. R., & Foster, V. A. (2007). A guide to just and fair remediation of counseling students with professional performance deficiencies. Counselor Education and Supervision, 47, 2-13. Nice summary of legal cases involving due process and remediation. Includes guidelines about how to make due process/remediation congruent with legal requirements.

Miller, D. S. S., Forrest, L., & Elman, N. S. (2009). Training directors’ conceptualizations of the intersection of diversity and trainee competence problems: A preliminary analysis. The Counseling Psychologist, 37, 482-518.Interesting qualitative study that provides recommendations for increasing the complexity and frequency of discussions of cultural variables within the context of trainee competency issues.

•Q & A/ Discussion

Thank you for your attendance and your attention!

Please don’t forget to complete your program evaluation!