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Eric Levin asks: I’m a 5th-year clinical student on internship at Penn in Philadelphia. I’m looking into my options for next year, and I’m wondering about the possibility of working with a private practitioner in Philadelphia in order to get my clinical hours towards licensure. Has anyone out there received both supervision and clients from a private practitioner and made it work as well as a formal post-doc in terms of accruing hours in an expedient fashion? Rachna Jain responds: I’m a recently licensed (June, 2000) psychologist in Maryland and I obtained my post-doc hours via a private practice position. In Maryland, a person working without a license is required to apply for a position as a Psychology Associate, which basically means that you’re unlicensed and practicing psychology under the supervision of a licensed doctoral level psychologist. You must be approved by the Board of Examiners of Psychologists to work in this capacity. I don’t know what the rules and regulations are for PA, but if you take a position in a private practice, just make sure that you’re following the rules of the State and that your supervision will meet the hours for licensure. You can probably obtain this information by reading the State laws that pertain to the exemptions for licensure for the State of PA. I found that working in a private practice as a “post-doc” went pretty well; the money was better than in other settings, the hours were flexible, and I learned a lot about how to set up my own practice, which I’m now in the midst of doing. As long as your work hours will count towards licensure, and assuming that gaining experience in private practice is part of your long-term career plan, I’d say it’s a very good option. Jeff Barnett adds: I agree that there are factors that must be considered that may be jurisdiction specific. I believe the first step is to talk with your current and past supervisors in PA and get their input. Have other students done this there? Do they have contacts they can put you in touch with? Have you done any training with local psychologists who may possibly have positions available or at least leads? You can tell I believe that professional networking is very important. Are you a member of PPA? If yes, definitely get in touch with them and see how they can help you. Your local State Psychological Association is a wonderful resource that’s just waiting to be of assistance to you. They may have programs for graduate students and those entering the profession, mentoring programs, training programs, and leads of training and work positions. They have a lot to offer. If you’re not a member, call them anyway and they’ll be of great help; but I hope you’ll join. Your State Psychological Association can be a great resource in so many ways. You can contact Dr. Sam Knapp, PPA’s executive director at sam@papsy.org and at (717)-232-3817. (this is true for all State Associations). Others in a similar situation should contact their State or Provincial Psychological Association. Links to them are available on the APA website. The APA Practice Directorate can likely be of help too. Check out the APA website at www.apa.org. As Rachna said, in Maryland one must first be licensed to provide psychological services unless you are in an exempted group such as students, interns, etc, and also those with a Masters degree or its equivalent who are practicing under the supervision of a licensed psychologist approved by the Board of Examiners. And, because the Psychology Associate hasn’t yet met the requirements for independent practice and licensure (education, training, supervised experience, and knowledge) the supervision is mandated by law. It also must be a minimum of one hour of supervision for every five hours of direct patient contact and a minimum of one hour of supervision for every comprehensive evaluation completed. The supervision must all be in person, one-on-one, and provided by the licensed psychologist approved by the Board. Laws like this can have a significant impact on just what you can and can’t do for your post-doctoral year. You also may have difficulties finding a private practice setting due to your inability to get on managed care panels prior to being licensed. Whatever you do, be sure to utilize some kind of contract that specifies what will be expected of you throughout the experience, what you can expect of the supervisor/employer, all financial arrangements, all supervisory arrangements, and so on. One problem with doing the post-doctoral year in a private practice is, for some, the lack of uniformity of the training experience; and there should be training provided. You’re not just cheap labor. So, while a formal post-doctoral program is not for everyone, and there just aren’t enough of them to go around, you should seek consultation within your State, do some active networking, get a private practitioner mentor in PA, and be sure whatever you do for that year meets the requirement for licensure in your State. You’re quite wise to address these issues now to be sure it all turns out well for you. My final thought is that a formal post-doctoral training program can provide great training and preparation for entering private practice. The big issues are the quality of training and supervision. The clinical experience need not be in a private practice setting to prepare you for it. There are workshops and seminars on starting a private practice you can attend in your State and at the APA convention. Rachna Jain adds: In reading Jeff’s post, I had a couple other issues you might want to consider. I think formal post-docs are going to be uniformly better at providing a comprehensive training experience, which means lectures, readings, seminars, etc. I think, too, it can be a more social experience and more immersive in the sense that you’ll be around other people who are working on the same things that you are. Private practice can sometimes be lonely and isolating, especially if you’re going into an established practice, and you’re the only post-doc there, which was my experience. I did my internship at the Pittsburgh VA and had opportunity to work with the Pennsylvania Psychological Association. I think Jeff’s point was excellent as far as tapping into this resource. On the whole, I found PPA very open and responsive, and very large, which is great for creating opportunities. One last issue that comes to mind is that of a contract. One issue that you should also consider is where you might be working after licensure and if your post-doc employer will require a “no-compete” clause in your contract. This clause can prevent you from working in the same building or prevent you from working in a 25 mile radius, which can be a significant issue if you plan to practice in the same geographic area after licensure. Just make sure your no-compete is something you can live with. Jeff adds: Rachna is correct about non-compete clauses. In many contracts practitioners sign this is a common clause that is included. The principle behind it is as follows; If I have a thriving private practice that I worked long and hard to establish and I bring you in, I am providing you with referrals to fill your schedule since you won’t have any of your own. Thus, I am helping you to get established in the local community. Then, if you decide to leave my practice where I receive some amount of money for each patient you see and which adds to the reputation and success of my practice, you will in fact be a competitor. You could open an office near by, take your current patients with you, and market yourself to the same referral sources. To protect myself, I would have a non-compete clause in the contract. It might state that if you leave my group you may not work in private practice (working for an agency is fine since that won’t compete with me) within five miles for a period of two years. Or if you do, you will have to pay me a sum of $20,000. to compensate me for the damage to my practice that will occur. Making such payment will release you from all obligations of our contract. The distance and time period covered by the non-compete clause as well as the penalty charged are just representative examples, but courts have generally ruled that such provisions of contracts are enforceable except when one has a specialty that is not offered by anyone else in the local area and to enforce the non-compete clause would not be in the best interests of the local community. These are things I learned over the years and never even heard of in graduate school. My final point is to always have all contracts reviewed by an attorney before signing them. This is true no matter how straight forward and simple they may seem and is true for managed care contracts too. Contracts that are offered to us are generally written to protect the best interests of the originating party, not us. Stacey Nitschelm asked the following on the Mentors’ listserv: I have a hypothetical ethical dilemma and am looking for input. I have ended an appointment with a client and have entered the reception area at which point she hands me a bottle of wine as a “thank you.” What should I do? Jeff: Stacey, a lot of this has to do with your comfort level, your theoretical orientation, and your understanding of this individual. It’s important to understand the meaning of the gift giving to this patient so that it can be understood accurately and not misinterpreted. There are two sides to this issue. One is that this is a boundary crossing and to engage in it is troublesome because it may lead to other more significant boundary crossings and then to boundary violations that are likely to be harmful and exploitative. The other side is that boundary crossings can and do occur, and don’t necessarily need to lead to anything else; they don’t necessarily need to lead to anything inappropriate or to any harm occurring. Boundaries such as time, place, space, money, touch, etc. are established to set the parameters of the psychotherapy relationship. They are typically very useful and important for a variety of reasons, to include the patient’s security in this special relationship. They establish the ‘rules’ of the relationship. Some psychotherapists want the patient to follow all their rules. Others negotiate some of it with their patients. You raise an issue that could lead to difficulties in the psychotherapy relationship, but presents from the outset a great opportunity to negotiate some of these ‘rules.’ Not knowing anything about the dynamics and history of the individual in question, I would say the following: If I didn’t have another appointment right away I would invite the patient back into my office to discuss it. If I did have another appointment shortly thereafter, I would graciously accept it and thank the patient, but would keep it in my office for us to discuss at the next session. Whether right after the gift is given or at the following session I would discuss my genuine thanks and appreciation for the kindness of giving the gift, try to address the meaning of giving the gift, and share with the patient my reasons for not being able to accept the gift. I would endeavor to return the gift using my clinical judgement to do it in a way so that it would not be harmful to the patient. The discussion or explanation of why I could not accept it would be crucial. Since this is the first session, my guess (not knowing anything else about the individual) would be that this would be a good time to set this boundary (in a positive, non-punitive way). If this happened at a different time during treatment I might interpret it differently and might respond differently. I always graciously accept gifts from patients around Hanukkah/Christmas time, however, they are typically cookies, etc. This certainly seems situation specific and a socially accepted practice. I also accept drawings from children, etc. Some look at the cost/value of the gift as a determining factor. I hope it stimulates some discussion among our listmates. There are no clearly right or wrong answers in this situation as there aren’t in many situations where we face an ethics dilemma. Some questions to ask ourselves when we face these situations include: Would it likely be helpful or harmful to the patient for me to engage in this action? Whose needs are being met by engaging in this action? Is this action consistent with my treatment plan for this patient? Is this action consistent with my professional obligation to this patient and consistent with our informed consent agreement? Would I be comfortable documenting this action and having my colleagues knowing about it? If I am unsure, have I consulted with experienced colleagues about this? If I choose to go against my colleagues’ advice, why? Have I consulted the APA Ethics Code and relevant State law? What guidance do they provide me? And, somewhat tongue-in-cheek, do I have that queasy feeling in my stomach? If so, I probably shouldn’t be doing it. Kaki York adds: I have haven’t had a client offer gifts while I’ve been in graduate school but, in my former (pre-graduate school) life as a case manager/social worker for persons with severe mental illness, I frequently had clients who would bring me little things here and there. Usually, it was something like a thank you or Christmas cards (sometimes home made), which, although I assured them was unnecessary, I did accept because I felt it would have been counterproductive to refuse and the items were of little or no monetary value. However, there were occasions when clients would offer items of some value (the most unusual item was purebred puppy) and at these times, I politely explained that while I was very flattered that they wanted to give me something, it was inappropriate for me to accept gifts. Generally, speaking they responded well to this. I think that the important thing is to make it clear to the client that you are not rejecting them by refusing the gift. Linda Centeno adds: Great topic to bring up on this listserv, Stacey. I work in a clinic in a major metropolitan hospital where most of our clients live on fixed-incomes. During the holidays, gifts become an issue. Most of us are psychodynamicly trained. However, we also feel that interpreting or shaming a client for giving a gift often is counterproductive and even harmful. We deal with gifts on a case-by-case basis. For example, a male patient of mine who is a senior citizen brought me a stuffed animal for the holidays (in the context of an erotic transference). For this man, intimate feelings are very frightening and have been avoided for years. In one sense, it was nice to see him risk enough to open himself up in giving this gift. I chose to accept it and later have used it as a way to discuss those feelings that are in the room, but often avoided by him (and sometimes me). I think, for this man, rejecting the gift would have been humiliating and rejecting. And perhaps most of all, I felt comfortable in accepting the gift. There are patients from whom I would not feel comfortable receiving a gift. And I usually try to be gentle and at the same time, thankful for the thought. I would love to hear more thoughts on this topic. Paula Conneran adds: You do raise some important issues. However I would like to comment on part of your response. I think that stating, “interpreting the gift giving from a patient IS counterproductive and even harmful” is too severe of a statement to make. It depends on the patient, where the patient is at in therapy, the presenting problems for the patient, and what the gift from the patient is. In my humble opinion then, to state that interpreting gift giving from a patient as counterproductive and even harmful is not only too severe but inaccurate as well. I would like to end by stating that I agree wholeheartedly with you that, a therapist must determine their response on a “case-by-case” basis. Geneva Reynaga adds: I would try to place the giving of the gift in context. How expensive was the bottle of wine? How much of a financial burden was this gift for your client? Has she ever given you anything before? Have you ever accepted anything from her before? What are her issues? Is giving one of them? Are boundaries an issue for her? Are boundaries an issue for you? Consider all the of the possible countertransference reactions you may be having and why you may want to accept the gift, if you do. I personally would only accept the gift if it was of little financial consequence to her and it would harm her more than it would help her if I declined the gift. Otherwise, I would reiterate the nature and boundaries of the therapeutic relationship, explaining that the fee is compensation for your time and is all that is required as far as gifts are concerned. I hope this helps you. Kimberly Watson posted the following questions regarding internships on the Mentors’ Listserv:
Here are our responses: Mike: There are two issues that arise when considering the importance of an accredited internship. The first issue deals with quality control and the second deals with practical implications in terms of credentialing. With regard to quality, CPA or APA accreditation require periodic review to assure that the internship has a system of training that is based on a philosophy of training, has appropriate goals, objectives, and criteria and a well-articulated system of training to achieve them. Accreditation also expects that the host of the internship has the necessary resources in terms of clinical experiences, supervisors, office space, testing materials, stipends, etc. Accreditation also insures that there are mechanisms in place to insure appropriate evaluation, support, and treatment of interns and a system for evaluating outcomes and improving the program. Accreditation standards also address how the internship deals with issues of diversity and represents itself to potential applicants and the public. Because accredited internships meet the standards set by the profession, psychologists who have been trained in them find that they can meet the requirements for internship in all states and do not have to go through the process of documenting equivalence. The same advantages obtain in seeking other credentials such as recognition by the National Register and ABPP. Accredited internships also strengthen credentials in terms of employment and seeking postdoctoral training. Regarding the issue of research, internships tend to vary with regard to emphasis on trainee characteristics. Most are interested in clinical experience and would give preference to a person with strong experience over those with a strong dissertation. The main issue is the progress of the trainee on completing the dissertation. I would anticipate that the main way that research would have a bearing is if the topic deals with an issue important to the site. A dissertation regardless of method that deals with a clinical aspect of parent child interaction would be viewed better by a child guidance center than a prison setting. Jeff: I have also found that having an APA-accredited internship has been helpful in streamlining the licensure process, obtaining employment, being listed in the National Register, and for insurance/managed care purposes. Graduation from an APA-accredited doctoral program and completion of an APA-accredited internship seem be the recognized standard that make all of the above much easier. They are not requirements for successful practice, but, depending on one’s goals, they may be very helpful. In the doctoral program where I teach, when a student can’t obtain an APA-accredited internship, we look for one that meets APIC guidelines. This helps to address the important concerns you address concerning available resources and the training experience. I have also been a clinical supervisor at the Clinical Psychology Internship in the Department of Child Psychiatry at the University of Maryland Medical Center. There, strong research skills and interests, as well as a good publication history are part of what they look for in potential interns because their mission is to train psychologists who will have academic appointments in medical schools and do research in addition to clinical work. In contrast, at Counseling Center internships I am familiar with there is no preference given to those with strong research credentials. They look primarily for strong clinical skills and as many hours of clinical experience as possible. So, it seems that one should research different training sites, see what they emphasize, and talk to current interns in addition to reviewing published listings and descriptions. Mike Gallardo adds: Whether or not you choose to do an APA accredited internship really depends on your long-term goals. If you look down the road a bit and envision what you anticipate doing, you can then identify whether it is necessary or not. Many places of employment continue to require that their applicants have an APA accredited internship and have graduated from an accredited school. Many governmental agencies, university settings, and some hospitals require you to have an accredited internship. If you are unsure of your future plans, it is best to obtain an accredited site. This way you will not limit your opportunities upon graduation. When looking into post-docs as well, many will require you to have an accredited internship site. I am a big advocate for creating as many opportunities for oneself as possible and this is one more way to do so. You will also begin to receive more focused training that meets certain guidelines that many other placements may not meet otherwise. Overall, the training is of higher quality and more specialized. With regard to question 2, what is more important here is your clinical experience. Yes, they will look at your research, but depending on what type of site you are applying for, will depend on how much they look at your research, etc. More times than not, they are going to be looking at you as a whole, which includes clinical experiences, volunteering, and related experiences. |
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