Core Values in Training

The Augusta University/Medical College of Georgia-Charlie Norwood Veterans Affairs Medical Center Psychology Internship (AU/MCG-Charlie Norwood VAMC Psychology Internship) was formed with the guiding principle that synergy could be achieved by pooling resources and interrelating the respective institutional education efforts in regard to psychology internship training with a focus on interdisciplinary health care settings. Our training model focuses on four primary facets of training in the development of professional psychologists: (1) Training in the implementation of essential practice skills in key field settings; (2) Training in an empirical approach to practice (fostering attitudes of empiricism and reflection), and; (3) Training in the provision of care for underserved populations and areas. The distinguishing characteristic of our training efforts, however, has been our focus on producing professional and racially/ethnically diverse psychologists who are well prepared for and seek out careers that are directed toward integrated approaches to health care issues and who aspire to greater cultural awareness and humility in their practice. Consequently, the AU/MCG-Charlie Norwood VAMC Psychology Internship has combined solid grounding in core clinical psychology skills with emphasis training in the areas of integrated health psychology and health behavior care.  Integral to all required rotations are joint educational and clinical service activities with primary care physicians, psychiatrists and other physician specialists, nurse practitioners, physician’s assistants, social workers, and other allied health professionals.  Furthermore, core competencies that are taught include skills specifically relevant to the provision of mental health care in medical settings: (1) the application of clinical assessment and treatment in medical settings; (2) the ability to function effectively as a member of an interdisciplinary team, and; (3) the development of consultation strategies in medical contexts. Consistent with overarching principles of professional psychology training, the curriculum of AU/MCG-Charlie Norwood VAMC Psychology Internship is intended to provide sequential and cumulative opportunities for the development and demonstration of core competencies. Furthermore, we strive to foster a culture of humility and inclusivity, prioritizing a training environment that is supportive of lifelong learning in multicultural orientation and structural competencies. 

Core Values in Training: The AU/MCG-Charlie Norwood VAMC Internship supports the foundational value of the scientist-practitioner model of training for the professional psychologist. Scientific methods can both inform us of the human experience and guide in the development and implementation of therapeutic responses to life problems. Therefore, training in scientific methods should be a core endeavor for the development of the professional psychologist. For the information achieved through scientific methods to be effectively integrated into clinical practice, however, systematic methods of observation and inquiry along with critical reasoning must be employed from an idiographic perspective. Furthermore, the practice of professional psychology entails an intense interpersonal experience that requires essential skills of communication and social interchange that enable the Clinician to successfully engage another in diagnostic and therapeutic processes. Therefore, training in the Clinician’s idiographic perspective and critical interpersonal skills is also fundamental for the development of the professional psychologist. The traditional conceptualization of the scientist-practitioner model of training advocates that graduate programs and internship/internship sites share the responsibility for teaching scientific research skills and professional practice skills in an integrative manner. The ideals of this integrative approach represent the core identity of professional psychology. Nevertheless, the implementation of this model at both academic and practicum contexts remains incomplete. Specific to the internship training, we argue that attempts to integrate science and practice have been hindered by:

The limited practice relevance of research conducted by Interns. Practice relevant research is time consuming and typically progresses slowly in producing knowledge pertinent to assessment and therapy enterprises. In the context of a one-year training experience, it is often impractical for Interns to conduct practice-oriented research that will inform them of issues pertaining to their practice. Therefore, research and practice activities in the Intern setting have often become parallel but not integrative events. This has been partially addressed by having faculty maintain ongoing research relevant to practice issues, such that the Intern can become engaged in practice relevant research. Nevertheless, tagging onto faculty research often does not provide for the Intern the needed integrative experience of conceptualizing, planning, implementing and interpreting research findings from a practice perspective.

The limited training in scientific approaches to practice. Intern training traditionally has been focused on the development of practice skills, including a broad base of psychological assessment and therapy techniques.  Skills taught should be based on scientific evidence of their efficacy. In practice, however, there are notable obstacles to the direct linear application of science to practice. For example, important contextual differences between research and applied settings can hinder a direct translation of research findings to individual treatments. To elaborate, the impact of an empirically supported treatment is likely to depend upon such complex factors as the severity of symptoms, patient characteristics that influence treatment adherence, therapist characteristics that influence treatment adherence, alternative processes that emerge within treatment, and other conditions of administration. The extent to which such contextual factors complicate the effective implementation of empirically supported treatments should not be underestimated. More to the point, we agree with Hoshmand and Polkinghorne (1992) in their analysis of the novice Clinician whom they describe as “often unable to make sense of problems of practice until he or she has had the opportunity to apply the conceptual understanding and inquiry skills developed in academic training and to modify them according to the requirements of practice” (p.58). Although relevant research may be presented and empirically supported practices may be taught, inadequate attention is often placed on how the Intern applies these data and practices in patient specific work.

To address the limitations of the traditional implementation of the scientist-practitioner model at the internship site, we aspire to a training model that we will identify as The Empirical Clinician model of training. This model focuses on two primary facets of training in the development of professional psychologists: (1) Training in the implementation of essential practice skills in key field settings; (2) Training in an empirical approach to practice.

Training in the implementation of essential practice skills in key field settings: Our internship emphasizes the training of professional psychologists to practice their skills in medical settings as well as more traditional mental health contexts. Incoming Interns are expected to demonstrate the basic component skills of practice.  We propose that the internship year should represent a consolidation and integration phase of professional development and thus the fundamental components of clinical knowledge, conceptual/ theoretical models, and assessment/therapy skills should be present upon entry to the internship. Of course, broadening the training in the implementation of essential practice skills has been a traditional role fulfilled by internship sites. Consequently, our training efforts seek not only to instruct and practice interns in critical assessment and treatment skills but also to ensure that interns learn to adapt these skills in diverse interdisciplinary health care settings. Moreover, they are taught training methods of consultation and collaboration with other health care professionals. Finally, we endeavor to prepare professional psychologists to provide quality psychological services to underserved populations with a particular interest in providing services for individuals living with HIV/AIDS, Black, Indigenous, People of Color (BIPOC), LGBTQIA, children and their families, and individuals from medically underserved areas.

Training in an empirical approach to practice: The “scientist” facet of training, as narrowly defined by participation in research activities leading to nomothetic data, would not represent a major focus of training efforts during the internship year. Research skills and thinking are viewed as integral to the success of the Empirical Clinician Model of training and demonstration of these skills by a completed, or at least a proposed dissertation is a prerequisite for entry into the training program. Also, participation in research/scholarship activities are required and facilitated for Interns throughout the training year. The distinguishing characteristic of this training model, however, is the direct attention paid to using empirical studies and data critically to guide the clinician’s practice. Stricker and Trierweiler (1995) have pointed out that the integration of science and practice can be accomplished by the common ground of a scientific attitude, and we would suggest that integral to this attitude is an emphasis on empiricism and reflection. The Empirical Clinician Model of Training attempts to instill in Interns the attitude of empiricism as they develop their skills in gathering and integrating data from four key Data Domains:

Research Data. The Empirical Clinician maintains an ongoing vigilance of research pertinent to the clinical enterprise. When presented with diagnostic and treatment issues, the Clinician should routinely query as to what research has to offer in the matter. To be included in the Empirical Clinician’s database is a working knowledge of the empirically supported assessment instruments and treatments relevant to their field of practice.

Idiographic Patient Data. The Empirical Clinician values and systematically gathers the patient-specific data at hand, recognizing that each patient brings to the clinical enterprise a unique set of biopsychosocial characteristics that can inform the clinician in understanding the patient’s life problems as well as offer avenues for healing and growth. To be included in the idiographic patient database are objective data (i.e., data that can be directly observed by the Clinician), subjective data (i.e., data that cannot be directly observed by the Clinician but can be self-reported by the patient or their parent/legal guardian/significant other), and associative data (i.e., data obtained through projective and interpretive tools that may not be readily observed by the patient). Each of these sources of data have their virtues and liabilities in regard to their reliability and validity, and thus the Empirical Clinician seeks to maximize their benefits to the patient by maintaining a comprehensive and psychometrically sound approach to idiographic patient data collection and interpretation.

Idiographic Clinician Data. The Empirical Clinician understands that their own unique characteristics (including one’s own cultural/diversity factors) affect the diagnostic and treatment process.  In particular, the Clinician maintains a vigilance on the reciprocal effects of the observer on the observed and the treater on the treated.  Therefore, the Empirical Clinician continually gathers data from self-examination and process-oriented observations of the Clinician-patient relationship. 

Nomothetic and Idiographic Cultural Data. The Empirical Clinician recognizes the unique contribution that cultural and diversity data may lend to the clinical enterprise. Cultural/diversity data provides the framework from which the Clinician is better able to understand the diverse values, interactional styles, and cultural expectations that can impact diagnostic and treatment processes.  Research findings regarding cultural and diversity issues should represent the baseline data only, however, given that each patient has their own idiographic cultural and diversity experiences.  Therefore, the Empirical Clinician maintains ongoing inquiry regarding pertinent research findings relevant to these issues, yet they do not mechanistically apply this nomothetic data but rather seek to integrate this data with the more unique cultural and diversity experiences of the patient. 

The Empirical Clinician Model of Training attempts to instill in Interns the attitude of reflection as well. Effective integration of the data obtained requires a systematic process of evaluation and interpretation of data.  This facet of training should represent a continuation of the critical thinking processes that were initially taught in the context of scientific experimentation. Fundamental to this critical thinking process are the following reflective components:

  1. The development of hypotheses based on the data available.
  2. Reflection upon data that confirm and disconfirm proposed hypotheses.
  3. Inquiry as to what additional data is needed and what procedures should be followed to obtain it efficiently and validly.
  4. The development of an “experiment” to obtain the additional data.
  5. Interpretation of the additional data obtained in light of the proposed hypotheses.
  6. Reformulation of the hypotheses.
  7. Development of generalizable conceptual models.

The attitude of reflection, however, entails more than fundamental critical thinking processes and the application of empirically supported treatments. The Empirical Clinician begins in a professional setting, addresses a problem of significance to the patient who presents it, and is faced with a need to respond to that problem in a humane and effective manner. If scientific knowledge is sufficient to the task, the situation is an easy one and desirable behavior for the clinician is readily apparent. In such a situation the clinician can apply easy-to-use or supported techniques. At times, a more dynamic reflection by the Empirical Clinician is required to deal with problems that do not clearly lend themselves to scientifically verified approaches. It is here, where science only presents at best a partial solution, that critical judgment becomes crucial. The Empirical Clinician must recognize the gap between the global nature of research findings and the usual specific nature of clinical dilemmas. At the least, the clinician should recognize that scientific training can provide an attitude and an orientation to the problem at hand that will lead to an informed solution that is considered, and hopefully falls within acceptable professional canons. To develop this informed solution, the nomothetic task is to develop a therapeutic plan based on those prototypes assessed as being most relevant to the individual’s pattern of behaviors, personality traits, and situational stressors. The idiographic task, however, holds that the therapeutic plan must be elaborated on to accommodate the idiosyncratic features that may not fit readily into the schema of clinical prototypes. In effect, the diagnosis of a prototype is only a starting point for the many departures for clinical care that will be derived from an individual’s particular responses and pathologies and strengths, the extent to which the prototype is supported with actuarial data or clinical skills, and the feedback review of its effectiveness. This dynamic of moving from the nomothetic to the idiographic tasks involves a process of theory building at the individual patient level that requires reflection, the goal of which is to construct a circle - from established nomothetic commonalities to idiographic individuality to nomothetic individuality. The result of this reflective process is a “theory of the patient.” The development of the capability for dynamic reflection entails a system of practice that incorporates routinized habits that encourage the Clinician to “stop and think” and also requires developing capabilities to reflect while in action. Consistent with Schon’s (1983) conceptualization of the reflective clinician, the Empirical Clinician Training Model seeks to teach the Intern the ability to consider multiple points of data and associated hypotheses, while actively engaged in the diagnostic/treatment process. Yet, this model also emphases the value of a disciplined reflection that integrates the more objective and nonparticipant perspective of the scientist. 

The AU/MCG-Charlie Norwood VAMC Internship also incorporates recovery-oriented principles of care into training experiences. Instead of focusing solely on symptom reduction, our training model endeavors to promote collaborative approaches to care that prioritize the following recovery-oriented principles (Leamy, et al., 2011):

  • Connectedness (e.g., being a part of a community, having relationships, receiving support from others),
  • Hope and optimism about the future,
  • Identity (e.g., rebuilding/redefining positive sense of identity, overcoming stigma),
  • Meaning in life (e.g., meaningful life goals and social roles, quality of life), and
  • Empowerment (e.g., personal responsibility, control over life, and focusing on strengths).

References

Belar, C.D., & Perry, N.W. (1992) National Conference on Scientist-Practitioner Education and Training for the Professional Practice of Psychology.  American Psychologist, 47, 71-75.

Hoshmand, L.T., & Polkinghorne, D.E. (1992) Redefining the science-practice relationship and professional training.  American Psychologist, 47, 55-66.

Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. The British Journal of Psychiatry, 199(6), 445-452.

Schon, D. (1983) The Reflective Practitioner: How professionals think in action. New York: Basic Books.

Stricker, G., & Trierweiler, S.J. (1995) The local clinical scientist.  American Psychologist, 50, 995-1002.