Abstract
Psychology in South Africa continues to develop within the changing socio-historical context. Domains of competence are anticipated to develop over the course of the career of a clinical psychology student and professional. Guidelines from the Health Professions Council of South Africa stipulate that the internship year should be dedicated to developing functional competences. It is also required that students provide psychological services to a wide spectrum of patients to prepare for the mental health care needs of the diverse South African population. This preliminary study set out to describe the nature of practical training completed by clinical psychology students that may aid in the development of functional competence domains. Surveys assessing practical training during Master’s coursework were completed by clinical psychology students (n = 20) during the first week of their internship. Interns placed at 1 Military Hospital for the years 2018, 2019, and 2020 participated in the study, and the completed surveys were examined. Results indicated a variance in the number of patients consulted, the hours spent consulting patients as well as the diversity of patient exposure. Some students reported limited to no practical training in psychological tests, which is a cause for concern. Students also rated their perceived competence in report writing as average, which may reflect socially desirable responses. Study outcomes suggest a need to develop agreement among psychology trainers at various stages of the training process regarding the priority to be placed on different practical training aspects. This may assist in training clinical psychologists who can adequately provide much-needed community-based services.
Keywords
Psychology as a discipline in South Africa has undergone changes within the country’s social and political history (Pillay & Kramers-Olen, 2014). The clinical psychology training programme with a formalised 12-month internship began over 40 years ago. Currently, students are required to serve the 1-year internship period in a health care setting with at least 6 months in a psychiatric facility (Health Professions Council of South Africa [HPCSA], 2019a), following the completion of a 1- (M1) or 2-year (M2) Master’s programme. Most universities offer a 1-year Master’s programme in clinical psychology, but a few institutions conduct the programme over 2 years. Although academic training programmes vary across the country in terms of their theoretical orientations, specialty focus areas, and how established they are, there are many commonalities (Pillay et al., 2013). The training provided in the programmes is generally informed by the unique history of South Africa and the evolution of the health care systems (HPCSA, 2019a).
In the last three decades, training in the discipline of professional psychology has shifted to a culture of competence (Hatcher et al., 2013; Roberts et al., 2005; Rodolfa et al., 2013); with a focus on the teaching and assessment of identified competencies to develop a competent professional (Kaslow, 2004; Kaslow et al., 2004). Kaslow (2004) defines competence as ‘an individual’s capability and demonstrated ability to understand and do certain tasks in an appropriate and effective manner consistent with the expectations for a person qualified by education and training in a particular profession or specialty thereof’ (p. 775). Competencies are therefore conceptualised as an individual’s professional skills across various domains (Stevens et al., 2017); they can be functional (major activities performed by psychologists, such as assessment, diagnosis, intervention, and communication) or foundational (i.e., knowledge, skills, and attitudes that underlie all psychologists’ functional activities) (Rodolfa et al., 2005; Stevens et al., 2017).
The rules of conduct for the profession of psychology require psychologists to obtain and maintain a certain level of competence when providing mental health services and to avoid practicing outside of their areas of competence. The minimum core competencies to qualify as a clinical psychologist in South Africa include psychological assessment, psychological interventions, professional practice, research, policy development, programme design, presentation of cases in multi-disciplinary settings, knowledge, and upholding of professional ethics and legislative frameworks. These identified competencies apply to the M1/M2 years as well as the internship year of professional training (HPCSA, 2019b), and are in line with international best practices (American Psychological Association [APA], 2015).
Standards of competence represent the foundation for the credibility of any profession (von Treuer & Reynolds, 2017). Domains of competence in the psychology profession are expected to develop over the course of postgraduate training, with refinement occurring during the clinical internship to ensure the minimum core competencies (APA, 2015; Humphreys et al., 2018; Kaslow & Egan, 2017; Kaslow et al., 2004; Rodolfa et al., 2005). With regard to clinical psychology training in South Africa, the HPCSA policy states that internship sites must collaborate with universities in the training of intern psychologists (HPCSA, 2011). The guidelines further stipulate that 20% of the internship should be dedicated to patient evaluation and the use of psychological instruments; 30% should be dedicated to the application of psychological intervention (i.e., prevention, promotion, treatment, and rehabilitation of individuals through the utilisation of relevant formulations, diagnostics, and therapy using various modalities); 10% should be dedicated to clinical conferences and ward round discussions; 10% should be dedicated to neuropsychology; 5% to forensic psychology work; and 5% to community psychology. Ethics should be allocated 10%; personal development should be allocated 5%; and professional development should be allocated 5% (HPCSA, 2019b). In principle, about 80% of the internship should be dedicated to developing functional competencies, and the remaining 20% towards the development of foundational competencies. The focus of the internship is therefore the practical application of the theoretical knowledge gained during the Master’s coursework programme. Systematic assessment and research to determine whether benchmark competencies (such as those stipulated by the HPCSA) are being incorporated into training, and whether students are attaining these competencies, can be valuable (Grust et al., 2016).
Intern clinical psychologists must have access to a wide spectrum of cases, including children and adults, as well as a diverse South African population (HPCSA, 2019b). The South African population is culturally, linguistically, and ethnically diverse (Johnston, 2015). The majority of South Africa’s clinical psychologists, however, practice in the country’s urban and peri-urban private sector. This results in the need for clinical psychologists to practice in the rural primary health care sector, where a treatment gap between human resources and the burden of disease for mental illness is as high as 85% (De Kock & Pillay, 2017). Siyothula (2019) reports a similar challenge in KwaZulu-Natal, where rural communities have far less access to psychological services in comparison to urban communities. Despite some notable gains in the last 20 years, there remains a substantial need for clinical psychologists in rural community settings (De Kock & Pillay, 2017; Pillay et al., 2009). It may be thus useful to examine whether clinical psychologists are receiving training to assist them in developing competencies that are applicable in addressing the pressing mental health needs of community-based settings.
South African literature is scanty concerning clinical psychology students’ perspectives on the competencies they have acquired in preparation for the internship and beyond. Pillay and Johnston (2011) report that only 34.9% of intern clinical psychologists (from a sample of n = 83) in South Africa felt adequately prepared by their university for the internship, while 53.0% of the participants felt partly prepared for the internship. Considering that the sample of interns was spread across seven provinces in the country, it must be acknowledged that 87.9% felt at least partly prepared for the internship, which may reflect important commonalities within the training (Pillay et al., 2013). These commonalities in training appear to be yielding encouraging results, at least within the context of the study by Pillay and Johnston (2011). More work is required to determine what type of practical training is provided across clinical psychology university programmes in South Africa; and whether this training translates into competencies that can be adequately developed during internship. The current preliminary study therefore set out to describe the type of practical training completed by clinical psychology students that may aid in the development of functional competence domains. This practical training was reported by students at the beginning of their internship in clinical psychology.
Method
Participants
Records of surveys completed by clinical psychology students during the first week of internship (orientation week) at 1 Military Hospital were used in the current study. These surveys reported on the practical training completed by students during their programme. Survey results obtained were initially used to amend the training programme to suit the needs of the intern group. The surveys were administered and analysed by the researcher, who is not part of the clinical psychology supervisory team. During the administration of the surveys, interns were made aware of the importance of their truthful responses. It was further clarified that interns’ accurate responses would assist in providing a report to the clinical supervisory team that would result in the appropriate adjustment of the internship programme to suit their needs. From a target sample of 22 students, 20 students (n = 20) consented to their survey records being included in the current study. More specifically, the surveys had been completed by seven students in the first week of January 2018, eight students in January 2019, and five students in January 2020.
Instrument
The survey assessing practical training during Master’s was developed in the following manner: Towards the end of 2017, the 1 Military Hospital clinical psychology supervisors identified a need for a formalised approach to describe the practical exposure and competencies that clinical psychology students had obtained during their Master’s training. This information served to provide a basis for focussed, relevant training, and supervision in the clinical internship programme. The survey development was facilitated during November 2017 by the researcher in consultation with clinical psychology supervisors, who served as subject matter experts (SMEs) to facilitate content validity (Taherdoost, 2016). The SMEs were selected for this role because they oversee and guide the development of service provision competence in interns (Falender & Shafranske, 2004). Based on their experience, they were able to provide input on the competence ‘expectations for a person qualified by education and training’ (Kaslow, 2004, p.775) who is commencing an internship in clinical psychology.
A group discussion was facilitated by the researcher. Open-ended questions were posed to five SMEs for item generation. The researcher took notes on prominent themes that emerged, which included adequate patient contact, psychological test practical training, and report writing practical training. Patient contact refers to the number of patients consulted by the student during Master’s coursework, as well the number of hours spent consulting those patients. The types of mental health conditions that students encountered in their work with patients were also identified as prominent fields. Psychological test practical training refers collectively to theoretical training, administration, scoring, and interpretation of specified psychological tests (i.e., psychological assessment competence). Report writing refers to the number of psychological reports written, as well as the students’ perception of their report writing ability. The type of psychological interventions conducted during Master’s coursework was not included in the survey. In the internship context, this was discussed individually with the allocated supervisor. The in-depth discussion facilitated the setting of suitable goals for learning and supervision. The researcher constructed a survey with open-ended and closed-ended items relating identified themes. Prior to finalisation, the survey was circulated for individual inputs and comments from each of the SMEs. Given the limited research in this area and the preliminary nature of this study, an attempt was made to establish some (qualitative) content validity. The content validity was, however, not quantitatively ascertained (i.e., using statistical tests) due to the small sample size (Taherdoost, 2016).
Procedure
The complete set of survey records of consenting students for the years 2018, 2019, and 2020 was included in the study. The data were extracted from the surveys onto a data sheet, including both quantitative and qualitative responses. More components had been added to the original survey each year to address other areas of practical training. The current report, however, focusses on components of practical training that were measured across all 3 years (patient contact, exposure to various mental health conditions, psychological test training, and report writing practical training).
Ethical considerations
Ethics approval for the research was provided by the 1 Military Hospital Research Ethics Committee and regulatory bodies within the Department of Defence. Participants were contacted telephonically and via email to provide them with the research information. They were informed about what participation in the research study would entail, and those who were interested in participating provided written consent. Participants were assured of confidentiality and consented for their anonymised responses to be used in the study.
Data analysis
All the data were entered onto a spreadsheet, removing identifying information. The data were analysed using Microsoft Excel. Descriptive statistics was conducted for the quantitative data and content analysis for the qualitative data.
Results
Sample description
The sample consisted of records of 20 students (n = 20) who had completed their M1 and/or M2 training at Sefako Makgatho Health Sciences University (n = 4), University of Johannesburg (n = 3), University of KwaZulu-Natal (n = 3), University of Limpopo (n = 3), University of Pretoria (n = 2), University of South Africa (n = 1), University of the Free State (n = 1), Stellenbosch University (n = 1), University of the Western Cape (n = 1), and North-West University (n = 1). Most students (15) had completed a 1-year Master’s programme prior to their internship, while five students had completed a 2-year Master’s programme. The descriptive results below include the combined sample of students who completed both the M1 and M2 programme, as opposed to contrasting them with each other. This is due to the sample size being too small to separate the two groups in terms of the duration of the programme. In addition, clinical psychology Master’s programmes (whether 1 or 2 years in duration) are audited regularly by the HPCSA to ensure compliance to training requirements in preparation for the internship. All students completed their Master’s academic training at institutions that were on the list of accredited universities, which was last updated in December 2020 (HPCSA, 2020).
Patient contact practical training
The total number of patients (see Table 1) reported to have been consulted by students during Master’s training ranged from 3 to 29 patients (M = 9.55, SD = 6.58). In terms of the reported time spent consulting patients (see Table 2), the number of hours ranged from 15 to 100 hr. The mean number of hours spent consulting patients was 41 hr (SD = 25.01) and 27.50 hr (SD = 28.60) on long-term therapy patients (⩾ 5 contact sessions per patient). The high standard deviation in the hours spent consulting patients illustrates a lack of consistent responses within the sample of students. This may indicate that some students completed far less patient contact practical training than others, or this may simply highlight some concerns regarding the reliability of the survey.
The number of patients consulted by students during Master’s training.
Children = up to 12 years of age; adolescents = 13–18 years; adults = 19–64 years; older adults = above 65 years; long-term patients = ⩾ 5 therapy sessions. Each group session held was counted as 1. Calculation to determine the total number of patients: N (patients) = n (children) + n (adolescents) + n (adults) + (n couples × 2) + n (older adults) + (n families × 3). Long-term patients and group sessions were not included in tallying the total number of patients.
The number of hours spent consulting patients during Master’s training.
Children = up to 12 years of age; adolescents = 13–18 years; adults: 19–64 years; older adults = above 65 years; long-term patients = ⩾ 5 therapy sessions. Calculation to determine the total number of hours = children hours + adolescents hours + adults hours + couples hours + older adults hours + families hours + groups hours. Long-term patients were not included in tallying the total number of hours.
Students reported the most practical training with adult patients (M = 15.65, SD = 14.77), followed by children (M = 10.10, SD = 8.88). It also appears that students had the least practical training with families (M = 0.50 hr, SD = 1.47), couples (M = 1.15 hr, SD = 4.04) and older adults (M = 2.40 hr, SD = 3.73). The number of group sessions conducted ranged from 0 to 12 (M = 1.80, SD = 3.02) (see Table 1). A similar pattern is observed in Table 2, where the number of hours spent conducting groups ranged from 0 to 20 hr, with a mean of 6 hr (SD = 6.40).
Mental health conditions practical training
The types of mental health conditions that each student encountered during consultations with patients ranged from three to nine different mental health conditions. Students reported having diagnosed a mean of 5.5 (SD = 1.70) different mental health conditions during their Master’s practical training. Furthermore, the most common types of mental health condition that students reported included: trauma and related disorders (n = 23); depressive disorders (n = 19); neurodevelopmental disorders (n = 11), schizophrenia spectrum, and other psychotic disorders (n = 11), and personality disorders (n = 11) (see Table 3).
Mental health conditions diagnosed in patients by students during Master’s training.
Psychological test training
Psychological test training was operationalised holistically as theory, administration, scoring, and interpretation of the specified psychological test. If the students only reported one aspect of the four mentioned above, the exposure did not qualify as psychological test training. In addition, the training did not refer to the number of times the psychological test was utilised. The average number of psychological tests students reported to have conducted ranged from 0 to 21 assessments per student (M = 9.35, SD = 6.01). Seventy-five percent of the students reported having practical training using the draw-a-person test and the kinetic family drawing test. Furthermore, 70% of students reported having practical training using the Wechsler adult intelligence scale-IV (see Table 4).
Psychological test training during the Master’s training.
Psychological report writing practical training
The number of psychological reports compiled during the Master’s training ranged from 2 to 20 reports (M = 7.15, SD = 5.59) (see Table 5). It appears that most of these reports were compiled on the general psychotherapeutic process.
The number of reports completed during Master’s training.
Students rated their perceived level of competence in report writing from 1 (least competent) to 10 (most competent) (see Table 6). The sample of students rated themselves average to above average in terms of their awareness of all the components that should be included in a report (M = 6.60, SD = 1.43); their experience in writing psychological reports (M = 5.10, SD = 1.17); and their ability to integrate background information, clinical observations and assessment findings coherently (M = 6.10, SD = 1.29). In summary, the students’ perceptions of their report writing ability are generally reported as average.
Perceived competence in report writing (1 = least; 10 = most).
Discussion
On a descriptive level, there appears to be a variance in the quantity of patient contact practical training that students received during their Master’s training. This variance is evident in the number of patients consulted, the number of hours spent consulting patients, as well as the diversity of patient exposure. A study by Ko and Rodolfa (2005) reported that although university lecturers and internship coordinators agreed that professional psychology students should complete a set number of hours of practical training during coursework, university lecturers endorsed fewer hours than internship coordinators. That study and the current study results suggest that the consensus among universities and internship sites regarding patient contact practical training requires attention. In addition, the limited number of patient contacts reported by some students may also imply a limited diversity in the patients consulted. If such a gap is not bridged during the internship year, it may impact on the preparedness of newly qualified clinical psychologists for independent clinical practice, including work in more isolated rural and community settings where there is no collegial support (De Kock & Pillay, 2017; Pillay et al., 2009).
Students in the current study reported consulting a majority of patients with diagnosed mental disorders, as opposed to other conditions that may be a focus of clinical attention (APA, 2013). This may be useful in preparation for a clinical psychology internship, where at least 6 months in a psychiatric facility is a requirement (HPCSA, 2019a).
Results also suggest a notable variance within the sample in terms of the number of psychological tests in which the students had training. Psychological assessment remains a central functional competence in the field of clinical psychology (APA, 2015; Rodolfa et al., 2005). Kaslow and Egan (2017) assert that little wide-scale attention has been given to developing agreement among psychology trainers at various stages in the training process and between trainers and accreditors concerning the priority to be placed on this competence throughout the training process and beyond. This may explain the variation in the level and type of exposure reported. Kaslow and Egan (2017) further note that none of the competency-based efforts to date specify the approaches to assessment that must be taught and practised. It is therefore possible that students who reported limited to no practical training in psychological tests (one aspect of psychological assessment), received only theoretical training, or some other limited teaching of the psychological test. Whether such exposure is sufficient, is not within the scope of this study, but it is a clear cause for concern.
Rodolfa et al. (2013) stated that sharing findings of interventions, assessments, and recommendations in an organised and understandable manner is one of the key competencies required by a professional psychologist. The present sample of students reported a fair perceived competence in (1) knowledge of the components expected in a report, (2) experience in writing clinical reports, and (3) ability to integrate report information. Considering the variance in the responses concerning the number of reports written during the Master’s training, the results suggest that some of the students had little practical exposure to writing reports in comparison to other students, even though the students perceive themselves to have an acceptable grasp of this competence. Of course, social desirability responding must be factored into this finding. Also, at this stage of training, students are unlikely to know what a good report should look like, and therefore may be responding based on assumptions of what they believe is expected.
Across all training areas explored in this study, there was a notable variance in terms of the students’ reported practical training during their Master’s training. Grust et al. (2016) stated that although lecturers and supervisors value the mastery of particular competencies, the training programme they provide may not support the acquisition and assessment of these competencies, and the current study results may be reflecting this. Discussion on other competencies (i.e., foundational competencies) within the South African psychology training context is beyond the scope of the current study, but a discussion of this nature may be valuable.
The current study was preliminary in nature, focussing on a sample at one internship site. Generalisations can, therefore, not be made. Future studies are recommended with larger samples from internship sites nationally. The current study relied on the students’ ability to recall the type and level of exposure they received in the previous year(s), thus results are vulnerable to recall bias. Furthermore, the study relied on truthful responses. Surveys were conducted at the beginning of each internship year, where students would be likely to present a favourable image of themselves to the supervisory team. Attempts were made during the survey administration to alleviate the prospect of socially desirable responses through the explanation of the importance of truthful responses. However one cannot completely eliminate the students’ tendency towards social approval and avoidance of criticism within the context of internship (Krumpal, 2013). The survey used in the current study is under development and has not been adequately validated. The SMEs who provided input on the constructs to be included in the survey are supervisors from one internship site in the country. Further studies can include evaluation of the survey items by supervisors from various internship sites across the country, as well as the statistical determination of content validity facilitated by a large enough sample.
Conclusion
An intern training programme must be adaptable to the changing circumstances and the needs of interns, the institution, and society. The internship programme must ideally build on competencies that have been attained or a least activated during Master’s training (Pillay & Kramers-Olen, 2014). Despite the conflicted history of psychological training in South Africa, training programmes have provided an excellent benchmark for developing professional training. There are strengths in existing programmes across the country. It is, however, important that in the face of continued growth and transformation, assessment of the significant shortcomings and developmental areas of these programmes is continuously undertaken. Continuous assessment can assist to adequately equip clinical psychology students in innovative ways for independent clinical practice (Pillay et al., 2013) and community-based services, particularly within the rural areas which are desperately needed in South Africa (Pillay et al., 2009).
Although competency-based education and training is widely adopted in South Africa, relatively little consistency exists in what competency models Master’s degree programmes in clinical psychology are employing. It does appear that clinical psychology programmes develop their content, outcomes and metrics that reflect the emphasis and leanings of specific university departments, but this may lead to a lack of clarity about the specific competencies that define a qualified clinical psychologist (Hatcher et al., 2013) within the South African setting. A process of mainstreaming the training at a national level is recommended to prepare clinical psychology students for clinical practice in the South African context. This process requires increased collaboration amongst universities and clinical psychology internship sites, under the guidance of the HPCSA.
Footnotes
Acknowledgements
The author extends sincere thanks and gratitude to the interns who agreed for their survey records to be used in this study, as well as the clinical psychologists who were SMEs in developing the survey (A. Neale, P.M.W. Mphehlo, B. Mahlobo, B.G. Tshabalala, and C.P. Haarhoff). The author also specially thanks A. Neale, the Head of Department during the research conceptualisation phase, for his key contributions.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Disclaimer
The content is solely the responsibility of the author and does not necessarily represent the official views of the South African National Defence Force, the South African Military Health Service, or the 1 Military Hospital Research Ethics Committee.
