Abstract
Couples, marriage, and family therapy (CMFT) educators and supervisors are required to differentiate between typical developmental struggles and more severe competency concerns. This process has the potential to become highly subjective and supervisors may differ in their perceptions of severity of trainee concerns, the need for intervention and/or remediation efforts, types of interventions utilized, and when to discontinue remediation efforts after interventions have failed to be effective. Ethical and competency standards, Council on Accreditation of Counseling and Related Educational Programs (CACREP) guidelines, and American Association for Marriage and Family Therapy (AAMFT) core competencies can be utilized in combination with a collaborative supportive approach to identify and encourage remediation of competency concerns for couples, marriage, and family therapists in training (CMFT-ITs). A composite case study is utilized to illustrate the unique demands of CMFT programs, promote early identification of ineffective trainee behaviors, consider ethical and legal mandates, and provide recommendations for intervention and remediation.
Couples, marriage, and family therapists in training (CMFT-ITs) face a unique dilemma, as they develop clinical skills while simultaneously engaging in extensive personal growth (Gaubatz & Vera, 2006). This process of personal growth and development may reveal struggles with competency or ineffective counseling skills that can be addressed through intervention and remediation efforts (Russell, DuPree, Beggs, Peterson, & Anderson, 2007). Competency concerns might manifest in the form of inadequate behaviors and skills such as a lack of attentiveness, difficulties communicating empathy, and challenges with interpersonal behaviors and are considered a significant gatekeeping issue related to professional ability (Lumadue & Duffey, 1999). Ineffective or incomplete knowledge on the part of a CMFT-IT may be an area that requires supervisory support and intervention in order to properly acquire and develop sufficient skills. Alternatively, CMFT-IT difficulties with professional functioning can potentially signify a more pervasive problem of fit with the profession itself. Concerns about CMFT-IT performance can also originate from limited self-awareness, significant life stressors, physical or mental health concerns, and interpersonal difficulties (Frame & Stevens-Smith, 1995; Gizara & Forrest, 2004).
The subjective nature of trainee development and competency can create challenging conditions where solutions can be arduous. The difficult nature of making a distinction between typical developmental struggles that can be addressed through supervisory intervention and more severe competency concerns is exemplified by a lack of consistency and guidance presented within the counseling literature (Russell et al., 2007).
Problems With Competency: Performance Improvement
The process of clearly defining problematic competency for CMFT-ITs can be elusive, as multiple definitions exist (Russell et al., 2007). Previous literature has conceptualized CMFT-IT competence as involving three distinct areas: knowledge, training, and experience; theoretical orientation; and personal characteristics of the trainee (Herman, 1993). According to Russell and Peterson (2003), concerns identified in any of these three areas may signify more severe problems that could potentially result in impaired counseling abilities and potential harm to clients. Gizara and Forrest (2004) conducted a study examining supervisors’ perceptions of when trainee behavior became problematic enough to warrant intervention and remediation.
Gizara and Forrest (2004) found that this process was highly subjective and that supervisors differed in their perceptions of severity of trainee concerns, the need for intervention and/or remediation efforts, types of interventions utilized, and when to discontinue remediation efforts after interventions have failed to be effective. When describing trainee behaviors and skills that were identified as potentially problematic, supervisors took a variety of contextual variables into account. Contextual variables included the nature of the concern (e.g., ongoing skill deficit or a clear shift in performance), the potential degree of harm to clients or others, the trainee’s developmental level, personal characteristics of the trainee, patterns of trainee behavior across time, consultations with faculty or other mental health professionals that have observed the trainee, and trainee receptiveness to intervention (Gizara & Forrest, 2004). The variability represented in identifying the need and magnitude of performance improvement for trainees offers a glimpse at why identification and remediation strategies are often challenging.
Ethical and Competency Standards
Ethical and competency standards can be one guiding factor when considering whether CMFT-IT behavior should be deemed insufficient and in determining the level of intervention required to appropriately address trainee concerns (Frame & Stevens-Smith, 1995). Exploring the ethical and competency standards set forth by professional accreditation organizations such as the Council on Accreditation of Counseling and Related Educational Programs (CACREP), and the American Association for Marriage and Family Therapy (AAMFT) may be a valuable way to begin identifying behaviors and skills that may indicate struggles with performance that encourage competency development.
CACREP Guidelines
CACREP (2009) guidelines offer a comprehensive overview of the best practices for counselor training programs, specific to marriage, couple, and family counseling. There are eight core curricular areas that are the foundation of CACREP-accredited training programs. Professional orientation and ethical practice, Social and cultural diversity, Human growth and development, Career development, Helping relationships, Group work, Assessment, Research and program evaluation.
CACREP provides additional competencies, which are specific to CMFT counseling. Those competencies include foundational knowledge, prevention and intervention, diversity and advocacy, assessment, and research and evaluation.
There is considerable overlap between the sets of standards developed by CACREP and AAMFT, which include a strength emphasis on ethical practice, theoretical application and knowledge, diversity, and appropriate assessment. The prevailing theme of nonmaleficence within each set of competency standards speaks to the importance of addressing CMFT-ITs that struggle with competency concerns as a professional duty of gatekeeping within the counseling and MFT professions.
AAMFT Core Competencies
In 2004, the AAMFT identified best practices for MFTs by creating a gold standard of competencies that should be considered the minimum acceptable skill level for licensed MFTs to practice. The core competencies include six core domains with five subdomains.
The six domains of the MFT core competencies are as follows: Admission to treatment, Clinical assessment and diagnosis, Treatment planning and case management, Therapeutic interventions, Legal, ethics, and standards, Research and program evaluation.
The subdomains are specifically focused on developing a skill set that represents the knowledge a CMFT-IT must develop to competently practice across multiple contexts in various treatment settings with diverse clientele (Reiter, 2014). The subdomains include conceptual, perceptual, executive, evaluative, and professional skills.
Conceptual skills refer to clinical knowledge and understanding of underlying individual and systemic concepts, theories, techniques, and application (Reiter, 2014). Developmentally it is necessary for CMFT-ITs to have a foundational understanding of how to work with individuals, form a therapeutic alliance, and utilize theory to inform treatment and techniques before they are ready to work with multiple clients simultaneously. For example, it is imperative that CMFT-ITs have some mastery of core common factors and skills including relationship building, warmth, genuineness, empathy, openness, reframing, challenging, and modeling behavioral and emotional regulation before they are able to apply these skills to multiple clients while concurrently applying more advanced systemic principles (Lambert, 1997; Lee & Nelson, 2014). Core systemic principles include an understanding that individuals are nested within multiple systems simultaneously (family, community, society, etc.), these systems tend to have identifiable relational patterns, are organized, hierarchically structured, goal oriented, able to adapt, and reciprocally influence individual members thoughts, feelings, and behaviors (Blume, 2006). This understanding is necessary in order to create a shift in thinking to conceptualize individuals in a relational multidirectional context as opposed to viewing the individual in isolation as the origin and manifestation of a problem (Ajay, Marquez, & Nazaro, 2013).
Perceptual skills refer to a CMFT-IT’s ability to assess clients in the therapeutic process in order to construct hypotheses about interpersonal relational patterns and their impact on the system as a whole including the ways in which the system is coping with the presenting concern (Reiter, 2014). Executive skills involve the ability to execute knowledge using a specific skill set to determine the most appropriate action based on various contextual variables in the moment. For example, a CMFT-IT would utilize executive skills in order to determine which family members would be most appropriate to include in the therapeutic process, when to conduct specific assessments, when to block unproductive communication, and in selecting theoretical approaches and techniques that are congruent with clients’ worldviews, beliefs, values, and goals (Reiter, 2014). Evaluative skills include the ability to objectively assess one’s skills and performance, the ability to communicate areas of growth to supervisors in order to improve competency, and the ability to modify approaches or refer clients when counseling interventions are determined to be unsuccessful (Reiter, 2014). Lastly, professional skills refer to the ability to understand and adhere to professional and ethical standards and to avoid causing client harm (Reiter, 2014).
Identifying Barriers to Intervention
While identifying insufficient skill sets for CMFT-ITs is imperative, literature shows that proactive exploration of systemic barriers to intervention may lead to more useful applications for prevention (Elman, Forrest, Vaha-Haase, & Gizara, 1999; Gaubatz & Vera, 2006). These barriers include a lack of collegial support, personal emotional impact, legal connotations, and conflicting university policies and protocols (Elman & Forrest, 2007; Gizara & Forrest, 2004; Sampson et al., 2013). Gizara and Forrest (2004) explored the personal impact of confronting competency concerns in a CMFT-IT and found that identifying CMFT-ITs in need of performance improvement can be professionally and emotionally challenging for supervisors. These challenges are hypothesized to be results of the close relationship supervisors tend to form with trainees, as well as the aspiration and mandate to provide support and instruction with developmental learning (Gizara & Forrest, 2004). While various authors have explored the implications of trainee competence, little consideration has been given to how the concerns influence educators and supervisors (Shen-Miller, Forrest, & Burt, 2012).
Role Conflict: Gatekeeping and Student Development
Educators and supervisors may experience conflict as a result of their dual role as gatekeepers and nurturers of student development (Sampson, Kelly-Trombley, Zubatsky, & Harris, 2013). Counselor educators have the added responsibility of distinguishing typical developmental obstacles and struggles from a lack of effective skills (Elman & Forrest, 2007). Sampson, Kelly-Trombley, Zubatsky, and Harris (2013) describe students who fail to progress despite remediation efforts as one of the most complicated and emotional situations faced by counselor educators and supervisors. Supervisors often value fostering strong relationships with students, as this can enhance learning while meeting supervisory goals (Gunn & Pistole, 2012). Thus, supervisee struggles with competency may be devastating to the supervisor or educator (Gizara & Forrest, 2004). Supervisors and educators have reported feeling a great deal of sadness when competency concerns are identified (Gizara & Forrest, 2004).
Role Conflict: Utilizing a Systemic Lens
The personal toll experienced by a supervisor or faculty is significant in that a mutual rapport was built with the intention of growth and learning; however, the reality of the outcome is often time consuming, emotional, and isolating (Gizara & Forrest, 2004). This emotional impact is likely exacerbated when educators and supervisors employ a systemic perspective to training CMFT-ITs. Supervisors and educators practicing from a systemic lens tend to view trainee difficulties in a relational context and are more likely to consider a wide variety of contextual factors and interactional systems that may be influencing trainee competence (Lee & Nelson, 2014).
Taking a systemic perspective necessitates a view that performance concerns and problematic behavior are not the sole problem of a CMFT-IT and that multiple individuals within the training system may have contributed to the trainees difficulty (Lee & Nelson, 2014). Systemically oriented supervisors and educators are more likely to share a belief that individuals are reacting to larger contextual events, that these events push CMFT-ITs to respond in certain ways, and that these responses are likely based on positive intentions (Lee & Nelson, 2014). The belief that individuals do the best they can given their unique life circumstances and that all individuals have the potential for growth, development, and improvement can seem directly at odds with the idea that some individuals may not be an appropriate fit for the counseling profession. However, it could be argued that a particular CMFT-IT is not an adequate fit for the profession at this particular point in time given their unique contextual circumstances and it could be feasible that with time and personal growth the CMFT-IT could return to the profession. This creates a complex role conflict for educators and supervisors who must simultaneously serve as evaluators and gatekeepers while facilitating CMFT-IT growth and development. At times it may be necessary for supervisors to temporarily constrain a CMFT-IT’s activities until adequate competency is demonstrated, to refer CMFT-ITs to their own counseling, to advise CMFT-ITs against continuation in the profession, and to take action to ensure a CMFT-IT does not threaten client welfare (Lee & Nelson, 2014). These discussions are likely to be painful and at the same time they can occur in respectful and empathetic ways that communicate the supervisor’s desire to protect the CMFT-IT from further investing time and money into a profession that they are unlikely to succeed in at this point in time.
Role conflict can potentially result in decreased recognition of impairment or tolerance of ineffective skills (Tribbensee, 2003). Educators and supervisors often demonstrate a great deal of empathy and support for beginning students to facilitate skill development while modeling appropriate interpersonal behaviors to promote a therapeutic alliance. This process has the potential to increase distress and confusion when the educator/supervisor transitions into an evaluative/gatekeeping role and the implications of remediation are observed (Kerl, Garcia, McCullough, & Maxwell, 2002).
Recommendations for Intervention
A number of recommendations have been put forth for addressing trainees in need of performance improvement (e.g., Baldo, Softas-Nall, & Shaw, 1997; Elman & Forrest, 2007; Gaubatz & Vera, 2002, 2006; Gizara & Forrest, 2004; Lumadue & Duffey, 1999; Russell et al., 2007; Sampson et al., 2013; Wilkerson, 2006). Similar to providing clients with informed consent, it is recommended that educators/supervisors provide informed consent to students who are entering couples and family therapy and counseling programs. Best practices dictate that CMFT-ITs be provided with a well-defined set of expectations regarding their performance within the program (American Counseling Association [ACA], 2014; Baldo et al., 1997; Sampson et al., 2013). CMFT-ITs can be made aware of and encouraged to ask questions about formalized gatekeeping practices, systematized evaluations, remediation procedures, trainee rights, review and retention practices, and reasons for dismissal (Baldo et al., 1997; Russell et al., 2007; Sampson et al., 2013).
Expectations for professional behavior can be communicated and included across all course work and applied clinical experiences. Some counselor education and supervision departments include professionalism as an evaluation criterion across all departmental classes. Including a professionalism criterion ensures students get formative feedback on professional behaviors prior to practicum or internship and allows supportive interventions to begin early. For example, if a student begins to show signs of lack of attentiveness, a faculty could respectfully approach them after class from a place of concern to communicate a desire to be helpful and supportive in the student’s success in the course (M. A. Bruce, personal communication, October 4, 2014). Additionally, professionalism comprises a substantial enough portion of the course grade to temporarily block a student from progressing in the program when professional issues are determined to be a significant concern. This allows faculty to uphold their gatekeeping duty while slowing down a student’s program to match more closely with their developmental trajectory, potentially allowing more time for students to be supported in performance improvement prior to their work with clients (M. A. Bruce, personal communication, October 4, 2014).
For example, a CMFT-IT who continues to show a lack of attentiveness, shows up late for class, is frequently absent, and dismisses others students perspectives that differ from his or her own may be in need of additional support, as his or her behaviors may be indicative of more significant distress or lack of skills. A faculty member could once again approach the student from a place of genuine concern by asking the student to set up a meeting with the faculty member and the student’s advisor to ensure that the student is receiving the support necessary to be academically and interpersonally successful. Faculty and advisors who approach such conversations empathetically and allow for CMFT-ITs to share personal life stressors, knowledge, skills, or systemic barriers to success while recognizing positive intentions and strengths may be able to more effectively diffuse defensiveness potentially allowing the CMFT-IT to be more receptive to growth-oriented feedback and interventions. Through encouraging the CMFT-IT to share their perspective, the student is provided with an opportunity to observe the ways in which their faculty and advisor model respect for multiple viewpoints and avoid blaming or pathologizing, while simultaneously communicating clear behavioral expectations.
Growth-oriented feedback should include the specific behavioral concerns that the faculty member has observed and the concerns should be directly tied to the CMFT-IT’s ability to work successfully with couples and families. A student’s lack of attentiveness, showing up late or missing class, and dismissing others with differing perspectives can be directly related to a concern that similar behaviors with clients would likely lead to significant harm. CMFT-ITs who perceive their faculty and advisors as invested and wanting to provide support toward improvement may be more likely to share obstacles in their life that may be hindering their success, therefore potentially increasing systemic understanding of the difficulty and enhancing faculty and supervisors’ ability to intervene at multiple levels. A willingness to openly express personal concerns (e.g., relational and financial stress) and a desire to address these concerns should be positively validated by faculty and advisors. During the meeting a collaborative written performance contract can be created to help CMFT-ITs identify the ways in which they can address barriers to success (e.g., dropping a course to have more time to invest in coursework, increasing self-care behaviors, meeting with financial aid to pursue additional financial options, completing recorded role plays to practice multidirected partiality, journaling about how personal values have the potential to impact professional decision making, etc.). The performance contract should also include the role and expectations of each person involved in the plan and whom the plan will be shared with (i.e., advisor, faculty members, and CMFT-IT). Lastly, the performance contract should include additional and ongoing steps that may need to be taken if contextual circumstances or barriers continue to impede growth and development. These steps may include referrals to counseling, remediation plans, and in some cases repeating coursework. Retaking one or more courses can be presented as an opportunity to bridge some of the gaps in knowledge while providing a supportive environment to practice the required skills.
Proactive Early Identification and Remediation
Some authors hypothesize that intervention efforts that are introduced earlier in trainees’ programs may lead to better outcomes for the trainees and the program (Gaubatz & Vera, 2006). Preventative efforts have the potential to help students gain skills and access supportive resources, such as counseling, before serious ethical violation(s) have occurred. These efforts can also protect clients while safeguarding programs’ reputations. Early intervention may give trainees more time to seek assistance and develop their skills (Russell et al., 2007).
ACA ethical standards require that trainees be given adequate opportunities to engage in remedial activities and also states that trainees are only to be dismissed when remedial efforts have failed (ACA, 2014; Elman & Forrest, 2007). AAMFT and CACREP have put forth similar recommendations regarding remediation resources and due process recommending that supervisors of CMFT-IT’s struggling with competence appreciate the context in which the problematic behavior is occurring, supervisors augment contact and supervision with the CMFT-IT, and that they provide the CMFT-IT with clear expectations for how functioning can become effective through performance contracts, ongoing written and verbal feedback, and a formal remediation plan addressing both the individual and the systemic context in which the ineffective behaviors are occurring (CACREP, 2009; Russell et al., 2007).
Utilizing a Collaborative Approach to Remediation
It has also been recommended that faculty make decisions collectively regarding trainee struggles with competent performance (Baldo et al., 1997; Gizara & Forrest, 2004). Discussing trainee performance collaboratively may provide faculty with an opportunity to become aware of a trainee’s behavior across multiple contexts, which increases the chances of accurately identifying individual and systemic concerns, while generating specific examples of behaviors that are in need of remediation (Russel et al., 2007). Systemic consultation can potentially increase contextual and empathetic understanding of a CMFT-IT through encouraging multiple perspectives and understandings.
Involving multiple faculty members who have experienced a student in multiple contexts can help to identify areas for growth as well as strengths that can be built upon as part of the remediation process. Consulting across faculty fosters an approach to remediation, which is inherently less subjective and biased (Baldo et al., 1997; Gizara & Forrest, 2004; McAdams & Foster, 2007; Sampson et al., 2013). Full-time faculty members may be more likely to have exposure to students across various contexts (multiple classes, presentations, professional organization meetings, etc.), which may result in their being able to identify trainees who struggle with competency earlier in their programs (Gaubatz & Vera, 2002).
For example, including a CMFT-IT advisor as an advocate in the follow-up meeting with a faculty who has expressed concern may help students to feel more supported and willing to share personal concerns. Ideally, the advisor will have a preexisting relationship with the student and will have had exposure to the student in multiple contexts which may allow the advisor to provide concrete examples of positive behaviors and strengths that can be built upon in the collaborative performance contract. The performance contract may address the ways in which improvement can occur at multiple levels including the course of concern, any additional courses in which the student is enrolled, professional activities, and interactions with faculty and peers. Transparency regarding the collaboration of the CMFT-IT’s advisor and faculty across courses can be used to foster systemic understanding by explaining the ways in which inclusion of multiple viewpoints and contexts may help to provide a more holistic picture of the students challenges, growth, and development while providing additional opportunity for supportive intervention
Legal Implications and Ensuring Due Process
Proactive interventions help faculty protect due process while maximizing learning opportunities for trainees who struggle. Due process begins when remedial efforts for CMFT-ITs in need of performance improvement are initiated before dismissal (McAdams & Foster, 2007; Russell et al., 2007). Careful documentation of behavioral concerns, interpersonal concerns, review and retention decisions, meetings with the CMFT-IT, recommendations, and remedial plans must occur consistently throughout the remediation process (Baldo et al., 1997; Sampson et al., 2013). Faculty should seek to involve CMFT-ITs in this process by including them in meetings so they can clarify concerns, respond to feedback, and confirm understanding of specific expectations they must meet in order to be considered successful in the program (Baldo et al., 1997; Sampson et al., 2013). Including students in these processes allows for ongoing learning and understanding and provides opportunities for trainees to demonstrate openness to feedback and a desire for personal and professional growth.
In situations where CMFT-ITs are struggling with feedback one might treat the CMFT-IT with respect while expressing care and concern for client welfare and student development (Baldo et al., 1997; McAdams & Foster, 2007; Sampson et al., 2013). Remediation plans should be relevant to the specific identified concerns regarding student behavior, be congruent with the severity of identified behavioral concerns, provide opportunities for learning and growth rather than being punitive in nature, and should utilize behaviorally specific evaluation measures (Lumadue & Duffey, 1999; McAdams & Foster, 2007). If faculty are able to validate, through careful documentation, that faculty and supervisors have provided reasonable opportunities for remediation then it is probable that dismissal choices will be perceived as ethically and legally valid (Baldo et al., 1997; McAdams & Foster, 2007; Sampson et al., 2013).
For example, if a CMFT-IT continues to struggle to meet the expectations of their collaborative performance contract despite enhanced contact and support from their advisor and faculty members it would be necessary for the CMFT-IT advisor to include the student in a meeting in which faculty can clarify concerns further. At this time, the CMFT-IT can respond to additional concerns and feedback, and performance expectations can be revised and updated in the form of a written remediation plan. It is recommended that each step of performance improvement be carefully documented. Documentation can include communication of an initial concern, creation of a written performance contract, implemented interventions (e.g., weekly meetings with advisor, written feedback and assessments from recorded role plays, feedback on journal entries, course schedule showing the student dropped a course, written self-care plans, etc.), notes regarding ongoing assessment of the appropriateness of interventions, written copies of feedback provided on performance, notes regarding student receptivity to feedback, and documentation of a written remediation plan. Sharing this documentation with students creates transparency, consistency, and safety while allowing students various opportunities to demonstrate improvement across multiple contexts.
Understanding the Demands of CMFT Programs
Couples and family therapy and counseling training programs place unique demands on trainees, as they require personal and professional awareness as well as academic skills (Sampson et al., 2013). It is recommended that students be advised of these expectations from the onset of their program and that they are consistently evaluated on both academic and professional expectations throughout their coursework. By communicating congruent expectations throughout coursework and practicums, trainees may be able to make better informed decisions regarding the fit of a program with their personal values and beliefs. Educating students upon entering a program about expectations specific to the development of counseling skills, academic ability, ethical standards, development of self-awareness, development of interpersonal skills, and ability to manage life stressors may allow trainees to self-select out of programs that are unlikely to meet their expectations (Gaubatz & Vera, 2002). Being transparent about how couples and family therapy and counseling programs differ from graduate programs in other disciplines that emphasize academic performance is a necessary part of the informed consent process (Sampson et al., 2013). Additionally, faculty can educate CMFT-ITs about their role as a gatekeeper and their responsibility to protect client welfare, communicating that student development is secondary to this responsibility (Lumadue & Duffey, 1999; Russell et al., 2007). It can be challenging for educators and supervisors to effectively integrate evaluation of personal and professional development with academic coursework.
It is recommended that educators/supervisors assess students on professional behaviors throughout their academic coursework, rather than assessing professionalism solely within the context of applied clinical experiences such as practicum(s) and/or internship(s). Integrating professionalism and academics may allow supervisors/educators to more proactively address student struggles while documenting professional concerns. Including a statement in syllabi emphasizing professionalism while simultaneously tying professional behaviors to academic performance and assignments communicates consistent behavioral expectations and consequences. Further, it has the possibility to prevent confusion for students who are performing well academically while struggling professionally. Trainees can be evaluated on professional behaviors including their ability to be on time, attentive during class meetings, prepared to participate in class discussions, assignments, and activities; to demonstrate awareness of ethical mandates in their interactions, behaviors, and assignments; to respectfully and confidentially manage clinical materials; to communicate respect for diverse perspectives; to assume responsibility for behaviors that could negatively impact client welfare, colleague development, the reputation of program, and the reputation of the counseling profession; and to demonstrate a commitment to deepening self-awareness, personal growth, and wellness.
Systemically Addressing Competency Concerns for CMFT-ITs
While a number of recommendations have been put forth regarding addressing trainees in need of performance improvement within counseling psychology programs, clinical psychology programs, and counselor education and supervision programs, very little has been written specific to addressing competency concerns for CMFT-ITs in couples and family therapy and counseling programs (Russell et al., 2007; Sampson et al., 2013). Appropriately addressing ineffective CMFT-ITs protects client welfare while maintaining the reputation of the profession (Lumadue & Duffey, 1999; Russell et al., 2007; Sampson et al., 2013). Faculty members in these programs can increase dialogue around gatekeeping procedures, early identification of ineffective CMFT-ITs, implementation of appropriate systemic remediation resources, and the dismissal process in cases where remediation has been unsuccessful (Sampson et al., 2013).
There may be a greater risk of client harm in couples and family therapy and counseling training programs compared to individual counseling programs, as there may be an increased potential for client harm when multiple clients receive services at the same time (Lee & Nelson, 2014). As the number of clients being treated concurrently increases, so does professional liability. Couples and family therapy and counseling requires more advanced skills than individual counseling as well as knowledge of ethical and legal codes that are specific to couples and family therapy and counseling. For example, CMFT-ITs are required to form a therapeutic alliance with multiple people simultaneously; balance confidentiality with multiple family members; assess for risk or harm and violence among family members; and demonstrate multidirected partiality through respect and understanding of multiple worldviews, beliefs, and values (Lee & Nelson, 2014; Storm, 2007).
Assessments
When confronted with an issue of potential CMFT-IT ineffectiveness, it’s imperative to have familiarity with the resources that can help identity, confirm, and establish consequences for such encounters. Resources identified in best practice literature by professional organizations as well as institutions can be beneficial in order to maintain professional objectivity, client protection, and student due process. Evaluative standards such as academic rating forms, professional competency standards, and supervisory guidelines are helpful in determining distinct steps for addressing competency concerns with a CMFT-IT. Gatekeeping during training periods is helpful in attending to a disruption in counseling competence that may hinder the ability to obtain professional licensure and engage in professional practice.
Assessing Performance Improvement: Counselor Interview Rating Form (CIRF)
Identification of CMFT-IT ineffective behaviors is typically the initial phase where recognition of a problem is established. Depending on the nature of trainee concerns, it may be necessary to revisit foundational skill development. A rating form such as the CIRF (Russell-Chapin& Sherman, 2000) is a tool used to establish patterns showing the demonstration or lack of micro skills of a CMFT-IT. These micro skills can be conceptualized as the foundational skill set that clinicians develop when learning to work with clients individually, irrespective of theoretical orientation (Lambert & Ogles, 1997). These skills are a requisite to more advanced systemic competencies, as CMFT-ITs must be able to interpersonally engage and connect with clients within diverse systems (Lee & Nelson, 2014; Reiter, 2014). The CIRF provides counselor educators and supervisors with a framework to conceptualize and evaluate micro-counseling and influencing skills (Ivey, Normington, Miller, Morrill, & Haase, 1968) across the counseling interview stages (Ivey, 1994). Operationalized definitions of each micro skill including specific directions for documenting and assessing strengths and areas of growth are provided, along with space for the evaluator to provide comments (Russell-Chapin & Sherman, 2000).
Skills are observed and given a point value, and a grade is provided to the student depending on the points earned during the session. For example, a point is provided for developing opening rapport with a client, reflecting feelings, defining goals, and overall professionalism. If a certain number of points are earned, a corresponding grade is provided. Utilizing the CIRF could be one practical and concrete way for CMFT-ITs to identify areas of competence and skills in need of improvement in order to be an effective counselor. Additionally, the CIRF can be used as a systematic way for an evaluator to document areas of growth and potential problems across multiple contexts (e.g., across multiple clients and training settings). Using standardized forms, like the CIRF, has the potential to decrease subjectivity of training evaluation, provides consistency of evaluation across trainees, and allows the CMFT-IT to either demonstrate a skill or show a need for growth (Russell-Chapin & Sherman, 2000).
Assessing Performance Improvement: American Association of Marriage and Family Therapy (AAMFT) Core Competencies
According to the AAMFT, the six core competencies were created with the aim of increasing skill of the services provided by couples, marriage, and family therapists (Reiter, 2014). The domains can be used to evaluate new CMFT-ITs as well as provide ongoing exploration of skills and effectiveness (Lee & Nelson, 2014). The AAMFT core competencies can be used as a strategy for decision making and as a way of distinguishing between specific skill sets (i.e., conceptual, perceptual, executive, evaluative, and professional skills) that may be targeted for improvement (Lee & Nelson, 2014; Reiter, 2014). Using core competency standards in supervision could be one way to facilitate a collaborative conversation with CMFT-ITs about their areas of strength and their goals for performance improvement (Lee & Nelson, 2014). The core competencies also have the potential to make behavioral expectations more clearly defined while providing supervisors with a method for evaluating the CMFT-ITs’ goals (Lee & Nelson, 2014).
Applying these core competencies to issues such as the development of micro skills in addition to the ability to conceptualize systemically, to use theory to inform treatment, to maintain professional and ethical standards, and to apply therapeutic interventions is a useful supervisory and pedagogical evaluative practice. It is important to note that the authors are not advocating for the identified evaluation measures to be used in isolation, rather they are best used as part of a holistic process to identify CMFT-IT’s specific strengths and areas of improvement. These tools work well in combination with an intentional systemic approach to assessing concerns with CMFT-ITs. Evaluation tools are best used in combination with consultation and collaboration with faculty to assess systemic variables impacting trainee development in order to tailor a remediation plan that is specific to the CMFT-IT’s unique needs.
Composite Case Study
Isabelle is a 35-year-old self-identified heterosexual Latina student, enrolled in a clinical counseling program with an emphasis in couples and family therapy. She states that she has been married for the past 15 years and has three children. Isabelle reports that she made the sacrifice to return to school to pursue her lifelong passion of working with couples. She’s often stated, “I’ve always imagined helping couples and now my dream is finally coming true.” She demonstrates appropriate academic skills and she consistently commits time outside of class to read relevant literature related to counseling couples. Isabelle was eager to finish her coursework and to begin her first individual practicum, expressing that she was excited to finally apply her learning to working with clients rather than in the classroom. She has been well liked among her peers as well as her professors, and displays a responsible, dedicated attitude toward learning.
Throughout Isabelle’s individual practicum experience, she appeared to work comfortably with clients, particularly those with a similar background to herself (e.g., ethnicity, socioeconomic status, gender, sexual orientation, etc.). However, professional concerns were identified toward the end of her individual practicum experience when Isabelle observed a colleague’s session and began to communicate a strong discomfort with a client who revealed significantly different beliefs and values from her own. These professional concerns were primarily addressed through individual supervision in an attempt to help her understand the importance and ethical mandate for CMFT-ITs to communicate respect for diverse perspectives and to assume responsibility for behaviors that could negatively impact client welfare. Isabelle appeared receptive to the feedback and passed her individual practicum despite these professional concerns.
The following semester Isabelle enrolled in couples and family practicum. Isabelle was assigned to work with a same-sex couple. Initially, she admitted to some discomfort working with the couple; however, she stated her discomfort was related to a lack of exposure to lesbian, gay, and bisexual (LGB) populations and a desire to be perceived as multiculturally competent. Isabelle is open to supervisory suggestions to read literature specific to working with LGB couples, and she demonstrates the ability to form a therapeutic alliance with the couple. During the third session, the couple revealed low levels of situational domestic violence within their relationship related to an argument in which objects were thrown across the room leading one member of the couple to shove the other member. Isabelle appeared comfortable within the session but failed to address the safety or the relational concerns expressed by the clients and instead focused on strengths the clients displayed in their careers and as parents. The session proceeded with Isabelle providing advice about how the clients could be more confident at work and with their children. Isabelle’s supervisor and peers were surprised by her response although many of her peers felt that she may have been nervous and proceeded to protect her intentions.
During supervision, her reaction to same-sex relationships and domestic violence was explored in an attempt to gain an understanding of her avoidance of these issues. Isabelle stated, “The couple came in asking for help because they both have a lot of confidence problems and I feel their relationship is to blame.” When you inquire further Isabelle discloses that she personally feels like same-sex relationships are inappropriate based on her religious beliefs and that she believes same-sex relationships are more likely to lead to violence based on some of the literature she has read. Isabelle states, “It is difficult for me to affirm their same-sex relationship because I believe that it is unhealthy and abusive. However, I feel like I can still help them with some of the struggles they are encountering as professionals and as parents.”
When directly confronted with the necessity for affirming diversity, including affirming client’s sexual orientations and understanding the importance of assessment of abuse and safety concerns within a relationship, Isabelle expressed a deficit in clinical assessment by stating, “There are so many ethical standards and clinic policies that it is hard for me to remember all of them. I had no idea what to do when faced with this situation especially because violence seems pretty normal for same-sex couples. I guess I’m confused about how to help them because I think the best option would be for me to help them peacefully end their relationship.” Despite supervisory attempts at increasing awareness and understanding, Isabelle maintained that her intentions were effective and that it was important for her to focus on positive characteristics of each individual member of the couple to help increase their confidence so that both can feel good enough about themselves to leave the unhealthy relationship.
This example represents the dilemma faced by supervisors when working with students who may be struggling with competency while demonstrating a lack of cognitive complexity despite a strong desire to join the counseling profession. Is it possible for remediation efforts help a student who maintains a lifelong dream of working as a couples and family therapist yet lacks awareness in order to develop essential clinical skills needed to ethically and effectively work with clients?
Ethical Dilemma
When considering a course of action, it may be helpful to start by considering ethical principles that can guide the way in which supervisors and educators approach CMFT-ITs in need of performance improvement. Following an examination of ethical principles, it is necessary to identify Isabelle’s strengths, her specific problematic behaviors, potential barriers to intervention, and a preferred course of action to support performance improvement.
The principles of nonmaleficence, justice, and fidelity are central to this decision-making process. Supervisors should consider the potential for harm that could occur on multiple levels (e.g., to clients, to the training system, and to Isabelle and her family if she was dismissed). The principle of justice reminds supervisors to consistently apply competency standards across all CMFT-ITs while simultaneously considering contextual differences among students that may increase the individual impact of remediation efforts (e.g., CMFT-IT developmental level, nature of the concern in behavioral terms, ongoing pattern across time or a shift in performance, potential harm, personal characteristics of CMFT-ITs, receptiveness to remediation efforts, and outcome of consultation with multiple faculty members). Lastly, the principle of fidelity reminds supervisors and educators to clearly communicate expectations for competency, identify behavioral concerns and ways to remediate concerns, collaboratively provide the necessary supports to facilitate performance improvement, and to follow through with remediation plans and consequences.
Conceptualization
Isabelle has a number of strengths that can potentially be built upon to foster performance improvement. Isabelle is highly motivated and has strong academic and interpersonal skills. Because Isabelle possesses many of the necessary foundational interpersonal skills (e.g., empathy, warmth, ability to reflect feelings/content, etc.) she is likely to score well on measures like the CIRF (Russell-Chapin & Sherman, 2000). However, supervisors would be likely to uncover competency concerns when evaluating Isabelle’s performance using the AAMFT core competencies. It is likely that Isabelle is struggling with conceptual, perceptual, executive, evaluative, and professional skills. For example, professionally Isabelle has been unable to communicate respect for multiple perspectives. Conceptually, it seems that Isabelle is likely struggling to understand basic systems concepts, which is likely interrelated with her perceptual difficulty in recognizing the intersectionality of contextual variables in her client’s lives. It also seems likely that Isabelle is struggling executively to provide appropriate screening and safety planning for domestic violence which is likely interrelated with her evaluative skills in monitoring personal reactions to clients and evaluating the level of risk specific to domestic violence. Evaluating performance through the lens of the core competencies allows supervisors to identify CMFT-IT patterns of competency and struggles (Lee & Nelson, 2014).
Through collaborative identification of areas in need of performance improvement supervisors and CMFT-ITs can coconstruct specific behavioral goals to address each area of concern (Lee & Nelson, 2014). Specific identified behavioral concerns for Isabelle include struggles with cognitive complexity, struggles with basic systemic thinking (i.e., the capacity to understand the ways in which multiple contextual variables intersect and impact client’s thoughts, feelings, behaviors, and beliefs), difficulty considering multiple perspectives, worldviews, and values, and failure to recognize safety risks, the need for assessment, and the importance of safety planning. “Sometimes therapists are missing things because they are focused on their own perspective of events rather than the families, or on information that does not fit the concepts or hypotheses. We tend to see what we are looking for” (Lee & Nelson, 2014, p. 106). Isabelle’s assertions that same-sex relationships are inappropriate and are more likely to lead to violence demonstrate a difficulty with cognitive complexity and managing her own feelings and beliefs as well as struggles with multicultural and professional competency.
Supervisors may find it difficult to intervene with Isabelle because she is near graduation, is well liked, and displays adequate motivation, academic knowledge, interpersonal skills, and positive intentions to provide effective client care. Isabelle has overcome adversity in her own life by coming back to college as a nontraditional student despite financial and familial barriers. At the same time, Isabelle’s resistance to feedback in this situation and her difficulty considering diverse perspectives has a strong potential to cause client harm.
Isabelle’s statement that she is unwilling to affirm same-sex relationships is a direct violation of the ACA (2014) code of ethics and her insistence that there is something pathological about all same-sex relationships illuminates her struggles with cognitive complexity. It would be necessary to consult with and involve the rest of the faculty in remediation efforts intended to develop cognitive complexity, tolerance for ambiguity, systemic thinking, appreciation for multiple perspectives, ability to set personal beliefs aside within the counseling relationship, and multicultural and professional competencies. It would also be necessary for supervisors and educators working with Isabelle to carefully monitor their own reactions and values related to her spiritual belief system to ensure that Isabelle is treated fairly and is not discriminated against based on her religious convictions. Thus, there is potential for a parallel process to develop, as the faculty demonstrate acceptance of Isabelle’s spirituality and Isabelle develops the ability to demonstrate acceptance of her client’s sexuality. At the same time, if Isabelle is unwilling to examine her beliefs, including ways that she can avoid imposing values on clients, she is unlikely to meet the ethical mandates of the profession.
The Power of Prevention
It is likely that preventative steps could have been implemented earlier in Isabelle’s program in order to address her competency struggles. It is unclear the extent to which Isabelle was informed of professional expectations at the onset of her program. It is possible that had Isabelle been fully informed regarding professional expectations, ethical mandates, program training objectives, and the nature and degree of skill and knowledge attainment necessary for successful completion of the program she may have may be able to make better informed decisions regarding the fit of the program with her personal values and beliefs.
Further, if Isabelle’s professional behavior had been assessed from the outset of her program, it is possible that competency concerns would have been identified through her assignments and interactions with faculty and colleagues. Assessment of Isabelle’s professional behaviors prior to her practicum course could have potentially led to behaviorally specific constructive feedback related to her struggles with communicating respect for multiple perspectives and demonstrating cognitive complexity. If faculty efforts to initially address these concerns within the classroom were ineffective, then collaborative remediation could have been initiated prior to Isabelle’s work with clients, potentially decreasing the likelihood of client harm while simultaneously increasing the potential likelihood of successful remediation efforts. Supportive early intervention from a trusted faculty member or advisor who gently expressed sincere concern for Isabelle and a desire to help her develop the necessary skill sets could have potentially led to more positive outcomes for Isabelle, her clients, the program, and the profession.
Conclusion
While identifying and working with CMFT-ITs who are struggling with competency can be personally and professional challenging, supervisors and educators have access to a number of procedures and strategies that can be collectively utilized to help to ensure that remediation and gatekeeping decisions are just for CMFT-ITs as well as current and future clients. This article responds to a critical need in the counseling and psychotherapy fields, to provide faculty and supervisors with specific examples, resources, and procedures that could be systemically applied when CMFT-ITs struggle in their programs. While interventions with students who struggle can be emotionally taxing, early documentation and intervention has the potential to generate more positive outcomes for students and the clients they serve.
Footnotes
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.