c h a p t e r 8 Professional Competence and Training Introduction In this chapter we focus on the ethical and legal aspects of professional compe- tence and the ongoing education and training required for mental health profes- sionals. We discuss issues related to professional licensing and certification as well as approaches to continuing education. Ability is not easy to assess, but competence is a major concern for mental health professionals. Striving for competence is a lifelong endeavor. We are called upon to devote the entire span of our careers to developing, achieving, maintain- ing, and enhancing our competence. Competence at one point in our career does not assure competence at a later time. To remain current, we must take active steps to maintain our knowledge and skills. Continuing education is particularly impor- tant in learning about emerging areas of practice. Barnett and Johnson (2015) remind us to consider the scope of our compe- tence. Being competent in one area of counseling does not mean we are compe- tent or feel comfortable handling client concerns in other areas. It is important to accurately assess each area of our practice to ensure competence. In one study examining school counselors’ comfort and perceived competence in addressing student issues pertaining to spirituality, 80% of participants felt they needed to improve their competence level even though they said they were comfortable with these issues (Smith-Augustine, 2011). Practitioners and students can develop com- petence both as generalists and as specialists. A generalist is a practitioner who is able to work with a broad range of problems and client populations. A specialist is a worker who has developed competence in a particular area of practice such as career development, addiction counseling, eating disorders, or family therapy. Definitions of competence center around a practitioner’s ability to perform cer- tain tasks and roles appropriately and effectively (Johnson et al., 2008). Competent practitioners have the necessary self-awareness, knowledge, skills, and abilities to provide effective services. To apply our knowledge and skills competently, we must consistently attend to our physical, emotional, mental, and spiritual well-being. As we saw in Chapter 2, self-care and wellness are basic to being able to function com- petently in our professional work and are considered ethical issues. We give the education and training of mental health professionals special attention because of the unique ethical issues involved. Indeed, ethical issues must be considered from the very beginning, starting with admission and screening procedures for graduate programs. One key issue is the role of training programs in safeguarding the public when it becomes clear that a trainee has problems that are likely to interfere with professional functioning. LO1 Therapist Competence: Ethical and Legal Aspects In this section we examine therapist competence, or the skills and training required to effectively and appropriately treat clients in a specific area of practice. We discuss what competence is, how we can assess it, and what some of its ethical and legal dimensions are. We explore these questions: What ethical standards offer guidance in determining competence? What ethical issues are involved in training therapists? To what degree is professional licensing an accurate and valid measure of competence? What are the ethical responsibilities of mental health professionals to continue to upgrade their knowledge and skills? Competence can best be considered on a continuum from incompetent to highly competent. Competence is both an ethical and a legal concept. From an ethical perspective, competence is based on the principles of beneficence and non- maleficence (Knapp, Gottlieb, & Handelsman, 2015). Ethical practitioners protect and serve their clients. Even though mental health professionals may not intend to harm clients, incompetence is often a major contributing factor in causing harm. From a legal standpoint, incompetent practitioners are vulnerable to malpractice suits. Perspectives on Competence We continue this discussion of competence with an overview of specific guidelines from various professional associations. They are summarized in the Ethics Codes box titled “Professional Competence.” 304 / chaPter 8 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. ETHICS CODES: Professional Competence American Mental Health Counselors Association (2015) Mental health counselors recognize the boundaries of their particular competencies and the limitations of their expertise. (C.1.a.) American Association for Marriage and Family Therapy (2015) Marriage and family therapists do not diagnose, treat, or advise on problems outside the recognized boundaries of their competencies. (3.10.) American Psychological Association (2010) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience. (2.01.a.) American Counseling Association (2014) Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Whereas multicultural counseling competency is required across all counseling specialties, counselors gain knowledge, personal awareness, sensitivity, disposi- tions, and skills pertinent to being a culturally competent counselor in working with a diverse client population. (C.2.a.) American Psychiatric Association (2013b) A psychiatrist who regularly practices outside his or her area of professional competence should be considered unethical. Determination of professional competence should be made by peer review boards or other appropriate bodies. (2.3.) American School Counselor Association (2016) School counselors monitor their emotional and physical health and practice wellness to ensure optimal professional effectiveness. School counselors seek physical or mental health support when needed to ensure professional competence. (B.3.f.) These guidelines leave several questions unanswered. What are the bound- aries of competence, and how do professionals know when they have crossed them? How can practitioners determine whether they should accept a client when their experience and training are questionable? What should be the minimal degree required for entry-level professional counseling? Counselors may need to be both generalists and specialists to be competent to practice with some client populations. Many substance abuse counselors argue that if you are licensed as a generalist, you are not qualified to work in the area of treatment of addictions. To qualify as a substance abuse counselor, the CACREP (2016) standards identify specific knowledge, skills, and practices in the following areas: foundations; con- textual dimensions, counseling, prevention, and intervention; diversity and advo- cacy; assessment; research and evaluation; and diagnosis. Mental health professionals bear the responsibility of ensuring that we meet minimal standards of competence. Ongoing self-assessment and self-reflection are necessary throughout our careers. When unsure of our competence to provide services in a particular area of counseling practice, we consult with colleagues (Barnett & Johnson, 2015). Gathering anonymous feedback from current and for- mer clients can be beneficial in assessing the degree to which clients experienced us as competent. It is a good practice to routinely ask clients for feedback about what is working in the sessions and how they view us as their therapist. By reflecting on some positive and unhelpful interventions, counselors can make it safe for clients to share their own critiques. Routine self-assessment and an honest appraisal of our skills provide the foundation for continued growth and positive changes that will increase our competency and benefit future clients. Assessment of Competence LO2 Assessing competence is an extremely difficult task. Some who complete a doc- toral program lack the skills or knowledge needed to carry out certain thera- peutic tasks. It is especially important for counselor trainees seeing clients as part of a practicum or internship to learn to assess their own competence. As future professionals, you need to monitor your competence and take steps to acquire the knowledge and skills required for effective practice. Kaslow and col- leagues (2007) suggest that assessment approaches are most effective when they integrate both formative and summative evaluations. Formative assessment is a developmentally informed process that provides useful feedback during one’s training and throughout one’s professional career. Summative assessment is an end point evaluation typically completed at the end of a professional program or when applying for licensure status. Together these assessments address an indi- vidual practitioner’s strengths and provide useful information for developing remedial education plans, if needed, for the person whose competence is being evaluated. Johnson and colleagues (2012) acknowledge that formative and sum- mative assessments of trainees provide rigor and efficacy, but they note some problems associated with self-assessment. Clinicians often fail to recognize their own problems with competence, and some may be reluctant to address problems of competence in colleagues even when there is evidence that these problems exist. Johnson and colleagues (2008) contend that those who are responsible for educating and training mental health professionals are ethically and profession- ally obligated to balance their roles as advocate and mentor of trainees with their gatekeeping role. One way to manage these sometimes conflicting roles is to thor- oughly and accurately provide routine formative and summative assessment for trainees, carefully document these evaluations, and ensure that multiple profes- sionals give independent evaluations of each trainee. Training faculty are ethi- cally obligated to provide accurate, relevant, and timely feedback for all trainees throughout the program. Jacobs and colleagues (2011) address the importance of initiating difficult conversations with trainees when formative and summative feedback given to trainees has not been effective. How do beginning counselors assess their readiness to practice indepen- dently? Is the number of supervised hours a sufficient criterion, or are other mea- sures needed? If you are unsure of your ability to provide services in a particular area of counseling practice, you should consult with colleagues. When it becomes clear that a client’s counseling needs exceed your competence, you must either develop the competence necessary to effectively treat the client or refer this client to another competent professional. The decision to refer must be made for the benefit of the client rather than for the comfort of the counselor. Self-reflection and colleague consultation are important steps in making this decision. As a beginning counselor, if you were to refer all the clients whose problems seemed too difficult for you, it is likely that you would have few clients. You must be able to make an objective and honest assessment of how far you can safely go with clients and recognize when to refer clients to other therapists or when to seek consultations with other professionals. It is not at all unusual for even highly expe- rienced therapists to question whether they have the personal and professional abilities needed to work with some clients. Thériault and Gazzola (2005) suggest that “many therapists continue to worry about their competence despite years of experience” (p. 11) and that “questioning one’s competence is a significant aspect of being a therapist” (p. 16). It is more troubling to think of therapists who rarely question their competence. Difficulty working with some clients does not by itself imply incompetence, nor does lack of difficulty imply competence. One way to develop or upgrade your skills is to work with colleagues or professionals who have more experience, especially when you go into new areas of practice. Seek consultation before you practice in areas where you have not received education and training, and continue to seek supervision throughout the process of developing competence in those areas. Doll (as cited in Barnett, Doll, Younggren, & Rubin, 2007) contends that practitioners must constantly build com- petence in new knowledge, skills, and practices, long after they leave their training programs. Doll notes that when therapists extend the boundaries of their prac- tice, or when they branch out into an area requiring specialty competence, they should seek collegial consultation or professional supervision with acknowledged experts. Ongoing training and continuing education should be sought throughout the duration of one’s career. New skills can be learned by attending conferences and conventions, by read- ing books and professional journal articles, by taking additional courses in areas you do not know well and in theories that you are not necessarily drawn to, and by participating in workshops that combine didactic work with supervised practice. The feedback you receive can give you an additional resource for evaluating your readiness to undertake certain therapeutic tasks. Making Referrals LO3 Although you may be competent in a certain area, you still may need to refer a client if the resources are limited in the setting in which you work or if the bound- aries of your professional role restrict you from effectively delivering the services your client needs. For example, a school counselor may make a referral to a mental health professional outside of the school for a student needing individual psycho- therapy. The school counselor is practicing ethically by referring the student for more intensive services because these services cannot be provided within a school context. If your work setting limits the number of counseling sessions for clients, develop a list of appropriate, qualified referral resources in your area. The counseling process can be unpredictable at times, and you could encoun- ter situations in which the ethical path is to refer your client. For example, a school counselor was working with Quan, whose presenting problem was anxiety per- taining to academic success in college, which was within the scope of the school counselor’s training. However, after meeting with Quan a few times, the counselor sensed that this student was very depressed and learned that he had engaged in self-mutilation and other forms of self-destructive behavior. Quan’s counselor recognized that these symptoms and behaviors reflected a problem area that was outside the scope of his practice. Ethical practice required that he make a referral to another professional who was competent to treat Quan’s problems. Possessing the expertise to effectively work with a client’s problem is one benchmark, but other circumstances can also make you wonder if a referral is in order. However, as you will recall from Chapter 3, referring a client because of a conflict with your value system is not an ethically acceptable reason for a refer- ral. Wise and her colleagues (2015) have eloquently delivered the message that attaining competence to work with a diverse public is not optional: “students do not have the option to avoid working with particular client populations or refuse to develop professional competencies because of conflicts with their attitudes, beliefs, or values” (p. 268). Linde (2016) states that if counselors lack knowledge about clients with whom they are working, they have the obligation to seek addi- tional training, consultation, or supervision to acquire the knowledge and skills to work with these clients. Linde acknowledges that it is ethical to make a referral in some situations: “If the client needs a higher level of care than the counselor can provide, then the counselor may refer the client” (p. 20). You need to develop a framework for evaluating when to refer a client. It is imperative that you make skillful referrals when the limits of your competence are reached. Your clients deserve to understand the reason for the referral, and you will need to learn how to make this referral in such a manner that your client will be open to accepting your suggestion rather than feeling rejected or abandoned. We hope you would not see referring a client with whom you have difficulty as a cure-all. If you are inclined to make frequent referrals, explore your reasons for being unwilling or unable to counsel these individuals. You may need to refer yourself for further help! Most codes of ethics have a guideline pertaining to con- ditions for making a referral, such as this one from the code of ethics for social workers: Social workers should refer clients to other professionals when the other profession- als’ specialized knowledge or expertise is needed to serve clients fully or when social workers believe that they are not being effective or making reasonable progress with clients and that additional service is required. (NASW, 2008, 2.06.a.) The Case of Binh binh is 45 years old and has seen a counselor at a community mental health center for six ses- sions. she suffers from periods of depression and frequently talks about how hard it is to wake up to a new day. it is very difficult for binh to express what she feels, and most of the time she sits silently during the session. the counselor decides that binh’s problems warrant long-term therapy, which he doesn’t feel competent to provide. in addition, the center has a policy of referring clients who need long-term treatment to therapists in private practice. the counselor therefore approaches binh with the suggestion of a referral: Counselor: Binh: Counselor: Binh: Counselor: Binh: Counselor: Binh: binh, during your intake session i let you know that we are generally expected to limit the number of our sessions to six visits. today is our sixth session, and i’d like to discuss the matter of referring you to another therapist. Well, you did say that the agency generally limits the number of visits to six, but what about exceptions? i mean, i feel as if i’ve just started with you, and i really don’t want to begin all over again with someone i don’t know or trust. i can understand that, but you may not have to begin all over again. i could meet with the new therapist to talk about what we’ve done these past weeks. i still don’t like the idea at all. i don’t know whether i’ll see another person if you won’t continue with me. Why can’t i stay with you? i think you need more intensive therapy than i’m trained to offer you. as i’ve explained, i’m expected to do only short-term counseling. intensive therapy! Do you think that my problems are that serious? it’s not just a question of you having serious problems. i am concerned about your prolonged depressions, and we’ve talked about my concerns over your suicidal fantasies. i think it is in your best interest to see someone who is trained to work with depression. i think you’ve worked well with me. if you won’t let me come back, then i’ll forget about counseling. consider the ethical issues involved in binh’s case by addressing these questions: • What do you think of the way binh’s counselor approached her? Would you have done anything differently? • Was the counselor working beyond the scope of his practice, or was binh not very sophisti- cated about the process of therapy? • is it possible that the counselor was not clear enough regarding the limitation of six visits? at what point would you have discussed the six session limitation with binh? • if you were binh’s counselor and you did not think you were competent to treat her, would you agree to continue seeing her if she refused to be referred to someone else? Why or why not? Commentary. this exchange reflects a common problem; counselors and clients often have different perspectives on termination and referral issues. it is unethical for this therapist to continue counseling binh, even though she opposes ending therapy with him. continued treatment of a client’s problem that is beyond the scope of the therapist’s competence is a serious violation of the standard of care (younggren & gottlieb, 2008). When a therapist deems termination and referral to be the appropriate course of action, to do otherwise violates the fiduciary obligation to the client and the ethics code that prohibits rendering unnecessary treatment sessions. the counselor may have a duty to terminate regardless of the perception and wishes of the client. in extreme cases termination may occur over the objections of the client, yet such objections do not make termination inappropriate (younggren et al., 2011). how the counselor suggests the referral is critical. this counselor would have been wise to suggest a referral before the last session. With rare exceptions, a therapist should be able to determine whether he or she is competent to treat a given client by the end of the initial inter- view. the counselor should have stressed the short-term nature of the help he was qualified to provide during the informed consent process at the first session. Ultimately, it is the client’s choice whether to accept or decline a referral. if this counselor can demonstrate that a referral is in binh’s best interest, there is a greater chance that she will accept the referral. in this case, the counselor would have been wise to consider not accepting a client like binh whose prob- lems would clearly be better served on a long-term basis. • LO4 Ethical Issues in Training Therapists Training is a basic component of practitioner competence. You will be able to assume an active role in your training program if you have some basic knowl- edge about policy matters that affect the quality of your education and training. Although providing adequate training is primarily the responsibility of the faculty in your program, you too have a role and a responsibility to ascertain that your training will provide you with the experiences necessary to become a competent practitioner. In this section, our discussion of the central ethical and professional issues in training is organized around questions pertaining to selection of trainees and the content of training programs. Selection of Trainees LO5 A core ethical and professional issue involves formulating policies and procedures for selecting appropriate candidates for a training program. Here are some issues that training program faculty need to consider: • What criteria should be used for admission to training programs? • Should the selection of trainees be based solely on traditional academic stan- dards, or should it take into account factors such as personal characteristics, character, and psychological fitness? • Is there a good fit between the candidate and the training program? • To what degree is a candidate for training open to learning and to considering new perspectives? • Does the candidate have problems that are likely to interfere with training and with the practice of psychotherapy? • What are some ways to increase applications to programs by diverse groups of candidates? Your training program has an ethical responsibility to establish clear selection criteria, and you, as a candidate, have a right to know the nature of these criteria when you apply. Although grade-point averages, scores on the Graduate Record Examination (GRE), and letters of recommendation are often considered in the selection process, relying on these measures alone does not provide a comprehen- sive picture of you as a candidate. As part of the screening process, ethical practice requires that candidates be given information about what will be expected of them if they enroll in the pro- gram. Just as potential therapy clients have a right to informed consent, students applying for a program have a right to know the material they will be expected to learn and the manner in which education and training will take place. In most training programs, students are expected to engage in appropriate self-disclosure and to participate in various self-growth activities. Programs should make sure that applicants understand these requirements. The language in the informed con- sent document must be unambiguous, and the criteria for successful completion of the program easily understood by all concerned. Screening can be viewed as a two-way process. Faculty screen candidates and make decisions on whom to admit, and at the same time candidates are screening the program and faculty to decide whether this is the right program for them. As students progress in a program, some may come to the realization that the counseling profession is not for them. If you have doubts about contin- uing in a program, discuss the matter with a faculty person whom you trust. It is easy to feel overwhelmed and come to a hasty self-assessment about being unsuitable for the profession when in fact you are simply feeling discouraged at the moment. The Case of Leo julius is on a review committee in a graduate counseling program. Leo has taken several intro- ductory courses in the program, and he has just completed an ethics course taught by julius. it is clear to this professor that Leo has a rigid approach to human problems, particularly in areas such as interracial marriage, same-sex relationships, and abortion. Over the course of the semester, Leo appeared to be either unwilling or unable to challenge his beliefs. When challenged by other students in the class about his views, Leo responded by saying that he felt he was in a double bind. his faith gave him very clear guidelines on what is acceptable church teaching. at the same time, in this supervision class he is being asked to violate those values, so he feels conflicted no matter which decision he makes. nobody offers him a solution. if he refers a future client with whom he has value conflicts, he is behaving unethically; if he were to accept such a client, he would be violating his church’s teachings. in meeting with the committee charged with determining whether candidates should be advanced in the program, julius expresses his strong concern about retaining Leo in the program. his colleagues share this concern. • What reactions do you have to this case? how would you respond to Leo’s dilemma? • Do you see any benefit to Leo expressing his values openly in his training program? • are any other avenues open in working with Leo short of disqualifying him from the program? • if Leo’s values reflected his cultural background, would that make a difference? Would the committee be culturally insensitive for rejecting him from the program? • What if Leo said that when he eventually obtained his license he intended to work exclu- sively with people from his cultural and religious background? should he be denied the opportunity to pursue a degree in counseling if his career goal is to work with a specific population that shares his views and values? • if you were on the committee, how would you handle candidates who seemed to exhibit racism, homophobia, and rigid thinking? • are there any informed consent issues pertaining to graduate students that should be addressed in a case such as this? if so, what are they? Commentary. Leo’s case illustrates the dilemma counselor educators sometimes face when they have serious concerns about trainees who are likely to impose their values on their future clients. ethically, the client’s problems need to be explored and resolved in a way that matches the client’s values, not the therapist’s values. Leo will be expected to help clients understand and address the concerns they bring to therapy. although Leo is not seeing clients now, he has the potential to do harm to clients if the rigidity of his value system is not challenged. Leo’s openness about his beliefs gives the faculty and his supervisors a place to begin to work with him. the greater concern is that Leo seems unwilling to examine how his beliefs might hinder his ability to work with clients who do not share his values. educators and supervisors have several ethical obligations to students and trainees who may be impaired or incompetent. at least one faculty representative should meet with Leo to explore with him how his religious values might affect his work with clients. Leo has a right to his own values, but it would be unethical for him to impose them on clients. Leo must learn to bracket his values in sessions, and he should be given the opportunity to receive supervised practice in bracketing his values with mock clients. the faculty should document consistent and clear formative feedback to Leo as well as efforts to encourage remediation or personal development before deciding to dismiss him from the program. educators who fail to adequately orient prospective and current students regarding expec- tations and evaluation procedures heighten the risk of conflicts with ill-informed students (barnett & johnson, 2015). Leo should have been clearly oriented to the graduate program’s expectations for students, including minimum competencies such as working with culturally different clients and avoiding the imposition or the intrusion of one’s own values. • Content of a Program It is important to ask questions about the content of your own training program and to seek ways to become as actively involved as possible in your own learn- ing. From an ethical perspective, counselor educators and trainers are expected to present varied theoretical positions. Training programs would do well to offer students a variety of therapeutic techniques and strategies that can be applied to a wide range of problems with a diverse clientele. Look at your program and ask how it measures up against these questions: • Is the curriculum inclusive of many cultures, or is it culturally biased? • What does your program tell you about imposing your values on clients? Or about referring clients with whom you have a conflict of values? • Does the curriculum give central attention to the ethics of professional practice? • What core knowledge is being taught in your training program? In training programs for various mental health professions, general content areas are part of the core curriculum, which are generally outlined by CACREP (2016) standards. Content areas typically required for all students in counseling programs include professional counseling orientation and ethical practice, social and cultural diversity, human growth and development, career development, counseling and helping relationships, group counseling and group work, assess- ment and testing, and research and program evaluation. Effective training programs are designed to help you acquire a more complete understanding of yourself as well as gain theoretical knowledge and develop clin- ical skills. Ideally, you will be introduced to various content areas, will acquire a range of skills you can utilize in working with diverse clients, will learn how to apply theory to practice through supervised fieldwork experiences, will learn a great deal about yourself personally, and will develop a commitment to acquir- ing or enhancing personal wellness. A good program does more than impart knowledge and skills essential to the helping pr
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