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Is Clinical Training Turning Into a Checklist?

We are always tempted to measure what is easily measured.

Some clinical psychology trainees don’t know how to do some things that every psychologist ought to know, including diagnosing correctly, administering a mental status exam, writing SOAP notes, and safety planning for people thinking about suicide. I agree that every trainee should know these things, but my concern is that an emphasis on knowing them will turn these sorts of administrivia skills into the definition of competence. I have the same concern about the psychology licensing exam and the ethical code and the regulations governing casework in child welfare practice. I think all psychologists should know the difference between criterion validity and construct validity, and I think they should obey the ethical code. I think every caseworker should follow every rule and regulation governing casework. But my concern is that once a host of easily measured rules are mastered, our field will forget that these are not the same as competence.

One way to look at the problem is that we want to know who is competent and who is not, but we are always tempted to measure what is easily measured, like the old joke about the guy who looks for his keys under the street lamp where the light is good rather than on his darkened porch where he dropped them. In fact, when Aaron Beck started redefining brief psychoanalytic therapy as a whole new approach called cognitive therapy, he predicted his approach would gain favor not (only) because he thought it was more effective, but because the approach conceptualizes change in a way that is easily measured (by self-report, and psychoanalysts are suspicious of self-report). The danger is that clinical training will turn into a checklist, and the only things that the checklist will not have are the only things that matter: critical thinking about emotional material, mastery of analogy, probing curiosity, empathy, humility, courage, and a welcoming attitude toward what is marginalized.

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My view is that most diagnoses (some actually matter because they imply a treatment plan), SOAP notes, and so on are like punctuation. You really ought to punctuate perfectly; it’s not that difficult. But don’t confuse punctuation with writing ability or with the quality of the ideas of the writer.

I confess I’ve never written a SOAP note, diagnosed more than two axes, given a mental status exam, or done a safety plan. But I’m pretty sure I could figure out how to do it if I needed to.

These skills also seem to me to be like the skill of looking in the mirror before giving a lecture to make sure there’s no spinach in your teeth or anomalous discharges around various orifices. Learning to write a SOAP note is like checking your fly before greeting a patient. It doesn’t mean you’re a good therapist if your fly is always up or a bad therapist if you left it down once or twice, but you really ought to check it.

Actually, all American education looks to me to be in danger of turning into a checklist. That would be fine if we were training robots to work with other robots, but we’re not.

Michael Karson, Ph.D., is a professor of psychology at the University of Denver.

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