It takes a long time to become a clinical psychologist: People have to go to graduate school, do an internship, and apply for licensure from the state. Thus, there are lots of places in training where "bad apples," people who are not competent and/or not ethical, can be weeded out. In theory, it looks so easy: If a trainee is behaving badly, just kick ‘em out of the school, internship, or profession. In practice, it's not that easy.
W. Brad Johnson and his colleagues (see reference 1 below) have thought long and hard about the difficulty of weeding out students and trainees during their training. Johnson talks of the "hot potato game": "I refer to the perception that graduate training programs, training sites, and licensing boards often pass problematic students, supervisees, and licensure applicants along while blaming one another for the problem." We don't know how bad the problem is, but it seems hard to find a professor in a psychology training program who doesn't have a story (or six) to tell about students they graduated whom they didn't feel entirely comfortable with.
Here's how the hot potato game appears to work: When students run into ethical problems, graduate programs think something like, "When the student goes on internship and the problems reappear, they'll be sure to catch it and won't let the student pass the internship." Internship supervisors bemoan the fact that graduate programs send them bad interns: "It's the program's fault. We only have the students for a year; surely the program won't allow the student to graduate. And besides, the licensing board will detect the problem and not grant a license." Licensing boards complain about programs and internships letting these students get this far, but think, "We can only act on the credentials presented to us, so if the licensure applicant has a degree, supervision, and no felonies, we have to let them take the exams and get licensed." To quote Vonnegut: So it goes.
Why is it so difficult for graduate programs to "pluck" the bad apples before they become hot potatoes and are passed further up the line? After all, programs have an ethical obligation to evaluate their trainees and to prevent future harm by kicking out poorly-performing students. I'm not trying to explain this problem away or to make excuses for the profession. But there are lots of influences and pressures that make it hard to actualize our ethical ideals.
Here's one issue: Johnson cites data published in the New England Journal of Medicine (see Reference 2) that shows that "physicians disciplined by a medical board were significantly more likely to have had negative evaluations and incidents involving unprofessional conduct in medical school." We don't (yet) have data for psychology programs. But even assuming that we found a similar connection between students' problems in training and later disciplinary action, that doesn't mean every student with an "incident" winds up in front of a disciplinary board. Some ethical problems are minor and/or temporary; some students improve their performance and do quite well. No matter where they draw the line, programs will have to make judgment calls about when problem behavior is bad enough to warrant dismissal from the program.
Part of the problem has to do with professional identities. Professors play (at least) two roles for students: First, we are teachers and advocates. Second, we are gate-keepers and evaluators. These roles are in constant tension. As educators we want to do what's best for students and help them overcome obstacles in their training. We consider it a personal success when our students graduate. We're not so proud when students leave our program, no matter what the reason.
We belong to a profession that's dedicated to helping people and facilitating their growth. It may not be in our collective nature, nor our nature as individuals, to playing play the gatekeeper role with gusto and grace. We may not be as good as we need to be in confronting students with their bad behavior and then counseling—or throwing—them out of our program. The harm we do to trainees by kicking them out of programs is more immediate and harder to take than the harm that these trainees may or may not do to future clients.
Another set of influences are financial and practical: Programs invest lots of time and money in selecting and educating their students. Some programs have financial incentives to keep students in, and it looks good on paper to graduate a high percentage of admitted students.
And let's face it—it's hard to take drastic action with the specter of students suing us looming over us. Kicking students out for bad grades is one thing—we can marshal proof that our judgments are good. It's harder to prove that a student poses a significant risk to some unnamed future clients and that the risk is severe enough to warrant giving up on the investment that we've already made.
Let's end on a positive note: Some programs do a better weeding job than others. Johnson and his colleagues have many good suggestions about how programs can improve. For example, they can better train their faculty to detect problems and to have difficult evaluative conversations with students. They might also do a better job of "career counseling," and be more willing to talk with students about the possibility that a career in clinical psychology is not the only way to live one's life. (For more on this, check out "The Right Choice?" on Sharon Anderson's blog.)
In his book Outliers, Malcom Gladwell discusses the factors involved in the lives of very successful people. Maybe we also need to pay attention to what might be called "ethical outliers" at the other end: prospective psychologists who might be headed towards failure.
1. Johnson, W. B., Elman, N. S., Forrest, L., Robiner, W. N., Rodolfa, E., & Schaffer, J. B. (2008). Addressing professional competence problems in trainees: Some ethical considerations. Professional Psychology: Research and Practice, 39, 589-599.
2. Papadakis, M., Teherani, A., Banach, M., Knettler, T., Rattner, S., Stern, D., et al. (2005). Disciplinary action by medical boards and prior behavior in medical school. New England Journal of Medicine, 353, 2673-2682.
Hot potato image from: bleacherreport.com
Mitch Handelsman is a professor of psychology at the University of Colorado Denver and the co-author (with Sharon Anderson) of Ethics for Psychotherapists and Counselors: A Proactive Approach (Wiley-Blackwell, 2010).