Clinic Profiles: Sean O'Halloran's Magical Mystery Tour
The Peripatetic Clinic Director: Travels Near and Far
M. S. O'Halloran
As part of my 2007 - 2008 sabbatical I had the pleasure of traveling to ten clinics in four different states. I interviewed clinic directors and other key personnel, toured the clinics, campus and wider communities where the clinics are located. My goals were to compare what we do in my clinic with what other clinics do. I hoped that learning about what other clinics do would help me to further develop my clinic, inform the administration in my department and at my university about common practices and standards in the field, and help me in my overall goal to gain greater resources (money and facilitates) for the clinic. I hoped I would return from sabbatical ready to incite change or be happy with what I have. I knew the latter would not be the case.
Abbreviations used here: PSC is ‘Psychological Services Clinic', even thought not everyone uses that name. CD stands for clinic director.
This is an informal report. Given that my ‘research' was really quite casual you will not find grand answers for some of the problems that plague us as clinic directors.
The broadest and most conclusive summary I can make after my travels is that every clinic director I met with was exceedingly welcoming, proud of what their clinic had to offer, very willing to tell me about and even show me around the community where the clinic is located. Each clinic serves a different clientele and students are well trained to offer effective services. Training is taken very seriously and meets the highest standards in the field. The students I spoke to at the clinics I visited were equally welcoming and had very favorable things to say about their training, the supervisors and the clinic directors. I also found that CD's are incredibly resourceful and that is one reason it is hard to replace us! Many of us develop contacts in the community and know where to go for just about anything or know someone who can help us to find a doctor, lawyer, education or community resource to assist clients. This is hardly surprising given how much we help each other on line!
WHO
Clinic Directors degrees and rank: We are a diverse group. Clinic directors (CD's) have doctorates in clinical psychology, counseling psychology, or counselor education.
Rank: CD's range from adjunct or clinical faculty to tenured/full professors and everything in between. FTE: CD's jobs range from part time to full time in running the clinic. Those who are part-time CD's usually teach an additional course (or two) every semester or if they are clinic faculty, they often have a part-time private practice.
Clinical faculty (non-tenure line, term) sometimes serve on dissertation committees, attend regular faculty meeting and, some have voting privileges regarding clinical matters, but may not vote on personnel matters such as tenure and promotion for regular faculty.
Several CD's with part time clinical faculty position discussed concerns about their level of perceived authority. These concerns include perceiving that their position does not give them the authority to address problematic faculty supervisors, at times, even students, and that their authority depended on support from the department chair. More full time faculty who were CD's seemed satisfied with their level of authority in implementing clinic policy. Most felt supported by the department chair or that their chair pretty much left them alone to do their jobs as they saw fit.
When I asked about the relative permanence of the CD position, most CD's were unambiguous that being a CD is not a position that is easily shifted from one faculty member to another. In fact all but one of the CD's I spoke to have been in their position for over 5 years and several have had the position for many years. One person had been the CD for 18 years! I raise the question about tenure of CD as several administrators at my university wonder why the CD position does not rotate amongst faculty every few years as our program chair positions do.
Other staff: Several clinics have assistant clinic directors and/or assessment supervisors. There are clinics with assessment specialties due to the research interests of faculty. All clinics have some level of administrative support in the form of secretaries, receptionists, administrative assistants, graduate student assistant, and undergraduate work-study students. However this ranges greatly from my clinic where I had only an 8 hour per week graduate assistant to several well supported clinics that have personnel in all of the categories named above!
Psychiatrists are not a common feature of PSC's, although several do have psychiatrists on staff. Most CD's consult with psychiatrists at times. Some speak to friends and colleagues in the field; consult with psychiatrists at the university health center, or local medical agency.
Clinicians: Several clinics have doctorate students only, most received their bachelor's degrees before matriculating into a doctoral program, and several have both masters and doctoral degree students. Programs offered include doctorates in clinical psychology, counseling psychology, and school psychology. All of these programs were APA-accredited. The master's degree programs included clinical counseling, school counseling, and couples and family counseling. The programs visited were CACREP accredited. The doctorate in Counselor Education and Supervision is also a CACREP accredited program.
Supervisors: Supervisors for student clinicians include regular faculty, adjunct faculty, and community supervisors at onsite and offsite placements. Several clinics require adjunct and community supervisors to attend at least one general meeting where clinic policies are explained, and paperwork and procedures are discussed. Some clinics require such supervisors to attend meetings regularly. In a couple of clinics the oversight of external and adjuncts supervisors was less formal and clinic directors perceived this to be a problem because irregular or ineffective communication channels made for a greater number of problems. My take away message is that mandatory and regular meetings with adjunct and community supervisor helps everyone stays current on policies, procedures, evaluations of students, etc.
Clients: Population served. The types of clientele ranged from serving a) primarily university students on campus; b) university students, staff, faculty and community members; c) mostly community members. Some clinics target d) specific clientele such as students in local elementary and secondary schools, very low income clients living in federally assisted housing, felons, and one clinic focuses specifically on working with senior citizens.
WHAT
What types of services: The types of services offered uniformly include counseling (individual, family couples, groups, some offer specific training in play therapy, thus offer that modality), cognitive and intellectual assessments, some offer consultation. Many would like to offer Spanish speaking services, but few actually do. The primary reason for not offering more are that the counselors in training do not speak Spanish or the faculty observing live supervision are not Spanish-speaking.
Relationships with other campus and community agencies: Most of the sites I visited have positive relationships with other mental health services on the campus or in the community? Comments indicated that it is important to develop a good relationship with campus counseling centers so that we do not tread on each others ‘territory' when both agencies are able to provide services to students. After all, most university counseling centers are, to some degree, student funded while PSC's are not. It is not uncommon for university counseling centers with session limits to refer to the PSC. In most communities the PSC is very welcome as we typically provide lower cost services and individuals in private practice are glad to have a lower cost service to refer to. In several cases there are multiple training clinics on campus. For example, on one campus there was a clinical psychology training clinic and a counselor education clinic in the college of education. It is very savvy to develop good partnerships with other programs where different accrediting bodies may be involved (i.e. APA and CACREP). A few ADPTC members are CD's in clinics with programs accredited by both organizations. In this case, we need to be ‘fluent' in the language of both organizations to help our departments maintain accreditation.
Crises/Emergencies: How do you handle crisis/emergencies in your clinic? Every clinic I visited has plans for dealing with crises and emergencies. There is a distinct and growing trend to work closely with university counseling centers on a coordinated response to campus violence and other crises. During the 2008 ADPTC meeting in San Antonio this was a topic of significant interest. Some of our clinics have clearly articulated plans while others are developing such plans. Given the too many recent tragedies on college campuses this coordination is essential. At an upcoming mental health summit on my own campus, Dr. Christopher Flynn from the Virginia Tech University Counseling Center will be speaking on threat assessment and safety on college campuses.
It was common to find clinics did not offer 24 hour emergency services, most without these services endeavor to conduct careful screenings and refer clients with obvious suicidal tendencies to other agencies with greater resources and licensed staff. Clinics willing to work with just about any client do give clients hotline and emergency phone numbers.
Research: Research in clinics is quite common. Several big research programs build on clinical interests of faculty and external funding helps to support research and graduate assistants. CD's are very interested in developing research programs in their clinics. This interest is evident as I consider how many people asked to be on a Practice Research Network at the 2008 meeting in San Antonio. However making time to attend to research is a challenge. CD's who are expected to publish and present as part of the jobs find that the clinic can be a valuable research site. Competing demands is often a problem. Perhaps I speak only for myself here though. I try to juggle many hats in my job. Much of my position as CD is spent dealing with day to day business and putting out the proverbial fires. To develop an ongoing research program it seems essential to have interested graduate students and institutional support.
WHERE
Facilities: Facilities for providing services vary widely from the typical on campus clinic to creative and innovative service centers. On campus it is common to find counseling rooms with one-way mirrors, observation corridors and taping capacity. Some clinics have very new facilities that include comfortable and large waiting rooms, ideal group and family therapy rooms, fabulous play therapy rooms replete with sand tray and water tray capabilities. Some clinics have off campus facilities. These included the wing of a health care center, a strip mall with services oriented to senior citizens, offices in a federally funded housing project and in local schools where ‘satellite' clinics exist. Services are sometimes provided by trainees at community agencies such as schools, police or sheriff's departments, and federal prisons.
WHEN
Most clinics run year round. Clinic directors deal with vacations, sabbatical breaks, and other away times in a variety of ways. These include having assistant directors take over or another faculty member assumes CD responsibilities. During my sabbatical I still supervised as CD with the help of a fabulous graduate assistant and two faculty who are part of my clinic committee. When I left the U.S. to teach in Thailand one of the other faculty members on the clinic committee took over for me, but kept in contact via e-mail or Skype.
HOW
Technology: Technology discussions focused on scheduling and billing systems, and on the recording counseling and assessment sessions. Virtually all clinics have the technology to record live sessions. Technology varies from the very basic to highly sophisticated systems. Systems include video, digital, and webcams. Clinic directors with very sophisticated technology mentioned that the learning curve was steep as they began transforming their clinic from outdated recording practices to state of the art technology. Several directors relied on ‘the technology people' at their universities to handle the majority of the transformation from old to new. Careful attention was focused on providing safeguards such as firewalls to deal with possible security leaks. Issues regarding security seem to be an ongoing concern for most clinic directors.
Policies & Procedures. Not surprisingly all of these high quality training sites have myriad policies, procedures, protocols and clinic manuals. The ADPTC website offers links to many of these documents and websites.
Funding: In general, the university, school, and department support the clinic to varying degrees. Clients usually pay for services on a sliding fee scale. Sometimes the client fees go directly to the clinic, sometimes to the department or the school within which the department is housed. There was great variability in this from clinic to clinic. Most clients are low income and fees generated are not the mainstay of any budget. A significant part of the budget may come from contracts with agencies the clinic has particular relationships with. These sometimes include campus athletic departments and disabilities student service offices. Community agencies sometimes include departments of housing, social services, law enforcement, and federal prisons. Several clinics have contracts with schools. Several clinics have subspecialties such as assessment and at least one is well funded by a philanthropist. A couple of clinics have grant writing experts and get some of their funding from foundations or granting agencies. At least one clinic has a major fundraising event each year. It is rare that clinics accept Medicaid, but this does happen at several clinics that focus on serving the needs of specific populations the larger community.
Marketing: Typical strategies for marketing include: websites, brochures, presentations to the community or to campus agencies, public service ads, campus news online and hard copy, such as the campus newspaper, making key connections with community resources who serve as good referral sources. Level of effort involved in marketing varied widely. Views here range from making great efforts to get clients to being overloaded with clients and needing to ask referral sources to stop sending clients.
Acknowledgements:
I am very grateful to the clinic directors who took time from their busy schedule to meet with me. Several even had time to show me around the campus, the town, and to go out to dinner. I really enjoyed my visits with everyone and would love to visit you all again. I hope to visit other clinics whenever time and travel opportunities permit. In another newsletter I will tell you about my visit to a PSC in Thailand.
My sincere thanks to Drs. Mary Alice Conroy, Richard Watts, Rob Heffer, William Rae, Sheila C. Ribordy, Michael Kenny, Patricia Larsen, Lee Rosen, Emily Richardson, and Mary Alice Bruce. I am extremely grateful to Dr. Robbyn Wackker, Dean of the Graduate School at the University of Northern Colorado. Her encouragement and support for this project was essential.
