Psychology Learning and Teaching 9(2), 6364
Assessing Trainee Clinical Psychologists Clinical Competence:
ACommentary
Ian C. Smith1
Lancaster University, UK
This paper by Tweed et al. addresses an extremely
important issue that has far too long been avoided in
clinical psychology training i.e., how one assesses the
development of competent practice in the clinical
psychology trainee.
We have some very good reasons to believe that applying
the skills taught in clinical practice may not be
straightforward and to wish to go beyond assessing the
knows how level of learning. Kirkpatrick (1967) identified
four levels at which the success of training in practical
skills can be assessed, which can be summarised as:
trainee satisfaction; knowledge gain; transfer of skills to
practice, and the effect of the training on outcomes. Whilst
studies which aim to evaluate training in psychotherapeutic
skills in practitioners almost universally find high levels of
participant satisfaction and gains in theoretical knowledge
(e.g., Appleby et al., 2003; Brooker & Brabban, 2004;
Farhall et al., 1998; Thomas, Guy, & Ogilvie, 1999; Willetts
& Leff, 1997; Zipple, Spaniol, & Rogers, 1990), consistent
transfer of the skills learned into clinical practice following
training has proved much more difficult to demonstrate
(e.g., Jahr, 1998; Milne, Gorenski, Westerman, Leek, &
Keegan, 2000; Smith, in press). One cannot assume,
therefore, that theoretical knowledge will necessarily lead
to skills being displayed in practice.
As Tweed et al. identify, we know that trainees tend to
select positive examples to report to supervisors
(Scaife, 2001). Indeed, in our training programme at
Lancaster we go as far as selecting for candidates who
provide narratives that show themselves in a positive
light. Such selectivity of reporting will of course preclude
accurate assessment of the consistency with which
trainees are applying skills. In addition to such
difficulties, we know from research in medical training
that supervisors, for a host of (mainly psychological)
reasons, can be extremely reluctant to identify and act
to correct poor practice in their trainees (Cleland,
Knight, Rees, Tracey, & Bond, 2008; Rees, Knight, &
Cleland, 2009), and we have no reason to conclude
that the same effects are not present in those who train
clinical psychologists.
The need for an assessment of implemented skills over
and above trainee report is therefore clear. However,
when considering the assessment of clinical skills in
Correspondence concerning this commentary should be addressed to the author at: Clinical Psychology, School of
1
Health & Medicine, Lancaster University, Lancaster LA1 4YT, UK. Email: i.smith@lancaster.ac.uk
trainee clinical psychologists, it is also worth considering
exactly which skills should be assessed. In a profession
which is undergoing changes in both its regulation
and in the roles its practitioners are being expected
to undertake, this choice is not necessarily as
straightforward as one might assume.
Psychotherapeutic skills are undoubtedly important for
the clinical psychologist, and in recent years some leading
figures in the profession have argued that the main role of
many clinical psychologists in future might be through
delivering and supervising the delivery of psychological
therapy (particularly cognitive therapy), as seen in the
drive toward producing trainees who are IAPT ready or
even encouraging newly qualified clinical psychologists to
then train as IAPT therapists (e.g., Clark & Turpin, 2008).
Similarly, the British Psychological Society Committee on
Training in Clinical Psychology controversially revised its
Criteria for the Accreditation of Postgraduate Training
Programmes in Clinical Psychology in 2008 to reflect this
increased focus on competence in specific psychological
therapies (BPS Committee on Training in Clinical
Psychology, 2008), and their latest draft document (BPS,
2010) appears to continue this trend.
However, the lead up to statutory regulation of clinical
psychologists prompted some prominent figures in the
profession to emphasise the unique skills of clinical
psychologists over and above the delivery of psychological
therapy. In a letter to the Health Professions Council
(HPC), Fonagy, Roth, Adams, and John (2009)
emphasised the integration and use of research methods
in clinical practice as the defining skill set unique to the
profession. When the HPC took responsibility for
regulating the profession in July last year, it issued its own
Standards of Proficiency (HPC, 2009), which superseded
the CTCP accreditation criteria. This document
emphasises clinical practice competencies such as clear
and appropriate communication, and the application of
formulation and problem solving skills, rather than skills
specific to delivering psychological therapy according to a
particular model.
In their approach, Tweed et al. opted to generate the
factors to be assessed by use of a panel of experts
and in identifying their seven domains they choose
tofocus on skills in settingconditions for undertaking
63
Smith
psychological therapy rather than other clinical
psychology skills. This is also reflected in their use of
therapy training rating scales to help generate their
scale items for the CSA-RF. At Lancaster we chose to
use a similar bottom up system to generate the
competencies that we use in assessment. However, an
alternative approach might be to utilise directly the
competencies set out by the HPC (2009) and/or the BPS
(2010) as factors to be assessed. Whilst such an
approach sounds logical in theory, whether it can be
achieved in practice will depend on the extent to which
clinicians can recognise in vivo the discrete display of
the skills described by these bodies and whether
appropriate behavioural indicators to assist with such a
process could be generated.
Whichever clinical competencies are focused on, Tweed
et al.s use of live video footage of actual clinical work is
an important step forward. The system itself still has
potential difficulties, such as bias created by trainees
selecting which work to submit, and possible halo and/or
order effects which could impact on the ratings given.
However, these effects can be minimised through
techniques such as the use of multiple assessors and
operationalising the factors being assessed using very
detailed behavioural indicators. The latter may also help
overcome Tweed et al.s difficulties with their assessors
tending to rate each trainees performance globally rather
than distinguishing performance on specific factors.
Beyond this, however, what strikes me as the single most
important achievement by Tweed et al. in this project (but
one that they barely mention) is that they managed to get
the agreement of all clinical supervisors in their region to the
regular videoing of clinical work on placement as part of
normal practice. This represents an important cultural shift,
which in the longer term is likely to significantly change how
supervisors understand the function of clinical placements.
One would hope that in the longer term this will also lead to
supervisors being more willing to directly assess trainee
work through both in vivo observation and through reviewing
the recordings of trainee clinical work as a matter of routine.
By developing assessments along the lines of Tweed et al.,
hopefully training programmes will be able to assist
supervisors by providing them with more tools to do this.
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