PART1- Due Thursday Respond to the following in a minimum of 175 words: 

Review this week’s course materials and learning activities, and reflect on your learning so far this week. Respond to one or more of the following prompts in one to two paragraphs:

1. Provide citation and reference to the material(s) you discuss. Describe what you found interesting regarding this topic, and why.
2. Describe how you will apply that learning in your daily life, including your work life.
3. Describe what may be unclear to you, and what you would like to learn.

PART2-    

University of Phoenix Material 

Case Study Four Worksheet

Respond to the following questions in 1,500 to 1,750 words.

1. Why is this an ethical dilemma? Which APA Ethical Principles help frame the nature of the dilemma? 

2. Does this situation meet the standards set by the duty to protect statue? How might whether or not Dr. Yeung’s state includes researchers under such a statute influence Dr. Yeung’s ethical decision making? How might the fact that Dr. Yeung is a research psychologist without training or licensure in clinical practice influence the ethical decision? 

3. How are APA Ethical Standards 2.01a b, and c; 2.04; 3.04; 3.06; 4.01; 4.02; and 10.10a relevant to this case? Which other standards might apply?

4. What are Dr. Yeung’s ethical alternatives for resolving this dilemma? Which alternative best reflects the Ethics Code aspirational principle and enforceable standard, as well as legal standards and Dr. Yeung’s obligations to stakeholders? 

5. What steps should Dr. Yeung take to ethically implement her decision and monitor its effects?

Reference

Fisher, C. B. (2013). Decoding the ethics code: A practical guide for psychologists. Thousand Oaks, CA: Sage. 

PART3- I will post part 3 Tuesday, it will consist of two power-point slides.

Reference

Psychologists responsible for education and training programs have an obligation to establish relationships of loyalty and trust with their institutions, students, and members of society who rely on academic institutions to provide the knowledge, skills, and career opportunities claimed by the specific degree program (Principle B: Fidelity and Responsibility). This requires knowledge of system change and competencies in academic program management and leadership skills (APA, 2012f; Standard 2.03, Maintaining Competence). Psychologists responsible for administering academic programs must ensure that course requirements meet recognized standards in the relevant field and that students have sufficient practicum, externship, and research experiences to meet the career outcome goals articulated by the program (Wise & Cellucci, 2014).

• Department chairs and other faculty responsible for undergraduate curricula development need to ensure that course requirements expose undergraduates majoring and minoring in psychology and students taking survey courses to the knowledge and skills considered fundamental to the discipline.
• Chairs or directors of doctoral programs claiming to produce graduates competent to conduct psychological research need to ensure that students receive education and training in research ethics and the theoretical, methodological, and statistical skills required to competently conduct psychological science in the specific fields emphasized by the program (APA, 2011b; Fisher, Fried, & Feldman, 2009).
• Psychologists responsible for professional degree programs need to ensure that course requirements and field experiences meet those required by potential employers, relevant state or professional organizations for program accreditation, internship placements where relevant, and applicable individual licensure and credentialing bodies.
• Psychologists administering internship programs must ensure that supervisory and training experiences meet the standards of the specific areas of psychological practice claimed, appropriate state and professional accreditation criteria, and state licensing board requirements (APA, 2015e).

The term reasonable steps reflects recognition that despite a program administrator’s best efforts, there may be periods during which curriculum adjustments must be made in reaction to changes in faculty composition, departmental reorganizations, institutional demands, modifications in accreditation or licensure regulations, or evolving disciplinary standards.

Interprofessional Training for Practice and Research in Primary Care

Doctoral programs in psychology will increasingly need to equip students with the skills necessary for professional practice, quality improvement and outcomes research, and team management and consulting in the integrated patient care systems of the future. Systems such as patient-centered medical homes (PCMH) and accountable care organizations (ACO) will need psychologists trained in applying patient-centered, accountability-focused, evidence-based, and team-based approaches to enhancing access to quality (Belar, 2014; DeLeon, Sells, Cassidy, Waters, & Kasper, 2015; see also the section on the Patient Protection and Affordable Care Act (ACA) in Chapter 1). Program administrators need to be aware of evolving APA accreditation requirements for externships and internships that provide trainees with opportunities to acquire direct experience and supervision in interprofessional systems of care and when appropriate documentation of specialization as a basic credential for a practicing psychologist once licensed (Standard 7.01, Design of Education and Training Programs). Compliance with Standard 7.01 will also require curricula that foster competencies in the following:

• Implementation of ACA and related health policy goals and infrastructure
• Application of team science to outcome research within integrated health organizations
• Selection and integration of evidence-based practices within an interprofessional care model
• Appropriate integrated care patient electronic record keeping and billing
• Skills facilitating consultation with medical providers on behavioral management techniques to improve patient adherence to health care regimens

Readers might also refer to Standards 2.04, Bases for Scientific and Professional Judgments; 3.09, Cooperation with Other Professionals; 6.01 Documentation of Professional and Scientific Work and Maintenance of Records as well as Nash et al. (2013) and Rozensky (2014a, 2014 b is not kept pace with the rapid evolution and availability of online education. Distance learning using information technology raises complex questions regarding the adequacy of psychology programs to meet education and training requirements for a diverse student body from across the United States and in different countries. Psychologists administering online distance education might consider the following questions (Anderson & Simpson, 2007; Brey, 2006):

• Can the use of information technology ensure that the appropriate knowledge can be transmitted to students and that student acquisition of such knowledge can be appropriately evaluated?
• To what extent does the program meet accreditation, certification, licensure, or other requirements across different localities? Is the program description clear regarding the states or countries in which it meets such requirements (see also Standard 7.02, Descriptions of Education and Training Programs)?
• Does the use of web-based or Internet-mediated technology in higher education foster or undermine student diversity?
• Are the program admissions criteria and educational materials appropriate for the diversity of students who will apply for and be admitted into the program?
• Can experiential requirements be adequately provided, supervised, monitored, and evaluated at a distance through informational technology?
• Can the ethical values of the discipline be successfully transmitted and student ethical behavior adequately monitored through electronic media?
• Are faculty adequately trained in the use of online distance learning?

Department and program chairs and psychologists responsible for internship training programs must also ensure that prospective and current students have an accurate description of the nature of the academic and training programs to which they may apply or have been admitted. This standard of the APA Ethics Code (APA, 2010c) requires psychologists responsible for these programs to keep program descriptions up-to-date regarding (a) required coursework and field experiences; (b) educational and career objectives supported by the program; (c) current faculty or supervisory staff; (d) currently offered courses; and (e) the dollar amount of available student stipends and benefits, the process of applying for these, and the obligations incurred by students, interns, or postdoctoral fellows who receive stipends or benefits.

Standard 7.02 specifically obligates teaching psychologists to ensure that prospective and current students, externs, or interns are aware of program requirements to participate in personal psychotherapy or counseling, experiential groups, or any other courses or activities that require them to reveal personal thoughts or feelings. Many program descriptions now appear on university or institutional websites. Psychologists need to ensure to the extent possible that these websites are appropriately updated. The term reasonable steps recognizes that efforts to ensure up-to-date information may be constrained by publication schedules for course catalogs, webmasters not directly under the auspices of the department or program, and other institutional functions over which psychologists may have limited control.

• ☒ A psychology graduate department described itself as offering an industrial–organizational track that included paid summer placements at companies in the city in which the university is located. The required curriculum included only one class in industrial–organizational psychology taught by an adjunct professor. Other required courses for the industrial–organizational track consisted of traditional intelligence and personality test administration classes, test construction classes, and statistics courses offered by faculty in the department’s clinical and psychometric programs. For the past 2 years, the department had been able to place only one or two students in paid summer internships.

Need to Know: Language-Matching Training Experiences

The increasing language diversity of client/patient populations in the United States sometimes leads to matching bilingual graduate students with externship and internship populations for which their language skills are considered an advantage. Limiting bilingual trainees to work experiences with non-English-speaking clients or to one cultural–language group may deprive students of the broad educational training opportunities promised by the graduate or training program (Fields, 2010; see also Standard 3.08, Exploitative Relationships). Such assignments may also implicitly lead to misconceptions by bilingual and other students in the program that language competence is equivalent to multicultural treatment competence (Schwartz, Rodríguez, Santiago-Rivera, Arredondo, & Field, 2010). Faculty advisers and supervisors should actively assess bilingual students’ training needs as well as their comfort and desire to work with same-language populations to ensure these students are afforded the same quality of education, respect, and autonomy that other trainees enjoy (Schwartz et al., 2010). English-only-speaking supervisors who rely on a trainee’s language translations of sessions should also be aware that they may be providing feedback on clients that they cannot actually work with themselves (Standard 2.01b, Boundaries of Competence), and in some states, this lack of “proper” supervision might mean that the trainee is perceived to be practicing “independently” without a license (Schwartz et al., 2010).

7.03 Accuracy in Teaching

©iStockphoto.com/voinSveta

Standard 7.03a requires that teaching psychologists provide students with accurate and timely information regarding course content; required and recommended readings; exams, required papers, or other forms of evaluation; and extra-classroom experiences if required. Psychologists who provide their syllabi via the Internet or who require students to use web-based references need to keep these websites accurate and appropriately updated.

Modifying Course Content or Requirements

This standard also recognizes that syllabi may sometimes include an unintentional error, required readings may become unavailable, changes in institutional scheduling may create conflicts in dates set for exams, and many times, psychologists have valid pedagogical reasons for changing course content or requirements at the beginning or middle of a semester. For example, a professor may find that assigned readings are too difficult or not sufficiently advanced for the academic level of students in the class. In such instances, it would be appropriate for professors to modify course reading requirements as long as materials are available to students and they are given sufficient time to obtain and read the materials. Similarly, in response to constraints imposed by publishers, bookstores, other professors, or the institution, psychologists may rightly need to modify required texts or exam schedules.

Modifications to course content or requirements do not violate this standard as long as students are made aware of such modifications in a clear and timely manner that enables them to fulfill course requirements without undue hardship. However, a professor who has neither discussed nor specified how students will be evaluated until the last week of class or one who fails to update an old syllabus that does not reflect the current content of the course would be in violation of this standard.

Standards prescribing the nature of information that teachers should provide raise legitimate concerns about academic freedom. At the same time, in many ways, teaching is a “process of persuasion” where instructors are in the unique socially sanctioned and desired role of systematically influencing the knowledge base and belief systems of students (Friedrich & Douglass, 1998). Standard 7.03b reflects the pedagogical obligation of psychologists to share with students their scholarly judgment and expertise along with the right of students to receive an accurate representation of the subject matter that enables them to evaluate where a professor’s views fit within the larger discipline.

The narrowness or breadth of information required to fulfill this standard will depend on the nature of the course. For example, a psychologist who presented readings and lectures only on psychodynamic theories of personality would be presenting accurate information in a course by that name but inaccurate information if teaching a general survey course on theories of personality. A professor who has been teaching the same material for 20 years when such material is considered obsolete in terms of the discipline’s recognized standards would be providing students inaccurate information about the current state of the subject matter.

• ☑ In his first year of teaching, an assistant professor prepared a syllabus for an undergraduate developmental psychology course that drew largely on required readings from books by well-known developmental theorists. He carefully planned weekly quizzes, a midterm exam, and a term paper requiring a critique of several journal articles. Students performed very poorly on the first two quizzes and did not seem to be involved in class discussions. The professor learned that for reasons unknown to the department chair, the dean’s office had assigned this class as a “non-major” section. The students were therefore not as prepared as had been anticipated because, unlike psychology majors, most had not taken an introductory psychology course. The psychologist decided to modify the curriculum to ensure that students received a basic foundation in developmental psychology. He rush-ordered a basic developmental psychology text, extended the date of the midterm, and changed the topic of the term paper to a review of sections of the originally assigned books. He distributed a revised syllabus detailing the changes and gave the students the option of using the first two quizzes as extra credit.

7.04 Student Disclosure of Personal Information

This standard requires psychologists to respect the privacy rights of students and supervisees. In many instances, information about students’ or supervisees’ sexual history; their personal experience of abuse or neglect; whether they have or are currently receiving psychotherapy; and their relationships with relatives, friends, or significant others is outside the legitimate boundaries of academic or supervisory program inquiry.

With two exceptions, Standard 7.04 prohibits psychologists from requiring students or supervisees to disclose such information.

Clear Identification of Requirements

Teaching and supervisory psychologists may require disclosure of information about sexual experiences, history of abuse, psychological treatment, or relationships with significant others only if the admissions and program materials have clearly identified that students or supervisees will be expected to reveal such information if admitted to the program. The requirement for advance notification includes programs that explore countertransference reactions during supervisory sessions if questions about such reactions will tap into any of the categories listed above. Clear and advance notification about the types of disclosures that programs require will allow potential students to elect not to apply to a program if they find such a requirement intrusive or otherwise discomforting.

Interference With Academic Performance or Self-Harm or Other Harm

The standard also recognizes that there are times when students’ personal problems may interfere with their ability to competently perform professionally related activities or pose a threat of self-harm or harm to others. In such instances, psychologists are permitted to require students or supervisees to disclose the personal information necessary to help evaluate the nature of the problem, to obtain assistance for the student or supervisee, or to protect others’ welfare.

• ☑ A psychologist supervising a third-year clinical student’s work at the university counseling center was growing increasingly concerned about the sexual nature of verbal exchanges the student reported having with one of her undergraduate clients. The psychologist also suspected from one of the student’s comments that she had been meeting with the client outside of the counseling sessions. Concerned that the student might be in violation of Standards 3.05, Multiple Relationships, or 10.05, Sexual Intimacies With Current Therapy Clients/Patients, the supervisor asked the student whether she had been seeing the client socially. When she responded yes, the psychologist probed further to find out if she was having a romantic relationship with the client.
• ☒ A student came to see a professor during office hours to discuss his poor grade on the midterm exam in a graduate course on human sexuality. The professor asked the student if he might be doing poorly in the course because of anxieties about his own sexuality.

Need to Know: Supervision of Trainees With Disabilities

The field of rehabilitation psychology is increasing the discipline’s familiarity with reasonable accommodations and training requirements for students with disabilities (Americans with Disabilities Act [ADA], 1990; Falender, Collins, & Shafranske, 2009). The nascent status of the field leaves unexplored potentially prejudicial beliefs held by supervisors that may unintentionally lead to inequities and inadequacies in the training experiences of graduate students with disabilities enrolled in psychology practitioner programs. For example, there is no empirical support for the assumption that a trainee with disabilities cannot perform the essential functions of a psychologist or that this individual is at a disadvantage in establishing a therapeutic alliance with clients/patients (Taube & Olkin, 2011).

Supervision competencies in the area of disability require familiarity with the ADA, models of ableness, and influence of multiple minority statuses and group histories of oppression on the perspectives of individuals with disabilities. Supervisors will also need to acquire the skills to neither over- nor underattend to a supervisee’s disability, support necessary adaptations to clinical tools, and create a safe environment for supervisees to discuss issues relevant to their disability that may emerge in their clinical or supervisory settings (Cornish & Monson, 2014).

Digital Ethics: Disclosure of Student Personal Information Through Social Media

Teaching psychologists may use Facebook, Twitter, blogs, chat rooms, and other forms of social media to engage students in discussions regarding academic material or university events. However, students may sometimes use these sites to share or link to information about themselves or other students that describes sexual behaviors, family relationships, or other personal information. Faculty access to such information may be inconsistent with the goal of Standard 7.04, which is to protect students from disclosing personal information that may unfairly influence evaluation of their academic performance (Standard 7.06b, Assessing Student and Supervisee Performance). Psychologists who utilize electronic media for instructional purposes should clarify in advance restrictions on the type of information that can be posted on these sites. Instructors should also educate students on their responsibilities and strategies to avoid privacy violations that may emerge when academic sites are linked to other sources of personal information. Furthermore, faculty should develop procedures for removing such information if it appears. If a situation arises and faculty are concerned that becoming aware of such information may bias their evaluation of student performance, they should seek consultation while at the same time protecting the student’s identity (Standards 4.04b, Minimizing Intrusions on Privacy; 4.06, Consultations).

7.05 Mandatory Individual or Group Therapy

Standard 7.05a addresses the privacy rights of psychology students enrolled in programs that require individual or group psychotherapy. During the commenting period for the revision of the current APA Ethics Code, a number of graduate students raised concerns about revealing personal information (a) in the presence of other students in required group therapy or experiential courses and (b) to therapists in required individual psychotherapy if the therapist was closely affiliated with their graduate program. In response to these concerns, this standard requires programs that have such requirements to allow students to select a therapist unaffiliated with the program.

Standard 7.05a does not prevent programs from instituting a screening and approval process for practitioners outside the program whom students may see for required psychotherapy. It is sound policy for programs to ensure that required individual or group therapy is conducted by a qualified mental health professional. In addition, in some programs, the therapeutic experience may be seen as one facet of training about a particular form of psychotherapy, and the program is entitled to require students to select a private therapist who conducts treatment consistent with the program’s training goals.

Postdoctoral Training

This standard does not apply to postdoctoral programs, such as postgraduate psychoanalytic programs, that require a training analysis with a member of the faculty. These advanced programs, unlike graduate programs, are optional for individuals who seek specialized training beyond a doctoral degree in psychology, and a decision not to enroll in such programs because of therapy requirements does not restrict opportunities to pursue a career in professional psychology.

This standard is designed to protect the integrity and fairness of evaluations of student academic performance. Whereas Standard 7.05a protects a student’s right to keep personal information private from program-affiliated practitioners, Standard 7.05b protects the student from grading or performance evaluation biases that might arise if a faculty member who serves as the student’s psychotherapist is also involved in judging his or her academic performance. This standard pertains not only to faculty who might teach a course in which a student who is in therapy with them might enroll but also to faculty who may be involved in decisions regarding passing or failing of comprehensive exams, advancement from master’s-level to doctoral-level status, training supervision, and dissertation committees. As indicated by the cross-reference to Standard 3.05, Multiple Relationships, serving in the dual roles of therapist and academic evaluator can impair the therapist’s objectivity when knowledge gained from one role is applied to the other, or it can undermine treatment effectiveness when students are afraid to reveal personal information that might negatively affect their academic evaluations.

Need to Know: Ethical Criteria for Mandatory Personal Psychotherapy (MPP)

The training goal of program-mandated personal psychotherapy (MPP) is to maximize therapeutic efficacy through self-awareness that heightens appreciation of the therapeutic relationship and client/patient vulnerability and minimizes the possibility of harming clients or acting in ways that are not in their best interests (Norcross, 2005). However, due to the diversity of theoretical frameworks for clinical care and the paucity of empirical data to support its efficacy in comparison to other training models, the value of MPP remains contested. One issue is whether imposing psychotherapy on well-functioning trainees who display no pathological behavior and feel no need for treatment is consistent with the ethical practice of psychotherapy, including respect for client/patient autonomy and obligation to terminate treatment when the client/patient does not need health services (Ivey, 2014; Principle E: Respect for People’s Rights and Dignity; Standards 3.10, Informed Consent; 10.01, Informed Consent to Therapy; 10.10, Terminating Therapy). Below are useful guidelines for programs requiring MPP (see Ivey, 2014, for an excellent summary):

• The requirement must be justified by the nature and training objectives of the program (Standard 7.01, Design of Education and Training Programs).
• The MPP requirement as well as the risks and benefits and planned safeguards should be clear in application materials (Standard 7.02, Descriptions of Education and Training Programs).
• There should be no multiple relationships between therapists and trainee–clients, and trainees should have some choice in selecting a psychotherapist (Standards 3.05, Multiple Relationships; 7.05, Mandatory Individual or Group Therapy).
• Students should be provided with financially feasible alternatives to ensure affordable treatment without undue hardship (Principle D: Justice).
• ☒ A clinical psychology program that required first-year graduate students to receive 1 year of individual psychotherapy had a referral list of 20 “approved” independent practitioners in the area that students could select as their therapist. The program often drew on these same practitioners as adjunct professors to teach required courses when regular faculty were on sabbatical.

7.06 Assessing Student and Supervisee Performance

Psychologists establish academic and supervisory relationships of trust with students and supervisees based on fair processes of evaluation that provide students and supervisees with the opportunity to learn from positive and negative feedback of their work (Principle B: Fidelity and Responsibility). As in other domains of psychological activities, supervisors need to be familiar with the knowledge base for models of enhancing and monitoring the professional functioning of supervisees (APA, 2012f; Standards 2.01, Competence; 2.03, Maintaining Competence). Under Standard 7.06a, psychologists must inform students and supervisees (a) when and how often they will be evaluated, (b) the basis for evaluation (e.g., performance in exams, attendance, implementation of various phases of research, summaries of client/patient sessions, and administration and interpretation of psychological assessments), and (c) the timing and manner in which feedback will be provided.

Providing specific information about student evaluation at the beginning of the process is especially important for the supervision of clinical work, psychological assessment, or research because these supervisory activities are often less uniformly structured than classroom teaching.

Group Supervision

Group supervisees can benefit from the multiple input, support, and shared experiences of their peer colleagues while also learning how to provide effective feedback and gain initial competencies required for their own future skills as supervisors. Psychologists engaged in group supervision must develop competencies in creating a safe environment for group discussion and disagreement and for clarifying the roles of supervisor and supervisees. At the beginning of the supervision, they need to clarify the purpose of group supervision and how responsibilities and supervisee evaluation differ from those under individual supervision. For example, most students will be unfamiliar with the unique learning experiences and responsibilities of group supervisees, which include providing feedback to one another, both formally and informally, at specified periods in a respectful manner; preparing case presentations and questions on group materials prior to each meeting; refraining from discussing material about an absent supervisee; and maintaining the confidentiality of group discussions, including information pertaining to other group members, their clients, and specific training sites (see Smith, Cornish & Riva, 2014, for additional details).

• ☒ A psychology professor teaching a graduate course in statistics used a midterm and final exam to evaluate students. The professor delayed returning the midterm, telling the students they should not worry because most of them would do very well. When she returned the graded midterms during the last week of class, most students were shocked to discover they had received Cs and Ds on the exam. Many felt the delay caused them to miss opportunities to learn what aspects of course material they had misunderstood and to prepare adequately for the final.
• ☒ A student in a PhD program in school psychology had a second-year externship in a residential school for students with severe emotional disorders. The school psychologist serving as her on-site supervisor relied on “countertransference” techniques to train his externs. Each time the student asked her supervisor for specific information on how her work with student clients would be evaluated, the supervisor would shift the discussion to how the extern’s personal reactions to her clients were causing her anxiety about the evaluation of her performance. The extern felt increasingly frustrated and anxious about the lack of specific feedback. At the end of the year, the supervisor gave her a poor evaluation, stating that the student’s anxieties had interfered with her ability to take direction.
• ☒ A research psychologist who agreed to mentor a graduate student’s doctoral research consistently postponed or missed meetings with the student, resulting in the student missing the departmental deadline for dissertation proposals. The mentor gave the student an incomplete for the semester, and the student had to pay additional tuition to propose the following semester.

Military Supervision

Johnson and Kennedy (2010) eloquently described the unique responsibilities of military psychologists supervising trainees in American combat theaters and the need to provide timely and constructive feedback under intense and fast-paced conditions. Military supervisors are often torn between a duty to help trainees meet their active duty responsibilities and concerns that some trainees may not be adequately prepared during the initially agreed-upon time frame. According to the authors, military supervisors need enhanced competencies to address the unique nature of trainee stress produced by almost continuous exposure to life-threatening combat conditions and deceased and severely injured and traumatized service members (Standard 2.01, Boundaries of Competence). They recommended that for each trainee soon to be deployed, supervisors develop “the best mix of training and supervision in psychotherapy, battlefield triage, combat-related psychopathology, treatments for trauma-related disorders, neuropsychology, and ethical decision making” (p. 300) and make sure the trainee is clear about the training components and expectations of the supervised experience, including the physical dangers and stresses of performing their roles in combat situations.

Fairness and justice require that academic and supervisory evaluations should never be based on student personal characteristics that have not been observed to affect their performance or that are outside the established bounds of program requirements.

Additional discussion regarding psychologists’ ethical responsibilities during supervision can be found in the Hot Topic “Ethical Supervision of Trainees” at the end of this chapter.

Digital Ethics: Use of Technology for Supervision

Increasingly, state licensure boards are permitting email, teleconferencing, or other forms of online supervision on their own or as adjuncts to face-to-face supervision to satisfy training requirements. As noted by Dombo et al. (2014), whether or not the use of these modalities fulfills obligations to trainees depends upon how accessible the supervisor is to the trainee, the timeliness of the supervision, the supervisor’s experience with using these technologies, and the trainee’s comfort level. Supervisors should also keep in mind that through their online supervision, they are modeling ethical practice and decision making regarding the use of social media and other technologies (Falender, Shafranske, & Falicov, 2014). Issues to consider include the following:

• Is the supervisor licensed to practice in the state in which the trainee is conducting treatment?
• Does the supervisor have sufficient familiarity with the clients and treatment context in which the trainee is working?
• Does the modality inhibit rapport building, engagement, and sensitivity to verbal or nonverbal cues essential to effective supervisor–trainee communication?
• Has the supervisor considered the appropriate and inappropriate use of the Internet to search for information regarding the trainee’s ability to perform professionally related activities?
• ☒ A psychologist learned from a member of the clinic staff that one of her supervisees had expressed harsh, racially prejudiced attitudes at a staff party. Over the course of the supervisory period, there was no evidence that the supervisee treated clients in a racially biased manner. However, in the final written evaluation, the psychologist reported that the supervisee appeared to have difficulty working with clients from other racial backgrounds.
• ☒ During a health psychology class discussion, an undergraduate student made disparaging remarks about individuals with mental disorders. Although the student had met all course requirements and his grade point average entitled him to a grade of B, the psychologist gave him a C+ because she felt his class comments indicated he had not really digested the material. However, the course outline did not indicate class participation would be included in the final grade.

7.07 Sexual Relationships With Students and Supervisees

Having sexual relationships with students or supervisees is specifically prohibited by Standard 7.07. The student–professor/supervisor role is inherently asymmetrical in terms of power. Teachers and supervisors have the power to affect student careers through grading, research and professional opportunities, letters of recommendation, scholarships and stipends, and reputation among other faculty or staff. Using this power to coerce or otherwise unduly influence a student to enter a sexual relationship is exploitative (Standard 3.08, Exploitative Relationships). The prohibition against sex with students and supervisees applies not only to those over whom the psychologist has evaluative or direct authority but also to anyone who is a student or supervisee in the psychologist’s department, agency, or training center or over whom the psychologist might be likely to have evaluative authority in the program or supervised setting.

Sexual relationships with students and supervisees are a specific example of an unethical multiple relationship (Standard 3.05, Multiple Relationships). When psychologists enter into a sexual relationship with a student or supervisee, their ability to judge the student’s/supervisee’s academic, professional, or scientific performance objectively is impaired. In addition, when other students learn about such relationships, their knowledge can jeopardize the psychologist’s ability to maintain an impression of professional impartiality. Furthermore, the behavior provides students with a model of unethical conduct that jeopardizes the psychologist’s effectiveness as a teacher or supervisor. Such relationships also risk compromising psychologists’ ability to exert appropriate authority or make objective evaluations regarding the student/supervisee and others with whom they work if the sexual partner can manipulate the psychologist through threats of exposure or complaints of misconduct.

In many psychology programs, graduate students serve as teaching or research assistants charged with evaluating undergraduate or graduate students’ academic performance or supervising their research projects. Standard 7.07 applies to sexual relationships between graduate assistants and students when assistants are either student members of the American Psychology Association or their department has adopted the APA Ethics Code in its policies and procedures.

Hot Topic: Ethical Supervision of Trainees in Professional Psychology Programs

Supervision is a primary means by which students in professional psychology programs acquire and develop skills needed to provide effective and ethical mental health services (Shallcross, Johnson, & Lincoln, 2010). Competent and ethical supervision provides a foundation for the attitudes, skills, and commitment supervisees will need to know what is right and the motivation for self-evaluation and lifelong learning necessary to do what is right throughout their careers (see Chapter 3). The American Psychological Association (APA, 2011b), the Health Service Psychology Education Collaborative (2013), and proposed Standards for Accreditation for Health Service Providers (APA, 2015e) now include supervision as an essential competency for psychologists at the highest levels of the profession. Thus, psychology graduate students need to have training in supervisory competencies through classroom lectures and readings as well as learning through modeling the practices of their own supervisors.

Supervisors have a fiduciary obligation to their supervisees, the clients/patients under the supervisees’ care, and the public (Principle B: Fidelity and Responsibility). They must (a) nurture the supervisees’ professional skills and attitudes, (b) ensure that supervisees’ clients/patients are provided appropriate mental health treatment, and (c) serve as gatekeepers who take appropriate actions to prevent supervisees not able to demonstrate the needed professional competence from entering the profession and practicing independently (Principle A: Beneficence and Nonmaleficence; Barnett & Molzon, 2014). Supervision should be marked by mutual respect, with supervisor and supervisee both contributing to the process of establishing goals and role responsibilities (Principle E: Respect for People’s Rights and Dignity; Pettifor, McCarron, Schoepp, Stark, & Stewart, 2011). The goal of this Hot Topic is to describe the competencies needed to provide effective and ethical supervision, desired outcomes on which to fairly evaluate supervisee performance, and how trainees can contribute to their supervisory experience.

Competencies for Effective Supervision

Efforts to provide faculty with the skills necessary for competent supervision have not kept pace with psychology’s growing commitment to a culture of competence in training and supervision (Standard 2.01, Boundaries of Competence; APA, 2011b). Competencies for effective supervision include professional knowledge and expertise and the interpersonal skills necessary to create a trusting supervisory alliance (Falender et al., 2004). A competence-based approach to supervision also requires techniques for successfully monitoring, assessing, and providing feedback to trainees and an emphasis on self-reflection and self-assessment on the part of supervisor and trainee (Kaslow, Falender, & Grus, 2012).

Professional Knowledge and Expertise

Supervisors must have the necessary clinical knowledge and expertise to identify client mental health needs within a diversity-sensitive context, guide supervisees in client-appropriate treatment techniques, and recognize when clients are not responding to supervisee interventions (Accurso, Taylor, & Garland, 2011). They must also be familiar with academic credit or credentialing supervision requirements, on-site institutional policies, and relevant laws as well as appropriate risk management strategies. Adequate preparation includes the following (see Baird, 2014; Barnett & Molzon, 2014; Moffett, Becker & Patton, 2014; Wise & Cellucci, 2014):

• Helping supervisees understand their obligations under HIPAA or FERPA policies and obtain the skills necessary to protect client/patient confidentiality when using different treatment modalities (e.g., group therapy, telehealth) and within interprofessional settings (Standards 3.09, Cooperation With Other Professionals; 6.01, Maintenance, Dissemination, and Dissemination of Confidential Records of Professional and Scientific Work; and 6.02, Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work).
• Discussing supervisees’ legal and ethical obligations to determine whether disclosure of confidential information is necessary to protect clients/patients or third parties from harm and the importance of documenting the rationale and steps taken in deciding whether or not disclosure was required (Standards 4.01, Maintaining Confidentiality; 4.02, Discussing the Limits of Confidentiality).
• Being alert to potential boundary violations that may arise between supervisees and their clients/patients as well as within the supervisory relationship itself and the steps necessary to avoid exploitation, harm, and diminished objectivity (Standard 3.05, Multiple Relationships).
• Becoming aware of supervisees’ personal problems or biases that may interfere with their ability to provide effective treatment and establishing a trusting relationship in which these problems or biases can be adequately addressed (Standard 2.06, Personal Problems and Conflicts).
• Preparing students for orderly and appropriate resolution of client responsibility when the training rotation ends (Standards 10.09, Interruption of Therapy; 10.10, Terminating Therapy).

Interpersonal Competencies

The supervisory context should encourage open discussion of treatment challenges and attempt to try new strategies by providing constructive feedback in a manner that minimizes trainee anxiety and decreased feelings of self-efficacy (Barnett et al., 2007; Daniels & Larson, 2001). At the same time, supervisors cannot shy away from providing negative feedback when it is necessary to ensure that clients are receiving adequate care; supervisors’ evaluations of supervisee clinical acumen must be objective and in accord with the standards of the profession.

Diversity Competencies

There is increasing recognition that competent supervision requires sensitivity to the attitudes, values, and sociopolitical experiences of supervisees from diverse racial/ethnic, cultural, sexual minority, disability, social class, immigrant, and other groups, including when multiple identities intersect (Falender, Shafranske, & Falicov, 2014). The dynamic and continuously evolving nature of group identity and experiences requires supervisors to acquire the skills to engage in a collaborative process in which the effect of differing supervisor–supervisee worldviews is respectfully discussed (including targeted self-disclosure when appropriate), and the important role of diversity factors should be clearly introduced and reinforced throughout the supervision (Pettifor, Sinclair, & Falender, 2014). Competent diversity supervision also includes (a) recognizing factors of power, privilege, and personal bias that may be barriers to a trainee’s full participation in the supervisory relationship; (b) being alert to the fact that trainees may be wary of honest engagement in the supervisory process based on previous training experiences that were diversity insensitive; (c) acquiring the skills to help trainees overcome past dignitary harms as well as the consequences of the supervisor’s own actions that may result from diversity misunderstandings; (d) being mindful that through their supervision, they are modeling the ethical practice of diversity sensitivity for supervisees to apply to clinical work and future positions as supervisors (Falender et al., 2014; Fouad & Chavez-Korell, 2014).

Structuring the Supervisory Process

Structuring the supervisory process requires the ability to tailor training to the supervisee’s level of competence, identify appropriate outcome measures for evaluation, and present clear standards for assessment. Both supervisors and supervisees need to be familiar with the APA core benchmark components (APA, 2011b) that their program has designated as appropriate for its training goals (see discussion under Standard 7.01, Design of Education and Training Programs).

Identifying Supervisee’s Competencies

The goals and desired outcomes of a training experience need to be tailored to the supervisee’s current competencies in relation to client needs and institutional requirements. To meet obligations to trainees and the trainees’ clients, supervisors need to evaluate each supervisee’s developing competence and the clinical responsibilities with which he or she can be entrusted (Falender & Shafranske, 2007; Standard 2.05, Delegation of Work to Others).

Identifying Appropriate Training Outcomes

Evaluations must be based on the supervisee’s actual performance on relevant and established requirements (Standard 7.06, Assessing Student and Supervisee Performance). Falender and Shafranske (2007) identified the following general abilities by which the trainee’s professional growth can be evaluated:

• Apply clinical knowledge and skills in a consistent fashion and incorporate new knowledge into existing competencies.
• Deal with increased confusions and varied situational aspects that shape clinical work.
• Respond to constructive feedback.
• Carry out recommendations to ensure adequate client care.
• Use problem-solving and clinical reasoning skills appropriate to specific clinical tasks and ethical challenges.
• Master technical and facilitative variables appropriate to the student’s stage of training.

The APA also provides a “Competency Remediation Plan” template to assist supervisors and supervisees in planning and evaluating progress (http://www.apa.org/ed/graduate/competency.aspx). The plan begins with an identification of competency weaknesses, when the problem(s) was brought to the trainee’s attention, steps already taken by the supervisor to address the problem(s), and steps already taken by the trainee to rectify the problem(s). This is followed by a written plan identifying the essential competency domain and problem behaviors, expectations for acceptable performance, trainee’s and supervisee’s responsibilities, a time frame for acceptable performance, assessment methods, and consequences for unsuccessful remediation.

Feedback and Evaluation

Standard 7.06 also requires that supervisors establish a timely and specific process for providing feedback to supervisees and explain the process to trainees at the beginning of supervision. This includes delineating setting-specific competencies the supervisee must attain for successful completion of the supervised interval (Falender & Shafranske, 2007).

Meaningful evaluations, scheduled at predetermined intervals, provide trainees with adequate time to improve their skills and the supervisor with opportunity to evaluate the trainee’s responsiveness to constructive feedback. When supervisees are unresponsive, fail to demonstrate needed competence, or exhibit impaired professional competence as a result of personal problems, these issues should be addressed in supervision, and the trainee should be provided reasonable opportunities for remediation or intervention. When necessary, the supervisor must act to prevent inappropriate actions resulting in poor-quality client care, violation of ethical standards, or harm to the institution through the supervisee’s violation of policy or law. When appropriate, supervisors should inform their institution or the students’ academic program and provide a written report documenting the reasons for their concerns (see Gizara & Forest, 2004).

Off-Site Supervision

Externships and internships in professional psychology programs are often off-site and supervised by nonfaculty members. Supervisors at practicum, externship, and internship sites need to provide supervisees with copies of the relevant institutional and agency policies and procedural manuals, including mandatory and discretionary reporting policies and steps to be taken in case of an emergency.

When applying for training at these sites, students should obtain the following information:

• Has the graduate program and externship training site entered into a formal relationship that includes articulation of specific training goals and standards, open communication between program faculty and on-site supervisors, and a system of formalized feedback from students regarding the quality of the training experience?
• Whom in their graduate program or externship or internship site can students go to if they have a problem with an off-site supervisor? Is there a formal complaint process?
• If a supervisor is providing inadequate training, will the department or training site assist the student in obtaining the necessary clinical experience and supervision?

Responsibilities of Supervisees

Self-reflection, ethical commitment, and the motivation to improve one’s clinical knowledge and skills are fundamental to having a successful supervisory relationship. To help supervisors establish appropriate training experiences and evaluation criteria, supervisees should do the following:

• Be honest and open when asked to discuss their current level of clinical competence and training goals.
• Ask questions at the beginning of supervision to ensure that they clearly understand the goals of and evaluation process for the supervision and the criteria on which they will be assessed.
• Ask for all relevant information describing practicum, externship, or internship site institutional policies and legal responsibilities (e.g., HIPAA, FERPA, or ACA requirements; child abuse–reporting duties; policies regarding record creation, storage, and sharing of information with other professionals at the site).
• Come prepared with case material, questions, and other relevant materials for supervisory feedback and discussion.
• Be open to constructive feedback and integrate such feedback into subsequent clinical encounters.
• Be frank about and ask for guidance in addressing concerns regarding professional anxieties, personal biases, or lack of diversity training that may be a barrier to providing effective clinical services.
• Ask for guidance in cultivating patterns of self-care into their professional growth and development.
• Let their graduate program supervisor know if they are having difficulties in obtaining sufficient client/patient assignments or adequate on-site supervision at their practicum or externship site.
• Continue throughout the training experience to ask for additional or more focused training in a specific area of clinical or ethical concern, including asking the supervisor about APA Ethics Code requirements and how they relate to current treatment issues.

Chapter Cases and Ethics Discussion Questions

Dr. Kekoa is mentoring the dissertation of a psychology student who emails him that she has collected half of her dissertation data. She comes to his office to report that the preliminary analyses support her research hypotheses. He reviews the data and realizes that, in fact, the results are in the opposite direction of her hypotheses. He corrects her confusion about the type of statistical results that would support her thesis. Two months later, the student returns with her completed data collection, and this time the analysis indicates that all the data collected since their last conversation support the hypotheses. Dr. Kekoa is concerned that the student may be fabricating or biasing the data. Drawing on the ethical decision model in Chapter 3, how might Dr. Kekoa best approach this dilemma?

Dr. Braithwaite, a psychologist at a popular externship site, is conducting clinical supervision with Derek, a clinical graduate student with legal blindness. This is the first time Dr. Braithwaite has supervised a student with an apparent disability. She wants to ensure that Derek’s clinical externship is a positive experience for him and his potential clients. She is unsure whether she should disclose Derek’s disability to his potential clients before their first session so that clients who would be uncomfortable have the opportunity to request another therapist. Drawing on the Ethics Code Principles and relevant standards (i.e., Standards 2.01, Boundaries of Competence; 3.01, Unfair Discrimination; 3.04, Avoiding Harm; 7.06 Assessing Student and Supervisee Performance), discuss whether client preferences for practitioner attributes in general (e.g., race/ethnicity, gender, age, religion) and disability specifically should be considered in assigning trainees to clients (see also Taube & Olkin, 2011).

REFERENCE-

Ethical Principles and Standards That Inform Educational Gatekeeping Practices in Psychology

Kimberly E. Bodner Department of Psychological Sciences University of Missouri–Columbia

Educational gatekeeping functions in psychology serve to assess, remediate, and/or dismiss students and trainees with problematic professional competencies (STPPC). Recently, professional psychology graduate programs have increasingly focused on problems with professional competency, and they have begun to implement formal procedures to intervene with STPPC (Rubin et al., 2007). However, there has been considerably less literature addressing the ethics and ethical considerations of instituting these gatekeeping functions, especially in different stages of education and training in psychology. The American Psychological Association (APA; 2002) Ethical Principles of Psychologists and Code of Conduct (Ethics Code) offers faculty and supervisors ethical principles and obligatory standards that provide guidance about how to implement highly ethical gatekeeping practices.Thepurposeofthisarticleistohighlightthemajorethicalissuesanddilemmasthatfaculty and supervisors may face when intervening with STPPC and provide recommendations for ethical gatekeeping practices that are inspired by the APA Ethics Code. Keywords: ethics, gatekeeping, competence, competence problems, undergraduate, graduate, internship, postdoctoral

Educational gatekeeping practices in psychology are implemented to benefit students and trainees, and the individuals with whom they interact. Faculty and supervisors have a responsibility to assess, remediate, and/or dismiss students and trainees with problematic professional competencies (STPPC). However, faculty and supervisors may receive little guidance on how to implement such procedures in a highly ethical manner and/or how to approach complex and challenging gatekeeping dilemmas, especially in different stages of education and training in psychology. Faculty and supervisors in psychology must consider multiple aspects of the American PsychologicalAssociation(APA;2002)EthicalPrinciplesofPsychologistsandCodeofConduct (hereafter referred to as the Ethics Code) during their professional and educational activities, especially during educational gatekeeping functions with STPPC. The ethical principles provide guidance to faculty and supervisors on how to implement ethical gatekeeping functions (General Principles A–E). Although the ethical principles are not enforceable, the ethical standards identified in the Ethics Code are obligatory and enforceable. The purpose of this article is to identify the ethical principles that faculty and supervisors should aspire to uphold, the ethical standards

Correspondence should be addressed to Kimberly E. Bodner, University of Missouri–Columbia, Columbia, MO 65211. E-mail: [email protected]

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thatmustbemet,andtheissuesandethicaldilemmasthatmayarisewheninstitutinggatekeeping practices for undergraduate, graduate, internship, and postdoctoral STPPC. Finally, recommendations are provided on how to implement ethical educational gatekeeping functions in various stagesofeducationandtraininginpsychology,andsuggestionsareprovidedforfuturedirections of this line of work.

GATEKEEPING

Typical gatekeeping functions are put into place to assess acceptable professional competency in students and trainees, and to remediate or dismiss STPPC (Vacha-Haase, Davenport, & Kerewsky, 2004). Remediation may require students and trainees to take further training or coursework; attend therapy; extend practica, internships, or postdoctoral training; and/or even change career focus (Forrest, Elman, Gizara, & Vacha-Haase, 1999). Students and trainees develop professional competency skills at different rates as they progress through their programs, and faculty and supervisors may find it difficult to determine if problematic professional competencies are developmental in nature and can be remediated. At times, student and trainee professional competency problems may be so severe that remediation may not be successful. Graduate programs have increasingly focused on problems with professional competency, and they have begun to implement formal procedures to intervene with STPPC (Rubin et al., 2007).

DEFINITION OF STUDENTS AND TRAINEES WITH PROBLEMS OF PROFESSIONAL COMPETENCE (STPPC)

For the purpose of this article, the term “students” refers to undergraduate and graduate students and the term “trainees” refers to internship and postdoctoral trainees. Students and trainees may display problematic professional competency at any stage of education or training. In their Benchmark document, Fouad and colleagues (2009) identified 15 core competencies, defined their essential components that are necessary for each stage of training and education, and described how to assess these competencies across educational levels (e.g., readiness for practica, internship, and entry to practice). The authors further characterized each core competency through its multiple elements. For example, the core competency of professionalism is characterized by the elements of integrity/honesty, deportment, accountability, concern for the welfare of others, and professional identity. An example of a student or trainee who displays problematic professional competence in professionalism might be cheating on assignments, falsifying information, and/or being disrespectful during interpersonal interactions with clients or colleagues. A description of each core competency and its elements is beyond the scope of this article (see Fouad et al., 2009, for a complete list).Student and trainees that display problems in one or more of the 15 core competencies are identified as STPPC for the purpose of this article.

Prevalence and Type of Competency Problems

There is little to no research evaluating the prevalence rate of undergraduate students with problematic professional competency. White and Franzoni (1990) evaluated 1st-year counseling

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graduate students and found that they had significantly higher levels of psychopathology in comparison to the population in general, suggesting that undergraduate students with psychological problems may well advance to graduate training in psychology, where professional competence problems may arise (Vacha-Haase et al., 2004). A few studies have evaluated the presence of problematic professional competency in graduate students (e.g., counseling, clinical, school psychology) through the use of questionnaires (Huprich & Rudd, 2004; Vacha-Haase et al., 2004). In a study of 81 graduate programs, Huprich and his colleague (2004) reported that 65% of programs had at least one or more current students with problematic professional competency, and 60% reported three or more within the past 10 years. In a study of 103 graduate programs, Vacha-Haase and colleagues (2004) reported that 52% of programs terminated at least one student in 3 years, which was typically attributed to clinical work problems. However, faculty and supervisors may not always be able to intervene with all students with problems in professional competence, or foresee students who may have problematic competency in the future. In a study of 118 internship sites, 10% of programs reported knowing of at least one current trainee with professional competency problems and 35% reported three or more over the past 10years(Huprich&Rudd,2004).Thestudyindicatedthatthemostcommonproblemsidentified during graduate programs and internships were difficulties with clinical work due to adjustment disorders, alcohol abuse, anxiety and depression, and personality disorders. At this time, the prevalence rate of competency problems in postdoctoral trainees is unknown.

MAJOR ETHICAL ISSUES OF GATEKEEPING

There are major ethical issues to consider when instituting gatekeeping functions during undergraduate, graduate, internship, and postdoctoral education and training. Ethical gatekeeping issues are highlighted by applying findings from previous literature and the Ethics Code (APA, 2002). Faculty and supervisors should aspire to uphold the ethical principles of beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, and respect for people’s rights and dignity in their educational and professional interactions with STPPC. Faculty and supervisors mustalsoadheretothestandardsoftheEthicsCode,specificallythestandardsrelevanttoresolving ethical issues, competence, human relations, privacy and confidentiality, record keeping, and education and training (APA, 2002, pp. 1063–1069). Subsequent sections discuss each ethical principle (General Principles A–E) as it applies to educational gatekeeping practices in psychology, the standards that support the themes of the ethical principles, and special considerations and ethical dilemmas that faculty and supervisors may encounter.

General Principle A (Beneficence and Nonmaleficence)

Principle A guides psychologists to “strive to benefit those with whom they work and take care to do no harm” (APA, 2002, p. 1062). Principle A is especially important in guiding educational gatekeeping practices, because it advises faculty and supervisors to be cognizant of the welfare of their students and trainees as well as the welfare of individuals with whom students and trainees interact (e.g., clients). Specifically, faculty and supervisors should seek to benefit their students and trainees by providing education and training that is developmentally

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appropriate while making sure that these students and trainees are providing good care to their clients. At times, these two goals may conflict with each other and create an ethical dilemma (Kitchener, 1984). Faculty and supervisors must determine the amount of potential harm that clients might experience in the service of helping students and trainees develop professional skills. One way that faculty and supervisors manage this ethical dilemma is to aspire to implement ethical gatekeeping procedures to assess and remediate STPPC in a timely manner. Timely remediation that provides developmental road maps for STPPC merges faculty’s ethical commitments to their students with their ethical commitments to the clients served by students in training.Thus,PrincipleAprovidesguidancetofacultyandsupervisorsatanystageofeducation or training.

Supporting standards. In support of General Principle A, Standard 3.04 explicitly states that “psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees …and others with whom they work, and to minimize harm where it is foreseeable and unavoidable” (APA, 2002, p. 1065). Overall, the purpose of gatekeeping functioning at every stage of education and training in psychology is to avoid harm or foreseeable harm to clients, patients,students,supervisees,andotherswithwhomtheywork.Individualswhoenterandeventually graduate from doctoral internship and postdoctoral programs will ultimately benefit the public through competent research and practice. STPPC may be more likely to make poor judgments, exploit others, make mistakes, provide poor clinical care, and “project their own personal issues”(p.21)ontoothers(Bemak, Epp, &Keys, 1999). Thesebehaviors arepotentiallyharmful to students and trainees when they pursue education and training in an area for which they will ultimately be unsuccessful. Such students and trainees may face increased rates of failure and be more likely to be exposed to increased stress, anxiety, damage to self-esteem, and depression as a result. Students and trainees may spend time and resources on education and training in psychology that may have been better spent on educational costs associated with another career that better matches their strengths. As part of the remediation process, faculty and supervisors may require students and trainees to obtain individual or group therapy. Psychotherapy was cited as the most common remediation method for STPPC by faculty and supervisors (Forrest et al., 1999). When psychotherapy is used in remediation, Standard 7.05 requires faculty and supervisors to provide students and trainees with the option to choose “therapy from practitioners unaffiliated with the program” (APA, 2002, p. 1069). Faculty and supervisors must make their role as an educator/trainer clear andavoid entering intoamultiplerelationshipwithSTPPC by providing therapy (Standard 3.05, APA, 2002, p. 1069). However, when faculty and supervisors use personal therapy as the sole form of remediation without any monitoring components, faculty are unable to evaluate STPPC progress to ascertain if the personal therapy remediation is positively affecting the professional competencies of concern (Elman & Forrest, 2004).

General Principle B (Fidelity and Responsibility)

General Principle B (Fidelity and Responsibility) advises psychologists to “consult with, refer to, or cooperate with other professionals …to serve the best interests of those with whom they work. They are concerned about the ethical compliance of their colleagues’ scientific and professional conduct” (APA, 2002, p. 1062). Principle B advises psychologists to consult with each other, a principle that would apply to faculty and supervisors implementing their gatekeeping

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responsibilities with STPPC. Psychologists are also encouraged to be cognizant of maintaining competency, a principle that would apply to faculty and supervisors responsible for students and trainees’ professional behavior and performance during their education and training.

Supporting standards. General Principle B (Fidelity and Responsibility) is supported by multiple standards of the Ethics Code. The most basic method of intervening with STPPC is notifying students and trainees that there are potential problems with specific professional competencies. Standard 1.04 requires psychologists to informally notify fellow psychologists of their potential ethical violations (APA, 2002, p. 1063). Applying this standard to education and training, faculty and supervisors have a responsibility to inform STPPC of their professional competency problems. Informally notifying STPPC of competency problems may be enough to resolve the problematic behaviors. However, at times, informal resolution may not be sufficient in remedying a problem and/or appropriate to the situation. In these cases, Standard 1.05 directs psychologists to take “further action appropriate to the situation” (APA, 2002, p. 1063). This standard suggests that faculty and supervisors take formal and/or additional action to address STPPC, such as initiating a formal remediation process. Attimes,facultyandsupervisorswillbepresentedwithchallengingandcomplexgatekeeping decisions regarding STPPC. Standard 3.09 states that “when indicated and professionally appropriate, psychologists cooperate with other professionals in order to serve their clients/patients effectively and appropriately” (APA, 2002, p. 1065). Faculty and supervisors are encouraged to consult with each other to “serve” their students and trainees “effectively and appropriately.” Standard 4.06 directly addresses the use of consultations by stating that psychologists “disclose information only to the extent necessary to achieve the purposes of the consultation” (APA, 2002, p. 1066). Oliver, Bernstein, Anderson, Blashfield, and Roberts (2004) reported that clinicalpsychologystudentsendorsedtheuseofconfidential“facultyconsensusorextradepartmental consultation” (p. 144) in identifying students with competency problems. Faculty and supervisors should consult with colleagues when deemed necessary and provide information about the student or trainee that is pertinent to situation. Standard 2.02 requires that psychologists “obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services” (APA, 2002, p. 1065). This standardsuggeststhatfacultyandsupervisorsneedtobewellversedinthescholarshiponSTPPC and able to enact their gatekeeping responsibilities. Faculty and supervisors may not always be aware of the most appropriate gatekeeping practices for every situation presented with STPPC. For example, the intersection of diversity issues and STPPC can produce complex and challenging gatekeeping issues, and faculty and supervisors can greatly benefit from further development oftheircompetenceandconsultations(Shen-Miller,Forrest,&Burt,inpress).Facultyandsupervisors are more likely to receive diverse insights and recommendations for implementing ethical gatekeeping practices with STPPC by consulting with each other. However, faculty and supervisors may also disagree on aspects of the most appropriate assessment, remediation, and/or termination procedures (Gizara & Forrest, 2004).

General Principle C (Integrity)

General Principle C (Integrity) encourages “psychologists to seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology” (APA, 2002, p. 1062). Faculty and supervisors are encouraged to be accurate, honest, and truthful in their “teaching” of

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students and trainees, which is especially important when enacting their gatekeeping responsibilities. Principle C guides faculty and supervisors to strive to be transparent in their programs’ design, content, and expected outcomes. Faculty and supervisors should also aspire to be accurate and honest in their assessment and communication with students and trainees about their evaluation of their performance.

Supporting standards. In support of General Principle C, faculty and supervisors must abide by several standards to “promote accuracy, honesty, and truthfulness” in the education and trainingofpsychology(APA,2002,p.1062).Psychologyprograms,atanystageoftrainingfrom undergraduate to postdoctoral, are designed to “provide appropriate knowledge and proper experiences, meet requirements for licensure, certification, or other goals for which claims are made about the program” (Standard 7.01, APA, 2002, p. 1068). In doing so, students and trainees are aware of the purpose of the programs they are applying to or entering and the expected outcomes upon completion. For example, Loewy, Juntunen, and Duan (2009) highlighted that counseling students need a core set of virtues “to work competently and justly with diverse populations … andforsuccessfulcompletionoftraining”(p.706).Theauthorsstatedthattrainingvaluesshould be made readily available to students and trainees during the admissions process because this knowledge assistsstudentsandtraineestoself-assessiftheywant/areabletopursuefurthereducation and training in the area the program is intended. Programs need to provide information for students and trainees to ascertain if the program is appropriate for the career they intend to pursue. Furthermore, Standard 7.02 states that programs should “provide an accurate description of program content, training goals and objectives, and requirements that must be met for satisfactory completion of the program …made readily available to all interested parties” (APA, 2002, p. 1068). Accurate descriptions ensure that students and trainees are aware of the requirements that must be met to complete the program, as well as assessment, remediation, and termination procedures should the student or trainee fall short of the set expectations. In a study by Oliver and colleagues (2004), 53% of 46 surveyed clinical psychology students were unaware of “program protocols and procedures” for assessing students with problematic professional competencies. Also Standard 7.06 states that faculty and supervisors should provide accurate and timely feedback to students and trainees to improve in areas where they are not meeting standards (APA, 2002, p. 1069). In general, students and trainees should be aware of expectations prior to entering programs, as well as receive feedback on their performance to amend it if necessary.

General Principle D (Justice) and E (Respect for People’s Rights and Dignity)

The General Principles of Justice (D) and Respect for People’s Rights and Dignity (E) relate to issues of fairness and human rights. Principles D and E complement each other and are endorsed by similar standards in the Ethics Code; therefore they are discussed together. General Principle D states that “psychologists recognize that fairness and justice entitle all persons to …equal quality in the processes, procedures, and services being conducted by psychologists. Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases …do not lead to or condone unjust practices” (APA, 2002, p. 1062–1063). At times, psychologists may have difficulty determining what is “just” and “fair” in a given situation,

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as the individuals with whom they work are not identical on all variables (Kitchener, 1984). Psychologists should seek to be fair and just while being cognizant of relevant cultural, individual, and/or role differences. According to Principle D, faculty and supervisors should behave this way themselves and aspire to educate and train students and trainees in a similar manner, as well as attempt to keep gatekeeping practices fair and just for each STPPC. PrincipleEstatesthat“psychologistsrespectthedignityandworthofallpeople,andtherights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware of and respect cultural, individual, and role differences …and consider these factors when working with members of such groups” as well as “try to eliminate the effect on their work of biases based on those factors” (APA, 2002, p. 1063). In relation to educational gatekeeping procedures, Principle E asks faculty and supervisors to respect the dignity and worth of their students and trainees. STPPC may have cultural, individual, and/or role differences that may or may not be related to their problems with professional competence. Faculty and supervisors should aspire to be sensitive to these individual and cultural differences, and prevent unwarranted personal biases from interfering with their gatekeeping practices.

Supporting standards. In support of Principles D and E, the Ethics Code requires faculty and supervisors to abide by multiple standards. Faculty and supervisors should be cognizant of the potential for unfair discrimination of students and trainees due to variables of “age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any basis proscribed by law” (Standard 3.01, APA, 2002, p. 1064). These variables are complex and should be considered when appropriate (Shen-Miller et al., in press; Shen-Miller, Forrest, & Elman, 2009). Shen-Miller and colleagues highlighted the complexities that occur when diversity and STPPC interact, as well as how these interactions influence faculty and supervisors during gatekeeping practices. However, these variables should not be used to unfairly and/or negatively influence the assessments of students or trainees. Faculty and supervisors should take care to ensure that unfair discrimination does not occur when evaluating students and trainees with potentially problematic professional competency. Precautions should be taken to ensure that students and trainees are evaluated fairly and objectively, and all efforts should be documented to protect programs from litigation from terminated STPPC (Forrest et al., 1999). Gilfoyle (2008) identified precautions that faculty and supervisors should take to minimize the legal risk to programs by ensuring fairness in the gatekeeping practices among students and trainees. Faculty and supervisors should also be respectful of students’ and trainees’ rights to privacy, and not require them to “disclose personal information …either orally or in writing, regarding sexual history, history of abuse or neglect, psychological treatment, relationships with parents, peers,andspousesorsignificantothers”(Standard7.04,APA,2002,p.1068).Irrelevantpersonal information can be problematic in evaluating student and trainee performance and may unjustly skew faculty and other supervisors’ perceptions and assessments of the student or trainee. The only exception is if the program requires such information, as stipulated ahead of time, or if the information is needed to “evaluate or obtain assistance for students whose personal problems could reasonably be judged to prevent them from performing their training or professionally related activities in a competent manner or posing a threat to the students or others” (Standard 7.04, APA, 2002, p. 1068). Programs should make students and trainees aware of a mandatory disclosure requirement before or upon entry into programs.

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In all cases where any action is taken, from identification to termination of STPPC, programs and supervisors need to create, control, maintain, and store records and data relating to students’ and trainees’ professional work in a confidential manner (Standards 6.01 and 6.02, APA, 2002, p. 1067). Professional and confidential documentation is especially important with regard to the physical location of personal information, whether stored on computers and/or in physical files, and special care should be taken to ensure these documents are secure (Pope & Vasquez, 2007). Faculty and supervisors should take “precautions to protect confidentiality” and limit knowledge to individuals that are “clearly concerned with such matters” (Standards 4.01 and 4.04, APA, 2002, p. 1066). They must use their best judgment to determine the individuals that are “clearly concerned with such matters,” or have a need to know, to gain information or provide information to/from relevant parties. At times, faculty and supervisors may determine that fellow students and trainees have a need to know about aspects of gatekeeping procedures of STPPC in their programs. In a study of clinical psychology students, Oliver and colleagues (2004) reported that students generally felt that problematic competency issues were not sufficiently addressed by their programs. By informing peers about gatekeeping procedures of STPPC, peers can be made fully aware of competency standards and gatekeeping procedures and reassured that faculty and supervisors will enforce standards of professional competency through remediation and/ordismissalofSTPPC.Alternatively,iffacultyandsupervisorsincludepeersingatekeeping procedures, STPPC may feel embarrassment and/or be stigmatized even after they are remediated. Therefore, the decision to inform peers about faculty gatekeeping processes is a sensitive issue, creates an ethical dilemma for faculty and supervisors, and should be considered carefully. However, faculty and supervisors should not discuss sensitive information about STPPC with anyone other than relevant individuals—this includes refraining from discussing information in public, gossiping about the student/trainee situation, and/or leaving information where it can be easily overheard or viewed (Pope & Vasquez, 2007). In general, these principles and standards should be applied throughout the gatekeeping process in undergraduate, graduate, internship and postdoctoral training programs. Programs should institute these practices in an appropriate manner by maintaining the ethical principles and standards identified in the Ethics Code. Each stage of education and training carries its own unique ethical considerations.

UNDERGRADUATE STUDENTS

Althoughthereareoverlappingethicalaspectsofgatekeepinginundergraduateandgraduateprograms, the undergraduate program brings its own distinct set of ethical issues. The completion of an undergraduate degree is the first stepping stone toward a career in psychology. Undergraduate students are initially exposed to the field of psychology through the completion of introductory coursework and research. Undergraduate students are at the very beginning of their training in psychology and will develop professional competencies at different rates. As a result, faculty may have more difficulty assessing and/or remediating undergraduate students with problematic professional competencies. Undoubtedly, undergraduate students may consider pursuing further education and ultimately a career in psychology. Faculty have an ethical obligation to serve not just as mentors but as gatekeepers into the field, to direct students into careers in which they will be successful (psychology or otherwise).

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Gatekeeping in undergraduate programs may be more difficult than more advanced training programs because students are less likely to be accurately assessed across a range of abilities and to receive guidance. Undergraduate students typically attend larger classes, and therefore they have less direct interaction with faculty, supervisors, or individuals who may serve to evaluate theirsuitabilityandprogress.Infact,undergraduatesmayonlyattendclassesandhavelessexposure to clinical experience, which limits students’ evaluations to “grades only” and hinders the faculty’sabilitytoevaluateinterpersonalcompetencies.Finally,duetolessdirectfacultyinteraction, students who are interested in more advanced training may be left without formal guidance into appropriate education and careers. These limitations may hinder a thorough evaluation for everystudentinanundergraduateprogram,butinstitutingsomeaspectsofgatekeepingfunctions is possible. For example, an undergraduate program at the University of Oregon implements a rigorous application and screening process, diverse training experiences to assess competencies (e.g., clinical settings, seminars, supervisions), and informal/formal remediation efforts (Lichtenstein, Lindstrom, & Kerewsky, 2005). There are unique aspects of undergraduate gatekeeping practices that should be addressed. At this stage, the crux of the gatekeeping responsibilities falls on undergraduate advisors, psychologyfaculty,andevengraduatestudents.Graduatestudentsmayworkdirectlywithundergraduate students, and therefore they may be the closest individuals to assess undergraduate students’ suitability for the field and provide in depth career guidance. Undergraduate advisors, faculty, and graduate students should take an active role to evaluate students objectively, implement remediation if necessary, and/or provide career guidance (APA, 2002). The gatekeeping process may prevent undergraduate students from spending time and resources in an area of study in which they are not well suited and may not be successful. Whereas the number of graduate, internship, and postdoctoral students and trainees in a programisusuallyquitesmall,thenumberofundergraduatepsychologystudentsiscommonlyquite large in comparison. Faculty and supervisors may expect more diversity within this population, especially related to cognitive abilities. Advisors and professors must take special care to ensure that students are not unfairly discriminated against (Standard 3.01, APA, 2002, p. 1064). Formal training for advisors and professors, and even graduate students, should be provided on how to assess students with potential problems with professional competence (academic, interpersonal), as well as clear procedures for intervening with these students if needed (Standards 7.01 and 7.02, APA, 2002, p. 1068). At this stage of education, appropriate gatekeeping techniques are primarily focused on identifying and remediating students with problematic professional competencies (e.g., academic abilities, interpersonal skills, professionalism). In more severe cases, faculty may advise undergraduate students with competency problems to pursue alternative career opportunities that are better suited to their strengths.

GRADUATE TRAINING

During graduate training, students are exposed to coursework, practica, and externships that specifically prepare them for a career in professional psychology. Whereas graduate training is more advanced than undergraduate education, graduate training also permits more scaffolding than internship and postdoctoral training programs. Faculty and supervisors are able to assess graduatestudentsinmultiplesettingsacrossmultiplecompetenciesthroughavarietyofmethods,

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such as grades, formal evaluations of clinical work, and informal feedback. As previously discussed,studentsdevelopprofessionalcompetenciesatdifferentrates,andthelengthofagraduate program permits students the time to develop differentially and where necessary remediate problematic professional competencies. There are special ethical considerations of implementing ethical gatekeeping procedures that are unique to professional psychology academic programs. Graduate students make a major decision to commit to advanced education in psychology. Currently, the average length of time to complete a doctoral degree is 5 to 6 years (APA, 2011). Furthermore, the amount of debt accrued related to graduate education can potentially be quite large, with 2011 internship applicants reporting an average debt of $85,545 and approximately 44% reporting more than $100,000 of debt (Association of Psychology Postdoctoral and Internship Centers, 2011). Graduate students must be made aware of program content, goals, objectives, and requirements to self-assess if a specific academic program is appropriate for their career goals and abilities (Standard 7.02, APA, 2002, p. 1068). The Council of Chairs of Training Councils (CCTC; 2004) endorses that, prior to entry to a program, students and trainees be made aware of methods used to assess and ensure competencies at graduation. Graduate students should also be made aware of assessment, remediation, and termination procedures should theydisplayproblemswithprofessionalcompetencies.Graduatestudentsaremorelikelytocomplete and be successful in programs when they are aware of program content and expectations, thus avoiding potential competency problems and subsequent gatekeeping efforts. Incontrasttoundergraduatestudents,graduatestudentsareformallyintroducedtoandtrained in clinical work through coursework, practica, and externships. Faculty and supervisors have the opportunity to observe and assess graduate student clinical competency skills, such as interpersonal, assessment, and intervention skills. Graduate students are beginning to learn the functions ofaprofessionalpsychologist,andfacultyandsupervisorsareawarethatdevelopingprofessional competency skills may take time. As previously discussed, the Benchmark document assists faculty and supervisors on how to assess graduate student competencies of readiness for practica and readiness for internship (Fouad et al., 2009). Graduate programs prepare students for more advanced clinical training in internship and postdoctoral work. Implementing ethical and effective gatekeeping practices during graduate training is especially important for promoting success during internship and postdoctoral training. Problems may arise when there is a lack of communication and/or miscommunication betweengraduateprogramsandpracticaorinternshipprogramsregardingstudentswithproblematic professional competencies. For example, letters of recommendation provided to internship programs may be “exaggerated …unrealistic …inflated” (p. 115), with student competency problemsminimizedorevenhidden(Miller&VanRybroek,1988).Internshipprogramsmaynot always be aware of trainees’ history of problematic professional competencies unless graduate programs provide this information. The CCTC (2007) fully endorses two-way communications between graduate and internship programs regarding known student and trainee competency problems and remediation efforts. When internship programs are fully and accurately informed about incoming trainees with a history of problematic professional competencies, they can focus their training efforts in a timely manner (CCTC, 2007). Similarly, graduate programs would benefit from receiving information from internship programs about trainee progress, which could lead graduate programs to amend their education and training efforts. Faculty and supervisors should consider issues of confidentially (Standards 4.01, 4.02, and 4.06, APA, 2002, p. 1066) in

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two-way communications between graduate and internship programs, and students should be informed in advance that such communications will occur. Two-way communications that are accurate and representative may ultimately benefit the STPPC and prevent harm to those with whom they interact and serve (Standard 3.04, APA, 2002, p. 1065).

INTERNSHIP AND POSTDOCTORATE TRAINING

Implementing gatekeeping functions during the internship and postdoctoral stages may also prove to be more difficult than during graduate programs and carry unique ethical considerations. The internship and postdoctorate placements are the final training steps toward a career in psychology and the last opportunity to implement gatekeeping functions (McCutcheon, 2008). Trainees participate in internship training for only a brief time (usually 1 year) in comparison to multiyear practica and extern experiences to demonstrate that they are able to work independently and effectively. Upon graduating from an internship or postdoctoral site, the program is “endorsing” the trainee as a competent clinician who is capable of working independently in a professional capacity. There is an ethical obligation of supervisors to implement gatekeeping functions at this final point in the formal training process to protect the public. Several authors have discussed how to implement recognition, assessment, remediation, and termination procedures of trainees with problematic professional competence in the setting of internship sites (Elman, Illfelder-Kaye, & Robiner, 2005; Falender, Collins, & Shafranske, 2009; Forrest et al., 1999; Fouad et al., 2009; Gizara & Forrest, 2004; Kaslow et al., 2007; Lamb et al., 1987). These authors recommended formal gatekeeping procedures, which include supervision training for supervisors, establishing clear definitions of minimum standards of competence, outlining program policies for trainees, establishing benchmarks of performance, creating a collaborative effort among supervisors to identify and determine appropriate actions, and protocols for interacting with the trainee’s peers. Although thoroughly exploring these processes are beyond the scope of this article, major ethical considerations must be addressed when implementing these practices. During internship and postdoctoral training, supervisors may be less likely to intervene with problematic trainees because trainees have already attained previous education and experience, invested a large amount of time and financial resources, and have been passed by their academic programs. The late stage of training makes the process of remediating trainees with problematic professional competence more difficult. Furthermore, the process of assessing and intervening with such trainees may also be confrontational, and supervisors may fear litigation (Enochs & Etzbach, 2004; Finch, 2010; Lichtenberg et al., 2007). These limitations highlight the need for standardized assessment procedures, training for supervisors, consultations, and timely feedback within internship and postdoctoral sites as well as with the faculty at the academic program. Internship and postdoctoral trainees also rely heavily on faculty and supervisor networks for training and employment opportunities; therefore, confidentiality during gatekeeping practices is extremely important (Standard 4.01, APA, 2002, p. 1066). Information regarding identification and remediation with a trainee with competence problems should be limited to individuals involved with the trainee or for consultation purposes, as revealing such information to others could be quite damaging to the trainee (Standards 4.01, 4.04, and 4.06, APA, 2002, p. 1066). Trainees with competency problems can be remediated and successfully complete professional

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training programs. When personal information about trainees with competence problems is revealed to uninvolved individuals, obtaining objective evaluation by other supervisors may be more difficult and/or may negatively impact the ability of the trainee to obtain future employment. However, determining the degree to which individuals with a need to know should be informedofcompetencyproblemscreatesanethicaldilemmaforfacultyandsupervisors.Aspreviously discussed, faculty and supervisors must make difficult decisions regarding the amount of potential harm others (e.g., clients) may experience as a result of trainee development. Special ethical considerations should be made for postdoctoral trainees. At this stage, the individual has been passed by multiple programs (graduate and internship) and has obtained the doctorate title. The ethics of the gatekeeping functions previously discussed apply to the postdoctoral stage of training. However, it may be more appropriate to view this type of intervention as career counseling rather than gatekeeping.

RECOMMENDATIONS FOR ETHICAL EDUCATIONAL GATEKEEPING PRACTICES IN PSYCHOLOGY

Thefollowingarerecommendationsforfacultyandsupervisorstoimplementethicaleducational gatekeeping functions throughout the various stages of education and training in psychology. Although these recommendations may be difficult to implement, they are important for students, trainees,faculty,supervisors,andtheindividualswithwhomtheywork.Theserecommendations are supported by the Ethics Code (APA, 2002, pp. 1063–1069). Faculty and supervisor recommendations include

• minimizing harm to students and trainees (as well as those whom they interact) by implementingethicalandappropriategatekeepingpoliciesandprocedures(Standard3.04); • notifying students and trainees of potentially problematic competency issues and facilitating remediation when appropriate (Standard 1.04); • recognizing that students and trainees develop competency at differential rates and developing remediation efforts that allow for enough time to correct deficiencies; • ethically consulting with colleagues regarding challenging, complex, and/or diversityrelated issues (Standards 2.02, 3.09, and 4.06); • respecting cultural, individual, and role differences, and being cognizant of how these factors interact with competency judgments (Standards 3.01); • maintaining agreements about boundaries of privacy and confidentiality among all parties involved with gatekeeping functions (Standards 4.01, 4.02, 4.04, 6.01, 6.02, and 7.04); • documenting and maintaining records of gatekeeping efforts (Standards 6.01 and 6.02); • providingprogrampoliciesinapubliclyaccessibleformat,specificallydescribingprogram content and outcomes as well as gatekeeping procedures (Standard 7.01 and 7.02); • carefully evaluating required psychotherapy remediation efforts for STPPC to ensure that agreementsabouttheboundariesofprivacyareinplaceinadvanceandanylaterdisclosures do not surprise the STPPC (Standard 7.05); and • providing timely feedback to STPPC that establishes clear goals and promoting an active chance to achieve goals (Standard 7.06).

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CONCLUSION

Educational gatekeeping functions in psychology should serve the best interests of students and trainees, as well as the individuals with whom they work. Faculty and supervisors should be cognizant of the diverse ethical considerations that may arise when implementing gatekeeping functions with undergraduate, graduate, internship, and postdoctoral STPPC. Implementing highly ethical gatekeeping practices may often be difficult and lead to ethical dilemmas, as faculty and supervisors may determine that there are “good, but contradictory ethical reasons to take conflicting and incompatible courses of action” (Kitchener, 1984, p. 43). The issues and recommendations discussed in this article have implications for faculty, supervisors, and students/trainees at a program level. Future directions of this line of work may be applied at an organizational level. Faculty and supervisors may benefit from more direct guidance from the APA regarding ethical gatekeeping procedures, such as including specific gatekeeping standards in future amendments of the Ethics Code (APA, 2002). At any stage of education and training, faculty and supervisors should refer to the principles and standards identified in the Ethics Code during their professional and educational activities, and especially when implementing ethical educational gatekeeping functions with STPPC.

ACKNOWLEDGMENTS

I express gratitude to Nan R. Presser for providing education and training on the ethics of psychology, as well as for her invaluable feedback during the development of this article. I am also grateful to APA Ethics Committee members Linda Forrest, Nadya Fouad, and Jennifer Cornish for their time, insight, and guidance on revisions of this paper.

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