The University of Denver Graduate School of Professional Psychology Internship Consortium, an APA-accredited internship consortium, consists of seven sites in the Denver metropolitan area including a state psychiatric hospital, residential treatment home for children and adolescents, health maintenance organization, community mental health center, police psychology agency, and two university counseling centers. The global pandemic caused by COVID-19 and the related public health response has posed personal, clinical, technological, and systemic challenges to each agency within the DU GSPP Internship Consortium and to internship agencies across the United States. While natural disasters and other extreme events have posed challenges to organizations within specific geographical regions, the challenges posed to predoctoral interns during the COVID-19 pandemic are unique, far-reaching, and require unprecedented considerations and accommodations.

Literature Review and Considerations

Although natural disasters have historically and regularly disrupted graduate training, limited research exists regarding short- and long-term outcomes and recommendations (Townsend, 2007). The most applicable literature examining graduate training responses to natural disasters has been work focused primarily on medical training responses to Hurricane Katrina. Hurricane Katrina, which devastated the Gulf Coast in 2005, resulted in physical damage to buildings and equipment and led to acute trauma in students, faculty, and the local population. Graduate training programs supported students affected by this acute trauma by implementing online classes and forums, regular conferences, individual counseling, and both faculty- and student-led support groups (Kahn et al., 2007; Osofsky, 2007; Winstead & Legeai, 2007). Programs relied on the generosity and resources of nearby educational administrations to cope with the significant logistical issues brought on by this disaster (Kahn et al., 2007; Townsend, 2007).

The COVID-19 pandemic has resulted in similar challenges to graduate training, such as the limited use of training facilities and a catalyst for acute trauma in students, faculty, and the local population. These psychology training difficulties have likely been compounded by the fact that most programs do not foster educational opportunities in disaster psychology and global trauma (Fox et al., 2018; Schulenberg et al., 2008). Although research on disaster psychology is improving, prior work in this area has focused little on graduate and internship training (Piotrowski, 2012). The present paper seeks to continue the theme of research in the area of disaster psychology, with a focus on the context of psychology training during a predoctoral clinical internship.

Personal Challenges and Considerations

Several personal challenges related to professional responsibilities have surfaced from this pandemic. Many interns have been working remotely from home, which poses its own set of challenges such as lack of control over the workspace, distractions (e.g., children home due to lack of childcare), and time management. Though working remotely poses the safest option, interns have struggled with wanting to support clients and essential staff at their placements as well as meet requirements for clinical hours in order to graduate and obtain licensure. Additionally, some interns are the only trainees at their placements and experience their own unique struggles as they feel even more of a responsibility to be there in person providing services to those in need. With the reality being that most interns are working remotely, support networks have needed to be re-established virtually, which makes them feel more distanced and less personal. Further, given that interns in the consortium are all at very different sites, we are dealing with site-specific issues that are difficult to address effectively in the whole group setting.

Clinical Challenges and Considerations

A myriad of clinical challenges has surfaced as a result of the unforeseen pandemic.  As the American Psychological Association and other regulatory agencies have updated legal and ethical standards, it is imperative that clinicians remain as current as possible with ever-evolving statutes and regulations. It is additionally important to stay up to date with trainings that meet the minimum competencies for current standards and to remain well-versed in policies around best practice as they are developed. Many agencies have switched to providing services on a virtual platform in order to further maintain the safety of both staff and patients. This brings up noteworthy concerns regarding how to best manage risk, including suicide, homicide, self-harm, child abuse, and grave disability.  Risk management has largely been managed on an individual site basis. The clinical skills that staff normally rely on to manage risk do not always translate in virtual formats, so receiving additional training on how to manage this virtually is important.

Specific services including, group therapies, assessment, and specialty services, may have been impacted during COVID-19. This has resulted in agencies finding ways to provide care that is considered competent care while still adjusting to pandemic circumstances with modified services. The switch to teletherapy services, provided over the phone or through virtual platforms, has provided solutions to one set of challenges while creating additional challenges. Concerns regarding how to best maintain therapeutic relationships and how to do deeper clinical work have been brought up commonly. While these challenges are present during individual therapy, they are particularly pronounced during couples therapy, family therapy, and group therapy. Furthermore, each site has also approached assessment during the COVID-19 on an individual basis. Whereas some sites have essentially shut down their assessment department, some sites have been working on developing guidelines that encompass social distancing for in-person assessment to administer the tests.  However, there are several challenges with socially distanced assessment for tests such as the Rorschach Performance Assessment System (R-PAS). For measures such as the R-PAS, without additional technical developments to ensure an accurate and uniform presentation of the inkblot stimuli, completely online administration is currently infeasible.

While these challenges are noteworthy for even the most experienced clinicians, they are particularly pronounced for trainees. As such, providing and receiving adequate supervision has become tantamount to clinical success. Developing set standards of communication surrounding clinical, legal, and ethical changes is now more important than ever. Supervisors and supervisees alike must learn to communicate these changes and navigate their roles through a new medium. Formalized supervision blocks may no longer be adequate to address frequently changing standards and ever-developing clinical challenges. In some cases, supervision may have to occur more frequently and for shorter amounts of time. These changes may help to ensure clinical follow-through. With these modifications, all parties involved in the supervisory process need to be increasingly aware of how they are communicating their power and their needs.

Technological and Workspace Challenges and Considerations

One important consideration when planning for a period of disruption during internship is access to technological resources. The most basic needs include a personal computer that is approved for internship-related work or a portable office laptop that the intern can bring to their home. Reliable and secure internet access from home is also a necessity. It is important to consider that a personal laptop and internet service are both likely to be personal expenses incurred by the intern. Additionally, the ability to remotely access a secure electronic records system is critical to providing continuity of contact and care with clients if the physical office or clinic is closed. A secure, reliable, and comprehensive electronic record will also allow an intern to both access and share client information with other approved users, such as their supervisor, in order to maintain and ensure appropriate clinical oversight, ethical considerations, and HIPAA compliance.

Among many adjustments necessary to transition to remote work, interns are newly responsible for managing technological issues that often arise in doing telehealth. With limited technological support available to most, the challenge of becoming technologically competent in a short period of time has been a common experience amongst interns. This includes not only our own concerns that arise but helping clients navigate through their issues in accessing services through a new and unfamiliar forum to most. Additionally, it is inherent to such a transition that policy changes and requirements of clinician’s shift, requiring a necessity for increased communication among staff. This has posed its own challenges in that an inundation of emails and more frequent communication amongst staff is an additional time constraint that interns must factor into their workday. These significant changes have also impacted hours accrual as some interns are unable to perform all previous job duties, which for some, has increased anxiety around post-doctoral positions and licensure.

Systemic Challenges and Considerations

Systemic differences in equity, inclusivity, and equality create varied experiences for individuals who are located within those systems. In the case of predoctoral internships in psychology, this stands out in sharp relief amid a global crisis. Depending on the organization’s preexisting funding sources, technology resources, management, and IT structures, and the populations served, interns were enabled to transition to remote work, and keep themselves and their communities safe, based on their setting. The differences in these organizations are reflective of the patterns of inequality of the larger society’s macrosystem as well. The following issues have systemic roots and future implications that play out on a larger scale:

• How the broader society has historically responded to individual differences in identity, social location, family structure, histories, and resources is reflected in how sites treat its interns (e.g., whether an intern has children and needs childcare, whether an intern owns their own computer or has internet, interns with chronic medical conditions or vulnerable family members).
• Organizations differ in their cultures around how power and privilege are managed. These cultural differences have a ripple effect on how the needs of interns are responded to and valued during times of crisis. This is also visible in how much power middle management, supervisors, and training directors have in advocating for the needs of interns with upper management.
• Interns having to manage the uncertainty of what the future holds (and all other kinds of environmental stressors) while the people they serve are struggling with managing the same issues is influenced by the organization’s existing culture.
• Even differences in whether an organization has access to and the budget for different kinds of equipment, such as personal protective equipment (PPE), can reflect the systemic issues that have historically plagued that organization.

Recommendations

The COVID-19 pandemic has created a new landscape of unique and complex challenges in the field of Health Service Psychology. Given the presented concerns, the following guidelines were created to help inform graduate training programs, clinical training sites, accrediting institutions, and licensure bodies in providing and implementing flexible accommodations for interns based on health and well-being, individualized needs, and considering a variety of identities.

• Health & Safety
  • Limit in-person contact and prioritizing trainee health and well-being
• Flexibility/creativity
  • Prioritizing developmentally sensitive trainee focus
    • Recognizing that trainees will vary in their developmental level and how they respond to expectations and responsibilities, especially within the context of a global pandemic.
  • Balance
    • Recognizing that a significant challenge for students has to do with the many roles and responsibilities they hold (i.e., doctoral intern, parent, partner, caregiver, etc.) and that there is a need to balance and maintain these roles within the delivery of health service while maintaining personal and public health and safety.
  • Understand and utilize a compassionate lens when considering that trainees are making decisions, learning, and working within parameters and constraints that have never been encountered.
  • Adjusting educational, training, and licensing requirements
  • Minimize adverse impact on trainee finances and program completion
• Social Justice/responsiveness
  • Considering the inequities maintained by differences in race and ethnicity, socioeconomic status, age, gender, physical ability, sexual orientation, along with other identity factors, we encourage decision-making to recognize the power differentials that may make self-advocacy challenging for such individuals.
  • Minimize critical resource disparities
• APPIC Informal Problem Consultation
  • APPIC provides Informal Problem Consultation (IPC) for any intern on a wide variety of issues, including those related to COVID19. The intern just needs to complete the IPC request form available on the APPIC website and will be assigned to a Board member who can help them navigate the issues with their site.  This service is free, and the IPC process has already been used successfully many times this year helping interns with all the points raised above including health and safety, flexibility/creativity, and social justice/responsiveness.

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Maya Badwan