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Counseling and Psychological Services

Due Process, Grievance and Intern Complaint Procedures

CAPS interns work under the supervision of licensed staff clinicians. Their performance is evaluated and they are provided with feedback at planned intervals during their tenure at CAPS. Due process ensures that decisions made regarding interns are not arbitrary or personally biased. Specific evaluative procedures are applied to all interns. Appropriate appeal procedures are available to interns so that they may challenge the program’s action.

This section describes general guidelines for due process at CAPS, the program’s definition of “Learning Need,” interns “Not Meeting Performance Standards,” procedures for intervention, and the levels of appeal which are available to interns if they disagree with evaluations or decisions made by their supervisors and evaluators.

Due Process

Due process at CAPS includes:

  1. Presenting the interns with the program’s expectations related to professional functioning in written form (see Goals and Objectives, Section II of Intern Manual).
  2. Stipulating the procedures for evaluation, including when and how evaluations will be conducted (see Evaluation Philosophy and Procedures in this document above).
  3. Articulating the various procedures and actions involved in making decisions regarding interns not meeting performance standards (see Due Process and Grievance Procedures in this document below; see definition of “Not Meeting Performance Standards below).
  4. Communicating with graduate programs about any identified occurrences that represent significant “learning needs” and seeking input from those academic programs as to how to address such difficulties (see definition of “learning needs” below).
  5. Communicating promptly in writing with graduate programs about any instance of intern not meeting performance standards in accordance with the procedures set forth below.
  6. Instituting, with the input and knowledge of the graduate program, a remedial plan for identified unmet performance standards, including a time frame for expected remediation and consequences of not rectifying the unmet performance standards in accordance with the procedures set forth below.
  7. Ensuring that the appropriate person(s)/group(s) meet with the intern to discuss the unmet performance standards, the remedial plan to be instituted, the timing and procedures involved in the remedial plan, and the consequences of not rectifying the unmet performance standards.
  8. Providing the intern with a procedure for appealing the program’s action (see Grievance Procedure in this document below).
  9. Ensuring that the intern has sufficient time to respond to any action taken by the program.
  10. Using input from multiple professional sources including but not limited to training committee members, CAPS administrators, outside supervisors and interested third parties when making decisions or recommendations regarding the intern’s performance of the remedial plan.
  11. Communicating to all relevant parties, both verbally and in writing, the final action taken by the program and its rationale for that action.

Definitions of “Learning Need” and “Not Meeting Performance Standards”

For the purposes of this document a “Learning Need” is defined as:

  • An intern’s competency, behavior, and/or a characteristic that is identified as an important area for growth, focused learning, or remediation.
  • Developmentally expected and/or non-extreme for professionals in training.
  • An intern who does not maintain an average of 3 on each section of the Intern Evaluation Form may at the discretion of the Director of Training and the training committee be deemed to be experiencing a “learning need” or to be “not meeting performance standards” based on the criteria listed in this document.

For the purpose of this document, “Not Meeting Performance Standards” is defined broadly as an interference in an intern’s professional functioning that is manifested in one or more of the following ways:

  • Professional Standards: An inability and/or unwillingness to acquire and integrate professional standards into one’s repertoire of professional behavior. This would include negligent, unethical or unprofessional conduct. Any intern who knowingly and intentionally violates ethical and legal guidelines governing the practice of psychology will be not meeting performance standards and may be subject to termination and/or failure of the training program. Likewise, failure to abide by University rules and policies, if of a serious nature, will be deemed as not meeting performance standards which may also lead to termination and/or failure of the training program.
  • Skills: an inability to acquire sufficient clinical skills to reach an acceptable level of competency in the skill areas outlined as internship Goals and Objectives (see Section II of the Intern Manual).
  • Personal Functioning: An inability to address personal stress, psychological difficulties, and/or strong emotional reactions such that they substantially interfere with professional functioning.
  • A “Learning Need” typically becomes identified as “Not Meeting Performance Standards” when the situation includes one or more of the following characteristics:
    • The quality of services delivered by the intern is significantly compromised by the problem.
    • The intern does not comprehend, acknowledge, or address the problem once it has been identified.
    • The problem is not a reflection of a skill deficit that can be rectified by academic or didactic training.
    • The problem affects multiple areas of clinical or professional functioning.
    • A disproportionate amount of attention by training personnel is required as a result of the problem.
    • The intern’s behavior does not change as a function of feedback, remedial attention, and/or time.

Assessment of these criteria may be made at any time during the training period and is incorporated into mid-semester and end-of-semester evaluations.

Procedures for Responding to an Intern Experiencing a Learning Need

At any point in the year, a CAPS training staff member may designate some aspect of an intern’s performance as a learning need. The same designation may also be made during the aforementioned verbal or written evaluation periods. In either case, the Director of Training in conjunction with the intern’s supervisors and other members of the Training Committee (as deemed appropriate by the Director of Training) will meet to discuss and agree upon an appropriate response to the intern’s learning need. This includes but is not limited to improvement plans and/or additional consultation or supervision.

Procedures for Responding to an Intern Not Meeting Performance Standards

At any time during the year, a CAPS training staff member may designate some aspect(s) of an intern’s performance as “Not Meeting Performance Standards.” The same designation may also be made during the aforementioned verbal or written evaluation periods. In either case, the following procedures will be initiated:

  1. A Review Committee will be formed, chaired by the Director of Training or by a chair selected by the CAPS Director if (a) the Director of Training is the staff member making the unmet performance designation, or (b) the CAPS Director deems that the Director of Training has an unacceptable dual relationship with or personal bias toward the intern. The Chair will appoint two Training Committee members to the Review Committee, taking into consideration the need to minimize dual relationships or the possibility/perception of unacceptable personal bias. The intern will appoint one member from the CAPS and/or LNEC licensed staff.
  2. The intern will be notified, in writing, that such a review is occurring and the Review Committee will request information and/or a statement from the intern in response to designated unmet performance standards.
  3. In discussing the unmet performance standards and the intern’s statement, the Review Committee may adopt any one or more of the following measures or may take any other appropriate action, referred to as the “Initial Review Committee Decision”. It may:
    1. determine that the criteria of not meeting performance standards has not been met and consequently does not warrant further action or;
    2. issue an “Acknowledgement Notice” which formally acknowledges:
      1. that the Review Committee concurs with the designation of not meeting performance standards,
      2. that the unmet performance standards have been brought to the attention of the intern,
      3. that the Review Committee will work with the intern to rectify the problem(s) addressed by the unmet performance standards and will establish a time frame for this rectification, or
    3. issue a “Probation Statement” indicating that the Review Committee will actively and systematically monitor for a specific length of time, the degree to which the intern addresses, changes, and/or otherwise improves the behavior associated with the unmet performance standards. The Probation Statement is a written statement to the intern which includes:
      1. a description of the behaviors associated with the unmet performance standards
      2. the specific recommendations for rectifying the problem,
      3. the time frame for the probation during which the problem is expected to be ameliorated, and
      4. the procedures designed to ascertain whether the problem has been appropriately rectified, or
        Note: Means of addressing the problematic behaviors are listed below in the Remediation Options section
    4. recommend to the Director of CAPS that the Director terminate the intern’s participation in the training program. The Director of CAPS will have discretion as to whether or not to issue a “Termination Statement,” terminating the intern’s participation in the training program. If the Director determines not to issue a Termination Statement, the Director will consult with the Review Committee to arrive at an appropriate Probation Statement. The Director of CAPS, in consultation with Student Health and/or Student Affairs administration, will have final discretion in regard to intern termination.
  4. If a Probation Statement is issued (C-3 above), the Chair of the Review Committee will meet with the intern to review the probationary conditions. The intern may also request to meet with the Review Committee. The intern may choose to accept the conditions of the Probation Statement or may choose to challenge the Review Committee’s action and Probation Statement. An Acknowledgement Notice may also be challenged. The procedures for challenging the action are presented in Section D: Intern Grievance Procedures.
  5. If a Probation Statement is issued, the Director of Training will inform the intern’s sponsoring university, indicating the nature of the unmet performance standards, the rationale for Review Committee action and the specific action taken by the Review Committee. The intern shall receive a copy of the letter to the sponsoring university. If an Acknowledgement Notice is issued, the graduate program will also be informed if deemed appropriate.
  6. If the Acknowledgement Notice or Probation Statement is not challenged, it is expected that the status of the unmet performance standards will be reviewed no later than the time limits identified in the Acknowledgement Notice or Probation Statement.
  7. If the unmet performance standards have been rectified to the satisfaction of the Review Committee, the intern, sponsoring university and other appropriate individuals will be informed in writing and no further action will be taken.
  8. If the Review Committee determines that there has not been sufficient improvement of the unmet performance standards under the conditions stipulated in the Probation Statement, the Review Committee may adopt any one of the following measures:
    1. Issue an extension of the probation for a specified time period, whereupon the Review Committee will once again determine if sufficient improvement in the intern’s behavior has rectified the unmet performance standards.
    2. Issue a suspension whereby the intern is not allowed to continue engaging in certain professional activities until there is evidence that the behavior in question has sufficiently improved.
    3. Determine that the intern be permitted to complete his or her CAPS duties with or without restrictions, but receive no endorsement for having completed the training program. Under these circumstances, the intern will have received training and provided services for the year, but will not have satisfactorily completed the training program or be certified as such.
    4. Recommend to the Director of CAPS that the intern’s participation be immediately terminated.
  9. Within three working days of the Review Committee’s decision per item 8 above, the Review Committee will communicate in writing to the intern, the Director of Training and CAPS Director that the conditions for revoking the probation have not been met. The decision to implement one of the four options listed under item 8 above is contained in that letter.
  10. Within five working days of receipt of letter containing the Review Committee’s determination and proposed course of action, the intern may respond to the Review Committee’s action by a) accepting the determination and/or action or b) challenging the determination and/or action (see Section D: Intern Grievance Procedures).
  11. Once the intern has made a decision under item 10 above, the intern, sponsoring university, Director of CAPS and other appropriate individuals are informed in writing by the Review Committee of the action taken by the Review Committee and intern’s response to such action.

Remediation Options

It is important to have meaningful ways to address “not meeting performance standards” once it has been identified. Several possible and perhaps concurrent courses of action designed to remediate such problems include, but are not limited to:

  1. increasing supervision, either with the same or other supervisors;
  2. changing the format, emphasis, and/or focus of supervision;
  3. recommending personal therapy and/or psychological assessment with all parties involved having clarified the manner in which therapy or assessment contacts will be used in the intern evaluation process;
  4. reducing the intern’s clinical or other work load and/or requiring specific academic course work or other forms of training; and/or
  5. recommending, when appropriate, a leave of absence and/or a second training:

Intern Grievance Procedures in connection with Intern “Not Meeting Performance Standards”

  1. Interns can institute formal grievance procedures in order to: a) challenge an Initial Review Committee Decision, b) challenge an initial decision of the CAPS Director or c) challenge consequent Review Committee decision(s).
  2. If the intern wishes to challenge the Initial Review Committee Decision or an initial decision by the CAPS Director, he/she must, within five working days of receipt of the this decision, provide the Chair of the Review Committee his/her formal grievance in writing and explain the grounds for the challenge.
  3. The Chair of the Review Committee will convene a Grievance Panel consisting of two staff members selected by the Chair of the Review Committee and two selected by the intern. The staff complainant will not sit on the Grievance Panel. The Director of CAPS, who has final decision-making authority, will not sit on the Grievance Panel. The intern retains the right to hear all facts with the opportunity to dispute and/or explain his/her behavior.
  4. A grievance hearing is conducted, chaired by the Chair of the Review Committee, in which the challenge is heard. Within five working days of the completion of the review hearing, the Grievance Panel submits a report to the Director of CAPS, including any recommendations for further action. Recommendations to the Director are determined by majority vote of the Grievance Panel.
  5. Within five working days of receipt of the recommendation of the Grievance Panel, the Director of CAPS, in consultation with Student Health and Student Affairs administration, accepts the Grievance Panel’s action, rejects the Grievance Panel’s action and provides an alternative, or refers the matter back to the Grievance Panel for further deliberation. In the latter case, the Grievance Panel then reports back to the Director within ten working days of the receipt of the Director’s request for further deliberation. The Director then makes a final decision regarding what action is to be taken with similar consultation as noted above.
  6. Once a decision has been made, the intern, sponsoring university and other appropriate individuals are informed in writing of the action taken.
  7. If the intern wishes to challenge the final decision of the Director, he/she must within five working days of receipt of the Director’s final decision, file a petition in writing with the Vice President and Chief Student Affairs Officer of the University informing them of the situation and the grounds for challenge. The Vice President and Chief Student Affairs Officer will have discretion on the handling of such a challenge.
  8. CAPS will maintain a confidential and de-identified log of all formal intern complaints and grievances filed against CAPS, training staff members of CAPS or other individuals associated with CAPS and/or the training program. The Director of Training will also maintain complete documentation of all such formal intern complaints and grievances in a locked cabinet in the office of the Director of Training. The Director of Training will also maintain copies of such documentation in the intern’s internship file that resides in a locked cabinet in the office of the Director of Training.

Intern Complaint Procedures for Conflict-based Situations

In order to protect the needs and rights of all interns, a complaint procedure has been developed. While it is hoped that any concerns or complaints can be discussed and resolved informally, a formal mechanism is appropriate in light of the power differential between interns and supervisors.

In general, interns and supervisors are encouraged to speak openly in order to facilitate a congenial learning environment that fits the needs and interests of the interns. Giving feedback to staff members/supervisors or the Director of Training is encouraged.

Procedures covered in this document may be initiated in the following situations:

  1. Conflict with Another Intern
    Level 1: Make an attempt to work through conflict with the other intern
    Level 2: Bring matter to the attention of a supervisor who will intervene as appropriate.
    Level 3: Intern(s) and/or supervisor(s) bring matter to the Director of Training who will intervene as appropriate.
    Level 4: Matter is brought to the Director.
  2. Conflict With an Administrative Staff Member
    Level 1: Make attempt to work through conflict with administrative staff member.
    Level 2: Bring matter to the attention of a supervisor.
    Level 3: Matter is brought to the Office Manager.
    Level 4: Matter is brought to the Director of Training
    Level 5: Matter is brought to the Director.
  3. Conflict With Assistant Director or Staff Psychiatrist
    Level 1: Make an attempt to work through conflict with Assistant Director or Staff Psychiatrist.
    Level 2: Bring matter to the attention of a supervisor.
    Level 3: Intern and supervisor bring matter to the Director of Training.
    Level 4: Matter is brought to the Director.
  4. Conflict With Supervisor
    Level 1: Make an attempt to work through conflict with supervisor.
    Level 2: Matter is brought to Director of Training.
    Level 3: Matter is brought to the Director.
  5. Conflict With the Director of Training
    Level 1: Make an attempt to work through conflict with Director of Training.
    Level 2: Bring matter to the attention of a supervisor.
    Level 3: Intern and supervisor attempt to work through conflict with Director of Training.
    Level 4: Matter is brought to the Director.
  6. Conflict With Director
    Level 1: Make an attempt to work through conflict with Director.
    Level 2: Bring matter to the attention of a supervisor, who will intervene as appropriate.
    Level 3: Intern and supervisor bring matter to the attention of Director of Training, who will intervene as appropriate.

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