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Article 22

Developing a Counselor Education Training Clinic

The First Year

Jo Hittner and Mary Fawcett

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Introduction

University-based training clinics in counselor education are important establishments for their respective programs and practicum/internship level students. These clinics generally function as a training laboratory for students to gain experience working in the field of counseling. Students receive supervision from experienced counselors and professors, and in turn gain the necessary experience to fulfill practicum and internship hours needed to graduate.

Myers and Smith (1994) state that since 1966, most clinical psychology doctoral programs have established and maintained in-house clinics for pre-internship training of students. On the other hand, though some training clinics have been developed and are being used today in conjunction with counseling master’s programs, many counselor education programs have yet to implement a training clinic into their program for master’s-level students because of barriers such as cost, lack of university administrative support, and insufficient available supervision by credentialed staff. Additionally, there is limited information available for potential clinic developers describing facilities in which training clinics are typically implemented and the various challenges that may arise in the process of providing on campus training (Myers and Smith, 1994). In an effort to understand these and related practical aspects of developing a training clinic within a counselor education department, the authors discuss the purpose of training clinics and suggest ways in which to approach the daunting task of setting one up.

University Training Clinics

The first American psychology lab was developed in 1896 at the University of Pennsylvania (Witmer, 1996). This lab was a central ingredient in a doctoral training program and set the example for trainers on how to create onsite practicum experiences for students (Sauer & Huber, 2007).

In 1992, a national think tank sponsored by the Association for Counselor Education and Supervision (ACES) gathered to discuss development, implementation and ongoing operation of on-campus laboratories, or training clinics (Myers & Smith, 1995). Several models were described as functioning as both a resource that provides counseling services to the university as well as a curricular experience for the counselor education students. As of 1994, it was found that training clinics had a dual purpose of training for students and counseling services for the university and community (Myers & Smith, 1994). Levinson, Black, Rafoth, and Slonim (2010) described the benefits to both the counselor education program and to the community that the clinic serves. These benefits include low- or no-cost mental health services offered to community members and focused live supervision for trainees of a counselor education program.

The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2009) includes in their standards for counselor trainees to have access to a training clinic for clinical instruction. Although training clinics are not a requirement in CACREP programs, they are recommended for optimum supervision.

Training laboratories may serve a dual purpose, but a training clinic must have a clear mission statement that complies with ethical and legal standards of the counseling profession. Myers and Smith (1995) found that the primary mission of the laboratories is training and not necessarily service, even though two-thirds of the clients seen in laboratories by practicum and internship students are clients from the university and community. A training clinic in this position, therefore, becomes a community mental health agency rather than a training clinic. The authors of this article see the dual purposes of training and service as complementary and not conflictual, and created their training clinic at Winona State University with this philosophy.

When on-site training clinics are supported by university professional staff from the university departments of the counseling center, student affairs, and student wellness and health center, counselors-in-training can gain multidisciplinary experiences and clinical supervision that can broaden their experiences in clinical training (Juhnke et al., 2002). It is ideal that training clinics offer diverse experiences for students from a variety of disciplines in order to serve a community client population. Integrating prevention, intervention, psychoeducation about general wellness, specific mental health issues, and substance abuse offers trainees a more holistic experience in professional development. As a result, counselors-in-training can gain specialty knowledge in a variety of presenting issues and in return serve their university or community (Juhnke et al., 2002).

Pragmatic Considerations of Clients

A potential benefit for the members of a local community being served is the opportunity to work with counselors with whom important demographic characteristics are shared. Strohmer, Leierer, Hotard, and Stuckey, (2003) stated that the demographic characteristics that stood out most for potential clients were age and gender. When assessing for counselor qualities at a rehabilitation center, McCarthy and Leierer (2001) found the most resounding message from clients was their desire for a counselor to communicate to them that she or he was committed to serving as their advocate while relating to them in an affirming, nurturing way. Because of the nature of the setting, clients attending a clinic for rehabilitation may have very different preferences than clients attending a training clinic on a university campus. However, it is important to note client preferences toward trusting his or her counselor to advocate and empathize as much as possible. Qualities such as age, race, gender, or disability status may not be as important as how the counselor regards his or her clients and the willingness of the counselor to learn and understand the worldview of the client.

Specifically related to the clinic experience, Halgin (1986) found three main issues presented by clients who sought services at a training clinic. First, clients felt that the supervisory needs of the student interfered with the flow of therapy. Specifically, complaints were expressed regarding the use of videotaping for the session. Second, some clients felt as though they had been poorly matched with a counselor. Third, some clients felt as though they were not receiving proper care from counselors-in-training. Recommendations given to address these concerns include increasing the effort to explain the need for supervision and recording in an informed consent process, becoming more intentional about matching client with trainee after the initial intake, and flexibility in policy that allows a client to change counselors.

Nurturing the Idea of a Counseling Clinic at Winona State University

The clinic at Winona State University (WSU) was an idea that began in 2005 with Mary Fawcett and other faculty members at WSU. Reviewing the literature and related research about onsite training clinics, Mary and colleagues developed a structure for the clinic that took into consideration CACREP standards, the Association for Counselor Education and Supervision requirements for clinical supervisors, and ACA ethical guidelines. These considerations, combined with an exploration of literature recommendations about informed consent, client care (such as client preferences for counselor demographic characteristics), and related practical issues were the conceptual framework for what would eventually become the Winona State University Counselor Education Community Training Clinic.

Due to limits on faculty and department resources, the clinic did not officially open until December 2010. Jo Hittner was hired specifically to direct the clinic and have it open as soon as possible. Jo had a history of many years of experience as a mental health counselor in a community mental health center as well as years of private practice, which she developed on her own. She was able to provide the impetus and information on how to get a clinic started and what barriers to overcome in the process. The original idea was to have a free or reduced fee clinic where clients from the community without mental health insurance would be able to obtain services at WSU with counselor education interns serving as their counselors. The interns would be supervised by licensed professionals from the counselor education faculty. With the research Mary had done and Jo’s management expertise, the idea of a having a community training clinic at WSU seemed to be a goal that would be able to be accomplished.

The clients were originally planned to be people referred from the local hospital behavioral mental health center and Southeast Minnesota Technical Workforce Center, each of which had graduates from the CE program as directors who would understand the needs of the clients and understand the type of clients that would be appropriate referrals to the clinic. The local community mental health center would also be a source of referrals. Because Jo continued a small practice with them after her employment with the university, they had interns from the CE program and they would also be knowledgeable about the types of clients that would be appropriate referrals.

The original plan was to begin the clinic in January 2011 with an advisory board, contracts with the agencies, protocols and procedures in place, and support staff (a graduate assistant for this purpose).

The Beginning of the Clinic

Mary and Jo named the clinic Winona State University Counselor Education Community Training Clinic, and gave it a mission statement of A center to provide affordable counseling to area citizens and training for future therapists. The next step was to make the counseling room an inviting and welcoming place for clients to receive therapy. The university’s videotaping rooms in the counselor education department were given new curtains, sewn by one of the interns, and matching comfortable chairs were placed in the rooms. The budget was zero so we had to make do with what was available and it worked with a bit of ingenuity and elbow grease.

First Things First

We realized early on that we needed the permission of the university to have the training clinic within the university. The President of the university was excited about the project and stated that she would help in any way possible. She referred us to the WSU nursing department which was beginning a partnership with the local clinic to have physical health screenings for community members without insurance at the local health clinic. The director of the screening program was contacted and she was also excited about partnering with the counselor education department. We sought legal advice from our legal analyst who obtained permission from the MnSCU system and the state of Minnesota to begin having clients come to the university as long as they were not on medication. This needed to be altered within a short period of time because it was too restrictive for our clinic. We obtained permission to accept clients from the community who were either not on medication or were stabilized on medication. We wrote a contract with Winona Health and Winona State University and had it approved by the CEO of Winona Health, our legal analyst, and the College of Education dean. We were then able to work with clients who went through the screening process with the nursing students and scored above average on the PHQ-9 (Patient Health Questionnaire-9 questions) regarding depression. We were available at the screenings and interviewed clients who indicated some measure of depression. Some qualified for the clinic, others needed a referral for services not offered by the training clinic (e.g. alcohol assessment), others did not need counseling but rather some education on depression and suggestions for lifestyle changes.

The First Clients

Each client who was referred was informed that the training clinic involved work with students, that each session would be videotaped, that the student would be supervised by a licensed professional from the counselor education faculty, and that they needed to either not be on medication or be stabilized on their medication. We began with one client in December 2010 who was referred by the mental health center, expanded to two clients in early 2011, and through referrals from the screening clinic, the mental health center, and referrals from word of mouth, we are now serving four clients with three therapists and two supervisors. We had several clients show interest, but they were no shows for their first appointments. We also had two clients terminate prematurely and one client terminate by mutual agreement of the client and the therapist. Since there is no extra money in the budget for the clinic, the faculty supervisors are doing the supervision in their free time. At this time we do not have a charge for the clients to obtain services.

Marketing the Clinic

A brochure was made by one of the intern counselors and it was distributed to the local women’s resource center, County Human Services, County Department of Community Health, other community counseling agencies, and the local food shelf. The brochures were distributed in person to these agencies and an explanation of the services was given in person. This did not prove to be a successful marketing approach and further marketing will be addressed. A suggestion was made by a student that we approach companies in Winona that hire people part time and who then do not get health benefits from their companies. This is something we will think about as our needs increase. We have also considered expanding to Rochester with another faculty member who is willing to supervise students at the Winona State University campus in that community.

Record Keeping and Appointment Making

The client charts are stored in a locking file cabinet in Jo’s office. The forms that are used for basic information for the client are also stored there.

The interns are responsible for making appointments with the clients after the first appointment has been set up. The clients use a waiting area in the department office which is furnished with comfortable chairs and is away from the general student area. The clients are greeted by their counselors and/or Mary or Jo with limited waiting time. The counselor education administrative assistant does not facilitate appointment making and does not have any information regarding the clients, including their names or when they have appointments.

Future Goals for the Clinic

Because the training clinic is now nearly at capacity for two faculty, there is a possibility of engaging a third faculty member. The WSU Counseling Center which serves the student population on campus is requesting that we consider seeing students who need longer term therapy than their short term therapy allows. These students would be those that fit the criteria of our training clinic; that is, they would not have mental health insurance and would either not be on medications or their medications would be stabilized. If the clinic is to grow beyond the three clients per faculty member, we would be looking for some way to compensate the faculty with time and/or money. The connection with the nursing department is dependent on Winona Health being interested in continuing the free screening clinic which is going to be reviewed in 2012. If that connection is no longer available, alternative referral sources will be addressed. We are beginning to have more student interest as word of the training clinic spreads among the students.

Evaluation

We have begun giving clients who have been seen in the clinic satisfaction surveys regarding their experiences with the training clinic. Students who have been involved have already unanimously stated it has been an excellent experience for them and express disappointment when they have to leave the clinic when their internships have been completed. Further evaluation is another of our goals as we finish our first year and begin to assess what our needs are for the second year and beyond.

Summary

The psychology and counselor training literature has focused on the benefits and usefulness of an on-site training clinic. Much of the research and discussion is about how these clinics serve communities and provide program-focused supervision to counselors- in-training. The authors found their journey to be slow and cautious and the result is a solid foundation for future growth of a training clinic that serves the mental health needs of community members. The training clinic has provided multi-faceted results. The interns are obtaining live supervision and increasing the variety of clients they are serving; clients in the community are being seen who would not otherwise obtain counseling services; the faculty are able to know firsthand what skills the students have and which skills need more practice; and CACREP recommendations are being followed, thus improving the quality of the counseling program.

At the time of this writing, discussions between university administration, the university counseling services center, and the clinic director are focused on potential referrals of WSU students in need of more than “brief therapy” to the training clinic. The authors remain open and flexible to further opportunities to grow their clinic in unimaginable ways.