Competence to Practice

Building and Maintaining a Foundation for Doing

Good and Avoiding Harm
 Incompetent practice dramatically
increases the likelihood of harm to
a client
professional competence
O professional competence has three major
components
1. Knowledge
2. Skill
3. diligence
 COMPONENTS OF PROFESSIONAL
COMPETENCE

Knowledge
To be knowledgeable means:

 being schooled and up to date in the theory

and research of one’s field professional
 has a set of objective and scientifically
validated criteria for evaluating new theory
and research
 COMPONENTS OF PROFESSIONAL
COMPETENCE
O Pope and Vasquez (2011) refer to this
component as intellectual competence, or in
more simple terms, knowing about

O a graduate degree, even from an accredited

program, is only a starting point for
intellectual competence.
O Without continued study, a professional’s
knowledge base quickly erodes
O More recent research in professional psychology has
reduced the half life of knowledge related to clinical
practice to approximately seven years, and practice in
specializations such as clinical health psychology to
less than six years
 COMPONENTS OF PROFESSIONAL
COMPETENCE
Skill

O The second component of competence is

skill in successfully applying interventions
with clients, or as Pope and Vasquez (2011)
term it, knowing how.
COMPONENTS OF
PROFESSIONAL
COMPETENCE
 Researches divide this component into two
kinds of skills:

1. Clinical skill is the counselor’s appropriate

use of basic interviewing skills
2. Technical skill concerns effective use of
specific therapeutic interventions
 Clinical skills
O capacity to build a productive therapeutic
alliance, experience empathy, communicate
effectively, and sensitively explore a client’s
problem
O cultural competence, knowledge of ethical
and legal guidelines, and the ability to think
critically as additional foundational clinical
skills
 Technical skills
O exemplified by the ability to conduct desensitization for a
client with test anxiety or to administer an individual
intelligence test.
O Implicit in the general concept of skill is the capacity of the
professional to make judgments about which interventions
are appropriate in which situations.
O These judgments should be informed by the current
research on evidence-based practice which includes the
data from clinical trials and naturalistic studies of
interventions, evidence regarding the role of the
therapeutic relationship, client values and preferences for
services, and the judgment and skill of the professional
O To help students develop clinical judgment and
intervention skills, all mental health training programs
require field experiences such as practice and
internships as major parts of their degree
requirements.

O Applying knowledge with a client is a higher-order

process than comprehending that information, and no
one is competent until he or she has mastered both.
O The complexity of counseling and psychotherapy also
means that no single individual will be skillful in all
interventions, either at graduation or at any point in
his or her career.

O The staggering range of human problems, coupled

with the diversity of client backgrounds and
therapeutic interventions, renders universal
competence impossible.

O All practitioners must limit their work to some

subsample of problems nd populations. A clinician’s
limits of competence are also referred to as the scope
of practice
 Diligence
O Diligence, the third component of competence, has
two aspects.
O The first is a consistent attentiveness to the client’s
needs that takes priority over other concerns.
O A diligent professional gives deliberate care to
appropriate assessment and intervention for a client’s
problem and maintains that care until services are
completed.
O He or she also plans for follow-up and evaluation of
the quality and endurance of treatment effects
 Diligence means that the professional is
willing to work hard to benefit a client and is
ready to refer the client elsewhere if unable to
give competent help.
O The second aspect of diligence is self-knowledge,
rooted in self-reflection and humility about the
accuracy and comprehensiveness of our own
strengths and limitations.

O This aspect of competence has been called emotional

competence, that refers to capacity of the individual
for “self awareness and respect for ourselves as
unique, fallible human beings”
O It also encompasses a professional’s
commitment to self-care and self-monitoring

O We must be humble about our ability to

accurately identify our strengths and
weaknesses
O A diligent professional wants to be as sure as
reasonably possible about the diagnosis and the
treatment.
O (Note the words reasonably and sure; diligence does
not require obsessive concern with detail.)
O Diligence is also present in one’s willingness to engage
in additional research and consultation about a client’s
diagnosis and treatment.
O A diligent professional is also interested in following up
with clients who complete services, to gather data on
the long-term effectiveness of their interventions
The Competence Continuum
O competence takes intellectual and
emotional energy and is both a goal and a
reality for the individual and the profession.

O The competence continuum runs from

incompetent to exceptionally competent
 Spruill et al. (2004) used a similar model to
delineate five levels of competence from novice to
expert.
O A competent professional is always seeking
to enhance current skills and knowledge but
the aim is not perfection.

O one is deemed competent if, after education

and supervised practice, one can carry out
an intervention at least as well as
supervisors or colleagues.
 criterion
O A preferable criterion for competence is
one’s effectiveness in helping clients, in
developing plans for counseling, in
implementing those plans, and in evaluating
the outcomes of services
 aiming toward competent
counseling and psychotherapy
O —to be a “positive deviant,” to avoid settling
for minimally acceptable work and seek
instead to provide services to clients that
would be of the quality one desires for a
loved one.
professional performance
O Competence refers to a person’s
professional performance, not to abilities.
One may have the ability to perform
competently, but competence is judged in
the performance of the task itself
factors that can interfere
O Many factors can interfere with a capable
person’s performance.
O These factors range from environmental
circumstances (such as impossible work
demands) to unpredictable events (such as
a sudden illness in the middle of a session)
to a therapist’s mental health problems
(such as depression or burnout).
O Competent performance probably also varies from
client to client and day to day.

O No mental health professional performs at the

identical level of skill and diligence with every client.

O Fatigue, distraction, and stress are typical problems

that compromise competent performance.

O A more realistic standard is a set threshold level for

competent practice, defined as service that provides
the client with the likelihood of benefit
PROFESSIONAL STANDARDS
FOR PRACTICE
O All the major codes of ethics governing
mental health professions contain
statements about competence.

O Both the ACA and APA codes make lengthy

comments on the topic, underscoring its
importance
 ethical principles
O These standards derive from the ethical
principles of beneficence and non-
maleficence, the duty to do good and avoid
harm.
The codes designate the duty to monitor one’s
competence and make improvements as the
responsibility of the individual professional.

Finally, the codes stipulate that competence results

from a combination of formal education, supervised
practice, and continuing education, and indicate that
competence is a career-long endeavor not to be left to
chance or incidental encounters.
 Expanding the Scope of
Practice
O Professionals seeking to extend their
competence to a new area should develop a
systematic and comprehensive plan
consistent with existing standards.

O The APA Code also offers guidance for

establishing competence in emerging areas
of practice.
 untested approaches

O This standard imposes a duty to act to

become competent and to protect clients
and other consumers of such untested
approaches
 Case example
O The case of Candace Newmaker, the 9-year-
old girl who lost her life in a “rebirthing”
treatment for an attachment disorder, is the
most outrageous example of therapists who
were so convinced that they were justified to
use this highly risky intervention that they
allowed this girl to suffocate in the
constricting blanket that they used to
simulate rebirth.
 Emergency Situations
O Sometimes no one else is immediately
available to offer service to a client. The APA
Code, Standard 2.01e, clarifies the
responsibility of professionals in situations
where alternative service is not reasonably
accessible.
 Attaining competence
O It advises professionals that if their
competence is in an area closely related to
the service the client needs, professionals
may proceed with treatment, provided that
they make efforts to become competent
through training, consultation, and
supervision.
 Code
O The APA also advises professionals about
the ethics of competent service in
emergency situations in Standard 2.02,
stating that it may be permissible to provide
care beyond the scope of one’s competence
in an urgent situation, but that the duty is
also to refer to a qualified person as soon as
feasible
The Relationship Between Competence and
Professional Credentials
O Woody (1997) points out that some
“dubious and bogus” credentials have
emerged in mental health partly because of
increased competition in the marketplace
for clients and reimbursement.
O Practitioners “earn” these credentials by
paying the requisite fees; little additional
verification of their training or qualifications
is required.
CHALLENGES IN DEFINING THE
LIMITS OF COMPETENCE
O How do professionals determine the areas in
which they are competent, and how do they
develop new areas of competence during
the years they are practicing?
O The codes give reasonable direction in this
area in Sections C.2.a and C.2.b (ACA, 2014)
and APA Code, Standard 2.01 (2010a).
Before one can claim competence in any
new procedure, population, or assessment
tool, formal training is necessary.
O Formal training typically entails structured
learning, reading, and discussion with
experts. The length and intensity of
instruction depends on the complexity of the
new competence, its potential to help or
harm, and the prior background of the
professional.
O Some weekend workshops and brief
seminars are advertised as training for
professionals in new interventions
O Thus, when looking for continuing education
experiences to expand their competencies,
professionals need to ascertain whether the
proposed training
O (1) is based on scientific evidence, objectively
obtained;
O (2) includes sufficient classroom time for learning;
O (3) is offered by a professional with expertise in the
area; and
O (4) provides opportunities for supervised practice
and recommendations for obtaining additional
supervised experience.
Limits of Competence With
New Client Populations
O The boundaries of competence extend not
just to interventions such as play therapy or
career counseling but also to new
populations.
O A person may be skilled in career counseling
for one cultural group or age group but may
be insufficiently competent to use that
intervention with other age groups or
cultural groups
 particular populations
O Competent work with particular populations
also assumes knowledge of the group and
demonstrated skill in working with that
group. A college counselor who applies the
career counseling approaches he uses with
university students to middle school
students is unlikely to help those children
 Adapting the therapy
O The counselor has failed to adapt his
intervention to their developmental level and
may thereby have inflicted unintended
negative effects on the children.
O The professional associations recognize the
need for knowledge and skill in working with
different populations in two major ways.
O First, in addition to its statements in the
ethics code, the APA has published
numerous guidelines for working with
diverse populations
 Limits of Competence in Rural
Environments
and Small Communities
O One challenge in working within the boundaries of
competence arises from the geographical location of a
given professional practice

O practitioners in rural areas and small communities do

not have many referral sources nearby

O local mental health professional is the only available

source of services. If he or she cannot provide
services, clients may not seek further help and may try
to cope on their own.
 professionals in rural areas usually practice as
generalists

O The ethical challenge for rural and small community

professionals is to provide
O competent service across a wide range of issues, age
groups, and populations
 What criteria should rural practitioners use
when client request is beyond the limits of
their competence?
O First, principle of non maleficence—avoiding harm to
clients.
O Clients who are at risk for significant harm from an
incompetently administered intervention are better
served by a referral, in spite of the inconvenience.

O Second, professionals should evaluate the opportunity

to do good and compare the risk of harm to the
opportunity to help.
 online treatment options

O Thankfully, the advent of the Internet has

provided easier access to a variety of
educational and consultation resources for
rural mental health professionals.
O It has also offered consumers online
treatment options
 Haas and Malouf (2005) recommend that mental health
professionals ask themselves two other questions when
they are unsure about their competence

 The first question is, “Are you emotionally able to help the
client?”

 They suggest that counselors and therapists ask

themselves whether they can maintain objectivity in the
situation.
 some client issues can be strong triggers for some
practitioners, and those safeguards are insufficient.

 Referral is then the safest choice.

 Taking these steps helps the professional maintain what
Pope and Vasquez (2011) refer to as emotional
competence.
O The second question Haas and Malouf suggest is,
“Could you justify your decision to a group of your
peers?”

O They also refer to this as the “clean, well-lit room

standard,”

O which means that any action that a practitioner would

feel comfortable describing in an open discussion with
his or her peers is likely to be appropriate.
The Limits of Competence: Case Examples
 The first step in determining whether Mrs. Varos
should accept this couple as clients is to
ascertain whether she has the requisite
knowledge of sex therapy.
 Knowledge usually means formal education,
which she lacks
 The second issue is whether she has
enough supervised experience in sex
therapy to be skillful in its application.

 She has no such experience, which is a

significant obstacle to demonstrating
competence in sex therapy
 argument for referral
 On the other hand, the availability of a
colleague with expertise to help this couple
may constitute an argument for referral.
 Why risk harming or simply not helping this
couple when another professional with
proven skill is easily accessible?
 The clean, well-lit room standard also can be
useful in evaluating the situation.
 Informed consent
O Regardless, if Mrs. Varos is to continue as
their counselor, the clients must be informed
of her novice status (in this intervention) and
of the close supervision she is receiving.

O If they agree to service under these

conditions, then it would be ethical to
continue working with them.
 DISTRESS, BURNOUT, AND OTHER
COMPETENCE PROBLEMS
O One of the hallmarks of clinical work is the
pervasiveness of ambiguity and uncertainty

O As Skovholt and Starkey (2010) suggest, no

Holy Grail of counseling exists and no
amount of experience guarantees perfectly
competent service
 We repeatedly see the pain and destructiveness of
people, and although we can usually offer help and
hope to those in need, we have no magic wand to
cure suffering.

 The cumulative effects of witnessing so much human

suffering can wear down even the most competent
professionals unless they are committed to self-care.
 burnout
syndrome
O A true burnout syndrome consists of
emotional exhaustion, the loss of a sense of
accomplishment in one’s work, and a
depersonalization of those served
 work in crisis situations
o Professionals who regularly work in crisis situations
with those traumatized by violence, war, and natural
disasters sometimes experience a form of trauma
themselves.
o They may suffer from the very symptoms of post-
traumatic stress that they are treating, a
phenomenon labeled in the literature as
o compassion fatigue, vicarious traumatization, or
secondary post-traumatic stress disorder
According to VandeCreek and Jackson
(2000), the primary manifestations of
compassion fatigue include

 withdrawal and isolation from others,

 inappropriate emotionality,
 loss of pleasure,
 loss of boundaries with the client
 a sense of being overwhelmed or pressured
 therapists who feel a very high level of responsibility
for their clients, avoid strong emotions, rigidly adhere
to a preferred clinical model, and have strong
allegiance to the stance of the therapist as an agent
of change have higher levels of these problems.

 On a positive note, Thompson, Amatea, and

Thompson (2014) found that a supportive work
environment reduced the intensity of compassion
fatigue in mental health workers when treating
trauma.
 personal lives
 Counselors and therapists have their share of
emotional challenge in their personal lives, too.
 They simultaneously juggle careers, family
responsibilities, relationships, and civic duties, and
sometimes get hit broadside by unexpected problems.
 If the distress is temporary, the usual coping
mechanisms of taking time off, restructuring
responsibilities, or getting support from colleagues
and loved ones usually prevent any compromise in
competent performance
 comprehensive model for self-
care
O that focuses on four principles:

1. an emphasis on flourishing
2. intentionality in action
3. awareness of reciprocity in care of self and others
4. and the incorporation of deliberate self-care
strategies into daily professional and personal
activities
 compassion satisfaction
 Thompson et al. (2014) also suggest that
compassion satisfaction.

 a term they apply to the experience of

feeling satisfaction from helping clients and
seeing them recover from distress and
trauma.
 Bearse, McMinn, Seegobin, and Free (2013) have
identified a number of barriers that interfere with
psychologists’ willingness to seek therapy:

 problems in finding the right therapist

 lack of time, money, or both;
 the stigma of being less than fully
stable;
 difficulty in admitting personal distress.
Avoiding Harm to Clients From Distress
and Emotional Exhaustion
 monitoring their own emotional status and
stress levels, counselors and therapists can
take additional actions to prevent a level of
distress that compromises work
performance
Recognize the risks of mental health
practice, and celebrate its rewards

 get support from colleagues.

 Isolation increases the risk of compromised
competence
 Many flourish! They feel wiser, more aware,
and more able to enjoy life because of their
profession.
 In the face of the stresses of the work,
professionals need to maintain focus on the
less tangible benefits it provides them.
 Set clear limits about how much help
you can humanly give
O Out of good intentions, mental health professionals
sometimes overpromise and overcommit.
O Also related to the personality characteristics
that initially drew these professionals to this work—

 a heightened capacity for empathy with people in

need,
 a perfectionism about work tasks,
 a sense of self-doubt that encourages one to keep
doing more to be worthy of others’ good judgments.
 Use the advice you give to
clients about self-care
All too often counselors fail to take time
for themselves even as they admonish
client after client about the importance
of self-care
 divides self-care into two
major components
1. professional self-care, including continuing
education, consultation and supervision,
networking, and stress management;
2. personal self-care, including healthy
personal habits, attention to relationships,
opportunities for relaxation and
centeredness, and self-exploration and
awareness.
Recognize your vulnerability, and seek
support when overwhelmed
O The combination of work stress and life’s
complexity often leads to emotional
difficulties.
O Acknowledging these difficulties is a
strength, not a weakness
 Consider counseling or
psychotherapy
O Consider counseling or psychotherapy for personal
problems, even if not overwhelmed by them.

O Practicing clinicians might also consider occasional

returns to therapy, perhaps for just a session or two, to
bolster their current functioning and redress any
emerging problems
O Prepare for possible symptoms of secondary post-
traumatic stress when crisis intervention is the
predominant mode of service and take full
advantage of support services.

O Professionals should be especially careful to avoid

emotional isolation and social withdrawal from others
when undertaking this form of practice.
 quality assurance programs
O Work to develop quality assurance programs in
your work setting to reduce errors and thereby
improved the overall effectiveness of service.