Administrative Policies and Procedures

Each trainee has areas of growth that need to be addressed over the course of the training year. In most cases, these issues are addressed and resolved through ongoing supervision. In other cases, an individualized remediation plan is needed. The University of San Diego Counseling Center Internship has several benchmarks on the Intern Evaluation form that interns need to meet on all learning elements throughout the year. If an intern does not meet those benchmarks, an individualized remediation plan will be created. The intention of an individualized remediation plan is to assist the intern in meeting the minimum level of achievement by the end of the internship. Although such problem areas could, in the worst-case scenario, result in trainee dismissal, the great majority of trainees participate in remediation plans and successfully meet the minimum level of achievement by the end of the internship. While considering these issues can be anxiety-provoking for the trainee, it is also important that procedures are clear so those for whom problems do arise have a predictable and non-arbitrary process of resolution.

This section considers trainee concerns; procedures for trainee grievances regarding training staff or the training program are provided later in this section and the university’s policies and procedures manual outlines the steps followed when corrective action is taken for university employees. The Policies and Procedures Manual is located at sandiego.edu/legal/policies/ Section 2.2.2.

Throughout this document, the use of the term “Coordinator” will refer to the Coordinator of Training. When needing to refer to these procedures in an abbreviated fashion, the term “procedures” will be used. Finally, although this document provides detailed steps that serve as the general framework for our procedures, these steps may be modified depending on the needs of the situation. In such cases, the rationale for the modifications will be documented.

The components of Procedures to Address Remediation Issues include:

• Orientation. During trainee orientation, trainees are informed of the overall evaluation process and the guidelines for processing trainee competency and performance issues. Trainees are issued a copy of the MHBH Training Program and Procedures and Guidelines, which includes written descriptions of these procedures. Trainees are encouraged to consult with the Coordinator with any questions about these procedures.
• The evaluation process. Evaluation is ongoing throughout the internship and involves the input of many training staff. Written evaluations (Intern Evaluation Forms) of the intern’s progress occur at 4 points of the internship: id-Fall, mid-year, mid-Spring, and end-of-year. Primary responsibility for the collection of data about trainee skills and growth areas rests with the primary supervisor, the trainee, the Coordinator, and other training staff. Settings in which this process may happen include supervision, group supervision, supervision of supervision, seminars, trainee meetings with the Coordinator, and staff meetings.

Aspects of the evaluation process take place as follows:

1. At the beginning of each supervision period (August-January, February–July) an intern is paired with a primary supervisor and goals are defined for supervision.
2. Interns are given verbal feedback throughout the supervision process. They are given written feedback (Intern Evaluation Form) at the midpoint of the academic semesters (mid-Fall and mid-Spring).
3. Feedback may be provided as needed to any trainee as needed by any member of the supervisory staff.
4. Written evaluations also take place at the end of the supervisory periods (mid-year and end-of-year). These evaluations are sent to the trainee’s home program describing their progress/completion of the internship.
5. Further information about the evaluation process is delineated in the evaluation section of the intern training manual.
6. Guidelines for processing trainee competency and performance issues are described below.
7. Intern grievance procedures are described below.
8. Interns are subject to university procedural guidelines and codes of conduct, outlined in the USD Policy Manual (see sandiego.edu/legal/policies/).

Trainee performance standards

• Act at all times within the bounds of the APA Ethical Principles of Psychologists and Codes of Conduct.
• Act at all times within the bounds of the laws and regulations of the State of California.
• Follow the policies and procedures defined in the USDCC Policies and Procedures Manual.
• Demonstrate adequate proficiency in all learning elements defined in the trainee evaluation forms.
• Maintain professional and collegial relationships within the USDCC and the larger university community.
• Maintain timely, accurate documentation of clinical services.
• Communicate clearly, accurately, and professionally in both verbal and written formats.
• Demonstrate sensitivity to diversity in all professional activities.
• Demonstrate engagement in the training experience with active participation in seminars and evaluation processes.
• Assist as needed with general counseling center duties, including crisis coverage and outreach.

Intern and Program Rights

As employees of the USDCC, trainees have rights and responsibilities regarding evaluation. The following summarizes trainees’ rights and responsibilities while completing their training year at the USDCC.

Trainee rights regarding these procedures:

1. USDCC will provide the intern with a reasonable opportunity to remediate problems.
2. USDCC will provide the intern with clear structured steps to remediate the problems.
3. USDCC will provide adequate support and supervision to assist the intern with their individualized remediation plan
4. USDCC will treat the intern with respect, and handle all manners in a professional and ethical way.
5. USDCC will inform interns of procedural guidelines, including appeal and grievance procedures.
6. USDCC will provide interns with a written summary of evaluation processes and procedures.
7. USDCC will provide interns with timely feedback on problem areas and areas of strength.
8. USDCC will communicate regularly with interns’ home programs about difficulties with an intern’s performance and will solicit input when appropriate.
9. USDCC will create appropriate documentation of any disciplinary action.

Doctoral Internship Program rights regarding these procedures:

1. USDCC has the right to implement Due Process procedures at any time if they feel that trainee competency or behavioral problems occur.
2. USDCC has the right to be treated in a manner that is respectful, professional, and ethical.
3. USDCC has the right to determine the appropriate course of action for an intern (e.g., individualized remediation plan, probation, suspension, termination)

Due Process Procedures

At any point during the training year, the trainee’s performance/behavior may be observed to be inadequate or problematic. When a trainee demonstrates inadequate performance or fails to meet performance expectations delineated above, the following guidelines will be followed.

A. Defining Problematic Behavior

Problems are broadly defined as “an interference in professional functioning that is reflected in one or more of the following ways:

1. An inability and/or unwillingness to acquire and integrate professional standards into one’s repertoire of professional behavior;
2. an inability to acquire professional skills to reach an acceptable level of competency;
3. an inability to control personal stress, psychological dysfunction, and/or excessive emotional reactions that interfere with professional functioning” (Lamb et al., 1987, p. 598; Elman & Forrest, 2007).

It is at times quite difficult to discern whether a training problem is transitional, or whether it constitutes a more serious difficulty. While professional judgment must be exercised in making this assessment, the presence of one or more of the following factors would tend to imply the presence of a serious problem:

1. The trainee does not acknowledge, understand, or address the problem when it is identified;
2. The problem is not merely a reflection of a skill deficit that can be rectified by academic or didactic training;
3. The quality of services delivered by the trainee is sufficiently adversely affected;
4. The problem is not restricted to one area of professional functioning;
5. A disproportionate amount of attention by training personnel is required,
6. and/or the trainee’s behavior does not change as a function of feedback, remediation efforts, and/or time (Lamb et al., 1987)
7. The level of responsiveness a supervisee is to general feedback (Falender and Shafranske, 2021)

It should be noted that such problems reflect situations of departure from a baseline level of functioning (Forrest et al., 1999). This should be distinguished from incompetence, where the functioning was never at the expected level to begin with.

B. Procedures for Responding to Inadequate Performance by a Trainee

Consultation with the USD Human Resources may occur at any time during any remediation process. The following notes describe the steps that will generally be taken when assessing and dealing with a trainee problem area. Because each situation is unique, these procedures may be modified when needed, but the general intent of the document should be preserved.

Initial Procedures: Assessing the Problem

1. In the first stage of the process, a problem area is identified. At any point during the training year, any member of the training staff may identify an area of concern regarding a trainee.
2. When a problem area is identified, the involved staff member consults with the Coordinator and primary supervisor, if applicable.
3. The Coordinator and the involved staff member(s) determine whether the problem can be resolved with an informal review or formal review.

Informal Review

The problem would be typical of many interns, believed to be amenable to change through supervision/support, and unlikely to cause serious harm to the clients, students, staff, or agency. The primary supervisor or Coordinator of Training will meet with the intern, express their concerns, and point out specific learning elements AND/OR USD Policies and Procedures that the intern is failing to meet. This may include increased supervision, didactic training, and/or structured readings. The Primary Supervisor or Coordinator of Training should clearly inform the intern that they are receiving an “Informal Review.” Interns will also be informed of how USDCC plans to monitor the progress through the informal review. The Primary Supervisor and/or the Coordinator of Training should monitor the progress throughout the informal review.

Formal Review

A Formal Review can occur if:

1. A problem continues to occur following an informal review
2. An intern does not meet a set benchmark for any learning element at any of the intern evaluations (e.g., 2 or less at mid-Fall, 5 or less at mid-year, 6 or less at mid-Spring)
3. The problem is deemed severe enough to bypass an informal review

Procedures for a Formal Review:

1. When the Coordinator of Training and the Primary Supervisor has determined that a Formal Review is needed, the intern will be provided with a Written Notice that a Formal Review process is beginning and a hearing will be held.
   1. The Coordinator of Training has the right to place the intern on temporary suspension (with pay) if the problem is deemed to cause potential harm to clients, staff, or the University. This temporary suspension can take place as soon as the written notice is provided to the intern, and will be lifted (or extended depending on the outcome of the hearing) as soon as the Outcome of the hearing is given.
2. The Hearing must take place within 10 business days of the written notice. The Hearing will involve the Coordinator of Training and the Primary Supervisor (or another licensed psychologist if the CoT is the Primary Supervisor). The problem will be reviewed and a plan will be developed to address the issue. The intern will have the opportunity to present their perspective as well as an option to submit a written response to the problem.
3. The Outcome of the Hearing must be communicated to the intern in writing within 5 business days. The result of the Hearing can result in the options listed below:
   1. Official Notification of a Problem. One option is an intern can be provided with a written notice that acknowledges that:
      1. The Coordinator of Training and Primary Supervisor are aware of the problem and have concerns
      2. The problem has been brought to the attention of the intern
      3. The supervisors will work with the intern, identify specific steps the intern needs to take to rectify the problem or increase their evaluation rating on a learning element
      4. That the problem is not severe enough to require an individualized remediation plan at this time
   2. Individualized Remediation Plan. The outcome of the hearing might also result in an individualized remediation plan. This results in the Coordinator of Training, the Primary Supervisor, and the Training Committee actively monitoring, for a set period, the degree to which the intern addresses, changes, and/or improves the problematic behavior and/or skill deficit. Being placed on an Individualized Remediation Plan is considered a probationary status for the intern. The length of the Individualized Remediation Plan is set by the Hearing Outcome. The Remediation Plan will be shared with the intern in writing, and USDCC will also notify and provide the documentation of the Individualized Remediation Plan to the intern’s home doctoral program. The Individualized Remediation plan will include:
      1. Detailed information about the problematic behaviors or skill deficits
      2. Specific actions being taken to rectify the problem
      3. The time frame in which the problematic behavior or skill is expected to be appropriately remediated
      4. The procedures in place that will determine whether the problem has been appropriately remediated

At the end of the set time frame for the Individualized Remediation Plan, the Coordinator of Training will provide a written statement to the intern and the intern’s home program regarding whether the intern has successfully remediated the problem. This written statement will be added to the intern’s permanent file. If the problem has not been remediated, the Coordinator of Training may choose to extend the remediation timeline and/or adopt specific actions to rectify the problem. A new specified time frame and changes in the remediation plan will be documented and sent to the intern and the intern’s home program.

C. Suspension

The intern is placed on paid suspension. Suspension includes being removed from all clinical services for a specified time period. During suspension, the intern may be assigned additional readings, supervision, and didactic training. The intern may also be required to shadow or be shadowed by staff for a set period of time whenever doing clinical work or engaging with students or campus partners. The intern and intern’s home program will also be provided with a written Suspension Plan. The written Suspension plan will include:

1. Detailed information about the problematic behaviors or skill deficits
2. Specific actions being taken to rectify the problem
3. The time frame in which the problematic behavior or skill is expected to be appropriately remediated
4. The procedures in place that will determine whether the problem has been appropriately remediated

At the end of the set time frame for the Suspension Plan, the Coordinator of Training will provide a written statement to the intern and the intern’s home program regarding whether the intern has successfully remediated the problem and if the suspension will be lifted. The intern may also be placed on an Individualized Remediation Plan following suspension (see steps for an Individualized Remediation Plan above). This written statement will be added to the intern’s permanent file. If the problem has not been remediated, the Coordinator of Training may choose to extend the suspension timeline and/or adopt specific actions to rectify the problem. A new specified time frame and changes in the suspension will be documented and sent to the intern and the intern’s home program. The intern may also face Termination following the end of a suspension period.

D. Termination

If the problem is not rectified by the above processes, or if the problem represents gross misconduct or ethical violations that have the potential to cause harm, the intern’s placement within the internship program may be terminated. This decision will be made by the Training Committee and a Human Resources representative. Termination is final, and the intern will not have the option to start again in the new training year. Termination also indicates that the intern has failed the training program and will not receive a certificate of completion. USDCC will notify the intern in writing, the home program in writing, and APPIC of the decision to terminate.

Appeal Process

The intern is able to challenge any decision made at any step of the Due Process procedures. The intern has the option of requesting an Appeal Hearing before the Training Committee. In order to request an Appeal Hearing, the intern must submit in writing to the Coordinator of training an “Appeal Hearing Request” within 5 working days of the initial Due Process notification. The Appeals Hearing must be held within 10 working days following the submission of the written “Appeal Hearing Request.” The Appeal hearing will be conducted by a review panel which will include the Coordinator of Training, the Director, and the Primary Supervisor (or another licensed psychologist if the Coordinator of Training or the Director is the primary supervisor). The intern may also request a specific member of the training committee to serve on the review panel. The Appeal Hearing will include a review of the written materials, and the intern will have the opportunity to explain their case, as well as answer questions. The Appeal Hearing can result in the following options:

1. Uphold the previous Due Process decision
2. Modify the Due Process decision
   • If the intern is dissatisfied with the result of the review panel, they may appeal the decision in writing to the Director of the Counseling Center. If the intern is dissatisfied with the decision of the Director of the Counseling Center, they may appeal the decision in writing to the AVP of Student Wellness. The decision of the AVP of Student Wellness is final, and no further appeals may be made. Decisions regarding the appeal process will be shared with the intern and the intern’s home program.

Grievance Procedures

When a trainee has a complaint or grievance about a supervisor, staff member, fellow trainee, or the program itself, the Trainee may wish to file a formal grievance. These cases are divided below into separate sections, appeals (of evaluations and of other issues) and grievances. Trainees who pursue grievances in good faith will not be penalized in any way for taking this action.

Informal Review

When the trainee has an issue with a staff member’s behavior, the trainee should first attempt to discuss the situation with the staff member in question.

Formal Review

If this is not possible, if this does not resolve the situation to the trainee’s satisfaction, or if the trainee prefers not to handle the complaint directly, the trainee may submit a formal grievance in writing to the Coordinator of Training. If the grievance is regarding the Coordinator of Training, the trainee may go directly to the Director. The Coordinator of Training (or the Director if the grievance is about the Coordinator of Training) must meet with the trainee within 10 business days of filing the grievance.

The Coordinator of Training (or Director) may meet with the intern and individual the grievance is filed against separately first. The Coordinator will ordinarily convene a meeting with the trainee and the staff member involved in an attempt to mediate the situation and arbitrate a resolution. If the grievance is related to an aspect of the training program (e.g., policy, requirements) the Coordinator of Training and the Director will meet with the intern jointly. The goal of the meeting is to develop a plan to resolve the matter.

Meeting agenda:

• Document the behavior/issue associated with the grievance
• Develop specific steps to rectify the problem
• Design a way to determine if the problem has been rectified
• Plan to meet 10 business days following the meeting to discuss whether the issues have been adequately resolved
• Document the process and outcome of the meeting

If the plan to rectify the problem fails, a review panel consisting of the Coordinator, the Director, and two staff members chosen by the trainee (if the grievance is about the Coordinator of Training or the Director, the AVP of Student Wellness will take their place). The review panel must take place within 10 working days for the meeting that determined the plan failed. The review panel will review all written material and have the opportunity to interview the parties involved. The review panel will have final discretion regarding the outcome.

The review panel should involve Human Resources if it is inappropriate to resolve the issue internally. The review panel also has the right to involve Human Resources at any time.

Other Resources

APPIC provides an informal problem-resolution consultation service. Trainees or training staff experiencing concerns about the conduct of either a training staff member or a trainee may consult APPIC. Trainees always have the right to consult with their academic training programs in the event that problems arise in their traineeship. Finally, if problems are not resolved to their satisfaction, trainees have the option of making formal complaints to APA, APPIC, or the California Board of Psychology.

Nondiscrimination Policies

The University of San Diego Internship Program abides by the University of San Diego’s nondiscrimination policies.

The internship program is also consistent with APA’s “Preparing Professional Psychologists to Serve a Diverse Public.”

Training environments foster the ability of trainees to provide competent care to the general public, and trainees’ competencies in professional practice are evaluated regularly. Some trainees possess worldviews, values, or religious beliefs that conflict with serving specific subgroups within the public. For example, they may experience strong negative reactions toward clients/patients who are of a particular sexual orientation, religious tradition, age, or disability status. Trainers take a developmental approach to trainee skill and competency acquisition and support individual trainees in the process of developing competencies to work with diverse populations. Trainers respect the right of trainees to maintain their personal belief systems while acquiring such professional competencies. Trainers also model the process of personal introspection; the exploration of personal beliefs, attitudes, and values; and the development of cognitive flexibility required to serve a wide diversity of clients/patients. Training to work with diverse clients/patients is integral to the curriculum and consists of both didactic coursework and practical training.

Training programs, trainers, and trainees cannot be selective about the core competencies needed for the practice of psychology because these competencies are determined by the profession for the benefit of the public. Further, training programs are accountable for ensuring that trainees exhibit the ability to work effectively with clients/patients whose group membership, demographic characteristics, or worldviews create conflict with their own. Trainers respectfully work with trainees to beneficially navigate value- or belief-related tensions. At times, training programs may wish to consider client/patient reassignment so trainees have time to develop their competence to work with clients/patients who challenge trainees’ sincerely held beliefs. Trainers utilize professional judgment in determining when client/patient re-assignment may be indicated in this situation as in all other possible situations in which client/patient re-assignment may be considered. The overriding consideration in such cases must always be the welfare of the client/patient. In such cases, trainers focus on the trainees’ development, recognizing that tensions arising from sincerely held beliefs or values require pedagogical support and time to understand and integrate with standards for professional conduct. Thus trainees entering professional psychology training programs should have no reasonable expectation of being exempted from having any particular category of potential clients/patients assigned to them for the duration of training.”

https://www.apa.org/ed/graduate/diversity-preparation?tab=1

Interns are also evaluated for nondiscrimination practices under the Individual and Cultural Diversity competency.

The University of San Diego is committed to upholding standards that promote respect and human dignity in an environment that fosters academic excellence and professionalism. It is the policy of the university to maintain an educational and work environment free from all forms of unlawful discrimination and harassment.

The University of San Diego Internship Program prohibits and does not tolerate unlawful discrimination against or harassment of its employees, students, or applicants for employment or admission on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, age, physical disability, mental disability, or other characteristic protected by federal or state law unless a particular characteristic is a bona fide requirement of the position.

All members of the university community are expected to uphold this policy. Engaging in unlawful discrimination or harassment will result in appropriate disciplinary action, up to and including dismissal from the university.

Discrimination

Unlawful discrimination may occur when an individual is treated less favorably than with respect to the terms and conditions of employment or education, or with respect to the individual’s receipt of employment or educational benefits, because of their membership in a protected class. Accordingly, all employment-related decisions, including but not limited to decisions relating to recruitment, hiring, promotion, transfers, benefits, and any other terms and conditions of employment, will be made without regard to the employee’s or applicant’s race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, age, physical disability, mental disability, medical condition, covered veteran status, genetic information, or other characteristic protected by federal or state law. Similarly, all education-related programs and activities, including but not limited to admissions, financial aid, academic programs, research, housing, athletics, and other extracurricular activities, will be administered without regard to the student’s or applicant’s race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, age, physical disability, mental disability, or other characteristic protected by federal or state law.

The university does not by this non-discrimination statement disclaim any right it might otherwise lawfully have to maintain its commitment to its Catholic identity or the teachings of the Catholic Church.

Harassment (Sexual Misconduct and Relationship Violence)

Title IX of the Educational Amendments of 1972 prohibits discrimination on the basis of sex in education programs and activities operated by recipients of federal financial aid assistance. Sex harassment, including sexual violence, is a form of prohibited sex discrimination. The Violence Against Women Reauthorization Act of 2013, including the Campus Sexual Violence Elimination Act, requires colleges and universities to have procedures in place to respond to incidents of sexual assault, domestic violence, dating violence, and stalking. In order to address its responsibilities under these laws, the university has implemented standards, reporting procedures, and response protocols that apply to incidents of sexual assault, domestic violence, dating violence, stalking, and sexual exploitation. For more information, please see the university’s Sexual Misconduct and Relationship Violence Reporting and Response Standards and Protocols.

Complaint Procedure

The university encourages any person who feels that they have been unlawfully discriminated against or harassed, or observes or is otherwise aware of an incident of unlawful discrimination or harassment, to report the incident promptly. To assist in the investigation, the university may request that a complaint be made in writing with a detailed description of the facts giving rise to the complaint, the names of any individuals involved, including any witnesses, and copies of any documents that support or relate to the complaint. Although the university may request the submission of a written complaint, an oral complaint is sufficient to initiate the procedures set forth under this policy.

Complaints should be made to any of the following people who are the university’s designated officers for handling the complaints and implementing the university’s policy against unlawful discrimination and harassment:

1. Complaints Against Administrators or Staff:
   • Director of Title IX, EEO, and Employee Relations
     Maher Hall, Room 101
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4594
2. 2. Complaints Against Students:
   • Vice President for Student Affairs
     Hann University Center 232
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4588
   • Dean of Students
     Hann University Center 232
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4588
3. Complaints Against Faculty:
   • Vice President for Academic Affairs and Provost
     Hughes Administration Center 214
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4533
   • Dean, College of Arts and Sciences
     Founders Hall 114
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4545
   • Dean, School of Business
     Olin Hall 341
     5998 Alcalá Park
     San Diego, CA 92110
   • Dean, School of Leadership and Education Sciences
     Mother Rosalie Hill Hall 205
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4540
   • Dean, School of Law
     Warren Hall 200
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4527
   • Dean, Hann School of Nursing and Health Sciences
     Hann School of Nursing
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4550
   • Dean, Joan B. Kroc School of Peace Studies
     KIPJ 123
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-7919
   • Dean, Shiley-Marcos School of Engineering
     Loma Hall 336
     5998 Alcalá Park
     San Diego, CA 92110
     (619) 260-4627