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Remediation and Termination of Impaired Students in CACREP-Accredited Counseling Programs

Module by: Chi-Sing Li, Jerry Trusty, Richard Lampe, Yu Fen Lin. E-mail the authors

Summary: The researchers of this study investigated how frequently a set of 17 non-academic behavioral indicators were used to determine impairment of master’s-level counseling students that resulted in remediation and termination. Thirty-five academic unit leaders of the Council for Accreditation of Counseling and Related Educational Programs (CACREP) participated in a telephone survey, and information about 86 cases of impaired students were collected and analyzed using descriptive methods. Of the 17 impairment indicators, 15 were cited by participants as reasons for remediation of impaired students in their programs. All 17 were cited as reasons for termination of impaired students in their programs.

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This module has been peer-reviewed, accepted, and sanctioned by the National Council of Professors of Educational Administration (NCPEA) as a scholarly contribution to the knowledge base in educational administration.

The issue of impaired students in the field of counseling and psychology according to Huprich and Rudd (2004) has been a growing concern, and the literature on impairment has been more available in the last decade. Gizara and Forrest (2004) stated that training programs carry a burden to protect entry to the profession and recommended that counselor educators should address impairment during training, because many problems begin during the period of academic and clinical training. Moreover, the demands of training render some students vulnerable to stress and burnout which may result in impairment (Lamb & Swerdlik, 2003). Therefore, it is important to address impaired students early in their career preparation because impaired students may become impaired professionals.

Student Impairment and Ethical Guidelines

The American Counseling Association (ACA) Code of Ethics provides guidelines for addressing the issue of impairment (ACA, 2005). The standard requires supervisors to assess students on academic and personal limitations, provide remedial assistance, and dismiss those who are unable to provide competent services.

The Association for Counselor Education and Supervision Ethical Guidelines for Counseling Supervisors (ACES) provide basically the same directives regarding assessment, remedial assistance and dismissal of impaired students (ACES, 1993, Section 2.12). In addition, they instruct supervisors not to endorse a supervisee for certification, licensure, completion of an academic training program, or continued employment if the supervisor believes the supervisee is impaired.

The Council for Accreditation of Counseling and Related Educational Programs standards (CACREP, 2001) as well as the Ethical guidelines of ACA (2005) and ACES (1993), all require faculty and supervisors to assist students who are impaired by developing a remediation plan with the students, giving them an opportunity to address concerns. Clearly it is the ethical obligation of the faculty to protect clients and to recommend remediation alternatives to impaired students (Enochs & Etzbach, 2004).

Remediation Alternatives and Termination of Impaired Students

Burgress (1995) stated that remediation was the most frequently reported method of handling impaired students, and remediation was attempted (77%) more than termination (31%). Referring the student to therapy was one of the most recommended prescriptions (Russell & Peterson, 2003). Besides attending therapy, two other frequently used remedial alternatives were increased supervision and repeating academic coursework. Other possible ways of remediation include “tutoring, special seminars or extra coursework, peer support groups, special assignments, and referral to an ombudsperson” (Russell & Peterson, p. 331).

When remediation attempts are unsuccessful or when an impaired student refuses assistance, counselor educators are challenged with the decision of whether or not to terminate the student (McAdams III, Foster, & Ward, 2007). According to Burgress (1995), there is a three to four percent impairment rate among counseling programs over a five-year period. Research in this area also focused on due process which ensures students’ rights and the proper program procedures (Kerl, Garcia, McCullough, & Maxwell, 2002). Research suggested that a lack of due process rights and termination procedures could affect all students and programs (McAdams III et al.).

Problems and the Purpose of the Study

Identifying student impairment, however, is not a simple task. There are various explanations of impairment, but there is no single acceptable definition among counselor educators (Burgress, 1995; Huprich & Rudd, 2004; Woodyard, 1997). Huprich and Rudd stated that the lack of uniform meaning of impairment can be problematic in dealing with the issue. There are different types of impairment ranging from academic difficulties to major psychological disorders (Bradey & Post, 1991; Gizara & Forrest, 2004; Mearns & Allen, 1991). However, descriptions of these types are broad and overlapping and are not agreed upon by counselor educators and supervisors (Woodyard). Bemak, Epp and Keys (1999) concluded that it is necessary to define impairment with greater clarity. In order to more objectively and effectively identify student impairment, a set of specific non-academic behavioral indicators that reflect students’ serious personal limitations are necessary (Li, Trusty, Nichter, Serres, & Lin, 2007).

Huprich and Rudd (2004) suggested that the lack of a clear definition of student impairment creates difficulty for counselor educators and prevents them from taking action in evaluating students. Having a set of non-academic behavioral indicators of student impairment would help to establish formal evaluation policy and procedures and also strengthen the ongoing screening process (Li et al., 2007). Counselor educators would be able to communicate program expectations with their students by providing more concrete written guidelines. Counselor educators would be poised to identify impaired students more effectively and to address impairment with specific remediation plans or termination.

Identification of non-academic behavioral indicators of impairment, when applied to counseling programs, can help students identify problem areas and provide a means for self-evaluation and self-screening while they are in those programs (Li et al., 2007; Woodyard, 1997). With the recognition of behavioral indicators of impairment, students will more clearly understand expectations and requirements of their counseling programs.

Researchers have attempted to identify specific behavioral indicators of impairment (Burgress, 1995; Li et al., 2007). However, different studies have produced various outcomes as to which indicator(s) depict student impairment. In addition, there is no understanding of how frequently specific non-academic indicators are used to help counselor educators in identifying impaired students. The following research questions, related to counselor preparation units with one or more CACREP-accredited programs, were investigated during this study:

1. How frequently, among cases identified by the participants, was each of the indicators of impairment used as a basis for requiring remediation in order for the student to continue in the program?

2. How frequently, among cases identified by the participants, was each of the indicators of impairment used as a basis for terminating the student from the program?

Method

Participants

Participants were academic unit leaders identified in CACREP approved programs listed in the year 2000. All CACREP academic unit leaders of different accredited programs in the U.S. were invited to participate in this study. Of the 144 CACREP academic unit leaders who were asked to participate in this study, a total of 48 responded by e-mail. Forty-one of those who responded indicated that they were willing to participate in this study, and seven refused to participate. The reported reasons for refusal were busy workload and difficulty handling too many research invitations. Of the 41 who were interested, 35 CACREP academic unit leaders actually participated in the phone interview and completed the questionnaire. During the phone interviews, 86 cases of impaired students who were remediated or terminated were reported. Therefore, the number of participants for Research Questions was 86 (N=86).

Instrument

The instrument used in this study was a survey, the Behavioral Indicators of Student Impairment Survey (see Appendix 1), which consisted of questions that investigated student impairment based on a set of non-academic behavioral indicators created from the results of prior research studies (Burgress, 1995; Li et al., 2007; Vacha-Haase, 1995; Woodyard, 1997). All the indicators of impairment found from the results of these studies were combined into one list, and the overlapping ones were truncated to form the set of indicators for this study. The resulting list of 17 non-academic behavioral indicators of impairment included the following.

The student:

  1. lies.
  2. exhibits addictive behavior.
  3. refuses to consider personal counseling when recommended.
  4. touches clients inappropriately.
  5. has inappropriate boundaries.
  6. is seductive toward clients.
  7. displays anger toward a specific gender, race, sexual orientation, etc.
  8. displays psychotic symptoms.
  9. misrepresents his or her skill level.
  10. engages in sexual contact with a client.
  11. is doing therapy/attending class under the influence of drugs or alcohol.
  12. is sexually harassing clients/other students.
  13. has suicidal attempts/ideation.
  14. has a personality disorder.
  15. has deficient interpersonal skills.
  16. has difficulty receiving supervision.
  17. displays academic dishonesty.

The instrument was field tested with the assistance of five experts in counselor education. Practical problems in wording during a telephone conversation were identified and the implementation of the instrument was revised.

Procedures

A cover letter, stating the purpose of the telephone survey and inviting participation in the study, was mailed electronically to 144 CACREP academic unit leaders. They were informed that the information they shared would be strictly confidential and would only be used for the purpose of this study. They were also informed that no information that is traceable to a specific university or student would be revealed. If they agreed to participate in the study, CACREP academic unit leaders were asked to return a brief email, stating their willingness to participate, together with two possible interview times during which they would be available for the actual telephone survey. A second mailing was sent two weeks following the first to invite more participants. Finally, a third mailing was sent two weeks following the second.

During the telephone survey, participants were reassured of confidentiality and asked to give their verbal consent to participate in the study. They were asked to spend approximately 15 minutes answering questions regarding student impairment. They were also told that they could receive a copy of the results of this study if they wished. Participants were then asked to respond to each question on the Behavioral Indicators of Student Impairment Survey.

Results

The frequency and the percentage of each of the indicators used as reason(s) for remediation are presented in Table 1. Of the 86 cases of impairment that were reported, 55 resulted in the requirement of remediation. Had deficient interpersonal skills and had difficulty receiving supervision were reported as reasons for remediation in 40 (73%) of the 55 cases. Had inappropriate boundaries was reported as a reason in 32 (58%) cases. Lied was reported in 23 (42%) cases. Moreover, 20 (36%) of the cases cited refused to consider personal counseling when recommended as a reason for remediation, and 20 (36%) cited misrepresented his or her skill level as a reason for remediation. On the other hand, touched clients inappropriately and was seductive toward clients were cited only in 2 (4%) cases. Engaged in sexual contact with a client and was sexually harassing clients/other students were not reasons for remediation in any cases.

Table 1

Frequency and Percentage of Reasons Cited for Remediation

Table 1
Impairment Indicator Frequency Percentage
Lied 23 42
Exhibited addictive behavior 7 13
Refused to consider counseling 20 36
Touched clients inappropriately 2 4
Had inappropriate boundaries 32 58
Was seductive toward clients 2 4
Anger toward a specific gender, race… 11 20
Displayed psychotic symptoms 5 9
Misrepresented his/her skill level 20 36
Drug/alcohol abuse in class or in session 8 15
Engaged in sexual contact with a client 0 0
Sexually harassing clients/other students 0 0
Had suicidal attempts/ideation 4 7
Had a personality disorder 17 31
Had deficient interpersonal skills 40 73
Had difficulty receiving supervision 40 73
Displayed academic dishonesty 9 16

Other reasons for remediation cited were criminal charge(s); mood disorder or other kinds of mental illness; displayed judgment on physical limitations of other people; irresponsible/avoidance behaviors such as missing appointments; calling in sick or not showing up; ethical violations; anger and belligerent attitude toward professors or other students; rigidity or unwillingness to listen to different points of view; verbally harassed clients, professors, or other students; seductive toward professors or other students; and disrespectful toward authorities. These other reasons were given but were not on the original list.

The frequency and the percentage of each indicator used as reason(s) for termination are provided in Table 2. Of the 86 cases of impairment reported, 31 of these cases resulted in termination of students. Had inappropriate boundaries was reported as a reason in 26 (84%) of the 31 cases. Had deficient interpersonal skills was reported in 25 (81%) of the cases. Lied was reported as a reason for termination in 22 (71%) cases, had difficulty receiving supervision was reported in 19 (61%) cases and had a personality disorder was reported in 18 (58%) cases. All 17 of the indicators on the original list were cited at least once as reasons for termination.

Table 2

Frequency and Percentage of Reasons Cited for Termination

Table 2
Impairment Indicator Frequency Percentage
Lied 22 71
Exhibited addictive behavior 6 19
Refused to consider counseling 14 45
Touched clients inappropriately 5 16
Had inappropriate boundaries 26 84
Was seductive toward clients 6 19
Anger toward a specific gender, race… 11 36
Displayed psychotic symptoms 5 16
Misrepresented his/her skill level 12 39
Drug/alcohol abuse in class or in session 3 10
Engaged in sexual contact with a client 2 7
Sexually harassing clients/other students 4 13
Had suicidal attempts/ideation 1 3
Had a personality disorder 18 58
Had deficient interpersonal skills 25 81
Had difficulty receiving supervision 19 61
Displayed academic dishonesty 12 39

Beyond the initial list of indicators, other reasons for termination cited were irresponsible/avoidance behaviors such as missing appointment, calling in sick or not showing up, disruptive and dominating in class, seductive toward professors or other students, mood disorders or other mental illnesses, anger and belligerent attitude toward professors or other students, criminal charge(s) and ethical violations.

Limitations

The results of this research, however, were limited to CACREP academic unit leaders who chose to respond to requests for participation. The information gathered was based on the subjective perception of the participants. In addition, this study was limited to the impairment of students identified in master’s-level counseling programs and was based on the pre-determined list of non-academic behavioral indicators as derived from the literature.

Summary and Conclusions

Of the 17 impairment indicators in the original list, 15 were cited by participants as reasons for remediation of impaired students in their programs. All 17 were cited as reasons for termination of impaired students in their programs. The five most frequently cited reasons for remediation in order from high to low were had deficient interpersonal skills, has difficulty receiving supervision, had inappropriate boundaries, lied, and refused to consider personal counseling when recommended. The five most frequently cited reasons for termination in order from high to low were had inappropriate boundaries, had deficient interpersonal skills, lied, had difficulty receiving supervision, and had a personality disorder.

Some indicators were cited more frequently than others for both remediation and termination. Those were had difficulty receiving supervision, had deficient interpersonal skills, had inappropriate boundaries, lied, and had a personality disorder. This may be because these five impairment indicators are more observable, or that impaired students exhibit these behaviors more often. The findings of Research Question 2 were consistent with prior research done by Vacha-Hasse (1995), who reported that deficient interpersonal skills, supervision difficulties, and personality disorders were the most cited reasons for termination.

Also in viewing the results of Research Question 1, 15 of the 17 impairment indicators were used in cases that resulted in remediation. The two absent indicators were engaged in sexual contact with a client and was sexually harassing clients/other students. On the other hand, these two indicators were reported as reasons for termination. Once students are identified with either of these two impairment indicators, they may be asked to leave the program immediately. Engages in sexual contact with a client and is sexually harassing clients/other students are such strong ethical violations that there may not be opportunity for remediation to take place. The findings of Research Question 1 also add new information to the literature. The list of impairment indicators, and specifically the indicators that were cited most frequently, can help counselor educators identify impaired students and increase awareness of potential problematic behaviors which may require remediation in their counseling programs.

It was noted that among the list of indicators had deficient interpersonal skills and had difficulty receiving supervision were most frequently reported as reasons for remediation and termination. These two indicators may have been perceived by participants as relatively less problematic than other indicators. However, when asked about actual cases of impairment, participants realized that these two indicators were frequently used. Has deficient interpersonal skills and has difficulty receiving supervision is the first indicators used to identify impaired students because these indicators manifest themselves more frequently in the classroom and clinical environment.

Had inappropriate boundaries was another indicator frequently reported. This indicator was used in 58% of the cases of remediation, 84% of cases of termination, and was reported most frequently among cases of termination. As mentioned earlier, has inappropriate boundaries may be more observable when impaired students interact with supervisors, clients or other students. This suggests a need for counselor educators to pay more attention to the issue of boundaries. It would be helpful for counselor educators to provide personal growth activities to assist students in becoming more aware of this issue and its impact on counseling effectiveness.

Additional indicators reported by participants, apart from those on the original list, are worth examining. These indicators were listed as other reasons that impaired students were identified, remediated, or terminated among the 86 cases of impairment. Five of the indicators that were reported more frequently than others were anger and belligerent attitude toward professors or other students, disrespectful toward authority, irresponsible/avoidance behaviors such as missing appointment, calling in sick, or not showing up, mood disorders or other kinds of mental illness, and rigidity or unwillingness to listen to different points of view. Mood disorders or other kinds of mental illness seem to overlay displays psychotic symptoms on the initial list. The other four additional indicators are in the category of resistant behaviors.

To conclude, it has been suggested that there is a need for counselor educators to responsibly screen, remediate and dismiss impaired students from their programs (McAdams III et al., 2007). This suggestion also coincides with the American Counseling Association Code of Ethics (ACA, 2005). Based on the findings of this study, counselor educators may be able to establish more useful and concrete guidelines and procedures to address student impairment through screening, remediation and termination.

Suggestions for Further Research

Although results of this study supported some of the findings of previous research studies and offered new findings related to impairment indicators, several questions remain unanswered, and therefore further research is recommended. This study should be replicated comparing CACREP and non-CACREP programs to determine if similar results would be obtained regarding indicators and clusters of student impairment. Since CACREP programs are required to have polices in place to address student impairment, and non-CACREP programs do not, there are possibly differences of opinions between counselor educators in these two types of programs regarding how impairment is addressed. Additional studies should be conducted by incorporating other impairment indicators that were added to the initial list by the participants. It would be informative to get opinions from counselor educators regarding the validity of these indicators.

Further studies should be conducted to clarify or exemplify some of the indicators that were less defined than the others. For example, had inappropriate boundaries was cited frequently as reason for remediation and termination. It would be helpful to gain more understanding as to what behaviors counselor educators refer to when they identify students with inappropriate boundaries. Some participants suggested that they have less impaired students because of their vigorous screening procedures. It would be advantageous to learn if there are relationships between percentages and characteristics of impaired students and the vigor of screening procedures used in programs.

This study should also be expanded beyond the scope of students to address impairment in practicing professionals. The indicators of impairment could be easily applied to professional counselors. The participants would be agency clinical supervisors of professional counselors.

References

American Counseling Association (2005). Code of Ethics. Counseling Today: Alexandria, VA.

Association for Counselor Education and Supervision (1993). Ethical Guidelines for Counseling Supervisors. ACES Spectrum: Alexandra, VA.

Bemak, F., Epp, L., & Keys, S. G. (1999). Impaired graduate students: A process model of graduate program monitoring and intervention. International Journal for the Advancement of Counselling, 21, 19-30.

Bradey, J., & Post, P. (1991). Impaired students: Do we eliminate them from counselor education programs. Counselor Education and Supervision, 31, 100-108.

Burgress, S. L. (1995). The impaired clinical and counseling psychology doctoral student. (Doctoral dissertation, California school of Professional Psychology-Berkeley/Alameda, 1995). Dissertation Abstracts International, 56, 02-B.

Council for Accreditation of Counseling and Related Educational Programs. (2001). CACREP Accreditation Standards and Procedures Manual. Alexandria, VA: Author.

Enochs, W. K., & Etzbach, C. A. (2004). Impaired student counselors: Ethical and legal considerations for the family. The Family Journal: Counseling and Therapy for Couples and Families, 12, 396-400.

Gizara, S. S., & Forrest, L. (2004). Supervisors’ experiences of trainee impairment and incompetence at APA-accredited internship sites. Professional Psychology: Research and Practice 35, 131-140.

Huprich, S. K., & Rudd, M. R. (2004). A national survey of trainee impairment in clinical counseling, and school psychology doctoral programs and internships. Journal of Clinical Psychology, 60, 43-52.

Kerl, S. B., Garcia, J. L., McCullough, C. S., & Maxwell, M. E. (2002). Systematic evaluation of professional performance: Legally supported procedure and process. Counselor Education & Supervision, 41, 321-332.

Lamb, D. H., & Swerdlik, M. E. (2003). Identifying and responding to problematic school psychology supervisees: The evaluation process and issues of impairment. Clinical Supervisor, 22, 87-110.

Li, C., Trusty, J., Nichter, M., Serres, S., & Lin, Y. F. (2007). Non-academic behavioral indicators of student impairment: A survey of CACREP-accredited master’s level counseling programs. Journal of Education and Human Development, 1 (2). Retrieved August 20, 2008, from http://www.scientificjournals.org/journals2007/j_of_edu2.htm

McAdams III, C. R., Foster, V. A., & Ward, T. J. (2007). Remediation and dismissal policies in counselor education: Lessons learned from a challenged in federal court. Counselor Education & Supervision, 46, 212- 229.

Mearns, J., & Allen, G. J. (1991). Graduate students’ experiences in dealing with impaired peers, compared with faculty predictions: An exploratory study. Ethics & Behavior, 1, 191-202.

Russell, C. S., & Peterson, C. M. (2003). Student impairment and remediation in accredited marriage and family therapy programs. Journal of Marital and Family Therapy, 29, 329-337.

Vacha-Haase, T. R. (1995). Impaired graduate students in APA-accredited clinical, counseling, and school psychology programs. (Doctoral dissertation, Texas A&M University, 1995). Dissertation Abstracts International, 56, 09-A.

Woodyard, C. L. (1997). Indicators of impairment in incoming and ongoing master’s-level counseling students (Doctoral dissertation, Texas A&M University-Commerce, 1997). Dissertation Abstracts International, 58, 03-A.

Appendix 1

The Behavioral Indicators of Student Impairment Survey

Hello. This is Denny Li calling from the Department of Counseling of Texas A&M University-Commerce. I thank you for returning my mail showing your willingness to participate in this study. As you know, I am surveying your opinions on a set of non-academic behavioral indicators of student impairment. Also with reference to the indicators, I will ask you to recall two recent cases of remediation and two recent cases of termination of impaired students in your program(s) during the last five years.

I would like to have 15 minutes of your time to collect some information. I want to make a statement about this study that all information is kept confidential and is strictly used for the purpose of this survey only. May I have your verbal consent to participate in this study?

Part One. Do you agree/disagree that the following non-academic behavior indicators of impairment are serious enough to impede a student’s counseling performance or to cause harm to clients?

(5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree)

The student:

1. _____ lies.

2. _____ exhibits addictive behavior.

3. _____ refuses to consider personal counseling when recommended.

4. _____ touches clients inappropriately.

5. _____ has inappropriate boundaries.

6. _____ is seductive toward clients.

7. _____ displays anger toward a specific gender, race, sexual orientation, etc.

8. _____ displays psychotic symptoms.

9. _____ misrepresents his or her skill level.

10._____ engages in sexual contact with a client.

11._____ is doing therapy/attending class under the influence of drugs or alcohol.

12._____ is sexually harassing clients/other students.

13._____ has suicidal attempts/ideation.

14._____ has a personality disorder.

15._____ has deficient interpersonal skills.

16._____ has difficulty receiving supervision.

17._____ displays academic dishonesty.

Are there any other non-academic indicators that were not included in the previous list?

_______________________________________

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