By Kimberly L. Rust, LCSW and Joshua B. Rust, PhD

Otherwise thoughtful policies can sometimes have a detrimental impact on the client-therapist relationship. Prescribed practicums and internships give doctoral students invaluable experience and help standardize an education in psychology across the country. But clients are not organizational roles, and they can suffer when a training period terminates.

I have had a private practice as a Licensed Clinical Social Worker since 2010, but in 2016 I began a doctoral program in psychology with the hopes of better serving the small town where I live, particularly families with children on the autism spectrum. I have found myself reflecting on the impact that short-term training sites have on clients. In my private practice there are children that I met at the age of five, struggling with kindergarten, who have returned to work through the transition to middle school. These families have told me that they wanted to come back because they knew me.

But things changed when I took up a short-term practicum as a prescribed part of my doctoral program. Such assignments artificially curtail therapeutic relationships. Some safeguards may be put in place, such as not assigning new clients in the last month or so of the student’s time at a site. However, even this is not always enough. For example, while I started seeing a client in December, by the time sufficient trust had been established I was only a month out from having to pass her on to someone else. Although such transitions are handled as carefully as possible, they are still a significant disruption in the client’s therapy, and a side effect of the bureaucratic nature of doctoral student training.

The sociologist, Max Weber, described modern bureaucracy in a way that resonates with my experience as a student clinician moving through a series of temporary roles (1978). Weber described modern bureaucracy as an “impersonal order” that can standardize and increase the efficacy of our institutions (1978, pp.215-16). Such organizations proceed “without regard for persons” in the sense that roles become modular or interchangeable, requiring us to become more responsive to offices than the individuals who happen to occupy them (Weber, 1978, p.975).

Doctoral students move through a series of such interchangeable roles. While this serves the needs of both the student and the site, the difficulty is, of course, that the psychotherapeutic relationship itself resists substitutions of this kind. Psychotherapy is inherently personal and irreducible to the logic of bureaucratic organization. In my private practice, clients have returned years later because they knew me. I had formed a unique relationship with these clients. In medical settings, bureaucracy is less concerning. You do not need to have strong rapport with your doctor to get accurately diagnosed with a physical health problem. However, psychotherapy requires a special type of connection, and therapeutic alliance has been robustly linked with outcomes (Flückiger, Del Re, Wampold, & Horvath, 2018). Although the structure of doctoral training is unlikely to change anytime soon, our field needs to think carefully about how to mitigate the effects of short-term training on the clients we serve.

References
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult
psychotherapy: A meta-analytic synthesis. Psychotherapy relationships that work, 3.
Weber, M. (1978). Economy and society: An outline of interpretive sociology. University of
California Press.