MFT Trainees’ Experience Working in an Alternative Clinical Setting: A Qualitative Exploration of the AAMFT Core Competencies Gained ()
1. Introduction
Historically, marriage and family therapists (MFTs) have worked primarily in settings consisting of weekly 50-minute therapy sessions with couples, families, and individuals. The 50-minute session is still the most common format in which MFTs work with clients. However, it is increasingly more common for MFTs to provide therapy in alternative settings which can require providing services in formats beyond the 50-minute session. The AAMFT website (AAMFT, 2021b) includes 13 different work environments in which MFT’s commonly practice, and the Careers in Psychology website (Careers in Psychology, n.d.) lists 17 settings. Both websites include employment settings that are likely to require MFT’s to work in ways beyond the standard 50-minute therapeutic hour, including after-school programming, schools, in-home services, corrections/prison facilities, inpatient facilities, hospitals, Veterans Affairs/military, social services agencies that may employ in-home therapy services. In a telephone survey of 292 randomly selected Clinical Members of AAMFT, it was found that approximately half of MFTs work exclusively in private practice (Northey, 2002) . Of the MFTs who worked in other settings, 38% were found to work in out-patient treatment facilities, 27% in hospitals or healthcare settings, 23% in community or religious organizations, 17% in university settings, 10% in residential treatment settings, and 9% in school settings. Additionally, the mean age of clients seen by MFTs in private practice was over the age of 25 for the majority of clinicians, one third of MFTs in other settings had clients with a mean age under the age of 18 (Northey, 2002) . However, despite the growing trends for MFTs to work in alternative settings, much of the research on MFT trainees focuses on training setting consistent with the traditional 50-minute session structure. This creates a gap in the literature related to understanding how alternative settings for MFT trainees can help to develop skills and therapeutic competencies that would prepare them for future career success. It may be useful to provide MFT trainees’ opportunities to work in settings beyond the 50-minute session structure particularly as MFT’s are addressing the needs of underserved communities in which service delivery may look a variety of ways.
A recent resource for early career MFT’s (Rambo et al., 2016) describes the various settings and experiences of therapists working in setting such as private nonprofit agencies, residential treatment centers, school-based setting, collaborative settings with other professionals such as medicine and law, coaching, military settings, university and postgraduate setting, Indian health service settings, corporate setting, and more. The authors report that early career MFT’s often begin their careers working with youth in alternative settings, even if they end up in a private practice setting as an ultimate career. Many of the alternative settings discussed such as schools, residential and at home includes youth clients.
In recognition of the need to prepare MFT’s to work in a variety of settings, the new Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) Accreditation Standards 12.5 (COAMFTE, 2021) , effective January 1, 2022, include an additional required Foundational Curriculum Area, FCA 9: Community Intersections and Collaboration. FCA 9 is defined as “…facilitat[ing] students developing competencies in practice within defined contexts (e.g., healthcare settings, schools, military settings, private practice) and/or nontraditional MFT professional practice using therapeutic competencies congruent with the program’s mission, goals, and outcomes (e.g., community advocacy, psycho-educational groups). It also addresses developing competency in multidisciplinary collaboration.” (COAMFTE, 2021: p. 22) This additional FCA encourages accredited programs to develop opportunities for MFT’s to work in alternate settings. As part of following this standard, it is important to understand how MFT trainees develop important clinical skills and the Core Competencies when their training occurs in alternative clinical settings.
Given the professional trajectories available to MFT’s, it is important to provide opportunities for trainees to gain clinical experiences in alternative settings where they can develop the skills necessary to provide therapeutic services outside of the standard 50-minutes therapy session. It is also important to evaluate the outcomes and experiences of trainees in these settings. Barretti & Beitin (2010) investigated the development of a partnership between an MFT training program and an offender reentry facility and reported on the experiences of students trained in this program. Some research has been conducted on postgraduate experiences in alternate work settings such as incarcerated facilities (Tadros et al., 2020) and in-home settings (McWey et al., 2011) . Medical family therapy, as an alternative setting, is an example of training MFTs in a specific site-based work environment (Zubatsky et al., 2016) . Further research is needed to better understand the experiences of MFT trainees in their internship placements, as well as how the experience in a variety of alternative settings support their training.
1.1. Campus Connections Therapeutic Youth Mentoring Program
In this study, the alternative setting explored was an after-school mentoring program called Campus Connections (CC) Therapeutic Youth Mentoring, which currently operates at three universities in Colorado as well as one university in New Zealand (Weiler et al., 2015; Weiler et al., 2013; Campus Connections, n.d.; Haddock et al., 2017; Haddock et al., 2013; Kazlauskaite et al., 2020; Boat et al., 2019) . The goals of this study were to explore the experiences of MFT trainees in this alternative setting and understand how this experience aligns with the MFT core competencies. In CC, trainees provide integrated therapeutic services with youth (ages 10 - 18) in the context of an after-school mentoring environment. In this setting, trainees have opportunities for multidisciplinary collaborations as they interface with referring professionals from agencies such as human services caseworkers, school counselors, juvenile justice professionals (e.g., probation officers or diversion coordinators), as well as parents and guardians. They also provide therapy to youth, as needed and requested, throughout the mentoring program. This setting is similar to a school environment in which youth can stop in to meet with a counselor throughout their school day. With an increasing number of MFT’s working in schools, corrections environments, and residential facilities for youth (Christenson & Gutierrez, 2016; Tadros et al., 2020; Vennum & Vennum, 2012; AAMFT, 2021a) , this type of experience can prepare trainees with skills for working effectively in systems in which therapists are providing interventions as part of the day-to-day programming.
Campus Connections was designed using a family systems perspective, and integrates therapy services, mentoring, homework help, and pro-social activities. Most youth who are referred to this program have experienced one or more Adverse Childhood Experiences (ACES) (Zyromski et al., 2020) . ACE’s are traumatic event(s) that a child experiences before the age of 18. ACE’s include abuse and neglect, parental substance abuse, incarceration, and domestic violence, having a parent with a mental illness or having parents that divorce. Each youth is paired with an undergraduate student mentor who is enrolled in a 3-credit service-learning course. Pairs meet on campus in a structured group setting for four hours, once per week over twelve weeks and are organized into groups of four dyads with similar aged youth, known as mentor families. Throughout the 4 hours, pairs engage in prosocial activities (i.e. art, sports, games, social justice experiential curriculum), homework help or studying for the GED, take a walk on campus, and have a family style dinner. The MFT trainees provide therapy throughout the evening in a variety of ways including assessment and intervention. Mentors communicate concerns to the therapist when clinical issues arise using a system called TIME Cards. Given the rise in other mentoring programs, such as Big Brothers, Big Sisters, adding in therapeutic staff to their mentoring programs to better support youth, this setting may be particularly relevant to clinical opportunities post-graduation for new MFTs (Norman, 2002) .
1.2. TIME Card System
The TIME (Therapy in the Moment for Everyone) card system was developed as a tool to request time with a therapist. Index cards are located on tables around the CC room for a mentee or a mentor (on behalf of the mentee) to write a brief note and request time with a therapist. TIME cards are given to the MFT trainee who then approaches the mentee and initiates a check-in (brief therapy session). Clinical supervision is available for therapists throughout the evening, such as reviewing TIME cards from mentors and mentees. In addition to TIME cards, MFT trainees will also initiate meetings with mentees to follow-up from previous weeks. These examples illustrate the range of clinical issues that MFT trainees encounter in this alternative setting.
1.3. The Current Study
The aim of the current study was to explore the experiences of MFT trainees who provided therapy in Campus Connections (CC), through their own voices. More specifically, we were interested in understanding whether, and in what way, these experiences contributed to trainees’ perceptions of their development of the AAMFT Core Competencies or other areas of professional development (AAMFT, 2004) . Using core competencies as a framework for the evaluation of trainees’ skills and experiences has been previously recommended (Gehart, 2011) . The research question for this exploratory study is: “From the perspective of trainees, does participation in an alternative setting such as CC promote their competencies as outlined by the AAMFT Core Competencies, and if so, which competencies are most salient in their professional development?” Exploring this topic can provide valuable information about which core competencies trainees may have opportunities to learn and apply in the Campus Connections or other related alternative settings.
2. Method
2.1. Participants
A total of 10 therapists/MFT trainees agreed to participate in the study. Of the 10 participants, 7 were female and 3 were male. Participants were between the ages of 24 and 29. Eight of the participants were white and 2 were Latinx. All participants served as clinical staff in Campus Connections while they were enrolled in the MFT graduate program. To recruit participants, all MFT graduate student trainees who spent at least one semester providing therapeutic services within the Campus Connections programs over a two-year period were invited to participate in the study. The participants included all of the MFT graduate students who responded and agreed to be interviewed for the study.
2.2. Procedures
Recruitment. A member of the research team sent emails to therapists/MFT trainees who had recently served as a therapist in Campus Connections. The email provided information about the study including details of what their participation would involve. Participants were informed that all information would be kept confidential. IRB approval was obtained prior to the collection of data. All participants who agreed to participate in the study were interviewed.
Data Collection. Participants provided informed consent prior to the interview. The interviews were conducted by a trained research assistant in a one-to-one session that lasted approximately 45 minutes. Interviews were semi-structured with prompts to guide the discussion and to allow space for each participant to share their own experiences in their own words. Each interview was audio-recorded and transcribed. The goal of the interview was to explore participant’s experiences providing therapy in Campus Connections. The interviewer asked each therapist “Tell me about your experience working as a therapist in Campus Connections?” The interviewer was trained to ask further probing questions based on the responses of the participants. Sample questions of the interview include “Can you tell me about your experience in Campus Connections?” “How was working in Campus Connections for you?” and “Would you like to share anything that stood out for you working in Campus Connections?” The interview questions were deliberately open-ended to have participants share what felt most relevant to them from their experiences in the Campus Connections program, so a structured interview form was not used.
Establishing Trustworthiness. To achieve trustworthiness of the results of this study several measures were implemented. Participants were encouraged to be honest in the interview and told that no answer was right or wrong. Also, to promote honesty and transparency, the interviewer was not a member of the Campus Connections team (Shenton, 2004) . Participants were informed that only quotes that represent themes across participants would be reported (Shenton, 2004; Creswell, 2007) .
2.3. Coding Framework
MFT Condensed Core Competencies. The MFT Condensed Core Competencies were created by collapsing the original 128 MFT-CCs into 16 distinct categories with the intent to make the Core Competencies easier to use by researchers, supervisors, and trainees without substantially changing the essence of any of the competencies (Northey & Gehart, 2019) . The 16 categories include the following: 1) MFT Theories (application of systems concepts, theories, and techniques; 2) Human and Family Development (understanding of principles related to areas such as human development, family development, human sexuality, gender development, and trauma and their implications on treatment); 3) Cultural and Contextual Awareness (ability to assess and provide services with awareness of contextual dynamics such as gender, age, socioeconomic status, race/ethnicity, culture, sexual orientation, larger systems, etc.); 4) Selecting Treatment Models (ability to recognize the strengths and limitations of various MFT models and adapt/integrate models to fit client needs); 5) Therapeutic Relationship (ability to establish and maintain effective therapeutic alliances with clients and recognizing when to involve outside individuals or systems); 6) Diagnosis (ability to assess and diagnose behavioral and relational health concerns utilizing current models); 7) Relational Assessment (ability to assess interpersonal patterns, family history, social positions using tools such as a genogram, systemic interviewing techniques, etc to provide systematic treatment and develop relational hypotheses); 8) Treatment Planning (ability to develop measurable outcomes, treatment goals/plans, and to provide appropriate plans and aftercare); 9) Treatment, Intervention, and Practice, (ability to provide systemic interventions consistent with therapeutic model, evidence based, contextual dynamics, setting, and treatment plan); 10) Safety Planning (ability to assess for and develop safety plans related to substance abuse, maltreatment of children/vulnerable adults, violence, suicidal ideation, and potential danger to self or others); 11) Collaboration (ability to work with stakeholders such as family members, significant persons, and other professionals to empower clients to navigate systems of care); 12) Law and Ethics (ability to practice within ethical standards and laws/regulations); 13) Supervision and Consultation (ability to contribute to supervision and consultation); 14) Self-of-Therapist (ability to monitor personal reactions and their impact on clinical outcomes); 15) Measure Effectiveness (ability to measure the effectiveness of one’s clinician practice using outcomes measures and client feedback); and 16) Research (ability to use current research to inform clinical practice) (Northey & Gehart, 2019) . The condensed core competencies were used as the coding framework for this study.
2.4. Data Analysis
Recordings of the interviews were transcribed and assigned a unique ID number to ensure the confidentiality of participants. Three coders, including two of the authors and one trained research assistant, independently coded each transcript utilizing a deductive coding method (Linneberg & Korsgaard, 2019) . Quotes were identified by each coder independently that aligned with one or more of the condensed core competencies. In addition to coding for each condensed competency, each coder also identified quotes that did not fit within the competencies and thus were unanticipated but were noteworthy in the interview data. These emerging themes were added to the framework. This approach to creating the codebook using both deductive and inductive approaches is consistent with recent literature related to methodology in qualitative research (Hemmler et al., 2020) . Coders reviewed 2 - 3 interviews in each round of coding, meeting to reach consensus for each code in the interviews in that round. After each round of coding, the coding manual was refined with code definitions being further clarified, supporting the achievement of intercoder consensus (Hemmler et al., 2020) . To address unionization, the coders followed the approach recommended by Hemmler et al. (2020) with a new unit of analysis beginning with each new interview topic. The coders discussed the unit length that were used to identify the codes to further establish consistency and to be inclusive of multiple codes if participants mentioned multiple themes within the same response. Given the small number of transcripts, all codes were consensus coded to ensure inter-coder reliability in the final codes. Coders additionally coded “Not Sure” in times when they were uncertain of what code to apply, to be discussed in each coding meeting, to support the consistent application of codes (Hemmler et al., 2020) . This methodology of consensus coding is consistent the evaluative criteria for establishing trustworthiness and credibility in qualitative coding (Lincoln & Guba, 1985) . The final consensus coded values are reported in the counts and results of this paper. This transparent, team-based approach to coding has been suggested to reduce coders’ subjectivity from influencing what was actually represented in the data (Hemmler et al., 2020) .
3. Results
Overall, the participants reported that they had a positive experience in Campus Connections and their participation contributed to their professional development in unique and meaningful ways. Interviews were coded both based on the MFT Condensed Core Competencies (Northey & Gehart, 2019) and for new codes which emerged throughout the coding process.
3.1. MFT Condensed Core Competencies
Each condensed Core Competency was mentioned at least once across the 10 interviews with the exception of Measure Effectiveness and Research and Diagnosis. The remaining 13 MFT Condensed Core Competencies were mentioned in at least two interviews. Table 1 provides a summary of the number of times each MFT Condensed Core Competency was mentioned and the number of interviews in which each was mentioned (N = 10). Below are quotes from the interviews with the trainee participants that illustrate each of the MFT Condensed Core Competencies as they were discussed in this study.
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Table 1. Frequency ratings of the MFT core competencies and emerging themes.
MFT Theories. Across the 10 interviews in this study, eight participants identified how they used MFT theories, including a broad systems perspective of the use of specific theoretical approaches, in the Campus Connections alternate setting or how this experience supported their understanding of these theories. This theme was identified a total of 15 separate times across the interviews. For example, trainees mentioned that participation in the alternative setting helped them to understand a broader systemic perspective stating “…given me a greater appreciation of how everything is just interconnected you know like our family and our peers and ourselves and our contacts at school and you know that nothing occurs in isolation…everything is connected (Interview 4).” Another participant highlighted this same concept, stating “Bioecological system, like absolutely, if there is this and this and this and this going on in the home of course the youth is going to be affected or their environment…just based on theory of change and how kids thrive under consistency and structure, which a lot of our kids do not have (Interview 7).”
Human and Family Development. Understanding of elements of human and family development particularly related to working with adolescents was identified by nine participants for a total of 22 distinct times. For example, participants shared that they appreciated the opportunity to gain experience working with adolescents, stating “You have this awesome opportunity to get involved, to learn more about this population and learn more about this kind of treatment model…even though adolescents are not my population of choice necessarily to work with, I think I have learned…that I can work with them and I can be successful and help them be successful (Interview 4).” Participants also highlighted that the experience of working with adolescents helped to build connections with the developmental milestones of that developmental period, such as “I think definitely adolescent development and what is going on in their brain when they are learning [and I think] okay this is why they sort of freaked out, because they are learning to handle their emotions and their bodies, that was definitely useful (Interview 7).”
Cultural and Contextual Awareness. All ten participants in this study discussed how their experience supported their understanding and ability to provide therapeutic services that are sensitive to cultural and systemic differences. This competency was identified a total of 19 times throughout the interviews. Key areas of understanding that were mentioned included understanding diverse populations in the context of the larger system specific to the social context and socioeconomic status. For example, one participant stated “Campus Connections has really taught me also the importance of cultural competency and diversity within a family system…[In] my undergraduate bachelors and some experience leaving undergraduate, I don’t think I really prioritized as much the importance of those differences and that could be for a variety of reasons but I think what is important now from working with Campus Connections and this educational program in marriage and family therapy, my awareness and ability to apply cultural competence and diversity (Interview 8).”
Participants also reflected on how the context of the youth’s experiences shaped their understanding and compassion towards their clients. For example, one participant stated, “I think all these kids are such great kids and not that I didn’t think they were but I think it has opened my eyes to kind of the role of chance and circumstance (Interview 4).” Another participant highlighted this same point by sharing how the understanding of the environmental context and experiences of the youth helped to reduce feelings of stigma or bias related to the youth’s presenting problems “…the stigmatism of, ‘oh this kid has smoked weed’ or ‘this kid is involved in the court system, this kid is a bad kid’, but really just knowing that they’re not bad kids they’re just good kids that took a wrong turn somewhere (Interview 5).”
Selecting Treatment Models. The ability to assess the strengths, limitations, evidence base or contraindications of various MFT treatment models was indicated by four participants for a total of seven statements. For example, one participant discussed how to adjust the use of their clinical skills into the different structure of the alternative setting, they stated “It’s very different than sitting in a therapy room with a family or with teenagers for 50 minutes because they come once a week for 50 minutes, and doing Campus Connections it’s more just, you’re doing it on the fly, you’re dealing with more than one family, more than one youth every night (Interview 5).”
Therapeutic Relationship. Five participants discussed ways in which participation in this alternative setting helped to develop their skills related to building or maintaining effective therapeutic relationships with their adolescent clients. Across these five participants, this competency was mentioned an aggregate of 10 separate times. For example, when talking about working with an adolescent client, the participant shared about taking a slower process to build rapport stating, “I have to just be a little more careful to make sure like I can actually connect with them [clients] and they know I care about them and that I want what’s best for them opposed to just jumping in to an assessment with a client” (Interview 4). Another participant reflected on shifting to a more collaborative or informal therapeutic style, particularly with youth who have had negative experiences with professionals in systems such as human services, judicial, etc to support alliance building with adolescents stating, I think the first is kind of meeting the [clients] at their level. You do kind of have that therapist hat on, but the [clients] won’t trust you unless you are able to get to know them and have that friendship with them, and be able to relate to them on some level. And so you definitely need to gain their trust before them being OK to open up with you” (Interview 5).
Diagnosis. The ability to assess and diagnose behavioral and relational health concerns was not identified in this study.
Relational Assessment. This competency, which focuses on the ability to track interpersonal patterns, using systemic interviewing approaches, and conceptualizing systematic treatments was discussed by four participants for a total of five distinct times. For example, one participant discussed how they involved parents in the treatment of a youth to better advocate within the school system highlighting their use of a relational intervention. This participant shared, “We might call the parent and the parent might be like ‘oh my gosh I know this has been happening and I have been in contact with teacher and the counselor and I have been to the school’ and then you can go to the next level of ‘okay what can we do? How can we intervene with the school’ you know like the parents have done everything they can. And then sometimes you call parents and they are like, they are just not for whatever reason able to put in the time and energy that’s really necessary to intervene or they might minimize it or they might be socialized in such a way that the kid just needs to toughen up or whatever it is so it’s just really interesting kind of again how it is all just connected.” (Interview 4)
Treatment Planning. The development of the ability to create measurable outcomes, treatment goals/plans, and to make appropriate referrals to clients was discussed by two participants for a total of three times. One participant highlighted the importance of needing to look at all aspects of a case to create a plan for treatment, saying, “So I guess in MFT you have to conceptualize the fit of the issues [with the intervention]…I think sometimes I need to slow down more because I’m like well you can grab this, this and this [interventions] and yeah these things are going on so we need to target those [goals] and from a case conceptualization standpoint (Interview 7).”
Treatment, Intervention, and Practice. All 10 participants discussed ways in which participation in this alternate setting supported their development in areas related to delivering systemic interventions consistent with the treatment setting, goals, and client. This competency was identified 27 times across the interviews. Participants reflected on the different approaches that fit best in an alternative setting, sharing “I used kind of Solution Focused, quick brief techniques, a lot of scaling, a lot of hearing their story, a lot of what we relied on was common factors types of things, just being there and making the kids feel validated (Interview 6).” Other participants focused on discussing what approaches fit best with the adolescent population they were exposed to working with in this experience stating, “The Motivational Interviewing piece I think was really good in that you can talk with the youth and help them make better choices through that process of them feeling empowered to make the choices that they need to do so that training and then also coaching the mentors (Interview 7).”
Safety Planning. The ways in which participating in an alternate setting supported competency in assessing for safety and building safety plans in areas such as child abuse/neglect, suicidal potential, and danger to self or others was identified by all 10 participants and was indicated an aggregate of 15 times. Participants reflected on the types of issues that frequently required safety planning stating, “Intervening when there were hot potatoes [i.e. urgent clinical issues] that came up, be it kids talking about suicide, kids talking about struggles in the home, possible areas of there being abuse or neglect, lots of dealing with that on a daily basis” (Interview 6) and “I did have suicide assessments…working with kids that were working on drug addiction problems or drug use problems…Lots of conflict, lots of anxiety, lots of helping kids deal with social anxiety and conflict resolutions. We had some kids get into fights and helped them work through that and resolve things, and then figure out how to come back the next week and be in the same room together for the whole night” (Interview 10). Another participant shared about experiences safety planning from a systemic perspective, sharing “I had multiple youth who were suicidal, who were cutting themselves. We had youth who would say, ‘oh, my friend at school is suicidal’. And we’d have to track down who that friend was. So, yeah, I had to deal with a lot of crisis situations” (Interview 2).
Collaboration. Nine participants shared how their experience in this alternative setting influenced their ability to work collaboratively with key stakeholders such as family members and other professionals and to navigate complex systems of care, identifying this code a total of 29 times. For example, participants shared how they worked to get their clients involved with other support services in addition to participation in the program and how their comfort in facilitating these connections increased over time in this setting, “If I would have had a parent say something in the intake that first semester about ‘oh, we are running out of food stamps’, I probably didn’t say anything about, ‘oh well let’s go look up the number for food stamps and see if you can give them a call’, or you know, I probably didn’t, it probably just wasn’t on my radar to hook people up with services or listen to them in a therapeutic manner (Interview 2).” Another participant reflect on how collaborating with other providers supported a better overall ability to identify areas where extra support are needed, sharing “Exactly, I keep thinking of that one kid who, he was in therapy [at the on campus clinic] and he was in Campus Connections and he was telling his therapist he was getting great grades and he was telling his mentor he was getting great grades and then his [probation officer] shows up and she is like he has not been to school for months (Interview 7).”
Law and Ethics. The ways that practicing within this setting influenced the participants ability to practice therapy in adherence to the regulating laws and codes of ethics was discussed by four participants for a total of five times. One participant shared about how they gained confidence in the ability to determine the appropriate course of action when concerns were shared “Then kind of determining, when is it something that I just talk with the youth about or when is it something that we get the parents involved, or, is it something that I need to call Child Protective Services (Interview 2).” Similarly, another participant reflected on the skill building related to navigating legal and ethical decision-making stating, “I think the biggest things would be how to complete or kind of having that practice of doing suicide assessments and things like that and making CPS [Child Protective Services] reports (Interview 5).”
Supervision and Consultation. The ability to effectively engage in supervision and consultation in this alternative setting was discussed by seven participants for a total of seventeen times. Participants shared about how they were able to use their supervision team, stating “I just brought it up in the meeting and then [the supervisors] were there and the other instructors were there, and we just brainstormed different solutions for crises (Interview 2).” Another participant highlighted how they were able to rely on their supervisors to help navigate managing and prioritizing urgent situation sharing that “One of the big helpful things that I often reminded myself was something that [the supervisor] told us that very few things come up at Campus Connections need to be immediately dealt with so that took some of the pressure off, you don’t need to make a snap decision just reminding myself that okay the building is not on fire here (Interview 9).”
Self-of-Therapist. The ways in which this clinical experience influenced the participant’s ability to effectively monitor their reactions to their clients and the treatment process was discussed by all 10 participants for a total of 57 times. For example, participants reflected on their own backgrounds that were similar or different to the youth they worked with and how this influenced their therapeutic presence. One participant shared, “I grew up so differently than a lot of the youth that we serve, so I mean it has really opened my eyes to what they are experiencing and what kinds of things are going on for them at school and at home, that I personally didn’t experience, at first I kind of felt like, I don’t know how to relate to these kids, my experience was so different, so just being able to embrace those differences and just know that I can still empathize and I can still help them, it’s just I have to realize that you know my experience was just different (Interview 1).” Other participants shared how their experiences helped them to develop new skills, both as a therapist and in their overall lives. For example, “Before, I wasn’t too much of a leader or that assertive, and now those are things I would definitely use to define myself, is that I love being a leader and being a good role model. And so I wouldn’t have said those things before Campus Connections (Interview 5).” Lastly, participants reflected on how their own perceptions and biases changed through their experience such as stating that they were “Trying to really open my mind up to that population of [youth who have experienced adversity], just noticing that most of them were just incredibly sweet kids who were bright and talented and really helpful (Interview 9).”
Measure Effectiveness. The ability to measure the effectiveness of one’s own clinical effectiveness and the treatment process was not identified in this study.
Research. The ability to use current MFT literature to inform clinical practice was mentioned by one participant was not discussed in this study.
3.2. Additional Themes That Emerged
In addition to the MFT Condensed Core Competencies, four additional themes emerged related to the MFT trainees’ experiences from participating in the Campus Connections alternative setting. The themes include 1) Providing Training; 2) Community Engagement and Service Mindset; 3) Professional Development and Development of Unique Skills; 4) Unique Setting Experience. Table 1 provides aggregate count for times each theme was coded and the number of interviews in which each of the four themes was discussed (N = 10).
Providing Training. In addition to providing therapy and receiving supervision eight of the ten participants also described experiences training mentors (undergraduate students) related to clinical skill development. This theme was identified a total of 17 times. Participants shared that this opportunity was a unique component of this setting, stating “I think what’s really unique about this is that [MFT trainees] get to help with both the undergraduate students and with the youth and their families, so it just kind of broadens [the MFT trainees] horizons in terms of what kind of experience they can get” (Interview 1) and “you are really working with the mentors as far as their skills and interpersonal skills” (Interview 11).
Community Engagement and Service Mindset. Another theme that emerged through the coding process was the ways in which participation in this alternative clinical setting helped MFT trainees to develop an overall service mindset or desire to engage and give back to their community beyond their clinical work. This theme was identified by four participants for a total of five times. One participant reflected on how the experience motivated them to become more involved in their community stating, “Personally it really has made me want to be involved with the community somehow, like give back whether that is through a private practice or working through an agency, it’s really tough to think about ever leaving here in the long run I definitely want to be able to give back to Campus Connections at some point down the road and for me it just shows me how important these programs are to have in the community and really just to give options for these families (Interview 1).” Another participant shared how the experience shifted their mindset to wanting to engage positively in their community stating, “I think that…Campus Connections definitely affects you…I think I myself try to embody those lifestyles [recommended as the therapist to youth] so I’m not just a hypocrite trying to talk to the youth about it. So I would go out and volunteer at the humane society and go out and do different things. Like I went to a couple 5 ks and had different sponsors and things like that. So, I think you really have to live thinking about different types of service so that you can like make it seem cool to the kids, and also not be like ‘Oh you should recycle’ but then if I don’t recycle, like, it’s kind of a hypocritical message (Interview 2).”
Professional Development and Unique Skill Sets. The participants in this study also shared ways that they viewed their participation in this alternative setting helped their professional development and development of skill sets beyond those currently represented in the core competencies. Eight of the participants mentioned this theme for a total of 19 times. For example, one therapist highlighted their skill development by sharing, “I think that I’m better at multi-tasking now um I think that I, I am more assertive you know overcoming some of those really uncomfortable situations (Interview 9).”
Unique Practice Setting. The last theme that emerged during the coding process was the idea that participation in an alternative setting provided clinicians with a unique training opportunity that they would not have experienced in a traditional clinical setting. Three participants identified this theme for a total of five times. This theme is reflected in one participant on the different elements that made this setting unique by sharing “I think it’s just really a unique opportunity…my first main opportunity to work with [youth who have experienced adversity] in that way and I really believe in the idea of mentoring, and I think especially when mentors are well trained that they can really make a difference…It’s like you have this awesome opportunity to get involved, to learn more about this population, and to learn more about this kind of treatment model (Interview 4).”
4. Discussion
Specifically, the aims of this study were to understand from the perspective of MFT trainees how the participation in Campus Connections (CC) promoted their competencies as outlined by the AAMFT-CC (Northey & Gehart, 2019) , and which competencies are most salient in their professional development. Through individual interviews and qualitative analysis, the alignment of MFT trainee experiences with the condensed AAMFT-CC was explored. An additional four themes emerged from the data that did not fit with the established competencies. In terms of professional development, it is important to explore how the themes align with the COAMFTE Core Competencies (AAMFT, 2004) which are essential to the development and training of MFTs especially as there may be gaps in what graduate therapists are able to do and what supervisors expect their abilities to be at graduation (Nelson & Graves, 2011) . In the following section we will address each competency and emergent themes categorized by frequency mentioned in terms of number of participants who addressed each theme.
4.1. Highest Endorsed Condensed Competencies
The highest endorsed condensed core competencies are identified if 9 or 10 of the 10 participants discussed the competency in their interview. These competencies include Human Development (specifically adolescent development), Cultural Awareness, Treatment/Intervention/Practice, Safety Planning, Collaboration, and Self-of-Therapist. Given the unique components of this specific alternate setting which focuses on providing treatment to youth aged 10 - 18 from diverse backgrounds in a team treatment model, it aligns with the structure and goals of the program for these to be the highest endorsed competencies. Specifically, trainees gain experience in understanding developmental and cultural implications, as well as the intersectionality of these domains, by working with adolescents from diverse backgrounds (i.e. involvement in juvenile justice, foster/kinship/adoptive families, low SES, ethnic/racial diversity, gender diversity, sexual orientation, neurodiversity). In this work, most trainees shared the need to explore their self-of-therapist reactions, particularly related to navigating biases that they encountered by working with these youth. The program is structured in a team-based setting including multiple trainees, supervisors, and undergraduate students providing trainees with experience gathering information from multiple sources to integrate into their treatment and interventions. Lastly, when working with approximately 20 - 28 youth per evening for four hours, emergent situations often occur that require a safety intervention. For example, a mentee might mention to their mentor when working on homework that they do not feel safe at home. The mentor would then inform the therapist who would conduct a safety assessment and therapeutic intervention with the mentee. The mentor may also be included in portions of this intervention as appropriate. Additionally, a situation may arise where one mentee makes a derogatory comment, such as a racial slur, which felt threatening to another youth. In this case, the trainee would intervene with both mentees to ensure safety and increase understanding of discrimination and appropriate communication. All of these experiences contribute to an increase skill in addressing complex clinical issues that may emerge in alternative settings and provide therapists with transferable skills to bring into their careers.
4.2. Moderately Endorsed Condensed Competencies
The moderately endorsed condensed core competencies are identified if 5 to 8 of the 10 participants (i.e. half or more) discussed the competency in their interview. These competencies include MFT Theories, Therapeutic Relationship, and Supervision/Consultation. Although these are included as moderately endorsed, they still had a salient level of endorsement and contributed to professional growth and skill building, with MFT Theories being mentioned by eight participants, Supervision and Consultation being mentioned by seven participants, and the Therapeutic Relationship being mentioned by five participants. The utilization of Family Systems Theory was the most commonly mentioned MFT Theory which aligns with the program setting which involves multiple systems (i.e. mentor/mentee dyads and mentor family groups, schools, case managers, families including parents/guardians and siblings which may attend on the same night). The therapeutic relationship was primarily discussed in terms of developing ways to build an alliance in this setting which may look different than how it would develop in a traditional setting. For example, the trainees might join a mentee/mentee pair or mentor family for dinner or one of the pro-social activities as a way of gaining trust and connection prior to engaging in a private therapy session. Lastly, an integral design feature of this program with a supervisor available all four hours of each night with an additional group supervision meeting weekly with the supervisor and trainees from each evening. It is common for trainees to meet with the supervisor briefly about the content of a TIME card and how to provide a brief intervention/assessment prior to meeting with the youth.
4.3. Lower Endorsed Condensed Competencies
The lower endorsed condensed core competencies are identified if four or less of the 10 participants discussed the competency in their interview. These competencies include Selecting a Treatment Model, Treatment Planning, Relational Assessment, and Law and Ethics. Additionally, Diagnosis, Measure Effectiveness and Research were not mentioned by any of the participants. It is possible that this is a result of the structure of the interviews which focused on the experience during the service provision and measuring the effectiveness of the therapeutic intervention or utilizing research may be more saliently remembered as part of course work or semester evaluations in the context of the overall graduate program. Additionally, this setting is a highly researched and grant-funded program with a research and program team that evaluates effectiveness of all aspects of the program using focus groups, surveys, and interviews and this information is provided to trainees. As such, trainees may be less likely to focus on these skills given the evidence-base for effectiveness and vast feedback provided to the trainees compared to other settings where there is less focus on research.
Diagnosis was also not mentioned in the interviews which may be due to the intensive intake and referral process which often includes diagnosis from other sources. As such, the trainees are provided with clinical background to rely on during this program, which often occurs in conjunction with other treatments (i.e. depression, anxiety, PTSD, substance abuse, relational aggression). Similarly, Treatment Planning was endorsed by two participants which could be explained because the treatment planning portion of the program occurs weekly outside of the four evening hours. Based on the structure of the interviews, participants were encouraged to discuss their time during Campus Connections which may lead them to think more of the evening portion vs the case planning portion of the program. Given this design, minimal planning takes place during the evening as there is a 2 hour meeting for this to occur between sessions.
The other four lower endorsed competencies were all mentioned four times. Participants selected treatment models based on the best fit for the youth which for some was the alternate setting and for others could include referrals to more traditional therapeutic services. Brief therapy models, such as Solution Focused, are highly endorsed by the program, which is a strong fit for many, but not all, youth who may participate. Relational assessment was mentioned by four participants focusing on the times in which they interacted with other invested parties and used information from multiple sources to build an assessment and treatment plan. In many cases, trainees reach out to parents, case managers, teachers, probation officers, etc. This collaboration is also facilitated by the case manager who serves as a bridge between the therapist and the families given the frequent contact of this position. Lastly, law and ethics were also mentioned by four participants particularly related to making mandated reports of child abuse or neglect or informing parents of safety related issues. While these often occur during the program, some trainees may have more or less experience based on the youth present on their evening.
4.4. Competencies Not Addressed
Several competencies, Measure Effectiveness and Research, were not addressed in the interviews. It is possible that these competencies were not addressed for several reasons. First, the interview structure was designed to allow for participants to discuss the topics that occurred to them without prompting or specific questions related to the Core Competencies. It is possible that the experience of utilizing measures to address clinical effectiveness or integrating research to practice were not the most salient aspects of the setting and therefore were not discussed in the interviews. Alternatively, it is possible that these Core Competencies were not a significant part of the experience that the MFT trainees had during their clinical experience and therefore they did not discuss experiences related to these competencies.
Ultimately, because of the structure of the interviews which did not specifically address these competencies, it is not possible to determine from the data of this study why these competencies were not addressed. Future research could address this limitation by specifically asking participants about each of the Core Competencies, reducing the ambiguity for why specific competencies were not addressed.
4.5. Emerging Themes
When coding for the condensed core competencies, the coding team discovered that some content did not fit in the predetermined categories. As such, four additional themes emerged with salience from the data. The two themes with higher endorsement, Providing Training and Professional Development/Unique Skill Sets, each had eight of the ten participants endorse the theme. Trainees in this program stated that they valued the leadership role to provide training to undergraduate mentors throughout the program. Trainees facilitate a one hour pre- and post-lab experience for the mentors in which they provide training related to mentoring best practices, social justice principles, and provide support in navigating difficult areas with their youth and celebrating successes. Some participants mentioned that this supported their future career development by providing basic supervision skills. Professional Development/Unique Skill Sets was endorsed when participants shared their appreciation for developing new skills such as assertiveness, multitasking, and facilitating therapeutic programming, that they might not have been able to nurture in standard clinical settings.
The next two themes were endorsed less frequently but still with salience with Community Engagement/Service Orientation being mentioned by four of the 10 participants and Unique Setting being mentioned by three of the 10 participants. Participants reported that participation in this setting led them to become more aware of community needs such as food insecurity or homelessness, that they developed a stronger desire to become engaged in their communities through volunteering and advocacy. Similarly, participants mentioned that engagement in this setting provided them with a unique clinical experience which helped to prepare them to work in settings such as schools, residential treatment, and after-school programming which provide therapeutic intervention outside the 50-minute session.
Overall, these findings support the value of alternative settings for graduate student MFT trainees. Practicing in an alternate setting supports clinical development across the condensed core competencies and also provides students with additional skills which they may not receive in more traditional settings. MFT training programs may benefit from placing graduate students in alternative settings to provide additional opportunities for trainees to gain diverse experiences in preparation for their career particularly as the career guide by Rambo & colleges (2016) indicated many opportunities for working in alternative settings including residential treatment settings, school-based settings, university, and postgraduate settings, and more. Training programs may also find it useful to explore the ways in which their trainees’ participation in alternative settings contributes to achieving the clinical training and professional development goals.
4.6. Clinical Implications
Although MFT’s have worked in alternative settings in the past, the rate of employment is exponentially growing. Alternative settings are a significant growing area of employment for MFTs with 54% reporting working in a setting other than a private practice setting (AAMFT, 2022) . These settings include but are not limited to schools, medical facilities, judicial agencies, inpatient units, veterans’ affairs /military, home based therapy, after school programming, crisis centers residential treatment centers, and bringing systems to businesses and policy agencies. Given the growth in post-graduation employment in alternative settings, MFT training programs may want to consider a broad range of practicum and internship experiences for trainees. The 50-minute session setting is central to MFT training programs. Adding placement experiences on or off campus, in person or virtually, that are not the traditional 50-minute session may prepare trainees for employment where a different set of skills may be needed. All MFT training programs share a goal of graduating competent trainees. Programs use a variety of methods to evaluate the clinical experiences of trainees to ensure they meet the Student Learning Outcomes set by the program. Many programs use the AAMFT Core Competences in measuring outcomes. This study offers one method of evaluating trainee experiences providing therapy in an alternative setting. This method can be utilized to explore which Core Competencies are most salient in which placement sites. This method may be useful to add to the traditional survey that most programs utilize. The outcome of this study can serve as an example of what Core Competencies might be experienced by trainees in a school or youth mentoring setting. Additionally, the results of this study highlight the importance that MFT trainees may place on experiences related to social justice, self-of-the-therapist, and community engagement which are important focus area for emerging professionals to have the opportunity to explore in their placement sites.
5. Future Directions
As MFT Programs create alternative practicum and internship sites, it will be important to understand the experiences of trainees practicing at those sites. Understanding which Core Competencies are most salient and at which sites from the perspective of the trainee can be useful. Research in this area would contribute to filling a gap in the MFT literature related to understanding placement sites and Core Competencies. For instance, if a MFT training program places trainees at crisis centers it would be useful for other programs to learn what Core Competencies might be salient for their trainees in a similar placement. Although outcomes of qualitative studies, including the one presented in this paper, are usually not generalizable they would offer a window into possible experiences that programs may want to provide to their trainees. Additionally, quantitative studies would also be very useful in further evaluating the Core Competencies saliency in placement sites.
6. Limitations
There are several limitations to this study. Though the participants generally reported that they were satisfied with their experiences in the program, these findings may be due to participants agreeing to be in the study were the ones that had a positive experience in Campus Connections. The participants provided therapy in one alternative setting where therapy was integrated into a mentor program for adolescence. The results are not generalizable to other alternative settings. The results of this study were based on self-report interviews and not observations. The results of this study were very positive, which may indicate that the therapists who agreed to be interviewed were those who had a positive experience in this alternative setting and could be a limitation. The findings should be viewed with these limitations in mind. Future research could be used to replicate these findings in other alternate settings. Further, replicated studies could ask more specifically about the core competencies to receive more specific and nuanced information.
7. Conclusion
MFT trainees can benefit from diverse clinical experiences in their training programs including working with a variety of populations, in multiple settings, and addressing a multitude of presenting problems. These diverse experiences can prepare them for the contemporary job market which includes positions that require clinical skills beyond the 50-minute session. Providing graduate student therapists with these training opportunities may help to better prepare them to work in a variety of settings and to achieve higher levels of mastery related to the core competencies during their training.