Preparing Master of Clinical Psychology students for the workforce: a qualitative investigation of the benefits of a youth dialectic behavioural therapy placement

ABSTRACT

Objective

Clinical psychology master’s degree students require intern placements that support them to attain work-ready competencies. With the growing focus in Australia on addressing rising youth mental health issues, dealing with complexity, suicidality and self-harm are critical workforce skills. Yet, students are often not exposed to such presentations during their practicums. This study examined students’ experience of such exposure through a youth dialectic behaviour therapy placement.

Methods

Participants were 11 clinical master’s degree students who completed a youth dialectic behaviour therapy practicum placement and participated in semi-structured interviews reflecting on their placement experiences. Interviews were transcribed and thematically analysed.

Results

Five themes were identified: a community working as a community; beyond the training manual; confidence to work with complexity and risk; enhanced personal development; and acknowledging and overcoming stigma. The results clearly demonstrated that a highly supported, collaborative, learning experience with high-risk and complex clients, and their families, could provide clinical students with the skills and confidence to work with this client group.

Conclusions

The five themes revealed key learning supports and opportunities that enabled clinical psychology students to gain experience and confidence working with high-risk young people, a much-needed mental health workforce capability. Other practicum experiences may benefit from considering these approaches to learning.

Key points

What is already known about this topic:

• (1) There is a need for highly skilled, confident psychologists to work with high-risk and complex clients.

• (2) Graduate training programs offer limited training and exposure to risk and complex clients.

• (3) Psychologists, especially early career psychologists, are not confident or well-skilled to work with complex client presentations, including self-harm.

What this topic adds:

• (1) A highly supportive learning community that includes peers and supervisors is highly valued by clinical master’s degree students and enables them to work with high-risk clients.

• (2) The interaction of a supportive learning community, exposure to high-risk presentations, and appropriate resources facilitate both professional and personal development for clinical students.

• (3) Well-supported practicum training and exposure to high-risk and complex clients ensures clinical graduates are confident and prepared to work with complex client presentations in the future.

KEYWORDS:

• Clinical psychology practicum
• supportive community
• professional development
• confidence
• complex presentations
• youth mental health

The incidence and prevalence of mental health problems are rising and the current mental health workforce is not able to meet demand (Rehm & Shield, 2019). This increase is most evident among young people in their teens and early adult years, labelled an epidemic by some experts in the field (Shim et al., 2022). Increased symptom severity, including self-harm and suicidal ideation, are common among young people presenting to services with mental health concerns (Lustig et al., 2021), raising the risk and complexity of working therapeutically with this client group. The critical involvement of family is also finally receiving greater attention for mental health practitioners working with young people (National Mental Health Commission, 2021). Consequently, the workforce needs to have the capacity to meet rising demand, including being able to work with young people and their families, and working with those with more complex presentations and at high risk of suicide and self-harm (Patel et al., 2018). The need for well-equipped, newly trained psychologists has never been more critical to address the increasing and changing nature of service demand.

Training to become a registered psychologist is an extensive and demanding pathway. From 2023, commencing psychology students in Australia must complete at least five years of university level education and students wishing to be endorsed in a specific field (e.g., clinical psychology) require a minimum of six years of university education (Australian Psychology Accreditation Council [APAC], 2021b). Clinical psychology training is one of the main pathways for the mental health workforce, and this will increasingly be the case with the retirement of the 4 + 2 pathway, which previously allowed professional registration after four years’ university training and two years’ of supervised practice.

Clinical psychology master’s degree training in Australia is bound by the APAC guidelines, which require students to complete theory, supervised practice and research components. Importantly, the guidelines state that “programs of study are designed to reflect that psychology is a science-based and evidence-based discipline” (Australian Psychology Accreditation Council [APAC], 2021a). Given the strong evidence base for cognitive behavioural therapy (CBT) for many mental health conditions, this is the most popular evidence-based model included in clinical psychology degrees. Kazantzis and Munro (2011) identified that across Australia and New Zealand, 74 percent of all clinical training programmes offered CBT training. More specifically, within master level degrees, 83 percent of the programs integrated CBT into their training programs, with the majority offering supervised clinical work in this approach. Considering APAC accreditation requirements and wider national influences, such as the Medicare system (Australia’s publicly funded universal healthcare insurance) (Moulding et al., 2020), which both require evidence-based practice, it is no surprise that university graduate programs are orientated towards traditional CBT.

Although it is a therapy with a strong evidence base, traditional CBT is not always the most appropriate or beneficial treatment option. In treating complex mental health issues, such as clients struggling with emotion dysregulation or those who regularly engage in acts of self-harm and/or suicidal behaviours and/or ideation, CBT may not be the best approach (Cristea et al., 2017). Developed to help clients experiencing suicidal behaviours and/or struggling with borderline personality disorder (BPD), dialectic behaviour therapy (DBT) works with clients to establish behavioural control and stability through developing awareness and skills around emotion regulation, interpersonal difficulties, and distress tolerance (Linehan, 1993). As a framework, DBT enables clinicians to work effectively with clients displaying high levels of risk, including suicidal ideation and self-harming behaviours (DeCou et al., 2019; Kothgassner et al., 2021).

The DBT approach presents particular opportunities for skill development in clinicians. Firstly, it provides exposure, training, and engagement with high-risk clients. As such, clinicians who opt to practice DBT are likely to engage with and introduce an evidence-based framework and perspective to manage risk and an array of other presenting problems; subsequently, increasing competency and confidence within this space (Kene et al., 2019). Generally, early career psychologists have limited exposure and training with high-risk client groups (Cramer et al., 2013; Jacobson et al., 2012; Schmitz et al., 2012).

Secondly, as part of the DBT framework, clinicians routinely engage in regular consultation groups/teams (Swales, 2010; Toms et al., 2019). Consultation offers clinicians the chance to develop and enrich their learning, skills, and overall practice in a variety of ways (Toms et al., 2019; Walsh et al., 2018). Importantly, group consultations are a safe place for peer support where therapists can focus on their treatment fidelity, manage burnout, and provide support to one another (Linehan & Wilks, 2015; Swales, 2010).

Clinicians are given a highly supportive and constructive learning environment to learn a new therapy and how to work with risk, with support from both peers and their consultation team. This is something that may be of particular value for psychology intern students (Robillard et al., 2021), who are generally shielded from high-risk clients and often find clinical supervision intimidating and risk averse (Kene et al., 2019; O’Donovan et al., 2011; Scott et al., 2011). Recognising the benefits of DBT to clinician skill development, DBT may be an important and helpful skillset for early career clinicians.

Acknowledging the emphasis on CBT, lack of exposure to high-risk clients, and supervision practices that are noted by students to be insufficient (Nedeljkovic et al., 2014), it is likely that many graduate psychology students are not well versed in dealing with complex and/or risky clients when entering the workforce (Kene et al., 2019). In fact, the work-readiness of psychology graduates has been called into question and noted as a concern (Robillard et al., 2021; Schmitz et al., 2012).

The ‘WOKE’ program placement

An opportunity arose at the University of Canberra to provide Master of Clinical Psychology students with a unique intern placement as part of the “WOKE” (Working On Key Emotions) program. This program was funded by the Capital Health Network to fill a service gap regarding early intervention for young people aged 15 to 21 years experiencing multiple social and emotional problems including being vulnerable to developing BPD. The program uses an acceptance and change skills-based approach to treating life-threatening, therapy-interfering, and quality of life-interfering behaviours. The program consists of four phases including initial intake and assessment, pre-treatment, 14-week program, followed by graduation and follow-up planning. The program is an external placement for second-year clinical psychology students operating over two days per week. The placement is led by a clinical psychologist experienced in the delivery of DBT and supported by two registered psychologists. Students receive weekly individual supervision and engage in weekly consultation group. In addition to regular supervision, students participate in a concurrent training program including workshops, seminars, and skills practice sessions. Initially, students participate in three workshops to build a core understanding of DBT including working with complex cases, personality disorder, DBT philosophy, the biosocial theory of BPD, the structure of DBT, dialectical and behavioural underpinnings, and initial training in individual therapy and skills group treatment strategies. Following this, more in-depth training is provided on aspects of DBT considered core to effective practice. Students attend two workshops, one on preparing clients for treatment followed by DBT case conceptualisation. Students then undertake three workshops and a learning forum on chain and solution analysis, followed by a workshop about working with parents using DBT principles and strategies. At week 10 of the program, students attend the final workshop on strategies for effectively finishing with clients and setting up post-program plans and treatment options. For the duration of the WOKE placement, a peer-learning approach is taken through involvement in regular peer-group meetings, and clinical supervision emphasises a coaching approach, providing a safe and constructive space to learn new skills. More importantly, interns are encouraged to be open and “radically” genuine about their challenges, which are expected as part of the DBT learning process.

The current study

The current study examined the practicum experience of Master of Clinical Psychology students in the WOKE program. This was part of a larger program evaluation investigating outcomes for clients and the experience of parents (see Rickwood et al., 2021). Our aim in this paper is to explore the students’ experience of participation in the program as a clinical placement, including how it affected their confidence working with a high-risk client group and how it affected their perceptions of preparedness for their future roles in the workforce.

Methods

Research team positioning

All researchers on this paper have a background in psychology. Three of the team members are clinical psychologists, with two working within the DBT space. The two other members are researchers with both quantitative and qualitative methods expertise. As such, we all approached this study from a biopsychosocial perspective and with an understanding of psychological services and working with populations experiencing mental health concerns.

The two DBT specialists were the clinical supervisors involved in delivering the WOKE program. Their expertise was used to ground our understanding of DBT throughout the research project. The other members of the research team developed the interview guide and undertook the data analysis. Collaboratively, all researchers contributed to the interview guide and discussed themes to increase the face validity and applicability of the questions and findings to both the program and the research.

Importantly, none of the authors were involved in data collection. All interviews were completed by a researcher who was not involved in the clinical master’s degree program nor the program evaluation, but was experienced in conducting qualitative research interviews. This was done to ensure that participants felt safe to confidentially express their views.

Participants

Participants were 11 of the 16 students who undertook the WOKE program as one of their final year placements in their Master of Clinical Psychology course between 2019 and 2021. All students were invited to participate, and 68.8% volunteered. Of those who did not participate, two did not respond to the email invitation and the remaining three were not available at the scheduled interview times. Most were female (n = 9) and participants were aged between 25 and 45 years (mean age = 32.29, SD = 7.73).

Procedure

Ethics approval was obtained from the University of Canberra HREC (HREC 2235, 4704, 9130).

Participants were recruited directly through the WOKE program. At the completion of each program implementation all Master of Clinical Psychology students involved were emailed a research information sheet to their student email address and offered the chance to participate in a research interview. Students who responded provided informed consent and selected a time to complete the interviews. Interviews were undertaken by a researcher who was not involved in planning or delivery of the program. Interviews were completed either in-person (n = 6) or via Zoom (n = 5). Interviews took an average of 29 minutes (range = 13–43 minutes). No reimbursement was received for participation. Interviews were recorded then transcribed verbatim using NVivo.

Interview guide

Interviews were conducted using a semi-structured interview guide. The interview guide was established to assess the effectiveness of the WOKE program in delivering a training resource that actively contributed to professional development of the Master of Clinical Psychology students. The guiding questions related to five key aspects: expectations, training experience, professional development, working with the client group, and recommendations. The guiding questions are available in Supplementary File 1.

Data analysis

Interviews were transcribed verbatim using NVivo 12. An inductive thematic analysis approach, as outlined by Braun and Clarke (Braun & Clarke, 2006, 2019, 2022), was conducted. The themes derived were, however, influenced by the overarching evaluation framework and the guiding interview questions, which necessarily meant that some deductive structure was superimposed. Analysis comprised: (1) familiarisation with data, by checking the transcription and relistening and rereading each transcript. During this phase general overarching ideas were noted and roughly categorised. (2) Initial coding was conducted in NVivo. Based on some of the overarching ideas identified during the familiarisation steps, individual codes were identified. In step (3) each of the individual codes were considered, reviewed and categorised into broader overarching themes. From there, themes were reviewed (step 4) and reworked to consolidate and refine each respective overarching theme and its sub-themes. Based on the initial thematic map, themes identified and developed by the first author were presented to the research group. Through a process of peer debriefing the themes were refined; as a team we discussed how themes were presented and how they were semantically and conceptually different. We also discussed the importance of each concept and the relationship between the themes, sub-themes, and overarching student experiences. After the first phase of refinement, the first and last authors independently reviewed and recategorised the data. In doing so, we were able to ensure the true essence of the data was captured in the themes, while ensuring no other concepts were overlooked in stage one of peer debriefing. From there, the themes and sub-themes were again presented to the research team. After another round of team debriefing, consensus was reached and step (5) commenced, which involved defining and naming each of the relevant themes and sub-themes. Names and definitions were discussed among researchers. When all researchers agreed with the definition and connection of each theme, the production of the report (step 6) commenced.

Results

Themes are presented in an order that represents their importance in showing how the factors contributed to the progression of the student experience. Illustrative quotes are provided, identified by the program implementation group number and interview number. There were five themes derived, as shown in Figure 1.

Figure 1. Concept map of the themes and sub-themes.

Bold face text represent the main themes presented in the results. Italicised text represents the sub-themes. Non-bolded text represents the key attributes within themes. The timeline at the bottom of the figure indicates at what point in the placement the themes were most evident/relevant.

Theme 1 - a community working as a community

Acknowledged by all participants was an overarching sense of togetherness and community, which was seen as the greatest factor of the WOKE placement. The idea of identifying as a community, and working and developing within that community, played a significant role in how the students perceived their placement and ongoing role in the psychology profession. The commitment of other community members facilitated an environment of safety, warmth and growth.

Recognising this overarching sense of camaraderie, students reflected on feelings of respect and responsibility which were dispersed through the entire clinical team (other students, student mentors, and supervisors).

Within this community environment, both formal and informal supervision and training were facilitated, enabling consistent and continuous learning and development.

being accepting of ourselves and that set the environment for how we were going to support each other it was different to any kind of supervision we had ever had before. Umm quite often you feel like, as a student you feel like you have to perform and impress people and prove that you are really good. And we just kind of threw all those things out the door and went to authentically be there in a way where we could be vulnerable, we could be raw. And that meant what was actually going on for us could be addressed. If we were, you know, we could ask the real questions, we didn’t have to worry that anyone was going to think we were a bad provisional psychologist or anything. Um and so with that set up right at the beginning we had this beautiful working environment where we could, you know, genuinely support each other which really makes a difference because it’s sometimes really stressful working in this, you know, with this population. But we had this kind of safe warm space that we could go back to which was really lovely. And that was I said it was formal and informal but we had the consult group with others and the supervisors, that was kind of our formal space for working with stuff that was going on with our clients and getting support from each other umm and that was also new compared to other ways of working where we got to draw on everyone’s knowledge and that really helped. … Then we had incidental kind of supervision cause the supervisors over there made themselves super available to us, so it wasn’t only a set time, you could get support whenever you needed to. Which is really crucial when you have someone in half an hour and you don’t know what you’re going to do or you’re half way through an appointment and something happened and you are really worried. Umm there is always someone there. C1.4

Theme 2 – beyond the training manual

Enabled by the community atmosphere was the opportunity for training and development to go “beyond the training manual”. When beginning their DBT placement, many students had not been exposed to in-depth training or opportunities in relation to working clinically in a DBT framework, “we all sort of started with a base level of very little knowledge about DBT”. C1.4. Over the course of the placement, students identified the “specialised” nature of the placement and consequently the ability to “tailor their learning” significantly enhanced their learning opportunities. Additionally, the community enabled the learning to be an evolving process whereby continuous training could occur.

Students were surprised and appreciative of the training modules and training opportunities. They noted that the specialised nature of the training workshops meant they were in-depth and comprehensive, following both traditional textbook learning and real-life applications.

I don’t think there’s like any other placement would offer as much training, particularly in such ah I guess, comprehensive model. And yeah, I feel like [supervisor] done that really well, where it’s like we’re not going in blind, like the training is so good and continues throughout. It’s and it’s I guess integrated into the placement. Not aww yep, there is the manual you have got to read that in your own time, where like yes, you do get a lot out of reading the manual and like it is really helpful. But yet you need the more face to face and integrated within the placement to actually get the most out of that. So, I think that’s a really. yeah, huge factor. C2.12

Due to the specialised nature of the placement, students could tailor their learning. Students noted they were given the chance to consolidate, reflect and ask questions throughout the training modules.

I really liked, again, how with the training, it was very much like [supervisor] had this overarching idea of what they wanted to teach us. But we could also then ask lots and lots of questions around it and got lots more, I guess, personalised questions answered as well. So, it was really valuable. And I think because it was a small group, we were able to then keep learning and evolving as we went through. C2.13

Not only could they ask questions throughout training modules, they were also able to draw on the expertise of the community throughout the placement, fostering an opportunity for continuous supported learning.

the biggest plus side of that, like the placement is the training and just what you learn from the supervisors, both formally like in the workshops, but also just in supervision and just hearing how they would deal with that situation or treat that issue. I think that’s really probably the best thing about the placement that you get. So, like so much learning happens. C2.12

Theme 3 – confidence to work with complexity and risk

In recognising the benefit of the community environment and highly supportive training, students’ confidence to work with complexity and risk significantly improved. A key factor contributing to the students’ confidence was the ability to “develop and apply a new skillset”. Students reflected that the process of working with high-risk clients and receiving training at the same time allowed them to develop a skillset enabling them to work with risk and complexity.

in a lot of ways I’ve built skills across a lot of areas that are important to me professionally and personally. In a professional sense, kind of ticking off some really big things that I feel like are important. Working with people who have significant risk issues is a good area to be skilled up in. Getting your head around behaviourism, being able to use those principles effectively, especially in terms of contingency management, has been powerful for me. And I think whether I am working with this group in the future or any other population, those skills are going to carry on with me. C2.10

While apprehensive at the beginning of the placement, students were grateful for the skill development and opportunities to work with complexity in a safe and supported way. It was within this environment that students felt confident to explore and understand risk.

Assessing those kind of behaviours in young people. So I guess just having a bit more knowledge around self-harm and kind of different levels of risk around that, so. And knowing kind of what, what might be needed. What would feed into an early intervention program with risk and suicidal risk kind of learning the difference between different types like passive suicidal intent vs more active for ideation or planning and just running around like the risk factors. So definitely learning more about just it as a concept and definitely working with self-harm. C1.3

Capacity to work with people who self-harm and suicide because it is exposure to it in a safe supported way. So I think it would be terrifying to go out into the real world post grad, be a psychologist on your own and not have had that exposure before you go out and graduate. In this circumstance you can do it in a way where you know there is someone around the corner you can call if you get into a situation where you are stuck you know there are people there that can back you up. Umm the making those decisions like risk assessment decisions for the first time, is important to have support with that process so umm you can make the decision and run them by someone and have their input. Umm really, it’s changed my preparedness, really increased my level of feeling confident to work with clients in the population. C1.4

Working with families

An important sub-theme regarding complexity was working with families. Noting a lack of exposure, students found working with parents challenging at first.

I was nervous about that in the beginning, because I haven’t had done a lot of work with families and I certainly got more confidence with that as we went through. C1.6.

However, throughout the placement, supervised exposure and development of professional skills for working in an integrated way with parents was a valued opportunity enhancing the students’ abilities to work effectively with young people and their families.

Professionally, I’ve built on a lot of different things that I really wanted to. Working with families is another area and working with parents in particular, both in the area of parenting kind of skills and relationship skills, and just that skill of working with multiple people at the same time in the same room, it can be really the big one to have to practice. And I am glad that I got to practice it while a student that has been important to me. C2.11

Theme 4 – enhanced personal development

While skill development and confidence in this space were vital outcomes of the placement, the opportunities for personal development were also a key factor. Students highlighted the emphasis on self-reflection and using the skills for their own development and the impact that had on them personally and also in how they now carry themselves professionally.

I guess personally, there has been a lot of growth around facing challenging things. It is a funny thing about doing DBT is that there is an expectation that you practice it yourself and if you practice it yourself, you cannot help but grow … . And so in practicing the DBT skills myself, I’ve approached things that I might not have approached in the past, and I’ve been able to manage my own feelings and experiences in a more effective way. And I have been interpersonally way more effective than I have in the past. And that is cool. C2.10

In turn, through learning and practicing the skills themselves, the students felt more in touch with themselves but also more genuine about promoting the approach to the clients. This allowed them as therapists to be more transparent and authentic with their clients, a value that many students appreciated.

as a therapist, you get to do these sort of like training skills group where you get to learn the skill, practice the skill, so that you kind of know how you’re going to pitch it to clients and then teach them how to use it. And it’s just, yeah, it’s just really nice because you get to sort of use these skills yourselves and be like, oh my gosh, this really works for me. And then you get that. Yeah, like you can really sell it to clients, and I think I really loved that. I love the fact that it’s practical, it helps me and I’ve seen it help other clients. C4.19

Theme 5 – acknowledging and overcoming stigma

While developing personally and professionally throughout the placement, students acknowledged and overcame their stigma of working with a “challenging group”. In refection, students recognised that they had held stigma about the client group and the uncertainties surrounding risk.

It was a bit nerve racking to start with, and I think that ties into the kind of stigma there that is present with people who have, you know, personality vulnerabilities and kind of, you know, those more high-risk behaviours like, you know, self-harm and severe emotion dysregulation and anger and stuff, substance use. So those kinds of behaviours, I guess, elicit a bit of fear in clinicians, I think if you’ve not experienced working with that population before. And so that was probably I mean, I think just going into it, I was a little bit nervy just because of the nature of the population and the risk surrounding them. C1.7

However, as the students embraced the community and the placement opportunity, their perceptions of the client group changed. Many students left the placement confident and eager to continue working with this client population.

I think now I was saying before that it has really changed my, my opinions around maybe more complex clients. And it’s, it’s interesting. I think, you know, when you have somebody that has a bit more sort of complex presentation, it is challenging. There are challenges that come with that. But it’s also just incredibly interesting. And I think there’s a lot of value that comes from it when you, you are working with them and you can see them making progress like that, more rewarding work. And I think that’s something that I’d love to continue doing. So I yeah, I would really love to continue working with this population in the future. C4.19

Altogether, the five themes are presented graphically in the concept map in Figure 1. At the bottom of the Figure is a timeline of the students’ journey as they progress over the course of the placement. The overarching element of this concept map is the community “bubble”. Inside this supportive community are the key attributes of the placement experience. Reading left to right, the student experience starts with the specialised, tailored and continuous training provided within the highly supportive learning community. The three triangles show the key changes or outcomes achieved by the students. The triangles deliberately overlap with each other and with the training aspects to demonstrate that this is an evolving process that allowed for movement back and forth between development, training, implementation, and the peer learning within the community. Finally, presented at the bottom of the Figure in bold text, students could acknowledge the stigma they held pre-placement and how, by working within the community “bubble”, they overcame this stigma. The reduction of stigma at the end of placement allowed them to want to continue to work with this client population and share their experiences in their careers as psychologists.

Discussion

The current study set out to investigate the experiences of Master of Clinical Psychology students in the WOKE program, a DBT placement offered in the second year of their course. Specifically, we aimed to explore the students’ experiences of the program, including how it affected their confidence working with a high-risk client group and how it affected their perceptions of preparedness for their future roles in the workforce.

After listening to students’ experiences and the subsequent data analysis, five main themes were identified. Students identified that while DBT was a new framework, the unique community-based learning environment fostered an opportunity for learning, growth and development in a highly supportive space. As a result of the placement, students felt confident and well-equipped to enter the workforce and engage with complex clients. Overall, students felt that there were key aspects of the placement, which were unusual and exemplary in their experience, that were beneficial to their professional development as psychologists.

The environment of camaraderie and community were the most beneficial aspects of the placement. Facilitated by the guiding principles of DBT, participants allowed themselves to be fallible and open to critique and learning opportunities. Within the community, there were three key aspects of support available to students: individual supervision, consult group, and the informal support provided through the community environment. The implementation of numerous support avenues meant students felt consistently supported and guided throughout the entire placement, a fundamental part of student development (O’Donovan et al., 2011; Salter & Rhodes, 2018) and an aspect that clinical psychology students often feel is lacking on placement (Ellis et al., 2014; Nedeljkovic et al., 2014). The constant, varied, non-judgemental and genuine support and encouragement from supervisors and peers within the community were key attributes linked to the enjoyment and positive outcomes experienced by students.

Also attributed to the community approach was the availability of enhanced training and support. For these students, like most clinical psychology students in Australia, DBT was a new clinical framework to learn and work with (Impala et al., 2019; Kazantzis & Munro, 2011). However, within the community space and placement opportunity there were numerous learning opportunities, including ongoing workshops, consult group and informal peer learning, all of which were learning strategies that impacted outcomes, understanding and application (Herschell et al., 2014; Toms et al., 2019; Walsh et al., 2018). Students had the time and support to engage, learn and develop a DBT mindset and skillset, which had multiple professional and personal benefits.

As a result of the successful completion of the placement, students felt upskilled and prepared to work with sometimes avoided clients. In line with previous research (Mackelprang et al., 2014; Monahan & Karver, 2021), students highlighted the upskilling in dealing with complex clients and risk as a valuable aspect that is rare within placement opportunities. Consequently, students felt confident and eager to enter the workforce and continue working with this population. The attitude shift and preparedness to work with complex clients is perhaps the most important outcome in terms of real-life application. Qualified clinicians are historically concerned and unwilling to work with complex presentations (Cramer et al., 2013; Jacobson et al., 2012). Further, there has been criticism of new graduates as being ill prepared and non-work ready when it comes to complex presentations (Jahn et al., 2017; Robillard et al., 2021; Schmidt, 2016). Particularly within youth mental health, it is critical that psychologists can work confidently and effectively with self-harm and suicide risk as these issues are common comorbidities and presenting issues for young people (Lustig et al., 2021; Shim et al., 2022). As such, the addition of new registered psychologists who are enthusiastic to work with this population is a major benefit to mental health communities and the mental health workforce.

Strengths and limitations

A key strength is that this study allowed us to hear directly about the students’ experience, to contribute to the literature about clinical psychology students’ experiences and outcomes from the first-hand experiences of students enrolled in the clinical program. Nevertheless, this is also a limitation, as our results are bound by this particular student placement experience, which may not reflect more broadly on psychology student placements. Likewise, we have only captured the students’ self-perception of increased skill and confidence without any other measures of student success and growth. Nevertheless, all students successfully completed their placement, attained the required competencies, and are subsequently all employed as psychologists.

Care was taken in the research design to ensure that the researchers were independent of the WOKE program, so that the students would feel assured of confidentiality and were comfortable openly discussing their experiences, even if they were negative. We received no negative feedback, which we have interpreted as a positive outcome, but there is the possibility that students may have had concerns that they did not feel appropriate to disclose. One-third of the students did not participate, which appeared to be due to lack of contact or conflicting commitments, but these students also may have had a different placement experience.

Finally, the transferability of the findings is a potential limitation. One of the main strengths of the WOKE program was the availability of expert clinical training and extensive supervision, contextualised within a DBT framework. However, this may not be appropriate or feasible for many placement settings. The well-resourced and specialised nature of the WOKE placement enabled a deliberate focus on attaining the best possible outcomes for students. Such a highly supportive, community learning environment may not be possible in some circumstances.

Implications for clinical psychology training and future directions

This study shows that these clinical psychology intern students had a positive placement experience and gained skills and confidence working with clients with high-risk and typically stigmatised presentations. The factors attributed to success were: (1) working collaboratively as a community with supervisors and peers (and clients); (2) being well-supported in training beyond reference to the treatment manual; (3) being exposed to complex and high-risk clients, including engaging with family (parents), within a highly supportive, well-supervised learning environment; (4) being emersed in the treatment skills and encouraged and enabled to apply them personally, thereby enhancing professional uptake and promotion; and (5) acknowledging and moving beyond stigma related to a particular disorder and client group.

The emphasis and integration of each of these five factors could be considered in all clinical placements to improve students’ learning experience and workforce readiness. Placement providers should consider whether these factors are relevant to other placement settings and how they could be incorporated or enhanced. Placement coordinators could consider opportunities for placements with complex client presentations, ensuring there is appropriate supervision, training and support, as indicated from this research. Future research could investigate whether enhanced competencies are reflected in assessments, and investigate the long-term benefits of such placement opportunities by studying how graduate clinicians transfer the newly acquired principles and skillset into different clinical work settings.

Implications for the psychology profession include the urgent need for the psychology workforce to have the skills and motivation to work with young people with severe emotional dysregulation, including self-harm and suicidal thoughts, including working with their families. Upskilling clinical psychology graduates so that they are work-ready through appropriate placement opportunities is a way forward to build workforce capacity. The placement factors identified as valuable by clinical psychology students in this study were not only valuable for learning to work with clients at risk of BPD, but are also likely to comprise exemplary practice in practicum learning in clinical psychology more broadly.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author [D. R.], upon reasonable request.

Supplementary material

Supplemental data for this article can be accessed at https://doi.org/10.1080/13284207.2023.2227768

Additional information

Funding

This work was supported by the Capital Health Network under Grant [PAC050].