Official Position of the American Academy of Clinical Neuropsychology (AACN): Guidelines for Practicum Training in Clinical Neuropsychology

Abstract

Practical experience is central to the education and training of neuropsychologists, beginning in graduate school and extending through postdoctoral fellowship. However, historically, little attention has been given to the structure and requirements of practicum training in clinical neuropsychology. A working group of senior-level neuropsychologists, as well as a current postdoctoral fellow, all from a diverse range of settings (The AACN Practicum Guidelines Workgroup), was formed to propose guidelines for practicum training in clinical neuropsychology. The Workgroup reviewed relevant literature and sought input from professional organizations involved in education and training in neuropsychology. The proposed guidelines provide a definition of practicum training in clinical neuropsychology, detail entry and exit criteria across competencies relevant to practicum training in clinical neuropsychology, and discuss the relationship between doctoral training programs and practicum training sites. The proposed guidelines also provide a methodology for competency-based evaluation of clinical neuropsychology practicum trainees and outline characteristics and features that are integral to an effective training environment. Although the guidelines discussed below may not be implemented in their entirety across all clinical neuropsychology practicum training sites, they are consistent with the latest developments in competency-based education.

Keywords:

• Practicum
• Competencies
• Guidelines
• Training
• Clinical neuropsychology.

Introduction

Practical experience has a long history in the education and training of psychologists and other healthcare providers. Although didactic methods and coursework form the basis for imparting foundational knowledge, utilizing this knowledge in clinical interaction with patients in a professional context is an essential learning experience. In the training of doctoral-level psychologists in the USA, there are three general levels of experiential learning (practicum, internship, and residency) that are aligned with typical waypoints in the overall training sequence. Experiential learning during graduate school years includes practicum experiences and the traditional year-long internship. The training sequence in clinical neuropsychology specifically is capped by a two-year residency. Although internship and residency are discussed in broad terms within the Houston Conference Guidelines (Hannay et al., 1998), there is no mention of practical training at the pre-internship level.

Commensurate with the overall movement within broader health service psychology to operationalize training, the guidelines herein are offered to articulate an overall vision for practicum-level training in clinical neuropsychology. Toward that end, the following pages highlight core aspects of practicum training within the specialty of clinical neuropsychology as well as clinical neuropsychology practicum training within the broader context of training health service psychologists. More specifically, the following areas are addressed:

•	Competencies and competency-based evaluation at the practica level in clinical neuropsychology.
•	Characteristics of practica in clinical neuropsychology.
•	Supervision of practicum students in clinical neuropsychology.
•	Relationships between doctoral programs and clinical neuropsychology practica training sites.

Importantly, herein, the term guidelines is used in a manner consistent with that described by the Board of Educational Affairs of the American Psychological Association (American Psychological Association, 2004, p. 5). Specifically, the term refers to recommendations for a set of guiding principles or suggested goals; guidelines are not intended to be exhaustive or mandatory but rather aspirational.

These guidelines are intended as a development tool for practicum sites involved in neuropsychology training. New clinical training sites as well as existing clinical neuropsychology practicum training programs may wish to use these guidelines as a template to ensure that an optimum training environment for clinical neuropsychology has been created. In addition, students whose goal is to pursue specialization in clinical neuropsychology may choose to use these guidelines when evaluating prospective practicum training sites to determine if a site includes the latest developments in competency-based education. Finally, doctoral training programs can utilize these guidelines to evaluate the training offered at an external clinical neuropsychology practicum training site as well as to shape internal neuropsychology clinical training at the practicum level.

These guidelines were developed by a working group consisting of senior-level neuropsychologists and a current postdoctoral fellow (The AACN Practicum Guidelines Workgroup). Members were drawn from a diverse range of settings, all sharing a common commitment to and substantial experience with practicum training. Additional input and perspective from representatives of professional organizations involved in education and training in neuropsychology were sought. A series of teleconferences was convened beginning in July 2013 and concluding in May 2015. Key documents related to training in neuropsychology and the role of the practicum in the overall field of health service psychology were reviewed. Initial writing was accomplished in small groups and reviewed by the group as a whole. A second phase entailed intensive review of the manuscript by a smaller subgroup. This work comprised a lengthy, iterative conversation in which concepts were debated freely in order to achieve consensus.

Development of the guidelines relied heavily upon a competency-based model. Within that frame of reference, practicum training is defined, entry and exit criteria competencies are detailed, and a methodology for competency-based evaluation of practicum trainees is proposed. While these guidelines are offered as an initial effort to operationalize practicum training in clinical neuropsychology and were formulated with sensitivity to various constraints that may exist around the training enterprise, they are not intended to contravene the training requirements of doctoral programs, institutional policies, evolving requirements imposed by APA, or state laws. Furthermore, it is recognized that some contexts may limit the full adoption of some of the recommended elements of a clinical neuropsychology practicum experience.

Background and History of Practicum Training in Psychology

Practicum training has a long history in the preparation of psychology practitioners. It was developed to provide students with opportunities to apply knowledge and skills acquired in the classroom to a clinical setting. The need for practicum training was first recognized following the inception of the internship requirement as a capstone for training in professional psychology after World War II (Hatcher & Wise, 2014). Once the requirement of internship was established, pre-internship training that emphasized the acquisition of skills specific to psychologists, such as intelligence and personality assessment, was provided within the classroom setting. Subsequently, practicum training evolved in breadth and depth, extending pre-internship training to the provision of services to clients in clinical settings in order to better prepare students for the internship experience (Hatcher & Wise, 2014). Currently, practicum training is an essential bridge between graduate school didactics and internship, allowing the student to establish the basic applied competencies needed for internship and the subsequent transition to more advanced training.

Practicum experiences are developmental in nature and follow a sequence consistent with the program’s training goals and expected student competencies. In other words, the practicum is an extension and application of the student’s coursework. Specific competencies to be addressed within a practicum experience are determined by the graduate program in consultation with the practicum supervisor. Practica typically increase in complexity as students progress through their doctoral program, consistent with their skill development.

Several organizations have proposed similar definitions of practicum training within health service psychology. Definitions of a practicum have been put forth by the Council of Chairs of Training Councils (Council of Chairs of Training Councils, 2007), the National Council of Schools and Programs in Professional Psychology (National Council of Schools & Programs in Professional Psychology, 2009), and the Association of State and Provincial Psychology Boards (Association of State & Provincial Psychology Boards, 2009). All agree that practicum experiences are a component of an organized training sequence undertaken prior to internship, which are completed under the auspices of the graduate program and in coordination with the training site. In addition to “practicum,” various synonymous terms have been used to describe this type of training experience, including “externship,” “traineeship,” and “clerkship.” For the purposes of this paper, we will use the term “practicum;” however, the guidelines described below are intended to apply to any organized, pre-internship clinical neuropsychology training experience at the doctoral training level.

Toward a Definition of Practicum in Clinical Neuropsychology

Efforts to define practicum training generally, and neuropsychology practicum training in particular, are consistent with the overall movement in psychology toward developing a common terminology for describing training experiences. In 2012, the American Psychological Association (APA) began developing a taxonomy framework that set forth terminology and definitions related to education and training within psychological specialties (American Psychological Association, 2012). The taxonomy specifies four levels of intensity for education and training experiences; ranging from lowest to highest, these levels are “Exposure,” “Experience,” “Emphasis,” and “Major Area of Study.” Each of these levels may apply to doctoral, internship, postdoctoral, and post-licensure training, and training programs are expected to use the descriptors in order to improve the comparability of experiences across programs. The taxonomy framework also stipulates that the specialties themselves define the training experiences required for each of the intensity levels listed above. The Clinical Neuropsychology Synarchy (CNS), the specialty council composed of representatives from major neuropsychology organizations, has recently developed taxonomy definitions specific to training in clinical neuropsychology (Clinical Neuropsychology Synarchy, 2015). For more details on the CNS taxonomy, the reader is referred to the Council of Specialties in Professional Psychology (www.cospp.org).

According to the taxonomy for clinical neuropsychology, the number of practicum experiences completed contributes to the level of intensity of overall training within the doctoral program. Accordingly, a definition of what constitutes a single practicum is necessary. The clinical neuropsychology taxonomy defines a single practicum experience as extending for one academic year and consisting of supervised training for at least eight hours per week, with at least 50% of that time in the provision of clinical neuropsychological services. Beyond these requirements, practica may vary in many ways, such as in the type and range of patient populations and problems, length and purpose of assessments, clinical complexity, and number of evaluations performed. Furthermore, some experiences may serve as an appropriate initial practicum in clinical neuropsychology, whereas others may be appropriate only for advanced practicum students. For example, providing clinical services in a memory disorders clinic where the trainee encounters a recurring and circumscribed referral question may be appropriate for a beginning practicum experience. In contrast, working in a clinical setting that fields referrals from numerous sources within a large tertiary care medical center may be more appropriate for an advanced student in a later stage of training.

Whereas a practicum experience can be defined in terms of duration, intensity, populations, problems, etc., these descriptive terms are distinct from the overall goals or expected outcomes of the training experience. As discussed below, outcomes are expressed in terms of competencies. As such, the guidelines herein recommend the competencies that are expected prior to beginning practica in clinical neuropsychology (i.e., Readiness for Practicum) and the competencies that are expected prior to entering internship (i.e., Readiness for Internship). Before detailing the specific competencies expected at these levels, additional background regarding competency-based training is provided.

The Competency Movement

The development of practicum guidelines specific to clinical neuropsychology must be placed in the context of broader competency developments within professional psychology. Notably, the Houston Conference Policy Statement (Hannay et al., 1998) was formulated prior to most advances in what has been known as the “competency movement” in professional psychology, which itself was spurred by a 2002 conference related to competencies in education and training (Kaslow et al., 2004). In various articles that were derived from the 2002 competency conference, the “cube model” of competency development was introduced as a way to conceptualize the structure and formation of competencies (Rodolfa et al., 2005). Specifically, the model introduced a three-dimensional matrix consisting of Foundational Competency Domains, Functional Competency Domains, and stages of professional development. Foundational Competencies are those that apply across all professional activities, such as scientific knowledge and methods, relationship competencies, and ethics and legal standards. Functional competencies pertain to specific aspects of practice, such as assessment, intervention, and consultation. Finally, competencies progress through defined stages of professional development (e.g., doctoral program, internship, postdoctoral residency, and post-licensure training). Since the 2002 conference, several groups, organizations, and task forces have contributed for developing competencies for professional psychology practice. In 2006, the Assessment of Competency Benchmarks Work Group developed a document that identified 15 core competency areas at three developmental levels, including Readiness for Practicum, Readiness for Internship, and Readiness for Entry to Practice (Fouad et al., 2009). Since then, there have been periodic updates to the competencies benchmarks document. The most recent iterations may be found at http://www.apa.org/ed/graduate/competency.aspx.

In addition to developing general competencies for health service psychology (Belar, 2014), competency initiatives have taken place in various specialties and other practice settings, including clinical health psychology (France et al., 2008), professional geropsychology (Karel, Knight, Duffy, Hinrichsen, & Zeiss, 2010; Knight, Karel, Hinrichsen, Qualls, & Duffy, 2009), and primary care psychology (McDaniel et al., 2014), among others. Efforts to develop competencies originate within specialties, and may be reflected in the specialty’s postdoctoral training guidelines or their application for specialty recognition through the APA Commission for the Recognition of Specialties and Proficiencies in Professional Psychology. Rey-Casserly, Roper, and Bauer (2012) made an initial effort toward competency development for entry-level competencies in clinical neuropsychology. More recently, a modified version of those competencies is being considered by all major organizations within clinical neuropsychology via the CNS (Glenn Smith, personal communication, 5 February 2015). Consistent with the Houston Conference Policy Statement, formal training for entry-level practice is attained during a two-year postdoctoral residency in clinical neuropsychology. While the Houston guidelines specify that neuropsychology training takes place at doctoral, internship, and postdoctoral levels, the guidelines are vague regarding what type of training occurs at each level. Furthermore, the competency document currently being considered by CNS-member organizations makes no reference to the stages of competency development expected at the start of each level of training.

Competencies in Neuropsychology Practicum Training

To further refine competency expectations within clinical neuropsychology, these practicum guidelines developed by the AACN Practicum Guidelines Workgroup are meant to define competency expectations for entry into a first neuropsychology practicum placement (i.e., Readiness for Practicum) and exit from the final practicum experience (i.e., Readiness for Internship). With that in mind, the Workgroup reviewed the competencies within Rey-Casserly et al. (2012) to determine whether an individual competency is relevant to the practicum experience and, if so, what competency level constitutes Readiness for Practicum and Readiness for Internship. In undertaking the process, the Workgroup drew upon Hatcher and Lassiter (2007) and the practicum guidelines developed by the Association of Directors of Psychology Training Clinics (Hatcher & Lassiter, 2006). Rating descriptors were developed and appear in Table 1. The Workgroup added the term “Basic” as a rating level to that of the Hatcher and Lassiter schema. This modification allowed for more fine-grained assessment of competencies across the training trajectory. All members of the Workgroup then completed an individual, online opinion survey of the appropriate competency expectations (i.e., from Table 1) for Readiness for Practicum and Readiness for Internship. Responses were tabulated and summarized, and a series of conference calls were conducted to reach consensus on the relevance of each competency to practicum training and the appropriate minimum expectations for Readiness for Practicum and Readiness for Internship. Notably, several changes in the wording of competencies were made from the Rey-Casserly et al. (2012) version based on Workgroup consensus.

Table 1. Definitions for competency expectations

Descriptor	Definition
N: Novice	Possesses beginning skills related to general psychology practice; needs intensive supervision in neuropsychology
B: Basic	Has basic exposure and experience in neuropsychology, with many remaining gaps in knowledge and skills; still needs intensive supervision in neuropsychology
I: Intermediate	Has an intermediate level of exposure and experience in neuropsychology; ongoing supervision is needed
A: Advanced	Has solid experience, handles typical situations well; requires supervision for unusual or complex situations
P: Proficient	Functions autonomously, knows limits of ability; seeks supervision or consultation as needed
E: Expert	Serves as resource consultant to others; is recognized as having expertise

Competency expectations for practicum training in clinical neuropsychology appear in Tables 2–6. Table 2 specifies competencies related to professionalism, relationships, and science, which together constitute foundational competency domains. Tables 3–6 cover the functional competencies relevant to evidence-based practice, assessment, intervention, and consultation, respectively. Notably, several factors influenced the inclusion or exclusion of competencies derived from Rey-Casserly et al. (2012). For example, although research productivity is an important competency within clinical neuropsychology and presumably will be taking place at the doctoral level, it is not an expected part of practicum training. Additionally, the intervention component within a clinical neuropsychology practicum may be limited to provision of feedback, recommendations, and/or referral for treatment. As such, applied competencies related to providing interventions beyond the provision of assessment feedback were not included; however, knowledge-based competencies relating to intervention techniques were retained. Finally, several competency domains were deemed to be either inappropriate to practicum training or optional (i.e., the provision of supervision, teaching, interdisciplinary systems management/administration, and advocacy).

Table 2. Foundational competencies unique to clinical neuropsychology but common across functional domains

Cluster/Foundational Domain	Competency	Readiness for Practicum	Readiness for Internship
The clinical neuropsychology practicum student:
Professionalism:
Professionalism	• understands the unique contributions of neuropsychology to different contexts; demonstrates awareness of the roles of clinical neuropsychologists and how those roles vary across practice settings and assessment/intervention contexts	N	B
Individual and cultural diversity	• integrates knowledge of diversity issues in neuropsychological assessment, research, treatment, and consultation (e.g., Health disparities, language differences, educational level, cultural context, literacy, and individual differences)	N	I
	• understands and appreciates how cultural, linguistic, disability, and other demographic/socioeconomic factors affect the process and outcomes of neuropsychological assessments and the application of normative data and interpretations in specific populations, test selection, normative data, and treatment planning	N	I
Ethical, Legal standards and policy	• understands and applies ethical standards and concepts relevant to the professional activities of clinical neuropsychologists (e.g., informed consent, confidentiality, use of technicians/psychometrists, third-party observers, disclosure of test data, test security, etc.)	B	I
	• understands and applies legal standards and concepts relevant to the professional activities of clinical neuropsychologists (e.g., licensure, individuals with disabilities, protection and release of health information, mandatory reporting, copyright protection, etc.)	N	B
Reflective practice/Self-assessment/Self-care	• engages in reflective self-assessment regarding the dynamic knowledge base and skill sets necessary for practice in clinical neuropsychology across a range of practice settings with the goal of improving skill level over time; understands limits of competence in particular populations or settings and seeks to lessen their impact through continuing education and additional training	N	I
Relational:
Relationships	• maintains effective and productive relationships (e.g., patients, families, caregivers, colleagues, team members, and communities) across the complex interprofessional settings involved in neuropsychological practice	B	I
	• communicates clearly and effectively, explaining neuropsychological concepts and interpretations in a manner best suited to particular audience (e.g., patients, families, and caregivers as well as other professionals)	N	B
Science:
Scientific knowledge and methods	• demonstrates knowledge of the clinical and cognitive neurosciences, including neurology, neuroanatomy, neurobiology, brain development, and neurophysiology	N	I
Research/Evaluation	• demonstrates knowledge of scientific and scholarly developments in clinical neuropsychology	N	I
	• understands research design and analysis relevant to clinical neuropsychological science and practice	N	I
	• identifies and critically evaluates research as it informs clinical practice	N	I

Table 3. Functional competencies: evidence-based practice

Type	Content	Readiness for practicum	Readiness for internship
Knowledge-based competencies	The neuropsychology practicum student will have knowledge of:
	• key signs and symptoms of disease processes relevant to practice and how patient characteristics (e.g., demographic factors and comorbidities) affect their expression	N	I
	• age-related changes in brain functioning and behavior across the lifespan	N	I
	• scientific basis for assessment strategy, including test selection, use of appropriate normative standards, psychometric characteristics of selected tests, and test operating characteristics	N	I
	• decision-making strategies and their applications in differential diagnosis	N	I
	• scientific basis for diagnostic conclusions and interpretations across a range of neuropsychological disorders	N	B
Applied competencies	The clinical neuropsychology practicum student will be able to:
	• incorporate and use outcome research in neuropsychology in guiding assessments and formulating interventions, integrating patient and contextual factors	N	B
	• applies key components of evidence-based practice (i.e., best evidence, clinical expertise, and patient characteristics/values) in selecting appropriate assessment and intervention approaches	N	B

Table 4. Functional competencies: assessment

Type	Content	Readiness for practicum	Readiness for internship
Knowledge-based competencies	The clinical neuropsychology practicum student will have knowledge of:
	• neuropsychology of behavior, including information processing theories, cognitive/affective neuroscience, social processing, and behavioral neurology	N	I
	• patterns of behavioral, cognitive, and emotional impairments associated with neurological and related diseases and conditions that affect brain functioning	N	I
	• neurochemistry, neuropsychopharmacology, neuroendocrinology, and related areas relevant to practice	N	B
	• neuroimaging and other techniques relevant to neuropsychology practice	N	B
	• effects on brain functioning and behavior of common systemic medical illnesses	N	B
	• patterns of behavioral, cognitive, and emotional impairments associated with psychiatric disorders	B	I
	• medications used for common medical diseases and their effects on brain functioning and behavior	N	B
	• measurement and psychometrics relevant to cognitive abilities, social and emotional functioning, and brain–behavior relationships	B	I
	• potential functional implications of neuromedical conditions and neuropsychological impairments as they relate to everyday ability level and educational/working/social/living environments	N	I
Applied competencies	The clinical neuropsychology practicum student will be able to:
	• analyze and clarify referral questions based on the context, professional roles, and the patient/examinee presentation	N	B
	• gather information key in addressing the referral question, including interview(s), targeted behavioral observations, and review of records	N	I
	• appropriately select tests, measures, and other information sources consistent with best evidence and specific context of assessment, including assessment of effort if relevant	N	I
	• appropriately administer and score tests and measures	B	A
	• interpret assessment results, with formation of an integrated conceptualization that draws from all relevant information sources (e.g., interview, test results, behavioral observations, and records)	N	I
	• provide recommendations for management that are appropriate to the assessment context and consistent with evidence-based practices in neuropsychology	N	B
	• demonstrate written communication skills in the production of integrated neuropsychological assessment reports	N	B
	• provide feedback, as relevant to the assessment context, to patients, families, or caregivers in a sensitive manner adapting to the needs of the specific audience	N	B
	• address issues related to specific populations (e.g., cultural or linguistic differences, physical or mental disability, use of interpreters, and educational level) appropriately by referring to other providers with specialized competence, obtaining peer neuropsychological consultation, and describing limitations in assessment interpretation	N	I

Table 5. Functional competencies: intervention

Type	Content	Readiness for practicum	Readiness for internship
Knowledge-based competencies	The clinical neuropsychology practicum student will have knowledge of:
	• evidenced-based intervention practices to address cognitive and behavioral problems present in different clinical populations	N	B
	• theoretical and procedural bases of intervention methods appropriate to address disorders of attention, learning and memory, executive skills, problem-solving, perceptual processing, sensorimotor functioning, and psychological/emotional adjustment	N	B
	• how complex neurobehavioral disorders (e.g., aphasia, anosognosia, and neuropsychiatric illness) and sociocultural factors can affect the applicability of interventions	N	B
	• empirically supported interventions provided by psychologists and other mental health professionals	B	I
Applied competencies	The clinical neuropsychology practicum student will be able to:
	• employ assessment and provision of feedback for therapeutic benefit	N	B
	• develop treatment recommendations that address cognitive, behavioral, and emotional problems while accounting for patient preferences, individual differences, and social–cultural contexts	N	B

Table 6. Functional competencies: consultation

Type	Content	Readiness for practicum	Readiness for internship
Knowledge-based competencies	The clinical neuropsychology practicum student will have knowledge of:
	• professional roles and expectations of a consulting clinical neuropsychologist	N	B
Applied competencies	The clinical neuropsychology practicum student will be able to:
	• determine and clarify referral issues	N	I
	• educate referral sources regarding the utility and relevance of neuropsychological services	N	B
	• communicate findings to fellow professionals and referral sources regarding consultation activities	N	B

Characteristics of Practicum Sites in Clinical Neuropsychology

The organizational structure and mission of practicum sites reflect a commitment to the goal of training future neuropsychologists. Neuropsychology practicum sites designate a neuropsychologist to oversee the creation and execution of the site training plan. The training plan “shall describe how the trainee’s time is allotted and shall assure the quality, breadth, and depth of the training experience through specification of the goals and objectives of the practicum” (Association of State & Provincial Psychology Boards, 2009, p. 7).

The practicum experience can occur in a wide variety of settings, provided the minimum expectations for training (i.e., direct service provision and supervision) are met. Venues for training may include neuropsychological services within hospitals, university health centers, community mental health centers, community medical clinics, VA medical centers, schools, prisons, and private practices.

The time a student dedicates to a given practicum may vary according to site and circumstances. The practicum time commitment is sufficient to allow for student progression and ensure meeting the requirements for both direct service hours and supervision needs. The Association of State and Provincial Psychology Boards (2009) has made the recommendation that:

At least 50% of the total hours of supervised experience accrued shall be in service-related activities, defined as treatment/intervention, assessment, interviews, report-writing, case presentations, and consultations. At least 25% of the supervised professional experience shall be devoted to face-to-face patient/client contact. (p. 8).

While there are many possible variations in time commitment, a practicum would involve at least eight hours per week over the course of the academic year. More typically, a practicum would involve 16 h per week across the academic year.

The practicum training plan supports the students’ growth in clinical interviewing, records review, test selection, administration, and scoring, as well as provision of feedback. A particular emphasis in most neuropsychological practica is on case conceptualization and development of report writing skills, which is likely to require a substantial amount of time and supervision. In addition to the required face-to-face supervision between student and supervisor, the training plan may include a variety of other supplemental supervisory/learning experiences such as observation of more senior providers/trainees engaged in direct patient care and consultation, case presentations in group supervision, and didactics in neuropsychology and related fields. These components of supervision and training are further described below.

Supervision

Critical components of supervision

Supervision is a central feature of any neuropsychology practicum experience and includes observation of the student while engaged in interviews, testing, and the provision of feedback to patients and family members. Practicum students receive individual, face-to-face supervision on a regular and as-needed basis. The majority of supervision is completed on an in-person basis; however, periodic remote supervision via telephone or videoconference may play a role.

The intensity of individualized supervisory contact is sufficient to actively monitor all aspects of trainees’ activities, determine levels of competency as recommended in these guidelines, and promote professional growth within the specialty. As noted by Bernard and Goodyear (2004), the goals of individual supervision are threefold: (a) to enhance the clinical competencies of the trainee; (b) ensure the quality of services provided to patients; and (c) to provide a gatekeeping function for those entering the profession. The content of supervisory contact will vary depending on specific factors, including the student’s level of experience, the type of clinical services provided, and case complexity. We highlight the advice of Stucky, Bush, and Donders (2010) in noting “the student’s clinical responsibilities are conducted in a carefully supervised and graduated manner, allowing trainees to assume progressively increasing responsibility in accordance with their level of education, ability, and experience” (p. 743).

As written reports are the primary documentation of clinical service in many neuropsychology practicum settings, the supervising neuropsychologist is ultimately responsible for the final content of the work product. Report writing is likely to be a major focus of training in most practica and may consume a significant portion of dedicated supervision. As mentioned above, discussion of each case and associated documentation is a central teaching activity that provides the supervisor and trainee the opportunity to thoughtfully review how clinical information and reasoning are represented in the written record. As such, simply passing a document back and forth using word-processing tools such as “track changes” and comment provision does not constitute sufficient supervisory practice at the practicum level and is not a suitable replacement for face-to-face discussion and teaching.

Group supervision and didactics

Group supervision is also useful in practicum training. Group supervision occurs when multiple trainees meet together with a supervisor or supervisors for the purpose of clinical teaching and experiential learning. Training sites that include multiple trainees provide a richer learning environment. Group supervision allows for practicum students to learn from each other and leverage the diverse experiences of multiple trainees for the benefit of each individual trainee. For example, students can learn to administer tests by working together and simulating clinical encounters. Modeling appropriate clinical interactions and critiquing peers are useful aspects of group supervision. When available, practicum students can also learn from others at more advanced levels of training, such as interns and fellows. These interactions allow practicum students to develop a deeper understanding of the sequence and progression of advanced professional training in clinical neuropsychology while providing more advanced trainees with the opportunity to gain experience in teaching and supervision.

In addition to individual and group supervision, practicum sites may enhance training by providing access to didactic opportunities within neuropsychology and related disciplines. Didactic opportunities may take the form of journal clubs, seminars, conferences, interdisciplinary teaching and/or clinical rounds, grand rounds, special invited lectures, medical/graduate school courses, and other academic offerings. In some settings, didactic opportunities may be limited, for example, in a solo or small independent group practice. In these types of settings, didactic experience may take the form of the supervisor and trainee reading and discussing journal articles together.

Characteristics of supervisors

Supervisors are required to be clinical neuropsychologists. As defined by the American Academy of Clinical Neuropsychology (2009):

A clinical neuropsychologist is an independent, professional, doctoral level psychologist who provides assessment and intervention, based upon the scientific concepts of clinical neuropsychology. Training in clinical neuropsychology comprises a broad background in clinical psychology, as well as specialized training and experience in clinical neuropsychology. Training and preparation in clinical neuropsychology specifically entails: (1) completion of a doctoral degree in psychology from an accredited university training program; (2) internship in a clinically relevant area of professional psychology; (3) the equivalent of two years of additional specialized training in clinical neuropsychology; and (4) state or provincial licensure to practice psychology and/or clinical neuropsychology independently. Attainment of the ABCN/ABPP Diploma in Clinical Neuropsychology (i.e., board certification) is the clearest evidence of competence as a clinical neuropsychologist, assuring that all of these criteria have been met (p. 1).

Supervisors are expected to ensure maintenance of their own competence via ongoing clinical practice and regular continuing education. This dedication to lifelong learning fosters the maintenance of up-to-date scientific knowledge required for training others while also modeling to students the importance of commitment to continual professional growth. In addition to demonstrating ongoing competency specific for state licensure, supervisors are aware that ABPP has adopted a requirement for maintenance of certification (American Board of Professional Psychology, 2015). This process will provide a mechanism for board-certified clinical neuropsychologists to demonstrate that they remain abreast of advances in the scientific knowledge base and specialized technical skills in clinical neuropsychology.

Training and education in supervision is recommended. A number of authors have provided excellent discussions regarding the essential skills and characteristics of effective supervisors (Barnett, Erickson Cornish, Goodyear, & Lichtenberg, 2007; Ellis, 1991; Falender & Shafranske, 2012; Henderson, Cawyer, & Watkins, 1999); we refer the reader to those publications for a more comprehensive review of this important topic. Neuropsychology supervisors need to develop general supervisory competencies (American Psychological Association, 2015) as well as neuropsychology-specific competencies (Rey-Casserly et al., 2012; Shultz, Pedersen, Roper, & Rey-Casserly, 2014; Stucky et al., 2010).

Other considerations related to supervision

The supervising neuropsychologist has a direct and substantive role in the evaluation of patients seen by his or her students. When observed first-hand by the trainee, this professional interaction constitutes a vital aspect of clinical teaching and is a necessary component for the supervisor’s assumption of responsibility for the case.

“Vertical supervision” can be a useful component of the practicum experience. Specifically, in some settings in which there are trainees at more advanced levels, postdoctoral fellows or interns with a primary neuropsychology emphasis, may supervise practicum students, all under the supervision of a neuropsychologist. This approach can complement, but does not replace, direct supervision from a clinical neuropsychologist. When vertical supervision is employed:

(1)	The clinical neuropsychologist closely supervises the postdoctoral fellow or intern in clinical work as well as the supervision of the lower level trainee.
(2)	The clinical neuropsychologist assumes ultimate responsibility for the disposition of the patients seen by the practicum student and supervised by the fellow or intern.
(3)	The clinical neuropsychologist also has regular individual supervision with the practicum student.

To ensure patient and trainee safety, supervisors are available for consultation during the time students are interacting with patients. Availability entails being in immediate physical proximity or reachable by telephone, and able to be in close physical proximity within minutes. Contact via other electronic communications such as text messaging is limited to noncritical matters only, with all appropriate measures taken to protect patient confidentiality (e.g., avoiding use of patient names). While there may be additional regulations governing a supervisor’s presence (e.g., reimbursement by third-party payers), such constraints are not fundamental to a clinical neuropsychology training setting and may not be relevant to all training sites (e.g., clinics that do not bill for services provided by students).

Relationship Between Doctoral Programs and Training Sites

The relationship between the doctoral program and the training site begins with the site articulating the prerequisites for training in their setting and the degree to which they can calibrate the experience to students with varied backgrounds in neuropsychology-related coursework and experience. This information will facilitate appropriate matches between students and practicum settings, and help the doctoral programs best understand how to prepare students who are interested in neuropsychology practicum training.

Policies and procedures

After determining that a neuropsychology practicum site has the necessary elements for appropriate training (see Characteristics of Practicum Sites in Clinical Neuropsychology above), the doctoral program and the neuropsychology training site develop a formal written affiliation agreement that includes policies, procedures, training plans, and methods of communication. The following guidelines are meant to facilitate communication between neuropsychology practicum sites and doctoral programs. Of note, the present guidelines are consistent with prior guidelines (Association of State & Provincial Psychology Boards, 2009; National Council of Schools & Programs in Professional Psychology, 2009) regarding communication between sites and programs for general psychology practicum training as articulated below.

Orientation to practicum procedures:

(1)	Graduate programs establish written policies governing practicum and disseminate them to students and practicum supervisors. Programs also provide opportunities for discussion and clarification among students, programs, and sites.
(2)	If training sites have institutional policies governing practicum, they are clearly communicated to the student and doctoral programs.

Training plans:

(1)	Neuropsychology practicum experiences are aligned with the training needs of the individual student. Thus, there shall be an agreed-upon training plan between the student, the training site, and the graduate program as to the content and process of the practicum experience.
(2)	The training plan addresses how the trainee’s time is allocated and assures the quality, breadth, and depth of the training experience, including:

(a)	Rationale for the experience in light of previous academic preparation and practicum training to ensure that the overall training experience is organized, sequential, meets the needs of the student, and provides for protection of the public,
(b)	nature of supervision, designated supervisors, and the form and frequency of feedback from the practicum training site supervisor to the doctoral program, and
(c)	methods and timing of formal evaluation of the trainee’s performance.

Method and frequency of communication:

(1)

Neuropsychology practicum sites provide written feedback to doctoral programs at least twice per year (e.g., mid-point and end-of-year). In the event of a problem with a student’s performance or ability to meet the expectations of the training site, practicum staff and doctoral program faculty communicate as frequently as necessary in order to develop a plan for remediation and/or resolution. Similarly, in the event that a student has concerns regarding the training experience at the site, this concern is brought to the attention of both practicum supervisors and program faculty.

(2)

The doctoral program assures the quality of the practicum experience through careful communication with designated training site personnel and periodic site reviews.

Competency-based evaluation

Most doctoral programs that offer specialty training in clinical neuropsychology are APA-accredited in clinical psychology. All students are expected to meet competency expectations consistent with the program’s area of accreditation, regardless of what specialty track (e.g., Health Psychology and Clinical Neuropsychology) they may be within the program. Competency evaluations attest to the student’s progress and document the number of hours spent in direct and indirect clinical service and supervision. The evaluation forms required by doctoral programs for practica typically address a range of skills/experiences and are used to document credit and hours required for graduate training and/or professional licensure. Specific evaluation of clinical neuropsychology competencies, such as assessment proficiencies, in these forms is often minimal and at times consists of only one or two questions about “assessment;” evaluation of proficiency in neuropsychological evaluation is often nonexistent. In order to provide students who are pursuing specialty training in clinical neuropsychology with optimal feedback, an evaluation process that is more specific to neuropsychology competencies is needed. This is in keeping with the competency-based model described above, wherein the evaluation process surveys the skills and knowledge that are the focus of training. Accordingly, the competencies in clinical neuropsychology provided in Tables 2–6 are delineated in an effort to assist practicum training supervisors with providing more specific feedback to trainees who seek to specialize in clinical neuropsychology. The competencies are taken directly from the document provided by the CNS-member organizations and align with accreditation guidelines for all doctoral programs regarding professional competencies, assessment, intervention, and consultation (American Psychological Association, 2013).

The evaluation form provided in Appendix A is grounded in the competencies framework detailed above and is offered as a helpful tool to clinical neuropsychology practicum supervisors for guiding students toward competency development in clinical neuropsychology. The form brings together the rating levels that appear in Table 1, with the competencies and expectations corresponding to Readiness for Practicum and Readiness for Internship that appear in Tables 2–6. It is recognized that assessment approaches, selection of test batteries, and the content or emphases of reports can vary between and within practicum sites, depending on the referral base and various subspecialties within the field, and thus have taken a broad approach. Although a given practicum experience may not address all of the competencies listed in Tables 2–6, the competencies specified in Appendix A are considered to be fundamental elements of training at the practicum level. Although not part of the required student evaluation forms that graduate programs expect from practicum training sites, neuropsychology practicum supervisors may wish to share this neuropsychology competencies-based evaluation form with the student’s graduate program so that programs may have a better sense of how their neuropsychology-oriented students are developing within that domain of skills. As indicated above, the forms developed by graduate programs to meet various APA and other requirements contain little evaluative information regarding neuropsychology-specific competencies.

In addition to summative evaluation at specified time points during a practicum experience, beginning students typically need more frequent formative feedback in the initial stages as they integrate an extensive amount of novel information and develop new technical skills. The beginning student needs to master a large number of test measures, become familiar with a wide range of neuropathological syndromes, and embark on learning the process of clinical reasoning. Students will benefit from frequent verbal feedback throughout the practicum, as well as formal written feedback at designated intervals.

A designated supervising clinical neuropsychologist is responsible for providing feedback and completing periodic formal evaluations. Input from other faculty, intermediary supervisors (interns or postdoctoral fellows), psychometrists, and staff members may be helpful as well in evaluating the student’s strengths and weaknesses. Feedback from patients about their experience with the student can also be informative.

Conclusions

The Houston Conference Guidelines (Hannay et al., 1998) assert that specialty training in clinical neuropsychology takes place at the doctoral, internship, and postdoctoral levels. Practicum experiences in clinical neuropsychology are a crucial component of doctoral-level training and set the stage for more focused experiential training at the internship and postdoctoral levels. However, little attention has been given to the essential features of neuropsychology practica, including the definition of practicum training, characteristics of practicum sites, the nature of supervision, and qualifications of supervisors. Additionally, since the development of the Houston Conference Guidelines, competency-based education and training has been increasingly emphasized within psychology and in other healthcare disciplines.

The AACN Practicum Guidelines Workgroup developed guidelines regarding the essential components of clinical neuropsychology practicum experiences, the competencies relevant to those experiences, and the competency expectations for students at both the outset and the conclusion of practicum training. The Workgroup also developed a method of rating competencies that includes a rating form. The Workgroup’s explicit competency-based approach was designed to draw on the latest developments in professional education and training.

The primary purpose of these guidelines is to promote quality of training in clinical neuropsychology at the practicum level. As the initial supervised training experience in clinical neuropsychology, the practicum focuses on foundational professional competencies related to practice as well as key knowledge and applied competencies that are relevant to neuropsychological assessment and related activities. It is hoped that these guidelines will be a useful resource for new clinical neuropsychology practicum training sites, practicum training directors at clinical setting with established practicum training programs, students who are evaluating prospective clinical neuropsychology practicum training sites, as well as doctoral training programs as they consider the content of both external and internal neuropsychology practica training.

To our knowledge, these guidelines reflect the first attempt within our specialty to clearly specify competency expectations for a specific training level. Additional work is needed to more fully specify competency expectations at the doctoral level, including aspects of training that are outside of the scope of the practicum experience. Likewise, competency expectations need to be more clearly specified at the internship and postdoctoral levels. The consensus expectations of Readiness for Internship developed as part of these guidelines could serve as a starting point for elaboration of competencies at the internships level. Finally, efforts are currently underway to reach broad, inter-organizational consensus on entry-level competencies in neuropsychology. It is hoped that development of these practicum guidelines will further competency-based initiatives in clinical neuropsychology.

Disclosure statement

No potential conflict of interest was reported by the authors.

Appendix A. COMPETENCY BENCHMARKS FOR PRACTICUM TRAINING IN CLINICAL NEUROPSYCHOLOGY

How to Use this Form: This form lists the essential competencies that are relevant to practicum training in clinical neuropsychology. Rating levels are defined in the following table:

Table

Rating	Definition
N/O	No opportunity to observe
N	Novice: Possesses beginning skills related to general psychology practice; needs intensive supervision in neuropsychology.
B	Basic: Has basic exposure and experience in neuropsychology, with many remaining gaps in knowledge and skills; still needs intensive supervision in neuropsychology.
I	Intermediate: Has an intermediate level of exposure and experience in neuropsychology; ongoing supervision is needed.
A	Advanced: Has solid experience, handles typical situations well; requires supervision for unusual or complex situations.
P	Proficient: Functions autonomously, knows limits of ability; seeks supervision or consultation as needed.
E	Expert: Serves as resource consultant to others; is recognized as having expertise.

For each competency, the form also includes expected ratings at the following points during training:

Readiness for Practicum (RP): The student is ready to begin practicum training in clinical neuropsychology with respect to the competency.

Readiness for Internship (RI): The student is ready to continue to the internship level with respect to the competency.

Different competencies have different expectations. For example, “Ability to administer and score tests and measures” has an expectation of “B = Basic” for Readiness for Practicum, whereas the competency “Demonstrate written communication skills in the production of integrated neuropsychological assessment reports” has an expectation of “N = Novice” for Readiness for Practicum. For reference purposes, competency expectations for Readiness for Practicum (RP) and Readiness for Internship (RI) appear in the columns to the left of the rating you provide to the student.

Please note that this form is designed to cover only those competencies relevant to practicum training, and not all competencies required for entry-level practice in clinical neuropsychology.

Foundational Competencies Unique to Clinical Neuropsychology

Table

Cluster/Foundational Domain	RP	RI	Student Rating (circle one)
Competency: The clinical neuropsychology practicum student:
Professionalism:
Professionalism: Understands the unique contributions of neuropsychology to different contexts; demonstrates awareness of the roles of clinical neuropsychologists and how those roles vary across practice settings and assessment/intervention contexts	N	B	N/O	N	B	I	A	P	E
Individual and Cultural Diversity: Integrates knowledge of diversity issues in neuropsychological assessment, research, treatment, and consultation (e.g., Health disparities, language differences, educational level, cultural context, literacy, and individual differences)	N	I	N/O	N	B	I	A	P	E
Individual and Cultural Diversity: Understands and appreciates how cultural, linguistic, disability, and other demographic/socioeconomic factors affect the process and outcomes of neuropsychological assessments and the application of normative data and interpretations in specific populations, test selection, normative data, and treatment planning	N	I	N/O	N	B	I	A	P	E
Ethical, Legal Standards and Policy: Understands and applies ethical standards and concepts relevant to the professional activities of clinical neuropsychologists (e.g., informed consent, confidentiality, use of technicians/psychometrists, third-party observers, disclosure of test data, test security, etc.)	B	I	N/O	N	B	I	A	P	E
Ethical, Legal Standards and Policy: Understands and applies legal standards and concepts relevant to the professional activities of clinical neuropsychologists (e.g., licensure, individuals with disabilities, protection and release of health information, mandatory reporting, copyright protection, etc.)	N	B	N/O	N	B	I	A	P	E
Reflective Practice/Self-Assessment/Self-Care: Engages in reflective self-assessment regarding the dynamic knowledge base and skill sets necessary for practice in clinical neuropsychology across a range of practice settings with the goal of improving skill level over time; understands limits of competence in particular populations or settings and seeks to lessen their impact through continuing education and additional training	N	I	N/O	N	B	I	A	P	E
Relational:
Relationships: Maintains effective and productive relationships (e.g., patients, families, caregivers, colleagues, team members, and communities) across the complex interprofessional settings involved in neuropsychological practice	B	I	N/O	N	B	I	A	P	E
Relationships: Communicates clearly and effectively, explaining neuropsychological concepts and interpretations in a manner best suited to particular audience (e.g., patients, families, and caregivers as well as other professionals).	N	B	N/O	N	B	I	A	P	E
Science:
Scientific Knowledge and Methods: Demonstrates knowledge of the clinical and cognitive neurosciences, including neurology, neuroanatomy, neurobiology, brain development, and neurophysiology	N	I	N/O	N	B	I	A	P	E
Research/Evaluation: Demonstrates knowledge of scientific and scholarly developments in clinical neuropsychology	N	I	N/O	N	B	I	A	P	E
Research/Evaluation: Understands research design and analysis relevant to clinical neuropsychological science and practice	N	I	N/O	N	B	I	A	P	E
Research/Evaluation: Identifies and critically evaluates research as it informs clinical practice	N	I	N/O	N	B	I	A	P	E

Functional Competencies:

Evidence-based Practice

Table

Competency	RP	RI	Student Rating (circle one)
Knowledge-based competencies: The clinical neuropsychology practicum student will have knowledge of:
Key signs and symptoms of disease processes relevant to practice and how patient characteristics (e.g., demographic factors and comorbidities) affect their expression	N	I	N/O	N	B	I	A	P	E
Age-related changes in brain functioning and behavior across the lifespan	N	I	N/O	N	B	I	A	P	E
Scientific basis for assessment strategy, including test selection, use of appropriate normative standards, psychometric characteristics of selected tests, and test operating characteristics	N	I	N/O	N	B	I	A	P	E
Decision-making strategies and their applications in differential diagnosis	N	I	N/O	N	B	I	A	P	E
Scientific basis for diagnostic conclusions and interpretations across a range of neuropsychological disorders	N	B	N/O	N	B	I	A	P	E
Applied competencies: The clinical neuropsychology practicum student will be able to:
Incorporate and use outcome research in neuropsychology in guiding assessments and formulating interventions, integrating patient and contextual factors	N	B	N/O	N	B	I	A	P	E
Applies key components of evidence-based practice (i.e., best evidence, clinical expertise, and patient characteristics/values) in selecting appropriate assessment and intervention approaches	N	B	N/O	N	B	I	A	P	E

Assessment

Table

Competency	RP	RI	Student Rating (circle one)
Knowledge-based competencies: The clinical neuropsychology practicum student will have knowledge of:
Neuropsychology of behavior, including information processing theories, cognitive/affective neuroscience, social processing, and behavioral neurology	N	I	N/O	N	B	I	A	P	E
Patterns of behavioral, cognitive, and emotional impairments associated with neurological and related diseases and conditions that affect brain functioning	N	I	N/O	N	B	I	A	P	E
Neurochemistry, neuropsychopharmacology, neuroendocrinology, and related areas relevant to practice	N	B	N/O	N	B	I	A	P	E
Neuroimaging and other techniques relevant to neuropsychology practice	N	B	N/O	N	B	I	A	P	E
Effects on brain functioning and behavior of common systemic medical illnesses	N	B	N/O	N	B	I	A	P	E
Patterns of behavioral, cognitive, and emotional impairments associated with psychiatric disorders	B	I	N/O	N	B	I	A	P	E
Medications used for common medical diseases and their effects on brain functioning and behavior	N	B	N/O	N	B	I	A	P	E
Measurement and psychometrics relevant to cognitive abilities, social and emotional functioning, and brain–behavior relationships	B	I	N/O	N	B	I	A	P	E
Potential functional implications of neuromedical conditions and neuropsychological impairments as they relate to everyday ability level and educational/working/social/living environments	N	I	N/O	N	B	I	A	P	E
Applied competencies: The clinical neuropsychology practicum student will be able to:
Analyze and clarify referral questions based on the context, professional roles, and the patient/examinee presentation	N	B	N/O	N	B	I	A	P	E
Gather information key in addressing the referral question, including interview(s), targeted behavioral observations, and review of records	N	I	N/O	N	B	I	A	P	E
Appropriately select tests, measures, and other information sources consistent with best evidence and specific context of assessment, including assessment of effort if relevant	N	I	N/O	N	B	I	A	P	E
Appropriately administer and score tests and measures	B	A	N/O	N	B	I	A	P	E
Interpret assessment results, with formation of an integrated conceptualization that draws from all relevant information sources (e.g., interview, test results, behavioral observations, and records)	N	I	N/O	N	B	I	A	P	E
Provide recommendations for management that are appropriate to the assessment context and consistent with evidence-based practices in neuropsychology	N	B	N/O	N	B	I	A	P	E
Demonstrate written communication skills in the production of integrated neuropsychological assessment reports	N	B	N/O	N	B	I	A	P	E
Provide feedback, as relevant to the assessment context, to patients, families, or caregivers in a sensitive manner adapting to the needs of the specific audience	N	B	N/O	N	B	I	A	P	E
Address issues related to specific populations (e.g. Cultural or linguistic differences, physical or mental disability, use of interpreters, and educational level) appropriately by referring to other providers with specialized competence, obtaining peer neuropsychological consultation, and describing limitations in assessment interpretation	N	I	N/O	N	B	I	A	P	E

Intervention

Table

Competency	RP	RI	Student Rating (circle one)
Knowledge-based competencies: The clinical neuropsychology practicum student will have knowledge of:
Evidenced-based intervention practices to address cognitive and behavioral problems present in different clinical populations	N	B	N/O	N	B	I	A	P	E
Theoretical and procedural bases of intervention methods appropriate to address disorders of attention, learning and memory, executive skills, problem-solving, perceptual processing, sensorimotor functioning, and psychological/emotional adjustment	N	B	N/O	N	B	I	A	P	E
How complex neurobehavioral disorders (e.g., aphasia, anosognosia, and neuropsychiatric illness) and sociocultural factors can affect the applicability of interventions	N	B	N/O	N	B	I	A	P	E
Empirically supported interventions provided by psychologists and other mental health professionals	B	I	N/O	N	B	I	A	P	E
Applied competencies: The clinical neuropsychology practicum student will be able to:
Employ assessment and provision of feedback for therapeutic benefit	N	B	N/O	N	B	I	A	P	E
Develop treatment recommendations that address cognitive, behavioral, and emotional problems while accounting for patient preferences, individual differences, and social–cultural contexts	N	B	N/O	N	B	I	A	P	E

Consultation

Table

Competency	RP	RI	Student Rating (circle one)
Knowledge-based competencies: The clinical neuropsychology practicum student will have knowledge of:
Professional roles and expectations of a consulting clinical neuropsychologist	N	B	N/O	N	B	I	A	P	E
Applied competencies: The clinical neuropsychology practicum student will be able to:
Determine and clarify referral issues	N	I	N/O	N	B	I	A	P	E
Educate referral sources regarding the utility and relevance of neuropsychological services	N	B	N/O	N	B	I	A	P	E
Communicate findings to fellow professionals and referral sources regarding consultation activities	N	B	N/O	N	B	I	A	P	E

Supervisor Comments (summary of strengths, areas in need of additional development):

If below expected competency level on any competency, please provide recommendations:

Student Comments: