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This research addresses the extent of student impairment in Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) accredited marriage and family therapy programs, indicators of impairment used by program directors, faculty time devoted to impaired students, and the frequency of student dismissal. The data come from a survey of 44 COAMFTE program directors that was conducted during the spring of 2001, as well as responses to an open-ended item asking for a description of "the most troublesome student" to come to the attention of the respondent. The authors discuss the findings with respect to similar studies in counseling psychology and the larger literature on clinical training. Finally, the authors offer suggestions for future research.

Marriage and family therapy (MFT) training programs are in the business of preparing therapists who are self-aware, conceptually sound, ethically sensitive, and effective in the work that they do with clients. Faculty in Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) accredited programs are gatekeepers to the profession, assuring that those who graduate from their programs have the knowledge, skills, and personal characteristics to practice competently. Therapist competence, in general terms, is a therapist's ability to bring about desired change with clients (Herman, 1993; Shaw & Dobson, 1988). In his assessment of the predictors of therapist competence, Herman (1993) summarized the relevant research in counseling psychology and identified three general areas of therapist competence. These include knowledge, training, and experience; theoretical orientation; and therapist personal characteristics (Herman, 1993). A deficiency or ineptitude in any of these areas could be considered to be "impairment."

A significant component of knowledge, training, and experience would include the ability to recognize when circumstances pose an ethical dilemma and to generate responses that arc informed by professional ethics. Training sensitizes students to the importance of the principles of autonomy, beneficence, and non-maleficence, as well as justice and fidelity (Kitchener, 1984) and teaches them to apply these principles with the consultation and support of supervisors. Students who are unable to apply these principles appropriately would be considered to be deficient.

Herman's (1993) second category of therapist competence, theoretical orientation, includes the ability to translate theory into practice. Students who do well in didactic classes but are unable to apply the material in clinical situations would show a deficiency in theoretical orientation.

Herman's (1993) final area of competency is receiving increasing attention in the MFT literature and is sometimes referred to as "the person of the therapist" (Aponte, 1994, p. 5). This component of training is of special concern because of its impact on therapy outcome. Asay and Lambert (1999) suggest that of the four common factors that contribute to variance in therapy outcome, the therapeutic relationship accounts for 30%, a contribution more potent than anything else that happens within the session, including technique. Students who graduate from accredited programs must be prepared to engage clients from backgrounds similar to and different from their own in a meaningful way. The emotional well-being of therapists-in-training is also a legitimate concern of program faculty. Beutler, Crago, and Arizmendi, in their 1986 review of studies related to therapist emotional well-being, concluded that therapist emotional well-being facilitates both the process of treatment and the outcome. Eight years later, Beutler, Machado, and Neufeldt (1994) reviewed an additional set of studies related to therapist emotional well-being and client outcome and concluded that "high therapist distress or disturbance levels may not only prevent client growth, but actually induce negative changes" (p. 238). The authors go on to state "the possibility that emotional problems on the part of the therapist may negatively affect even relatively well functioning clients should be given considerably more attention" (p. 238).

Although rates of student impairment in clinical training programs are generally reported to be below 5% (Bernard, 1975; Biaggio, Gasparikova-Krasnec, & Bauer, 1983; Boxley, Drew, & Rangel, 1986; Burgess, 1994; Forrest, Elman, Gizara, & Vacha-Haase, 1999; Keppers, 1960; Olkin & Gaughen, 1991; Sweeney, 1969; Tedesco, 1982), the potential risk to clients, the drain on faculty and program resources, and the stress experienced by trainees are all significant and legitimate concerns. Only one of the studies conducted in clinical training programs cited above included MFT programs in their sample (Olkin & Gaughen, 1991), and even then only included a small number of MFT programs and did not analyze data for MFT programs separately. The research presented here rectifies that problem by surveying all programs listed as accredited on the COAMFTE web site as of spring of 2001. The data was collected in the spring of 2001.

RESEARCH QUESTIONS

The following questions guided the research reported here:

1. What is the extent of student impairment in COAMFTE accredited MFT programs?

2. What indicators do program directors think should be used in assessing student impairment?

3. How much time do faculty and program directors invest in addressing "problem students"?

4. What strategies do faculty use to respond to student impairment?

5. How do program directors perceive the institutional support they receive in addressing student impairment?

6. How often are students dismissed and what are the outcomes of dismissal decisions?

7. How do program directors describe their "most troublesome problem student"?

METHOD

Our 5-page questionnaire, a modification of those used by Olkin and Gaughen (1991) and Burgess (1994), was sent to directors of all 80 COAMFTE accredited programs in the spring of 2001. The questionnaire included both closed- and open-ended questions. No code numbers were used to link returned questionnaires with a master list, and respondents were assured that there was no way to link their responses to their program. Respondents were asked to send copies of their grievance and dismissal policies (to be analyzed at a later date). These were removed from the return envelope and separated from the questionnaire so as to protect the anonymity of questionnaire responses. Requests for a summary of the research were separated from questionnaires in a similar manner. Responses to open-ended questions were collapsed into categories and paraphrased to further protect confidentiality. In addition, respondents were told that they could remove their institution's name from any printed material they shared with us. Two follow-up mailings to the initial mailing were conducted using Dillman's (2000) "tailored design method," including a reminder postcard and a second packet of materials. The use of this strategy yielded a return rate of 55% (N = 44).

RESULTS

Description of Programs

Half of the questionnaires returned (n = 22) were from accredited master's programs, with another 20% from programs that offered both the master's degree and a PhD or a master's degree and a postdegree certificate (n = 9). Eleven percent of the questionnaires were from doctoral programs (n = 5) and 14% were from postdegree programs (n = 6). Two respondents failed to indicate level of program. More than two-thirds of the programs interview prospective students before entry into their program and require the Graduate Record Exam (GRE) or the Miller Analogy Test (MAT). Our questionnaire did not distinguish between face-to-face and telephone interviews. Eighty percent (n = 35) reported requiring a personal biography of applicants. Only two programs reported requiring objective personality measures. Eighty-six percent of the programs (n = 38) do a global evaluation of each student at least annually. Three of the program directors reported requiring personal psychotherapy for all their students, although others noted that they "strongly encourage" it during supervision.

Frequency of Impairment in Last 5 Years

Using Burgess's (1994) definition of impairment as "an objective and negative change in a student's functioning that is pervasive and affects more than one area of the student's functioning, goes beyond problems typically expected in professional training, is emotional, physical or academic and is impervious to feedback" (p. 10), program directors were asked how many impaired students their program had dealt with in the last 5 years. A total of 108 impaired students were identified by our respondents. The range was 0-8 per program. The mean was 2.5, and the modal response was 2 impaired students in the last five years.

Indicators of Impairment