Clinical Trainee Perspectives on the Implementation of Trauma-Focused Training

After receiving institutional review board approval from the University of Pittsburgh, a convenience sample of participants was recruited from the university’s doctoral clinical psychology program in spring 2021. Participants were contacted through the program’s student e-mail list with an offer to complete an anonymous and voluntary online survey, hosted by Qualtrics, for $15. Of the 37 eligible students, 18 (49%) provided informed consent and responded to the survey.

Missing data were present; thus, the sample size used to calculate proportionality varies across question domains. Descriptive statistics were computed in RStudio, version 4.1.2 (31). Seventeen participants provided qualitative data. Qualitative survey data were coded using an open thematic coding strategy guided by grounded theory analysis techniques (32). Intercoder reliability surpassed the 85% threshold (33). Coding memos were continuously written to document insights. Results from each set of analyses were reformatted in joint displays to evaluate convergence, divergence, and the unique strengths and challenges of each set (34). Broad themes were established and refined in a final round of memos to improve the quality of our conclusions.

Of the full sample (N=18), six trainees (33%) reported having prior experience providing trauma-responsive care for at least one client with a posttraumatic stress disorder (PTSD) diagnosis. Half (N=9) of the trainees reported feeling “a little prepared” to provide trauma-responsive care to clients with PTSD, whereas six trainees reported feeling “not at all prepared.” Only one trainee reported feeling adequately prepared to support clients with PTSD. Twelve trainees (67%) reported having provided trauma-responsive care for at least one client with a trauma history but without PTSD, and trainees reported feeling “not at all” (N=5), “a little” (N=8), or “somewhat” (N=5) prepared to support clients with a trauma history. Only three trainees (17%) had not provided clinical treatment to a client with PTSD or a trauma history.

Qualitative data corroborated that many trainees reported feeling unprepared to support trauma-affected clients. For example, one shared, “I have always felt not prepared to handle one [of their trauma-affected clients].” Reflecting on their past clinical experiences, another trainee reported low self-efficacy as a result of insufficient training, saying, “I felt like I was failing this client because I didn’t have adequate training.” After being asked to read the NHC in the survey, another trainee wrote, “I am now feeling very not confident in my ability to ethically provide support to someone who has a trauma history.”

Trainees rated their perceived need for additional training in each of the five foundational competencies (Table 2). In the full sample, the most frequently reported need (56%, N=10) was for training on trauma-focused psychological intervention. Trainees reported needing and wanting trauma-specific training, saying, for example, “It would help me tremendously with one of my clients.” Beyond individual clients, trainees viewed encounters with clients affected by trauma as eventualities for which they need to be prepared. As one said, “Whether clients are coming to treatment for trauma or another reason, nearly all clinicians will have a client [who] has experienced trauma.”

Trainees reported the overarching competencies to be highly relevant to their clinical goals (Table 3). Only one trainee reported that the competencies were moderately relevant, saying, “I do think I could use some training in trauma, but it is somewhat unrelated to my clinical and research goals.” Overall, the trauma competencies were described as “extremely valuable to develop (and largely generalizable)” and “an important framework . . . particularly when considering intersectional factors (e.g., racial identity, gender, socioeconomic status, citizenship).” Another perceived them as “crucial for any clinician.” Finally, trainees commented on the NHC’s importance regarding professional ethics. They said that overarching competencies are fundamentally “critical to the principle of nonmaleficence” and that trauma-informed assessment competencies are “necessary to be an ethical and competent clinician.”

Seventeen participants answered questions focused on training integration. Ten trainees (59%) believed that some trauma-specific clinical training should be required and that some should be optional. Six trainees (35%) believed that trauma-specific training should be a requirement for all clinicians; one trainee said all trauma-specific training should be optional. The qualitative data mirrored these findings.

Those who favored required trauma-specific training referenced the high prevalence of trauma exposure as their rationale. For example, “Given how prevalent experiences of trauma are, I think that basic competencies should be required for all.” Those who reported a preference for some training to be required also noted prevalence and preparedness factors but noted heterogeneity in trainee goals. For example, “Not everyone has the same interest . . . their time may be better spent in other coursework.” Another trainee suggested that “students who want [more in-depth training] could seek out additional opportunities.” The only trainee who said that trauma-specific training should be entirely optional cited concerns about time constraints.

Trainees rated a 1- to 2-day workshop as the most preferable format for trauma-specific training (seven top preference votes; mean=2.12), followed by a half-semester course (four top preference votes; mean=2.24) and a semester-long course (four top preference votes; mean=2.88). The least favored formats included a self-paced online module and “no additional training needed.” Trainees also expressed differing preferences for either adding coursework or integrating trauma-specific training into existing coursework. Whereas some trainees indicated that “this material could easily be an additional course or half-course,” others shared that they “would love to see this integrated more into our existing courses and clinical training” and that they “would vastly prefer to see any required components integrated into current [clinical] training [rather] than added.”

Trainees expressed a preference for learning environments to be in person, as opposed to virtual, and to include smaller groups rather than one large group. As one trainee recommended, “Allow for smaller group discussions. [Expect] that folks can engage or not as they feel comfortable.” Nine trainees identified choice and flexibility as the most important elements of any learning environment. One noted, “Definitely some choice and flexibility in how to complete requirements would be important!” Coconstructed norms were also highly favored by participants (N=5). As one said, “Coconstructed class norms are critical to creating [a] safe and effective environment for learning about trauma. . . . Flexible engagement is critical as well, because it maximizes student autonomy when engaging in potentially psychologically distressing content.” Similarly, another requested “choice and flexibility to engage with the content in different ways (I think I personally would feel uncomfortable engaging in a trauma-related role-play, for example, but wouldn’t mind watching others do so).” Other suggestions included incorporating breaks and grounding activities into instruction. For example, one student recommended “building in some mindfulness/training in coping with learning about another’s trauma.” Finally, trainees indicated “easy access to the exit for all students” to be important.

Two trainees reported having no concerns about the integration of trauma-specific training. For example, “I’m 100% supportive of more robust clinical training opportunities!” and “Integrating trauma-specific training makes me excited to learn more!” Concerns that were noted by trainees included the emotional toll of the material and the need for more support. One trainee remarked, “It is important that supervisors and professors are aware that student clinicians may have also experienced trauma, and lack of sensitivity or awareness on their part may make this type of training emotionally taxing.” Another agreed, saying, “We need to ensure that we are supporting the emotional health of graduate students more than we historically have.” One trainee suggested that programs could “have someone in the clinic who specializes in trauma and could be a consultant when additional supervision is needed.” Concerns about time constraints were also noted—for example, “our clinical training is already overwhelming” and “a full additional course would be challenging.”

Trainee perspectives are critical to the successful implementation of trauma-focused training within graduate clinical psychology programs. We offer one model for soliciting these perspectives. Although these perspectives may guide initial programmatic changes, communication must be maintained. Dialogue between current and incoming trainees, instructors, and program directors should continue throughout the implementation process. These conversations should be grounded in intersectional frameworks to understand identities, power dynamics, privilege, and oppression in trauma exposure and sequelae (40–42). Organizational culture, climate, readiness for change, and effective leadership also have the potential to promote or undermine implementation processes and outcomes (38, 43).

Finally, trauma-focused instruction must be deeply intentional, be trauma informed, and actively resist the (re)traumatization of trainees to the extent possible (17, 18, 23, 44). Without deep consideration of trainees’ experiences, well-intentioned practices may be implemented that are countertherapeutic. For example, trigger warnings, once theorized to support learners with trauma histories, may be not only ineffective but also countertherapeutic. They may increase survivors’ beliefs in the centrality of their trauma to their identity instead of buffering them against past trauma-related responses (45). Although it is impossible to prevent all adverse reactions to trauma-focused material (18), precautions are necessary.

We used a convenience sample from multiple cohorts within one doctoral clinical psychology training program, which may limit the generalizability of our results. Further, results may have been subject to self-selection bias; trainees interested in trauma-specific training may have been more likely to complete the survey. That said, trainees who were personally less invested in trauma-specific training still noted the ethical imperative of providing trauma-specific clinical training. Finally, limited demographic information was collected in an effort to protect participants’ anonymity. Future research should replicate this study with a larger, interinstitutional sample to better understand how trainees’ identities and experiences may relate to their perspectives.