‘They couldn’t really gauge where we were and what we were struggling with’: intern psychologists’ experiences of support within their placement during COVID-19

Abstract

The COVID-19 pandemic had detrimental impacts on academic and professional training globally. There were demands to salvage the academic year, ensure maximum competencies under the circumstances and safeguard training psychologists. Given these demands, it is no surprise that training psychologists often experience burnout and threats to their mental well-being. We conducted seven semi-structured interviews with South African intern psychologists from the 2020 cohort about their internship experience during the COVID-19 pandemic. Thematic analysis of the interview transcripts revealed two predominant themes regarding the influence of supportive and unsupportive experiences. First, while some interns reported receiving support from their psychotherapy supervisors, most highlighted the general disconnect from them during COVID-19-imposed lockdowns. The latter mostly led to a rupture in the supervisory alliance, leaving the participants feeling a sense of loss. Despite this disconnect, many interns nonetheless expressed empathy for their supervisors, who also had to navigate the unchartered territory of online psychotherapeutic and supervisory work. In stark contrast to this disconnect from their supervisors, the second theme illuminates the strong connection between interns. Reportedly, the hardship of COVID-19 strengthened the connection between the interns and provided them with a safe space where they could get emotional and practical support. The research reiterates the role of support and the importance of a broader conceptualisation of competency that goes beyond abilities and skills towards a more integrated professional identity.

Keywords

COVID-19 professional training psychology internship psychotherapy supervision support

The internship year is a space for emerging psychologists to transition into registered professionals. In other words, this year marks the time when interns attain and implement the core competencies of a psychologist (Mele et al., 2021). In South Africa, intern psychologists play a crucial role in providing accessible mental health care in academic institutions, schools, non-governmental organisations (NGOs), government military services, government hospitals, and clinics. The COVID-19 pandemic of 2020 significantly influenced professional training (Bergvall et al., 2023; Sheerin et al., 2021). For example, due to gaps in training and time away from the internship sites due to lockdown restrictions, the professional career development, competency, and professional identity of intern nurses, physicians, and psychologists were compromised during the outbreak of the COVID-19 pandemic (Kinnear et al., 2021; Lourens & Uren, 2023). During this time, swift decisions were required to ‘save’ and prioritise the academic year (Lawton-Misra & Pretorius, 2021).

The COVID-19 pandemic had varying effects on intern psychologists, which often depended on the nature and the context of internship sites. For example, the experience of intern psychologists at university counselling centres differed from that of those placed at psychiatric hospitals (Lourens & Uren, 2023). Due to the initial closure of educational facilities during the COVID-19 pandemic, interns placed at university counselling centres generally had to provide telehealth and online therapy for clients (Lourens & Uren, 2023; Ortiz & Levine, 2022). While intern psychologists in high-income countries had access to technology to aid in online psychotherapy (Bergvall et al., 2023; Stein et al., 2023), in South Africa, they often had to provide distanced psychotherapy without efficient technological equipment nor sufficient internet data connectivity (Goldschmidt et al., 2021; Lourens & Uren, 2023). The latter, therefore, often incurred extra financial costs to mitigate the aforementioned challenges – despite the fact that they often struggled financially (Lourens & Uren, 2023). In instances where interns faced challenges, such as not having sufficient internet connectivity or unreliable connectivity, they worried these challenges would negatively influence their therapeutic alliance, containment, and rapport with clients (Agazzi et al., 2022; Lourens & Uren, 2023).

Not only did intern psychologists provide remote online support to clients, but they also received supervision in these virtual spaces (Bergvall et al., 2023; Sheerin et al., 2021). Since online psychotherapy and supervision require a certain skill set that was mostly unfamiliar to many practitioners (Bergvall et al., 2023; Frye et al., 2022), some interns found online supervision problematic – particularly in terms of role-playing, skills training (Bergvall et al., 2023), and training in assessments (Frye et al., 2022).

On the other hand, those intern psychologists who worked in psychiatric hospitals and community clinics formed part of frontline workers and were thus continuing face-to-face psychotherapy. While they often gained valuable experience working for these institutions, they mostly carried an overwhelming burden to cater to the increasing mental health needs of the general population (Segers, 2020). In addition, frontline staff – including general practitioners, psychologists, and nursing staff – were often anxious about contracting COVID-19, feared that they would infect family members, and experienced increased emotional distress (Segers, 2020). It should therefore come as no surprise that, during the COVID-19 pandemic, there was an increase in anxiety and depression among health care workers, including intern psychologists (Dos Santos et al., 2020).

While support and supervision are usually invaluable to the development of emerging professionals to scaffold their progression towards becoming independent practitioners (Norrman Harling et al., 2020), they also serve to protect interns against burnout and other threats to their mental health (Warlick et al., 2021). Support within psychotherapy supervision explicitly facilitates professional identity formation (Kinnear et al., 2021), which in turn influences the professional development through the training process (Sonday, 2021).

Due to the increase in anxiety and depression among health care workers during the unpredictable and unexpected time of COVID-19 (Dos Santos et al., 2020), it can be hypothesised that support became even more crucial to intern psychologists’ mental health and general well-being (Stein et al., 2023).

In light of the above, this research focussed on clinical and counselling psychology interns’ experience of support during their professional training amid a pandemic. We also explored implications for these emerging psychologists. After all, ‘We have less information surrounding the development of their [interns’] professional identity and if/how this was affected by the pandemic’ (Stein et al., 2023, p. 67).

Method

We adopted a qualitative research design, since we wanted to explore the lived experiences, realities and perceptions of participants (Tomaszewski et al., 2020).

Participants

We used purposive criterion inclusive sampling strategies (Palinkas et al., 2015) to invite intern psychologists to participate in the study. We asked the programme coordinator of one Master’s psychology programme to circulate invitation e-mails to intern psychologists. The participants who were interested in participating in the study then contacted us directly via e-mail. We also used a snowball sampling technique, since we invited participants to invite other interns to the study by providing them with our (the researchers’) contact details. The interns were required to be registered with the Health Professions Council of South Africa (HPCSA) in clinical or counselling psychology categories. A further inclusion criterion was the completion of their internship year in 2020, during the COVID-19 pandemic in South Africa. One of the researchers conducted the interviews with all seven participants (four registered in the counselling category and three in the clinical category). Of the participants, five identified as female and two as male. All participants were completing their internship year in Gauteng province. The demographic categories they represented included Black (2), Indian (2), White (2), and Coloured¹ (1). Internship placements included South African government mental health services (clinics, hospitals, and military services) and student, university-based counselling centres.

Procedure and ethical considerations

Data collection commenced following ethical clearance from the Faculty of Humanities at the University of Johannesburg (REC-01-251-2020). Once participants indicated that they were interested in the research, we emailed the informed consent form to them. After they had returned the signed consent form (a day or two after they had received the form), we scheduled an interview at a time that was convenient for them. Before commencing with the interview, we also asked participants whether they understood the consent form. We conducted one-on-one, semi-structured Zoom interviews with each participant. We selected semi-structured interviews for data collection as this provides flexibility and openness within the interview – permitting interviewees to freely share their experiences (Magaldi & Berler, 2020). The semi-structured interviews consisted of open-ended questions to explore their internship experiences during the COVID-19 pandemic. Questions included, among others, ‘Tell us about your experience as an intern psychologist during the COVID-19 pandemic?’ and ‘Tell us about your experience of supervision during the COVID-19 pandemic?’

Interviews of approximately 45–60 minutes in duration were audio-recorded and were thereafter transcribed verbatim. During the data collection, we utilised Zoom safeguards, such as password protection. We assigned pseudonyms to the participants to protect their identities in the write-up of the findings.

Data analysis

We used thematic analysis (TA) to systematically analyse the data because it reflects participants’ perspectives (Braun & Clarke, 2006). In addition, TA is both theoretically flexible and well-suited to psychotherapy research (Clarke & Braun, 2018). The analysis involved the six phases proposed by Braun and Clarke (2006). First, we familiarised ourselves with the data by reading and re-reading the transcripts. In this process, we searched for underlying meanings and patterns within the text. The fact that the second author had conducted the interviews with participants further enhanced the familiarisation process.

Second, the process of coding was undertaken. Codes entail the smallest unit of the data which is meaningful, interesting, and can be assessed (Braun & Clarke, 2006). Among the codes emerging from our data were ‘a sense of loss’, ‘physical distance’, and ‘rupture in supervisory alliance’. In the third step, we generated initial themes. During this phase, we clustered codes together to form themes. For example, codes such as ‘a sense of loss’, ‘physical distance’, ‘emotional distance’, and ‘rupture in supervisory alliance’ were clustered together to form a theme that encapsulated support from supervisors.

In the fourth step, we developed and reviewed our themes. While the themes largely remained the same, we had to remove one theme which described support from family and friends as it did not fit with the overall aim and scope of the article. In the fifth step, we refined, defined, and named our themes. For example, while we knew that the first theme encapsulated support from supervisors, we realised that this theme also addressed the lack of support from supervisors during the COVID-19 pandemic. We therefore renamed this theme as ‘supervisory support or supervisory chaos’. Finally, we wrote up our findings and produced the article in its current form.

Findings and discussion

Two key themes regarding support within the internship environment arose, each of which centred on a specific source of support. The first was psychotherapy supervision, in respect of which participants highlighted both supportive and unsupportive experiences. The second was the unwavering peer support and the role this played in intern psychologists’ training experience.

Supervisory support or supervisory chaos?

The supervisory relationship is ‘an intervention provided by a more senior member of a profession to a more junior member or members of that same profession’ (Bernard & Goodyear, 2014, p. 7). The supervisory relationship intends to develop the professional competencies of supervisees, work towards establishing their professional identity, and ensure that they do effective and ethical work with clients (Basa, 2017). Therefore, a positive supervisory relationship is essential for useful work in supervision (Basa, 2017).

This being said, a positive supervisory relationship is not only important in facilitating the professional competencies of intern psychologists, but it also has a restorative function (Bradley & Becker, 2021). This function entails promoting the well-being of interns and protecting them against burnout (Martin, Kumar, et al., 2022). The perceived support from supervisors, furthermore, ‘has the potential to change their [interns’] perception of their self-confidence, self-efficacy, cognitive complexity, and commitment for the profession’ (Basa, 2017, p. 2). The supervisory relationship is, therefore, crucial in fostering a positive practical and emotional internship experience (Creaner & Timulak, 2016).

For the participants of this study, the fundamentals of supervision changed with the outbreak of the COVID-19 pandemic. They started the year with typical face-to-face, in-person supervision. However, enforcing lockdown regulations required that supervision be moved to virtual platforms such as Zoom and WhatsApp. Most participants, therefore, did not physically see their supervisors for long periods of time:

From the beginning of April until end of my internship in the middle of January this year, I never saw my supervisors face-to-face. Everything was done online. (Participant 3)

According to Watkins and Scaturo (2013), a secure, facilitating environment forms an important part of a positive supervisory relationship and alliance. Watkins and Scaturo (2013) liken the supervisory space to a holding environment – a safe haven wherein the supervisee should feel contained and safe enough to engage openly within the supervisory space. Therefore, the question arises whether the move to a different environment – from face-to-face to virtual platforms – affected the experience of a facilitating environment and supervisory alliance. The participants reported differing experiences in this regard. Some participants reported that they continued to feel supported and contained by their supervisors:

We had a wonderful team, managers, supervisors and my colleagues. There was a lot of debriefing, there was a lot of . . . talking about our experiences. (Participant 4)

We were helping each other, we were complaining with each other, we formed a strong bond. It was lovely interacting with these people and also other staff members, interacting with them online and through WhatsApp, through phone calls, engaging with them. And it was just the realisation that, despite not being there physically, things could still get done. (Participant 3)

On the other hand, some participants reported a sense of loss when supervision moved to a virtual space. Participant 2, for example, portrayed the physical supervisory environment as a place of energetic excitement and anticipation – something that was dampened down in the online environment:

I remember you would have to take about three or two files of clients with you and videos to show her (supervisor). I would rush to her office with so much excitement, and then I never saw that again until the end of the year. (Participant 2)

However, the participants’ sense of loss ran deeper than a mere loss of excitement. Many felt that the distance between them and their supervisors was not restricted to the sudden physical divide – it also encapsulated a feeling of disconnect and lack of support:

The biggest take-away for me was the whole sense of support. Specifically I’m talking about the internship side of things, the uncertainty, the breakdown of communication, the difficulties connecting with the supervisors and things like that. For me that was the biggest effect of doing the internship during this period. (Participant 6)

In other words, the physical distance between the supervisor and supervisee was often experienced as a rupture in the supervisory alliance. An experience of this kind is defined as a ‘strain, breakdown, or deterioration in relatedness and communication in the inter-action or the failure to develop a collaboration at the outset of the supervisory relationship’ (Watkins & Scaturo, 2013, p. 80). As the participant comments below exemplify, while this rupture in the supervisory alliance was not present ‘at the outset of the supervisory relationship’ (Watkins & Scaturo, 2013, p. 80), it did manifest as ‘a deterioration in relatedness and communication’ (Watkins & Scaturo, 2013, p. 80) when supervision moved to online platforms. The participants cited many reasons for this deterioration of the supervisory relationship. First, some mentioned that supervision became inconsistent:

They used to try and have weekly check-ins, but it wasn’t regular; it wasn’t all the time. (Participant 3)

Second, the disconnect within the supervisory relationship was not only due to inconsistent contact between the supervisor and supervisee. From the participants’ narratives, it was evident that, while supervisors addressed specific matters, they were often not attuned to the specific journey of their supervisees – including their emotional needs:

The specific matters that we raised, those got addressed, but in terms of just the overall support, that was slightly lacking because they couldn’t really gauge where we were and what we were struggling with. (Participant 6)

Emotional support we didn’t really have. (Participant 7)

It could be assumed that during the outbreak of the COVID-19 pandemic, the need for support and guidance was more essential than before, because ‘in this new situation with rapidly evolving information, competing demands, the need to make time-sensitive decisions, the paths forward were frequently unclear’ (Bell et al., 2020, p. 920). While literature suggests that intern psychologists were primarily familiar with face-to-face therapeutic work expectations, they needed more guidance regarding the unexpected and largely unfamiliar territory with clients in online work (Lourens & Uren, 2023). Yet, from the narratives of the participants, it appears that, as for other allied health professionals in training, ‘just when they need the most support, they are likely to receive none’ (Martin, Lizarondo, et al., 2022, p. 5556).

From the discussion above, it seems that interns had certain expectations of the supervisory relationship. They expected, for example, more from their supervisors than mere guidance in terms of ‘specific matters’ – they expected emotional support as well. Apart from ensuring ethical standards and helping interns to increase their competence as psychologists, supervisors also hold the responsibility to monitor and facilitate the well-being of interns (Bradley & Becker, 2021). It can be assumed that the interns felt the physical distance more acutely, due to the lack of emotional support they experienced from their supervisors.

In addition to feeling unsupported, some interns experienced their supervisors as inflexible in the face of changing demands:

Sometimes a supervisor did something a certain way and if you didn’t do it the way they were doing things, they weren’t very happy about that. I felt Covid required flexibility; it required change; it required learning and doing things differently, whereas some of them, they couldn’t see beyond their traditional way of doing things. (Participant 3)

Despite the lack of support that was deeply felt by the interns, some did express empathy for their supervisors. They realised that their supervisors were likely also feeling overwhelmed, as most psychologists had no experience of online therapeutic work prior to the outbreak of the COVID-19 pandemic. Similarly, the impact on supervisors could not be overlooked or denied as they were working within the same system that was difficult for most (Bell et al., 2020; Martin, Lizarondo, et al., 2022). Participants even highlighted the need for supervisors themselves to access support and/or supervision, highlighting the dearth of support in institutions as a whole:

I guess supervisors were also going through a difficult time, but it did work out. I really feel that therapists need to be going for supervision and I don’t think these supervisors were going for supervision themselves. (Participant 3)

In summary, participants reported that moving psychotherapy supervision from face-to-face to online platforms posed particular challenges to the supervisory relationship and alliance. In many instances, it was no longer a containing and supportive space. Instead, interns felt disconnected from their supervisors – they had to work through the unexpected, and often unknown territory of online work on their own, and manage their own emotional difficulties. Despite this disconnect, many participants still empathised with their supervisors, realising that they, too, were navigating uncharted territory.

The fellowship of the interns

Whereas the participants reported varying levels of support from their supervisors, all expressed that they could rely on their fellow interns. During the challenging, unexpected and unpredictable time of the COVID-19 lockdown, they had a strong sense that they were not alone – that they were facing the challenges ‘together’:

It also allowed for a space where you get to realise that you’re not on your own. You’re not the only one experiencing these challenges and it makes you a bit at ease. We supported each other. (Participant 1)

The above extract indicates the feelings of some interns that they could relate to each other, receiving mutual support from fellow interns. Relating to each other was evident from the statement, ‘You’re not the only one experiencing these challenges’. These relational experiences indicate group cohesion which provided ‘a sense of belonging, mutual support and identification with other group members’ (Bryde Christensen et al., 2021, Introduction, para. 1). Cohesion within a group is characterised by a sense of we-ness, referring to those qualities that create a bond between people and facilitate feelings of comfort and belonging (Bryde Christensen et al., 2021). Participant 6 expressed this sense of we-ness when she reported:

Rather than, ‘I’ve got to deal with everything myself’, it was, ‘we’ve got to deal with everything ourselves’. (Participant 6)

In this instance, it seems that their shared experience of being intern psychologists during the COVID-19 pandemic played an essential part in strengthening the connection between them. Literature indicates that shared adverse circumstances may strengthen team members’ support and bond (Bastian et al., 2018). It is, therefore, not an uncommon phenomenon that the participants of this study reported how the physical distance between the interns often developed into an emotional closeness between them:

I enjoyed my internship so much, because I found, like the other interns, we, we all supported each other. (Participant 5)

We would chat to each other if any of us were feeling scared or anything like that. (Participant 7)

There was kind of a bit of a breakdown in communication and support for the interns. Our internship group was amazing. From the get-go (prior to lockdown) we just all clicked. We had our own group. We’d go out together. There was a lot of support and help. But now, physically, we were separated. And then, because of the lockdown, we weren’t able to come together for trainings. We weren’t able to meet each other outside of work. But as a group, I think it created a better group cohesion between us, and I think that became the primary support for us throughout the year. (Participant 6)

In the previous extract, Participant 6 reported that the cohesiveness of the intern group was her primary support throughout the year. The question then arises: what was the nature of this support? First, many participants reported that they could lean on each other for practical, work-related support:

We (interns) checked up on each other every day. When we were not sure, we checked each other for validation. When we didn’t know what we were doing we would call each other; be it with therapy, be it with assessments, we would with anything. We were just there for each other. (Participant 2)

Support therefore went further than mere practical assistance. Checking up on each other daily, and turning to one another for validation, are indicative of care and emotional support. In many instances, the relationship between the participants provided a safe space for them – a space where they could offload and ‘vent’. This support was so valuable for them that one participant even shared that she enjoyed her internship as a result of this:

We (interns) all supported each other so much . . . . The support was amazing, like we could all vent to each other. I mean I cried a few times in front of the interns. Some did too. It felt like a very safe space. (Participant 5)

Interestingly, this support extended to interns from other internship sites. It could be hypothesised that since support became digital (e.g., through WhatsApp and phone calls), it became more natural to extend support to and receive support from interns from other placements:

We were very supportive as the interns, even with interns from the other placements. (Participant 7)

Participant 5 expressed her surprise that, as interns, they were able to show empathy towards each other. Her surprise stemmed from the fact that, reportedly, many of them suffered from compassion fatigue – yet they were able to show compassion and care for each other:

It was crazy how we all were able to express so much empathy towards each other when I think a lot of us were holding a lot on our shoulders, because the patients you work with, you get compassion-fatigue and stuff. Empathy is one thing that’s carried on throughout; throughout Covid and all the difficulties. (Participant 5)

The literature shows that receiving collegial support is critical in circumventing compassion fatigue (Norrman Harling et al., 2020; Plantiveau et al., 2018). So, although Participant 5 was surprised that they could still support each other despite compassion fatigue, it might have been precisely because of this support that they were able to continue supporting each other and their clients.

In sharp contrast to the distanced connection with their supervisors during the COVID-19 lockdown period, the participants reported that their relationship with their fellow interns strengthened during this time. They could rely on each other for practical and emotional support and experienced a strong sense of we-ness. It could be hypothesised that this group cohesion is one of the factors that kept interns in the programme, as group cohesion has been associated with lower dropout rates in group psychotherapy (Burlingame et al., 2018; Marziali et al., 1997). Mutual emotional support was the component that differentiated the supervisory relationship from their relationship with peers. Although both relationships and communication were conducted within physically distanced circumstances, the interns felt closer to their peers due to the emotional support and sense of cohesion.

Conclusion

In this research, we explored the experiences of support for intern psychologists during the outbreak of the COVID-19 pandemic. Our findings revealed that the physical distance between interns and their supervisors often led to a rupture in the supervisory relationship. Interns reported that contact with their supervisors was inconsistent, compromising their emotional connection within the supervisory relationship. Despite these challenges in the supervisory relationship, some interns expressed empathy for their supervisors, recognising that this was unchartered and challenging territory for them all.

Unlike their experience with their supervisors, the shared experience of the interns led to profound emotional closeness and group cohesion among them. As intern psychologists navigating their internship within a novel and unexpected worldwide pandemic, they found common ground and a strong sense of ‘we-ness’. As a result, they could lean on each other for practical, work-related assistance, and emotional support.

Although this research focussed on a unique moment in time, there are nevertheless lessons to be learned from the findings. This work showed the importance of peer support for intern psychologists. This support should thus be facilitated and encouraged by teams overseeing intern psychologists (even in COVID-free times). For example, team-building exercises could be implemented as a mandatory component of internships. Finally, under similar circumstances, we recommend that psychology supervisors find support – such as their own psychotherapy or supervision – to enhance their capacity to support intern psychologists more effectively.

There are a few limitations to this study, and we recommend that these could be used to inform future research. The findings of this work could have been enhanced through a longitudinal study. It would have been useful to explore the long-term effects of supervision on intern psychologists during the COVID-19 pandemic. Furthermore, we only included the voices of the interns – listening to the experiences of supervisors could have provided a more holistic picture of their challenges and successes during the COVID-19 pandemic. The aforementioned could have informed supervisors regarding the possible pitfalls and useful strategies during virtual supervision sessions.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

SA Uren

Notes

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