The professional identity of intern psychologists during the COVID-19 pandemic in South Africa

Participants, sampling and recruitment

After we obtained ethical clearance from an institutional research ethics committee, we emailed invitation letters to potential participants. To meet the inclusion criteria, participants should have completed their counselling or clinical psychology WBL/internship at a South African institution in 2020 (the year of the COVID-19 outbreak). Given the clear outline of our target population, we used a purposive sampling technique to select and recruit participants (Silverman, 2013). Four counselling and three clinical psychologists between the ages of 24–46 years agree to participate. Four participants completed their internship in a hospital setting (such as a psychiatric institution), while three were interns in a higher educational setting (such as student counselling facilities). Four participants identified as female and two as male. Two participants identified as Black, two as Indian, two as White, and one as Coloured [1]. In addition to using pseudonyms throughout this article, we decided against tabulating the participants' demographic details as an extra ethical precaution to safeguard the confidentiality of participants. There are generally few intern psychologists in South Africa each year, and linking their gender, race, age, and internship site would make it easy for some individuals in the profession to identify them.

Research design

The study used an interpretative phenomenological approach (IPA) to structure the interviews and analyse the data. This qualitative design provided us with the tools to explore participants' life-worlds (lebenswelt) and the meanings they attached to their experiences (Love et al., 2020). IPA emanated from three philosophical roots: phenomenology, hermeneutics and idiography (Smith et al., 2009). The principles of phenomenology guided the structure of the interviews and enabled us to listen to the lived experiences of each participant (Love et al., 2020). While participants' stories are never devoid of personal interpretations, we also made sense of their already-interpreted experiences – thereby engaging in “double hermeneutics” (Smith and Osborn, 2015). Lastly, we analysed each case individually and included verbatim quotes to provide a voice to the participants, adhering to the principle of idiography (Smith et al., 2009).

Data collection

We conducted one-on-one, semi-structured Zoom interviews with each participant. IPA researchers prefer semi-structured interviews because they “facilitate rapport and empathy” (Smith et al., 2009, p. 63). Furthermore, semi-structured interviews allow for an in-depth exploration of experiences, feelings and thoughts and thereby often generate “rich and interesting data” (Smith et al., 2009, p. 63). The participants answered open-ended questions such as, “Please tell us about your experience as an intern psychologist during the COVID-19 pandemic?”, “Tell us about your psychotherapy training/assessment training and supervision during COVID-19”. Interviews were approximately one hour in duration and were audio-recorded and transcribed verbatim.

Data analysis

We interpreted the data through the five steps of interpretative phenomenological analysis. We started with the four steps of within-case analysis (Smith and Osborn, 2015). First, we carefully read and re-read each transcript while adding comments and notes to relevant phrases. Second, we read and re-read the transcript in conjunction with the added comments and notes, thereby searching for underlying meanings behind the participants' words. Third, we searched for similarities within each transcript and clustered these together into themes. We concluded the within-case analysis by re-organising the interpreted themes to reconstruct each participant's individual story. Hereafter, we moved to the subsequent transcript and repeated the four steps above. After the detailed analysis of each interview, we proceeded with the cross-case analysis (Smith and Osborn, 2015). During this step, we searched for similarities and generated themes across the seven interview transcripts.

Theme 1: the uncertain intern

With COVID-19, the nature of internships and practical work needed to change (Békés and Aafjes-Van Doorn, 2020). Participants who worked in educational settings (Barbara, Daniel and Brian) were required to conduct therapy and assessments online or on telephonic platforms for a significant part of the year (from the middle of March to the beginning of October 2020). The remaining participants who worked in a hospital setting (Vicki, Michelle, Mia and Michael) continued to work on-site as essential workers, but they were also expected to conduct telephonic psychotherapy sessions for outpatients who could not attend face-to-face therapy.

This section consists of two subthemes that will explain how, in this unfamiliar space, interns found that they (1) had to improvise in the physical and relational therapeutic space, and this, along with other factors, (2) left them worried about the strength of the therapeutic alliance.

Improvisation in the physical and relational therapeutic space

Interns typically enter their WBL site with feelings of uncertainty and inadequacy (Dunstan, 2002; Leong and Crossman, 2015; McElhinney, 2008). In contrast to the literature, the participants in our study did not relay any initial uncertainties. Instead, they envisioned and were excited about a predictable, standard internship. They were excited to get a physical office where they could put theory into practice. Primarily, they seemed excited to develop their professional identities in a safe, predictable and typical internship environment. These expectations and fantasies came to fruition when they started their internship year. The participants got their own offices, heard how many clients they would see, were introduced to the community work they would do, and so on. These gradual introductions of what lay ahead in the year left the interns excited and largely feeling ready for what reasonably foreseeable challenges would come their way:

We were highly excited, and even when we got into the unit, we were ready to turn the experience into what our imagination was about, how it was gonna be. … And then we had clients and then uh you had your own office, you got excited that this is going to be a pretty good year in terms of trying to see all of that theory that you learnt. (Barbara)

All the participants recalled that their initial excitement was interrupted by the COVID-19 pandemic and the consequent lockdown and social distancing regulations—the new internship environment set in motion a host of uncertainties and anxieties for all the participants. The nature of the internship year no longer seemed predictable but became an environment filled with unforeseeable obstacles and challenges. They did not know what their new internship environment would look like, and they felt ill-equipped and unprepared for what lay ahead:

How are we going to do therapy, how are we going to do assessment, how are we going to do groups? There was a lot of scuffling around making decisions and deciding on how things were going to be done in a remote environment. For me that uncertainty was very scary. (Daniel)

The participants recalled that their uncertainties did not easily dissipate once they resumed their practical work. It seemed from their narratives that their anxieties and uncertainties increased as they immersed themselves in their practical work. Part of these feelings arose because, more often than not, they did not receive any formal training in new protocols or online psychotherapy. Those interns who continued face-to-face work in hospitals reported the unclear and ambiguous nature of the COVID-19 safety protocols:

What challenged me the most was that people didn't know what the protocol was; we kept getting all this protocol on what you must do if the ward has PPE, but then different people have different opinions. One will say, “No you can go, just keep a distance”, but then you go there, and you're not actually allowed to go see patients. So I think that was challenging for me, like mixed messages, because you're like, “What do I do?”. (Michelle)

Similarly, there was little to no formal training for those interns who were required to conduct their practical work on online or telephonic platforms:

In the beginning, it was difficult in a sense, because you're just like, “hey I've never done this before and I don't have any formal training in doing this.” (Brian)

From the above, the interns were left with feelings of uncertainty and anxiety, particularly regarding the ethical ramifications and boundary negotiations of psychotherapy on online platforms. Although they felt relatively confident in handling ethical issues within a physical therapy room, these ethical issues took on a different shape and became blurry within the online therapeutic space. With no formal training in online work and its ethical pitfalls, the interns needed to improvise as troublesome ethical dilemmas – that were intertwined with online work – arose:

What do I do when a client comes up onto Zoom and they are not in a private space? … what do I do when the client is now coming to Zoom meeting with their whole family, what do I do? (Barbara)

In addition to their uncertainty regarding the manifestation of ethical dilemmas in the online world, the interns expressed uncertainty regarding technology and the practical technological skills required of them for online work. Lester and Crawford-Lee (2022) reiterated the need for institutions to upskill and to ensure that there are support structures for work-based learning, which the participants echoed.

You had to be technologically savvy, you were not trained on all these programs. We were not trained on any of them, we had to learn them all ourselves going through YouTube channels and videos. (Daniel)

With little to no formal training in the new protocols and online psychotherapy, participants often felt incompetent in their capability as therapists. They had no script, no guidelines and they simply needed to improvise and make judgment calls from moment to moment:

It was like you are a baby learning how to walk and slipping and just falling. (Barbara)

Having that uncertainty and having to be so certain in that uncertainty as well, and just make decisions with very little supervision and just trust your gut and go with things and try things out. (Mia)

Improvisation is essential in building confidence and the professional identities of medical doctors (Shochet et al., 2013) – and therefore, we can assume similarly for psychologists. Improvisation “relies on listening, confidence and responding instinctively and spontaneously” (Shochet et al., 2013, p. 120) and thus learning how to respond ethically and empathically in unpredictable and uncertain spaces (Lourens et al., 2019). Even though COVID-19 is an extreme case of an unpredictable environment, we could hypothesise that, in some ways, the uncertain space of COVID-19 might have enhanced the capabilities and confidence of some interns (the last theme is a testament to this). Mia also eluded to this growth in confidence under unpredictable circumstances:

I think it definitely teaches you to trust your own instincts, because you learn what works and what doesn’t work … (Mia)

While improvisation often refers to improvising in the relational space and responding to the unique context of each individual, the outbreak of the COVID-19 pandemic exceeded these expectations. Suddenly, it was expected of interns to not only improvise in the relational space, but it was also expected of them to negotiate unfamiliar and sometimes unsafe environments.

Uncertainties regarding the therapeutic alliance

At the heart of participants' uncertainties lied the concern for establishing a therapeutic alliance under unusual circumstances. They feared that the online platform and wearing masks might have influenced the therapeutic alliance. Roesler (2017) reiterates these concerns, highlighting that building a good therapeutic alliance is a significant concern for psychotherapists while conducting online psychotherapy. The creation of a safe space for clients is crucial to a good and trusting therapeutic alliance (Allison and Rossouw, 2013), yet, on the somewhat unfamiliar online platforms, intern psychologists found themselves uncertain as to how to create a safe and private space for their clients, especially when they themselves did not feel safe or comfortable on these platforms:

Let's say your client was telling you that “my uncle is doing this a, b and c.” And then the uncle can come home at any time. You could hear sometimes in their voice that they don't feel comfortable speaking at home. (Brian)

Some participants reported that technological glitches – such as network problems – often disrupted their responsiveness to their clients. For example, one participant reported on their experience of an emotional client and then having network issues:

You'll be speaking to a client like going on and on and on and then they say, “sorry I couldn't hear that part”, or they're trying to speak or maybe they’re crying. And it's quite irritating, because it's like me speaking about something serious and then every single time you just like “I can't hear you”. (Brian)

Interns in face-to-face settings also experienced the same concerns as they found it challenging to conduct psychotherapy with a mask. For these interns, the mask felt like a barrier between them and their clients and they reported that it was challenging to convey empathy with a masked face:

Wearing that mask was the most frustrating thing ever, because I obviously kept it on, patients would take it off though, but I always kept a distance. But what frustrated me, I noticed that I had to really do eye movements to get them to see how I was reflecting to them and mirroring. (Michelle)

Michelle's experience concurs with existing and recent literature regarding facemasks and psychotherapy. Various studies found that standard facemasks – excluding transparent ones – could impair trusting relationships, empathy and the development of social bonds since the wearer can't visibly mimic the facial behaviours of their clients (see Hess and Fischer, 2013; Marini et al., 2021; Tramacere and Ferrari, 2016).

In summary, it is not uncommon for psychology interns to feel uncertain and nervous as they enter the unfamiliar environment of their internship placement (Leong and Crossman, 2015). At this stage, it is their initial engagement with work context and they are working towards establishing a professional identity yet still feel unsure of their own capabilities. The interns of this study recalled excitement and enthusiasm when they started their practical placement. Even though they did not refer to it, we can hypothesise that they felt excitement, combined with nervousness, when they entered their WBL/internship year. Perhaps they did not refer to this anxiety because it faded in the light of the extreme panic and anxiety they experienced in the months that followed the outbreak of the COVID-19 pandemic. As they entered the uncharted territory of working in unsafe conditions and online therapy, they needed to improvise without the somewhat predictable script that work-based learning context attempts to provide. In muddling their way through, they were often concerned about the effect of the new mode of working on the therapeutic alliance. And this left them asking:

Am I doing justice, am I, am I doing enough for my client? (Brian)

Theme 2: the depleted yet resilient intern

All participants highlighted some level of impact on their wellbeing and professional development. Interns at times struggled to navigate the demands of psychology (Kolar et al., 2017), whereas at other times, they were able to draw on their own resilience as an emerging psychologist. In this theme, we will discuss the sense of depletion of interns, their resilience, and the implications for their professional identity.

A pandemic of depletion

As the previous theme shows, the interns continued online or face-to-face work with no clear script. They often had to continue their work – that was drenched with practical challenges – against the backdrop of overwhelming personal realities in their home environment. Those interns who continued face-to-face work feared for the safety of their family members:

There was a lot of anxiety in the beginning with the whole COVID … what if you have it and you bring it home? That was quite stressful. (Michelle)

While those interns who worked from home generally did not worry about infecting their family members with COVID-19, they reported that the boundaries between home and work became blurred and permeable:

We were working from home and when you work in a space of a home environment and you’re having relatives that are sick, people that are dying, you’re confronted with a lot of your own personal problems in your workspace because your personal space and your work space intersect. (Daniel)

The interns reiterated the sense of feeling lost in working from home and making sense of boundaries that continued to cross in the COVID-19 era. Given all of these overwhelming work- and home-related realities, it should come as no surprise that all the participants reported severe exhaustion and even burnout:

I think just the biggest thing for me was in the long run mental health, because of COVID. We [the interns] were quite burnt out in the end and I think COVID had a big part of that, because you don’t realise how on edge you are all the time. (Michelle)

Although burnout is typically prevalent amongst mental health workers (Warlick et al., 2021), these “usual” mental health difficulties were often increased or triggered by the COVID-19 pandemic (De Kock et al., 2021). As Cullum et al. (2020) observed, “During COVID-19, health and social care professionals will be at particular risk of psychological symptoms” (p. 1).

In light of the previous theme and the context of the COVID-19 pandemic, it should come as no surprise that all the participants reported feelings of overwhelming exhaustion during their internship year:

I think that COVID actually played a big toll on burnout in the end, because your mind never stops. (Michelle)

Interestingly, Zhang et al. (2021) highlight that a sense of professional identity is a strong protective factor against burnout. This could explain the potentially increased risk for burnout in the interns who are still navigating their developing professional identity amidst the worldwide pandemic. This also meant that interns may have had limited space to make sense of their professional journey, and some participants reported that they had no time to contemplate and make sense of their circumstances. In other words, it seemed like they had no time to take care of themselves, were at increased risk for burnout, and just had to continue and “soldier through” troublesome and unpredictable realities:

I literally would say to myself; “you don’t have time to have a breakdown, just carry on”. (Michelle)

Despite carrying on and soldiering through, the emotional toll of the overwhelming COVID-related realities sometimes had an influence on their work. According to Zhang et al. (2021), people who suffer from burnout often struggle to meet their work-related demands. For some interns, this meant an inability to show empathy for their clients. Barbara acknowledged that she continued to work under a lot of pressure and anxiety; consequently, she could not connect with her clients:

I was told that “you are not emotionally connecting. … You are functioning like a robot”. And I wouldn’t defend, because I would know that it is true, because I’ll also know that I am going through quite a lot of anxiety. (Barbara)

In contrast to Barbara's experience, it seemed like Vicki's empathy for her clients protected her against burnout to some extent:

The anxiety didn’t linger on too long.… Because I was so involved with the patients and I loved the work that I was doing. (Vicki)

Such contrasting experiences are not surprising, since Wilkinson et al. (2017), in their systematic review, found that as burnout increases, empathy decreases and, as empathy increases, burnout tends to decrease. Overall, it became clear that all the participants had to continue their work against the backdrop of home-related anxieties. Some were concerned that they would “bring COVID home” to their families, while others could not escape the overwhelming realities at home while at work. For many, all the aforementioned anxieties, coupled with their uncertainties regarding navigating an unpredictable environment, accumulated into exhaustion and burnout. They had little time to tend to their mental health and, as a result, some experienced an inability to connect with their clients and make sense of their own role. In contrast, others found that their deeper engagement in their role facilitated empathy and provided a safeguard against burnout.

Professional losses and professional strength

As mentioned before, HPCSA requires intern psychologists to acquire specific competencies to meet the requirements of the degree and their professional board. Acquiring these competencies are important in order to establish proficiency and a professional identity as a psychologist (Leong and Crossman, 2015; McElhinney, 2008). Participants revealed that having an internship during COVID-19 meant limited (1) professional development and, (2) experiential learning.

Interns highlighted how they had to forgo opportunities to facilitate their professional development, such as workshops, ward rounds and case presentations:

I missed out on that because the MDT meetings were brilliant for learning. … And the bigger case presentations, the multi-disciplinary team for each ward would present, so we missed out on that because that had to stop because that would have meant many people in the same venue. That’s what we missed out on and also doing presentations there. (Vicki)

Probably more importantly, some participants reported missing opportunities for supervision, as well as having lighter caseloads:

We did ad-hoc supervision with the other line manager but there were too many for him to supervise all of us one-on-one. So that was quite frustrating. But I suppose because our patient load was significantly smaller it sort of worked. We definitely missed out on a huge chunk of supervision that we would have had if COVID hadn't happen. (Mia)

Supervision is crucial to the professional development of intern psychologists (Creaner and Timulak, 2016) and thus not surprising that the HPCSA prescribes at least one hour weekly supervisory sessions for intern psychologists (HPCSA, 2019a; b). However, engaging with clients and having professional spaces to develop and enhance therapeutic skills is a significant component working as a psychologist. Supervision also becomes a space for support that provides opportunities to learn and develop oneself as an emerging professional in a work context.

In addition to the gaps in professional training, the interns felt that experiential learning was limited, beyond the reduction in their caseloads. In particular, interns explained that this meant little to no experience with community and group work, as well as troublesome assessment and child work:

I think overall we did lose out on exposure, like we didn't get to do projects. We didn't really get to do community stuff, we didn't really get to do group stuff. …We stopped seeing a lot of clients, we stopped seeing children, we stopped doing assessments … . We only finally managed to work with children and do assessments in the last three months of the year. Fortunately, we did manage to get exposure towards the end of the year, but I think it’s not as much as we would have ideally liked to have gotten throughout the year. (Michael)

Given the significance of both psychotherapy and assessment in intern's minimum standards of competence, there is a clear sense of an “incomplete” or “lesser” internship. Leaving the question whether their professional identity was impacted:

We had no assessments with the kids, because we couldn’t do assessments. … It just affected the training quite a bit, but I feel like I made the most of what I could. (Michelle)

The interns explained having an awareness of the effects on their training, but at the same time, many interns took some responsibility for their professional development:

I think overall, the responsibility shifted more to us than to the internship and the supervisors. … Increasingly we had to take more responsibility and more independence in dealing with our own things and managing our own internship. (Michael)

The interns explained a sense of responsibility shift during the internship, and it seems as though that shift laid the foundation for them becoming more independent and prioritising their own development. This was not only evident in their practical skills but also in the development of their emotional skillset. They relied on their inner resources such as their strength, resilience and flexibility:

I think also during this time what developed was both my inner strength as well as my professional strength. And understanding also the value of team work, the value of asking for help, the value of being able to have a safe place where, yes, we're going out, we’re doing the frontline work, but then who takes care of us? (Vicki)

Interns highlighted that these challenges allowed for growth, developing an inner strength, but also a professional strength. These experiences point to the value of flexibility and the need for opportunities to challenge one to expose these strengths and weaknesses. As mentioned in the first theme, interns needed to improvise in the therapeutic space, and this evidently assisted in the development of their professional identity. As they worked without a script, as they improvised and “muddled” their way through, they learned that they could trust their judgment and that – despite gaps in training – they could become psychologists in their own right.