Doctoral programs consistently struggle with professional competence among their trainees, and numerous studies report significant numbers of expulsions from graduate study based on academic or nonacademic grounds. Widely attributed to Jung (1951), the wounded healer archetype assumes that clinicians, like all persons, have been negatively impacted by their personal histories, traumas, and interpersonal stressors. According to co-authors James Tobin and Anya Oleynik, a key role and responsibility of graduate programs in the helping professions and advanced training sites involves not only a gatekeeping function, but the capacity to identify and remediate students whose own personal challenges may be effectively resolved and transformed into the strengths ascribed to the wounded healer ideal.

1. The Wounded Healer or the Worried Well?
What We Know About the Graduate Student in Clinical Psychology
INTRODUCTION
 The current paper, a critical evaluation of evidence generated in the psychotherapy training literature,
seeks to determine the following: (1) the type, magnitude, and frequency of distress among graduate
trainees in clinical and counseling psychology; (2) the degree to which trainees’ personal issues
impact academic and clinical performance during their training years; and (3) the nature and
effectiveness of responses to and management of student problems offered by academic programs
and clinical training sites.
 Conducted in the shadow of the wounded healer archetype, this review represents our sentiment that
a central issue in the field is the need to specify and identity unsuitability for clinical practice as early
as possible, and to differentiate it from other problematic presentations that may be resolvable. This
achievement, if possible, would undoubtedly lead to the refinement of current pedagogical
perspectives on the education and clinical training of psychotherapists. We are inspired by Bissell’s
(1983) early call for the need to differentiate incompetence, impairment, and unethical practice
among medical practitioners, and are concerned that this important idea sorely needs to be applied
to the selection and development of mental health professionals.
PURPOSE OF REVIEW
 In order to generate empirically-based articles within the last 20 years that address
the interests of this review, three databases (PsycARTICLES, PsycINFO, and ProQuest
Psychology Journals) were consulted with the search terms “clinical psychology” and
“counseling psychology” in combination with “graduate student,” “mental health,”
“personality disorder,” and/or “stress.”
 After scanning a portion of the titles and abstracts of some of the articles generated
by this first step, we then modified our search process by replacing “mental health”
with the term “self-care” in order to produce a secondary set of publications. Next,
of the articles resulting from these two steps, we excluded investigations of
professional/licensed psychologists and counselors given that the focus of the
present review is on students who are training at the graduate level.
 Finally, a scan of two additional search engine resources (EBSCOhost and Google
Scholar) was conducted to check for other papers that may have not been captured
previously. Ultimately, 39 studies were chosen to be evaluated for this review.
METHOD
 Our review indicated that trainees experience a variety of problems, some of which may be caused or
exacerbated by the challenges of specific clinical settings and the socio-cultural dynamics of graduate
programs. Even though there is an awareness of distress, psychopathology, and impairment among
students, most programs seem to lack adequate directives for managing and preventing student
difficulties. There was also no evidence indicating that efforts were made to differentiate which
students are unsuitable for clinical work and which hold the potential to be effective if their issues can
be resolved.
 It is not clear if graduate training per se actually enhances students’ awareness of themselves and
their personal issues; this raises concerns and points to the need for more systematic inquiries as to
why doctoral programs appear deficient at facilitating progression toward the wounded healer ideal.
 At all levels of graduate training in the mental health professions, administrators, faculty members,
and supervisors need to be more effective at monitoring, identifying, and intervening when students
exhibit stress and dysfunction.
 A disturbing finding of our review is that graduate school students feel as if they are more successful
at identifying problems among their peers than faculty members and supervisors. The essence of the
gatekeeping function of graduate programs needs to be further elaborated and operationalized.
Confusion about this essential role on the part of those responsible for overseeing students is
probably responsible for the dualism of errors anecdotally present in most graduate programs:
administrative withdrawal (when the distressed student deserves significant attention, reprimand or
even dismissal) on the one hand, and administrative intrusion or over-reactivity (when the student has
potential yet is erroneously perceived as faulty, deficient, or unlikely to succeed) on the other hand.
 Additional issues deserving of more attention include: assessing the relationship between students’
personality factors and clinical performance (Beutler, Crago, & Arizmendi, 1986; O’Donovan & Dyck,
2005), preventing student impairment (Nicoletta, 2008), the role of the social and cultural context of
graduate programs in students’ difficulties (Oliver et al., 2004), how inexperienced trainees are
affected by challenging patient populations, and the capacity of admissions procedures to identify
applicants who may possess characteristics which increase their risk for ultimately being unsuitable
for clinical work (Regehr et al., 2001).
 Foundational clinical competencies such as critical thinking, ethical behavior, and self-awareness may
be inherent rather than teachable (Elman, Illfelder-Kaye, & Robiner, 2005), and negative trait
characteristics may not be surmountable in training (Kaslow et al., 2007). Mental health clinicians, the
clients served by these professionals, and the persons who aspire to enter the field would be well
served by a program of systematic, empirically-based study designed to clarity these controversies.
RESULTS
 Type, magnitude, and frequency of distress among graduate trainees in clinical and counseling
psychology. The most common reasons for students to seek personal therapy were personal growth,
desire to improve as a therapist, adjustment/development issues, and depression (see Holzman et al.,
1996). Other studies (e.g., Nicoletta, 2008) revealed that adjustment disorders, alcohol problems,
anxiety, depressive symptoms, and personality disorders were common issues among students.
Students’ social/relational issues were also frequently reported. Interpersonal problems were
manifest more often than ethical or academic violations (Nicoletta, 2008; Oliver, Bernstein, Anderson,
Blashfield, & Roberts, 2004). None of the studies we found provided definitive estimates of the
prevalence or frequency of distress experienced by trainees in clinical psychology compared to other
fields.
 The degree to which trainees’ personal issues impact academic and clinical performance during the
training years. Studies by Wulf (2008) and Riise (2011) indicated that higher levels of stress among
trainees were associated with maladaptive coping responses, deficient self-care, and poor physical
health. Students perceived as struggling or deficient by their peers may become socially isolated as
they tend to be avoided or rejected by student cliques (e.g., Kunze, 2012; Veilleux et al., 2012;
Zwickilton, 2009). Our review also yielded intriguing and conflicting findings regarding trainees’ self-
reflective capacities and emotional maturity (e.g., Brown, 2010; Iszak, 2006; Mothner, 2011).
 The nature and effectiveness of responses to and management of student problems offered by
academic programs and clinical training sites. On the whole, graduate programs are not especially
well-equipped to deal with students who may be impaired. Vacha-Haase et al. (2004) examined
gatekeeping practices used by training directors of APA-accredited professional psychology programs
and found that half of the programs dismissed one or more students within the past three years.
Although students who exhibit significant problems are often given the opportunity to undergo
remediation (e.g., psychotherapy, leave of absence, probation, and/or repetition of practicum or
internship trianing), some program directors consider student impairment to be grounds for dismissal
(Nicoletta, 2008). A study by Busseri, Tyler, & King (2005) found that common reasons for dismissal
or resignation included a lack of clinical skill proficiency, ethical violations, and failure to complete
remediation steps. Students do not find faculty to be particularly effective at identifying and
managing distressed or problematic students (Veilleux et al., 2012). Some evidence suggests that
clinical psychology graduate students recognized impairment in their peers more so than did faculty
members (Mearns & Allen, 1991; Nicoletta, 2008).
 Widely attributed to Jung (1951), the wounded healer archetype assumes that clinicians, like all
persons, have been negatively impacted by their personal histories, traumas, and interpersonal
stressors. Writers (Bryant, 2006; Merchant, 2012; Stone, 2008) report that the wounded healer
archetype first emerged in mythology, early Christian references, and shamanistic societies.
 We believe that a key role and responsibility of graduate programs in the helping professions and
advanced training sites involves not only a gatekeeping function (e.g., Boxley, Drew, & Rangel, 1986;
Vacha-Haase et al., 2004), but the capacity to identify and remediate students whose own personal
challenges may be effectively resolved and transformed into the strengths ascribed to the wounded
healer ideal.
 Doctoral programs consistently struggle with professional competence among their trainees (Elman &
Forrest, 2007), and numerous studies (Biaggio, Gasparikova-Krasnec, & Bauer, 1983; Gallessich &
Olmstead, 1987; Vacha-Haase, Davenport & Kerewsky, 2004) report significant numbers of expulsions
from graduate study based on academic or nonacademic grounds.
James Tobin, Ph.D. & Anya Oleynik
DISCUSSION