Thoughts on removing the predoctoral internship?

[Mama Bear]

Yeah, let’s see some outcome data. I get some of the arguments against internship in the predoc year, but I always looked at it as a gate keeping measure. In other words, having a third party evaluate a trainee’s skills prior to granting a degree. I’ve always despised captive internships for this reason.

There are other ways to ease the financial burden, some of which have been done:
1. Waive APPIC fees for students in need
2. Allow virtual internship interviews as an option, and do not penalize students for opting for this format
3. Raise internship stipends and/or provide a moving assistance stipend and/or provide housing for interns

There are drawbacks for the above as well, but compared to an overhaul in the entire system…

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[summerbabe]

For me, a lot of this starts with where you go to grad school and the likely need for students to make significant sacrifices given admissions difficulties and geographic disparity (why are there so few funded PhDs in the pacific and mountain time zones???).

Internship could be the chance to finally get closer to home/where they intend to settle but that move will likely cost a small fortune and be more logistically challenging.

Or if individuals prioritized cost and relative stability, what is the general availability of appropriate internships within a 1-10 hour drive (e.g., single day Uhaul trip) of their school? I applied to 2 internships that were cross-country while the rest were regional-ish and I ultimately landed about 8 hours away.

I can see more self-pay PsyDs creating captive internships and using that as both a recruitment tool and to stay in good outcome graces.

But is there an appetite to do this for funded grad programs? It sounds like a lot of additional work and liability for faculty, especially as many of their universities are receiving less and less public funding.

And for students who moved 1000+ miles to attend grad school, won’t some of them opt anyways to leave for geographic and family preferences, even at significant financial and personal cost?

Overall, the system is never going to put the needs of students/trainees first because they don’t even have a seat at the stakeholder table.

But measured incremental change is likely to be more beneficial than major changes like dropping internship all together.

 

[bcliff]

For me, a lot of this starts with where you go to grad school and the likely need for students to make significant sacrifices given admissions difficulties and geographic disparity (why are there so few funded PhDs in the pacific and mountain time zones???).

No clue how accurate this specific map is, but I do know that the vast majority of universities in the USA are east of the Mississippi, so I imagine that has something to do with it: Map of US Colleges and Universities

 

[Sanman]

For me, a lot of this starts with where you go to grad school and the likely need for students to make significant sacrifices given admissions difficulties and geographic disparity (why are there so few funded PhDs in the pacific and mountain time zones???).

Internship could be the chance to finally get closer to home/where they intend to settle but that move will likely cost a small fortune and be more logistically challenging.

Or if individuals prioritized cost and relative stability, what is the general availability of appropriate internships within a 1-10 hour drive (e.g., single day Uhaul trip) of their school? I applied to 2 internships that were cross-country while the rest were regional-ish and I ultimately landed about 8 hours away.

I can see more self-pay PsyDs creating captive internships and using that as both a recruitment tool and to stay in good outcome graces.

But is there an appetite to do this for funded grad programs? It sounds like a lot of additional work and liability for faculty, especially as many of their universities are receiving less and less public funding.

And for students who moved 1000+ miles to attend grad school, won’t some of them opt anyways to leave for geographic and family preferences, even at significant financial and personal cost?

Overall, the system is never going to put the needs of students/trainees first because they don’t even have a seat at the stakeholder table.

But measured incremental change is likely to be more beneficial than major changes like dropping internship all together.

At the end of the day, the pre-doctoral internship question posed here is part of a bigger question. Where is the good master's level option that most people want to become a therapist and make a living? Most people really want the mid-level training model that is missing in this field. You either pick one of the mid-level programs that has serious limitations or get the doctorate. I fell most people want something akin to the SLP or occupational therapy training model.

 

[bcliff]

At the end of the day, the pre-doctoral internship question posed here is part of a bigger question. Where is the good master's level option that most people want to become a therapist and make a living? Most people really want the mid-level training model that is missing in this field. You either pick one of the mid-level programs that has serious limitations or get the doctorate. I fell most people want something akin to the SLP or occupational therapy training model.

MSW

 

[Sanman]

MSW

The complaint with the MSW is that the degree itself often leaves a lot to be desired in terms of therapy training. However, from a career standpoint, I agree it is the best we have to offer. If APA had been smarter from the start, a more comprehensive option could have been available for healthcare trainees (yes, yes PsyD...but we all see how that has gone).

 

[depthpsych]

It’s a fair question about whether the predoctoral internship is anachronistic at this point for a number of reasons.

I think all clinical psychologists should read the following article and reflect on the points therein with the same level of critical thinking and thoughtfulness they apply elsewhere: It seems sometimes that emotions can get elevated when people question the utility of particular training models that other folks have already endured. You may not agree with their proposed solutions (I’m unsure I do) but their critiques of psychology’s “Rube Goldberg” model of training at this time are, I think, clear-eyed, scathing, and worth reflecting on in a serious way…

APA PsycNet

psycnet.apa.org

 

[jdawg2017]

The complaint with the MSW is that the degree itself often leaves a lot to be desired in terms of therapy training. However, from a career standpoint, I agree it is the best we have to offer. If APA had been smarter from the start, a more comprehensive option could have been available for healthcare trainees (yes, yes PsyD...but we all see how that has gone).

I agree that the training before the degree is conferred is less than adequate in many cases. However, to achieve independent practice the MSW recipient needs to practice in a supervised setting (I.e., associate licensure) for usually 2 full-time years after graduating.

My good friend has an MSW and had a similar number of therapy face-to-face hours as I did before I applied to internship. By the time internship and post-doc are over, the hours basically level out. The only difference is they had their degree a year ahead of me and even at an associate licensure were able to bill significantly higher than my pre-licensure rate, which as many folks have pointed out is $0 unless private insurers are allowing incident-to billing.

 

[Sanman]

I agree that the training before the degree is conferred is less than adequate in many cases. However, to achieve independent practice the MSW recipient needs to practice in a supervised setting (I.e., associate licensure) for usually 2 full-time years after graduating.

My good friend has an MSW and had a similar number of therapy face-to-face hours as I did before I applied to internship. By the time internship and post-doc are over, the hours basically level out. The only difference is they had their degree a year ahead of me and even at an associate licensure were able to bill significantly higher than my pre-licensure rate, which as many folks have pointed out is $0 unless private insurers are allowing incident-to billing.

Having known several MSW grads, the quality of those hours is more similar to an informal post-doc in many cases. I have yet to hear about an MSW getting anything similar to the quality of supervision offered in a doctoral internship. Social work got the licensing portion right, IMO. They are also ubiquitous enough to do your clinical training in a single place. That said, the quality of the clinical training does not compare to a clinical psych PhD/PsyD. Like I said, there is no perfect answer for what most people want (good training with an easy direct entry into a decent paying healthcare job.) Each path has its positives and negatives.

 

[PsyDr]

Yeah, let’s see some outcome data. I get some of the arguments against internship in the predoc year, but I always looked at it as a gate keeping measure. In other words, having a third party evaluate a trainee’s skills prior to granting a degree. I’ve always despised captive internships for this reason.

There are other ways to ease the financial burden, some of which have been done:
1. Waive APPIC fees for students in need
2. Allow virtual internship interviews as an option, and do not penalize students for opting for this format
3. Raise internship stipends and/or provide a moving assistance stipend and/or provide housing for interns

There are drawbacks for the above as well, but compared to an overhaul in the entire system…

1) ASPPB should take over APPIC, or overwrite them. It makes sense from a legislative position. It would allow ASPPB to ensure that internships meet criteria for whatever states they are lobbying in. Alternatively, schools should fund APPIC applications as it benefits their metrics.
2) Makes sense to me.
3) Every internship should pay NIH post doc level. Right now that is $56k. Every post doc should pay $80k, because there is at least one postdoc already paying $80k.
b. I have grave reservations about provided housing. If someone gets fired from residency, they'd also have a housing problem. I could envision an executive putting a dollar value on housing, and saying "we pay you $36k in housing, $5k in health insurance, and $1k in cash". It's just too risky.

 

[WisNeuro]

If you want to fix funding issues on internship, first you have to advocate for the ability to bill for those services. Trying to get a doubling of internship salary, when many sites still lose a good deal of money on interns, will lead to a lot of sites noping right out of training.

 

[Pragma]

If you want to fix funding issues on internship, first you have to advocate for the ability to bill for those services. Trying to get a doubling of internship salary, when many sites still lose a good deal of money on interns, will lead to a lot of sites noping right out of training.

Agreed. I do not think that trainees realize how much of a time-suck internship is for involved faculty or that we generally are not profiting on their caseloads. It is a business and the cost of the intern has to be accounted for somewhere.

 

[Sanman]

If you want to fix funding issues on internship, first you have to advocate for the ability to bill for those services. Trying to get a doubling of internship salary, when many sites still lose a good deal of money on interns, will lead to a lot of sites noping right out of training.

No one has time for that...too busy frying other fish...see the Minnesota Guidelines thread.

 

[Mama Bear]

b. I have grave reservations about provided housing. If someone gets fired from residency, they'd also have a housing problem. I could envision an executive putting a dollar value on housing, and saying "we pay you $36k in housing, $5k in health insurance, and $1k in cash". It's just too risky.

Yes, there would need to be some parameters. When I’ve seen this model done, it is at institutions that have housing available and are offering it as a benefit to offset the poor internship salary. In other words, free or extremely low cost housing in addition to the $22,000 stipend. Thereby giving interns more things even if it can’t be more pay. What I’m not sure on is how much time is given to move if someone is fired. If I ruled the world, I would say the institution must allow at least 60 days to move out if you’re fired.

 

[WisNeuro]

No one has time for that...too busy frying other fish...see the Minnesota Guidelines thread.

Pretty much. Just go look at the pitiful response numbers of the current call for CMS comments. Don't be surprised when you're sitting at the midlevels table, folks.

 

[smalltownpsych]

Pretty much. Just go look at the pitiful response numbers of the current call for CMS comments. Don't be surprised when you're sitting at the midlevels table, folks.

We are not competing very well in the marketplace. My employee who just got her MA in counseling, got her license and is able to go online and is being promised 70 dollars per session. She has about the same level of clinical experience as a doctoral student who has just done a year of practicum. I’m trying to figure out how to compete with that and keep her working for us because she does have a lot of potential. The landscape is changing rapidly and psychologists are not doing a good job of exhibiting leadership. I sometimes wonder if we lost the battle a long time ago.

 

[BuckeyeLove]

Conservative Public: "Therapy is just talking to someone about yourself and feeling validated, it doesn't actually help or fix anything, just keeps therapists with a job."
(Some) Psychologists: "No that's not it at all. Actual therapy is based in empiricism and years of education, training, and experience."
(Other) Psychologists: "I can treat everything with EMDR, reiki, and supportive listening. Your feelings are always valid and i will never challenge you. I went to the international school of professional psychology by the way and we were taught everything there."

We've done this to ourselves. There's more bad therapists than good ones. What other fields can we say that about? (i know there's probably some but I have a hard time thinking of one in healthcare....maybe chiropractic.).

 

[Sanman]

We are not competing very well in the marketplace. My employee who just got her MA in counseling, got her license and is able to go online and is being promised 70 dollars per session. She has about the same level of clinical experience as a doctoral student who has just done a year of practicum. I’m trying to figure out how to compete with that and keep her working for us because she does have a lot of potential. The landscape is changing rapidly and psychologists are not doing a good job of exhibiting leadership. I sometimes wonder if we lost the battle a long time ago.

I have to agree with this and COVID really accelerated this issue. We are really behind the ball but this has been coming. We have been pushing things like board certification and post-doc on new grads, lengthening the process. However, unlike our physician colleagues, specialty training outside of neuropsych or forensics confers little to nothing in terms of income because there are no specialty reimbursements. So, you get the pleasure of more work for no more money. I love what I do, but it is hard to justify when folks in PP doing telehealth from home are making significantly more than a specialist clinician in a hospital. This goes double for academia who make even less. Life is expensive and people are not that dumb.

 

[quickpsych]

From what I started hearing and reading about a few years ago, there was some movement to get rid of the predoctoral internship and make it something one did after graduating (aka a post doc internship). So for example you would shave a year off the doctoral program (and a year of tuition) , graduate then go on to your internship. I'm not sure how much steam this idea has as more and more states are no longer requiring a post doc for licensure, so the infrastructure and support for "post graduation" internships needed for licensure would likely be less in some states than others. It would , IMO, possibly recreate the internship shortages we had in the field in the late 2000s-through late 2010s.

IMO I think it's best to keep the internship as part of the doctoral degree requirements. Many programs have consortiums which are APA accredited , can ensure continued standardization and quality control of training (a la how they try to do it in every other health care profession), and ensures people don't keep graduating from schools that are ill equipped or just don't provide the resources or infrastructure needed to ensure one can actually get a path to licensing.

The ship has sailed I think on trying to make our profession in line with the medical model of 4 years of medical school then onto residency. Since unlike medical licenses, you now don't need "residency" aka post docs in psychology in more and more states anymore, getting rid of the pre doc internship as part of the education puts the burden back on a system that's moving away from post education formal X number of hours training. I don't think we need to mimic the medical model of training and education exactly, as it's likely impossible at this point given all of the above, but we do need better standardization of licensure requirements across the country.

 

[Therapist4Chnge]

/pessimism ahead

I started this journey 20 years ago and the healthcare industry was already having issues, then the internship imbalance (psych specific), and now the industry is a dumpster fire. Unless someone can work in a niche area (psych: legal, neuro, child custody) (medicine: ROADS, PM&R), I don't recommend pursuing psych or medicine. The internship experience is valuable and I hope they keep it because taking it away w/o a really good reason could severely (& negatively) impact our field.

Psych and medicine are more now than ever about ROI, and the ROI for the vast majority of specialty areas sucks. My only saving grace was I took the path that allowed me the most autonomy and the chance at the highest earning potential (when including legal work). This isn't to say that neuropsych is a good option for most or that the field isn't still a minefield of challenges, it is just better than being in college counseling or fighting with mid-levels for patients. Even RxP is limited in geography and income. There is still plenty of money to be made and comfortable lifestyles to achieve, but that mostly has to do with being good at business and investing, and less about training and abilities.

 

[NewNeuroDemic]

I am torn on this issue. On one hand, I agree that moving for internship, when you are perhaps at your most poor, is stupid. On the other, I learned on internship exactly what I DID NOT want for my professional life, so moving again for postdoc (while still laughably poor) was a huge, positive step. I would argue, however, that the relative value of internship compared to postdoc is miniscule. The whole internship process is outdated and stupid. So I guess I'm not torn on this issue at all.

Last thought. Someone above mentioned the gatekeeping aspect of intership. Please. Half of my cohort was unprepared and ill-equipped to be at internship, and they sailed on through. I would venture that most supervisors don't have the courage to actually gatekeep in a meaningful way.

 

[futureapppsy2]

My employee who just got her MA in counseling, got her license and is able to go online and is being promised 70 dollars per session.

This seems like a gross exaggeration--an accredited counseling program will require 300 face-to-face clinical hours minimum (minimum 700 fieldwork hours total) to graduate and then approximately 2,000 supervised post-masters clinical hours (maybe more, depending on the state) to get licensed. I don't know of any people who did 2,000+ hours in one year of doctoral practicum (and if they say they did, there was definitely sketch stuff going on).

 

[AcronymAllergy]

I am torn on this issue. On one hand, I agree that moving for internship, when you are perhaps at your most poor, is stupid. On the other, I learned on internship exactly what I DID NOT want for my professional life, so moving again for postdoc (while still laughably poor) was a huge, positive step. I would argue, however, that the relative value of internship compared to postdoc is miniscule. The whole internship process is outdated and stupid. So I guess I'm not torn on this issue at all.

Last thought. Someone above mentioned the gatekeeping aspect of intership. Please. Half of my cohort was unprepared and ill-equipped to be at internship, and they sailed on through. I would venture that most supervisors don't have the courage to actually gatekeep in a meaningful way.

Just like most things in psychology, I suspect this varies widely by location. Where I've trained and worked, supervisors were not at all shy about dismissing interns if that was deemed appropriate, nor about enacting probation plans and the like. I've been involved in dismissing trainees and enacting such plans myself. It is not at all enjoyable, but when things like probation plans work and you see trainees then succeed/flourish, you feel exceedingly happy for them.

Anecdotally--I agree that I learned more on postdoc, but part of that was because of what I'd learned in grad school and on internship up to that point. I'd had a lot of clinical experience in grad school, and even then, there were multiple rotations on internship where I saw patient populations and worked in settings I'd never seen before. On postdoc, the patients and settings were, therefore, already familiar to me, but the depth of training/knowledge was much greater.

I think internship is most beneficial for students who had limited clinical experience (in terms of raw hours or few practicum settings, such as only having worked in university clinics). For students with a broader array of clinical experiences, it does at least allow a separate "third party" to lay eyes on them before they get shipped off into the wild west of psychological practice.

 

[smalltownpsych]

This seems like a gross exaggeration--an accredited counseling program will require 300 face-to-face clinical hours minimum (minimum 700 fieldwork hours total) to graduate and then approximately 2,000 supervised post-masters clinical hours (maybe more, depending on the state) to get licensed. I don't know of any people who did 2,000+ hours in one year of doctoral practicum (and if they say they did, there was definitely sketch stuff going on).

The 2000 post masters is not a requirement in this state. They have two levels, LPC and then LCPC as far as practicing goes there is no distinction between the two. So her requirement was 600 hours total with 300 face to face and she’s ready to go. At my first year practicum I had about 600 hours with about 400 face to face and my first year was the lightest workload as the subsequent placements were more demanding of time and went through the summer.

 

[Spydra]

I ponder this topic off and on and I still go back to getting rid of the predoctoral internship so that trainees graduate and go straight into a postdoc. And sure there are plenty of people who had great internships and can't imagine that going away. Ok imagine that same great experience with you being called doctor and having a bigger paycheck. That's called a postdoc.

I know that some states have ended the postdoc requirement for licensing, but I suspect this is because the predoctoral internship is a required component of graduate programs, at least APA accredited ones (I can't speak for PCSAS, it's outside my scope). So I'm thinking that if APA eliminated the predoctoral internship entirely and instead required students pass the EPPP and complete dissertation prior to graduating, would get such states to rethink that. States that eliminated the postdoc would probably reinstate the postdoc requirement because what they don't want are trainees with less clinical training. For those states that don't care about that, something tells me that employers who want a doctoral level practitioner with more experience will extend their recruitment reach.

I also think that shifting the burden of EPPP passing to programs would force programs themselves to get involved in advocating for change in regard to the mess that is the EPPP in terms of pass rates and the inequities for BIPOC people. Not getting involved threatens their graduation rates and accreditation renewal and I don't know why they'd sit back and just let that happen. I suppose programs who don't want to push for changes here are more likely to have recruitment struggles and some may not stay open, but that may just be a good way to weed out bad apples. This seems like it would shift more of the fields gatekeeping to programs with ensuring quality practicum experiences and following the accreditation standards.

With everyone graduating and going straight into postdoc there is the opportunity to bill (if it's a clinical postdoc) and receive a salary much higher than the embarrassment that internship salaries are. States that have jurisprudence exams will likely keep those because that appears to be an additional layer of gatekeeping they require. I've always thought our field should place greater emphasis on ABPP and cutting out the predoctoral internship shaves a year off that timeline. It seems to me that more people in our field achieving ABPP is part of what is needed to obtain higher salaries for specialists. And isn't ABPP also additional gatekeeping, especially when it comes to specialties?

 

[chicandtoughness]

Medicine has been doing a postdoctoral training model. Obviously psychologists aren’t the same as physicians, but I believe right now psychology is the only healthcare profession that requires a year long full-time internship. Medicine, Dentistry, Podiatry, Optometry, etc. all have their full-time training available via postdoc.

Pharm still required a predoc last I checked. The landscape could have changed.

It’s not entirely accurate to say medicine gets all its training postdoc. I would actually liken MS3 to our “predoc”, as you are on clinical service full time (expected 40 hrs/wk, though depending on service line could be more or less). Our “practica” is more like the longitudinal clinics and other training we get through 1st and 2nd year.

This seems like a gross exaggeration--an accredited counseling program will require 300 face-to-face clinical hours minimum (minimum 700 fieldwork hours total) to graduate and then approximately 2,000 supervised post-masters clinical hours (maybe more, depending on the state) to get licensed. I don't know of any people who did 2,000+ hours in one year of doctoral practicum (and if they say they did, there was definitely sketch stuff going on).

A lot of states have a lower, associate license (LPC-A for Texas, or even the LMSW) that these online platforms will treat as equivalent to an independent license because <exploitative hiring and hope the patient doesn’t know any different to rake in that $$$>. It nauseates me.

 

[NeuroObsessed]

Pharm still required a predoc last I checked. The landscape could have changed.

It’s not entirely accurate to say medicine gets all its training postdoc. I would actually liken MS3 to our “predoc”, as you are on clinical service full time (expected 40 hrs/wk, though depending on service line could be more or less). Our “practica” is more like the longitudinal clinics and other training we get through 1st and 2nd year.


A lot of states have a lower, associate license (LPC-A for Texas, or even the LMSW) that these online platforms will treat as equivalent to an independent license because . It nauseates me.

I guess that makes more sense as to why we had to instill a large amount of our training in to a one a year internship prior to graduation. If med schools clinical training through year 3 and 4 is that much more intense and time consuming, I can see why we add on an additional year to of training. I actually sent you a PM, do you mind taking a look?

 

[chicandtoughness]

I guess that makes more sense as to why we had to instill a large amount of our training in to a one a year internship prior to graduation. If med schools clinical training through year 3 and 4 is that much more intense and time consuming, I can see why we add on an additional year to of training. I actually sent you a PM, do you mind taking a look?

Yep, just saw it! It’s a busy night but I’ll get back to you sometime tmrw!!