PhD/PsyD Unpaid internships (meaning unpaid practica)

[roryportman]

---

Members don't see this ad.

#unpaidinternships is currently trending on social media, so I wanted to start a discussion here if anyone else is so willing. The topic of whether unpaid labor in clinical psych is ethical has entered my mind quite a bit over the past few years, given that, you know, we literally have to track the number of unpaid hours we slave over.

The astounding majority of practica across the country are unpaid, no? I am located in the nyc area and as a student, I have accrued >1500+ total hours (beyond interventino/assessment). Will this field ever change? How can top hospitals not even consider a mere stipend/covering commute costs for students who do so much work? Do you think anything might change now, given the heated conversation today? It's a privilege to be able to do this work. Finances are obviously a gatekeeper to who can enter this field, which does not help in terms of the much-needed diversity for the field. I mean, the field needs allllll sorts of diversity, but it especially doesn't need any more super wealthy therapists "helping" individuals of low SES all the while wearing their 2 carat diamond rings and who have no idea what it's like to be without money (yes, I have seen too much of this in my limited time in the field)

I have also heard that the field will never change because senior people have said, "if I had to go through it and did it, future trainees can too." I cannot imagine having this selfish feeling, but who knows. I suppose I could feel resentful, petty, and bitter about it in the future and that would affect my feelings for future trainees.

Edit: though #unpaidinternships is the hashtag, in this case I mean unpaid clinical work of any kind; likely clinical practica

 

[WisNeuro]

I have also heard that the field will never change because senior people have said, "if I had to go through it and did it, future trainees can too." I cannot imagine having this selfish feeling, but who knows. I suppose I could feel resentful, petty, and bitter about it in the future and that would affect my feelings for future trainees.

Edit: though #unpaidinternships is the hashtag, in this case I mean unpaid clinical work of any kind; likely clinical practica

Honestly, a bigger issue is not being able to bill for a lot of services that trainees provide. Even at the internship level, by and large, trainees are a cost sink in many places.

 

[BuckeyeLove]

Can interns bill as "psych assistants?"

 

[WisNeuro]

Can interns bill as "psych assistants?"

In most places if someone is fulfilling requirements of a graduate program, we can't bill for many things, especially for CMS billing. Internship falls under this umbrella.

 

[Justanothergrad]

Honestly, a bigger issue is not being able to bill for a lot of services that trainees provide. Even at the internship level, by and large, trainees are a cost sink in many places.

This

In a lot of cases, people aren't making money on you. So expecting to be paid may be counter productive. Some may be able to use your services to demonstrate completion of a grant or public funding (e.g., community mental health), but in those cases money to the agency / solvency may be an underlying issue as well.


Bonus: This is why you should join Psych organizations that can advocate for greater funding and billing practices. IF psych makes more, some doors open up.

 

[WisNeuro]

And before anyone complains, yes APA knows about this and yes it is a topic of legislative advocacy that we continually engage in. Slowly clawing to a bigger seat at the CMS table has been ongoing. The fact that when we put out national calls to psychologists to submit comments to CMS or contact reps, we get very low response rates does not help.

 

[boba_psych]

I definitely see the point of externs being a cost sink in some ways, but what about externs that serve as unpaid psychometrists? (In a neuropsych setting). Wouldn't that increase the patient volume a practitioner can see, and therefore be beneficial financially?

I'm asking because I want to know from the licensed provider's perspective.

 

[WisNeuro]

I definitely see the point of externs being a cost sink in some ways, but what about externs that serve as unpaid psychometrists? (In a neuropsych setting). Wouldn't that increase the patient volume a practitioner can see, and therefore be beneficial financially?

I'm asking because I want to know from the licensed provider's perspective.

It'd make more sense financially to just hire an actual psychometrist so we could bill for that time. Also, we'd lose time/money on any time we needed to debrief and supervise that extern.

 

[WisNeuro]

Also, the time spent training someone up on tests and testing them out to make sure that they are doing it correctly can be a HUGE time sink. Bottom line, in many situations, trainees are a huge drain of money and time. Supervision and training at that level is done because we enjoy it and/or we have a duty to the field. People training the right way are not making money off of trainees. We're trying to find money/volunteer unpaid time so that we can train people.

 

[Ollie123]

Agree with the above, I think its unlikely to change unless services can be billed. Our state/institution has somehow figured out a way to bill for it from non-federal payors at the intern & above level - albeit with some restrictions. Maybe at the practicum level too, I just genuinely don't know. I don't fully understand it, but I trust the extremely large army of lawyers we have would let us know if we weren't supposed to be doing this.

I always just viewed it as part of school, just like I wouldn't expect pay for my thesis or dissertation. Given the standard model in psychology is free or near-free tuition plus an (admittedly very small) salary, it never occurred to me to ask for more. At least at my program, we did have a handful of paid practica that were used to ensure all students had 100% funding. They typically capped the hours you could work at unpaid practica at 10 hours/week. You could apply for exceptions (if for example - you needed more hours for internship). To me, it seemed a reasonable compromise.

I have heard that NYC sites tend to be unusually exploitative. Requiring prac students work insane hours with negligible support, ridiculous competition to get choice practicums in the first place, etc. So there may be some geographic variation in this.

 

[Mojito_15]

My school psych prac students who work in rural areas are paid. Not especially well- but they are hired as school psych paras and make hourly para pay. Some even get benefits.

 

[niceman]

My school psych prac students who work in rural areas are paid. Not especially well- but they are hired as school psych paras and make hourly para pay. Some even get benefits.

School settings/university counseling centers are probably different as school-based/UCC services are not billed per hour of service and in that case unpaid prac students are unlikely to be a cost sink (I know many school districts don't pay their prac students/interns, especially in urban areas). It is certainly easier for sites in big cities to be exploitative when they know there is a constant supply of psych students who need practicum experiences.

I know one big AMC's way of working around it is through a million-dollar training grant and a contract with the state Medicaid program so even interns can bill for virtually anything. It is rare and shouldn't replace systemic advocacy efforts though.

 

[WisNeuro]

School settings/university counseling centers are probably different as school-based/UCC services are not billed per hour of service and in that case unpaid prac students are unlikely to be a cost sink (I know many school districts don't pay their prac students/interns, especially in urban areas). It is certainly easier for sites in big cities to be exploitative when they know there is a constant supply of psych students who need practicum experiences.

I know one big AMC's way of working around it is through a million-dollar training grant and a contract with the state Medicaid program so even interns can bill for virtually anything. It is rare and shouldn't replace systemic advocacy efforts though.

This is the exception rather than the rule as most places cannot bill for Medicaid services. Which is unfortunate as Medicaid already pays so poorly.

 

[PsychPhDone]

This is the exception rather than the rule as most places cannot bill for Medicaid services. Which is unfortunate as Medicaid already pays so poorly.

I had a(n unpaid) practicum where I only saw medicaid patients independently because the staff said they wouldn't get paid for services anyway.

 

[roryportman]

I admit I understand little about how insurance works, and I can definitely see how providing supervision takes up much time. I do know that at my practica sites, at least for NP evals, my supervisors have somehow been able to bill and be reimbursed for trainees' work. For context, I have always trained at top hospitals/AMCs (top 10 in the country according to US news if that means anything) with large clinical psych training programs across different depts and areas (therapy, NP, rehab, etc). I suppose I say that to illustrate these are legitimate training experiences rather than something at a small, wonky private practice. Where I am currently, trainees are typically at "advanced" stages (3rd of 4th externship) and depending on the supervisor, may not receive/need a lot of supervision. So on my end, it sometimes looks like 10+ trainees pumping out a whole ton of work with multiple assessments daily, which mathematically turns out to be helluva lot more than these supervisors would ever be able to do on their own.


This makes sense, and yes, this is possibly how my sites have been able to do that they do.

School settings/university counseling centers are probably different as school-based/UCC services are not billed per hour of service and in that case unpaid prac students are unlikely to be a cost sink (I know many school districts don't pay their prac students/interns, especially in urban areas). It is certainly easier for sites in big cities to be exploitative when they know there is a constant supply of psych students who need practicum experiences.

I know one big AMC's way of working around it is through a million-dollar training grant and a contract with the state Medicaid program so even interns can bill for virtually anything. It is rare and shouldn't replace systemic advocacy efforts though.

What is CMS? I'll keep in mind to stay involved with advocacy now and in the future.

And before anyone complains, yes APA knows about this and yes it is a topic of legislative advocacy that we continually engage in. Slowly clawing to a bigger seat at the CMS table has been ongoing. The fact that when we put out national calls to psychologists to submit comments to CMS or contact reps, we get very low response rates does not help.

Yepppp... and our fun little match day is this Monday.

I have heard that NYC sites tend to be unusually exploitative. Requiring prac students work insane hours with negligible support, ridiculous competition to get choice practicums in the first place, etc. So there may be some geographic variation in this.

Appreciate everyone's thoughts! While I have had amazing clinical experiences and have frequently felt fortunate to be in nyc to work and learn at great hospitals, sometimes this system just gets me. Possibly currently exacerbated by what is hopefully my final externship match day coming up.

 

[AbnormalPsych]

I had both paid an unpaid practica. Before entering grad school I had paid and unpaid RA positions. I viewed the training, mentorship, and supervision, letters of rec I received for free as my payment. I know that there are a lot of issues here and I too would have liked to be paid for all this labor. However, if these places did that for even minimum wage, a lot of those positions wouldn't have existed, I never would have been trained/supervised, and I may not be here as a psychologist today.

People charge a lot of money for independent supervision. So it was quite a steal looking back and doing the math on # hours of training/supervision x hourly rate for that in my area.

 

[MAClinician]

This is the exception rather than the rule as most places cannot bill for Medicaid services. Which is unfortunate as Medicaid already pays so poorly.

Are some states able to apply for State Plan Amendments and get grants or other changes that allow them to do this? For example in MA the Medicaid program developed a group of services under a waiver that allows masters level interns to bill for services on a reduced reimbursement rate. There are criteria that needs to be met and some restrictions. We don’t have psychologists though at the place I work so I’m not sure if it would apply to doctoral trainees.

What is CMS? I'll keep in mind to stay involved with advocacy now and in the future

Centers for Medicare and Medicaid Services, the federal agency that determines reimbursement rates, policies, and regulations for Medicaid and Medicare. Private commercial insurances often follow CMS lead with respect to reimbursement, some pay the same rate some less some more.

 

[psych.meout]

I had a(n unpaid) practicum where I only saw medicaid patients independently because the staff said they wouldn't get paid for services anyway.

This is similar to what has happened for me at AMC prac sites, where they don't bill for any prac students, interns, or post docs. These patients and their families would not be able to afford the cost if we did bill and therefore would most likely be without care. Yes, I would (really) like to be paid for my work, but I view this as a way to help the community while gaining valuable experience.

That said, I have been paid as an interventionist on research grants, which is really nice.

 

[AcronymAllergy]

In general (and as has been already mentioned), I suspect whether or not a practicum is paid depends largely on whether or not the site can bill for the student's time. If they can, or if there's some sort of training grant, the placement is usually paid. The majority of full-time practica in my grad program, for example, came with stipends in much the same way TA/RA positions did. Part-time practica are less likely to be paid largely because, I would guess, the administrative burden of having the trainee classified as a paid employee would be prohibitive.

A reasonable analogy might be the clerkship years for medical students, although the schools actually often have to pay the placement site for those. Practicum trainees may also have a bit more autonomy than med students.

 

[AlmostaPhD]

I think this does vary a bit by state, as where I did internship I could bill Medicaid as a trainee but in my current state we can't do that. I recently wrote lobbying my state govt about this into a grant.

Both where I trained and where I am faculty have paid clinical practica analogous to TA/RA positions as @AcronymAllergy said. There are some volunteer positions one can do for less hours/week, but many advanced students are paid their stipend through their clinical placement and don't work in the department. I've heard things are not great in the NYC area, but at least in some college town type places the paid model seems to work. I don't know how sites make it work financially, but sometimes it has to do with funding mandates (e.g., we have one placement that is required to have certain MH services and supervised grad students are cheaper than going through a local CMHC) or sometimes students get certified as things like RBTs so they can bill. I think it also sometimes helps if trainees work as psychometrists so the psychologist can see more folks, plus some people just like being involved in training and the affiliation with the university. This can help agencies recruit and retain psychologists.

 

[ClinicalABA]

In my program we had a policy where our tuition waivers were contingent upon earning a certain amount (~8k per semester) through practicum, RA, or TA work, thus non-paid practica were doubly disincentivized. We were also unionized (United Auto Workers!) and had some good protections in our contract regarding exploitation through non-paid labor.

 

[WisNeuro]

I admit I understand little about how insurance works, and I can definitely see how providing supervision takes up much time. I do know that at my practica sites, at least for NP evals, my supervisors have somehow been able to bill and be reimbursed for trainees' work. For context, I have always trained at top hospitals/AMCs (top 10 in the country according to US news if that means anything) with large clinical psych training programs across different depts and areas (therapy, NP, rehab, etc). I suppose I say that to illustrate these are legitimate training experiences rather than something at a small, wonky private practice. Where I am currently, trainees are typically at "advanced" stages (3rd of 4th externship) and depending on the supervisor, may not receive/need a lot of supervision. So on my end, it sometimes looks like 10+ trainees pumping out a whole ton of work with multiple assessments daily, which mathematically turns out to be helluva lot more than these supervisors would ever be able to do on their own.

I have to spend much more time verifying/editing trainee reports than it takes me to simply write the report myself. It is rare to have a trainee good enough that the time needed to edit is less than or equal to our own. I always caution people to wait to work on the other side before they criticize aspects of the process that they do not see. I'm sure there are some shady outfits that simply signoff on this stuff with little supervision, but I enjoy having my license and providing high quality care to my patients.

 

[ClinicalABA]

I have to spend much more time verifying/editing trainee reports than it takes me to simply write the report myself. It is rare to have a trainee good enough that the time needed to edit is less than or equal to our own. I always caution people to wait to work on the other side before they criticize aspects of the process that they do not see. I'm sure there are some shady outfits that simply signoff on this stuff with little supervision, but I enjoy having my license and providing high quality care to my patients.

This. I'm down to billing 1-2 hours (mode 1) for all that goes into report prep. All the back and forth emails, edits, etc., with practica students takes at least that amount of time. I work for a well run agency, with good business sense. If we could increase productivity and billables with non-paid practica students, we'd have more (and I be forced to take one- I've been offered but declined for the last several years).

I will point out that there are many non-financial benefits of practica students (good ones, at least). As a supervisor, it keeps you on your game to have someone observing you and asking questions. It has made me keep up on the literature more than I might have otherwise. It can also be good for recruitment- we currently have two post-docs that were previously practica students, as well as a psychologist who did both practica and post-doc. Practica and post doc students are also a big help with research and conference prep and presentations. I actually got involved with this board as a result of my previous agency beginning a practicum (paid) with my alma mater, as I was looking for some up to date info and perspectives on the needs of practica students.

 

[Sanman]

This. I'm down to billing 1-2 hours (mode 1) for all that goes into report prep. All the back and forth emails, edits, etc., with practica students takes at least that amount of time. I work for a well run agency, with good business sense. If we could increase productivity and billables with non-paid practica students, we'd have more (and I be forced to take one- I've been offered but declined for the last several years).

I will point out that there are many non-financial benefits of practica students (good ones, at least). As a supervisor, it keeps you on your game to have someone observing you and asking questions. It has made me keep up on the literature more than I might have otherwise. It can also be good for recruitment- we currently have two post-docs that were previously practica students, as well as a psychologist who did both practica and post-doc. Practica and post doc students are also a big help with research and conference prep and presentations. I actually got involved with this board as a result of my previous agency beginning a practicum (paid) with my alma mater, as I was looking for some up to date info and perspectives on the needs of practica students.

I will add a couple of other things to this. I am a VA staff psychologist. While it can be argued the hospital makes money on some trainees as cheap labor, I am paid exactly zero extra dollars for supervising you. Yes, I get workload credit for the work that students do. However, as other have mentioned, I can get the work done faster on my own. For example, I recently allowed an intern my rotation to complete an intake assessment and brief testing because they are required to complete a certain number of integrated assessments for the year. I did not save any time as I was required to be in the VVC room supervising. The testing was longer than it needed to be because the intern needed the experience multiple assessment measures. I usually keep anything I do bare bones (usually a GDS, MOCA/SLUMS, maybe an RBANS if I feel it is necessary). Seeing them, assessing, charting, is 1-3 hrs max. I spent 2 hours on VVC with the intern to do the intake and brief assessment. Intern wrote up the assessment, I had to go through two revisions (two hours of no extra billing), and sign off on paperwork that the intern completed the assessment for the person's internship paperwork. Figure 5 hours instead of 1-3 hours. I am not paid for any of this.

If they are going to pay trainees at all or more, they are going to need to pay me more to supervise and accept liability/headaches. So now, the hospital would have to pay me and the trainee. Even if they negotiate reimbursement, the hospital will make minimal money with all the pay increases. So, why would they push to negotiate for this if they will not receive much money?

 

[Shiori]

After landing a post-doc, I finally have some breathing room to think about the experience of becoming a psychologist. I can't help but worry about the fairly homogeneous group of people who make it through this process. I am heartened that there are efforts to expand opportunities for trainees by examining the reimbursement of services. I am often the only African American in the room at this level, and I have regularly been asked for my feedback on how to recruit and keep more diverse trainees. The financial commitment is daunting. I have been a TA pretty regularly and have had undergrads of colors ask about the process of becoming a psychologist. Many of them don't have access to financial resources that would make psychology a viable option. It's frustrating, and it's an expensive problem to fix. I'm definitely going to commit more of my energy to doing what I can.

Sorry for the random new post! I joined when I was panicking about getting into a PhD program. It was a wild ride, and now I'm closer to the other side of the process.

 

[cara susanna]

My program actually had paid practica--that was how they funded us our 3rd and 4th year--and it was a mess, IMO. The pay disparity was huge and some people were barely making any money, especially compared to what we had made with graduate teaching assistantships. My third year finances would have been very rough had my partner not been working. Our program was afraid to ask for more pay for the reasons discussed above, they didn't want to alienate the sites and they knew the sites may not be able to afford it.

Basically, although it's a great idea in theory I'm afraid that it might end with programs no longer funding students themselves and making them rely on the practica for their funding, just like my program did.

 

[WisNeuro]

My program actually had paid practica--that was how they funded us our 3rd and 4th year--and it was a mess, IMO. The pay disparity was huge and some people were barely making any money, especially compared to what we had made with graduate teaching assistantships. My third year finances would have been very rough had my partner not been working. Our program was afraid to ask for more pay for the reasons discussed above, they didn't want to alienate the sites and they knew the sites may not be able to afford it.

Basically, although it's a great idea in theory I'm afraid that it might end with programs no longer funding students themselves and making them rely on the practica for their funding, just like my program did.

I would guarantee that if paid practica were mandated, without securing state/federal monies to cover all/most of it, you would see a huge number of practicum placements disappear. I'd be willing to bet that most training would then have to take place in program-run clinics.

 

[MiniLop]

I did an (unpaid) externship at a (university affiliated) outpatient clinic that was private pay only. Sessions with me were $155, of which I saw exactly $0. I received 2 hours of supervision per week and had a caseload of about 8 clients, so it seemed unlikely that the cost of supervising me exceeded the amount of money I brought in. I did another (again, unpaid) externship at an (big name) IOP that charged ludicrous amounts of money (again, private pay only) for 4 weeks of treatment, which was largely done by externs. Again, I received 2 hours of supervision per week, but the cost of that seemed far less than what I brought in. So there are definitely times when training is a cost sink for an organization, but that's not a blanket rule. I also did my internship at an inpatient psych hospital where ALL clinical services were conducted by interns or externs, and where supervision was minimal.

I'm not bitter. I got great training at the first two sites, and that experience helped me secure a real, paying adult job. But I still have some iffy feelings.

 

[Sanman]

I did an (unpaid) externship at a (university affiliated) outpatient clinic that was private pay only. Sessions with me were $155, of which I saw exactly $0. I received 2 hours of supervision per week and had a caseload of about 8 clients, so it seemed unlikely that the cost of supervising me exceeded the amount of money I brought in. I did another (again, unpaid) externship at an (big name) IOP that charged ludicrous amounts of money (again, private pay only) for 4 weeks of treatment, which was largely done by externs. Again, I received 2 hours of supervision per week, but the cost of that seemed far less than what I brought in. So there are definitely times when training is a cost sink for an organization, but that's not a blanket rule. I also did my internship at an inpatient psych hospital where ALL clinical services were conducted by interns or externs, and where supervision was minimal.

I'm not bitter. I got great training at the first two sites, and that experience helped me secure a real, paying adult job. But I still have some iffy feelings.

Was this a HCOL area? $155 a session is more than I charged as an unlicensed post-doc. My therapy practica were VA and university counseling center. The other options available were a school system associated program, a community mental health center, and a rural clinic where the a fellow grad student was once paid for services with a sweet potato pie (no joke, it was pretty good). Certainly no one was charging anywhere close to that kind of money.

 

[MiniLop]

Was this a HCOL area? $155 a session is more than I charged as an unlicensed post-doc. My therapy practica were VA and university counseling center. The other options available were a school system associated program, a community mental health center, and a rural clinic where the a fellow grad student was once paid for services with a sweet potato pie (no joke, it was pretty good). Certainly no one was charging anywhere close to that kind of money.

Yeah, it was definitely a high COL area. The first two sites were also both "name" sites.

 

[WisNeuro]

I did an (unpaid) externship at a (university affiliated) outpatient clinic that was private pay only. Sessions with me were $155, of which I saw exactly $0. I received 2 hours of supervision per week and had a caseload of about 8 clients, so it seemed unlikely that the cost of supervising me exceeded the amount of money I brought in. I did another (again, unpaid) externship at an (big name) IOP that charged ludicrous amounts of money (again, private pay only) for 4 weeks of treatment, which was largely done by externs. Again, I received 2 hours of supervision per week, but the cost of that seemed far less than what I brought in. So there are definitely times when training is a cost sink for an organization, but that's not a blanket rule. I also did my internship at an inpatient psych hospital where ALL clinical services were conducted by interns or externs, and where supervision was minimal.

I'm not bitter. I got great training at the first two sites, and that experience helped me secure a real, paying adult job. But I still have some iffy feelings.

Most university clinics run sliding scale. They also employ many other people, some outside of the faculty. At least several of the university clinics I worked/supervised in were lucky to break even, even though grad student clinicians charged patients. I would not assume that they made money on you after paying overhead.

I'm sure some places are predatory, but trainees and even ECPs usually have a terrible grasp of the business dealings that go on and what the balance sheet actually looks like.

 

[DynamicDidactic]

I also find it ethically more shaky to pay for externships. Once money is involved then there is a lot more perverse incentives.

More importantly, I considered the clinical training to be training just like research training. I do not think I should be paid for completing my dissertation or taking my courses, same with clinical work. I understand why it feels different to go to a clinical setting and work but it is still training.

but it especially doesn't need any more super wealthy therapists "helping" individuals of low SES all the while wearing their 2 carat diamond rings and who have no idea what it's like to be without money (yes, I have seen too much of this in my limited time in the field)

Not sure how representative your experience is across the country. Perhaps you have a biased sample of programs/students. Free food on campus was a popular event for me and my peers during training. I counted my cents closely and I don't believe anyone in my program was super wealthy. Though, anecdotally I have run into that type of student and they came from high-debt, large-cohort, large metro, poor-matching programs.

 

[DynamicDidactic]

Also to be clear, I am in support of paid predoctoral internships. I was applying for internship during the peak of the match imbalance and I remember some people complaining that APA accreditation requires paid internships. Since internship is more like a residential placement that no longer allows students to stay at their university full time and thus lose any funding, they need to be paid (though, off course a $15 an hour would be a significant raise on what I made as an intern).

 

[DynamicDidactic]

I have also heard that the field will never change because senior people have said, "if I had to go through it and did it, future trainees can too." I cannot imagine having this selfish feeling, but who knows. I suppose I could feel resentful, petty, and bitter about it in the future and that would affect my feelings for future trainees.

I am not sure what is selfish about that thinking, perhaps horse blinders or self-centered. I think this is better addressed by putting this under the antiquity fallacy. However, I am not sure paid externships would fall under this thinking since the major reasons not to do it are rather strong.

Also, I finding myself having more and more contempt for Twitter. Just bc a hastag sounds appeaking does not make it accurate. There are a lot of factors that can benefit the field and increase diversity. Shifting the costs of training onto externship sites, rather than training program is not one of them. Why don't we get rid of the 50k-a-year programs with large cohorts of students with high attrition rates as a starting point and replace them with smaller, more affordable programs.

 

[Sanman]

Not sure how representative your experience is across the country. Perhaps you have a biased sample of programs/students. Free food on campus was a popular event for me and my peers during training. I counted my cents closely and I don't believe anyone in my program was super wealthy. Though, anecdotally I have run into that type of student and they came from high-debt, large-cohort, large metro, poor-matching programs.

OP mentioned being in NYC. I know plenty of people that fit that description, including a few in my program. The ones from my program did not grow up rich. Being educated attractive women they did meet educated men with MBAs (because NYC metro area) or IT degrees that make 250k/yr and can afford a 2 carat diamond ring. Not sure who the OP wants to help low SES folks? A therapist also on food stamps? That MBA/ IT guy husband allowed some of those women to stay in NYC treating low SES folks for $60k. Less affluent folks like me opted for greener pastures and left for better paying gigs because I had loans to pay off and wanted a nice house and fancy stuff as well.

 

[ClinicalABA]

The astounding majority of practica across the country are unpaid, no?

I legitimately don't know if this is true. All mine were paid, and we had to get special permission from the department to do unpaid practicum. Unlike you in NYC , I was in an area where we were the only doctoral program, with relatively small cohorts (5-7 students per year, with only years 3 onward doing external practica). We didcsee clients in the training clinic every year, and this was unpaid. I expected my external practicum to be paid. When I was later in a position to take on practica students, I expected that I would have to pay them.

Will this field ever change?

Historically speaking, things probably won't change all that much unless your generation of trainees and- ultimately- psychologists- work to advocate for and affect said change.

I mean, the field needs allllll sorts of diversity, but it especially doesn't need any more super wealthy therapists "helping" individuals of low SES all the while wearing their 2 carat diamond rings and who have no idea what it's like to be without money (yes, I have seen too much of this in my limited time in the field)

I suspect that your experiences might be somewhat related to where you are located. I just am not seeing the flashy, rich psychologist making big bucks off of medicaid patients.

That said, I have to disagree with the "especially" qualifier. I feel that this field "especially" doesn't need anymore poorly trained, lazy clinicians who just coast by because a) their clients don't have the knowledge or ability to accurately assess the quality of their clinician; and b) even if they did, don't have a choice. I see mainly low SES clients. I think I do a good job with them because I was trained by people who were good, not because I was raised in a low SES family. Also while I'm not flashy in any way, I clearly am now of a higher SES status than most of my clients (just as, for example, the orthopedic surgeon who did my knee is of higher SES than me). I've been poor before, and I'm not going back there if I have anything to say about it (though I do acknowledge that my poor, white, rural experience was drastically different than the poor, Latinx, urban experience of my clients).

I have also heard that the field will never change because senior people have said, "if I had to go through it and did it, future trainees can too."

I hate that attitude. Training models and practices should reflect best practices, and not the random past experiences of the current trainers. I hope that there's been some empirically based changes in graduate training in the decades since I was in graduate school! (I still insist that you need to calculate an anova with a pen and paper, for no other reason than I had to!).

In summary:
- practica should be paid
-clinical competence should be the most valuable trait of clinicians. Hopefully the next generation of trainnees/psychologists will enact change that results in a more diverse group of students having access to high quality doctoral education. My generation has made some strides in this area, but more work is needed.
-every generation is entitled to say "back in my day, we had to (insert exaggerated unpleasant experience here), but should not impose those experiences on others unless there is empirical support that said experiences result in better clinicians

 

[PikminOC]

The therapists I see getting their 2000 gave supervisors who bill for the time. I've seen 100 to 150 per session. They aren't supposed to bill for this?

 

[Sanman]

The therapists I see getting their 2000 gave supervisors who bill for the time. I've seen 100 to 150 per session. They aren't supposed to bill for this?

By getting their 2000 I assume you are referring to internship or post-doc? Those are paid positions (the equivalent to medical residency and fellowship). We are talking practica (think med school rotations 3rd-4th yr) that are unpaid.

 

[PsychPhDone]

The therapists I see getting their 2000 gave supervisors who bill for the time. I've seen 100 to 150 per session. They aren't supposed to bill for this?

Are you asking if supervisors can bill trainees for providing supervision or if supervisors can bill patients for their trainees' services?

Either way I treated exactly zero patients in a setting who paid for treatment during any of my training. Maybe very very few of my VA patients had the copay? There was little in the way of PP practica at my grad program. We were all fully funded on merit based fellowships, research assistantships, or teaching assistantships.

 

[Ollie123]

Being educated attractive women they did meet educated men with MBAs (because NYC metro area) or IT degrees that make 250k/yr and can afford a 2 carat diamond ring.

Off-topic, but these posts always make me feel good about avoiding the large metros. Adjusted for cost-of-living, that MBA is actually earning less than most psychologists I know. Significantly less if they are in Manhattan.

 

[WisNeuro]

Off-topic, but these posts always make me feel good about avoiding the large metros. Adjusted for cost-of-living, that MBA is actually earning less than most psychologists I know. Significantly less if they are in Manhattan.

Yeah, I'm glad i never felt the need to live in one of the large metros, aside from training. Even now, it can be nice to go to NYC for a conference, but after a few days, I am ready to leave. The noise and smell start to get to you after a while.

 

[cara susanna]

I guess I'm not sure why practica should be paid if the program is providing funding to the students already. As mentioned, wouldn't that be considered part of the training provided by the program?

 

[WisNeuro]

I guess I'm not sure why practica should be paid if the program is providing funding to the students already. As mentioned, wouldn't that be considered part of the training provided by the program?

That's pretty much how CMS sees it according to their wording on the topic. And, some third party payors have essentially copy and pasted that verbiage.

 

[foreverbull]

My thoughts are still evolving on this, but given that my program itself only provided enough assistantships for about half of its students or slightly less than that (the others had to compete for assistantships outside of the dept that other grad students were also vying for), and those were underpaid at that, I wouldn’t put it on the training sites to have to make up the difference.

Adequate funding is a huge problem for many students in even mostly funded or fully funded programs, but for many types of sites, to have to pay students for the time and energy commitment that will not be billable doesn’t seem like the best solution. Not to say nothing can be done about this issue, but I definitely see it as a programmatic issue rather than one of prac sites not paying students.

The reality is, my program shouldn’t have taken on as many students as they did at times because they knew that some of us would be scrambling to figure out how to find assistantships. One year I only had a 3/4 assistantship that paid $750 and didn’t provide any tuition reimbursement for a full year. I would’ve liked to make money in my practica, but I don’t know that I see it as their responsibility to make up the difference, especially when they aren’t able to bill.

Counseling centers benefit from prac students because counseling is usually included as part of students’ fees and not billed, but their funding is usually terrible already, so they usually aren’t in a place to pay students often, either.

I’m not against paying prac students if it’s across the board everyone gets paid, but if it’s just some sites paying, that really does start to create more issues if students are all vying for those few positions and some students receive more funding than others because of that, which isn’t an equitable solution.

That said, I’d much rather see programs pay their students a higher rate and limit their cohorts so that students are well-funded throughout grad school instead of placing that burden on training sites.

 

[boba_psych]

I guess I'm not sure why practica should be paid if the program is providing funding to the students already. As mentioned, wouldn't that be considered part of the training provided by the program?

Even a few extra thousand dollars for a years worth of work could substantially increase quality of life for clinical psych grad students. Especially since many program's stipends are in the 15000-20000 dollar range, even in high COL areas.

 

[WisNeuro]

Increased stipends would be great, start contacting your state and federal legislators for higher ed funding, as this is an area that states/fed govt have been dropping funding for pretty regularly over the years. That money has to come from somewhere.

 

[Shiori]

I am really thankful that this discussion is happening because it appears that there are many angles that might be leverage points for change. I was inspired by some of the suggestions here and reached out to some of my supervisors and a training director for more insight. When I asked about how this looks for just for interns, I received a thousand-yard-stare from all of them. When I started to dive into the state-wide policies, it became murky really quickly. I don't feel like I have solid footing at all in the nuances, but I'm not sure I'd even know what to search for without some of the suggestions of people struggling through the training process now and those on the other side working through the aftermath.

I do think there is something to be said about the state of funding at training sites as well. I have been at a couple of campuses and know the students received between $9,000-$15,000 a year. One of my professors said there hasn't been a raise in stipends since the 70s. There have been efforts by the graduate students as a whole at our school to get more financial resources such as stipend increases and some level of health insurance help, but they have been thwarted so far. Money is a hard thing to come by in the best of times. That battle continues. I was able to cushion my earning with grant money, but it was incredibly stressful. I think I went into grad school with decent mental health, but I think I'm going to leave it with some work to do. The training itself was rigorous and fair. The real-life part plus school almost broke me. I also went to school later in life with savings. I am very worried about some of many of colleagues and hope relief comes soon.

 

[ClinicalABA]

The therapists I see getting their 2000 gave supervisors who bill for the time. I've seen 100 to 150 per session. They aren't supposed to bill for this?

You aren't supposed to bill insurance or clients for services you do not provide. If a supervisee does the work, billing it at a psychologist rate or under a psychologist billing code is fraud. In private pay cases, if you are billing doctoral level rates for supervisee's work, you better have a long paper trail where you can prove that the client knew EXACTLY what they were paying for (and in that case, a savvy private pay client would just find a licensed/experienced provider at the same rate as the trainee?).

In my practice. If the supervisee (e.g. postdoc) does the work independent of me (I'm NOT in the room/zoom AND actively participating), we either attempt to bill under an appropriate billing codes for their credentialling level or we don't bill at all. If I'm sitting in the room working on a report for another client while the trainee does the assessment, that doesn't allow me to bill (and it shouldn't count as a direct supervision hour, either).

 

[PsyDr]

Some opinions.

1) Federal labor laws prohibit using unpaid interns for a job that a paid person usually does. Because one has to prove that the unpaid person is doing the work of a paid person, the issue of being licensed comes into play. Medicine has solved this by granting licenses before residency.

2) CMS is part of the Department of Health and Human Services. CMS was created in the 1960s. Like a lot of bills, the law creating CMS had a bunch of other things. One of these things was the creation of a fund to pay for medical residencies salaries (i.e., Direct Graduate Medical Education funds). That Graduate Medical Education fund is administered by CMS. Because CMS is paying a flat fee for resident's salaries, they created rules to prevent double dipping (i.e.,, paying for resident's salaries, and then also being billed for each thins done by a trainee).

3) It gets a bit more complicated. CMS has both medicare and medicaid. Every year, CMS is given an annual budget. Then they have to divide up how that pool of money is distributed. Medicare is administered at the federal level (i.e., same rules in each state). Medicaid is federally funded, but administered by each state (e.g., CMS gives Delaware $500MM to run their medicaid program for a year, Delaware's medicaid office makes up their own rules). So why medicare might not pay for stuff billed by trainees, some states' medicaid programs might allow training institution to bill for trainees work.
4) When psychology is added, it gets even more complicated. Psychology doesn't get any of that sweet sweet CMS Direct Graduate Medical Education funding. Instead, the Department of Health and Human Services gives us some funding under a different branch (i.e., Health Resources and Service Administration). This pays a lot less than CMS.

5) Ready for it to get more complicated? By default, ALL providers in the USA are CMS providers. You literally have to write CMS a letter saying "I do not want to be a CMS provider". So we are bound by CMS rules.

6) Now we add in private insurance companies. So long as there is a licensed professional that is supervising, they can allow trainees to bill or not.

7) The VA gets their own funding for trainees, and they have their own laws. I don't know how that works.

8) Putting it all together: Psychologists are usually governed by CMS rules, but we don't get CMS money for training. Usually we cannot bill for trainees services. Unless they are in a state where medicaid says they can. Or if they are in a state where the state law supervisors can bill for trainee services, and the insurance contracts say they can do that. But usually that isn't the case. In order for a trainee to fix this problem, they would have to prove the supervisor is billing for their services, and that the trainee has replaced a paid person.

 

[ClinicalABA]

One of my professors said there hasn't been a raise in stipends since the 70s. There have been efforts by the graduate students as a whole at our school to get more financial resources such as stipend increases and some level of health insurance help, but they have been thwarted so far. Money is a hard thing to come by in the best of times...

I had the advantage of going to grad school at a time where there was a large proportion of professors who were trained in the late 60s through the 70s, and talked about how they didn't pay for anything and had reasonable- if not desirable- stipends during there training. They felt that it wasn't right to give our labor away for free, and enacted policies and procedures with that in mind.

As to grad students advocating for higher stipends, doing so haphazardly or in an unorganized manner ("lets's protest at the Student Union, then go get some beers!") is unlikely to lead to much. On the other hand, start a unionization campaign and secure the right to collective bargaining, then you will have more say. While it's certainly tough times for universities, those endowments are shrinking, not disappearing.