The origins of the predoctoral internship in psychology date most officially to the 1940s, meaning that nearly a century of psychologists have navigated the intense process that stands between dissertation and doctorate (Morrow, 1946). Currently, psychology graduates enter the match in the year before their intended internship and are not eligible for conferral of the Ph.D. until completion of the internship year. However, this structure has led to many difficulties for students, and recent discourse has seen many calls for the shifting to a postdoctoral internship year, similar in structure to our M.D. counterparts. This proposal has multiple merits but has also faced its share of criticism.
Diversity, Equity, and Inclusion
A major concern for the majority of students applying to the match is that of financial hardship. Although the past several years have seen the transition to virtual interviews as a result of the COVID-19 pandemic, reducing costs of travel for interviews (Erickson Cornish & Baker, 2023), students continue to face significant financial burden. Internship often means relocation, in many cases at great distance across the country and at great cost to the student. Facing increasing costs of living and education, large numbers of psychologists are finishing their training with student debt; this debt burden is even higher for psychologists and students of marginalized backgrounds, including people of color, low socioeconomic status students, and women (Wilcox et al., 2021). Internship stipends remain low compared to the rising living wage, with more than two thirds of internship sites in the Association of Psychology Postdoctoral and Internship Center (APPIC) match paying stipends that linger below the living wage for their area (Hood et al., 2023). One contributing factor to these low stipends is the fact that interns are unable to bill insurance due to their lack of licensure. Medical residents (who are granted their M.D. before departing on their intern year) are granted conditional licensure which allows for billing insurance for their clinical services; similar processes could exist for psychology interns if the internship were made postdoctoral. In the current system, prospective psychologists face many years of minimal financial support and no ability to save for future expenses or retirement; this favors those groups who benefit from generational wealth and family support, while disadvantaging students with less wealth to rely upon during the lean years of graduate school and internship (Aladangady & Forde, 2021).
Training, Specialization, and Flexibility
Currently, most specialization in training occurs during the postdoctoral training period (Silberbogen et al., 2018). However, recent insightful publications have called attention to the need for greater flexibility in psychological training to permit the greatest progress in reducing mental health burdens (Berenbaum et al., 2021). Transition to a postdoctoral internship rather than predoctoral would allow for psychologists who intend to provide direct care to obtain more direct clinical experience and specialize their training to their preference. In addition, it would allow psychologists who intend to pursue other paths (e.g., public policy, research, teaching, or numerous other options) to spend their training time specializing in those competencies and forgo the postdoctoral internship altogether and instead pursue other postdoctoral training in their field of interest. Berenbaum and colleagues present a compelling argument for restructuring the current training arrangement to allow for more diverse opportunities which reflect the wide variety of positions open to a clinical psychologist.
An additional concern for many interns is the title itself. Being described as a “psychology intern” connotes a lower level of expertise, equivalent to a medical student or undergraduate. Thus, the APCS and other authors have called for a shift in title to “resident” to reflect the advanced training achieved by the point of the predoctoral internship year (APCS | Internship Recommendations, 2023; Knowles et al., 2023). While this has been recommended, a move to a postdoctoral internship would codify this universally. It is worthy of note, however, that APCS has not directly recommended a move to a postdoctoral internship, for a variety of reasons.
Considerations
APCS cites several obstacles to the implementation of postdoctoral internships, including state licensure laws and reticence on the part of internship training directors. There are other considerations that may complicate these calls for action as well. One topic that would require more investigation before changing policy would be how these alterations might affect visa status and residency for international students seeking licensure. Challenges facing international students are unique and understudied, but pathways to licensure and continued residency during internship would need to be enshrined in the policies before moving forward (Lee, 2013).
Ongoing discussion at all levels of training and education will help to clarify the goals of internship moving forward and identify obstructions to equity and seek common ground among all involved parties. It is imperative that student voices be featured in these discussions, as students have unique perspectives. A trainee call to action has recently enumerated several systemic changes required for equity and sustainability in training (Palitsky et al., 2022). Efforts to address these concerns, potentially including a reorganization of internship training, will enhance equity and diversity while allowing for greater flexibility in degree application and dissemination of knowledge to the general public. While much of the effort for change rests on systemic adjustments and changes, trainees may contribute by continuing to advocate for equity in their training and universities and pushing to make their voices heard.
Aladangady, A., & Forde, A. (2021). Wealth Inequality and the Racial Wealth Gap. https://www.federalreserve.gov/econres/notes/feds-notes/wealth-inequality-and-the-racial-wealth-gap-20211022.html
APCS | Internship Recommendations. (2023, November 1). https://www.acadpsychclinicalscience.org/internship.html
Berenbaum, H., Washburn, J. J., Sbarra, D., Reardon, K. W., Schuler, T., Teachman, B. A., Hollon, S. D., Atkins, M. S., Hamilton, J. L., Hetrick, W. P., Tackett, J. L., Cody, M. W., Klepac, R. K., & Lee, S. S. (2021). Accelerating the rate of progress in reducing mental health burdens: Recommendations for training the next generation of clinical psychologists. Clinical Psychology: Science and Practice, 28(2), 107–123. https://doi.org/10.1037/cps0000007
Erickson Cornish, J. A., & Baker, J. (2023). A brief history of the association of psychology postdoctoral and internship centers: Trends and directions for the education and training of health service psychologists. Training and Education in Professional Psychology, 17(2), 115–125. https://doi.org/10.1037/tep0000401
Hood, C. O., Schick, M. R., Cusack, S. E., Fahey, M. C., Giff, S. T., Guty, E. T., Hellman, N., Henry, L. M., Hinkson, K., Long, E. E., McCoy, K., O’Connor, K., Padron Wilborn, A., Reuben, A., Sackey, E. T., Tilstra-Ferrell, E. L., Walters, K. J., & Witcraft, S. M. (2023). Short-changing the future: The systemic gap between psychology internship stipends and living wages. Training and Education in Professional Psychology, No Pagination Specified-No Pagination Specified. https://doi.org/10.1037/tep0000449
Knowles, K. A., Cox, R. C., & Olatunji, B. O. (2023). Toward a Postdoctoral-Residency Training Model. Clinical Psychological Science, 21677026231156594. https://doi.org/10.1177/21677026231156594
Lee, K. C. (George). (2013). Training and educating international students in professional psychology: What graduate programs should know. Training and Education in Professional Psychology, 7(1), 61–69. https://doi.org/10.1037/a0031186
Morrow, W. R. (1946). The development of psychological internship training. Journal of Consulting Psychology, 10(4), 165–183. https://doi.org/10.1037/h0053807
Palitsky, R., Kaplan, D. M., Brodt, M. A., Anderson, M. R., Athey, A., Coffino, J. A., Egbert, A., Hallowell, E. S., Han, G. T., Hartmann, M.-A., Herbitter, C., Herrera Legon, M., Hughes, C. D., Jao, N. C., Kassel, M. T., Le, T.-A. P., Levin-Aspenson, H. F., López, G., Maroney, M. R., … Stevenson, B. (2022). Systemic Challenges in Internship Training for Health-Service Psychology: A Call to Action From Trainee Stakeholders. Clinical Psychological Science, 10(5), 819–845. https://doi.org/10.1177/21677026211072232
Silberbogen, A. K., Aosved, A. C., Cross, W. F., Cox, D. R., & Felleman, B. I. (2018). Postdoctoral training in health service psychology: Current perspectives in an evolving profession. Training and Education in Professional Psychology, 12(2), 66–73. https://doi.org/10.1037/tep0000182
Wilcox, M. M., Barbaro-Kukade, L., Pietrantonio, K. R., Franks, D. N., & Davis, B. L. (2021). It takes money to make money: Inequity in psychology graduate student borrowing and financial stressors. Training and Education in Professional Psychology, 15(1), 2–17. https://doi.org/10.1037/tep0000294