for the Study of
Healthcare Organizations & Transactions
Clinical Psychology Internships
Note. In order to practice professionally, clinical psychologists must complete an internship in a clinical setting; most clinical psychology programs require that their core faculty have completed internships as well. The most prestigious of these internships are those accredited by the American Psychological Association. However, the number of graduate students receiving clinical training is increasing at a greater rate than the number of APA-accredited internship slots. Click on Figure 1 to see a graphic that illustrates this point.
The following paper was presented at the Mini-Convention, "Training Psychologists for the 21st Century", held during the annual meeting of the American Psychological Association, San Francisco, August 1998. Comprehensive coverage of training issues in clinical psychology is provided by Barlow, Hayes, & Nelson (1984), Edelstein & Brasted (1991), Rough (1994), and Hayes, Follette, Dawes, & Grady (1994). Click on References to obtain the full citations.
The Living Material of the Field
F. Kihlstrom and Lucy Canter Kihlstrom
University of California, Berkeley and
Institute for the Study of Healthcare Organizations & Transactions
Clinical training, and indeed all professional training in psychology, stands on three legs: (1) general psychology; (2) clinical science; and (3) fieldwork with real patients in real clinical settings, exposing the student to what Julius Wishner often called "the living material of the field". A fourth leg, necessary for those who wish to pursue scholarly careers in clinical psychology, is the doctoral dissertation.
Instruction in general psychology and clinical science is critical to clinical training, regardless of whether that training proceeds according to the Boulder model or some alternative, whether it is conducted in universities or free-standing professional schools, and whether it culminates in the PhD or the PsyD -- or, for that matter, a terminal master's degree. This is because the professional status of clinical psychology, including its independence from psychiatry and its claim to third-party payments for services rendered, derives from the assumption that its practices are firmly based on scientifically validated principles and techniques. So long as clinical psychology wishes to retain its identity, autonomy, and status as a profession, scientific training is critical, and there can be no conflict between science and practice (Kihlstrom & Canter Kihlstrom, 1998).
Traditionally, the scientific foundation of professional practice includes study of the biological, cognitive-affective, social, and individual bases of behavior. Clinical science includes specialized coursework in descriptive and experimental psychopathology, methods of assessment, and modes of intervention.
The official list of foundational courses, provided in the APA Accreditation Procedures and Criteria, includes nine subject areas: (1) scientific and professional ethics and standards; (2) research design and methodology; (3) statistics; (4) psychological measurement; (5) history and systems of psychology; (6) biological bases of behavior; (7) cognitive-affective bases of behavior; (8) social bases of behavior; and (9) individual bases of behavior. This may seem like a lot of basic science, but these days one wonders whether it is enough. For example, why do we combine the cognitive and affective bases of behavior? Both areas of research are highly developed, so why not require specialized coursework in each of them? And what happened to motivation? Given our increasing knowledge of psychobiology, do future practitioners need training in genetics and endocrinology as well as in neuroscience? As far as the social bases of behavior are concerned, cultural psychology and organizational behavior might well be added to traditional social psychology. And the individual bases of behavior could easily be expanded to encompass separate courses in cognitive and social development as well as in traditional personality research and theory.
Similar considerations apply to didactic clinical training. If clinical psychology is successful in its pursuit of prescription privileges, physiology and pharmacology will have to be added to the current mix. In medical settings, clinicians find increasing employment opportunities outside traditional departments of psychiatry, in pediatrics, internal medicine, and cancer centers, for example, so training in health psychology in order. Clinical work takes place in an increasingly complicated environment of class and culture, and practitioners work in an increasingly wide variety of organizations, so perhaps we should add some sociology and anthropology. And in the emerging environment of managed care, clinical practitioners must learn to document the validity of assessments and the outcomes of interventions, take account of the costs as well as the benefits of their treatments, and especially attend to issues of quality of care that go beyond symptom relief or client satisfaction. Clinical psychologists (and other psychologists as well, for that matter) must be trained to appreciate and participate in the rapidly developing interdisciplinary field of mental health services research (Canter Kihlstrom, 1998).
No matter how you look at the first two legs of clinical training, there is an awful lot of basic knowledge for the budding practitioner to acquire, and so it is not too surprising that, in both David Shakow's (1938) original proposal, as well as in the Boulder model of the scientist practitioner established in 1949, the fieldwork component of clinical training was largely put off to the internship. But clearly, exposure to the living material of the field cannot wait for the internship: future interns must first be prepared by practicum experiences which allow them to "form an early identification with their profession" (APA, 1980, p. 5). Moreover, clinical students need early practicum experiences so that they can connect what they see in the clinic to what they hear in the classroom, read in the library, and do in the laboratory. Accordingly, it is important that practicum experiences be carefully organized so that the practitioners and practice settings with whom the student comes into contact embody the scientific values which undergird the student's didactic training. Ideally, these practica would be offered by the tenure-track program faculty themselves, supplemented by adjuncts recruited from the community. In any event, every practicum supervisor should share the commitment to scientific values embodied in the program's didactic training. Clinical practice cannot remain on its scientific base if science and practice are dissociated as soon as the student walks out the classroom door and into the real world of service delivery.
One purpose of clinical practica is to prepare the student for the intensive experience of the full-fledged clinical internship. Here we encounter serious problems, because the internship itself is currently undergoing radical change. The original purpose of the internship was purely educational. Clinical psychology interns were seen as trainees, not service providers in their own right. However, for a variety of reasons clinical interns are now often required to generate revenue as well as receive training.
If interns cannot generate revenue for the organization, the number of internships available may be reduced, or the internship program may be eliminated entirely. This trend, coupled with increasing numbers of students in clinical training, has created intense pressure on internship sites. For example, data provided by the Association of Professional Psychology Internship Centers (APPIC) indicates that, from 1986 to 1997, the number of applicants unplaced three weeks afterUniform Notification Day increased more than 700%, from 65 to 469 (see the figure below). Of the unplaced applicants in 1997, 85% were from APA-accredited programs. At the same time, the number of internship vacancies decreased by more than 50%, from 79 to 34; and most of the vacant slots available in 1997 were from sites which did not have APA accreditation.
Put another way: in 1986, there was a vacant internship slot for every unplaced applicant from an APA-approved program. In 1997, 99% of unplaced applicants from APA-accredited programs were turned away from APA-accredited internships. Presumably these disappointed applicants renewed their efforts the following year, thus increasing the pressure on internship sites, and creating a kind of snowball effect from one year to the next. No wonder APPIC discontinued reporting this data in 1998!
The changing economy of mental health has meant that interns must be fairly thoroughly trained before they go on internship, so that they will be able to provide reimbursable services with a minimum of costly supervision. It also means that they will have little opportunity, while on their internship, to engage in clinical research as opposed to clinical practice. Research activities, after all, are not reimbursable. This situation exacerbates the science-practice split, because it implies that research is not a normal part of clinical activity. Furthermore, it threatens to severely distort pre-internship training: if the time to degree is to remain the equivalent of four or five years of full-time study, then any increase in practical training in preparation for the internship must come at the expense of didactic training in general psychology.
For their part, students respond to both the crisis in internship placement and the changing nature of the internship by attempting to make themselves more competitive by acquiring clinical skills and experience at the expense of their training in general psychology. Frankly, the internship centers do not help this situation much. Consider the uniform internship application form generated by APPIC, which asks the applicant to indicate how many hours, with how many individuals, he or she has spent providing individual and group therapy to a wide variety of cultural groups (African-American, Asian-American, disabled, gay/lesbian/bisexual, Latino and Hispanic, Native American, as well as whites) to a wide variety of age groups (adults, adolescents, school-age children, preschoolers, and infants and toddlers) in each of a variety of settings (including community mental health centers, inpatient and outpatient hospital units, university counseling centers, and departmental clinics). Then they are asked how many times they have administered, scored, and reported on, excluding "practice administration", 47 different psychological tests for adults and 78 different tests for children and adolescents. APPIC's intention here is just to gather information, but students will read the form quite differently: they will figure that the more of these things they have done, and the more often they have done them, the more attractive they will be to internship settings. And so they will spend precious predoctoral time acquiring these experiences -- again, and necessarily, at the expense of training in basic science -- never mind their dissertation (and predissertation) research.
In view of these trends, it has recently been proposed that the internship be made a postdoctoral, rather than a predoctoral, experience. But this idea is simply an abdication of responsibility on the part of the clinical training programs. Under such a system, they will be able to admit large numbers of doctoral students without regard to market forces, and four years later turn them loose with their doctoral degrees to sink or swim in the world of practice. And again, this proposal seems to assume that students should enter into their internships already fully trained and ready to provide reimbursable services -- thus eliminating the original training function of the internship, further reducing the amount of pre-internship time devoted to training in general psychological science, and further exacerbating the dissociation between science and practice.
An alternative proposal is that the internship experience be made a responsibility of each individual clinical training program. Under this scheme, each clinical training program would mount its own "in-house" or "captive" internship. The internship might be located in a medical school, hospital, or other appropriate clinic, but it would be organized by the clinical program itself, in accordance with its own training goals, and it would have enough slots to accommodate all of its own students. All students in good standing would be automatically guaranteed a slot in their own program's internship. There would be no internship applications, no competitive piling of client upon client and test upon test, no Uniform Notification Day, no vacancies, and no disappointed, unplaced applicants clogging the pipeline the next year. The internship might even include substantive exposure to clinical research as well as clinical practice; or interns might get some released time to work on their dissertations. Financial arrangements for interns would be in the hands of their home departments, not the internship centers, so there would be no pressure to divert their time and energy from training to service. Depending on local circumstances, interns might be able to receive tuition waivers and stipends from fellowships and assistantships. Or perhaps, like other professionals in training, they might be asked to support themselves for this part of their education. The internship, then, would be coequal to the dissertation as a capstone to the student's doctoral work.
In clinical psychology's original vision of the practicum and the internship, "the living material of the field" was defined largely in terms of patients, illnesses, and problems in living. They were opportunities for students to match textbook descriptions of symptoms and syndromes with the kinds of individuals encountered in actual practice, and abstract accounts of therapy with what is actually done. They were opportunities to hone skills at interviewing and testing people, and at treating and preventing mental illness and other problems in living. But it is now clear that the living material of the field goes far beyond individual practitioners and clients, and encompasses the field itself. In 1949 there were physicians, psychologists, and social workers, patients and their families, hospitals, clinics, and private practices. But the environment for modern clinical practice is much more complex, and like clients and practitioners, it is dynamically alive.
The health care environment is made up of organizations, clinical practitioners, clients, and payers. Each segment has developed a new language that appears to be a complicated and confusing "alphabet soup" (Tables 2 and 3). As an illustration, consider some of the organizational types that have evolved just within the last two decades (culled from Kongstvedt, 1996). There are, for example, more than a half-dozen different types of health maintenance organization! In the group model, the HMO contracts with a practice group for the provision of services, while in the staff model, the HMO employs providers directly. Both forms involve a closed panel of providers, whereas with direct contract HMOs, and independent practice associations, the organization contracts directly with private practitioners or with an association representing individual providers in the community. Not only are there HMOs, but there are also SHMOs, which provide social as well as medical services. And there are "carve out firms", which contract to provide particular benefits, such as mental-health or substance-abuse services, separate from the basic health plan (Canter Kihlstrom, 1997, 1998).
Payers and practitioners have acronyms and jargon terms of their own (Kongstvedt, 1996). There's a big difference, for example, between capitation, and risk contracting, between the adjusted community rate and the average payment rate. In this environment, "TAT" refers to Turn Around Time. There are lots of other examples. The point is that the mental-health care environment is exceedingly complicated, and getting more so. Students preparing for careers in practice need to learn about it, as well as about the forms of mental illness, techniques of assessment, and modes of treatment.
The mental-health care
environment is increasingly complicated, but it is also increasingly focused on
questions of value -- questions which are asked by organizations, payers and
clients alike. But what is it that we mean by value? If we consider a simple
definition such as: worth in usefulness or a fair price or return for goods or
services, we begin to get a vague idea about its meaning. However, consider a
rather concrete example. Some of us who live in California became acutely aware
of the weather phenomenon, El Nino. Now suppose that you lived here and
experienced roof damage this past winter. You seek out a roofing contractor who
tells you the following:
I can help you repair the damage for X dollars and your homeowner's insurance will most likely cover the cost of the repair. However, I'm not sure if the process and materials that I'm about to use will actually repair your roof because they haven't been tested, and I haven't kept a record of what happened to past jobs I've done. Also, it may take awhile to repair this damage but I can't tell you how long it will take. And, finally, I can't tell you how long this repair work will hold. You may need to call me again for another repair, and if you do I'll fix it again under exactly the same terms.Now, maybe the definition of value is vague but I think that we would all agree that our hypothetical contractor's services do not represent value; and if our insurance company is willing to pay for his services the first time, it is unlikely to be willing to do so a second time.
We suggest that all too often the words of our hypothetical contractor represent the state of mental health services. We're not exactly sure what process works under which circumstances. Too often the length of the service is indeterminate and finally too often we don't know if our services will "fix" the problem.
Value will be the key as we move into the 21st century, and it will be increasingly incumbent on clinicians to demonstrate that what they do has value. A good place to start is with additions and changes to the curriculum of clinical training programs. First, we need to provide training about the environment and the organizations in which our clinical students will be based. For example, what is an "Integrated Delivery System" and what does it mean for the way in which clinicians must practice. We then need to provide some basic training in mental health economics and insurance. For example, what is adverse selection and how might it, if present, harm clinical practice? Or, what exactly is the difference between experience rating and community rating? The purpose is not to turn our clinical students into mini economists or actuaries; the purpose would be solely to give our students a level playing field from which they can practice. In so doing, we must ensure that the presentation of any of this material be done by individuals who are sympathetic with the clinical enterprise, and who will go beyond costs to consider access, quality, outcomes, and value. Otherwise, out efforts will not achieve the desired end.
In addition to the environment and the organizations in it, in the coming years, our clinical students will need to understand more about how to evaluate the outcomes and costs of the interventions and techniques that they use (Sederer & Dickey, 1996). Assessing treatment outcomes effectively involves understanding risk-adjustment, identifying the parameters of The Treatment, e.g., the nature, duration, and intensity of the treatment intervention, including the context or setting in which treatment is delivered, and designing a set of measurable outcome variables.
Considering the costs of treatment has been repugnant to many clinical practitioners who seem to fear that cost cutting rather than quality of care is the overriding feature of today's health care world. It is good to remember at this point the piece of the definition of value that emphasizes fair price for a service. The cost of a service is an integral part of the value that clients, payers, and employers will look for.
The technique of cost-effectiveness analysis provides estimates of outcomes and costs and demonstrates the tradeoffs involved in choosing among interventions or variants of an intervention (Gold, Siegel, Russell, & Weinstein, 1996). Conducting a cost-effectiveness analysis can be daunting as it requires identifying and measuring all relevant costs, measuring multiple outcomes, and factoring in time, e.g., how long must a study continue before we can be confident of the assessment of the result. But it can be done, and our students must learn how to do it.
In the past, when clinical
students went on their practica and internships, they've always been expected to
know the difference between schizophrenia and agoraphobia, and between the WAIS
and the MMPI. But anyone who wishes to practice in today's health care
environment needs more than a passing knowledge of that environment. Clinical
curricula need to be expanded so that they teach our students about the
health-care environment itself, not just the patients in it and the disorders
they present, the practitioners and what they do. We must also teach our
students how to conduct well-designed outcomes studies that balance costs and
quality of care, by carefully monitoring what treatment or intervention works
under which circumstances and not merely by reducing the amount of care or the
costs of treatment. If clinical practice is to survive and thrive in the 21st
century, the clinical curriculum, including practicum and internship
experiences, must be altered to incorporate this expanded vision of the living
material of the field.
American Psychological Association. (1980). Accreditation handbook. Washington, D.C.: American Psychological Association.Association of Professional Psychology Internship Centers. (1997, February 28). APPIC Clearinghouse data from 1986-1997.
Barlow, D.H., Hayes, S.C., & Nelson, R.O. (1984). The scientist practitioner: Research and accountability in clinical and educational settings. Boston: Allyn & Bacon.Canter Kihlstrom, L. (1997). Characteristics and growth of managed behavioral health care firms. Health Affairs, 16, 127-130.
Canter Kihlstrom, L. (1998). Managed behavioral health care: A case for institutional theory? In J.J. Kronenfeld (Ed.), Changing organizational forms of delivering health care: The impact of managed care and other changes on patients and providers. Research in the sociology of health care (Vol. 15), pp 35-55). Westport, Ct.: JAI Press. (a)
Canter Kihlstrom, L. (1998). Mental health services research. In H. Friedman (Ed.), Encyclopedia of mental health (Vol. 2, pp. 653-663). San Diego, Ca.: Academic. (b)
Edelstein, B.A., & Brasted, W.S. (1991). Clinical training. In M. Hersen, A.E. Kazdin, & A.S. Bellack (Eds.), The clinical psychology handbook, 2nd ed. (pp. 45-65). New York: Pergamon.Gold, M.R., Siegel, J.E.,Russell, L.B., & Weinstein, M.C. (1996). Cost-effectiveness in health and medicine. New York: Oxford University Press.
Hayes, S.C., Follette, V.M., Dawes, R.M., & Grady, K.E. (1995). Scientific standards of psychological practice: Issues and recommendations. Reno, Nv.: Context.
Kihlstrom, J.F., & Canter Kihlstrom, L. (1998). Integrating science and practice in an environment of managed care. In D.K. Routh & R.J. DeRubeis (Eds.), The science of clinical psychology: Accomplishments and future directions (pp. 281-293). Washington, D.C.: American Psychological Association.
Kongstvedt, P.R. (Ed.). (1996). The managed health care handbook, 3rd. ed. Gaithersburg, Md.: Aspen.
Routh, D.K. (1994). Clinical psychology since 1917: Science, practice, and organization. New York: Plenum.
Sederer, L.I., & Dickey, B. (1996). Outcomes assessment in clinical practice. Baltimore, Md.: Williams & Wilkins.Shakow, D. (1938). An internship year for psychologists (with special reference to psychiatric hospitals). Journal of Consulting Psychology, 2, 73-76.
John F. Kihlstrom, PhD and Lucy Canter Kihlstrom, PhD
Copyright © 2000 Institute for the Study of Healthcare Organizations & Transactions
Last modified: 04.08.2010 02:58 PM