Building Better: Systemic Challenges in Health Service Psychology Internships and What to do About Them
Entry authored by: Roman Palitsky, Ph.D., Deanna Kaplan, Ph.D., Brittany Stevenson, Ph.D., Madeline Brodt, Ph.D.
Clinical internship is an essential part of training for clinical and counseling psychologists. The internship spans one year at the end of graduate training and is a requirement for most clinical and counseling psychologists to receive their PhDs. Internship has been part of the DNA for professional psychologists in the US for almost a century and, along with licensure exams, represents one of the few certain commonalities shared by clinical and counseling psychologists. It has also, unmistakably, been a dysfunctional link in the training pipeline for generations, held together with the spandrels and duct tape of quick fixes and short-term solutions. A system like this may appear to work for a time (although for many of us it surely didn’t), until an unexpected stressor strains the system and gaskets begin to burst.
The COVID-19 pandemic introduced profound challenges across all sectors of society; medical services and clinical training were particularly hard-hit. Amidst changes in the nature, capacity, risk, and security of clinical training, pre-existing problems in the training system were revealed through the challenges they wrought for current trainees and supervisors. The uncertain status of trainees, their lack of autonomy, their economically precarious conditions, and the setbacks they experienced in advocating for their health and wellbeing, could be traced back to long-unresolved dilemmas in clinical training. They also magnified the stratifying nature of these challenges, putting the most burden on the least socially, culturally, and economically resourced trainees. During a time of turmoil and what has been called a “double pandemic” of COVID-19 and violence against people belonging to racially minoritized groups, it became clear to many interns that this is a system that tacitly condones — and sometimes encourages — inequity.
In the first year of the pandemic, as we tried to make sense of the changes to our training and find a coherent way of responding, a group of us health service psychology trainees began working on a paper examining the underlying causes to the frailty and inequity of the training system. This process culminated in an analysis and call to action, which is now a part of a cascade of recent calls [1–5] that we hope will ignite dialogue and–crucially–change in our training systems. We identified a list of 10 major challenges, 21 recommendations to address these challenges, and a set of 22 questions for collaborative inquiry that training programs and interns can jointly undertake to proactively assess where they could make necessary changes. In this work, we observed that trainee voices have been historically left out of discourse about training, especially with regard to the crucial period of the internship. In contrast, we advocate for a trainee-stakeholder model focused on making training more collaborative–all the more critical, we felt, due to the brief one-year tenure of trainees.
Rather than summarize our paper, we hope that this blog post can be an opportunity to address two recurrent themes we have received among responses to it. The first often takes the form of a query: how applicable are our recommendations and suggestions to improving diversity and equity in clinical training? The second theme of response concerns identification of “culprits” (e.g., specific programs or training policies, problematic supervisors, or–in general–“bad apples” in training).
Understanding that Systemic Challenges in Health Service Psychology are Fundamentally about Inequity
The first theme strikes at a vital training issue in the science of clinical psychology: It is all too common for equity to be treated as a separate, “bonus” topic of research, policy, or clinical practice, in a way that can silo it from other concerns, or even flag it as a tertiary issue. Although our paper addresses trainee diversity in a targeted way in a section titled “The Need to Support a Diverse Body of HSP Trainees,” it is crucial for the field to begin recognizing that these problems are coextensive. An equitable training and professional landscape is also an evidence-based and clinically effective profession, which is also an economically and structurally sustainable field.
Part of the challenge to recognizing that DEI concerns are inherently woven through the structural challenges in HSP training is an implicit, normative regard for internship as a necessary and often difficult “investment” on the part of the trainee. We observe in our paper that at present, grounding assumptions of the clinical internship follow what Paulo Freire called a “banking model” of education [6], “where training sites are assumed to provide knowledge–a type of capital–to trainees who are without it. This assumption underlies the representation of economic sacrifices of training as ‘an investment,’ without due attention to the differences in resources that people can invest” (Palitsky et al., 2022 p. 18). When viewed this way, internship is supposed to be hard, separate wheat from chaff, and function as a rite of passage. Under this guise, the inequities of traineeship can be glossed over as part of its regrettable but necessary difficulty, an externality of training.
In contrast, treating the systemic challenges in training as fundamental issues of diversity, equity, and inclusion paves the way for empirically rigorous and clinically effective health service psychology. All of our recommendations, including shifting the focus of training toward competency (vs. amassing clinical hours), ensuring accessibility across disability status, locale, and economic circumstances through appropriate use of technology, and ensuring that interns are not in economic precarity, are intended to make training more equitable and to maintain its focus on training effective clinicians.
From Bobbing for Apples to Building Better Barrels
An unanticipated response to our article — which aimed to focus on broad systemic issues — was an interest in specific “bad apples”. Several of us have received hushed inquiries about who the “culprit” programs are, as well as indignant responses from programs that did not wish to be implicated in the challenges we described. These two responses are related because they assume responsibility can be localized in single entities and can miss the focus on systemic challenges and–relatedly–shared complicity. We suggest that seeking out “bad apples” overlooks the fundamental problem — the construction of the apple barrel itself. Seeking out culprits can prevent, or even undermine, necessary systemic change through attempts to alleviate one’s own sense of responsibility for change in the system we inhabit.
Accumulating evidence suggests that when it comes to workplace, educational, and ethics challenges, “bad apples” may be less likely to spoil the barrel than the other way around [7,8]. Indeed, even in the case of bad apples, paradoxically building a better barrel may be the most effective recourse at the end of the day [9,10]. Instead of externalizing the problems highlighted in our paper, we encourage programs to look critically for the influence of our systematically flawed barrel–inherited practices and attitudes that implicitly support inequity.
When half of interns did not match to a training site in 2007 a massive self-examination and overhaul was conducted — one which was effective in addressing the match crisis [11,12]. As we wrote in our paper, it is high time for our field to engage in another self-study about the health service psychology internship as we all grapple with the larger questions of how effective HSP psychology treatment is and, inseparably, for whom it is effective.
We include a link to our paper here (the free pre-print can also be found here), which contains a list of HSP training challenges as well as the questions for collaborative inquiry. We are also hopeful that anyone reading this post who would like to join the developing dialogues on internship training will reach out to us. Our work in this area is ongoing and will be improved by additional voices and stakeholders. Please email us if you would like to be involved[i].
We leave four of the 22 questions for collaborative inquiry provided in our article here. These may represent a beginning-place for some discussions about inclusion, equity, and diversity of interns.
● What opportunities exist for trainees from underprivileged backgrounds to voice concerns about inequities in a way that is heard and responded to by the training program?
● In what ways does the training program model a commitment to equity, beyond statements and advertisement? What concrete actions are being taken to increase equity in the program?
What are the barriers to including interns as collaborators in making decisions that have impacts on training or clinical care?
● How does the internship ensure that it is receiving and integrating feedback from interns about topics that matter for interns?
[i] Please contact the corresponding author of Palitsky et al., 2022 if you would have additional questions or want to be involved in the dialogue/actions towards creating change: roman_palitsky@brown.edu
References
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