Short-changing the future: The systemic gap between psychology internship stipends and living wages

Caitlyn O Hood; Melissa R Schick; Shannon E Cusack; Margaret C Fahey; Sarah T Giff; Erin T Guty; Natalie Hellman; Lauren M Henry; Kent Hinkson; Erin E Long; Kelsey McCoy; Kelly O’Connor; Adaixa Padron Wilborn; Aaron Reuben; Enoch T Sackey; Emily L Tilstra-Ferrell; Kyle J Walters; Sara M Witcraft

doi:10.1037/tep0000449

. Author manuscript; available in PMC: 2025 Feb 1.

Published in final edited form as: Train Educ Prof Psychol. 2023 May 18;18(1):49–58. doi: 10.1037/tep0000449

Short-changing the future: The systemic gap between psychology internship stipends and living wages

Caitlyn O Hood ^a,^b,^*, Melissa R Schick ^a,^c,^*, Shannon E Cusack ^a,^d, Margaret C Fahey ^a, Sarah T Giff ^a,^e, Erin T Guty ^a,^f, Natalie Hellman ^a,^g, Lauren M Henry ^a, Kent Hinkson ^a,^h, Erin E Long ^a,^I, Kelsey McCoy ^a,^j, Kelly O’Connor ^a,^k, Adaixa Padron Wilborn ^a, Aaron Reuben ^a,^l, Enoch T Sackey ^a, Emily L Tilstra-Ferrell ^a, Kyle J Walters ^a, Sara M Witcraft ^a

^aDepartment of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC

^bDepartment of Psychiatry; University of Kentucky, Lexington, KY

^cDivision of Prevention and Community Research, Yale School of Medicine, New Haven, CT

^dVirginia Institute of Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA

^eRalph H. Johnson Veterans Affairs Medical Center, Charleston, SC

^fMental Health Service, VA Maryland Health Care System, Baltimore, MD

^gEmory University School of Medicine, Atlanta, GA

^hSouth Central MIRECC, North Little Rock, AR

ⁱDepartment of Pediatrics, Division of Developmental and Behavioral Pediatrics, Medical University of South Carolina, Charleston, SC

^jCognitive Behavioral Consultants

^kDepartment of Surgery, Virginia Commonwealth University, Richmond, VA

^lPsychology & Neuroscience Department, Duke University, Durham, NC

^✉

Correspondence: Caitlyn Hood (caitlyn.hood@uky.edu) or Melissa Schick (melissa.schick@yale.edu)

Author contributions: Authors Hood and Schick contributed equally and share joint first-authorship. All remaining authors appear in alphabetical order; author order does not denote the level of contribution to the final published manuscript.

Caitlyn O. Hood, PhD, is an assistant professor in the Department of Psychiatry at the University of Kentucky. She received her doctorate in clinical psychology from the University of Kentucky and completed a clinical internship at the Medical University of South Carolina/Ralph H. Johnson VA Medical Center. Her research and professional interests focus on increasing access to mental health and substance use treatments for trauma-exposed populations by designing, testing, and scaling novel delivery models.

Melissa R Schick, PhD, is a postdoctoral fellow in the Division of Prevention and Community Research at Yale University. She received her doctorate in clinical psychology from the University of Rhode Island and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her program of research focuses on intra- and inter-individual processes underlying the etiology, course, maintenance, and treatment of substance use and substance-related health disparities in populations characterized by trauma.

Shannon E. Cusack, PhD, is a T32 Research Postdoctoral Fellow at the Virginia Institute of Psychiatric and Behavioral Genetics. She received her PhD in clinical psychology from Virginia Commonwealth University and completed a clinical internship at the Medical University of South Carolina/Ralph H. Johnson VA Medical Center. Her primary line of research is focused on applying statistical genetic techniques into deeply phenotyped samples to better understand trauma-related mental and physical health sequelae. Clinically, Dr. Cusack is passionate about using evidenced-based treatment to treat stress-related psychopathology.

Margaret C. Fahey, PhD, is a NIDA T32 postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina. She received her doctorate in clinical psychology at The University of Memphis and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research program focuses on the intersecting areas of tobacco use and cessation, digital health, and geriatric health. She is interested in reducing age-related health disparities and improving health across the lifespan by implementing age-inclusive technology-based behavioral health interventions for substance use disorders in older age.

Sarah T. Giff, PhD, is a Mental Illness Research and Training (MIRT) postdoctoral fellow with the Ralph H. Johnson VA Medical Center and the Medical University of South Carolina. She received her doctorate in clinical psychology from George Mason University and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research and professional interests include the interpersonal impacts of traumatic stress, particularly within family systems, Veterans and military families, and emotion regulation.

Erin T. Guty, PhD, is a postdoctoral fellow in Clinical Neuropsychology at the VA Maryland Health Care System. She received her doctorate from the Pennsylvania State University and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research and professional interests include translational neuropsychology and psychiatric sequelae of neurological conditions.

Natalie Hellman, PhD, is a postdoctoral Fellow at Emory University. She received her doctorate from the University of Tulsa and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research and professional interests include exploring the psychobiological impact of trauma exposure, with a focus on the etiology and treatment of chronic pain.

Lauren Henry, PhD, is a post-doctoral Intramural Research Training Award (IRTA) fellow with the Neuroscience and Novel Therapeutics Unit (NNT) in the Emotion and Development Branch at the National Institute of Mental Health. She received her MS in psychology and PhD in clinical psychology with a minor in quantitative sciences from Vanderbilt University. She completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Dr. Henry is interested in contributing to the prevention of psychopathology in children and adolescents. Her research focuses on leveraging technology (e.g., ecological momentary assessment, digital phenotyping) to: (1) investigate neural and behavioral mechanisms of risk for psychopathology and (2) develop, evaluate, and implement neuroscience-informed preventive interventions for internalizing and externalizing psychopathology to improve public health.

Kent D. Hinkson Jr., PhD, is a postdoctoral fellow at the Little Rock VA in the MIRECC program, and an instructor at the University of Arkansas Medical Sciences. He received his doctorate at the University of Utah and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. His research and professional interests include the prediction of suicidal behaviors, as well as the mechanisms of treatment for trauma-related sequelae including PTSD, depression, and suicidal ideation/behaviors.

Erin E. Long, Ph.D., is a postdoctoral fellow in the Division of Developmental and Behavioral Pediatrics at the Medical University of South Carolina. She received her doctorate in clinical-community psychology from the University of Illinois at Urbana-Champaign and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research and clinical interests include the assessment and treatment of internalizing disorders in children and adolescents on the autism spectrum.

Kelsey McCoy, PhD, is a postdoctoral fellow at Cognitive & Behavioral Consultants. She received her doctoral degree in Clinical Psychology from the University of Nebraska-Lincoln and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research interests are focused on identifying contextual, organizational, and systems-level factors that contribute to the successful delivery of evidence-based practices within community- and school-based settings.

Kelly O'Connor, PhD, is Postdoctoral Fellow in the Department of Surgery at Virginia Commonwealth University within the Injury and Violence Prevention Program. She received her PhD in clinical psychology from Virginia Commonwealth University and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research and clinical interests focus on preventing violence and enhancing resilience among adolescents living in urban, economically disadvantaged communities. Her program of research aims to inform strengths-based programs, policies, and practices that mitigate adolescents' risk for violence exposure and bolster positive youth development.

Adaixa Padron Wilborn, PhD, is a post-doctoral fellow within the Rehabilitation and Health Psychology Program at Tampa General Hospital. She received her doctoral degree in Psychology with a specialization in Clinical Health from the University of Florida; she went on to complete clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center with a specialization in Health Psychology. Dr. Wilborn’s research primarily focuses on biopsychosocial factors affecting cancer outcomes, particularly as it pertains to the utilization of salivary biomarkers to (1) expand current understanding of multidirectional associations among psychosocial stress, neuro-immune functioning, inflammatory processes, circadian rhythms, and tumor initiation/progression and (2) improve cancer screening methodologies, treatment outcomes, and disease-free survivorship.

Aaron Reuben, PhD, is a US-National Institutes of Health-funded Postdoctoral Scholar in neuropsychology and environmental health at Duke University and the Medical University of South Carolina. He investigates social determinants of healthy brain development and aging, focusing on modifiable environmental factors, including air quality, water quality, natural amenities, and diverse aspects of the built environment. He holds a PhD in clinical psychology from Duke University and a Masters in Environmental Management from Yale University. He is a former study coordinator for Columbia University's Taub Institute for Research on Alzheimer's Disease and the Aging Brain, an environmental policy researcher at the Yale Center for Environmental Law & Policy, a presidential policy intern at the White House Council on Environmental Quality, and a communications officers for the International Union for Conservation of Nature. He holds the Richard Merritt Jr. Memorial Award for Excellence in Science Journalism and is a current nominee for the Cozzarelli Prize of the Proceedings of the US National Academy of Sciences.

Enoch T. Sackey, PhD, is a postdoctoral scholar at the University of Washington, Seattle. He received his doctorate from University of Mississippi and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. His research interests include understanding social determinants of health and how to effectively support community settings in integrating evidence-based practices into care, including measuring and evaluating if the practices help their clients in the long term.

Emily Tilstra-Ferrell, PhD, is postdoctoral fellow at the National Crime Victims Research and Treatment Center within the Medical University of South Carolina. She received her doctorate from Bowling Green State University and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research and professional interests include the etiology and treatment of co-occurring PTSD and eating disorders, addressing barriers to evidence-based trauma treatment, and early interventions for traumatic stress.

Kyle J. Walters, PhD, is a NIAAA T32 postdoctoral fellow at the Medical University of South Carolina. He received his doctorate from the University of South Dakota and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. His research focuses on substance use, emotion dynamics, and self-regulation.

Sara M. Witcraft, PhD, is a postdoctoral scholar in the College of Nursing at the Medical University of South Carolina. She received her doctorate in clinical psychology at the University of Mississippi and completed a clinical internship at the Medical University of South Carolina/Ralph H Johnson VA Medical Center. Her research focuses on identifying transdiagnostic mechanisms (e.g., insomnia, emotion dysregulation) conferring risk for substance use disorders and comorbid diagnoses and leveraging these risk factors to improve functional outcomes of high-risk substance-using populations (e.g., pregnant and postpartum women, anxiety disorders).

PMCID: PMC10923383 NIHMSID: NIHMS1893886 PMID: 38464500

Abstract

Introduction:

Providing doctoral internship stipends below living wages may harm interns, the clinical services they provide, and the field of health service psychology as a whole. This study evaluated the extent to which doctoral psychology internship stipends from the 2021-2022 training year for APA-accredited, APPIC-member programs in the US are consistent with living wages in the geographic region where sites are located.

Methods:

We obtained data reflecting internship sites’ geographic location and stipends for the 2021-2022 academic year. Using the Massachusetts Institute of Technology Living Wage Calculator, we computed a living wage for the county in which each internship site is located. Descriptive statistics, discrepancies, ratios, and correlations were calculated to reflect the associations between internship sites’ stipends and their local living wages.

Results:

The average internship stipend was $31,783, which was lower than the average living wage by $2,091. Stipends ranged widely, from a low of $15,000 to a high of $94,595–reflecting a six-fold difference in wages. Although internship sites in higher cost of living areas paid higher stipends, over two-thirds (67.0%) of sites did not pay a stipend that equaled or exceeded a living wage. Ninety-eight sites (15.3%) had deficits of over $10,000 when comparing their stipends to local living wages, with $33,240 as the highest deficit.

Discussion:

Eliminating obstacles to educating health service psychologists by decreasing the financial burden of training will likely have subsequent critical benefits towards bridging the workforce gap between mental healthcare service needs and available providers, ultimately leading to improved population health.

Keywords: doctoral psychology internship, stipend, living wage, financial stress, health service psychology training

Workforce projections highlight an insufficient supply of healthcare providers to address the national mental health crisis in the United States (US; Center for Workforce Studies, 2018; The White House, Office of the Press Secretary 2022). Approximately 151 million Americans—45% of the population—live in an area with a shortage of mental health professionals (Health Resources & Services Administration [HRSA], 2022). The provider shortage is particularly detrimental to communities of color, as individuals from minoritized racial and ethnic backgrounds experience inadequate access to culturally responsive mental health services (Substance Abuse and Mental Health Services Administration, n.d.). There is a dire need to build and retain a larger, more diverse workforce of health service psychologists (e.g., clinical, counseling, and school psychologists) to meet the nation’s mental healthcare needs (Berenbaum et al., 2021). Our field must eliminate obstacles unrelated to capability for individuals interested in pursuing doctoral degrees in health service psychology.

The financial ramifications of pursuing graduate training in health service psychology represent one possible barrier to increasing the number of mental healthcare professionals. Graduate trainees in psychology incur a high student loan debt burden, which disproportionately affects trainees of color and those from low-income households (Wilcox et al., 2021). Yet, psychologists’ average starting salaries are relatively low compared to debt accrued. For example, a survey of early career professionals in health service psychology found the average total debt from graduate training was $102,807 while average starting salaries equaled $63,253 (Doran et al., 2016a). The debt-to-income ratio for early career health service psychologists exceeds the rate at which loan repayment is considered a financial hardship (Lee, Kim, & Hong, 2018). Moreover, the impact of student loan debt extends beyond high monthly payments; emerging and early career psychologists report delaying major life milestones (e.g., getting married, having children, buying a house, building savings) due to debt burden (Doran et al., 2016b). Over the past two decades, the number of graduates with doctorates in psychology who entered industry positions increased (Christidis et al., 2020). The debt-to-income ratio may contribute to trainees opting out of traditional roles in health service psychology and seeking higher-paying jobs that may not include a clinical service component, as industry positions pay nearly two times more than academic postdoctoral and faculty positions (National Center for Science and Engineering Statistics [NCSES], 2021). Reducing barriers to educating psychologists by decreasing the financial burden of training will likely have subsequent critical benefits towards eliminating the gap between mental healthcare service needs and available providers, ultimately leading to improved population health.

The financial hardship experienced by health service psychologists with high student loan debt calls into question training requirements that may exacerbate economic strain, including doctoral internship (Gee et al., 2022; Palitsky et al., 2022). Internship is a year-long capstone training requirement for health service psychology doctoral students, in which trainees provide full-time supervised clinical services, typically at a site external to their graduate institutions. Internship is a stepping-stone to independent practice; it is typically completed after trainees finish at least 3-5 years of coursework and supervised clinical services but before they earn their doctorates. Depending on state licensure regulations, many health service psychology graduates are required to provide an additional year of post-doctoral supervised clinical services after completing internship and before they can apply for licensure. The American Psychological Association (APA) and the Association of Psychology Postdoctoral and Internship Center (APPIC)—the governing bodies that set standards for health service psychology internship programs in the US—require that sites pay interns a “fair and reasonable” stipend (APA, 2015a; APPIC, 2020). Both APPIC and APA use regional parity as the primary standard by which fair and reasonable stipends are evaluated (APA, 2015a; APPIC, 2020). Although regional parity emphasizes consistency in pay across sites in the same geographic region, it does not ensure that interns’ basic needs are met, nor does it take into consideration factors such as inflation, which is currently on the rise (Bureau of Labor Statistics, 2022). APPIC reported internship sites provided an average stipend of $31,100 for the 2020-2021 training year (APPIC, 2021), which is approximately $7,500 less than the estimated annual expenditures of single adults in the US (Bureau of Labor Statistics, 2020). Insufficient stipends may contribute to mental health difficulties and burnout among interns (Dijkstra-Kersten et al., 2015; Doran et al., 2016b; Sweet et al., 2013; Swords & Ellis, 2017; Victor et al., 2022), which may subsequently impact their ability to deliver quality clinical services (Simionato, Simpson, & Reid, 2019). This raises an important ethical question: are APPIC and APA’s current pay determination systems for compensating psychology interns adequate and equitable?

Instead of regional parity, an alternative strategy is to base stipends on the living wage for each internship site’s geographic location. A living wage, by definition, refers to the minimum income required for an individual to meet their basic needs, including food, housing, transportation, and clothing (Glasmeier, n.d.). A living wage exceeds the federal poverty threshold and allows individuals to avoid requiring subsidies from the government and other public entities. It does not include excess funds necessary for establishing personal savings, paying off accrued debt, or participating in social activities. It also does not guarantee economic security or good quality of life. A living wage represents a minimum income required to live.

Providing stipends below the living wage may be harmful to interns, the clinical services they provide, and the field of health service psychology as a whole. The purpose of the present study was to examine the extent to which doctoral psychology internship stipends from the 2021-2022 training year for APA-accredited, APPIC-member programs in the US are consistent with living wages in the geographic region in which sites are located.

Method

Procedures & Measures

Site and stipend data for the 2021-2022 intern year were requested from APPIC’s executive director. Data of interest for each site included the name and registration number, location (city, state), accreditation status, primary institution type (e.g., academic health center, community mental health center, etc.), and annual stipend. Table 1 summarizes the number of sites in each category of primary institution type and descriptive statistics on their stipends.

Table 1.

Descriptive Statistics for Internship Stipends by Institution Type

Institution Type	number of sites (%)	Stipend
Institution Type	number of sites (%)	Mean (SD)	Median	Minimum	Maximum
Academic Health Center	36 (5.6)	$30,809.48 ($5,519.58)	$30,000.00	$17,250.00	$47,752.80
Armed Forces Medical Center	9 (1.4)	$77,224.40 ($14,726.77)	$78,970.56	$54,176.00	$94,595.00
Child/Adolescent Psychiatric or Pediatrics	31 (4.9)	$32,084.79 ($5,274.84)	$31,003.00	$24,374.40	$47,000.00
Community Health Center	6 (0.9)	$30,181.17 ($2,539.87)	$29,560.00	$27,700.00	$34,715.00
Community Mental Health Center	70 (11.0)	$28,412.98 ($4,612.89)	$28,000.00	$20,000.00	$42,387.00
Consortia	46 (7.2)	$26,692.33 ($5,445.88)	$26,380.00	$18,000.00	$54,080.00
Medical School	36 (5.6)	$30,418.61 ($3,690.91)	$30,000.00	$24,843.00	$39,300.00
Other	16 (2.5)	$32,467.75 ($7,864.35)	$31,200.00	$20,000.00	$47,125.00
Prison or Other Correctional Facility	24 (3.8)	$49,738.50 ($10,403.12)	$54,274.00	$30,000.00	$63,052.00
Private General Hospital	21 (3.3)	$31,239.24 ($4,254.84)	$31,200.00	$24,960.00	$40,000.00
Private Outpatient Clinic	12 (1.9)	$28,309.33 ($7,543.63)	$27,000.00	$19,500.00	$47,132.00
Private Psychiatric Hospital	11 (1.7)	$32,837.55 ($5,226.56)	$31,200.00	$27,000.00	$45,760.00
Psychology Department	3 (0.5)	$26,000.00 ($3,605.55)	$25,000.00	$23,000.00	$30,000.00
School District	9 (1.4)	$29,994.44 ($12,018.02)	$28,000.00	$15,000.00	$59,000.00
State/County/Other Public Hospital	47 (7.4)	$33,227.62 ($7,068.51)	$32,304.00	$24,000.00	$49,392.00
University Counseling Center	148 (23.2)	$33,082.49 ($4,614.20)	$34,000.00	$22,500.00	$52,704.00
Veterans Affairs Medical Center	114 (18.0)	$27,560.68 ($1,606.63)	$26,735.00	$26,166.00	$32,079.00
Total	639 (100)	$31,783.46 ($8,820.38)	$30,000.00	$15,000.00	$94,595.00

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Note. All stipend information is reported in USD.

A living wage for each internship site was calculated using the Massachusetts Institute of Technology Living Wage Calculator (LWC; Glasmeier, 2020), generated at the county level, by multiplying the hourly rate by 2080 (40 hours per week x 52 weeks per year) to reflect the annual salary earned by a full-time employee. The LWC combines data from the Bureau of Labor Statistics, the US Department of Housing and Urban Development, and the National Association of Child Care Resources and Referral Agencies. Data are updated annually in the first quarter using available information through the end of the prior calendar year. In the present study, data were abstracted in January and February 2022 and reflected living wage estimates for 2020. Living wages were summarized for single adults without children since this is exemplary of most psychology interns (APPIC, 2021). Only sites located within the contiguous US, Alaska, and Hawaii were included in the present analyses since estimates of living wages for Puerto Rico and Canada are not included in the LWC.

Given that the procedures described herein are not human subjects research, approval from the university’s Institutional Review Board was not required to conduct this study.

Positionality

Recognizing that researchers’ backgrounds and positions influence the ways in which they interpret findings and the conclusions they draw (Malterud, 2001), the authors wish to acknowledge their viewpoint as 18 trainees who were enrolled in clinical psychology PhD programs and matched to a consortium for doctoral internship. Among the authors, 11 co-authors accrued debt throughout their undergraduate and/or graduate training. Several authors who did not accrue debt reported receiving financial support from a partner or family members. One co-author was not eligible for financial aid as an international student and was dependent solely on their graduate school stipend. Among the co-authors are individuals who identify as Black, Hispanic, Multiracial, women, neurodivergent, disabled, and chronically ill, who immigrated to the United States as children, for whom English is a second language, military veterans, and who are first-generation students. We recognize that our interpretations of these findings may differ from those of individuals who obtained degrees from other types of health service psychology graduate programs and who attended internship programs other than consortiums, as well as from other stakeholders (e.g., supervisors and training directors).

Data Analysis

Descriptive statistics were calculated for annual stipends and living wages for the counties where internship sites are located. Stipends were subtracted from living wages to reflect discrepancies (surpluses or deficits) in wages. Percentages were calculated to reflect the number of sites in each institute type that provide stipends above the living wage. Stipends were divided by living wage to compute ratios reflecting the extent to which stipends fell above or below the living wage for the county in which each site is located. Correlations were computed to summarize the association between stipends and living wages.

Results

All sites were APA-accredited (N = 639),¹ including sites that were on contingency (n = 22; 3.4%) or inactive (n = 1; 0.2%). Table 1 summarizes the descriptive statistics for stipends overall and by type of internship institution. Stipends ranged widely, from a low of $15,000 to a high of $94,595–reflecting a six-fold difference in wages (Mdn = $30,000). Psychology departments, consortia, and Veterans Affairs medical centers reported paying interns the lowest average stipends (n = 163, M = $27,286.90, SD = $3,222.27), whereas armed forces medical centers, state/county/other public hospitals, and prisons/other correctional facilities reported paying interns the highest average stipends (n = 80; M = $43,130.52, SD = $16,929.19).

Table 2 depicts the average living wages of the counties in which internship sites are located, specified by institute type. In total, 428 out of 639 (67.0%) psychology internship stipends fell below the living wage for the counties in which they are located. Ninety-eight sites (15.3%) had deficits of over −$10,000 when comparing their stipends to local living wages, with −$33,240 as the highest deficit. The average living wage across all internship site locations was $33,874, which is higher than the average internship stipend by $2,091. The mean stipends of only two institution types (out of 17) were at or above the average living wages for the counties in which they are located. Armed forces medical centers and prisons/other correctional facilities had a surplus (n = 33; M_Surplus = 23,429.61, SD = $17,038.79), whereas psychology departments, private general hospitals, and community mental health centers had the largest deficits between stipends and living wages (n = 94; M_Deficit = −$7,528.22, SD = 7,900.78). Figure 1 reflects internship stipends as percentages of living wages.

Table 2.

Comparisons Between Internship Stipends and Living Wages

Institution Type	LW M (SD)	Difference between Stipend and LW M (SD)	Stipend at or above LW n (%)	Correlation between Stipend and LW
Academic Health Center	$32,115.20 ($5,391.94)	−$1,305.72 ($6,903.46)	20 (55.6)	r = .20, p = .24
Armed Forces Medical Center	$35,480.18 ($7,539.08)	$41,744.22 ($16,641.28)	9 (100.0)	r = −.01, p = .97
Child/Adolescent Psychiatric or Pediatrics	$35,164.08 ($7,232.38)	−$3,079.29 ($9,178.67)	9 (29.0)	r = −.05, p = .77
Community Health Center	$35,824.53 ($8,752.91)	−$5,643.37 ($10,874.51)	3 (50.0)	r = −.79, p = .06
Community Mental Health Center	$36,009.55 ($8,110.14)	−$7,596.57 ($8,032.53)	9 (12.9)	r = .30, p = .01
Consortia	$31,843.90 ($5,544.78)	−$5,151.57 ($4,560.70)	4 (8.7)	r = .66, p < .001
Medical School	$34,195.20 ($6,022.90)	−$3,776.59 ($6,183.77)	12 (33.3)	r = .26, p = .12
Other	$36,272.60 ($6,285.97)	−$3,804.85 ($7,939.13)	3 (18.8)	r = .39, p = .14
Prison or Other Correctional Facility	$33,176.87 ($5,035.43)	$16,561.63 ($11,275.04)	23 (95.8)	r = .06, p = .78
Private General Hospital	$38,298.74 ($8,267.82)	−$7,059.50 ($7,934.06)	4 (19.0)	r = .33, p = .14
Private Outpatient Clinic	$34,593.87 ($5,371.45)	−$6,284.53 ($6,792.18)	3 (25.0)	r = .49, p = .11
Private Psychiatric Hospital	$33,856.73 ($6,436.16)	−$1,019.18 ($4,497.70)	5 (45.5)	r = .72, p = .01
Psychology Department	$35,214.40 ($9,091.96)	−$9,214.40 ($6,357.58)	0 (0.0)	r = .84, p = .36
School District	$34,276.09 ($5,450.83)	−$4,281.64 ($10,474.87)	3 (33.3)	r = .49, p = .18
State/County/Other Public Hospital	$34,812.69 ($5,971.34)	−$1,585.08 ($8,217.76)	17 (36.2)	r = .21, p = .15
University Counseling Center	$33,485.47 ($6,733.41)	−$402.98 ($8,084.39)	79 (53.4)	r = .02, p = .80
Veterans Affairs Medical Center	$32,231.24 ($5,932.40)	−$4,670.57 ($4,797.93)	8 (7.0)	r = .77, p < .001
Total	$33,874.78 ($6,647.94)	−$2,091.32 ($10,205.13)	211 (33.0)	r = .15, p < .001

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Note. LW = Living Wage.

Figure 1. — Psychology Internship Stipends as Percentages of Living Wages

Overall, there was a positive correlation between internship stipends and living wages. This association appears to be driven by consortia, community mental health centers, private psychiatric hospitals, and Veterans Affairs medical centers. In other words, for each of the aforementioned institution types, sites in higher cost of living areas provided higher stipends, resulting in the observed individual and overall positive correlations between stipend and living wage. However, each of these institution types also offered average stipends below the average living wages for their counties. Our findings suggest that even though sites in higher cost of living areas provide higher stipends, the stipends (on average) are below the local living wages needed for interns to meet basic needs.

Discussion

This paper examined the extent to which doctoral health service psychology internship stipends are consistent with living wages in the geographic region in which internship sites are located. Our findings suggest that although internship sites in higher cost of living areas paid higher stipends, over two-thirds of US internship sites did not pay a living wage in 2021-2022. In other words, the vast majority of doctoral interns had insufficient income during the last year of doctoral training to meet their basic needs. The large discrepancy between the lowest ($15,000) and highest ($94,595) internship stipends raises a question about whether regional parity is an adequate and equitable strategy for compensating interns. Although further exploration is needed to understand why this discrepancy exists, it may underscore the lack of parity between medical and mental health service coverage (King, 2019), as well as standards that do not allow unlicensed mental health trainees to bill for services (APA, 2022).

The training sites currently offering stipends consistent with their local living wage should be commended, and their strategies for funding higher stipends should be explored. Only two types of institutions, on average, offered stipends above their local living wages: armed forces medical centers and prisons or other correctional facilities. These institution types may provide higher stipends to attract candidates or to compensate for the additional requirements imposed on interns (e.g., commissioned military service). Alternatively, correctional facilities and armed forces medical centers may be more well-resourced than other institution types and may, therefore, be more readily able to afford to pay interns higher stipends. Additional work is needed to explore the reasons underlying these discrepancies to perhaps inform pathways for other sites to offer higher stipends to doctoral interns.

There are several reasons why the discrepancy between stipends and living wages may be harmful to interns. First, the discrepancy may place undue strain on interns related to securing their daily needs (e.g., having enough resources to find adequate housing or transportation) and can contribute to increased burnout (Dijkstra-Kersten et al., 2015; McCormack et al., 2018; Sweet et al., 2013; Victor et al., 2022). Burnout among psychologists is both an ethical and occupational problem, as it interferes both with their quality of life and with their ability to provide effective clinical services (Simionato et al., 2019). Even without considering the direct financial strain related to being paid lower than a living wage, the internship year is characterized by numerous challenges including working long hours, relocating twice in 12 months (often away from established support networks), defending dissertations, and securing post-internship employment (Palitsky et al., 2022; Tabur et al., 2022). Moreover, the debt incurred during internship may disproportionately affect trainees of color and those from low-income households (Wilcox et al., 2021). Addressing the economic strain interns face may alleviate one contributor to stress and burnout. Second, the stipend-living-wage discrepancy may contribute to interns opting out of traditional roles in health service psychology and seeking higher-paying jobs that may not include a clinical service component. Starting salaries for health service psychologists are generally insufficient to make up for the financial ramifications of graduate training and doctoral internship (Doran et al., 2016a; Lee et al., 2018), and industry positions pay nearly two times more than academic postdoctoral and faculty positions (NCSES, 2021). Eliminating the economic barriers to entry and retention in health service psychology training have the potential to increase our field’s chances of meeting the nation’s mental healthcare needs.

APPIC’s stipend requirement aims to strike a balance between maintaining the number of quality training programs (i.e., by not requiring such a high stipend that it would disincentivize sites to offer placements) and avoiding undue burden on trainees by adding to their debt load (APPIC, 2020). The drive to maintain the number of quality training programs is often emphasized as a priority in light of a historic—and continuing—discrepancy between the number of positions available and the number of applicants. For example, in 2013, there were only enough positions in APA-accredited internship programs for 56% of applicants (APPIC Board of Directors, 2013; Grus et al., 2011; Wells et al., 2014). There remains a shortage of accredited internship positions, as the number of registered applicants exceeded the number of accredited positions by 446 during the 2022 match cycle (APPIC Board of Directors, 2022). Nevertheless, if mandating an increase in interns’ stipends to meet or exceed a living wage disincentivizes internship sites from offering internship positions, significant changes to training policies in health service psychology are necessary, and alternative funding mechanisms must be explored.

Recommendations

Below we list recommendations for bringing internship stipends in line with living wages. We recognize that the solutions described herein are not a panacea for the complex problem of increasing psychology interns’ compensation. Rather, we hope our recommendations spark conversations amongst health service psychologists, and the field as a whole can work towards finding a sustainable solution ensuring interns can meet their basic needs.

Reform APA and APPIC Standards to base Stipends on Living Wages

First and foremost, we advocate for APA and APPIC to modify the criteria they use to evaluate sites for accreditation and membership, respectively, and eliminate regional parity in favor of providing interns with living wages. Regional parity appears to be a subjective metric by which stipends of sites in the same state are compared against each other (APA, 2015a; APPIC, 2020). In other words, stipends from sites in higher cost of living areas may be compared against and driven down by stipends from sites in lower cost of living areas. Moreover, it is unclear to what extent stipends of sites in the same state (or even in the same county) can deviate from one another while still being deemed “fair and reasonable” (APA, 2015a; APPIC, 2020). Using regional parity as the standard by which stipends are justified may further exacerbate the financial strain experienced by interns. APA and APPIC criteria need to be re-evaluated to ensure sites provide living wages—rather than regional parity—and accreditation and membership should be contingent on meeting these new standards. Otherwise, sites may continue to use cost-benefit analyses to justify paying low wages to highly interns providing valuable clinical services (APA, 2015b). APA and APPIC may consider implementing a grace period, whereby sites are able to work towards increasing stipends to meet living wage estimates within a given time frame before their accreditation or membership is negatively impacted.

Restructuring Health Service Psychology Training Programs

Another potential avenue to increase stipends is to reconfigure graduate training in health service psychology so interns can bill insurance for their clinical services. Our training approach could more closely align with the model used to train physicians, wherein internship would be a postdoctoral training activity (rather than predoctoral). The Coalition for the Advancement and Application of Psychological Science (CAAPS) has advocated for such changes and suggests that we break psychology graduate training into three phases: (1) basic and applied psychology to gain foundational competency and a path to conditional licensure; (2) advanced experience in areas relevant to trainees’ expertise and interests; and (3) postdoctoral internship (Berenbaum et al., 2021).

In physician education programs, trainees obtain conditional licensure after graduating from medical school and passing licensure exams, in which case they are able to bill for their services during medical internship and residency before becoming fully licensed independent practitioners (Federation of State Medical Boards, n.d.). Health service psychology could adopt such a practice, such that trainees graduate from their home institutions and apply for conditional licensure before starting postdoctoral internship. Then, completing supervised postdoctoral clinical hours within a set period could be a requirement to obtain full licensure (depending on state guidelines). Changing the structure of graduate and postdoctoral training in health service psychology may require the field’s governing bodies to adjust the expectation for when knowledge-based competencies are achieved (i.e., passing the Examination for Professional Practice in Psychology prior to graduation rather than after), as well as to identify and operationalize skill-based competencies for trainees to demonstrate before obtaining conditional and full licensure. And yet, the ability to bill insurance for the work psychology trainees provide would be, under this model, one avenue to generating revenue and subsequently increasing stipends for trainees. If billing patients does not align with an internship site's mission or values, other funding avenues should be prioritized to ensure their interns receive a living wage.

Allocation of Funds to Prioritize Health Service Psychologist Training

To further facilitate increased internship stipends, alternative funding sources should be explored. The Graduate Medical Education (GME) program–funded predominantly through Medicare and Medicaid–provides financial resources to physician training programs for medical interns and residents’ educational expenses, including salary support and benefits (He et al., 2021). GME funds are offset through supplementary revenue generated by medical interns and residents’ provision of billable clinical services. The Graduate Psychology Education (GPE) program–funded through HRSA–is meant to be the GME equivalent for health service psychology and currently provides some grant funding for internship stipends. However, the GPE budget is substantially lower (i.e., $18 million dollars in the 2020 fiscal year; HRSA, n.d.) than the GME budget (i.e., over $15 billion annually; He et al., 2021), which could impact psychology internship programs’ ability to pay interns living wages. Indeed, the average pay for first-year resident physicians ($60,000) is over twice the pay for psychology interns, which is capped by HRSA at $25,000 (HRSA, n.d.; Murphy, 2022). Moreover, securing funds from GPE requires that sites undergo a competitive application process, and GPE places limits on how sites can use awarded grants, which may disincentivize some programs from applying. The discrepancy between GME and GPE budgets—and between stipends for physicians and psychologists in training—may reflect a relative devaluation of health service psychology and speaks to the need for a reallocation of federal funds to prioritize psychology training to best address the mental health needs of the nation. Potential steps to improving interns’ stipends include increasing the stipend cap set forth by HRSA guidelines, suggesting a graded minimum stipend depending on the geographic location in which sites are located, or requiring sites to supplement HRSA funds to increase interns’ pay to meet living wages.

Limitations and Future Directions

Our findings should be considered in the context of the study’s limitations. First, we used living wage estimates that reflect a single-person household with no dependents, which does not capture the experiences of many trainees. In 2021, 13% of interns supported dependent children, and 6% supported dependent adults (Keilin, 2021). Thus, our findings may underestimate the financial strain experienced by trainees who provide financially for other family members. Second, we were unable to access data from APPIC on which internship sites offer fringe benefits (e.g., health insurance and retirement). We, therefore, could not consider fringe benefits as part of interns’ total compensation package. Third, our data reflect living wages in 2020 and stipends from the 2021-2022 training year. Given inflation increased by nearly 9% in the past year alone (US Inflation Calculator, n.d.), the data we used likely underestimated the financial needs of interns. Fourth, our data does not include estimates for Puerto Rico or Canada since these locations are not included in the Living Wage Calculator. Lastly, we also did not include non-APA-accredited sites in our analyses given that sites that are not accredited by APA do not have to follow APA regulations, including standards regarding interns’ stipends. Thus, additional examination is needed to understand the extent to which stipends at non-APA-accredited sites are commensurate with the cost of living in the geographic locations in which they are located.

Continued research is needed to replicate our findings and examine how interns’ stipends change over time in comparison to living wage estimates. We recommend APPIC and APA systematically evaluate the relationship between stipends and living wages on a regular basis, as findings from this line of work should inform policies and procedures on interns’ compensation. We also encourage future research to focus on the intern- and site-level characteristics that may contribute to disparities in where interns match. For example, individuals who highly rank sites that provide low stipends or that lack fringe benefits (site-level characteristics) may be more likely to have other sources of financial support (intern-level characteristic).

Conclusions

Providing doctoral internship stipends below the living wage may be harmful to interns, the clinical services they provide, and the field of health service psychology as a whole. Yet, most health service psychology internship sites do not provide stipends commensurate with their local living wages, which poses a possible barrier to increasing the overall number of psychologists, along with the proportion of psychologists from underrepresented backgrounds. It will not be possible to recruit the most talented trainees and build a workforce of diverse psychologists without first addressing concerns related to compensation during internship. Eliminating obstacles to educating health service psychologists by decreasing the overall financial burden of training will likely have subsequent critical benefits towards bridging the gap between mental healthcare service needs and available providers, ultimately leading to improved population health.

Public Significance Statement:

Providing stipends below the living wage may be harmful to interns, the clinical services they provide, and the field of health service psychology as a whole. Yet, most health service psychology internship sites do not provide stipends commensurate with their local living wages, which poses a possible barrier to increasing the overall number of psychologists, along with the proportion of psychologists from underrepresented backgrounds. Eliminating obstacles to educating health service psychologists by decreasing the financial burden of training will likely have subsequent critical benefits towards bridging the gap between mental healthcare service needs and available providers, ultimately leading to improved population health.

Acknowledgments:

We would like to thank Dr. Daniel Smith at the Medical University of South Carolina for his consultation on the project.

Funding Statement:

Effort on this manuscript was supported by the National Institute on Drug Abuse (Schick: T32DA019426; Fahey: T32DA007288), the National Institute of Mental Health (Cusack: T32MH020030; Henry: T32MH18921; Tilstra-Ferrell: T32MH018869), and the National Institute of Environmental Health Sciences (Reuben: F32ES34238). The contents of this manuscript do not represent the views of the National Institute of Health, the U.S. Department of Veterans Affairs or the United States Government.

Footnotes

Resource Sharing: Dataset has been made publicly available on Open Science Framework, available here: https://osf.io/tcnbq/?view_only=78047184e5e04041a55d189a920c615c.

Only APA-accredited internship sites were included in the present analyses because sites that are not accredited by APA do not have to follow APA regulations (including mandates regarding interns’ stipends). Data for non-APA-accredited internship programs can be found in the dataset on Open Science Framework.

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[R2] American Psychological Association. (2015b). Psychology Internship Development Toolkit.

[R3] American Psychological Association. (2022). Mental health crisis: CMS issues proposals to help psychologists meet the demand.

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[R14] Doran JM, Kraha A, Marks LR, Ameen EJ, & El-Ghoroury NH (2016a). Graduate debt in psychology: A quantitative analysis. Training and Education in Professional Psychology, 10(1), 3–13. 10.1037/tep0000112 [DOI] [Google Scholar]

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[R22] He K, Whang E, & Kristo G (2021). Graduate medical education funding mechanisms, challenges, and solutions: A narrative review. American Journal of Surgery, 221(1) 65–71. 10.1016/j.amjsurg.2020.06.007 [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

Short-changing the future: The systemic gap between psychology internship stipends and living wages

Caitlyn O Hood, PhD

Melissa R Schick, PhD

Shannon E Cusack, PhD

Margaret C Fahey, PhD

Sarah T Giff, PhD

Erin T Guty, PhD

Natalie Hellman, PhD

Lauren M Henry, PhD

Kent Hinkson, PhD

Erin E Long, Ph.D.

Kelsey McCoy, PhD

Kelly O’Connor, PhD

Adaixa Padron Wilborn, PhD

Aaron Reuben, PhD

Enoch T Sackey, PhD

Emily L Tilstra-Ferrell, PhD

Kyle J Walters, PhD

Sara M Witcraft, PhD

Abstract

Introduction:

Methods:

Results:

Discussion:

Method

Procedures & Measures

Table 1.

Positionality

Data Analysis

Results

Table 2.

Figure 1.

Discussion

Recommendations

Reform APA and APPIC Standards to base Stipends on Living Wages

Restructuring Health Service Psychology Training Programs

Allocation of Funds to Prioritize Health Service Psychologist Training

Limitations and Future Directions

Conclusions

Public Significance Statement:

Acknowledgments:

Funding Statement:

Footnotes

References

ACTIONS

PERMALINK

RESOURCES

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