Look What Appeared From Under the Rug: A Commentary on Palitsky et al. 2022

Will this finally be the impetus to substantive change? Will this inspiring paper push our field to address long-standing inequities in internship training? In a manner both thorough and eloquent, this talented group of twenty-three recent psychology interns document the history of concerns with the health-service psychology internship and provide no less than twenty-four specific recommendations for reform. It is hard to read this and not be enraged and disappointed by the inaction of our field amid a plethora of inequities. A few examples:

• A recent survey of 400 interns during the pandemic found that 43% felt unsafe at work.

• Average debt following internship is over $91,000.

• An intern was required to work two additional jobs while on internship to support their family, while others struggling to live on an intern’s salary are unable to supplement their income due to program restrictions.

• An “elite program” responds to financial concerns noted by students by telling them to “ask for financial help from their families.”

• Interns required to stay home due to Covid restrictions are docked their pay and denied opportunities to make up their hours thereby putting them at risk of not completing the required number of hours for internship.

Written during the height of Covid, the problems they described were exacerbated by Covid but the problems themselves are hardly new as concerns for the quality of internship training have been prominent at least since the Gainesville Report of 1989 (Belar, Bieliauskas, Larsen, Mensh, Poey, & Roelke, 1989), more than 30 years ago! Clearly, the field has recognized the need for structural change but failed to act. Furthermore, there have been no lack of ideas for how to improve the system, as Palitsky et al. review. Yet, we know of no other paper that has itemized these concerns with such precision and thoughtfulness. For example, their discussion of diversity issues is compelling -- most notably the lack of accommodations for marginalized students including a shameful lack of concern for students without financial resources -- in part given the credibility of their very personal examples. In addition, they offer constructive solutions and associated “questions for collaborative inquiry” that are impressive in scope and thoughtfulness. We do not have the space to review them all, but we do want to emphasize a few key points.

First, this entire paper and its quality makes the case for the importance of including the voice and perspective of interns, a major point of the paper. As with all activists, they ask that we stop talking about them without them. They also point out that the inclusion of interns’ voices and perspectives can provide a self-corrective on the top-down approach that has too long dominated psychology training. What they describe as collaborative inquiry is an opportunity to engage in a serious discussion of seemingly intractable problems to arrive at solutions that will promote equity and high-quality training. As noted, these issues are not new, and many of the solutions have been proposed previously. Where this paper differs dramatically from most prior efforts is their sense of urgency.

A second point to highlight is their careful description of the complex net of systems and structures that maintain the status quo. Graduate programs have delegated authority of the internship experiences of their students to non-affiliated hospitals and agencies which leaves interns in what Palitsky et al. note as an “underprivileged bargaining position” (p. 32), an obvious understatement. With few guardrails on a cottage industry of cheap and high-quality labor, and few restrictions on their employment, the economic incentives for internship training sites promote more service and less training. Furthermore, whereas the American Psychological Association (APA) Office of Accreditation and the Association of Psychology Postdoctoral and Internship Centers (APPIC) provide guidelines to promote quality over quantity, the guidelines are only broad strokes with little enforcement (as is apparent from the descriptions of interns’ experiences). We should also note that the Association for Psychological Science (APS)-affiliated Psychological Clinical Science Accreditation System (PCSAS) has yet to identify internship standards after more than a decade into its formation. This despite proposals outlined in a 2014 paper written by three current and one former internship director, describing variations on a new model for clinical internship addressed specifically to the then newly developed PCSAS “to reconceptualize internship training within clinical science” (Atkins, Strauman, Cyranowski, & Kolden, 2014, p. 50). Perhaps now, with the impetus of this cogent paper, graduate training programs -- that is those who hold the most power and authority over training -- will embrace this opportunity to be at the forefront of shaping an equitable system to train the next generation of clinical psychologists.

We should note that an alignment of graduate programs and internships reflects some of the initial recommendations in the middle of the twentieth century when internship experiences were first formalized: ”… increasing emphasis has been given to the need of close affiliations between university and clinical institution, and to the necessity for initiative to rest with the university in this matter.” (Morrow, 1945, p. 179). This is not to take the onus off internships to improve working standards but, if aligned, graduate programs and internships could work collaboratively to define the experiences and needs of the interns, providing interns the guidance and support of their graduate training directors, presumably knowledgeable of their unique training and educational needs and therefore able to help advocate for them. This is relevant to the discussion regarding the status of interns as essential vs. non-essential workers – again, brought to the fore by Covid but exposing the long-standing precarious position of interns in these organizations.

Palitsky et al. offer several opportunities for immediate action. We especially appreciate the idea of public ratings of internships to provide information to applicants and serve as a quality control mechanism to programs. Our program, as do many others, provides applicants a confidential lunch with our current interns to allow an honest discussion of our program without concern for how it might impact their status. We have found that our interns take this responsibility quite seriously and maintain these discussions in strictest confidence. That this can serve as a built-in corrective to ensure that current and past interns’ concerns are acknowledged is an added bonus. Having a national rating review would be a welcome addition to provide feedback regarding relative program strengths and deficits. But one addition we would recommend is to link these ratings directly to students’ graduate programs and perhaps even including these ratings in their program’s accreditation review. After all, is there another profession that requires an experience for the degree but takes no responsibility for its availability or quality; an issue medical education addressed over a century ago (Flexner, 1910)?

We also greatly appreciated the case for interns having a voice in policy issues related to internship training and, relatedly, allowed discretion over the content of their training. However, for the former, given the limitation of their (typically) one-year status, we suggest consideration of some safeguards to encourage an honest appraisal of programs. For example, we wonder how comfortable an intern would be, new to the organization and to the internship faculty who are in an evaluative role, to address issues of fairness and equity? Perhaps this would best be implemented at a regional level with graduate students and interns serving in an advisory capacity protected from the judgement of specific program and faculty. For the second feature in which interns are given voice over their training, we wholeheartedly concur as this has been a core feature of our internship for over two decades. Two aspects of our process are especially relevant to this review.

One, in our program, no faculty are guaranteed an intern as each faculty member is allotted time to present their program to the interns as a group and each intern then decides whether they are interested in that experience. This avoids assigning interns to experiences that are not in line with their training goals. Two, interns are provided the nine competencies required by the APA Commission on Accreditation (CoA) and, with guidance from our director of training, decide how they will acquire those experiences. This produces a set of experiences uniquely tailored to each intern’s training needs while acknowledging their advanced status as early career professionals; an example of collaborative decision making as Palitsky et al. describe it. We should note that our internship is specifically designed for academically oriented interns, but we suggest that this model would be appropriate for interns with other career aspirations as well.

Individualizing training goals in this way works especially well in our setting because our internship is entirely funded by a line item on our department’s state budget. No clinical revenue is allocated to the internship and therefore there is no incentive to require one or another clinical experience. However, while this offers an advantage of flexibility that internships funded by fee-for-service models may not be able to replicate, it is not without fault. Specifically, this line item is a fixed sum and therefore increases in stipends are generated through our department’s general fund. And although we have been able to advocate successfully to have our stipend raised to meet regional standards, it is still below the minimum salary for a full-time employee at our university, an issue correctly noted as problematic by this paper. In addition, state budget shortfalls have seriously impacted the viability of the program at times, which led to the loss of several positions that we are just now beginning to recoup. These exigencies may be specific to our program, but they represent the larger issue of the vulnerability of internship programs and trainees in a volatile health care environment as noted eloquently in this paper.

Related to salaries, we suggest the solution will again require an alignment of graduate programs and internships as it is unlikely that improving interns’ salaries can be accomplished by internships alone. For one, internship programs run on tight budgets, often funded through clinical revenue, or, as with our program, department or university resources. Without a formal affiliation with a graduate program, their stake in training is influenced by the benefits their setting would derive from the interns’ activities. As noted, these incentives, without additional support, will work against providing interns many of the rights and high-quality training that they deserve, even despite the best efforts of the internship training faculty who must answer to their respective department leadership. Ideally, therefore, if the internship was jointly funded by the graduate program as an affiliated program, as long recommended, it would balance these incentives and allow for some of the innovations recommended in this paper, including (and especially) a livable wage.

Obviously, this is not an easy fix as funding in graduate training also has many limitations. But, as Palitsky et al. note, there are several options including collaborative grants and shared clinical reimbursement. In our case, we have a formal agreement, negotiated with APPIC and APA CoA, for the Northwestern University clinical psychology graduate program to fund one dedicated position in our internship for a graduate student from their program, assuming that student meets our program selection criteria. Because our respective programs are aligned philosophically in a clinical science model, this has been a fruitful collaboration. Although limited to only one student, it is an example of one way to align graduate programs and internships.

In closing, we offer the experience of Big Pharma and medical education for some perspective and foretelling. In 2009, concerned with the cavalier attitude of his pharmacology professor on the side effects of cholesterol drugs, a Harvard medical student searched this faculty member online and found that he was a consultant to ten pharmaceutical companies, including several that sold cholesterol drugs. He shared this information with his classmates and faculty and over two hundred signed a petition to follow the lead of other medical schools and eliminate the influence of Big Pharma on their training. The issue was picked up by the American Medical Student Association and before long the policy of restricting drug company influence on medical training was a national debate (Magee, 2019; Wilson, 2009) and is now almost universal policy.

We offer this historical precedent both to encourage our students to continue to speak out and as advance notice to clinical science faculty that our students have waited long enough and now is the time to push these ideas forward. We congratulate our colleagues for what we believe will be a seminal paper on psychology training and, we hope, an impetus for graduate training programs and internships to accept the invitation to engage in much needed discussion and change. After all, sweeping these issues back under the rug will be so much harder now.