Reforming clinical psychological science training: The importance of collaborative decision-making with trainees

Abstract

To effectively address the staggering burden of mental illness, clinical psychological science will need to face some uncomfortable truths about current training practices. In a commentary authored by 23 current or recent trainees, Palitsky and colleagues highlight a number of urgent challenges facing today’s clinical interns. They provide a thoughtful framework for reform, with specific recommendations and guiding questions for a broad spectrum of stakeholders. Key suggestions are applicable to the entire sequence of clinical training. While there is cause for cautious optimism, overcoming these systemic barriers will require a coordinated, all-hands approach and a more collaborative approach to policy-making.

“We cannot perpetuate the status quo in clinical training simply because it is familiar and comfortable.… If evolving circumstances render past approaches no longer defensible or sustainable, then we must face this reality and deal with it forthrightly.”

—Richard McFall (2006, p. 22–23)

“The status quo is no longer tenable, and the field must begin to actively find ways to shift these interlocking systems.”

—Palitsky and colleagues (2022, p. XX)

The fundamental goal of clinical psychological science is to reduce the immense suffering caused by mental illness. Tackling this challenge will require new etiological insights and the development and dissemination of intervention strategies that are more effective, sustainable, and equitable. Clinical psychological science is uniquely poised to serve as a transdisciplinary hub for this work (Gee et al., 2022; Teachman et al., 2019). Rising to this challenge also requires us to carefully consider the strengths and weaknesses of current training practices, which are typically more anchored in anecdote and historical practices than evidence (Levenson, 2017). Clinical internship is a core component of clinical psychological science training, an opportunity for trainees to deeply immerse themselves in the practical realities of clinical assessment and treatment.

In this issue, Palitsky and colleagues (2022) delineate some of the most urgent concerns facing today’s interns, including:

• Ambiguous professional status (students vs. employees)

• Arbitrary training benchmarks (hours) and inadequate skills-based competency assessments

• Adverse consequences of making the internship a pre-doctoral requirement

• Challenges and opportunities of telehealth and remote work

• Economic insecurity

• Diversity, equity, and inclusion

• Power-sharing and collaborative decision-making

Three features of the paper make it an especially valuable addition to the training literature. First, all 23 authors are current or recent interns, and their grassroots perspective reflects a thoughtful synthesis of new data and their own experiences as trainees, something that has been largely absent from other high-profile calls for reform (Baker et al., 2008; Berenbaum et al., 2021; Levenson, 2017; McFall, 2006) (see Galán et al., 2021; Gee et al., 2022; Victor, Devendorf, et al., 2022; Victor, Schleider, et al., 2022 for exceptions). Critically, trainees have a unique vantage point that allows them to offer practical suggestions and novel insights—about both challenges and solutions—that are not available from other sources in the training ecosystem. Attempts to change the system without trainee input are more likely to fail or to create ‘knock-on’ problems (Palitsky et al., 2022).

Second, Palitsky and colleagues provide a thoughtful framework for reform, with specific and highly actionable recommendations for a broad spectrum of stakeholders—from funders and accreditors to program directors and trainees—and an emphasis on sustainable solutions that have the potential to foster clinical rigor and enhance the health and wellbeing of trainees and clients alike. We encourage programs to creatively experiment and empirically examine the impact of modifying local training models. Implementing the recommendations outlined by Palitsky and colleagues—from more closely aligning trainee compensation with local living costs to strengthening diversity and inclusion efforts—would go a long way to creating a more rigorous and humane training environment, with the potential to enhance quality of care and patient satisfaction. As Palitsky and colleagues note, focusing reform efforts on the Veterans Administration and other large internship sites that serve as de facto national or regional benchmarks is likely to be especially fruitful, both in terms of the number of interns impacted and the possibility of nudging smaller programs to adopt similar policies.

Third, recognizing that there is no straightforward or universal answer to the systemic challenges besetting the field, much of the paper is instead organized around a series of questions. For example,

• What provisions exist to balance quality of [training] hours with quantity?

• What are we doing to ensure that…competency [assessments] are unbiased and support the growth of all trainees?

• What opportunities exist for trainees from underprivileged backgrounds to voice concerns about inequities in a way that is heard and [acted upon]?

• What kind of safety net is available to trainees who experience sudden life disruptions?

• What are the barriers to including interns as collaborators in [policy-making]?

Palitsky and colleagues’ questions are aimed at sparking honest conversations between trainers, trainees, and other stakeholders (e.g., institutional leadership, patients) and have the potential to provide a framework for collaborative problem-solving at the local and national levels.

Palitsky and colleagues’ paper is squarely focused on the challenges of clinical internship. Backed by new data and the authors’ own “in-the-trenches” experience, they make it clear that there are considerable opportunities for improving internship norms and training practices, which run the gamut from suboptimal to downright inequitable and unsustainable. Of course, internship is just one stage of doctoral training in clinical psychological science, and many of their concerns and suggestions for improvement are broadly applicable to the entire sequence of graduate training. In the sections that follow, we expand upon three recommendations that cut across specific challenges, all focused on the process of enacting constructive change.

Developing New Data Streams for Recursive Refinement

Contemporary clinical psychology training is “based on a patchwork of accumulated wisdom, historical practices, observation of past successes and failures, and feedback from past trainees. It is particularly seductive … to enumerate the students … who have gone on to do great things … and to conclude that we must be doing something (probably a lot of things) right. However, we all know that good intentions, anecdotal outcomes, and personal endorsements are a weak basis for making important decisions.”

—Robert Levenson (2017, p. 18)

“When given voice, trainees have spoken to problems often sidelined in the broader training literature.”

“without a forum for voicing [trainee] concerns, training programs [often remain] under-informed about the real-world impact of their policies. Soliciting trainee experiences and input …[is]a crucial touchstone.”

—Palitsky and colleagues (2022, p. XX)

Palitsky and colleagues remind us that existing data streams are not sufficient for recursive refinement of training practices at either the local or national levels (Gee et al., 2022; Victor, Devendorf, et al., 2022). For example, financial and occupational surveys administered by the Association of Psychology Postdoctoral and Internship Centers (APPIC) and American Psychological Association are aggregated across degrees and programs. Accreditor surveys lack detailed assessments of workload, climate, mental health, financial strain, discrimination, and other key challenges highlighted by Palitsky et al.

To clearly understand the challenges facing today’s trainers and trainees and determine whether revised practices are having the intended consequences, we urgently need new data streams. Ultimately, these can inform the development of evidence-based standards for training (Gee et al., 2022; Levenson, 2017), including the kinds of competency standards recommended by Palitsky and colleagues. At the local level, we encourage programs to collect anonymous surveys of trainees and trainers on an annual or more frequent basis. As Palitsky and colleagues emphasize, trainees should be involved in the development of such surveys to ensure adequate coverage of grassroots concerns. Naturally, survey developers, respondents, and data users must remain mindful of potential confidentiality concerns. Survey data should be carefully screened and, in the case of open-ended narrative responses, censored or aggregated before dissemination. Longitudinal data collection will be particularly useful. In some cases, it may be possible to conduct randomized trials of specific interventions, potentially using patient-reported experience as a complementary outcome. At the national level, we recommend that accreditors harmonize and institutionalize these efforts. As noted by Palitsky et al., this has the potential to serve as an institutional incentive to invest the resources necessary to foster more equitable and sustainable training environments. While they are often less actionable at the local level, anonymous surveys conducted by accreditors or other national organizations have the potential to encourage more open and honest reporting. We urge professional groups to advocate for these changes, accreditors to facilitate them, and funders to invest the modest level of support necessary to enact them.

Power-Sharing and Collaborative Policy-Making

“Without clear structures for integrating [trainee] feedback…there may be little accountability …A more equitable model …[would] feature stakeholder (trainee) involvement in decision-making.”

—Palitsky and colleagues (2022, p. XX)

More and better data are important, but in the absence of meaningful power-sharing, trainee concerns and suggestions can easily be ignored. Palitsky and colleagues underscore the value of collaborative policy-making for driving positive changes in the training environment. We strongly endorse their recommendation that trainees be formally involved in policy-making at both the program and national levels. As Palitsky and colleagues note, to be effective, this must be a genuine collaboration. Student representatives must be granted appropriate decision-making power (e.g., voting rights), respect, and recognition. Of course, privacy and other practical concerns will somewhat limit the extent of power-sharing at the local level—particularly at sites with small cohorts of trainees—but a number of institutions have demonstrated that these challenges can be overcome and trainee representatives can be fruitfully involved in policy development and other aspects of governance (e.g.., hiring) at the department and program levels. Many of the challenges inherent to shared policy-making can be best addressed through actively involving trainees in the process of shaping practices (e.g., opportunities to inform how trainees are involved in program discussions and decision-making). We urge professional groups and accreditors (e.g., Commission on Accreditation and APPIC) to nurture these changes (see Berenbaum et al., 2021 and Gee et al., 2022 for broader discussions of specific ways in which national stakeholders can facilitate positive change).

Boulder Revisions

“Because the status quo surrounding internship training is maintained by a regulatory gridlock, with no entity being able to make meaningful change without accommodation from other entities, solutions must be carried out with involvement from multi-sector stakeholders.”

—Palitsky and colleagues (2022, p. XX)

To have the best chance of tackling the immense burden of mental illness, clinical psychological science needs to face some uncomfortable realities about the current state of training norms and practices. Fully addressing the challenges identified by Palitsky and colleagues and other recent commentators will require an all-hands approach and bolder kinds of systemic change (Berenbaum et al., 2021; Gee et al., 2022; Strauman, 2021). These changes are necessary and, in many cases, long overdue. Some of these changes will be difficult to implement and disruptive in the near-term. In short, they need to be made with the greatest care, transparency, and attention to potential ‘off-target’ effects. This will require debate, advocacy, and action at the local and national levels. We strongly endorse Palitsky and colleagues’ call for professional organizations, accreditors, and funders to organize and invest in the necessary meetings (‘Boulder 2.0’). It is essential that clinical interns and other kinds of pre- and post-doctoral trainees have a robust voice in these discussions. Of course, discussion alone will not be adequate to overcome the urgent challenges in clinical psychological science training. Bold thinking, creative partnerships, novel incentives, and new institutional investments will be necessary to create sustainable training environments where trainees and trainers can focus their efforts on understanding and reducing the suffering caused by mental illness.

Concluding Thoughts—A Cause for Cautious Optimism

Palitsky and colleagues openly acknowledge the many barriers to reforming clinical science training. Yet they also provide a rationale for hope, reminding us that radical shifts in training practices are not only possible, but are in fact a recurring theme in the history of clinical psychological science training and service provision, beginning with the rapid implementation of current norms in the aftermath of World War II, and culminating in the warp-speed adoption of digital tools for mental healthcare delivery (‘telehealthcare’) in response to the global COVID-19 pandemic.