Rethinking Clinical Psychology Doctoral Programs

The coronavirus pandemic has forced many people to reconsider their prior assumptions. Are in-person meetings really that important, or does email suffice in most situations? How many trips to the grocery store are really necessary? Should insurance companies reimburse clinicians for delivering psychotherapy via telehealth? In the realm of graduate school in clinical psychology, many fifth-year internships programs have recently decided that it is perfectly fine to conduct interviews for the 2020-2021 positions via teleconference.

The question is, why wasn't this change implement years ago, as soon as Skype came onto the scene? Why have fourth-year doctoral students fly out to a half dozen or so potential sites to spend all day meeting clinical supervisors and current interns? The cost of this travel is out-of-pocket and can run into thousands of dollars.

Doctoral programs in clinical psychology typically require 5 years, with the fifth year being the clinical internship year. During that year, the doctoral student, ideally having already completed her dissertation, leaves her home academic institution and takes up residence near her internship program, for one year of intensive, very well supervised clinical training. This often involves moving to a new city or even to a new state, and then moving again just 12 months later, either to the site of a one or two year postdoctoral program, or off to a new job.

This scheme was first derived in the 1950s, when there was less competition for internship sites, moving costs and living expenses were less onerous, and doctoral students were, on average, younger than they are today. The current system disadvantages doctoral students who are not already rich or who don't have the generous support of rich parents. It also disadvantages those who do not have a supportive spouse or partner who is a) willing to uproot three or more times in eight or so years (once for the doctoral program itself, the second for the internship, the third for the postdoc, and the fourth for the first "real job"), and b) able to find work in a new city with little trouble. A third group disadvantaged by the current system is comprised of those who feel unable to relocate due to existing familial and social connections. (That's right -- the current system of doctoral training in clinical psychology encourages people to treat relationships as temporary and disposable.)

Here is a brief outline of what a reformed system of training doctoral students in clinical psychology might look like:

1. Award the doctorate prior to the 5th-year internship.

This might sound petty but one of the awkward aspects of the internship year for clinical psychology doctoral students is that they are often interacting with recent medical school graduates who are just starting their residencies and who are addressed as, you guessed it, "Doctor." Clinical psych interns, on the other hand, tend to go by their first names. If a patient calls them "doctor," they are expected to correct them.

In most cases these days, interns have already completed their doctoral dissertations -- that big piece of research that is judged to make an original contribution to the scientific literature. In fact, many internship sites seem to give preference to applicants who indicate that the dissertation will be completed prior to the internship year, and hence not a distraction to clinical training.

Why not just award the doctorate when the doctoral dissertation is completed at the end of Year Four of training? Then, send the newly minted doctors out for the next step of their education.

2. Require 2,000 hours of pre-internship clinical experience

It might have made sense not to award the doctorate prior to the completion of clinical internship, back when many students were still finishing their dissertations during the fifth year, or when they had not yet accrued any significant amount of clinical experience. However, I propose that clinical psychology doctoral students accrue 2,000 hours of clinical experience prior to going on internship.

I am frankly baffled by the negative response this suggestion sometimes receives. "Impossible!" some say. "Careful training in evidence-based interventions is more important than accruing garbage hours!" say others. "We're training to advance clinical science, not to be direct service providers!" say still others. First of all, this is far fewer hours than the typical medical student gets during their four years of medical school, which is typically two years of classroom work and then two years (4,000 hours) of supervised clinical work. Two thousand hours can be earned thusly:

Year 1

200 hours in the academic institution's community clinic.

Beginning in the second semester of the first year, 6 patients a week in individual psychotherapy, plus one hour individual supervision, and one hour group supervision, for 25 weeks.

Year 2

600 hours in the academic institution's community clinic. 10 patients a week in individual psychotherapy (or assessment), plus one hour individual supervision, and one hour group supervision, for 50 weeks. At the end of this year they will have submitted their proposal for their dissertation research and once it is approved, the Masters of Science degree is conferred.

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By the way, this is the level of clinical contact that the great academic clinical psychologist, Dr. Paul Meehl of the University of Minnesota, kept up throughout his career, and which he felt was the minimum necessary to keep grounded in clinical reality.

Year 3

800 hours in an external placement (externship). With classwork mostly behind them, students can work 20-hours per week at a local agency. They could work at one agency for 40 weeks or two agencies for 20 weeks each (e.g., working with patients with eating disorders and then with patients with schizophrenia). They will be also working on their dissertation research at this time.

Year 4

400 hours in an external placement (externship). Either 10 hours a week for 40 weeks, or 20 hours a week for 20 weeks, depending on the demands of finishing the dissertation. Ideally this last externship will be with yet another different patient population. It would be best if at least one externship experience involved working with psychiatric inpatients.

I hope that most people can see that this really isn't an onerous clinical load. In fact, I would think that many people would be shocked to find that many trainees are not getting anywhere near this amount of clinical training. I worry that some people in the field feel that clinical work is somehow not a good use of trainees' time. Restricting clinical hours means more time for publishing scientific articles, which makes trainees more competitive on the academic job market. But the word "clinical" is from the ancient Greek, klinikos, bed, suggesting that a clinician is a healer who sat at the patient's bedside. I would think that a person interested in clinical psychology would want to get as many hours of clinical experience as they could.

3. Combine the internship and postdoctoral years.

To become a psychiatrist, students complete four years of medical school and then a four-year residency program, ending with Board Certification. This seems rather reasonable to me. Thus far, under the proposed new system, trainees have completed four years of clinical psychology training: two years of coursework, 2,000 hours of clinical work, a dissertation proposal that confers the M.S. degree, and a dissertation that earns them the Ph.D. (or Psy.D.)

Now, instead of applying to internships, and then almost immediately applying to postdoctoral residencies, why not make these the same thing? In fact why not just call the entire experience a postdoctoral residency and end the use of the somewhat demeaning term "internship"? Clinical psychology residents should do three years of postdoctoral training. The first year should be as varied as possible, exposing residents to interventions and patient populations that have had little experience with previously. Again, there should be an emphasis on making sure that residents work with the severely mentally ill at some point in their training.

The next two years can take a specialized direction -- in forensic psychology, neuropsychology, eating disorder treatment, treatment of OCD, working with children and adolescents, etc. There can even be postdoctoral programs in which the last two years focus on research and not clinical work. At the end of those two years, those so inclined more than enough experience (and publications) to prepare them for academic jobs.

I will address a few more points about doctoral training in clinical psychology in my next post.