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Internship Training

Abstract and Keywords

Doctoral education of health service psychologists includes a year of clinical experience as a required element for conferral of the degree. This chapter reviews the historical development of the internship and describes common structural components, including governance structures, funding mechanisms, and issues related to timing in the sequence of training. Special attention is paid to current problems and controversies, including the supply/demand imbalance, stipend support, broad and general training, emerging markets, financial responsibilities of doctoral programs, and accreditation as a national standard.

Keywords: internship, internship imbalance, supply/demand imbalance, doctoral education of health service psychologists, accreditation

Internship Training

The internship has long been a critical element in the sequence of training leading to the doctoral degree in clinical, counseling, or school psychology. Indeed, the internship has variously been called the capstone, and more recently, the keystone experience for health service psychologists (HSP), reflecting its special importance (McCutcheon, 2011). As currently conceptualized, the internship is an immersion experience, constituted primarily of supervised, direct contact with the recipients of services (which may include individuals, families, communities/systems, or other providers). This supervised direct service is complemented by other structured learning activities (e.g., seminars, patient care rounds, case conferences). Thus, the internship is an educational experience that serves to extend and integrate prior learning, rather than being on-the-job training. It usually follows upon successful completion of all classroom requirements and practica experiences, which, in combination, provide students with a foundation of scientific knowledge, professional values and attitudes, and the rudiments of clinical practice.

Though occurring later in the sequence of training, the internship remains broad and general in emphasis (Zlotlow, Nelson & Peterson, 2011), and is intended to promote intermediate to advanced knowledge, skills, and attitudes in a wide array of HSP competencies (APA, 1996). Broad and general training, in the context of supervised clinical immersion, aims to solidify trainee competencies, to prepare new professionals in adapting to newly emerging practice opportunities and professional roles, and very importantly, to integrate knowledge of psychological science and practice at a qualitatively higher level of organization. Finally, the internship is intended as preparation for entry to practice and eventual licensure, or for entry to specialty training at the postdoctoral level.

Key Historical Developments

Wars have far-reaching impacts on societies, including how health care is organized and delivered. The calamity of World War II greatly impacted the health professions, and particularly altered the identity and role of health service psychologists in (p. 156) the United States. Concerned with meeting the burgeoning demand for mental health services, the Department of Veterans Affairs (VA) and the United States Public Health Service (PHS) hired large numbers of clinical and counseling psychologists. This initiative greatly expanded employment opportunities for psychologists in the nation’s medical care system, and cemented the professional psychologist’s identity as being a valuable front-line clinical provider. To accomplish this expansion, VA and PHS solicited the APA to develop mechanisms by which the quality of doctoral education could be evaluated. Beginning in 1946, with the appointment of a roundtable on internship training of Clinical Psychologists, APA launched a major initiative a year later when it created a Special Committee on Training in Clinical Psychology. The report of this committee included important standards for the development of internship training (Shakow, 1965).

Other developments and conferences that would come to form the bedrock of training for HSP, as well as the role and function of the internship, followed in quick succession. The 1949 Boulder Conference is widely recognized for articulating the scientist-practitioner model and for underscoring the central importance of science-practice integration in service delivery. Equally important, though less widely recognized, the Boulder Conference firmly established the internship as a required element of the doctoral degree (Raimy, 1950). Counseling Psychology followed suit in 1951 by likewise requiring completion of an internship, and a year later, while establishing practicum standards, reaffirmed the value of the internship as a culminating experience in the sequence of training (Kaslow & Webb, 2011). This bifurcated model of doctoral education in professional psychology was further institutionalized as a consequence of federal training dollars funneled to doctoral programs (e.g., National Institute of Mental Health training grants) and internships (e.g., VA internships). An underlying assumption prevalent during these times was that residency in the doctoral program primarily provided students with a knowledge base of scientific psychology, but that skillful application of this science required supervised experience in an applied setting, which was not necessarily or frequently available within the academic institution. In many doctoral programs, science and practice might frequently occur in different settings, and their integration (to the extent that it occurred) might take place sequentially and not necessarily simultaneously. That is, science often occurred in the home doctoral program and clinical practice skills often were developed outside academic walls.

Following upon the VA’s establishment of internship programs designed to fuel a much-needed workforce, the APA’s Office of Accreditation invited internship programs to undergo external review beginning in 1956 (Belar & Kaslow, 2003). By the end of that year, 28 internship programs had achieved accredited status [as of 2013, that number has increased to 461, with an additional 26 programs accredited by the Canadian Psychological Association (CPA) and three programs with joint accreditation]. Early models of internship training were greatly influenced by the preponderance of VA programs (and their associated clinical needs), by newly emerging accreditation standards and conference reports, and by historical definitions of the psychologist’s role. As a result, internship programs during this period emphasized training in personality and cognitive assessment, and individual psychotherapy and counseling (directed toward pathological and nonpathological conditions, respectively). The 1965 Chicago Conference on the Professional Preparation of Clinical Psychologists further confirmed the importance of the year-long, culminating clinical experience. It also highlighted the value of a greater breadth of experience that should include exposure to a range of clinical conditions, with a diverse population of clients, and employing an array of intervention approaches and modalities (i.e., not solely individual psychotherapy) (Hoch, Ross, & Winder, 1966).

Internship training certainly reached a maturational milestone with the appearance, in 1968, of the Association of Psychology Internship Centers (APIC). This organization began as an informal group of educators primarily concerned with developing a venue for the exchange of information and discussion of internship issues of common concern (Kaslow & Keilin, 2004). It fairly quickly evolved to become the highly organized force it is today, functioning as one of the most visible and influential training councils in professional psychology. Today, the Association of Psychology Postdoctoral and Internship Centers (or APPIC, having changed its name in 1992 in order to more accurately reflect its added focus on postdoctoral training) is a national organization representing internship and postdoctoral programs in North America. Its primary activity is administration of the computerized internship Match, which now annually involves nearly 4,500 students in Clinical, Counseling and (p. 157) School Psychology programs, and more than 700 internship sites.

APPIC is a voluntary membership organization that requires applicant programs to meet sixteen criteria related to minimum standards for educational resources, processes, and structures (e.g., required hours of supervision, number of supervisors and interns, evaluation and due process procedures). These membership criteria are in accord with important APA/CPA accreditation criteria but are considerably less stringent. Furthermore, APPIC membership is granted on the basis of a paper review of a membership application, whereas APA/CPA accreditation involves a lengthy self-study (usually running several hundred pages) along with a site visit that provides observable verification. APPIC views membership as a critical step in a program’s quality improvement but repeatedly reminds its membership that accreditation remains a desired goal. In this regard, it is important to note that roughly 30% of APPIC member programs are not accredited.

In addition to administering the Match, APPIC provides a menu of other services, including assistance in the creation and development of new programs, the dissemination of training resources, the publication (in partnership with APA) of a journal devoted to HSP education and training (Training and Education in Professional Psychology), and resources and leadership in a number of initiatives and conferences that have advanced internship training. Notable examples include the 1987 National Conference on Internship Training in Psychology (co-sponsored with the Department of Clinical and Health Psychology at the University of Florida, Gainesville), which produced a detailed policy statement on a host of issues that greatly influenced the conceptualization of the internship (Belar et al., 1989). Delegates at the Gainesville conference endorsed statements regarding which psychologists required an internship, when it should occur in the sequence of training, minimal expectations for entry to the internship, and the relationship between the internship and doctoral program. Regarding the latter, delegates asserted that internship “must be an extension of and consistent with prior graduate education and training” (Belar et al., 1989, p. 7). That is, the culminating year should not reflect a basic change in the student’s direction or course of training, but should be an experience that builds upon, elaborates, and integrates that prior learning. No longer should the internship be viewed as something distinct and set apart, or worse yet, considered as a necessary evil; it should be viewed as an integral element in a seamless sequence of training leading to conferral of the doctoral degree and eventually, entry to practice and licensure. Also noteworthy was the endorsement—made in 1987—that training should occur within accredited internship programs, as a means of ensuring minimum quality standards. This aspiration remains unfulfilled 25 years later. As previously mentioned, only 70% of APPIC member programs are accredited in 2013, and a recent APA Board of Educational Affairs (BEA) statement calling for accreditation as a standard in HSP education remains controversial (APA, 2011).

Reflecting its role as a major voice for the community of internship educators, APPIC co-sponsored other notable conferences and meetings, including the 1997 “Supply and Demand” conference (APA, 1998); the 2002 Competencies Conference (from which came the concept of foundational and functional competencies, as embodied in the Cube model, which, in turn, laid the groundwork for the Competency Benchmarks) (chapter 7, this volume) (Kaslow et al., 2004; Rodolfa et al., 2005); and the 2008 Imbalance meeting (colloquially dubbed the Courageous Conversation), which produced the Imbalance Grid that specifies eleven action items that the attendant training councils agreed upon in order to mitigate the imbalance between the number of students seeking an internship and the number of available positions (Grus, McCutcheon, & Berry, 2011).

Reminiscent of APPIC’s founding, the Council of Chairs of Training Councils (CCTC) began in 1985 as an informal forum in which the Chairs or Presidents of seven doctoral and internship training councils could meet to exchange information and discuss issues of common concern, with the aim of improving and strengthening professional education and its teaching. Today, CCTC includes 17 member councils (across the entire sequence of training, including practicum and postdoctoral councils) and numerous other groups in observer status. CCTC is partially underwritten by APA but remains an independent group that works closely and collaboratively with its member councils, and with APA and its Boards and committees. CCTC might best be thought of as a “round table” at which competing values and interests are debated. It operates largely by consensus and is explicitly not a decision-making body, and thus its deliberations have no binding authority over its individual member councils. Nonetheless, CCTC has emerged as (p. 158) an important group in terms of drafting policies, launching initiatives, creating accountability, and bringing increased coordination to the sequence of HSP education and training. In particular, CCTC has been an instrumental partner in the development and implementation of competency initiatives, and in efforts to mitigate the internship imbalance. Because it can speak with a single voice for the interests of its disparate Training Council members, CCTC has become an influential advisor and advocate on issues related to internship training. In this capacity, CCTC joined with APA in 2012 to hold a follow-up to the 2008 Imbalance meeting (dubbed Courageous Conversation II), and participated in the interorganizational Health Service Psychology Education Collaborative (HSPEC). A proposed follow-up conference will, among other substantive topics, likely revisit the placement of the internship in the sequence of training.

Internship Structures and Mechanisms

Duration.

The vast majority of internships are one-year, full-time placements in service-delivery settings. The profession recognizes an alternative model consisting of a half-time, two-year internship. Such positions are felt to better accommodate the needs of some students, especially nontraditional or older students, who have financial, health, or family needs that constrain them from a full-time commitment. Surveys conducted by APPIC have indicated that approximately 5% of students who participate in the APPIC Match preferred a two-year, half-time program. However, this arrangement is less cost-effective for a training site and can be difficult to implement. For example, a site must be very thoughtful to ensure that a part-time intern has experiences and responsibilities that are substantially advanced when compared to the similarly part-time practicum student, and must, likewise, be thoughtful about implementing training (e.g., seminars) that may include both first- and second-year cohorts. For such reasons, the number of half-time positions in the APPIC Match is negligible, and such positions are largely confined to California, where the California Psychology Internship Council (CAPIC) has promoted this as an alternative model.

In contrast, the model of full-time internship training confers many significant advantages. In particular, full-time training allows for a clinical immersion that promotes a qualitatively different learning experience when compared to prior practicum experiences. Working with clients and other providers on a daily basis to manage a succession of clinical challenges, the intern can achieve a more advanced level of competence across foundational and functional competency domains than could be achieved in practicum placements. In large part, these advanced competencies develop as a function of the responsibility or “ownership” that the full-time intern can achieve as a consequence of being present throughout the work week. Likewise, interprofessional skills (including consultation, nascent leadership, patient advocacy, and harmonious team functioning) are promoted precisely because the full-time intern can become a member of a team of providers. The practicum student or part-time intern is often more a “visitor” than an essential team member, and is less likely to assume full clinical responsibility simply as a consequence of their absence during large portions of the week.

A one-year internship most typically entails 1500–2000 hours, depending on how a site calculates personal leave, sick leave, professional leave, and holidays (Tracy, Bucchianeri, & Rodolfa, 2011). Nonetheless, despite this variability, this range of accumulated hours is in accord with accreditation and licensure standards, and is intended to ensure that interns have sufficient experience for conferral of the doctoral degree and to qualify for licensure.

Models of training.

APA accreditation requires that an internship program identify its model of training (e.g., scientist-practitioner, scholar-practitioner) and articulate the linkages between that model and the program’s goals, objectives and learning methods. However, there is evidence that, in most cases, the pragmatic nature of clinical work in an internship setting does not lend itself easily to formulating training strictly within the framework of these models (Rodolfa, Kaslow, Stewart, Keilin, & Baker, 2005). Although programs may differ in their broad orientation or viewpoint, and differ in the degree to which they support or promote research activities, the internship year remains fundamentally a clinical immersion experience that occurs within a service-delivery system. The practicalities of such work tend to promote an integrative and pragmatic approach to clinical work and training. Practices that achieve measurable positive outcomes in a particular setting are passed along; effective professional roles and functions in a particular workplace are modeled; training is driven more directly by what “works” in the specific, local circumstances and less by abstractions and theories.

Organizational structures.

The basic organization of internship sites differs in some meaningful (p. 159) ways. These distinctions include the nature of the relationship between the doctoral and internship program, the timing of the internship relative to the completion of coursework, and the internship governance structure. As discussed in a later section, these issues of organizational structure have important implications for financial viability of the internship and, thus, for mitigation of the internship imbalance.

Historically, internship sites generally have been entirely independent of the doctoral program. Indeed, the APPIC Match allows students to locate internships anywhere in North America that best fit their background, learning needs, and career preferences. The implicit assumption is that the internship is an autonomous and self-contained experience. For precisely this reason, CCTC adopted recommendations for communication between doctoral and internship programs so that the two parties would share information regarding the student for whom they shared responsibility (CCTC, 2007). As previously mentioned, the continuity between doctoral and internship training was affirmed as an important value at the Gainesville Conference (Belar et al., 1989). In this context, three distinct models for program relationships have emerged:

Non-affiliated independent internships.

Internship training most frequently occurs in agencies or institutions that are administratively and legally independent of doctoral programs. The internship site assumes responsibility for all aspects of training, including financial support of the program and trainees, supervision, and didactics. Training objectives, learning methods, and evaluation of learner outcomes conform to the internship program’s mission and goals, rather than those of the doctoral program. In this arrangement, trainers must pay attention to several tasks, such as selecting students of differing educational backgrounds who will nonetheless provide a “good fit” with the internship site, providing a coordinated internship curriculum that meets the needs of students who necessarily vary in their learning backgrounds and needs, and maintaining communication with home doctoral programs that might vary substantially in their expectations for student outcomes.

This arrangement provides distinct advantages for both training sites and students. The autonomous internship can select students from a regional or national pool that includes students from a wide range of doctoral programs. Diversity of intern experiences and educational backgrounds is a highly valued quality among internship faculty. Such diversity consistently brings fresh perspectives and new knowledge to the site’s faculty, which is often cited as an important incentive to providing internship training. Such diversity greatly enriches the learning environment for all involved. Likewise, the opportunity to complete training in an institution other than the home doctoral program provides an enriching experience for students that broadens their professional horizons.

Exclusively-affiliated internships.

This organizational structure sits at the opposite end of the continuum from the independent internship. An exclusively-affiliated internship (formerly known as a captive internship) is administratively connected to a doctoral program, and is often to be operated by the doctoral program for the benefit of its own students (CCTC, 2010). It serves, essentially, as an extension of the doctoral program’s educational offerings, and is likely to provide some degree of financial underwriting. In such an arrangement, interns are selected entirely from the student body of the affiliated doctoral program. This structure represents the highest degree of responsibility that a doctoral program may demonstrate in providing access to internship for its students.

Partially-affiliated internships.

This arrangement sits midway on the continuum of affiliation with a doctoral program. A partially-affiliated internship site has entered into an agreement with a local doctoral program to reserve a portion of its internship positions for students from that program. This can be accomplished by designating a “track” in the APPIC Match for students from a specified program, or by a less formal agreement to give preference to students from that program in constructing the rank-order list submitted to the Match. Although not as common, it is possible for an internship site to develop affiliations with more than one doctoral program. This partial affiliation has benefits for both parties to the arrangement: doctoral programs benefit by assurance that their students are advantaged in ranking by a particular internship site, and in exchange, that site typically receives financial or in-kind support from the affiliated doctoral program (e.g., faculty to conduct seminars).

Given the economic challenges experienced by some sites in maintaining an internship program, even modest tangible support from a doctoral program may allow for an otherwise financially marginal site to achieve sustainability. Additionally, both exclusively and partially affiliated programs have an administrative relationship with a doctoral program that makes continuity of educational goals and (p. 160) objectives more likely across the sequence of training. In large part, the affiliated internship exists in order to extend and fulfill the mission of the supporting doctoral program.

There are also a number of potential risks and disadvantages to affiliated (exclusively or partially) internships (Collins, Callahan, & Klonoff, 2007). First, affiliation with a doctoral program is no guarantee of quality. In fact, a doctoral program that has a poor track record of placing students via the Match can use an affiliated arrangement to conceal its deficiencies rather than solve them. Thus, as with all internship programs, affiliated arrangements should be subject to external review at the highest standard.

Another potential disadvantage of this type of arrangement is that students who attend an affiliated internship will often have similar clinical experiences, and even some of the same supervisors, as they did throughout their doctoral program, particularly when doctoral faculty play a key role in the affiliated internship program. This can result in less diversity of experiences, supervisors, and perspectives for the student and less diversity of interns for the internship program. These factors diminish many of the advantages of the internship experience that were described earlier.

Timing of internship in the sequence of training.

The vast majority of doctoral students complete internship during their final year in the doctoral program, following completion of all required practicum and coursework. Completion of the internship and dissertation are final requirements for conferral of the doctoral degree, and are most commonly completed simultaneously. Thus, the internship has been described as a capstone experience, emphasizing its place as a culminating year (Lamb, Baker, Jennings, & Yarris, 1982), or as a keystone experience, emphasizing the significance of the year in the integration of competencies (McCutcheon, 2011). In the majority of states, provinces, and jurisdictions in North America, graduates are required to complete an additional year of postdoctoral supervised experience in order to qualify for licensure as an independent health services practitioner. A substantial minority of jurisdictions now allow licensure upon completion of the internship, in accordance with the APA policy on postdoctoral experience required for licensure. One outcome of this policy change is to give heightened importance to clinical experiences (especially practicum) that occur earlier in the sequence of training. Because capstone or keystone internships are most commonly independent of doctoral programs, and because the internship year may lead directly to licensure for an increasing number of students, this model places an extra burden on sites to communicate and collaborate in the overall education of the intern, as well as imposes an increased responsibility on the internship for gatekeeping of students prior to entry to the profession (CCTC, 2007).

It is noteworthy that the capstone or keystone models are commonly found in affiliated internships. Although the burden of communication may be eased by the formal administrative relationship that spans the divide between doctoral and internship years, this type of arrangement can also present challenging ethical issues that should be carefully considered by the affiliated doctoral and internship programs. One such issue is that the “gatekeeping” role of the internship may conflict with the affiliated doctoral program’s desire to move its students through the program to graduation (see APA ethical standard 3.06, Conflict of Interest; American Psychological Association [2010]). Similarly, financial or other incentives provided by the doctoral program to the internship site may conflict with the internship’s ethical responsibility to provide accurate trainee evaluations (see APA ethical standard 7.06, Assessing Student and Supervisory Performance).

A variation on the capstone/keystone models is worth noting. In the integrated training structure model, internship is conducted half-time across two years, during which the student continues coursework at the affiliated doctoral program (CCTC, 2010). The intent is to maximize the integration of classroom knowledge and direct clinical experience. A major challenge is to distinguish such part-time clinical experience from earlier practicum training (which may have been completed in the same setting); to promote professional-level responsibility, clinical care continuity, and leadership within the constraints of part-time attendance; and to foster the development of professional identity in a person, who for major portions of time, remains in a student role. Perhaps due to such challenges and the fact that this structure can be at odds with some APPIC requirements, the integrated training structure is not a widely implemented alternative to the capstone model and is largely limited to professional school programs at this time.

Governance structures.

As already mentioned, the governing relationship between internship and doctoral programs is a distinguishing feature with many implications for implementation of training. The autonomous, capstone internship is most likely to operate in an independent institution (p. 161) devoted to providing health, behavioral health and/or mental health services to a variety of recipients (e.g., patients, families, other health-care providers, teachers, systems). In such a setting, the internship program will be administratively embedded within the host institution (e.g., medical school internship), and the mission, goals, and policies of the internship will be consistent with, and promoting of, the larger institution’s priorities. The independent internship will collaborate with interns’ home doctoral programs for the benefit of the intern, but the doctoral program will have no actual managerial authority in the conduct of their students’ final year of training.

In an allied governance structure, a partially- or exclusively-affiliated internship will be embedded within the administrative structure of the host institution, but will have additionally forged a formal administrative relationship with a “feeder” doctoral program. Without compromising the administrative integrity of either institution, such a formal relationship between school and site for purposes of operating the internship allows for greater shared responsibilities and exchange of resources. Of course, such an arrangement also introduces complexities that make management of the program more difficult. These complexities are exacerbated when the affiliated sites are themselves housed within independent institutions (e.g., a University-based doctoral program and a state-financed Community Mental Health Center). The complexities are eased when both doctoral and internship programs are housed within a larger, single institution (e.g., a University doctoral program and a University Student Counseling Center).

Consortia models are a final governance structure of great importance. In a consortium, independent entities that otherwise lack sufficient resources to offer internship training on their own create a formal contractual relationship to pool their training resources, and by doing so, have the means and ability to host an internship program that spans their individual sites. Consortia arrangements are a critical tool in building internship capacity; small or underfunded sites can combine to offer training that would otherwise not exist. Consortia sometimes are created with encouragement and financial support of a doctoral program, which, in an allied framework, brings together community-based clinic sites with which the doctoral program has previously worked, perhaps in providing practicum training. In this hub-and-spoke structure, the doctoral program provides a valuable organizational impetus and expertise that can lead to an affiliated pool of internship positions. Alternatively, independent sites within a community or region may link together in a network of relative equal partners for the purpose of pooling training resources. The impetus in such a case is more likely to arise from the personnel or service needs of the involved internship sites and not the needs of a local doctoral program.

In forming a consortium, the training partners accrue many economies of scale as well as access to shared resources (including practical resources, such as assessment instruments, and less tangible resources, such as faculty diversity or professional esteem). At the same time, consortia require formal agreements that specify contractual obligations between the entities. These can be complicated to obtain and maintain, especially when they involve shared financial and staffing obligations, or when they occur across sites with differing service orientations or missions. Moreover, successful construction and implementation of a consortium requires careful consideration of a shared training model, policies and practices. Despite these hurdles, the consortium model continues to hold promise for growth and innovation in internship training.

Internship Supply and Demand Imbalance

Over the past 20 years, the profession has become increasingly concerned with the imbalance between the number of students seeking a predoctoral internship and the number of positions available through the APPIC Match (APPIC, 2007). More recently, the term “internship crisis” is almost routinely used in order to describe the severity of the imbalance, with more and more students seeking internships without a concomitant increase in available positions. The internship imbalance has generated personal hardship and distress, numerous professional meetings, scholarly activity, and various calls to action and proposed mitigations. This section will provide some recent data about the scope of the imbalance, discuss its impact on the quality of the experience, and review the activities of the profession to date in addressing these concerns.

Scope of the problem.

Although long discussed and debated, the internship imbalance has become more acute in recent years. Between 2002 and 2012, the number of registered applicants grew from 3,073 to 4,435—an increase of 1,362 applicants or 44%. A substantial portion of this growth occurred just recently, with an increase of 545 applicants between 2010 and 2012. (p. 162)

Over this same 10-year period, the number of positions available for these applicants grew at a much slower pace, increasing by 438 positions (from 2,752 to 3,190, or 16%). Of these new positions, the majority (279 or 64%) were created in a two-year period, between 2006 and 2008. This period of growth ended with the onset of the economic downturn that occurred in the United States in 2008–2009. In fact, APPIC reported that initial registration figures for the 2009 Match predicted a very significant increase in positions, but that increase (nearly 250 positions) vanished as the economic situation became more serious and sites removed positions from the Match.

Thus, in 2012, the imbalance was the worst at any point in APPIC’s history, with the number of registered applicants (4,435) exceeding the number of positions (3,190) by 1,245. Preliminary data from the 2013 APPIC Match, still in process at this writing, suggests a slight improvement in the imbalance, as the number of positions increased by 186 (as compared to the previous year), whereas the number of registered applicants increased by 46.

Internship quality.

If one is to understand the true scope of the imbalance between applicants and internship positions, one must look beyond the numbers to the quality of the positions available. In the 2012 APPIC Match (APPIC, 2012), a total of 2,363 accredited positions were available, which means that an accredited position was available for only 53% of all registered applicants, a figure that can only be described as alarming. Not only does this lack of accredited positions threaten the quality of the internship experience for many students, it also raises questions about protection of the public and the credibility of the profession (McCutcheon, 2011).

Trainees who are not successful in the Match are left with several less-than-optimal options. They can choose to apply again the following year and hope for a better outcome, an option that delays the completion of their degree and increases their financial burden (e.g., an additional year of tuition, costs to apply and travel for interviews, more student loans). A second possibility is to contact training directors to see if an extra (usually unpaid) position can be created at an existing internship site. A small number of trainees are able to find such placements each year (Keilin, Baker, McCutcheon, & Peranson, 2007), even though APA and APPIC policies do not permit unfunded positions except in unusual and infrequent circumstances.

A third option is to try to create an “internship” experience at a facility that does not have an internship program, an approach that appears to be occurring with increasing frequency. Although such placements might have the advantage of allowing students to graduate, and helps to prevent these trainees from rolling over into the following year’s Match. thus increasing the imbalance, it also means that these students are completing internships that have not been externally reviewed and are of unknown or questionable quality. It is also an approach that puts trainees at risk for having significant difficulties with future employment and/or licensure, depending upon their geographic and career aspirations.

Because the increasing imbalance forces more and more trainees to pursue nonaccredited, non-APPIC internships, and because it opens the door for such internships to be created to take advantage of the free labor that can be provided by these students, concern has been raised that we are inadvertently creating a “two-tiered” system of internship training (Baker, McCutcheon, & Keilin, 2007). Few barriers exist to the development and proliferation of such programs, as the laws and licensing board regulations in many jurisdictions do not set minimum requirements for an internship or even require one at all (Hatcher, 2011; DeMers, 2011). Thus, it is often the sole responsibility of doctoral programs to set and enforce standards for the internship experience, a responsibility that can conflict with the pressure of accreditation standards that value the successful placement of trainees into internship programs.

Potential solutions.

Trainees who face an approximately one-in-four chance of not securing a position in the APPIC Match are understandably eager for information that improves their odds relative to other competitors. Such information aimed to improve one’s personal odds of matching represents a strategic approach to the imbalance (i.e., what activities and accomplishments will make me more competitive when I apply for internship?). This strategic approach to the imbalance contrasts with the structural approach, which seeks to understand and explain the underlying structural factors in the education and workforce pipelines that result in a substantial mismatch between the number of students accepted into doctoral training, the number of available internship positions, and the number of positions predicted to become available in the professional workforce. More finely detailed analyses focus not only on the quantity of positions, but also on quality indicators of enrolled students, costs of training, quality assurance at the program level, (p. 163) and “right sizing” the education pipeline not solely in terms of numbers but also in regard to specific professional skills and practice specialties predicted to be needed in an evolving health care environment. Unfortunately, predictions about the future of health service psychology employment opportunities and wage stability in the face of increased trainee enrollment remain clouded in the absence of a professional psychology workforce analysis (Rozensky, Grus, Belar, Nelson, & Kohut, 2007).

The chronic nature of the imbalance demonstrates that it is not the result of short-term or transient misallocations in the educational pipeline; instead, it is the result of structural forces (e.g., economic) that advantage the enrollment of large numbers of students and the proliferation of doctoral programs, while disadvantaging a comparable growth in settings that traditionally house internship programs. For this reason, the 2008 Imbalance meeting produced this pivotal outcome: an agreement among the doctoral training councils responsible for educating HSP that their constituent doctoral program members would commit to altering the Match imbalance by either increasing the supply of quality-vetted internship positions or by reducing enrollment, proportional to a given program’s success or difficulty in placing students in internships (Grus, McCutcheon, & Berry, 2011). For example, programs that consistently failed to place at least 75% of their students would either voluntarily reduce future enrollment (on the assumption that the low placement rate was de facto evidence that the program had saturated the internship “market” available to that particular program) or alternatively, would build internship capacity by providing financial or in-kind contributions to local entities for the benefit of their own students (i.e., create partially-affiliated internships). The central feature of this agreement is worth making explicit: doctoral programs should assume responsibility for access to all required elements of the doctoral degree, including the internship. In a system built largely of independent internship entities, essentially all doctoral programs will have a role to play in mitigating the imbalance by fine-tuning their class sizes and/or by contributing to internship capacity. Doctoral programs that have a substantial and persistent lack of success in placing their students will have a correspondingly greater duty to adjust enrollment or contribute to the creation of new internship positions. Given this obligation to build capacity, it is useful to review the advantages to a site in providing internship training, as well as the fundamentals of internship financing.

Benefits of providing an internship program.

Education and training in many professions often is characterized by a relatively lengthy professional “adolescence” in which the developing professional learns the competencies, attitudes, ethics, and culture of the profession they are entering by direct instruction and complementary experience. The internship year serves just such a purpose (Kaslow & Rice, 1985), and as such, is often remembered later by many psychologists as having been a transformative or catalytic year. Because sharing in the responsibility to educate the next generation, through individual mentorship and apprenticeship, is another common feature of professions, many psychologists find reward and value in designing, building, and maintaining internship programs. These advantages include:

  1. 1. Creating a pipeline of potential employees by educating a new generation of likely candidates, especially in domains of special local need or capability (e.g., integrated primary care providers, multicultural providers).

  2. 2. Attracting a higher caliber pool of potential employees by training them at sites that might otherwise be overlooked in the workforce by virtue of location or reputation (e.g., rural or remote sites, state hospitals serving the seriously mentally ill).

  3. 3. Expanding access to services in marginalized communities or with underserved populations by utilizing lower-cost trainee providers.

  4. 4. Improving staff morale and professional growth through participation in training.

  5. 5. Enhancing the quality of service delivery by the necessity to emphasize best practices and newly emerging practices within the context of training.

  6. 6. Improving overall program quality by submitting oneself to review, whether the review is conducted informally by students who provide feedback simply in the course of being consumers or formally through external quality assurance mechanisms (e.g., accreditation).

Funding considerations.

Establishing an internship program brings substantial advantages to a clinical service organization. Building internship capacity also entails incorporating the costs associated with training, including staffing (especially staff time devoted to program administration, supervision and training), office space, clerical and technical support, technology (including computers, telephones, and remote devices, such as secure messaging), and stipends (including benefits, leave, (p. 164) and liability coverage). Such internship costs are most frequently supported by agency operational budgets, which are justified on the grounds that the advantages of hosting a program (as outlined above) outweigh the direct and indirect costs. On the face of it, these costs can seem substantial, particularly to a service agency that might already be operating on the margin. At the same time, many agencies discover that the cost of internship training can be partially or fully offset by the increased service delivery functions provided by the interns.

As one product of the 2008 Imbalance meeting, CCTC created an internship toolkit that includes comprehensive and detailed instructions for conducting a cost-benefit analysis, as well as suggestions for securing external funding (CCTC, 2010). Among these suggested resources are contracts provided by local and state governments, federal grants (e.g., Graduate Psychology Education, or GPE), private foundation grants (e.g., Hogg Foundation), cost offsets (e.g., income-generating sponsorship of continuing education programs for psychologists in the community), and scholarships (e.g., Federal Work Study programs administered on University campuses). The CCTC toolkit makes special mention of fee-for-service reimbursement in underwriting internship training. Although some agencies have succeeded in billing for intern services, almost all third-party payers limit reimbursement to licensed, independent providers (LIPs). A relative few agencies have created work-arounds to this limitation: (a) out of pocket payment on a sliding-scale for services provided by interns relative to the full fee paid for LIP services in the same agency, or (b) third-party payment for interns who are registered, licensed, or credentialed by the state as a master’s-level provider. This latter arrangement carries risk for the intern, in that some state licensing boards have been unwilling to accept such hours for purposes of establishing eligibility for licensure as a psychologist, on the grounds that the hours were accrued in the conduct of another profession (for which the intern was already licensed or registered) and not in the conduct of training to become a psychologist.

The various funding streams reviewed in the CCTC toolkit offer creative opportunities for securing moderate sources of funding, yet also underscore the essential need for internship training to be embedded in the operating budgets of host agencies or educational institutions. The central importance of internships in the education of HSP cannot depend primarily on the quixotic nature of external government funding or the generosity of sympathetic foundations. We will return to this point in our later discussion of the responsibility that doctoral programs bear for supporting the required elements of the doctoral degree.

Current Issues and Controversies

The internship imbalance and workforce analysis.

When psychologists gather to talk about the internship, the imbalance is the engine that drives most discussions. The imbalance touches upon issues of equity, quality, opportunity, identity, social justice, and workforce. It causes us to ask where we have gone aground as a profession, and how we might reshape our future to ensure both quality of education and access to opportunity. Many agree that, as now constituted, the current situation is not sustainable.

As described earlier, the causes of the imbalance are complex. Depending on one’s perspective, it is caused by: (a) insufficient capacity among internship sites, which is itself, due to the economics of internships that are financially divorced from doctoral programs, as well as the historical underfunding of mental and behavioral health programs; (b) excess trainee enrollment, which is fueled by economic incentives to increase class size and tuition payments; or (c) a combination of both forces.

As a consequence, efforts to mitigate the imbalance have tended to emphasize one or the other side of the equation (supply versus demand), though the complexity of the situation requires a coordinated series of incremental actions that address the multiple factors contributing to the imbalance (Grus, McCutcheon, & Berry, 2011). Although such a multipronged approach has gained widespread acceptance among the doctoral training councils, others advocate more radical changes to the internship structure in order to more quickly resolve the imbalance (Larkin, 2011). All of these approaches, whether incremental or more sweeping in scope, are seriously hampered by the lack of a workforce analysis for health service psychology. In the absence of quality data regarding the number of students in the educational pipeline, their internship placement outcomes, their job attainments, and workforce opportunities for psychologists (including geographic distribution, specialty needs, and reimbursement patterns), we are limited in devising a rational plan to mitigate the imbalance. Without a clear understanding of workforce needs and employment trends in the next five, 10, or 20 years, we are in the dark when arguing that (p. 165) enrollments should be lowered or that internship capacity should be increased to meet health care needs. Central to solving the internship imbalance is production of a workforce analysis for health service psychology.

Necessary steps to mitigate, let alone solve, the imbalance remain in dispute. Less in dispute is the increasing realization that successful mitigation will take many years, very substantial changes to the internship system, or both.

Broad and general training.

Doctoral training in professional psychology requires broad and general training (Zlotlow, Nelson, & Peterson, 2011). Being both a science and a practice (grounded in the biological, psychological, and social sciences), psychology education requires the integrative experience provided by generalist training. At the same time, scientific advances, new employment opportunities, and the maturing of psychology as a discipline all provide countervailing weight in the direction of increased specialization earlier in the sequence of training.

It was not so many years ago that internship and postdoctoral training emphasized the elaboration and refinement of skills in diagnostic assessment and individual psychotherapy targeted primarily at mental health disorders rather than health conditions more broadly (Kaslow & Webb, 2011). However, coincident with the redefinition of professional psychology as a discipline and practice devoted to improving patient and community health, and with the consolidation and formal recognition of an increasing number of HSP specialties, the character of broad and general training, as well as the utility of our traditional models of training (e.g., scientist-practitioner, practitioner-scholar) during the internship year have been questioned (Berenbaum & Shoham, 2011).

Some argue that broad and general education is more appropriately offered at the undergraduate level, allowing for advanced and increasingly specialized training at the doctoral and internship levels (e.g., clinical health doctoral programs, child clinical internships). Although internship programs continue to demonstrate broad and general training through underlying programmatic structures (e.g., expected learning outcomes, student competency evaluations, cross-cutting seminars), the organization of clinics in many internships naturally lend themselves to learning experiences that are either highly focused or frankly specialized (e.g., traumatic brain injury evaluations, mood disorders clinics, rehabilitation care). Because systems of service delivery continue to become more highly articulated or “branded” for marketing purposes, it is likely that clinical training experiences will follow the same pattern. Internship programs likely will offer training in focused areas where the public expresses a need and a demand, and will grapple to identify the best methods of educating interns in the underlying and unifying science of psychology while still promoting experience in cutting edge practices.

Financial relationship between doctoral and internship programs.

Historically, university-based doctoral programs had insufficient access to clinical care settings that would be necessary for the practice and attainment of students’ clinical competencies. Thus, it was sensible for students to leave the academic environment of their doctoral program in order to immerse themselves in clinical care, for the purposes of integrating science and practice, of refining their knowledge in the real-world forge of health care settings, and of expanding their perspectives through interaction with a greater diversity of supervisors and mentors. However, this disjunction between doctoral and internship programs comes at a cost. The separation of training sites often requires students to move far from home for their final year of training, leaving friends and sometimes family behind. The advantage of greater diversity in supervision risks discontinuity in students’ educational plans and trajectories. Perhaps most importantly, this bifurcated model of training creates a situation in which doctoral programs have financial incentive to increase enrollment, whereas internship programs face various limitations imposed by the economics of health care settings (McGrath, 2011). Inevitably, doctoral programs can accommodate a greater number of students than can internship programs, a structural imbalance that almost guarantees a bottleneck at the point of entry to internship.

To date, most efforts aimed at mitigating the imbalance have emphasized building internship capacity. This may be due to the belief that more HSP are needed to address unmet health needs. It may also result from the fact that discussions focusing on capacity building are easier and less conflictual than discussions focused on moderating enrollment. However, underlying these discussions is the question regarding the appropriate role of doctoral programs in ensuring student completion of the entire sequence of training leading to the doctoral degree. In particular, what should be the obligation of the doctoral program in financially supporting the internship requirement? This (p. 166) discussion has taken many directions. Some have questioned the need for an internship year, arguing that an increased focus on practicum training, or alternatively, an increased focus on clinical science in lieu of clinical practice and licensure, both obviate the need for an internship year. In contrast, conferees at the 2008 Imbalance meeting agreed on the principle that doctoral programs bore responsibility for internship placement, to the extent that they should either adjust enrollment or financially contribute to increasing capacity to a degree that is proportional to each program’s success in placing students in internships.

Given that the internship is a required element of the doctoral degree, it is reasonable that doctoral programs should share responsibility for ensuring their students’ access to such a required element. This acknowledgment serves to link enrollment decisions to internship placement rates, providing a necessary link between these two events that introduces a natural market force. Such acknowledgment of responsibility is most easily observed in doctoral programs that have initiated, developed and financially supported partial and wholly affiliated internship programs. These arrangements recognize that doctoral programs bear responsibility to provide students access to the entire array of required elements, and serve as a check and balance on enrollment and placement.

Intern stipends.

The number of internship positions is limited by the costs incurred in supporting an internship program. Intern stipends and benefits are a major driver of these costs. From one perspective, the imbalance can be “solved” if programs are not required to pay stipends, thereby allowing internship programs to offer as many positions as can be accommodated by their other resources (e.g., number of supervisors, access to clients) rather than by their budget for intern stipends. It has been argued, particularly in financially strapped jurisdictions, that access to mental health services sometimes relies on care by unpaid interns, and that requirement of a stipend both limits intern opportunity as well as care for the underserved. Although this position has been argued with force, the preponderance of opinion is in favor of providing intern stipends. In part, there is concern that acquiescence to accepting unpaid services by interns in a harsh budget environment only undermines the profession’s efforts to gain parity in healthcare. Why value something that is readily made available for free? Why pay professional staff if similar services can be provided by unpaid labor? More fundamentally, the payment of a stipend in exchange for service is evidence of the profession’s respect for its own students. This is the central feature of the APA Graduate Students’ (APAGS) position on the necessity of intern stipends: “respectful internship sites pay emerging health services psychologists a reasonable stipend, provide benefits, and set manageable working hours for interns” (APAGS, 2012).

Competency-based education.

Competency-based education has become firmly rooted in current conceptualizations of internship training (Kaslow et al., 2004). The Competency Benchmarks (and associated initiatives) articulate a range of knowledge, skills, and attitudes that characterize preparation for HSP at the prepracticum, practicum, and internship levels (Fouad et al., 2009). Aside from providing both students and educators with concrete examples of expected performance throughout the sequence of training, the Benchmark document very importantly provides operational definitions for the education of HSP. No longer limited to assessment and intervention, the health service psychologist is characterized by a great many competencies (the Benchmarks document identifies 16 such domains). Correspondingly, HSP internships invariably offer supervised experiences that promote many, if not most or all, of these competencies. Adopting a competency framework at the internship level provides an impetus for re-conceptualizing the training experience, for improving efficiency of training, and for describing expected student learning outcomes. At the least, a competency-based approach requires us to specify how various competencies are achieved through the variety of clinical experiences available at a given internship site, as well as how they are behaviorally defined and measured. In a competency-based approach, training inputs (e.g., length of time in training) become less the focus than training outputs (e.g., intern ability to produce treatment gains).

The timing of internship in the sequence of training.

If the internship imbalance is viewed as a “bottleneck” due to insufficient positions at a critical point in the pipeline (rather than as a systemic imbalance between student enrollment and later employment opportunities), then it is reasonable to ask if the imbalance could be solved simply by granting the degree at the completion of the dissertation requirement and by making the clinical internship a postdoctoral experience. Those who argue for this change offer the following arguments: (a) expanded practicum hours fulfill the need for clinical training that was the original purpose of the pre-doctoral (p. 167) internship; (b) the internship creates a discontinuity in the sequence of training whereby doctoral programs are held accountable for intern training outcomes that are not in their control; (c) a clinical internship slows the pace of students who intend to pursue research careers and who do not intend to become licensed practitioners; (d) continued enrollment in the doctoral program during the internship year creates a financial burden for students who must pay at least nominal tuition; (e) entering the internship with a doctoral degree creates an approximate parity with medical residents, and increases the potential for billing of services that would be used to underwrite internship costs; and (f) the scarcity of internship positions creates an ethically precarious position for doctoral programs that are unable to guarantee access to an internship, even though they require it for conferral of the degree.

These arguments are countered with the following: (a) in the relatively less regulated and less controlled arena of practicum training, there is great variability in quantity and quality of experiences reported by students when applying for internship, calling into question whether practicum supplants the need for a clinical immersion experience (McCutcheon, 2009; Hatcher, Wise, Grus, Mangione, & Emmons, 2012); (b) changes to state licensing laws allowing entry to practice following completion of the internship have resulted in a proliferation of regulations related to practicum hours that has increased rather than reduced barriers to mobility (Schaffer & Rodolfa, 2011); (c) efforts to make the internship postdoctoral will require many state licensing boards to return to legislatures very soon after having made the argument that postdoctoral experience is not necessary for licensure. This position runs the risk of seeming contradictory and self-serving, and has the potential for unintended consequences from state legislatures that might think the profession is seeking to reduce protections for the public in exchange for benefit to the profession; (d) science-oriented students who hope to obtain faculty positions in clinical training programs, and thereby become the primary mentors for future clinical providers, have a correspondingly greater responsibility to develop their clinical competencies and promote their integration of science and practice by completing an internship year. Perhaps paradoxically, the students who are most interested in pursuing a research career in a degree-granting doctoral program are most likely to have teaching responsibilities for clinical topics that require their own clinical experience. Allowing such students to “opt out” of an internship threatens to weaken graduate training for future classes of students; (e) in most jurisdictions, billing for services is linked to licensure status rather than degree status, making it unlikely that doctoral-level interns (in the absence of independent licensure) will be able to bill third-party payers; (f) the number of students who elect not to attend an “optional” postdoctoral internship is likely to be negligible, given the many employment forces that exist that would make it a de facto necessity (e.g., federal employment). The net contribution to solving the imbalance would likewise be negligible but would incur both costs and risks, and (g) internship sites that currently fund nondoctoral level interns would be faced with the prospect of determining stipends for doctoral-level (though not independently licensed) providers. Likely, this would lead to inflation of stipends, which, in the absence of third-party payment, would result in potentially significant cuts to the number of positions, thereby making the imbalance dramatically worse rather than better.

Accreditation as a national standard.

Although APA or CPA accreditation is widely accepted as the standard for doctoral programs in health service psychology, there has not been a similar consensus regarding accreditation at the internship level. Among the current 711 internship members of APPIC, only 490 (69%) of programs are APA/CPA accredited, whereas 221 (31%) are not accredited. These proportions have been relatively stable for a decade or more, despite APPIC’s strong encouragement that its members pursue accredited status. Because internships are more likely to operate in the community, lack the institutional support of academic departments, and operate on the financial margins in the arena of underfunded mental health care, such training programs are more likely than doctoral programs to suffer financial limitations or instabilities (McGrath, 2011), which make direct and indirect costs associated with accreditation a perceived barrier (Berry, 2012). The consequence, however, is that an important element of doctoral education (the internship) is allowed to operate without the external quality vetting required for earlier portions of a student’s education. If one agrees that doctoral training should occur in accredited programs, and that the clinical internship should be required for conferral of the degree, then arguably, it is inconsistent to argue that the internship should not also be completed in an accredited setting. How else can the accredited doctoral program ensure a minimal level of quality training for its students during their keystone year? (p. 168)

The question of accreditation as a standard for internships has resurfaced periodically, but was recently given new impetus by the confluence of key changes in health care as well as dialogues about the sequence of training leading to entry to practice. Foremost, the passage of the Affordable Care Act underscores the critical importance of psychology’s inclusion in the health care marketplace. In order to assert a legitimate role for HSP in newly designed health care delivery, it is essential that the profession takes responsibility for self-regulation and accountability to the public. Accreditation is the system through which this is demonstrated (Nelson & Messenger, 2003). For psychology to successfully compete with other professions that also seek health care dollars, the profession must support a process of quality vetting that guarantees acceptable standards throughout the sequence of training. This is central to our profession’s social contract with the public, and is a reasonable expectation in exchange for access to public dollars. Moreover, in an era of increasing federal oversight of education, it is in psychology’s interest as an independent profession to sincerely and actively self-regulate. Better that we take charge of ensuring quality at the internship level than to leave this task for state or federal governmental agencies. Finally, as discussed earlier, proposals to mitigate the internship imbalance sometimes have included suggestions that would have the impact of degrading training quality in favor of increasing access. Because such an outcome would be especially detrimental to the profession’s reputation in this time of health care transformation, the training councils responsible for educating HSP students affirmed at the 2008 Imbalance meeting (and repeatedly have reaffirmed at bi-annual meetings of CCTC) that any efforts to mitigate the imbalance must not have a deleterious impact on educational quality (Grus, McCutcheon & Berry, 2011). As more states adopt licensure laws that allow entry to practice following conferral of the degree, the clinical training obtained during internship takes on greater importance: for increasingly large numbers of our students, the internship year has become their final opportunity for clinically intensive practice under supervision. Given this reality, lowering standards in order to increase internship access is contrary to the public interest, and thereby, contrary to our profession’s interest.

In response to these various currents, there has been a revitalized interest in making accreditation a standard for the internship. The APA Board of Educational Affairs (BEA), CCTC, and APAGS recently endorsed APA/CPA accreditation as the standard for graduate training in health service psychology. At its March 2011 meeting, CCTC endorsed a vision statement that called for APA/CPA accreditation as the standard for all levels of training (doctoral, internship, and fellowship), with the understanding that this would be phased in over a period of years in order to allow currently nonaccredited programs reasonable time to achieve this status, thereby protecting currently enrolled students (CCTC, 2011). This proposal moved forward to BEA, which supported the standard of accreditation at the doctoral and internship levels in a much-expanded “Statement on Accreditation” (Belar, 2011), which describes in greater detail the rationale and a process for implementation. Student support for this development, as one element of an overall strategy, is found in the APAGs statement on the imbalance (APAGS, 2012).

Although momentum seems to be building to establish accreditation as a standard for internships, there is recognition of many complex implications and potential consequences that must be addressed simultaneously. For example, adoption of this standard has limited impact if it is not eventually linked to licensure. Thus, attendance at nonaccredited doctoral and internship programs is not discouraged unless access to licensure is made more difficult or not possible as a consequence. Further, legitimate empirical questions exist regarding whether attendance at an accredited internship results in improved trainee competence when compared to attendance at a nonaccredited program. Given that the movement in favor of accreditation is substantially a response to legitimate political sensitivities about the positioning of HSP vis-a-vis other health care professionals, it is also true that a profession committed to evidence-based educational practices has a duty to empirically investigate this question. Finally, there is widespread recognition that an abrupt adoption of accreditation as a standard threatens to dramatically worsen the imbalance in the short term (CCTC, 2011). If the very substantial number of nonaccredited APPIC-member programs were denied participation in the APPIC Match due to their noncompliance with the accreditation standard, the already-critical imbalance could become so intolerable that it could undermine support for the very existence of internship training. In recognition of this scenario, implementation of the standard would occur over a period of years so as to allow both APPIC-member and nonmember internship programs the time necessary to achieve accredited status. (p. 169)

Expanded roles and markets.

Psychology practice has greatly benefited from newly developed professional roles and expanding markets. This is seen most dramatically in psychology’s evolution from a discipline devoted primarily to mental health concerns to one that has expanded to embrace health conditions. New practice opportunities have been the result, and along with that, a need for new educational models and experiences. As U.S. health care is transformed in the wake of the Affordable Care Act, and as HSP continues to mature and further specialize, it is inevitable that internship training will advance to keep abreast of new opportunities (e.g., integrated primary care, interprofessional models of care delivery, and advances in neuroscience). Such changes will include new content areas and practice competencies, but may also include more substantial alterations in how training is delivered (e.g., remote technologies) and, perhaps, when it is delivered in the overall sequence of training leading to licensure.

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