Reimagining Health Service Psychology Internships and Advocating for Change after COVID-19

Roman Palitsky, MDiv, PhD¹ & the Integrative Health and Spirituality SIG

The health service psychology (HSP) internship is a one-year, predoctoral clinical training experience that is mandatory for becoming a licensed psychologist in the US and Canada. It has been an institution since the 1940s, though it has undergone periodic changes. For many trainees in HSP internships during the COVID-19 pandemic, it became apparent that the internship was a system that only worked under optimal conditions, and that for some trainees it barely worked at all. In the way that a cardiac stress test may reveal physiological vulnerabilities, the pandemic revealed fault lines in the clinical training pipeline. And, like a stress test might, it also served as a wakeup call for many of us.

HSP training programs responded nimbly to the challenges of the pandemic. New policies were rapidly developed and restrictions, such as those placed on telehealth, were quickly adapted to the needs of patients, trainees, and training institutions. Along with fellow trainees in different fields and across several institutions, several of us noticed that in the rapid adjustment to the pandemic trainee voices were left out of the conversation, leading to sometimes-disastrous consequences for trainees. As we reflected on the challenges of the pandemic, however, we came to a surprising set of realizations: the problems we were experiencing predated the pandemic and pointed to vital structural adjustments that needed to happen.

Chief among these were systemic obstacles to diversity, equity, inclusion, and belonging that replicated stratifications according to race, gender, class, and disability prevalent in society—obstacles that were being noted by others in the field who were arriving at similar conclusions (C. Galán et al., 2020). Like others, we noted that the incredibly low stipends of internships made it difficult for trainees with financial vulnerabilities to succeed in competitive internships, that representation of diverse trainees in training curricula was hampered by a rigid focus on hours rather than competencies, and that responsibility for diversifying curricula was often relegated as an extra duty to faculty and trainees from diverse backgrounds.

As an all-intern group of 23 coauthors, we composed a call to action for change in HSP internships that consisted of 24 recommendations across 8 domains that could help to address some of these challenges (Palitsky et al., 2022). One of our core recommendations was that collaborative decision-making that included trainees would be necessary, whatever the next steps in the field would be. Since the publication of our call to action we have been inspired to see major movements toward improved equity and inclusion in training.

In addition to a number of academic articles published over the last several years (many of which included trainees as coauthors) (Hood et al., 2022; Wilbur et al., 2023), there have been systemic shifts as well. In our article we noted that large entities such as the Veterans Administration would have to initiate many of the important changes in order for others to follow. Recently, the VA announced a 27% increase in intern salaries (G. Keillin, listserv communication, January 10, 2023), a difference that will mean a livable wage for many interns. Debate about making internships post-doctoral rather than predoctoral has renewed, and there have been increased calls for a “Boulder 2.0”, a training summit that would revise the HSP internship. This year the Academy of Psychological Clinical Science held a summit on clinical science training.

Four invited commentaries on our 2022 article revealed tremendous appetite for change in the field (Atkins & Mehta, 2023; C. A. Galán et al., 2023; Gee & Shackman, 2023; Knowles et al., 2023). These commentaries from leaders in the field—many of whom, as trainees, we have long admired—pointed to the need for better data on one hand, and for immediate action on the other. In our response we emphatically concurred, and added that neither data collection nor action should move forward without trainee involvement (Palitsky et al., 2023). Among the most critical sites for trainee involvement are professional organizations such as SBM. These societies, which have invested heavily in mentorship and the future of its trainees, are also ideal allies in advocating for change. And, without concerted efforts from mentors and leaders in these societies, all of these calls for action may ultimately go unanswered.

Affiliation

1. Woodruff Health Sciences Center at Emory University, Spiritual Health

References

1. Atkins, M. S., & Mehta, T. G. (2023). Look What Appeared From Under the Rug: A Commentary on Palitsky et al. (2022). Clinical Psychological Science, 21677026221129800. https://doi.org/10.1177/21677026221129799
2. Galán, C. A., Boness, C. L., Tung, I., Pedersen, S. L., & Jones, N. P. (2023). A Commentary on “Systemic Challenges in Health Service Psychology Internship Training: A Call to Action From Trainee Stakeholders.” Clinical Psychological Science, 21677026231156596. https://doi.org/10.1177/21677026231156597
3. Galán, C., Bekele, B., Boness, C. L., Bowdring, M., Call, C., Hails, K., McPhee, J., Mendes, S., Moses, J., Northrup, J., Rupert, P., Savell, S., Sequeira, S., Brenden Tervo-Clemmens, Tung, I., Vanwoerden, S., Womack, S., & Yilmaz, B. (2020). A Call to Action for an Antiracist Clinical Science. PsyArXiv. https://doi.org/10.31234/osf.io/xqwr4
4. Gee, D. G., & Shackman, A. J. (2023). Reforming Clinical Psychological Science Training: The Importance of Collaborative Decision-Making With Trainees. Clinical Psychological Science, 21677026221129820. https://doi.org/10.1177/21677026221129820
5. Hood, C. O., Schick, M., Cusack, S. E., Fahey, M. C., Giff, S. T., Guty, E. T., Hellman, N., Henry, L. M., Hinkson, K. D., Long, E. E., McCoy, K., O’Connor, K., Wilborn, A. P., Reuben, A., Sackey, E. T., Tilstra-Ferrell, E. L., Walters, K. J., & Witcraft, S. M. (2022). Short-changing the future: The systemic gap between psychology internship stipends and living wages. PsyArXiv. https://doi.org/10.31234/osf.io/rm3bk
6. Knowles, K. A., Cox, R. C., & Olatunji, B. O. (2023). Toward a Postdoctoral-Residency Training Model. Clinical Psychological Science, 21677026231156590. https://doi.org/10.1177/21677026231156594
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8. Palitsky, R., Reznik, S. J., Kaplan, D. M., Anderson, M. R., Athey, A., Brodt, M. A., Coffino, J. A., Egbert, A., Hallowell, E. S., Fox-Fuller, J. T., Han, G. T., Hartmann, M.-A., Herbitter, C., Herrera Legon, M., Hughes, C., Hosking, C. R., Jao, N. C., Kassel, M. T., Le, T.-A. P., … Stevenson, B. (2023). Inclusion of Trainee Stakeholders Is Necessary for Effective Change in Health-Service-Psychology Internship Training. Clinical Psychological Science, 21677026231156600. https://doi.org/10.1177/21677026231156598
9. Wilbur, R. C., Lund, E. M., Kuemmel, A. M., Balolong Publico, S., & Khazem, L. R. (2023). Supervising and supporting trainees with disabilities in the Veterans Administration Healthcare System: An overlooked but critical need and opportunity. Psychological Services, 20(2), 306–317. https://doi.org/10.1037/ser0000663