Predoctoral Internships

The predoctoral internship, a vital component of professional psychology education and training, is one of the formative experiences for individuals obtaining doctoral degrees and licenses in psychology. Generally considered the capstone year of doctoral training, it provides students the opportunity to expand upon and integrate their clinical experiences, to be exposed to diverse patient populations, and to experience a variety of perspectives both within and outside of psychology.

This entry begins by providing a historical backdrop of the predoctoral internship experience. The key issues and trends that dominate current thinking regarding internship training, with particular focus on supply and demand imbalance, financial considerations, areas of emphasis, the application process, and the APPIC Match are addressed. The student perspective on the internship experience also is offered.

History

The American Psychological Association (APA) inaugurated internship training at the Boulder conference in 1949. Conference participants mandated that a 1-year, full-time internship experience would be required for the doctoral degree in applied psychology. Accreditation of predoctoral internship programs through the APA began in 1956, and by the end of 2006 there were 455 APA-accredited programs. The Canadian Psychological Association began accrediting programs in 1984. While the accreditation system has been modified over the years, it has been continuously supported by the profession. However, there have been and remain various perspectives regarding the value and structure of the accreditation process.

In 1968, the Association of Psychology Internship Centers (APIC) was formed as an informal cadre of psychologists invested in training predoctoral interns. In 1992, the organization expanded its mission to include postdoctoral training and was renamed the Association of Psychology Postdoctoral and Internship Centers (APPIC). APPIC, which is committed to enhancing internship and postdoctoral training in professional psychology, establishes minimal standards for quality training programs, develops selection policies and procedures for matching applicants to internship programs, publishes a directory of programs, facilitates the placement of unmatched applicants, assists with the informal and formal resolution of problems related to internship and postdoctoral training, represents the views of internship and postdoctoral agencies at the North American level, and takes a leadership role in national and multinational psychology conferences. One such conference was the National Conference on Internship Training in Psychology held in Gainesville, Florida, in 1987, the only national meeting devoted exclusively to internship training. Delegates developed a policy statement on internship training and delineated core requirements for the internship experience.

From the 1972-1973 training year through the 1997-1998 year, APPIC coordinated a “uniform notification” system, a process by which internship offers were tendered and positions were accepted based on a specific set of rules. Given the multitude of problems associated with this system, APPIC in 1999 initiated a computer-based internship matching program (the APPIC Match) to facilitate the placement of applicants into available positions.

Psychology typically has emphasized 1-year, fulltime internships, although many students with family, financial, or other obligations have great difficulty in completing a full-time training program. While the 2006-2007 APPIC Directory lists only 15 2-year, half-time funded internship positions (0.5%), 5% of applicants who responded to a 2005 APPIC survey reported that they would prefer a half-time internship experience. In 2005, a national conference identified the benefits of half-time internship training, obstacles to implementing such training, and potential solutions for overcoming these barriers. A compelling case is being built for developing and promulgating systematic and coherent half-time internship program designs and structures. There are a number of excellent examples of half-time internship models and efforts to ensure the quality of these programs.

Supply and Demand

In the early to mid 1990s, concerns began to be raised about a potential imbalance between the number of applicants (supply) and the number of available internship positions (demand). This led to a 1997 APPIC-APA sponsored conference on “Supply and Demand: Training and Employment Opportunities in Professional Psychology.” This imbalance has become more pronounced over the last several years, with a total of 3,210 applicants competing for 2,779 available positions in the 2006 APPIC Match. These figures do not consider those applicants who withdrew from the Match because they were rejected from all sites to which they applied or the fact that some students and programs crafted new funded or unfunded positions after the Match had been completed. Between 2001 and 2005, the number of registered applicants increased by 275 and the number of available positions increased by only 16, suggesting that the growing imbalance reflects an increase in the number of students rather than a reduction in the number of positions.

As the supply-demand imbalance continues to increase, applicants may feel growing pressure to focus more on obtaining a placement than on the quality of the placement itself. Similarly, doctoral faculty may experience pressure to lower their standards for internship to ensure their students’ graduation. These phenomena can result in reduced incentives for new and existing internship programs to seek accreditation or APPIC membership, because those programs can easily fill their positions without meeting national standards. It also has increased pressure on students to complete more practicum hours to remain competitive, potentially interfering with their ability to complete other academic and research requirements. Further, students who accept nonaccredited or non-APPIC member internships run the risk of experiencing difficulties related to future licensure or employment.

Financial Considerations

Financial issues related to internship training need to be considered for students and programs. First, given the supply and demand imbalance, students feel compelled to apply to and interview at an increasing number of sites, which is associated with significant costs in terms of time and money. For the 2006 APPIC Match, applicants reported spending an average of $1,508 for the entire process. Second, intern applicants are underpaid; of the positions listed in the 2006-2007 APPIC Directory, the mean internship salary is $21,600 for all APPIC-member programs and $22,700 for all accredited programs. This is despite the fact that a growing number of programs have increased their stipends to $23,660 consistent with the standard set by Fair Labor Standards Act. Third, there are limited federal funds to support internship training, as only recently have graduate psychology education funds been accessible. Fourth, there are questions about the cost-effectiveness of programs given the time and resources required to train students and the fact that most agencies are not permitted to bill insurance companies for interns’ services.

Areas of Emphasis

Among the 621 member programs listed in the 2006-2007 APPIC Directory, internship training occurs in Veterans Affairs Medical Centers, medical schools, university counseling centers, state hospitals, community mental health centers, child and adolescent psychiatric or pediatric facilities, private general and psychiatric hospitals, military and correctional facilities, psychology departments, private outpatient clinics, and school districts. Some programs include the collaboration of multiple settings into a consortium model, and others involve affiliations between graduate programs and facilities at which internships are offered.

Sites vary in terms of populations served according to age, inpatient versus outpatient, individual and cultural diversity considerations, geographical location, and income of patients. They also differ in treatment modalities emphasized: therapy (individual, couples, family, group), community intervention, consultation and liaison, crisis intervention, brief and long-term therapy, and cognitive rehabilitation. Further, there is variability in the extent to which they provide training in supervision, although with the growing recognition in the field that supervision is a core competency, increasing numbers of sites offer extensive training in this domain. There is marked diversity with regard to specialty areas. Areas of special emphasis that have received considerable attention include those of children and older adults, health care in individuals across the life span, clinical neuropsychology, consultation, and working with individuals with severe and persistent mental illness. Internships also train psychologists for working in settings including managed care; market-driven practice; primary care; and public health, including prevention, public policy, and community action. Many programs highlight teaching in diversity, such as women’s issues, religion and spirituality, and multiculturalism. A growing number of programs emphasize training in empirically supported treatments and research.

Recently, it has been argued that the structure of internship programs is not sufficiently responsive to emerging trends and practice opportunities in the field but is rather overly focused on training individuals for the traditional clinical-provider role. This may contribute to an oversupply of clinical practitioners and a lack of adequate preparation for interns to compete for jobs in new areas of psychological practice.

Despite APA’s efforts over the past decade in requiring internship programs to define and articulate their model of training, characteristics of a training program may be better described by the setting and areas of emphasis than by the articulated training model. Similarly, there appears to be a poor relationship between the model of students’ doctoral programs and the model represented by students’ choices of internship. Clearly, more work is required in this area. Because current training models do not capture differences in training sites, new paradigms are needed to better capture similarities and differences in approaches to training across programs.

Application Process

There have been multiple changes to the internship application process in recent years. First, the APPIC Directory is now online, which allows students to more effectively search for sites that appear to be a good fit for their training interests. Second, instead of each internship site requiring its own unique application, most sites now accept a standardized application, the APPIC Application for Psychology Internships (AAPI). As of this writing, the AAPI includes background and educational information, documentation of supervised practicum experiences, test administration and report writing experience, professional conduct, and essay questions. Five essay questions require applicants to provide an autobiographical statement along with information about theoretical orientation, experience and training with diverse populations, research interests and experiences, and the fit between themselves and the specific site. Third, due to increasing concerns about the inflation of letters of recommendation and the lack of attention in such letters to applicants’ limitations and areas of growth, suggestions for more balanced and useful letters have been provided. Programs in Canada have established guidelines for a uniform letter of recommendation that includes information about how the recommender knows the applicant, current professional and personal competencies of the student, areas for personal growth and development, and a summary recommendation.

While requirements vary across sites, a typical internship application packet consists of a cover letter, AAPI, verification of internship readiness from the graduate program, copies of graduate transcripts, and three letters of recommendation. Some sites require work samples (e.g., testing reports). Manuals and articles guide students in preparing strong applications, and research findings shed light on factors associated with positive and negative match outcomes. Applicants are most likely to be matched at a site when the site perceives a good fit between the applicant’s goals and clinical experiences and the site’s opportunities, when the student has impressive letters of recommendation, and when the person interviews well. Conversely, applicants are less likely to be successfully matched to a site when they have not completed their comprehensives and dissertation proposal defense, have incomplete course work, are not from accredited doctoral programs, and are not viewed as being a good fit.

The APPIC Match

In 1999, APPIC made a dramatic change to the process in which students were placed into internship positions. Due to the myriad problems associated with the previous telephone-based system of making offers, APPIC implemented a computer-based matching program similar to the one used by medicine and other professions. The Match provides a number of benefits to participants: reduced stress, reduced violations of APPIC policies, better outcomes, elimination of gridlock, and improved experiences for couples. The APPIC Match is administered by National Matching Services, Incorporated (NMS), a Toronto-based company that specializes in the administration of matching programs. The matching process is governed by a set of rules called the “APPIC Match Policies” that are designed to ensure the smooth operation of the process and reduce stress and pressure on applicants.

Applicants typically begin the selection process in the summer or fall by identifying internship programs in which they are interested, usually with the assistance of the APPIC Directory Online. Application deadlines typically are between November 1 and December 1, with interviews occurring during December and January. Some programs offer telephone interviews, while others prefer applicants to interview on-site, usually at their own expense.

Upon completion of interviews, each applicant and program submits a “rank order list” (ROL) to NMS by a predetermined deadline (currently in early February). An applicant’s ROL consists of a list of programs in which he or she is interested in the order in which he or she prefers them. Similarly, a program’s ROL consists of a ranked list of applicants. Both applicants and programs are encouraged strongly to rank according to their true preferences, without considering other factors (e.g., how others ranked them, competitiveness of a program), as this maximizes their chances of getting the best possible match. Special ranking procedures are available for couples so they can attempt to geographically coordinate their placements.

Results of the Match are provided in a two-step process currently held on a Friday and the following Monday in late February. Match results are considered binding on all parties. On Friday, applicants are told whether or not they matched, but they are not told the specific program to which they matched. Programs are not provided any results on that day. On the following Monday, applicants learn the site at which they matched. Programs receive a list of students to whom they matched. This three-day delay allows unmatched applicants the chance to regroup and prepare to participate in the “APPIC Clearinghouse,” a process that facilitates placing unmatched applicants in positions left unfilled by the Match.

Student Perspective

There has been some attention paid to factors that determine whether or not applicants apply to a particular site. Students appear to apply to sites based on a gut feeling of sense of fit with the program; perception of good fit between personal interests and program’s strengths; program’s prestige or reputation; amount, quality, and content of the education in terms of supervision and didactic activities; breadth of populations served; areas of special emphasis; and geographic location. They also are drawn to programs in which they perceive a sense of community, respectful treatment of clients and colleagues, and support for authentic interactions. Individuals interested in pursuing academic careers often consider research opportunities at the site. Applicants tend not to apply to sites if they perceive they have a limited fit with the program or location or if there are financial or partner concerns associated with the program. Thus, professional, personal, and practical considerations influence decision making.

During the internship year, interns solidify their professional identities, refine their competencies, and gain entry to the next phase of their careers. Interns experience their training year as a time of personal and professional transitions, “passages,” and critical events, and they grapple in a condensed fashion with each of Erikson’s psychosocial challenges. They encounter developmental stressors during the year, including adjusting to a new training and clinical environment, developing trusting relationships with supervisors and peers, questioning their competence as psychologists, taking risks to acquire new competencies with a broad array of populations, engaging in self-assessment, and career planning. They participate in myriad self-care activities to assist them in managing these stressors, including seeking support of family and friends, active problem solving, participating in pleasurable activities, and humor.

Future Directions

Looking to the future, the profession may need to address a number of critical issues. First and foremost, the increasing supply-demand imbalance threatens professional psychologists’ ability to effectively train students seeking their doctoral degrees and imposes severe delays and hardships on hundreds of students each year. Although myriad strategies have been proposed to redress the supply-demand imbalance, a systematic or concerted national effort may help ameliorate this growing crisis.

In addition, the profession may benefit from increasing the opportunities for 2-year, half-time internship experiences, enhancing advocacy efforts at the federal and state levels for increased financial support of psychology internship programs (such as the recently established graduate psychology education program), and ensuring that internship programs are appropriately preparing students for the new and emerging practice opportunities in professional psychology.

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