Toward a Postdoctoral-Residency Training Model

We applaud Palitsky and colleagues (2022) for their efforts to include trainee stakeholders in the conversation about changes to the health-service-psychology (HSP) training model. Although we support many of the suggestions offered, present inequities in training may be maintained if institutions variably “pick and choose” which suggestions to adopt. Instead, we suggest that a more parsimonious approach is a universal shift to internship as a postdoctoral milestone, akin to medical residency. We believe that a postdoctoral-residency model directly addresses the problems that underpin many of the serious and legitimate concerns raised by Palitsky and colleagues about the current internship model. ¹ The proposal for postdoctoral internship/residency is not new. In their recent article, Berenbaum and colleagues (2021) also suggested a move to a postdoctoral internship, which was first discussed by the Association of Psychology Postdoctoral and Internship Centers (APPIC) in 1997 (Boggs & Douce, 2000; Christiansen, 1997). Although APPIC ultimately voted to keep internship as a predoctoral training experience, the Council of University Directors of Clinical Psychology voted in favor of changing the training experience to postdoctoral. To clarify trainee roles and improve economic equity without negatively affecting competency standards, we believe that now is the time for the transition to a postdoctoral residency. We propose that shifting internship to a postdoctoral milestone will resolve the concerns articulated by Palitsky and colleagues regarding trainee roles and equity and will promote training trajectories consistent with trainee goals.

The Role of the Postdoctoral Resident

Palitsky and colleagues (2022) highlighted how role confusion contributed to inequitable treatment of interns during the COVID-19 pandemic. In the current predoctoral internship, the intern role is ambiguous given interns’ simultaneous status as students and employees. A common point of confusion, especially within multidisciplinary and medical settings such as hospitals and Veterans Affairs Medical Centers, is the HSP intern’s level of experience and training. The term “intern,” as noted by Palitsky and colleagues, can suggest a more junior status akin to a “medical student” or “undergraduate student observer.” Indeed, we and other interns have experienced instances of being given less responsibility and independence on internship compared with our experiences at practicum sites because of supervisors misunderstanding our training level. Relatedly, the ambiguous classification of interns in larger institutions is a frequent source of confusion for onboarding (e.g., being added to the electronic medical record system, setting up accounts), and such problems frequently reemerge throughout the year for sites with multiple rotation options. Addressing these issues can waste valuable training time and institutional resources. Postdoctoral trainees will be better situated to take on clinical opportunities consistent with their experience level and training needs, thereby enhancing training outcomes.

Some programs have adopted the term “psychology resident” to convey a similar status to that of a medical resident with multiple years of clinical training in practice settings. The transition to a postdoctoral residency would make the status of HSP trainees even more clear. Similar to our physician colleagues, postdoctoral residents could use the title “Doctor” with colleagues and patients, conferring an additional level of respect and clarity in multidisciplinary teams. Likewise, using the title “Doctor” may facilitate building rapport with clients, who we have found are often confused by explanations of interns’ training status, and contribute to more positive treatment expectancies. Current and former interns have remarked that transitioning to internship is a substantial shift from student to a more independent professional. Postdoctoral residents would still hold training status, because the position requires supervision and is a requirement of licensure, but with a more clearly delineated level of experience and associated expectations.

Trainee Trajectories

A shift toward postdoctoral residency will also provide a valuable opportunity for the field to reevaluate what is being taught during internship and how this facilitates the desired trajectories of trainees. For example, what is the relationship between the current training structure and projected workforce needs? As noted by Berenbaum and colleagues (2021), the role of the clinical psychologist extends far beyond providing direct clinical service, including but not limited to research, program development, consultation, training and supervision, teaching, management, public-facing communication, policy development, and advocacy. In many cases, the predoctoral internship is a year of more dense, graduate-level clinical experiences. Given that “the primary focus and purpose [of internship] is assuring breadth and quality of training” (APPIC, 2020) and the empirical evidence that years of training is unrelated to therapeutic outcomes (e.g., Christensen & Jacobson, 1994; Stein & Lambert, 1984; Tracey et al., 2014), the postdoctoral residency could capitalize on trainee’s doctoral status to move beyond an accumulation of clinical hours to include richer opportunities for training in these crucial roles. Indeed, it may be beneficial to shift perspectives on clinical training to view the hours of direct clinical service obtained during graduate school as sufficient for clinical practice and to view the goals of the postdoctoral residency as specialization and higher-level training (e.g., supervision, program development). Such a paradigm shift would require advocacy and policy change regarding state-level licensure requirements.

In addition to breadth, quality of training is paramount. A postdoctoral-residency model must build on foundational competencies to promote a training structure that focuses training on evidence-based practice. Indeed, substantive training in evidence-based approaches is limited at many internship sites (Hays et al., 2002). Note that evidence-based practice does not mean that training should be limited to empirically supported treatments but should, rather, incorporate the best available research evidence, the expertise of supervisors, and patients’ preferences and values (Hollon et al., 2014; Spring et al., 2009). Beyond training in evidence-based practice, HSP trainees should also be trained in how to disseminate these approaches throughout the various systems in which they work. To address the treatment gap between individuals who need mental-health treatment and individuals who actually receive evidence-based, quality mental-health care (e.g., Kazdin, 2017), HSP trainees could serve a unique role in providing training in evidence-based practice to lay counselors or peer supports.

As in the present predoctoral model, postdoctoral residency would require only 1 year of full-time clinical training but would allow for additional opportunities for residents to remain at their institutions; subsequent training years could contain research and clinical time consistent with the training goals of the institution and the resident (similar to current postdoctoral positions). A postdoctoral residency also allows for increased flexibility among research-focused PhDs who do not intend to pursue licensure. These trainees could choose to forgo the clinical training year without having to sacrifice a “clinical psychology” degree. Such flexibility would also open spaces in postdoctoral residency for clinically oriented trainees, although consideration will need to be given to whether trainees who do not complete a clinically focused postdoctoral residency immediately after graduation could opt to do so at a future point. Moving forward, postdoctoral-residency programs must balance training in core competencies, foundational to any work in the field, with opportunities to specialize and participate in multiple facets of the roles of HSP professionals.

Economic Equity

Palitsky and colleagues (2022) also characterized the economic burden of predoctoral internship, particularly in cases in which interns are considered essential workers but not afforded salaries and benefits commensurate with this designation (e.g., living wages, health insurance). As a full-time employee, the postdoctoral resident would be eligible for employee benefits. To ensure that postdoctoral-resident salary is commensurate with doctoral-level experience and education, we suggest widespread adoption of the National Institutes of Health (NIH) stipend levels for postdoctoral trainees such that the postdoctoral-residency year is NIH postdoctoral Year 0. Postdoctoral residents could then be reasonably considered an essential worker given that their pay and benefits more equitably balance such risk. To enact these changes, we support continued advocacy for Medicare and Medicaid reimbursement for psychology-trainee services, which may be strengthened by the transition to a postdoctoral-residency model (American Psychological Association, 2014). As of 2019, 25 states permit Medicaid reimbursement for supervised trainees (Ashton et al., 2019). It is our hope that billable postdoctoral hours (at a prelicensed or provisional license rate) would generate revenue for the institution to help offset the increased cost of higher salaries and benefits. However, we also acknowledge that additional advocacy and policy change may be required for this goal to be realized. Likewise, careful consideration will need to be given to ensure that achieving equitable resident salaries does not result in inequity elsewhere, for example by reducing the number of internship positions available.

Postdoctoral residency also reduces internship-associated costs. Presently, many interns move to a new locality for internship and a second new locality for postdoctoral training. The costs associated with moving to two new localities in as many years is disproportionate relative to the average graduate-level and predoctoral-internship stipends, which were well described by Palitsky and colleagues (2022). A postdoctoral model would also eliminate the unnecessary expenses associated with interns paying tuition and fees to their graduate institution as well as the travel costs associated with returning to the graduate institution to defend the dissertation, as required by some programs. Reducing the economic burden of internship is crucial to diversity, equity, and inclusion initiatives.

Conclusion: The Time Is Now

The clinical internship was implemented because graduate students often acquired minimal clinical experience during graduate school, which became evident with rising demand for mental-health services during and following World War II (Thorp et al., 2005). However, modern graduate training involves extensive supervised direct clinical service that is often redundant with internship training (Thorp et al., 2005), and the available evidence suggests that years of experience is not predictive of treatment outcomes (e.g., Christensen & Jacobson, 1994), making the necessity of a predoctoral, clinically focused internship questionable. Making clinical internship postdoctoral capitalizes on an opportunity to facilitate more specialized training that is aligned with trainees’ goals and interests, which for many, extends beyond the acquisition of clinical hours. We recognize that the shift to a postdoctoral-training model is substantial and will require significant institutional efforts. A change of this scope will require a fundamental shift by accrediting bodies (i.e., American Psychological Association, Psychological Clinical Science Accreditation System) that will need to be coordinated with various clinical-training stakeholders (i.e., APPIC) to inform state-regulatory boards in revising requirements for licensure. Yet, as noted by Palitsky and colleagues (2022), COVID-19 has demonstrated how flexible training programs can be in exceptional circumstances. The benefits of a postdoctoral-residency model outweigh potential costs and would address a number of concerns raised by both trainee stakeholders and other professionals (Gee et al., 2022). Although small changes in the training model would likely lead to modest improvements, an overhaul of the system toward a postdoctoral-training model will have the broadest impact on both trainees and the HSP field as a whole.