A Commentary on “Systemic Challenges in Health Service Psychology Internship Training: A Call to Action From Trainee Stakeholders”

Palitsky et al. (2022) wrote a timely article that highlights long-standing issues in health service psychology (HSP) internship training and offers concrete recommendations for addressing these challenges. The authors offer suggestions for HSP internship-training reform and recommendations that may be feasible in the confines of current internship models including accreditation requirements. Their article focuses specifically on problematic practices that predated—and have been exacerbated by—the COVID-19 pandemic. These issues have disproportionately affected trainees who face marginalization because of race, ethnicity, socioeconomic status, disability, and other aspects of their social identity. We highlight four issues worth further discussion: (a) the integration of trainee perspectives, (b) the need for additional data to guide decisions about best training practices, (c) the importance of considering both trainees and clients when making decisions about whether to allow remote-internship options, and (d) the consideration of how discussions about internship training fit into conversations about larger HSP-training reform.

Integration of Trainees’ Voices

Written by 23 doctoral psychology trainees in HSP, all of whom completed their predoctoral internship during the first 2 years of the pandemic (i.e., 2019–2020 or 2020–2021), Palitsky et al. (2022) reflects an often-neglected perspective on HSP-internship issues—that of trainees. As the authors note, decisions concerning HSP-internship training have historically been made by individuals in leadership positions (i.e., from the top-down), including training directors, accreditation agencies, and corporate institutions such as hospitals. Note that individuals in these positions are often White, cisgender, heterosexual, able-bodied individuals from higher socioeconomic backgrounds. These individuals, in part because of the considerable amount of privilege they experience in society, may have a limited understanding of how their decisions about training and related issues (e.g., economic considerations, relocating) may cause undue stress and harm to interns with less privileged identities. Furthermore, given the historical lack of attention to cultural-humility training in HSP programs, many clinical supervisors are not equipped to support trainees in their capacity to deliver culturally humble services (Galán et al., in press). Yet anecdotally, the field is seeing a new generation of graduate trainees who are deeply committed to social justice and are proactive in seeking out training in cultural humility and multiculturalism, particularly given the proliferation of virtual trainings on these topics offered through several organizations. Thus, in some internship programs, trainees may actually have more up-to-date training in things such as cultural humility than some of their supervisors, particularly in programs with more diverse trainees but less diverse supervisors. This highlights why the trainee perspective, a group that tends to be more diverse than individuals in HSP leadership positions, is vital to ensuring that training practices are contextually grounded and designed to respond flexibly and sustainably to diverse needs (Brown et al., 2022).

Including trainees’ voices at all levels of the field requires a shift in the way we (as a field) define the relationship between “trainer/supervisor/teacher” and “trainee/student.” It means moving away from a hierarchical top-down approach to a more collective community approach in which trainers share power with trainees and value them as stakeholders with unique values, needs, and priorities. Examples could include having an intern representative be involved in the internship-training committee and attend ongoing meetings throughout the year, ensuring that interns are able to provide anonymous feedback at multiple points throughout the year, and involving current interns in the application-review process for the incoming class. Centering interns in these ways will shift the status quo by meaningfully embedding interns in internship leadership, providing unique training opportunities for interns, and allowing ongoing integration of feedback.

Need for More Data to Test Assumptions About What Constitutes “Good Clinical Training”

As we consider how to translate Palitsky et al.’s (2022) recommendations into practice, it is critical to consider barriers to enacting the changes recommended by the authors. We expect that there may be resistance to some of the suggestions recommended by the authors, such as remote-work and hybrid-training options (see Palitsky et al., 2022, Table 1). Such resistance may be related to specific assumptions or beliefs about what constitutes “good clinical training” and optimal methods for learning. However, many of these beliefs may actually represent speculation from more privileged individuals who are drawing from their own prior experiences and what worked for them in the past. These assumptions and insistence on traditional methods may not fit with the rapidly changing landscape of mental-health treatment (e.g., rise of telehealth) and are clearly contributing to inequities in training and trainee well-being (Buchanan & Wiklund, 2020; Galán et al., 2021). Collecting data to empirically test these assumptions is an important next step. On a program level, this means developing standardized systems for assessing internship-training outcomes. A multimethod, multiinformant approach should be used when operationalizing good clinical training, including but not limited to a combination of intern self-assessments, intern satisfaction with training, supervisor ratings of intern outcomes and growth during internship, client/patient outcome data, measures of therapeutic alliance, and standardized performance ratings of live or recorded clinical sessions (Sharpless & Barber, 2009). Specific strengths, limitations, and applications of each of these methods are outlined in resources such as the Council of Training Council’s “Benchmarks document” (Fouad et al., 2009) and “Competency Assessment Toolkit” (Kaslow et al., 2009).

Research on internship training can play a pivotal role in fueling large-scale systemic changes, helping to dispel erroneous assumptions about the necessity or superiority of certain training practices and providing a way to measure the risks and benefits of certain methods and policies for trainees. For instance, a study conducted with psychology doctoral students found that there were no differences between in-person supervision and telesupervision on supervisee-reported outcomes, including supervision satisfaction and supervisory working alliance (Tarlow et al., 2020). Although these findings tentatively suggest that telesupervision may be a viable alternative to in-person supervision, the study employed a multiple-baseline experimental design and involved only three trainees. Before the field can make definitive conclusions regarding the effects of supervision modality on training outcomes, researchers need additional research comparing telesupervision with in-person supervision, especially studies using larger samples and randomized trials. These recommendations echo those of others in the field who have called for more data to guide the design and refinement of training programs and accreditation systems (Gee et al., 2022; Levenson, 2017). As noted by Gee and colleagues (2022),

Longitudinal data collection will be particularly important for understanding the consequences of local innovations. To enhance efficiency and rigor, survey design should be coordinated across institutions via Academy of Psychological Clinical Science (APCS) or Council of University Directors of Clinical Psychology (CUDCP) workgroups. In some cases, it may be possible to organize randomized trials of particular training or climate interventions. (p. 63)

Such data will enable the field to anchor decisions about training and accreditation requirements in evidence rather than intuition. On a practical level, this also requires the field to generate more accessible tools and models for how to build sustainable systems of obtaining and integrating trainee feedback and other training outcome measures and considering who may not be reflected in any given set of findings (e.g., as a result of marginalization and/or exclusion).

Need for More Data on Client Outcomes When Evaluating Telehealth Options

An additional area in which more data are needed regards the efficacy of telehealth interventions and the barriers to engaging in such services. The COVID-19 pandemic catalyzed the rapid adoption of telehealth services because of social-distancing guidelines, stay-at-home orders, and increased psychological distress (Wosik et al., 2020). Palitsky et al. (2022) advocated for “embracing the added flexibility afforded by telehealth to participate in training and clinical activities remotely and from across state lines” (p. 828). Although the authors acknowledge some of the challenges that trainees have faced with the transition to telehealth and telesupervision, such as the lack of privacy and lack of access to affordable, high-speed Internet, missing from this discussion is a consideration of how the adoption of telehealth has affected clients. On the one hand, teletherapy has the potential to reduce barriers to mental-health access by increasing flexibility and reducing challenges associated with scheduling and transportation (e.g., for clients of lower socioeconomic status who do not have access to reliable transportation or childcare). However, it is also possible that because of inequalities in access to technology and the Internet (i.e., the “digital divide”), families of low socioeconomic status and individuals of color have faced the greatest disruptions in access to mental-health services, further amplifying inequities. Better understanding of whom we are reaching and who is being left out as a result of the transition to telehealth is essential (Willis et al., 2022).

In addition, although telehealth has been shown to be effective for delivering both individual- and group-level interventions (e.g., Hollis et al., 2017; Nelson & Sharp, 2016), most of this work has been conducted in non-Hispanic, White individuals, raising questions about whether these interventions are equally effective for people of color. Although models exist for adapting in-person services to telehealth and for adapting evidence-based treatments to be culturally responsive, research on how to tailor interventions to be culturally responsive and appropriate for telehealth platforms is lacking (Willis et al., 2022). Thus, although we agree with Palitsky et al. (2022) that telehealth may help to advance equity and improve sustainability in HSP training, better understanding of how telehealth can be adapted to meet the specific needs of historically marginalized populations is critical before the field can draw definitive conclusions about the circumstances under which trainees should be allowed to provide telehealth services.

Connecting Discussions About HSP Internship Training Within Broader Discussions of Reform

Discussions about HSP-internship training should be situated within discussions regarding larger HSP-training-model reform. Although Palitsky et al. (2022) emphasized the importance of integrating trainees’ voices during the internship year, it is also important that trainees have a voice in shaping other aspects of their training, including whether they complete an internship or receive training in other professional activities likely to reduce mental-health burdens (e.g., training prevention, mobile mental health). This article is largely predicated on the assumption that completing a predoctoral internship should continue to be a graduation requirement for HSP trainees and that all doctoral-level HSP-training programs are responsible for ensuring that their students are eligible for licensure after graduating. Berenbaum and colleagues (2021) challenge this dominant approach to training and advocating instead for a flexible two-phase model for clinical-psychology training. In Phase I (the “Foundational Knowledge and Competency Phase”), graduate students would develop foundational knowledge of psychopathology, assessment, and intervention and basic competency in the provision of clinical services. In Phase II (the “Focused Competency Phase”), students would receive advanced training and develop expertise in a subset of topics relevant to the professional roles they wish to pursue, such as research, public policy, or direct client care. Under this modular approach, internship would be part of postdoctoral, rather than predoctoral, training, empowering students to make their own decisions about what they want next in their training based on their personal values, goals, interests, and personal life circumstances (e.g., economic security, caregiving responsibilities). Although concerns about the two-phase model have been raised (e.g., Gee et al., 2022), we posit that several of the training issues raised by Palitsky and colleagues (2022) could be addressed by making internships part of postdoctoral training.

As an example, take the issue raised by Palitsky and colleagues (2022) regarding whether HSP trainees should be considered essential or nonessential personnel. Under the current training model, the goal of the HSP internship is to continue the development of clinical skills in the pursuit of degree completion. If training were to shift to a two-phase model as described by Berenbaum and colleagues (2021), internship would be a postdoctoral experience. The goals of the postdoctoral clinical internship may therefore differ from the goals of the current predoctoral-internship experience. Although internship would remain a training experience, it would occur after degree completion, similar to the current medical-school and residency-training sequence. This may shift the primary goal away from training and toward gaining experience through service activities and revenue generation, thus tipping their role toward that of essential personnel. Under a two-phase model, interns may also be afforded appropriate salaries and additional rights and protections as a result of being essential personnel, which may ultimately be in better alignment with their training and responsibilities compared with the current predoctoral-internship approach, which does not guarantee that interns are considered nonessential personnel. Furthermore, if internship became postdoctoral, there would be a stronger rationale for the importance of trainee voices/shared power. As postdoctoral fellows, interns could play a critical role in the evolution of internships. Interns’ proximity to changing career landscapes and opportunities (e.g., the inability to support ever-growing numbers of principal investigators or the rise of mHealth companies) best position them to be drivers of change and consultants to internship programs. This would facilitate the evolution of internships to best prepare future HSPs. Thus, it is key to consider how recently proposed changes to the HSP-training model, including internship training, interface with the internship challenges raised by Palitsky and colleagues.

Conclusion

Palitsky et al. (2022) offered a much-needed critique of the current HSP-internship-training model and raised several critical issues for stakeholders to consider moving forward. Although we share the sentiment that there is a critical need for the continued amplification of trainee voices and needs, we are also cognizant of the constraints that internship sites face because of factors such as funding and accreditation requirements and ongoing discussions regarding HSP-training reform more broadly. Thus, conversations regarding HSP-internship training must be situated within discussions regarding larger HSP-training-model reform. Any changes to training should be data-driven and evidence-based and consider diverse stakeholder perspectives, including not only those of trainees themselves but also those of the trainers, organizations, and the people HSP serves. Individuals leading these efforts must also critically consider which voices may be excluded from the data, keeping in mind how current systems are influenced by and uphold the perspectives of privileged groups.