Righting the imbalance

Three years ago, José Pons, PhD, found himself in a difficult situation. As chair of the psychology department at the Ponce School of Medicine in Ponce, Puerto Rico, he received a letter from APA's Commission on Accreditation saying that only 40 percent of his students were placing in internships accredited by APA or approved by the Association of Psychology Postdoctoral and Internship Centers (APPIC)—much lower than the rates of 75 percent or higher that many other psychology programs enjoy. The commission asked Pons to discuss how his program could ensure students had a quality education when his internship placement rate was so low, since doctoral programs cannot be accredited without high internship placement rates.

The reason for the sparse figures had largely to do with Puerto Rico's size: It has only two internship sites, one accredited by APA and the other approved by APPIC. And while Puerto Rico has adequate social and mental health services, "you're always competing to find slots for practicum and internship students," says Pons.

Pons knew he had to act swiftly. Over the next three years, he convinced his school to invest money in seeking APPIC membership for its internship program; to pay for new psychology internship slots in his school's psychiatry and psychology clinics; and to fund the development of an internship consortium made up of several hospitals and clinics in southern and central Puerto Rico. He also convinced Puerto Rico's Department of Labor to nominate psychology interns as "people in need of training"—a move that paid for 10 student interns in 2010 and 10 other interns in 2011 under a work-incentive program.

The result? "We're now placing more than 75 percent of our students in internships," says Pons, even more than the average doctoral program.

Pons is just one of several program directors who are tapping their creative skills to develop more psychology internships. Psychology programs nationwide have been forced to look for such solutions since only about three in four students have been securing internships over the past decade—the result of an increase in PsyD doctoral programs and the number of students enrolled in those programs, says Greg Keilin, PhD, who coordinates the APPIC Match. In 2011, for example, 4,199 students applied for an internship, yet only 3,095 received one. More than 800 students didn't get matched in the first or second phase of the match process and 300 withdrew for various reasons. (For more details, see the November  gradPSYCH.)

And even when a student does land an internship, it may not be of high quality: One-quarter of all internships are nonaccredited, according to APPIC statistics, meaning they're not vetted and therefore may lack essential ingredients for good training, says Steve McCutcheon, PhD. He chairs the Council of Chairs of Training Councils, the umbrella organization for doctoral, internship and postdoctoral training associations in psychology. Students who take such internships may face serious consequences later on, such as having difficulty getting licensed in some states and facing poorer job prospects than their peers.

There is still a long way to go in creating enough new, quality internships, McCutcheon adds. But by taking innovative approaches, Pons and others are serving as role models, paving the way for what will hopefully be an easier internship road for future graduate students, he and others say.

Philanthropy meets psychology

One of the most promising internship-creation efforts is an initiative that's using philanthropic funds to address mental health needs in Texas. The project is headed by Michele Guzmán, PhD, a clinical associate professor at the University of Texas at Austin. She also manages grants and coordinates evaluation efforts at the Hogg Foundation for Mental Health, an endowed philanthropy at the university that focuses on advancing mental health, recovery and wellness in Texas. Guzmán has blended her expertise in both areas to create psychology internships with Hogg Foundation funding.

Two key points helped convince her foundation colleagues to fund the internships as a way to develop the state's mental health workforce. First, Texas has a serious shortage of psychologists—in fact, 107 Texas counties have no psychologists at all. Second, it's easier to draw interns to underserved areas than it is to attract fully trained psychologists.

The foundation awarded $1.6 million in competitive grants to three sites to help them form internships over a five-year period: Scott & White, a major health-care system in Central Texas; the University of Houston–Clear Lake Office of Counseling Services, a university counseling center serving older, less affluent students; and Travis County Juvenile Probation Department, a juvenile probation center in Austin.

As a condition of the grant, the sites have agreed to work toward APA accreditation by demonstrating that they have enough psychologists and institutional support to adequately train students. In all, the program will train 38 students over five years, with each site taking between two and four interns each year. Seven new one-year positions will be available for the 2012 match, growing to 11 by 2016.

The development is exciting for Scott & White, which has a strong record of providing integrated care but wants to expand its range of practitioners, says the system's director of internship training, Michael Carey, PhD, who wrote the grant. The interns will work in a variety of settings and see a diverse range of clients including those in poor, rural areas as well as patients at a new children's hospital. They'll also have the opportunity to work with certified a peer specialist—a person who has personal experience with mental illness and is trained to help others achieve recovery and wellness. "I think the interns will have a synergistic effect on psychiatry residents, medical residents and other trainees, as well as on the faculty of these various disciplines," he says.

Keilin, who helped Guzmán write the request for proposals for the grants, says that while the Hogg Foundation only funds projects in Texas, its impact could reach far beyond that state. "There are other foundations and sources of funding out there, and this model provides a blueprint that will allow others to replicate this," he says.

Acting locally

Other programs are tackling the internship shortage by creating affiliated internships or internship consortia, an idea proposed in 1995 by University of Denver psychologist Jennifer Cornish, PhD. In the model, a program or professional school seeks out potential quality internship sites at nearby hospitals, clinics and other institutions. The psychology program provides organizational oversight so that internship site supervisors can share resources, ideas and sometimes students, who may do rotations at a variety of sites depending on how the consortium is organized. Because consortiums pool funding and expertise, they're able to collectively gain APPIC membership, which they wouldn't be able to do individually.

The clinical psychology program at Chestnut Hill College in Philadelphia is one example. There, Assistant Professor Jeanne DiVincenzo, PsyD, heads a "partially affiliated" internship started by the program in 2010 in which Chestnut Hill students get first dibs on internship slots in the first phase of the APPIC Match. The internships are then opened up to students nationally in the second phase of the match.

The college began by bringing together three sites it already had relationships with, and has since expanded to seven sites, including two mental health centers, a psychiatric hospital, an inpatient facility for eating disorders, a college counseling center and two outpatient facilities. The number of internship slots during that time has doubled from seven to 14. Sites fund the internships in a variety of ways, including through grants, Medicare billing and stipends written into their budgets, says DiVincenzo.

Joining forces has had advantages for everyone involved. Site supervisors gain APPIC membership through the consortium as well as the ability to share resources and ideas. Interns receive more comprehensive and deliberate training because they have a coordinated team working with and for them. And patients get better access to care and better care, as interns' presence helps reduce wait times and they bring the latest on ethics laws, assessment and treatment. "They contribute a lot of energy and insight to treatment teams," DiVincenzo says.

And thanks to weekly didactic meetings that include all of the students, DiVincenzo and guest speakers, the arrangement gives the sense of being in a professional cohort, says Chestnut Hill student Angelika Montalbano, who is doing her internship at Rider University Counseling Center in New Jersey, one of the consortium sites. "I knew that no matter which placement I got [within the consortium], that all of the students would come together at the didactic meetings and learn about each others' sites," she says. "This experience feels so much richer than it would if I were doing an internship at one independent site."

From McCutcheon's perspective, affiliated consortiums are an important development because they make doctoral programs responsible for ensuring students have access to quality internships. "The model says that students must attend a quality internship program, and that the program will provide resources to make sure those experiences are available," he says.

Toolkits and other efforts

Meanwhile, APA and related groups are spearheading other activities to address the internship imbalance, says Catherine Grus, PhD, APA's deputy executive director for education. For one, APA, along with several training councils, APPIC and the American Psychological Association of Graduate Students, has developed an internship toolkit that walks schools and psychology programs through the steps needed to create and expand internship programs.

In addition, APA's Government Relations Office continues to advocate for internship funds at the federal level, in particular for the Graduate Psychology Education Program, which funds internship programs, including intern salaries, in underserved areas through the Health Resources and Services Administration. Despite the current economic climate and significant cuts in other HRSA programs, APA was successful in securing $3 million for the program in 2011, the result of nearly 360 visits to Capitol Hill by psychologists and psychology students, says Nina G. Levitt, EdD, APA's associate executive director of government relations.

Meanwhile, Guzmán and her Hogg Foundation colleagues continue to think creatively about ways to address the internship problem. They are now exploring the possibility of helping existing non-accredited internship sites in Texas take the necessary steps to become accredited.

"In some ways, this is an even more creative way to influence training than developing new sites," says McCutcheon. "Providing support to already existing programs could help reduce the barriers to accreditation and could have an even greater impact in attracting a large number of high quality students."

Tori DeAngelis is a writer in Syracuse, NY