Letters

Righting the internship imbalance

While I appreciate the attention that APA has given to this major dilemma facing new professionals ("Righting the internship imbalance," February Monitor), I was disappointed by an opinion that PsyD programs are to be blamed for part of the mismatch between sites and applicants. I believe that this is an unfair characterization that only serves to polarize the field of psychology, rather than uniting us behind a common goal.

As an intern about to complete a PsyD program, I do not feel any less prepared for internship than any of my PhD colleagues. While some (especially the early programs) PsyD programs do accept and graduate large numbers of candidates, there are many more programs that are responsible training centers that aim to provide the field with competent practioner-scholars. According to APPIC, in 2011, the match rate discrepancy between PhD and PsyDs was less than 10 percent. It would appear as if PsyD programs are indeed preparing students well for internship. These numbers speak to degree programs that are both producing well-prepared future professionals.

I believe that while the internship imbalance is a very serious problem facing our field, attributing it partially to PsyD programs only contributes to an "us-versus-them" mentality. Rather than dividing us, we should be aiming to find ways to encourage programs to open new internships (as later discussed in the article). Also, initiating guidelines for cohort sizes may be helpful until the imbalance is addressed. Let us unite to solve this problem, rather than fostering this artificial divide between PsyD and PhD.

Thorayya Said Giovannelli
Memphis, Tenn.

"Righting the Imbalance" provided excellent ideas about funding internships and demonstrating their benefits. However, it is still unconscionable for any university to accept too many students and require internship completion while knowing some will not get internships no matter how well they complete courses and practicum. Universities should be forced to arrange enough internships for all of their students.

As a former hospital director of internship training, founder of New York state's annual internship fair, a former senior internship accreditation site visitor for APA, and founder of the Psychology Internship Directors of New York State, I did research on the imbalance in New York that went from a surplus of internships in 1987 to a shortage in 1994 and published an article warning that something should be done. APPIC tended to blame victims who could not relocate. APA said it could not control imbalances because of restraint-of-trade laws. Now, 18 years later, the situation is worse and likely to deteriorate in a horrible economy that cannot support additional internships (and their required supervisors) and students with huge loans and other commitments unable to relocate.

The solution: APA should require universities to have sufficient internships for every student as a prerequisite to accreditation.

Carol Goldberg, PhD
Syosset, N.Y.

Adult ADHD

The March Monitor had two articles on the trials and tribulations of adults with ADHD. Although we recognize that most children with ADHD continue to have symptoms as adults and that some individuals are not diagnosed with ADHD until adulthood, we believe that insufficient attention was given to assessment of adult ADHD and ensuring that symptoms are real. Published guidelines on ADHD diagnosis emphasize self-reported symptoms and history. This is problematic for several reasons. First, attentional disorders are pervasive in clinical practice. Similar to a fever, they can have many causes, one of which may be ADHD. Second, adults may not accurately report symptoms and may not accurately remember early history. Third, ADHD evaluations have potential secondary gain. Among these are access to psychostimulant medications and accommodations, either at school or at work, which individuals may seek to gain a cognitive edge, better grades or better test scores. A growing body of research has shown that ADHD symptoms and cognitive impairment are easily feigned. Internet websites are rife with advice on how to fake ADHD. Using specific and embedded measures of performance (symptom) validity, several studies have found evidence of feigned symptoms or impairment in as many as 50 percent of adults and college students seeking ADHD diagnosis (cf., Marshall, et al, 2010; Sullivan et al, 2007). Rather than relying on self-report alone, we believe that ADHD assessment should be comprehensive and, in addition to interview and behavioral ratings, should include academic record review, neuropsychological assessment and performance validity measures, and psychologists should investigate other potential causes, including exaggeration.

Robert L. Mapou, PhD
Silver Spring, Md.
Allyson Harrison, PhD
Queens University
Julie Suhr, PhD
Ohio University
Brian Sullivan, PsyD
College of Charleston

And 10 other colleagues in the United States and Canada. For a full list, go to our digital edition.

Is ADHD mostly a myth? Sometimes I wonder. When we define symptoms to invent a disorder, this action gives birth to what seems to be a reality. Years ago, I was assigned to find and evaluate all students in seven Rhode Island public elementary schools. At that time, ADHD was called "minimal brain disorder." However, after being unable to show actual damage to the brain, the experts quickly changed the name to "hyperkinetic" and "hyperactive" disorders before finally settling on "attention deficit" disorders.

It was easy to find the students. They were the lively ones: full of life! As I diagnosed one student after another, it soon became apparent that diagnosis and treatment suddenly reversed itself. When a student responded to Ritalin by better conforming to conventional schooling (by tolerating being kept still) it confirmed ADHD. If the student did not respond by settling down, we concluded he or she had "other problems." The official definition of ADHD simply defined high-energy children whose needs were not being met in their classrooms or schools. These were often bright, talented students.

Thus we might say that a school with an ADHD child has a disorder: SWOI (School Without Individualization disorder). When the child's needs are met in the classroom, including the need to be respected, ADHD disappears. One of my colleagues, Chris Mercagliano, accepted six elementary school students diagnosed with ADHD into his school. They all had been previously medicated. Without medication and with a totally individualized curriculum, the ADHD symptoms disappeared. They did so well that Mercagliano wrote a book, "Teaching the Restless." 

After over three decades of study, it seems to me that putting a label on a child or adult can be either helpful or damaging. It is helpful when the diagnosis leads to those involved with the person (including whole school systems) seeing the problem as one in need of individualizing and meeting the child's needs. It is damaging when it leads to sedating drugs that support a person enough to encourage a damaging system. These are usually ones that hurt not only those with ADHD symptoms, but also most other unidentified victims of that system. With adults, the same sort of thing can happen, as when the label can invite a couple to work together instead of against each other, as your author pointed out.

Emmanuel Bernstein, PhD
Saranac Lake, N.Y.

Correction

Due to a typo, a letter from Dr. Leon Hoffman in the March Monitor incorrectly used the phrase "one-on-one therapy." Dr. Hoffman was emphasizing that therapy should be known as "one-to-one psychotherapy."


Please send letters to Sara Martin, Monitor  Editor. Letters should be no more than 250 words and may be edited for space and clarity.