Cover Story
Danielle R. Biggs, PsyD, is at her wit's end. Since she earned her doctoral degree from the California School of Professional Psychology in Fresno last year, Biggs has been desperately searching for a position that will offer the year of supervised experience she needs to get a license and finally launch her career as a full-fledged psychologist.
Now that she has exhausted her list of personal contacts and the more traditional methods of job hunting, she plans to start cold-calling psychologists and asking if they have heard of any positions anywhere in the three counties surrounding her home in Coarsegold, Calif.
"Now what I'm finding out is that you can't find a position when you have a graduate degree... It's easier now to find a position that only requires a college degree."
Danielle R. Biggs, PsyD
Despite the enormous student loans hanging over her head, she's even willing to take the $9,000-a-year jobs she's seen--if only she could get one."What's ironic is that when you graduate from college, they tell you you had better go on to graduate school because you won't find a position paying any kind of money with just a bachelor's degree," says Biggs. "Now what I'm finding out is that you can't find a position when you have a graduate degree either. It's easier now to find a position that only requires a college degree."
Like Biggs, a growing number of new graduates hoping to practice psychology are finding themselves caught in a Catch 22 well-known to clinicians. Although rules vary from state to state, they typically need a year of postdoctoral supervised clinical experience before they can get a license, yet most major payers won't reimburse unlicensed psychologists.
The result? Graduates with up to $100,000 in debt who either can't find a job that provides a living wage or can't find a job at all.
Now APA has created a commission that, among other tasks, will examine and make recommendations regarding the education, training, examination and supervision requirements leading to licensure.
"Students and new psychologists are the future of our discipline," says Corey Habben, PsyD, chair of the American Psychological Association of Graduate Students (APAGS) Task Force on New Professionals. "But as they leave the starting gate, they're being tripped by their own professional restrictions."
Students leave graduate programs with three or four thousand hours of clinical training, says Dr. Corey Habben of the American Psychological Association of Graduate Students. The postdoctoral requirement is now "more of a stumbling block," he says. A vestige of the past?
It didn't used to be like that. The requirement for supervised postdoctoral experience was originally put in place because of the limited clinical experience many psychology students received in graduate school. It was believed that an additional year of supervised experience after graduation would enhance their readiness for independent practice and protect the public. But with the tremendous growth of predoctoral training and the rise of the professional school movement, many psychologists are convinced that the extra year has become outdated.
"Nowadays, students are leaving their programs with three or four thousand hours of clinical training even before they start their postdoctoral year," says Habben. "Instead of being a necessary part of training, the requirement is now more of a stumbling block."
What's more, the rise of managed care has made the requirement increasingly difficult to fulfill. Attempting to control costs by limiting the number of mental health providers on their panels, managed-care organizations often require providers to have several years of independent experience. Managed care's move into the public sector has also eliminated much of the work in community agencies, which used to represent an attractive option because they allowed as-yet unlicensed psychologists to work under supervision.
Things are no better in the private sector, where practices are often reluctant to take on unlicensed psychologists who can't bring in any revenue. Some private practitioners actually charge students for their supervision--a violation of the rules of supervision in many states.
Private practitioner Marlin C. Hoover, PhD, of Orland Park, Ill., was so struck by the number of calls he received from recent graduates desperately looking for supervised work that he and J.B. Goebel, PhD, launched a study of the situation in their state.
"Overall, there simply aren't enough formal doctoral residency positions to absorb the approximately 2,000 clinically oriented psychologists who graduate each year."
Paul D. NelsonAPA's Education Directorate
Working with the Illinois Department of Professional Registration and the Illinois Clinical Psychologists Licensing and Disciplinary Board, they confirmed that recent graduates faced a shortfall of training sites. Ten percent of the 327 people who applied to take the licensing exam during a 15-month period ending in 1996 received their postdoctoral supervision at two different sites because they couldn't find full-time positions; 3 percent received their supervision at three sites.The researchers also found that clinics and other outpatient facilities have replaced university hospitals and medical centers as the most common training sites for new graduates seeking supervision. And private practices are also becoming increasingly common training sites, especially for female PsyDs. That's potentially a problem, says Hoover, noting that this fast-growing group is being trained by the least experienced supervisors.
Of course, the extent of managed-care penetration and other factors make each state's experience different. At a recent APA meeting, for instance, one psychologist from Tennessee reported no problems for recent graduates from his university. And as Jean A. Carter, PhD, a member of APA's Committee for the Advancement of Professional Practice, points out, graduates have faced the supervised experience dilemma--and found solutions to the problem--since licensure began.
"Some of the creative ways graduates have found to get their clinical experience, people can still do," says Carter, citing such examples as freestanding clinics, counseling centers and private practices. "There are still a lot of opportunities."
Carter acknowledges that an increasing number of graduates face difficulties. That's a result, she says, of decreasing financial support for students and increasing numbers of women and other graduates who find themselves unable to relocate.
"When you're locked into a community for personal reasons, you're more likely to have to make other compromises," she says.
Although Carter believes that horror stories are still the exception rather than the rule, she is also convinced that senior psychologists must do everything they can to help graduates make the transition into independent practice. In her case, that means having a student and a postdoc working in her Washington, D.C., private practice. In Massachusetts, the plight of new graduates has actually become the number-one issue for the Massachusetts Psychological Association.
"Overall, there simply aren't enough formal doctoral residency positions to absorb the approximately 2,000 clinically oriented psychologists who graduate each year," says Paul D. Nelson, PhD, deputy executive director of APA's Education Directorate.
Graduates' stories
As a result, the job hunt can be arduous. That's especially true for those who aren't willing or able to move, admit job-seekers.
Finding a position in a major metropolitan area can be particularly difficult, says Nicole Shidler Sampson, PhD, who graduated from George Washington University last year. Committed to staying in Washington, D.C., for personal reasons, she soon discovered that finding a job was almost impossible.
After failing to find a psychology-related position, she applied for nonpsychology jobs and master's-level counseling jobs. "I was pretty desperate," she admits. "When you're looking for a job and can't find one, you consider just about everything."
About eight months after she started looking, Sampson finally found a position through her graduate school's listserv. Today she has a job she loves as a project manager for a National Cancer Institute-funded research grant at Georgetown University. The downside? The work she does for this research position won't count toward licensure in the District of Columbia.
Dr. Paul Decancq couldn't make his student loan payments during his postdoc year due to a salary below $30,000. "Meanwhile I'm just sitting there watching my loans getting bigger and the interest piling up," he says. Hardships can linger long after new psychologists land jobs.
Paul Decancq, PsyD, who spent his postdoctoral year at the Rochester Mental Health Center in New York, feels like his life is on hold until he can get his debt under control. With a salary in the high $20,000s, he simply couldn't make his monthly loan payments during his postdoctoral year and had to defer. He found the restrictions on how he could earn money maddening.
"Master's-level people could get licenses and see patients independently but I couldn't, even though I've got more education and training," says Decancq, now a licensed clinical psychologist at the center. "Meanwhile I'm just sitting there watching my loans getting bigger and the interest piling up."
For Jennifer A. Nardozzi, PsyD, the distress was compounded by isolation.
"You get kicked out into the world with no support and with the disadvantage of not having a license," says the newly licensed Nardozzi, who is now director of admissions and of extended care programs at the Renfrew Center of South Florida in Coconut Creek. "It was a real shock to spend all that time working toward a degree and then feel more helpless after I did than when I didn't have one."
Graduates planning careers in practice aren't the only ones who face problems either. Those pursuing academic careers often face the same problem of accumulating enough supervised hours for licensure.
"New faculty have found that the kinds of professional activities required by their jobs, such as clinical teaching, supervision and research, often don't qualify as supervised hours," says Cynthia Belar, PhD, executive director for education at APA. "Their Catch 22 is whether to pursue licensure or focus on what it takes to establish a successful teaching and research program."
To become a well-rounded academician, Dr. Melanie Domenech Rodriguez combines a research postdoc with eight hours of clinical work weekly. The preparation will take three years--a luxury many can't afford, she says.Take Melanie Domenech Rodriguez, PhD, for instance. Eager for a future career as a well-rounded academician, she does eight hours a week of clinical work on top of a research postdoc at the University of Washington in Seattle. She sees this three-year period of honing her research skills and accruing clinical hours as a luxury many can't afford. Without her husband's support, she says, she would have had to skip the postdoc, go straight into academia and give up her dreams of combining teaching, research and practice.
"Given the teaching, research and service requirements for a first-year academician, there's no way I could have gotten the clinical hours I would need for licensure if I had gone straight into academia," says Domenech Rodriguez, a postdoctoral fellow in the Family Research Consortium-III. "It's really a privilege to be able to do what I do."
Possible solutions
The profession is now searching for ways to address the problem. One proposal is provisional or temporary licensing. Designed to increase new psychologists' chances of being reimbursed, these licenses still require recipients to work under supervision. Seven states already use this mechanism. And although the Association of State and Provincial Psychology Boards doesn't promote provisional licensure, it does provide model language for creating a provisional category.
For Mitch Prinstein, PhD, who held a temporary license in Rhode Island, having the license allowed him to get on an insurance panel during his postdoctoral year. But such licenses aren't a panacea, says Prinstein, who funded his postdoctoral experience at Brown University School of Medicine with a research grant from the National Institute of Mental Health.
"It takes a long time to get a temporary license, six to eight months in my case, and then an additional six months to get on a panel," says Prinstein, who is now an assistant professor of psychology at Yale. "By then, the postdoc is almost over."
Plus, the provisional licenses often don't achieve their goal of helping licensees get reimbursed. When APA's Practice Directorate recently surveyed states that have gone this route, it found little evidence that the new license category was helping. In Florida, for instance, the approximately 50 psychologists with provisional licenses reported some success with reimbursement but an overall feeling of frustration. Instead of increased access to opportunities, provisional licensees often find only increased fees and hassles.
And it's not just a question of issuing licenses, warns Russ Newman, PhD, JD, executive director for professional practice at APA. At the Practice Directorate's request, Pricewater-houseCoopers LLP looked into whether managed care and other insurance companies would be willing to reimburse those with provisional licenses. The answer was a resounding "no."
According to the payers surveyed, there are already enough behavioral health practitioners and the potential liability of using provisionally licensed practitioners is too high. They also pointed out that Medicare regulations and many state laws governing managed care forbid the reimbursement of practitioners without full-fledged licenses.
"The marketplace looks for people who are able to provide independent services, which provisional or temporary licenses don't offer," says Newman. "The marketplace is not going to change its mind about things simply because a provisional license was issued."
Another frequently proposed solution is to rethink the sequence of training and licensure. APA's Council of Chairs of Training Councils (CCTC), for instance, believes that new graduates can get the postdoctoral experience they need without having it tied to licensing. In CCTC's proposal, psychologists would be eligible for regular licenses as soon as they graduate. Initial renewal of those licenses would depend upon their having completed a certain number of hours of supervised experience. The council is currently analyzing results from a survey of graduate programs, practicum training sites and internships.
Of course, following through on this proposal would mean changing the licensing laws in every state. Doing so would not only be difficult and time-consuming but could also open the door to unwelcome changes, critics warn. Once the laws are being changed, they say, psychiatrists, social workers and master's-level practitioners could jump in to try to restrict psychologists' scope of practice or widen their own.
CCTC chair Beverly E. Thorn, PhD, thinks the proposal's benefits outweigh its risks.
"We need to be mindful of our graduates, not just ourselves," says Thorn, clinical training director for psychology at the University of Alabama at Tuscaloosa.
APA's role
A new initiative will help APA do just that. In February, APA's Council of Representatives voted almost unanimously to earmark $98,200 to create and fund a Commission on Education and Training Leading to Licensure in Psychology. Chaired by APA President-elect Norine G. Johnson, PhD, the commission has been asked to examine and make recommendations regarding:
Education, training, examination and supervision requirements leading to licensure.
Contents of education and training in relation to quality and relevance to the changing marketplace and emerging specialties.
Issues of supply and demand at various steps in the sequence of training and practice.
The commission will bring together all the constituencies involved in the issue. The education, training, professional practice, licensure, student and new graduate communities will all have representatives on the commission. The first issue the commission will address is identifying the point at which competency for independent practice is achieved.
"It is vital to the success of this endeavor to consider the sequence and interlocking of education and training," says Johnson, who spent 18 years as the director of an APA-accredited training program. "The postgraduate training experience requirement is being considered within the context of both the changing marketplace and changes in training and education."
However, the commission's focus is intended to be broader.
"It is important to emphasize that the purpose of this commission is not to solve reimbursement problems for unlicensed postdoctoral psychologists," says Geoffrey M. Reed, PhD, assistant executive director for professional development in APA's Practice Directorate. "These problems are based on marketplace forces over which the commission will have limited control."
Further, says Reed, the commission is not seeking to eliminate the postdoctoral requirement.
"That may end up being a part of the solution, but we don't know that yet," he says. "A series of issues related to the sequence of education, training and licensure have come up over the past few years. Rather than continuing to address these problems using short-term, piecemeal solutions, this commission is being convened to consider long-term, integrative responses to some of the key issues for psychology."
Although the commission's work is limited to a year, everyone involved agrees change will take a long time. According to Ronald F. Levant, EdD, ABPP, dean of psychology at Nova Southeastern University and recording secretary and a member of APA's Board of Directors, there is something the profession can do now: encourage students to branch out beyond traditional areas.
New graduates going into outpatient psychotherapy are the ones who are facing the biggest crisis in finding appropriate postdoctoral experience, notes Levant. That's because managed care has focused its cost-cutting attentions there.
Levant urges his students to get around the managed-care roadblock by seeking nontraditional opportunities. A psychologist performing diagnostic work-ups and brief therapy in a primary-care setting such as a health clinic or physician's office may not have to worry about reimbursement, says Levant, because the office might be able to use medical rather than mental health diagnostic and procedure codes for billing. Similarly, forensic evaluations performed on behalf of a court system don't require reimbursement by an insurance company.
"Psychology has yet to respond to the massive changes taking place in our society," says Levant. "We need to consider how we can respond to society's most pressing social and public health problems, create new roles and conceptualize how our training programs can facilitate graduates moving into those new roles."
Rebecca A. Clay is a writer in Washington, D.C.
