Clinical Psychology Doctoral Programs

Part II: Some additional modest proposals.

Posted Jun 29, 2020

In my last post, I proposed three changes to the way doctoral training in clinical psychology is delivered in the United States: 1) Award the doctorate at the end of the 4th year of training, with the completion of the dissertation; 2) Require 2,000 supervised clinical hours prior to entering the 5th year of training; and, 3) Combine the clinical internship year and the two years of postdoctoral residency into a 3-year residency at the same agency or institution. These changes would: a) enhance the perceived status of clinical psychologists relative to the medical school graduates they often train alongside; b) ensure that even psychologists intent on academic careers gain a firm grounding in clinical reality; and, c) relieve trainees of some of costly relocations required by the current system.

In this post, I  propose two additional changes (4 & 5):

4. Stop forcing future clinical psychologists to earn a masters degree prior to beginning doctoral training.

As I noted in my previous article, the master of science in clinical psychology should be conferred upon doctoral trainees upon acceptance of their dissertation proposal. The MS degree is already held by increasing numbers of applicants for doctoral programs however, for a simple reason — the acceptance rate for clinical psychology doctoral programs is only 12%. In other words, 88% of people who applicants to doctoral programs in clinical psychology are rejected. What should they do then? Well, they could find another field of study: the overall acceptance rate for medical school in the United States is 44%, meaning that getting in there is a comparative breeze. Or, they could enroll in a masters program. Doing this won't help your undergraduate GPA, of course, but it will enhance your research experience, and it could garner you more impressive letters of recommendation, two of the most important criteria for graduate school admissions. Will earning a masters prior to entering a doctoral program make you a better clinical psychologist? I am not aware of any research that supports that hypothesis. Earning a predoctoral masters, will, however, make you an older clinical psychologist by the time you earn your Ph.D. or Psy.D.

If would-be psychologists are earning masters in order to increase their competitiveness for doctoral programs, what could be done instead? My radical solution is this: Accept a higher percentage of applicants. Does anyone think that every one of the rejected applicants are actually unfit to train as a doctoral candidate? If not, surely we are missing out on some perfectly wonderful potential clinical psychologists. If we could increase the acceptance rate to 25% we might actually be able to supply the number of clinical psychologists expected to be needed by the labor market over the next decade (15% growth predicted by the US Department of Labor). 

In 2016-2017, about 2,800 doctoral-level clinical psychologists entered the workforce for the first time. Increasing the acceptance rate to 25% would double that number. The trainees selected would still be highly qualified, but without having to first jump through a masters degree hoop, they would be younger when they finished training and therefore able to contribute more productive years to the field and to society.

5. Restructure where clinical psychology doctoral students are trained.

Each year, about 20,000 students matriculate at one of the 154 medical schools in the United States (there are 26,000 matriculants when you count those who attend one of the 38 Doctor of Osteopathy schools). In contrast, about 2,800 students begin a clinical psychology doctoral program, at one of over 400 such programs in the country. That's right — while there are only 154 schools granting the MD degree, there are over 400 that grant doctorates in clinical psychology. 

One practical implication of this arithmetic is that most doctoral programs in clinical psychology have extremely small class sizes. Having only 6 or 7 classmates in your Ph.D. program is not uncommon. In comparison, the typical medical school class is about 130 students; Harvard Medical School has an incoming class for Fall 2020 of 165 students. One of the greatest aspects of graduate school is being surrounded by bright, motivated, hard working people, not just your professors and supervisors but also your classmates. Increasing class sizes means increasing the number of people you can learn from.

On the other hand, having small class sizes can mean forming intimate, long-term working relationships with one or two primary research mentors. In academic psychology, people often talk about their doctoral lineages: "My Ph.D. was conferred upon me by famous Dr. X, who earned her doctorate working with the even more famous Dr. Y, who earned his doctorate from the super-exalted famous Dr. Z." There is a lot to be said for this kind of master-apprentice relationship. However,  what if your research interests or clinical approach don't quite jibe with those of your mentor? What if you find out that your mentor is a bully, a narcissist (plenty of those in academia), or a sexual harasser? Can you find another mentor? Is there another mentor available? Will switching mentors after starting a doctoral program brand you as a malcontent, or as "flighty?" Under the current system, where doctoral trainees enter a lab run by a certain mentor and spend four years working for that person, your choices are sometimes to either suck it up or quit.

The primary reason for the brutally low acceptance rate to clinical psychology programs is because you are often not applying to a program, but rather for a chance to work for the next four years with a specific research mentor. Many Ph.D. programs only have 10-15 core faculty and not all of them accept applications every year. One highly regarded program reports on its website that it had 450 applications last year and that only 7 students were accepted to work with 5 of their faculty. If nothing else, this system is madly inefficient. [By the way, with a $50 fee per application, that is a $22,500 windfall for the university.]

What is the ideal size of a class of clinical psychology trainees? Probably not so high as the typical medical school class. I propose a class size of 36 trainees, which is about the size of a U.S. Army rifle platoon (minus the 6-person leadership team). For the first two years of coursework, most classes should be conducted as seminars or workshops of no more than 12 students. Some courses, such as statistics, could be taught to the entire class at one time. If we adopt the faculty-student ratio of Harvard Medical School (1 : 3.6), then 40 tenured or tenure-track faculty should be able to accommodate the 144 students enrolled in a 4-year doctoral program (ideally assisted by plenty of clinical faculty from outside the academic institution). 

If we were to produce 5,600 doctorates in clinical psychology each year (twice the current number), each in graduating classes of 36, then we would only need 156 Schools of Clinical Psychology (versus the +400 programs we currently have). This doesn't mean that all of the small-scale, artisinal programs would have to close up shop. Some would continue to perform essential training in some niche areas. But many would surely be absorbed by larger programs.

The big sweetener used by traditional academic programs is that your doctorate is "free." That is, most students receive a fellowship that covers tuition and provides a stipend as well. But graduate students should be smart enough to know that nothing is free in this world. In addition to learning, you will be essentially working for your research mentor. You'll also be teaching classes to undergraduates.  Pretty soon you will be writing the grants that will pay for the fellowships of the students who come after you. At the end of four years, you will have contributed to plenty of publications in your mentor's research area, and you won't have additional student loan debt.

I wonder when universities will realize that these fellowships aren't necessary to attract brilliant, hard working people to the field and to the profession — that there are plenty of people who would gladly pay, let's say, $40,000 a year for four years in order to earn a doctorate in clinical psychology. Especially if those doctorates led directly to reasonably well paid 3-year residencies (i.e., getting paid to continue to learn). [$160,000 in loans, at 4% over 30 years, comes to a monthly payment of $763.86 — which is affordable given the typical income of a clinical psychologist]. The annual income from a 144 student program would be about $5.8 million per year. They could pay the 40 faculty $100,000 a year and still make nearly two million in profit, in addition to the money that would still be coming in from research grants (universities typically appropriate 50% of scientific grant money to cover their "overhead"). 

In my next post on this topic, I will discuss licensing exams and Board Certification.