Pre-School Preparation and Psychotherapy Study

Professional Psychology: Research and Practice 2000, Vol. 31, No. 3. 321-326

Copyright 2000 by the American Psychological Association, Inc. 0735-702MXVS5.00 DOI: 10.1037S0735-7028.3I.3.321

Preinternship Preparation in Psychological Testing and Psychotherapy:

What Internship Directors Say They Expect

James M. Stedman, John P. Hatch, and Lawrence S. Schoenfeld

The University of Texas Health Science Center at San Antonio

What levels of preinternship training in testing and psychotherapy do internship directors expect students to have as they enter internship? This study addressed the question by surveying internship directors of all members of the Association of Postdoctoral and Internship Centers and asking them to specify the numbers of testing and psychotherapy experiences they believe an intern candidate should have prior to entering the internship. The results demonstrate similarities and differences in director expectations and have implications for preinternship students, graduate programs, and internships themselves.

Internship directors prize clinical experience in their recruits. Previous investigations found that directors value clinical experi-ences generally and particularly desire strong backgrounds in personality assessment (Petzel & Beradt, 1980; Tipton, Watkins, & Ritz, 1991). Recently, clinical experience was once again af-firmed as an important selection variable in three studies (Gloria, Castillo, Choi-Pearson, & Rangel, 1997; Lopez, Oehlert, & Moberly, 1996; Lopez, Oehlert, & Moberly, 1997).

A few investigators have assessed intern directors' valuations of preinternship clinical experience more specifically. In two studies (Malouf, Hass, & Farah, 1983; Shemberg & Leventhal, 1981), intern directors were asked more specific questions about their satisfaction regarding interns' graduate school preparation. Both studies were critical of interns' experience in test-based assess-ment skills and hi psychotherapy. Malouf et al. (1983) found that interns claimed better early internship clinical skills than were attributed to them by their internship directors. Two recent inves-tigations (Goldberg, 1998; Lopez et al., 1996) found that internship directors continue to be particularly critical of preparation in

JAMES M. STEDMAN received his PhD from St. Louis University in 1966. He is currently a clinical professor in the Department of Psychiatry at The University of Texas Health Science Center at San Antonio and is a former director of the internship program at that institution. His research interests include training issues in psychology and issues related to clinical child psychology.

JOHN P. HATCH received his PhD from The University of Texas at Arling-ton in 1977. He is currently a professor in the Departments of Psychiatry and Orthodontics at The University of Texas Health Science Center at San Antonio. His research focuses on health-related issues.

LAWRENCE S. SCHOENFELD received his PhD from the University of Florida in 1967. He is director of the clinical psychology residency and fellowship training programs in the Department of Psychiatry at The University of Texas Health Science Center at San Antonio. His research interests center on psy-chology training issues, chronic pain, and health care ethics.

WE THANK Ann Curtis for her extensive and untiring help in the data-collection phase of this investigation.

CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to James M. Stedman, Department of Psychiatry, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78229-3900. Electronic mail may be sent to [email protected].

test-based assessment. However, these negative evaluations have not been universal; at least one report (Snepp & Peterson, 1988) indicated that intern directors generally were satisfied with the preinternship preparation of both PhD and PsyD students.

There is little doubt that internship directors highly prize direct clinical experience; but, as noted in four of the studies cited above, they have not been satisfied with preinternship preparation in two key aspects of clinical experience, namely test-based assessment and psychotherapy. These criticisms to date have been global; no investigation has asked intern directors to specify in detail the number of testing and psychotherapy experiences they think intern candidates should have prior to entering internship. Perhaps this lack of numerical specification has led students and training di-rectors to push for more and more testing and psychotherapy practica in order to meet the unknown expectations of internships, in essence creating a sort of "numbers hysteria" with no quantita-tive basis.

The Project

The present survey sought to remedy this problem by asking the internship directors of the Association of Psychology Postdoctoral and Internship Centers (APPIC) to specify real numbers for both test-based evaluation and psychotherapy. The questionnaire was designed to obtain specific information regarding internship direc-tors' expectations with respect to intern applicants' preinternship clinical training in psychological assessment and psychotherapy. For general test-based assessment, internship directors were given a list of psychological test categories (intelligence, achievement, objective personality, and projective personality) and asked how many integrated psychological test reports, using all or some combination of these test categories, an intern applicant should have completed prior to entering then: programs. To further specify director expectations for the most commonly used projective tests, directors were requested to state how many of the integrated reports should contain Rorschach tests and Thematic Apperception Tests (or other picture-story tests). For neuropsychological assess-ment directors were asked to specify the expected number of integrated reports without specifying test subcategories. Respon-dents selected a specific number from a list of numbers ranging

Table 1

Median Number of Integrated and Neuropsychological Testing Reports, Rorschach Tests, and Thematic Apperception Tests (TATs) as a Function of Internship Type

Internship type Veterans Affairs hospitals

(n = 43)

Medical schools (n = 41) Consortia (n = 26) Community mental health

centers (n = 33) Private general hospitals

(n = 14)

Private psychiatric hospitals

(n = 15) State institutions (n = 28) University counseling centers (n = 58) Child facilities (n = 36) Other-military facilities (n = 17) Correctional institutions (n - 11) Integrated test reports 15.0 (10.0:21.0) 25.0 (15.0;31.0) 27.5* (20.0;31.0) 20.0 (12.0;24.0) 20.5 (8.0;30.0) 25.0 (19.0;30.0) 10.5 (10.5:20.0) 10.0" (4.0;15.0) 20.0 (11.5;30.0) 16.0 (9.0;30.0) 20.0 (10.0:20.5) Integrated neuropsychological test reports 4.5 (2J);10.0) 5.0 (0:17.5) 1.0 (0;10.0) 2.0 (0;6.0) 6.0 (3.0;13.0) 3.0 (0;6.0) 2.0 (0;5.0) 0.0" (0:2.0) O.O> (0;4.5) 0 (0;0) 0 (2.0:5.0) Rorschach tests within integrated tests

5.0 (2.0;10.0) 8.0 (0;18.0) 3.0 (0:10.0) 12.0 (5.0;20.0) 11.0 (8.0;20.0) 20.04 (15.0:30.0) 10.0° (6.5;15.0) 1.0' (0:7.0) 10.0 (4.5;17.0) 5.0 (0:20.0) 4.0 (1.5:7.5) TATs within integrated tests 3.0" (0;7.0) 8.0 (0:13.5) 1.0s (0;10.0) 10.0 (5.0;15.0) 13.5 (8.0:20.0) 21.0 (8.0:30.0) 6.0 (5.0:14.5) 3.011 (0;7.0) 11.0 (9.5:20.0) 4.0 (0;12.0) 4.0 (0:12.5)

Note. Numbers in parentheses are at the 25th and 75th percentiles. Significant pairwise Mann-Whitney U tests at p = .05 with Bonferroni adjustment.

Total tests: * Consortia > Veterans Affairs (VA) hospitals, state institutions. b University counseling centers < VA hospitals, medical schools, consortia, community mental health centers, private general hospitals, private psychiatric hospitals, state institutions, child faculties. Neuropsychological tests: c University counseling centers and child facilities < VA hospitals, medical schools, private general hospitals. Rorschach tests: Private psychiatric hospitals > VA hospitals, consortia, correctional institutions. ' State institutions > VA hospitals. ' University counseling centers < community mental health centers, private general hospitals, private psychiatric hospitals, state institutions, child facilities. TATs: * VA hospitals and consortia < community mental health centers, private general hospitals, private psychiatric hospitals, child facilities. h University counseling centers < community mental health centers, private general hospitals, private psychiatric hospitals, state institutions, child facilities.

from 0 to 20+ and could specify numbers for all or some of three types of clients, including adults, adolescents, or children.

The questionnaire format was similar for psychotherapy. Direc-tors indicated how many different individual clients, groups, cou-ples, or families an intern applicant should have treated, using long-term psychodynamic, short-term psychodynamic, cognitive-behavioral, group, marital, family, interpersonal, or play therapy. Directors selected specific numbers from a list ranging from 0 to 10+. For the categories of long-term psychodynamic, cognitive-behavioral, and group, they could report for adults, adolescents, or children.

Questionnaires were mailed to the internship training directors of 524 of the 542 APPIC-member programs in the United States and Canada. Eighteen programs were excluded because they have only part-time positions or are having membership difficulties at present. Two mailings produced usable responses from 324 pro-grams for a 62% return.

APPIC-member programs are classified into 12 types. The rel-ative percent representation of each type in our sample very closely matched the representation of each type in the population of APPIC-member programs as reported in the APPIC Directory (Hall, Cantrell, & Boggs, 1997). Thus, our sample closely approx-imates the APPIC membership and included respondents from all U.S. states and all Canadian provinces conducting internship train-ing. In addition to type of program, respondents specified the client population served by their facilities as primarily adult, primarily child, or "mixed" (adults, adolescents, children). One APPIC cat-egory, Military Facilities, has few programs, so it was combined with the "other" category for the purposes of analysis.

The principal goal of this study was to develop descriptive profiles for the testing and psychotherapy training events expected by internship directors prior to the candidate's arrival at the in-ternship. Because of the nonnormal data distribution, results are reported as median and lower-upper quartile values. Internship comparisons using nonparametric statistical testing were con-ducted and receive comment.

Table 1 presents medians and lower-upper quartile results for the number of integrated test reports combining all or some of the testing categories previously described, the numbers of Rorschach tests and Thematic Apperception Tests (or other picture-story tests) expected within the integrated reports, and the number of integrated neuropsychological test reports expected by the direc-tors of the various types of internship training programs. Kruskal-Wallis one-way analysis of variance by ranks was conducted to assess differences in director expectations across the 11 types of internship settings with the following results: integrated test re-ports: ff(10) = 78.4,p < .0001; integrated neuropsychological test reports: H(10) = 44.5, p < .0001; Rorschach tests: H(10) = 62.9,

p < .0001; Thematic Apperception Tests: ff(10) = 63.2, p <

.0001. To further specify pairwise differences, comparisons were made using Mann-Whitney U tests with Bonferroni adjustments. Column 1 of Table 1 displays numbers of integrated test reports expected by directors of the 11 types of internship sites. Significant site differences occurred between university counseling centers and most other sites, with university counseling centers expecting the fewest integrated reports. Directors of consortia-based intern-ships also expected more total integrated reports than did directors

SPECIAL ISSUE: WHAT INTERN DIRECTORS EXPECT 323

at Veterans Affairs (VA) hospitals or state institutions. All other training sites did not differ their expectations.

Director expectations for projective testing were more complex. Directors of private psychiatric hospitals expected the most Ror-schach tests but not significantly more than medical schools, private general hospitals, community mental health centers, or child facilities. Directors of university counseling centers expected the least and were different from most other sites. In addition, directors at state institutions expected more reports to include the Rorschach test than did the directors of VA hospital facilities. Otherwise, sites were not significantly different from one another. Results for the Thematic Apperception Test and other picture-story tests were similar. University counseling centers expected significantly fewer than most others, while community mental health centers, private general and psychiatric hospitals, and child facilities expected more than VA hospitals and consortia. The other sites were not different.

Turning attention to neuropsychological assessment, results demonstrated that director expectations were less complex. Direc-tors of university counseling centers and child facilities expected fewer of these assessments than the directors of most other intern-ship types. Otherwise, there were no real differences in program expectations for this form of assessment.

Table 2 presents medians and lower-upper quartile results for the 8 types of psychotherapy. Again Kruskal-Wallis one-way analysis of variance by ranks was conducted to determine differ-ences in director expectations across the 11 types of internship settings. Significant differences occurred among the following therapy types: short-term psychodynamic therapy: #(10) = 78.0,

p < .0001; group therapy: H(W) = 23.5, p < .009; marital

therapy: ff(10) = 54.1, p < .0001; family therapy: tf(10) = 76.6,

p < .0001; interpersonal therapy: tf(10) = 39.6, p < .0001; and

play therapy: #(10) = 68.3, p < .0001. There were no significant differences in director expectations across settings for long-term psychodynamic therapy, cognitive-behavioral therapy, or group therapy. Again, pairwise comparisons with Bonferroni adjust-ments were conducted to further specify differences in director expectations.

Directors of university counseling centers expected the highest number of short-term cases (Mdn = 10), which is significantly more than the number expected by most other types of sites. Such high expectations are common among counseling center directors as witnessed by the fact that 75% of them expected at least 11 short-term cases. Not surprisingly, directors of child facilities expected the least and differed from most other programs. Inter-personal therapy, like short-term psychodynamic therapy, is adult oriented, so it is not surprising to see that directors of child facih'ties expected the least and differed from the more adult-oriented programs. University counseling center directors expected the most and differed from medical schools but not other adult-oriented programs.

With respect to marital therapy, directors of child facilities expected the least experience and differed from most other sites. State facility directors expected fewer marital therapy cases than directors of VA hospitals and university counseling centers. Re-sults for family therapy presented a more complex pattern, but, as might be anticipated, directors of child facilities expected the most experience and differed from most adult-oriented sites but not from the mixed patient-population sites. University counseling and

VA hospital directors expected the least family therapy and dif-fered from child and mixed-population sites.

Play therapy had the most complex pattern of the therapies. Not surprisingly, directors of the child facilities expected the most experience but did not differ from several mixed-population pro-grams (private general and psychiatric hospitals, consortia, com-munity mental health centers). Generally, directors of adult-oriented sites differed from mixed and child programs.

Implications

As mentioned, internship directors have criticized preparation in test-based assessment and psychotherapy since the early 1980s (Shemberg & Leventhal, 1981). However, these critiques were global and qualitative, offering little guidance to either intern candidates or graduate programs. This study offers the first quan-titative look at what internship directors report as their expecta-tions for preinternship preparation in testing and psychotherapy.

Our results demonstrate both similarities and significant differ-ences in director expectations for training in testing and psycho-therapy across the 11 types of internship programs. With regard to psychological testing, our data show that university counseling centers deemphasize psychological testing, whereas hospital and other settings serving mixed patient populations emphasize testing experience rather heavily. Settings aimed primarily at adult patient populations expect somewhat less overall testing, some signifi-cantly less, for example, VA hospitals. With regard to psycho-therapy, our findings demonstrate remarkable consistency across settings for director expectations regarding long-term psy-chodynamic, cognitive-behavioral, and group therapies. Expecta-tions for the other therapies vary primarily according to the patient populations being served.

In addition to these general remarks, these findings have more specific implications for preinternship students, for graduate train-ing programs, and for internship programs themselves. Each is discussed in turn.

For Students

Students should note that there are some real differences among training site directors in their expectations for preparation in psy-chological testing. The most notable occurs between university counseling centers and most other programs, and some real vari-ations occur among other sites, particularly with regard to projec-tive tests. However, in general, director expectations for total tests and neuropsychological tests are more similar than significantly different.

Profiles for psychotherapy demonstrate that directors do not have significantly different expectations for long-term psychody-namic, cognitive-behavioral, and group therapies. Expectations for short-term psychodynamic and interpersonal therapies, both pri-marily adult-oriented modalities, show expected differences from child programs. Directors of university counseling centers are therapy oriented and place a heavy emphasis on training in short-term dynamic, cognitive-behavioral, and interpersonal therapies. The child-adolescent-oriented therapies (family and play) tend to be differentially expected by directors of child-oriented and mixed sites compared with adult-oriented sites.

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SPECIAL ISSUE: WHAT INTERN DIRECTORS EXPECT

325

A second point for students to note is that Tables 1 and 2 offer the first quantitative look at internship directors' expectations for preintemship training in testing and psychotherapy. The tabled values (medians and lower-upper quartiles) demonstrate the vari-ation within each type of program. However, the median and upper quartile values appear to be the most important for students to note. The median values meet 50% of program directors' expectations across the 11 types of training sites; the upper quartile covers 75% of director expectations for preinternship experience. Prospective interns can easily compare their accumulated experience to direc-tor expectations. To take the VA hospitals as an example, our data show that a candidate with 15 integrated test reports, containing 5 Rorschachs and 3 Thematic Apperception Tests, 4-5 neuropsy-chological reports (important only for those programs having neuropsychological rotations), 2 long-term dynamic cases, 5 short-term dynamic cases, 11 cognitive-behavioral cases, 4 groups, 3 marital cases, and 3 interpersonal cases would meet director ex-pectations for 50% of VA sites.

How will internship directors use their reported numbers when the time comes to fill their training slots? Our study did not require directors to rank the importance of testing and psychotherapy experience relative to other selection criteria, such as letters of reference, personal interviews, and certain clinically oriented courses, criteria that have surfaced as important selection variables in previous studies (Lopez et al., 1996; Lopez et al., 1997). Therefore, these data provide no definitive insight into how much weight directors and their committees will assign to the numbers of testing or psychotherapy training events an intern candidate has accumulated in the past. However, given the fact that directors have consistently endorsed clinical experience as an important selection factor (the most important in the recent study by Lopez et al., 1997), it is reasonable to assume that directors will attempt to recruit candidates who match their reported numbers whenever possible.

For Graduate Schools

These data offer graduate programs a look at the quantitative testing and psychotherapy expectations of internship directors and suggest a question for graduate programs to reflect on. Are your students approaching these levels of preinternship training in test-ing and psychotherapy? The scientist-practitioner and the profes-sional psychology training models, while stressing basic academic psychology, also place a strong emphasis on practical training. Hence, given this emphasis on practical training and the fact that most students spend at least 5 years in graduate education, it seems reasonable to think that clinical and counseling students should be able to accrue testing and psychotherapy experiences approaching the numbers expected by internship directors without neglect of the basic psychology curriculum.

Of course, the answer to the question asked above is most relevant for those programs experiencing difficulty in placing their students in internships. If your students are experiencing difficulty in selection, you may need to reassess preinternship preparation in testing and psychotherapy in relation to these findings. These are key clinical experiences expected by internships.

For Internship Programs

These data reflect a picture of preintemship training expecta-tions at APPIC programs and offer internship directors and their staffs an opportunity for reflection on requirements. Internship directors might want to peruse Tables 1 and 2 to see what overall APPIC expectations are for preinternship preparation in testing and psychotherapy. Then they might want to see where their own particular program fits compared with the 25th, 50th, and 75th percentiles, either within their category or compared with other types of programs. It is conceivable, because numerical expecta-tions have not been available before, that a particular program might want to adjust its expectations up or down. For example, if you find that your testing expectations are above the 75th percen-tile for your group, you might decide that is where you want to be. On the other hand, you might decide that recruiting would go better if you cut back to the 50th percentile expectation. Each program has its own unique training goals and expectations. These numbers simply offer an opportunity to compare and reflect.

Traditionally, internship programs have published their clinical experience expectations only in terms of the "minimum number of practicum hours" required prior to internship. Our data might be used to create a more refined expectation for preinternship training in psychological assessment and psychotherapy. We recommend that each program establish and publish its own standards, either as specific numbers or as ranges expected by the program. This would remove much of the current mystery, so students would know what particular programs expect in the way of testing and psychotherapy experiences. If this practice were widely adopted, it would provide invaluable preinternship data that would benefit both students and graduate schools.

Stedman (1997) suggested the need for a data-based feedback system linking the graduate-professional schools, the internship programs, and current practitioners. Such feedback could provide vital training-related information necessary to shape an effective educational mode] geared to teach the clinical knowledge and skills essential to applied psychology of the 2000s. The present study is a first step in that direction, in that it translates previous qualitative judgments into numerical training expectations for two key areas of clinical knowledge and skill. However, like most first steps, this study has limitations. It answers some questions and surfaces others. Further investigations will be needed to clarify such questions as (a) whether the testing and therapy experiences of selected applicants actually approximate the expectations of training directors as reflected in this study and (b) whether candi-dates vary in then1 testing and therapy preparation as a function of graduate program type, for example, clinical versus counseling. We encourage investigators to pursue these questions.

References

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survey of training directors. Professional Psychology: Research and

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APA-aecredited internships stratified by type of site and

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Received August 30, 1999

Revision received November 15, 1999

Accepted February 7, 2000 •

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