The Odd Structure of Clinical Training

We have an odd structure for training clinical psychologists in the US, and it's really clear to me the contrast since I'm now visiting Canada. In the United States, we've made it fairly easy to start training programs in psychotherapy, but we've made it exceedingly difficult for practitioners to get licensed and into practice. Sadly, as a result, many psychotherapists are demoralized and fairly exhausted by the demands of training before they've ever been able to get into full practice. It's odd, when you think about it, because the very idea of a profession involves the public expectation that practitioners will be uniformly trained in a technical subject. In psychology, we've been talking for years about wanting a diversity of training models, but this makes it hard to achieve uniformity. To a consumer, the array of options must be bewildering. You can see a master's level practitioner (Marriage and Family Therapist, Master in Social Work) or a doctoral level practitioner (psychiatrist, Ph.D., Psy.D., or Ed.D.) or even a pastoral counselor or psychiatric nurse. Your therapist may have gone to a University, which also trains people in lots of other disciplines and professions, or they may have gone to a school that is very small and only exists to train psychotherapists.

In Canada, the idea of a for-profit educational institution is controversial. While therapists in the 1970's learned that they could make a living by starting schools to train others (especially in California), and there was indeed a terrible shortage of mental health practitioners, that has never been allowed on a large scale in Canada.

As a result, therapists in Canada are more uniformly trained, especially if they are doctoral level psychologists. All Ph.D.'s will have attended a University based program, and the University itself has no profit motive, so it can afford to be choosy and dismiss inappropriate students without a second thought. Whether that happens or not, I don't know.

On the other hand, clients don't have managed care plans, and the government rarely pays for therapy (outside of hospitalization, as I understand it). So Canada probably has better and more gifted therapists, on average, but their therapists are more expensive to see. Fortunately, people with good health insurance through their employers may have great access to a variety of practitioners, but people without such insurance may be out of luck.

The contrast reveals a fundamental problem in structuring health services. The needs of clients are antithetical to the desires of practitioners, and what is good for one tends to be bad for the other, at least in the fee-for-service market. If the cost of care comes down for clients, then the benefits of providing care come down for practitioners. You can then expect the best practitioners to feel demoralized, since they could usually make a better living elsewhere. Lest you think that psychotherapists are extravagantly paid, the average practitioner at a master's level makes about as much as, or less than, a schoolteacher, especially when benefits are included.

Having pondered this conundrum for years, I personally would recommend a system more similar to actuarial science, which has a series of 8 graded exams. People can stop after 4 and practice, or they can go for all 8. If you want the most stellar actuary out there, pick someone who has passed all 8 exams. If you want a less expensive choice, go for someone who just passed exam 4. Something like this, if implemented in a broad scale in psychotherapy, could help clients identify the best (most skilled) practitioner in their price range. It could be good for Canada, which shows signs of emulating the broken US system, as well as the US.

The existing system is endangered by widespread career dis-satisfaction. A substantial number of practitioners are considering leaving the field, and we may have a shortage in the distant future if we don't do something now to to make the field of practice fairer in its compensation given the extreme work and talent that go into training the best practitioners at top programs. We risk losing our brightest minds to business and government and research if we don't take action.